Impact of high-flow nasal oxygen therapy on postoperative atelectasis and reintubation rate after paediatric cardiac surgery.

INTRODUCTION: Airway problems emerging after congenital cardiac surgery operations may have an impact on mortality and morbidity. Recently, to improve alveolar gas exchange and reduce respiratory effort, high-flow nasal cannula (HFNC) has started to be used in paediatric cases. This study aimed to evaluate the potential effects of high-flow nasal oxygen therapy on postoperative atelectasis development and reintubation rate in paediatric cardiac surgery patients. METHODS: This study was conducted retrospectively in term newborns and infants younger than six months of age who underwent congenital cardiac surgery operation from 1 November 2022 to 1 November 2023 and were followed in the paediatric cardiac ICU. Patients who were receiving mechanical ventilator support at least 12 hours postoperatively were evaluated for the development of postoperative atelectasis and reintubation in the first 3 days of extubation. The patients were grouped as HFNC and non-HFNC users. Demographic characteristics, surgery type, and ICU clinical follow-up data were obtained from medical records. The results were statistically evaluated. RESULTS: A total of 40 patients who did not use HFNC in the early postoperative period and 40 patients with HFNC in the late period during the study period were included in the study. The median age was 1 month (IQR 15 days-2 months) with equal gender distribution. Among patients, 70% of them were in the neonatal age group. Reintubation rates in the first 72 hours in HFNC users and non-HFNC users were 2.5% and 12.5%, respectively (p < 0.05). The median postoperative atelectasis scores at 24, 48, and 72 hours of extubation were 2 versus 2.5 (p > 0.05), 1.5 versus 3.5 (p < 0.05), and 1 versus 3 (p < 0.05) in HFNC users and non-HFNC users, respectively. CONCLUSION: HFNC therapy may have a positive effect on preventing atelectasis and reducing the reintubation rate in the early postoperative period.

Nasal High-Flow Oxygen Therapy in Chronic Respiratory Failure for Homecare Applications-A Feasibility Study.

Background: While high-flow nasal cannulas (HFNCs) represent the standard of care in the intensive care unit for patients with severe hypoxemia, its use in homecare settings is uncommon despite its potential. The potential benefits and challenges of the high-flow nasal cannula (HFNC) in homecare settings compared to standard long-term oxygen via nasal low-flow therapy are unclear. Methods: We conducted a prospective monocentric feasibility study at the Department of Respiratory Medicine, University Hospital, Goethe University Frankfurt, Germany. Patients with interstitial lung disease or severe bronchiectasis (including cystic fibrosis) were enrolled into the study. The HFNC was introduced during hospitalization. The patients' compliance with home use advice and arterial blood gas results were evaluated at a 4-6-week follow-up. Results: A total of 12 patients were analyzed. HFNC initiation did not result in a significant improvement of the pO2/fiO2 (p/f) ratio. Only 8 out of 12 (66.6%) patients used the HFNC at home after the initial in-hospital initiation. Only 7 of the total 12 patients were using the therapy at a follow-up 3-6 weeks after HFNC onset. Two patients died during the observation, resulting in a surveillance mortality rate of 16.7%. Conclusions: The feasibility data showed low adherence to the HFNC at home. The lack of any positive effect on the p/f ratio may be due to low airflow rates and overall mild hypoxemia compared to patients with severe respiratory failure in the ICU.

Effect of noninvasive ventilation on mortality and clinical outcomes among patients with severe hypoxemic COVID-19 pneumonia after high-flow nasal oxygen failure: a multicenter retrospective French cohort with propensity score analysis.

