Ventilatory Support In Patients Research Articles

Home mechanical ventilation: a narrative review and a proposal of practical approach.

Growing evidence of the benefits of home ventilatory support in patients with chronic respiratory failure along with technological advances in ventilators have enabled their use in overly complex situations, shaping a new scenario for physicians. This has further given rise to new challenges related to their incorporation into current medical practice. However, this evolution needs to be coupled with knowledge and skills of physicians who are willing to prescribe Home Mechanical Ventilation (HMV), in order to prevent them from making inappropriate choices or adjustments that may ultimately have ethical and legal implications. This article aims to provide guidance and information to support the indication for HMV and the ventilation modalities to be implemented, review basic ventilation concepts, including the ventilator modes most commonly used in patients outside the hospital setting, list the brands and models available in the Brazilian market, provide the means for obtaining equipment for HMV, and finally, describe the requirements for selection of equipment, taking into account the individual characteristics of the patient to ensure safe perioperative care and earlier dehospitalization.

Comparative effectiveness of combination therapy with nirmatrelvir–ritonavir and remdesivir versus monotherapy with remdesivir or nirmatrelvir–ritonavir in patients hospitalised with COVID-19: a target trial emulation study

Remdesivir (Veklury, Gilead Sciences, Foster City, CA, USA) and nirmatrelvir-ritonavir (Paxlovid, Pfizer, New York, NY, USA) were reported to improve the outcome of patients with mild-to-moderate COVID-19 symptoms. Preclinical data suggest that nirmatrelvir-ritonavir might be more effective than remdesivir alone or in combination with nirmatrelvir-ritonavir for people at high risk of severe COVID-19. We aimed to assess the safety and effectiveness of combining remdesivir and nirmatrelvir-ritonavir compared with using each drug alone for adults hospitalised with COVID-19. In this target trial emulation study, we used electronic health records of patients aged 18 years or older who received either combination treatment of nirmatrelvir-ritonavir and remdesivir or monotherapy of either drug between March 16 and Dec 31, 2022, within 5 days of hospitalisation for COVID-19 in Hong Kong. Inverse probability of treatment weighting was applied to balance baseline patient characteristics across the treatment groups. The primary outcome was all-cause mortality. Cox proportional hazards regression adjusting weighting was used to compare the risk of all-cause mortality, intensive care unit (ICU) admission, or ventilatory support for 90 days of follow-up between groups. Between March 16 and Dec 31, 2022, 18 196 participants were identified from electronic health records and assigned to receive remdesivir (n=4232), nirmatrelvir-ritonavir (n=13 656), or nirmatrelvir-ritonavir and remdesivir (n=308). By applying an inverse probability of treatment weighting, a weighted sample composed of 18 410 recipients of nirmatrelvir-ritonavir and remdesivir combination treatment, 18 178 recipients of remdesivir monotherapy, and 18 287 recipients of nirmatrelvir-ritonavir monotherapy was obtained. After a median follow-up of 84 days (IQR 45-90), risk of mortality was lower in patients who received nirmatrelvir-ritonavir monotherapy (hazard ratio [HR] 0·18 [95% CI 0·15 to 0·20]; absolute risk reduction [ARR] -16·33% [95% CI -16·98 to -15·68]) or remdesivir and nirmatrelvir-ritonavir combination therapy (HR 0·66 [95% CI 0·49 to 0·89]; ARR -6·52% [95% CI -7·29 to -5·74]) than in patients who received remdesivir monotherapy. Similar results were observed for ICU admission or ventilatory support (nirmatrelvir-ritonavir monotherapy: HR 0·09 [95% CI 0·07 to 0·11]; ARR -10·04% [95% CI -10·53 to -9·56]; combination therapy: HR 0·68 [95% CI 0·42 to 1·12]; ARR -3·24% [95% CI -3·84 to -2·64]). Compared with combination therapy, nirmatrelvir-ritonavir monotherapy was associated with lower risk of mortality (HR 0·27 [95% CI 0·20 to 0·37]; ARR -9·81% [95% CI -10·39 to -9·24]) and ICU admission or ventilatory support (HR 0·13 [95% CI 0·08 to 0·22]; ARR -6·80% [95% CI -7·22 to -6·39]). Our study highlighted the potential for reduced risk of mortality, ICU admission, or the need for ventilatory support in patients hospitalised with COVID-19 treated with nirmatrelvir-ritonavir as a monotherapy compared with treatment regimens based on nirmatrelvir-ritonavir and remdesivir combination therapy or remdesivir monotherapy. Further randomised controlled trials are needed to support the validity of the current results. The Health and Medical Research Fund Commissioned Research on COVID-19. For the Chinese translation of the abstract see Supplementary Materials section.

