Severe Respiratory Acidosis Research Articles

Visual Diagnosis: Unusual Skin Findings in a Premature Infant.

1. Sneha Butala, MD* 2. Lauren Pronman, DO*,† 3. Michelle Baechtold, MD‡ 4. Timmie R. Sharma, MD‡ 5. Rebecca Fish, MD§ 6. Qin Yao, MD§ 1. *Department of Pediatrics and 2. §Division of Neonatology and Perinatal Medicine, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, OH 3. †Department of Genetics and Genomics and 4. ‡Department of Dermatology, University Hospitals Cleveland Medical Center, Cleveland, OH A 24-year-old gravida 2 para 1 woman presents at 32 weeks’ gestation with vaginal bleeding concerning for placental abruption. The prenatal history is unclear because the mother obtained most of her prenatal care in Mexico. She precipitously gives birth to a female infant via breech vaginal delivery. On delivery, the infant is intubated and given 1 dose of surfactant due to respiratory failure. Apgar scores are 2 and 3 at 1 and 5 minutes, respectively. The birthweight is 1,900 g. A chest radiograph demonstrates diffuse severe alveolar opacity in bilateral lung fields consistent with severe respiratory distress syndrome. The infant is transported to a tertiary center and develops worsening hypoxia requiring 100% oxygen. The blood gas on admission reveals severe mixed respiratory and metabolic acidosis. The infant receives additional doses of surfactant and a prolonged period of respiratory support. The severity of the infant’s respiratory distress syndrome is disproportionate to the degree of prematurity. Pertinent physical examination findings include mottling of the skin with thick white scale. The scale is symmetrical, involving the scalp, shoulders, and extremities (Figs 1 and 2). External ear canals are not visible; they may be absent or occluded by the scale, which is also found around the nares. Thin erosions in rectangular shapes on her abdomen are noted where cardiac leads have been placed. Erosions are also found on the right side of the face near the endotracheal tube securement device and on the bilateral dorsum of feet. Auscultation of the lungs reveals coarse breath sounds and diffuse crackles bilaterally, without increased work of breathing, retractions, or nasal flaring. There is no collodion membrane, ectropion (outturning of the eyelids), or eclabium (outturning of the lips) present. Figure 1. Thick adherent scales and erosions on day 1. Figure 2. Thick adherent scales and erosions at 4 weeks. The complete blood …

Physiologic Improvement in Respiratory Acidosis Using Extracorporeal Co2 Removal With Hemolung Respiratory Assist System in the Management of Severe Respiratory Failure From Coronavirus Disease 2019.

Objectives:About 15% of hospitalized coronavirus disease 2019 patients require ICU admission, and most (80%) of these require invasive mechanical ventilation. Lung-protective ventilation in coronavirus disease 2019 acute respiratory failure may result in severe respiratory acidosis without significant hypoxemia. Low-flow extracorporeal Co2 removal can facilitate lung-protective ventilation and avoid the adverse effects of severe respiratory acidosis. The objective was to evaluate the efficacy of extracorporeal Co2 removal using the Hemolung Respiratory Assist System in correcting severe respiratory acidosis in mechanically ventilated coronavirus disease 2019 patients with severe acute respiratory failure.Design:Retrospective cohort analysis of patients with coronavirus disease 2019 mechanically ventilated with severe hypercapnia and respiratory acidosis and treated with low-flow extracorporeal Co2 removal.Setting:Eight tertiary ICUs in the United States.Patients:Adult patients supported with the Hemolung Respiratory Assist System from March 1, to September 30, 2020.Interventions:Extracorporeal Co2 removal with Hemolung Respiratory Assist System under a Food and Drug Administration emergency use authorization for coronavirus disease 2019.Measurements and Main Results:The primary outcome was improvement in pH and Paco2 from baseline. Secondary outcomes included survival to decannulation, mortality, time on ventilator, and adverse events. Thirty-one patients were treated with Hemolung Respiratory Assist System with significant improvement in pH and Pco2 in this cohort. Two patients experienced complications that prevented treatment. Of the 29 treated patients, 58% survived to 48 hours post treatment and 38% to hospital discharge. No difference in age or comorbidities were noted between survivors and nonsurvivors. There was significant improvement in pH (7.24 ± 0.12 to 7.35 ± 0.07; p < 0.0001) and Paco2 (79 ± 23 to 58 ± 14; p < 0.0001) from baseline to 24 hours.Conclusions:In this retrospective case series of 29 patients, we have demonstrated efficacy of extracorporeal Co2 removal using the Hemolung Respiratory Assist System to improve respiratory acidosis in patients with severe hypercapnic respiratory failure due to coronavirus disease 2019.

