Place of high-flow nasal oxygen in nonoperating room anesthesia.

PURPOSE OF REVIEW: This article aims to assess the utility of high-flow nasal oxygen (HFNO) therapy in nonoperating room anesthesia (NORA) settings. RECENT FINDINGS: The number of procedural interventions under deep sedation in NORA is still increasing. Administration of oxygen is recommended to prevent hypoxemia and is usually delivered with standard oxygen through nasal cannula or a face mask. HFNO is a simple alternative with a high warmed humidified flow (ranging from 30 to 70 l/min) with a precise fraction inspired of oxygen (ranging from 21 to 100%). Compared to standard oxygen, HFNO has demonstrated efficacy in reducing the incidence of hypoxemia and the need for airway maneuvers. Research on HFNO has primarily focused on its application in gastrointestinal endoscopy procedures. Yet, it has also shown promising results in various other procedural interventions including bronchoscopy, cardiology, and endovascular procedures. However, the adoption of HFNO prompted considerations regarding cost-effectiveness and environmental impact. SUMMARY: HFNO emerges as a compelling alternative to conventional oxygen delivery methods for preventing hypoxemia during procedural interventions in NORA. However, its utilization should be reserved for patients at moderate-to-high risk to mitigate the impact of cost and environmental factors.

Accuracy of Pulse Oximetry for Long-Term Oxygen Therapy Assessment in Chronic Obstructive Pulmonary Disease.

Rationale: Landmark studies of long-term oxygen therapy (LTOT) in patients with chronic obstructive pulmonary disease (COPD) used arterial oxygen pressure (PaO2) to define severe hypoxemia; however, oxygen saturation as measured by pulse oximetry (SpO2) is commonly used instead. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend evaluation with arterial blood gas (ABG) analysis if SpO2 is ⩽92%. This recommendation has not been evaluated in stable outpatients with COPD undergoing testing for LTOT. Objectives: To evaluate the performance of SpO2 compared with ABG analysis of PaO2 and arterial oxygen saturation (SaO2) to detect severe resting hypoxemia in patients with COPD. Methods: Retrospective analysis of paired SpO2 and ABG values from stable outpatients with COPD who underwent LTOT assessment in a single center. We calculated false negatives (FNs) as an SpO2 >88% or >89% in the presence of pulmonary hypertension with a PaO2 ⩽55 mm Hg or ⩽59 mm Hg in the presence of pulmonary hypertension. Test performance was assessed using receiver operating characteristic (ROC) analysis, intraclass correlation coefficient (ICC), test bias, precision, and accuracy root-mean-square (Arms). An adjusted multivariate analysis was used to evaluate factors affecting SpO2 bias. Results: Of 518 patients, the prevalence of severe resting hypoxemia was 74 (14.3%), with 52 missed by SpO2 (FN, 10%), including 13 (2.5%) with an SpO2 > 92% (occult hypoxemia). FNs and occult hypoxemia in Black patients were 9% and 1.5%, respectively, and were 13% and 5%, respectively, among active smokers. The correlation between SpO2 and SaO2 was acceptable (ICC = 0.78; 95% confidence interval, 0.74-0.81); and the bias of SpO2 was 0.45%, with a precision of 2.6 (-4.65 to +5.55%) and Arms of 2.59. These measurements were similar in Black patients, but in active smokers, correlation was lower and bias showed greater overestimation of SpO2. ROC analysis suggests that the optimal SpO2 cutoff to warrant LTOT evaluation by ABG analysis is ⩽94%. Conclusions: SpO2 as the only measure of oxygenation carries a high FN rate in detecting severe resting hypoxemia in patients with COPD undergoing evaluation for LTOT. Reflex measurement of PaO2 by ABG analysis should be used as recommended by GOLD, ideally at a cutoff higher than an SpO2 ⩽92%, especially in active smokers.

Sleep Assessment in Critically Ill Patients With Acute Hypoxemic Respiratory Failure.

