Use Of Positive Pressure Ventilation Research Articles

High-intensity versus low-intensity noninvasive positive pressure ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease (HAPPEN): study protocol for a multicenter randomized controlled trial

BackgroundDespite the positive outcomes of the use of noninvasive positive pressure ventilation (NPPV) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD), NPPV fails in approximately 15% of patients with AECOPD, possibly because the inspiratory pressure delivered by conventional low-intensity NPPV is insufficient to improve ventilatory status for these patients. High-intensity NPPV, a novel form that delivers high inspiratory pressure, is believed to more efficiently augment alveolar ventilation than low-intensity NPPV, and it has been shown to improve ventilatory status more than low-intensity NPPV in stable AECOPD patients. Whether the application of high-intensity NPPV has therapeutic advantages over low-intensity NPPV in patients with AECOPD remains to be determined. The high-intensity versus low-intensity NPPV in patients with AECOPD (HAPPEN) study will examine whether high-intensity NPPV is more effective for correcting hypercapnia than low-intensity NPPV, hence reducing the need for intubation and improving survival.Methods/designThe HAPPEN study is a multicenter, two-arm, single-blind, prospective, randomized controlled trial. In total, 600 AECOPD patients with low to moderate hypercapnic respiratory failure will be included and randomized to receive high-intensity or low-intensity NPPV, with randomization stratified by study center. The primary endpoint is NPPV failure rate, defined as the need for endotracheal intubation and invasive ventilation. Secondary endpoints include the decrement of arterial carbon dioxide tension from baseline to 2 h after randomization, in-hospital and 28-day mortality, and 90-day survival. Patients will be followed up for 90 days after randomization.DiscussionThe HAPPEN study will be the first randomized controlled study to investigate whether high-intensity NPPV better corrects hypercapnia and reduces the need for intubation and mortality in AECOPD patients than low-intensity NPPV. The results will help critical care physicians decide the intensity of NPPV delivery to patients with AECOPD.Trial registrationClinicalTrials.gov, NCT02985918. Registered on 7 December 2016.

Implementation of the Early Essential Newborn Care (EENC) on neonatal outcomes in west China: an observational study

BackgroundWest China exhibits poorer newborn health outcomes than in other parts of mainland China. Therefore, we aimed to investigate the effect of the Early Essential Newborn Care (EENC) on neonatal outcomes in west China. MethodsWe did an observational study of 14 counties in three west provinces of China. Licensed doctors, nurses from obstetrics and paediatrics, and midwives in each county were trained by experienced EENC facilitators. 3 months after the first EENC coaching, we did a quality control assessment to examine the effects of the EENC coaching. We examined hospitals that had the highest number of births in each county and selected post-partum mothers to be interviewed and have their medical records checked by convenience sampling. Institutional ethics approval to do this study was obtained from the Institutional Review Boards at National Centre for Women and Children's Health Care, Chinese Center for Disease Control and Prevention. We obtained written informed consent from all participants. FindingsBetween March 25, 2018, and May 5, 2018, we examined 14 hospitals with the highest number of births in each county, of which we selected 126 post-partum mothers. EENC has turned out to be a useful and practical tool in west China. Out of the core interventions, some practices were relatively easy to implement, such as no routine suctioning for newborn babies (increasing from 0 at baseline to 100% after EENC coaching) and bathing after 24 h of birth (from 24% to 85%). However, hospitals encountered different kinds of difficulties in the EENC implementation. For example, 90 min of skin-to-skin contact was often interrupted because of inadequate facility resources (increasing from 0 to 62%). It was also noticed that hospitals that could guarantee 90 min of skin-to-skin contact could ensure early breastfeeding initiation (p=0·002), and successful first-time breast milk intake is associated with exclusive breastfeeding from birth till interview time (p=0·001). InterpretationHospitals need to remove all the obstacles and emphasise on the EENC recommended practices, including receiving 90 min of uninterrupted skin-to-skin contact within 1 min of birth, initiation of early and exclusive breastfeeding, and the use of neonatal nasal intermittent positive pressure ventilation. Additional communications should be encouraged among medical professionals from different regions, so ideas could be shared. FundingHong Kong Committee for UNICEF.

