Treatment Of Respiratory Distress Research Articles

Morphine versus hydromorphone in pediatrics: a narrative review of latest indications and optimal use in neonates and children.

The management of pain in pediatrics is multimodal and includes non-pharmacologic and pharmacologic approaches. Opioids, and particularly morphine and hydromorphone, are frequently used to treat moderate-to-severe pain. The goals of this review are to describe the pharmacological characteristics of both drugs, to cover the latest evidence of their respective indications, and to promote their safe use in pediatrics. Morphine is the most studied opioid in children and is known to be safe and effective. Morphine and hydromorphone can be used to manage acute pain and are usually avoided when treating chronic non-cancer pain. Current evidence suggests that both opioids have a similar efficacy and adverse effect profile. Hydromorphone has not been studied in neonates but in some centers, it has been used instead of morphine for certain patients. In palliative care, the use of opioids is often indicated and their benefits extend beyond analgesia; indications include treatment of central neuropathic pain in children with severe neurologic impairment and treatment of respiratory distress in the imminently dying patients. The longstanding belief that the use of well-titrated opioids hastens death should be abandoned as robust evidence has shown the opposite. With the current opioid crisis, a responsible use of opioids should be promoted, including limiting the opioid prescription to the patient's anticipated needs, optimizing a multimodal analgesic plan including the use of non-pharmacological measures and non-opioid medications, and providing information on safe storage and disposal to patients and families. More data is needed to better guide the use of morphine and hydromorphone in children.

Pierre Robin Sequence and Respiratory Distress: Long-Term Evolution in Patients Submitted to the Conservative Treatment.

Pierre Robin Sequence (PRS) is characterized by micrognathia, glossoptosis, cleft palate, and airway distress. The aims of initial treatment are the improvement of airway and feeding. There are many therapeutic options, including conservative techniques (prone positioning and nasopharyngeal tube) and invasive procedures (mandibular distraction and tracheostomy). In our center, initially conservative treatment is the rule and many patients have been treated with nasopharyngeal tube. The aim was to analyze of the clinical evolution of respiratory distress in infants with PRS submitted to nonsurgical treatment. A retrospective and observational descriptive evaluation was carried out with 56 patients with the PRS at Centro de Atendimento Integral ao Fissurado Labiopalatal (CAIF). 21 patients were selected to a transversal phase. The treatment has started in an average age of 1.5 months (±2.09) and 17 (94.4%) had respiratory distress at birth. Polysomnographic exams showed an average apnea/hypopnea index of 0.93, an average number of central apnea/hour of 0.3, an average number of obstructive apnea of 0.6 and an average oxygen saturation of 92%. There was the predominance of esthetic profile in class II with 16 (88.9%) patients in this group, and orthodontic profile in class II with 15 (83.3%) patients. The conservative treatment has presented remarkable results in the treatment of respiratory distress in bearers of PRS with a decrease of obstructive sleep events considering the growth of patient and the development of mandibular growth as well.

AB090. SOH21AS084. Awake prone positioning as treatment for respiratory distress: a systematic review

AB090. SOH21AS084. Awake prone positioning as treatment for respiratory distress: a systematic review

COVID-19-induced endotheliitis: emerging evidence and possible therapeutic strategies.

