Predictors for prescription of noninvasive ventilation in the postoperative period of cardiac surgery: a systematic review.

INTRODUCTION: The postoperative (PO) period after cardiac surgery is associated with the occurrence of respiratory complications. Noninvasive positive pressure ventilation (NIPPV) is largely used as a ventilatory support strategy after the interruption of invasive mechanical ventilation. However, the variables associated with NIPPV prescription are unclear. OBJECTIVE: To describe the literature on predictors of NIPPV prescription in patients during the PO period of cardiac surgery. MATERIALS AND METHODS: This systematic review was registered on the International Prospective Register of Systematic Reviews (PROSPERO) platform in December 2021 (CRD42021291973). Bibliographic searches were performed in February 2022 using the PubMed, Lilacs, Embase and PEDro databases, with no year or language restrictions. The Predictors for the prescription of NIPPV were considered among patients who achieved curative NIPPV. RESULTS: A total of 349 articles were identified, of which four were deemed eligible and were included in this review. Three studies were retrospective studies, and one was a prospective safety pilot study. The total sample size in each study ranged from 109 to 1657 subjects, with a total of 3456 participants, of whom 283 realized NIPPV. Curative NIPPV was the only form of NIPPV in 75% of the studies, which presented this form of prescription in 5-9% of the total sample size, with men around 65 years old being the majority of the participants receiving curative NIPPV. The main indication for curative NIPPV was acute respiratory failure. Only one study realized prophylactic NIPPV (28% of 32 participants). The main predictors for the prescription of curative NIPPV in the PO period of cardiac surgery observed in this study were elevated body mass index (BMI), hypercapnia, PO lung injury, cardiogenic oedema and pneumonia. CONCLUSIONS: BMI and lung alterations related to gas exchange disturbances are major predictors for NIPPV prescription in patients during the PO period of cardiac surgery. The identification of these predictors can benefit clinical decision-making regarding the prescription of NIPPV and help conserve human and material resources, thereby preventing the indiscriminate use of NIPPV.

Healthcare Use and Costs in Children Receiving Home Mechanical Ventilation in Ontario: A 14-Year Cohort Study.

Rationale: Home mechanical ventilation (HMV) is an advanced medical therapy offered to children with medical complexity. Despite the growing pediatric HMV population in North America, there are limited studies describing healthcare use and predictors of highest costs using robust health administrative data. Objectives: To describe patterns of healthcare use and costs in children receiving HMV over a 14-year period in Ontario, Canada. Methods: We conducted a retrospective population-based cohort study (April 1, 2003, to March 31, 2017) of children aged 0-18 years receiving HMV via invasive mechanical ventilation or noninvasive ventilation. Paired t tests compared healthcare system use and costs 2 years before and 2 years after HMV approval. We developed linear models to analyze variables associated with children in the top quartile of health service use and costs. Results: We identified 835 children receiving HMV. In the 2 years after HMV approval compared with the 2 years prior, children had decreased hospitalization days (median, 9 [interquartile range, 3-30] vs. 29 [6-99]; P < 0.0001) and intensive care unit admission days (6.6 [1.9-18.0] vs. 17.1 [3.3-70.9]; P < 0.0001) but had increased homecare service approvals (195 [24-522] vs. 40 [12-225]; P < 0.0001) and outpatient pulmonology visits (3 [1-4] vs. 2 [1-3]; P < 0.0001). Total healthcare costs were higher in the 2 years after HMV approval (mean, CAD$164,892 [standard deviation, CAD$214,187] vs. CAD$128,941 [CAD$194,199]; P < 0.0001). However, all-cause hospital admission costs were reduced (CAD$66,546 [CAD$142,401] vs. CAD$81,578 [CAD$164,672]; P < 0.0001). The highest total 2-year costs were associated with invasive mechanical ventilation (odds ratio [OR], 3.45; 95% confidence interval [CI], 2.24-5.31; reference noninvasive ventilation), number of medical devices at home (OR, 1.63; 95% CI, 1.35-1.96; reference no technology), and increased healthcare costs in the year before HMV initiation (OR, 2.23; 95% CI, 1.84-2.69). Conclusions: Children progressing to the need for HMV represent a worsening in their respiratory status that will undoubtedly increase healthcare use and costs. We found that the initiation of HMV in these children can reduce inpatient healthcare use and costs but can still increase overall healthcare expenditures, especially in the outpatient setting.

High flow nasal cannula oxygen therapy versus non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease with acute-moderate hypercapnic respiratory failure: a randomized controlled non-inferiority trial.

