Impact of High-Flow Nasal Cannula Oxygenation on the Prevention of Hypoxia During Endoscopic Retrograde Cholangiopancreatography in Elderly Patients: A Randomized Clinical Trial.

BACKGROUND: Hypoxia is the most frequently occurring adverse effect during endoscopic retrograde cholangiopancreatography (ERCP) under sedation; thus, oxygen must be properly supplied to prevent a reduction of oxygen saturation. In this study, we intend to verify the preventive effect for hypoxia during ERCP, using a high-flow nasal cannula (HFNC), in elderly patients. METHODS: As a multicenter prospective randomized trial, patients who underwent ERCP with propofol-based sedation were randomly assigned into two groups: Patients in the HFNC group were supplied with oxygen via an HFNC, and those in the standard nasal cannula group were supplied with oxygen via a low-flow nasal cannula. The co-primary end points were the lowest oxygen saturation rate and hypoxia during the overall procedure. RESULTS: A total of 187 patients (HFNC group: 95; standard nasal cannula group: 92) were included in the analysis. Unexpected hypoxia events were more frequently observed among patients in the standard nasal cannula group than among patients in the HFNC group (13% vs. 4%, odds ratio 3.41, 95% confidence interval 1.06-11.00, p = 0.031). The mean of the lowest oxygen saturation rate during ERCP was significantly lower in the standard nasal cannula group than in the HFNC group (95% vs. 97%, p = 0.002). CONCLUSION: Oxygen supplementation with an HFNC can prevent oxygen desaturation and hypoxia events in patients undergoing ERCP under sedation. Trial registration Clinical Research Information Service (CRIS; KCT0004960).

Neutrophil-to-Lymphocyte Ratio at Emergency Room Predicts Mechanical Complications of ST-segment Elevation Myocardial Infarction.

BACKGROUND: The neutrophil-to-lymphocyte ratio (NLR) has been proven to be a reliable inflammatory marker. A recent study reported that elevated NLR is associated with adverse cardiovascular events in patients with ST-segment elevation myocardial infarction (STEMI). We investigated whether NLR at emergency room (ER) is associated with mechanical complications of STEMI undergoing primary percutaneous coronary intervention (PCI). METHODS: A total of 744 patients with STEMI who underwent successful primary PCI from 2009 to 2018 were enrolled in this study. Total and differential leukocyte counts were measured at ER. The NLR was calculated as the ratio of neutrophil count to lymphocyte count. Patients were divided into tertiles according to NLR. Mechanical complications of STEMI were defined by STEMI combined with sudden cardiac arrest, stent thrombosis, pericardial effusion, post myocardial infarction (MI) pericarditis, and post MI ventricular septal rupture, free-wall rupture, left ventricular thrombus, and acute mitral regurgitation during hospitalization. RESULTS: Patients in the high NLR group (> 4.90) had higher risk of mechanical complications of STEMI (P = 0.001) compared with those in the low and intermediate groups (13% vs. 13% vs. 23%). On multivariable analysis, NLR remained an independent predictor for mechanical complications of STEMI (RR = 1.947, 95% CI = 1.136-3.339, P = 0.015) along with symptom-to balloon time (P = 0.002) and left ventricular dysfunction (P < 0.001). CONCLUSION: NLR at ER is an independent predictor of mechanical complications of STEMI undergoing primary PCI. STEMI patients with high NLR are at increased risk for complications during hospitalization, therefore, needs more intensive treatment after PCI.

Mechanical and Pharmacological Revascularization Strategies for Prevention of Microvascular Dysfunction in ST-Segment Elevation Myocardial Infarction: Analysis from Index of Microcirculatory Resistance Registry Data.

