Severe Desaturation Research Articles

Factors that impact second attempt success for neonatal intubation following first attempt failure: a report from the National Emergency Airway Registry for Neonates

ObjectiveTo determine the factors associated with second attempt success and the risk of adverse events following a failed first attempt at neonatal tracheal intubation.DesignRetrospective analysis of prospectively collected data on...

Ictal and Postictal Central Apnea in DEPDC5-Related Epilepsy.

DEPDC5-related epilepsy carries an increased risk of sudden unexpected death in epilepsy. We evaluated the occurrence and features of ictal central apnea (ICA) in patients with pathogenic sequence variant in DEPDC5. We reviewed data of 108 patients collected in 2 independent cohorts of patients with focal epilepsy who prospectively underwent long-term video-EEG monitoring (LTVM) with cardiorespiratory polygraphy. All patients underwent (1) at least an overnight polysomnography, (2) a high-field (3T) brain MRI study, and (3) CSF analysis when clinically indicated. Genetic testing (next-generation sequencing [NGS]) was offered for diagnostic purposes to patients with focal epilepsy of unknown etiology. In this cohort, NGS was finally performed in 29 patients, resulting in DEPDC5 pathogenic mutations in 5 patients. According to the presence of ictal apnea events, 5 of 14 patients with ICA showed pathogenic DEPDC5 variants (35%) while none of the 15 patients without ICA showed pathogenic mutation. Notably, DEPDC5 patients showed ICA in all recorded seizures (n = 15) with apnea duration ranging from 20 seconds to more than 1 minute. All seizures were characterized by motor arrest without overt automatic behaviors during ictal apnea. Scalp EEG showed the involvement of temporal lobe leads in all events. Severe oxygen desaturation was observed in 2 cases. In our cohort, ictal central apnea was a common finding in DEPDC5. These results support (1) the need for respiratory polygraphy during LTVM in DEPDC5-related epilepsy and (2) the potential relevance of genetic testing in patients with focal epilepsy of unknown etiology and ictal apnea.

Classification of Patients Based on Dyspnea and Desaturation During Exercise in Interstitial Lung Disease.

Dyspnea and desaturation during exercise are essential assessment items for pulmonary rehabilitation. Characterizing patients using these 2 factors may be important for providing more effective pulmonary rehabilitation. This study aimed to categorize subjects with interstitial lung disease (ILD) using dyspnea and desaturation at the end of the 6-min walk test (6MWT). This was a retrospective study including 230 stable subjects with ILD who underwent 6MWT in our out-patient department at a general hospital in Japan. The modified Borg scale and oxygen saturation determined by SpO2 at the end of the 6MWT were used for cluster analysis using the k-means method with k = 4. Subjects were classified into 4 characteristic clusters. SpO2 at the end of the 6MWT was lower in cluster 4 (80.5 ± 3.0%) than in clusters 1 (94.3 ± 2.0%), 2 (94.3 ± 1.9%), and 3 (87.9 ± 1.8%) and was lower in cluster 3 than in clusters 1 and 2. The modified Borg scale score at the end of the 6MWT was higher in clusters 2 (4 [3-8]), 3 (3 [0-9]), and 4 (4 [0-7]) than in cluster 1 (0.5 [0-2.0]) and was higher in cluster 2 than in cluster 3. Subjects with ILD were classified into 4 characteristic clusters using dyspnea and SpO2 at the end of the 6MWT. The 4 clusters are characterized as follows: Cluster 1 had mild desaturation and mild dyspnea; cluster 2 had mild desaturation and severe dyspnea; cluster 3 had both moderate desaturation and dyspnea, and cluster 4 had both severe desaturation and dyspnea. These classification data offer insight for individualized pulmonary rehabilitation for patients with ILD.

