[Home Respiratory Therapies: SEPAR Technical Document for Institutional Decision Support]. / Terapias respiratorias domiciliarias: documento técnico de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR) de apoyo institucional a la toma de decisiones.

Home Respiratory Therapies (HRT) encompass a variety of treatments for patients with chronic respiratory diseases, administered at home over extended periods. The Service Providers of HRT (SPHRT) collaborate with hospital resources to address chronic respiratory diseases, acting as strategic partners. The contracting of HRT in the public health system involves contests where the SPHRT present technical and economic offers. The purpose of this document is to provide a technical basis that can assist professionals, SPHRT, and the administration in making decisions when calling for, evaluating, and deciding on such contests.

Airways management in SARS-COV-2 acute respiratory failure: A prospective observational multi-center study.

Objective: Few studies have reported the implications and adverse events of performing endotracheal intubation for critically ill COVID-19 patients admitted to intensive care units. The aim of the present study was to determine the adverse events related to tracheal intubation in COVID-19 patients, defined as the onset of hemodynamic instability, severe hypoxemia, and cardiac arrest. Setting: Tertiary care medical hospitals, dual-centre study performed in Northern Italy from November 2020 to May 2021. Patients: Adult patients with positive SARS-CoV-2 PCR test, admitted for respiratory failure and need of advanced invasive airways management. Interventions: Endotracheal Intubation Adverse Events. Main variables of interests: The primary endpoint was to determine the occurrence of at least 1 of the following events within 30 minutes from the start of the intubation procedure and to describe the types of major adverse peri-intubation events: severe hypoxemia defined as an oxygen saturation as measured by pulse-oximetry <80%; hemodynamic instability defined as a SBP 65 mmHg recoded at least once or SBP < 90 mmHg for 30 minutes, a new requirement or increase of vasopressors, fluid bolus >15 mL/kg to maintain the target blood pressure; cardiac arrest. Results: Among 142 patients, 73.94% experienced at least one major adverse peri-intubation event. The predominant event was cardiovascular instability, observed in 65.49% of all patients undergoing emergency intubation, followed by severe hypoxemia (43.54%). 2.82% of the patients had a cardiac arrest. Conclusion: In this study of intubation practices in critically ill patients with COVID-19, major adverse peri-intubation events were frequent. Clinical Trial registration: www.clinicaltrials.gov identifier: NCT04909476.

Objetivo: Pocos estudios han informado las implicaciones y los eventos adversos de realizar una intubación endotraqueal para pacientes críticos con COVID-19 ingresados ​​en unidades de cuidados intensivos. El objetivo del presente estudio fue determinar los eventos adversos relacionados con la intubación traqueal en pacientes con COVID-19, definidos como la aparición de inestabilidad hemodinámica, hipoxemia severa y paro cardíaco. Ámbito: Hospitales médicos de atención terciaria, estudio de doble centro realizado en el norte de Italia desde noviembre de 2020 hasta mayo de 2021. Pacientes: Pacientes adultos con prueba PCR SARS-CoV-2 positiva, ingresados por insuficiencia respiratoria y necesidad de manejo avanzado de vías aéreas invasivas. Intervenciones: Eventos adversos de la intubación endotraqueal. Principales variables de interés: El punto final primario fue determinar la ocurrencia de al menos 1 de los siguientes eventos dentro de los 30 minutos posteriores al inicio del procedimiento de intubación y describir los tipos de eventos adversos periintubación mayores. : hipoxemia severa definida como una saturación de oxígeno medida por pulsioximetría <80%; inestabilidad hemodinámica definida como PAS 65 mmHg registrada al menos una vez o PAS < 90 mmHg durante 30 minutos, nuevo requerimiento o aumento de vasopresores, bolo de líquidos > 15 mL/kg para mantener la presión arterial objetivo; paro cardiaco. Resultados: Entre 142 pacientes, el 73,94% experimentó al menos un evento periintubación adverso importante. El evento predominante fue la inestabilidad cardiovascular, observada en el 65,49% de todos los pacientes sometidos a intubación de urgencia, seguido de la hipoxemia severa (43,54%). El 2,82% de los pacientes tuvo un paro cardíaco. Conclusión: En este estudio de prácticas de intubación en pacientes críticos con COVID-19, los eventos adversos periintubación mayores fueron frecuentes. Registro de ensayos clínicos: www.clinicaltrials.gov identificador: NCT04909476.

