Postextubation Period Research Articles

Kaf İçi ve Dışına Lidokain Uygulamasının Ekstübasyon Sonrası Görülen Kardiyovasküler ve Solunum Sistemi Yanıtlarına Etkileri

Objective: In our investigation, we aimed to assess the efficacy of employing lidocaine spray application around endotracheal tube cuff (ETTC) prior to intubation, alongside and the use of intracuff lidocaine application following intubation. Our primary objective encompassed an examination of the resultant effects on the cardiovascular and respiratory systems leading up to the extubation phase. Methods: Two hundred patients scheduled for gynecologic operations, with an ASA physical status of I or II and aged between 18 and 65 years, undergoing general anesthesia lasting over one hour, were recruited for the study. Patients were allocated into four groups. Group I involved the inflation of the endotracheal tube cuff with air following intubation. In Group II, 10% lidocaine was sprayed around the ETTC prior to intubation. Group III entailed the inflation of the ETTC with 2% lidocaine after intubation. Lastly, Group IV received both the pre-intubation application of 10% lidocaine spray around the ETTC and the inflation of the cuff with 2% lidocaine following intubation. Cardiovascular parameters in the early post-extubation period and occurrences of postoperative sore throat, cough, and hoarseness up to 48 hours post-operation were documented for analysis. Results: Increases were observed at cardiovasvular system parameters after extubation in all groups continued for 5 or 15 minutes. Postoperative data for sore throat, cough and hoarseness were smilar in all groups. Conclusion: The study revealed that the administration of 10% lidocaine spray around the ETTC, as well as the use of 2% lidocaine within the cuff alone or in combination, did not result in a reduction of cardiovascular system responses during the early post-extubation period. However, these interventions did lead to a decrease in postoperative respiratory system side effects, albeit not providing complete prevention of such occurrences. Keywords: Lidocaine, endotracheal tube cuff, extubation, hemodynamic, pulmonary

Management of adult mechanically ventilated patients: A UK-wide survey.

Mechanical ventilation is a common and often lifesaving intervention that is utilised in intensive care. However, the practices can vary between centres. Through this national survey we aim to gain more information about different strategies adopted across the UK. All adult intensive care units in the UK were approached to participate. The questionnaire was developed with an electronic survey engine and conducted between 09/11/2023 and 01/04/2024 (Survey Monkey®). The survey included questions on ventilator modes, settings, protocols/pathways, rescue strategies, immediate post-extubation period and follow-up. There were 196 responses from 104 hospitals. The most widely adopted start-up ventilation mode was pressure-regulated volume-controlled mode. For acute hypoxaemic respiratory failure (AHRF), most of respondents reported full (39.8%) or partial compliance (58.1%) with the ARDSnet protocol, with PEEP settings being the commonest deviation. Prone positioning (99.0%), followed by recruitment manoeuvres (91.3%) were commonly used rescue measures during AHRF. APRV (55.7%), inhaled (51.3%) and systemic pulmonary vasodilators (44.1%) were also commonly used. Conservative oxygen targets (SaO2 of 88%-92%) were commonly adopted (70.6%). As a care bundle, intermittent ETT cuff pressure monitoring was more common (65.5%) than continuous cuff pressure monitoring (20.0%). Propofol and alfentanil were the most common initial sedative and analgesia (99.5% and 56.9%) respectively. Routine volatile anaesthetic use was rare. Our survey has shown significant variation of practice in common but crucial elements of management of patients receiving mechanical ventilation. We hope the results in our survey highlight potential future areas of research. South-coast Peri-operative Audit and Research Collaborative (SPARC)Severn Trainee Anaesthetic and Critical Care Research group (STAR)Collaborative research in Anaesthesia in the Northeast (CRANE).

Time course of electrical activity of the diaphragm (EAdi) in the peri extubation period and its role as predictor of extubation failure in difficult to wean patients

