Receiving Ventilator Support Research Articles

Ventilatory Support Use in Hospitalized Patients With Community-Acquired Pneumonia. Fifteen-year Trends in Spain (2001–2015)

AimWe examined fifteen years trends (2001–2015) in the use of non-invasive ventilation (NIV), invasive mechanical ventilation (IMV) or both (NIV+IMV) among patients hospitalized for community acquired pneumonia (CAP). We also analyzed trends overtime and the influence of patient factors in the in-hospital mortality (IHM) after receiving NIV, IMV or NIV+IMV. MethodsObservational retrospective epidemiological study. Our data source was the Spanish National Hospital Discharge Database. ResultsOver a total of 1,486,240 hospitalized patients with CAP, we identified 56,158 who had received ventilator support in Spain over the study period. Of them, 54.82% received NIV, 37.04% IMV and 8.14% both procedures. The use of NIV and NIV+IMV increased significantly (p<0.001) over time (from 0.91 to 12.84 per 100.000 inhabitant and from 0.23 to 1.19 per 100.000 inhabitants, respectively), while the IMV utilization decreased (from 3.55 to 2.79 per 100,000 inhabitants; p<0.001). Patients receiving NIV were the oldest and had the highest mean value in the Charlson comorbidity index (CCI) score and readmission rate. Patients who received only IMV had the highest IHM. Factors associated with IHM for all groups analyzed included age, comorbidities and readmission. IHM decreased significantly over time in patients with CAP who received NIV, IMV and NIV+IMV. ConclusionsWe found an increase in NIV use and a decline in IMV utilization in patients hospitalized for CAP over the study period. Patients receiving NIV were the oldest and had the highest CCI score and readmission rate. IHM decreased significantly over time in patients with CAP who received NIV, IMV and NIV+IMV.

Genetic and Disability Discrimination During COVID-19.

Genetic and Disability Discrimination During COVID-19.

Abstract 16780: Disease Severity Assessed by Thromboelastography in a Minority Population With COVID-19

Background: Thromboelastography (TEG®) is used across a wide range of clinical settings to identify patients at risk for thrombosis and coagulopathic bleeding and may be a useful diagnostic tool to guide antithrombotic treatment in patients with COVID-19. Hypothesis: TEG® identifies symptom progression in COVID -19 patients, particularly in the high-risk minority population known to have worse clinical outcomes. Methods: Whole blood from African American and Hispanic hospitalized COVID positive (n=22) and negative outpatients (n=24) was analyzed using point-of-care TEG®6s (Haemonetics, Corp). TEG® parameters including clot initiation (R), fibrin clot strength (FCS), platelet-fibrin clot strength (PFCS) and clot lysis (LY30) were compared across disease severity groups (table). Routine labs including D-Dimer, C-reactive protein (CRP), ferritin, and procalcitonin were also collected. Results: Ninety- five percent of COVID positive patients had at least one co-morbidity with the incidence of hypertension (73%), diabetes (55%), and obesity (45%) being the most frequent. R time was more rapid, and FCS and PFCS was significantly higher in COVID positive as compared to negative groups (p&lt;0.03). A stepwise increase in FCS and PFCS was observed with worsening respiratory function (table). Similarly, D-Dimer, CRP, ferritin, and procalcitonin levels were highest in patients receiving ventilator support. No differences were observed in clot lysis between the groups despite elevated D-Dimer levels. Conclusion: We have demonstrated that TEG®6s can identify a prothrombotic phenotype characterized by rapid clot initiation and increased fibrin and platelet-fibrin clot strength in a minority population with COVID-19. Future studies are warranted implementing the TEG6s® in clinical trials to personalize antithrombotic therapy in COVID-19 and improve outcomes.