Extracorporeal Membrane Oxygenation in the Middle East and India During the COVID-19 Pandemic

Background: Extracorporeal membrane oxygenation (ECMO) use for severe Coronavirus disease 2019 (COVID-19) patients has evolved during the course of the pandemic. Early uncertainty regarding the role of ECMO during the current pandemic was based on the suboptimal initial experiences. However, more recent data suggests favorable outcomes in COVID-19 patients receiving ECMO support. We aimed to explore the epidemiology and outcomes of ECMO for COVID-19 related cardiopulmonary failure and evaluate outcomes of new centers versus established ones.Methods: This is a retrospective, multicenter international, observational study conducted in (19) ECMO centers in five countries from March 1, 2020, to September 30, 2020. We included 307 patients with COVID-19 who received ECMO for refractory hypoxemia and severe respiratory acidosis with or without circulatory failure. Data collection included Patients characteristics, demographic data, ECMO-related specific data, pre-ECMO patient condition, 24 hours post-ECMO initiation data, and outcome. The primary outcome is survival to home discharge. Secondary outcomes include mortality during ECMO, survival to decannulation, and outcomes stratified by center type in which patients were treated.Findings: Three hundred and seven COVID-19 patients received ECMO support during the study period. The median age was 45 years (37-52 IQR), and 81% were men. 178 (58%) patients survived ECMO, of whom 138 (45%) patients were discharged home, and 40 patients (13%) died post-ECMO decannulation while 128 patients (41.7%) died during ECMO. Patient outcomes in the new centers developed in response to the pandemic were similar to those of established centers.Interpretation: During pandemics, ECMO may provide favorable outcomes in highly select patients as resources allow. Outcomes in ECMO centers established during the pandemic were comparable to existing centers.Funding Statement: None.Declaration of Interests: Kiran Shekar acknowledges research support from the Metro North Hospital and Health Service and the Prince Charles Hospital Foundation. Dr. Brodie receives research support from ALung Technologies. He has been on the medical advisory boards for Baxter, Abiomed, Xenios, and Hemovent and is the President-Elect of the Extracorporeal Life Support Organization (ELSO). Dr. Combes reported receiving grants and personal fees from Maquet, Xenios, and Baxter and serving as the recent past president of the EuroELSO organization. Other authors have no conflict of interest.Ethics Approval Statement: After the SWAAC ELSO steering committee's authorization, IRB approval was obtained from the coordinating center King Saud Medical City in Riyadh - Saudi Arabia. The country representatives obtained IRB approval for each participating center as well.

A Presentation of Persistent Pulmonary Hypertension of a Newborn Mimicking Coarctation of Aorta

A male newborn was born to a 18y/o mother at gestational age of 38weeks, birth weight 3295gm via emergent Cesarean section with the indication of fetal distress. The mother was diagnosed with type II DM and pregnancy-induced hypertension. Aspirin was given by a family doctor for prevention of preeclampsia during gestational age of 29 to 36 weeks. After birth, the baby presented persistent desaturation (SpO2 77-85%) and severe respiratory acidosis despite of resuscitation. CXR revealed cardiomegaly. Echocardiography showed remarkable dilatation of right ventricle and a huge Patent Ductus of Arteriosus (PDA) with almost right-toleft shunt. Persistent Pulmonary Hypertension of Newborn (PPHN) was diagnosed. However, the isthmus of aorta was restricted (the narrowest diameter was 0.220cm) (Figure 1).