IntroductionWeaning patients from mechanical ventilation is crucial in the management of acute respiratory failure (ARF). Spontaneous breathing trials (SBT) are used to assess readiness for extubation, but extubation failure remains a challenge. Diaphragmatic function, measured by electrical activity of the diaphragm (EAdi), may provide insights into weaning outcomes.Materials and methodsThis prospective, observational study included difficult-to-wean patients undergoing invasive mechanical ventilation. EAdi was recorded before, during, and after extubation. Patients were categorized into extubation success and failure groups based on reintubation within 48 h. Statistical analysis assessed EAdi patterns and predictive value.ResultsThirty-one patients were analyzed, with six experiencing extubation failure. Overall, EAdi increased significantly between the phases before the SBT, the SBT and post-extubation period, up to 24 h (p < 0.001). EAdi values were higher in the extubation failure group during SBT (p = 0.01). An EAdi > 30 μV during SBT predicted extubation failure with 92% sensitivity and 67% specificity. Multivariable analysis confirmed EAdi as an independent predictor of extubation failure.ConclusionsIn difficult-to-wean patients, EAdi increases significantly between the phases before the SBT, the SBT and post-extubation period and is significantly higher in patients experiencing extubation failure. An EAdi > 30 μV during SBT may enhance extubation failure prediction compared to conventional parameters. Advanced monitoring of diaphragmatic function could improve weaning outcomes in critical care settings.

Comparison between intravenous lidocaine and dexamethasone in reducing postoperative sore throat after endotracheal extubation at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia; a prospective cohort study

BackgroundPost-operative sore throat is the common complaint and uncomfortable side effect in patients receiving general anesthesia with endotracheal intubation. Drugs with analgesic and anti-inflammatory properties, like steroids and local anesthetics, are the best options for postoperative sore throat prophylaxis. Therefore, this study aimed to compare the effects of intravenous lidocaine and dexamethasone in reducing postoperative sore throat following endotracheal extubation at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia, from January 1 to March 30, 2023 G.C.MethodsA prospective cohort study was carried out at Tikur Anbessa Specialized Hospital. Data from 50 patients in the lidocaine (1.5 mg/kg), 50 in the dexamethasone (8 mg), and 49 in the control groups were analyzed. The data were collected using observation based on structured questionnaires. A systematic random sampling technique was applied to select respondents. The data were entered into EpiData version 4.6.0.6 and transferred to STATA version 17 statistical software for analysis. A comparison of continuous data among the groups were performed using a one-way ANOVA test for parametric data. The Kruskal–Wallis rank test was used for non-parametric data. Associations between variables were tested using chi-squared test, Fisher’s exact test, and binary logistic regression. Bivariable and multivariable logistic regression was used to determine degree of association.ResultsThe incidence of POST was 40%, 32%, and 57.1% in the lidocaine, dexamethasone, and control groups, respectively (P = .0356). Dexamethasone reduced the incidence of POST during the first 24 h (AOR: 0.374, 95% CI: 0.149–0.939). However, no difference was observed in the severity of POST at 3 h (p = 0.130), 6 h (p = 0.096), 12 h (p = 0.313), and 24 h (p = 0.525) of the post-extubation period among the three groups. IV lidocaine did not effectively reduce the incidence and severity of postoperative sore throat at different time intervals.Conclusion and recommendationIntravenous dexamethasone is more effective than intravenous lidocaine in reducing the incidence of postoperative sore throat among the groups. Based on these findings, intravenous dexamethasone is recommended to decrease the incidence of postoperative sore throat.

Comparison of Propofol and Sevoflurane Anaesthesia in Terms of Postoperative Nausea-Vomiting Complication in Cardiac Surgery Patients Undergoing Enhanced Recovery After Surgery Protocol: A Prospective Randomized Study.

Postoperative nausea (PN) and vomiting (PONV) in cardiac surgery increases adrenergic stimulation, limits mobilization and oral intake, and can be distressing for patients. The primary aim of our study was to investigate the effect of sevoflurane and propofol anaesthesia on the incidence of PONV in cardiac surgery patients undergoing Enhanced Recovery After Surgery (ERAS) protocol. Following ethics committee approval, 62 patients undergoing elective coronary artery bypass surgery with ERAS protocol were included in this prospective randomized study. After standard induction of anaesthesia, Group S received 1.5-2% sevoflurane and Group P received 50-100 μg kg-1 min-1 propofol infusion as maintenance anaesthetic agent with a bispectral index of 40-50. The incidence of PN and PONV between 0-6 hours (early) and 6-24 hours (late) after extubation was compared as the primary outcome. The incidence of delirium was analyzed as a secondary outcome for similar periods. In the propofol group, 3 patients were excluded due to postoperative tamponade revision and prolonged mechanical ventilation. PN in the early post-extubation period (29% vs. 7.1%, P=0.031) was significantly higher in Group S. The incidence of delirium was similar between the groups in both periods. Propofol may reduce the incidence of PN in the first 6 hours after extubation compared with sevoflurane. We believe that this period will be beneficial for gastrointestinal tolerance as it is the period when oral intake is initiated in patients. In conclusion, propofol maintenance in cardiac surgery patients may facilitate patient rehabilitation as part of the ERAS protocol.