Experience of urgent surgical thrombolectomy of high-risk acute massive pulmonary embolism under parallel cardiopulmonary bypass: a case report

Massive acute pulmonary embolism is a rare and life-threatening condition that cardiac surgeons may encounter in their clinical practice. Although systemic thrombolysis is often prescribed in critically ill patients to improve pulmonary perfusion and reduce right ventricular afterload, surgical treatment is an objective alternative when thrombolytic therapy is ineffective or impossible. Aim. Determining the expediency of pulmonary thromboembolectomy in the case of unavailability or impossibility of systemic thrombolysis to optimize treatment protocols for patients with high-risk pulmonary embolism accompanied by hemodynamic instability. Materials and methods. We present clinical cases of patients with high-risk pulmonary embolism as determined by multispiral computed tomography with Miller index determination. In both cases, the condition of the patients upon admission was critical, due to rapidly progressing hemodynamic instability, severe pulmonary hypertension, and right ventricular failure. Results. The patients were urgently brought to the operating room with severe desaturation, bradycardia, in a state of medical sedation and with pronounced hypotension. Taking into account the patients’ severe condition and the results of the tomography, we performed emergency pulmonary thromboembolectomy using a modified surgical technique using cardiopulmonary bypass without deep hypothermia or transverse aorta clamping. Conclusions. The complete clinical remission resulting from the clinical observations described in this study demonstrates the feasibility of performing open pulmonary thromboembolectomy in combination with anticoagulant therapy in patients with high-risk pulmonary embolism accompanied by hemodynamic instability based on clinical diagnosis in specific individual cases.

Impact of Real-Time Assessment of Pulse Oximetry on the 6-Min Walk Distance in Patients With Chronic Respiratory Disease.

Continuous monitoring of pulse oximetry (SpO2 ) is recommended during the 6-min walk test (6MWT) to ensure that the lowest SpO2 is recorded. In this case, severe exercise-induced desaturation (EID; SpO2 < 80%) triggers walking interruption by the examiner. Our main objective was to assess the impact of this approach on 6MWT distance in patients with chronic respiratory diseases and, second, to evaluate the safety of the test without interruption due to severe EID. 6MWTs with continuous monitoring of SpO2 were prospectively performed in subjects with chronic respiratory disease. The participants were randomly allocated to walk with or without SpO2 real-time assessment. SpO2 visualization during the test execution was available only in the first group, and walking interruption was requested by the examiner if SpO2 < 80%. One hundred forty-five participants were included in each group (68.6% females, 62 [52-69] y old) without differences in demographic and resting lung function parameters between them. The main respiratory conditions were COPD (n = 101), asthma (n = 73), pulmonary hypertension (n = 47), and interstitial lung disease (n = 39). The walked distance was similar comparing groups (349.5 ± 117.5 m vs 351.2 ± 105.4 m). Twenty-five subjects presented with severe EID in the group with real-time SpO2 assessment, and 20 subjects had severe EID in the group without real-time assessment respectively (overall prevalence of 15.5%). The 23 participants who had their test interrupted by the examiner due to severe EID in the first group (2 subjects stopped by themselves due to excessive symptoms) walked a shorter distance compared to the 11 subjects with severe EID without test interruption in the second group (9 subjects stopped by themselves due to excessive symptoms): 240.6 ± 100.2 m versus 345.9 ± 73.4 m. No exercise-related serious adverse events were observed. Interruption driven by severe EID reduced the walked distance during the 6MWT. No serious adverse event, in turn, was observed in subjects with severe desaturation without real-time SpO2 assessment.

High flow oxygen therapy versus conventional oxygen therapy in dogs and cats undergoing bronchoscopy and bronchoalveolar lavage: a pilot study

