Management of analgosedation during noninvasive respiratory support: an expert Delphi consensus document developed by the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI).

BACKGROUND: Discomfort can be the cause of noninvasive respiratory support (NRS) failure in up to 50% of treated patients. Several studies have shown how analgosedation during NRS can reduce the rate of delirium, endotracheal intubation, and hospital length of stay in patients with acute respiratory failure. The purpose of this project was to explore consensus on which medications are currently available as analgosedatives during NRS, which types of patients may benefit from analgosedation while on NRS, and which clinical settings might be appropriate for the implementation of analgosedation during NRS. METHODS: The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) selected a panel of experts and asked them to define key aspects of the use of analgesics and sedatives during NRS treatment. The methodology applied is in line with the principles of the modified Delphi and RAND-UCLA methods. The experts developed statements and supportive rationales which were then subjected to blind votes for consensus. RESULTS: The use of an analgosedation strategy in adult patients with acute respiratory failure of different origins may be useful where there is a need to manage discomfort. This strategy should be considered after careful assessment of other potential factors associated with respiratory failure or inappropriate noninvasive respiratory support settings, which may, in turn, be responsible for NRS failure. Several drugs can be used, each of them specifically targeted to the main component of discomfort to treat. In addition, analgosedation during NRS treatment should always be combined with close cardiorespiratory monitoring in an appropriate clinical setting. CONCLUSIONS: The use of analgosedation during NRS has been studied in several clinical trials. However, its successful application relies on a thorough understanding of the pharmacological aspects of the sedative drugs used, the clinical conditions for which NRS is applied, and a careful selection of the appropriate clinical setting.

Association Between Baseline Driving Pressure and Mortality in Very Old Patients with ARDS.

RATIONALE: Due to effects of aging on the respiratory system, it is conceivable that the association between driving pressure and mortality depends on age. OBJECTIVE: We endeavored to evaluate whether the association between driving pressure and mortality of patients with acute respiratory distress syndrome (ARDS) varies across the adult lifespan, hypothesizing that it is stronger in older, including very old (≥80 years), patients. METHODS: We performed a secondary analysis of individual patient-level data from seven ARDS Network and PETAL Network randomized controlled trials ("ARDSNet cohort"). We tested our hypothesis in a second, independent, national cohort ("Hellenic cohort"). We performed both binary logistic and Cox regression analyses including the interaction term between age (as a continuous variable) and driving pressure at baseline (i.e., the day of trial enrollment) as the predictor, and 90-day mortality as the dependent variable. FINDINGS: Based on data from 4567 patients with ARDS included in the ARDSNet cohort, we found that the effect of driving pressure on mortality depended on age (p=0.01 for the interaction between age as a continuous variable and driving pressure). The difference in driving pressure between survivors and non-survivors significantly changed across the adult lifespan (p<0.01). In both cohorts, a driving pressure threshold of 11 cmH2O was associated with mortality in very old patients. INTERPRETATION: Data from randomized controlled trials with strict inclusion criteria suggest that the effect of driving pressure on mortality of patients with ARDS may depend on age. These results may advocate for a personalized age-dependent mechanical ventilation approach.

Comparison of Modified ROX Index Score and ROX Index Score for Early Prediction of High Flow Nasal Oxygen Therapy Outcome in Patients with Acute Respiratory Failure: A Prospective Observational Cohort Study.

Background: We compared the modified ROX index and ROX index scores in earlier predictions of high-flow nasal oxygen (HFNO) therapy outcomes in patients with acute respiratory failure. Methods: We conducted a prospective observational study on 151 acute respiratory failure patients initiated on HFNO therapy. The primary objective of this research was to compare the modified ROX index and ROX index to investigate which score predicted HFNO treatment outcome earlier. Results: The modified ROX index score had better predictive power than the ROX score at different time points, especially one hour following the start of HFNO therapy (AUC 0.790; 95% CI: 0.717-0.863; p < 0.001). For the ROX Index at 1 hour, the ideal cut-off value for HFNO outcome was 4.36 (sensitivity: 72.6%, specificity: 53.9%), and for the modified ROX index at 1 hour, it was 4.63 (sensitivity: 74.2%, specificity: 69.7%). The presence of various comorbidities didn't show any change in ROX-HR cut-off values. Conclusion: The modified ROX index is a better predictor of the success of HFNO therapy than the ROX index. Furthermore, the presence of any comorbidities did not affect modified ROX index cut-off values or the outcome of HFNO therapy. How to cite this article: Sarkar AG, Sharma A, Kothari N, Goyal S, Meshram T, Kumari K, et al. Comparison of Modified ROX Index Score and ROX Index Score for Early Prediction of High Flow Nasal Oxygen Therapy Outcome in Patients with Acute Respiratory Failure: A Prospective Observational Cohort Study. Indian J Crit Care Med 2024;28(9):842-846.