OBJECTIVES: We aimed to identify mechanical and pharmacological revascularization strategies correlated with the index of microcirculatory resistance (IMR) in ST-elevation myocardial infarction (STEMI) patients. BACKGROUND: Microvascular dysfunction (MVD) after STEMI is correlated with infarct size and poor long-term prognosis, and the IMR is a useful analytical method for the quantitative assessment of MVD. However, therapeutic strategies that can reliably reduce MVD remain uncertain. METHODS: Patients with STEMI who underwent primary percutaneous coronary intervention (PCI) were enrolled. The IMR was measured with a pressure sensor/thermistor-tipped guidewire immediately after primary PCI. High IMR was defined as values ≥66th percentile of IMR in enrolled patients (IMR > 30.9 IU). RESULTS: A total of 160 STEMI patients were analyzed (high IMR = 54 patients). Clinical factors for Killip class (P=0.006), delayed hospitalization from symptom onset (P=0.004), peak troponin-I level (P=0.042), and multivessel disease (P=0.003) were associated with high IMR. Achieving final thrombolysis in myocardial infarction myocardial perfusion grade 3 tended to be associated with low IMR (P=0.119), whereas the presence of distal embolization was significantly associated with high IMR (P=0.034). In terms of therapeutic strategies that involved adjusting clinical and angiographic factors associated with IMR, preloading of third-generation P2Y12 inhibitors correlated with reducing IMR value (ß = -10.30, P < 0.001). Mechanical therapeutic strategies including stent diameter/length, preballoon dilatation, direct stenting, and thrombectomy were not associated with low IMR value (all P > 0.05), and postballoon dilatation was associated with high IMR (ß = 8.30, P=0.020). CONCLUSIONS: In our study, mechanical strategies were suboptimal in achieving myocardial salvage. Preloading of third-generation P2Y12 inhibitors revealed decreased IMR value, indicative of MVD prevention.

Ivabradine-Induced Torsade de Pointes in Patients with Heart Failure Reduced Ejection Fraction.

Ivabradine is a selective inhibitor of the sinoatrial node "funny" current, prolonging the slow diastolic depolarization. As it has the ability to block the heart rate selectively, it is more effective at a faster heart rate. It is recommended for the treatment of heart failure reduced ejection fraction in the presence of beta-blocker therapy for the further reduction of the heart rate. However, previous reports have shown the association of Torsade de pointes (TdP) with concurrent use of ivabradine and drugs resulting in QT prolongation or blockage of the metabolic breakdown of ivabradine. In this article, we report two cases of patients with heart failure reduced ejection fraction who developed TdP after ivabradine use. Our report highlights the need to exercise caution with the administration of ivabradine in the presence of a reduced repolarization reserve, such as QT prolongation or metabolic insufficiency.

Case Report of Patients with Acute Respiratory Distress Syndrome Caused by COVID-19: Successfully Treated by Venovenous Extracorporeal Membrane Oxygenation and an Ultra-Protective Ventilation.

Coronavirus disease (COVID-19) started in Wuhan (China) at the end of 2019, and then increased rapidly. In patients with severe acute respiratory distress syndrome (ARDS) caused by COVID-19, venovenous extracorporeal membrane oxygenation (VV-ECMO) is considered a rescue therapy that provides adequate gas exchange. The way in which mechanical ventilation is applied during VV-ECMO is not clear, however it is associated with prognosis. Currently, the mortality rate of COVID-19 patients that receive VV-ECMO stands at approximately 50%. Here, we report three patients that successfully recovered from COVID-19-induced ARDS after VV-ECMO and implementation of an ultra-protective ventilation. This ventilation strategy involved maintaining a peak inspiratory pressure of ≤20 cmH2O and a positive end-expiratory pressure (PEEP) of ≤ 10 cmH2O, which are lower values than have been previously reported. Thus, we suggest that this ultra-protective ventilation be considered during VV-ECMO as it minimizes the ventilator-induced lung injury.

Evaluating the Outcome of Multi-Morbid Patients Cared for by Hospitalists: a Report of Integrated Medical Model in Korea.

