Prolonged non-invasive respiratory supports in a COVID-19 patient with severe acute hypoxemic respiratory failure.

A pandemic caused by the Severe Acute Respiratory Syndrome Coronavirus 2 was declared in 2020. Severe cases were characterized by the development of acute hypoxemic respiratory failure (AHRF) requiring advanced respiratory support. However, intensive care units (ICU) were saturated, and many patients had to be treated out of ICU. This case describes a 75-year-old man affected by AHRF due to Coronavirus Disease 2019 (COVID-19), hospitalized in a high-dependency unit, with PaO2/FiO2 <100 for 28 consecutive days. An experienced team with respiratory physiotherapists was in charge of the noninvasive ventilatory support (NIVS). The patient required permanent NIVS with continuous positive airway pressure, non-invasive ventilation, high flow nasal oxygen and body positioning. He was weaned from NIVS after 37 days and started exercise training afterwards. The patient was discharged at home with low-flow oxygen therapy. This case represents an example of a successful treatment of AHRF with the still controversial noninvasive respiratory support in one patient with COVID-19.

Respiratory physiotherapy in patients with COVID-19 infection in acute setting: a Position Paper of the Italian Association of Respiratory Physiotherapists (ARIR).

Respiratory physiotherapy in patients with COVID-19 infection in acute setting: a Position Paper of the Italian Association of Respiratory Physiotherapists (ARIR) On February 2020, Italy, especially the northern regions, was hit by an epidemic of the new SARS-Cov-2 coronavirus that spread from China between December 2019 and January 2020. The entire healthcare system had to respond promptly in a very short time to an exponential growth of the number of subjects affected by COVID-19 (Coronavirus disease 2019) with the need of semi-intensive and intensive care units.

Rate of reintubation in mechanically ventilated neurosurgical and neurologic patients: evaluation of a systematic approach to weaning and extubation.

OBJECTIVE: To assess whether a systematic approach to weaning and extubation (intervention) is superior to the sole physician's judgment (control) in preventing reintubation secondary to extubation failure in patients with neurologic disorders. DESIGN: Randomized controlled trial. SETTING: Intensive care unit of a large teaching hospital. PATIENTS: Three hundred eighteen intubated patients who had been receiving mechanical ventilation for at least 12 hrs and were able to trigger the ventilator. INTERVENTIONS: Patients were randomized to the intervention (n = 165) or control group (n = 153). MEASUREMENTS: Rate of reintubation after extubation failure occurring within 48 hrs (primary end point). Duration of mechanical ventilation, length of intensive care unit stay, mortality, rate of tracheotomy (secondary end points). The perception of the research protocol by the intensive care unit staff was also assessed. MAIN RESULTS: The rate of reintubation was lower in the intervention (5%) than in the control (12.5%) group (p = 0.047). There was no difference in any of the other outcome variables (secondary end points). Simplified Acute Physiologic Score II (adjusted odds ratio 1.042 per unit; 95% confidence interval 1.006-1.080; p = 0.022) and inclusion in the control group (adjusted odds ratio 2.393; 95% confidence interval 1.000-5.726; p = 0.05) were the only two independent predictive factors for the risk of extubation failure. The protocol was felt by the staff to determine an improvement in patients' clinical outcome, but to increase intensive care unit workload; nurses and physiotherapists considered its impact on their professional role more positively than physicians. CONCLUSIONS: In patients with neurologic diseases, a systematic approach to weaning and extubation reduces the rate of reintubation secondary to extubation failure without affecting the duration of mechanical ventilation, and is overall positively perceived by intensive care unit professionals.

Continuous positive airway pressure treatment with nasal pillows in obstructive sleep apnea: long-term effectiveness and adherence.