Left Ventricular Diastolic Dysfunction in the Critically Ill: The Rubik's Cube of Echocardiography.

How to cite this article: Kumar V. Left Ventricular Diastolic Dysfunction in the Critically Ill: The Rubik's Cube of Echocardiography. Indian J Crit Care Med 2024;28(9):813-815.

A case report of nasal myiasis caused by Musca domestica in a patient with respiratory failure.

Nasal myiasis is a nasal infestation caused by myiasis, a parasitic disease affecting the nasal cavity. It is a rare condition. The nasal cavity is in close proximity to the sinuses, eyes, and cranial cavity. If the fly larvae migrate into this location, it may result in significant complications. The prompt and appropriate removal of maggots and the administration of an efficacious treatment can effectively prevent further deterioration of the disease. In this case study, we present the case of a 55-year-old woman who was admitted to the intensive care unit with severe respiratory failure. On the fourth day following admission, the patient remained unconscious, and several white larvae emerged from the nasal cavity. Through identification, the larvae were determined to be Musca domestica larvae. Subsequently, saline irrigation was performed under nasal endoscopy, and anti-inflammatory therapy was administered to the patient to prevent intracranial infection. Following treatment, the patient's symptoms were effectively managed, and the prognosis remained favorable until the 1-month follow-up. This case report presents a literature review of the reported cases of nasal myiasis caused by M. domestica and discusses the susceptibility factors and treatment modalities for nasal myiasis.

Intravascular large B-cell lymphoma with respiratory failure diagnosed by random skin biopsy: A case report.

Intravascular large B-cell lymphoma (IVLBCL) typically involves nonspecific symptoms that complicate diagnosis. This report discusses the case of a 70-year-old man, who presented with dyspnea, fatigue, and weight loss that evolved into severe respiratory failure, diagnosed with IVLBCL via random skin biopsy. The initial improvement in respiratory symptoms was followed by coronavirus disease. Response to steroid therapy and elevated lactate dehydrogenase levels suggested IVLBCL, confirmed by a random skin biopsy. The combination chemotherapy of rituximab, cyclophosphamide, vincristine, doxorubicin, and prednisolone improved the respiratory condition. This case highlights the diagnostic challenges associated with IVLBCL and the crucial role of random skin biopsy.

Epidemiology and outcomes of patients with tuberculosis requiring extracorporeal membrane oxygenation: An ELSO registry analysis.

PURPOSE: This study aimed to analyze data from the Extracorporeal Life Support Organization (ELSO) registry to elucidate the epidemiology and outcomes of patients with tuberculosis necessitating extracorporeal membrane oxygenation (ECMO), an intervention typically employed in treating severe acute respiratory distress syndrome (ARDS), but infrequently reported in tuberculosis contexts. METHODS: A retrospective analysis was conducted utilizing the ELSO registry data spanning from 2003 to 2022, specifically targeting patients with tuberculosis who underwent ECMO. Primary outcomes included survival to hospital discharge, while secondary outcomes encompassed pre-ECMO support, ECMO duration, complications, and discharge destinations. Univariate and multivariate Cox proportional hazard regression analyses were employed to identify factors influencing survival rates. RESULTS: The analysis included 169 patients with tuberculosis, with a median ECMO support duration of 233 h. The weaning success rate was recorded at 62.7 %, and 55 % of patients achieved survival to hospital discharge. Complications arose in 69.8 % of cases, predominantly mechanical complications (46.6 %). Multivariate Cox regression analysis identified complications (HR: 0.448, 95 % CI: 0.222-0.748, P=0.001), infections (HR: 0.483, 95 % CI: 0.241-0.808, P=0.001), and prolonged intervals from admission to ECMO initiation (HR: 0.698, 95 % CI: 0.396-0.901, P=0.018) as significant factors correlated with decreased survival likelihood. CONCLUSION: ECMO presents as a viable treatment option for patients with tuberculosis; however, timely initiation and meticulous management are critical to mitigate complications and enhance patient outcomes. IMPLICATION FOR CLINICAL PRACTICE: Accurate identification of optimal ECMO initiation timing for eligible patients with tuberculosis can significantly enhance clinical outcomes in critical care settings, such as intensive care units.