BACKGROUND: We assessed the effect of noninvasive ventilation (NIV) on mortality and length of stay after high flow nasal oxygenation (HFNO) failure among patients with severe hypoxemic COVID-19 pneumonia. METHODS: In this multicenter, retrospective study, we enrolled COVID-19 patients admitted in intensive care unit (ICU) for severe COVID-19 pneumonia with a HFNO failure from December 2020 to January 2022. The primary outcome was to compare the 90-day mortality between patients who required a straight intubation after HFNO failure and patients who received NIV after HFNO failure. Secondary outcomes included ICU and hospital length of stay. A propensity score analysis was performed to control for confounding factors between groups. Exploratory outcomes included a subgroup analysis for 90-day mortality. RESULTS: We included 461 patients with HFNO failure in the analysis, 233 patients in the straight intubation group and 228 in the NIV group. The 90-day mortality did not significantly differ between groups, 58/228 (25.4%) int the NIV group compared with 59/233 (25.3%) in the straight intubation group, with an adjusted hazard ratio (HR) after propensity score weighting of 0.82 [95%CI, 0.50-1.35] (p = 0.434). ICU length of stay was significantly shorter in the NIV group compared to the straight intubation group, 10.0 days [IQR, 7.0-19.8] versus 18.0 days [IQR,11.0-31.0] with a propensity score weighted HR of 1.77 [95%CI, 1.29-2.43] (p < 0.001). A subgroup analysis showed a significant increase in mortality rate for intubated patients in the NIV group with 56/122 (45.9%), compared to 59/233 (25.3%) for patients in the straight intubation group (p < 0.001). CONCLUSIONS: In severely hypoxemic COVID-19 patients, no significant differences were observed on 90-day mortality between patients receiving straight intubation and those receiving NIV after HFNO failure. NIV strategy was associated with a significant reduction in ICU length of stay, despite an increase in mortality in the subgroup of patients finally intubated.

Association Between Spontaneous Breathing Trial Methods and Reintubation in Adult Critically Ill Patients: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Reintubation is associated with higher risk of mortality. There is no clear evidence on the best spontaneous breathing trial (SBT) method to reduce the risk of reintubation. RESEARCH QUESTION: Are different methods of conducting SBTs in critically ill patients associated with different risk of reintubation compared with T-tube? STUDY DESIGN AND METHODS: We conducted a systematic review and Bayesian network meta-analysis of randomized controlled trials investigating the effects of different SBT methods on reintubation. We surveyed PubMed, MEDLINE, CINAHL, and Cochrane Central Register of Controlled Trials databases from inception to January 26, 2024. The surface under the cumulative ranking curve (SUCRA) was used to determine the likelihood that an intervention was ranked as the best. Pairwise comparisons were also investigated by frequentist meta-analysis. Certainty of the evidence was assessed according to the Grading of Recommendations, Assessment, Development, and Evaluations approach. RESULTS: A total of 22 randomized controlled trials were included, for a total of 6,196 patients. The network included nine nodes, with 13 direct pairwise comparisons. About 71% of the patients were allocated to T-tube and pressure support ventilation with positive end-expiratory pressure, with 2,135 and 2,101 patients, respectively. The only intervention with a significantly lower risk of reintubation compared with T-tube was high flow oxygen (HFO) (risk ratio, 0.23; 95% credibility interval, 0.09-0.51; moderate quality evidence). HFO was associated with the highest probability of being the best intervention for reducing the risk of reintubation (81.86%; SUCRA, 96.42), followed by CPAP (11.8%; SUCRA, 76.75). INTERPRETATION: HFO SBT was associated with a lower risk of reintubation in comparison with other SBT methods. The results of our analysis should be considered with caution due to the low number of studies that investigated HFO SBTs and potential clinical heterogeneity related to cointerventions. Further trials should be performed to confirm the results on larger cohorts of patients and assess specific subgroups. TRIAL REGISTRATION: PROSPERO; No.: CRD42023449264; URL: https://www.crd.york.ac.uk/prospero/.

Impact of high-flow oxygen therapy via high velocity nasal insufflation on diaphragmatic thickening fraction in healthy subjects.