Systematic review and meta-analysis of efficacy and safety of continuous positive airways pressure versus high flow oxygen cannula in acute bronchiolitis.

INTRODUCTION: There are a trend towards increasing use of High-Flow Nasal Cannula (HFNC), outside of paediatric intensive care unit. Give this trend is necessary to update the actual evidence and to assess available published literature to determinate the efficacy of HFNC over Continuous Positive Air Pressure (CPAP) as treatment for children with severe bronchiolitis. METHODS: We searched MEDLINE, EMBASE, LILACS, and COCHRANE Central, and gray literature in clinical trials databases ( www. CLINICALTRIALS: gov ), from inception to June 2022. The inclusion criteria for the literature were randomized clinical trials (RCTs) that included children < 2 years old, with acute moderate or severe bronchiolitis. All study selection and data extractions are performed independently by two reviewers. RESULTS: The initial searches including 106 records. Only five randomized controlled trial that met the inclusion criteria were included in meta-analysis. The risk of invasive mechanical ventilation was not significantly different in CPAP group and HFNC group [OR: 1.18, 95% CI (0.74, 1.89), I² = 0%] (very low quality). The risk of treatment failure was less significantly in CPAP group than HFNC group [OR: 0.51, 95% CI (0.36, 0.75), I² = 0%] (very low quality). CONCLUSION: In conclusion, there was no significant difference between HFNC and CPAP in terms of risk of invasive mechanical ventilation. CPAP reduces de risk of therapeutic failure with a highest risk of non severe adverse events. More trials are needed to confirm theses results.

Telemetric Assessment of Continuous Positive Airways Pressure (CPAP) Effectiveness and Adherence in Obstructive Sleep Apnea during COVID-19 Pandemic.

Obstructive sleep apnea is the most common sleep-related breathing disorder. In the pandemic times of the new coronavirus SARS-CoV-2, CPAP (Continuous Positive Airway Pressure) therapy of obstructive sleep apnea became even more challenging. After the pandemic outbreak in March 2020, most CPAP treatment recommendations changed because of rising concerns about CPAP usage safety for patients and their families. Therefore, we examined the effectiveness of CPAP and adherence to the therapy of 149 adults with obstructive sleep apnea in the period of two years from 4 March 2019 to 3 March 2021 (before pandemic breakout and during the first year of pandemic). Data on CPAP parameters and adherence to therapy were obtained via a telemetric system. Together, our results demonstrated that the COVID-19 pandemic had no significant impact on CPAP therapy parameters and adherence in whole study group. However, detailed analysis acknowledged that some demographic and clinical features influenced CPAP therapy. The results showed that across subgroups of patients differentiated on the basis of age, gender, co-existing diabetes mellitus, or hypertension, the COVID-19 pandemic seemed to affect CPAP effectiveness. Our results provide a good starting point for discussion on CPAP therapy recommendations during pandemic times.

[Evolution of the USP and IPSS score after continuous positive airway pressure sleep apnea therapy at night]. / Évolution du score USP et IPSS après appareillage du syndrome d'apnées du sommeil par pression positive continue nocturne.

INTRODUCTION: To assess the impact of nocturnal continuous positive airway pressure (CPAP) treatment of obstructive sleep apnea (OSA) on lower urinary tract (LUTS) symptoms. MATERIALS AND METHODS: A prospective, monocentric study was conducted between June 2018 and August 2019. Patients with moderate to severe OSA with an indication for treatment with nocturnal CPAP in combination with SBAU were included. SBAUs and their impact were evaluated by completing two self-administered questionnaires (Urinary Symptom Profile (USP) and International Prostate Score Symptom (IPSS)) filled out during the night-time ventilatory polygraph or diagnostic polysomnography for OSA and after 4 months of CPAP treatment. RESULTS: In 79 patients, after four months of CPAP treatment, USP scores for stress urinary incontinence and overactive bladder were significantly improved, respectively 0.65±1.38 vs 1.13±2.10 ; p<0.0001 and 3.24±2.58 vs 5.43±3.66 ; p<0.0001, IPSS and IPSS-Qdv were significantly improved, respectively 5.20±3.78 vs. 7.44±5.05 ; p<0.0001 and 1.93±1.26 vs. 2.27±1.56 ; p=0.002 as well as IPSS score items on pollakiuria, urgency and nocturia. CONCLUSION: Treatment with CPAP significantly improved SBAU in four months. Testing urology patients for symptoms of OSA in urology patients seeking SBAU would allow referral of patients suspected of OSA to a specialist for diagnosis and management if necessary.

