Transcutaneous CO2 Monitoring Research Articles

Do Different Amounts of Exogenous Surfactant Differently Influence Cerebrovascular Instability in a Consecutive Group of Preterm Babies? Preliminary Results from a Single-Center Experience

Background: Thirty years ago, the first attempt by Saliba and colleagues was made to reduce the negative effects (hypercarbia) of exogenous surfactant (ES) by slowing its administration. Sixteen years later, we observed the first less invasive surfactant administration (LISA) attempt by Kribs and colleagues. Many studies, since that time, have tried to minimize the invasiveness of ES and subsequent cerebral blood flow perturbations through studies using near-infrared spectroscopy (NIRS). We sought to address this medical challenge by identifying a less problematic modality of ES administration by delivering multiple aliquots of ES instead of a single one, as typically performed. The aim of this study was to test the hypothesis that a different way of administering ES using more aliquots could be a safe alternative that should be assessed in further studies. Methods: Patients between 26 + 0 and 35 + 6 weeks of gestational age (GA) requiring ES administration were enrolled (April 2023–February 2024). Differently fractioned doses were delivered according to an arbitrary standard dosage (0.3 mL per aliquot in babies < 29 weeks; 0.6 mL in babies ≥ 29 weeks), while NIRS and transcutaneous CO2 (tCO2) monitoring were always performed. ES’s effectiveness was assessed based on the reduction in the Oxygen Saturation Index (OSI) after administration. Persistent desaturation, bradycardia, and airway obstruction were defined as adverse effects and used to evaluate safety during ES administration, as well as variability in NIRS-rSO2 values and tCO2. Results: Twenty-four patients were enrolled with a median GA of 29 weeks (IQR 4.5) and BW of 1223 ± 560 g. In addition, 50% of the cohort received fewer than three aliquots, whereas the other 50% received more than three. Monitoring was started before the procedure and continued 30′ after the last ES aliquot administration. The variability in NIRS-SpO2 values was significantly higher in the group (p = 0.007) with a lower number of aliquots administered. Similarly, increased NIRS-rSO2 values (p = 0.003) and increased tCO2 levels (p = 0.005) were observed in infants who underwent an ES split after the administration of a low number of aliquots. Conclusions: Our data obtained from the group with > 3 fractionated doses of ES seem to justify the preparation of a more robust study, as the combination of reduced NIRS variability and reduced tCO2 maximum levels is consistent with more stable cerebral blood flow during the challenging time of ES administration.

Hypoxic burden and sleep hypoventilation in obese patients

IntroductionNovel biomarkers of hypoxic load have emerged, as sleep apnea-specific hypoxic burden which provides more precise assessment of intermittent hypoxemia severity. Our main objective was to assess the potential benefit of hypoxic burden to identify obesity-related sleep hypoventilation. We hypothesized that hypoxic burden may help diagnose obesity-related sleep hypoventilation better than usual sleep respiratory measures (i.e., apnea-hypopnea index (AHI), mean SpO2, time with SpO2 < 90 %). MethodsThis retrospective study was conducted from June 2022 to October 2023 at the University Hospital of Rouen, France. All consecutive obese patients (BMI ≥30 kg/m2), adults, with no other respiratory or neurological diseases who underwent a polysomnography or polygraphy with concomitant capnography were included. Sleep hypoventilation was defined according to American Academy of Sleep Medicine criteria based on transcutaneous CO2 monitoring (PtcCO2). Diagnostic performance of sleep-related respiratory measures i.e., sleep apnea-specific hypoxic burden, apnea-hypopnea index (AHI), mean SpO2, time with SpO2 < 90 % was evaluated using Receiver Operating Characteristic (ROC) curves. Correlations between sleep-related respiratory measures were assessed by a Spearman correlation matrix. ResultsAmong 107 obese patients with analyzed capnography, 37 (35 %) had sleep hypoventilation. Patients were 53 ± 14 years old, mean BMI = 38 ± 6 kg/m2, mean AHI = 26.5 ± 25/h, mean hypoxic burden = 67 ± 109 %min/h, mean SpO2 = 91.5 ± 3 %, mean time with SpO2<90 % = 19.4 ± 28 %, mean PtcCO2 = 6.2 ± 0.7 kPa. A low positive correlation was found between hypoxic burden and mean PtcCO2 (r = 0.4, p < 0.001). Multivariate logistic regression model explaining sleep hypoventilation was insufficient with area under ROC curve of hypoxic burden estimated at 0.74 (95 % CI 0.65 to 0.84). ConclusionHypoxic burden has low correlation with transcutaneous CO2 pressure and a low ability to diagnose obesity-related sleep hypoventilation.

