Assessment of Non-Invasive Ventilation Combined with Naloxone for the Management of Acute Respiratory Failure in Patients with Chronic Obstructive Pulmonary Disease.

Background: Chronic obstructive pulmonary disease (COPD) poses a significant global health burden. Finding effective interventions for COPD is crucial to alleviating this health burden and enhancing patient outcomes and quality of life. Objective: This study aimed to evaluate the therapeutic efficacy of the combination of non-invasive ventilation and naloxone in the management of acute respiratory failure among patients with COPD. Methods: A retrospective analysis was conducted on the clinical data of 102 COPD patients experiencing acute respiratory failure who were treated at our hospital between October 2020 and October 2022. Patients were categorized into an observation group (receiving non-invasive ventilation combined with naloxone) and a control group (receiving non-invasive ventilation alone). Parameters such as lung function, blood gas levels, endocrine hormone concentrations, treatment efficacy, and patient prognosis were carefully recorded and compared. Results: The observation group demonstrated enhanced lung function, optimized endocrine hormone levels, and improved blood gas parameters compared to the control group. Following treatment, the observation group exhibited significant reductions in plasma renin activity (PRA), angiotensin II (AngII), aldosterone (ALD), and norepinephrine (NE) levels. The total effective rate was notably higher in the observation group. This group also presented higher scores for Acute Physiology and Chronic Health Evaluation II (APACHE II) and Chronic Obstructive Pulmonary Disease Assessment Test (CAT). Conclusions: The combination of non-invasive ventilation with naloxone emerged as a significantly effective strategy in managing acute respiratory failure in COPD patients. This approach led to improvements in lung function, endocrine hormone levels, and blood gas parameters and highlights its potential as an impactful treatment strategy for COPD patients experiencing acute respiratory failure.

High-intensity non-invasive ventilation during exercise-training versus without in people with very severe COPD and chronic hypercapnic respiratory failure: a randomised controlled trial.

BACKGROUND: People with very severe chronic obstructive pulmonary disease (COPD) using nocturnal non-invasive ventilation (NIV) for chronic hypercapnic respiratory failure (CHRF) experience reduced exercise capacity and severe dyspnoea during exercise training (ET). The use of NIV during ET can personalise training during pulmonary rehabilitation (PR) but whether high-intensity NIV (HI-NIV) during exercise is accepted and improves outcomes in these extremely physically limited patients is unknown. The aim of this trial was to determine if ET with HI-NIV during PR was more effective than without at improving exercise capacity and reducing dyspnoea during exercise. METHODS: Patients with COPD, CHRF and nocturnal-NIV were randomised to supervised cycle-ET as part of PR with HI-NIV or without (control). Primary outcome was change in cycle endurance time (ΔCETtime), while secondary outcomes were dyspnoea at isotime during the cycle endurance test and during ET-sessions and for the HI-NIV group, post-trial preferred exercising method. RESULTS: Twenty-six participants (forced expiratory volume in 1 s 22±7%pred, PaCO251±7 mm Hg) completed the trial (HI-NIV: n=13, ET: IPAP 26±3/EPAP 6±1 cm H2O; control n=13). At completion of a 3 week ET-programme, no significant between-group differences in ΔCETtime were seen (HI-NIV-control: Δ105 s 95% CI (-92 to 302), p=0.608). Within-group ΔCETtime was significant (HI-NIV: +246 s 95% CI (61 to 432); control: +141 s 95% CI (60 to 222); all p<0.05). The number of responders (Δ>minimal important difference (MID)101 s: n=53.8%) was the same in both groups for absolute ΔCETtime and 69.2% of control and 76.9% of the HI-NIV group had a %change>MID33%.Compared with control, the HI-NIV group reported less isotime dyspnoea (Δ-2.0 pts. 95% CI (-3.2 to -0.8), p=0.005) and during ET (Δ-3.2 pts. 95% CI (-4.6 to -1.9), p<0.001). Most of the HI-NIV group (n=12/13) preferred exercising with NIV. CONCLUSION: In this small group of patients with very severe COPD requiring nocturnal NIV, participation in an ET-programme during PR significantly improved exercise capacity irrespective of HI-NIV use. Reported dyspnoea was in favour of HI-NIV. TRIAL REGISTRATION NUMBER: NCT03803358.