A RARE TRIGGER OF ASTHMA EXACERBATION: THE SCOTCH MARIGOLD

SESSION TITLE: Medical Student/Resident Allergy and Airway Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Calendula officinalis, the common marigold, is a plant which has been ascribed a range of applications in traditional medicine, in both topical and oral forms, for the treatment of pain, superficial infections, and as a wound salve. We present a case of severe respiratory failure as a consequence of an asthma exacerbation in response to exposure to this agent. CASE PRESENTATION: A 26-year-old female with a history of mild intermittent asthma presented to the emergency department (ED) with acute respiratory distress. The patient reported mild productive cough over the preceding week. Earlier in the day, the patient had consumed the extract of Calendula officinalis, an herbal supplement, for the first time in an effort to alleviate chest soreness. About 30 minutes following ingestion, she developed progressive dyspnea and confusion. At presentation, the patient exhibited disorientation with visual hallucinations. She was hypoxic, with associated tachycardia (147 beats per minute), tachypnea (26 breaths per minute), and hypertension (193/100 mm Hg). She had diffuse expiratory wheezing. Arterial blood gas (ABG) on supplemental oxygen via nasal cannula demonstrated severe respiratory acidosis (pH: 6.9, pCO2: 123, pO2: 136), and she had leukocytosis (27.8 /µl). Chest radiography was unremarkable. She was intubated, and mechanical ventilation was initiated. Epinephrine, methylprednisolone, diphenhydramine, and albuterol were administered, given suspicion for an allergic etiology. A diagnosis of status asthmaticus was made, and she was started on methylprednisolone, inhaled bronchodilators, and empiric antibiotics. Her clinical course was complicated by laryngeal edema which made extubation challenging, but she improved and was successfully extubated. A discussion regarding the risks of unpredictable adverse effects of herbal supplements followed, and the patient was discharged with instructions to avoid similar supplements in the future. DISCUSSION: Calendula is a genus of plants which have been proposed to possess anti-inflammatory, anti-fungal, antipyretic, antispasmodic, anticancer, and other pharmacologic properties, prompting its use as oral tinctures, creams, and lotions in traditional medicine. C. officinalis has been demonstrated to have immunomodulatory properties, such as lymphocyte proliferation and granulocyte stimulation. Considerable evidence has illustrated the role of lymphocytes in modulating airway inflammation, and therefore may have played a role in the causation of the asthma exacerbation in this patient. There is scant documentation of any significant adverse reactions to this plant; to our knowledge, this is the first documented report of an asthma exacerbation triggered by Calendula. CONCLUSIONS: Healthcare providers should advise patients to exercise caution when using Calendula or other herbal remedies with unclear adverse reaction profiles. Reference #1: Arora D, Rani A, Sharma A. A review on phytochemistry and ethnopharmacological aspects of genus Calendula. Pharmacogn Rev. 2013;7(14):179–187. doi:10.4103/0973-7847.120520 Reference #2: Jiménez-Medina E, Garcia-Lora A, Paco L, Algarra I, Collado A, Garrido F. A new extract of the plant Calendula officinalis produces a dual in vitro effect: cytotoxic anti-tumor activity and lymphocyte activation. BMC Cancer. 2006;6:119. Published 2006 May 5. doi:10.1186/1471-2407-6-119 Reference #3: Cruceriu D, Balacescu O, Rakosy E. Calendula officinalis: Potential Roles in Cancer Treatment and Palliative Care. Integr Cancer Ther. 2018;17(4):1068–1078. doi:10.1177/1534735418803766 DISCLOSURES: No relevant relationships by Dan Kazmierski, source=Web Response No relevant relationships by Pius Ochieng, source=Web Response No relevant relationships by NISHANT SHARMA, source=Web Response No relevant relationships by Yichen Wang, source=Web Response

Suspected thyroid storm in a cat anaesthetised for bilateral thyroidectomy

A 14‐year‐old female neutered domestic short hair cat was referred for assessment of uncontrolled hyperthyroidism. The owners were advised that a bilateral thyroidectomy was required due to the presence of comorbidities that rendered radioiodine therapy inappropriate. During the procedure the cat exhibited unexpected extreme tachycardia, hypertension, hypercapnia, severe respiratory and metabolic acidosis and ventricular arrhythmias, which all resolved after removal of the thyroid glands. Recovery was complicated by the development of congestive heart failure and hypertension which were successfully managed and the cat was discharged five weeks after presentation. Thyroid storm was considered a possible explanation for the events that occurred during anaesthesia as well as the subsequent congestive heart failure and hypertension. Thyroid storm during anaesthesia has not been reported in animals. The similarities between the reported case and thyroid storm events in humans are discussed.