OBJECTIVE: The primary objective of this study was to evaluate the impact of high-flow nasal cannula oxygen therapy [HFNC] on the diaphragm thickening fraction. DESIGN: Prospective, descriptive, cohort study SETTING: The study was conducted in the Physiology and Respiratory Care Laboratory, Intensive Care Unit, Hospital Británico de Buenos Aires. PARTICIPANTS: Thirteen healthy subjects >18 years old INTERVENTIONS: High-flow nasal cannula oxygen therapy MAIN VARIABLES OF INTEREST: Demographic data (age and gender), anthropometric data (weight, height, and body mass index), and clinical and respiratory variables (Diaphragm thickening fraction [DTf], esophageal pressure swing, respiratory rate [RR], esophageal pressure-time product per minute [PTPes/min]). RESULTS: Median DTf decreased significantly as flow increased (p < 0.05). The baseline DTf measurement was 21.4 %, 18.3 % with 20 L/m, and 16.4 % with 40 L/m. We also observed a significant decrease in RR as flow increased in HFNC (p < 0.05). In the 8 subjects with recordings, the PTPes/min was 81.3 (±30.8) cmH2O/sec/min and 64.4 (±25.3) cmH2O/sec/min at baseline and 40 L/m respectively (p = 0.044). CONCLUSIONS: The use of high-flow oxygen therapy through nasal cannula of HFNC in healthy subjects decreases the DTf and RR in association with increased flow. In addition, the use of 40 L/m flow may reduce the muscular work associated with respiration.

Evaluating high-flow oxygen therapy after mechanical thrombectomy under general anesthesia in acute ischemic stroke: A retrospective single-center study.

BACKGROUND: The use of mechanical thrombectomy for acute intracranial vascular occlusion under general anesthesia with endotracheal intubation is well-established as a safe and effective method. However, the process of extubation post-surgery presents challenges for certain patients. This retrospective study assesses the safety and efficacy of combining mechanical ventilation with high-flow oxygen inhalation as an interim strategy, while also examining its impact on long-term clinical outcomes. METHODS: This research enrolled 119 patients with acute intracranial large vessel occlusion who underwent mechanical thrombectomy under general anesthesia with tracheal intubation between January 2020 and November 2023. Participants were categorized into two groups: Group 1 (n=55), which received high-flow oxygen (HFO) post-extubation, and Group 2 (n=64), which was treated with routine oxygen supplementation (RO). The study compared reintubation and tracheotomy rates between these groups to determine safety and effectiveness. Additionally, it analyzed long-term clinical outcomes by comparing NIHSS and mRS scores before treatment and at 90-day follow-up. RESULTS: The reintubation rate post-extubation was significantly lower in the HFO group (12.7 %, n=7) compared to the RO group (31.2 %, n=20, p=0.016). The incidence of tracheotomy within 7 days was also reduced in the HFO group compared to the RO group (7.3 %, n=4 vs 20.3 %, n=13, p=0.043). Moreover, a greater proportion of patients in the HFO group achieved mRS scores of 0-2 at 90 days post-stroke than those in the RO group (60 %, n=33 vs 40.6 %, n=26, p=0.035). The median NIHSS score at 90 days was more favorable in the HFO group than in the RO group (6, IQR [1-18] vs 8, IQR [1-20], p=0.005). CONCLUSION: The study suggests that high-flow oxygen therapy after mechanical thrombectomy under general anesthesia with tracheal intubation may lessen the need for reintubation and tracheotomy, potentially leading to improved long-term prognosis.

High flow oxygen therapy versus conventional oxygen therapy in dogs and cats undergoing bronchoscopy and bronchoalveolar lavage: a pilot study.

