Ventilated Chronic Obstructive Pulmonary Disease Patients Research Articles

Implementing Early Rehabilitation Strategies for Chronic Obstructive Pulmonary Disease (COPD) Patients Undergoing Mechanical Ventilation in the Intensive Care Unit.

Patients afflicted with chronic obstructive pulmonary disease (COPD) frequently manifest acute respiratory failure (ARF), characterized by hypercapnia, hypoxia, malnutrition, muscle weakness, heightened work of breathing (WOB), recurrent acute exacerbations, reliance on mechanical ventilation (MV), and difficulties in the weaning phase. Early implementation of rehabilitation interventions holds promise in mitigating prolonged MV and, consequently, reducing intensive care unit (ICU) morbidity and mortality. A prospective study was undertaken involving COPD type 2 respiratory failure patients receiving MV in an ICU setting. Random assignment was employed to allocate patients to either the experimental or control groups. Both groups received chest physiotherapy, range-of-motion exercises, and standard medical and nursing care. The experimental group additionally underwent early active rehabilitation exercises, including limb strength training and progressive mobility tasks. Various parameters such as mechanical ventilator duration, ICU length of stay (LOS), mortality, and occurrence of adverse events were documented. Group differences were analyzed using independent t-tests. Among 52 patients, 33 were assigned randomly to each group using sealed envelopes. After withdrawals, 15 patients remained in each group. The experimental group had significantly shorter durations of MV (2.29 ± 0.61 vs 2.86 ± 0.66 days; 95% CI: -1.06 to -0.07, t = -2.37, P = 0.02) and ICU stay (7.66 ± 1.17 vs 8.86 ± 1.68 days; 95% CI: -2.28 to -0.11, t = -2.26, P = 0.03) compared to the control group. ICU mortality rates were similar between groups (1.93 ± 0.25 vs 1.93 ± 0.25; 95% CI: -0.19 to 0.19, t = 0.00, P = 1.00). The experimental group had a higher incidence of non-serious adverse events (0.66 ± 0.48 vs 0.26 ± 0.45 events; 95% CI: -0.04 to -0.75, t = 2.31, P = 0.02) and primarily transient physiological changes. Engaging the early active rehabilitation exercises for mechanically ventilated COPD patients is practical and results in a reduction in MV duration, consequently shortening the ICU LOS.

Internet of things-based management versus standard management of home noninvasive ventilation in COPD patients with hypercapnic chronic respiratory failure: a multicentre randomized controlled non-inferiority trial

Effective monitoring and management are crucial during long-term home noninvasive positive pressure ventilation (NPPV) in patients with hypercapnic chronic obstructive pulmonary disease (COPD). This study investigated the benefit of Internet of Things (IOT)-based management of home NPPV. This multicenter, prospective, parallel-group, randomized controlled non-inferiority trial enrolled patients requiring long-term home NPPV for hypercapnic COPD. Patients were randomly assigned (1:1), via a computer-generated randomization sequence, to standard home management or IOT management based on telemonitoring of clinical and ventilator parameters over 12 months. The intervention was unblinded, but outcome assessment was blinded to management assignment. The primary outcome was the between-group comparison of the change in health-related quality of life, based on severe respiratory insufficiency questionnaire scores with a non-inferiority margin of-5. This study is registered with Chinese Clinical Trials Registry (No. ChiCTR1800019536). Overall, 148 patients (age: 72.7±6.8 years; male: 85.8%; forced expiratory volume in 1s: 0.7±0.3L; PaCO2: 66.4±12.0mmHg), recruited from 11 Chinese hospitals between January 24, 2019, and June 28, 2021, were randomly allocated to the intervention group (n=73) or the control group (n=75). At 12 months, the mean severe respiratory insufficiency questionnaire score was 56.5 in the intervention group and 50.0 in the control group (adjusted between-group difference: 6.26 [95% CI, 3.71-8.80]; P<0.001), satisfying the hypothesis of non-inferiority. The 12-month risk of readmission was 34.3% in intervention group compared with 56.0% in the control group, adjusted hazard ratio of 0.56 (95% CI, 0.34-0.92; P=0.023). No severe adverse events were reported. Among stable patients with hypercapnic COPD, using IOT-based management for home NPPV improved health-related quality of life and prolonged the time to readmission. Air Liquide Healthcare (Beijing) Co., Ltd.

Effect of high-flow nasal cannula versus non-invasive ventilation in preventing re-intubation in high-risk chronic obstructive pulmonary disease patients: A randomised controlled trial.

