Severe Oxygen Desaturation Research Articles

Effect of Colchicine vs Usual Care Alone on Intubation and 28-Day Mortality in Patients Hospitalized With COVID-19

Hospitalized patients with COVID-19 pneumonia have high rates of morbidity and mortality. To assess the efficacy of colchicine in hospitalized patients with COVID-19 pneumonia. The Estudios Clínicos Latino América (ECLA) Population Health Research Institute (PHRI) COLCOVID trial was a multicenter, open-label, randomized clinical trial performed from April 17, 2020, to March 28, 2021, in adults with confirmed or suspected SARS-CoV-2 infection followed for up to 28 days. Participants received colchicine vs usual care if they were hospitalized with COVID-19 symptoms and had severe acute respiratory syndrome or oxygen desaturation. The main exclusion criteria were clear indications or contraindications for colchicine, chronic kidney disease, and negative results on a reverse transcription-polymerase chain reaction test for SARS-CoV-2 before randomization. Data were analyzed from June 20 to July 25, 2021. Patients were assigned in a 1:1 ratio to usual care or usual care plus colchicine. Colchicine was administered orally in a loading dose of 1.5 mg immediately after randomization, followed by 0.5 mg orally within 2 hours of the initial dose and 0.5 mg orally twice a day for 14 days or discharge, whichever occurred first. The first coprimary outcome was the composite of a new requirement for mechanical ventilation or death evaluated at 28 days. The second coprimary outcome was death at 28 days. A total of 1279 hospitalized patients (mean [SD] age, 61.8 [14.6] years; 449 [35.1%] women and 830 [64.9%] men) were randomized, including 639 patients in the usual care group and 640 patients in the colchicine group. Corticosteroids were used in 1171 patients (91.5%). The coprimary outcome of mechanical ventilation or 28-day death occurred in 160 patients (25.0%) in the colchicine group and 184 patients (28.8%) in the usual care group (hazard ratio [HR], 0.83; 95% CI, 0.67-1.02; P = .08). The second coprimary outcome, 28-day death, occurred in 131 patients (20.5%) in the colchicine group and 142 patients (22.2%) in the usual care group (HR, 0.88; 95% CI, 0.70-1.12). Diarrhea was the most frequent adverse effect of colchicine, reported in 68 patients (11.3%). This randomized clinical trial found that compared with usual care, colchicine did not significantly reduce mechanical ventilation or 28-day mortality in patients hospitalized with COVID-19 pneumonia. ClinicalTrials.gov Identifier: NCT04328480.

P138 Nocturnal oxygen desaturation and MET call criteria during in-laboratory sleep studies

Abstract Introduction Patients undergoing sleep studies can experience frequent and profound oxygen desaturation. Most hospitals have standard MET (Medical Emergency Team) call criteria which obligate a response to severe oxygen desaturation. At our tertiary institution this is “Pulse oximetry/oxygen saturation: < 90 despite oxygen administration”. For most sleep studies provision of oxygen overnight would not be appropriate. We sought to examine the proportion of our sleep study patients who would meet MET call criteria. Method We retrospectively examined the data of all sleep studies which were performed in our laboratory between 01/01/2021 and 30/04/2021. Demographic and pulse oximetry data was collected. Results We collected data from 448 studies (95 CPAP, 342 diagnostic, 9 Split, 2 other). Patients were 40% female, 49±15 (mean±SD) years old and had a median AHI of 10 events per hour. 290 (65%) patients had a nadir SpO2 of <90%. The percentage of patients below with nadir SpO2 of 80%, 70%, 60% and 50% was 20%, 9%, 5% and 3% respectively. These proportions did not significantly change if treatment studies were excluded. In contrast, 23 (5%) of patients had a mean overnight SpO2 < 90%. During the period studied no serious adverse event was recorded. Discussion Most patients presenting for a sleep study to our tertiary institution would potentially meet standard hospital MET call criteria. This demonstrates the need for hospitals to be flexible in terms of hospital wide protocols when it comes to sleep laboratories. Evidence based criteria for medical escalation in sleep laboratories are required.