Precision and accuracy of transcutaneous CO2 monitoring in infants born at 32-36 weeks of pregnancy on respiratory support

Background Respiratory disorders in premature neonates often require respiratory support. Continous transcutaneous monitoring is an available non-invasive option to monitor CO2 pressure, substituting the need for blood gas analysis as the gold standard evaluation in practice. Most studies have been conducted on very and extremely preterm neonates, but rarely in late and moderately preterm neonates. Objective To determine the precision and accuracy of transcutaneous CO2 pressure measuring devices compared to arterial blood gas analysis in neonates of 32-36 weeks gestational age who received respiratory support. Methods This diagnostic, cross-sectional study was conducted on 35 late and moderately preterm neonates of 32–36 weeks gestation who received cardiopulmonary resuscitation (CPR) in the Neonatology Unit at Rumah Sakit Cipto Mangunkusumo, Jakarta. Subjects were monitored with a transcutaneous CO2 monitor and blood gas analysis (BGA). CO2 pressure measurements were made three times from the two devices. Data were analyzed using Spearman’s correlation and Bland-Altman tests to determine the precision and accuracy of transcutaneous monitoring by comparing its mean difference (MD) to BGA as the gold standard measurement. Results Spearman’s analysis revealed a significant positive correlation between BGA and transcutaneous CO2 monitoring (P&lt;0.001). However, the Bland - Altman test revealed a level of agreement between measuring devices was -14.46 to 6.9, with mean difference of -3.78; indicating poor precision of the transcutaneous evaluation regardless its high accuracy compared to its gold standard. Conclusion The transcutaneous CO2 monitoring device has low precision, but a strong positive correlation to BGA; underlining its high accuracy in practice. Transcutaneous CO2 monitoring cannot replace BGA, the gold standard examination.

Recent Technologies for Transcutaneous Oxygen and Carbon Dioxide Monitoring.

The measurement of partial pressures of oxygen (O2) and carbon dioxide (CO2) is fundamental for evaluating a patient's conditions in clinical practice. There are many ways to retrieve O2/CO2 partial pressures and concentrations. Arterial blood gas (ABG) analysis is the gold standard technique for such a purpose, but it is invasive, intermittent, and potentially painful. Among all the alternative methods for gas monitoring, non-invasive transcutaneous O2 and CO2 monitoring has been emerging since the 1970s, being able to overcome the main drawbacks of ABG analysis. Clark and Severinghaus electrodes enabled the breakthrough for transcutaneous O2 and CO2 monitoring, respectively, and in the last twenty years, many innovations have been introduced as alternatives to overcome their limitations. This review reports the most recent solutions for transcutaneous O2 and CO2 monitoring, with a particular consideration for wearable measurement systems. Luminescence-based electronic paramagnetic resonance and photoacoustic sensors are investigated. Optical sensors appear to be the most promising, giving fast and accurate measurements without the need for frequent calibrations and being suitable for integration into wearable measurement systems.

Understanding improved neonatal ventilation trends in a regional transport service.

Review changes in neonatal ventilation practice within our regional transport service, Embrace, identifying interventions with greatest impact on improved rates of normocapnia during transfer. Using internal transport databases and UK Neonatal Transport Group data submissions, we tracked local and national rates of ventilation and normocapnia. We correlated this with internal changes in practice, including introduction of new equipment, staffing changes, educational interventions and quality improvement projects. Data demonstrated improvement in normocapnia rates benchmarked against national figures, which was not explained by changes in ventilation methods or rates, or by changes in availability of post-transfer gases. Greatest improvement was identified following introduction of transcutaneous CO2 monitoring and ventilators enabling volume-guided ventilation strategies. Additionally, although less quantifiable, educational and quality improvement interventions, and case review mechanisms were felt to be influential. Volume guided ventilation and transcutaneous CO2 monitoring have had a positive influence on the maintenance of normocapnia during transfer at Embrace Transport Service, although introduction of new equipment still presents challenges which must be overcome. Recognising the significant impact of these technologies allows for ongoing financial, time and educational investment to emphasise their importance and ensure appropriate awareness of limitations and troubleshooting options, maximising their positive impact.

