Respiratory Failure Of Various Etiologies Research Articles

Safety and efficacy of noninvasive ventilation for acute respiratory failure in general medical ward: a prospective cohort study.

Noninvasive ventilation (NIV) is recommended for use in patients with acute respiratory failure of various etiologies. However, we do not know whether the use of NIV in general medical wards is safe and effective. This study aimed to evaluate the safety and efficacy of using NIV and factors associated with NIV failure in general medical wards. A prospective cohort study was conducted in general medical wards of the University Hospital. Adult patients with acute respiratory failure treated with NIV were enrolled. The subjects were managed by a multidisciplinary care team that was well trained in the NIV device. The primary outcome was the rate of NIV failure at 48 hours. Secondary outcomes included hospital mortality and factors associated with NIV failure. A total of 86 patients were enrolled. The mean age was 70±17 years old. The Acute Physiology and Chronic Health Evaluation (APACHE) III and the Sequential Organ Failure Assessment (SOFA) scores were 56±17 and 4±3, respectively. The most common indication of NIV use was cardiogenic pulmonary edema (34.9%). The rate of NIV failure at 48 hours and hospital mortality were 20.9% and 12.8%, respectively. The SOFA score was associated with failure of NIV at 48 hours [odds ratio (OR) 1.48, 95% confidence interval (CI): 1.16-1.89; P=0.002]. NIV was safe and effective on general medical wards. Cardiogenic pulmonary edema was the most common indication for the application of NIV. The SOFA score was associated with the failure of NIV at 48 hours.

Driving Pressure: What Is the Harm?

Driving Pressure: What Is the Harm?

Tracheostomy in the pediatric trisomy 21 population

IntroductionTracheostomy in children is often performed to alleviate airway obstruction (AO) or to facilitate long-term ventilator support due to respiratory failure of various etiologies, such as heart failure, and postoperative respiratory failure. Although many of these pathologies are common among trisomy 21 patients, tracheostomy rates among this population have not previously been reported. The aim of our study was to determine the incidence of trisomy 21 patients undergoing tracheostomy. Secondary objectives include decannulation rates and mortality associated with tracheostomy. Materials and methodsA retrospective cohort study was conducted on pediatric trisomy 21 patients undergoing tracheostomy between 2004 and 2013. ResultsTwenty patients underwent tracheostomy at a median age of 7.1 months (interquartile range [IQR] = 3.5,21.3). The estimated incidence of tracheostomy in trisomy 21 patients among our tracheostomy population was 1.7% (20/1173) over 10 years. The most common indications were airway obstruction (AO) (55%), cardiac/pulmonary respiratory failure (CRF) (25%), or both (20%). Overall mortality was 30%, much lower among AO patients (9%) than CRF (40%) or both (60%), (P = 0.029). Nine patients (45%) were successfully decannulated, with median duration of cannulation of 2.2 years (IQR = 1.7,3). ConclusionsThis study suggests a rate of tracheostomy in the pediatric trisomy 21 population approximately 3 times that of the general pediatric population. Over half in this cohort underwent tracheostomy for isolated AO, while the general pediatric tracheostomy population demonstrates a much higher prevalence of prematurity-related CRF. Overall mortality rate and decannulation rate approximated that of the general pediatric tracheostomy population, although outcomes were significantly poorer among patients trisomy 21 patients undergoing tracheostomy for CRF.

Outcome of neonates receiving high frequency oscillation ventilation in a tertiary care institution