Duration of Invasive Mechanical Ventilation before Veno-Venous ExtraCorporeal Membrane Oxygenation for Covid-19 related Acute Respiratory Distress Syndrome: The experience of a tertiary care center

BackgroundVeno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) is an efficient ventilatory support in patients with refractory Covid-19-related Acute Respiratory Distress Syndrome (ARDS), however the duration of invasive mechanical ventilation (IMV) before ECMO initiation as a contraindication is still controversial. The aim of this study was to investigate the impact of prolonged IMV prior to VV-ECMO in patients suffering from refractory Covid-19-related ARDS. MethodsThis single-center retrospective study included all patients treated with VV-ECMO for refractory Covid-19-related ARDS between January 1, 2020 and May 31, 2022. The impact of IMV duration was investigated by comparing patients on VV-ECMO during the 7 days (and 10 days) following IMV with those assisted after 7 days (and 10 days). The primary endpoint was in-hospital mortality. ResultsSixty-four patients were hospitalized in the ICU for Covid-19-related refractory ARDS requiring VV-ECMO. Global in-hospital mortality was 55 %. Median duration of IMV was 4 [2; 8] days before VV-ECMO initiation. There was no significant difference in in-hospital mortality between patients assisted with IMV pre-VV-ECMO for a duration of ≤7 days (≤10 days) and those assisted after 7 days (and 10 days) ((p = 0.59 and p = 0.45). ConclusionThis study suggests that patients assisted with VV-ECMO after prolonged IMV had the same prognosis than those assisted earlier in refractory Covid-19-related ARDS. Therefore, prolonged mechanical ventilation of more than 7–10 days should not contraindicate VV-ECMO support. An individual approach is necessary to balance the risks and benefits of ECMO in this population.

Malnutrition in patients with cerebral stroke

BACKGROUND: Acute cerebral circulatory failure is distinguished by high prevalence and mortality. The course and outcome of stroke are significantly influenced by malnutrition. AIM: To examine the prevalence and effect of malnutrition on the course and outcome of severe cerebral stroke in patients on ventilatory support. MATERIALS AND METHODS: This multicenter observational clinical trial entitled "Registry of Respiratory Therapy in Patients with Acute Cerebral Circulatory Failure (RETAS)" was conducted under the auspices of the Federation of Anesthesiologists and Resuscitators of Russia. The study included 14 centers and 1289 acute cerebral circulatory failure patients who received respiratory support. RESULTS: Acute cerebral circulatory failure patients with a National Institutes of Health Stroke Scale score 14 on ventilatory support who did not exhibit malnutrition were more likely to experience a positive outcome on the Glasgow Outcome Scale (4 and 5) compared to patients with evidence of malnutrition (p=0.000002). Malnutrition was associated with an extended duration of ventilatory support in patients with acute cerebral circulatory failure (p 0.0001). The patients requiring prolonged ventilatory support experienced a higher prevalence of pressure sores, hypoproteinemia, hypoalbuminemia, and body weight loss by ≥10% (p 0.0001). Malnutrition was linked to an increased risk of developing ventilator-associated tracheobronchitis in patients with acute cerebral circulatory failure (p 0.0001). CONCLUSION: Malnutrition substantially affects the course and outcome of severe cerebral stroke in patients on respiratory support (ventilator).

Elevation of D-dimer levels are associated with early need for mechanical ventilation support in patients with COVID-19

