Use Of Accessory Respiratory Muscles Research Articles

Anaphylaxis after COVID-19 vaccination: A registry-based study

Anaphylaxis after COVID-19 vaccination: A registry-based study

Use, timing and factors associated with tracheal intubation in septic shock: a prospective multicentric observational study

BackgroundNo recommendation exists about the timing and setting for tracheal intubation and mechanical ventilation in septic shock.Patients and methodsThis prospective multicenter observational study was conducted in 30 ICUs in France and Spain. All consecutive patients presenting with septic shock were eligible. The use of tracheal intubation was described across the participating ICUs. A multivariate analysis was performed to identify parameters associated with early intubation (before H8 following vasopressor onset).ResultsEight hundred and fifty-nine patients were enrolled. Two hundred and nine patients were intubated early (24%, range 4.5–47%), across the 18 centers with at least 20 patients included. The cumulative intubation rate during the ICU stay was 324/859 (38%, range 14–65%). In the multivariate analysis, seven parameters were significantly associated with early intubation and ranked as follows by decreasing weight: Glasgow score, center effect, use of accessory respiratory muscles, lactate level, vasopressor dose, pH and inability to clear tracheal secretions. Global R-square of the model was only 60% indicating that 40% of the variability of the intubation process was related to other parameters than those entered in this analysis.ConclusionNeurological, respiratory and hemodynamic parameters only partially explained the use of tracheal intubation in septic shock patients. Center effect was important. Finally, a vast part of the variability of intubation remained unexplained by patient characteristics.Trial registration Clinical trials NCT02780466, registered on May 23, 2016. https://clinicaltrials.gov/ct2/show/NCT02780466?term=intubatic&draw=2&rank=1.

Titration and characteristics of pressure-support ventilation use in Argentina: an online cross-sectional survey study.

ObjectiveTo identify common practices related to the use and titration of pressure-support ventilation (PC-CSV - pressure control-continuous spontaneous ventilation) in patients under mechanical ventilation and to analyze diagnostic criteria for over-assistance and under-assistance. The secondary objective was to compare the responses provided by physician, physiotherapists and nurses related to diagnostic criteria for over-assistance and under-assistance.MethodsAn online survey was conducted using the Survey Monkey tool. Physicians, nurses and physiotherapists from Argentina with access to PC-CSV in their usual clinical practice were included.ResultsA total of 509 surveys were collected from October to December 2018. Of these, 74.1% were completed by physiotherapists. A total of 77.6% reported using PC-CSV to initiate the partial ventilatory support phase, and 43.8% of respondents select inspiratory pressure support level based on tidal volume. The main objective for selecting positive end-expiratory pressure (PEEP) level was to decrease the work of breathing. High tidal volume was the primary variable for detecting over-assistance, while the use of accessory respiratory muscles was the most commonly chosen for under-assistance. Discrepancies were observed between physicians and physiotherapists in relation to the diagnostic criteria for over-assistance.ConclusionThe most commonly used mode to initiate the partial ventilatory support phase was PC-CSV. The most frequently selected variable to guide the titration of inspiratory pressure support level was tidal volume, and the main objective of PEEP was to decrease the work of breathing. Over-assistance was detected primarily by high tidal volume, while under-assistance by accessory respiratory muscles activation. Discrepancies were observed among professions in relation to the diagnostic criteria for over-assistance, but not for under-assistance.

Efficacy of Noninvasive Positive Pressure Ventilation for Improving the Respiratory Function, Use of Accessory Respiratory Muscles, Quality of Sleep and Nutrition of Cystic Fibrosis Patients

