Efficacy and safety of high-flow nasal cannula therapy in elderly patients with acute respiratory failure.

INTRODUCTION: To assess the efficacy and safety of high-flow nasal cannula (HFNC) in elderly patients with acute respiratory failure (ARF) not due to COVID-19, refractory to treatment with conventional oxygen therapy and/or intolerant to noninvasive ventilation (NIV) or continuous positive airway pressure (CPAP) and without criteria for admission to intensive care units (ICU). METHODS: Prospective observational study of patients with ARF treated with HFNC who presented clinical and arterial blood gas deterioration after 24 h of medical treatment and oxygenation by conventional systems. The degree of dyspnoea, gas exchange parameters (arterial O2 pressure/inspired O2 fraction ratio (PaO2/FiO2); oxygen saturation measured by oximetry/ inspired fraction of oxygen (Sp02/Fi02), ROX index), degree of patient tolerance and mortality were evaluated. These were measured at discharge from the emergency department (ED), 24 h after treatment with conventional oxygenation and 60, 120 min and 24 h after initiation of HFNC. The results were analyzed for all patients as a whole and for patients with hypercapnia (arterial carbon dioxide tension (PaCO2) < 45 mmHg) separately. RESULTS: 200 patients were included in the study between November 2019 and November 2020, with a mean age of 83 years, predominantly women (61.9%), obese (Body Mass Index (BMI) 31.1), with high comorbidity (Charlson index 4) and mild-moderate degree of dependence (Barthel 60). A number of 128 patients (64%) were hypercapnic. None had respiratory acidosis (pH 7.39). Evaluation at 60 min, 120 min and 24 h showed significant improvement in all patients and in the subgroup of hypercapnic patients with respect to baseline parameters in respiratory rate (RR), dyspnoea, ROX index, PaO2/FiO2, SpO2/FiO2 and patient comfort. No changes in PaCO2 or level of consciousness were observed. HFNC was well tolerated. Ten patients (5%) died due to progression of the disease causing ARF. CONCLUSIONS: HFNC is an effective and safe alternative in elderly patients with ARF not due to COVID-19, refractory to treatment with conventional oxygen therapy and/or intolerant to NIV or CPAP and without criteria for admission to ICU.

[Pre-clinical validation of a turbine-based ventilator for invasive ventilation-The ACUTE-19 ventilator]. / Validación preclínica de un respirador de turbina para la ventilación invasiva: el respirador ACUTE-19.

Background: The severe acute respiratory syndrome-coronavirus 2 pandemic pressure on healthcare systems can exhaust ventilator resources, especially where resources are restricted. Our objective was a rapid preclinical evaluation of a newly developed turbine-based ventilator, named the ACUTE-19, for invasive ventilation. Methods: Validation consisted of (a) testing tidal volume delivery in 11 simulated models, with various resistances and compliances; (b) comparison with a commercial ventilator (VIVO-50) adapting the United Kingdom Medicines and Healthcare products Regulatory Agency-recommendations for rapidly manufactured ventilators; and (c) in vivo testing in a sheep before and after inducing acute respiratory distress syndrome by saline lavage. Results: Differences in tidal volume in the simulated models were marginally different (largest difference 33 ml [95% CI 31 to 36]; P < .001). Plateau pressure was not different (-0.3 cmH2O [95% CI -0.9 to 0.3]; P = .409), and positive end-expiratory pressure was marginally different (0.3 cmH2O [95% CI 0.2 to 0.3]; P < .001) between the ACUTE-19 and the commercial ventilator. Bland-Altman analyses showed good agreement (mean bias -0.29 [limits of agreement 0.82 to -1.42], and mean bias 0.56 [limits of agreement 1.94 to -0.81], at a plateau pressure of 15 and 30 cmH2O, respectively). The ACUTE-19 achieved optimal oxygenation and ventilation before and after acute respiratory distress syndrome induction. Conclusions: The ACUTE-19 performed accurately in simulated and animal models yielding a comparable performance with a VIVO-50 commercial device. The ACUTE-19 can provide the basis for the development of a future affordable commercial ventilator.

Pre-clinical validation of a turbine-based ventilator for invasive ventilation-The ACUTE-19 ventilator.