Heterogeneous impact of Sighs on mortality in patients with acute hypoxemic respiratory failure: insights from the PROTECTION study.

BACKGROUND: Sigh breaths may impact outcomes in acute hypoxemic respiratory failure (AHRF) during assisted mechanical ventilation. We investigated whether sigh breaths may impact mortality in predefined subgroups of patients enrolled in the PROTECTION multicenter clinical trial according to: 1.the physiological response in oxygenation to Sigh (responders versus non-responders) and 2.the set levels of positive end-expiratory pressure (PEEP) (High vs. Low-PEEP). If mortality differed between Sigh and No Sigh, we explored physiological daily differences at 7-days. RESULTS: Patients were randomized to pressure support ventilation (PSV) with Sigh (Sigh group) versus PSV with no sigh (No Sigh group). (1) Sighs were not associated with differences in 28-day mortality in responders to baseline sigh-test. Contrarily-in non-responders-56 patients were randomized to Sigh (55%) and 28-day mortality was lower with sighs (17%vs.36%, log-rank p = 0.031). (2) In patients with PEEP > 8cmH2O no difference in mortality was observed with sighs. With Low-PEEP, 54 patients were randomized to Sigh (48%). Mortality at 28-day was reduced in patients randomised to sighs (13%vs.31%, log-rank p = 0.021). These findings were robust to multivariable adjustments. Tidal volume, respiratory rate and ventilatory ratio decreased with Sigh as compared with No Sigh at 7-days. Ventilatory ratio was associated with mortality and successful extubation in both non-responders and Low-PEEP. CONCLUSIONS: Addition of Sigh to PSV could reduce mortality in AHRF non-responder to Sigh and exposed to Low-PEEP. Results in non-responders were not expected. Findings in the low PEEP group may indicate that insufficient PEEP was used or that Low PEEP may be used with Sigh. Sigh may reduce mortality by decreasing physiologic dead space and ventilation intensity and/or optimizing ventilation/perfusion mismatch. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov; Identifier: NCT03201263.

Derivation and validation of generalized sepsis-induced acute respiratory failure phenotypes among critically ill patients: a retrospective study.

BACKGROUND: Septic patients who develop acute respiratory failure (ARF) requiring mechanical ventilation represent a heterogenous subgroup of critically ill patients with widely variable clinical characteristics. Identifying distinct phenotypes of these patients may reveal insights about the broader heterogeneity in the clinical course of sepsis, considering multi-organ dynamics. We aimed to derive novel phenotypes of sepsis-induced ARF using observational clinical data and investigate the generalizability of the derived phenotypes. METHODS: We performed a multi-center retrospective study of ICU patients with sepsis who required mechanical ventilation for ≥ 24 h. Data from two different high-volume academic hospital centers were used, where all phenotypes were derived in MICU of Hospital-I (N = 3225). The derived phenotypes were validated in MICU of Hospital-II (N = 848), SICU of Hospital-I (N = 1112), and SICU of Hospital-II (N = 465). Clinical data from 24 h preceding intubation was used to derive distinct phenotypes using an explainable machine learning-based clustering model interpreted by clinical experts. RESULTS: Four distinct ARF phenotypes were identified: A (severe multi-organ dysfunction (MOD) with a high likelihood of kidney injury and heart failure), B (severe hypoxemic respiratory failure [median P/F = 123]), C (mild hypoxia [median P/F = 240]), and D (severe MOD with a high likelihood of hepatic injury, coagulopathy, and lactic acidosis). Patients in each phenotype showed differences in clinical course and mortality rates despite similarities in demographics and admission co-morbidities. The phenotypes were reproduced in external validation utilizing the MICU of Hospital-II and SICUs from Hospital-I and -II. Kaplan-Meier analysis showed significant difference in 28-day mortality across the phenotypes (p < 0.01) and consistent across MICU and SICU of both Hospital-I and -II. The phenotypes demonstrated differences in treatment effects associated with high positive end-expiratory pressure (PEEP) strategy. CONCLUSION: The phenotypes demonstrated unique patterns of organ injury and differences in clinical outcomes, which may help inform future research and clinical trial design for tailored management strategies.