ObjectivesTo evaluate the safety and feasibility of high flow oxygen therapy (HFOT), and to record SpO2 and desaturation episodes in dogs and cats receiving HFOT or conventional oxygen therapy (COT) during bronchoscopy ± bronchoalveolar lavage (BAL).Materials and methodsDogs and cats undergoing bronchoscopy ± BAL between January and May 2023 were included in the study. Patients were randomly allocated to two groups: HFOT (HFOT group; two cats and four dogs) and COT (COT group; one cat and five dogs). HFOT and COT were started at the beginning of the bronchoscopy. HFOT was delivered with a gas flow rate of 1 L/kg/min at an FiO2 of 100% and a temperature of 34°C (pediatric mode) or 37°C (adult mode). COT was delivered through the working channel of the bronchoscope at a rate of 1.5 L/min. The safety and feasibility of HFOT were assessed, and peripheral oxygen saturation (SpO2) was measured by pulse oximetry every 30 s throughout the procedure.Measurements and main resultsHFOT was feasible and safe in both dogs and cats with no complications reported. While there was no significant difference in the number of desaturation episodes (SpO2 &amp;lt; 94%) between the two groups, none of the patients in the HFOT group experienced severe desaturation (SpO2 &amp;lt; 90%). In contrast, two patients in the COT group had an SpO2 &amp;lt; 90%. Mean SpO2 was significantly higher in the HFOT group compared to the COT group at T0 (98% ± 2% vs. 94 ± 2%), T0.5 (98% ± 2% vs. 94% ± 3%) and T1 (98% ± 2% vs. 94% ± 4%).ConclusionTo the authors’ knowledge, this is the largest study conducted to date using HFOT during bronchoscopy in dogs and cats. Our results suggest that HFOT is feasible and safe during bronchoscopy ± BAL. Furthermore, HFOT may reduce the risk of desaturation episodes in dogs and cats undergoing bronchoscopy and BAL.

Effective treatment with oral Salbutamol on late onset respiratory impairment in a DOK7 Congenital Myasthenia Syndrome: a case report.

DOK7 gene deficiency is a neuromuscular disease with an alteration in post-synaptic neuromuscular junction, leading to progressive respiratory impairment. Although, the therapy is not standardized, adrenergic agonists are suggested as first-line treatment. Case presentation: Our patient had an ambiguous late childhood-onset and had a generalized muscle weakness free of respiratory symptoms during the early phase of the disease. Subsequently, when the respiratory muscle and the diaphragm involvement was impaired, a substantial loss of respiratory function with hypopneas and severe desaturation was detected. It was noteworthy the striking respiratory beneficial impact of oral salbutamol in the resolution of symptoms and functional impairments, leading to a remarkable respiratory improvement and a better quality of life. Conclusion: Oral salbutamol treatment combined to a timely clinical recognition led to an outstanding respiratory improvement.

Cerebral tissue oxygen desaturations and increased fractional oxygen extraction events vary by gestational age in preterm infants

Background and objectivesCerebral tissue oxygen saturation (SctO2) and cerebral fractional tissue oxygen extraction (cFTOE) changes with GA in preterm infants. This study examines changes in frequency, duration, and severity of SctO2 desaturation and increased cFTOE with GA. Study designThe lower limit of normal SctO2, the event threshold, was calculated using a tolerance interval method with 95% confidence interval (CI) and 90% probability. Cerebral desaturation events were defined as: 1) a drop below event threshold for at least 30 s (s), 2) preceded by a period above the event threshold for at least 30s, and 3) followed by a period above the threshold for at least 60s. Results86% of infants <28 wk experienced one or more SctO2 desaturation event compared to 57% in >28 wk, odds ratios (OR) 4.5 (CI:1.3–15.3, p = 0.016). The severity of SctO2 desaturation events decreases at a rate of 77.9 units per wk increase in GA (p < 0.001). 39.3% of infants <28 wk experienced one or more increased cFTOE events compared to 28.6% in >28 wk, OR 1.6 (CI:0.6–4.4, p = 0.35). The severity of increasing cFTOE events decreased by 69.7 units per wk increase in GA (p < 0.001). ConclusionCerebral tissue oxygen desaturation events decrease in frequency and severity with increasing GA. The severity of increased cFTOE episodes decrease with GA.

Safety of primary nasotracheal intubation in the pediatric intensive care unit (PICU).