BACKGROUND: The lack of medical personnel has led to the employment of hospitalists in Korean hospitals to provide high-quality medical care. However, whether hospitalists' care can improve patients' outcomes remains unclear. We aimed to analyze the outcome in patients cared for by hospitalists. METHODS: A retrospective review was conducted in 1,015 patients diagnosed with pneumonia or urinary tract infection from March 2017 to July 2018. After excluding 306 patients, 709 in the general ward who were admitted via the emergency department were enrolled, including 169 and 540 who were cared for by hospitalists (HGs) and non-hospitalists (NHGs), respectively. We compared the length of hospital stay (LOS), in-hospital mortality, readmission rate, comorbidity, and disease severity between the two groups. Comorbidities were analyzed using Charlson comorbidity index (CCI). RESULTS: HG LOS (median, interquartile range [IQR], 8 [5-12] days) was lower than NHG LOS (median [IQR], 10 [7-15] days), (P < 0.001). Of the 30 (4.2%) patients who died during their hospital stay, a lower percentage of HG patients (2.4%) than that of NHG patients (4.8%) died, but the difference between the two groups was not significant (P = 0.170). In a subgroup analysis, HG LOS was shorter than NHG LOS (median [IQR], 8 [5-12] vs. 10 [7-16] days, respectively, P < 0.001) with CCI of ≥ 5 points. CONCLUSION: Hospitalist care can improve the LOS of patients, especially those with multiple comorbidities. Further studies are warranted to evaluate the impact of hospitalist care in Korea.

Impact of area strain by 3D speckle tracking on clinical outcome in patients after acute myocardial infarction.

BACKGROUND: Three-dimensional (3D) speckle tracking echocardiography (STE) has been developed to overcome the limitations of two-dimensional (2D) STE and has been applied in the several clinical settings. However, no data exist about the prognostic value of 3DSTE-based strain on clinical outcome after myocardial infarction (MI). This study was designed to investigate the prognostic value of area strain (AS) by 3D speckle tracking in predicting clinical outcome after acute MI. METHODS: We assessed 96 patients (62±14 years, 72% male) with acute MI and who had undergone a coronary angiography. Clinical parameters and conventional echocardiographic measurements including the left atrial (LA) size and tissue Doppler measurements were evaluated. The global left ventricular (LV) AS was measured using 3D speckle tracking software. The relationship between the AS and clinical outcome of death or hospitalization for heart failure (HF) was assessed. RESULTS: During a median follow-up of 33±10 months, primary endpoint of death or HF occurred in 12 patients (12.5%). AS was predictive of death or HF after adjustment for age, gender, peak CK-MB, LA volume, LV end-systolic volume, LV mass, the ratio of early mitral inflow velocity to early mitral annular velocity, and LV ejection fraction in a multivariate Cox model (HR 1.23, 95% CI 1.02-1.47, P=.03). In addition, AS added incremental value in predicting death or heart failure on a model based on clinical and standard echocardiographic measures (P=.008). CONCLUSION: AS is independently associated with increased risk of death or HF after acute MI, suggesting that it can be a useful prognostic parameter in the patients following MI.

Relationship between J Waves and Vagal Activity in Patients Who Do Not Have Structural Heart Disease.

BACKGROUND: J waves are associated with increased vagal activity in patients with idiopathic ventricular fibrillation in several studies to date. However, the relationship between J waves and autonomic nervous activity in patients without structural heart disease remains under investigation. We investigated whether the presence of a J wave on the surface electrocardiogram (ECG) was related to increased vagal activity in patients without structural heart disease. METHODS: This retrospective study included 684 patients without structural heart disease who had undergone Holter ECG and surface ECG monitoring. Based on the presence of J waves on the surface ECG, patients were divided into two groups: those with J waves (group 1) and those without J waves (group 2). We compared heart rate variability (HRV), reflecting autonomic nervous activity, using 24-h Holter ECG between the groups. RESULTS: J waves were present in 92 (13.4%) patients. Heart rate (HR) in group 1 was significantly lesser than that in group 2 (P = 0.031). The ratio of low-frequency (LF) components to high-frequency (HF) components (LF/HF) in group 1 was significantly lower than that in group 2 (P = 0.001). The square root of the mean squared differences of successive NN intervals in group 1 was also significantly higher than that in group 2 (P = 0.047). In a multivariate regression analysis, male sex, HR, and LF/HF ratio remained independent determinants for the presence of J waves (P = 0.039, P = 0.036, and P < 0.001, respectively). CONCLUSION: In patients without structural heart disease, the presence of a J wave was associated with a slow HR, male sex, and increased vagal activity, independently.

