Approach of pulmonologists in Turkey to noninvasive mechanical ventilation use at home for chronic respiratory failure.

INTRODUCTION: To define approach of pulmonologists in Turkey to noninvasive mechanical ventilation (NIV) use for chronic respiratory failure (CRF), the most currently applied technique for home mechanical ventilation. PATIENTS AND METHODS: A 38-question survey, developed and tested by the authors, was distributed throughout Turkey to 2205 pulmonologists by e-mail. RESULT: Twenty-seven percent of the pulmonologists responded (n=596). Domiciliary NIV was reported to be prescribed by 340 physicians [57.1% of all responders and 81% of pulmonologists practicing NIV at clinical practice (n= 420)]. NIV prescription was associated with physician's title, type of hospital, duration of medical license, total number of patients treated with NIV during residency and current number of patients treated with NIV per week (p< 0.05). Main estimated indications were listed as chronic obstructive pulmonary disease (median, 25-75 percentile of the prescriptions: 75%, 60-85), obesity hypoventilation syndrome (10%, 2-15), overlap syndrome (10%, 0-20) and restrictive lung disease (5%, 2-10). For utilization of NIV at home, Bilevel positive airway pressure-spontaneous mode (40%, 0-80) and oronasal mask (90%, 60-100) were stated as the most frequently recommended mode and interface, respectively. Pressure settings were most often titrated based on arterial blood gas findings (79.2%). Humidifier was stated not to be prescribed by approximately half of the physicians recommending domicilliary NIV, and the main reason for this (59.2%) was being un-refundable by social security foundation. CONCLUSION: There is a wide variation in Turkey for prescription of NIV, which is supposed to improve clinical course of patients with CRF. Further studies are required to determine the possible causes of these differences, frequency of use and patient outcomes in this setting.

Approach of pulmonologists in Turkey to noninvasive mechanical ventilation use in acute respiratory failure.

INTRODUCTION: Noninvasive mechanical ventilation (NIV) has been increasingly used worldwide for acute respiratory failure (ARF), especially in patients with chronic lung disorders. We aimed to define the approach of pulmonologists in Turkey to NIV use for ARF management. MATERIALS AND METHODS: A 38-question survey, developed and tested by authors, was distributed by e-mail to a total of 2.205 pulmonologists in Turkey. RESULT: Response rate was 27% (n= 596). Seventy-one percent of responders were practicing NIV in clinic. NIV use was found to be associated with responder's academic title, age, duration of medical license, type of physician's hospital and its region, patient load, NIV experience during residency, and duration of NIV and intensive care unit (ICU) experience (p< 0.001). Based on sub-group analysis of responders using NIV, median number of NIV patients followed-up per week was 4 [interquartile range (IQR): 2-6]. Most of the NIV users reported employment of wards (90%) and/or ICUs (86%) to follow-up patients, while 8.4% of the responders were applying NIV only in ICU's. Chronic obstructive lung disease (COPD) (99.5%), obesity hypoventilation syndrome (93.7%) and restrictive lung disease (89.4%) were the most common indications. Majority of NIV users (87%) were applying NIV to > 60% of patients with COPD, and success rate in COPD was reported as over 60% by 93% of users. Oronasal mask (median and IQR 90, 80-100%, respectively) and home care NIV ventilators (median and IQR 50, 10-85%, respectively) were the most commonly utilized equipment. CONCLUSIONS: NIV use in ARF varies based on hospital type, region and, especially, experience of the physician. Although consistent with guidelines and general practice, NIV use can still be improved and increased.

[The effect of acute internal problems for mortality in respiratory intensive care unit patients]. / Gögüs hastaliklari yogun bakim ünitesindeki akut dahili sorunlarin mortaliteye etkisi.

Acute internal problems in the respiratory intensive care unit (ICU) and risk factors affecting mortality in the acute treatment applications were investigated. All patients in 20-bed intensive care unit for chest diseases enrolled to this prospective observational cohort study during 2008. Patients were classified as living in group 1 and deaths in group 2. Demographics and acute internal problems (arrhythmias, acute kidney-liver failure, dopamine, doputamin, perlinganit infusion) were recorded. Multiple regression analysis was performed for factors affecting mortality. There were 603 patients during the study period, group 1, n= 503 (83.4%), group 2, n= 100 (16.6%). Both groups were similar in terms of age and gender. Odds ratio (OR), 95% confidence interval (CI), p value for internal problems of acute risk factors for mortality were found as; septic shock OR: 22.52, CI 8.11-62.57, p< 0.000; need of perlinganit infusion OR: 9.28, CI: 1.61-53.37, p< 0.012; the presence of arrhythmia, OR: 7.81, CI: 3.46-17.65, p< 0.000; acute renal failure, OR: 2.88, CI: 1.24-6.65, p< 0.013 and the need for dopamine OR: 2.83, CI: 1.06-7.65, p< 0.037, respectively. Internal problems such as cardiac and renal dysfunction can devolop in respiratory ICU patients with pulmonary diseases and these problems constitude additional risk factors for mortalitiy. While the number of ICU is increasing with new health policies, each internal requirement and personnel equipped to treat the problem quickly must be considered.