Nasal tracheal intubation (TI) represents a minority of all TI in the pediatric intensive care unit (PICU). The risks and benefits of nasal TI are not well quantified. As such, safety and descriptive data regarding this practice are warranted. We evaluated the association between TI route and safety outcomes in a prospectively collected quality improvement database (National Emergency Airway Registry for Children: NEAR4KIDS) from 2013 to 2020. The primary outcome was severe desaturation (SpO2 > 20% from baseline) and/or severe adverse TI-associated events (TIAEs), using NEAR4KIDS definitions. To balance patient, provider, and practice covariates, we utilized propensity score (PS) matching to compare the outcomes of nasal vs. oral TI. A total of 22,741 TIs [nasal 870 (3.8%), oral 21,871 (96.2%)] were reported from 60 PICUs. Infants were represented in higher proportion in the nasal TI than the oral TI (75.9%, vs 46.2%), as well as children with cardiac conditions (46.9% vs. 14.4%), both p < 0.001. Severe desaturation or severe TIAE occurred in 23.7% of nasal and 22.5% of oral TI (non-adjusted p = 0.408). With PS matching, the prevalence of severe desaturation and or severe adverse TIAEs was 23.6% of nasal vs. 19.8% of oral TI (absolute difference 3.8%, 95% confidence interval (CI): - 0.07, 7.7%), p = 0.055. First attempt success rate was 72.1% of nasal TI versus 69.2% of oral TI, p = 0.072. With PS matching, the success rate was not different between two groups (nasal 72.2% vs. oral 71.5%, p = 0.759). In this large international prospective cohort study, the risk of severe peri-intubation complications was not significantly higher. Nasal TI is used in a minority of TI in PICUs, with substantial differences in patient, provider, and practice compared to oral TI.A prospective multicenter trial may be warranted to address the potential selection bias and to confirm the safety of nasal TI.

Feasibility of ProVu™ Video Stylet for awake intubation of patients with severe obesity: A pilot observational study

BackgroundAirway management in the obese patient is known to be challenging as oxygenation may rapidly decrease after general anesthesia induction. Mask ventilation and tracheal intubation can be complicated due to obesity-related anatomical features. The reduced safe apnea time can put the patient at risk of severe and rapid desaturation. Recent guidelines recommend avoiding the suppression of spontaneous breathing in cases of predicted anatomically or physiologically difficult airway. Many different devices, such as video stylets and video laryngoscopes, have been proposed as alternatives to traditional gold standard flexible bronchoscope use for awake intubation. AimOur study reports the use of a new flexible ProVu™ Video Stylet (Flexicare Medical Ltd., Mountain Ash, UK) for awake intubations in 11 patients with severe obesity, who presented with at least one criterion for potentially difficult oxygenation (during ventilation and/or intubation attempts) after suppression of spontaneous breathing. MethodsIn total 11 consecutive patients with severe obesity and clinical indication for an awake tracheal intubation were enrolled over a 10-months period and intubated with the ProVu™ Video Stylet. ResultsAll 11 tracheal intubations were successfully performed. The procedures also highlighted potential limitations to consider while using the device in an awake intubation setting. ConclusionDespite the limitations of this small observational pilot study, our study showed that the ProVu™ Video Stylet may be a promising tool and a valid alternative for performing awake tracheal intubation in patients with severe obesity and predictors of difficult oxygenation. Future studies are needed to compare the performance of the ProVu™ Video Stylet with video laryngoscopy and flexible bronchoscopy, and to provide stronger evidence in favor or against the use of this new device. The possible availability of an alternative device, combined with the skill and confidence to use it, may provide the anesthesiologist an additional tool for managing awake intubation of at-risk airways, in accordance with recommendations from the most recent guidelines.

Efficacy and safety of fospropofol disodium sedation for same-day bidirectional endoscopy in elderly patients: protocol for a prospective, single-center, randomized, double-blind, non-inferiority trial.