Mass scale synthesis of graphene nanosheets using waste cardboard for application in perovskite solar cells and supercapacitors.

Advanced graphene-based materials have been proficiently incorporated into next-generation solar cells and supercapacitors because of their high electrical conductivity, large surface area, excellent charge-transport ability, and exceptional optical properties. Herein, we report the synthesis of graphene nanosheets (GNs) from waste cardboard via pyrolysis, with ethyl alcohol as the growth initiator. Additionally, we demonstrated the use of GNs in energy conversion and storage applications. Using the GN electrode in perovskite solar cells resulted in an excellent power conversion efficiency of ∼10.41 % for an active area of 1 cm2, indicating an enhancement of approximately 27 % compared to conventional electrodes. Furthermore, the GNs were used as active electrode materials in supercapacitors with excellent electrochemical performance and a high gravimetric specific capacitance of 167.5 F/g at a scan rate of 2 mV/s. The developed GNs can be efficiently used for energy storage, conversion, and electrochemical sensing applications.

Solution-Grown MAPbBr3 Single Crystals for Self-Powered Detection of X-rays with High Energies above One Megaelectron Volt.

Perovskite single crystals are actively studied as X-ray detection materials with enhanced sensitivity. Moreover, the feasibility of using perovskites for self-powered devices such as photodetectors, UV detectors, and X-ray detectors can significantly expand their application range. In this work, the charge carrier transport and photocurrent properties of MAPbBr3 single crystals (MSCs) are improved by the mechanochemical surface treatment using glycerin combined with an additional electrode design that forms an ohmic contact. The sensitivity of MSC-based detectors and pulse shape generated by X-rays are enhanced at various bias voltages. The synthesized MSC detectors generate direction-dependent photocurrents, which indicate the presence of a polarization-induced internal electric field. In addition, photocurrent signals are produced by X-rays with energies greater than 1 MeV under a zero-bias voltage. This work demonstrates a high application potential of perovskites as self-powered detectors for X-rays with energies exceeding 1 MeV.

Recent advances in carbon-based materials for high-performance perovskite solar cells: gaps, challenges and fulfillment.

Presently, carbon-based nanomaterials have shown tremendous potential for energy conversion applications. Especially, carbon-based materials have emerged as excellent candidates for the fabrication of halide perovskite-based solar cells, which may lead to their commercialization. In the last decade, PSCs have rapidly developed, and these hybrid devices demonstrate a comparable performance to silicon-based solar cells in terms of power conversion efficiency (PCE). However, PSCs lag behind silicon-based solar cells due to their poor stability and durability. Generally, noble metals such gold and silver are employed as back electrode materials during the fabrication of PSCs. However, the use of these expensive rare metals is associated with some issues, urgently necessitating the search for cost-effective materials, which can realize the commercial applications of PSCs due to their interesting properties. Thus, the present review shows how carbon-based materials can become the main candidates for the development of highly efficient and stable PSCs. Carbon-based materials such as carbon black, graphite, graphene nanosheets (2D/3D), carbon nanotubes (CNTs), carbon dots, graphene quantum dots (GQDs) and carbon nanosheets show potential for the laboratory and large-scale fabrication of solar cells and modules. Carbon-based PSCs can achieve efficient and long-term stability for both rigid and flexible substrates because of their high conductivity and excellent hydrophobicity, thus showing good results in comparison to metal electrode-based PSCs. Thus, the present review also demonstrates and discusses the latest state-of-the-art and recent advances for carbon-based PSCs. Furthermore, we present perspectives on the cost-effective synthesis of carbon-based materials for the broader view of the future sustainability of carbon-based PSCs.

Veno-venous extracorporeal membrane oxygenation rescue for pulmonary hypertension and hypoxemic respiratory failure to obesity hypoventilation syndrome: a case report.