[The influence of community-acquired pneumonia to the clinical course in COPD cases admitted to intensive care unit with acute respiratory failure]. / Yogun bakim ünitesine akut solunum yetmezligi ile kabul edilen KOAH olgularinda pnömoni varliginin klinik seyre etkisi.

In this study the influence of community-acquired pneumonia to the clinical course in 173 COPD patients admitted to ICU with acute respiratory failure (ARF) was evaluated. In prospective descriptive study, patients with pneumonia at admission to ICU were grouped as Group 1, others Group 2. The demographics, "Acute Physiology Assessment and Chronic Health Evaluation (APACHE) II" scores, body mass index (BMI), comorbidities, steroid use, admission arterial blood gases (ABG), leucocyte and CRP, utilization and duration of non-invasive and invasive mechanical ventilation (NIMV and IMV), development of ventilator associated pneumonia (VAP) and septic shock, length of stay (LOS) in ICU and mortality of groups were recorded and compared. No differences were found between demographics, but leucocyte and CRP levels were determined higher in Group 1(p= 005, 0.001). NIMV, IMV ratio and IMV days are similar (respectively p= 0.419, 0.170, 0.459); NIMV was applied longer in Group 2 (p= 0.019). 4 (17.6%) patients in group 1 and 7 (6.3%) patients in Group 2 were switched to IMV(p= 0.083) due to NIMV failure.While VAP was detected in 8 (17.7%) cases of intubated 45 (26%) patients, rate of VAP was similar in both groups (p= 0.657). 2 (6.7%) patients in Group 1 and 12 (8.3%) patients in Group 2 died and no difference was found in terms of LOS in ICU. Mortality was found 3 times higher (26.7%) than overall mortality (8.1%) in patients with IMV. Mortality risk factors are higher CRP levels (p< 0.016, OR: 1.01 CI 95%: 1.00-1.02), NIMV application determined to reduce the mortality. In conclusions, the presence of pneumonia, on admission to ICU in COPD patients with ARF, didn't influence IMV duration, LOS and mortality in ICU. Although mortality can be higher in COPD patients with high CRP levels, but NIMV is thought to be a mortality reducing treatment approach.

Influenza A (H1N1) virus pneumonia in intensive care unit.

Patients with influenza A (H1N1) virus infection have been admitted to intensive care units (ICU) due to development of severe respiratory failure. We described the clinical and epidemiologic characteristics of the 19 patients admitted to ICU due to influenza A (H1N1) virus infection. Study design is a descriptive case series in a third level-20 bed respiratory ICU at training hospital in Istanbul/Turkey. Influenza A (H1N1) virus infection was laboratory confirmed in specimens using real-time reverse transcriptase-polymerase-chain-reaction (RT-PCR). We collected data concerning demographic, epidemiologic and clinical characteristics of the patients, treatment mortality and outcome. From November 10 to December 31 2009, a total of 19 patients; 7 laboratory confirmed, 12 with high clinical suspicion were treated at ICU. Among 12 patients with high clinical suspicion; 3 patients had negative RT-PCR testing for influenza A (H1N1) virus, 9 patients had no tests. Mean age was 41.6 ± 11.9 (range 21 to 61). Median number of lung zone involvement was 4 (IQR= 3-4). Median PaO2/FiO2 was 105 (IQR= 85-165). Mean severity (APACHE II) and organ failure score (SOFA) were 13 ± 4 and 4.0 ± 1.3 respectively. Non-invasive mechanical ventilation (68.4%, n= 13), invasive mechanical ventilation (21.1%, n= 4) and nasal cannula oxygen (31.5%, n= 6) were implicated. The median length of ICU stay was 6 (IQR= 4-8). Oseltamivir therapy was given as 75 mg bid to 12 patients and 150 mg bid to 7 obese patients. ICU mortality rate was 21.1%. Presenting patients with pneumonia and acute respiratory failure due to influenza A (H1N1) virus infection were treated predominantly and successfully with non invasive mechanical ventilation. Clinicians should be aware of pulmonary complications of influenza A (H1N1) virus infection and that patients can be treated with non invasive mechanical ventilation paying attention to protective measures for health care providers.