BackgroundSevere COVID-19 disease is typically associated with an urgent need for supplemental oxygen therapy that may be successfully delivered through conventional methods or require invasive mechanical ventilation. Early prediction of the need for invasive mechanical ventilation could significantly improve outcomes of COVID-19 patients. Plasma levels of D-dimer and a number of inflammatory markers as well as values of complete blood counts, all measured in the first two days of hospital admission of COVID-19 patients, were evaluated for their significance as predictors of the eventual need for invasive mechanical ventilation support as well as their values as predictors of post-ventilation morbidly and mortality.MethodsThis retrospective cohort study was conducted at a single center and included data pertaining to 200 patients with previously confirmed moderate to severe COVID-19 disease in the period between May 2021 and the end of December 2022. Data were retrieved from medical records for further analysis.ResultsThe mean (SD) age of patients stood at 59 (14) years of age, and with a majority of patients being male (77%). About 18% of cases, all of significantly older age, had been connected to invasive mechanical ventilation (IMV). Total leucocytic count (TLC), as well as levels of urea, creatinine, D-dimer, ferritin, and CRP in IMV patients were significantly higher than non-ventilated patients (p < 0.01 for all). In contrast, lymphocytic count, hemoglobin level, and platelet count were significantly lower in IMV patients (p < 0.001, 0.04, and 0.002, respectively). The mortality rate was significantly higher in IMV patients (p < 0.001). D-dimer independently predicted IMV demand (OR = 1, p = 0.001 in adjusted and unadjusted models). The utility of D-dimer was excellent; and the cutoff level of above 1415 µ/L showed sensitivity and specificity of about 92% and 76%, respectively. Also, the D-dimer level was very effective in predicting post-IMV survival; the AUC = 0.86, p = 0.02, and a cutoff value below 4558 µ/L was associated with 100% and 66% sensitivity and specificity, respectively.ConclusionsHigh D-dimer levels independently correlated with the need for invasive mechanical ventilation. Low levels of this marker could evidently predict post-IMV survival of mechanically ventilated COVID-19 patients. Measuring D-dimer levels during routine follow up of those patients would thus be useful in predicting patient outcomes.

Effect of the modified snorkel mask as noninvasive ventilatory support in patients with acute hypoxemic respiratory failure due to COVID-19.

The shortage of mechanical ventilators during the COVID-19 pandemic led doctors to use alternative noninvasive ventilation systems, including a modified snorkel mask. Data on the use of the modified snorkel mask is limited. The study aims to describe the effect and clinical characteristics of patients with COVID-19 treated with a snorkel mask and to investigate the factors associated with the failure to use noninvasive ventilation with a snorkel mask. In this retrospective observational study, adult patients with COVID-19 who were treated with a snorkel mask at Daniel Alcides Carrion Hospital of Huancayo-Perú were selected. Of the 390 patients included, 158 (20.5%) received noninvasive ventilation with a snorkel, 84 (53.2%) patients were discharged alive without intubation, and the mortality rate was 22%. In the control group that received standard treatment, 129 patients (55.6%) failed (i.e., deceased or admitted to a mechanical ventilator). The mortality rate was 33.2%. ROX index < 4.8, consolidation-type tomographic pattern, and the presence of complications, such as bacterial pneumonia or thromboembolism, were independently associated with a higher risk of noninvasive ventilation failure with snorkels. Using the snorkel system resulted in an absolute mortality reduction of 11%, and recovery increased by 15% compared to the standard treatment system. Therefore, this device can be used as an acceptable alternative in the absence of mechanical ventilators.

Knowledge and attitudes of medical staff on infection control at Bac Ninh Obstetric and Pediatric Hospital 2022

Objective: To evaluate the knowledge and attitudes of healthcare workers toward standard precautions, prevention of Central Line-Associated Bloodstream Infections (CLABSI), and ventilator Associated Pneumonia (VAP) at Bac Ninh Obstetrics and Children’s Hospital in 2022. Methods: A descriptive cross-sectional study was conducted between November and December 2022 at Bac Ninh Obstetrics and Children’s Hospital. The survey on standard prevention was participated by 120 health workers, who were from 6 pediatric clinical departments. On the other hand, the prevention of hospital-acquired infections related to pulmonary health care survey had the participation of 47 health workers from 2 intensive care units. Results: The study revealed that the medical staff had good knowledge regarding the examination room content, ranging from 70.8% to 97.5%, however, they exhibited negative attitudes towards some infection control measures. The healthcare workers’ knowledge regarding the prevention of Central Line-Associated Bloodstream Infections (CLABSI) was inadequate, and they lacked knowledge about ventilator Associated Pneumonia. Nevertheless, the healthcare workers had a positive attitude toward implementing measures to prevent pneumonia in ventilator-supported patients, with 100%. Conclusion: The study showed that the knowledge and attitudes of healthcare workers regarding infection control were limited. Therefore, appropriate training programs must be planned and organized to improve their knowledge and attitudes toward infection control.

Invasive Ventilatory Support in Patients With Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference.