BACKGROUND: Effective pharmacological options for acute hypoxemic or hypercapnic respiratory failure, associated with obesity hypoventilation syndrome (OHS), have not been fully elucidated. Although weight reduction, non-invasive ventilation (NIV), and continuous positive airway pressure (CPAP) lead to improvements in long-term clinical outcomes and cardiac function, there is no rapid reversal method in serious situations requiring mechanical ventilation. Veno-venous extracorporeal life support by extracorporeal membrane oxygenation is a widely used modality that can support patients with refractory hypoxemia or hypercapnia as a bridging therapy for recovery. CASE DESCRIPTION: We present the case of a morbidly obese [body mass index (BMI) of 42 kg/m2] 58-year-old man with refractory hypoxemic respiratory failure, resulting from severe right ventricular failure and pulmonary hypertension (PH), who underwent emergency support with extracorporeal membrane oxygenation. During extracorporeal life support and mechanical ventilation, careful diuresis and nutritional control were provided for body weight loss, and body weight was significantly reduced by approximately 30 kg. Nocturnal NIV was initiated immediately after cessation of positive pressure ventilation and endotracheal intubation. After 5 weeks of hospitalization, transthoracic echocardiography (TTE) showed robust improvements in right ventricular cardiac function and PH. CONCLUSIONS: Here, we describe that veno-venous extracorporeal life support may sufficiently support patients with obesity and sleep hypoventilation who have suffered a pulmonary hypertensive crisis.

Prognostic Impact of Plasma Glucose on Patients With Cardiogenic Shock With or Without Diabetes Mellitus from the SMART RESCUE Trial.

Although the presence of hyperglycemia has been shown to affect the clinical outcome of patients with cardiogenic shock, the extent of hyperglycemia and its association with prognosis have not been fully addressed in a large population. A total of 1,177 consecutive patients with cardiogenic shock were enrolled from January 2014 to December 2018 at 12 hospitals in South Korea. The primary outcome was in-hospital mortality. Patients were divided into 4 groups according to their initial plasma glucose level in patients with diabetes mellitus (DM) (n = 752) and patients without DM (n=425); group 1 (≤8 mmol/L or 144 mg/100 ml), group 2 (8 to 12 mmol/L or 144 to 216 mg/100 ml), group 3 (12 to 16 mmol/L or 216 to 288 mg/100 ml), and group 4 (≥16 mmol/L or 288 mg/100 ml). The groups with higher admission plasma glucose were associated with lower systolic blood pressure and higher lactic acid levels in patients with and without DM. In-hospital mortality increased in groups with higher admission plasma glucose level in patients without DM (group 1:24.2%, group 2: 28.6%, group 3: 38.1%, group 4: 49.0%, p <0.01), whereas in patients with DM, mortality and admission plasma glucose level showed no significant association (group 1: 45%, group 2: 35.4%, group 3: 33.3%, group 4: 43.1%, p = 0.26). Even after multivariate analysis, high plasma glucose was an independent predictor of in-hospital mortality in patients without DM. In patients with cardiogenic shock, plasma glucose obtained at admission was associated with in-hospital mortality in patients without DM.

Incorrect depth sense due to focused object distance.

In stereoscopy, stereoscopic depth distortion is a serious problem in terms of determining the correct depth sense. There have been few studies pertaining to the problem in terms of the focused object distance (FOD). In this investigation, we discuss the FOD as one of the factors inducing an incorrect depth sense in using common stereo camera systems and propose a method for compensating the incorrect depth sense, which is strongly related to the process of demagnifying the size of displayed stereo image on the screen. The incorrect depth sense increases when the FOD becomes shortened. Our method illustrates that the depth sense difference between a correct depth sense and an induced depth error is compensated completely. We verified the validation of our concerns by both a theoretical simulation and a practical experiment.

Effect of a serum lactate monitoring recommendation policy on patients treated with linezolid.