Background: High-frequency ventilation is defined as ventilation at a frequency greater than four times normal respiratory rate. HFOV has been used as alternative to conventional ventilation and in respiratory failure of various etiologies. The aim of the study was to identify the indications of neonates receiving HFOV, following failure of conventional ventilation.Methods: Total 93 neonates were enrolled in the study who received HFOV. The criteria for starting HFOV, the ventilator settings, CBG and ABG analysis, oxygenation index (OI), duration of ventilation and complications of ventilation were recorded during CMV and subsequently when shifted over to HFOV. Outcomes such as oxygenation, lung recruitment and ventilation and survival were monitored.Results: Total 66 neonates (71%) were term babies. Among the 27 preterm 18 (18.4%) were 33-34±6 weeks of gestational age. Male were 50 in number (53.8%) and female were 43 (46.2%). The male: female ratio was 50:43. Disease specific survival analysis revealed more than 50% survival in cases of pneumonia, collapse, air leak, MAS and pulmonary hemorrhage. 16 out of 33 babies (48.5%) with PPHN survived. All 3 babies with CDH expired. Of the 93 neonates included in the study, 53 (57%) of them were discharged home. The major complications noted while on HFOV were- 38 neonates (40.8%) had air leaks. Instead of, ventilator associated pneumonia was present in 42 of them (45.1%) and none of them developed IVH or NTB (Necrotising tracheo bronchitis).Conclusions: HFOV is a safe and effective technique in the treatment of neonates with respiratory failure in whom CMV fails. The results of present study show that rescue HFOV improved oxygenation, ventilation and lung recruitment and there was no increased incidence of IVH.

Setting up home noninvasive ventilation.

Home noninvasive ventilation (NIV) is widely used to correct nocturnal alveolar hypoventilation in patients with chronic respiratory failure of various etiologies. The most commonly used ventilation mode is pressure support with a backup respiratory rate. This mode requires six main settings, as well as some additional settings that should be adjusted according to the individual patient. This review details the effect of each setting, how the settings should be adjusted according to each patient, and the risks if they are not adjusted correctly. The examples described here are based on real patient cases and bench simulations. Optimizing the settings for home NIV may improve the quality and tolerance of the treatment.

High-flow nasal cannula oxygen therapy decreases postextubation neuroventilatory drive and work of breathing in patients with chronic obstructive pulmonary disease

BackgroundThe physiological effects of high-flow nasal cannula O2 therapy (HFNC) have been evaluated mainly in patients with hypoxemic respiratory failure. In this study, we compared the effects of HFNC and conventional low-flow O2 therapy on the neuroventilatory drive and work of breathing postextubation in patients with a background of chronic obstructive pulmonary disease (COPD) who had received mechanical ventilation for hypercapnic respiratory failure.MethodsThis was a single center, unblinded, cross-over study on 14 postextubation COPD patients who were recovering from an episode of acute hypercapnic respiratory failure of various etiologies. After extubation, each patient received two 1-h periods of HFNC (HFNC1 and HFNC2) alternated with 1 h of conventional low-flow O2 therapy via a face mask. The inspiratory fraction of oxygen was titrated to achieve an arterial O2 saturation target of 88–92%. Gas exchange, breathing pattern, neuroventilatory drive (electrical diaphragmatic activity (EAdi)) and work of breathing (inspiratory trans-diaphragmatic pressure-time product per minute (PTPDI/min)) were recorded.ResultsEAdi peak increased from a mean (±SD) of 15.4 ± 6.4 to 23.6 ± 10.5 μV switching from HFNC1 to conventional O2, and then returned to 15.2 ± 6.4 μV during HFNC2 (conventional O2: p < 0.05 versus HFNC1 and HFNC2). Similarly, the PTPDI/min increased from 135 ± 60 to 211 ± 70 cmH2O/s/min, and then decreased again during HFNC2 to 132 ± 56 (conventional O2: p < 0.05 versus HFNC1 and HFNC2).ConclusionsIn patients with COPD, the application of HFNC postextubation significantly decreased the neuroventilatory drive and work of breathing compared with conventional O2 therapy.

Can fiberoptic bronchoscopy be applied to critically ill patients treated with noninvasive ventilation for acute respiratory distress syndrome? Prospective observational study.