Currently, a high-flow nasal cannula (HFNC) has been shown to improve extubation outcomes. However, there is a lack of evidence on the utilisation of HFNC in high-risk chronic obstructive pulmonary disease (COPD) patients. This study aimed to compare the effectiveness of HFNC versus non-invasive ventilation (NIV) in preventing re-intubation following planned extubation in high-risk COPD patients. In this prospective, randomised, controlled trial, 230 mechanically ventilated COPD patients at high risk for re-intubation who fulfilled the criteria for planned extubation were enrolled. Post-extubation blood gases and vital signs at 1, 24, and 48 hours were recorded. The primary outcome was the re-intubation rate within 72 hours. Secondary outcomes included post-extubation respiratory failure, respiratory infection, intensive care unit and hospital length of stay, and mortality rate at 60 days. 230 patients after planned extubation were randomly allocated to receive either HFNC (n = 120) or NIV (n = 110). Re-intubation within 72 hours was significantly lower in the high-flow group: 8 patients (6.6%) versus 23 patients (20.9%) in the NIV group {absolute difference, 14.3% [95% confidence interval (CI), 10.9-16.3]; P = 0.001}. The frequency of post-extubation respiratory failure was less in patients assigned to HFNC than in those allocated NIV (25% vs. 35.4%) [absolute difference, 10.4% (95% CI, 2.4-14.3); P = 0.001]. There was no significant difference between the two groups regarding reasons for respiratory failure after extubation. It was observed that the 60-day mortality rate was lower in patients who received HFNC than in those assigned to NIV (5% vs. 13.6%) [absolute difference, 8.6 (95% CI, 4.3 to 9.10); P = 0.001]. The use of HFNC after extubation appears to be superior to NIV in reducing the risk of re-intubation within 72 hours and 60-day mortality in high-risk COPD patients.

Internet of things-based home noninvasive ventilation in COPD patients with hypercapnic chronic respiratory failure: study protocol for a randomized controlled trial

BackgroundHome noninvasive positive pressure ventilation (NIPPV) has become evidence-based care for stable hypercapnic chronic obstructive pulmonary disease (COPD) patients. There are still other challenges including appropriate follow-up, telemonitor, and management to ensure treatment effectiveness, compliance, and security and to improve quality of life. The Internet of things (IOT) is the name given to the network of devices and other “things” with built-in sensors, software, electronics, and network connectivity, communicating these objects over wireless networks and sending data to a cloud platform. The study aims to evaluate the effectiveness and safety of the IOT-based management of NIPPV for the COPD patients with hypercapnic chronic respiratory failure.MethodsThis multicenter, prospective, randomized controlled trial was conducted with a total of 200 COPD patients with chronic hypercapnic respiratory failure. Using a computer-generated randomization process, patients were randomized (in a 1:1 ratio) into the usual NIPPV (control group) or to receive additional IOT-based management (intervention group) for 12 months. The primary outcome was the Severe Respiratory Insufficiency (SRI) questionnaire. Secondary outcomes included compliance with the ventilator, gas exchange, lung function, health-related quality of life, hospitalization frequency, time to death within 1-year, all-cause mortality, safety analysis, and cost-effectiveness analysis.DiscussionThis study will be the first and largest randomized trial in China to evaluate the effectiveness and safety of the IOT-based management of NIPPV for COPD patients with chronic hypercapnic respiratory failure. The results will help to understand the current situation of IOT-based home ventilation and may provide new evidence for home NIPPV treatment and management in the future.Trial registrationChinese Clinical Trials Registry ChiCTR1800019536. Registered on 17 November 2018.

Weaning success among COPD patients following ventilator care bundle application

Objective: Several studies evaluated the effectiveness of the ventilator care bundle in reducing the occurrence of ventilatorassociated pneumonia. The ventilator care bundle efficacy in early mechanical ventilation weaning has not been adequately assessed. The study aimed to investigate the weaning success among chronic obstructive pulmonary disease (COPD) patients following ventilator care bundle application.Methods: This study is quasi-experimental, recruiting 80 mechanically ventilated COPD patients (40 patients for each bundle and control group). It was conducted at the respiratory intensive care units (ICUs) at Mansoura University Hospital, Egypt. Data were collected using a mechanically ventilated patient (MVP) assessment tool, a ventilator care bundle compliance checklist, and MVP evaluation tools based on the Burns’ Wean Assessment Program (BWAP) checklist and the patient’s ventilation indicators.Results: The results revealed that almost 75% of the bundle group was successfully weaned from invasive mechanical ventilation at the first attempt of the spontaneous breathing trial compared with 32.5% of the control group. The ventilation duration and length of ICU stay were reduced in the bundle compared with the control group.Conclusions: The bundle group demonstrated higher weaning scores than the control group. Therefore, we recommend the integration of the ventilator care bundle in the weaning trial of MVPs to accelerate weaning and reduce the duration of mechanical ventilation.