BACKGROUND: Although cumulative studies have demonstrated a beneficial effect of high-flow nasal cannula oxygen (HFNC) in acute hypercapnic respiratory failure, randomized trials to compare HFNC with non-invasive ventilation (NIV) as initial treatment in acute exacerbations of chronic obstructive pulmonary disease (AECOPD) patients with acute-moderate hypercapnic respiratory failure are limited. The aim of this randomized, open label, non-inferiority trial was to compare treatment failure rates between HFNC and NIV in such patients. METHODS: Patients diagnosed with AECOPD with a baseline arterial blood gas pH between 7.25 and 7.35 and PaCO2 ≥ 50 mmHg admitted to two intensive care units (ICUs) at a large tertiary academic teaching hospital between March 2018 and December 2022 were randomly assigned to HFNC or NIV. The primary endpoint was the rate of treatment failure, defined as endotracheal intubation or a switch to the other study treatment modality. Secondary endpoints were rates of intubation or treatment change, blood gas values, vital signs at one, 12, and 48 h, 28-day mortality, as well as ICU and hospital lengths of stay. RESULTS: 225 total patients (113 in the HFNC group and 112 in the NIV group) were included in the intention-to-treat analysis. The failure rate of the HFNC group was 25.7%, while the NIV group was 14.3%. The failure rate risk difference between the two groups was 11.38% (95% CI 0.25-21.20, P = 0.033), which was higher than the non-inferiority cut-off of 9%. In the per-protocol analysis, treatment failure occurred in 28 of 110 patients (25.5%) in the HFNC group and 15 of 109 patients (13.8%) in the NIV group (risk difference, 11.69%; 95% CI 0.48-22.60). The intubation rate in the HFNC group was higher than in the NIV group (14.2% vs 5.4%, P = 0.026). The treatment switch rate, ICU and hospital length of stay or 28-day mortality in the HFNC group were not statistically different from the NIV group (all P > 0.05). CONCLUSION: HFNC was not shown to be non-inferior to NIV and resulted in a higher incidence of treatment failure than NIV when used as the initial respiratory support for AECOPD patients with acute-moderate hypercapnic respiratory failure. TRIAL REGISTRATION: chictr.org (ChiCTR1800014553). Registered 21 January 2018, http://www.chictr.org.cn.

Noninvasive ventilation on reintubation in patients with obesity and hypoxemic respiratory failure following abdominal surgery: a post hoc analysis of a randomized clinical trial.

PURPOSE: Although noninvasive ventilation (NIV) may reduce reintubation in patients with acute hypoxemic respiratory failure following abdominal surgery, this strategy has not been specifically assessed in patients with obesity. METHODS: We conducted a post hoc analysis of a multicenter randomized controlled trial comparing NIV delivered via facial mask to standard oxygen therapy among patients with obesity and acute hypoxemic respiratory failure within 7 days after abdominal surgery. The primary outcome was reintubation within 7 days. Secondary outcomes were invasive ventilation-free days at day 30, intensive care unit (ICU)-acquired pneumonia and 30-day survival. RESULTS: Among 293 patients with hypoxemic respiratory failure following abdominal surgery, 76 (26%) patients had obesity and were included in the intention-to-treat analysis. Reintubation rate was significantly lower with NIV (13/42, 31%) than with standard oxygen therapy (19/34, 56%) within 7 days (absolute difference: - 25%, 95% confidence interval (CI) - 49 to - 1%, p = 0.03). NIV was associated with significantly more invasive ventilation-free days compared with standard oxygen therapy (27.1 ± 8.6 vs 22.7 ± 11.1 days; p = 0.02), while fewer patients developed ICU-acquired pneumonia (1/42, 2% vs 6/34, 18%; p = 0.04). The 30-day survival was 98% in the NIV group (41/42) versus 85% in the standard oxygen therapy (p = 0.08). In patients with body mass index (BMI) < 30 kg/m2, no significant difference was observed between NIV (36/105, 34%) and standard oxygen therapy (47/109, 43%, p = 0.03). An interaction test showed no statistically significant difference between the two subsets (BMI ≥ 30 kg/m2 and BMI < 30 kg/m2). CONCLUSIONS: Among patients with obesity and hypoxemic respiratory failure following abdominal surgery, use of NIV compared with standard oxygen therapy reduced the risk of reintubation within 7 days, contrary to patients without obesity. However, no interaction was found according to the presence of obesity or not, suggesting either a lack of power to conclude in the non-obese subgroup despite existing differences, or that the statistical difference found in the overall sample was driven by a large effect in the obese subsets.

Implications of sedation during the use of noninvasive ventilation in children with acute respiratory failure (SEDANIV Study).

BACKGROUND: The objective of this study was to analyze the effects of sedation administration on clinical parameters, comfort status, intubation requirements, and the pediatric intensive care unit (PICU) length of stay (LOS) in children with acute respiratory failure (ARF) receiving noninvasive ventilation (NIV). METHODS: Thirteen PICUs in Spain participated in a prospective, multicenter, observational trial from January to December 2021. Children with ARF under the age of five who were receiving NIV were included. Clinical information and comfort levels were documented at the time of NIV initiation, as well as at 3, 6, 12, 24, and 48 h. The COMFORT-behavior (COMFORT-B) scale was used to assess the patients' level of comfort. NIV failure was considered to be a requirement for endotracheal intubation. RESULTS: A total of 457 patients were included, with a median age of 3.3 months (IQR 1.3-16.1). Two hundred and thirteen children (46.6%) received sedation (sedation group); these patients had a higher heart rate, higher COMFORT-B score, and lower SpO2/FiO2 ratio than did those who did not receive sedation (non-sedation group). A significantly greater improvement in the COMFORT-B score at 3, 6, 12, and 24 h, heart rate at 6 and 12 h, and SpO2/FiO2 ratio at 6 h was observed in the sedation group. Overall, the NIV success rate was 95.6%-intubation was required in 6.1% of the sedation group and in 2.9% of the other group (p = 0.092). Multivariate analysis revealed that the PRISM III score at NIV initiation (OR 1.408; 95% CI 1.230-1.611) and respiratory rate at 3 h (OR 1.043; 95% CI 1.009-1.079) were found to be independent predictors of NIV failure. The PICU LOS was correlated with weight, PRISM III score, respiratory rate at 12 h, SpO2 at 3 h, FiO2 at 12 h, NIV failure and NIV duration. Sedation use was not found to be independently related to NIV failure or to the PICU LOS. CONCLUSIONS: Sedation use may be useful in children with ARF treated with NIV, as it seems to improve clinical parameters and comfort status but may not increase the NIV failure rate or PICU LOS, even though sedated children were more severe at technique initiation in the present sample.