Efficacy of High Flow Nasal Cannula in the Treatment of Patients with COVID-19 with Acute Respiratory Distress Syndrome: Results of Single Centre Study in Vietnam.

INTRODUCTION: Most hospitalized patients required invasive or non-invasive ventilation and High Flow Nasal Cannula (HFNC). Therefore, this study was conducted to describe the characteristics of patients with severe Coronavirus Disease-2019 (COVID-19) treated by HFNC and its effectiveness for reducing the rate of intubated-mechanical ventilation in the Intensive Care Unit (ICU) of Phu Chanh COVID-19 Department-Binh Duong General Hospital. METHODS: It was a cross-sectional and descriptive study. All severe patients with COVID-19 with acute respiratory failure eligible for the study were included. Patient characteristics, clinical symptoms, laboratory results, and treatment methods were collected for analysis; parameters and data related to HFNC treatment and follow-up were analysed. RESULTS: 80 patients, aged of 49.7 ± 16.6 years, were treated with HFNC at admission in ICU. 14 patients had type 2 diabetes (17.5%), 3 patients had chronic respiratory disease (3.8%), 19 patients had high blood pressure (23.8%), and 5 patients with other comorbidities (7.4%). The majority of patients with severe COVID-19 had typical symptoms of COVID-19 such as shortness of breath (97.5%), intensive tired (81.3%), cough (73.7%), anosmia (48.3%), ageusia (41.3%), and fever (26.3%). The results of arterial blood gases demonstrated severe hypoxia under optimal conventional oxygen therapy (PaO2 = 52.5 ± 17.4 mmHg). Respiratory rate, SpO2, PaO2 were significantly improved after using HFNC at 1st day, 3rd day and 7th day (P < 0.05; P < 0.05; P < 0.01; respectively). Receiver operating characteristics (ROC) index was significantly increased after treating with HFNC vs before HFNC treatment (4.79 ± 1.86, 5.53 ± 2.39, and 7.41 ± 4.24 vs 2.97 ± 0.39; P < 0.05, P < 0.05 and P < 0.01, respectively). 54 (67.5%) patients were success with HFNC treatment and 26 (32.5%) patients with HFNC failure needed to treat with Continuous Positive Airway Pressure (CPAP) (13 patients; 50%) or intubated ventilation (13 patients; 50%). CONCLUSION: HFNC therapy could be considered as a useful and effective alternative treatment for patients with acute respiratory failure. HFNC might help to delay the intubated ventilation for patients with respiratory failure and to minimise the risk of invasive ventilation complications and mortality. However, it is crucial to closely monitor the evolution of patient's respiratory status and responsiveness of HFNC treatment to avoid unintended delay of intubation-mechanical ventilation. TRIAL REGISTRATION: An independent ethics committee approved the study (The Ethics Committee of Binh Duong General Hospital; No. HDDD-BVDK BINH DUONG 9.2021), which was performed in accordance with the Declaration of Helsinki, Guidelines for Good Clinical Practice.

Admission chest CT scan of intensive care patients with interstitial lung disease: Unveiling its limited predictive value through visual and automated analyses in a retrospective study (ILDICTO).

BACKGROUND: Clinical course prediction of patients with interstitial lung disease (ILD) admitted to the intensive care unit (ICU) for acute respiratory failure (ARF) can be challenging. This study aimed to characterize the prognostic value of admission chest CT-scan in this situation. METHODS: We retrospectively included ILD patients admitted to a French ICU for acute respiratory failure requiring oxygen. Patients with lymphangitis carcinomatosis and ANCA vasculitis were excluded. We analyzed every admission chest CT-scan using two different approaches: a visual analysis (grading the extent of traction bronchiectasis, ground glass and honeycomb) and an automated analysis (grading the extent of ground glass and consolidation with a dedicated software). The primary outcome was ICU mortality. RESULTS: Between January 2014 and October 2020, 81 patients presented an acute respiratory failure with ILD on the admission chest CT-scan. In univariate analysis, only the main pulmonary artery diameter differed between patients who survived and those who died in ICU (30 vs 32 mm, p = 0.021). In multivariate analysis, none of the radiological funding was associated with ICU mortality. Visual and automated analyses did not yield different results, with a strong correlation between the two methods. However, the identification of an UIP pattern (and the presence of honeycomb) was associated with a poorer response to corticosteroid therapy. CONCLUSION: Our study showed that the extent of radiological findings and the severity of fibrosis indices on admission chest CT scans of ILD patients admitted to the ICU for ARF were not associated with subsequent deterioration.