Association of obstructive sleep apnoea with acute severity of chronic obstructive pulmonary disease exacerbation: a population-based study.

Little is known about the association of obstructive sleep apnoea (OSA) with the severity of acute exacerbation of chronic obstructive pulmonary disease (AECOPD). This retrospective cohort study investigated the association of coexistent OSA with acute severity markers (i.e. invasive positive pressure ventilation (IPPV) use and hospital length of stay (LOS)) among adults hospitalised for AECOPD. Patients with coexistent OSA had a significantly higher risk of IPPV use and prolonged hospital LOS compared to those without OSA.

Outcomes and predictors of success of noninvasive ventilation in acute exacerbation of chronic obstructive pulmonary disease

BackgroundNoninvasive ventilation is appropriately used as a first-line treatment of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) in many emergency departments. It has been evaluated in a large number of trials, often with clinically important benefits, but the use of noninvasive positive pressure ventilation remains highly variable across institutions and geographical regions. The aim of the study was first to emphasize the superiority of noninvasive ventilation (NIV) in acute hypercapneic respiratory failure in patients with an AECOPD in comparison with conventional therapy alone and second was to identify the predictors of NIV failure in such patients.Patientsand methods A total of 50 patients were randomly allocated into two equal groups: 25 patients subjected to medical and oxygen therapy (group I) and 25 to medical and NIV (group II). All patients were followed until death or discharge.ResultsGroup II had a success rate (for weaning and discharge) of 76%, whereas in group I, it was 20% (odds ratio=0.0789, 95% confidence interval=0.021–0.302 and P<0.001). Hospital stay was significantly longer in group I. Complications were significantly higher in group I. Mortality was significantly higher in group I. Improvement of arterial blood gases, respiratory rate, dyspnea scores and hypercarbic encephalopathy was significantly better in non-invasive positive pressure ventilation (NIPPV) group.ConclusionThe addition of NIPPV to standard therapy confers more benefits in patients with AECOPD, with significant reduction of in-hospital mortality, rate of endotracheal intubation, incidence of complications and length of hospital stay compared with standard therapy alone. On the contrary, failure can be predicted by the presence of more comorbidities, signs of severe exacerbation, high BMI, high baseline blood sugar, rapid respiratory rate at admission, abnormal baseline renal functions, high baseline C-reactive protein, high baseline acute physiology and chronic health evaluation II and BAP 65: B=BUN; A=Altered mental status; P=Pulse rate; 65-age years (BAP 65) scores, severe acidosis before NIV treatment and persistent severe acidosis after 1 h of treatment.

Airway and ventilation management strategies for hemorrhagic shock. To tube, or not to tube, that is the question!

Review article, level IV.

Lower versus higher oxygen concentrations titrated to target oxygen saturations during resuscitation of preterm infants at birth.