Background: Respiratory failure secondary to recurrent respiratory infections is the most common cause of death in Cystic fibrosis (CF). Objectives: To assess the efficacy of noninvasive positive pressure ventilation (NIPPV) on respiratory function, use of accessory respiratory muscles, ease of physiotherapy for respiratory clearance, quality of sleep and nutritional status in CF patients with respiratory failure. Methods: All CF patients admitted to the pediatric department of Masih Daneshvari hospital, Tehran from March 2015 to January 2016 were studied. The inclusion criteria were clinical evidence of respiratory distress and signs of respiratory acidosis. The exclusion criteria were nausea and vomiting, not tolerating NIPPV, need for intubation, pneumothorax, presence of giant bullous emphysema or decreased level of consciousness. Baseline spirometry and venous blood gas (VBG) was obtained before and after NIPPV. A simple questionnaire was filled out for the nutritional status, sleep quality, ease of physiotherapy for airway clearance and the volume of secretions after NIPPV compared to baseline. Paired samples t-test and Wilcoxon Signed Rank test in SPSS version 16 were used for the before and after comparison of numerical and ordinal variables, respectively. Results: Out of a total of 53 CF hospitalized patients 17 met the inclusion criteria. There were 10 (58.8%) males and 7 (41.1%) females with a mean age of 11 ± 4.57 (10 - 25) years, mean weight of 31.85 ± 10.11 (13 - 48) kg and mean BMI of 14.16 ± 2.71 (5.9 - 18). The mean Saturation of peripheral oxygen (SPO2), respiratory rate (RR) and mean partial pressure of CO2 (PCO2) of patients before the intervention were 75 ± 13.25% (52 - 90%), 32 ± 11.17 (22 - 55) mmHg and 55.20 ± 17.62 (30.3 - 108), mmHg respectively. A significant difference was noted after the intervention in SPO2, venous PCO2 and RR compared to baseline (P < 0.05). The change in sleep quality (P = 0.001), nutritional status (P = 0.001) and ease of physiotherapy for respiratory clearance (P = 0.008) after NIPPV was statistically significant while the change in use of accessory respiratory muscles (P = 0.785) and the volume of secretions (P = 0.1) was not significant. Conclusions: NIPPV in CF patients with respiratory failure can improve the respiratory function, sleep quality and nutritional status of patients. Also, NIPPV enhances airway clearance during respiratory physiotherapy.

Indications of early intubation for patients with inhalation injury.

AimFor patients with inhalation injury, the indications for early intubation are diverse. The purpose of this study was to identify the most reliable symptoms, physical findings, and medical examinations with which to determine the indications for early intubation in patients with inhalation injury.MethodsWe retrospectively collected patient data from medical records. Collected data included age, sex, burn size, symptoms, physical findings, carboxyhemoglobin levels (COHb), and bronchial wall thickness (BWT) determined from chest computed tomography images. We analyzed the relationships between these findings and the early intubation. We performed fiberoptic bronchoscopy in all patients, and analyzed the relationships between bronchoscopic severity and other findings.ResultsOf the 205 patients, 80 patients were diagnosed as having inhalation injury, and 34 patients were intubated. Burn size, facial burns, neck burns, use of accessory respiratory muscles, and COHb seemed to be related with intubation, whereas singed nasal hair was not. If the patients suffered ≥27% total body surface area burn and BWT ≥3.5 mm, the positive predictive value for early intubation was 1.00. If the patients suffered smaller cutaneous burn without neck burn, and their COHb <4.0%, the negative predictive value for early intubation was 0.97. Fiberoptic bronchoscopy findings from above the glottis were mainly related with patients’ symptoms. Findings from below the glottis were mainly related with BWT and COHb.ConclusionsPatients’ symptoms, especially use of accessory respiratory muscles, are reliable, and BWT and COHb are also useful tools, for determining the indication for early intubation.

Relationship between transcutaneous C02 measurement and PAC02 during non invasive ventilation delivered because of hypercapnic acute respiratory failure

Non-invasive ventilation (NIV) is the first line supportive treatment in case of acute hypercapnic respiratory failure (AHRF). NIV efficacy is continuously monitored using clinical parameters (respiratory frequency, use of accessory respiratory muscles). The assessment of NIV efficacy however usually requires repeated blood gas analysis after 30 or 60 minutes of treatment. A reliable non-invasive technique to continuously monitor PaC02 during NIV could simplify this evaluation and allow an earlier adaptation of ventilator settings.

Prediction of short term re-exacerbation in patients with acute exacerbation of chronic obstructive pulmonary disease.