BACKGROUND: The Severe Acute Respiratory Syndrome (SARS)-Coronavirus 2 (CoV-2) pandemic pressure on healthcare systems can exhaust ventilator resources, especially where resources are restricted. Our objective was a rapid preclinical evaluation of a newly developed turbine-based ventilator, named the ACUTE-19, for invasive ventilation. METHODS: Validation consisted of (a) testing tidal volume (VT) delivery in 11 simulated models, with various resistances and compliances; (b) comparison with a commercial ventilator (VIVO-50) adapting the United Kingdom Medicines and Healthcare products Regulatory Agency-recommendations for rapidly manufactured ventilators; and (c) in vivo testing in a sheep before and after inducing acute respiratory distress syndrome (ARDS) by saline lavage. RESULTS: Differences in VT in the simulated models were marginally different (largest difference 33ml [95%-confidence interval (CI) 31-36]; P<.001ml). Plateau pressure (Pplat) was not different (-0.3cmH2O [95%-CI -0.9 to 0.3]; P=.409), and positive end-expiratory pressure (PEEP) was marginally different (0.3 cmH2O [95%-CI 0.2 to 0.3]; P<.001) between the ACUTE-19 and the commercial ventilator. Bland-Altman analyses showed good agreement (mean bias, -0.29, [limits of agreement, 0.82 to -1.42], and mean bias 0.56 [limits of agreement, 1.94 to -0.81], at a Pplat of 15 and 30cmH2O, respectively). The ACUTE-19 achieved optimal oxygenation and ventilation before and after ARDS induction. CONCLUSIONS: The ACUTE-19 performed accurately in simulated and animal models yielding a comparable performance with a VIVO-50 commercial device. The acute 19 can provide the basis for the development of a future affordable commercial ventilator.

Clinical evidence on high flow oxygen therapy and active humidification in adults.

Recently there has been growing interest in an alternative to conventional oxygen therapy: the heated, humidified high flow nasal cannula oxygen therapy (HFNC). A number of physiological effects have been described with HFNC: pharyngeal dead space washout, reduction of nasopharyngeal resistance, a positive expiratory pressure effect, an alveolar recruitment, greater humidification, more comfort and better tolerance by the patient, better control of FiO2 and mucociliary clearance. There is limited experience of HFNC in adults. There are no established guidelines or decision-making pathways to guide use of the HFNC therapy for adults. In this article we review the existing evidence of HFNC oxygen therapy in adult patients, its advantages, limitations and the current literature on clinical applications. Further research is required to determine the long-term effect of this therapy and identify the adult patient population to whom it is most beneficial.

[Effective long-term noninvasive ventilation of a woman with kyphoscoliosis and sinus venosus atrial septal defect]. / Eficacia de la ventilación no invasiva a largo plazo en una paciente con cifoscoliosis asociada a comunicación interauricular tipo seno venoso.

Atrial septal defects comprise one of the most common congenital cardiac malformations in adults and adolescents. However, such septal defects are rarely associated with chest wall diseases. When they are, respiratory failure soon develops and is severe. Cases in which the long-term course of disease is favorable with noninvasive ventilation have not been reported in the literature. We present the case of a 71-year-old woman with kyphoscoliosis, sinus venosus atrial septal defect, severe pulmonary hypertension, respiratory failure, and heart failure. We describe her response to treatment with noninvasive mechanical ventilation.

[Evaluation of a home hospitalization program in patients with exacerbations of chronic obstructive pulmonary disease]. / Evaluación de un programa de hospitalización domiciliaria en pacientes con EPOC agudizada.

OBJECTIVE: We carried out a randomized controlled trial to evaluate the efficacy of a home hospitalization (HH) program for patients hospitalized for exacerbation of chronic obstructive pulmonary disease (COPD). PATIENTS AND METHODS: Patients who were clinically stable and had stable arterial blood gases were randomized to the conventional hospitalization group or the HH group. RESULTS: Of the 88 patients evaluated, 40 (20 in each group) were enrolled. No differences were observed in baseline characteristics, in clinical recovery, or arterial blood gases between the 2 groups at discharge. At 1-month follow up there were no differences in mortality or in the number of readmissions. The mean length of hospitalization in patients with HH was 9.2 days (4 days in hospital and 5 days at home), compared to 12.2 days in patients with conventional hospitalization. CONCLUSIONS: Our results show that a hospital-supervised HH program including the participation of pneumologists and nursing staff allows for the recovery of patients hospitalized for exacerbation of COPD who have stable symptoms and arterial blood gases with no increase in the rate of readmission, relapse, or therapeutic failure.