Initial resuscitation with air is well tolerated by most infants born at term. However, the optimal fractional inspired oxygen concentration (FiO2 - proportion of the breathed air that is oxygen) targeted to oxygen saturation (SpO2 - an estimate of the amount of oxygen in the blood) for infants born preterm is unclear. To determine whether lower or higher initial oxygen concentrations, when titrated according to oxygen saturation targets during the resuscitation of preterm infants at birth, lead to improved short- and long-term mortality and morbidity. We conducted electronic searches of the Cochrane Central Register of Controlled Trials (13 October 2017), Ovid MEDLINE (1946 to 13 October 2017), Embase (1974 to 13 October 2017) and CINAHL (1982 to 13 October 2017); we also searched previous reviews (including cross-references), contacted expert informants, and handsearched journals. We included randomised controlled trials (including cluster- and quasi-randomised trials) which enrolled preterm infants requiring resuscitation following birth and allocated them to receive either lower (FiO2 < 0.4) or higher (FiO2 ≥ 0.4) initial oxygen concentrations titrated to target oxygen saturation. Two review authors independently assessed the eligibility of studies for inclusion, extracted data and assessed methodological quality. Primary outcomes included mortality near term or at discharge (latest reported) and neurodevelopmental disability. We conducted meta-analysis using a fixed-effect model. We assessed the quality of the evidence using GRADE. The search identified 10 eligible trials. Meta-analysis of the 10 included studies (914 infants) showed no difference in mortality to discharge between lower (FiO2 < 0.4) and higher (FiO2 ≥ 0.4) initial oxygen concentrations targeted to oxygen saturation (risk ratio (RR) 1.05, 95% confidence interval (CI) 0.68 to 1.63). We identified no heterogeneity in this analysis. We graded the quality of the evidence as low due to risk of bias and imprecision. There were no significant subgroup effects according to inspired oxygen concentration strata (FiO2 0.21 versus ≥ 0.4 to < 0.6; FiO2 0.21 versus ≥ 0.6 to 1.0; and FiO2 ≥ 0.3 to < 0.4 versus ≥ 0.6 to 1.0). Subgroup analysis identified a single trial that reported increased mortality from use of lower (FiO2 0.21) versus higher (FiO2 1.0) initial oxygen concentration targeted to a lowest SpO2 of less than 85%, whereas meta-analysis of nine trials targeting a lowest SpO2 of 85% to 90% found no difference in mortality.Meta-analysis of two trials (208 infants) showed no difference in neurodevelopmental disability at 24 months between infants receiving lower (FiO2 < 0.4) versus higher (FiO2 > 0.4) initial oxygen concentrations targeted to oxygen saturation. Other outcomes were incompletely reported by studies. Overall, we found no difference in use of intermittent positive pressure ventilation or intubation in the delivery room; retinopathy (damage to the retina of the eyes, measured as any retinopathy and severe retinopathy); intraventricular haemorrhage (any and severe); periventricular leukomalacia (a type of white-matter brain injury); necrotising enterocolitis (a condition where a portion of the bowel dies); chronic lung disease at 36 weeks' gestation; mortality to follow up; postnatal growth failure; and patent ductus arteriosus. We graded the quality of the evidence for these outcomes as low or very low. There is uncertainty as to whether initiating post birth resuscitation in preterm infants using lower (FiO2 < 0.4) or higher (FiO2 ≥ 0.4) oxygen concentrations, targeted to oxygen saturations in the first 10 minutes, has an important effect on mortality or major morbidity, intubation during post birth resuscitation, other resuscitation outcomes, and long-term outcomes including neurodevelopmental disability. We assessed the quality of the evidence for all outcomes as low to very low. Further large, well designed trials are needed to assess the effect of using different initial oxygen concentrations and the effect of targeting different oxygen saturations.

Variation in the Use of Mechanical Ventilation and Medications for Pediatric Status Asthmaticus

Purpose: Practice variation exists in the management of children with status asthmaticus. There are no explicit recommendations for the intensive treatment of asthma, particularly for the use of invasive and non-invasive positive pressure ventilation. Our purpose was to describe national practice and trends in the use of invasive positive pressure ventilation (IPPV), non-invasive positive pressure ventilation (NiPPV), and second-line medications; and, to report treatment complications for children with status asthmaticus. Methods: We conducted a retrospective cohort study of children ages 2-18 years admitted with status asthmaticus to 46 pediatric hospitals participating in the Pediatric Health Information System from 2010 to 2015. We excluded children who had complex chronic conditions, no asthma …

Association of Obesity With Severity of Heart Failure Exacerbation: A Population-Based Study.

