Use Of Noninvasive Positive Pressure Ventilation Research Articles

Airway Management With Noninvasive Positive Pressure Ventilation.

Noninvasive positive-pressure ventilation (NPPV) is a form of ventilatory support that does not require the placement of an advanced airway. The authors discuss the use of NPPV on patients who will likely benefit. The use of NPPV has reduced the need for patients to require intubation and/or mechanical ventilation in some cases, as well as benefits.

Out-of-hospital, non-invasive, positive-pressure ventilation for acute dyspnea.

BackgroundEmergency medical services (EMS) patients with acute dyspnea require prompt treatment. Limited data describe out‐of‐hospital dyspnea treatment with non‐invasive, positive‐pressure ventilation (NIPPV), including continuous positive airway pressure (CPAP) or bi‐level positive air pressure (BPAP). We sought to determine the course and outcomes of out‐of‐hospital acute dyspnea patients treated with NIPPV.MethodsWe analyzed retrospective data on 1289 EMS agencies from the ESO Data Collaborative (ESO, Inc., Austin, TX) between January and December 2018. We defined acute dyspnea as adults with an initial respiratory rate ≥ 30 breaths/min (bpm), with a primary or secondary EMS subjective impression of a respiratory condition, who received oxygen and/or a respiratory medication and had 2 or more recordings of respiratory rate (RR). We excluded patients with trauma and those with altered mental status. We identified cases receiving care with and without NIPPV. The primary outcome was change in respiratory rate (RR), censored at 90 minutes of treatment. We compared baseline characteristics between NIPPV and non‐NIPPV patients. We compared RR changes between NIPPV and non‐NIPPV patients at 20 and 40 minutes of treatment. Using mixed linear, fractional polynomial, and multiple spline models, we examined the association of out‐of‐hospital NIPPV with overall change in RR. Secondary outcomes included whether the patient received advanced airway treatment (intubation, supraglottic airway device, and/or cricothyroidotomy).ResultsWe analyzed 33,585 EMS encounters for patients with acute dyspnea, including 8,750 (26.1%) NIPPV and 24,835 (73.9%) non‐NIPPV encounters. Median treatment duration was similar between NIPPV and non‐NIPPV (23.3 minutes vs 23.6 minutes, rank‐sum P = 0.266). Common concurrent treatments included albuterol (NIPPV, 48.8%; non‐NIPPV, 46.2%), ipratropium bromide (27.9%, 24.8%), and methylprednisolone (24.9%, 18.5%). At 20 minutes, mean RR change was slightly lower for the NIPPV group than non‐NIPPV; −6.0 versus −6.8 breaths/min. At 40 minutes, mean RR change was similar between NIPPV and non‐NIPPV groups; −7.7 versus −7.9 breaths/min. On linear mixed modeling adjusted for age, sex, incident location, race, ethnicity, agency type, initial RR, and medication use, NIPPV was associated with a smaller RR decrease across time than NIPPV; [NIPPV × time] interaction P < 0.001. Out‐of‐hospital advanced airway placement (endotracheal intubation or supraglottic airway insertion) was higher for NIPPV than non‐NIPPV group (2.3% vs 1.3%, odds ratio = 2.23, 95% confidence interval = 2.01–2.47).ConclusionsNIPPV has been proven to be an effective treatment for out‐of‐hospital patients experiencing acute dyspnea through prior studies. Our findings provide detailed insight into characteristics and use of NIPPV and highlight the commonality of this treatment modality with use in over 1 in 4 patients in respiratory distress.

Association of Non-Invasive Positive Pressure Ventilation with Short-Term Clinical Outcomes in Patients Hospitalized for Acute Decompensated Heart Failure.

The real-world evidence has been sparse on the impact of non-invasive positive pressure ventilation (NPPV) on the outcomes in acute decompensated heart failure (ADHF) patients. We aim to explore this issue in the prospective multicenter WET-HF registry. Among 3927 patients (77 (67–84) years, male 60%), the NPPV was used in 775 patients (19.7%). The association of NPPV use with in-hospital outcome and length of hospital stay (LOS) was examined by two methods, propensity score (PS) matching and multivariable analysis with adjustment for PS. In these analyses the NPPV group exhibited a lower endotracheal intubation (ETI) rate and a comparable in-hospital mortality, but longer LOS compared to the non-NPPV group. In the stratified analysis, the NPPV group exhibited a significantly lower ETI rate in patients with ischemic etiology, systolic blood pressure (sBP) > 140 mmHg and the Controlling Nutritional Status (CONUT) score ≤ 3, indicating better nutritional status. On the contrary, NPPV use was associated with longer LOS in patients with non-ischemic etiology, sBP < 100 mmHg and CONUT score > 3. In conclusion, NPPV use was associated with a lower incidence of ETI. Particularly, patients with ischemic etiology, high sBP, and better nutritional status might benefit from NPPV use.