Objectives: To evaluate the safety and feasibility of high flow oxygen therapy (HFOT), and to record SpO2 and desaturation episodes in dogs and cats receiving HFOT or conventional oxygen therapy (COT) during bronchoscopy ± bronchoalveolar lavage (BAL). Materials and methods: Dogs and cats undergoing bronchoscopy ± BAL between January and May 2023 were included in the study. Patients were randomly allocated to two groups: HFOT (HFOT group; two cats and four dogs) and COT (COT group; one cat and five dogs). HFOT and COT were started at the beginning of the bronchoscopy. HFOT was delivered with a gas flow rate of 1 L/kg/min at an FiO2 of 100% and a temperature of 34°C (pediatric mode) or 37°C (adult mode). COT was delivered through the working channel of the bronchoscope at a rate of 1.5 L/min. The safety and feasibility of HFOT were assessed, and peripheral oxygen saturation (SpO2) was measured by pulse oximetry every 30 s throughout the procedure. Measurements and main results: HFOT was feasible and safe in both dogs and cats with no complications reported. While there was no significant difference in the number of desaturation episodes (SpO2 < 94%) between the two groups, none of the patients in the HFOT group experienced severe desaturation (SpO2 < 90%). In contrast, two patients in the COT group had an SpO2 < 90%. Mean SpO2 was significantly higher in the HFOT group compared to the COT group at T0 (98% ± 2% vs. 94 ± 2%), T0.5 (98% ± 2% vs. 94% ± 3%) and T1 (98% ± 2% vs. 94% ± 4%). Conclusion: To the authors' knowledge, this is the largest study conducted to date using HFOT during bronchoscopy in dogs and cats. Our results suggest that HFOT is feasible and safe during bronchoscopy ± BAL. Furthermore, HFOT may reduce the risk of desaturation episodes in dogs and cats undergoing bronchoscopy and BAL.

Dyspnea is severe and associated with a higher intubation rate in de novo acute hypoxemic respiratory failure.

BACKGROUND: Dyspnea is a key symptom of de novo acute hypoxemic respiratory failure. This study explores dyspnea and its association with intubation and mortality in this population. METHODS: This was a secondary analysis of a multicenter, randomized, controlled trial. Dyspnea was quantified by a visual analog scale (dyspnea-VAS) from zero to 100 mm. Dyspnea was measured in 259 of the 310 patients included. Factors associated with intubation were assessed with a competing risks model taking into account ICU discharge. The Cox model was used to evaluate factors associated with 90-day mortality. RESULTS: At baseline (randomization in the parent trial), median dyspnea-VAS was 46 (interquartile range, 16-65) mm and was ≥ 40 mm in 146 patients (56%). The intubation rate was 45%. Baseline variables independently associated with intubation were moderate (dyspnea-VAS 40-64 mm) and severe (dyspnea-VAS ≥ 65 mm) dyspnea at baseline (sHR 1.96 and 2.61, p = 0.023), systolic arterial pressure (sHR 2.56, p < 0.001), heart rate (sHR 1.94, p = 0.02) and PaO2/FiO2 (sHR 0.34, p = 0.028). 90-day mortality was 20%. The cumulative probability of survival was lower in patients with baseline dyspnea-VAS ≥ 40 mm (logrank test, p = 0.049). Variables independently associated with mortality were SAPS 2 ≥ 25 (p < 0.001), moderate-to-severe dyspnea at baseline (p = 0.073), PaO2/FiO2 (p = 0.118), and treatment arm (p = 0.046). CONCLUSIONS: In patients admitted to the ICU for de novo acute hypoxemic respiratory failure, dyspnea is associated with a higher risk of intubation and with a higher mortality. TRIAL REGISTRATION: clinicaltrials.gov Identifier # NCT01320384.

Development of clinical tools to estimate the breathing effort during high-flow oxygen therapy: A multicenter cohort study.