The Effect of High-Flow Nasal Oxygen on Carbon Dioxide Accumulation in Apneic or Spontaneously Breathing Adults During Airway Surgery: A Randomized-Controlled Trial.

High-flow nasal oxygen (HFNO) is an emerging technology that has generated interest in tubeless anesthesia for airway surgery. HFNO has been shown to maintain oxygenation and CO2 clearance in spontaneously breathing patients and is an effective approach to apneic oxygenation. Although it has been suggested that HFNO can enhance CO2 clearance during apnea, this has not been established. The true extent of CO2 accumulation and resulting acidosis using HFNO during prolonged tubeless anesthesia remains undefined. In a single-center trial, we randomly assigned 20 adults undergoing microlaryngoscopy to apnea or spontaneous ventilation (SV) using HFNO during 30 minutes of tubeless anesthesia. Serial arterial blood gas analysis was performed during preoxygenation and general anesthesia. The primary outcome was the partial pressure of CO2 (Paco2) after 30 minutes of general anesthesia, with each group compared using a Student t test. Nineteen patients completed the study protocol (9 in the SV group and 10 in the apnea group). The mean (standard deviation [SD]) Paco2 was 89.0 mm Hg (16.5 mm Hg) in the apnea group and 55.2 mm Hg (7.2 mm Hg) in the SV group (difference in means, 33.8; 95% confidence interval [CI], 20.6-47.0) after 30 minutes of general anesthesia (P < .001). The average rate of Paco2 rise during 30 minutes of general anesthesia was 1.8 mm Hg/min (SD = 0.5 mm Hg/min) in the apnea group and 0.8 mm Hg/min (SD = 0.3 mm Hg/min) in the SV group. The mean (SD) pH was 7.11 (0.04) in the apnea group and 7.29 (0.06) in the SV group (P < .001) at 30 minutes. Five (55%) of the apneic patients had a pH <7.10, of which the lowest measurement was 7.057. No significant difference in partial pressure of arterial O2 (Pao2) was observed after 30 minutes of general anesthesia. CO2 accumulation during apnea was more than double that of SV after 30 minutes of tubeless anesthesia using HFNO. The use of robust measurement confirms that apnea with HFNO is limited by CO2 accumulation and the concomitant severe respiratory acidosis, in contrast to SV. This extends previous knowledge and has implications for the safe application of HFNO during prolonged procedures.

Prehospital reversal of profound respiratory acidosis and hypercapnic coma by non-invasive ventilation: a report of two cases

BackgroundIn chronic obstructive pulmonary disease (COPD) patients with acute respiratory failure (ARF), non-invasive ventilation (NIV) is generally recommended and has proven its benefits by reducing endotracheal intubation (ETI) rates, intensive care unit (ICU) admissions, complications, and mortality. Choosing between immediate ETI or NIV trial is often difficult when such patients present with an altered mental status. Some guidelines recommend avoiding NIV when consciousness is impaired given the risk of aspiration, and some authors suggest that a pH < 7.25 is highly predictive of NIV failure. Though clinical response to a well-adjusted NIV treatment can be both swift and spectacular, these contraindications probably encourage physicians to proceed to immediate ETI. Some studies indeed report that NIV was not even considered in as many as 60% of patients who might have benefited from this therapy, though ETI related complications might have been avoided had NIV been successfully applied.Case presentationWe report two cases of ARF in COPD patients who were successfully treated by NIV in prehospital setting and avoided ETI despite contraindications (altered mental status with a Glasgow Coma Scale < 8) and failure risk factors (severe respiratory acidosis with pH < 7.25).ConclusionIn COPD patients presenting ARF, NIV trial could be considered even when relative contraindications such as an altered level of consciousness or a severe respiratory acidosis are present.

