Non-invasive ventilation for acute hypoxemic respiratory failure, including COVID-19.

Optimal initial non-invasive management of acute hypoxemic respiratory failure (AHRF), of both coronavirus disease 2019 (COVID-19) and non-COVID-19 etiologies, has been the subject of significant discussion. Avoidance of endotracheal intubation reduces related complications, but maintenance of spontaneous breathing with intense respiratory effort may increase risks of patients' self-inflicted lung injury, leading to delayed intubation and worse clinical outcomes. High-flow nasal oxygen is currently recommended as the optimal strategy for AHRF management for its simplicity and beneficial physiological effects. Non-invasive ventilation (NIV), delivered as either pressure support or continuous positive airway pressure via interfaces like face masks and helmets, can improve oxygenation and may be associated with reduced endotracheal intubation rates. However, treatment failure is common and associated with poor outcomes. Expertise and knowledge of the specific features of each interface are necessary to fully exploit their potential benefits and minimize risks. Strict clinical and physiological monitoring is necessary during any treatment to avoid delays in endotracheal intubation and protective ventilation. In this narrative review, we analyze the physiological benefits and risks of spontaneous breathing in AHRF, and the characteristics of tools for delivering NIV. The goal herein is to provide a contemporary, evidence-based overview of this highly relevant topic.

Non-invasive support for the hypoxaemic patient.

Optimisation of oxygenation strategies in patients with hypoxaemic respiratory failure is a top priority for acute care physicians, as hypoxaemic respiratory failure is one of the leading causes of admission. Various oxygenation methods range from non-invasive face masks to high flow nasal cannulae, which have advantages and disadvantages for this heterogeneous patient group. Focus has turned toward examining the benefits of non-invasive ventilation, as this was heavily researched in resource-limited settings during the COVID-19 pandemic. The oxygenation strategy should be determined on an individualised basis for patients, and with new evidence from the COVID-19 pandemic, providers may now consider placing further emphasis on non-invasive approaches. As non-invasive ventilation continues to be used in increasing frequency, new methods of monitoring patient response, including when to escalate ventilation strategy, will need to be validated.

Self-efficacy for medication management: a systematic review of instruments.

BACKGROUND: Medication self-efficacy is a potentially important construct in research around optimal use of prescription medications. A number of medication self-efficacy measures are available; however, there is no systematic review of existing instruments and cataloguing of their theoretical underpinnings or psychometric properties, strengths, and weaknesses. The aim of the study was to identify instruments that measure self-efficacy for medication management. The study also aimed to examine the quality, theoretical grounding, and psychometric evaluation of existing measures of self-efficacy for medication management. The study was a systematic review. METHODS: Data were extracted from PubMed, OVID, and MEDLINE using a predefined search strategy. Citations were included if they reported the development and/or psychometric evaluation of an instrument to measure self-efficacy for medication management and were in English. Abstracts were screened for studies potentially meeting eligibility criteria. Full articles of these studies were then reviewed in depth. The review was carried out independently by two members of the research team. RESULTS: The search identified 158 citations of which 12 were included after screening. Full review identified 3 articles fitting inclusion criteria for the review. Generally, development was theoretically grounded and included patients and experts in the field. Psychometric testing showed evidence of internal consistency (2/3 instruments) and test-retest reliability (1/3 instruments). All instruments showed some validity; however, assessment of all forms of validity for each instrument was lacking. CONCLUSION: Although our analysis would recommend the use of the Self-Efficacy for Appropriate Medication Use Scale because of the current evidence of validity and reliability, more psychometric evaluation is required, particularly in terms of responsiveness to change as self-efficacy is a malleable patient-level factor. Three measures of self-efficacy for medication management were identified. Overall, some evidence of reliability and/or validity was demonstrated for all instruments; however, other forms of validity were not tested (ie, responsiveness to change). Use of a well-validated measure of self-efficacy medication management is essential in order to understand relationships between medication self-efficacy and other patient-reported outcomes such as patient-centeredness, patient enablement, and burden of treatment, an important area of research that is currently lacking.

Repatriation to referral hospital after reperfusion of STEMI patients transferred for primary percutaneous coronary intervention: Insights of a Canadian regional STEMI care system.

BACKGROUND: In regional systems of ST-segment elevation myocardial infarction (STEMI) care, patients presenting to hospitals without percutaneous coronary intervention (PCI) are transferred to PCI-capable hospitals for primary PCI. Repatriation, a practice whereby such patients are transferred back to non-PCI referral hospitals after reperfusion is prevalent in many jurisdictions, yet little is known of this practice and its safety. METHODS: We studied 979 consecutive STEMI patients transported from the emergency department and catchment area of two non-PCI hospitals in Ontario, Canada to a regional PCI-hospital for primary PCI between January 2008 and June 2014. Logistic regression modeling was performed to determine factors associated with delayed repatriation beyond 24 hours and to evaluate the association between repatriation and index-admission mortality. RESULTS: Eight hundred and fifteen (83.2%) patients were repatriated with 524 (65.2%) patients repatriated within 24 hours. Factors independently associated with delayed repatriation included systolic blood pressure (OR 1.03 per 5 mmHg decrease, 95% CI 1.01-1.06, P= .04), requirement for mechanical ventilation (OR 24.9, 95% CI 5.4-115.3, P< .0001), ventricular arrhythmia (OR 3.0, 95% CI 1.3-6.6, P= .01), infarct-related artery (P= .03), final TIMI flow grade (P= .01) and access-site complications (OR 2.36, 95% CI 1.04-5.4, P= .04). After repatriation, 9 (1.3%) patients returned to the PCI-hospital for urgent care, and 16 (2.0%) died during index-admission. After adjustment, repatriation was not associated with increase in index-admission mortality (adjusted OR 0.46, 95% CI 0.16-1.32, P= .15). CONCLUSIONS: In a regional STEMI care system in Ontario, Canada, patients are routinely repatriated to non-PCI hospitals after primary PCI. This practice was associated with very low and acceptable rate of return to the PCI-hospital during index-admission without an adverse impact on short-term outcomes.