The effect of heated humidified nasal high flow oxygen supply on exercise tolerance in patients with interstitial lung disease: A pilot study

Background and objectivesPatients with interstitial lung disease (ILD) experience early symptoms of dyspnoea and leg fatigue during exercise together with severe and rapid oxygen desaturation. Heated and humidified nasal high flow oxygen (NHF) has been proven to enhance exercise endurance and physiological parameters in COPD patients. This study aims to evaluate the effect of NHF on exercise tolerance in ILD patients. MethodsTwenty-five patients (10 female) with severe ILD performed three constant-load (70% maximal workload) cycling tests to exhaustion under different breathing conditions: room air, oxygen supplementation (4 L min−1 O2) and NHF (inspiratory O2 fraction 0.5, 30–50 L min−1, heated 34 °C and humidified). ResultsEndurance time was significantly longer with NHF (618 ± 297 s) compared to O2 (369 ± 217 s, p < 0.001) and room air (171 ± 76 s, p < 0.001). Kinetics of oxygen desaturation, chronotropic response, dyspnoea and leg fatigue sensations were delayed with NHF. At exhaustion with NHF, compared to the two other conditions, oxygen desaturation was less severe while heart rate, dyspnoea and leg fatigue were similar. ConclusionNHF significantly improved endurance time, physiological parameters and sensations during exercise in severe ILD patients. NHF may be useful to improve functional capacities and facilitate pulmonary rehabilitation in ILD.

Impact of Physician Training Level on Neonatal Tracheal Intubation Success Rates and Adverse Events: A Report from National Emergency Airway Registry for Neonates (NEAR4NEOS)

Introduction: Neonatal tracheal intubation (TI) outcomes have been assessed by role, but training level may impact TI success and safety. Effect of physician training level (PTL) on the first-attempt success, adverse TI-associated events (TIAEs), and oxygen desaturation was assessed. Methods: Prospective cohort study in 11 international NEAR4NEOS sites between October 2014 and December 2017. Primary TIs performed by pediatric/neonatal physicians were included. Univariable analysis evaluated association between PTL, patient/practice characteristics, and outcomes. Multivariable analysis with generalized estimating equation assessed for independent association between PTL and outcomes (first-attempt success, TIAEs, and oxygen desaturation ≥20%; attending as reference). Results: Of 2,608 primary TIs, 1,298 were first attempted by pediatric/neonatal physicians. PTL was associated with patient age, weight, comorbidities, TI indication, difficult airway history, premedication, and device. First-attempt success rate differed across PTL (resident 23%, fellow 53%, and attending 60%; p < 0.001). There was no statistically significant difference in TIAEs (resident 22%, fellow 20%, and attending 25%; p = 0.34). Desaturation occurred more frequently with residents (60%), compared to fellows and attendings (46 and 53%; p < 0.001). In multivariable analysis, adjusted odds ratio of the first-attempt success was 0.18 (95% CI: 0.11–0.30) for residents and 0.80 (95% CI: 0.51–1.24) for fellows. PTL was not independently associated with adjusted odds of TIAEs or severe oxygen desaturation. Conclusion: Higher PTL was associated with increased first-attempt success but not TIAE/oxygen desaturation. Identifying strategies to decrease adverse events during neonatal TI remains critical.

Neuropsychological and socio–cognitive deficits in patients with obstructive sleep apnea

ABSTRACT Introduction: Patients with obstructive sleep apnea (OSA) suffer from several neurocognitive deficits. We investigated the cognitive and socio-cognitive profiles of patients with severe OSA, controlling for potentially relevant mediating variables (i.e. age, body-mass index, cognitive reserve and depression). Moreover, we studied the neuropsychological profile of a high-risk OSA phenotype characterized by severe OSA and severe nocturnal hypoxemia. Method: We assessed 29 previously untreated severe OSA patients with a mean age of 55.6 (± 9.9 years) and a mean apnea-hypopnea index (AHI) of 53.1 (± 17.4). A control group of 34 healthy participants was also enrolled. Participants completed an extensive neuropsychological battery that included social cognition, a relatively new investigation area among OSA patients. Data analysis: Data were analyzed with a Bayesian approach. Specifically, Bayesian ANCOVA was used to investigate whether the grouping variable could predict test performance. Age, body-mass index, cognitive reserve and state of depression were added as covariates to the null model to weight the effects of these potential confounding factors. Three groups were analyzed: healthy controls (H), OSA with severe apnea and severe nocturnal oxygen desaturation (D+), and OSA with severe apnea non-desaturators (D−). Performances on the various neuropsychological tests were treated as the dependent variables. Results: The results indicate that non-verbal reasoning, the theory of mind skills, and mental shifting ability were impaired in OSA patients. Patients with severe nocturnal hypoxemia underperformed compared to patients with the same severity of apnea but non-desaturators. Additionally, we observed a trend toward a worse performance among OSA desaturator patients in the following abilities: constructional ability, short term verbal memory, phonological fluency, and the ability to inhibit automatic and dominant responses. Conclusion: The data suggest a key role of hypoxemia in affecting cognitive functioning in OSA patients. Executive functions and the concomitant involvement of social cognition are particularly affected.