BackgroundObesity and heart failure (HF) are important public health problems in the United States. Although studies have reported the association between obesity and higher chronic morbidity of HF, little is known about the relations of obesity with severity of HF exacerbation and in‐hospital mortality; therefore, we aimed to investigate the associations of obesity with severity of HF exacerbation and in‐hospital mortality.Methods and ResultsThis retrospective cohort study of adults hospitalized for HF exacerbation used population‐based data sets (the State Inpatient Databases) of 7 US states from 2012 to 2013. The outcomes were acute severity measures—use of positive pressure ventilation and hospital length of stay—and in‐hospital mortality. We determined the associations between obesity and these outcomes, including adjustment for sociodemographic factors and comorbidities. We identified 219 465 patients hospitalized for HF exacerbation. Of those, 37 539 (17.1%) were obese. Obese patients had a significantly higher risk of positive pressure ventilation use compared with nonobese patients (13.6% versus 8.8%), with a corresponding adjusted odds ratio of 1.61 (95% confidence interval, 1.55–1.68; P<0.001). Likewise, obese patients were more likely to have hospital length of stay of ≥4 days compared with nonobese patients (62.5% versus 56.7%), with an adjusted odds ratio of 1.40 (95% confidence interval, 1.37–1.44; P<0.001). In contrast, obese patients had significantly lower in‐hospital mortality compared with nonobese patients (1.7% versus 3.3%), with an adjusted odds ratio of 0.87 (95% confidence interval, 0.80–0.95; P=0.002).ConclusionsBased on large population‐based data sets of patients with HF exacerbation, obesity was associated with higher acute severity measures but lower in‐hospital mortality.

The association of aspirin use with severity of acute exacerbation of chronic obstructive pulmonary disease: a retrospective cohort study

Little is known about the effect of long-term aspirin use on acute severity of COPD. We hypothesized that, in patients hospitalized for acute exacerbation of COPD (AECOPD), long-term aspirin use is associated with lower risks of disease severity (in-hospital death, mechanical ventilation use, and hospital length-of-stay). We conducted a retrospective cohort study using large population-based data from 2012 through 2013. Among 206,686 patients (aged ≥40 years) hospitalized for AECOPD, aspirin users had lower in-hospital mortality (1.0 vs. 1.4%; OR 0.60 [95% CI 0.50–0.72]; P < 0.001) and lower risk of invasive mechanical ventilation use (1.7 vs. 2.6%; OR 0.64 [95% CI 0.55–0.73]; P < 0.001) compared to non-users, while there was no significant difference in risks of non-invasive positive pressure ventilation use. Length-of-stay was shorter in aspirin users compared to non-users (P < 0.001). In sum, in patients with AECOPD, aspirin use was associated with lower rates of in-hospital mortality and invasive mechanical ventilation use, and shorter length-of-stay.

Association Between Obesity and Acute Severity Among Patients Hospitalized for Asthma Exacerbation

Although studies have demonstrated relations between obesity and incident asthma, little is known about the association of obesity with acute severity in adults hospitalized for asthma exacerbation. To investigate the association of obesity with acute severity of asthma exacerbation. This is a retrospective cohort study using population-based data of 8 geographically diverse US states from 2010 through 2013. We included adults (age 18-54 years) hospitalized for asthma exacerbation. The outcome measures were markers of acute severity-use of mechanical ventilation (defined by noninvasive positive pressure ventilation and/or invasive mechanical ventilation) and hospital length of stay. To determine the association of obesity with each outcome, we fit multivariable models adjusting for patient-level confounders (eg, age, sex, race/ethnicity, primary insurance, quartiles for household income, residential status, and comorbidities) and potential patient clustering within hospitals. Among the 72,086 patients hospitalized for asthma exacerbation, 24% were obese. Obesity was associated with a significantly higher risk of any mechanical ventilation use (8.3% vs 5.0%; adjusted odds ratio [OR], 1.77; 95% CI, 1.63-1.92; P < .001) driven by the higher risk of noninvasive positive pressure ventilation use (7.2% vs 3.4%; adjusted OR, 2.14; 95% CI, 1.96-2.35; P < .001). Likewise, obese patients were more likely to have a hospital length of stay of 3 or more days compared with nonobese patients (59.4% vs 46.5%; adjusted OR, 1.37; 95% CI, 1.32-1.43; P < .001). These findings were consistent with stratifications by age, sex, and race/ethnicity. In this population-based study of adults hospitalized for asthma exacerbation, obesity was associated with higher acute severity.