Heart Failure Patients and Implications of Obesity: A Single-Center Retrospective Study.

Background and objectiveThe prevalence of heart failure (HF) is on the rise; currently, it affects around five million people in the United States (US) and the prevalence is expected to rise from 2.42% in 2012 to 2.97% in 2030. HF is a leading cause of hospitalizations and readmissions, accounting for a major economic burden to the US healthcare system. Obesity is a widely accepted risk factor of HF; however, data regarding its independent association with HF mortality and morbidity is heterogeneous. Globally, more than two-thirds of deaths attributable to high body mass index (BMI) are due to cardiovascular diseases (CVD). This study aimed to investigate the potential role of obesity (BMI >30 Kg/m2) in HF patients in terms of 30-day readmissions, in-hospital mortality, and the use of noninvasive positive pressure ventilation (NIPPV).MethodsIn this single-center, retrospective study, all adult (age: >18 years) patients who were hospitalized with a primary diagnosis of HF at the Abington Jefferson Hospital from January 2015 to January 2018 were included. Demographic characteristics were collected manually from electronic medical records. Outcomes were 30-day readmission due to HF, all-cause in-hospital mortality, and requirement for NIPPV. Multivariable logistic regression analysis was conducted to investigate the association of obesity with HF outcomes.ResultsA total of 1,000 patients were initially studied, of these 800 patients were included in the final analysis based on the inclusion criteria. Obese patients showed higher odds for 30-day readmissions and the use of NIPPV compared to non-obese patients. There was no significant difference in in-hospital mortality in obese vs. non-obese patients.ConclusionsBased on our findings, BMI >30 Kg/m2 is an independent risk factor for HF readmissions. Additionally, our results highlight the importance of guidelines-directed medical therapy (GDMT) for HF exacerbation, a low threshold for use of NIPPV in obese patients, promotion of lifestyle modifications including weight loss, and early follow-up after discharge to prevent HF readmissions in the obese population.

Post-extubation oxygenation strategies in acute respiratory failure: a systematic review and network meta-analysis

BackgroundHigh-flow nasal cannula oxygenation (HFNC) and noninvasive positive-pressure ventilation (NPPV) possibly decrease tracheal reintubation rates better than conventional oxygen therapy (COT); however, few large-scale studies have compared HFNC and NPPV. We conducted a network meta-analysis (NMA) to compare the effectiveness of three post-extubation respiratory support devices (HFNC, NPPV, and COT) in reducing the mortality and reintubation risk.MethodsThe Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Ichushi databases were searched. COT, NPPV, and HFNC use were assessed in patients who were aged ≥ 16 years, underwent invasive mechanical ventilation for > 12 h for acute respiratory failure, and were scheduled for extubation after spontaneous breathing trials. The GRADE Working Group Approach was performed using a frequentist-based approach with multivariate random-effect meta-analysis. Short-term mortality and reintubation and post-extubation respiratory failure rates were compared.ResultsAfter evaluating 4631 records, 15 studies and 2600 patients were included. The main cause of acute hypoxic respiratory failure was pneumonia. Although NPPV/HFNC use did not significantly lower the mortality risk (relative risk [95% confidence interval] 0.75 [0.53–1.06] and 0.92 [0.67–1.27]; low and moderate certainty, respectively), HFNC use significantly lowered the reintubation risk (0.54 [0.32–0.89]; high certainty) compared to COT use. The associations of mortality with NPPV and HFNC use with respect to either outcome did not differ significantly (short-term mortality and reintubation, relative risk [95% confidence interval] 0.81 [0.61–1.08] and 1.02 [0.53–1.97]; moderate and very low certainty, respectively).ConclusionNPPV or HFNC use may not reduce the risk of short-term mortality; however, they may reduce the risk of endotracheal reintubation.Trial registration number and date of registrationPROSPERO (registration number: CRD42020139112, 01/21/2020).