Central venous pressure waveform analysis during sleep/rest: a novel approach to enhance intensive care unit post-extubation monitoring of extubation failure.

This pilot study aimed to investigate the relation between cardio-respiratory parameters derived from Central Venous Pressure (CVP) waveform and Extubation Failure (EF) in mechanically ventilated ICU patients during post-extubation period. This study also proposes a new methodology for analysing these parameters during rest/sleep periods to try to improve the identification of EF. We conducted a prospective observational study, computing CVP-derived parameters including breathing effort, spectral analyses, and entropy in twenty critically ill patients post-extubation. The Dynamic Warping Index (DWi) was calculated from the respiratory component extracted from the CVP signal to identify rest/sleep states. The obtained parameters from EF patients and patients without EF were compared both during arbitrary periods and during reduced DWi (rest/sleep). We have analysed data from twenty patients of which nine experienced EF. Our findings may suggest significantly increased respiratory effort in EF patients compared to those successfully extubated. Our study also suggests the occurrence of significant change in the frequency dispersion of the cardiac signal component. We also identified a possible improvement in the differentiation between the two groups of patients when assessed during rest/sleep states. Although with caveats regarding the sample size, the results of this pilot study may suggest that CVP-derived cardio-respiratory parameters are valuable for monitoring respiratory failure during post-extubation, which could aid in managing non-invasive interventions and possibly reduce the incidence of EF. Our findings also indicate the possible importance of considering sleep/rest state when assessing cardio-respiratory parameters, which could enhance respiratory failure detection/monitoring.

To evaluate the analgesic effectiveness of bilateral erector spinae plane block versus thoracic epidural analgesia in open cardiac surgeries approached through midline sternotomy

BackgroundThe efficacy of the erector spinae plane (ESP) block in mitigating postoperative pain has been shown for a range of thoracic and abdominal procedures. However, there is a paucity of literature investigating its impact on postoperative analgesia as well as its influence on weaning and subsequent recovery in comparison to thoracic epidural analgesia (TEA) in median sternotomy-based approach for open-cardiac surgeries and hence the study.MethodsIrrespective of gender or age, 74 adult patients scheduled to undergo open cardiac surgery were enrolled and randomly allocated into two groups: the Group TEA (thoracic epidural block) and the Group ESP (bilateral Erector Spinae Plane block). The following variables were analysed prospectively and compared among the groups with regard to pain control, as determined by the VAS Scale both at rest (VASR) and during spirometry (VASS), time to extubation, quantity and frequency of rescue analgesia delivered, day of first ambulation, length of stay in the intensive care unit (ICU), and any adverse cardiac events (ACE), respiratory events (ARE), or other events, if pertinent.ResultsClinical and demographic variables were similar in both groups. Both groups had overall good pain control, as determined by the VAS scale both at rest (VASR) and with spirometry (VASS) with Group ESP demonstrating superior pain regulation compared to Group TEA during the post-extubation period at 6, 9, and 12 h, respectively (P > 0.05). Although statistically insignificant, the postoperative mean rescue analgesic doses utilised in both groups were comparable, but there was a higher frequency requirement in Group TEA. The hemodynamic and respiratory profiles were comparable, except for a few arrhythmias in Group TEA. With comparable results, early recovery, fast-track extubation, and intensive care unit (ICU) stay were achieved.ConclusionsThe ESP block has been found to have optimal analgesic effects during open cardiac surgery, resulting in a decreased need for additional analgesic doses and eliminating the possibility of a coagulation emergency. Consequently, it presents itself as a safer alternative to the potentially invasive thoracic epidural analgesia (TEA).