BackgroundNoninvasive ventilation (NIV) is a cornerstone for the treatment of acute respiratory failure of various etiologies. Using NIV is discussed in mild-to-moderate acute respiratory distress syndrome (ARDS) patients (PaO2/FiO2 > 150). These patients often have comorbidities that increase the risk for bronchoscopy related complications. The primary outcome of this prospective observational study was to evaluate the feasibility, safety and contribution in diagnosis and/or modification of the ongoing treatment of fiberoptic bronchoscopy (FOB) in patients with ARDS treated with NIV.MethodsARDS patients treated with NIV and who require FOB as the diagnostic or therapeutic procedure were included the study. Intensive care ventilators or other dedicated NIV ventilators were used. NIV was applied via simple oro-nasal mask or full-face mask. Pressure support or inspiratory positive airway pressure (IPAP), external positive end expiratory pressure (PEEP) or expiratory positive airway pressure (EPAP) levels were titrated to achieve an expiratory tidal volume of 8 to 10 ml/kg according to ideal body weight, SpO2 > 90 % and respiratory rate below 25/min.ResultsTwenty eight subjects (mean age 63.3 ± 15.9 years, 15 men, 13 women, PaO2/FiO2 rate 145 ± 50.1 at admission) were included the study. Overall the procedure was well tolerated with only 5 (17.9 %) patients showing minor complications. There was no impairment in arterial blood gas and cardiopulmonary parameters after FOB. PaO2/FiO2 rate increased from 132.2 ± 49.8 to 172.9 ± 63.2 (p = 0.001). No patient was intubated within 2 h after the bronchoscopy. 10.7, 32.1 and 39.3 % of the patients required invasive mechanical ventilation after 8 h, 24 h and 48 h, respectively. Bronchoscopy provided diagnosis in 27 (96.4 %) patients. Appropriate treatment was decided according to the results of the bronchoscopic sampling in 20 (71.4 %) patients.ConclusionFOB under NIV could be considered as a feasible tool for diagnosis and guide for treatment of patients with ARDS treated via NIV in intensive care units. However, FOB-correlated life-treathening complications in severe hypoxemia should not be forgotten. Furthermore, further controlled studies involving a larger series of homogeneous ARDS patients undergoing FOB under NIV are needed to confirm these preliminary findings.

Use of High-Frequency Ventilation in the Pediatric Intensive Care Unit.

Objective To evaluate the clinical characteristics, ventilator settings, and gas exchange indices of patients placed on high-frequency percussive ventilation (HFPV) and high-frequency oscillatory ventilation (HFOV). Methods Retrospective observation of all consecutive patients aged 0 to 18 years with acute respiratory failure managed with high-frequency ventilation from the institution's introduction of HFPV on May 1, 2012, until July 10, 2013. Measurements and Main Results Twenty-seven patients underwent HFPV as a first mode of high-frequency ventilation and 16 patients underwent HFOV first. HFPV was used more frequently in patients with acute respiratory illnesses (p < 0.01), lower Pediatric Index of Mortality 2 scores (rank-sum p < 0.04), higher Spo 2/Fio 2 (SF) ratios (p < 0.01), and lower oxygen saturation indices (p < 0.01). HFPV patients showed increased SF ratios (p < 0.01) and decreased Paco 2 levels (p = 0.02) 6 hours after initiation, and HFOV patients showed no significant differences. Peak inspiratory pressures (HFPV) and mean airway pressures (HFOV) remained at or below 30 cm H2O at each time point. HFPV and HFOV patients had an average of 2.8 and 2.9 mode changes, respectively. Mortality was 15% in the HFPV group and 50% in the HFOV group. Conclusions HFPV is associated with rapid improvement in oxygenation and ventilation at acceptable airway pressures in patients with acute respiratory failure of various etiologies, primarily for those with difficulties of ventilation or secretion management. In our institution, HFOV appears to be initiated first in children with higher severity of illness.

Intensive Care Management of The Critically Ill Elderly Population: The Case of ‘Sotiria’ Regional Chest Diseases Hospital of Athens, Greece

AbstractThe aim of this study was to assess the characteristics and short-term outcome of elderly patients admitted to the ICU of ‘Sotiria’ Regional Chest Diseases Hospital of Athens. We examined retrospectively the records of 344 patients aged ≥70 years old admitted to the ICU of a tertiary hospital during a five-year period, from 2009-2013. We reported demographic and clinical data, length of ICU stay, need for mechanical ventilation and ICU mortality. Among 1730 admitted to the ICU during this period, the elderly comprised 344 (19.8%). The main causes of ICU admission were Chronic Obstructive Pulmonary Disease (COPD) exacerbation (n=169), postoperative respiratory failure (n=78), acute respiratory failure of various etiologies (n=76) and cardiogenic pulmonary edema (n=25). Overall mortality rate of elderly patients was 41.5%. According to age groups, 200 patients were 70-74 years old with a mortality rate of 47%, 42 patients were 80-84 years old presenting a mortality rate of 28.5%, while 14 patients aged over 85 years old, presented a mortality of 42.8%. The mean length of ICU stay (LOS) for the elderly patients was 11.2 days, while the corresponding LOS value for younger patients was 8.1 days. Elderly patients present highest mortality than younger population. However, mortality does not correlate exclusively with advancing age over 70 years, but mostly with the underlying disease. Therefore, age should not be the sole determinant of ICU admission.

