Modified high-flow nasal cannula oxygen therapy versus conventional oxygen therapy in patients undergoing bronchoscopy: a randomized clinical trial.

BACKGROUND: Hypoxemia frequently occurs during bronchoscopy. High-flow nasal cannula (HFNC) oxygen therapy may be a feasible alternative to prevent the deterioration of gas exchange during bronchoscopy. With the convenience of clinical use in mind, we modified an HFNC using a single cannula. This clinical trial was designed to test the hypothesis that a modified HFNC would decrease the proportion of patients with a single moment of peripheral arterial oxygen saturation (SpO2) < 90% during bronchoscopy. METHODS: In this single-center, prospective randomized controlled trial, hospitalized patients in the respiratory department in need of diagnostic bronchoscopy were randomly assigned to a modified HFNC oxygen therapy group or a conventional oxygen therapy (COT) group. The primary outcome was the proportion of patients with a single moment of SpO2 < 90% during bronchoscopy. RESULTS: Eight hundred and twelve patients were randomized to the modified HFNC (n = 406) or COT (n = 406) group. Twenty-four patients were unable to cooperate or comply with bronchoscopy. Thus, 788 patients were included in the analysis. The proportion of patients with a single moment of SpO2 < 90% during bronchoscopy in the modified HFNC group was significantly lower than that in the COT group (12.5% vs. 28.8%, p < 0.001). There were no significant differences in the fraction of inspired oxygen between the two groups. The lowest SpO2 during bronchoscopy and 5 min after bronchoscopy in the modified HFNC group was significantly higher than that in the COT group. Multivariate analysis showed that a baseline forced vital capacity (FVC) < 2.7 L (OR, 0.276; 95% CI, 0.083-0.919, p = 0.036) and a volume of fluid instilled > 60 ml (OR, 1.034; 95% CI, 1.002-1.067, p = 0.036) were independent risk factors for hypoxemia during bronchoscopy in the modified HFNC group. CONCLUSIONS: A modified HFNC could decrease the proportion of patients with a single moment of SpO2 < 90% during bronchoscopy. A lower baseline FVC and large-volume bronchoalveolar lavage may predict desaturation during bronchoscopy when using a modified HFNC. Trial registration ClinicalTrials. Gov: NCT02606188. Registered 17 November 2015.

Rapid-flow expulsion maneuver in subglottic secretion clearance to prevent ventilator-associated pneumonia: a randomized controlled study.

BACKGROUND: Following endotracheal intubation, clearing secretions above the endotracheal tube cuff decreases the incidence of ventilator-associated pneumonia (VAP); therefore, subglottic secretion drainage (SSD) is widely advocated. Our group developed a novel technique to remove the subglottic secretions, the rapid-flow expulsion maneuver (RFEM). The objective of this study was to explore the effectiveness and safety of RFEM compared with SSD. METHODS: This study was a single-center, prospective, randomized and controlled trial, conducted at Respiratory Intensive Care Unit (ICU) of Beijing Chao-Yang Hospital, a university-affiliated tertiary hospital. The primary outcome was the incidence of VAP, assessed for non-inferiority. RESULTS: Patients with an endotracheal tube allowing drainage of subglottic secretions (n = 241) were randomly assigned to either the RFEM group (n = 120) or SSD group (n = 121). Eleven patients (9.17%) in the RFEM group and 13 (10.74%) in the SSD group developed VAP (difference, - 1.59; 95% confidence interval [CI] [- 9.20 6.03]), as the upper limit of 95% CI was not greater than the pre-defined non-inferiority limit (10%), RFEM was declared non-inferior to SSD. There were no statistically significant differences in the duration of mechanical ventilation, ICU mortality, or ICU length of stay and costs between groups. In terms of safety, no accidental extubation or maneuver-related barotrauma occurred in the RFEM group. The incidence of post-extubation laryngeal edema and reintubation was similar in both groups. CONCLUSIONS: RFEM is effective and safe, with non-inferiority compared to SSD in terms of the incidence of VAP. RFEM could be an alternative method in first-line treatment of respiratory ICU patients. Trial registration This study has been registered on ClinicalTrials.gov (Registration Number: NCT02032849, https://clinicaltrials.gov/ct2/show/NCT02032849 ); registered on January 2014.

High-Flow Nasal Cannula for Chronic Obstructive Pulmonary Disease with Acute Compensated Hypercapnic Respiratory Failure: A Randomized, Controlled Trial.

Introduction: Currently, there is a lack of evidence on the utilization of high-flow nasal cannula (HFNC) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) accompanied by hypercapnic respiratory failure. We aimed to explore the efficacy and safety of HFNC compared with conventional oxygen therapy (COT) in such patients. Methods: This was a prospective, randomized, controlled trial. Patients with AECOPD with a baseline arterial blood gas pH ≥7.35, PaO2 <60 mmHg, and PaCO2 >45 mmHg were enrolled. The primary endpoint was treatment failure, which needs mechanical ventilation. Results: A total of 320 patients were randomized to either the HFNC group (n = 160) or the COT group (n = 160). Sixteen (10.0%) patients in the HFNC group had treatment failure during hospitalization, which was significantly lower than the COT group figure of 31 (19.4%) patients (p = 0.026). Twenty-four hours after recruitment, the PaCO2 of the HFNC group was lower than that of the COT group (54.1 ± 9.79 mmHg vs 56.9 ± 10.1 mmHg, p = 0.030). PaCO2 higher than 59 mmHg after HFNC for 24 h was identified as an independent risk factor for treatment failure [OR 1.078, 95% CI 1.006-1.154, p = 0.032]. Conclusion: In AECOPD patients with acute compensated hypercapnic respiratory failure, HFNC improved the prognosis compared with COT. Therefore, HFNC might be considered for first-line oxygen therapy in select patients. Trial Registration Number: ClinicalTrials.Gov: NCT02439333.