Helmet CPAP to treat hypoxic pneumonia outside the ICU: an observational study during the COVID-19 outbreak.

BACKGROUND: Respiratory failure due to COVID-19 pneumonia is associated with high mortality and may overwhelm health care systems, due to the surge of patients requiring advanced respiratory support. Shortage of intensive care unit (ICU) beds required many patients to be treated outside the ICU despite severe gas exchange impairment. Helmet is an effective interface to provide continuous positive airway pressure (CPAP) noninvasively. We report data about the usefulness of helmet CPAP during pandemic, either as treatment, a bridge to intubation or a rescue therapy for patients with care limitations (DNI). METHODS: In this observational study we collected data regarding patients failing standard oxygen therapy (i.e., non-rebreathing mask) due to COVID-19 pneumonia treated with a free flow helmet CPAP system. Patients' data were recorded before, at initiation of CPAP treatment and once a day, thereafter. CPAP failure was defined as a composite outcome of intubation or death. RESULTS: A total of 306 patients were included; 42% were deemed as DNI. Helmet CPAP treatment was successful in 69% of the full treatment and 28% of the DNI patients (P < 0.001). With helmet CPAP, PaO2/FiO2 ratio doubled from about 100 to 200 mmHg (P < 0.001); respiratory rate decreased from 28 [22-32] to 24 [20-29] breaths per minute, P < 0.001). C-reactive protein, time to oxygen mask failure, age, PaO2/FiO2 during CPAP, number of comorbidities were independently associated with CPAP failure. Helmet CPAP was maintained for 6 [3-9] days, almost continuously during the first two days. None of the full treatment patients died before intubation in the wards. CONCLUSIONS: Helmet CPAP treatment is feasible for several days outside the ICU, despite persistent impairment in gas exchange. It was used, without escalating to intubation, in the majority of full treatment patients after standard oxygen therapy failed. DNI patients could benefit from helmet CPAP as rescue therapy to improve survival. TRIAL REGISTRATION: NCT04424992.

COVID-19 and respiratory support devices.

There are significant logistical challenges to providing respiratory support devices, beyond simple oxygen flow, when centres run out of supplies or do not have these devices at all, such as in low resource settings. At the peak of the COVID-19 crisis, it was extremely difficult to import medical equipment and supplies, because most countries prohibited the medical industry from selling outside of their own countries. As a consequence, engineering teams worldwide volunteered to develop emergency devices, and medical experts in mechanical ventilation helped to guide the design and evaluation of prototypes. Although regulations vary among countries, given the emergency situation, some Regulatory Agencies facilitated expedited procedures. However, laboratory and animal model testing are crucial to minimize the potential risk for patients when treated with a device that may worsen clinical outcome if poorly designed or misused.

Flowchart for non-invasive ventilation support in COVID-19 patients from a northern Italy Emergency Department.

With the rapid pandemic spread of the novel coronavirus (SARS-CoV2), Emergency Departments of affected countries are facing an increasing number of patients presenting with hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19). Providing mechanical support and endotracheal intubation can be challenging due to a number of patients larger than usual, often exceeding available resources. Considering the lack of recommendations available, we developed a flowchart to standardize the first approach to patients presenting to the Emergency Department with hypoxemic respiratory failure due to COVID-19.

Cambios en índice de masa corporal en pacientes portadores de apnea del sueño a un año de tratamiento con dispositivo de presión de aire positiva continua (CPAP) / Changes in body mass index in sleep apnea patients with a year of continuous positive airway pressure treatment (CPAP)

Resumen El síndrome de apnea hipoapnea del sueño (SAHS), está asociado fuertemente a la obesidad. El objetivo de este estudio es determinar las variaciones en el índice de masa corporal (IMC) en pacientes portadores de SAHS luego de un año de tratamiento con CPAP. Resultados: 104 pacientes varones fueron incluidos en este estudio, las variables analizadas fueron: índice de apnea-hipopnea (IAH), índice de masa corporal (IMC) y cuestionario de somnolencia diurna Epworth. Respecto a los datos obtenidos de IMC, se encontró tras un año de tratamiento con CPAP un descenso significativo de esta variable (p < 0,001). En la escala de somnolencia también se obtuvo un descenso significativo. Discusión: La evidencia ha sugerido regularmente que a mayor peso corporal existirían también niveles más elevados de IAH, las mejoras en el IMC referidas en este estudio, resaltan la importancia del correcto tratamiento no solo en el control de los eventos respiratorios, sino que en la disminución del peso corporal.