Non – Invasive Ventilation in Patients with Type 2 Respiratory Failure

Non-invasive positive pressure ventilation (NIPPV) as an alternative to the endotracheal intubation is associated with less infectious complications and injury to the airways. In a study cohort which included 50 patients with type 2 respiratory failure with the commonest diagnosis of copd exacerbation with or without associated co-morbidities, mechanical ventilation with nippv was applied and the response was observed. There was significant improvement with nippv in form of increase in pH, pao2 and decrease in paco2 and hco3 after one hour of nippv application which also persisted after successful weaning. This is a prospective and Observational study was carried out during April 2018 to March 2019. In a BiPAP mode inspiratory pressure (IP) is kept 8-10 cm above the end-expiratory pressure (EP). If PSV mode used for NIPPV the IP to start with was kept on 15-20 cm H2O with a small PEEP of 4-5 cm H2O. Nippv was successful in 84 patients in our study cohort with 62 patients weaned successfully off Nippv. Use of NIPPV was associated with lesser risk of nosocomial infections, less antibiotic use and lower mortality as compared to patients who are equally ill and do not received Nippv. Nippv is a METHOD of providing ventilatory support using a noninvasive interface with the patient and thus circumvents the complications of invasive mechanical ventilation like ventilatorassociatedpneumonias (vap), injury to airways, barotrauma and post intubation laryngeal and tracheal stenosis.The study, demonstrated that nippv is not only a feasible ventilatory modality but also a treatment that is associated with significant improvements in clinical outcomes.

Effectiveness and safety of noninvasive positive pressure ventilation in the treatment of COVID-19-associated acute hypoxemic respiratory failure: a single center, non-ICU setting experience.

The role of noninvasive positive pressure ventilation (NIPPV) in COVID-19 patients with acute hypoxemic respiratory failure (AHRF) is uncertain, as no direct evidence exists to support NIPPV use in such patients. We retrospectively assessed the effectiveness and safety of NIPPV in a cohort of COVID-19 patients consecutively admitted to the COVID-19 general wards of a medium-size Italian hospital, from March 6 to May 7, 2020. Healthcare workers (HCWs) caring for COVID-19 patients were monitored, undergoing nasopharyngeal swab for SARS-CoV-2 in case of onset of COVID-19 symptoms, and periodic SARS-CoV-2 screening serology. Overall, 50 patients (mean age 74.6 years) received NIPPV, of which 22 (44%) were successfully weaned, avoiding endotracheal intubation (ETI) and AHRF-related death. Due to limited life expectancy, 25 (50%) of 50 NIPPV-treated patients received a “do not intubate” (DNI) order. Among these, only 6 (24%) were weaned from NIPPV. Of the remaining 25 NIPPV-treated patients without treatment limitations, 16 (64%) were successfully weaned, 9 (36%) underwent delayed ETI and, of these, 3 (33.3%) died. NIPPV success was predicted by the use of corticosteroids (OR 15.4, CI 1.79–132.57, p 0.013) and the increase in the PaO2/FiO2 ratio measured 24–48 h after NIPPV initiation (OR 1.02, CI 1–1.03, p 0.015), while it was inversely correlated with the presence of a DNI order (OR 0.03, CI 0.001–0.57, p 0.020). During the study period, 2 of 124 (1.6%) HCWs caring for COVID-19 patients were diagnosed with SARS-CoV-2 infection. Apart from patients with limited life expectancy, NIPPV was effective in a substantially high percentage of patients with COVID-19-associated AHRF. The risk of SARS-CoV-2 infection among HCWs was low.

Association of Non-Invasive Respiratory Support with Mortality and Intubation Rates in Acute Respiratory Failure: A Systematic Network Meta-Analysis