Mechanical Ventilation Strategy Guided by Transpulmonary Pressure in Severe Acute Respiratory Distress Syndrome Treated With Venovenous Extracorporeal Membrane Oxygenation.

OBJECTIVES: Previous studies have suggested that adjusting ventilator settings based on transpulmonary pressure measurements may minimize ventilator-induced lung injury, but this has never been investigated in patients with severe acute respiratory distress syndrome supported with venovenous extracorporeal membrane oxygenation. We aimed to evaluate whether a transpulmonary pressure-guided ventilation strategy would increase the proportion of patients successfully weaned from venovenous extracorporeal membrane oxygenation support in patients with severe acute respiratory distress syndrome. DESIGN: Single-center, prospective, randomized controlled trial. SETTING: Sixteen-bed, respiratory ICU at a tertiary academic medical center. PATIENTS: Severe acute respiratory distress syndrome patients receiving venovenous extracorporeal membrane oxygenation. INTERVENTIONS: One-hundred four patients were randomized to transpulmonary pressure-guided ventilation group (n = 52) or lung rest strategy group (n = 52) groups. Two patients had cardiac arrest during establishment of venovenous extracorporeal membrane oxygenation in the lung rest group did not receive the assigned intervention. Thus, 102 patients were included in the analysis. MEASUREMENTS AND MAIN RESULTS: The proportion of patients successfully weaned from venovenous extracorporeal membrane oxygenation in the transpulmonary pressure-guided group was significantly higher than that in the lung rest group (71.2% vs 48.0%; p = 0.017). Compared with the lung rest group, driving pressure, tidal volumes, and mechanical power were significantly lower, and positive end-expiratory pressure was significantly higher, in the transpulmonary pressure-guided group during venovenous extracorporeal membrane oxygenation support. In the transpulmonary pressure-guided group, levels of interleukin-1ß, interleukin-6, and interleukin-8 were significantly lower, and interleukin-10 was significantly higher, than those of the lung rest group over time. Lung density was significantly lower in the transpulmonary pressure-guided group after venovenous extracorporeal membrane oxygenation support than in the lung rest group. CONCLUSIONS: A transpulmonary pressure-guided ventilation strategy could increase the proportion of patients with severe acute respiratory distress syndrome successfully weaned from venovenous extracorporeal membrane oxygenation.

Pulmonary rehabilitation after lung transplantation with severe complications: A case report.

This case study describes a 59-year-old male with a body mass index of 14.4 kg/m2 and a diagnosis of interstitial lung disease, pneumoconiosis, and severe pulmonary hypertension who received a bilateral lung transplant in a hospital in mainland China. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was initiated before the lung transplant; in addition, an emergency thoracotomy was performed three hours afterwards due to uncontrolled bleeding. VA-ECMO was weaned 34 hours later, but weaning from the ventilator failed multiple times due to bilateral pneumothorax, weak neuromuscular drive, and muscle strength. A full, personalized rehabilitation program was initiated with the help of a respiratory therapy team and the physician, drawing on the American Thoracic Society/European Respiratory Society Statement on Pulmonary Rehabilitation. This included nutrition support, draining air from the chest pleural cavity, aggressive bronchial-hygiene therapy, a weaning plan, breathing and physical exercises, and psychological support. Eighty-one days after the tracheotomy, the patient was successfully weaned, decannulated, and discharged. A careful, ongoing evaluation and a personalized program assisted with weaning this difficult patient.

Social physique anxiety, obligation to exercise, and exercise choices among college students.

OBJECTIVE: The authors examined relationships among social physique anxiety, obligation to exercise, and exercise choices. PARTICIPANTS AND METHODS: College students (N = 337; 200 women, 137 men) volunteered to complete 3 questionnaires: the Social Physique Anxiety Scale (SPAS), Obligatory Exercise Questionnaire (OEQ), and Physical Activity Specification Survey (PASS). RESULTS: On the SPAS, men (M score = 31.9 +/- 8.8) differed from women (M score = 37.3 +/- 8.3; p = .001). Men (M score = 43.0 +/- 9.9) and women (M score = 43.0 +/- 9.6) responded similarly (p = .94) on the OEQ. There was no interaction between sex and exercise level on the SPAS or OEQ. When separated by low, medium, and high SPAS scores, neither OEQ nor exercise scores differed. CONCLUSIONS: Obligation to exercise appears to be similar for both sexes. Women, however, appear to have higher levels of anxiety regarding how others evaluate their physique than do men. The combination of level of activity and sex do not appear to be associated with social physique anxiety or obligation to exercise.