HOSPITALIZATIONS AND OUTCOMES IN PATIENTS WITH IDIOPATHIC PULMONARY FIBROSIS (IPF): INSIGHTS FROM THE IPF-PRO REGISTRY

SESSION TITLE: Diffuse Lung Disease Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Limited studies have examined hospitalizations and outcomes in patients with IPF. We sought to understand diagnostic testing, ventilator support and outcomes after hospitalization in a large prospective cohort of patients with IPF. METHODS: The IPF-PRO Registry is a multicenter observational US registry that enrolled patients with IPF that was diagnosed or confirmed at the enrolling center in the past 6 months. We analyzed the first hospitalizations in patients enrolled in the IPF-PRO Registry using data collected between June 2014 and December 2019. Patient demographics, cause of hospitalization, medical procedures and outcomes were analyzed descriptively. RESULTS: Among the 1002 patients enrolled in the registry, 365 experienced at least one hospitalization during the observation period. Of patients’ first hospitalizations, 171 (46.8%) were primarily respiratory-related. At the time of the first hospitalization, median (Q1, Q3) age was 71 (66, 76) years and median time since enrollment was 10.1 (4.9, 17.1) months. These characteristics were similar when limited to respiratory-related hospitalizations. Overall, the median duration of hospitalization was 2 (1, 7) days, but in patients whose first hospitalization was respiratory-related, the median duration of hospitalization was 6 (2, 14) days. About half (56.7%) of the respiratory-related hospitalizations took place at the enrolling center. Overall, 329 (90.4%) of the patients who were hospitalized survived to discharge; most (87.6%) were discharged to home. In-hospital mortality was higher in patients hospitalized for a respiratory cause than for a non-respiratory cause (12.3% vs 1.6%). For the respiratory hospitalizations, 41.0% of patients had a chest CT, 35.1% had an echocardiogram, 20.9% had a bronchoscopy and 41.0% had respiratory cultures; 51 (29.8%) patients received ventilator support (15 non-invasive ventilator support, 22 invasive mechanical ventilation, and 14 both types of ventilatory support). Among the patients who received any type of ventilatory support, 38 (74.5%) were discharged, which was a lower proportion than among patients who did not receive ventilator support (93.0%). In-hospital mortality was higher in patients who received than did not receive ventilator support (17.7% vs 4.8%). CONCLUSIONS: Hospitalizations are common in patients with IPF. Approximately half of hospitalizations are respiratory-related. Most patients are discharged after a first hospitalization, but mortality is higher in those hospitalized for a respiratory cause or receiving ventilator support. CLINICAL IMPLICATIONS: In patients with IPF, hospitalization for a respiratory-related cause is associated with significant mortality, particularly in those who require ventilator support. DISCLOSURES: Speaker/Speaker's Bureau relationship with Boehringer Ingelheim Please note: $20001 - $100000 Added 03/30/2020 by Ayodeji Adegunsoye, source=Web Response, value=Honoraria Removed 03/30/2020 by Ayodeji Adegunsoye, source=Web Response Speaker/Speaker's Bureau relationship with Boehringer Ingelheim Please note: $20001 - $100000 Added 03/30/2020 by Ayodeji Adegunsoye, source=Web Response, value=Grant/Research Support Removed 03/30/2020 by Ayodeji Adegunsoye, source=Web Response Advisory Committee Member relationship with Genentech Please note: $1-$1000 Added 03/30/2020 by Ayodeji Adegunsoye, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Boehringer Ingelheim Please note: $20001 - $100000 Added 03/30/2020 by Ayodeji Adegunsoye, source=Web Response, value=Honoraria Employee relationship with Boehringer Ingelheim Pharmaceuticals Please note: >$100000 Added 03/25/2020 by Craig Conoscenti, source=Web Response, value=Salary No relevant relationships by Katherine Janssen, source=Web Response No relevant relationships by Hyun Kim, source=Web Response Employee relationship with Boehringer-Ingelheim Inc Please note: >$100000 Added 03/30/2020 by Thomas Leonard, source=Web Response, value=Salary No relevant relationships by Megan Neely, source=Web Response No relevant relationships by Laurie Snyder, source=Web Response PI relationship with Boehringer-Ingelheim Please note: >$100000 by Mary Strek, source=Web Response, value=Grant/Research Support PI relationship with Galapagos Please note: $5001 - $20000 by Mary Strek, source=Web Response, value=Grant/Research Support PI relationship with Novartis Please note: $5001 - $20000 by Mary Strek, source=Web Response, value=Grant/Research Support Statistical support for IPF-PRO Registry relationship with Boehringer Ingelheim Please note: $5001 - $20000 Added 03/24/2020 by Eric Yow, source=Web Response, value=Grant/Research Support Removed 03/24/2020 by Eric Yow, source=Web Response Statistical support for IPF-PRO Registry relationship with Boehringer Ingelheim Please note: $5001 - $20000 Added 03/24/2020 by Eric Yow, source=Web Response, value=Salary

Clinical Course of 195 Critically Ill COVID-19 Patients: A Retrospective Multicenter Study.