Preliminary bronchodilator dose effect on aerosol-delivery through different nebulizers in noninvasively ventilated COPD patients

Objectives: This study aimed to evaluate the effect of a preliminary bronchodilator dose on the aerosol-d elivery by different nebulizers in noninvasively ventilated chronic obstructive pulmonary disease (COPD) patients. Method: COPD patients were randomized to receive study doses of 800 µg beclomethasone dipropionate (BPD) nebulized by either a vibrating mesh nebulizer (VMN) or a jet nebulizer (JN) connected to MinimHal spacer device. On a different day, the nebulized dose of beclomethasone was given to each patient by the same aerosol generator with and without preceded two puffs (100 µg each) of salbutamol delivered by a pressurized-metered dose inhaler. Urinary BPD and its metabolites in 30 min post-inhalation samples and pooled up to 24 h post-inhalation were measured. On day 2, ex-vivo studies were performed with BPD collected on filters before reaching patients which were eluted from filters and analyzed to estimate the total emitted dose. Results: The highest urinary excretion amounts of BPD and its metabolites 30 min and 24 h post-inhalation were identified with pMDI + VMN compared with other regimens(p < 0.001). The amounts of BPD and its metabolites excreted 30 min post inhalation had approximately doubled with pMDI + JN compared with JN delivery (p < 0.05). No significant effect was found in the ex-vivo study results except between VMN and JN with a significant superiority of the VMN (p < 0.001). Conclusion: Using a preliminary bronchodilator dose before drug nebulization significantly increased the effective lung dose of the nebulized drug with both VMNs and JNs. However, adding a preliminary bronchodilator dose increased the 24 hr cumulative urinary amount of the drug representing higher systemic delivery of the drug, which in turn could result in higher systemic side effects.

Intelligent volume assured pressure support (iVAPS) vs. spontaneous/timed mode as a weaning strategy for intubated COPD patients with acute exacerbation.

Noninvasive positive-pressure ventilation (NPPV) is applied to facilitate weaning process and decrease complications associated with prolonged intubation. Interest has emerged in using Intelligent Volume Assured Pressure Support (iVAPS) to facilitate earlier removal of an endotracheal tube. This study was conducted to compare the effectiveness of iVAPS versus standard Spontaneous/timed (S/T) mode in facilitating weaning process of mechanically ventilated chronic obstructive pulmonary disease (COPD) in acute exacerbation. In a prospective randomized study, 80 invasively ventilated COPD patients in acute exacerbations were extubated then immediate applicationof NPPV using either S/T mode (Group I) or iVAPS mode (Group II) was done. Clinical parameters (heart rate, respiratory rate, and arterial blood gas parameters at selected time intervals of treatment were recorded for both groups and analyzed. No significant differences were found between both groups regarding age, sex, mMRC dyspnea scale, CAT score and APACHE II score. Heart rate and mean arterial blood pressure in the two groups decreased with time, but no significant differences were found between the two groups. Likewise, there was no significant difference in RR between S/T and iVAPS groups. Regarding arterial blood gas analysis, there were no detectable differences in PaCO₂ level, PaO₂ level or oxygen saturation. The successful outcome was achieved in (82.5%) in the S/T group vs (80%) in the iVAPS group. The two modes achieved comparable levels of comfort as assessed by VAS and the total Mask Fitness Score. There was no statistically significant difference in reintubation, the duration of NPPV, duration of ICU stay or in mortality rate. iVAPS mode is as effective as fixed-pressure S/T mode in facilitating weaning of hypercapnic COPD patients.