BACKGROUND: Sleep deprivation alters respiratory muscle performance and may precipitate respiratory failure. This study aimed to assess sleep in subjects admitted to ICU for acute hypoxemic respiratory failure and its role in the risk of intubation. METHODS: This was a prospective observational single-center cohort study including subjects admitted to ICU for de novo acute hypoxemic respiratory failure defined as breathing frequency ≥ 25 breaths/min or clinical signs of respiratory distress and PaO2 /FIO2 < 300 mm Hg while receiving high-flow nasal oxygen. Subjects with altered consciousness, central nervous or psychiatric disorders, continuous sedation or neuroleptic medication, or were uncooperative were excluded. Sleep was assessed by complete polysomnography (PSG) the night following ICU admission. The main outcome was to assess sleep among subjects with acute hypoxemic respiratory failure and to compare sleep between subjects who eventually required intubation to those who did not. RESULTS: Over a 24-month inclusion period, 34 subjects had complete PSG, among whom 5 (15%) required intubation in the ICU. Total sleep time was 4.2 h in median (interquartile range 2.9-6.8); deep-sleep duration was 70 min (34-127), and rapid eye movement (REM) sleep duration was 9 min (0-28). Among them, 13 subjects (38%) had no REM sleep. Total sleep time and duration of deep and REM sleep stages did not differ between subjects who required intubation and those successfully treated with high-flow nasal oxygen. CONCLUSIONS: Whereas total sleep time remained relatively preserved in critically ill subjects with acute hypoxemic respiratory failure, REM sleep time was uncommon or completely absent in a large number of subjects. Sleep did not differ between subjects who required intubation and those who did not. However, given a trend toward an increased risk of intubation in subjects with a complete absence of REM sleep, further studies are needed to better explore the impact of REM sleep on the risk of intubation.

Comparison of effectiveness, cost and safety between moderate sedation and deep sedation under esophagogastroduodenoscopy in Chinese population: a quasi-experimental study.

OBJECTIVE: Most endoscopists routinely perform moderate or deep sedation for esophagogastroduodenoscopy (EGD). Considering that there is no consensus on the optimal sedation depth and it varies from country to country, our study aims to compare the effectiveness, cost and safety of these two sedation methods in the Chinese population. METHODS: This quasi-experimental study included a total of 556 eligible patients from July 2020 to June 2021, and they entered the moderate sedation group or deep sedation group based on their choices. Baseline information, scores of Patient Satisfaction with Sedation Instrument (PSSI) and Clinician Satisfaction with Sedation Instrument (CSSI), examination time, sedation time, recovery time, expenses before medicare reimbursement, hypoxaemia and hypotension were compared between the two groups. Propensity Score Matching (PSM) analysis was conducted to balance the confounding factors. RESULTS: After PSM, 470 patients were involved in the analysis, with 235 for each group. The moderate sedation was clearly superior to the deep sedation group in terms of PSSI score (98.00 ± 0.94 vs. 97.29 ± 1.26), CSSI score (98.00 ± 0.78 vs. 97.67 ± 1.30), sedation time (11.90 ± 2.04 min vs. 13.21 ± 2.75 min), recovery time (25.40 ± 3.77 min vs. 28.0 ± 4.85 min), expenses (433.04 ± 0.00 Yuan vs. 789.85 ± 0.21 Yuan), with all p < .001. Examination time was not significantly different between the two groups (p = .124). In addition, the moderate sedation group had a lower occurrence rate of hypoxaemia (0.36% vs. 3.27%, p = .010) and hypotension (17.44% vs. 44.00%, p < .001) compared to the deep sedation group. CONCLUSIONS: Moderate sedation presented better effectiveness and safety and lower cost, and thereby it should be recommended as a widely used sedation method in clinical practice in China. Trial registration: This trial was registered on http://www.chictr.org.cn/index.aspx (ChiCTR2000038050).

Assessment of Awake Prone Positioning in Hospitalized Adults With COVID-19: A Nonrandomized Controlled Trial.