P084 Characteristics of sleep hypoventilation during polysomnography in a large Australian clinical sleep laboratory cohort.

Abstract BACKGROUND Sleep hypoventilation complicates a range of neurological and respiratory conditions. However, robust definitions are based mainly on expert consensus, and clinically significant thresholds remain unclear. This study thus aims to provide a descriptive analysis of capnography results in a large clinical cohort of patients referred for overnight polysomnography (PSG). METHODS Retrospective clinical audit of overnight in-lab PSGs, between Jan 2015 and June 2023, at a tertiary hospital housing the State-wide referral centre for chronic domiciliary ventilation. Diagnostic PSGs with transcutaneous CO2 (PTcCO2) monitoring and without supplemental oxygen were included. The following data will be extracted from each PSG: Patient demographics: -Primary and secondary clinical diagnoses -PTcCO2 values (e.g. Mean, Minimum and Maximum PTcCO2 in Wake, Sleep, NREM and REM) -Sleep fragmentation measures -Sleep macro-architecture measures -AHI -SpO2 values Data analysis will be performed with IBM SPSS Statistics software, version 26 (Armonk, NY: IBM Corp) PROGRESS TO DATE 525 PSGs meeting initial criteria have been identified. Currently processing PSG data files to extract parameters and complete exploratory data cleaning and analysis. INTENDED OUTCOME AND IMPACT We aim to explore and clarify: -Differences in patterns of hypoventilation between different diagnostic groups. -Relationships between awake hypoventilation, sleep hypoventilation and REM-isolated hypoventilation. -Effects of applying differing criteria for hypoventilation available in the literature. -Relationships between measures of sleep fragmentation, AHI, SpO2 and hypoventilation parameters. The results of this study will also support and inform future research into associations between severity, duration and patterns of hypoventilation and clinically significant outcomes including morbidity and mortality.

Transcutaneous CO2 Monitoring in Extremely Low Birth Weight Premature Infants.

Extremely low birth weight (ELBW) premature infants are particularly susceptible to hypocarbia and hypercarbia, which are associated with brain and lung morbidities. Transcutaneous CO2 (TcCO2) monitoring allows for continuous non-invasive CO2 monitoring during invasive and non-invasive ventilation and is becoming more popular in the NICU. We aimed to evaluate the correlation and agreement between CO2 levels measured by a TcCO2 monitor and blood gas CO2 (bgCO2) among ELBW infants. This was a prospective observational multicenter study. All infants < 1000 g admitted to the participating NICUs during the study period were monitored by a TcCO2 monitor, if available. For each bgCO2 measured, a simultaneous TcCO2 measurement was documented. In total, 1828 pairs of TcCO2-bgCO2 values of 94 infants were collected, with a median (IQR) gestational age of 26.4 (26.0, 28.3) weeks and birth weight of 800 (702, 900) g. A moderate correlation (Pearson: r = 0.64) and good agreement (bias (95% limits of agreement)):(2.9 [-11.8, 17.6] mmHg) were found between the TcCO2 and bgCO2 values in the 25-70 mmHg TcCO2 range. The correlation between the TcCO2 and bgCO2 trends was moderate. CO2 measurements by TcCO2 are in good agreement (bias < 5 mmHg) with bgCO2 among premature infants < 1000 g during the first week of life, regardless of day of life, ventilation mode (invasive/non-invasive), and sampling method (arterial/capillary/venous). However, wide limits of agreement and moderate correlation dictate the use of TcCO2 as a complementary tool to blood gas sampling, to assess CO2 levels and trends in individual patients.

Use of transcutaneous CO2 monitoring in adult anaesthesia

Use of transcutaneous CO2 monitoring in adult anaesthesia

The Precision Between Transcutaneous Carbon Dioxide Versus PaCO2 in Infants Undergoing Therapeutic Hypothermia.