Insufficient Pulmonary Rehabilitation Uptake After Severe Exacerbation of COPD: A Multicentre Study in the South West Region of France.

Purpose: Pulmonary rehabilitation (PR) is a type of multidisciplinary care strongly recommended after severe exacerbation of chronic obstructive pulmonary disease (COPD). Recently, a national French study reported a very low rate of PR uptake (8.6%); however, important clinical data were missing. Here, we aimed to identify the main factors associated with insufficient PR uptake after hospitalisation for COPD exacerbation. Patients and Methods: This multicentre retrospective study included patients hospitalised with COPD exacerbation between 1 January 2017 and 31 December 2018, as identified by both coding and a detailed review of medical records. PR was defined as inpatient care in a specialised centre or unit within 90 days of discharge. Multivariate logistic regression was used to identify associations between PR uptake and patient characteristics, such as comorbidities, non-invasive ventilation (NIV), inhaled treatment, and forced expiratory volume in 1 second (FEV1). Results: Among the 325 patients admitted for severe COPD exacerbation, 92 (28.3%) underwent PR within 90 days of discharge. In univariate analysis, relative to those who underwent PR, patients without PR had significantly more comorbidities, were less often treated with triple bronchodilator therapy or NIV, and had a higher FEV1. In multivariate analysis, variables independently associated with the lack of PR uptake were the presence of comorbidities (adjusted odds ratio (aOR) = 1.28 [1.10-1.53], p = 0.003) and a higher FEV1 (aOR = 1.04 [1.02-1.06], p < 0.001). There was no significant correlation between PR uptake and departmental PR centre capacity (notably, some departments had no PR facilities). Conclusion: These data highlight the lack of PR in the early stages of COPD. Collaboration among all healthcare providers involved in patient management is crucial for improved PR uptake.

Pulmonary rehabilitation (PR) is multidisciplinary care strongly recommended after severe exacerbation of chronic obstructive pulmonary disease (COPD); however, referral remains very low in France. We have shown, in three French centres, that early-stage COPD and associated comorbidities are the main factors contributing to insufficient PR after hospitalisation for exacerbation. Collaboration among all healthcare providers involved in patient management is crucial to improve PR uptake in the years ahead because physical medicine and rehabilitation professionals play key roles in the promotion and early initiation of PR programs.

Exploring intensivist involvement: Patient characteristics, interventions and outcomes.

Introduction: Intensivists play a critical role in the management of intensive care units (ICUs) and in providing high quality care. While international guidelines recommend intensivist staffing for improved patient outcomes, there is a shortage of qualified intensivists in many regions, including Türkiye. This study aimed to assess the impact of introducing a full-time intensivist to a medical ICU on patient characteristics, outcomes, and ICU interventions. Materials and Methods: This retrospective study analyzed data from the Internal Medicine ICU at Van Yüzüncü Yil University Dursun Odabas Medical Center over two periods: Pre- and post-intensivist recruitment. The study included adult patients admitted to the ICU from February 2018 to January 2020. Patient demographics, reasons for ICU admission, APACHE-II and SOFA scores, ICU interventions, and outcomes were recorded and compared between the two periods. Result: Of the 868 patients admitted during the study period, 820 were included in the analysis. There were no significant differences in demographic characteristics between the pre- and post-intensivist periods. However, patients in the post-intensivist period had higher APACHE-II and SOFA scores. Intensive care units mortality rates were comparable between the two periods. The post-intensivist period saw increased use of invasive mechanical ventilation and non-invasive ventilation compared to the pre-intensivist period. Renal replacement therapy usage and enteral nutrition provision also increased in the post-intensivist period. ICU and hospital lengths of stay remained similar between the two periods. Conclusions: The introduction of a full-time intensivist to the medical ICU led to changes in ICU interventions, including increased use of mechanical ventilation and renal replacement therapy. Despite these changes, ICU mortality rates remained unchanged. Further research is needed to explore the longterm impact of intensivist staffing on patient outcomes in Türkiye.

Long-term outcomes in patients with COPD treated with non-invasive ventilation for acute hypercapnic respiratory failure.

PURPOSE: Chronic Obstructive Lung Disease (COPD) remains a major cause of morbidity and mortality across the world. We evaluated survival over 9 years in a cohort of patients with COPD requiring acute inpatient non-invasive ventilation (NIV). We analyzed prognostic indices to evaluate if they were associated with mortality. PATIENTS AND METHODS: We performed a retrospective chart review of all patients who were admitted to St. James's Hospital respiratory ward with COPD and acute hypercapnic respiratory failure who required NIV over a 12-month period and followed their outcomes over 9 years. We investigated the association between survival and potential prognostic variables using univariate analysis and multivariate Cox proportional hazards model. We evaluated the association between survival and the following parameters: age, gender, multiple admissions requiring NIV (> 1 admission in within 12 months of index presentation), home NIV use preadmission, initial arterial blood gas pH, days spent on NIV, serum albumin and serum albumin to serum CRP ratio at admission. RESULTS: Ninety-nine patients with COPD and acute hypercapnic respiratory failure were identified over a 12-month period from January to December 2011. Survival at 1, 2, 5 and 9 years was 65% (n = 64), 42% (n = 42), 25% (n = 25) and 21% (n = 21), respectively. Increasing age (p value < 0.001) and a lower serum albumin (p value < 0.005) were associated with a higher mortality. There was a trend towards improved survival in the group who were treated with home NIV prior to admission compared to no NIV therapy at home but this did not reach statistical significance (Fig. 3, p value = 0.088). CONCLUSION: This study highlights the long-term mortality in patients with COPD admitted with hypercapnic respiratory failure requiring NIV and correlates with prior studies. Increasing age and lower serum albumin were associated with increased mortality. Home NIV may have a protective long-term survival benefit in patients with COPD who have been admitted for acute NIV.