Circulating 25-hydroxyvitamin D, nasopharyngeal airway metabolome, and bronchiolitis severity.

Low circulating 25-hydroxyvitamin D (25OHD) levels are a risk factor for acute respiratory infection (eg, bronchiolitis) in children. However, little is known about the relation of circulating 25OHD with the many downstream functional molecules in target organs-such as the airway-and with clinical outcomes. In this prospective multicenter study of infants (age <1 year) hospitalized with bronchiolitis, we measured serum 25OHD levels and profiled the metabolome of 144 nasopharyngeal airway samples. Among 254 metabolites identified, we defined a set of 20 metabolites that are related to lower serum 25OHD and higher vitamin D-binding protein levels. Of these metabolites, 9 metabolites were associated with a significantly higher risk of positive pressure ventilation use. These metabolites were glycerophosphocholines esterified with proinflammatory fatty acids (palmitate, arachidonate, linoleate, and stearate), sphingomyelins, alpha-hydroxyisovalerate, 2-hydroxybutyrate, and 3-(4-hydroxyphenyl)lactate (all FDR<0.05). Based on the multicenter data, vitamin D-related airway metabolites were associated with risks of bronchiolitis severity.

Surfactant Administration through Laryngeal Mask Airway: A Randomized Controlled Study in Rabbits.

Minimally invasive techniques for surfactant administration for infants with respiratory distress syndrome (RDS) of moderate severity have been proposed. The laryngeal mask airway (LMA) helps in securing the airway without the need of laryngoscopy, but still requires the use of positive pressure ventilation (PPV) to flush surfactant into the lungs. This article compares the effectiveness of two techniques for LMA surfactant administration, instillation into the LMA lumen followed by PPV versus direct laryngeal instillation through a preinserted feeding tube inside the LMA during spontaneous respirations. This is a randomized controlled trial (RCT) of 18 rabbits with acquired respiratory distress after lung lavage. After surfactant was given, the rabbits remained on continuous positive airway pressure (CPAP). Gas exchange parameters were assessed at baseline and at 30 minutes and lung parenchyma pathology features were analyzed. Time required for surfactant administration, oxygenation improvement, and histopathologic findings did not differ between groups. The new technique decreased the need of PPV (p < 0.05). In this animal model, surfactant administration through a preinserted feeding tube within the LMA lumen is safe and effective while providing the benefits of a minimally invasive approach. This technique reduces the need of PPV and may prevent its potential risks.

Enteral Nutrition Practices in Critically Ill Children Requiring Noninvasive Positive Pressure Ventilation.

Evaluate the practice of providing enteral nutrition in critically ill children requiring noninvasive positive pressure ventilation. Retrospective cohort study. PICU within a quaternary care children's hospital. PICU patients older than 30 days requiring noninvasive positive pressure ventilation for greater than or equal to 24 hours from August 2014 to June 2015. Invasive mechanical ventilation prior to noninvasive positive pressure ventilation and inability to receive enteral nutrition at baseline were additional exclusionary criteria. None. The primary outcome was enteral nutrition initiation within 24 hours of admission. Secondary outcomes included time to goal enteral nutrition rate, adequacy of nutrition, adverse events (pneumonia not present at admission, intubation after enteral nutrition initiation, feeding tube misplacement), and lengths of noninvasive positive pressure ventilation and PICU stay. Among those included (n = 562), the median age was 2 years (interquartile range, 39 d to 6.8 yr), 54% had at least one chronic condition, and 43% had malnutrition at baseline. The most common primary diagnosis was bronchiolitis/viral pneumonia. The median length of time on noninvasive positive pressure ventilation was 2 days (interquartile range, 2.0-4.0). Most (83%) required continuous positive airway pressure or bi-level support during their PICU course. Sixty-four percent started enteral nutrition within 24 hours, with 72% achieving goal enteral nutrition rate within 72 hours. Forty-nine percent and 44% received an adequate cumulative calorie and protein intake, respectively, during their PICU admission. Oral feeding was the most common delivery method. On multivariable analysis, use of bi-level noninvasive positive pressure ventilation (odds ratio, 0.40; 95% CI, 0.25-0.63) and continuous dexmedetomidine (odds ratio, 0.59; 95% CI, 0.35-0.97) were independently associated with decreased likelihood of early enteral nutrition. Twelve percent of patients had at least one adverse event. A majority of patients requiring noninvasive positive pressure ventilation received enteral nutrition within 24 hours. However, less than half achieved caloric and protein goals during their PICU admission. Further investigation is warranted to determine the safety and effectiveness of early enteral nutrition in this population.