Nutrition therapy during noninvasive ventilation: oral or enteral?

PURPOSE OF REVIEW: Critical care nutrition guidelines primarily focus on patients receiving invasive mechanical ventilation, yet noninvasive ventilation (NIV) is an increasingly common intervention. The optimal route of nutrition delivery in patients receiving NIV has not been established. This review aims to describe the implications of NIV on the route of feeding prescribed. RECENT FINDINGS: Five small, mostly observational, studies have quantified energy or protein intake in patients receiving NIV in critical care, which demonstrate intake to be poor. No study has assessed the impact of feeding route on outcomes. The predominant route of feeding observed is oral intake, yet nutrition intake via this route is lower than that from enteral or parenteral nutrition. Barriers to oral intake include fasting for intubation, the inability to remove NIV apparatus to eat, breathlessness, fatigue and poor appetite, while barriers to enteral nutrition include the impact of the naso-enteric tube on the mask seal and potential aspiration. SUMMARY: Until evidence to support the optimal route of feeding is developed, patient safety should be the key driver of route selection, followed by the ability to achieve nutrition targets, perhaps utilizing a combination of routes to overcome barriers to nutrition delivery.

[Weaning from invasive ventilation : Challenges in the clinical routine]. / Weaning von invasiver Beatmung : Herausforderungen im klinischen Alltag.

Modern intensive care medicine is caught between the conflicting demands of an efficient but also increasingly more technical intensive care treatment with numerous therapeutic options and, at the same time, an ageing society with increasing morbidity. This is reflected, among other things, in an increasing number of ventilated patients in intensive care units and an increasing proportion of patients for whom ventilation cannot easily be discontinued. Weaning from a ventilator, which can account for more than 50% of the total ventilation time, therefore plays a central role in this process. This main topic article presents the need for strategically wise and holistic actions to minimize the consequences of invasive mechanical ventilation for patients. An attempt is made to shed more light on individual aspects of the ventilation weaning process with high relevance for clinical practice. Especially for prolonged weaning from ventilation, many more concepts are needed than simply ending ventilation.

Effect of Different Oxygen Delivery Methods on Transcutaneous Oxygen Pressure and Fraction of Inspired Oxygen During Noninvasive Positive Pressure Ventilation.

Objective: The aim of this study was to investigate the effects of different oxygen delivery methods during noninvasive positive-pressure ventilation (NPPV) on transcutaneous oxygen pressure (PtcO2), transcutaneous carbon dioxide pressure (PtcCO2) and fraction of inspired oxygen (FiO2) in order to find more effective oxygen delivery methods. Methods: A total of 20 healthy volunteers participated in this study, all of whom received NPPV. All volunteers received oxygen through a nasal cannula (NC) located in a mask or through a mask alone (OSTM) (oxygen flow rate was 3L/min and 5L/min), PtcO2 and PtcCO2 were measured, and the effects of the 2 methods of oxygen concentration on PtcO2 and PtcCO2 levels were evaluated during noninvasive ventilation. Then, the additional oxygen concentration was stopped, oxygen was delivered through the ventilator, and the oxygen concentration was adjusted so that the PtcO2 reached the same oxygen concentration level as noted through the NC or OSTM. This concentration of oxygen indirectly reflects FiO2 in different oxygen delivery methods. Results: When NPPV was used under the same pressure, FiO2 increased from 44.4% to 65.3% when oxygen was delivered through an NC compared with oxygen supplied by OSTM alone. PtcO2 was also significantly increased from 18.9% to 24.9%; the difference was significant (P < .05), while there was no significant change in PtcCO2 (P > .05). Conclusion: When NPPV is used, an NC can obviously improve FiO2 and PtcO2 without increasing PtcCO2. It can save oxygen and is more suitable for NPPV during an emergency and for home use.

Validation of Respiratory Rate-Oxygenation Index in Patients With COVID-19-Related Respiratory Failure.