A comparison of two weaning strategies for non-invasive ventilation in chronic obstructive pulmonary disease patients with acute respiratory failure.

INTRODUCTION: Non-Invasive Ventilation (NIV) is a crucial therapy for managing acute exacerbations of Chronic Obstructive Pulmonary Disease (COPD) with hypercapnic respiratory failure. Research has shown that NIV can decrease the rate of endotracheal intubation, length of hospital and Intensive Care Unit stays, and mortality. There are three main strategies for weaning patients off NIV: gradual reduction of NIV duration, gradual reduction of NIV pressure support, and immediate cessation of NIV. AIM: To compare the rate of successful withdrawal of COPD patients with acute hypercapnic respiratory failure, one group will use a stepwise reduction of duration of NIV, while the other group will use a stepwise reduction of pressure support. MATERIALS AND METHODS: This study was a prospective observational study conducted at the Department of Pulmonary Medicine, Institute of Chest Diseases, Government Medical College, Kozhikode, over a period of 15 months. The study population consisted of all COPD patients admitted to the Pulmonary Medicine ward or ICU with acute hypercapnic respiratory failure who were managed with non-invasive ventilation (NIV) without the need for invasive mechanical ventilation. Exclusions included patients requiring NIV for respiratory diseases other than COPD, those with significant comorbidities like acute left ventricular failure or fluid overload states as in chronic kidney disease, COVID-19 positive patients, patients on home NIV, patients who needed intubation early in treatment, and patients unwilling to participate in the study. The sample size was 140. Initial NIV settings and other management decisions prior to enrolment in the study were made by the treating physician according to standard protocols. Once weaning criteria were met (i.e., arterial pH > 7.35, SpO2 ≥ 90% at an FiO2 ≤ 50%, respiratory rate ≤ 25 breaths per minute, heart rate ≤ 120 beats per minute, systolic BP > 90 mm Hg, and no signs of respiratory distress), patients were assigned to either group 1 or group 2 by purposive sampling. Group 1: stepwise reduction of duration of NIV use, with a reduction to 16 h per day on day 1 of enrolment, 12 h on day 2 (including 6-8 h of nocturnal NIV), 6-8 h on day 3, and NIV withdrawal on day 4. Group 2: stepwise reduction of pressure support, with pressure support reduced by 2-4 cm every 4-6 h until Inspiratory Positive Airway Pressure is < 8 cm H2O and Expiratory Positive Airway Pressure is < 4 cm H2O, followed by NIV withdrawal. The clinical outcome was classified as either improved or weaning failure. Improved was defined as an objective or subjective sense of improvement. Weaning failure was defined as the presence of any of the following: respiratory rate ≥ 25/minute or increase of ≥ 50% from baseline, heart rate ≥ 140/minute or increase of ≥ 20% from baseline, SpO2 ≤ 90% on FiO2 ≥ 50%, arterial pH ≤ 7.35, or respiratory distress. Data was collected using a pro forma that included demographic details, smoking status, GOLD COPD category, comorbidities, and vital signs. ABG parameters, NIV settings at the time of hospital admission, at the time of study enrolment, and 48 h after weaning were also recorded. Independent sample t-test was used to test the statistical significance of the difference between means of variables between the two groups. Pearson Chi square test and Fisher's exact test were used to compare categorical variables between the groups. A p-value of < 0.05 was considered statistically significant. RESULTS: NIV was successfully withdrawn in 56/70 (80%) and 50/70 (71.4%) patients in Groups 1 and 2, respectively. This difference was not statistically significant. The length of hospital stay was longer in the stepwise reduction of duration group (Group 1), but this was not statistically significant. CONCLUSION: On comparison of two methods of NIV withdrawal, it was found that neither method is superior to the other in terms of weaning failure, intubation rates, and average length of hospital stay.

Respiratory Support Practices for Bronchiolitis in the Pediatric Intensive Care Unit.