Associations of Stylet Use during Neonatal Intubation with Intubation Success, Adverse Events, and Severe Desaturation: A Report from NEAR4NEOS

Introduction: Intubations are frequently performed procedures in neonatal intensive care units (NICU) and delivery rooms (DR). Unsuccessful first attempts are common as are tracheal intubation-associated events (TIAEs) and severe desaturations. Stylets are often used during intubation, but their association with intubation outcomes is unclear. Objective: To compare intubation success, rate of relevant TIAEs, and severe desaturations in neonates intubated with and without stylets. Methods: Tracheal intubations of neonates in the NICU or DR from 16 centers between October 2014 and December 2018, performed by neonatology or pediatric providers, were collected from the NEAR4NEOs international registry. Primary oral intubations with a laryngoscope were included in the analysis. First-attempt success, the occurrence of relevant TIAEs, and severe oxygen desaturation (≥20% saturation drop from baseline) were compared between intubations performed with versus without a stylet. Logistic regression with generalized estimate equations was used to control for covariates and clustering by sites. Results: Out of 5,292 primary oral intubations, 3,877 (73%) utilized stylets. Stylet use varied considerably across the centers with a range between 0.5 and 100%. Stylet use was not associated with first-attempt intubation success, esophageal intubation, mainstem intubation, or severe desaturations after controlling for confounders. Patient size was associated with these outcomes and much more predictive of success. Conclusions: Stylet use during neonatal intubation was not associated with higher first-attempt intubation success, fewer relevant TIAEs, or less severe desaturations. These data suggest that stylets can be used based on individual preference, but stylet use may not be associated with better intubation outcomes.

835 Ictal Central Apneic Events Detected on Polysomnogram: An Educational Case Report

Abstract Introduction Ictal central apneas (ICA) are frequently observed in focal epilepsy, mostly with temporal lobe seizures, and have been considered as potential biomarkers of sudden unexpected death in epilepsy (SUDEP), particularly when they are prolonged and associated with significant hypoxemia. We present an interesting educational case report of occurrence of such ictal apneic events as recorded during a nocturnal diagnostic polysomnogram (PSG). Report of case(s) A 39-year-old woman with history of left focal epilepsy, hypertension, and headaches was referred to the sleep clinic for loud snoring, witnessed apneic events, and excessive daytime sleepiness. She subsequently underwent a diagnostic (PSG) that demonstrated severe obstructive sleep apnea (apnea-hypopnea index of 63.1) associated with significant hypoxemia (nadir SpO2 of 58%). In addition, the patient had one ictal discharge detected on the PSG’s limited electroencephalogram that occurred in N2 sleep and lasted for almost three minutes with a focal onset and progression in the left hemisphere. The ictal discharge was briefly preceded by central apneic events that continued to occur during and shortly after the termination of the ictal discharge. These ICA events were associated with severe oxygen desaturations down to an SpO2 of 62%. The only time during the PSG recording that the patient had central apneic events was around the ictal event. There were no behavior changes on the video during the seizure, but the ictal discharge was associated with a sustained increase in the mentalis muscles activity and a brief tachycardia. The patient’s neurologist was alerted about the above findings on PSG. The patient was taking a lower dose then prescribed of her anti-epileptic medication (topiramate) that was adjusted, and the patient was counseled on the risks associated with the above findings and positive airway pressure therapy was recommended for her severe sleep apnea. Conclusion The above case report illustrates the importance of polysomnography (specifically the recording of respiratory variables rarely performed in epilepsy monitoring units) in the evaluation of patients with epilepsy given that central apneic events (ICA and post-convulsive central apneas) potentially underlie SUDEP, the most common cause of mortality in refractory epilepsy patients and usually occurring during sleep. Support (if any) None

Implementing capnography to help improve patient safety during procedural sedation: quality improvement in a high-volume gastroenterology department.