The use of non-invasive ventilation to treat acute respiratory failure in long term care setting: clinical experience in elderly patient

Background. Nowadays older patients with acute respiratory failure (ARF) leading to a severe respiratory acidosis are frequently ventilated using a non-invasive approach in intensive care unit (ICU). Current guidelines suggest that patients with more severe acidosis should be managed in a higher dependency area. However, the use of non-invasive ventilation (NIV) is effective and safe in treating ARF in general wards in elderly. Case report. a 82 years old male patient was admitted to a long term care facility due to a severe chronic obstructive pulmonary disease (COPD). Three days after the admission, he suffered of severe acute exacerbation of COPD leading to hypercapnic coma. NIV in Bi-PAP mode and standard medical therapy was started, taking into consideration the do-not-intubate order of the patient. His state of consciousness improved after 48 hours of NIV with decreasing of PaCO2 values and the patient was progressively weaned from the ventilator. Conclusions. NIV should be considered a successful approach even in unusual setting of long term facility. The choice of use NIV should be taken by multidisciplinary medical staff in a setting where nurses and medical team are trained in NIV protocol, in order to reduce ICU admission, intubation rates and mortality.

A case of glutathione-induced life-threatening asthma attack

Baek-ok injection (glutathione) has been widely used antioxidant therapy to whiten and has antiaging effects in Korea. Glutathione is an enzyme which synthesizes leukotriene, then it can induce asthma attack theoretically; however, there have been few case re ports concerning this therapy. In this report, we described a 41-year-old woman who developed glutathione-induced life-threaten ing asthma attack. She has asthma history controlled by an intermittent salbutamol inhaler. She developed general weakness and dyspnea right after glutathione injection, and injection was discontinued. Dyspnea was progressively aggravated, and she lost con sciousness with shock. Cardiopulmonary resuscitation was started, and she arrived at the Emergency Department with wheezing, hypoxia, severe respiratory acidosis, and nonmeasurable blood pressure. Intubation and mechanical ventilation were started with intramuscular epinephrine/intravenous methylprednisolone injection and repeated salbutamol/ipratropium/budesonide inhala tion. After 5 hours, extubation and spontaneous breathing were successful without wheezing. Next day, pulmonary function test showed moderate an obstructive airway disease pattern, and she was discharged with inhaled fluticasone/salmeterol, oral methyl prednisolone, and montelukast. We can exclude anaphylaxis, because serum tryptase obtained at the Emergency Department was 0.0 mg/dL and the absence of skin lesions and angioedema at arrival. Baek-ok injection (glutathione) should be carefully performed in asthma patients. (Allergy Asthma Respir Dis 2020;8:89-91)

High-frequency oscillatory ventilation in a tertiary paediatric intensive care unit in an academic hospital in Johannesburg, South Africa.

High-frequency oscillatory ventilation (HFOV) remains an option for the management of critically ill children when conventional mechanical ventilation fails. However, its use is not widespread, and there is wide variability reported with respect to how it is used. To describe the frequency, indications, settings and outcomes of HFOV use among paediatric patients with a primary respiratory disorder admitted to a tertiary paediatric intensive care unit (PICU). The study was a 2-year, single-centre, retrospective chart review. Thirty-four (32.7%) patients were managed with HFOV in the PICU during the study period. Thirty-three of the 34 patients had paediatric acute respiratory distress syndrome. Indications for HFOV were inadequate oxygenation in 17 patients (50%), and refractory respiratory acidosis in 15 patients (44.1%) (2 patients did not fit into either category). Approaches to the setting of HFOV varied considerably, particularly with respect to initial pressure around the airways. HFOV was effective at improving both oxygenation, with a median (interquartile range (IQR)) decrease in oxygenation index of 6.34 (5.0 - 9.5), and ventilation with a the median decrease in PaCO2 of 67.6 (46.2 - 105.7) mmHg after 24 hours. Overall mortality was 29.4% in the HFOV group, which is consistent with other studies. HFOV remains an effective rescue ventilatory strategy, which resulted in rapid and sustained improvement in gas exchange in patients with severe hypoxaemia and/or severe respiratory acidosis, particularly in the absence of extracorporeal support. However, the variability in practice and the adverse effects described highlight the need for future high-quality randomised controlled trials to allow for development of meaningful guidelines to optimise HFOV use. This study describes the use and outcomes of high-frequency oscillatory ventilation (HFOV) in a South African paediatric intensive care unit, thus addressing a local knowledge gap and providing evidence of the continued efficacy of HFOV for severe hypoxaemia and refractory respiratory acidosis in settings without access to extracorporeal technologies.