The coronavirus disease 2019 (COVID‐19) pandemic, a viral illness caused by the severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2), 1 has produced at the time of this writing nearly 33 million cases of infection, with over a million deaths in 235 countries, 2 causing an unprecedented burden on healthcare systems and a severe global socioeconomic crisis. As the pandemic spreads, knowledge on the disease course, as well as potential risk factors and predictors of severity is increasing daily, and initial data from randomised controlled studies have allowed care providers to refine therapeutic strategies. Nonetheless, mortality is markedly elevated among those presenting with severe disease, long‐term sequelae among survivors are unknown, and vaccine‐based therapies currently remain at early stages of development. Most reported cases are asymptomatic or present with mild symptoms; however, 7–26% of hospitalised patients experience severe disease, often requiring admission to intensive care units (ICUs), with progressive multiple organ dysfunction and high mortality. 3 , 4 , 5 Such differences in clinical outcomes have led physicians to initiate diverse pharmacological therapies at various stages of the disease, generating challenges as to the most appropriate therapeutic choice for COVID‐19. In this context, the use of dexamethasone has significantly reduced mortality rates in critically ill patients requiring supplemental oxygen or mechanical ventilation, 6 and remdesivir has demonstrated clinical benefit in hospitalised patients, but with unknown survival benefit to date 7 ; additional effective treatment options are therefore urgently needed. In an initial attempt to provide a uniform and widely reproducible methodology to guide systematic treatment strategies, a three‐stage classification of COVID‐19 has been proposed. 8 The Stage I or ‘early infection’ occurs at the initial establishment of disease with high viral replication, and commonly presents with a range of complaints that can include mild and often non‐specific influenza‐like signs and symptoms. Stage II is the ‘pulmonary phase’, with preferential viral‐mediated injury of the lung parenchyma and this is characterised by shortness of breath, hypoxia and pulmonary infiltrates with some degree of lung inflammation. Stage III is characterised by an exaggerated host immune‐inflammatory response to the virus, leading to acute respiratory distress syndrome (ARDS) and multi‐organ failure (MOF).

Respiratory Distress in Full and Post Term Neonates: Prevalence, Etiologies and Outcomes in a Tertiary Health Center in Yaoundé

Introduction: Respiratory pathologies are top listed amongst neonatal morbidities. Our objective was to describe the clinical features, causes and treatment of respiratory distress (RD) in full and post term neonates in a tertiary health center in Yaoundé, the Essos Hospital Centre (EHC). Patients and Method: This was a retrospective study. Full/post term neonates with RD from January 2017-December 2018 were included. Main parameters: incidence of RD, etiologies, risk factors for severity and mortality. Results: We included 186 neonates among 2312 newborn babies. The RD prevalence rate was 8%. Sex ratio of 2.15 was favoring male, median gestational age of 38 weeks. Clinical signs of RD were dominated by a Silverman score above 4/10 in 64%. Main etiologies were pneumonia (44%), followed by transient tachypnea (35.4). Perinatal asphyxia (OR = 9.412, P = 0.005) and cyanosis (OR = 6.509; P 0.001) were worsening RD, while caesarian section was protective (OR = 0.412; P = 0.050). Mortality rate (MR) was 10.4%. Therapeutic measures briefly consisted in oxygen therapy for 98.9% of patients and probabilistic antibiotic therapy. Conclusion: Neonatal pneumonia was the preeminent etiology of RD in this population; the MR was high.

Evaluation of the Management of Infant Respiratory Distress at the CNHU-HKM Pediatric Emergency Department

Introduction: Respiratory distress (RD) is a major emergency to which infants are particularly vulnerable. It can lead to neurological sequelae and even death when treatment is not adequate and rapid. Objective: To evaluate the management of RD in infants at the CNHU-HKM in Cotonou. Methods: The study was of a transversal and analytical nature and took place over a period of 06 months, from 1st January to 30th June 2015. Included in the study were all infants hospitalised for DR. The therapeutic modalities were analysed according to the recommendations of the World Health Organization. Results: A total of 96 infants were included. The hospital frequency of DR was 38%. The average age was 12 months. One in 3 infants had SaO2 less than 90% on admission, and in 58.3% of cases, the infant showed at least 3 signs of struggle. The initial assessment was as recommended. The systematic use of oxygenrequires a revision of the criteria for oxygentherapy in the unit. The three main causes were severe pneumonia (31.3%), severe malaria (18.8%) and bronchiolitis (15.6%), and their treatment was correct. However, none of the infants had been able to benefit from ventilatory support. Mortality was high (31.2%) linked to the intensity of DR (p = 0.04) and sepsis (p = 0.006). Conclusion: The procedures for the diagnosis and treatment of RD in infants at the CNHU are fairly consistent with WHO guidelines. Ventilatory support is necessary for some children with severe RD.

Saturation oxygenation pressure index: a non-invasive bedside measure for severity of respiratory disease in neonates on CPAP.