Respiratory compromise is a major cause of adverse events during procedural sedation; continuous monitoring is vital for identifying and halting decompensation. We performed a quality improvement investigation to assess patient safety during procedural sedation in gastroenterology and the impact of implementing capnography monitoring. Sedation-related adverse events and interventions were prospectively recorded during the endoscopic procedure and in recovery. Assuming rates in published literature, power analysis determined that at least 1332 patients were required to show a 20% improvement in patient safety. Recorded sedation-related adverse events (mild and severe oxygen desaturations, bradycardia and tachycardia) and interventions were anonymized and aggregated to evaluate the quality improvement. Patient safety under current care was determined before capnography (Medtronic) was implemented in combination with training. Between February 2018 and April 2018, a baseline (1092 patients) for outcomes under current care was completed, with 11.45 events per 100 procedures recorded. Between May 2018 and July 2018, 1044 procedures including capnography monitoring were performed with 5.08 events per 100 procedures recorded. The distribution of American Society of Anesthesiologists scores and procedure types between baseline and capnography were comparable. The absolute difference between baseline and capnography was -6.4 events per 100 procedures [95% confidence interval (CI), -4.1 to -8.7; P ≤ 0.0001]. The 55% reduction in adverse events surpassed the 20% improvement in patient safety set as the goal of this quality improvement. After multivariate regression, the adjusted odds ratio for events after implementation of capnography was 0.46 (95% CI, 0.32-0.66). Addition of capnography to current care significantly decreased procedure-related safety events.

EFFECT OF CONTINUOUS POSITIVE AIRWAY PRESSURE TREATMENT ON GLYCEMIC AND LIPID PROFILES IN PATIENTS WITH OBSTRUCTIVE SLEEP APNEA: A SYSTEMATIC REVIEW AND META-ANALYSIS

Objective: Continuous Positive Airway Pressure (CPAP) is the main therapy for obstructive sleep apnea (OSA); nevertheless, uncertainty remains about the effectiveness of CPAP not only in controlling OSA-related hypertension, but also in improving the metabolic dysregulation that characterizes OSA patients. This meta-analysis of randomized controlled trials (RCTs) aimed to investigate whether CPAP, compared to other control treatments (sham CPAP, oral placebo or standard care), could improve glucose metabolism (fasting plasma glucose [FPG] or glycated haemoglobin or fasting plasma insulin [FPI] or homeostasis model assessment [HOMA] of insulin resistance [IR]) and/or lipid metabolism (total, HDL, LDL-cholesterol or triglycerides) in OSA patients. Design and method: Relevant papers were searched in three different databases (MEDLINE, EMBASE and Web of Science) from inception to 31st Dec 2018 through specific search terms and selection criteria. Results: From 2,289 articles, 26 RCTs were included. Regarding glycemic metabolism, neither FPG nor glycated haemoglobin were reduced by CPAP. However, patients on CPAP showed an improvement in insulin sensitivity, as witnessed by a significant reduction of FPI (Standardized difference in means [SDM] = 0.205 [95%CI, 0.07–0.339], p = 0.003) and HOMA IR (SDM = 0.176 [95%CI, 0.056–0.296], p = 0.004). In sensitivity analysis the favourable effects of CPAP were maintained in prediabetic/type 2 diabetic patients and in those presenting an apnoea-hypopnea index &gt; 30 events/h. Regarding lipid metabolism, OSA patients treated with CPAP showed a significant reduction in total cholesterol (TC; SDM = 0.138 [95%CI, 0.034–0.242], p = 0.009). In subgroups analysis, greater adherence to CPAP along with severe nocturnal oxygen desaturations at baseline (SpO2-nadir &lt; 77%) was associated with a significant decrease of TC. Furthermore, dividing the primary studies according to the median TC at baseline (198 mg/dL), the positive effects of CPAP were maintained only in those that presented a TC above the median. Conversely, CPAP did not modify triglycerides, HDL- and LDL-cholesterol. Conclusions: CPAP treatment significantly improves insulin sensitivity and reduces TC in OSA patients but with a low effect size. The effectiveness of CPAP is higher in patients with greater CPAP usage, and with a greater number of apnoeic events and oxygen desaturations at baseline. Concerning TC, patients presenting higher levels at baseline benefit the most from CPAP.