ABSTRACT: Lactic acidosis is one of the most fatal adverse effects of linezolid, an antibiotic used to treat serious infections caused by antibiotic-resistant bacteria. However, the measures to prevent lactic acidosis have not been well established.We performed a retrospective study to analyze the impact of applying a serum lactate monitoring recommendation policy in patients treated with linezolid.Since September 2011, we have recommended inpatient monitoring of serum lactate levels in patients treated with linezolid at our hospital. Patients were divided into two groups according to whether they were seen during the non-recommendation or recommendation periods. The frequency of serum lactate monitoring, linezolid-induced lactatemia, lactic acidosis, critical illness, and death were compared between the two periods.After September 2011, adherence to the recommendation to monitor serum lactate increased from 6.1% to 60.1%. No difference was observed in the incidence of linezolid-induced lactatemia and lactic acidosis between the two periods. However, there was a significant difference in the incidence of linezolid-induced critical illness between the non-recommendation and recommendation periods (3 vs 0 cases, P = .044).In patients treated with linezolid, serum lactate monitoring led to early detection of lactatemia, thus enabling rapid rescue. We recommend regular monitoring of serum lactate in all patients treated with linezolid.

Clinical efficacy of high-flow nasal oxygen in patients undergoing ERCP under sedation.

Hypoxemia can occur during endoscopic retrograde cholangiography (ERCP) and it is difficult to achieve adequate ventilation with the prone position. High-flow nasal oxygen (HFNO) has been recommended to be more effectively help ventilation than conventional low flow oxygen. The aim of this study was to evaluate the effect of HFNO during sedated ERCP and to identify predictors of desaturation during ERCP. The investigated variables were age, gender, American Society of Anesthesiologists classes (ASA), duration of exam, and sedative used for midazolam or/and propofol of 262 patients with sedated ERCP. The differences between categorical and continuous variables were analyzed using the Student's t test and the chi-square test. Desaturation (SpO2 ≤ 90%) occurred in 9(3.4%) patients among 262 patients during sedated ERCP. The variables found to predict desaturation were older age (p < 0.01), higher sedation dose for midazolam or propofol (p < 0.01), and use of midazolam (p < 0.01). Desaturation rate was lower during sedated ERCP with HFNO compared to the preliminary study with conventional low flow nasal oxygen. Patients with older age, higher sedation dose, or the use of midazolam might require close monitoring for desaturation and hypoventilation by nursing staff. The study shows the use of high-flow nasal oxygen reduces the incidence of desaturation during ERCP.

The Index of Microcirculatory Resistance after Primary Percutaneous Coronary Intervention Predicts Long-Term Clinical Outcomes in Patients with ST-Segment Elevation Myocardial Infarction.

The index of microcirculatory resistance (IMR) is a simple method that can measure microvascular function after primary percutaneous coronary intervention (PCI) in patients with ST-segment Elevation Myocardial Infarction (STEMI). This study is to find out whether IMR predicts clinical long-term outcomes in STEMI patients. A total of 316 patients with STEMI who underwent primary PCI from 2005 to 2015 were enrolled. The IMR was measured using pressure sensor/thermistor-tipped guidewire after primary PCI. The primary endpoint was the rate of death or hospitalization for heart failure (HF) over a mean follow-up period of 65 months. The mean corrected IMR was 29.4 ± 20.0. Patients with an IMR > 29 had a higher rate of the primary endpoint compared to patients with an IMR ≤ 29 (10.3% vs. 2.1%, p = 0.001). During the follow-up period, 13 patients (4.1%) died and 6 patients (1.9%) were hospitalized for HF. An IMR > 29 was associated with an increased risk of death or hospitalization for HF (OR 5.378, p = 0.004). On multivariable analysis, IMR > 29 (OR 3.962, p = 0.022) remained an independent predictor of death or hospitalization for HF with age (OR 1.048, p = 0.049) and symptom-to-balloon time (OR 1.002, p = 0.049). High IMR was an independent predictor for poor long-term clinical outcomes in STEMI patients after primary PCI.

A multicentre validation study of the deep learning-based early warning score for predicting in-hospital cardiac arrest in patients admitted to general wards.