Sleep Apnea Syndrome (SAS) it is highly related to obesity. The main purpose of this study is to determine the variation between Apnea Hypopnea Index (AHI) and Body Mass Index (BMI) on sleep apnea patients after a year of CPAP treatment on the Linde Sleep Center. Results: 104 male patients were included in this study, the variables analyzed were; AHI, BMI, Epworth daytime somnolence. As for the data obtained from BMI, after one year of treatment with CPAP, the BMI showed a significant decrease (p < 0.001). In the daytime sleepiness scale, a significant decrease was also found between pre and post treatment values. Discussion: Evidence has consistently suggested that higher body weight would also have higher levels of AHI, and the improvements in BMI referred to in this study emphasize the importance of proper treatment not only in control of respiratory events, but in the reduction of body weight.

The ACUTE (Ambulance CPAP: Use, Treatment effect and economics) feasibility study: a pilot randomised controlled trial of prehospital CPAP for acute respiratory failure.

BACKGROUND: Acute respiratory failure (ARF) is a common and life-threatening medical emergency. Standard prehospital management involves controlled oxygen therapy and disease-specific ancillary treatments. Continuous positive airway pressure (CPAP) is a potentially beneficial alternative treatment that could be delivered by emergency medical services. However, it is uncertain whether this treatment could work effectively in United Kingdom National Health Service (NHS) ambulance services and if it represents value for money. METHODS: An individual patient randomised controlled external pilot trial will be conducted comparing prehospital CPAP to standard oxygen therapy for ARF. Adults presenting to ambulance service clinicians will be eligible if they have respiratory distress with peripheral oxygen saturation below British Thoracic Society (BTS) target levels, despite titrated supplemental oxygen. Enrolled patients will be allocated (1:1 simple randomisation) to prehospital CPAP (O_two system) or standard oxygen therapy using identical sealed boxes. Feasibility outcomes will include incidence of recruited eligible patients, number of erroneously recruited patients and proportion of cases adhering to allocation schedule and treatment, followed up at 30 days and with complete data collection. Effectiveness outcomes will comprise survival at 30 days (definitive trial primary end point), endotracheal intubation, admission to critical care, length of hospital stay, visual analogue scale (VAS) dyspnoea score, EQ-5D-5L and health care resource use at 30 days. The cost-effectiveness of CPAP, and of conducting a definitive trial, will be evaluated by updating an existing economic model. The trial aims to recruit 120 patients over 12 months from four regional ambulance hubs within the West Midlands Ambulance Service (WMAS). This sample size will allow estimation of feasibility outcomes with a precision of < 5%. Feasibility and effectiveness outcomes will be reported descriptively for the whole trial population, and each trial arm, together with their 95% confidence intervals. DISCUSSION: This study will determine if it is feasible, acceptable and cost-effective to undertake a full-scale trial comparing CPAP and standard oxygen treatment, delivered by ambulance service clinicians for ARF. This will inform NHS practice and prevent inappropriate prehospital CPAP adoption on the basis of limited evidence and at a potentially substantial cost. TRIAL REGISTRATION: ISRCTN12048261. Registered on 30 August 2017. http://www.isrctn.com/ISRCTN12048261.

Evaluation of 'TRY': an algorithm for neonatal continuous positive airways pressure in low-income settings.

BACKGROUND: Non-invasive respiratory support using bubble continuous positive airway pressure (bCPAP) is useful in treating babies with respiratory distress syndrome. Despite its proven clinical and cost-effectiveness, implementation is hampered by the inappropriate administration of bCPAP in low-resource settings. A clinical algorithm-'TRY' (based on Tone: good; Respiratory distress; Yes, heart rate above 100 beats/min)-has been developed to correctly identify which newborns would benefit most from bCPAP in a teaching hospital in Malawi. OBJECTIVE: To evaluate the reliability, sensitivity and specificity of TRY when employed by nurses in a Malawian district hospital. METHODS: Nursing staff in a Malawian district hospital baby unit were asked, over a 2-month period, to complete TRY assessments for every newly admitted baby with the following inclusion criteria: clinical evidence of respiratory distress and/or birth weight less than 1.3 kg. A visiting paediatrician, blinded to nurses' assessments, concurrently assessed each baby, providing both a TRY assessment and a clinical decision regarding the need for CPAP administration. Inter-rater reliability was calculated comparing nursing and paediatrician TRY assessment outcomes. Sensitivity and specificity were estimated comparing nurse TRY assessments against the paediatrician's clinical decision. RESULTS: Two hundred and eighty-seven infants were admitted during the study period; 145 (51%) of these met the inclusion criteria, and of these 57 (39%) received joint assessments. The inter-rater reliability was high (kappa 0.822). Sensitivity and specificity were 92% and 96%, respectively. CONCLUSIONS: District hospital nurses, using the TRY-CPAP algorithm, reliably identified babies that might benefit from bCPAP and thus improved its effective implementation.