[Aberrant left subclavian artery associated with Kommerell's diverticulum: chance finding in a 75-year-old patient]. / Arteria subclavia izquierda aberrante asociada a divertículo de Kommerell. Hallazgo casual en un paciente de 75 años.

The most common anomaly of the aortic arch is the occurrence of a left aortic arch with an aberrant right subclavian artery. Other, less common anomalies have also been described. These include the occurrence of a right aortic arch with an aberrant left subclavian artery that, in addition, has a diverticulum at its site of origin known as Kommerell's diverticulum. All cases described in the literature have occurred in individuals younger than 35 years of age, generally with symptoms related to tracheal or esophageal compression. We present the case of a patient diagnosed by chance with this rare anomaly at 75 years of age.

[Aerophagia due to noninvasive mechanical ventilation: a first manifestation of silent gastric carcinoma]. / Aerophagia due to noninvasive mechanical ventilation: a first manifestation of silent gastric carcinoma.

Noninvasive mechanical ventilation (NIV) techniques have proven useful in treating patients with respiratory insufficiency of various etiologies. The problems most frequently associated with this ventilatory technique are the appearance of nasal and oropharyngeal dryness, pressure sores where the nasal mask touches the skin, ocular irritation due to air leakage and epistaxis. Aerophagia appears in up to half the patients with NIV and may lead to discontinuing treatment. Drugs that accelerate gastrointestinal transit, changes in the respirator settings or changing the ventilatory modality may help to ameliorate the problem. When the symptoms arising from abdominal distension due to NIV are intense and persistent, the coexistence of an underlying abdominal pathology must be ruled out. We report the cases of two patients with these characteristics in whom gastroscopy revealed gastric carcinoma. We think that patients with persistent symptoms of aerophagia that cannot be controlled by the usual measures should undergo endoscopic exploration to rule out silent gastric disease.

[Analysis of logistical and organizational aspects of a cruise for patients with chronic respiratory insufficiency. The RESpIRA Expedition and the COPD Cruise]. / Análisis de los aspectos logísticos y organizativos de un crucero para pacientes con insuficiencia respiratoria crónica. La Expedición RESpIRA y el Crucero de la EPOC.

Patients with chronic respiratory insufficiency who are receiving domiciliary oxygen therapy and mechanical ventilation report great difficulty in taking complex trips involving several destinations and prolonged stays away from home. Such patients share a common need for home equipment whose technology is relatively sophisticated, a condition that limits their freedom of movement. We are referring to systems for delivering oxygen therapy and mechanical respirators. Given that such patients have problems traveling by air, we hypothesized that a cruise would be an ideal alternative, given that travel would take place in the hotel itself. A cruise would facilitate the logistics of the journey, given that the equipment would have to be set up at only one setting. Working with these assumptions, we have thus far organized two cruises for chronic respiratory insufficiency patients: the "RESpIRA Expedition" and the "COPD Cruise". Our experience shows that the organizational problems to be coped with are patient recruitment, financing and choice of itinerary. With those aspects clear, organizers must then obtain the authorization of the cruise operator, including the approval of the medical and safety personnel on board. After obtaining permission for the cruise and as soon as the organizers know how many patients will travel, a list of oxygen therapy equipment (respirators and disposable supplies) must be compiled. Finally, equipment suppliers must be found. Afterwards, all that remains is to enjoy the trip. The participation of physicians responsible for domiciliary oxygen therapy and mechanical ventilation programs is essential for making patients feel safe and for assuring solutions for technical and medical problems that might arise.

Noninvasive mechanical ventilation and corrective surgery for treatment of a child with severe kyphoscoliosis.

We report on an 11-year-old boy with severe kyphoscoliosis and respiratory failure. Noninvasive mechanical ventilation by nasal mask and hospitalization resulted in improved pulmonary function, thus facilitating corrective surgery for kyphoscoliosis. Following surgery, the patient remained on mechanical ventilation at home. Clinical and pulmonary function stabilized after discharge, as noted on a 1-month follow-up visit.