End-Tidal Oxygen Saturation with Nasal Cannula During Noninvasive Positive Pressure Ventilation: A Randomized Crossover Trial.

BACKGROUND: Simultaneous use of nasal cannula (NC) with noninvasive positive pressure ventilation (NIPPV) may help streamline the transition from preoxygenation to intubation with apneic oxygenation in patients with deteriorating respiratory status, but may also compromise preoxygenation by impairing NIPPV mask seal. OBJECTIVES: To demonstrate that end-tidal oxygen (EtO2) after NIPPV with NC is noninferior to that of NIPPV without NC. METHODS: We conducted a randomized cross-over noninferiority study using healthy volunteers. All subjects underwent a 3-min trial of NIPPV with or without high-flow NC at 15 L/min of oxygen, followed by a 5-min washout period, and then a second 3-min trial of the opposite intervention. We randomized subjects to order of interventions. The primary outcome was postintervention EtO2 as measured by immediate exhalation into an oxygen analyzer after the 3-min ventilation period. We compared this outcome between the two study arms using an absolute 5% noninferiority margin. RESULTS: We enrolled 37 subjects, each of whom underwent both interventions of NIPPV alone and NIPPV with 15 L/min NC. The paired mean difference in EtO2 between NIPPV with NC measurements vs. NC alone measurements was 0.5% (95% confidence interval -∞ to 2.7%). Analyses stratified by order of intervention yielded similar results. CONCLUSIONS: The mean difference confidence interval did not include the noninferiority margin. Hence, NIPPV with NC seems noninferior to NIPPV alone with regard to EtO2. These results indicate that concomitant use of NC with NIPPV may be an appropriate preoxygenation strategy in anticipation of the potential need for transition to intubation.

Reconsidering "inattention" in attention-deficit hyperactivity disorder: implications for neuropsychological assessment and intervention.

Attention-deficit hyperactivity disorder (ADHD) does not exist. This explicit statement needs elucidation of course given ADHD is a common neurodevelopmental disorder, but it provides the reader with the impetus to reconsider long-held beliefs about this condition and its treatment. Surely, there is a disorder called ADHD from which this thesis is framed, but primary attention and hyperactivity-impulsivity problems are mediated by different albeit interrelated brain systems. Like many neurodevelopmental disorders (e.g., learning disabilities, autism spectrum disorder), the medical and psychological professions have used a single, large inclusive ADHD diagnostic category to represent children with different etiologies for their overt symptoms. Despite neurobiological differences among children diagnosed with ADHD, the clinical position that attention-deficit or primary attention problems are sufficient for ADHD identification undermines clinical practice. This commonly accepted dubious position not only undermines the diagnostic utility of our neuropsychological measures, but it attenuates treatment effects as well. Supported with evidence from our ongoing ADHD research program, this data-based review will support these contentions and provide implications for diagnosis and treatment of children with attention problems.

Psychosocial and Adaptive Deficits Associated With Learning Disability Subtypes.

Children with specific learning disabilities (SLD) have deficits in the basic psychological processes that interfere with learning and academic achievement, and for some SLD subtypes, these deficits can also lead to emotional and/or behavior problems. This study examined psychosocial functioning in 123 students, aged 6 to 11, who underwent comprehensive evaluations for learning and/or behavior problems in two Pacific Northwest school districts. Using concordance-discordance model (C-DM) processing strengths and weaknesses SLD identification criteria, results revealed working memory SLD (n = 20), processing speed SLD (n = 30), executive SLD (n = 32), and no disability groups (n = 41). Of the SLD subtypes, repeated measures MANOVA results revealed the processing speed SLD subtype exhibited the greatest psychosocial and adaptive impairment according to teacher behavior ratings. Findings suggest processing speed deficits may be behind the cognitive and psychosocial disturbances found in what has been termed "nonverbal" SLD. Limitations, implications, and future research needs are addressed.