[Adherence to treatment with continuous positive airways pressure]. / L'observance du traitement par pression positive continue : étude prospective de 103 patients suivis au service de pneumologie de Nabeul-Tunisie.

INTRODUCTION: Continuous positive airways pressure (CPAP) is the standard treatment for obstructive sleep apnea syndrome (OSAS). It produces substantial benefits if used for the appropriate indication and if patients adhere to treatment. METHODS: We conducted a prospective study of 103 patients treated with CPAP over four years follow-up. RESULTS: Our population had a mean age of 52 years with a sex ratio of 0.63. Face to face, individual education was provided in all cases. CPAP titration was performed by an unattended domiciliary autoadjusted CPAP device in 83.5% of patients for 15 days to one month. Twenty patients refused CPAP treatment after the period of titration. Eighty two patients (98.8%) were treated by constant CPAP. Seventy five percent of the patients complained of at least one side effect. The more common were nasal (56.6%) and mask related problems (40%). Seventy six percent of patients used CPAP for more than 4hours per day. Eleven patients stopped CPAP therapy because of intolerance (10 cases) and reluctance to instrumental therapy (one case). Adherence to CPAP therapy was associated with the severity of OSAS, the level of daytime sleepiness, higher pressures, repeated education during the course of follow up, clinical efficacy and the presence of fewer side-effects. CONCLUSIONS: We obtained satisfactory rates of adherence and tolerance of CPAP assisted by regular medical and technical follow-up of patients.

Overnight auto-adjusting continuous airway pressure + standard care compared with standard care alone in the prevention of morbidity in sickle cell disease phase II (POMS2b): study protocol for a randomised controlled trial.

BACKGROUND: In addition to pain, sickle cell anaemia (HbSS) complications include neurocognitive difficulties in attention and processing speed associated with low daytime and night-time oxygen saturation compounded by obstructive sleep apnoea (OSA). In the general population OSA is treated with continuous positive airways pressure (CPAP). The aim of this single-blind, randomised, controlled phase II trial is to compare auto-adjusting CPAP (APAP) with standard care to standard care alone in individuals with HbSS to determine whether the intervention improves attention and processing speed, brain structure, pain and quality of life. METHODS/DESIGN: Eligibility criteria include: ability to provide informed consent; age > 8 years; diagnosis of HbSS; and mean overnight saturation of < 90% for < 30% of the night (i.e. not meeting current criteria for overnight oxygen therapy). Key exclusion criteria are: overnight respiratory support; respiratory or decompensated cardiac failure; chronic transfusion; or contraindications to APAP therapy or magnetic resonance imaging (MRI). Sixty individuals with HbSS (30 children and 30 adults) will be randomised to standard care + APAP or standard care alone for six months. Minimisation factors are: age group (8-11, 12-15, 16-22 and > 23 years); silent infarction on MRI; minimum overnight oxygen saturation > 90% or < 90%; and hydroxyurea use. For APAP individuals, the intervention is administered at home. Adherence and effectiveness are recorded using software documenting hours of use each night and overnight oximetry. Participant support in terms of appropriate facemask and facilitating adherence are provided by an unblinded sleep physiologist. The primary outcome is change in the cancellation subtest from the Wechsler scales. Secondary outcomes include general cognitive functioning, quantitative brain MRI, blood and urine chemistry, quality of life and daily pain via a smartphone App (GoMedSolutions, Inc) and, where possible MRI heart, echocardiography, and 6-min walk. These outcomes will be assessed at baseline and after six months of treatment by assessors blind to treatment assignment. DISCUSSION: Altering oxygen saturation in HbSS may lead to bone marrow suppression. This risk will be reduced by monitoring full blood counts at baseline, two weeks, three months and six months, providing treatment as appropriate and reporting as safety events. TRIAL REGISTRATION: ISRCTN46012373 . Registered on 10 July 2015. Protocol Version: 6.0 Date: 24th December 2015 Sponsor: University Hospital Southampton. Sponsor's protocol code: RHMCHIOT53.