INTRODUCTION AND OBJECTIVES: Quantifying breathing effort in non-intubated patients is important but difficult. We aimed to develop two models to estimate it in patients treated with high-flow oxygen therapy. PATIENTS AND METHODS: We analyzed the data of 260 patients from previous studies who received high-flow oxygen therapy. Their breathing effort was measured as the maximal deflection of esophageal pressure (ΔPes). We developed a multivariable linear regression model to estimate ΔPes (in cmH2O) and a multivariable logistic regression model to predict the risk of ΔPes being >10 cmH2O. Candidate predictors included age, sex, diagnosis of the coronavirus disease 2019 (COVID-19), respiratory rate, heart rate, mean arterial pressure, the results of arterial blood gas analysis, including base excess concentration (BEa) and the ratio of arterial tension to the inspiratory fraction of oxygen (PaO2:FiO2), and the product term between COVID-19 and PaO2:FiO2. RESULTS: We found that ΔPes can be estimated from the presence or absence of COVID-19, BEa, respiratory rate, PaO2:FiO2, and the product term between COVID-19 and PaO2:FiO2. The adjusted R2 was 0.39. The risk of ΔPes being >10 cmH2O can be predicted from BEa, respiratory rate, and PaO2:FiO2. The area under the receiver operating characteristic curve was 0.79 (0.73-0.85). We called these two models BREF, where BREF stands for BReathing EFfort and the three common predictors: BEa (B), respiratory rate (RE), and PaO2:FiO2 (F). CONCLUSIONS: We developed two models to estimate the breathing effort of patients on high-flow oxygen therapy. Our initial findings are promising and suggest that these models merit further evaluation.

New Insight into Laryngo-Tracheal Surgery: High-Flow Oxygen Therapy to Prevent Early Complications after Surgery.

BACKGROUND: Early post-operative airway management after laryngo-tracheal surgery is crucial. Acute respiratory failure due to glottis' edema may occur, requiring reintubation. This can prolong ventilatory assistance, jeopardizing anastomosis. To date, only judicious steroid administration and fluid management are available to avoid more invasive procedures. High-flow oxygen therapy (HFOT) is a noninvasive O2 support method providing humidification, warmed air, and Positive End-Expiratory Pressure (AIRVO2). No data about HFOT use to prevent early complications after laryngo-tracheal surgery are reported in the literature. METHODS: Between September 2020 and September 2022, 107 consecutive patients who underwent laryngo-tracheal surgery received HFOT (Group A). Data and long-term results were compared with those of 80 patients operated between September 2018 and August 2020 (Group B), when HFOT was not available. All patients were operated in a single center. No pre- or post-operative settings changed, except for HFOT introduction. We analyzed and compared the risk for "delayed" reintubation (unexpected reintubation within the first 24-48 h after extubating/laryngeal mask removal) in the two groups. RESULTS: No patients reported HFOT-related adverse events. The control group (B) presented "delayed" reintubation in 37% (p = 0.027), intensive care unit admission in 67% (p = 0.005) and longer hospital stay (p = 0.001) compared to the HFOT group (A). The minor complications' rate was 3% in both group and overall mortality was 0%. Re-stenosis was described in 4.6% of the HFOT group, without a statistically significant difference (p = 0.7006). CONCLUSIONS: Our study is the first to investigate HFOT use in patients undergoing laryngo-tracheal surgery, potentially representing a consistent innovation in the peri-operative management of these patients. With the limitation of a retrospective series, we would suggest HFOT use for preventing post-operative reintubation rate, possibly reducing ICU admissions and hospital stays.

Performance Characterisation of the Airvo2TM Nebuliser Adapter in Combination with the Aerogen SoloTM Vibrating Mesh Nebuliser for in Line Aerosol Therapy during High Flow Nasal Oxygen Therapy.

High flow oxygen (HFO) therapy is a well-established treatment in respiratory disease. Concurrent aerosol delivery can greatly expediate their recovery. The aim of this work was to complete a comprehensive characterisation of one such HFO therapy system, the Airvo2TM, used in combination with the Aerogen SoloTM vibrating mesh nebuliser. Representative adult, infant, and paediatric head models were connected to a breathing simulator via a collection filter placed at the level of the trachea. A tracheostomy interface and nasal cannulas were used to deliver the aerosol. Cannula size and gas flow rate were varied across the full operating range recommended by the manufacturer. The tracheal and emitted doses were quantified via UV-spectrophotometry. The aerosol droplet diameter at the exit of the nares and tracheal interface was measured via cascade impaction. High gas flow rates resulted in low emitted and tracheal doses (%). Nasal cannula size had no significant effect on the tracheal dose (%) available in infant and paediatric models. Higher gas flow rates resulted in smaller aerosol droplets at the exit of the nares and tracheostomy interface. Gas flow rate was found to be the primary parameter affecting aerosol delivery. Thus, gas flow rates should be kept low and where possible, delivered using larger nasal cannulas to maximise aerosol delivery.