The treatment of respiratory distress in neonates ranges from non-invasive continuous positive airway pressure (CPAP) to advanced invasive mechanical ventilation. Monitoring on CPAP is often done by calculating oxygenation after blood gas analysis which is an invasive procedure. Saturation oxygen pressure index (SOPI) is a simple, non-invasive, bedside tool to monitor the severity of respiratory illness in neonates on CPAP. This study was aimed at validation of SOP index against AaDO2 and determine the cut-off values of SOPI for A-aDO2 of 70, 85 and100. This was a prospective observational study on 126 neonates with respiratory distress and treated with CPAP. The correlation between SOPI and A-aDO2 was validated using Bootstrap method. There was a significant positive correlation between SOPI and A-aDO2 with the Spearman correlation coefficient (rho) being 0.815 (p = 0). The mean coefficient of correlation after Bootstrap was 0.827 (p value < 0.0001). SOPI values of 1.52, 1.57 and 1.6 predicted A-aDO2 value of 70, 85 and 100 with a sensitivity of above 80% and specificity above 90%, respectively.Conclusion: SOPI has a significant positive correlation of 82.7% against A-aDO2 and can be a valuable tool to assess respiratory distress in neonates without arterial blood gas.What is Known:• Saturation oxygen pressure index (SOPI) is a non-invasive monitoring tool for neonates on N-CPAP.• SOPI has a good correlation with AaDO2.What is New:• Correlation of SOPI with AaDO2 is now validated.• Values between 1.52 and 1.88 indicate clinically useful range of AaDO2 for escalation of respiratory support from CPAP.

Early versus delayed continuous positive airway pressure (CPAP) for respiratory distress in preterm infants.

The application of continuous positive airway pressure (CPAP) has been shown to have some benefits in the treatment of preterm infants with respiratory distress. CPAP has the potential to reduce lung damage, particularly if applied early before atelectasis has occurred. Early application may better conserve an infant's own surfactant stores and consequently may be more effective than later application. • To determine if early compared with delayed initiation of CPAP results in lower mortality and reduced need for intermittent positive-pressure ventilation in preterm infants in respiratory distress ○ Subgroup analyses were planned a priori on the basis of weight (with subdivisions at 1000 grams and 1500 grams), gestation (with subdivisions at 28 and 32 weeks), and according to whether surfactant was used ▫ Sensitivity analyses based on trial quality were also planned ○ For this update, we have excluded trials using continuous negative pressure SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 6), in the Cochrane Library; Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations Daily and Versions(R); and the Cumulative Index to Nursing and Allied Health Literatue (CINAHL), on 30 June 2020. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs. We included trials that used random or quasi-random allocation to either early or delayed CPAP for spontaneously breathing preterm infants in respiratory distress. We used the standard methods of Cochrane and Cochrane Neonatal, including independent assessment of trial quality and extraction of data by two review authors. We used the GRADE approach to assess the certainty of evidence. We found four studies that recruited a total of 119 infants. Two were quasi-randomised, and the other two did not provide details on the method of randomisation or allocation used. None of these studies used blinding of the intervention or the outcome assessor. Evidence showed uncertainty about whether early CPAP has an effect on subsequent use of intermittent positive-pressure ventilation (IPPV) (typical risk ratio (RR) 0.77, 95% confidence interval (CI) 0.43 to 1.38; typical risk difference (RD) -0.08, 95% CI -0.23 to 0.08; I² = 0%, 4 studies, 119 infants; very low-certainty evidence) or mortality (typical RR 0.93, 95% CI 0.43 to 2.03; typical RD -0.02, 95% CI -0.15 to 0.12; I² = 33%, 4 studies, 119 infants; very low-certainty evidence). The outcome 'failed treatment' was not reported in any of these studies. There was an uncertain effect on air leak (pneumothorax) (typical RR 1.09, 95% CI 0.39 to 3.04, I² = 0%, 3 studies, 98 infants; very low-certainty evidence). No trials reported intraventricular haemorrhage or necrotising enterocolitis. No cases of retinopathy of prematurity were reported in one study (21 infants). One case of bronchopulmonary dysplasia was reported in each group in one study involving 29 infants. Long-term outcomes were not reported. All four small trials included in this review were performed in the 1970s or the early 1980s, and we are very uncertain whether early application of CPAP confers clinical benefit in the treatment of respiratory distress, or whether it is associated with any adverse effects. Further trials should be directed towards establishing the appropriate level of CPAP and the timing and method of administration of surfactant when used along with CPAP.