Importance: Awake prone positioning may improve hypoxemia among patients with COVID-19, but whether it is associated with improved clinical outcomes remains unknown. Objective: To determine whether the recommendation of awake prone positioning is associated with improved outcomes among patients with COVID-19-related hypoxemia who have not received mechanical ventilation. Design, Setting, and Participants: This pragmatic nonrandomized controlled trial was conducted at 2 academic medical centers (Vanderbilt University Medical Center and NorthShore University HealthSystem) during the COVID-19 pandemic. A total of 501 adult patients with COVID-19-associated hypoxemia who had not received mechanical ventilation were enrolled from May 13 to December 11, 2020. Interventions: Patients were assigned 1:1 to receive either the practitioner-recommended awake prone positioning intervention (intervention group) or usual care (usual care group). Main Outcomes and Measures: Primary outcome analyses were performed using a bayesian proportional odds model with covariate adjustment for clinical severity ranking based on the World Health Organization ordinal outcome scale, which was modified to highlight the worst level of hypoxemia on study day 5. Results: A total of 501 patients (mean [SD] age, 61.0 [15.3] years; 284 [56.7%] were male; and most [417 (83.2%)] were self-reported non-Hispanic or non-Latinx) were included. Baseline severity was comparable between the intervention vs usual care groups, with 170 patients (65.9%) vs 162 patients (66.7%) receiving oxygen via standard low-flow nasal cannula, 71 patients (27.5%) vs 62 patients (25.5%) receiving oxygen via high-flow nasal cannula, and 16 patients (6.2%) vs 19 patients (7.8%) receiving noninvasive positive-pressure ventilation. Nursing observations estimated that patients in the intervention group spent a median of 4.2 hours (IQR, 1.8-6.7 hours) in the prone position per day compared with 0 hours (IQR, 0-0.7 hours) per day in the usual care group. On study day 5, the bayesian posterior probability of the intervention group having worse outcomes than the usual care group on the modified World Health Organization ordinal outcome scale was 0.998 (posterior median adjusted odds ratio [aOR], 1.63; 95% credibility interval [CrI], 1.16-2.31). However, on study days 14 and 28, the posterior probabilities of harm were 0.874 (aOR, 1.29; 95% CrI, 0.84-1.99) and 0.673 (aOR, 1.12; 95% CrI, 0.67-1.86), respectively. Exploratory outcomes (progression to mechanical ventilation, length of stay, and 28-day mortality) did not differ between groups. Conclusions and Relevance: In this nonrandomized controlled trial, prone positioning offered no observed clinical benefit among patients with COVID-19-associated hypoxemia who had not received mechanical ventilation. Moreover, there was substantial evidence of worsened clinical outcomes at study day 5 among patients recommended to receive the awake prone positioning intervention, suggesting potential harm. Trial Registration: ClinicalTrials.gov Identifier: NCT04359797.

Videographic Assessment of Tracheal Intubation Technique in a Network of Pediatric Emergency Departments: A Report by the Videography in Pediatric Resuscitation (VIPER) Collaborative.

STUDY OBJECTIVE: We sought to describe the tracheal intubation technique across a network of children's hospitals and explore the association between intubation technical adjuncts and first-attempt success as well as between laryngoscopy duration and the incidence of hypoxemia. METHODS: We conducted a prospective observational study in 4 tertiary pediatric emergency departments of the Videography in Pediatric Resuscitation Collaborative. Children undergoing tracheal intubation captured on video were eligible for inclusion. Data on intubator background, patient characteristics, technical characteristics (eg, use of videolaryngoscopy and apneic oxygenation), and procedural outcomes were obtained through a video review. RESULTS: We obtained complete data on first attempts in 494 patients. The first-attempt success rate was 67%, the median laryngoscopy duration was 35 seconds (interquartile range 25 to 40), and hypoxemia occurred in 15% of the patients. Videolaryngoscopy was used for at least a part of the procedure in 48% of the attempts, and it had no association with success or the incidence of hypoxemia. Attempts in which videolaryngoscopy was used for the entire procedure (compared with direct laryngoscopy for the entire procedure) had a longer duration (the difference between the medians was 6 seconds; 95% confidence interval, 1 to 12 seconds). Intubation attempts longer than 45 seconds had a greater incidence of hypoxemia (29% versus 6%). Furthermore, apneic oxygenation was used in 8% of the first attempts. CONCLUSION: Among children undergoing tracheal intubation in a group of pediatric emergency departments, first-attempt success occurred in 67% of the patients. Videolaryngoscopy use was associated with longer laryngoscopy durations but was not associated with success or the incidence of hypoxemia.

Pulse Oximeter Performance, Racial Inequity, and the Work Ahead.

It has long been known that many pulse oximeters function less accurately in patients with darker skin. Reasons for this observation are incompletely characterized and potentially enabled by limitations in existing regulatory oversight. Based on decades of experience and unpublished data, we believe it is feasible to fully characterize, in the public domain, the factors that contribute to missing clinically important hypoxemia in patients with darkly pigmented skin. Here we propose 5 priority areas of inquiry for the research community and actionable changes to current regulations that will help improve oximeter accuracy. We propose that leading regulatory agencies should immediately modify standards for measuring accuracy and precision of oximeter performance, analyzing and reporting performance outliers, diversifying study subject pools, thoughtfully defining skin pigmentation, reporting data transparently, and accounting for performance during low-perfusion states. These changes will help reduce bias in pulse oximeter performance and improve access to safe oximeters.