Fospropofol disodium is a novel prodrug that has improved pharmacokinetic and pharmacodynamic properties when compared with propofol. This trial aims to compare the efficacy and safety of fospropofol versus propofol sedation for same-day bidirectional endoscopy in elderly patients. This is a prospective, single-center, double-blind, randomized, propofol-controlled, non-inferiority trial. A total of 256 patients aged 65years or older, who are scheduled for same-day bidirectional endoscopy under sedation, will be randomly allocated, in a 1:1 ratio, to either fospropofol group or propofol group (n = 128 in each group). All patients will receive analgesic pre-treatment with sufentanil 5μg. Two minutes later, an initial bolus dose of fospropofol 6.5mg/kg or 1.5mg/kg propofol and supplemental doses of fospropofol 1.6mg/kg or 0.5mg/kg propofol will be titrated as needed to achieve target sedation levels during the procedures. The primary outcome is the success rate of same-day bidirectional endoscopy. Secondary outcomes include the time to successful induction of sedation, duration, time to being fully alert, time to patient discharge, endoscopist satisfaction, patient satisfaction, and the top-up frequency and dosage of sedative medications. The safety endpoints consist of adverse events concerning cough reflex, gag reflexes, body movement, muscular tremor, and pain on injection. Sedation-related AEs, including episodes of desaturation, severe desaturation (SpO2 < 90%), hypotension, severe hypotension (decrease in MBP ≥30% of baseline), and bradycardia, will also be recorded. Data will be analyzed on an intention-to-treat basis. We hypothesize that the efficacy and safety of fospropofol sedation for elderly patients undergoing same-visit bidirectional endoscopy will not be inferior to that of propofol. Our findings will potentially provide a new sedation regimen for same-visit bidirectional endoscopy in elderly patients. clinicaltrials.gov, identifier NCT02875639.

Association between Nocturnal Hypoxemia and COPD Severity: A Cross-sectional Study

Introduction: Globally, Chronic Obstructive Pulmonary Disease (COPD) is the third most common cause of mortality. More than 80% of these fatalities happened in low- and middleincome nations. Transient desaturation during sleep occurs in healthy persons during Rapid Eye Movement (REM) sleep. This phenomenon is aggravated in COPD patients. As Nocturnal Desaturation (NOD) in COPD has been suggested to increase mortality, its early identification will aid in early initiation of treatment and prevention of associated complications. Aim: To estimate the prevalence of nocturnal hypoxemia in COPD and determine its association with COPD severity. Materials and Methods: A cross-sectional study was carried out at the Department of General Medicine, Apollo Hospitals, Guwahati, Assam, India during January to December 2021 involving 100 patients who had COPD symptoms. Continuous oxygen saturation monitoring with transcutaneous finger probe was done for the entire duration of sleep at night. Patients whose oxygen saturation falls below 90% for at least 30% of recording time in sleep were classified as desaturators. Statistical Package for Social Sciences (SPSS) Version 26.0 was used for data analysis. Using the Chi-square test, the relationship between the qualitative variables was evaluated. The Mann-Whitney test or the unpaired t-test was used to analyse the quantitative data between the two groups. A p-value of less than 0.05 was considered significant. Results: Prevalence of NOD among cases of COPD was observed as 26% in present study. A significant association was observed between presence of NOD in COPD cases with severity of COPD and with desaturation in 6-Minute Walk Test (6-MWT) (p&lt;0.01). Severe cases had a prevalence of NOD as 65% as compared to 28.2% and 4.9% in moderate and mild cases respectively (p&lt;0.01). A total of 61.9% cases with desaturation during 6-MWT showed NOD as compared to 38.1% without desaturation (p&lt;0.01). Conclusion: One fourth of the normoxemic COPD patients had significant NOD. NOD episodes were observed to be positively associated with increasing severity of COPD. Assessing variations in oxygen saturation during a 6-MWT can be helpful in identifying COPD patients who may be at risk for severe night time desaturation.

Reversal of arterial oxygen desaturation with the use of an oxygen concentrator during injectable anaesthesia in feral cats positioned in the Trendelenburg, dorsal or lateral surgical position.