To provide evidence for the Second Pediatric Acute Lung Injury Consensus Conference updated recommendations and consensus statements for clinical practice and future research on invasive mechanical ventilation support of patients with pediatric acute respiratory distress syndrome (PARDS). MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). We included clinical studies of critically ill patients undergoing invasive mechanical ventilation for PARDS, January 2013 to April 2022. In addition, meta-analyses and systematic reviews focused on the adult acute respiratory distress syndrome population were included to explore new relevant concepts (e.g., mechanical power, driving pressure, etc.) still underrepresented in the contemporary pediatric literature. Title/abstract review, full text review, and data extraction using a standardized data collection form. The Grading of Recommendations Assessment, Development and Evaluation approach was used to identify and summarize relevant evidence and develop recommendations, good practice statements and research statements. We identified 26 pediatric studies for inclusion and 36 meta-analyses or systematic reviews in adults. We generated 12 recommendations, two research statements, and five good practice statements related to modes of ventilation, tidal volume, ventilation pressures, lung-protective ventilation bundles, driving pressure, mechanical power, recruitment maneuvers, prone positioning, and high-frequency ventilation. Only one recommendation, related to use of positive end-expiratory pressure, is classified as strong, with moderate certainty of evidence. Limited pediatric data exist to make definitive recommendations for the management of invasive mechanical ventilation for patients with PARDS. Ongoing research is needed to better understand how to guide best practices and improve outcomes for patients with PARDS requiring invasive mechanical ventilation.

Neutrophil-lymphocyte and leuko-glycemic indices as predictive markers for ventilatory support in patients with Guillain-Barre syndrome

Background: Guillain-Barré syndrome (GBS) is the most common cause of acute flaccid paralysis worldwide. Lymphocytes and neutrophils are associated with systemic inflammation and production of proinflammatory mediators. GBS, as an autoimmune disease, elicits an upregulation in inflammatory and metabolic pathways, with increased production of lymphocytes and neutrophils. Serum markers such as the neutrophil-lymphocyte (NLR) and leuko-glycemic (LGR) ratios have been studied for the severity and prognosis of non-neurological disorders. Methods: A cross-sectional study from a prospective cohort of patients with GBS was conducted, from January 2018 to February 2021. Comparison between patients with or without ventilatory support was performed with student´s t test or Mann-Whitney U test based on distribution. Chi-square for was used for categorical variables, Fisher´s exact test was applied when necessary. A logistic regression analysis was performed. Results: One hundred and twenty-three patients were included. Logistic regression analysis demonstrated NLI to be an independent factor for mechanical ventilation in GBS, but not for LGI and OR 2.0, respectively. Both LGI and NLI demonstrated a high performance for ventilatory support prediction, with 0.70 and 0.81, respectively. Best cut-off values, according to Youden index, are for LGI 1.12 (sensitivity 0.70, specificity 0.40) and for NLI 3.59 (sensitivity 0.78, specificity 0.33). Conclusions: Despite the wide use of the EGRIS scale in estimating respiratory insufficiency in patients with GBS, we portray a new and easy to obtain laboratory tool that can further help non-neurologists and other clinicians to predict the risk for ventilatory support.

‘Do-not-intubate’ orders in patients assisted by noninvasive respiratory support for acute hypoxaemic failure caused by coronavirus disease 2019; a systematic review and meta-analysis

BACKGROUND Noninvasive respiratory support (NIRS) has been revealed feasible solutions to cope with the massive request for ventilatory support in patients subjected to ‘do-not-intubate’ order (DNI). OBJECTIVES The aims of the present systematic review and meta-analysis was to estimate pooled incidence of DNI orders and the associated in-hospital mortality in patients undergoing NIRS for hypoxaemic acute respiratory failure (ARF) related to coronavirus disease 2019 (COVID-19). DESIGN Systematic review of observational studies and randomized-controlled trials with meta-analyses DATA SOURCES PUBMED, EMBASE, and Cochrane Controlled Clinical trials register were searched for observational studies and randomised-controlled trials from inception to the end of April 2022. ELIGIBILITY CRITERIA Inclusion criteria were: observational studies enrolling ≥50 hospitalised patients with hypoxaemic COVID-19-related ARF requiring NIRS and DNI order application. Two authors independently extracted data from enrolled investigations. Data are presented as proportions with 95% confidence interval. RESULTS Thirty-one observational studies were included for a total of 6645 COVID-19 patients undergoing NIRS, of whom 1590 received DNI orders. Among patients assisted by NIRS, a DNI order was expressed in a summary estimate of 25.4% [20.0–31.1] of the cases with a high between-study heterogeneity. The summary estimated of in-hospital mortality was 83.6% [75.3–90.7] for DNI patients and 20.0% [14.2–26.5] for full treatment patients, both with a high between-study heterogeneity. CONCLUSIONS In COVID-19 patients assisted through NIRS for hypoxaemic ARF, a DNI order was frequently issued and associated with a high in-hospital mortality TRIAL REGISTRATION Prospero registration number: CRD42021271313.