Ischemic priapism as a model of exhausted metabolism.

In vivo metabolic studies typically concern complex open systems. However, a closed system allows better assessment of the metabolic limits. Ischemic priapism (IP) constitutes a special model of the compartment syndrome that allows direct sampling from a relatively large blood compartment formed by the corpora cavernosa (CC). The purpose of our study was to measure metabolic changes and the accumulation of end products within the CC during IP. Blood gas and biochemical analyses of aspirates of the CC were analyzed over an 8‐year period. Mean ± SD pH, pCO 2, pO 2, O2‐saturation, lactate, and glucose of the aspirated blood were determined with a point‐of‐care analyzer. Forty‐seven initial samples from 21 patients had a pH of 6.91 ± 0.16, pCO 2 of 15.3 ± 4.4 kPa, pO 2 of 2.4 ± 2.0 kPa, and an O2‐saturation of 19 ± 24% indicating severe hypoxia with severe combined respiratory and metabolic acidosis. Glucose and lactate levels were 1.1 ± 1.5 and 14.6 ± 4.8 mmol/L, respectively. pH and pCO 2 were inversely correlated (R 2 = 0.86; P < 0.001), glucose and O2‐saturation were positively correlated (R 2 = 0.83; P < 0.001), and glucose and lactate were inversely correlated (R 2 = 0.72; P < 0.001). The positive correlation of CO 2 and lactate (R 2 = 0.69; P < 0.001) was similar to that observed in vitro, when blood was titrated with lactic acid. The observed combined acidosis underscores that IP behaves as a closed system where severe hypoxia and glycopenia coexist, indicating that virtually all energy reserves have been consumed.

Therapeutic hypernatremia management during continuous renal replacement therapy with elevated intracranial pressures and respiratory failure.

Cerebral edema and elevated intracranial pressure (ICP) are common complications of acute brain injury. Hypertonic solutions are routinely used in acute brain injury as effective osmotic agents to lower ICP by increasing the extracellular fluid tonicity. Acute kidney injury in a patient with traumatic brain injury and elevated ICP requiring renal replacement therapy represents a significant therapeutic challenge due to an increased risk of cerebral edema associated with intermittent conventional hemodialysis. Therefore, continuous renal replacement therapy (CRRT) has emerged as the preferred modality of therapy in this patient population. We present our current treatment approach, with demonstrative case vignette illustrations, utilizing hypertonic saline protocols (3% sodium-chloride or, with coexisting severe combined metabolic and respiratory acidosis, with 4.2% sodium-bicarbonate) in conjunction with the CRRT platform, to induce controlled hypernatremia of approximately 155mEq/L in hemodynamically unstable patients with acute kidney injury and elevated ICP due to acute brain injury. Rationale, mechanism of activation, benefits and potential pitfalls of the therapy are reviewed. The impact of hypertonic citrate solution during regional citrate anticoagulation is specificallydiscussed. Maintaining plasma hypertonicity in the setting of increased ICP and acute kidney injury could prevent the worsening of ICP during renal replacement therapy by minimizing the osmotic gradient across the blood-brain barrier and maximizing cardiovascular stability.

When Equipment Misbehaves: Severe Respiratory Acidosis Resulting from a Compromised Coaxial Circuit

When Equipment Misbehaves: Severe Respiratory Acidosis Resulting from a Compromised Coaxial Circuit

ECCO2R case study

Hypercapnic respiratory failure is common in ICU due to ARDS and COPD exacerbations. The use of ECCO2R has changed the way we manage these patients. We report a patient with COPD exacerbation that failed NIV and placed on low flow ECCO2R. Low flow ECCO2R does not support oxygenation and only clears a proportion of the CO2 produced.Presentation of the case: a 64 y old women with severe COPD who failed NIV was placed on ECCO2R with the Hemolung system. The severe respiratory acidosis cleared and intubation was avoided. After a few days, she became more hypoxic, and the decision was made not to intubate this patient.There is increased CO2 production and decreased clearance of CO2 during COPD exacerbation. ECCO2R has been shown to improve mortality and decrease the need for intubation. There are various ECCO2R systems on the market with different flows and differently sized oxygenators.The use of ECCO2R in selected patients is a promising add-on to conventional management of these patients. The difficulty in predicting the progression of the disease will always be a challenge. Extracorporeal therapies should be performed in centres that are experienced in the management of these patients.