OBJECTIVES: The respiratory rate-oxygenation (ROX) index is a fraction of oxygen saturation, Fio2, and respiratory rate that has been validated to predict receipt of invasive mechanical ventilation in patients receiving high-flow nasal cannula (HFNC). This study aimed to validate ROX in a cohort of inpatients with COVID-19-related respiratory failure. DESIGN: Retrospective validation of the ROX index. We calculated sensitivity, specificity, positive predictive value, negative predictive value, and 95% CIs of ROX for invasive mechanical ventilation any time during hospitalization. SETTING: Twenty-one hospitals of Kaiser Permanente Northern California, an integrated healthcare delivery system. PATIENTS: We identified adults with positive severe acute respiratory syndrome coronavirus 2 polymerase chain reaction test within 3 weeks of, or during, hospitalization between February 1, 2020, and December 31, 2020. We calculated ROX at 12 hours after HFNC initiation. We grouped patients as low (≥ 4.88), intermediate (< 4.88 and ≥ 3.85), or high (< 3.85) risk using previously published thresholds. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We identified 1,847 patients who had no limitation of life support. Of these, 525 (31.7%) received invasive mechanical ventilation any time during hospitalization and 511 died (27.7%). The sensitivity, specificity, positive predictive value, and negative predictive value of 12-hour ROX threshold (< 3.85) predicting invasive mechanical ventilation were 32.3% (95% CI, 28.5-36.3%), 89.8% (95% CI, 88.0-91.4%), 59.4% (95% CI, 53.8-64.9%), and 74.1% (95% CI, 71.8-76.3%), respectively. CONCLUSIONS: The 12-hour ROX index has a positive predictive value (59.4%) using threshold of less than 3.85 for COVID-19 patients needing invasive mechanical ventilation. Our health system has embedded ROX into the electronic health record to prioritize rounding during periods of inpatient surge.

Comparison of the Effect of Foot and Palm Reflexology Massage on Respiratory Distress Syndrome in Premature Infants under Noninvasive Ventilation.

INTRODUCTION: Respiratory distress is one of the life-threatening conditions in preterm infants. Sensory deprivation in preterm infants hospitalized in the intensive care units affects their physiological and psychological development. Therefore, this study is an attempt to compare the effects of foot and palm reflexology on respiratory distress in infants subjected to noninvasive ventilation. METHODS: In this clinical study, 150 infants hospitalized at Fatemieh Hospital in Hamadan were randomly assigned to 3 groups. In the intervention groups, the reflexology massage to foot and palm was performed for 10 min within 3 days in 6 rounds. In the control group, leg warming was performed. In each group, the personal information checklist, the respiratory distress score, oxygen saturation percentage, and respiratory rate before and after the daily intervention were examined. Data analysis was performed using the standard statistical tests in SPSS. RESULTS: The results mirrored the statistically significant difference between the intervention and control groups 3 days into the intervention with regard to the average oxygen saturation percentage, respiratory rate, and the respiratory distress score (p < 0.05). When eliminating the effect of confounding variables, therapeutic intervention applied to palm compared to foot had a greater effect on reducing respiratory distress score in the studied infants. CONCLUSION: The reflexology massage method, especially palm reflexology massage, contributes to the mitigation of respiratory distress in preterm infants subjected to noninvasive ventilation. Hence, this low-cost and efficient intervention program can be recommended as a complementary method for preterm infants with respiratory distress.

The Impact of Non-Invasive Ventilation Combined with Montelukast on Clinical Efficiency and Pulmonary Function in Patients with Bronchial Asthma Complicated by Obstructive Sleep Apnea Hypopnea Syndrome.

PURPOSE: Our study aims to explore the impact of non-invasive ventilation (NIV) alone or combined with montelukast on clinical efficiency and pulmonary function (PF) in treating patients with bronchial asthma complicated by obstructive sleep apnea hypopnea syndrome (OSAHS). METHODS: A total of 386 patients with bronchial asthma underwent sleep monitoring. Patients were divided into 3 groups according to the different treatment methods. The changes in PF, apnea hypopnea index (AHI) score and the level of inflammatory factors in all patients before and after treatment were recorded, and the clinical effect following treatment was noted. RESULTS: Following treatment, the clinical efficiency of Group 2 was significantly better than that of both Group 1and the control group, and the therapeutic effect in Group 1 was better than in the control group (P < .05). Before treatment, vital capacity (VC), peak expiratory flow (PEF), forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) and asthma control test (ACT) scores, AHI scores, C-reactive protein (CRP), tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) index were compared between the 3 groups (P > .05). In contrast, after treatment the VC, PEF, FEV1/FVC and ACT, AHI, CRP and TNF-α scores and the IL-6 index in the 3 groups were improved compared with before treatment. The indices in Groups 1 and 2 were better than in the control group, and the VC, PEF, FEV1/FVC and ACT, AHI, CRP, and TNF-α scores and IL-6 index in Group 2 reported greater beneficial effect than in Group 1. CONCLUSION: The combination of NIV and montelukast exerts a beneficial effect in treating patients with bronchial asthma complicated with OSAHS, which holds the potential of effectively improving clinical symptoms and PF, reducing ACT and AHI scores and alleviating inflammatory reactions. Hence, the combination is valid and appropriate for clinical application.