Background: Non-invasive respiratory support devices may reduce the tracheal intubation rate compared with conventional oxygen therapy (COT). To date, few studies have compared high-flow nasal cannula (HFNC) use with non-invasive positive-pressure ventilation(NPPV). We conducted a network meta-analysis (NMA) to compare the effectiveness of three respiratory support devices in patients with acute respiratory failure. Methods: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Ichushi databases were searched. Adults ≥16 years of age with acute hypoxic respiratory failure and randomised controlled trials that compared two different respiratory support devices(COT,NPPV, or HFNC) before tracheal intubation were included. NMA was performed using a frequentist-based approach with multivariate random effects meta-analysis. The meta-analysis was performed using the GRADE Working Group Approach for an NMA. The primary outcome was short-term mortality, and the secondary outcome was the rate of intubation. Findings: Among 5,093 records, 25 studies (4,372 patients) were included. Compared with COT, NPPV and HFNC tended to reduce mortality (relative risk, 0·88 and 0·92; 95% confidence interval 0·76–1.01 and 0·80–1·07; low and moderate certainties, respectively); however, a significantly lower risk of endotracheal intubation(0·81 and 0·79; 0·71–0·91 and 0·69–0·91; low and moderate certainty, respectively) was observed. There were no significant differences in short-term mortality or endotracheal intubation (0·95 and 1·02;0·78–1·16 and0·86–1·20; respectively; both low certainty) for NPPV and HFNC use. Interpretation: NPPV and HFNC are associated with decreased endotracheal intubation risk, but there are no significant differences in short-term mortality. Funding: None. Declaration of Interests: The authors declare no competing interests.

SUCCESSFUL USE OF HIGH FLOW NASAL CANNULA OUTSIDE OF THE CRITICAL CARE AREAS

SESSION TITLE: Respiratory Care Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: We continued to monitor and adjust our High Flow Nasal Cannula (HFNC) use in all areas. Our previous success of HFNC use outside of the critical care areas on our medical floors resulted in decreased ICU days and decreased noninvasive positive pressure ventilation (NIPPV) use. This study continues to evaluate the success of our HFNC use, including where to care for the patient, as well as whether we continue to use HFNC instead of NIPPV. Prior to our initiation of HFNC use on the medical floors, all patients on HFNC would have gone to the ICU on NIPPV. METHODS: We evaluated all patients on HFNC from 1/1/2016 to 12/31/2019. We looked at where HFNC was initiated, whether it was used on the medical floors or whether an ICU admission was needed. If an ICU transfer occurred, we then reviewed each case to determine if that patient required an escalation to NIPPV once in ICU. We then looked at the number of HFNC and NIPPV treatments from 1/1/2011 to 12/31/2019. RESULTS: From 2016-19 there were 1,517 patients admitted through the Emergency Department that were placed on HFNC. 564 patients were admitted directly to the medical floor on HFNC. 70 of these patients required a transfer to the ICU, where only 26 required NIPPV (26/564, 4.6%). 1,023 patients were admitted to the ICU and 568 were managed without NIPPV (56%). 188 patients were discharged to the floor from the ICU on HFNC, with none requiring rescue NIPPV. 129 HFNC ICU patients required NIPPV. 188 patients initially on NIPPV were transitioned to HFNC. 138 patients were on both during the day of admission to the ICU, not clear which was used first. HFNC patients treated on the medical floors were managed successfully without NIPPV 95.6% of the time. 494 ICU admissions were avoided, and many ICU days were decreased using HFNC. Over the 9-year period, there was a large increase in treatments with a shrinking percentage of NIPPV use. The average days on NIPPV was 1.65 and on HFNC was 2.96, many of these days on the floors. The average direct cost for patients treated with NIPPV, without HFNC, was $19,475. The average direct cost for HFNC, and no NIPPV was $10,194. CONCLUSIONS: Patients requiring HFNC can be safely managed outside of the critical care areas. Overall hospital costs were reduced. CLINICAL IMPLICATIONS: Managing HFNC outside of the critical care areas can free up ICU resources and decrease NIPPV use. Decreased NIPPV use allows for increased available therapist time, as NIPPV is time and labor-intensive for RTs. DISCLOSURES: Consultant relationship with Monaghan Medical Please note: $1001 - $5000 Added 03/02/2020 by Russell Acevedo, source=Web Response, value=Travel Consultant relationship with Vapotherm Please note: $1001 - $5000 Added 03/02/2020 by Russell Acevedo, source=Web Response, value=Travel Consultant relationship with Fisher & Paycal Please note: $1001 - $5000 Added 03/02/2020 by Russell Acevedo, source=Web Response, value=Grant/Research Support Consultant relationship with Fisher & Paykel Please note: $1001 - $5000 Added 03/03/2020 by Wendy Fascia, source=Web Response, value=Travel Consultant relationship with Fisher & Paykel Please note: $1001 - $5000 Added 03/03/2020 by Wendy Fascia, source=Web Response, value=Travel Removed 03/03/2020 by Wendy Fascia, source=Web Response Speaker/Speaker's Bureau relationship with Fisher Paykel Please note: $1001 - $5000 Added 03/03/2020 by Jennifer Pedley, source=Web Response, value=Travel