Comparison of Haemodynamic Effects of Clonidine and Dexmedetomidine for Intubation using Intubating Laryngeal Mask Airway in Patients undergoing Elective Surgery under General Anaesthesia: A Randomised Clinical Study

Introduction: The Intubating Laryngeal Mask Airway (LMA) is a Supraglottic Airway (SGA) device through which endotracheal intubation can be performed. Laryngoscopy and intubation are known to initiate a haemodynamic response. LMAs in general produce a lesser pressor response, but intubating LMA provokes a higher response due to the invasiveness of tracheal intubation. Aim: To compare dexmedetomidine and clonidine in attenuating the haemodynamic response to intubating LMA, Ramsay sedation score, and the incidence of laryngopharyngeal injury. Materials and Methods: A randomised clinical study was conducted in the Department of Anaesthesiology, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim, India, over a period of one year spanning from June 2020 to May 2021 to compare the two drugs in patients with American Soceity of Anaesthesiology (ASA)-I. The doses of clonidine and dexmedetomidine were 2.5 mcg/kg and 0.5 mcg/kg, respectively. The study parameters {Heart Rate (HR), Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), and Mean Blood Pressure (MBP), Peripheral Saturation of Oxygen (SpO2 ) were recorded at baseline, pre- and post-induction, and at various time intervals (0, 1, 3, 5 minutes) after intubation. Sedation score was also recorded before intubation and after extubation. Statistical Packages of Social Sciences (SPSS) version 23.0 was used to analyse the data (χ2 test for categorical variables and analysis of variance for continuous data). Results: There was no statistically significant difference between the two groups for the duration of surgery (p=0.267), duration of anaesthesia (p=0.197), and the duration between closure and extubation (p=0.407). Dexmedetomidine better attenuated the response of HR and SBP just before induction, post-induction, and immediately post-intubation. All the haemodynamic parameters were better controlled by dexmedetomidine immediately after intubation. Sedation was better with dexmedetomidine in the pre-intubation as well as post-extubation period, except at five minutes post-drug infusion when clonidine was better. Conclusion: Compared to clonidine, dexmedetomidine was more effective in attenuating the patient’s haemodynamic response to intubating LMA in the immediate peri-intubation period. However, from 1 minute post-intubation onward, both drugs behaved similarly in controlling the pressor response.

Analgesia and sedation strategy for mechanically ventilated patients in the respiratory ICU

Abstract Background Mechanical ventilation is typically required for ICU patients as part of their care. This recommends the use of analgesia and sedation in a balanced strategy to alter patients’ comfort and assist synchronization with mechanical ventilation while avoiding the downsides of excessive sedation. Objective The aim of the study was to compare between deep sedation and light sedation, analgesia, and no sedation strategies and their effects on the length of mechanical ventilation, and their effects on patients’ prognosis. Patients and methods This cohort prospective pilot study was conducted at the medical respiratory ICU at Ain Shams University Hospital in Cairo, Egypt, on 54 patients separated into four groups according to the type of sedation and analgesia suited for each patient’s severity condition. Results In this study, 54 mechanically ventilated patients in respiratory ICU were recruited. The patients were divided into group 1: no sedation or analgesia, group 2: analgesia only, group 3: light sedation, and group 4: deep sedation. There was a significant difference in Acute Physiology and Chronic Health Evaluation score and severity%, although the Acute Physiology and Chronic Health Evaluation score and severity % were the highest in group 1 (25.53, 55.11%) and group 4 (23.40, 47.68%), but the prognosis was poorer in group 4 and was affected by deep sedation (100% death rate) than that in group 1 (60.0%). The average infusion rate of fentanyl and the total dose were significantly different between groups, the highest being in the deep sedation group. ICU length of stay was nonsignificant between groups but it was lower in group 4 (median: 9 days) than other groups. The average rate of dormicum infusion in the deep sedation group was 5 µg, while there was no daily vacation period; so, it can be explained that higher doses of sedation and analgesia in group 4 affected their prognosis to be poorer than other groups. Delirium occurred in 80% of group 4 patients, but only in 6.7% of subgroups, indicating a highly significant difference. Complications either metabolic, cardiac, or hematologic in the postextubation period were higher in group 4 (60%), than in group 1 (47.7%), group 2 (40%), and group 3 (15%). Conclusion Light sedation and analgesia strategies with daily sedation interruption would have a better survival outcome and cause fewer issues in patients, who were on mechanical ventilation than a heavy sedation approach.

Predictors of Noninvasive Ventilation Failure in the Post-Extubation Period: A Systematic Review and Meta-Analysis.