This study observed the effects of oxygen supplementation, via an oxygen concentrator, on peripheral arterial blood oxygenation (SpO2) measured by pulse oximetry in anaesthetised cats undergoing spay in three different surgical positions. A total of 192 female feral cats were investigated for a large-scale trap-neuter-release program. Cats were anaesthetised with an intramuscular combination of butorphanol (0,4 mg / kg), ketamine (7-10 mg / kg) and medetomidine (0,03-0,05 mg / kg). Cats were randomly allocated to undergo spay in either Trendelenburg (TR) (70° downward head tilt), lateral (LR) or dorsal (DR) recumbency. Cats were breathing spontaneously either room air or 2 L/minute oxygen via a tight-fitting face mask. Pulse rate (in beats per minute), respiratory rate (in breaths per minute) and SpO2 (in percentage) were measured at baseline in left lateral recumbency and afterwards continuously after being positioned in allocated surgical position. At the end of surgery, cats were placed again in left recumbency, and all parameters were re-evaluated after five minutes. Overall, 33 % of cats showed severe arterial oxygen desaturation (SpO2 < 90 %) at baseline when breathing room air. When oxygen was supplemented during the procedure, arterial oxygen desaturation resolved in all cats. At the end of the procedure, 29 % of cats were hypoxaemic when oxygen was not supplemented, with an overall higher percentage of hypoxaemic cats in TR as compared to DR and LR recumbencies. All cats recovered well from surgery and were released within 24 hours post-anaesthesia. Arterial oxygen desaturation is frequent in cats anaesthetised with injectable anaesthesia for spay under field conditions. Oxygen supplementation administered via a tight-fitting mask resolved arterial oxygen desaturation in this feral cat population regardless of the surgical position and therefore oxygen supplementation is recommended in any case.

Physiological Responses during Prolonged Immersed Static Apnea in Well-Trained Apneists

Breath-hold diving has been traditionally practiced for professional and recreational reasons and has recently emerged as a competitive sport. The physiological response during breath-holding, also known as diving response, consists mainly of bradycardia and peripheral vasoconstriction. Elite apneists can suppress the urge to breathe, sustain greater arterial desaturation and develop pronounced bradycardia, thus accomplishing impressively long breath-hold times. This study explored physiological responses during static apnea and their association with apnea duration in breath-hold divers with high physiological adaptations acquired from long-term apnea training. Nine well-trained competitive divers held their breath for as long as possible while floating motionlessly in a swimming pool (26–27 °C), simulating an actual “static apnea competition”. Long apnea durations (302 ± 60 s) as well as severe oxygen desaturation (minSaO2 46 ± 11%) and bradycardia (minHR 49 ± 8 bpm) were achieved. Apnea duration was positively correlated with forced vital capacity (r = 0.771) and apnea duration until initiation of desaturation (r = 0.736) and negatively correlated with minSaO2 (r = −0.672) (p &lt; 0.05). Moreover, minHR during apnea was correlated with pre-apneic hemoglobin concentration (r = 0.685) (p &lt; 0.05). The prolonged apnea durations achieved by the well-trained divers in this study, while performing maximum immersed static apnea under competitive simulated conditions, were related to their high lung volumes and their delayed and profound O2 desaturation, whereas their bradycardic response was not a decisive factor.

Impact of Optimal Fenestration Size on Outcomes of High-Risk Fontan Patients.

We aimed to analyze mid-term outcomes of the fenestrated Fontan procedure, focusing on the fenestration size. We retrospectively reviewed the outcomes of the fenestrated Fontan procedure. Among 165 patients who underwent the Fontan procedure from 2011 to 2021, fenestration was created in 27 patients with the highest risks, including those with hypoplastic left heart syndrome, hypoplastic pulmonary arteries, heterotaxy syndrome with high pulmonary vascular resistance, and pulmonary arterial pressure >15 mm Hg. The patients underwent the procedure at a median age of three years (body weight, 11.4 kg; body surface area, 0.54 m2). Fenestration sizes were 3.5 to 5 mm. Spontaneous fenestration closure occurred within one year postoperatively in nine patients. Among them, three experienced Fontan failure, necessitating refenestration. Although fenestration size did not differ, the size corrected by body surface area at the time of surgery was smaller in patients with fenestration closure (6.4 mm/m2 vs 8.3 mm/m2, P < .05). Patients with a fenestration <7 mm/m2 were more likely to have fenestration closure within one year postoperatively, and those with a fenestration >9 mm/m2 were more likely to have severe desaturation and require home oxygen therapy following discharge. Spontaneous fenestration closure affected the frequency of Fontan complications. A very small fenestration size corrected by body surface area was a significant risk factor for spontaneous closure. Conversely, a very large fenestration size corrected by body surface area resulted in severe desaturation. The optimal fenestration size to prevent early spontaneous closure and severe desaturation is approximately 8 mm/m2.