Critically Ill Adults With Coronavirus Disease 2019 in New Orleans and Care With an Evidence-Based Protocol

BackgroundCharacteristics of critically ill adults with coronavirus disease 2019 (COVID-19) in an academic safety net hospital and the effect of evidence-based practices in these patients are unknown.Research QuestionWhat are the outcomes of critically ill adults with COVID-19 admitted to a network of hospitals in New Orleans, Louisiana, and what is an evidence-based protocol for care associated with improved outcomes?Study Design and MethodsIn this multi-center, retrospective, observational cohort study of ICUs in four hospitals in New Orleans, Louisiana, we collected data on adults admitted to an ICU and tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) between March 9, 2020 and April 14, 2020. The exposure of interest was admission to an ICU that implemented an evidence-based protocol for COVID-19 care. The primary outcome was ventilator-free days.ResultsThe initial 147 patients admitted to any ICU and tested positive for SARS-CoV-2 constituted the cohort for this study. In the entire network, exposure to an evidence-based protocol was associated with more ventilator-free days (25 days; 0-28) compared with non-protocolized ICUs (0 days; 0-23, P = .005), including in adjusted analyses (P = .02). Twenty patients (37%) admitted to protocolized ICUs died compared with 51 (56%; P = .02) in non-protocolized ICUs. Among 82 patients admitted to the academic safety net hospital’s ICUs, the median number of ventilator-free days was 22 (interquartile range, 0-27) and mortality rate was 39%.InterpretationCare of critically ill COVID-19 patients with an evidence-based protocol is associated with increased time alive and free of invasive mechanical ventilation. In-hospital survival occurred in most critically ill adults with COVID-19 admitted to an academic safety net hospital’s ICUs despite a high rate of comorbidities.

Progression of Respiratory Support Following Pediatric Extubation.

High-flow nasal cannula and noninvasive positive pressure ventilation have become ubiquitous in contemporary PICUs. Practice patterns associated with the use of these modalities have not been well described. In this study, we aimed to describe the use of high-flow nasal cannula and noninvasive positive pressure ventilation in children after extubation and analyze the progression of usage in association with patient factors. Our secondary aim was to describe interventions used for postextubation stridor. Single-center retrospective cohort study. A 36-bed quaternary medical-surgical PICU. Mechanically ventilated pediatric patients admitted between April 2017 and March 2018. Exclusions were patients in the cardiac ICU, patients requiring a tracheostomy or chronic ventilatory support, and patients with limited resuscitation status. None. Data regarding respiratory modality use was collected for the first 72 hours after extubation. There were 427 patients included in the analysis; 51 patients (11.9%) were extubated to room air, 221 (51.8%) to nasal cannula, 132 (30.9%) to high-flow nasal cannula, and 23 (5.4%) to noninvasive positive pressure ventilation. By 72 hours, 314 patients (73.5%) were on room air, 52 (12.2%) on nasal cannula, 29 (6.8%) on high-flow nasal cannula, eight (1.9%) on noninvasive positive pressure ventilation, and 24 (5.6%) were reintubated. High-flow nasal cannula was the most used respiratory modality for postextubation stridor. Multivariate analysis demonstrated that longer duration of invasive mechanical ventilation increased the odds of initial high-flow nasal cannula and noninvasive positive pressure ventilation use, and a diagnosis of cerebral palsy increased the odds of escalating from high-flow nasal cannula to noninvasive positive pressure ventilation in the first 24 hours post extubation. High-flow nasal cannula is commonly used immediately after pediatric extubation and the development of postextubation stridor; however, its usage sharply declines over the following 72 hours. Larger multicenter trials are needed to identify high-risk patients for extubation failure that might benefit the most from prophylactic use of high-flow nasal cannula and noninvasive positive pressure ventilation after extubation.

Effect of the COVID-19 Pandemic on Acute Respiratory Care of Hypoxemic Patients With Acute Heart Failure in Japan - A Cross-Sectional Study.