P.17 Importance of routine pulmonary check-up prior to ventilatory support in patients with Duchenne muscular dystrophy

P.17 Importance of routine pulmonary check-up prior to ventilatory support in patients with Duchenne muscular dystrophy

Effect of nadir hematocrit during cardiopulmonary bypass on the early outcomes after surgical repair of acute type A aortic dissection

Although hemodilution during hypothermic cardiopulmonary bypass (CPB) had been thought to improve microcirculation and reduce blood viscosity, there has been no report investigating the effect of low nadir hematocrit (Hct) values caused by severe hemodilution on the surgical outcomes of patients with acute type A aortic dissection (ATAAD). We retrospectively reviewed 112 consecutive patients who emergently underwent emergency surgical repair of ATAAD at our institution. The patients were classified into the high Hct (nadir Hct ≥ 21% during CPB; n = 51) and low Hct (nadir Hct < 21% during CPB; n = 61) groups. After propensity score matching of preoperative characteristics, surgical outcomes were compared between the groups. Although there was no difference in the surgical procedure, longer CPB time and more blood transfusion during surgery were needed in the low Hct group than in the high Hct group. After surgery, estimated glomerular filtration rate was significantly lower (p = .015), lactaic acid was higher (p = .045), and intubation time was longer (p = .018) in the low Hct group than in the high Hct group, although there was no difference in hospital mortality between the groups. The AUC of the nadir Hct during CPB as a prognostic indicator of prolonged postoperative ventilator support was 0.8, with the highest accuracy at 16.7% (sensitivity 88%, specificity 76.9%). In all cohorts, female sex was an independent risk factor for a lower nadir Hct value of <21% during CPB. A lower nadir Hct value of <21% during CPB may be associated with postoperative renal dysfunction and prolonged ventilator support in patients with ATAAD.

The novel use of diaphragmatic excursion on hospital admission to predict the need for ventilatory support in patients with coronavirus disease 2019

BackgroundWe aimed to evaluate the ability of diaphragmatic excursion at hospital admission to predict outcomes in patients with coronavirus disease-2019 (COVID-19). MethodsIn this prospective observational study, we included adult patients with severe COVID-19 admitted to a tertiary hospital. Ultrasound examination of the diaphragm was performed within 12 h of admission. Other collected data included peripheral oxygen saturation (SpO2), respiratory rate, and computed tomography (CT) score. The outcomes included the ability of diaphragmatic excursion, respiratory rate, SpO2, and CT score at admission to predict the need for ventilatory support (need for non-invasive or invasive ventilation) and patient mortality using the area under the receiver operating characteristic curve (AUC) analysis. Univariate and multivariable analyses about the need for ventilatory support and mortality were performed. ResultsDiaphragmatic excursion showed an excellent ability to predict the need for ventilatory support, which was the highest among respiratory rate, SpO2, and CT score; the AUCs (95% confidence interval [CI]) was 0.96 (0.85–1.00) for the right diaphragmatic excursion and 0.94 (0.82–0.99) for the left diaphragmatic excursion. The right diaphragmatic excursion also had the highest AUC for predicting mortality in relation to respiratory rate, SpO2, and CT score. Multivariable analysis revealed that low diaphragmatic excursion was an independent predictor of mortality with an odds ratio (95% CI) of 0.55 (0.31–0.98). ConclusionDiaphragmatic excursion on hospital admission can accurately predict the need for ventilatory support and mortality in patients with severe COVID-19. Low diaphragmatic excursion was an independent risk factor for in-hospital mortality.