Optimal NIV Medicare Access Promotion: Patients With Central Sleep Apnea: A Technical Expert Panel Report From the American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society.

This document summarizes suggestions of the central sleep apnea (CSA) Technical Expert Panel working group. This paper shares our vision for bringing the right device to the right patient at the right time. For patients with CSA, current coverage criteria do not align with guideline treatment recommendations. For example, CPAP and oxygen therapy are recommended but not covered for CSA. On the other hand, bilevel positive airway pressure (BPAP) without a backup rate may be a covered therapy for OSA, but it may worsen CSA. Narrow coverage criteria that require near elimination of obstructive breathing events on CPAP or BPAP in the spontaneous mode, even if at poorly tolerated pressure levels, may preclude therapy with BPAP with backup rate or adaptive servoventilation, even when those devices provide demonstrably better therapy. CSA is a dynamic disorder that may require different treatments over time, sometimes switching from one device to another; an example is switching from BPAP with backup rate to an adaptive servoventilation with automatic end-expiratory pressure adjustments, which may not be covered. To address these challenges, we suggest several changes to the coverage determinations, including: (1) a single simplified initial and continuing coverage definition of CSA that aligns with OSA; (2) removal of hypoventilation terminology from coverage criteria for CSA; (3) all effective therapies for CSA should be covered, including oxygen and all PAP devices with or without backup rates or servo-mechanisms; and (4) patients shown to have a suboptimal response to one PAP device should be allowed to add oxygen or change to another PAP device with different capabilities if shown to be effective with testing.

Optimal NIV Medicare Access Promotion: Patients With OSA: A Technical Expert Panel Report From the American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society.

This document summarizes the work of the CPAP and bilevel PAP therapy for OSA Technical Expert Panel working group. For positive airway pressure (PAP) therapy, the most pressing current coverage barriers identified were: an insufficient symptom list describing all potential symptoms in patients with mild OSA; the 4 h per night of PAP usage requirement to keep the device; the additional sleep studies requirement to re-qualify for PAP or supplemental oxygen; and the inability to use telehealth visits for follow-up visits. Critical evidence supports changes to current policies and includes: symptom list inadequate to cover all scenarios based on updated clinical practice guidelines; published evidence that 2 h per night of PAP use can result in benefit to quality of life and other metrics; the costs of another sleep study not justified for all nonadherent patients or for supplemental oxygen due to other types of assessment currently available; and the remarkable success and acceptance of telehealth visits. To achieve optimal access for patients on PAP therapy, we make the following key suggestions: removing symptom criteria for mild OSA; reduce continued coverage criteria to > 2 h per night; eliminate the need for a sleep study to re-qualify if nonadherent or for new Centers for Medicare & Medicaid Services beneficiaries already on and adherent to PAP therapy; allow telehealth visits for documenting benefit and adherence; and allow PAP reports and domiciliary oximetry to qualify for supplemental oxygen with PAP if needed. This paper shares our best vision for bringing the right device to the right patient at the right time.

Uso de concentradores de oxígeno de uso hospitalario en el contexto de COVID-19 / Use of hospital use oxygen concentrators in the context of COVID-19