Background: The effect of the COVID-19 pandemic on the respiratory management strategy with regard to the use of non-invasive positive pressure ventilation (NPPV) and high-flow nasal cannula (HFNC) in patients with acute heart failure (AHF) in Japan is unclear.Methods and Results: This cross-sectional study used a self-reported online questionnaire, with responses from 174 institutions across Japan. More than 60% of institutions responded that the treatment of AHF patients requiring respiratory management became fairly or very difficult during the COVID-19 pandemic than earlier, with institutions in alert areas considering such treatment significantly more difficult than those in non-alert areas (P=0.004). Overall, 61.7% and 58.8% of institutions changed their indications for NPPV and HFNC, respectively. Significantly more institutions in the alert area changed their practices for the use of NPPV and HFNC during the COVID-19 pandemic (P=0.004 and P=0.002, respectively). When there was insufficient time or information to determine whether AHF patients may have concomitant COVID-19, institutions in alert areas were significantly more likely to refrain from using NPPV and HFNC than institutions in non-alert areas.Conclusions: The COVID-19 pandemic has compelled healthcare providers to change the respiratory management of AHF, especially in alert areas.

Long-term outcome with focus on pulmonary hypertension in Obesity Hypoventilation Syndrome.

Pulmonary Hypertension (PH) is a frequent comorbidity in Obesity Hypoventilation Syndrome (OHS). We investigated long-term outcome of OHS with a particular emphasis on PH. In a prospective design, 64 patients with OHS and established noninvasive positive pressure ventilation (NPPV), were assessed by serum biomarkers, right heart catheterization, blood gases analysis, lung function, Epworth-Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), World Health Organization-functional class (WHO-FC) and health-related quality of life (HRQL) via the Severe Respiratory Insufficiency (SRI) questionnaire. After a planned follow-up of 5years patients were reassessed regarding vital status, WHO-FC, ESS, SRI, PSQI, body mass index (BMI) and NPPV use. Prognostic markers were explored using univariate and multivariate Cox regression analyses. At the 5-year follow-up, BMI tended to decrease (P=0.05), while WHO-FC, ESS and PSQI remained unchanged. HRQL deteriorated in terms of SRI summary score and most subdomains (P<.05 each). NPPV adherence still was high (89%), while daily NPPV use increased from 6.7 (5.1; 8.0)h/d to 8.2 (7.4; 9.0)h/d (P<.05). After a 5-year follow-up, mortality was 25.8%. In univariate regression analyses only age>69.5years (HR=4.145, 95%-CI=1.180-14.565, P=0.016), NT-proBNP>1256pg/mL (HR=5.162, 95%-CI=1.136-23.467, P=0.018), diffusion capacity for carbon monoxide (DLCO, %pred) (HR=0.341, 95%-CI=0.114-1.019, P=0.043) and higher oxygen use during daytime (HR=5.236, 95%-CI=1.489-18.406, P=0.004) predicted mortality. No independent factor predicting mortality was detected in multivariate analysis. Despite a high long-term NPPV use HRQL worsened. Age, oxygen use at baseline, DLCO (%pred) and NT-proBNP, as a surrogate parameter for PH, were related to long-term survival.

1264 Innovation and Ingenuity to Improve Treatment Efficacy of Non-Invasive Positive Pressure Ventilation

Abstract Introduction Use of chronic non-invasive-positive-pressure ventilation (NIPPV) in individuals with neuromuscular disease allows for increased independence and mobility in this population. Optimal mask fit is imperative due to the chronic and extensive device use. Commonly cited side effects of improper mask fit include air leak, dermatitis, skin breakdown, nasal discomfort, and claustrophobia. Report of Case This is a case report of a 46-year-old female with rigid spine muscular dystrophy leading to chronic hypercarbic respiratory failure secondary to neuromuscular weakness and thoracic cage abnormalities. The patient is dependent on continuous use of NIPPV with a PLV 100 device (Philips Respironics; discontinued model). The patient prefers this model because of its unique ventilation delivery mode, which allows her to pause breaths to speak. The patient developed a significant air leak with her nasal mask and was unable to be fitted properly with commercially available nasal masks. In order to minimize her air leak her husband used an innovative approach using 3D printing technology. He created a 3D print of her facial and nose features and then used this to print a 3D mask. Additionally he 3D printed silicone nose clips, that reinforced the seal on the outside of her nose. The patient had a significant decrease in her air leak and subjectively reported improved comfort with use of the 3D printed mask. Conclusion This represents a case where application of ingenuity and innovative technology improved treatment efficacy and compliance with NIPPV. The combination of 3D custom fit mask (currently available from a limited number of vendors), with custom fit nasal clips may possibly be applied to a wider category of patients with similar complaints of nasal discomfort and frequent air leaks.