Continuous positive airway pressure (CPAP) for respiratory distress in preterm infants.

Respiratory distress, particularly respiratory distress syndrome (RDS), is the single most important cause of morbidity and mortality in preterm infants. In infants with progressive respiratory insufficiency, intermittent positive pressure ventilation (IPPV) with surfactant has been the usual treatment, but it is invasive, potentially resulting in airway and lung injury. Continuous positive airway pressure (CPAP) has been used for the prevention and treatment of respiratory distress, as well as for the prevention of apnoea, and in weaning from IPPV. Its use in the treatment of RDS might reduce the need for IPPV and its sequelae. To determine the effect of continuous distending pressure in the form of CPAP on the need for IPPV and associated morbidity in spontaneously breathing preterm infants with respiratory distress. We used the standard strategy of Cochrane Neonatal to search CENTRAL (2020, Issue 6); Ovid MEDLINE and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions; and CINAHL on 30 June 2020. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. All randomised or quasi-randomised trials of preterm infants with respiratory distress were eligible. Interventions were CPAP by mask, nasal prong, nasopharyngeal tube or endotracheal tube, compared with spontaneous breathing with supplemental oxygen as necessary. We used standard methods of Cochrane and its Neonatal Review Group, including independent assessment of risk of bias and extraction of data by two review authors. We used the GRADE approach to assess the certainty of evidence. Subgroup analyses were planned on the basis of birth weight (greater than or less than 1000 g or 1500 g), gestational age (groups divided at about 28 weeks and 32 weeks), timing of application (early versus late in the course of respiratory distress), pressure applied (high versus low) and trial setting (tertiary compared with non-tertiary hospitals; high income compared with low income) MAIN RESULTS: We included five studies involving 322 infants; two studies used face mask CPAP, two studies used nasal CPAP and one study used endotracheal CPAP and continuing negative pressure for a small number of less ill babies. For this update, we included one new trial. CPAP was associated with lower risk of treatment failure (death or use of assisted ventilation) (typical risk ratio (RR) 0.64, 95% confidence interval (CI) 0.50 to 0.82; typical risk difference (RD) -0.19, 95% CI -0.28 to -0.09; number needed to treat for an additional beneficial outcome (NNTB) 6, 95% CI 4 to 11; I2 = 50%; 5 studies, 322 infants; very low-certainty evidence), lower use of ventilatory assistance (typical RR 0.72, 95% CI 0.54 to 0.96; typical RD -0.13, 95% CI -0.25 to -0.02; NNTB 8, 95% CI 4 to 50; I2 = 55%; very low-certainty evidence) and lower overall mortality (typical RR 0.53, 95% CI 0.34 to 0.83; typical RD -0.11, 95% CI -0.18 to -0.04; NNTB 9, 95% CI 2 to 13; I2 = 0%; 5 studies, 322 infants; moderate-certainty evidence). CPAP was associated with increased risk of pneumothorax (typical RR 2.48, 95% CI 1.16 to 5.30; typical RD 0.09, 95% CI 0.02 to 0.16; number needed to treat for an additional harmful outcome (NNTH) 11, 95% CI 7 to 50; I2 = 0%; 4 studies, 274 infants; low-certainty evidence). There was no evidence of a difference in bronchopulmonary dysplasia, defined as oxygen dependency at 28 days (RR 1.04, 95% CI 0.35 to 3.13; I2 = 0%; 2 studies, 209 infants; very low-certainty evidence). The trials did not report use of surfactant, intraventricular haemorrhage, retinopathy of prematurity, necrotising enterocolitis and neurodevelopment outcomes in childhood. In preterm infants with respiratory distress, the application of CPAP is associated with reduced respiratory failure, use of mechanical ventilation and mortality and an increased rate of pneumothorax compared to spontaneous breathing with supplemental oxygen as necessary. Three out of five of these trials were conducted in the 1970s. Therefore, the applicability of these results to current practice is unclear. Further studies in resource-poor settings should be considered and research to determine the most appropriate pressure level needs to be considered.