BACKGROUNDS: Mask-related side effects can negatively influence adherence to continuous positive airway pressure (CPAP). Nasal pillows (P) can be an alternative to the standard nasal masks (N), although there are no data about their long-term efficacy. This study aimed to assess long-term effectiveness and adherence to CPAP therapy delivered with nasal pillows in obstructive sleep apnea syndrome (OSAS) patients. METHODS: A retrospective observational design involving a series of consecutive CPAP-naïve patients affected by OSAS. After an initial mask fitting session all patients were allowed to choose the type of nasal interface (N or P) they preferred. Outcomes were assessed 5 days after CPAP titration, and after 2 and 12 months. Patients were offered the option of switching to an alternative mask if needed. RESULTS: Data from 144 patients were analyzed. Subjects were predominantly male (76%), middle aged (58.14 ± 12.86), moderately obese (body mass index: 33.89 ± 7.56), and affected by severe OSAS (apnea-hypopnea index: 47.60 ± 21.31). A total of 102 patients (70.8%) chose P, and 42 (29.2%) chose N. Clinical and polygraphic features, and CPAP pressure levels were similar in P and N groups, both at baseline and at 12 months. A good adherence to treatment was observed in both groups (P, 5.5 ± 1.8 h; N, 5.3 ± 1.5 h). Seventy-six patients (53%) reported at least one side effect during the whole study period, without statistically significant between-group differences. Nostril pain was the most frequent side effect in P. CONCLUSIONS: Nasal pillows showed equal long-term effectiveness and objective adherence as standard nasal masks.

Clinical Criteria for Tracheostomy Decannulation in Subjects with Acquired Brain Injury.

BACKGROUND: Patients with acquired brain injury (ABI) often require long periods of having a tracheostomy tube for airway protection and prolonged mechanical ventilation. It has been recognized that fast and safe decannulation improves outcomes and facilitates the recovery process. Nevertheless, few studies have provided evidence for decannulation criteria, despite the high prevalence of ABI subjects with tracheostomies. The aim of our study was to assess which clinical parameters are the best predictors for decannulation in subjects with ABI. METHODS: In this cross-sectional study, we recruited 74 consecutive ABI subjects (mean age 51.52 ± 16.76) with tracheostomy tubes. First, the subjects underwent the original decannulation assessment for cannula removal. Second, they underwent our experimental decannulation protocol. The experimental protocol included: voluntary cough (cough peak flow ≥160 L/min), reflex cough, tracheostomy tube capping (≥72 h), swallowing instrumental assessment (penetration aspiration scale ≤5), blue dye test, number of trachea suctions, endoscopic assessment of airway patency (lumen diameter ≥50%), saturation (SpO2 >95%), and level of consciousness evaluation (Glasgow coma scale ≥8). The reference standard was clinical removal of the tracheostomy tube within 48 h. RESULTS: Parameters showing the highest values of sensitivity and specificity, respectively, were tracheostomy tube capping (80%, 100%), endoscopy assessment of airway patency (100%, 30%), swallowing instrumental assessment (85%, 96%), and the blue dye test (65%, 85%). All these were combined in a clinical cluster parameter, which had higher sensitivity (100%) and specificity (82%). CONCLUSION: These results suggest that the best clinical prediction rule for decannulation in acquired brain injury subjects is a combination of the following assessments: (1) tracheostomy tube capping, (2) endoscopic assessment of patency of airways, (3) swallowing instrumental assessment, and (4) blue dye test.

Evaluation of a systematic approach to weaning of tracheotomized neurological patients: an early interrupted randomized controlled trial.

BACKGROUND: While a systematic approach to weaning reduces the rate of extubation failure in intubated brain-injured patients, no data are available on the weaning outcome of these patients after tracheotomy. We aimed to assess whether a systematic approach to disconnect tracheotomized neurological and neurosurgical patients off the ventilator (intervention) is superior to the sole physician's judgment (control). Based on previous work in intubated patients, we hypothesized a reduction of the rate of failure within 48 h from 15 to 5 %. Secondary endpoints were duration of mechanical ventilation, ICU length of stay and mortality. METHODS: We designed a single center randomized controlled study. Since no data are available on tracheotomized patients, we based our a priori power analysis on results derived from intubated patients and calculated an overall sample size of 280 patients. RESULTS: After inclusion of 168 consecutive patients, the trial was interrupted because the attending physicians judged the observed rate of reconnection to be much greater than expected. The overall rate of failure was 29 %, confirming the physicians' judgment. Twenty-one patients (24 %) in the intervention group and 27 (33 %) controls were reconnected to the ventilator within 48 h (p = 0.222). The main reasons for failure were respiratory distress (80 and 88 % in the treatment and control group, respectively), hemodynamic impairment (15 and 4 % in the treatment and control group, respectively), neurological deterioration (4 % in the control group only). The duration of mechanical ventilation was of 412 ± 202 h and 402 ± 189 h, in the control and intervention group, respectively. ICU length of stay was on average of 23 days for both groups. ICU mortality was 6 % in the control and 2 % in the intervention group without significant differences. CONCLUSION: We found no difference between the two groups under evaluation, with a rate of failure much higher than expected. Consequent to the early interruption, our study results to be underpowered. Based on the results of the present study, a further trial should overall enroll 790 patients. TRIAL REGISTRATION: ACTRN12612000372886.