Combining high-flow nasal cannula oxygen therapy with repeated toilet bronchoscopies for respiratory failure due to excessive infected airway secretions: a case report and series from a non-intensive hospital ward.

Fiberoptic bronchoscopy (FBO) has diagnostic or therapeutic purposes but can cause respiratory deterioration, particularly in patients with pre-existing acute respiratory failure (ARF). Non-invasive ventilation (NIV) and high-flow nasal cannula oxygen therapy (HFNC) are used as respiratory support for ARF as well as to prevent significant oxygen deterioration during FBO. The combined use of NIV and early therapeutic FBO to clear retained abundant infected secretions from the airways may be an alternative to intubation and invasive mechanical ventilation (IMV), but no data exist on the combined use of FBO and HFNC. A 78-year-old male patient with ARF secondary to chronic obstructive pulmonary disease (COPD) exacerbation and pneumonia was admitted to our non-intensive geriatric ward. After an initial improvement, his respiratory conditions worsened. While continuing HFNC, he underwent a series of eight FBOs over 9 days, each performed in response to significant decreases in peripheral oxygen saturation (SpO2). The goal was to remove copious and occlusive infected secretions from the airways, with each procedure resulting in good SpO2 recovery. After etiological targeted antibiotic therapy based on bronchial aspirate, the patient improved and was discharged. Next, six consecutive similar ARF patients were treated using the same strategy of combining HFNC with repeated toilet FBO performed within the ward to clear secretions. All patients showed improvement and were discharged. The combination of HFNC and repeated toilet FBO could be a safe and effective intervention in non-intensive wards to prevent intubation and IMV in frail and elderly patients with ARF secondary to copious and occlusive infected secretions in the airways.

Hyperoxia-Induced Secondary Respiratory Failure in a Systemic Ischaemia-Reperfusion Injury.

Recent studies revealed that excessive supplemental oxygen, such as inhaled 100% O2, damages various organ functions in post-cardiac arrest (CA) patients. Optimal indicators of supplemental oxygen are therefore important to prevent hyperoxic organ injuries. In this study, we evaluated a hyperoxic pulmonary injury and assessed the association between alveolar-arterial oxygen difference (AaDO2) and a degree of lung oedema. In this study, we focused on the hyperoxia-induced lung injury and its association with changes of gas-exchange parameters in post-CA rats. Rats were resuscitated from 10 min of asphyxial CA and stratified into two groups: those with inhaled 100% O2 (CA-FiO2 1.0) and those with 30% O2 (CA-FiO2 0.3). We prepared a sham surgery group for comparison (sham-FiO2 0.3). After 2 h, animals were sacrificed, and the lung wet-to-dry (W/D) weight ratio was measured. We collected blood gas results and measured the ratio of partial pressure arterial oxygen and fraction of inspired oxygen (p/f ratio), and calculated AaDO2. The lung W/D ratio in the CA-FiO2 1.0 group (5.8 ± 0.26) was higher than in the CA-FiO2 0.3 (4.6 ± 0.42) and sham-FiO2 0.3 groups (4.6 ± 0.38, p < 0.01). There was a significant difference in AaDO2 between CA-FiO2 1.0 (215 ± 49.3) and, CA-FiO2 0.3 (36.8 ± 32.3), and sham-FiO2 0.3 groups (49.0 ± 20.5, p < 0.01). There were also significant changes in pH and blood lactate levels in the early phase among the three groups. AaDO2 showed the strongest correlation with W/D ratio (r = 0.9415, p < 0.0001), followed by pH (r = -0.5131, p = 0.0294) and p/f ratio (r = -0.3861, p = 0.1135). Hyperoxic injury might cause the pulmonary oedema after CA. Measuring respiratory quotient (RQ) in rodents enabled an accurate calculation for AaDO2 at a variety level of inhaled O2. Given that AaDO2 measurement is non-invasive, we therefore consider AaDO2 to be a potentially optimal indicator of post-CA hyperoxic pulmonary injury.

Comparison of programmed sedation care with conventional care in patients receiving mechanical ventilation for acute respiratory failure.