RIGID BRONCHOSCOPY AND DEBULKING IN CASE OF CENTRAL AIRWAY OBSTRUCTION BY METASTATIC ESOPHAGEAL TUMOR RESCUED BY ECMO

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Veno-venous extracorporeal membrane oxygenation( ECMO) has been used to provide the ventilatory support in patients with refractory hypoxia that does not respond to traditional methods of ventilation. Its use to support the ventilation while the patient undergoes life saving central airway procedures has been increasing. We present a rare case of metastatic esophageal tumor obstructing the central airway where VV-ECMO was used to provide the ventilation to the patient while undergoing rigid bronchoscopy and debulking of the tumor. CASE PRESENTATION: A 44-year-old male with a past medical history of chronic tobacco use, alcoholic dependence was transferred from an outside hospital for further workup of 4.7x6.5cm subcarinal mass centered on the esophagus with invasion to the trachea and complete occlusion of the right main stem and about 80% occlusion of the left main stem. He was saturating 95% on room air and hemodynamically stable. Physical examination revealed diminished breath sounds on the left lung, and coarse breath sounds on the right lung. Given the concern for near-complete tracheal obstruction with impending respiratory failure, urgent rigid bronchoscopy and debulking were planned. However, the tumor was found to be friable and started to bleed on flexible bronchoscopy. The procedure was aborted in the middle due to a friable tumor and high risk of complete tracheal obstruction . Subsequently, patient was put on the VV ECMO circuit. Debulking was done on both sides of the tumor using CO2 laser, cryoablation, coring through 11 mm rigid bronchoscope. Further, wire stents were placed with a tracheal length of 5 cm, left length of 4.5, and the right length of 2.5 cm. The post-procedure course was unremarkable. DISCUSSION: Recent exploration of ECMO use has led physicians to utilize it for interventional procedures with high risk of complications that can lead to cardiopulmonary failure. Yu et al intervened on a patient with advanced esophageal cancer with metastasis to trachea under ECMO support, a case similar to ours, and reported a successful resection of the mass using high-frequency electric knife and cryotherapy. 1 The literature published thus far is encouraging for the use of ECMO in cases of central airway interventions especially in malignant masses that otherwise would have been impossible to resect due to risks of severe bleeding and complete airway obstruction.2 CONCLUSIONS: It is essential to realize the high risk of complete airway obstruction and impending respiratory failure in case of tumors obstructing the trachea. Further, interventional pulmonologists should be prepared for an alternate ventilation method like VV ECMO in such cases. REFERENCE #1: Yu W, Zhou P, Chen K, Tang W, Xia Q, Ma J. Bronchoscopy-guided intervention therapy with extracorporeal membrane oxygenation support for advanced cancer metastasis to the central airway: A case report. Medicine (Baltimore). 2020;99(11):e19488. doi:10.1097/MD.0000000000019488 REFERENCE #2: Hong Y, Jo KW, Lyu J, Huh JW, Hong SB, Jung SH, Kim JH, Choi CM. Use of venovenous extracorporeal membrane oxygenation in central airway obstruction to facilitate interventions leading to definitive airway security. J Crit Care. 2013 Oct;28(5):669-74. doi: 10.1016/j.jcrc.2013.05.020. Epub 2013 Jul 8. PMID: 23845793. DISCLOSURES: No relevant relationships by Fernando Figueroa Rodriguez, source=Web Response No relevant relationships by Samiksha Gupta, source=Web Response no disclosure on file for Taha Khan; No relevant relationships by Miloni Parmar, source=Web Response No relevant relationships by Mukund Tiwari, source=Web Response

Observation of the curative effect of conservative oxygen therapy in mechanical ventilation of patients with severe pneumonia

To compare the effects of conservative oxygen therapy and conventional oxygen therapy on the efficacy and prognosis of mechanical ventilation support in patients with severe pneumonia. A prospective randomized controlled study were conducted, 110 patients with severe pneumonia requiring mechanical ventilation in intensive care unit (ICU) of Hefei First People's Hospital from May 2019 to May 2021 were selected and divided into conventional oxygen therapy group (51 cases) and conservative oxygen therapy group (55 cases) according to random number table method. Patients in both groups were treated with invasive to non-invasive sequential mechanical ventilation strategy, and the target of oxygen therapy in the conventional oxygen therapy group was set as the arterial partial pressure of oxygen (PaO2) > 150 mmHg (1 mmHg = 0.133 kPa) or pulse oxygen saturation (SpO2) > 0.96. In the conservative oxygen therapy group, PaO2 was set at 70-100 mmHg or SpO2 at 0.90-0.92. The changes of blood gas analysis, mechanical ventilation time, ICU stay time, ICU mortality, new organ dysfunction and infection more than 48 hours after admission were observed in two groups before and after treatment. Kaplan-Meier method was used to analyze the difference in cumulative survival rate between the two groups. After treatment, pH value, PaO2 and oxygenation index (PaO2/FiO2) in both groups were significantly higher than before treatment, and arterial partial pressure of carbon dioxide (PaCO2) was significantly lower than before treatment. pH value in the conservative oxygen therapy group was significantly higher than that in the conventional oxygen therapy group (7.4±0.1 vs. 7.3±0.3). PaO2, PaCO2 and PaO2/FiO2 were significantly lower than those in conventional oxygen therapy group [PaO2 (mmHg): 68.9±4.7 vs. 75.2±6.0, PaCO2 (mmHg): 42.1±5.6 vs. 50.5±7.5, PaO2/FiO2 (mmHg): 329±126 vs. 365±108, all P < 0.05]. The mechanical ventilation time in the conservative oxygen therapy group was significantly longer than that in the conventional oxygen therapy group (days: 19.7±3.5 vs. 13.9±4.5, P < 0.05), but there was no significant difference in ICU hospitalization time between the conservative oxygen therapy group and the conventional oxygen therapy group (days: 26.5±5.0 vs. 25.5±4.6, P > 0.05). Compared with the conventional oxygen therapy group, the ICU mortality, the incidence of nosocomial bloodstream infection, and the incidence of liver insufficiency, shock, and ICU acquired weakness (ICUAW) were decreased significantly in the conservative oxygen therapy group [ICU mortality: 27.3% (15/55) vs. 45.1% (23/51), liver insufficiency: 1.8% (1/55) vs. 7.8% (4/51), shock: 3.6% (2/55) vs. 9.8% (5/51), ICUAW: 5.5% (3/55) vs. 11.8% (6/51), the incidence of new bloodstream infection: 5.5% (3/55) vs. 11.8% (6/51), all P < 0.05]. Kaplan-Meier analysis showed that the cumulative survival rate of the conservative oxygen therapy group was significantly higher than that of the conventional oxygen therapy group (72.7% vs. 54.9%; Log-Rank test: χ2 = 4.244, P = 0.039). Conservative oxygen therapy can reduce ICU mortality, the incidence of shock, liver insufficiency, ICUAW, and bloodstream infection in patients with severe pneumonia, but prolong mechanical ventilation time.