Clinical efficacy of non-invasive ventilation combined with Chinese medicine for intestinal regulation in Chinese children with respiratory disorders.

Chinese medicine for intestinal regulation is an emerging method for pediatric respiratory disorders, which has better clinical value when combined with NIV (Non-invasive ventilation). This study aims to observe the clinical efficacy of NIV plus Chinese medicine for intestinal regulation in Chinese children with respiratory disorders. Thirty-nine patients admitted to Huaihua First People's Hospital, between March 2016 and July 2018 were enrolled, including 14 children with chronic hypercapnic respiratory failure, 19 with non-surgical OSAS, 5 with OB and 1 with central hypoventilation syndrome. After NIV, the blood gas carbon dioxide retention and labored breathing were improved, respiratory rate and heart rate were decreased and the feeding condition of some children improved. After NIV treatment, clinical symptoms of children with OSAS were significantly ameliorated. In polysomnography monitoring, the AHI, OAI and SpO2 were significantly enhanced following NIV. In addition, patients with OB and central hypoventilation had different degrees of improvement of their symptoms. NIV plus Chinese medicine for intestinal regulation alleviate the clinical symptoms and enhances the quality of life of children with chronic hypercapnic respiratory failure. Some children could be transferred out of the intensive care unit and into home mechanical ventilation.

Intermittent Abdominal Pressure Ventilation: An Alternative for Respiratory Support.

Intermittent abdominal pressure ventilation is a positive pressure ventilation technique that works with abdominal compressions. It has been known since 1938; however, for many years, it was out of production. In recent years, a new device has been produced that has captured the attention to this old respiratory support technique. We considered eight patients with respiratory failure secondary to a neuromuscular disease (congenital myopathy, Duchenne dystrophy, and amyotrophic lateral sclerosis) intolerant to daytime noninvasive ventilation (NIV). IAPV was proposed as an alternative to NIV. We performed baseline and post-IAPV respiratory function assessment. All patients, two years later, are still using intermittent abdominal ventilation. Intermittent positive abdominal mechanical ventilation can be a valid alternative to noninvasive mechanical ventilation with a nasal or face mask. It improves gas exchange, symptoms, and quality of life, decreases the incidence of pneumonia, and can avert the need for intubation and tracheotomy.

Nutrition Therapy in Non-intubated Patients with Acute Respiratory Failure.

PURPOSE OF REVIEW: A challenging aspect of the care for patients with acute respiratory failure is their nutrition management. This manuscript consists of a literature review on nutrition therapy in non-intubated patients with acute respiratory failure receiving high-flow nasal cannula oxygenation or non-invasive positive pressure ventilation. RECENT FINDINGS: Studies show that non-intubated patients with acute respiratory failure either on non-invasive ventilation or high-flow nasal cannula are largely underfed in the initial phase of their hospitalization. Although data is limited, the available evidence suggests the feasibility of initiating oral diet in the majority of these patients in the early phase. Initial evaluation includes mental status evaluation, the Yale swallowing screening protocol, and an assessment of severity of illness. The goal should be to initiate oral diet within 24 h. If patient cannot initiate oral diet, the reason for not initiating oral diet should dictate the next step. For instance, if the reason is failure of the swallow screening, further evaluation with fiberoptic endoscopy is warranted. The inability to provide oral diet for a patient in respiratory distress may a harbinger of failure of non-invasive oxygen therapy and should prompt consideration for endotracheal intubation. We suggest placement of a small-bore feeding tube for enteral nutrition if patient is unable receive oral diet after 48 h. CONCLUSIONS: The nutrition management of these patients is better provided by a multidisciplinary team in a protocolized manner.