Coronavirus disease-2019 (COVID-19) outbreak has spread around the world. However, the dynamic course of critically ill COVID-19 has not been described thoroughly. We retrospectively analyzed 195 critically ill COVID-19 patients in Hubei province, China, between January 5, 2020 and April 3, 2020. Epidemiologic data, clinical features, treatments, and outcomes were collected and analyzed. Most critically ill patients were older with higher Acute Physiology and Chronic Health Evaluation II scores. After critical illness onset, a total of 181 (92.8%) patients received ventilation support, of which 84 (43.1%) received noninvasive and 97 (49.7%) received invasive mechanic ventilation (IMV). Among the 97 patients with IMV, 28 (28.9%) received prone ventilation, 57 (58.8%) received neuromuscular blocked therapy, and 22 (11.3%) received tracheostomy due to prolonged ventilator use. Early hypoxemia, subsequent hypercapnia, pulmonary hypertension, and finally pulmonary fibrosis were notable in the clinical course of acute respiratory distress syndrome (ARDS). Eighty-nine (45.6%) patients presented with shock. Acute kidney injury (29.7%) and secondary infection (28.2%) were also notable. The overall mortality of critically ill patients at day 28 was 42.1%. Intensive care unit (ICU) mortality was around 33%, as 16 patients died prior to ICU admission. A low PaO2/FiO2 ratio was an independent risk factor for death. High viral load was observed in most non-survivors. ARDS and shock were notable in the critical illness of COVID-19. Ventilation support and hemodynamic support were the cornerstones for critical care. High viral load was associated with death of critically ill COVID-19 patients.

Ventilatory Support Use in Hospitalized Patients With Community-Acquired Pneumonia. Fifteen-year Trends in Spain (2001–2015)

AimWe examined fifteen years trends (2001–2015) in the use of non-invasive ventilation (NIV), invasive mechanical ventilation (IMV) or both (NIV+IMV) among patients hospitalized for community acquired pneumonia (CAP). We also analyzed trends overtime and the influence of patient factors in the in-hospital mortality (IHM) after receiving NIV, IMV or NIV+IMV. MethodsObservational retrospective epidemiological study. Our data source was the Spanish National Hospital Discharge Database. ResultsOver a total of 1,486,240 hospitalized patients with CAP, we identified 56,158 who had received ventilator support in Spain over the study period. Of them, 54.82% received NIV, 37.04% IMV and 8.14% both procedures. The use of NIV and NIV+IMV increased significantly (p<0.001) over time (from 0.91 to 12.84 per 100.000 inhabitant and from 0.23 to 1.19 per 100.000 inhabitants, respectively), while the IMV utilization decreased (from 3.55 to 2.79 per 100,000 inhabitants; p<0.001). Patients receiving NIV were the oldest and had the highest mean value in the Charlson comorbidity index (CCI) score and readmission rate. Patients who received only IMV had the highest IHM. Factors associated with IHM for all groups analyzed included age, comorbidities and readmission. IHM decreased significantly over time in patients with CAP who received NIV, IMV and NIV+IMV. ConclusionsWe found an increase in NIV use and a decline in IMV utilization in patients hospitalized for CAP over the study period. Patients receiving NIV were the oldest and had the highest CCI score and readmission rate. IHM decreased significantly over time in patients with CAP who received NIV, IMV and NIV+IMV.

Trends in mechanical ventilation use and mortality over time in patients receiving mechanical ventilation in Spain from 2001 to 2015.

BackgroundWe examined trends in the incidence of ventilator support with noninvasive ventilation (NIV) or invasive mechanical ventilation (IMV) among patients hospitalized in Spain from 2001 to 2015. We also assessed in-hospital mortality (IHM) after receiving these types of ventilator support. MethodsThis study was an observational retrospective epidemiological study. Our data source was the Spanish National Hospital Discharge Database. ResultsIn total, 1,031,497 patients received ventilator support in Spain over the study period. NIV use increased from 18.8 patients per 100.000 inhabitants in 2001 to 108.7 in 2015. IMV utilization increased significantly from 2001 to 2003 and then decreased from 2003 until 2015. Patients who required NIV had the highest mean Charlson Comorbidity Index (CCI) score. Patients who received IMV had the highest in-hospital mortality. Factors associated with an increased risk for IHM were sex, age, conditions included in the CCI (except for COPD and diabetes), haemodialysis, presence of a peripheral arterial catheter, presence of a central venous catheter, readmission and emergency room admission. Undergoing a surgical procedure was a risk factor only for IMV. IHM decreased significantly from 2001 to 2015 in patients who underwent NIV or IMV. ConclusionsWe identified an increase in the utilization of NIV over time, whereas use of IMV decreased from 2003 until 2015 after an initial increase from 2001 to 2003. We also found a significant decrease in IHM over time.