Infants with hypoxic-ischemic encephalopathy are often treated with therapeutic hypothermia and high-frequency ventilation. Fluctuations in PaCO2 during therapeutic hypothermia are associated with poor neurodevelopmental outcomes. Transcutaneous CO2 monitors offer a noninvasive estimate of PaCO2 represented by transcutaneously measured partial pressure of carbon dioxide (PtcCO2 ). We aimed to assess the precision between PtcCO2 and PaCO2 values in neonates undergoing therapeutic hypothermia. This was a retrospective chart review of 10 neonates who underwent therapeutic hypothermia requiring respiratory support over 2 y. A range of 2-27 simultaneous PtcCO2 and PaCO2 pairs of measurements per neonate were analyzed via linear mixed models and a Bland-Altman plot for multiple observations per neonate. A linear mixed-effect model demonstrated that PtcCO2 and PaCO2 (controlling for sex) were similar. The 95% CI of the mean difference ranged from -2.3 to 5.7 mm Hg (P = .41). However, precision was poor as the PtcCO2 ranged from > 18 mm Hg to < 13 mm Hg than PaCO2 values for 95% of observations. The neonates' PtcCO2 was as much as 18 mm Hg higher to 13 mm Hg lower than the PaCO2 95% of the time. Transcutaneous CO2 monitoring may not be a good trending tool, nor is it appropriate for estimating PaCO2 in patients undergoing therapeutic hypothermia.

An Educational Intervention to Improve Comfort with Applying and Interpreting Transcutaneous CO2 and End-tidal CO2 Monitoring in the PACU

The purpose of this study was to assess the effectiveness of an educational program about measuring ventilation using devices that assess carbon dioxide levels in patients recovering from a surgical procedure. A pre-post survey of knowledge attainment from an educational intervention about measuring ventilation using end-tidal carbon dioxide (EtCO2) and transcutaneous carbon dioxide (tcPCO2) devices in the postanesthesia care unit (PACU) was distributed to current members of the American Society of PeriAnesthesia Nurses. Participants received a 12-question pre-intervention (five were related to demographics) and a five-question post-intervention survey. Non-demographic survey questions used a one to five Likert scale to assess comfortability or confidence. The intervention created was a voice-over presentation designed to improve PACU RN's comfort and confidence with using and interpreting tcPCO2 or EtCO2 in the PACU. PACU RNs (N=108) reported they 'never' or 'rarely' used EtCO2 (n=57, 52.7%) monitoring or tcPCO2 (n=93, 86.1%) monitoring in the PACU. A paired t test revealed statistically significant differences in the PACU RN's pre-survey and posttest comfortability of applying and interpreting EtCO2 or tcPCO2 monitors (P < .05). Capnography monitoring should be considered a standard of care for PACU patients. Education of registered nurses working in the PACU is critical before implementing EtCO2 or tcPCO2 monitoring.

A Patient-Ready Wearable Transcutaneous CO2 Sensor

Continuously monitoring transcutaneous CO2 partial pressure is of crucial importance in the diagnosis and treatment of respiratory and cardiac diseases. Despite significant progress in the development of CO2 sensors, their implementation as portable or wearable devices for real-time monitoring remains under-explored. Here, we report on the creation of a wearable prototype device for transcutaneous CO2 monitoring based on quantifying the fluorescence of a highly breathable CO2-sensing film. The developed materials are based on a fluorescent pH indicator (8-hydroxy-1,3,6-pyrenetrisulfonic acid trisodium salt or HPTS) embedded into hydrophobic polymer matrices. The film’s fluorescence is highly sensitive to changes in CO2 partial pressure in the physiological range, as well as photostable and insensitive to humidity. The device and medical-grade films are based on our prior work on transcutaneous oxygen-sensing technology, which has been extensively validated clinically.