Participation in physical activity is associated with reduced nocturnal hypoxaemia in males.

Moderate to vigorous physical activity (MVPA) interventions reduce the severity of obstructive sleep apnoea (OSA); however, little epidemiological research exists to confirm these findings.789 participants from the population-based Men Androgen Inflammation Lifestyle Environment and Stress (MAILES) Study underwent polysomnography. MVPA was assessed using the Active Australia questionnaire, which was completed when participants were first recruited to the MAILES study (2002–2006), and again in 2010. Multinomial logistic regressions established odds ratio between OSA severity categories with MVPA, whilst adjusted linear models determined associations between OSA metrics with MVPA.Cross-sectionally, each hour of MVPA was associated with reduced severity of mean oxygen desaturation (unstandardised β (B)=−0.002, p=0.043) and reduced time below 90% oxygen saturation (B=−0.03, p=0.034).Longitudinally, each hour increase in MVPA was associated with a 4% reduction in the odds of severe OSA and less severe mean oxygen desaturation (B=−0.003, p=0.014), time below 90% oxygen saturation (B=−0.02, p=0.02), and mean duration of apnoeas (B=−0.004, p=0.016).MVPA is associated with reduced hypoxaemia in a cohort of community dwelling males, approximately half of whom had untreated OSA. As nocturnal intermittent hypoxaemia is associated with cardiometabolic disorders, MVPA may offer protection for patients with OSA.

Associations between family presence and neonatal intubation outcomes: a report from the National Emergency Airway Registry for Neonates: NEAR4NEOS

ObjectiveDescribe the current practice of family presence during neonatal tracheal intubations (TIs) across neonatal intensive care units (NICUs) and examine the association with outcomes.DesignRetrospective analysis of TIs performed in NICUs...

Nasal Obstruction as a Potential Factor Contributing to Hypoxemia in Obstructive Sleep Apnea.

PurposeThis study aimed to evaluate the correlation between nasal resistance and oxygen desaturation to better elucidate the role of nasal obstruction in the pathophysiology of obstructive sleep apnea (OSA).Patients and MethodsEighty-eight OSA patients aged between 22 and 77 years were enrolled in this study. Nasal resistance was measured at pressures of 75, 150, and 300 Pa, with the patients first in the seated position than in the supine position. Relationships between the oximetric variables and nasal resistance in the seated and supine positions were analyzed.ResultsFrom seated to supine position, a statistically significant increase in nasal resistance was observed at pressures of 75 and 150 Pa (p=0.001 and p=0.006, respectively). Significant positive correlations were noted between nasal resistance in the supine position at 75 Pa (SupineNR75) and oximetry variables, including oxygen desaturation index (ODI, p=0.015) and the percentage of total time with oxygen saturation level lower than 90% (T < 90%, p=0.012). However, significant positive correlations existed only in moderate to severe OSA when the study group was further divided into two subgroups (mild vs moderate to severe OSA). Body mass index (β = 0.476, p<0.001) and SupineNR75 (β = 0.303, p=0.004) were identified as independent predictors for increased ODI.ConclusionNasal resistance in the supine position measured at 75 Pa significantly correlated with the severity of oxygen desaturation. Therefore, nasal obstruction may play an important role in the pathophysiology of hypoxemia in OSA patients, especially in patients with moderate to severe OSA.

Sleep-disordered breathing, respiratory patterns during wakefulness and functional capacity in pediatric patients with rapid-onset obesity with hypothalamic dysfunction, hypoventilation and autonomic dysregulation syndrome.