Effect of Eye Masks on Neonatal Stress Following Dilated Retinal Examination

Although screening examinations for retinopathy of prematurity (ROP) prevent blindness, they are physiologically stressful for infants. Photosensitivity during mydriasis may contribute to postexamination stress, and reducing light stimulation may make infants more comfortable. To determine the effect of a phototherapy mask worn during mydriasis on infant stress in the 12-hour period following ROP screening. The Effect of Eyemasks on Neonatal Stress Following Dilated Retinal Examination (MASK-ROP) randomized clinical trial with patient recruitment from April 2016 to June 2017 at neonatal intensive care units at St Michael's Hospital and Sunnybrook Health Sciences Center in Toronto, Ontario, Canada. A consecutive series of infants with birth weight of less than 1500 g and/or gestational age of less than 32 weeks undergoing their first ROP screening were analyzed beginning in July 2017. Analysis was intention to treat. Patients were randomized to wear a phototherapy mask for a minimum of 4 hours after dilating drop instillation in addition to standard comfort measures. Number of desaturation, bradycardic, or apneic events during the 12-hour postexamination period. Of 51 infants who were examined, 28 (54.9%) were randomized to the treatment group (ie, used a mask) and 23 (45.1%) to the control group. Overall, 10 (35.7%) and 13 infants (56.5%) received ventilator support at the time of examination in the treatment and control groups, respectively. The mean (SD) gestational age was 27.9 (2.4) weeks, 32 (63%) were boys, and the mean (SD) birth weight was 1058.6 (312.0) g. The number of all stressful events were lower in the treatment group compared with controls in the 12-hour postexamination period, adjusted for events prior to examination and ventilation status (mean [95% CI] events, 1.0 [0.6-1.8] vs 1.7 [1.0-1.7]; rate ratio [RR], 0.57; 95% CI, 0.3-1.2; P = .12). Risk factors associated with increased stress included younger gestational age (RR, 1.32; 95% CI, 1.2-1.5 per week), lower birth weight (RR, 1.39; 95% CI, 1.2-1.5 per 100 g), ventilator support around the time of examination (RR, 2.67; 95% CI, 1.3-5.6), intraventricular hemorrhage (RR, 3.78; 95% CI, 1.9-7.3), and hyponatremia (RR, 3.42; 95% CI, 1.8-6.6). No adverse events occurred while using eye masks. This randomized clinical trial found that light sensitivity may play a role in stress observed in the late postexamination period. However, unequal distribution of infants receiving ventilator support placed certain neonates at higher risk of stress, and the clinical significance of this intervention's benefit could not be concluded with confidence. ClinicalTrials.gov identifier: NCT03824782.

Clinical effects of lentinan combined with budesonide inhalation in treating acute exacerbation of chronic obstructive pulmonary disease under mechanical ventilation.

In the present study, the clinical efficacy of the immune modulator lentinan combined with inhalation of the corticosteroid budesonide in treating acute exacerbation of chronic obstructive pulmonary disease (AECOPD) under mechanical ventilation was assessed. A total of 72 cases of AECOPD treated at Shanghai Jiao Tong University Affiliated Sixth People's Hospital (Shanghai, China) between June 2016 and September 2017 were enrolled. The AECOPD patients were randomly divided into an experimental group (n=36) and a control group (n=36). All of the patients received ventilator support and endotracheal intubation was performed. The experimental group was orally administered lentinan and budesonide was administered via atomization inhalation through a Y-tube and the control group received only budesonide via Y-tube. After the treatment, airway pressure, the time of mechanical ventilation and the time of stay at the intensive care unit for the experimental group were significantly lower than those for the control group (P<0.001). The plasma levels of adiponectin, D-dimer, interleukin-17 and high-sensitivity C-reactive protein, as well as the pressure of CO2 in the experimental group were significantly lower than those in control group (P<0.001). Furthermore, the partial O2 pressure in the experimental group was significantly higher than that in the control group (P<0.001). After the combined treatment, the proportions of CD3+ and CD4+T-cells in the blood were elevated, while the proportion of CD8+T-cells was decreased, compared with those in the experimental group at baseline or the control group post-treatment. In conclusion, the strategy of lentinan treatment combined with budesonide inhalation for AECOPD patients under mechanical ventilation demonstrated improved clinical efficacy compared with budesonide alone. (Chinese Clinical Trial Registry no. ChiCTR1800019088).

Clinical profile and outcome of dengue in children admitted in pediatric intensive care unit in a tertiary center in South India

Background: As dengue being a tropical infection presenting with varying degrees of severity of illness in Indian children, present study is aimed at studying the clinical profile, outcome, predictors for mortality of moderate and severe dengue cases admitted to PICU in a tertiary care center in South India. Methods: It is a retrospective observational study. All patients admitted in PICU from April 2016 to March 2017 were included in the study. Patients were classified based on National Vector Borne Disease Control Program (NVBDP). Clinical characteristics, laboratory parameters, complications, outcome and predictors for mortality were studied. Results: All 58 seropositive dengue cases admitted were included. Most common presenting symptoms were fever in 58 (100%), vomiting in 33 (56.8%) and abdomen pain in 19 (32.7%). Among severe dengue, expanded dengue syndrome was present in 10 (30%), expanded dengue syndrome with shock was present in 10 (30%), significant hemorrhage with shock in 2 (6%), hemorrhage without shock in 1(3%) and combination of expanded dengue syndrome with hemorrhage and shock in 10 (30%).Pleural effusion was present in 38 (65.5%) and ascites in 18(31%) children. Among severe dengue,12(36.3%) received invasive mechanical ventilation,8(24%) received inotropes,19(57.5%) received steroids and 7 (21%) had abdomen compartment syndrome requiring drainage of ascites. Conclusion: Significantly more number of children who died received ventilator support and inotropes. Commonest cause of death is catecholamine resistant shock. There is no major adverse effect of steroids when used in severe dengue.