Importance: Admissions to the pediatric intensive care unit (PICU) due to bronchiolitis are increasing. Whether this increase is associated with changes in noninvasive respiratory support practices is unknown. Objective: To assess whether the number of PICU admissions for bronchiolitis between 2013 and 2022 was associated with changes in the use of high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), and invasive mechanical ventilation (IMV) and to identify factors associated with HFNC and NIV success and failure. Design, Setting, and Participants: This cross-sectional study examined encounter data from the Virtual Pediatric Systems database on annual PICU admissions for bronchiolitis and ventilation practices among patients aged younger than 2 years admitted to 27 PICUs between January 1, 2013, and December 31, 2022. Use of HFNC and NIV was defined as successful if patients were weaned to less invasive support (room air or low-flow nasal cannula for HFNC; room air, low-flow nasal cannula, or HFNC for NIV). Main Outcomes and Measures: The main outcome was the number of PICU admissions for bronchiolitis requiring the use of HFNC, NIV, or IMV. Linear regression was used to analyze the association between admission year and absolute numbers of encounters stratified by the maximum level of respiratory support required. Multivariable logistic regression was used to analyze factors associated with HFNC and NIV success and failure (defined as not meeting the criteria for success). Results: Included in the analysis were 33 816 encounters for patients with bronchiolitis (20 186 males [59.7%]; 1910 patients [5.6%] aged ≤28 days and 31 906 patients [94.4%] aged 29 days to <2 years) treated at 27 PICUs from 2013 to 2022. A total of 7615 of 15 518 patients (49.1%) had respiratory syncytial virus infection and 1522 of 33 816 (4.5%) had preexisting cardiac disease. Admissions to the PICU increased by 350 (95% CI, 170-531) encounters annually. When data were grouped by the maximum level of respiratory support required, HFNC use increased by 242 (95% CI, 139-345) encounters per year and NIV use increased by 126 (95% CI, 64-189) encounters per year. The use of IMV did not significantly change (10 [95% CI, -11 to 31] encounters per year). In all, 22 381 patients (81.8%) were successfully weaned from HFNC to low-flow oxygen therapy or room air, 431 (1.6%) were restarted on HFNC, 3057 (11.2%) were escalated to NIV, and 1476 (5.4%) were escalated to IMV or extracorporeal membrane oxygenation (ECMO). Successful use of HFNC increased from 820 of 1027 encounters (79.8%) in 2013 to 3693 of 4399 encounters (84.0%) in 2022 (P = .002). In all, 8476 patients (81.5%) were successfully weaned from NIV, 787 (7.6%) were restarted on NIV, and 1135 (10.9%) were escalated to IMV or ECMO. Success with NIV increased from 224 of 306 encounters (73.2%) in 2013 to 1335 of 1589 encounters (84.0%) in 2022 (P < .001). In multivariable logistic regression, lower weight, higher Pediatric Risk of Mortality III score, cardiac disease, and PICU admission from outside the emergency department were associated with greater odds of HFNC and NIV failure. Conclusions and Relevance: Findings of this cross-sectional study of patients aged younger than 2 years admitted for bronchiolitis suggest there was a 3-fold increase in PICU admissions between 2013 and 2022 associated with a 4.8-fold increase in HFNC use and a 5.8-fold increase in NIV use. Further research is needed to standardize approaches to HFNC and NIV support in bronchiolitis to reduce resource strain.

High-flow nasal cannula in Spanish Pediatric Intensive Care Services: A national web survey about its use and indications.

OBJECTIVE: To describe the high-flow nasal cannula (HFNC) indications in the Spanish pediatric critical care units (PICUs). DESIGN: Descriptive cross-sectional observational study. SETTING: Electronic survey among members of the Spanish Society of Pediatric Intensive Care (SECIP). It was sent weekly from April 10, 2023, to May 21, 2023. PARTICIPANTS: All SECIP members. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: The questions focused on workplace, years of experience, use or non-use of HFNC, justification and expectations regarding its application, starting point within each center, clinical criteria for indication, existence of clinical guidelines, evaluation during its use, and criteria and mode of withdrawal. RESULTS: Two hundred and two participants, 176 were from Spain. Of these, 87/176 had over ten years of experience. One hundred sixty two use HFNC and 66/162 have HFNC clinical guidelines. Acute bronchiolitis (138/162) and respiratory assistance after extubation (106/56) are the two main indications. For 62/162 HFNC may reduce therapeutic escalation. Neuromuscular diseases (105/162) and anatomical airway diseases (135/162) are the two main contraindications. The reasons to do not use HFNC were the absence of evidence about it effectiveness (8/14) and its inadequate cost/effectiveness balance (8/14). CONCLUSIONS: A majority of Spanish pediatric intensivists use HFNC. Its application and withdrawal appears to be primarily based on clinical experience. Besides, those who use HFNC are aware of its limitations and the lack of evidence in some cases. It is necessary to develop single-center and multicenter studies to elucidate the effectiveness of this therapy in the context of critically ill children.

Risk factors of in-hospital mortality and discriminating capacity of NIVO score in exacerbations of COPD requiring noninvasive ventilation.

BACKGROUND: Noninvasive mechanical ventilation (NIV) is recommended as the initial mode of ventilation to treat acute respiratory failure in patients with AECOPD. The Noninvasive Ventilation Outcomes (NIVO) score has been proposed to evaluate the prognosis in patients with AECOPD requiring assisted NIV. However, it is not validated in Chinese patients. METHODS: We used data from the MAGNET AECOPD Registry study, which is a prospective, noninterventional, multicenter, real-world study conducted between September 2017 and July 2021 in China. Data for the potential risk factors of mortality were collected and the NIVO score was calculated, and the in-hospital mortality was evaluated using the NIVO risk score. RESULTS: A total of 1164 patients were included in the study, and 57 patients (4.9%) died during their hospital stay. Multiple logistic regression analysis revealed that age ≥75 years, DBP <60 mmHg, Glasgow Coma Scale ≤14, anemia and BUN >7 mmol/L were independent predictors of in-hospital mortality. The in-hospital mortality was associated with an increase in the risk level of NIVO score and the difference was statistically significant (p < .001). The NIVO risk score showed an acceptable accuracy for predicting the in-hospital mortality in AECOPD requiring assisted NIV (AUC: 0.657, 95% CI: 0.584-0.729, p < .001). CONCLUSION: Our findings identified predictors of mortality in patients with AECOPD receiving NIV, providing useful information to identify severe patients and guide the management of AECOPD. The NIVO score showed an acceptable predictive value for AECOPD receiving NIV in Chinese patients, and additional studies are needed to develop and validate predictive scores based on specific populations.