Patient-ventilator asynchrony as a predictor of weaning failure in mechanically ventilated COPD patients

BackgroundPatient-ventilator asynchrony is a common problem in mechanically ventilated patients. It is associated with adverse effects including increased work of breathing, patient discomfort, increased need for sedation, prolonged mechanical ventilation, weaning difficulties, and weaning failure. The purpose of the present was to describe patient-ventilator asynchrony and its impact on weaning outcomes in mechanically ventilated chronic obstructive pulmonary disease (COPD) patients.ResultsOne hundred mechanically ventilated COPD patients were enrolled in this prospective study. Weaning failure (need of NIV or reintubation within 48 h) was noticed in 27 (27%) patients while 73 (73%) patients had successful weaning. Patients with failed weaning had significantly higher asynchrony index (A.I) and ineffective trigger index (ITI) in comparison with those with successful weaning (7.69 ± 3.71, 3.46 ± 2.59 versus 6.27 ± 3.14, 2.47 ± 2.08, respectively; P value< 0.04). Data were expressed as mean ± standard deviation.ConclusionHigh asynchrony index and high ineffective trigger index may be early predictors of weaning failure in mechanically ventilated COPD patients.

Prospective Comparative Evaluation of Noninvasive and Invasive Mechanical Ventilation in Patients of Chronic Obstructive Pulmonary Disease with Acute Respiratory Failure Type II.

Introduction:Acute respiratory failure is a potential complication of chronic obstructive pulmonary disease (COPD) that severely affects the health of the patient and may require mechanical ventilation. We compared noninvasive and invasive mechanical ventilation in COPD patients with acute respiratory failure type II to validate clinical outcome based on biochemical analysis of arterial blood gases (ABGs) and pulmonary parameters in terms of duration of mechanical ventilation, period spent in intensive care unit (ICU) and mortality.Materials and Methods:After approval of institutional ethical committee 100 patients were selected for randomized prospective controlled trial and divided into two groups of 50 each according to mode of mechanical ventilation. Group-I patients managed with noninvasive ventilation (NIV) Group-ll managed with invasive ventilation.Results:Demographic data between two groups were comparable. ABG parameters were better at 2 h and 6 h interval in NIV as compared to invasive ventilation (P < 0.05). The duration of ventilation and total time spent in ICU was 106±10 hours and 168±8 hours respectively in NIV group and 218 ± 12 and 280 ± 20 in invasive group. On intergroup comparison these were significantly less in noninvasive group (P < 0.05). Hospital acquired pneumonia occurred in 10% of patients in invasive group whereas no incidence of pneumonia found in noninvasive group. Mortality rate was 12% in invasive groups and 2% in noninvasive groups.Conclusion:NIV leads to significant improvement in ABG and pulmonary parameters and it reduces duration of ventilation and total period of hospital stay so it can be used as an alternative to invasive ventilation as first-line treatment in COPD.

Respiratory support in COPD patients after acute exacerbation with monitoring the quality of support (Rescue2-monitor): an open-label, prospective randomized, controlled, superiority clinical trial comparing hospital- versus home-based acute non-invasive ventilation for patients with hypercapnic chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is expected to be the 3rd leading cause of death worldwide by 2020. Despite improvements in survival by using acute non-invasive ventilation (NIV) to treat patients with exacerbations of COPD complicated by acute hypercapnic respiratory failure (AHRF), these patients are at high risk of readmission and further life-threatening events, including death. Recent studies suggested that NIV at home can reduce readmissions, but in a small proportion of patients, and with a high level of expertise. Other studies, however, do not show any benefit of home NIV. This could be related to the fact that respiratory failure in patients with stable COPD and their response to mechanical ventilation are influenced by several pathophysiological factors which frequently coexist in the same patient to varying degrees. These pathophysiological factors might influence the success of home NIV in stable COPD, thus long-term NIV specifically adapted to a patient’s “phenotype” is likely to improve prognosis, reduce readmission to hospital, and prevent death. In view of this conundrum, Rescue2-monitor (R2M), an open-label, prospective randomized, controlled study performed in patients with hypercapnic COPD post-AHRF, will investigate the impact of the quality of nocturnal NIV on the readmission-free survival. The primary objective is to show that any of 3 home NIV strategies (“rescue,” “non-targeted,” and “targeted”) will improve readmission-free survival in comparison to no-home NIV. The “targeted” group of patients will receive a treatment with personalized (targeted) ventilation settings and extensive monitoring. Furthermore, the influence of comorbidities typical for COPD patients, such as cardiac insufficiency, OSA, or associated asthma, on ventilation outcomes will be taken into consideration and reasons for non-inclusion of patients will be recorded in order to evaluate the percentage of ventilated COPD patients that are screening failures. ClinicalTrials.gov NCT03890224. Registered on March 26, 2019.