Preadmission statin use improves the outcome of less severe sepsis patients - a population-based propensity score matched cohort study

BackgroundRandomized controlled trials on the post-admission use of statins in sepsis patients have not shown a survival benefit. Whether preadmission use of statins would confer any beneficial effects in sepsis patients has not been well studied. MethodsWe conducted a population-based cohort study on a national health insurance claims database between 1999 and 2011. Sepsis patients were identified by ICD-9 codes compatible with the third International consensus definitions for sepsis. Use of statin was defined as the cumulative use of any statin for more than 30 days before the indexed sepsis admission. We determined the association between statin use and sepsis outcome by multivariate-adjusted Cox proportional hazard models and propensity score matched analysis. To minimize baseline imbalance between statin users and non-statin users, we matched/adjusted for social economic status, comorbidities, proxies for healthy lifestyle, health care facility utilization, and use of medications. ResultsWe identified 52 737 sepsis patients, of which 3599 received statin treatment. Statins use was associated with a reduced 30-day mortality after multivariable adjustment (HR 0.86, 95% CI, 0.78–0.94) and propensity score matching (HR, 0.88; 95% CI, 0.78–0.99). On subgroup analysis, the beneficial effects of statins were not significant in patients receiving ventilator support or requiring ICU admission. ConclusionsIn this national cohort study, preadmission statin therapy before sepsis development was associated with a 12% reduction in mortality when compared with patients who never received a statin. There were no consistent beneficial effects of statins in all patient subgroups.

Intensive care unit admissions and ventilation support in infants with bronchiolitis.

To describe the rate of intensive care unit (ICU) admission, type of ventilation support provided and risk factors for ICU admission in infants with bronchiolitis. Retrospective review of hospital records and Australia and New Zealand Paediatric Intensive Care (ANZPIC) registry data for infants 2-12 months old admitted with bronchiolitis. Seven Australian and New Zealand hospitals. These infants were prospectively identified through the comparative rehydration in bronchiolitis (CRIB) study between 2009 and 2011. Of 3884 infants identified, 3589 charts were available for analysis. Of 204 (5.7%) infants with bronchiolitis admitted to ICU, 162 (79.4%) received ventilation support. Of those 133 (82.1%) received non-invasive ventilation (high flow nasal cannula [HFNC] or continuous positive airway pressure [CPAP]) 7 (4.3%) received invasive ventilation alone and 21 (13.6%) received a combination of ventilation modes. Infants with comorbidities such as chronic lung disease (OR 1.6 [95% CI 1.0-2.6]), congenital heart disease (OR 2.3 [1.5-3.5]), neurological disease (OR 2.2 [1.2-4.1]) or prematurity (OR 1.5 [1.0-2.1]), and infants 2-6 months of age (OR 1.5 [1.1-2.0]) were more likely to be admitted to ICU. Respiratory syncitial virus positivity did not increase the likelihood of being admitted to ICU (OR 1.1 [95% CI 0.8-1.4]). HFNC use changed from 13/53 (24.5% [95% CI 13.7-38.3]) patient episodes in 2009 to 39/91 (42.9% [95% CI 32.5-53.7]) patient episodes in 2011. Admission to ICU is an uncommon occurrence in infants admitted with bronchiolitis, but more common in infants with comorbidities and prematurity. The majority are managed with non-invasive ventilation, with increasing use of HFNC.