Transcutaneous CO2 monitoring as indication for inpatient non-invasive ventilation initiation in patients with amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) is characterized by profound muscle weakness, including diaphragmatic weakness resulting in hypercapnic respiratory failure. While non-invasive ventilation (NIV) is usually initiated in the home, patients presenting with hypercapnic respiratory failure may be at high risk of adverse outcomes with delays in treatment. We aim to describe the clinical utility of transcutaneous CO2 (TCO2 ) to assess the need for inpatient initiation of NIV. Eight patients from the University of Michigan Pranger ALS clinic were directly admitted to the hospital for urgent initiation of NIV between May 2020-May 2021. A retrospective review of electronic medical records, including pre-hospital pulmonary function assessments, hospitalization blood gases, and NIV use metrics was performed. All eight patients had symptoms of respiratory insufficiency at time of admission, although not all patients had forced vital capacity (FVC) measurements that would identify need for NIV. All patients had measured TCO2 > 45 mmHg. Seven of eight patients had worsening hypercapnia after admission, indicating advanced respiratory failure. All patients were titrated to tolerance of continuous nocturnal NIV while in the hospital, with an average length of stay of 6.5 days (range, 3-8). All patients demonstrated compliance with NIV, >4h, at post-hospital follow-up. Many current ambulatory measurements underestimate, or incompletely evaluate, respiratory dysfunction, and arterial blood gases are not typically readily available. Outpatient TCO2 measurements can serve as a useful screening tool to identify ALS patients who would benefit from inpatient initiation and titration of NIV.

O047 Sleep quality and fatigue in children and adolescents with multiple sclerosis

Abstract Background Fatigue is common in children and adolescents with multiple sclerosis (MS) and its aetiology is assumed to be multifactorial, however, its relationship to sleep quality in this population remains unknown. This study aims to examine the prevalence of fatigue and sleep disturbance in this population and their relationship to mood, quality of life, physical activity, and MS disease characteristics. Methods Children with pediatric onset multiple sclerosis (POMS) aged 0–18 were recruited. Subjective sleep quality was assessed by the Pediatric Daytime Sleepiness Scale (PDSS), Sleep Disturbance Scale for Children (SDSC) and OSA-18. All children were referred for polysomnography (PSG) including transcutaneous CO2 and video monitoring. Fatigue was assessed using the PedsQL Multidimensional Fatigue Scale (PedsQL-MFS). Progress to date: Fifteen children with relapsing remitting MS (mean age 15.73±1.44, mean EDSS score 1.11±1.12) have been enrolled to date. 73% of children were fatigued according to the PedsQL-MFS (mean transformed score 52.04). 67% and 60% of children scored higher than the clinical cutoff for the PDSS (17.87) and SDSC (42.73) respectively. However, all children scored within the normal range for the OSA-18 (34.00). To date, eleven children have completed PSG. Intended outcome and impact: This is the first study utilising PSG to objectively assess sleep quality in children with POMS. Findings from this study will document the magnitude of sleep disturbance in this population and have implications for the management of fatigue and other related impairments observed in paediatric MS.

O049 Sleep quality and its impact on children with primary ciliary dyskinesia

Abstract Background PCD is a rare, progressive disease resulting in upper respiratory manifestations and abnormal lung mechanics that increase one’s risk of obstructive sleep apnoea. This study aims to characterise the sleep quality of children with PCD and its impacts on mood and HRQOL. Methods Children with PCD aged 0–19 years with stable respiratory symptoms were recruited. Subjective sleep quality was assessed by the Sleep Disturbance Scale for Children (SDSC), OSA-18, and Paediatric Daytime Sleepiness Scale (PDSS). Mood and depressive symptoms were assessed via QOL-PCD and Children’s Depressive Inventory (CDI) as age-appropriate. Pulmonary function testing was performed via spirometry and Multiple Breath Washout. Patients underwent an ENT assessment. All children completed one night of polysomnography including transcutaneous CO2 and video monitoring. Progress to date: Twenty participants (45% female) have been recruited with a mean age of 8.5 years. Mean (±SD) FEV1 is 76.5±22.9%. 73% of children assessed have chronic rhinosinusitis. Clinically significant scores for SDSC were observed in 79% of patients and in 30% of patients for OSA-18. 38% of children reported clinically significant scores for PDSS. To date, 7 children have completed polysomnography. Intended outcome and impact: This is the first study to characterise sleep quality and the impact of sleep disturbance in Australian children with PCD. We aim to identify clinical markers of poor sleep quality to better inform the development of a sleep screening program for use in paediatric PCD clinics.