To identify factors associated with failure of noninvasive ventilation (NIV) in the post-extubation period. We searched Embase Classic +, MEDLINE, and the Cochrane Database of Systematic Reviews from inception to February 28, 2022. We included English language studies that provided predictors of post-extubation NIV failure necessitating reintubation. Two authors conducted data abstraction and risk-of-bias assessments independently. We used a random-effects model to pool binary and continuous data and summarized estimates of effect using odds ratios (ORs) mean difference (MD), respectively. We used the Quality in Prognosis Studies tool to assess risk of bias and the Grading of Recommendations, Assessment, Development and Evaluations to assess certainty. We included 25 studies ( n = 2,327). Illness-related factors associated with increased odds of post-extubation NIV failure were higher critical illness severity (OR, 3.56; 95% CI, 1.96-6.45; high certainty) and a diagnosis of pneumonia (OR, 6.16; 95% CI, 2.59-14.66; moderate certainty). Clinical and biochemical factors associated with moderate certainty of increased risk of NIV failure post-extubation include higher respiratory rate (MD, 1.54; 95% CI, 0.61-2.47), higher heart rate (MD, 4.46; 95% CI, 1.67-7.25), lower Pa o2 :F io2 (MD, -30.78; 95% CI, -50.02 to -11.54) 1-hour after NIV initiation, and higher rapid shallow breathing index (MD, 15.21; 95% CI, 12.04-18.38) prior to NIV start. Elevated body mass index was the only patient-related factor that may be associated with a protective effect (OR, 0.21; 95% CI, 0.09-0.52; moderate certainty) on post-extubation NIV failure. We identified several prognostic factors before and 1 hour after NIV initiation associated with increased risk of NIV failure in the post-extubation period. Well-designed prospective studies are required to confirm the prognostic importance of these factors to help further guide clinical decision-making.

A randomized controlled trial to compare the success rates and efficacy of high flow nasal cannulae versus nasal continuous positive airway pressure in post extubation period in neonates

Background: Nasal continuous positive airway pressure (nCPAP) is the mainstay for non-invasive respiratory support for all respiratory distress neonates. Recent advances in Heated humidified high flow nasal cannula (HHHFNC) usage with enhanced humidity, and improved comfort factors have led to its widespread use, at times replacing nCPAP in many neonatal settings. The present study was to assess the efficacy and safety of HHHFNC compared with nCPAP for non-invasive respiratory support in post-extubation period. Methods: A hospital based randomized controlled trial was conducted in neonatal intensive care unit (NICU) of S. Nijalingappa Medical College and HSK Hospital, Bagalkot from January 2019 to June 2020. 140 post-extubated neonates were enrolled for the study after obtaining informed consent from parents, and those who were directly extubated to no support and with major congenital anomalies were excluded from the study. Randomization was done by computer generated random number allocation method. Results: Of the140 babies, 60% were males and 40% were females. Out of 84 male neonates, 47 (67.1%) were on nCPAP and 37 (32.9%) on HHHFNC and out of 56 female neonates 23 (32.9%) were on nCPAP and 33 (47.1%) on HFNC. In this study, 4 babies on nCPAP required re-intubation within 72 hours. 5 babies on HHHFNC, 3 babies required re-intubation within 72 hours and 2 babies within 5 days. The incidence of nasal trauma, hospital stay and duration of NIV support were less in HHHFNC group as compared to nCPAP group. Conclusions: HHHFNC therapy is as effective as nCPAP therapy for the facilitation of extubation in neonates.

Cánula nasal de alto flujo en pacientes críticos: una revisión narrativa

High-flow nasal cannula has become one of the main strategies for non-invasive ventilatory support in hypoxemic acute respiratory failure, mainly after the COVID-19 pandemic. However, its use extends beyond this scenario and covers different clinical conditions such as the post-extubation period, post-surgical period, hypercapnic respiratory failure and life support in immunosuppressed, trasplant or cancer patients. Manuscripts that support its application have been widely disseminated and the degree of evidence is high enough to recommend its use. Therefore, it is necessary to highlight its physiological effects such as comfort, precise fraction of inspiratory oxygen, CO2 lavage or optimize end-expiratory lung volume to understand its mechanism of action and improve patients’ outcomes. The objective of this narrative review is to offer a brief and concise summary of the benefits of applying this therapy in different clinical scenarios without the rigid structure of a systematic review. Based on these lines, the curious reader can expand the scientific evidence that supports the use of the high-flow nasal cannula in each particular scenario.