Patient Safety during Propofol Sedation before and after Implementation of Capnography Monitoring.

Endoscopic procedures are routinely applied to cancer screening programs and surveillance. The preferred technique is usually deep sedation with propofol being a convenient agent allowing for a quicker patient recovery while maintaining a similar safety profile compared to traditional agents. However, adverse events, including respiratory depression and consequent undesirable cardiovascular side effects, may occur. The goal of this work is to evaluate the patient safety impact of adding capnography during endoscopic procedures under deep propofol sedation. Data were retrospectively collected from patients undergoing deep, procedural sedation for gastrointestinal (GI) endoscopy in October 2019 to January 2021 in a single Turkish university hospital. Included in the analysis were all adult patients classified by the American Society of Anesthesiologists (ASA) as I-IV, who were scheduled for GI endoscopy utilizing propofol alone or in combination. Data on 1840 patients were collected, of whom 1610 (730 pre- and 880 post-capnography implemention) met inclusion criteria. The primary outcome was a change in the composite incidence of mild oxygen desaturation (SpO2 75-90% for <60 s), severe oxygen desaturation (SpO2 < 75% anytime or <90% for >60 s), bradycardia (<60 ppm), and tachycardia (>25% from baseline). Without capnography, on average, 7.5 events of the primary endpoint were observed per 100 procedures and 2.9 with additional capnography monitoring (p < 0.001). A significant reduction was observed for mild oxygen desaturation, with a resulting odds ratio of 0.25 (95% CI 0.14 to 0.46). ASA I patients had the highest difference in combined incidence of any oxygen desaturation of 5.85% in the pre-capnography group and 0.64% in the post-capnography group. Although procedural sedation using propofol is not associated with severe adverse events, the incidence of composite adverse events could be reduced with the addition of capnography monitoring.

Small airway disease in post-acute COVID-19 syndrome, a non-conventional approach in three years follow-up of a patient with long COVID: a case report

BackgroundSmall airways disease (SAD), a novel finding described in post-acute COVID-19 patients, should be suspected when respiratory symptoms continue, air trapping persists on expiratory CT scans, and imaging findings fail to improve despite objectively better conventional pulmonary function test (PFT) parameters. The forced oscillation technique (FOT) and Multiple breathing washout (MBW) are both very sensitive methods for detecting anomalies in the peripheral airways.Case presentationWe discuss the case of a 60-year-old Hispanic patient who had severe COVID-19 pneumonia and developed dyspnea, fatigue, and limited daily activity a year later. The PFTs revealed restrictive lung disease, as seen by significant diffusing capacity of the lungs for carbon monoxide (DLCO) decrease, severe desaturation, and poor 6-min walk test (6MWT) performance. The patient was treated with lowering corticosteroids as well as pulmonary rehabilitation (PR). During the 24-month follow-up, the dyspnea and fatigue persisted. On PFTs, 6MWT performance and restricted pattern improved slightly, but MBW discovered significant ventilatory inhomogeneity. FOT revealed substantial peripheral airway obstructive abnormalities. On CT scans, air trapping and ground-glass opacities (GGO) improved somewhat. The patient used a bronchodilator twice a day and low-dose inhaled corticosteroids (160 µg of budesonide and 4.5 µg of formoterol fumarate dihydrate) for nine months. PR sessions were resuming. The restricting parameters were stabilized and the DLCO had normalized after 36 months, with a 6MWT performance of 87% but significant desaturation. The CT scan revealed traction bronchiectasis, low GGO, and persistent air trapping. Without normalization, FOT and MBW scores improved, indicating small airway disease.ConclusionsThe necessity of integrating these tests when detecting SAD is emphasized in our paper. This article lays the foundation for future research into the best ways to manage and monitor SAD in post-acute COVID-19 patients.

Associations With Severe Desaturation Events Among Children Receiving Noninvasive Respiratory Support at Time of Intubation.