The effect of high-flow oxygen via tracheostomy on respiratory pattern and diaphragmatic function in patients with prolonged mechanical ventilation: A randomized, physiological, crossover study.

Background: Compared to conventional oxygen devices, high-flow oxygen treatment (HFOT) through the nasal cannulae has demonstrated clinical benefits. Limited data exist on whether such effects are also present in HFOT through tracheostomy. Hence, we aimed to examine the short-term effects of HFOT through tracheostomy on diaphragmatic function and respiratory parameters in tracheostomized patients on prolonged mechanical ventilation. Methods: A randomized, crossover, physiological study was conducted in our ICU between December 2020 and April 2021, in patients with tracheostomy and prolonged mechanical ventilation. The patients underwent a 30-min spontaneous breathing trial (SBT) and received oxygen either via T-piece or by HFOT through tracheostomy, followed by a washout period of 15-min breathing through the T-piece and receipt of 30-min oxygen with the other modality in a randomized crossover manner. At the start and end of each session, blood gasses, breathing frequency (f), and tidal volume (VT) via a Wright's spirometer were measured, along with diaphragm ultrasonography including diaphragm excursion and diaphragmatic thickening fraction, which expressed the inspiratory muscle effort. Results: Eleven patients were enrolled in whom 19 sessions were uneventfully completed; eight patients were studied twice on two different days with alternate sessions; and three patients were studied once. Patients were randomly assigned to start the SBT with a T-piece (n=10 sessions) or with HFOT (n=9 sessions). With HFOT, VT and minute ventilation (VE) significantly increased during SBT (from [465±119] mL to [549±134] mL, P <0.001 and from [12.4±4.3] L/min to [13.1±4.2] L/min, P <0.05, respectively), but they did not change significantly during SBT with T-piece (from [495±132] mL to [461±123] mL and from [12.8±4.4] mL to [12.0±4.4] mL, respectively); f/VT decreased during HFOT (from [64±31] breaths/(min∙L) to [49±24] breaths/(min∙L), P <0.001), but it did not change significantly during SBT with T-piece (from [59±28] breaths/(min∙L) to [64±33] breaths/(min∙L)); partial pressure of arterial oxygen increased during HFOT (from [99±39] mmHg to [132±48] mmHg, P <0.001), but it decreased during SBT with T-piece (from [124±50] mmHg to [83±22] mmHg, P <0.01). In addition, with HFOT, diaphragmatic excursion increased (from [12.9±3.3] mm to [15.7±4.4] mm, P <0.001), but it did not change significantly during SBT with T-piece (from [13.4±3.3] mm to [13.6±3.3] mm). The diaphragmatic thickening fraction did not change during SBT either with T-piece or with HFOT. Conclusion: In patients with prolonged mechanical ventilation, HFOT through tracheostomy compared with T-piece improves ventilation, pattern of breathing, and oxygenation without increasing the inspiratory muscle effort. Trial Registration: Clinicaltrials.gov ldentifer: NCT04758910.

Swallowing and feeding of young children on high-flow oxygen therapy.