Efeitos da musicoterapia nas respostas fisiológicas dos recém-nascidos pré-termos em ventilação não invasiva: estudo quase-experimental / Effects of music therapy on the physiological responses of preterm newborns on non-invasive ventilation: a quasi-experimental study / Efectos de la musicoterapia sobre las respuestas fisiológicas de los recién nacidos prematuros con ventilación no invasiva: estudio cuasiexperimental

OBJETIVO: Avaliar os efeitos da musicoterapia nas respostas fisiológicas do recém-nascido pré-termo (RNPT) em ventilação não invasiva. MÉTODO: Estudo quase-experimental, de grupo único, do tipo antes e depois, com trinta prematuros, hospitalizados em uma Unidade de Terapia Intensiva Neonatal. RESULTADOS: Em relação à frequência respiratória (FR), observou-se redução de até seis incursões por minuto (p=<0,001) e em relação à frequência cardíaca (FC), de até sete batimentos por minuto (p=<0,002). Na saturação de oxigênio, identificou-se o aumento em média de 2% (p=0,003). A temperatura axilar apresentou aumento de 0,1ºC após a intervenção (p=0,05). Na escala de dor, identificou-se uma redução de um ponto (p=0,001). DISCUSSÃO: A musicoterapia apresenta efeitos benéficos em relação a redução da FR, da FC e do nível de dor, bem como, aumento da saturação de oxigênio e da temperatura axilar. CONCLUSÃO: A musicoterapia interfere positivamente nas respostas fisiológicas do RNPT em ventilação não invasiva.

OBJECTIVE: To evaluate the effects of music therapy on the physiological responses of preterm newborns (PTNBs) on non-invasive ventilation. METHOD: A quasi-experimental study, with a single group and of the before-and-after type, conducted with thirty premature infants in a Neonatal Intensive Care Unit. RESULTS: As for respiratory frequency (RF), a reduction of up to six breaths per minute was observed (p=<0.001) and, in relation to heart rate (HR), the reduction was up to seven beats per minute (p=<0.002). In oxygen saturation, a 2% (p=0.003) mean increase was identified. Axillary temperature presented a 0.1ºC increase after the intervention (p=0.05). In the pain scale, a one-point reduction (p=0.001) was identified. DISCUSSION: Music therapy presents beneficial effects in relation to reductions in RF, HR and pain level, as well as an increase in oxygen saturation and axillary temperature. CONCLUSION: Music therapy interferes positively with the physiological responses of PTNBs on non-invasive ventilation.

OBJETIVO: Evaluar los efectos de la musicoterapia sobre las respuestas fisiológicas de los recién nacidos prematuros (RNP) con ventilación no invasiva. MÉTODO: Estudio cuasiexperimental, de un solo grupo, del tipo antes y después, con treinta prematuros, hospitalizados en una Unidad de Terapia Intensiva Neonatal. RESULTADOS: Se observó una reducción de la frecuencia respiratoria (FR) de hasta seis respiraciones por minuto (p=<0,001) y de la frecuencia cardíaca (FC) de hasta siete latidos por minuto (p=<0,002). Se detectó un aumento del 2% (p=0,003) en la saturación de oxígeno. La temperatura axilar aumentó 0,1ºC tras la intervención (p=0,05). Se identificó la reducción de un punto (p=0,001) en la escala de dolor. DISCUSIÓN: La musicoterapia tiene efectos beneficiosos en cuanto a la reducción de la FR, FC y el nivel de dolor, así como también, un aumento de la saturación de oxígeno y temperatura axilar. CONCLUSIÓN: La musicoterapia interfiere positivamente en las respuestas fisiológicas del RNP con ventilación no invasiva.

The combined therapy of a traditional Chinese medicine formula and Western medicine for a critically ill case infected with COVID-19.