Endotracheal intubation is a common procedure associated with adverse events, including severe desaturation. Many patients receive noninvasive respiratory support to reduce the need for intubation. There are minimal data about the association between noninvasive respiratory support and the risk of a severe desaturation event during intubation. We aim to differentiate patients based on the level of noninvasive respiratory support, analyze the severe desaturation event by groups, and identify modifiable risk factors. Oral intubations, excluding tube exchanges or re-intubation after unplanned extubation, from October 2018 through July 2020, at the study site were reviewed. A severe desaturation event was defined as [Formula: see text] < 70% or a >15% decrease from baseline in cyanotic heart disease. We analyzed outcomes by 4 groups: room air/nasal cannula (≤0.5 L/kg/min), high-flow nasal cannula (HFNC) (0.5-2 L/kg/min), high HFNC (≥2 L/kg/min), and noninvasive ventilation (NIV). Of 243 subjects who were intubated, 31% were receiving room air/nasal cannula, 25% were receiving HFNC, 18% were receiving high HFNC, and 26% were receiving NIV. Twelve percent of all the subjects had a severe desaturation event. In a univariate analysis, the incidence of a severe desaturation event was similar among all levels of respiratory support (P = .14). A severe desaturation event was more likely in those subjects who were receiving [Formula: see text] ≥ 0.6 at the time of the decision to intubate (19.6%) versus [Formula: see text] < 0.6 (8.1%) (P = .02). The duration of noninvasive respiratory support was longer (5 vs 1 h; P = .02) among those with a severe desaturation event. In a regression analysis, when adjusting for ≥2 intubation attempts pre-intubation, NIV use was independently associated with increased odds of severe desaturation events (odds ratio 3.14, CI 1.08-10.5). Results of our study suggest that [Formula: see text] > 0.60, the duration of noninvasive respiratory support, and exposure to NIV before an intubation are risk factors of severe desaturation events during intubation.

Severe refractory arterial blood desaturation in the course of acute pulmonary embolism successfully reversed with catheter-directed therapy.

Severe refractory arterial blood desaturation in the course of acute pulmonary embolism successfully reversed with catheter-directed therapy.

Nasal continuous positive pressure versus simple face mask oxygenation for adult obese and obstructive sleep apnea patients undergoing colonoscopy under propofol-based general anesthesia without tracheal intubation: A randomized controlled trial

Study objectiveTo determine if a nasal positive airway pressure (nasal CPAP) mask would decrease the number of hypoxemic events in obese and obstructive sleep apnea patients undergoing colonoscopy. DesignSingle-center prospective randomized controlled trial. SettingTertiary academic center. PatientsWe enrolled 109 patients with diagnosis of obesity and/or obstructive sleep apnea scheduled to undergo colonoscopy under propofol general anesthesia without planned tracheal intubation. InterventionPatients were randomly allocated (1:1 ratio) to receive supplementary oxygen at a flow of 10 L/min, either through a nasal CPAP or a simple facemask. MeasurementsThe primary endpoint was the difference in the mean percentage of time spent with oxygen saturation below 90% between the two groups. Secondary outcomes included the need for airway maneuvers/interventions, average SpO2 during the case, duration and severity of oxygen desaturation, incidence and duration of procedural interruptions, and satisfaction and tolerance scores. Main results54 were allocated to the simple face mask and 55 to the nasal CPAP mask arms, respectively. A total of 6 patients experienced a hypoxemic event. Among these patients, the difference in the percentage of time spent with oxygen saturation below 90% was not clinically relevant (p = 1.0). However, patients in the nasal CPAP group required less chin lift (20% vs. 42.6%; p = 0.01) and oral cannula insertion (12.7% vs.29.6%; p = 0.03). The percentage of patients with at least one airway maneuver was higher in the simple face mask arm (68.5% vs. 41.8%; p = 0.005). Patient tolerance to device score was lower in the nasal CPAP group (8.85 vs. 9.56; p = 0.003). ConclusionsA nasal CPAP did not prevent hypoxemia and should not be used routinely for colonoscopy in obese or OSA patients if a simple face mask is an alternative therapy. However, potential advantages of its use include fewer airway maneuvers or interventions, which may be desirable in certain clinical settings. Trial registrationClinicaltrials.gov, identifier: NCT05175573.