INTRODUCIÓN La hipoxemia, (una disminución anormal de la presión parcial de oxígeno en la sangre arterial por debajo de 60 mmHg), es una condición presente en diversas condiciones clínicas, incluyendo COVID-19. Para el tratamiento de la hipoxemia, se requiere la administración de oxígeno medicinal (también denominado oxígeno suplementario), gas que forma parte de la lista modelo de medicamentos esenciales de la Organización Mundial de la Salud (OMS). El oxígeno medicinal no solo tiene el objetivo de revertir la hipoxia tisular (daño fisiológico causado por falta de oxígeno en un determinado tejido) sino que también aumenta las probabilidades de sobrevida en pacientes afectados con esta condición. Por ello, la OMS señala que es necesario que en los establecimientos de salud se cuente con un suministro seguro de oxígeno, siendo necesario que figure en los presupuestos de asistencia sanitaria y exista en los establecimientos de salud (OMS 2016). En Perú, el oxígeno medicinal está considerado en el grupo de medicamentos denominados gases medicinales. La Dirección General de Medicamentos Insumos y Drogas (DIGEMID), señala que el oxígeno medicinal debe tener una concentración de entre 99 a 100 % de O2 (MINSA 2018). Sin embargo, en el contexto de la pandemia de COVID-19, se ha autorizado el uso del oxígeno medicinal de concentración no menor al 93 % (Presidente de la República 2020). Cabe precisar que la definición de oxígeno medicinal al 93 % contempla al oxígeno extraído del aire mediante un proceso de tamizado molecular (U.S. Pharmacopeia 2018). TECNOLOGÍA DE INTERÉS: La OMS señala que los concentradores de oxígeno representan una opción adecuada y favorable para suministrar oxígeno para el tratamiento de pacientes en países en desarrollo, especialmente cuando los cilindros y otros sistemas convencionales son inapropiados o no estén disponibles. También señala que los concentradores de oxígeno pueden ser considerados como una fuente de este gas medicinal aun disponiéndose de suministro de oxígeno por los métodos convencionales cuando el acceso a este gas pueda verse reducido por la falta de accesorios, suministro eléctrico y la escasez de personal calificado (OMS 2016). METODOLOGÍA: Se realizó una búsqueda sistemática de la literatura hasta el día 9 de julio de 2020 con respecto al uso de concentradores de oxígeno en el contexto de COVID-19. Para ello se emplearon las bases de datos bibliográficas: PubMed, Medline vía OVID y LILACS. Asimismo, se realizó una búsqueda manual avanzada en el motor de búsqueda Google, y en páginas web de sociedades o instituciones tales como: Organización Mundial de la Salud. RESULTADOS: Como resultado de la búsqueda, no se encontraron guías de práctica clínica, evaluaciones de tecnologías sanitarias, revisiones sistemáticas o estudios primarios que evalúen el uso de concentradores de oxígeno en el contexto de COVID-19. Tampoco se han publicado series que describan la experiencia de uso de este dispositivo médico en el contexto de la pandemia por COVID-19. A la fecha, se han publicado documentos técnicos de la OMS respecto al empleo de tecnologías sanitarias para suplir la necesidad de oxígeno en el tratamiento de pacientes con COVID-19 y una guía de la National Health Service del Reino Unido donde se describe al concentrador de oxígeno entre las alternativas de suministro de oxígeno para uso en pacientes con COVID-19 que requieren oxigenoterapia. CONCLUSIONES: En el contexto de la emergencia sanitaria nacional debido a la pandemia de COVID-19, la alta demanda de administración de oxígeno suplementario para la atención de un grupo rápidamente creciente de pacientes, impone la necesidad de explorar el uso de alternativas tecnológicas sanitarias que puedan servir como suministro de este gas en aras de resguardar la salud pública y la vida de la población. Así, se ha realizado el presente reporte breve el cual informa acerca del uso hospitalario de los concentradores de oxígeno, sus características tecnológicas y sus usos para oxigenoterapia, a la luz de la literatura técnica disponible al 9 de julio de 2020. De acuerdo con los documentos técnicos incluidos en el presente reporte breve, es razonable proponer que los concentradores de oxígeno constituyen una alternativa viable en entornos de escasos recursos o disponibilidad limitada de otras fuentes de oxígeno más avanzadas. Siendo que tienen una capacidad limitada de proveer flujos y concentraciones de oxígeno, la utilidad de este equipo médico estaría orientada principalmente para la oxigenoterapia de bajo flujo, la misma que debe ser prescrita por el equipo médico tratante de acuerdo con las necesidades del paciente.

Thresholds for oximetry alarms and target range in the NICU: an observational assessment based on likely oxygen tension and maturity.