The Underlying Causes of Respiratory Distress in Late-Preterm and Full-Term Infants Are Different From Those of Early-Preterm Infants

Background: A diagnosis of neonatal respiratory distress syndrome (RDS) is common among newborns in China. Some late-preterm and full-term (LP/FT) infants with respiratory distress (RD) symptoms but not primary surfactant deficiency are also diagnosed with RDS and given exogenous surfactant replacement therapy (SRT). Objectives: An increasing number of neonatologists have proposed that RD etiologies should be specifically classified to guide clinical treatment. Methods: The therapeutic effects of SRT on infants of different gestational ages (GAs) were compared in a large retrospective multicenter cohort study performed at 26 Neonatal Intensive Care units in China. The cause of RD at different GAs was further analyzed by comparing the different risk factors closely related to RDS severity at different GAs. Results: Analysis of 1240 infants diagnosed with RDS showed that SRT was less effective in LP/FT infants than in early-preterm (EP) infants. GA &lt; 30 weeks and no prenatal corticosteroid use were closely related to RDS severity in EP infants, whereas perinatal infection- and perinatal hypoxia-associated risk factors and a high cesarean rate were closely related to RDS severity in LP/FT infants. Conclusions: The causes of RD might differ between LP/FT and EP infants, and the diagnosis of RDS might be overused in LP/FT infants. RD in LP/FT infants is more likely related to perinatal infection, perinatal hypoxia, elective cesarean and hereditary factors, which are important causes of neonatal pulmonary edema. New strategies for the treatment of refractory RD in LP/FT infants should concentrate more on pulmonary edema and neonatal ARDS.

Bubble Nasal Continuous Positive Airway Pressure (bCPAP) versus Control in Neonates with Respiratory Distress.

To compare the effectiveness of bubble continuous positive airway pressure (bCPAP) and oxygen inhalation via nasal cannula in neonates presenting with respiratory distress, using Silverman Anderson Retraction Score (SARS). Randomised clinical trial. Department of Paediatrics, Unit-1, KEMU/Mayo Hospital, Lahore, Pakistan, from April 2017 to June 2018. A total of 120 neonates fulfilling inclusion and exclusion criteria were enrolled and were randomly allocated in two groups: Group A and Group B. In group A, neonates were given bCPAP for respiratory support, while neonates in group B were given nasal oxygen as control group. Neonates in both groups were followed for 48 hours. The effectiveness was determined by the reduction in SARS, up to or less than score 3, at the end of a 48-hour period. Data were collected and analysed by SPSS version 20.0. P-value ≤0.05 was taken as significant. In Group A, effectiveness was found to be 93.3%, and in Group B effectiveness was 71.7% (p = 0.003). Median reduction in SARS from 00 to 48 hours, in group A (bCPAP) was 4 (4 - 5) while in group B (control), it was 3 (2 - 3); statistically significant (p <0.001). Bubble CPAP was more effective than nasal oxygen alone, in treatment of respiratory distress among neonates. This study suggested that bCPAP should be used more frequently in NICUs of Pakistan to reduce burden of neonatal morbidity due to respiratory distress. Key Words: Bubble CPAP, Respiratory distress, Neonates, Silverman Anderson Retraction Score.