BackgroundThe objective of the study is to develop a scoring system for predicting a 90-day re-exacerbation in hospitalized patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD).MethodsA total of 176 consecutive hospitalized patients with AECOPD were included. The sociodemographic characteristics, status before acute exacerbation (AE), presentations of and treatment for the current AE, and the re-exacerbation in 90 days after discharge from hospital were collected.ResultsThe re-exacerbation rate in 90 days was 48.9% (86 out of 176). It was associated with the degree of lung function impairment (Global initiative for chronic Obstructive Lung Disease [GOLD] grades), frequency of AE in the previous year, and parameters of the current AE, including pleural effusion, use of accessory respiratory muscles, inhaled long-acting β-2-agonists, inhaled corticosteroids, controlled oxygen therapy, noninvasive mechanical ventilation, and length of hospital stay, but was not associated with body mass index, modified Medical Research Council scale, or chronic obstructive pulmonary disease assessment test. A subgroup of ten variables was selected and developed into the re-exacerbation index scoring system (age grades, GOLD grades, AE times in the previous year, pleural effusion, use of accessory respiratory muscles, noninvasive mechanical ventilation, controlled oxygen therapy, inhaled long-acting β-2-agonists and inhaled corticosteroids, and length of hospital stay). The re-exacerbation index showed good discrimination for re-exacerbation, with a C-statistic of 0.750 (P<0.001).ConclusionA comprehensive assessment integrating parameters of stable chronic obstructive pulmonary disease, clinical presentations at exacerbation, and treatment showed a strong predictive capacity for short-term outcome in patients with AECOPD. Further studies are required to verify these findings.

Assessing inhalation injury in the emergency room.

Respiratory tract injuries caused by inhalation of smoke or chemical products are related to significant morbidity and mortality. While many strategies have been built up to manage cutaneous burn injuries, few logical diagnostic strategies for patients with inhalation injuries exist and almost all treatment is supportive. The goals of initial management are to ensure that the airway allows adequate oxygenation and ventilation and to avoid ventilator-induced lung injury and substances that may complicate subsequent care. Intubation should be considered if any of the following signs exist: respiratory distress, stridor, hypoventilation, use of accessory respiratory muscles, blistering or edema of the oropharynx, or deep burns to the face or neck. Any patients suspected to have inhalation injuries should receive a high concentration of supplemental oxygen to quickly reverse hypoxia and to displace carbon monoxide from protein binding sites. Management of carbon monoxide and cyanide exposure in smoke inhalation patients remains controversial. Absolute indications for hyperbaric oxygen therapy do not exist because there is a low correlation between carboxyhemoglobin levels and the severity of the clinical state. A cyanide antidote should be administered when cyanide poisoning is clinically suspected. Although an ideal approach for respiratory support of patients with inhalation injuries do not exist, it is important that they are supported using techniques that do not further exacerbate respiratory failure. A well-organized strategy for patients with inhalation injury is critical to reduce morbidity and mortality.

Analysis of body posture in children with mild to moderate asthma

The mechanical alterations related to the excessive use of accessory respiratory muscles and the mouth breathing observed in children with asthma may lead to the development of alterations in head posture, shoulders, thoracic region and, consequently, in alterations of body posture. The purpose of this study was to assess body posture changes of children with asthma compared to a non-asthmatic control group matched for gender, age, weight, and height. Thirty children with asthma and 30 non-asthmatic children aged 7 to 12 years were enrolled in this study. Digital photographic records were obtained for analysis of the body posture of the children by computed photogrammetry. The intraclass correlation coefficient and Student's t test (p < 0.05) were used for statistical analysis. There were no significant differences between groups for the angles analyzed, except for the knee flexor angle. These results demonstrate that children with asthma did not present postural alterations compared to non-asthmatic controls since the only angle for which there was a significant difference between groups showed weak reproducibility. The findings of this study do not support the notion that children with asthma present alterations in body posture.

NIPSV for acute cardiogenic pulmonary oedema does not increase the risk of myocardial infarction compared to CPAP