Role of non invasive ventilation in limiting re-intubation after planned extubation

IntroductionIn critically ill adult patients, particularly patients with chronic obstructive pulmonary disease (COPD), early use of non invasive ventilation (NIV) after weaning may be associated with the decrease of mortality. The effect of this benefit is not so clear in ICU mixed populations. Aim of the workCompare the efficacy of NIV to Oxygen Mask in preventing re-intubation if NIV was used immediately following planned extubation in patients with respiratory failure of various etiologies requiring mechanical ventilation for more than 48h. Patients and methodsOne hundred and twenty patients were randomly enrolled in this study. Sixty patients assigned to the noninvasive-ventilation group received ventilation through a full facial mask from a BIPAP ventilator located in the intensive care unit immediately after extubation (group I) while the other sixty patients put on oxygen mask group will be (group II) and act as control group. ResultsThere was no significant difference regarding sex distribution and smoking pattern, also APACHE II score, hemodynamic and electrolytes which might have a role in respiratory failure showed no statistically significant differences between both studied groups .The mean duration of mechanical ventilation was lower in group I than in group II, 6.2±1.6 versus 7.1±1.8days, respectively, however this difference was not significant (p-0.09). The overall re-intubation rate (15%) was significantly lower in group I compared to group II which was 25% and p-value 0.04. The re-intubation rate of COPD patients in group I was statistically lower than group II (p-0.019). Hospital mortality rate showed a statistically significant difference between both groups, with four deaths during ICU stay in the NIV group (6.6%), while there were 10 deaths (16.6%) in the Oxygen Mask group (p<0.035). ConclusionEarly application of non invasive ventilation could be effective in limiting the need for re-intubation and decrease mortality in electively extubated patients with various aetiologies of respiratory failure. Also selected patients with respiratory failure (COPD) may get more benefit from this therapy.

Noninvasive ventilation immediately after extubation improves weaning outcome after acute respiratory failure: a randomized controlled trial.

IntroductionNoninvasive ventilation (NIV), as a weaning-facilitating strategy in predominantly chronic obstructive pulmonary disease (COPD) mechanically ventilated patients, is associated with reduced ventilator-associated pneumonia, total duration of mechanical ventilation, length of intensive care unit (ICU) and hospital stay, and mortality. However, this benefit after planned extubation in patients with acute respiratory failure of various etiologies remains to be elucidated. The aim of this study was to determine the efficacy of NIV applied immediately after planned extubation in contrast to oxygen mask (OM) in patients with acute respiratory failure (ARF).MethodsA randomized, prospective, controlled, unblinded clinical study in a single center of a 24-bed adult general ICU in a university hospital was carried out in a 12-month period. Included patients met extubation criteria with at least 72 hours of mechanical ventilation due to acute respiratory failure, after following the ICU weaning protocol. Patients were randomized immediately before elective extubation, being randomly allocated to one of the study groups: NIV or OM. We compared both groups regarding gas exchange 15 minutes, 2 hours, and 24 hours after extubation, reintubation rate after 48 hours, duration of mechanical ventilation, ICU length of stay, and hospital mortality.ResultsForty patients were randomized to receive NIV (20 patients) or OM (20 patients) after the following extubation criteria were met: pressure support (PSV) of 7 cm H2O, positive end-expiratory pressure (PEEP) of 5 cm H2O, oxygen inspiratory fraction (FiO2) ≤ 40%, arterial oxygen saturation (SaO2) ≥ 90%, and ratio of respiratory rate and tidal volume in liters (f/TV) < 105. Comparing the 20 patients (NIV) with the 18 patients (OM) that finished the study 48 hours after extubation, the rate of reintubation in NIV group was 5% and 39% in OM group (P = 0.016). Relative risk for reintubation was 0.13 (CI = 0.017 to 0.946). Absolute risk reduction for reintubation showed a decrease of 33.9%, and analysis of the number needed to treat was three. No difference was found in the length of ICU stay (P = 0.681). Hospital mortality was zero in NIV group and 22.2% in OM group (P = 0.041).ConclusionsIn this study population, NIV prevented 48 hours reintubation if applied immediately after elective extubation in patients with more than 3 days of ARF when compared with the OM group.Trial Registration numberISRCTN: 41524441.