OBJECTIVE: The aim of this study is to evaluate the effectiveness of planned sedation therapy in comparison to standard care for patients receiving mechanical ventilation for acute respiratory failure (ARF). METHOD: The research included a total of sixty individuals who underwent mechanical ventilation for acute respiratory failure (ARF). Utilizing the random number table method, these patients were randomized at random to either the planned sedation care group (Group PSC) or the conventional care group (Group C). The objective was to assess and contrast the impact of treatment on the two groups. Significantly shorter durations of mechanical ventilation, sedative use, ICU therapy, length of stay, incidence of delirium, and adverse events were observed in Group PSC compared with Group C (P < 0.05). A higher 1-month survival rate following mechanical ventilation, a higher post-intervention forced expiratory volume in one second (FEV1) as a percentage of the expected value, a higher post-intervention forced vital capacity (FVC), and a higher patient family care satisfaction rate were observed in Group PSC compared to Group C (P < 0.05). CONCLUSION: The scheduled administration of sedative therapy in patients receiving mechanical ventilation for acute respiratory failure (ARF) offers significant, reliable, and effective therapeutic benefits.

Critically Ill Patients with Newly Diagnosed Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis: Case Series and Literature Review.

ANCA-associated vasculitides (AAVs) are rare diseases with a prevalence of less than 200 cases per million persons and an incidence of less than 25 cases per million person-years. Their presenting features can vary from prodromal and nonspecific symptoms to dramatic organ-specific symptoms such as respiratory failure due to diffuse alveolar hemorrhage (DAH) and acute kidney injury (AKI). The latter two are hallmark features of pulmonary-renal syndrome, a potentially fatal condition that necessitates early recognition and treatment in intensive care units (ICUs) and rapid induction of immunosuppressive therapy. Background and case summaries: We described three patients with newly diagnosed AAV during the treatment of critical illness. All patients had DAH and two had AKI. The initial disease severity was extremely high in patients with myeloperoxidase (MPO)-AAV, reaching Sequential Organ Failure Assessment (SOFA) scores of 15 and 14 with predicted mortality ≥ 95.2%. Both patients needed mechanical ventilation, one additional venovenous extracorporeal membrane oxygenation (VV-ECMO), and renal replacement therapy. The patient with proteinase 3 (PR3)-AAV had a less severe disease, SOFA 3, requiring only modest oxygen supplementation and exhibiting only hematuria with normal renal function parameters. Immunosuppressive therapy was initiated during the ICU stay. The patient with the most severe clinical presentation died during the ICU stay because of sepsis, and the other two patients were discharged home. Conclusions: Patients with AAV presenting with pulmonary-renal syndrome necessitate various degrees of organ support. Nevertheless, these patients can be successfully treated in the early, critical stages of the disease and achieve remission.

Efficacy of noninvasive ventilator treatment in patients with severe chronic obstructive pulmonary disease (COPD) type II respiratory failure.

OBJECTIVE: To investigate the efficacy of noninvasive ventilator usage for type II respiratory failure in patients with severe chronic obstructive pulmonary disease (COPD). METHODS: A total of 124 patients with COPD complicated with type II respiratory failure were divided into an observation group (n = 63) and a control group (n = 61) according to their intervention protocols. The patients in the observation group received noninvasive ventilator intervention, and the patients in the control group received bronchodilators, cough suppressants, oxygen therapy, anti-infection medications, nutritional support, and correction of electrolyte imbalances. Lung function indexes, arterial blood gas index, and inflammatory indicators were collected to assess the efficacy of noninvasive ventilator treatment in patients with severe COPD and type II respiratory failure. RESULTS: The levels of FEV1, FEV1/FVC and FEV1% of the two groups after treatment were significantly higher than those before treatment (P<0.05), with significantly higher levels in the observation group than the control group (all P<0.05). Post-treatment levels of PaCO2 decreased significantly while the post-treatment levels of PaO2 increased significantly (all P<0.05). Additionally, the levels of WBC, CRP and PCT of the control group was significantly higher than that of the observation group after treatment (all P<0.05). CONCLUSION: Noninvasive ventilator treatment can improve hypoxemia, improve lung function and reduce inflammatory responses in patients with COPD complicated with type II respiratory failure, suggesting its potential for wider clinical application.

Rave gone wrong: MDMA- induced medical emergency at electrical daisy carnival. A case report.