To characterize the clinical presentation of sleep-disordered breathing and respiratory patterns at rest and during a 6-min walk test (6MWT) in children with rapid-onset obesity, hypothalamic dysfunction, hypoventilation, and autonomic dysregulation (ROHHAD) syndrome. Retrospective study of children with ROHHAD who had a diagnostic baseline polysomnography, daytime cardiorespiratory monitoring at rest and a 6MWT. Polysomnography data were also compared with body mass index-, age-, and sex-matched controls. Of the eight children with ROHHAD, all eight (100%) had obstructive sleep apnea (OSA) and 2/8 (25%) had nocturnal hypoventilation (NH) on their baseline polysomnography. Comparing the ROHHAD group to the control group, there were no significant differences in the median (interquartile range [IQR]) obstructive apnea-hypopnea index (11.1 [4.3-58.4] vs. 14.4 [10.3-23.3] events/h, respectively; p = .78). However, children with ROHHAD showed a significantly higher desaturation index compared to the control group (37.9 [13.7-59.8] vs. 14.7 [4.3-27.6] events/h; p = .05). While awake at rest, some children with ROHHAD experienced significant desaturations associated with central pauses. During the 6MWT, no significant desaturations were observed, but two children showed moderate functional limitation. Among children with ROHHAD, respiratory instability may be demonstrated by a significant number and severity of oxygen desaturations during sleep in the presence of OSA, with or without NH, and oxygen desaturations with central pauses at rest during wakefulness. Interestingly, during daily activities that require submaximal effort, children may not experience oxygen desaturations. Early recognition of respiratory abnormalities and targeted therapeutic interventions are important to limit associated morbidity and mortality in ROHHAD.

Systemic thrombolysis and anticoagulation improved biomarker measurements in massive-like pulmonary embolism and severe COVID-19 pneumonia: a case report.

BackgroundFrom asymptomatic patients to severe acute respiratory distress syndrome, COVID-19 has a wide range of clinical presentations, and venous thromboembolism has emerged as a critical and frequent complication.Case summaryWe present a case of a 69-year-old man with a clinical presentation of massive-like pulmonary embolism (PE) overlapping with severe COVID-19 pneumonia. The diagnosis was made based on hypotension, severe oxygen desaturation (33%), and right ventricular dysfunction (RVD). We used alteplase and low-molecular-weight heparin, obtaining immediate clinical improvement. Also, we identified an extremely elevated D-dimer (31.2 mcg/mL), and computed tomography pulmonary angiography (CTPA) revealed an unexpected low thrombus burden and a crazy-paving pattern. Considering this, we decided to discontinue the alteplase. Therefore, the mechanisms of pulmonary hypertension and RVD could be multifactorial. Despite the patient’s respiratory status worsening and ongoing mechanical ventilation, biomarkers kept lowering to normal ranges. It appears a favourable outcome was related to early PE diagnosis and a multimodal therapeutic approach.DiscussionPhysicians in the ER should be warned about extremely high D-dimer measurements and severe oxygen desaturation as possible markers of severe COVID-19 pneumonia in patients with high-clinical suspicion of PE. Although ESC guidelines recommend immediate reperfusion in cardiogenic shock secondary to PE, we suggest initial CTPA in patients with high-clinical suspicion of severe COVID-19.

Gender Differences in the Clinical and Polysomnographic Characteristics Among Australian Aboriginal Patients with Obstructive Sleep Apnea.

BackgroundIn this study, we assessed the clinical and polysomnographic (PSG) characteristics according to gender among Australian Aboriginal men and woman diagnosed to have obstructive sleep apnea (OSA).MethodsIn this retrospective study, all adult Aboriginal patients over 18 years of age diagnosed to have OSA with an apnea hypopnea index (AHI) > 5/hour over a 5 year period were included.ResultsOf the 337 patients (168 females and 169 males), who underwent a diagnostic PSG, 297 (88%) were diagnosed to have OSA (AHI) >5/hour), 154/297 males (52%) and 143/297 females (48%). Amongst male and female patients with OSA, 63% and 37% were in the severe spectrum (AHI>30/hour). The male cohort had higher stage N1 NREM sleep (P<0.001), reduced N3 NREM sleep (P<0.001), higher AHI severity (P<0.001), higher NREM AHI (P<0.001), and high arousal index (P<0.005). REM sleep-related AHI was higher among female patients with all severity of OSA, along with severe oxygen desaturation during REM sleep. Among patients with severe OSA, the female cohort were younger (age 46 years vs 49 years, P=0.030) and had higher BMI with all severity of OSA, while males had larger neck circumference compared to females. Hypertension increased the odds of severe OSA versus the combined odds of mild and moderate OSA for both genders.ConclusionThis study highlights some important differences in the way sleep apnea manifests in Australian Aboriginal males and females and further studies are warranted to explore avenues to look for a physiological basis for these observations and targeted interventions.