Obesity and Severity of Acute Exacerbation of Chronic Obstructive Pulmonary Disease.

Obesity is relatively common among individuals with chronic obstructive pulmonary disease (COPD). However, little is known about the association of obesity with severity of acute exacerbation of COPD and in-hospital mortality. To examine the association of obesity with markers of severity of acute exacerbation of COPD and in-hospital mortality. This is a population-based, retrospective cohort study using the 2012-2013 State Inpatient Databases of seven U.S. states (Arkansas, Florida, Iowa, Nebraska, New York, Utah, and Washington). We included adults (aged ≥40 yr) hospitalized for acute exacerbation of COPD. Obesity, use of noninvasive positive pressure ventilation (NIPPV), and use of invasive mechanical ventilation were determined by International Classification of Diseases, Ninth Revision codes. To examine associations between obesity and each outcome (NIPPV, invasive mechanical ventilation, hospital length of stay (LOS), and in-hospital mortality), we fit unadjusted and adjusted logistic regression models using generalized estimating equations to account for patient clustering within hospitals. We adjusted for age, sex, race/ethnicity, primary payer, median household income, patient residence, hospitalization year, chronic comorbidities, and hospital state. In the sensitivity analysis, we used stabilized inverse probability weighting to estimate the causal relation of obesity with outcomes in this observational study. Of 187,647 patients hospitalized for an acute exacerbation of COPD, 17% were obese. Obesity was associated with increased use of both NIPPV (12.0% vs. 6.5%; adjusted odds ratio [OR] = 1.86; 95% confidence interval [CI] = 1.77-1.95; P < 0.001) and invasive mechanical ventilation (3.5% vs. 2.8%; adjusted OR = 1.13; 95% CI = 1.04-1.22; P = 0.003). Similarly, obese patients were more likely to have a hospital LOS of 4 days or longer (57.9% vs. 50.3%; adjusted OR = 1.37; 95% CI = 1.33-1.41; P < 0.001). In contrast, obesity was associated with a lower in-hospital mortality (0.9% vs. 1.4%; unadjusted OR = 0.63; 95% CI = 0.56-0.72; P < 0.001). After adjusting for potential confounders, this association was no longer statistically significant (adjusted OR = 0.86; 95% CI = 0.75-1.00; P = 0.06). Results were similar in sensitivity analyses using stabilized inverse probability weighting. In this population-based study of adults hospitalized with an acute exacerbation of COPD, obesity was associated with increased use of noninvasive and invasive ventilation, increased hospital LOS, but was not associated with increased in-hospital mortality.

Associations of Nasopharyngeal Metabolome and Microbiome with Severity among Infants with Bronchiolitis. A Multiomic Analysis.

Bronchiolitis is the most common lower respiratory infection in infants; however, it remains unclear which infants with bronchiolitis will develop severe illness. In addition, although emerging evidence indicates associations of the upper-airway microbiome with bronchiolitis severity, little is known about the mechanisms linking airway microbes and host response to disease severity. To determine the relations among the nasopharyngeal airway metabolome profiles, microbiome profiles, and severity in infants with bronchiolitis. We conducted a multicenter prospective cohort study of infants (age <1 yr) hospitalized with bronchiolitis. By applying metabolomic and metagenomic (16S ribosomal RNA gene and whole-genome shotgun sequencing) approaches to 144 nasopharyngeal airway samples collected within 24 hours of hospitalization, we determined metabolome and microbiome profiles and their association with higher severity, defined by the use of positive pressure ventilation (i.e., continuous positive airway pressure and/or intubation). Nasopharyngeal airway metabolome profiles significantly differed by bronchiolitis severity (P < 0.001). Among 254 metabolites identified, a panel of 25 metabolites showed high sensitivity (84%) and specificity (86%) in predicting the use of positive pressure ventilation. The intensity of these metabolites was correlated with relative abundance of Streptococcus pneumoniae. In the pathway analysis, sphingolipid metabolism was the most significantly enriched subpathway in infants with positive pressure ventilation use compared with those without (P < 0.001). Enrichment of sphingolipid metabolites was positively correlated with the relative abundance of S. pneumoniae. Although further validation is needed, our multiomic analyses demonstrate the potential of metabolomics to predict bronchiolitis severity and better understand microbe-host interaction.