Evaluation of the Relationship between Transcutaneous Carbondioxide Monitorization and End-tidal Carbondioxide and Partial Carbondioxide Monitorization

MonitorizationNon-invasive methods have replaced invasive methods in line with developments in pediatric intensive care units. (Especially methods that enable continuous monitoring) Although arterial carbon dioxide measurement is still the gold standard for the evaluation of alveolar ventilation, the need for continuous monitoring of PaCO2 and the invasive nature of this method have led to the investigation of alternative methods. To evaluate the correlation of transcutaneous CO2 (TcCO2) monitoring with PaCO2 and ETCO2 in mechanically ventilated patients in peditaric intensive care units. Single-center, prospective, observational cohort study. We enrolled 60 patients between the age of 1 month-18 years who were mechanically ventilated in pediatric intensive care unit for this single-center, prospective, observational cohort study from February 2019 through March 2019. Correlation analysis was performed for arterial PaCO2, end-tidal CO2, TcCO2 parameters. P&lt;0.05 values were considered significant. The Bland-Altman plot was created for determining the agreement between the methods. The correlation of transcutaneous CO2 and end-tidal CO2 with arterial PaCO2 was evaluated, both parameters were found to be positively and highly correlated (r=0.864, p&lt;0.001, r:0.962, p&lt;0.001, respectively). The mean bias between the arterial carbondioxide mesaurement and transcutaneous measurement was 5.5, and limits of agreement (bias ±1.96 SD) ranged from -13.9 to 2.9. The mean bias between the arterial carbondioxide mesaurement and end-tidal carbondioxide measurement was 2.3, and limits of agreement (bias ±1.96 SD) ranged from -4.1 to 8.6. In 44 measurements (88%), the TcCO2 was ±7.5 mm Hg of the PaCO2. TcCO2 seems to be a good alternative for carbon dioxide measurement, as it is non-invasive and allows continuous monitoring in view of today's intensive care conditions, but arterial PaCO2 measurement is still the gold standard method. Continuous TcCO2 monitoring provides a promising alternative to repeated blood sampling in subjects requiring mechanical ventilation for critically ill children.

Wearable Transcutaneous CO2 Monitor Based on Miniaturized Nondispersive Infrared Sensor.

Transcutaneous oxygen and carbon dioxide provide the status of pulmonary gas exchange and are of importance in diagnosis and management of respiratory diseases. Though significant progress has been made in oximetry, not much has been explored in developing wearable technologies for continuous monitoring of transcutaneous carbon dioxide. This research reports the development of a truly wearable sensor for continuous monitoring of transcutaneous carbon dioxide using miniaturized nondispersive infrared sensor augmented by hydrophobic membrane to address the humidity interference. The wearable transcutaneous CO2 monitor shows well-behaved response curve to humid CO2 with linear response to CO2 concentration. The profile of transcutaneous CO2 monitored by the wearable device correlates well with the end-tidal CO2 trend in human test. The feasibility of the wearable device for passive and unobstructed tracking of transcutaneous CO2 in free-living conditions has also been demonstrated in field test. The wearable transcutaneous CO2 monitoring technology developed in this research can be widely used in remote assessment of pulmonary gas exchange efficiency for patients with respiratory diseases, such as COVID-19, sleep apnea, and chronic obstructive pulmonary disease (COPD).