EARLY USE OF CONTINUOUS POSITIVE AIR WAY PRESSURE FOR PREVENTION AND TREATMENT OF RESPIRATORY DISTRESS SYNDROME IN PRETERM INFANTS

Respiratory support is the mainstay intervention for support of postnatal respiratory adaptation and treatment of preterm infants. There is no doubt today about the clinical benefits of early use of non-invasive respiratory support over traditional tracheal intubation and mechanical ventilation in the context of reducing the risk of death, lung injury, and long-term chronic morbidity. In particular, continuous positive airway pressure (CPAP) is the most commonly used method of initial non-invasive respiratory support (NRS) for spontaneously breathing preterm newborns. This method of NRS is preferred in practice because of its easy use, accessibility and effectiveness. Application of CPAP increases functional residual lung capacity and tidal volume, which is important for the prevention and treatment of respiratory distress- syndrome. However, significant proportion of preterm infants managed on CPAP require transfer to mechanical ventilation as NRS becomes ineffective ultimately. The requirement for tracheal intubationand initiation of mechanical ventilation increases the risk of complications and adverse outcomes in such infants. In particular, CPAP failure is associated with higher rate of intraventricular hemorrhages, bronchopulmonary dysplasia, and increases the risk of death. Therefore, the priority is to maximize effectiveness of CPAP application. This can be achieved by identifying a risk group, namely the infants, who have a high probability of this respiratory support type failure, and by timely adding supplementary measures that can increase the effectiveness of CPAP. This review substantiates the expediency of early CPAP use for treatment of preterm newborns, describes the risk factors of CPAP failure and ways to improve the effectiveness of this method of NRS.

After the First Wave of COVID-19: Reflections From Italy.

After the First Wave of COVID-19: Reflections From Italy.

A pilot study of improvised CPAP (iCPAP) via face mask for the treatment of adult respiratory distress in low-resource settings

BackgroundContinuous positive airway pressure (CPAP) is a mode of non-invasive ventilation used to treat a variety of respiratory conditions in the emergency department and intensive care unit. In low-resource settings where ventilators are not available, the ability to improvise a CPAP system from locally available equipment would provide a previously unavailable means of respiratory support for patients in respiratory distress. This manuscript details the design of such a system and its performance in healthy volunteers.MethodsAn improvised CPAP system was assembled from standard emergency department equipment and tested in 10 healthy volunteers (6 male, 4 female; ages 29–33). The system utilizes a water seal and high-flow air to create airway pressure; it was set to provide a pressure of 5 cmH2O for the purposes of this pilot study. Subjects used the system in a monitored setting for 30 min. Airway pressure, heart rate, oxygen saturation, and end-tidal CO2 were monitored. Comfort with the device was assessed via questionnaire.ResultsThe system maintained positive airway pressure for the full trial period in all subjects, with a mean expiratory pressure (EP) of 5.1 cmH2O (SD 0.7) and mean inspiratory pressure (IP) of 3.2 cmH2O (SD 0.8). There was a small decrease in average EP (5.28 vs 4.88 cmH2O, p = 0.03) and a trend toward decreasing IP (3.26 vs 3.07 cmH2O, p = 0.22) during the trial. No significant change in heart rate, O2 saturation, respiratory rate, or end-tidal CO2 was observed. The system was well tolerated, ranked an average of 4.0 on a 1–5 scale for comfort (with 5 = very comfortable).ConclusionsThis improvised CPAP system maintained positive airway pressure for 30 min in healthy volunteers. Use did not cause tachycardia, hypoxia, or hypoventilation and was well tolerated. This system may be a useful adjunctive treatment for respiratory distress in low-resource settings. Further research should test this system in settings where other positive pressure modalities are not available.

Analytical study for neonates with respiratory distress on Bubble Continuous Positive Airway Pressure admitted to NICU of Minia University Hospital