BACKGROUND: Continuous monitoring of SpO2 in the neonatal ICU is the standard of care. Changes in SpO2 exposure have been shown to markedly impact outcome, but limiting extreme episodes is an arduous task. Much more complicated than setting alarm policy, it is fraught with balancing alarm fatigue and compliance. Information on optimum strategies is limited. METHODS: This is a retrospective observational study intended to describe the relative chance of normoxemia, and risks of hypoxemia and hyperoxemia at relevant SpO2 levels in the neonatal ICU. The data, paired SpO2-PaO2 and post-menstrual age, are from a single tertiary care unit. They reflect all infants receiving supplemental oxygen and mechanical ventilation during a 3-year period. The primary measures were the chance of normoxemia (PaO2 50-80 mmHg), risks of severe hypoxemia (PaO2 ≤ 40 mmHg), and of severe hyperoxemia (PaO2 ≥ 100 mmHg) at relevant SpO2 levels. RESULTS: Neonates were categorized by postmenstrual age: < 33 (n = 155), 33-36 (n = 192) and > 36 (n = 1031) weeks. From these infants, 26,162 SpO2-PaO2 pairs were evaluated. The post-menstrual weeks (median and IQR) of the three groups were: 26 (24-28) n = 2603; 34 (33-35) n = 2501; and 38 (37-39) n = 21,058. The chance of normoxemia (65, 95%-CI 64-67%) was similar across the SpO2 range of 88-95%, and independent of PMA. The increasing risk of severe hypoxemia became marked at a SpO2 of 85% (25, 95%-CI 21-29%), and was independent of PMA. The risk of severe hyperoxemia was dependent on PMA. For infants < 33 weeks it was marked at 98% SpO2 (25, 95%-CI 18-33%), for infants 33-36 weeks at 97% SpO2 (24, 95%-CI 14-25%) and for those > 36 weeks at 96% SpO2 (20, 95%-CI 17-22%). CONCLUSIONS: The risk of hyperoxemia and hypoxemia increases exponentially as SpO2 moves towards extremes. Postmenstrual age influences the threshold at which the risk of hyperoxemia became pronounced, but not the thresholds of hypoxemia or normoxemia. The thresholds at which a marked change in the risk of hyperoxemia and hypoxemia occur can be used to guide the setting of alarm thresholds. Optimal management of neonatal oxygen saturation must take into account concerns of alarm fatigue, staffing levels, and FiO2 titration practices.

A Retrospective Observational Study of Domiciliary Oxygen Usage in a Subset of Veterans.

BACKGROUND: Long-term oxygen therapy (LTOT) delivered continuously is known to decrease mortality in patients with COPD and who are hypoxemic; however, supportive data for LTOT use in patients without COPD is lacking. In addition, many patients may be prescribed LTOT without a definitive etiology for hypoxemia. First, we investigated the diagnoses for which oxygen was prescribed to a sample of veterans and whether each diagnosis was supported by confirmatory testing. Second, we looked at the proportion of subjects who were prescribed non-continuous therapy. METHODS: We retrospectively studied subjects prescribed domiciliary oxygen at the Veterans Administration Western New York Healthcare System. The subjects who met inclusion criteria were identified by using a computerized patient record system; data were collected on subject characteristics, oxygen prescription information, diagnosis for hypoxia, and diagnostic workup. Descriptive data were presented as mean ± SD and median (range). Statistical analysis was performed by using the chi-square test and an unpaired t test. RESULTS: A total of 494 subjects were included: 96.8% men, mean ± SD ages 74.2 ± 10.8 y. Most of the subjects were prescribed oxygen as out-patients (68.5%). A total of 335 (67.8%) were prescribed oxygen for continuous therapy, 72 (14.1%) for nocturnal therapy, 50 (10.1%) for exertion, and 30 (6.1%) for both exertion and nocturnal use. At 3 months, 19.6% of the initial cohort had oxygen discontinued. In those subjects with oxygen continued at 3 months, COPD was the most common diagnosis (63.6%), of which 76.1% had pulmonary function tests (PFTs), with 85.7% showing obstruction on spirometry. CONCLUSIONS: Results of our study showed a 99.4% adherence to Medicare criteria for domiciliary oxygen prescription. Also, 30.3% of the subjects were prescribed LTOT for exertional or nocturnal desaturation or both. Repeated testing at 3 months identified subjects who no longer required oxygen. COPD was the most common etiology for domiciliary oxygen. A small proportion of the subjects (6.9%) were prescribed oxygen without underlying etiology for hypoxia. Exertional and/or nocturnal oxygen prescription was common, and further research to elucidate its utility is clearly warranted.