Impact of Failure of Noninvasive Ventilation on the Safety of Pediatric Tracheal Intubation.

Noninvasive ventilation is widely used to avoid tracheal intubation in critically ill children. The objective of this study was to assess whether noninvasive ventilation failure was associated with severe tracheal intubation-associated events and severe oxygen desaturation during tracheal intubation. Prospective multicenter cohort study of consecutive intubated patients using the National Emergency Airway Registry for Children registry. Thirteen PICUs (in 12 institutions) in the United States and Canada. All patients undergoing tracheal intubation in participating sites were included. Noninvasive ventilation failure group included children with any use of high-flow nasal cannula, continuous positive airway pressure, or bilevel noninvasive ventilation in the 6 hours prior to tracheal intubation. Primary tracheal intubation group included children without exposure to noninvasive ventilation within 6 hours before tracheal intubation. None. Severe tracheal intubation-associated events (cardiac arrest, esophageal intubation with delayed recognition, emesis with aspiration, hypotension requiring intervention, laryngospasm, pneumothorax, pneumomediastinum) and severe oxygen desaturation (< 70%) were recorded prospectively. The study included 956 tracheal intubation encounters; 424 tracheal intubations (44%) occurred after noninvasive ventilation failure, with a median of 13 hours (interquartile range, 4-38 hr) of noninvasive ventilation. Noninvasive ventilation failure group included more infants (47% vs 33%; p < 0.001) and patients with a respiratory diagnosis (56% vs 30%; p < 0.001). Noninvasive ventilation failure was not associated with severe tracheal intubation-associated events (5% vs 5% without noninvasive ventilation; p = 0.96) but was associated with severe desaturation (15% vs 9% without noninvasive ventilation; p = 0.005). After controlling for baseline differences, noninvasive ventilation failure was not independently associated with severe tracheal intubation-associated events (p = 0.35) or severe desaturation (p = 0.08). In the noninvasive ventilation failure group, higher FIO2 before tracheal intubation (≥ 70%) was associated with severe tracheal intubation-associated events. Critically ill children are frequently exposed to noninvasive ventilation before intubation. Noninvasive ventilation failure was not independently associated with severe tracheal intubation-associated events or severe oxygen desaturation compared to primary tracheal intubation.

When will we ditch the AHI?

When will we ditch the AHI?

Improvements in quality of life in female obstructive sleep apnea patients using a gender specific positive airway pressure device

Study Objectives: Females with obstructive sleep apnea (OSA) have more flow limitation, lower apnea-hypopnea index (AHI), shorter apneas, and less severe oxygen desaturations than males. A female-specific auto-adjusting continuous positive airway pressure (fAPAP) algorithm has been developed to target these characteristics. This study investigated the effects of fAPAP therapy on quality of life (QoL) in women with OSA. Methods: Female patients with AHI ≥ 15/h were eligible. Participants underwent polygraphy or polysomnography. The primary endpoint was change from baseline in Functional Outcomes of Sleep Questionnaire (FOSQ) score after 3 months’ fAPAP (AutoSet for Her, ResMed). Secondary endpoints included other sleep-related and QoL questionnaires. Results: A total of 122 patients were enrolled in the study (age 53.7 ± 9.5 years, body mass index 32.8 ± 6.2 kg/m2, apnea-hypopnea index [AHI] 39.0 ± 18.2/h); 111/122 completed the study. There was a significant improvement (p<0.0001) in FOSQ score from baseline (15.0 ± 3.3) to 3 months (16.9 ± 3.2). Significant improvements were also seen in the Patient Health Questionnaire-9 score (12.3 ± 6.0 vs. 7.2 ± 5.4), Epworth Sleepiness Scale score (10.8 ± 4.9 vs. 7.3 ± 4.7), EuroQol (EQ)-5D Index score (0.636 ± 0.248 vs. 0.763 ± 0.210), EQ-5D visual analogue scale score (54.4 ± 21.7 vs. 64.5 ± 21.5) (all p<0.0001), and Changes in Sexual Functioning Questionnaire score (38.7 ± 9.5 vs. 42.4 ± 8.5; p=0.001). In patients with PSG data, fAPAP improved other respiratory parameters (AHI, oxygen desaturation index, oxygen saturation; all p<0.0001), and increased time spent in rapid eye movement (REM) sleep (39.7 ± 24.0 vs. 48.1 ± 24.5 min; p=0.022). Average daily fAPAP usage was 4.8 ± 2.0 h/night. Conclusion: Usage of fAPAP significantly improved QoL and increased REM sleep, with good treatment compliance.