Comparing the Efficacy, Mask Leak, Patient Adherence, and Patient Preference of Three Different CPAP Interfaces to Treat Moderate-Severe Obstructive Sleep Apnea.

STUDY OBJECTIVES: To determine if the type of continuous positive airway pressure (CPAP) mask interface influences CPAP treatment efficacy, adherence, side effects, comfort and sleep quality in patients with moderate-severe obstructive sleep apnea (OSA). METHODS: This took place in a hospital-based tertiary sleep disorders unit. It is a prospective, randomized, crossover trial comparing three CPAP interfaces: nasal mask (NM), nasal mask plus chinstrap (NM-CS) and oronasal mask (ONM) each tried in random order, for 4 weeks. After each 4-week period, patient outcomes were assessed. Participants had a new diagnosis of obstructive sleep apneas. Forty-eight patients with moderate-severe OSA (32 males, mean ± standard deviation apnea-hypopnea index (AHI) 55.6 ± 21.1 events/h, age 54.9 ± 13.1 years, body mass index 35.8 ± 7.2 kg/m2) were randomized. Thirty-five participants completed the full study, with complete data available for 34 patients. RESULTS: There was no statistically significant difference in CPAP adherence; however, residual AHI was higher with ONM than NM and NM-CS (residual AHI 7.1 ± 7.7, 4.0 ± 3.1, 4.2 ± 3.7 events/h respectively, main effect P = .001). Patient satisfaction and quality of sleep were higher with the NM and NM-CS than the ONM. Fewer leak and mask fit problems were reported with NM (all chi-square P < .05), which patients preferred over the NM-CS and ONM options (n = 22, 9 and 4 respectively, P = .001). CONCLUSIONS: The CPAP adherence did not differ between the three different mask interfaces but the residual AHI was lower with NM than ONM and patients reported greater mask comfort, better sleep, and overall preference for a NM. A nasal mask with or without chinstrap should be the first choice for patients with OSA referred for CPAP treatment. CLINICAL TRIAL REGISTRATION: Registry: Australian and New Zealand Clinical Trials Registry, URL: https://www.anzctr.org.au, title: A comparison of continuous positive airway pressure (CPAP) interface in the control of leak, patient compliance and patient preference: nasal CPAP mask and chinstrap versus full face mask in patients with obstructive sleep apnoea (OSA), identifier: ACTRN12609000029291.

A health partnership to reduce neonatal mortality in four hospitals in Rwanda.

BACKGROUND: A health partnership to improve hospital based neonatal care in Rwanda to reduce neonatal mortality was requested by the Rwandan Ministry of Health. Although many health system improvements have been made, there is a severe shortage of health professionals with neonatal training. METHODS: Following a needs assessment, a health partnership grant for 2 years was obtained. A team of volunteer neonatologists and paediatricians, neonatal nurses, lactation consultants and technicians with experience in Rwanda or low-income countries was assembled. A neonatal training program was provided in four hospitals (the 2 University hospitals and 2 district hospitals), which focused on nutrition, provision of basic respiratory support with nasal CPAP (Continuous Positive Airway Pressure), enhanced record keeping, thermoregulation, vital signs monitoring and infection control. To identify if care delivery improved, audits of nutritional support, CPAP use and its complications, and documentation in newly developed neonatal medical records were conducted. Mortality data of neonatal admissions was obtained. RESULTS: Intensive neonatal training was provided on 27 short-term visits by 10 specialist health professionals. In addition, a paediatric doctor spent 3 months and two spent 6 months each providing training. A total of 472 training days was conducted in the neonatal units. For nutritional support, significant improvements were demonstrated in reduction in time to initiation of enteral feeds and to achieve full milk feeds, in reduction in maximum postnatal weight loss, but not in days for regaining birth weight. Respiratory support with bubble CPAP was applied to 365 infants in the first 18 months. There were no significant technical problems, but tissue damage, usually transient, to the nose and face was recorded in 13%. New medical records improved documentation by doctors, but nursing staff were reluctant to use them. Mortality for University teaching hospital admissions was reduced from 23.6% in the 18 months before the project to 21.7%. For the two district hospitals, mortality reduced from 10% to 8.1%. A major barrier to training and improved care was low number of nurses working on neonatal units and staff turnover. CONCLUSION: This health partnership delivered an intensive program of capacity building by volunteer specialists. Improved care and documentation were demonstrated. CPAP was successfully introduced. Mortality was reduced. This format can be adapted for further training and improvement programs to improve the quality of facility-based care.