Oxigenação por membrana extracorpórea (ECMO) para tratamento de pacientes com COVID-19 / Extracorporeal membrane oxygenation (ECMO) for treatment of patients with COVID-19

ANÁLISE: O coronavírus da Síndrome Respiratória Aguda Grave 2 (abreviado para SARS-CoV-2, do inglês Severe Acute Respiratory Syndrome Coronavirus 2), anteriormente conhecida como novo coronavírus (2019-nCoV), é um agente zoonótico recém-emergente que surgiu em dezembro de 2019, em Wuhan, China, causando manifestações respiratórias, digestivas e sistêmicas, que se articulam no quadro clínico da doença denominada de COVID-19 (do inglês Coronavirus Disease 2019. Ainda não há informações robustas sobre a história natural da doença, nem medidas de efetividade para manejo clínico dos casos de infecção pelo COVID-19, restando ainda muitos detalhes a serem esclarecidos. No entanto, sabe-se que o vírus tem alta transmissibilidade e provoca uma síndrome respiratória aguda que varia de casos leves (cerca de 80%) a casos muito graves com insuficiência respiratória (5% e 10% dos casos), que podem requerer tratamento especializado em unidades de terapia intensiva (UTI). Sua letalidade varia, principalmente conforme a faixa etária. A TECNOLOGIA: O suporte de vida extracorpóreo ou oxigenação por membrana extracorpórea (ECMO) é uma modalidade terapêutica que possibilita suporte temporário à falência pulmonar e/ou cardíaca refratária ao tratamento clínico convencional. Fazem parte essencial de um circuito de ECMO duas cânulas de drenagem e retorno do sangue (inflow/outflow), uma bomba de propulsão de sangue, um oxigenador, sensores de fluxo e pressão, sistema de controle de temperatura para resfriamento ou aquecimento do sangue e pontos de acesso arterial e venoso para coleta de sangue no circuito. A função da bomba de propulsão é impulsionar o sangue do paciente para a membrana oxigenadora, gerando fluxo para o sistema. O oxigenador é um dispositivo de troca de gases que usa uma membrana semipermeável (membrana de oxigenação) para separar compartimento sanguíneo e um gasoso. O sangue desoxigenado é drenado pela força da bomba externa, atravessa o oxigenador (onde se processa a troca de dióxido de carbono por oxigênio) e é devolvido ao paciente. ANÁLISE DA EVIDÊNCIA: O objetivo deste relatório é analisar as evidências científicas sobre eficácia e segurança da oxigenação por membrana extracorpórea (ECMO) para tratamento de pacientes graves com COVID-19. Com o objetivo de nortear a busca da literatura, foi formulada a pergunta estruturada, de acordo com o acrônimo PICO (População, Intervenção, Comparador e Outcomes [desfechos]. CONSIDERAÇÕES ÉTICAS Usar critérios de consenso predeterminados para o racionamento da ECMO, se indicado; reavaliar todos os aspectos do plano de tratamento de um paciente regularmente, incluindo a necessidade de continuar ou encerrar a ECMO; invocar justiça distributiva somente em circunstâncias em que o racionamento exclua a capacidade de cuidar de cada indivíduo de maneira ideal; buscar opiniões de comitês de ética hospitalar e médico-legais em cenários eticamente desafiadores. GARANTIA DE QUALIDADE E PESQUISA COLABORATIVA: Manter estruturas de garantia de qualidade e governança clínica com análises frequentes da qualidade da ECMO; garantir a coleta e o compartilhamento de dados para informar a preparação e o atendimento ao paciente; objetivar a aprovação da ética em vigor ou desenvolver mecanismos para processos de revisão e aprovação da ética. CONCLUSÕES Ao todo, foram analisados 11 estudos que incluíram pacientes com COVID-19 em uso de ECMO. Uma taxa maior de mortalidade foi atribuída à ECMO, no entanto, análises agrupadas não mostraram diferença estatisticamente significativa na mortalidade entre pacientes tratados com ECMO e com terapia padrão. Não há evidências claras do benefício do uso do ECMO em pacientes com COVID-19 até o momento. As diretrizes provisórias da OMS recomendam oferecer oxigenação por membrana extracorpórea (ECMO) a pacientes elegíveis com síndrome do desconforto respiratório agudo relacionada à COVID-19. A utilização do equipamento é recomendada pela OMS em casos de hipoxemia refratária e apenas em centros especializados que conte uma equipe capacitada para a utilização do equipamento (24,25). A Organização Extracorpórea de Suporte à Vida (ELSO - The Extracorporeal Life Support Organization) orienta que uso de ECMO em pacientes com COVID19 irá depender do caso e deve ser reavaliada regularmente com base na carga geral do paciente, na capacitação da equipe e na disponibilidade de outros recursos. A AARC também recomenda o uso de ECMO apenas em pacientes adultos com COVID19 e SRAG grave, cuidadosamente selecionados, ventilados mecanicamente e com hipoxemia refratária. A complexidade da ECMO exige uma equipe de UTI bem qualificada para prestar atendimento a pacientes graves, sendo limitado seu uso a centros especializados. As evidências disponíveis de populações semelhantes de pacientes sugerem que pacientes cuidadosamente selecionados com SRAG grave que não se beneficiam do tratamento convencional podem obter bons resultados com a ECMO venovenosa.