Survival of amyotrophic lateral sclerosis patients after admission to the intensive care unit for acute respiratory failure: an observational cohort study

PurposeAmyotrophic lateral sclerosis (ALS) entails a risk of acute respiratory failure (ARF). The decision to admit such patients to the intensive care unit (ICU) is difficult given the inexorable prognosis of ALS. To fuel this discussion, this study describes the ICU and post-ICU survival of ALS-related ARF. Material and methodsRetrospective cohort analysis over 10 years (university hospital setting, ALS reference center). ResultsOf 90 patients (66 men, median age: 67 [IQR 59–71], median interval since ALS diagnosis: 26.5 months [14–53], ALSFRS-R: 19 [12−30], bulbar signs 73%), 48 were managed by noninvasive ventilation (NIV) only, 7 were already tracheotomized upon admission, 12 were tracheotomized during the ICU stay (advance care planning project), 18 were already intubated before admission, 5 received oxygen and physiotherapy only. Median ICU stay was 4 days [2-9] with 20% mortality. Median hospital stay was 10 days [5–22] with 33% mortality. The 3-month and one year mortality wer 46% and 71%. Hospital mortality was higher in patients with more severe respiratory acidosis and higher simplified acute physiology scores on admission. ConclusionsThe prognosis of ALS-related ARF requiring ICU admission resembles that of ARF complicating other conditions with high short-term mortality (e.g. lung cancer).

Beyond Low Tidal Volume Ventilation: Treatment Adjuncts for Severe Respiratory Failure in Acute Respiratory Distress Syndrome.

Despite decades of research, the acute respiratory distress syndrome remains associated with significant morbidity and mortality. This Concise Definitive Review provides a practical and evidence-based summary of treatments in addition to low tidal volume ventilation and their role in the management of severe respiratory failure in acute respiratory distress syndrome. We searched the PubMed database for clinical trials, observational studies, and review articles describing treatment adjuncts in acute respiratory distress syndrome patients, including high positive end-expiratory pressure strategies, recruitment maneuvers, high-frequency oscillatory ventilation, neuromuscular blockade, prone positioning, inhaled pulmonary vasodilators, extracorporeal membrane oxygenation, glucocorticoids, and renal replacement therapy. Results were reviewed by the primary author in depth. Disputed findings and conclusions were then reviewed with the other authors until consensus was achieved. Severe respiratory failure in acute respiratory distress syndrome may present with refractory hypoxemia, severe respiratory acidosis, or elevated plateau airway pressures despite lung-protective ventilation according to acute respiratory distress syndrome Network protocol. For severe hypoxemia, first-line treatment adjuncts include high positive end-expiratory pressure strategies, recruitment maneuvers, neuromuscular blockade, and prone positioning. For refractory acidosis, we recommend initial modest liberalization of tidal volumes, followed by neuromuscular blockade and prone positioning. For elevated plateau airway pressures, we suggest first decreasing tidal volumes, followed by neuromuscular blockade, modification of positive end-expiratory pressure, and prone positioning. Therapies such as inhaled pulmonary vasodilators, glucocorticoids, and renal replacement therapy have significantly less evidence in favor of their use and should be considered second line. Extracorporeal membrane oxygenation may be life-saving in selected patients with severe acute respiratory distress syndrome but should be used only when other alternatives have been applied. Severe respiratory failure in acute respiratory distress syndrome often necessitates the use of treatment adjuncts. Evidence-based application of these therapies in acute respiratory distress syndrome remains a significant challenge. However, a rational stepwise approach with frequent monitoring for improvement or harm can be achieved.