Acute cardiogenic pulmonary oedema (ACPO) can be managed with either non-invasive pressure support ventilation (NIPSV) or non-invasive continuous positive airway pressure (CPAP). Does management with NIPSV increase the risk of myocardial infarction compared to management with CPAP? Randomised controlled trial with concealed allocation. High-dependency unit of a hospital emergency department in Turin, Italy. 52 adults with severe ACPO, defined as acute dyspnoea, > 30 breaths per minute, use of accessory respiratory muscles, oxygen saturation (SpO 2 ) < 90% with F i O 2 60%, and radiological signs of ACPO. Patients with signs of acute coronary syndrome (ACS) on hospital admission were excluded from the study. All patients received standard medications (diuretic, nitroglycerin, morphine) and oxygen. NIPSV was applied by a Pulmonetics Systems LTV 1000 ventilator. CPAP was administered by means of a flow generator (Whisper-Flow) with an expiratory (PEEP) valve. Patients randomised to NIPSV (n = 25) received sufficient inspiratory pressure (IPAP) to generate a tidal volume of ∼7 mL/kg, and oxygen to maintain SpO 2 at ∼93%, via an oronasal mask. Expiratory pressure (EPAP) was gradually increased until SpO 2 ≥ 96% (maximum of 12 cmH 2 O). Those randomised to CPAP (n = 27) commenced at 5 cmH 2 O via an oronasal mask with oxygen to maintain SpO 2 at ∼93%. The CPAP was gradually increased until SpO 2 ≥ 96% (maximum of 12 cmH 2 O). Treatment failure was defined as cardiac arrest, respiratory distress and arterial blood gas deterioration for > 60 min, PaO 2 /F i O 2 < 100 mmHg, coma or psychomotor agitation, haemodynamic instability, or life-threatening arrhythmias. Otherwise, treatment continued until the participant met objective criteria of recovery. The primary outcome was the rate of acute myocardial infarction (AMI). Secondary outcomes included rate of endotracheal intubation, death, duration of ventilatory assistance, and lengths of stay in the hospital and high-dependency unit. In the NIPSV group, the average EPAP and IPAP applied were 7 ± 1 and 15 ± 3 cm H 2 O, respectively. In the CPAP group, the mean pressure applied was 9 ± 2 cm H 2 O. AMI occurred in four patients on NIPSV and eight patients on CPAP, which was not significantly different, absolute risk reduction (ARR) 0.14, 95% CI –0.10 to 0.34. Also not significantly different were the number of intubations with only one in the NIPSV group, ARR –0.04, 95% CI –0.20 to 0.09, and the number of deaths with three in the NIPSV group and two in the CPAP group, ARR –0.05, 95% CI –0.23 to 0.13. The lengths of stay in hospital and in the high-dependency unit also did not significantly differ between the groups. This study demonstrated no significant difference in AMI among patients with ACPO managed with NIPSV versus CPAP.

FDG Uptake in Intercostal Muscles is an Indicator of Severe Respiratory Disease

A 40-year-old man with a history of pharyngeal wall cancer status postradiation therapy for 6 months underwent FDG-PET scan twice with in an interval of 5 months. The first PET images were normal. On the later PET images,incidental increased FDG uptake was noted in the intercostal muscles and in bilateral diaphragmatic crura. The patient had shortness of breath and a chest x-ray revealed marked biapical pleural thickening and scarring consistent with radiation fibrosis. This case demonstrates that FDG uptake in intercostal muscles in PET imaging can be an indicator of respiratory dysfunction and the use of accessory respiratory muscles.

Steroids and the Acute Management of Viral-Induced Wheezing

Emergency Medicine| March 01 2004 Steroids and the Acute Management of Viral-Induced Wheezing AAP Grand Rounds (2004) 11 (3): 31–32. https://doi.org/10.1542/gr.11-3-31 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Steroids and the Acute Management of Viral-Induced Wheezing. AAP Grand Rounds March 2004; 11 (3): 31–32. https://doi.org/10.1542/gr.11-3-31 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: steroids, wheezing, prednisolone Source: Csonka P, Kaila M, Laippala P, et al. Oral prednisolone in the acute management of children age 6 to 35 months with viral respiratory infection-induced lower airway disease: a randomized placebo-controlled trial. J Pediatr. 2003:143:725–730. Although bronchiolitis is a self-limiting disease for most patients, some have prolonged symptoms and require hospitalization. The use of steroids in the acute management of bronchiolitis in infants and young children remains controversial. Therefore, investigators at the Pediatric Research Center, Tampere University Hospital in Tampere, Finland completed a randomized, double-blind, placebo-controlled study on 230 children, age 6 to 35 months, who were seen in the emergency department (ED) with acute wheezing, tachypnea, or use of accessory respiratory muscles in the presence of an apparent viral respiratory infection (rhinorrhea or temperature >37.5°C). Patients with asthma were excluded. Eligible patients were randomized to receive either 2 mg/kg of oral prednisolone in the ED and 1 mg/kg twice daily for 3 more days, or an equivalent amount of placebo. Hospitalization and the use of other bronchodilator medications were at the discretion of the attending physicians. The primary outcome measured was development of severe respiratory symptoms that required additional asthma medications. Secondary outcomes included hospitalization rate from the ED, hospital length of stay, long hospitalizations (≥3 days), and duration of symptoms. There was no difference in hospitalization rate between the 2 groups, with 53% of placebo patients and 54% of prednisolone patients requiring admission. Of the hospitalized patients, a larger number who received placebo needed additional asthma medications (39%) than those that received prednisolone (19%, P=.018). Median length of stay in the hospital was shorter in the prednisolone group (2.0 versus 3.0 days, P=.06), and fewer prednisolone patients required prolonged hospitalizations (47.5% versus 67.7%, P=.023). Median duration of symptoms was also less in the prednisolone group (1.0 versus 2.0, P<.001). Several studies have been published on the effectiveness of steroids in bronchiolitis, and they have led to varying conclusions.1–,5 A recent study of ED patients who received 1 mg/kg of dexamethasone or placebo showed a lower hospitalization rate in the steroid group (19% versus 44%).1 Other studies including a meta-analysis have shown significant improvement in symptoms and length of hospitalization when steroids are provided to patients with bronchiolitis.2,3 However, there are other published trials of steroid use in bronchiolitis that showed no efficacy.4,5 The current study adds further evidence that steroids provide a significant benefit to patients with bronchiolitis. However, there are some methodologic features of the present study that require careful consideration. Despite the authors’ attempts to concentrate on "a relatively homogenous group of children," the lack of viral testing most likely resulted in the inclusion of a heterogenous group of study subjects. Enrollment included patients up to age 35 months, with a mean age of over 16 months in both randomized groups. This represents an older study population than most other studies. This study also included patients that... You do not currently have access to this content.