Introduction:Using nasal continuous positive airway pressure (CPAP) for neonatal respiratory support is highly increasing in low and middle-income countries. It reduces the needs for mechanical ventilation in neonates with respiratory distress (RD) in tertiary hospitals.Objectives:This is a prospective non-randomized study aims to evaluate the role and efficiency of bubble CPAP in treatment of neonatal respiratory distress and correlation of bubble CPAP failure with different studied demographic, clinical and laboratory variable data.Patients and methods: The study included all neonates with respiratory distress admitted to neonatal intensive care unit (NICU) - Minia University hospital from 1st of January to 31st of December 2017.The study analyzed the rate of failure and response of management of those patients on bubble CPAP and compared them with other different treatment modalities according to variable recorded demographic, clinical and laboratory data.Results: Among the 280 cases, 149 patients (53.2%) were treated with oxygen, 52 patients (18.6%) needed to be treated with bubble CPAP, 79 patients (28.2%) needed to be intubated and mechanically ventilated (MV). Our study showed more incidences of bubble CPAP therapy of RD cases with higher gestational ages and birth weight, milder grades of RD, absence of sepsis in comparison with mechanical ventilation and vice versa for comparison with nasal oxygen therapy.Conclusion:CPAP is an effective treatment of RD leading to significant improvement of outcome reducing hospital stay, need for invasive mechanical ventilation with its harmful adverse effects and thus the case fatality rate of RD cases and so the overall mortality rate of the NICU.

Ensuring Breathing Comfort at the End of Life: The Integral Role of the Critical Care Nurse.

This article describes the author's program of clinical research focused on assessment and treatment of respiratory distress among critically ill patients at the end of life. Dyspnea is a subjective experience of breathing discomfort that occurs in the presence of cardiopulmonary and neuromuscular diseases. Dyspnea is one of the most common and most distressing symptoms experienced by critically ill patients. Many critically ill patients, particularly those not expected to survive, become cognitively impaired or unconscious and lose the ability to report symptoms, although dyspnea can be known only from a patient's report. When self-reporting ability is lost, the critical care nurse must rely on signs indicative of a patient's respiratory distress. The critically ill patient unable to self-report is vulnerable to under-recognition of symptom distress and subsequent over-treatment or undertreatment. When the patient is dying, there is only 1 chance to optimize the assessment and treatment of symptoms.

The impact of the BLUE protocol ultrasonography on the time taken to treat acute respiratory distress in the ED

Respiratory distress is one of the most common complaints in the emergency department (ED) [1]. In extreme scenarios, during which respiratory distress becomes respiratory failure, the survival of the patients will significantly drop [2]. For instance, a recent cohort study showed that the mortality rate among hospitalized patients with respiratory distress was as much as 10% [3]. Hence, in the management of a patient with respiratory distress, using a timely approach to differentiate the underlying causes and initiating specific therapies (decompression of the pneumothorax, intubation and ventilation support, bronchodilators or corticosteroid nebulization, anticoagulation and fibrinolytic therapy in pulmonary thromboembolisms, etc.) is of undisputed importance. In 2008, the Bedside Lung Ultrasound in Emergency (BLUE) protocol was developed to guide the diagnosis of respiratory distress [4]. Lichtenstein and his colleagues who proposed the BLUE protocol, showed that the diagnostic accuracy of lung ultrasound (LUS) in the Intensive Care Unit (ICU) was 90.5%. Similarly, Silva et al. demonstrated that LUS was more accurate in cases of acute respiratory failure than routine approaches (patient history and physical examination, radiologic and laboratory evidence) [5]. The BLUE protocol enables physicians to differentiate the underlying causes of respiratory failure. More to the point, LUS was proved to be effective in the monitoring of therapeutic responses in acute respiratory distress syndrome (ARDS) [6]. The BLUE protocol can be applied using a simple ultrasound machine equipped with a micro-convex array transducer [7]. Nevertheless, performing an accurate LUS requires specific training [8]. Although current evidence encourages the use of LUS in treating respiratory distress in critical care, it is not widely accepted in EDs [9]. We hypothesized that utilizing a bedside testing protocol such as the BLUE protocol in the ED may shorten the time interval between patient admission and the delivery of any definitive treatment [10]. We have therefore conducted a randomized clinical trial to assess whether or not the application of the BLUE protocol by a trained emergency physician has an impact on the timely diagnosis and treatment of respiratory distress in the ED.