TRASTUZUMAB-INDUCED RESPIRATORY DISTRESS: A CASE REPORT

Trastuzumab is a monoclonal antibody effective in treating metastatic breast carcinomas. Cardiotoxicity is the most commonly reported adverse event occurring when used in combination with anthracycline derivatives. Even though pulmonary toxicities are uncommon, immediate withdrawal of the drug is recommended and only reinitiates after the vitals of the patient have become normal. Here, we discuss the case of an 81-year-old female patient who was treated with Injection Trastuzumab for the treatment of breast cancer with metastasis to lungs and received 6 cycles without any major complications. However, 24 h post the last dose; the patient developed a sudden onset of breathlessness and desaturation and was intubated in view of severe metabolic and respiratory acidosis. Blood investigations revealed elevated brain natriuretic peptide, aspartate transaminase, and alkaline phosphatase. Her blood and urine cultures were found to be sterile. She was managed with IV antibiotics, nebulizations, IV fluids, and other supportive medications and had improved considerably. However, on the 11th day, her condition had deteriorated and developed bradycardia. The patient could not be revived and died. Review of the patient’s medication did not reveal the presence of any other possible drugs capable of producing pulmonary toxicity. Trastuzumab should be avoided in patients with underlying respiratory or cardiac issues.

Long-term outcomes after acute hypercapnic COPD exacerbation : First-ever episode of non-invasive ventilation.

SummaryBackgroundNon-invasive ventilation (NIV) is used to treat acute hypercapnic respiratory failure (AHRF) in patients with chronic obstructive pulmonary disease (COPD); however, long-term outcomes following discharge are largely unknown. This study aimed to characterize long-term outcomes and identify associated markers in patients with COPD after surviving the first episode of HRF requiring NIV.MethodsThis study retrospectively analyzed 122 patients, mean age 62 ± 8 years, 52% female and forced expiratory volume in 1 s (FEV1) predicted 30 ± 13%, admitted with an acute hypercapnic exacerbation of COPD and receiving a first-ever NIV treatment between 2000 and 2012.ResultsA total of 40% of the patients required hospital readmission due to respiratory reasons within 1 year. Persistent hypercapnia leading to the prescription of domiciliary NIV, older age and lower body mass index (BMI) were risk factors for readmission due to respiratory reasons. Survival rates were 79% and 63% at 1 and 2 years after discharge, respectively. A shorter time to readmission and recurrent hypercapnic failure, lower BMI and acidemia on the first admission, as well as hypercapnia at hospital discharge were correlated with a decreased long-term survival.ConclusionPatients with COPD surviving their first episode of AHRF requiring NIV are at high risk for readmission and death. Severe respiratory acidosis, chronic respiratory failure and a lower BMI imply shorter long-term survival.Electronic supplementary materialThe online version of this article (10.1007/s00508-018-1364-6) contains supplementary material, which is available to authorized users.

Central Sleep Apnea – a Rare Cause for Acute Respiratory Insufficiency in Children. Case Report

Central sleep apnea is characterized by frequent cessation of breathing during sleep, resulting in repetitive episodes of insufficient ventilation and abnormalities of acid-base balance. It may be primary or secondary, and it is uncommon in children, with limited data for this population. We present here the case of a five-year-old girl, known to have thoracolumbar myelomeningocele (for which she underwent a surgical procedure in infancy), secondary hydrocephalus (with a ventriculoperitoneal shunt) and flaccid paralysis, who was admitted in our hospital with prolonged fever syndrome, productive cough, severe dyspnea and perioral cyanosis. Following physical examination, laboratory investigations and thoracic radiography, we established the diagnosis of aspiration pneumonia with acute respiratory failure. Medical treatment with multiple systemic antibiotics, antifungal agents, systemic and inhaled bronchodilator, oxygen therapy and respiratory nursing were initiated, with favorable evolution. During the entire hospitalization, the patient showed nocturnal respiratory rhythm disorders, with sleep apnea crisis of approximately 20 seconds and desaturation, followed by severe hypercapnic respiratory acidosis, manifestations that persisted even after the remission of pulmonary infection, raising the suspicion of an apnea syndrome. After excluding the causes of obstructive apnea, a cerebral CT scan was performed, revealing isolated fourth ventricle compressing the brainstem. The patient underwent neurosurgical intervention and postoperatively, the evolution was favorable, with remission of apnea crisis.