BACKGROUND:  Oral feeding practices of young patients on high-flow oxygen (HFO2) have been controversial. Limited literature exists on this topic, but new studies suggest introducing oral feeds. OBJECTIVE:  This study aims to describe the changes in swallowing and feeding of a group of young children on HFO2. METHOD:  Twelve participants (mean age 34.17 months [s.d. = 3.97]) on HFO2 were assessed clinically at the bedside using the Schedule of Oral Motor Assessment. Assessments were conducted twice to determine the change in characteristics: upon approval from the managing doctor when respiratory stability on HFO2 was achieved and for a second time on the last day of receiving HFO2 (mean 2.6 days apart). Patients received standard in-patient care and speech therapy intervention. RESULTS:  Most participants displayed typical oral motor function at initial and final assessments for liquid, puree and semi-solid consistencies. Purees and soft solid consistencies were introduced to most participants (n = 11, 91.7%). Solids and chewables were challenging for all participants during both assessments. Half of the participants displayed gagging and a wet vocal quality with thin liquids at the initial assessment only. CONCLUSION:  This small-scale study found that HFO2 should not preclude oral diets, but in this sample, small amounts of oral feeding could be introduced with caution, in an individualised manner, and with a collaborative multidisciplinary approach. Further research is essential.Contribution: Partial oral feeding of specific consistencies was possible during the assessment of young paediatric in-patients on HFO2. Monitoring of individual patient characteristics and risk factors by a specialist feeding team is essential.

Surfactant therapy using vibrating-mesh nebulizers in adults with COVID-19-induced ARDS: A case series.

Coronavirus adult respiratory distress syndrome, characterized by decreased surfactant due to lysis of type II pneumocytes and hyaline membrane formation, contributes to severe hypoxemia. The administration of surfactant via high-flow nasal cannula (HFNC) may positively affect lung structure and function in this context. In this study, we report on five clinical cases, encompassing patients aged 40-60 years of both sexes, who tested positive for coronavirus disease 2019 via real-time polymerase chain reaction and exhibited significant pulmonary compromise with elevated inflammatory biomarkers. These patients were treated with aerosol therapy using surfactant delivered through vibrating-mesh nebulizers alongside HFNC. Of these patients, four demonstrated positive responses to the treatment, suggesting that aerosol therapy with surfactant through vibrating-mesh nebulizers could be a viable rescue therapy in adults receiving HFNC oxygen therapy for hypoxemic respiratory failure caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Unfortunately, one patient had a negative outcome and succumbed. The findings from these cases indicate that the use of aerosol therapy with vibrating-mesh nebulizers as rescue therapy might offer an alternative approach for managing adults with hypoxemic respiratory failure due to SARS-CoV-2, as evidenced by the positive outcomes in four out of the five cases presented.

Intraoperative high flow oxygen therapy for tubeless anaesthesia in thoracoscopic surgery.

Tubeless anaesthesia has become widespread in videothoracoscopic surgery, even in major procedures such as lobectomies. There are several advantages in avoiding general anaesthesia and one-lung mechanical ventilation, such as faster recovery and shorter hospital stays. However, hypoxaemia and hypercapnia are the most reported causes of conversion to general anaesthesia. High Flow Oxygen Therapy (HFOT) generates flow-dependent positive end-expiratory pressure, improves oxygenation and also carbon dioxide washout by flow-dependent dead space flushing. For this reason, intraoperative HFOT may reduce the rate of conversion to general anaesthesia. We report our experience with intraoperative HFOT in a 71-year-old female with lung adenocarcinoma undergoing VATS upper left lobectomy.

Non-invasive ventilation in neonates: a review of current literature.

Moving from an era of invasive ventilation to that of non-invasive respiratory support, various modalities have emerged resulting in improved neonatal outcomes. Respiratory distress is the commonest problem seen both in preterm and term neonates, and the use of appropriate respiratory support could be lifesaving. This article reviews the currently available non-invasive ventilation (NIV) strategies in neonates including nasal continuous positive airway pressure, nasal intermittent positive pressure ventilation (NIPPV), bi-level CPAP, heated humidified high flow nasal cannula, nasal high-frequency ventilation (NHFV) and non-invasive neutrally adjusted ventilatory assist (NIV-NAVA). Though multiple systematic reviews and meta-analyses have indicated the superiority of synchronized NIPPV over the other forms of non-invasive respiratory support in neonates, there is no single NIV modality that universally suits all. Hence, the choice of NIV for a neonate should be individualized based on its efficacy, the disease pathology, resource settings, the clinician's familiarity and parental values. Future studies should evaluate emerging modalities such as NIV-NAVA and NHFV in the respiratory management of neonates as the evidence pertaining to these is insufficient.