Obstructive sleep apnoea treatment and blood pressure: which phenotypes predict a response? A systematic review and meta-analysis.

The treatment for obstructive sleep apnoea (OSA) with continuous positive airway pressure (CPAP) or mandibular advancement devices (MADs) is associated with blood pressure (BP) reduction; however, the overall effect is modest. The aim of this systematic review and meta-analysis of randomised controlled trials (RCTs) comparing the effect of such treatments on BP was to identify subgroups of patients who respond best to treatment.The article search was performed in three different databases with specific search terms and selection criteria. From 2289 articles, we included 68 RCTs that compared CPAP or MADs with either passive or active treatment. When all the studies were pooled together, CPAP and MADs were associated with a mean BP reduction of -2.09 (95% CI -2.78- -1.40) mmHg for systolic BP and -1.92 (95% CI -2.40- -1.43) mmHg for diastolic BP and -1.27 (95% CI -2.34- -0.20) mmHg for systolic BP and -1.11 (95% CI -1.82- -0.41) mmHg for diastolic BP, respectively. The subgroups of patients who showed a greater response were those aged <60 years (systolic BP -2.93 mmHg), with uncontrolled BP at baseline (systolic BP -4.14 mmHg) and with severe oxygen desaturations (minimum arterial oxygen saturation measured by pulse oximetry <77%) at baseline (24-h systolic BP -7.57 mmHg).Although this meta-analysis shows that the expected reduction of BP by CPAP/MADs is modest, it identifies specific characteristics that may predict a pronounced benefit from CPAP in terms of BP control. These findings should be interpreted with caution; however, they are particularly important in identifying potential phenotypes associated with BP reduction in patients treated for OSA.

Apneic Oxygenation As a Quality Improvement Intervention in an Academic PICU.

To evaluate if the use of apneic oxygenation during tracheal intubation in children is feasible and would decrease the occurrence of oxygen desaturation. Prospective pre/post observational study. A large single-center noncardiac PICU in North America. All patients less than 18 years old who underwent primary tracheal intubation from August 1, 2014, to September 30, 2018. Implementation of apneic oxygenation for all primary tracheal intubation as quality improvement. Total of 1,373 tracheal intubations (661 preimplementation and 712 postimplementation) took place during study period. Within 2 months, apneic oxygenation use reached to predefined adherence threshold (> 80% of primary tracheal intubations) after implementation and sustained at greater than 70% level throughout the postimplementation. Between the preimplementation and postimplementation, no significant differences were observed in patient demographics, difficult airway features, or providers. Respiratory and procedural indications were more common during preintervention. Video laryngoscopy devices were used more often during the postimplementation (pre 5% vs post 75%; p < 0.001). Moderate oxygen desaturation less than 80% were observed in fewer tracheal intubations after apneic oxygenation implementation (pre 15.4% vs post 11.8%; p = 0.049); severe oxygen desaturation less than 70% was also observed in fewer tracheal intubations after implementation (pre 10.4% vs post 7.2%; p = 0.032). Hemodynamic tracheal intubation associated events (i.e., cardiac arrests, hypotension, dysrhythmia) were unchanged (pre 3.2% vs post 2.0%; p = 0.155). Multivariable analyses showed apneic oxygenation implementation was significantly associated with a decrease in moderate desaturation less than 80% (adjusted odds ratio, 0.55; 95% CI, 0.34-0.88) and with severe desaturation less than 70% (adjusted odds ratio, 0.54; 95% CI, 0.31-0.96) while adjusting for tracheal intubation indications and device. Implementation of apneic oxygenation in PICU was feasible, and was associated with significant reduction in moderate and severe oxygen desaturation. Use of apneic oxygenation should be considered when intubating critically ill children.