Invasive Candidiasis in Pediatric Patients at King Fahad Medical City in Riyadh, Saudi Arabia: A 5-year Retrospective Study

BackgroundInvasive candidiasis in children is associated with high morbidity and mortality. We aim to identify predisposing factors, species distribution, antifungal susceptibility, and outcomes among patients with candidemia.MethodsA data collection form composed of seven sections including 51 questions was designed to gather demographic and clinical information. We collected data from all 129 patients with invasive candidiasis from January 2010 to January 2015.ResultsThe 129 patients had the following risk factors: 30 (23.26%) were premature, 34 (26.36%) had low birth weight, 59 (45.74%) had a central venous catheter, 21 (16.28%) had a malignancy, 20 (15.5%) received immunotherapy, and 56 (43.41%) received ventilator support. A multivariate analysis revealed a more than two-fold mortality rate in patients who had vegetation in the heart (OR 2.9), and patients who had Candida isolated from their blood were more than twice as likely to die as patients with Candida isolated from other sites (OR 2.2). A total of 48.33% of patients on ventilator support died, and 26.09% of patients who were not on ventilator support died (P = 0.009); 43.75% of patients in the intensive care unit (ICU) died vs. only 24.49% of patients who were not in the ICU (P = 0.03). C. parapsilosis exhibited the highest mortality rate among all Candida species (56.2%).ConclusionThe study revealed that C. albicans was the most common isolate among all Candida species. Mechanical ventilation and an ICU stay were significant risk factors for death in children with invasive candidiasis.Disclosures All authors: No reported disclosures.

Spectrum of neonatal diseases requiring respiratory support in UBTH, Benin City, Edo State, Nigeria

Introduction: In Nigeria, eighty two percent of the three leading causes of neonatal mortality may require respiratory support for their management, yet this is unavailable.Objective: To review the spectrum of respiratory disorders that were ventilated, their outcomes and the contribution of such support to survivalMethods: A data base of cases managed in the unit is maintained and reviewed regularly for enhancement of quality of care. Such prospectively documented information on babies who received respiratory support over the period 1st January to 31st June 2014 were analysed.Results: Five hundred and seventy six babies were admitted. Fortynine (8, 5%) received ventilator support. These comprised preterm (77.6%) and term (22.4%) babies with mean gestational age of 33.2 weeks (range 28-41). The spectrum of disorders supported were: respiratory distress syndrome (RDS) 55.1%, asphyxia 20.4%, sepsis12.3%, acute bilirubin encephalopathy (ABE) 8.2%, transient tachypnoea of the new-born (TTNB) 2% and neonatal tetanus (NT) 2%. They were non- invasive support (NIVRS) 33(67.3%) for respiratory distress; invasive support (IVRS) 16(32.7%) for respiratory failure. NIVRS was mostly for RDS (88.9%); ABE (100%) received invasive support. Mortality was: NIVRS7/33(21.2%); IVRS 11/16(68.75 %). Respiratory dysfunction contributed 25.4% of the total neonatal mortality of 123 per thousand. Survival was 63.3%.Conclusion: The morbidities were: asphyxia, prematurity, sepsis, ABE, and tetanus. Ventilator support was non-invasive with bubble CPAP and invasive with mechanical ventilation through endotracheal intubation. Survival was improved. There is the urgent need to commence and sustain basic non -invasive respiratory support in all neonatal units in Nigeria.Keywords: Spectrum; Neonatal diseases; Respiratory support

Frequency of endotracheal suctioning for the prevention of respiratory morbidity in ventilated newborns.

Endotracheal suctioning consists of the mechanical aspiration of pulmonary secretions from the endotracheal tube (ETT) to prevent obstruction. The optimal frequency of ETT suctioning has not been defined. To determine the effect of specific ordered frequency of ETT suctioning ('as scheduled') versus ETT suctioning only in case of indications ('as needed') and of more frequent ETT suctioning versus less frequent ETT suctioning on respiratory morbidity in ventilated newborns. We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 10), MEDLINE via PubMed (1966 to 31 October 2015), EMBASE (1980 to 31 October 2015), and CINAHL (1982 to 31 October 2015). We checked the reference lists of retrieved articles and contacted study authors to identify additional studies. We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials. Randomized, quasi-randomized, and cluster randomized controlled trials comparing different strategies regarding the frequency of ETT suctioning of newborn infants receiving ventilator support. We used the standard methods of the Cochrane Neonatal Review Group. Two review authors independently extracted data and assessed the risk of bias of trials. The primary outcome was bronchopulmonary dysplasia or chronic lung disease. We identified one randomized controlled study recruiting 97 low birthweight infants that met the inclusion criteria. The study was conducted in the UK in 1987 and 1988. Randomized infants received ETT suctioning every six or 12 hours during the first three days of life. The quality of reporting was limited and we rated the trial at high risk of bias. Furthermore, the trial lacked adequate power. There were no statistically significant differences in any of reported outcomes: bronchopulmonary dysplasia (defined as oxygen at more than 30 days; risk ratio (RR) 0.49, 95% confidence interval (CI) 0.20 to 1.20); incidence of pneumothorax (RR 0.70, 95% CI 0.24 to 2.05); intraventricular hemorrhage (RR 1.12, 95% CI 0.44 to 2.85); neonatal death (RR 1.40, 95% CI 0.58 to 3.37); and time on ventilation (median time 39 hours in the 12-hourly group and 28 hours in the six-hourly group; RD not applicable for this outcome as mean and standard deviation were not reported). Tests for heterogeneity were not applicable as only one study was included. There was insufficient evidence to identify the ideal frequency of ETT suctioning in ventilated neonates. Future research should focus on the effects in the very preterm newborns, that is, the most vulnerable population as concerns the risk of both lung and brain damage. Assessment should include the cases of prolonged ventilation, when more abundant, dense secretions are common. Clinical trials might include comparisons between 'as-scheduled' versus 'as-needed' endotracheal suctioning, that is, based on specific indications, as well frequent versus less frequent suctioning schedules.