High-Flow Tracheal Oxygen for Tracheostomy Tube Removal in Lung Transplant Recipients.

(1) Background: Because of a complicated intraoperative course and/or poor recovery of graft function, approximately 15% of lung transplant (LT) recipients require prolonged mechanical ventilation (PMV) and receive a tracheostomy. This prospective study aimed to assess the effect of High-Flow Tracheal Oxygen (HFTO) on tracheostomy tube removal in LT recipients receiving PMV postoperatively. (2) Methods: The clinical course of 14 LT recipients receiving HFTO was prospectively evaluated and compared to that of 13 comparable controls receiving conventional oxygen therapy (COT) via tracheostomy. The study's primary endpoint was the number of patients whose tracheostomy tube was removed at discharge from an Intermediate Respiratory Care Unit (IRCU). (3) Results: Setting up HFTO proved easy, and it was well tolerated by all the patients. The number of patients whose tracheostomy tube was removed was significantly higher in the HFOT group compared to the COT group [13/14 vs. 6/13 (p = 0.0128)]. (4) Conclusions: HFTO is an effective, safe therapy that facilitates tracheostomy tube removal in LT recipients after weaning from PMV.

Influence of different noninvasive oxygenation support devices on tidal volume.

BACKGROUND: Multiple devices are available for noninvasive oxygenation support, including non-rebreather oxygen mask (O2-mask), high-flow oxygen through nasal cannula (HFNC), continuous positive airway pressure (CPAP), mask noninvasive ventilation (Mask-NIV) and helmet NIV (Helmet-NIV). As tidal volume is a key determinant of efficacy and safety during ventilatory support, we assessed whether it was influenced by the type of noninvasive oxygenation device. METHODS: A bench study using a manikin with a realistic face connected to a lung simulator was performed. Six conditions were assessed: no device, O2-mask, HFNC, CPAP, Mask-NIV and Helmet-NIV. Three respiratory mechanics were simulated (normal, obstructive, restrictive), at three simulated efforts (low, moderate, respiratory distress). Flow was recorded at the lung simulator inlet and mouth pressure into the manikin mouth. The same devices were evaluated on healthy volunteers with tidal volume assessed by electrical impedance tomography (EIT). RESULTS: Tidal volume was significantly influenced by oxygenation devices in bench model. As compared to O2-mask, HFNC and CPAP delivered significantly lower tidal volumes (440 ± 352 mL, 414 ± 333 mL and 377 ± 297 mL, respectively), while Mask-NIV or Helmet-NIV were associated with significantly higher tidal volumes (690 ± 321 mL and 652 ± 366 mL, respectively). Tidal volume was strongly correlated with the specific effect of each device on mouth pressure during inspiration: HFNC and CPAP were characterized by a negative PTPmouth (- 0.3 [- 0.8 to - 0.2] and - 0.7 [- 2.2 to - 0.5] cmH2O.sec/cycle, respectively), while Helmet-NIV and Mask-NIV were associated with a positive PTPmouth (4.5 [4.1-4.6] and 6.1 [5.9-7.1] cmH2O.sec/cycle, respectively). Tidal volume was also significantly influenced by oxygenation devices in healthy volunteers, with similar tidal volumes between O2-mask and CPAP (644 [571-764] and 648 [586-770] mL) but higher with HFNC, Mask-NIV and Helmet-NIV (819 [609-918], 1110 [661-1305] and 1086 [833-1243] mL). CONCLUSIONS: Tidal volume is significantly influenced by noninvasive oxygenation support devices, with a strong correlation with the pressure variation generated into the mouth during inspiration. NIV was associated with the highest tidal volumes and CPAP with the lowest ones. Clinical studies are needed to clarify the clinical implications of these effects.