Mortality rates and risk factors associated with nosocomial Candida infection in a respiratory intensive care unit.

To determine the incidence and mortality rate of nosocomial Candida infections (NCI) with respect to associated risk factors in the respiratory intensive care unit (RICU) patients. Data of 163 RICU patients were analyzed for NCI in 2006 retrospectively. Diagnosis of NCI; at least one Candida spp. was isolated in patients with severe sepsis, hospitalized > 1 day intensive care unit (ICU). NCI positive vs. NCI negative were compared with respect to invasive procedure, comorbidities, mortality. Risk factors were analyzed by logistic regression test. NCI positive in 26 (15.9%) patients were mean age: 65 +/- 15 years (female/male ratio: 8/18). Candida albicans/non-albicans ratio was 13/13. ICU stay was longer in NCI positive than NCI negative (48.2 +/- 7.5 days vs. 10.3 +/- 0.8 days; p< 0.001). Higher mortality rates were demonstrated in NCI positive (14.6% vs. 30.8%; p< 0.05). Risk factors for NCI were as follow: Invasive mechanical ventilations (IMV), central catheters and related infections, total parenteral nutrition, multiple antibiotics, ventilator associated tracheobronchitis (VAT) (p< 001 for all and, odd ratio: 95% CI: 6.27, 2.05-19.16; 28.3, 4.61-32.04; 10.93, 4.04-29.56; 2.12-88.98; 14.99, 5.6-40.08, respectively) and sepsis and ventilator associated pneumonia (VAP) (p< 0.01, 7.34, 1.66-32.35; 3.87, 1.42-10.52, respectively). Presence of catheters and related infections, IMV, multiple antibiotics use, parenteral nutrition, VAT, sepsis and VAP were founded as major risk factors for our patients with NCI. Because of longer ICU duration and higher mortality in NCI patients with treated antifungal drugs, risk factors must be evaluated carefully in the ICU.

The impact of exposure to biomass smoke versus cigarette smoke on inflammatory markers and pulmonary function parameters in patients with chronic respiratory failure.

PURPOSE: The aim of this study was to evaluate the impact of exposure to biomass smoke vs cigarette smoke on serum inflammatory markers and pulmonary function parameters in patients with chronic respiratory failure (CRF). PATIENTS AND METHODS: A total of 106 patients with CRF divided into age and gender-matched groups of cigarette-smoke exposure (n=55, mean [SD] age: 71.0 [12.0] years, 92.7% were females) and biomass smoke exposure (n=51, mean [SD] age: 73.0 [11.0] years, 94.1% were females) were included in this retrospective study. Data on patient demographics (age and gender), inflammatory markers, including neutrophil-to-lymphocyte ratio, C-reactive protein, platelet/mean platelet volume ratio, arterial blood gas analysis, and pulmonary function test findings, including forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and FEV1/FVC were obtained from medical records. RESULTS: Carbon dioxide partial pressure levels were significantly higher in the biomass smoke exposure than in the cigarette smoke exposure group (mean [SD] 51.0 [8.0] vs 47.0 [8.0] mmHg, p=0.026, respectively). Spirometry revealed similarly low levels for FEV1 (%) (38.0 [16.0] vs 40.0 [12.0]%) and FVC (%) (45.0 [19.0] vs 39.0 [19.0]%) in cigarette-smoke and biomass smoke exposure groups, whereas biomass smoke exposure was associated with significantly higher FEV1/FVC (75.0 [14.0] vs 58.0 [12.0]%, p=0.001), lower FVC (mL) (mean [SD] 744.0 [410.0] vs 1,063.0 [592.0] mL, p=0.035) and lower percentage of patients with FEV1/FVC <70% (36.8% vs 82.0%, p<0.001) than cigarette smoke exposure. CONCLUSION: Our findings indicate similarly increased inflammatory markers and abnormally low pulmonary function test findings in both biomass smoke exposure and cigarette smoke exposure groups, emphasizing the adverse effects of biomass smoke exposure on lungs to be as significant as cigarette smoke exposure. Association of biomass smoke exposure with higher likelihood of FEV1/FVC ratio of >70% and more prominent loss of vital capacity than cigarette smoke exposure seems to indicate the likelihood of at least 18 years of biomass exposure to be sufficiently high to be responsible for both obstructive and restrictive pulmonary diseases.