ОПЫТ ПРИМЕНЕНИЯ ВЫСОКОЧАСТОТНОЙ ПЕРКУССИОННОЙ ИСКУСCТВЕННОЙ ВЕНТИЛЯЦИИ ЛЕГКИХ У НЕДОНОШЕННОГО НОВОРОЖДЕННОГО С ОДНОСТОРОННЕЙ ЭМФИЗЕМОЙ ЛЕГКОГО

High frequency percussion ventilation (HFPV) is a specific variant of high frequency ventilation in which high-velocity flow oscillations are delivered to the patient's airway in combination with convection breathing cycles through a special open circuit. The aerodynamic effects implemented in this device make it possible to achieve uniform ventilation of both the atelectatic zones of the lungs and the overinflated areas. Authors discuss the mechanisms of aerial exchange in HFPV and present a clinical case observation of its use in a premature newborn with a severe respiratory disorder complicated by the development of left-sided diffuse emphysema. The anamnestic data, dynamics of ventilation support parameters and respiratory saturation index, radiological and clinical dynamics of the patient’s condition, as well as the method for managing the post-extubation period using the non-invasive HFPV technique that the Authors believe to be an effective protective respiratory stabilization technology with the possibility of using neonatal intensive care in practice, are also demonstrated and described.

Effects of mechanical in-exsufflation in preventing postextubation acute respiratory failure in intensive care acquired weakness patients: a randomized controlled trial.

We hypothesized that the use of mechanical insufflation-exsufflation can reduce the incidence of acute respiratory failure within the 48-hour post-extubation period in intensive care unit-acquired weakness patients. This was a prospective randomized controlled open-label trial. Patients diagnosed with intensive care unit-acquired weakness were consecutively enrolled based on a Medical Research Council score ≤ 48/60. The patients randomly received two daily sessions; in the control group, conventional chest physiotherapy was performed, while in the intervention group, chest physiotherapy was associated with mechanical insufflation-exsufflation. The incidence of acute respiratory failure within 48 hours of extubation was evaluated. Similarly, the reintubation rate, intensive care unit length of stay, mortality at 28 days, and survival probability at 90 days were assessed. The study was stopped after futility results in the interim analysis. We included 122 consecutive patients (n = 61 per group). There was no significant difference in the incidence of acute respiratory failure between treatments (11.5% control group versus 16.4%, intervention group; p = 0.60), the need for reintubation (3.6% versus 10.7%; p = 0.27), mean length of stay (3 versus 4 days; p = 0.33), mortality at Day 28 (9.8% versus 15.0%; p = 0.42), or survival probability at Day 90 (21.3% versus 28.3%; p = 0.41). Mechanical insufflation-exsufflation combined with chest physiotherapy seems to have no impact in preventing postextubation acute respiratory failure in intensive care unit-acquired weakness patients. Similarly, mortality and survival probability were similar in both groups. Nevertheless, given the early termination of the trial, further clinical investigation is strongly recommended. NCT01931228.

Early Use of High-Flow Nasal Cannula in Postextubation Period: Can It Reduce Reintubation Rate? Authors' Reply.

Early Use of High-Flow Nasal Cannula in Postextubation Period: Can It Reduce Reintubation Rate? Authors' Reply.

Early Use of High Flow Nasal Cannula in Postextubation Period: Can It Reduce Reintubation Rate?

See the letter "Early Use of High-Flow Nasal Cannula in Postextubation Period: Can It Reduce Reintubation Rate? Authors’ Reply" on page 65.

Comparison of High-Flow Nasal Cannula and Conventional Oxygen Therapy Following Extubation After Pediatric Cardiac Surgery: A Retrospective Study

Introduction: Infants and children with congenital heart disease may develop respiratory failure in association with cardiac surgery or as a result of heart disease. In fact, the postextubation period in this group of patients can be complex and the use of continuous positive airway pressure or non-invasive ventilation may be necessary if conventional oxygen therapy is not sufficient. The aim of our study was to compare efficiency and outcomes of high-flow nasal cannula or conventional oxygen therapy post-extubation after pediatric cardiac surgery. Patients and Methods: A single centre retrospective study was conducted between January and December 2020 in our 12 beds pediatric cardiac intensive care unit. Patients were divided into two groups. In one group 45 patients (Group I), those who received high-flow nasal cannula after extubation, and in the other group 45 patients (Group II), those who received oxygen therapy with a mask after extubation. The aim of the study was to evaluate the rela- tive efficacy of high flow nasal cannula and conventional oxygen therapy on PaCO2, PaO2 and PaO2/FiO2. Results: PaO2 values at 1, 6, 12, 24 and 48 hour post-extubation were significantly higher in high-flow nasal cannula group (p&lt; 0.05). PaCO2 values were significantly lower in the high-flow nasal cannula group at 1, 6, 12, 24 and 48 hour post-extubation (p= 0.01). PaO2/FiO2 values in high-flow nasal cannula group at all-time points post-extubation were significantly higher than in conventional oxygen therapy group (p= 0.01). Conclusion: High-flow nasal cannula is useful in decreasing PaCO2 and improving PaO2 in children follow- ing extubation after cardiac surgery. In addition, the simplicity of and tolerability to high-flow nasal cannula is also important. Although more expensive, the use of high-flow nasal cannula can be considered as a safe and effective alternative to conventional oxygen therapy following pediatric cardiac surgery.