Effect of asthma on the quality of life among children and their caregivers in the Atlanta Empowerment Zone.

Asthma is the most common chronic pediatric disease and exacts a toll on the health-related quality of life of affected children and their primary caregivers. This investigation describes the relationship between the clinical severity of asthma among inner-city children and their quality of life and that of their primary adult caregivers. Telephone interview data were collected from individual adult caregivers of 5-12-year-old children with asthma. Questions addressed the history, diagnosis, and management of the child's asthma, the child's family and social background, the family's socioeconomic status, the caregiver's knowledge and attitude about asthma, and the health-related quality of life of both the child and the caregiver. An asthma severity score was calculated from the caregiver's responses to questions about their child's wheezing frequency, nocturnal and early morning symptoms, and speaking during an asthma attack, as well as the impact of the disease on their child's physical activity and breathing during the prior 4-month period. A clinical asthma triage score was determined from information collected at the emergency department about the child's oxygen saturation, alertness, use of accessory respiratory muscles, extent of breathlessness, and peak expiratory flow. Spearman correlation coefficients were used to identify association between quality of life and disease severity, caretaker's asthma knowledge, and functional impact of asthma symptoms. Data from 240 of 755 eligible children were analyzed. Most children were younger than 11 years, male, black, and non-Hispanic. The children's median duration of asthma diagnosis was 86% of their life (range less than 1 to 11.3 years, median 5.0 years). Of the primary caregivers, 69% had at least completed high school, and 90% reported a total monthly household income of $1,600 or less. The maximum possible quality-of-life score and the median for caregivers were 91 and 70, respectively; for children, the same scores were 69 and 58, respectively. In addition, there was significant negative correlation of the quality-of-life scores of both the caregivers and children with the number of schooldays the children missed (r = -0.24 and r = -0.26, respectively, P < .001 for both) and the caregivers' and children's asthma severity scores (r = -0.39 and r = -0.47, respectively, P < .001 for both). The quality-of-life scores of the children and caregivers did not correlate significantly with the asthma triage scores. The questionnaires captured baseline quality-of-life information about this urban population and will facilitate longitudinal monitoring. The fact that the quality-of-life scores of children with asthma correlated with those of their adult caregivers, but not with their clinical triage scores, highlights the impact of asthma on families and the importance of having a long-term comprehensive management plan that is not based on exacerbations, but that includes both the children and their primary caregivers.

Urgent adenotonsillectomy for upper airway obstruction

Adenotonsillar hypertrophy has been documented to cause chronic upper airway obstruction resulting in cardiopulmonary sequelae in children. It has been less recognized that long-term adenotonsillar hypertrophy may additionally cause acute, life-threatening airway obstruction. A review of 5000 adenotonsillectomies performed at 3 New York Medical College affiliated hospitals from 1982 to 1989 showed 6 pediatric patients with progressive upper airway obstruction severe enough to necessitate intubation in the emergency room or operating room, and subsequent urgent adenotonsillectomy after cardiorespiratory stabilization. Patients were monitored in the ICU with pre- and postoperative blood gases. Observations of cyanosis, cor pulmonale, and use of accessory respiratory muscles were carefully recorded. This study illustrates that life-threatening upper airway obstruction may be due to chronic adenotonsillar enlargement and require treatment by urgent adenotonsillectomy.