OBJECTIVE: Presentation of a case illustrating the benefits of traditional Chinese medicine (TCM) for treatment of Coronavirus disease 2019 (COVID-19) in critically ill patients. CLINICAL FEATURES AND OUTCOME: A 58-year-old woman presented with cough, fever, dizziness, chest tightness, polypnea and poor appetite. She was admitted to Guizhou Provincial People's hospital, and diagnosed with critically ill type of COVID-19 in February 2020. According to the patient's symptoms and signs, the TCM syndrome differentiation was qi deficiency, dampness-stasis and toxin accumulation. Then she received the combined therapy of a modified Chinese herbal formula and Western medicine. During a twelve-day period of treatment, her respiratory distress and appetite quickly improved. Abnormal laboratory indicators were resumed in time and lung lesions in CT scan largely absorbed. No side effects associated with this Chinese herbal formula were found. Before discharge, two consecutive nasopharyngeal swabs were shown to be negative for severe acute respiratory coronavirus 2 (SARS-CoV-2). CONCLUSIONS: Our case report suggests that collaborative treatments with traditional Chinese medicine prove beneficial in the management of COVID-19 in critically ill patients. In order to give optimal care for this COVID-19 crisis for the whole world, Chinese medicine practitioners and Western medical doctors should work together in frontline.

Effect of sitting and lying Liuzijue for lung rehabilitation in acute exacerbation of chronic obstructive pulmonary disease patients with non-invasive ventilation: Study protocol for a randomized controlled trial.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is a lung disease with the highest incidence and high mortality in the world. Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) can significantly accelerate the progression of the disease. Pulmonary rehabilitation is one of the effective treatment methods in COPD patients, but few studies have focused on the effect of pulmonary rehabilitation in AECOPD patients. Liuzijue can improve the pulmonary function and relieve symptoms of COPD patients. However, due to the influence of disease and non-invasive ventilation (NIV), AECOPD patients have poor compliance with getting out of bed at the early stage. Sitting and lying Liuzijue is more suitable in AECOPD patients with NIV. Therefore, this study will evaluate the effect of sitting and lying Liuzijue for lung function, exercise endurance, and quality of life in AEOPD patients with NIV. METHODS: This study is a clinical randomized controlled trial. Sixty four AECOPD patients with NIV will be randomly divided into the experimental group and the control group. All participants will be treated with routine treatment and nursing according to their specific condition. The experimental group will be combined with sitting and lying Liuzijue on the basis of the control group. The duration of the exercise will be 3 months. The primary outcomes are the pulmonary function test and 6-minute walking test (6MWT). The secondary outcome measures include blood gas parameters, dyspnea index (the Modified Medical Research Council Dyspnea Scale [mMRC]), the body-mass, airflow obstruction, dyspnea and exercise capacity (BODE) index, anxiety, and depression (Hospital Anxiety and Depression Scale [HADS]), and quality of life (St·George Respiratory Questionnaire [SGRQ]). The measurement of outcomes will be evaluated at week 13. DISCUSSION: It's imperative to focus on pulmonary rehabilitation in AECOPD patients. The purpose of this study is to evaluate the effect of sitting and lying Liuzijue for pulmonary rehabilitation in AECOPD patients with NIV. TRIAL REGISTRATION: ChiCTR2000034530, Registered on July 8th, 2020.

Heart, lungs, and muscle interplay in worsening activity-related breathlessness in advanced cardiopulmonary disease.

PURPOSE OF REVIEW: Activity-related breathlessness is a key determinant of poor quality of life in patients with advanced cardiorespiratory disease. Accordingly, palliative care has assumed a prominent role in their care. The severity of breathlessness depends on a complex combination of negative cardiopulmonary interactions and increased afferent stimulation from systemic sources. We review recent data exposing the seeds and consequences of these abnormalities in combined heart failure and chronic obstructive pulmonary disease (COPD). RECENT FINDINGS: The drive to breathe increases ('excessive breathing') secondary to an enlarged dead space and hypoxemia (largely COPD-related) and heightened afferent stimuli, for example, sympathetic overexcitation, muscle ergorreceptor activation, and anaerobic metabolism (largely heart failure-related). Increased ventilatory drive might not be fully translated into the expected lung-chest wall displacement because of the mechanical derangements brought by COPD ('inappropriate breathing'). The latter abnormalities, in turn, negatively affect the central hemodynamics which are already compromised by heart failure. Physical activity then decreases, worsening muscle atrophy and dysfunction. SUMMARY: Beyond the imperative of optimal pharmacological treatment of each disease, strategies to lessen ventilation (e.g., walking aids, oxygen, opiates and anxiolytics, and cardiopulmonary rehabilitation) and improve mechanics (heliox, noninvasive ventilation, and inspiratory muscle training) might mitigate the burden of this devastating symptom in advanced heart failure-COPD.