3, 4-methylenedioxyamphetamine (MDMA) has gained significance over the years, especially at rave festivals, as a recreational drug for its noted effects in mood enhancement and autonomic stimulation. While these effects have been noted, severe adverse outcomes, and even death, following the ingestion of MDMA have been recorded. We present a 35-year-old male who ingested the drug at the Electric Daisy Carnival (EDC), the largest electronic dance music festival in North America as of 2024 [1]. Every year, many young adults are brought to local hospitals from the festival for drug overdoses, hyperthermia, and dehydration. At the festival, the patient was witnessed to have a seizure, presented with altered mental status and deemed hyperthermic at 109 degrees Fahrenheit. For these reasons, he was rapidly intubated and submerged in an ice bath at the festival's medical tent. At the county hospital, the patient was diagnosed with multiorgan failure, cerebrovascular ischemia, and coagulopathy. He received life-saving treatment such as continuous renal replacement therapy as well as intubation for acute hypoxemic respiratory failure. MRI of the brain showed central- embolic infarcts and the patient was closely monitored in the intensive care unit (ICU) for eight days. After twenty days of inpatient treatment, the patient was discharged. He was discharged with his mental status at baseline and without gross neurologic deficits. A permacath was placed for hemodialysis to be continued outpatient. This case report highlights the importance of prompt medical management which can be crucial for patient survival following a life-threatening overdose with MDMA. It also exemplifies the need for increasing social awareness regarding the severe and detrimental outcomes an MDMA overdose can cause as this drug continues to be widely used in the setting of rave and music festivals.

Effect of high-flow nasal oxygen therapy combined with ipratropium bromide on Th1/Th2 balance and inflammation in patients with chronic obstructive pulmonary disease and respiratory failure.

Objective: To investigate the effect of a combination of high-flow nasal oxygen therapy (HFNO) and ipratropium bromide (IB) on Th1/Th2 balance and inflammation in patients with chronic obstructive pulmonary disease (COPD) and respiratory failure (RF). Methods: A retrospective analysis was conducted on the clinical data of patients with COPD and RF admitted to the Affiliated Nanjing Brain Hospital of Nanjing Medical University from June 2021 to March 2023. A total of 162 patients were included, with 79 patients received respiratory support using HFNO (HFNO group) and 83 patients who were treated using combined HFNO/IB (combined group). Treatment effect, lung function, levels of Th1/Th2, and inflammatory state were compared before and after the treatment. Results: Total effeicacy of patients in the combined group was significantly higher than that of the HFNO group (P<0.05). After the treatment, pulmonary function levels of the two groups was higher than that before the treatment, and was significantly better in the combined group compared to the HFNO group (P<0.05). The treatment was associated with a significant increase in the levels of Th1/Th2 in both groups. Post-treatment levels of these indexes in the combined group were markedly higher compared to the HFNO group (P<0.05). After the treatment, the inflammatory response of the two groups decreased, and was lower in the combined group that in the HFNO group (P<0.05). Conclusions: In COPD patients with RF, HFNO combined with IB is efficient in alleviating the inflammatory state of patients, restoring Th1/Th2 balance, and improving lung function compared to HFNO alone.

LDH and NLR, as inflammatory markers, the independent risk factors for COVID-19 complicated with respiratory failure in elderly patients.

Objective: Lactate dehydrogenase (LDH) is an enzyme that is responsible for the production of lactic acid, which is a necessary byproduct when the body does not have enough oxygen. LDH levels in the blood can be used as a marker to predict mortality in patients with ARDS, severe COVID-19, and cancer. To analyze the clinical characteristics of COVID-19 in the elderly and the correlation between LDH and respiratory failure in COVID-19 patients, to improve the identification and management of this type of pneumonia by clinicians. Methods: This was a single-center retrospective study. We performed routine laboratory tests in 105 COVID-19 patients admitted to the affiliated hospital of Qingdao University (Qingdao, China) from October 1, 2022 to February 1, 2023. The diagnosis of respiratory failure was established based on the results of blood gas analysis upon admission. Results: The median age was 79 years. Among all univariable parameters, LDH, neutrophil to lymphocyte ratio (NLR) and Prothrombin Time (PT) were significantly independent risk factors of RF in elderly COVID-19 patients. LDH (AUC=0.829) also had a maximum specificity (96.5%), with the cutoff value of 280.5. Conclusion: The levels of LDH, NLR, and PT may serve as potential indicators for elderly COVID-19 patients combined with respiratory failure. LDH, NLR and PT assays can be beneficial for patients who need closer respiratory monitoring and more aggressive supportive care to prevent a negative prognosis.