Effect of acute kidney injury on weaning from mechanical ventilation in chronic obstructive pulmonary diseases patients with respiratory failure

BackgroundAcute kidney injury (AKI) worsens the outcome in mechanically ventilated patients. The occurrence of AKI may have an effect on weaning from mechanical ventilation (MV). The purpose of this work is to study the effect of AKI on weaning from MV for chronic obstructive pulmonary disease (COPD) patients with respiratory failure (RF). The study included 100 mechanically ventilated COPD patients with RF. Patients were classified into group 1, mechanically ventilated COPD patients with type 2 RF who developed AKI, and group 2, mechanically ventilated COPD patients with type 2 RF, who did not develop AKI.ResultsThe age of the studied group ranged between 46 and 80 years, and serum creatinine on admission was within normal. There is a significant difference in a serum creatinine level after 2 days and after 1 week of MV in an intensive care unit (ICU) among AKI cases. There is a significant difference in weaning success between AKI and non-AKI patients with much higher weaning success in non-AKI group. Also, there is a significant reduction in glomerular filtration rate (GFR) in AKI patients after 48 h of admission.ConclusionsAKI is frequent in COPD patients within 48 h of ICU admission and MV increases the risk of AKI in COPD patients.

Advanced COPD in a patient treated in the Intensive Care Unit

Chronic obstructive pulmonary disease (COPD) is the 3rd leading cause of death worldwide and 7th in the classification of years of life lost or lived with disability. Indeed, COPD prevalence is still increasing. Moreover, chronic respiratory failure in advanced COPD is one of the most common indications for palliative care. The deterioration of general health, including respiratory failure, raises many doubts as to the need for hospitalization, prognosis and medical interventions. The decision to start palliative care provision in COPD patients is based on poor prognosis, but it is not clear when it should be started. Proper and specialized palliative care in this patient population can limit hospital, Intensive Care Unit (ICU), and emergency admissions. A case of a patient with advanced COPD receiving palliative care and the treatment in the ICU is presented. Due to pneumonia with permanent respiratory hypercapnia, the patient was hospitalized and qualified to tracheostomy and invasive ventilation. In bronchofiberoscopy granulation tissue narrowing the airways below the tracheotomy tube, confirmed by the CT scan. The patient was qualified for rigid bronchofiberoscopy to widen the trachea. Antibiotic therapy with multidirectional pharmacological treatment was provided at the ICU. The patient was discharged home in a fairly good general condition, on his breathing with passive oxygen therapy, periodically requiring assisted mechanical ventilation, without carbon dioxide retention, and with effective cough reflexes. Mechanical causes of respiratory failure in ventilated advanced COPD patients should be considered. Short–time-intensive therapy treatment may improve the general condition of ventilated advanced COPD patients.

Disease specific thresholds for determining extubation readiness: The optimal negative inspiratory force for chronic obstructive pulmonary disease patients.

Objectives:The negative inspiratory force (NIF) has been used to help clinicians predict a patient's likelihood of successful liberation from mechanical ventilation (MV). However, the utility of the traditional threshold of ≤−30 cmH 2O may not be appropriate for patients with chronic obstructive pulmonary disease (COPD). This study aims to define the optimal predictive NIF threshold for COPD patients.Methods:A prospective-observational multi-center study was conducted in intensive care units of six academic medical centers. All patients had COPD and were intubated for hypercapnic respiratory failure. The process of weaning from MV was conducted according to the defined hospital protocol. NIF was measured after 120 min of spontaneous breathing trial (SBT). The sensitivity, specificity, positive, and negative predictive value (PPV, NPV), positive and negative likelihood ratios (LR+, LR−) were calculated, and the diagnostic accuracy recorded.Results:A total of 90 patients with COPD (39 males and 51 females) were included. Of these, 43 patients (47.8%) were successfully extubated whereas 47 patients (52.2%) failed SBT or required re-intubation (P = 0.654). The threshold value of ≤−25 cmH2O offered the optimal performance in COPD patients: area under the receiver operating characteristic (ROC) curves ROC curves 0.836, sensitivity 95.0%, specificity 86.0%, PPV 84.4%, and NPV 95.6%., LR+ 6.79, LR− 0.06, and the diagnostic accuracy 90.7%.Conclusions:In mechanically ventilated COPD patients with hypercapnic respiratory failure, the NIF threshold of ≤−25 cmH2O was a moderate-to-good predictor for successful ventilator liberation, and outperforms the traditional threshold of ≤−30 cmH2O.