Severe respiratory illness associated with a nationwide outbreak of enterovirus D68 in the USA (2014): a descriptive epidemiological investigation

BackgroundEnterovirus D68 (EV-D68) has been infrequently reported historically, and is typically associated with isolated cases or small clusters of respiratory illness. Beginning in August, 2014, increases in severe respiratory illness associated with EV-D68 were reported across the USA. We aimed to describe the clinical, epidemiological, and laboratory features of this outbreak, and to better understand the role of EV-D68 in severe respiratory illness.MethodsWe collected regional syndromic surveillance data for epidemiological weeks 23 to 44, 2014, (June 1 to Nov 1, 2014) and hospital admissions data for epidemiological weeks 27 to 44, 2014, (June 29 to Nov 1, 2014) from three states: Missouri, Illinois and Colorado. Data were also collected for the same time period of 2013 and 2012. Respiratory specimens from severely ill patients nationwide, who were rhinovirus-positive or enterovirus-positive in hospital testing, were submitted between Aug 1, and Oct 31, 2014, and typed by molecular sequencing. We collected basic clinical and epidemiological characteristics of EV-D68 cases with a standard data collection form submitted with each specimen. We compared patients requiring intensive care with those who did not, and patients requiring ventilator support with those who did not. Mantel-Haenszel χ2 tests were used to test for statistical significance.FindingsRegional and hospital-level data from Missouri, Illinois, and Colorado showed increases in respiratory illness between August and September, 2014, compared with in 2013 and 2012. Nationwide, 699 (46%) of 1529 patients tested were confirmed as EV-D68. Among the 614 EV-D68-positive patients admitted to hospital, age ranged from 3 days to 92 years (median 5 years). Common symptoms included dyspnoea (n=513 [84%]), cough (n=500 [81%]), and wheezing (n=427 [70%]); 294 (48%) patients had fever. 338 [59%] of 574 were admitted to intensive care units, and 145 (28%) of 511 received ventilator support; 322 (52%) of 614 had a history of asthma or reactive airway disease; 200 (66%) of 304 patients with a history of asthma or reactive airway disease required intensive care compared with 138 (51%) of 270 with no history of asthma or reactive airway disease (p=0·0004). Similarly, 89 (32%) of 276 patients with a history of asthma or reactive airway disease required ventilator support compared with 56 (24%) of 235 patients with no history of asthma or reactive airway disease (p=0·039).InterpretationIn 2014, EV-D68 caused widespread severe respiratory illness across the USA, disproportionately affecting those with asthma. This unexpected event underscores the need for robust surveillance of enterovirus types, enabling improved understanding of virus circulation and disease burden.FundingNone.

Non-occlusive Mesenteric Ischemia Complicated by Intramural Hematomas: A Case Report

Introduction: Acute mesenteric ischemia (AMI) often mimics coagulopathy related intestinal intramural hematomas because their similar clinical settings and imaging features. However, their managements are difference. We report a case of non-occlusive mesenteric ischemia (NOMI) complicated by transmural hematoma. Case Presentation: A 49-year-old woman was admitted to the intensive care unit because of septic shock. She had an underlying diseases of undifferentiated connective tissue disease and severe pulmonary hypertension. She presented with fever, hypotension, respiratory failure and acute kidney injury. She received ventilator support, renal dialysis and a high dose intravenous of the combination of norepinephrine and adrenaline for maintaining her hemodynamic condition. Three days after admission, she developed abdominal distension and mucous bloody stool. Physical examination showed fever, marked abdominal distension, and absence bowel sound. Laboratory results showed platelet count 5,000/uL, prolong prothrombin time with INR at 1.58, and prolonged activated partial thromboplastin time 51.3 sec (control 26 sec). Stool examination demonstrated WBC 20-30 cell/mm3, RBC 10-20/mm3, negative C. difficile toxin test, and negative culture for bacterial pathogen. A computed tomography of abdomen demonstrated dilated and thickened bowel wall at the ileum and ascending colon with intramural hematomas. Pneumatosis intestinalis and ascites were demonstrated. (Figure 1) The vascular structures (SMA, SMV, IMA and IMV) were patent. Therefore, NOMI complicating bowel infarction with spontaneous intramural hematomas was diagnosed. She underwent an emergency surgery. The operation showed a gangrenous colon and distal ileum. The remaining bowel was non-gangrenous ischemia. Total colectomy with end ileostomy was successfully performed. Pathology revealed transmural hemorrhagic necrosis of the colon, appendix, and terminal ileum. (Figure 2) Unfortunately, she died from multiple organ failure a week later.Figure 1Figure 2Discussion: This patient initially presented with septic shock requiring inotropic drugs. With poor perfusion status, she was susceptible to AMI. While her condition had been worsening; she developed disseminated intravascular coagulation (DIC) on top of NOMI. As AMI progressed, an element of intramural hemorrhage could be seen. A combination of medical history, physical examination, and laboratory values are all important in establishing the correct diagnosis and activating the prompt treatment. AMI may necessitate emergency intervention to restore blood flow whereas coagulopathy related intramural hematoma requires medical management to correct coagulopathy.