Effect of OSA on hypoxic and inflammatory markers during CPAP withdrawal: Further evidence from three randomized control trials.

BACKGROUND AND OBJECTIVE: Obstructive sleep apnoea (OSA) is associated with cardiovascular disease. Intermittent hypoxia, endothelial dysfunction and adipose tissue-mediated inflammation have all been linked to cardiovascular disease in OSA. We therefore explored the effect of OSA on relevant associated blood markers: adrenomedullin (ADM), endocan, endothelin-1 (ET-1), resistin and vascular endothelial growth factor (VEGF). METHODS: Patients with OSA, established on and compliant with continuous positive airways pressure (CPAP) therapy for >1 year were included from three randomized controlled trials, conducted at two centres. Patients were randomized to either continued therapeutic CPAP or sham CPAP (CPAP withdrawal) for 2 weeks. Blood markers were measured at baseline and at 14 days and the treatment effect between sham CPAP and therapeutic CPAP was analysed. RESULTS: A total of 109 patients were studied (therapeutic CPAP n = 54, sham CPAP n = 55). Sham CPAP was associated with a return of OSA (between-group difference in oxygen desaturation index (ODI) 36.0/h, 95% CI 29.9-42.2, P < 0.001). Sham CPAP was associated with a reduction in ADM levels at 14 days (-26.0 pg/mL, 95% CI -47.8 to -4.3, P = 0.02), compared to therapeutic CPAP. Return of OSA was not associated with changes in endocan, ET-1, resistin or VEGF. CONCLUSION: Whilst CPAP withdrawal was associated with return of OSA, it was associated with an unexpected significant reduction in the vasodilator ADM and not with expected increases in hypoxia-induced markers, markers of endothelial function or resistin. We propose that the vascular effects occurring in OSA may be brought about by other mechanisms, perhaps partly through a reduction in ADM.

CPAP therapy induces favorable short-term changes in epicardial fat thickness and vascular and metabolic markers in apparently healthy subjects with obstructive sleep apnea-hypopnea syndrome (OSAHS).

BACKGROUND: Obstructive sleep apnea-hypopnea syndrome (OSAHS) is an independent risk factor for hypertension, coronary artery disease, and diabetes mellitus. Epicardial fat has been recently recognized as a new risk factor and active participant on cardiometabolic risk. The aim of this study was to assess an independent relationship between sleep apnea severity, metabolic and vascular markers, and epicardial fat, at baseline and after 3 months of continuous positive airway pressure (CPAP) therapy. MATERIALS AND METHOD: Our study group consisted of 48 patients with suspected OSAHS and no prior history of cardiovascular disease or diabetes mellitus. All patients underwent full overnight polysomnography. Thickness of epicardial and visceral adipose tissue, brachial artery flow-mediated dilation (FMD), carotid intima media thickness (cIMT), pulse wave velocity (PWV), plasma C-reactive protein (CRP) levels, fasting glucose levels, HbA1c, homeostatic model assessment of insulin resistance index (HOMA), and lipid profile were measured at baseline and after 3 months of CPAP use in patients with moderate to severe OSAHS. RESULTS: In OSAHS patients (Apnea-hypopnea index (AHI) ≥15/h, N = 28), epicardial fat correlated with fasting glucose (rho = 0.406, p = 0.04) and HOMA (rho = 0.525, p = 0.049) but was not associated with visceral fat (rho = 0.126, p = 0.595). Epicardial adipose tissue (EAT) (p = 0.022) increased across AHI severity along with PWV (p = 0.045) and carotid intima media thickness (IMT) (p = 0.034) while FMD (p = 0.017) decreased. Therapy with CPAP reduced both epicardial (p < 0.001) and visceral fat (p = 0.001). Alterations in epicardial fat across the follow-up were associated with changes in PWV (p = 0.026) and HOMA (p = 0.037) independently of major confounders. CONCLUSIONS: Epicardial fat thickness was associated with OSA severity and may be an additional marker of cardiovascular risk as well as of future diabetes in these patients. CPAP therapy reduced epicardial fat, suggesting its potentially beneficial role in reducing cardiometabolic risk in OSA patients.

AHI Outcomes Are Superior after Upper Airway Reconstructive Surgery in Adult CPAP Failure Patients.