Airway ciliary dysfunction: Association with adverse postoperative outcomes in nonheterotaxy congenital heart disease patients

ObjectiveHeterotaxy (HTX) congenital heart disease (CHD) patients with ciliary dysfunction (CD) have been shown to have increased postoperative respiratory morbidity. We hypothesized that non-HTX CHD infants with CD also will have increased postoperative morbidity, particularly respiratory complications. MethodsSixty-three infants with non-HTX CHD undergoing cardiac surgery were enrolled. Tests commonly used to assess for CD, nasal nitric oxide (nNO) measurements and nasal epithelial ciliary motion (CM) assessment, were obtained. Baseline characteristics and postoperative outcomes were collected and analyzed. ResultsNon-HTX CHD infants exhibited a high prevalence of abnormal CM (32%) and low nNO (39%). This finding was not correlated with demographics or surgical complexity. Infants with abnormal CM had increased odds of requiring noninvasive positive pressure ventilation (odds ratio [OR], 6.5; 95% confidence interval [CI], 1.5-29.4; P = .016) and respiratory medication use (OR, 4.4; 95% CI, 1.5-13.3; P = .01). In contrast, infants with low nNO showed evidence of abnormal pre- and postoperative systolic function (40% vs 4%; P = .004, and 34% vs 13%; P = .056, respectively) and had greater odds of acquiring infections (OR, 4.9; 95% CI, 1.4-17; P = .014). ConclusionsNon-HTX CHD infants with abnormal CM showed increased postoperative morbidity associated with poor respiratory outcomes. In contrast, low nNO correlated with reduced hemodynamic function. These findings suggest screening for abnormal CM may allow perioperative interventions to reduce pulmonary morbidities. Whether low nNO may prognosticate poor hemodynamic function warrants further investigation.

Impact of bradycardia or asystole on neonatal cardiopulmonary resuscitation at birth.

Fetal hypoxia from intrapartum events can lead to absent heart rate (HR) or bradycardia at birth requiring aggressive neonatal resuscitation. Neonatal resuscitation guidelines do not differentiate bradycardia (HR <100 beats/min) from absent HR at birth. Given that HR is the primary determinant of resuscitation, we hypothesize that infants with no HR at 1 min would require more extensive resuscitation with worse clinical outcome than infants with bradycardia at 1 min. A retrospective analysis was performed in infants born between 1 January 2000 and 31 December 2015 with no HR at 1 min (defined as Apgar score [AS] = 0 at 1 min; absent HR [AHR] group) or bradycardia at 1 min (AS = 1 at 1 min). Patient demographics, resuscitation characteristics and clinical outcomes were analyzed in both the groups. Apgar score was significantly lower in the AHR group over time. The AHR group had significantly higher rates of intubation, chest compression (CC) and i.v. epinephrine (i.v. epi); resulting in longer duration of CC, time to HR > 100 beats/min and duration of resuscitation. Systematic hypotension and death were higher in the AHR group. On logistic regression, CC and cord pH were significantly correlated with AS = 0 at 1 min. Gestational age, birthweight, AS at 5 min, cord pH and first blood gas pH after resuscitation were related to overall mortality. Infants with AHR at 1 min did worse than infants with bradycardia. Education focused on effective positive pressure ventilation and early use of i.v. epinephrine is essential for successful resuscitation of the depressed newborn.