Delayed ventilation assessment using fast dynamic hyperpolarised Xenon-129 magnetic resonance imaging

ObjectivesTo investigate the use of a fast dynamic hyperpolarised 129Xe ventilation magnetic resonance imaging (DXeV-MRI) method for detecting and quantifying delayed ventilation in patients with chronic obstructive pulmonary disease (COPD).MethodsThree male participants (age range 31–43) with healthy lungs and 15 patients (M/F = 12:3, age range = 48–73) with COPD (stages II–IV) underwent spirometry tests, quantitative chest computed tomography (QCT), and DXeV-MRI at 1.5-Tesla. Regional delayed ventilation was captured by measuring the temporal signal change in each lung region of interest (ROI) in comparison to that in the trachea. In addition to its qualitative assessment through visual inspection by a clinical radiologist, delayed ventilation was quantitatively captured by calculating a covariance measurement of the lung ROI and trachea signals, and quantified using both the time delay, and the difference between the integrated areas covered by the signal-time curves of the two signals.ResultsRegional temporal ventilation, consistent with the expected physiological changes across a free breathing cycle, was demonstrated with DXeV-MRI in all patients. Delayed ventilation was observed in 13 of the 15 COPD patients and involved variable lung ROIs. This was in contrast to the control group, where no delayed ventilation was demonstrated (p = 0.0173).ConclusionsDXeV-MRI offers a non-invasive way of detecting and quantifying delayed ventilation in patients with COPD, and provides physiological information on regional pulmonary function during a full breathing cycle.Key Points• Dynamic xenon MRI allows for the non-invasive detection and measurement of delayed ventilation in COPD patients.• Dynamic xenon MRI during a free breathing cycle can provide unique information about pulmonary physiology and pulmonary disease pathophysiology.• With further validation, dynamic xenon MRI could offer a non-invasive way of measuring collateral ventilation which can then be used to guide lung volume reduction therapy (LVRT) for certain COPD patients.

High-flow nasal therapy versus noninvasive ventilation in COPD patients with mild-to-moderate hypercapnic acute respiratory failure: study protocol for a noninferiority randomized clinical trial

BackgroundNoninvasive ventilation (NIV) is indicated to treat respiratory acidosis due to exacerbation of chronic obstructive pulmonary disease (COPD). Recent nonrandomized studies also demonstrated some physiological effects of high-flow nasal therapy (HFNT) in COPD patients. We designed a prospective, unblinded, multicenter, randomized controlled trial to assess the noninferiority of HFNT compared to NIV with respect to the reduction of arterial partial pressure of carbon dioxide (PaCO2) in patients with hypercapnic acute respiratory failure with mild-to-moderate respiratory acidosis.MethodsWe will enroll adult patients with acute hypercapnic respiratory failure, as defined by arterial pH between 7.25 and 7.35 and PaCO2 ≥ 55 mmHg. Patients will be randomly assigned 1:1 to receive NIV or HFNT. NIV will be applied through a mask with a dedicated ventilator in pressure support mode. Positive end-expiratory pressure will be set at 3–5 cmH2O with inspiratory support to obtain a tidal volume between 6 and 8 ml/kg of ideal body weight. HFNT will be initially set at a temperature of 37 °C and a flow of 60 L/min. At 2 and 6 h we will assess arterial blood gases, vital parameters, respiratory rate, treatment intolerance and failure, need for endotracheal intubation, time spent under mechanical ventilation (both invasive and NIV), intensive care unit and hospital length of stay, and hospital mortality.Based on an α error of 5% and a β error of 80%, with a standard deviation for PaCO2 equal to 15 mmHg and a noninferiority limit of 10 mmHg, we computed a sample size of 56 patients. Considering potential drop-outs and nonparametric analysis, the final computed sample size was 80 patients (40 per group).DiscussionHFNT is more comfortable than NIV in COPD patients recovering from an episode of exacerbation. If HFNT would not be inferior to NIV, HFNT could be considered as an alternative to NIV to treat COPD patients with mild-to-moderate respiratory acidosis.Trial registrationClinicalTrials.gov, NCT03370666. Registered on December 12, 2017.