Utilización de soportes respiratorios no invasivos post extubación en pacientes adultos críticos: revisión narrativa SRNI post extubación en adultos críticos / Use of Non-Invasive Respiratory Support in Critically Ill Patients Post-Extubation: a Narrative Review NIRS Post-Extubation in Critically Ill Adults

La tasa de reintubación orotraqueal luego de la extubación se registra entre un 10 a 20%. La aplicación de soportes respiratorios no-invasivos (SRNI) posterior a la extuba-ción como cánula nasal de alto-flujo, ventilación no invasiva (dos niveles de presión) y presión positiva continua en la vía aérea demostraron ser seguras y efectivas post ex-tubación. El período pre-destete representa un momento crucial en el manejo de los pa-cientes críticos ya que el fracaso de la extubación, definido como la necesidad de reintu-bación dentro de los 2 a 7 días, demostró peores resultados al aumentar la mortalidad entre un 25-50%. Esta situación conlleva al requerimiento de ventilación mecánica prolongada, neumonía asociada a la ventilación mecánica y estancias prolongadas de internación. Por lo tanto, es esencial identificar a los pacientes que se beneficiarán utilizando SRNI post extubación.

The rate of re-intubation after extubation is recorded at 10-20%. The use of non-invasive respiratory support (NIRS) post-extubation such as high-flow nasal cannula, non-invasive ventilation (bilevel pressure) and continuous positive airway pressure (CPAP) have been shown to be safe and effective post-extubation. The pre-weaning period represents a crucial time in the management of critically ill patients, as extubation failure, defined as the need for reintubation within 2-7 days, showed worse outcomes with mortality increasing by 25-50%. This situation leads to the requirement for prolonged mechanical ventilation, ventilator-associated pneumonia and long lengths of hospital stay. Therefore, it is essential to identify patients who will benefit from NIRS post extubation.

Non-invasive ventilation usage and adherence in children and adults with Duchenne muscular dystrophy: A multicenter analysis.

INTRODUCTION/AIMS: Non-invasive ventilation (NIV) is routinely prescribed to support the respiratory system in Duchenne muscular dystrophy (DMD) patients; however, factors improving NIV usage are unclear. We aimed to identify predictors of NIV adherence in DMD patients. METHODS: This was a multicenter retrospective analysis of DMD patients prescribed NIV and followed at (1) The Hospital for Sick Children, Canada; (2) Rady Children's Hospital San Diego, USA; and (3) University of California San Diego Health, USA, between February 2016 and October 2020. The primary and secondary outcomes were 90-day period NIV adherence and clinical and socioeconomic predictors of NIV adherence. RESULTS: We identified 59 DMD patients prescribed NIV (mean ± SD age = 20.1 ± 6.7 y). Overall, percentage of nights used, and average nightly usage, were 79.9 ± 31.1% and 7.23 ± 4.12 h, respectively. Compared with children, adults had higher percentage of nights used (92.9 ± 16.9% vs. 70.4 ± 36.9%; P < .05), and average nightly usage (9.5 ± 4.7 h vs. 5.3 ± 3.7 h; P < .05). Non-English language (P = .01), and absence of deflazacort prescription (P = .02) were significantly associated with higher percentage of nights used while Hispanic ethnicity (P = .01), low household income (P = .02), and absence of deflazacort prescription (P = .02) were significantly associated with higher nightly usage. Based on univariable analysis, older age and declining forced vital capacity were associated with increased percentage of nights used and increased average nightly usage. DISCUSSION: Certain clinical and socioeconomic determinants had a significant impact on NIV adherence in DMD patients, providing insight into those at risk for high versus low compliance with respiratory therapy.

Potential for the lung recruitment and the risk of lung overdistension during 21 days of mechanical ventilation in patients with COVID-19 after noninvasive ventilation failure: the COVID-VENT observational trial.

BACKGROUND: Data on the lung respiratory mechanics and gas exchange in the time course of COVID-19-associated respiratory failure is limited. This study aimed to explore respiratory mechanics and gas exchange, the lung recruitability and risk of overdistension during the time course of mechanical ventilation. METHODS: This was a prospective observational study in critically ill mechanically ventilated patients (n = 116) with COVID-19 admitted into Intensive Care Units of Sechenov University. The primary endpoints were: «optimum¼ positive end-expiratory pressure (PEEP) level balanced between the lowest driving pressure and the highest SpO2 and number of patients with recruitable lung on Days 1 and 7 of mechanical ventilation. We measured driving pressure at different levels of PEEP (14, 12, 10 and 8 cmH2O) with preset tidal volume, and with the increase of tidal volume by 100 ml and 200 ml at preset PEEP level, and calculated static respiratory system compliance (CRS), PaO2/FiO2, alveolar dead space and ventilatory ratio on Days 1, 3, 5, 7, 10, 14 and 21. RESULTS: The «optimum¼ PEEP levels on Day 1 were 11.0 (10.0-12.8) cmH2O and 10.0 (9.0-12.0) cmH2O on Day 7. Positive response to recruitment was observed on Day 1 in 27.6% and on Day 7 in 9.2% of patients. PEEP increase from 10 to 14 cmH2O and VT increase by 100 and 200 ml led to a significant decrease in CRS from Day 1 to Day 14 (p < 0.05). Ventilatory ratio was 2.2 (1.7-2,7) in non-survivors and in 1.9 (1.6-2.6) survivors on Day 1 and decreased on Day 7 in survivors only (p < 0.01). PaO2/FiO2 was 105.5 (76.2-141.7) mmHg in non-survivors on Day 1 and 136.6 (106.7-160.8) in survivors (p = 0.002). In survivors, PaO2/FiO2 rose on Day 3 (p = 0.008) and then between Days 7 and 10 (p = 0.046). CONCLUSION: Lung recruitability was low in COVID-19 and decreased during the course of the disease, but lung overdistension occurred at «intermediate¼ PEEP and VT levels. In survivors gas exchange improvements after Day 7 mismatched CRS. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04445961 . Registered 24 June 2020-Retrospectively registered.