451 Change of sleep disordered breathing severity in obese patients receiving Laparoscopic sleeve gastrectomy

Abstract Introduction Bariatric surgery via laparoscopic sleeve gastrectomy (LSG) was proved to alleviate significantly in apnea hypopnea index (AHI) in obesity patients. We aimed to investigate LSG effects on AHI in different sleep stage (REM vs NREM) and in position (supine vs non-supine) and on CO2 reduction and to identify the factors associated of AHI reduction. Methods From April 2016 to December 2020, 22 obese patients who underwent PSG before and after bariatric surgery at National Taiwan university Hospital were retrospectively studied. The simultaneously nocturnal percutaneous transcutaneous CO2 (PtcCO2) monitoring was applied. Demographic, anthropometric characteristics, Epworth sleepiness scale (ESS), Pittsburgh Sleep Quality Index (PSQI), PSG parameters were reviewed. Responsive to treatment was defined as AHI reduction ≥50% and residual AHI&amp;lt; 10/hour. Results Postoperative PSG was performed in 22 patients [13 men and 9 women, median age 38 years (interquartile range, 32.8–46.5), median body mass index (BMI) 44.5 kg/m2 (39–52.5)] and median follow up days of 535 days (440–687) after LSG. The median post-op BMI was 32.4 kg/m2 (28.3–37.1). The AHI decreased from 51.9/h (27–85.9) to 10.7/h (2–16.3) (p&amp;lt;0.01). The AHINREM decreased from 49.9/h (31.8–91.5) to 5.8/h (1.1–17.3) while the AHIREM decreased from 63.7/h (52.5–83.2) to 19.6/h (4.4–49.7) /h. The AHIsupine decreased from 64.1/h (40.1–88.8) to 11.9/h (2.3–18.7) while the AHInon-supine decreased from 27.5 /h (17.6–78.3) to 1 /h (0–2). The average PtcCO2 decreased from 51.6 mmHg (39.3–54.7) to 46 mmHg (36.6–49.3) while %PtcCO2-total sleep time&amp;gt;50mmHg decreased from 84.5% (0.1–99.1) to 0% (0–44.6). Logistic regression showed baseline higher AHI was independently associated with less treatment responsive [odds ratio, 0.909 (0.84–0.985)]. Conclusion The AHI and PtcCO2 marked decreased via LSG where the residual AHI was lower in NREM than REM sleep; and in non-supine than supine. Baseline AHI is inversely associated with the residual AHI Support (if any) Ministry of Science and Technology (MOST 109-2314-B-002-252)

Noninvasive Ventilation in Amyotrophic Lateral Sclerosis.

Amyotrophic lateral sclerosis is a progressive neurodegenerative disease involving upper and lower motor neurons and has limited treatment options. The weakness progresses to involve the diaphragms, resulting in respiratory failure and death. Home noninvasive ventilation has been shown to improve survival and quality of life, especially in those with intact bulbar function. Once initiated, close monitoring with nocturnal oximetry, remote downloads from the home noninvasive ventilation machine, and measurement of serum bicarbonate should be conducted. Additionally, transcutaneous CO2 monitoring can be considered if available. This article discusses the indications, timing, initiation, and management of noninvasive ventilation in amyotrophic lateral sclerosis.

Extremely low gestational age infants: Developing a multidisciplinary care bundle.

Clinical experience in managing extremely low gestational age infants, particularly those born <24 weeks' gestation, is limited in Canada. Our goal was to develop a bedside care bundle for infants born <26 weeks' gestation, with special considerations for infants of <24 weeks, to harmonize and improve quality of care. We created a multidisciplinary working group with experience in caring for preterm infants, searched the literature from 2000 to 2019 to identify best practices for the care of extremely preterm infants and consulted colleagues across Canada and internationally. Iterative improvements were made following the Plan-Do-Study-Act methodology. A care bundle, created in October 2015, was divided into three time periods: initial resuscitation/stabilization, the first 72 hours and days 4 to 7, with each period subdivided in 8 to 12 care themes. Revisions and practice changes were implemented to improve skin integrity, admission temperature, timing of initiation of feeds, reliability of transcutaneous CO2 monitoring and ventilation. Of 127 infants <26 weeks admitted between implementation and end of 2019, 78 survived to discharge (61%). It will be important to determine, with ongoing auditing and further evaluation, whether our care bundle led to improvements of short- and long-term outcomes in this population. Our experience may be useful to others caring for extremely low gestational age infants.

Noninvasive Ventilation Downloads and Monitoring.

"Home noninvasive ventilation (NIV) is indicated for numerous conditions including neuromuscular disease, thoracic cage disorders, chronic obstructive pulmonary disease, and hypoventilation syndromes. Effective management of patients on home NIV requires clinicians to interpret data downloads from NIV devices. Clinicians must first look at adherence and factors that may impact this including mask comfort and fit. Next, leak assessment is undertaken. Once these are addressed, such information as apnea-hypopnea index, exhaled tidal volume, and percent triggered breaths help clinicians troubleshoot setting changes. Finally, overnight oximetry and transcutaneous CO2 monitoring are useful adjuncts to the data download to optimize NIV settings."