Role of Assessment of The Diaphragm by Ultrasound During Weaning from Mechanical Ventilation in Patients with Chronic Obstructive Pulmonary Disease

Background: Diaphragmatic Rapid Shallow Breathing Index (D-RSBI) is a new promising tool to predict weaning outcome. The D-RSB), which is the ratio between respiratory rate (RR) and the ultrasonographic evaluation of diaphragmatic displacement. Its accuracy in predicting weaning failure, in ready-to-wean mechanically ventilated chronic obstructive pulmonary disease (COPD) patients, needs to be evaluated. Objective: Assessment of diaphragm using ultrasound during weaning from mechanical ventilation in COPD patients and to compare the new (D-RSBI) with traditional rapid shallow breathing index (RSBI). Patients and Methods: A prospective observational study was carried out on mechanically ventilated COPD patients who were ready-to-wean. During spontaneous breathing trial (SBT), evaluation of the right hemi-diaphragmatic displacement and diaphragmatic thickness by using M-mode ultrasonography. Then calculation of D-RSBI (RR/DD) and RSBI (RR/tidal volume [VT]) were carried out simultaneously. Outcome of the weaning trials were recorded. Receiver operating characteristic curves were used to evaluate the diagnostic accuracy of D-RSBI and RSBI. Results: A total of 104 patients with acute excerptions chronic obstructive pulmonary disease AECOPD who were ready to perform a SBT from mechanical ventilation. 86 (82.7%) were successfully liberated from mechanical ventilation and 18 patients (17.3%) had failure of weaning. The sensitivity and specificity of diaphragmatic displacement were 72.2% and 93.0% respectively. The sensitivity and specificity of RSBI were 77.8% and 70.9%. While the sensitivity and specificity of D-RSBI were 83.3% and 90.7% respectively. Conclusion: D-RSBI (RR/DD) is superior than the traditional RSBI (RR/VT) in predicting weaning outcome patients with AECOPD.

Comparison between volume-controlled and pressure-controlled ventilation in COPD patients undergoing laparoscopic cholecystectomy

Background: Chronic obstructive pulmonary disease (COPD) is a well-known independent risk factor for the development of postoperative pulmonary complications. Managing ventilation and oxygenation during laparoscopic cholecystectomy (with creation of pneumoperitoneum) in these patients presents many challenges. Aim of this study: was to compare between volume-controlled and pressure-controlled ventilation in COPD patients undergoing laparoscopic cholecystectomy. Methods: A case control study was conducted on 60 participants aged between 18 and 60 years, diagnosed with COPD and scheduled for laparoscopic cholecystectomy. To start with, all patients received volume-controlled ventilation (VCV). Fifteen minutes after creation of pneumoperitoneum, they were randomized to receive either VCV (Group A) or pressure-controlled ventilation; PCV (Group B). Hemodynamics, ventilatory parameters, arterial blood gas analyses were noted. All data were analyzed statistically. Results: There was no significant difference between study groups as regards hemodynamic variables. Peak airway pressure was significantly lower in PCV group compared with VCV group. Mean airway pressure was significantly higher in PCV group compared with VCV group. As regards arterial blood gas analyses, there was no significant difference between study groups as regards PaO2 and SpO2. Patients in PCV group had higher PaCO2 (yet not clinically significant) at 35 min, compared with patients in VCV group. Conclusion: PCV and VCV were generally effective in maintaining adequate ventilation, oxygenation and hemodynamic stability. Peak airway pressure was significantly lower in PCV group compared with VCV group, thus decreasing the risk of barotrauma. PCV may be a better choice than VCV in COPD patients undergoing laparoscopic cholecystectomy.

Comparison between volume-controlled and pressure-controlled ventilation in COPD patients undergoing laparoscopic cholecystectomy

Background: Chronic obstructive pulmonary disease (COPD) is a well-known independent risk factor for the development of postoperative pulmonary complications. Managing ventilation and oxygenation during laparoscopic cholecystectomy (with creation of pneumoperitoneum) in these patients presents many challenges. Aim of this study: was to compare between volume-controlled and pressure-controlled ventilation in COPD patients undergoing laparoscopic cholecystectomy. Methods: A case control study was conducted on 60 participants aged between 18 and 60 years, diagnosed with COPD and scheduled for laparoscopic cholecystectomy. To start with, all patients received volume-controlled ventilation (VCV). Fifteen minutes after creation of pneumoperitoneum, they were randomized to receive either VCV (Group A) or pressure-controlled ventilation; PCV (Group B). Hemodynamics, ventilatory parameters, arterial blood gas analyses were noted. All data were analyzed statistically. Results: There was no significant difference between study groups as regards hemodynamic variables. Peak airway pressure was significantly lower in PCV group compared with VCV group. Mean airway pressure was significantly higher in PCV group compared with VCV group. As regards arterial blood gas analyses, there was no significant difference between study groups as regards PaO2 and SpO2. Patients in PCV group had higher PaCO2 (yet not clinically significant) at 35 min, compared with patients in VCV group. Conclusion: PCV and VCV were generally effective in maintaining adequate ventilation, oxygenation and hemodynamic stability. Peak airway pressure was significantly lower in PCV group compared with VCV group, thus decreasing the risk of barotrauma. PCV may be a better choice than VCV in COPD patients undergoing laparoscopic cholecystectomy.