Admission SpO2 and ROX index predict outcome in patients with COVID-19.

BackgroundThis study aimed to evaluate the accuracy of pulse oximetry-derived oxygen saturation (SpO2) on room air, determined at hospital admission, as a predictor for the need for mechanical ventilatory support in patients with Coronavirus Disease-2019 (COVID-19).MethodsIn this retrospective observational study, demographic and clinical details of the patients were obtained during ICU admission. SpO2 and respiratory rate (RR) on room air were determined within the first 6 h of hospital admission. As all measurements were obtained on room air, we calculated the simplified respiratory rate‑oxygenation (ROX) index by dividing the SpO2 by the RR. Based on the use of any assistance of mechanical ventilator (invasive or noninvasive), patients were divided into mechanical ventilation (MV) group and oxygen therapy group. The accuracy of the SpO2, CT score, and ROX index to predict the need to MV were determined using the Area under receiver operating curve (AUC).ResultsWe included 72 critically ill patients who tested COVID-19-positive. SpO2 on the room air could predict any MV requirement (AUC [95% confidence interval]: 0.9 [0.8–0.96], sensitivity: 70%, specificity 100%, cut-off value ≤78%, P < 0.001). Within the MV group, the use of noninvasive ventilation (NIV) was successful in 37 (74%) patients, whereas 13 patients (26%) required endotracheal intubation. The cut-off ROX value for predicting early NIV failure was ≤1.4, with a sensitivity of 85%, a specificity of 86%, and an AUC of 0.86 (95% confidence interval of 0.73–0.94, P < 0.0001).ConclusionsA baseline SpO2 ≤78% is an excellent predictor of MV requirement with a positive predictive value of 100%. Moreover, the ROX index measured within the first 6 h of hospital admission is a good indicator of early NIV failure.

Impact of Using a Non-Rebreathing Mask in Patients With Respiratory Failure

BackgroundLiberal oxygen therapy might increase the mortality rate of patients. Non-rebreathing masks (NRM) are a high-flow, non-invasive oxygen device that can provide oxygen concentration up to 95%. This study aimed to determine the impact of using NRM in patients with respiratory failure. MethodsThis retrospective cohort study was conducted in four medical institutions in Taiwan from January 2010 to December 2016. The association between mortality and NRM use before receiving ventilator support in patients with respiratory failure in the emergency department was analyzed. Patients were divided into the NRM treatment and no NRM treatment groups. A 1:4 propensity score matching was conducted. Regarding the duration of NRM use, treatments were grouped as 0 h, 0–1 h, 1–2 h, and >2 h. ResultsA total of 18,749 patients were included, with 1074 using NRM. After propensity score matching, 1028 patients using NRM (0–1 h: 508, 1–2 h: 193, and >2 h: 327) and 4112 patients not using NRM were analyzed. The 30-day mortality rates were 29.1%, 28.5%, 27.5%, and 35.5% in the 0 h, 0–1 h, 1–2 h, and >2 h treatment groups, respectively. Patients with respiratory failure due to pulmonary disease using NRM over 2 h had a higher mortality rate than patients not using NRM (hazard ratio: 1.3, 95% CI: 1.01–1.66). ConclusionsProlonged use of NRM in patients with respiratory failure due to pulmonary disease possibly increases mortality.