Aerosol Drug Delivery During Mechanical Ventilation

Aerosolized medications are increasingly being used in ventilator-dependent patients. There are many issues with selection and use of aerosol delivery devices in patients receiving ventilator support. The purpose of this paper is to explain potential problems associated with aerosol devices, delivery technique, and clinical response to therapy to assure patient well-being and safety during inhalation therapy.

Palliative Care Consultation to Assist Discussion of Ventilator Withdrawal in a Medical Center in Taiwan

Objective: The decision to withdraw ventilator support for terminal patients is difficult for health professionals and patients’ surrogates. Some intensive care unit physicians attempt to discuss the issue with surrogates. This retrospective study aimed to explore current dilemmas of ventilator withdrawal. Methods: This is a retrospective review and analysis of medical records of terminal patients receiving ventilator support. The medical records of thirty-eight terminal patients who had received palliative care consultation for ventilator withdrawal at the National Cheng Kung University Hospital from August 2007 to January 2014 were reviewed retrospectively. Patients’ characteristics, including age, gender, diagnosis, withdrawal medications for symptom relief, and period from withdrawal to death, were analyzed. Results: Thirteen patients were withdrawn from ventilator support and seven were weaned successfully. Eight surrogates signed consents for ventilator withdrawal, but patients died before withdrawal. Patients median age at withdrawal was 75 years (range: 53~80 years), and 46% had terminal cancer. The median period from withdrawal to death was 1.17 hours (range: 0.1~80.92 hours). Withdrawal was performed by palliative care physicians (23%), and 77% of withdrawal was performed in the intensive care unit. Conclusion: Family conference, good symptom control and psychosocial support are necessary for surrogates’ ventilator withdrawal decisions. Encouraging more health care professionals to establish shared decision-making relationships could reduce the application of futile medical treatment.

Biphasic cuirass ventilation is better than bag-valve mask ventilation for resuscitation following organophosphate poisoning

ObjectiveExposure to organophosphates (OP) may lead to a life threatening cholinergic crisis with death attributed to a rapidly progressive respiratory failure. In a toxicological mass casualty event involving organophosphate exposure, many of the victims may depend on immediate short-term ventilation to overcome the respiratory distress which may exhaust life supporting resources. In addition, the mandatory use of personal protective gear by first responders emphasizes the need for a noninvasive, easy-to-operate ventilation device. Our objective was to assess the efficacy of MRTX, a Biphasic Cuirass Ventilation device, in comparison with standard bag-valve mask ventilation following acute organophosphate poisoning. MethodsPigs were exposed to paraoxon poisoning (1.4LD50), and treated 8min later with atropine (0.05mg/kg). The control group received no further support (n=9), the two experimental groups received ventilation support initiated 15min post exposure and lasted for 25min: one group was ventilated with the commonly used bag-valve mask (Mask group, n=7) and the other was ventilated with the Biphasic Cuirass Ventilation device (Cuirass group, n=7). Clinical signs and physiological parameters were monitored during the first hour, and mortality up to 24h post exposure was recorded. ResultsNo mortality was observed in the Cuirass group following OP poisoning, while mortality in the Control and in the Mask groups was high (67% and 71%, respectively). Mouth excretions of the cuirass-ventilated animals were frothy white as in deep suctioning, as opposed to the clear saliva-like appearance of secretions in the other two groups. No further group differences were recorded. ConclusionsThe noninvasive, easy-to-operate Biphasic Cuirass Ventilation device was effective in reducing OP-induced mortality and might be advantageous in an organophosphate mass casualty event. This finding should be validated in further investigations.