OBJECTIVE: This study aims to evaluate Apnea-Hypopnea Index (AHI) outcomes of upper airway adult obstructive sleep apnea (OSA) reconstructive surgery, as compared with outcomes of suboptimal continuous positive airway pressure (CPAP) therapy, in response to reviews claiming unreliable surgical AHI reduction. STUDY DESIGN: Prospective cohort study. SETTING: Single-surgeon series at medical centers within Wollongong, Australia. SUBJECTS AND METHODS: Adult patients with OSA who were partial device users or who refused CPAP were considered candidates for upper airway surgery (N = 48). Subjects underwent physical examination and polysomnography before and after surgery. Three groups were delineated on the nature of their suboptimal CPAP therapy: group 1, partially using CPAP or refusing long-term CPAP despite adherence (with available download data); group 2, unable or refusing to use CPAP with 2 sleep studies over time; group 3, unable or refusing to use CPAP with 1 sleep study over time. Collected data included demographics and AHI outcomes. RESULTS: Average AHI across all 3 groups with suboptimal CPAP therapy before surgery was 30.24 ± 17.17 events per hour sleep, as compared with the average postoperative AHI of 7.65 ± 6.59 events per hour sleep. This decrease was shown to be statistically significant with Wilcoxon signed-rank test (P < .0001). CONCLUSIONS: AHI outcomes are superior with surgery in untreated or suboptimally treated adult OSA patients prescribed CPAP.

Presión positiva continua nasal en neonatos de Villa Clara / Nasal continuous positive pressure in neonates from Villa Clara

INTRODUCCIÓN: la presión positiva continua en la vía aérea en pacientes que respiran espontáneamente se define como CPAP (en inglés, de Continuous Positive Airways Pressure), y consiste en la modalidad de ventilación mecánica no invasiva más sencilla. OBJETIVO: caracterizar el uso de la presión positiva continua en la vía aérea nasal, en recién nacidos con dificultad respiratoria. MÉTODOS: se realizó un estudio observacional descriptivo transversal, que incluyó a los 149 recién nacidos que recibieron esta técnica ventilatoria, en el Hospital Provincial Universitario Ginecoobstétrico "Mariana Grajales", de Santa Clara, en los años 2012-2013. Se aplicó un instrumento confeccionado al efecto, que incluyó variables perinatales y neonatales Se analizaron variables como: edad gestacional, peso, vía del parto, diagnóstico, edad posnatal al inicio y tiempo del tratamiento, evolución clínica, gasométrica y/o radiológica. Se obtuvieron los datos del departamento de estadística, historias clínicas pediátricas y obstétricas, y los libros de registro de parto; así como, los registros de morbilidad y mortalidad continua del servicio. Para el análisis descriptivo de la muestra se utilizaron frecuencias absolutas y relativas según el tipo de información. RESULTADOS: el mayor porcentaje de los recién nacidos fueron pretérminos (83,2 %) y con peso inferior a 2 500 g. Se ventilaron en la primera hora de vida 78 neonatos, y la duración del tratamiento inferior a las 24 horas fue más frecuente. La principal indicación médica fue el edema pulmonar. CONCLUSIONES: la mayoría de los neonatos presentó una evolución clínica, gasométrica y/o radiológica satisfactoria.

INTRODUCTION: continuous positive airways pressure in patients who normally breathes (known as CPAP) is a simpler modality of noninvasive mechanical ventilation. OBJECTIVE: to characterize the use of the nasal continuous positive airways pressure in newborns with respiratory distress. METHODS: cross-sectional, descriptive and observational study of 149 newborns that were treated with this ventilation technique at "Mariana Grajales" provincial university gynecobstetric hospital in Santa Clara in 2012 and 2013. An instrument including perinatal and neonatal variables was particularly designed for this purpose. These variables covered gestational age, weight, delivery, diagnosis, postnatal age at the beginning of treatment and length of time, clinical progress, gasometric and/or radiological progress. The study used data from the statistical department in addition to pediatric and obstetric medical histories, delivery register books, and continuous morbidity and mortality records of the service. For statistical analysis of the sample, absolute and relative frequencies were used depending on the type of information. RESULTS: the highest percentage of newborns was preterm (83.2 %) weighing less than 2 500 g. Seventy eight neonates were ventilated during their first hour of life and the treatment mostly lasted less than 24 hours. The main medical indication for treatment was pulmonary edema. CONCLUSIONS: most of neonates had satisfactory clinical, gasometric and/or radiological progression.