The Value of Positive Pressure Ventilations for Clients in Acute Respiratory Distress as a Result of Cardiac and Pulmonary Issues

Objective: Research was conducted to examine benefits to using non-invasive ventilation (NIV) or continuous positive airway pressure (CPAP) early in the treatment of respiratory distress caused by pulmonary edema, chronic obstructive pulmonary disease (COPD) and asthma. Limitations to successful NIV and CPAP therapy were evaluated to determine how prolonged initiation of treatment may lead to hypoxemia (decreased oxygen in the blood) and hypercapnia (increased carbon dioxide in the blood) resulting in poor outcomes. Method: Reviews of literature from nursing and allied health data bases (CINAHL and ProQuest) with terms pulmonary edema, positive pressure device and non-invasive ventilation from 2010 to 2014 were used. Studies were conducted in the hospital and prehospital settings. Results: The literature search located 7 articles from CINAHL and 25 articles from ProQuest. A total of 6 of these articles were analyzed. Additional sources of data were obtained from Ignatavicius and Workman (2013) Medical-Surgical Nursing Patient-Centered Collaborative Care 7th edition and American Journal of Nursing (02/2013) Volume 113: 2. Conclusion: All of the articles concluded that early initiation of continuous positive airway pressure ventilations in the short-term was beneficial; however, late initiation of therapy required additional interventions. The studies indicated that early use of positive airway pressure in acute respiratory distress improved breath rate, heart rate and blood pressure. The use of positive airway pressure for respiratory distress may decrease the need for endotracheal intubation.

Residue specific partitioning of KL4 into phospholipid bilayers

KL4, which has demonstrated success in the treatment of respiratory distress, is a synthetic helical, amphipathic peptide mimetic of lung surfactant protein B. The unusual periodicity of charged residues within KL4 and its relatively high hydrophobicity distinguish it from canonical amphipathic helical peptides. Here we utilized site specific spin labeling of both lipids and the peptide coupled with EPR spectroscopy to discern the effects of KL4 on lipid dynamics, the residue specific dynamics of hydrophobic regions within KL4, and the partitioning depths of specific KL4 residues into the DPPC/POPG and POPC/POPG lipid bilayers under physiologically relevant conditions. KL4 induces alterations in acyl chain dynamics in a lipid-dependent manner, with the peptide partitioning more deeply into DPPC-rich bilayers. Combined with an earlier NMR study of changes in lipid dynamics on addition of KL4 (V.C. Antharam et al., 2009), we are able to distinguish how KL4 affects both collective bilayer motions and intramolecular acyl chain dynamics in a lipid-dependent manner. EPR power saturation results for spin labeled lipids demonstrate that KL4 also alters the accessibility profiles of paramagnetic colliders in a lipid-dependent manner. Measurements of dynamics and depth parameters for individual spin-labeled residues within KL4 are consistent with a model where the peptide partitions deeply into the lipid bilayers but lies parallel to the bilayer interface in both lipid environments; the depth of partitioning is dependent on the degree of lipid acyl chain saturation within the bilayer.

ABSTRACT 13

Background and aims: High-flow nasal cannula (HFNC) therapy is a treatment for respiratory distress in neonates and children. Aims: The aim the study was to assess the effectiveness of HFCN therapy in a pediatric intensive care unit (PICU). Methods: In this observational study, we included all consecutive patients from 1 month to 18 years of age who were admitted to the PICU in Tepecik Teaching and Research Hospital, Izmir, Turkey and treated with a high-flow nasal cannula between October 1, 2013, and December 31, 2013. The vital parameters, respiratory clinical score (RCS), The Brussels Sedation Scale (BSS) and sPO2/FiO2 ratio were evaluated. Results: A total of 19 patients (median age: 48 month; 1–180 months; male/female: 12/7) were included the study. The indication for HFNC were postextubation (6 cases), asthma (5), bronchiolitis (2), pneumonia (2), pulmonary edema (2), croup syndrome (1), extrapulmonary acute lung injury (1). There were significant improvements in the oxygene saturation, pulse rate, respiratory rate, RCS, BSS and sPO2/FiO2 ratio. Conclusions: The HFCN therapy improves the respiratory parameters and sedation scale in pediatric respiratory distress syndrome. HFCN treatment carries an important role in PICU.