Negative Pressure Pulmonary Edema

Negative pressure pulmonary edema (NPPE) develops when a patient makes a forced inspiration against a closed upper airway resulting in transudation of pulmonary capillary fluid into the interstitium. Young, healthy athletic males are more susceptible to this complication, and NPPE is most frequently encountered during oral and maxillofacial surgeries. Patients who have undergone septorhinoplasty surgery have a significant risk for NPPE, unlike other cosmetic surgeries. Herein, we describe two cases of postoperative NPPE following a septorhinoplasty. Early symptoms of NPPE are severe respiratory distress, tachypnea, agitation, and crushed strawberry-colored bloody sputum during the early postextubation period. An early diagnosis of NPPE is very important, and patient recovery is quick when an early diagnosis is made.

Physiological Effects of High-Flow Nasal Cannula Therapy and Its Use in Acute Cardiogenic Pulmonary Edema.

High-flow nasal cannula (HFNC) is an open oxygen delivery system, which provides heated and humidified oxygen at a high flow (up to 60 L/min). This effect can improve mucociliary function, airway clearance, and level of comfort to the patient. It can provide controlled and adequate fraction of inspired oxygen (FiO2) between 21% and 100%. Generation of end-expiratory pressure helps in carbon dioxide washout, reduction of anatomical dead space, and recruitment of collapsed alveoli, ultimately improving tissue oxygenation.The use of HFNC in acute hypoxemic respiratory failure, post-extubation period, pre-intubation period, respiratory infection, and obstructive airway disease has been extensively studied, but there are very few studies regarding its use in cardiogenic pulmonary edema. This review provides the current understanding of the physiological effect of HFNC and its application in acute cardiogenic pulmonary edema (ACPE). We conducted a literature search on PubMed using appropriate terms and reviewed relevant articles published within the last 10 years. We found that initial therapy with HFNC in ACPE patients can improve oxygenation and respiratory rate. HFNC can potentially be an alternative to non-invasive positive-pressure ventilation in terms of initial oxygen therapy in patients with ACPE. There is a need for larger prospective studies to evaluate and develop guidelines to consider the use of HFNC in patients with ACPE. We also highlight the fact that if there is no improvement in arterial blood gas parameters after HFNC therapy, initiation of invasive ventilation should not be delayed.

Incidence and Risk Model Development for Severe Tachypnea Following Terminal Extubation

Palliative ventilator withdrawal (PVW) in the ICU is a common occurrence. The goal of this study was to measure the rate of severe tachypnea as a proxy for dyspnea and to identify characteristics associated with episodes of tachypnea. This study assessed a retrospective cohort of ICU patients from 2008 to 2012 mechanically ventilated at a single academic medical center who underwent PVW. The primary outcome of at least one episode of severe tachypnea (respiratory rate > 30 breaths/min) within 6h after PVW was measured by using detailed physiologic and medical record data. Multivariable logistic regression was used to examine the association between patient and treatment characteristics with the occurrence of a severe episode of tachypnea post extubation. Among 822 patients undergoing PVW, 19%and 30%had an episode of severe tachypnea during the 1-h and 6-h postextubation period, respectively. Within 1h postextubation, patients with the following characteristics were more likely to experience tachypnea: no pre-extubation opiates (adjusted OR [aOR], 2.08; 95%CI, 1.03-4.19), lung injury (aOR, 3.33; 95%CI, 2.19-5.04), Glasgow Coma Scale score > 8 (aOR, 2.21; 95%CI, 1.30-3.77), and no postextubation opiates (aOR, 1.90; 95%CI, 1.19-3.00). Up to one-third of ICU patients undergoing PVW experience severe tachypnea. Administration of pre-extubation opiates (anticipatory dosing) represents a key modifiable factor that may reduce poor symptom control.