Better airway resistance reduction profile in intubated COPD patients by personalized bronchodilator dosing: A pilot randomized control trial

IntroductionThe optimal dose of inhaled metered-dose bronchodilators for intubated patients with chronic obstructive pulmonary disease (COPD) is unknown. In this study, we proposed a bronchodilator dosing schedule based on an individual's airway resistance (Raw) and tested its efficacy in reducing Raw. MethodsA total of 51 newly admitted patients with invasively ventilated COPD were randomly assigned to receive personalized or fixed bronchodilator dosing. Personal target Raw was defined by measuring each individual's Raw after maximal pharmacologic bronchodilatation. Thereafter, Raw was measured every 8 h until the 28th day. Patients in the fixed-dosing group received only predetermined doses. Additional doses of bronchodilators were given to patients in the personalized-dosing group when the measured Raw exceeded their target Raw. ResultsThe median daily doses of salmeterol/fluticasone were 9.2 (personalized-dosing) vs 7.6 (fixed-dosing) puffs (P < 0.001). The relative deviation of Raw from the personal target was expressed as (measured Raw – target Raw)/target Raw. The experimental group showed a smaller relative Raw deviation than the control group (0.09 ± 0.10 vs 0.44 ± 0.11, P = 0.02). There were no differences between the two groups in terms of ventilator-free days from day 1 to day 28, number of episodes of nosocomial pneumonia, total number of puffs of rescue bronchodilator, number of drug-related adverse effects or mortality rate at day 180. ConclusionPersonalized dosing of inhaled bronchodilator administered to invasively ventilated COPD patients can produce a better reduction in Raw. Further studies with larger sample size are required to verify the conclusion of this pilot study.

The situation about cognitive performance of critical care staffs in nutrition therapy for mechanical ventilated COPD patients in county hospitals

Objective To investigate the situation about cognitive performance of critical care staffs in nutrition therapy for mechanical ventilated chronic obstructive pulmonary disease (COPD) patients in county hospitals. Methods A chart of questionnaire about nutrition therapy was formulated according to the current guidelines. Critical care staffs from 12 hospitals of county-level of Hang Zhou city were enrolled. The role of staffs in management of nutritional therapy for patients was observed to assess their cognitive performance and influence factors were analyzed according logistic analysis. Results A total of 137 staffs were enrolled. Almost all of the staffs thought that nutrition therapy for ventilated COPD patients was very important. About 90% of the staffs never heard about the use of NRS2002 (nutritional risk screening 2002) to evaluation COPD patients but the rate of using it was higher among senior staffs (OR=1.08, 95%CI: 1.01-1.16, P=0.04). Most of staffs assess the nutritional status of patients according to biomarkers and other methods. However, doctors might assess nutritional status more often according to their experience. The majority of staffs did choose enteral nutrition for patients especially seen in doctors and senior staffs (OR=3.10 and1.13, 95%CI: 1.27-7.55 and 1.03-1.23, both P=0.01). For those without malnutrition, senior staffs did not choose parenteral nutrition (OR=0.14, 95%CI: 0.04-0.57, P=0.01). Besides, senior staffs did not continue the enteral nutrition in patients with unstable haemodynamics (OR=1.10, 95%CI: 1.03-1.16, P=0.002). Most of staffs considered that the head piece of bed was raised up to 30-45 degree and gastric residual volume monitoring was very important. However, compared with nurses, the cognitive performance of doctors was poorer (OR=0.39, 95%CI: 0.18-0.83, P=0.01). Most of staffs thought that the nutrition therapy implementation checklist was necessary but it was used in only 20% institutions. The understanding and demand for nutritional knowledge was more urgent among doctors than nurses (OR=3.13 and 5.33, 95%CI: 1.45-6.75 and 1.13-25.02, P=0.004 and 0.03). Conclusions Nutrition therapy was important for ventilated COPD patients, but the staffs were not very familiar with nutritional knowledge. The cognitive performance of medical staffs was influenced by their profession and experience of practice. Key words: COPD; Mechanical ventilation; Nutrition therapy; NRS2002; Cognitive situation; Survey