Diaphragm Atrophy During Pediatric Acute Respiratory Failure Is Associated With Prolonged Noninvasive Ventilation Requirement Following Extubation.

Diaphragm atrophy is evident during invasive ventilation for pediatric acute respiratory failure, but with unknown significance. We hypothesized that diaphragm atrophy in pediatric acute respiratory failure is associated with prolonged noninvasive positive pressure ventilation following extubation. Prospective observational study. Single-center academic PICU. Invasively ventilated children with acute respiratory failure. Diaphragm ultrasound was performed within 36 hours after intubation and repeated within 48 hours preceding extubation. Rapid shallow breathing index at 15 and 30 minutes of a spontaneous breathing trial and negative inspiratory force were collected in a subset of patients concurrently with the ultrasound measurements. Diaphragm thickness at end-expiration was measured to assess for diaphragm atrophy during mechanical ventilation. Percentage change in diaphragm thickness at end-expiration was defined as baseline diaphragm thickness at end-expiration minus final, preextubation diaphragm thickness at end-expiration divided by baseline diaphragm thickness at end-expiration. The primary outcome measure was duration of noninvasive positive pressure ventilation following extubation with prolonged use defined as noninvasive positive pressure ventilation use for greater than 24 hours postextubation. Among 56 children, 47 (median age, 15.5 mo; interquartile range, 6-53 mo) had diaphragm thickness at end-expiration measured within 48 hours prior to extubation. Fourteen (30%) had prolonged noninvasive positive pressure ventilation use with median duration 110 hours (interquartile range, 52-130 hr). The median percentage change of diaphragm thickness at end-expiration from baseline among those with and without prolonged noninvasive positive pressure ventilation use was -20% (interquartile range, -32% to -10%) versus -7% (interquartile range, -21% to 0%) (p = 0.04). Diaphragm atrophy is associated with prolonged postextubation noninvasive positive pressure ventilation in children with acute respiratory failure. Serial bedside diaphragm ultrasound may identify children at risk for prolonged noninvasive positive pressure ventilation use after extubation.

Non-invasive respiratory support for patients with novel coronavirus pneumonia: clinical efficacy and reduction in risk of infection transmission.

Non-invasive respiratory support for patients with novel coronavirus pneumonia: clinical efficacy and reduction in risk of infection transmission.

Noninvasive respiratory support in the hypoxaemic peri-operative/periprocedural patient: A joint ESA/ESICM guideline.

: Hypoxaemia is a potential life-threatening yet common complication in the peri-operative and periprocedural patient (e.g. during an invasive procedure with risk of deterioration of gas exchange, such as bronchoscopy). The European Society of Anaesthesiology (ESA) and the European Society of Intensive Care Medicine (ESICM) have developed guidelines for the use of noninvasive respiratory support techniques in the hypoxaemic patient in the peri-operative and periprocedural period. The panel outlined five clinical questions regarding treatment with noninvasive respiratory support techniques [conventional oxygen therapy (COT), high flow nasal cannula (HFNC), noninvasive positive pressure ventilation (NIPPV) and continuous positive airway pressure (CPAP)] for hypoxaemic patients with acute peri-operative/periprocedural respiratory failure. The goal was to assess the available literature on the various noninvasive respiratory support techniques, specifically studies that included adult participants with hypoxaemia in the peri-operative/periprocedural period. The literature search strategy was developed by a Cochrane Anaesthesia and Intensive Care trial search specialist in close collaboration with the panel members and the ESA group methodologist. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to assess the level of evidence and to grade recommendations. The final process was then validated by both ESA and ESICM scientific committees. Among 19 recommendations, the two grade 1B recommendations state that in the peri-operative/periprocedural hypoxaemic patient, the use of either NIPPV or CPAP (based on local expertise) is preferred to COT for improvement of oxygenation; and that the panel suggests using NIPPV or CPAP immediately postextubation for hypoxaemic patients at risk of developing acute respiratory failure after abdominal surgery.

Mechanisms of Urgently Presenting Acute Heart Failure.