BACKGROUND: The recently developed deep learning (DL)-based early warning score (DEWS) has shown potential in predicting deteriorating patients. We aimed to validate DEWS in multiple centres and compare the prediction, alarming and timeliness performance with the modified early warning score (MEWS) to identify patients at risk for in-hospital cardiac arrest (IHCA). METHOD/RESEARCH DESIGN: This retrospective cohort study included adult patients admitted to the general wards of five hospitals during a 12-month period. The occurrence of IHCA within 24 h of vital sign observation was the outcome of interest. We assessed the discrimination using the area under the receiver operating characteristic curve (AUROC). RESULTS: The study population consists of 173,368 patients (224 IHCAs). The predictive performance of DEWS was superior to that of MEWS in both the internal (AUROC: 0.860 vs. 0.754, respectively) and external (AUROC: 0.905 vs. 0.785, respectively) validation cohorts. At the same specificity, DEWS had a higher sensitivity than MEWS, and at the same sensitivity, DEWS reduced the mean alarm count by nearly half of MEWS. Additionally, DEWS was able to predict more IHCA patients in the 24-0.5 h before the outcome, and DEWS was reasonably calibrated. CONCLUSION: Our study showed that DEWS was superior to MEWS in three key aspects (IHCA predictive, alarming, and timeliness performance). This study demonstrates the potential of DEWS as an effective, efficient screening tool in rapid response systems (RRSs) to identify high-risk patients.

Role of the Rapid Response System in End-of-Life Care Decisions.

PURPOSE: An important role of the rapid response system (RRS) is to provide opportunities for end-of-life care (EOLC) decisions to be appropriately operationalized. We investigated whether EOLC decisions were made after the RRS-recommended EOLC decision to the primary physician. MATERIALS AND METHODS: We studied whether patients made EOLC decisions consistent with the rapid response team's (RRT) recommendations, between January 1, 2017, and February 28, 2019. The primary outcome was the EOLC decision after the RRT's recommendation to the primary physician. The secondary outcome was the mechanism of EOLC decision-making: through institutional do-not-resuscitate forms or the Korean legal forms of Life-Sustaining Treatment Plan (LSTP). RESULTS: Korean LSTPs were used in 26 of the 58 patients who selected EOLC, from among the 75 patients for whom the RRS made an EOLC recommendation. Approximately 7.2% of EOLC decisions for inpatients were related to the RRT's interventions in EOLC decisions. Patients who made EOLC decisions did not receive cardiopulmonary resuscitation, mechanical ventilation, or dialysis. CONCLUSION: The timely intervention of the RRS in EOLC facilitates an objective assessment of the patient's medical conditions, the limitation of treatments that may be minimally beneficial to the patient, and the choice of a higher quality of care. The EOLC decision using the legal process defined in the relevant Korean Act has advantages, wherein patients can clarify their preference, the family can prioritize the patient's preference for EOLC decisions, and physicians can make transparent EOLC decisions based on medical evidence and informed patient consent.

Helmet-based noninvasive ventilation for acute exacerbation of chronic obstructive pulmonary disease: A case report.

BACKGROUND: Noninvasive ventilation (NIV) reduces intubation rates, mortalities, and lengths of hospital and intensive care unit stays in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Helmet-based NIV is better tolerated than oronasal mask-based ventilation, and thus, allows NIV to be conducted for prolonged periods at higher pressures with minimal air leaks. CASE SUMMARY: A 73-year-old man with a previous diagnosis of COPD stage 4 was admitted to our medical intensive care unit with chief complaints of cough, sputum, and dyspnea of several days' duration. For 10 mo, he had been on oxygen at home by day and had used an oronasal mask-based NIV at night. At intensive care unit admission, he breathed using respiratory accessory muscles. Hypercapnia and signs of infection were detected, and infiltration was observed in the right lower lung field by chest radiography. Thus, we diagnosed AECOPD by community-acquired pneumonia. After admission, respiratory distress steadily deteriorated and invasive mechanical ventilation became necessary. However, the patient refused this option, and thus, we selected helmet-based NIV as a salvage treatment. After 3 d of helmet-based NIV, his consciousness level and hypercapnia recovered to his pre-hospitalization level. CONCLUSION: Helmet-based NIV could be considered as a salvage treatment when AECOPD patients refuse invasive mechanical ventilation and oronasal mask-based NIV is ineffective.