Ventilatory Support in Patients with COVID-19.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused the novel coronavirus disease 2019 (COVID-19) pandemic, which spread throughout the world. Acute hypoxemic respiratory failure is the most dangerous complication of COVID-19 pneumonia. To date, no specific therapeutic drugs or vaccines have been proven efficacious. Ventilatory support is still a significant challenge for physicians facing COVID-19. The mechanisms underlying hypoxemia in those patients are not fully understood, but a new physiopathology model has been proposed. Oxygen therapy should be delivered to patients with mild to moderate hypoxemia. More severe patients could benefit from other treatments (high-flow nasal cannula, noninvasive ventilation or intubation, and invasive ventilation). Given the rapid evolution of COVID-19, there has been a paucity of the high-quality data that typically inform clinical practice guidelines from professional societies, and a worldwide consensus is still lacking. This chapter aims to illustrate the potentials of ventilatory support as therapeutic options for adult and pediatric patients affected by COVID-19 pneumonia.

Covid 19: última evidencia

Esta actualización forma parte de la serie de actualizaciones clínicas, publicadas en los dos números anteriores de la Revista Practica Familiar Rural, el objetivo, es poner a la disposición de profesionales en salud la evidencia actualizada alrededor de la epidemiologia, la transmisión comunitaria, el riesgo de infección de personal de salud la fisiopatología y las manifestaciones clínicas extra-pulmonares, tomado en cuenta que en la primera etapa de la pandemia se puso mucho enfoque sobre el aparato respiratorio.Finalmente trascribimos las guías sobre el apoyo ventilatorio en pacientes que pueden requerir Cuidados Intensivos y las nuevas recomendaciones sobre el tratamiento farmacológico.

Risk factors for non-invasive/invasive ventilatory support in patients with COVID-19 pneumonia: A retrospective study within a multidisciplinary approach

ObjectivesTo investigate risk factors for non-invasive/invasive ventilatory support (NI/I-VS) in patients with coronavirus disease 2019 (COVID-19). MethodsAll consecutive patients admitted to the Infectious Diseases Unit and Intensive Care Unit (ICU) of Santa Maria Annunziata Hospital (Florence, Italy), from February 25 to April 25, 2020, with a confirmed COVID-19 diagnosis were enrolled in this retrospective cohort study. NI/I-VS was defined as the need for continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BPAP) (non-invasive ventilation) or mechanical ventilation, not including low-flow systems of oxygen therapy such as the Venturi mask or nasal cannula. ResultsNinety-seven patients were enrolled; 61.9% (60/97) were male and the median patient age was 64 years. The in-hospital mortality was 9.3%. Thirty-five of the 97 patients (36%) required ICU admission and 94.8% (92/97) were prescribed oxygen therapy: 10.8% (10/92) by nasal cannula, 44.5% (41/92) by Venturi mask, 31.5% (29/92) by CPAP, 2.2% (2/92) by BPAP, and 10.8% (10/92) by mechanical ventilation following intubation. On univariate analysis, patients with a body mass index >30, type II diabetes mellitus, and those presenting with dyspnoea, asthenia, SOFA score ≥2 points, PaO2/FiO2 <300, temperature >38 °C, increased levels of lactate dehydrogenase (LDH), alanine aminotransferase, and C-reactive protein, and a d-dimer >1000 ng/mL at admission more frequently underwent NI/I-VS. Multivariate logistic regression analysis confirmed temperature >38 °C (odds ratio (OR) 21.2, 95% confidential interval (95% CI) 3.5–124.5, p = 0.001), LDH >250 U/l (OR 15.2, 95% CI 1.8–128.8, p = 0.012), and d-dimer >1000 ng/mL (OR 4.5, 95% CI 1.2–17.3, p = 0.027) as significantly associated with the requirement for NI/I-VS. A non-significant trend (p = 0.051) was described for PaO2/FiO2 <300. ConclusionsTemperature >38 °C, LDH > 250 U/l, and d-dimer >1000 ng/mL were found to be independent risk factors for NI/I-VS in COVID-19 patients. In order to quickly identify patients likely at risk of developing a critical illness, inflammatory markers should be assessed upon hospital admission.