The mechanisms of urgently presenting acute heart failure (AHF) are not clear. We evaluated the serum catecholamine values of AHF patients immediately after admission. A total of 1,475 AHF patients were screened, and 484 who were admitted from their homes and in whom serum catecholamine could be evaluated immediately after admission were analyzed. The patients were divided into three groups according to the time interval from the onset of symptoms to admission (OA): < 3 hours (early-OA group; n = 283), 3-24 hours (middle-OA group; n = 142), and ≥24 hours (late-OA group; n = 59). In the early-OA group, the systolic blood pressure (SBP) was significantly higher, orthopnea was more frequent, the pH value was significantly decreased, and the use of noninvasive positive-pressure ventilation was required significantly more often than in the other groups. The serum noradrenaline level was significantly increased in the early-OA group (1.96 [1.02-3.60] ng/mL) than in the middle-OA (1.49 [0.73-3.41] ng/mL) and late-OA (1.40 [0.91-2.42] ng/mL) groups, and the adrenaline level was significantly increased in the early-OA group (0.36 [0.13-1.17] ng/mL) than in the late-OA (0.22 [0.09-0.52] ng/mL) group. A multivariate logistic regression model indicated the early-OA group was independently associated with the SBP > 140 mmHg (odds ratio [OR]: 2.219, 95% CI: 1.375-3.581), midnight/early morning admission (OR: 3.158, 95% CI: 2.048-4.868), and high serum catecholamine value (adrenaline > 0.96 ng/mL, noradrenaline > 3.39 ng/mL, and dopamine > 0.21 ng/mL) (OR 2.091, 95% CI: 1.161-3.767). In conclusion, urgently presented AHF might be induced by an endogenous catecholamine surge, which causes an excessive rise in blood pressure leading to increased after-overload and volume-shift lung congestion.

Noninvasive respiratory support in the hypoxaemic peri-operative/periprocedural patient: a joint ESA/ESICM guideline.

Hypoxaemia is a potential life-threatening yet common complication in the peri-operative and periprocedural patient (e.g. during an invasive procedure at risk of deterioration of gas exchange, such as bronchoscopy). The European Society of Anaesthesiology (ESA) and the European Society of Intensive Care Medicine (ESICM) developed guidelines for the use of noninvasive respiratory support techniques in the hypoxaemic patient in the peri-operative and periprocedural period. The panel outlined five clinical questions regarding treatment with noninvasive respiratory support techniques [conventional oxygen therapy (COT), high flow nasal cannula, noninvasive positive pressure ventilation (NIPPV) and continuous positive airway pressure (CPAP)] for hypoxaemic patients with acute peri-operative/periprocedural respiratory failure. The goal was to assess the available literature on the various noninvasive respiratory support techniques, specifically studies that included adult participants with hypoxaemia in the peri-operative/periprocedural period. The literature search strategy was developed by a Cochrane Anaesthesia and Intensive Care trial search specialist in close collaboration with the panel members and the ESA group methodologist. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to assess the level of evidence and to grade recommendations. The final process was then validated by both ESA and ESICM scientific committees. Among 19 recommendations, the two grade 1B recommendations state that: in the peri-operative/periprocedural hypoxaemic patient, the use of either NIPPV or CPAP (based on local expertise) is preferred to COT for improvement of oxygenation; and that the panel suggests using NIPPV or CPAP immediately post-extubation for hypoxaemic patients at risk of developing acute respiratory failure after abdominal surgery. Electronic supplementary materialThe online version of this article (10.1007/s00134-020-05948-0) contains supplementary material, which is available to authorized users.

Noninvasive positive pressure ventilation in stable patients with COPD.

Long-term noninvasive positive pressure ventilation (NIV) used to be a controversial form of therapy for patients with stable hypercapnic chronic obstructive pulmonary disease (SH-COPD). New evidence described in this review defines the optimal settings, timing and target population for NIV utilization in SH-COPD necessary to maximize its benefit. NIV, when titrated appropriately, leads to improved clinical outcomes. High inspiratory positive airway pressures aimed at decreasing CO2 levels can ensure NIV success in SH-COPD. NIV initiated when patients remain hypercapnic whereas in a clinical stable state following an acute exacerbation can prolong the time to a readmission. Technological advances in NIV algorithms and remote monitoring have the potential to improve use and titration. NIV and portable NIV improve exercise tolerance and may accentuate the benefits derived from pulmonary rehabilitation alone. Use of high-intensity NIV in SH-COPD is beneficial yet appropriate patient selection and implementation is paramount.