Efficacy of Non-Invasive Positive Pressure Ventilation (NIPPV) combined with minitracheostomy in management of difficult to wean patients.

Background: To investigate the efficacy of NIPPV in combination with minitracheostomy as weaning adjunct in difficult to wean patients.Method: Prospective analysis of 10 non-consecutive patients with respiratory failure of various etiologies in 20 bedded adult multidisciplinary Intensive Care Unit of a tertiary care hospital. These patients were ventilator dependent and were difficult to extubate and wean off. They were subjected to NIPPV through facemask in combination with minitracheostomy using 4.5 mm percutaneous minitracheostomy tube (Minitrach II SIMS Portex, Hythe, Kent, UK) for removal of tracheobronchial secretions. Mortality, duration of treatment with NIPPV with minitracheostomy and duration of ICU stay were evaluated. Results: Mean age of the study group was 55± 20 years and M: F was 1:1. Average duration of intubation was 21.8 days. Minitracheostomy was performed after mean duration of 2.8 days of NIPPV support following extubation. Average period of NIPPV with in situ minitracheostomy tube was 8.2 days. 90% of the patients those underwent minitracheostomy could be discharged successfully from the ICU after a mean stay of 12.8 days following their last extubation.Conclusion: NIPPV in combination with minitracheostomy may be considered as safe and effective weaning adjunct to wean off difficult to wean patients.DOI: http://dx.doi.org/10.4038/sljcc.v2i1.2951 Sri Lanka Journal of Critical Care Vol.2(1) 2011 16-19

Pressure-Time Product during Continuous Positive Airway Pressure, Pressure Support Ventilation, and T-Piece during Weaning from Mechanical Ventilation

The objective of this study was to compare the effects of continuous positive airway pressure (CPAP), pressure support ventilation (PS), and T-piece on the pressure-time product (PTP) during weaning from mechanical ventilation. The PTP is an estimate of the metabolic work or oxygen consumption of the respiratory muscles. We studied 10 intubated patients recovering from acute respiratory failure of various etiologies. A modified continuous flow (flow-by) CPAP of 0 and 5 cm H2O (CPAP-0 and CPAP-5, respectively), PS of 5 cm H2O (PS-5), and T-piece were applied in random order for 30 min each. In the last 5 min of the 30-min periods, we measured the esophageal pressure and transdiaphragmatic pressure-time products--PTP(es) and PTP(di), cm H2O.s/min, respectively-multiplied by respiratory frequency. Breathing pattern, total lung resistance (RL), quasi-static lung compliance (CL), intrinsic positive end-expiratory pressure (PEEPi), end-expiratory transpulmonary pressure (Ptpexp), arterial blood gases, blood pressure, and heart rate were also measured. In comparison to T-piece, CPAP-5 decreased PTP(es) 40% (p less than 0.01) and PTP(di) 43% (p less than 0.02), whereas PS-5 decreased PTP(es) 34% (p less than 0.01) and PTP(di) 38% (p less than 0.05). The decrease in PTP(es) with CPAP-5 was associated with a significant reduction in RL, and to a less extent in PEEPi relative to airway pressure. The contribution of the decrease in PEEPi to the reduction in PTP(es) amounted to 36%. With PS-5, respiratory system mechanics and PEEPi were not significantly different compared with T-piece. With CPAP-0, PTP tended to be lower than with T-piece.(ABSTRACT TRUNCATED AT 250 WORDS)