Integrated Care Intervention Supported by a Mobile Health Tool for Patients Using Noninvasive Ventilation at Home: Randomized Controlled Trial.

BACKGROUND: Home-based noninvasive ventilation has proven cost-effective. But, adherence to therapy still constitutes a common clinical problem. We hypothesized that a behavioral intervention supported by a mobile health (mHealth) app could enhance patient self-efficacy. It is widely accepted that mHealth-supported services can enhance productive interactions among the stakeholders involved in home-based respiratory therapies. OBJECTIVE: This study aimed to measure changes in self-efficacy in patients with chronic respiratory failure due to diverse etiologies during a 3-month follow-up period after the intervention. Ancillary objectives were assessment of usability and acceptability of the mobile app as well as its potential contribution to collaborative work among stakeholders. METHODS: A single-blind, single-center, randomized controlled trial was conducted between February 2019 and June 2019 with 67 adult patients with chronic respiratory failure undergoing home-based noninvasive ventilation. In the intervention group, a psychologist delivered a face-to-face motivational intervention. Follow-up was supported by a mobile app that allowed patients to report the number of hours of daily noninvasive ventilation use and problems with the therapy. Advice was automatically delivered by the mobile app in case of a reported problem. The control group received usual care. The primary outcome was the change in the Self Efficacy in Sleep Apnea questionnaire score. Secondary outcomes included app usability, app acceptability, continuity of care, person-centered care, and ventilatory parameters. RESULTS: Self-efficacy was not significantly different in the intervention group after the intervention (before: mean 3.4, SD 0.6; after: mean 3.4, SD 0.5, P=.51). No changes were observed in adherence to therapy nor quality of life. Overall, the mHealth tool had a good usability score (mean 78 points) and high acceptance rate (mean score of 7.5/10 on a Likert scale). It was considered user-friendly (mean score of 8.2/10 on a Likert scale) and easy to use without assistance (mean score of 8.5/10 on a Likert scale). Patients also scored the perception of continuity of care and person-centered care as high. CONCLUSIONS: The integrated care intervention supported by the mobile app did not improve patient self-management. However, the high acceptance of the mobile app might indicate potential for enhanced communication among stakeholders. The study identified key elements required for mHealth tools to provide effective support to collaborative work and personalized care. TRIAL REGISTRATION: ClinicalTrials.gov NCT03932175; https://clinicaltrials.gov/ct2/show/NCT03932175.

Comparison of preoxygenation with a high-flow nasal cannula and a simple mask before intubation during induction of general anesthesia in patients undergoing head and neck surgery: Study protocol clinical trial (SPIRIT Compliant).

BACKGROUND: To assess the arterial oxygen partial pressure (PaO2) at defined time points during preoxygenation and to compare high-flow heated humidified nasal oxygenation with standard preoxygenation using oxygen insufflation via a facemask for at least 5 minutes, before intubation during induction of general anesthesia. METHODS: This randomized, single-blinded, prospective study will be conducted in patients undergoing head and neck surgery. After standard monitoring, the artery catheter at the radial artery or dorsalis pedis artery will be placed and arterial blood gas analysis (ABGA) for baseline values will be performed simultaneously. Each group will be subjected to 1 of 2 preoxygenation methods (high-flow nasal cannula or simple facemask) for 5 minutes, and ABGA will be performed twice. After confirming intubation, we will start mechanical ventilation and check the vital signs and perform the final ABGA. DISCUSSION: This trial aims to examine the trajectory of PaO2 levels during the whole preoxygenation procedure and after intubation. We hypothesize that preoxygenation with the high-flow nasal cannula will be superior to that with the face mask. STUDY REGISTRATION: This trial was registered with the Clinical Trial Registry (NCT03896906; ClinicalTrials.gov).