introduce nationwide pulse oximetry screening for the detection of critical congenital heart disease and other hypoxaemic conditions in the newborn.

The mortality risk for infants with critical congenital heart disease (CCHD) unrecognised at the time of birth is high. Pulse oximetry has been utilised as a screening tool for the detection of these anomalies in the newborn as the majority will have a degree of hypoxaemia. This screening strategy has a moderate sensitivity and excellent specificity for the detection of CCHD, and a low false-positive rate. Respiratory and infective diseases are responsible for a large number of positive test results. The early recognition of these diseases can also improve health outcomes. Different approaches have been taken to introduce screening, ranging from hospital-led initiatives to mandatory state-wide policies. A study conducted in New Zealand demonstrated that sector-led screening initiatives are unlikely to result in equitable outcomes. In this midwifery-led maternity setting a nationwide pulse oximetry screening programme with adequate human and material resources should be introduced.

Case Report of an Autopsy of a Child Who Died in a Drum-Type Washing Machine Tub: Pathophysiology Resulting in Death and Assessment of Previous Literature.

The patient was a 5-year-old boy who was found in a state of cardiorespiratory arrest in the tub of a washing machine without water with the door closed. The autopsy findings included severe facial congestion and petechiae of the facial skin and palpebral conjunctiva. Several organs exhibited congestion. Hemorrhagic spots were seen on the serous membranes of various organs, with particularly marked hemorrhagic spots seen on the lungs. The heart contained fluid blood without soft clots. There were no findings indicative of marked trauma, intoxication, or hyperthermia. The examination results suggested that asphyxia had occurred in this case. However, there were no findings indicative of cervical compression, oronasal obstruction, or the presence of a foreign body in the respiratory tract. Image analysis showed the child could make postural changes inside the washing machine tub. Consequently, impaired thoracic movement and postural asphyxia were considered unlikely to have occurred. The results of blood gas analysis showed no evidence of marked hypercapnia. We, therefore, concluded that the cause of the child's death was asphyxia due to hypoxia caused by being in a closed space, that is, a washing machine tub.

Bedside clinical assessment predicts recurrence after hospitalization due to viral lower respiratory tract infection in young children.

Infants requiring hospitalization due to a viral lower respiratory tract infection (LRTI) have a high risk of developing recurrent respiratory illnesses in early life and asthma beyond childhood. Notably, all validated clinical scales for viral LRTI have focused on predicting acute severity instead of recurrence. We present a novel clinical approach combining individual risk factors with bedside clinical parameters to predict recurrence after viral LRTI hospitalization in young children. A retrospective longitudinal cohort of young children (≤3 years) designed to define clinical predictive factors of recurrent respiratory illnesses within 12 months after hospitalization due to PCR-confirmed viral LRTI. Data collection was through electronic medical record. We included 138 children hospitalized with viral LRTI. Using automatic stepwise logistic model selection, we found that the strongest predictors of recurrence in infants hospitalized for the first time were severe prematurity (≤32 weeks' gestational age, OR=5.19; 95% CI 1.76 to 15.32; p=0.002) and a clinical score that weighted hypoxemia, subcostal retractions and wheezing (OR=3.33; 95% CI 1.59 to 6.98; p<0.001). After the first hospitalization, the strongest predictors of subsequent episodes were wheezing (OR=5.62; 95% CI 1.03 to 30.62; p=0.04) and family history of asthma (OR=5.39; 95% CI 1.04 to 27.96; p=0.04). We found that integrating individual risk factors (eg, prematurity or family history of asthma) with bedside clinical assessment (eg, wheezing, subcostal retractions or hypoxemia) can predict the risk of recurrence after viral LRTI hospitalization in infants. This strategy may enable clinically oriented subsetting of infants with viral LRTI based on individual predictors for recurrent respiratory illnesses during early life.