Mortality Rates Among Hospitalized Patients With COVID-19 Infection Treated With Tocilizumab and Corticosteroids: A Bayesian Reanalysis of a Previous Meta-analysis.

Importance: A World Health Organization (WHO) meta-analysis found that tocilizumab was associated with reduced mortality in hospitalized patients with COVID-19. However, uncertainty remains concerning the magnitude of tocilizumab's benefits and whether its association with mortality benefit is similar across respiratory subgroups. Objective: To use bayesian methods to assess the magnitude of mortality benefit associated with tocilizumab and the differences between respiratory support subgroups in hospitalized patients with COVID-19. Design, Setting, and Participants: A bayesian hierarchical reanalysis of the WHO meta-analysis of tocilizumab studies published in 2020 and 2021 was performed. Main results were estimated using weakly informative priors to exert little influence on the observed data. The robustness of these results was evaluated using vague and informative priors. The studies featured in the meta-analysis were randomized clinical tocilizumab trials of hospitalized patients with COVID-19. Only patients receiving corticosteroids were included. Interventions: Usual care plus tocilizumab in comparison with usual care or placebo. Main Outcomes and Measures: All-cause mortality at 28 days after randomization. Results: Among the 5339 patients included in this analysis, most were men, with mean ages between 56 and 66 years. There were 2117 patients receiving simple oxygen only, 2505 receiving noninvasive ventilation (NIV), and 717 receiving invasive mechanical ventilation (IMV) in 15 studies from multiple countries and continents. Assuming weakly informative priors, the overall odds ratios (ORs) for survival were 0.70 (95% credible interval [CrI], 0.50-0.91) for patients receiving simple oxygen only, 0.81 (95% CrI, 0.63-1.03) for patients receiving NIV, and 0.89 (95% CrI, 0.61-1.22) for patients receiving IMV, respectively. The posterior probabilities of any benefit (OR <1) were notably different between patients receiving simple oxygen only (98.9%), NIV (95.5%), and IMV (75.4%). The posterior probabilities of a clinically meaningful association (absolute mortality risk difference >1%) were greater than 95% in patients receiving simple oxygen only and greater than 90% in patients receiving NIV. In contrast, the posterior probability of this clinically meaningful association was only approximately 67% in patients receiving IMV. The probabilities of tocilizumab superiority in the simple oxygen only subgroup compared with the NIV and IMV subgroups were 85% and 90%, respectively. Predictive intervals highlighted that only 72.1% of future tocilizumab IMV studies would show benefit. The conclusions did not change with different prior distributions. Conclusions and Relevance: In this bayesian reanalysis of a previous meta-analysis of 15 studies of hospitalized patients with COVID-19 treated with tocilizumab and corticosteroids, use of simple oxygen only and NIV was associated with a probability of a clinically meaningful mortality benefit from tocilizumab. Future research should clarify whether patients receiving IMV also benefit from tocilizumab.

Observational study of changes in utilization and outcomes in mechanical ventilation in COVID-19.

BACKGROUND: The role of non-invasive ventilation (NIV) in severe COVID-19 remains a matter of debate. Therefore, the utilization and outcome of NIV in COVID-19 in an unbiased cohort was determined. AIM: The aim was to provide a detailed account of hospitalized COVID-19 patients requiring non-invasive ventilation during their hospital stay. Furthermore, differences of patients treated with NIV between the first and second wave are explored. METHODS: Confirmed COVID-19 cases of claims data of the Local Health Care Funds with non-invasive and/or invasive mechanical ventilation (MV) in the spring and autumn pandemic period in 2020 were comparable analysed. RESULTS: Nationwide cohort of 17.023 cases (median/IQR age 71/61-80 years, 64% male) 7235 (42.5%) patients primarily received IMV without NIV, 4469 (26.3%) patients received NIV without subsequent intubation, and 3472 (20.4%) patients had NIV failure (NIV-F), defined by subsequent endotracheal intubation. The proportion of patients who received invasive MV decreased from 75% to 37% during the second period. Accordingly, the proportion of patients with NIV exclusively increased from 9% to 30%, and those failing NIV increased from 9% to 23%. Median length of hospital stay decreased from 26 to 21 days, and duration of MV decreased from 11.9 to 7.3 days. The NIV failure rate decreased from 49% to 43%. Overall mortality increased from 51% versus 54%. Mortality was 44% with NIV-only, 54% with IMV and 66% with NIV-F with mortality rates steadily increasing from 62% in early NIV-F (day 1) to 72% in late NIV-F (>4 days). CONCLUSIONS: Utilization of NIV rapidly increased during the autumn period, which was associated with a reduced duration of MV, but not with overall mortality. High NIV-F rates are associated with increased mortality, particularly in late NIV-F.