Effectiveness assessment of a guideline based protocol for ventilatory support management of COPD exacerbations in an emergency department

ObjectivesTo investigate clinical outcomes according to ventilatory support indication in subjects with chronic obstructive pulmonary disease exacerbation in a “real-life” Emergency Department and to analyze potential predictors of successful noninvasive positive pressure ventilation. MethodsRetrospective cohort performed over an 18-month period, comparing the following patient groups with chronic obstructive pulmonary disease exacerbation: Group A composed of patients initially selected to receive noninvasive positive pressure ventilation without the subsequent need for invasive mechanical ventilation (successful-noninvasive positive pressure ventilation); Group B composed of patients transitioning from noninvasive positive pressure ventilation to invasive mechanical ventilation (failed-noninvasive positive pressure ventilation); and Group C composed of patients who presented with immediate need for invasive mechanical ventilation (without prior noninvasive positive pressure ventilation). Results117 consecutive chronic obstructive pulmonary disease exacerbation admissions (Group A=96; Group B=13; Group C=8) of candidates for ventilatory support were reviewed. No differences in baseline disease severity and physiological parameters were found between the groups at Emergency Department admission. Nevertheless, Group B had higher intensive care unit admission, length of hospital stay, length of intensive care unit stay, and higher in-hospital mortality compared to Group A. Group C also had worse outcomes when compared to Group A. The only independent variable associated with the successful use of noninvasive positive pressure ventilation were improvement in arterial carbon dioxide pressure after 1h of noninvasive positive pressure ventilation use and its tolerance. ConclusionOur data confirmed in a “real life” Emergency Department cohort that successful management of chronic obstructive pulmonary disease exacerbation with noninvasive positive pressure ventilation showed lower in-hospital mortality and Intensive Care Unit stay when compared to patients transitioning from noninvasive positive pressure ventilation to invasive mechanical ventilation or patients who presented an immediate need for invasive mechanical ventilation. noninvasive positive pressure ventilation tolerance and higher arterial carbon dioxide pressure reduction after 1-h of noninvasive positive pressure ventilation were predictors of successful treatment. These results should be confirmed in a prospective randomized controlled trial.

Thomas L Petty

Thomas L Petty

High-dose prednisolone after intravenous methylprednisolone improves prognosis of acute exacerbation in idiopathic interstitial pneumonias.

Acute exacerbation (AE) of idiopathic pulmonary fibrosis (IPF) (AE-IPF) is a poor prognostic disorder. AE is also reported to occur in other idiopathic interstitial pneumonias (IIPs). There are limited data available regarding the effectiveness of treatment for AE-IIPs. The objective of this study was to clarify the prognostic impact of the initial dose of prednisolone (PSL) for treating AE-IIPs. Eighty-five patients with AE-IIPs, diagnosed according to the criteria of the Japanese Respiratory Society, were enrolled in this study (IPF/non-IPF: 63/22 patients) from 2004 to 2013. We performed multivariate Cox proportional hazard regression analysis to identify poor prognostic factors. HRCT patterns at the onset of AE-IIPs were classified as diffuse or non-diffuse. We evaluated the prognostic significance of the initial dose of PSL by adjusting for other prognostic factors. Median survival time (MST) after AE-IIPs diagnosis was 49 days. MST of AE-IPF and AE-non-IPF was 39 and 49 days, respectively. A diffuse HRCT pattern, lower serum IgG and higher serum surfactant protein-D at AE diagnosis, long-term oxygen therapy (LTOT) before AE and positive pressure ventilation (PPV) use for AE were significant poor prognostic factors for all patients, as were LTOT before AE and lower serum IgG for no-PPV patients. High-dose PSL ≥ 0.6 mg/kg was a significant prognostic factor for no-PPV patients after adjusting for other prognostic factors. We concluded that a dose of PSL ≥ 0.6 mg/kg after i.v. high-dose methylprednisolone therapy should be recommended for the treatment of AE-IIPs.