Sleep apnea and periodic leg movements in the first year after spinal cord injury.

BACKGROUND: Sleep disturbances are frequently reported by patients with spinal cord injury (SCI). Studies have shown an increased incidence of sleep-disordered breathing (SDB) and periodic leg movements during sleep (PLMS) in people with stable long-term SCI. METHODS: This was a prospective observational study in order to evaluate the features and possible predisposing factors of SDB and PLMS in a heterogenic population of consecutive SCI patients admitted at the Spinal Unit of the Niguarda Hospital within the first year after injury. Each patient underwent a clinical assessment, full polysomnography, and arterial blood gas analysis before and immediately after sleep. Multiple logistic regressions were applied in order to evaluate factors associated with SDB and PLMS. RESULTS: Thirty-five (15 tetraplegic and 20 paraplegic) patients were enrolled. Nine patients (25.7%) had an obstructive SDB and 10 (28.6%) had PLMS. The frequency of SDB was higher in tetraplegic with respect to paraplegic patients (Wald statistic: 7.71; P = 0.0055), whereas PLMs were significantly more frequent in patients with an incomplete motor lesion than in subjects with a complete motor lesion (Wald statistic: 6.14; P = 0.013). CONCLUSION: This study confirms a high frequency of SDB and PLMS in SCI patients in the first year following injury. Independently from possible sub-acute and chronic clinical variables, the level and the completeness of the spinal cord lesion are the main factors associated respectively with an early development of SDB and PLMS.

Bench Comparative Assessment of Mechanically Assisted Cough Devices.

BACKGROUND: Mechanically assisted cough devices are used in patients with impaired cough to avoid secretion accumulation. We compared 5 mechanically assisted cough devices by bench testing using a breathing simulator and assessed their user-friendliness. METHODS: We measured inspiratory and expiratory airway pressures and peak expiratory flow, the strongest indicator of cough efficacy. We performed 2 bench tests: 1) to ascertain the differences between preset and actual settings in 3 different machines of each mechanically assisted cough device and 2) to assess the effects of varying respiratory impedance and air leaks on performance of the devices. We also evaluated the user-friendliness of the devices by measuring the time required and errors in accomplishing 4 tasks by 10 physicians unfamiliar with mechanically assisted cough devices compared with product specialists from the distributing companies. Physicians also scored the ease of use. RESULTS: Four mechanically assisted cough devices during insufflation and all 5 during exsufflation showed differences between preset and actual airway pressures. All but one device showed uneven actual pressure values between models of the same type. Peak expiratory flow was significantly influenced by the mechanical properties in 2 devices and by air leaks in 4 devices. The median time to accomplish all tasks by the product specialist (10 [interquartile range of 2-29] s) was overall significantly shorter compared with all physicians (from 19 [14-65] to 36 [19-116] s). The number of procedural errors, but not the perceived ease of use, differed significantly between the devices. CONCLUSIONS: The performance of different mechanically assisted cough devices was erratic and included variance between models from the same manufacturer; it was affected by respiratory system impedance and air leaks. Time and rate of errors for performing procedures were elevated. These findings indicate that the devices are not interchangeable and that the settings should be targeted for each patient with the specific machine being used. Improvements in reliability, performance, and user-friendliness are advisable.