Noninvasive ventilation and high-flow nasal cannula in patients with acute hypoxemic respiratory failure by covid-19: A retrospective study of the feasibility, safety and outcomes.

BACKGROUND: Noninvasive ventilation (NIV) and High-flow nasal cannula (HFNC) are the main forms of treatment for acute respiratory failure. This study aimed to evaluate the effect, safety, and applicability of the NIV and HFNC in patients with acute hypoxemic respiratory failure (AHRF) caused by COVID-19. METHODS: In this retrospective study, we monitored the effect of NIV and HFNC on the SpO2 and respiratory rate before, during, and after treatment, length of stay, rates of endotracheal intubation, and mortality in patients with AHRF caused by COVID-19. Additionally, data regarding RT-PCR from physiotherapists who were directly involved in assisting COVID-19 patients and non-COVID-19. RESULTS: 62.2 % of patients were treated with HFNC. ROX index increased during and after NIV and HFNC treatment (P < 0.05). SpO2 increased during NIV treatment (P < 0.05), but was not maintained after treatment (P = 0.17). In addition, there was no difference in the respiratory rate during or after the NIV (P = 0.95) or HFNC (P = 0.60) treatment. The mortality rate was 35.7 % for NIV vs 21.4 % for HFNC (P = 0.45), while the total endotracheal intubation rate was 57.1 % for NIV vs 69.6 % for HFNC (P = 0.49). Two adverse events occurred during treatment with NIV and eight occurred during treatment with HFNC. There was no difference in the physiotherapists who tested positive for SARS-COV-2 directly involved in assisting COVID-19 patients and non-COVID-19 ones (P = 0.81). CONCLUSION: The application of NIV and HFNC in the critical care unit is feasible and associated with favorable outcomes. In addition, there was no increase in the infection of physiotherapists with SARS-CoV-2.

Noninvasive Ventilation in the Management of Respiratory Failure Due to COVID-19 Infection: Experience From a Resource-Limited Setting.

OBJECTIVE: To study the role of noninvasive ventilation (NIV) in Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV2) related acute respiratory failure (C-ARF). PATIENTS AND METHODS: Patients with C-ARF managed on NIV were categorized as NIV success or failure (death or intubation). Factors associated with failure were explored using regression analysis and expressed as odds ratio (OR) with 95% CI. RESULTS: Between April 1, 2020, and September 15, 2020, a total of 286 patients with a mean ± SD age of 53.1±11.6 years and Acute Physiology and Chronic Health Evaluation II score of 11.1±5.5 were initiated on NIV. Of the 182 patients (63.6%) successfully managed on NIV alone, 118 had moderate or severe acute respiratory distress syndrome. When compared with NIV success, NIV failure was associated with lower admission PaO2 to fraction of inspired oxygen ratio (P<.001) and higher respiratory rate (P<.001). On penalized logistic regression analysis, NIV failure was associated with higher Acute Physiology and Chronic Health Evaluation II score (OR, 1.12; 95% CI, 1.01 to 1.24), severe acute respiratory distress syndrome (OR, 3.99; 95% CI, 1.24 to 12.9), D-dimer level of 1000 ng/mL DDU (to convert to mg/L, divide by 1000) or greater (OR, 2.60; 95% CI, 1.16 to 5.87), need for inotropes or dialysis (OR, 12.7; 95% CI, 4.3 to 37.7), and nosocomial infections (OR, 13.6; 95% CI, 4.06 to 45.9). Overall mortality was 30.1% (86/286). In patients requiring intubation, time to intubation was longer in nonsurvivors than survivors (median, 5; interquartile range, 3-8 vs 3; interquartile range, 2-3 days; P<.001). CONCLUSION: Noninvasive ventilation can be used successfully in C-ARF. Illness severity and need for non-respiratory organ support predict NIV failure.

Clinical Outcomes of Noninvasive Ventilation in Asthma, Bronchiectasis, and Other COPD.

OBJECTIVES: Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality and disability worldwide. Use of noninvasive ventilation (NIV) appears to be associated with a significant decrease in frequency of exacerbation, hospital admissions, and mortality in patients with COPD. In this study, we sought to determine clinical outcomes, prevalence, patient profiles and systems characteristics associated with the use of NIV in patients with asthma, bronchiectasis, and other COPD. METHODS: In this retrospective study, the Nationwide Inpatient Sample dataset was used to evaluate patient characteristics for adult hospitalizations for asthma, bronchiectasis, and other COPD between January 2002 and December 2017. Using the adjusted survey logistic regression model, the association between NIV and in-hospital mortality for asthma, bronchiectasis, and other COPD was ascertained. RESULTS: Other COPD hospitalization prevalence was nearly two times higher among non-Hispanic Black patients compared with non-Hispanic White patients (8.32/1000 vs 4.46/1000). There was a 4.3% average annual decrease in the rates of NIV among hospitalized patients with other COPD during the study period. Furthermore, nonusage of NIV was associated with increased in-hospital mortality for asthma (odds ratio [OR] 1.53, 95% confidence interval [CI] 1.50-1.57), bronchiectasis (OR 2.01, 95% CI 1.69-2.41), and other COPD (OR 1.24, 95% CI 1.16-1.32), respectively. CONCLUSIONS: Inpatient use of NIV has a clear mortality benefit in asthma, bronchiectasis, and COPD. These findings support a signal for potential benefit, particularly among certain populations and warrant further investigation.