Soporte ventilatorio no invasivo en insuficiencia ventilatoria aguda severa en adolescentes con enfermedad neuromuscular y obesidad: estudio de casos / Non-invasive ventilatory support in severe acute ventilatory failure in adolescents with neuromuscular disease and obesity: study of cases

Noninvasive ventilatory support (NIVS) combined with mechanical cough assist (MI-E) is an effective tool to treat patients with acute ventilatory failure due to neuromuscular disorders (NMD). Airway respiratory infection could be lethal or with risk of endotraqueal intubation, especially when vital capacity (VC) is less than 15 ml/k. We report 2 obese adolescents, aged 11 and 14 years old, with myasthenic crisis (MC) and Duchenne muscular dystrophy (DMD). The last one with a severe cifoescoliosis treated with nocturnal noninvasive ventilation at home. MC girl has been treated with pyridostigmine, prednisolone and mycophenolate. They were admitted for thymectomy and spinal surgery arthrodesis respectively. After admission they developed airway respiratory infection triggering by Methaneumovirus and were treated with oxygen therapy, non-invasive ventilation with low-pressure support and EV immunoglobulin for the MC girl. After 48 h both patients developed severe respiratory failure, Sa/FiO2 < 200, atelectasis of lower lobes and difficulty to swallow, a peak cough flow (PFT)

El soporte ventilatorio no invasivo (SVNI) y la rehabilitación respiratoria con apilamiento de aire más tos asistida manual o mecánica, son efectivas para tratar la insuficiencia ventilatoria aguda en pacientes con enfermedades neuromusculares (ENM) y deterioro progresivo de la bomba respiratoria. Las agudizaciones gatilladas por infecciones respiratorias causan insuficiencia ventilatoria aguda potencialmente mortal y con alto riesgo de intubación, en especial cuando la capacidad vital (CV) es < de 15ml/k. Se reportan 2 adolescentes obesos con ENM de 11 y 14 años con miastenia gravis y distrofia muscular de Duchenne (DMD) con asistencia ventilatoria no invasiva nocturna con baja presión de soporte (AVNI), ingresados para timectomía y artrodesis de columna respectivamente. Una vez ingresados evolucionan con insuficiencia ventilatoria aguda secundaria a una infección respiratoria por Metaneumovirus. Inicialmente fueron manejados con oxigenoterapia, AVNI y gamaglobulina endovenosa en el caso de la paciente con crisis miasténica (CM). A las 48h presentan dificultad respiratoria severa, Sa/FiO2 < 200, atelectasias bibasales y disfagia, CV de 800ml (11ml/k) en el paciente con CM y de 200 ml (2,5ml/k) en el paciente con DMD y un pico flujo tosido (PFT) < 100 l/m. Se cambia a SVNI con equipo Trilogy® y BipapA40®, en modalidad S/T (espontáneo/tiempo) y AVAPS (volumen promedio asegurado en presión de soporte) con altos parámetros ventilatorios; suspendiendo rápidamente la oxigenoterapia, al combinar tos mecánicamente asistida con in-exsufflator (MI-E) en forma intensiva. Ambos pacientes presentan mejoría clínica sostenida, de la CV, PFT y pico flujo exuflado máximo con MI-E (PFE-MI-E). El SVNI más la aplicación sistemática del MI-E hasta lograr SaO2 de al menos 95% con oxígeno ambiental evita la intubación endotraqueal en ENM, a diferencia del agravamiento producido por AVNI y oxigenoterapia con criterios clásicos.

Acute Ventilatory Support During Whole-Body Hybrid Rowing in Patients With High-Level Spinal Cord Injury: A Randomized Controlled Crossover Trial.

BACKGROUND: High-level spinal cord injury (SCI) results in profound spinal and supraspinal deficits, leading to substantial ventilatory limitations during whole-body hybrid functional electrical stimulation (FES)-rowing, a form of exercise that markedly increases the active muscle mass via electrically induced leg contractions. This study tested the effect of noninvasive ventilation (NIV) on ventilatory and aerobic capacities in SCI. METHODS: This blinded, randomized crossover study enrolled 19 patients with SCI (level of injury ranging from C4 to T8). All patients were familiar with FES-rowing and had plateaued in their training-related increases in aerobic capacity. Patients performed two FES-rowing peak exercise tests with NIV or without NIV (sham). RESULTS: NIV increased exercise tidal volume (peak, 1.50 ± 0.31 L vs 1.36 ± 0.34 L; P < .05) and reduced breathing frequency (peak, 35 ± 7 beats/min vs 38 ± 6 beats/min; P < .05) compared with the sham test, leading to no change in alveolar ventilation but a trend toward increased oxygen uptake efficiency (P = .06). In those who reached peak oxygen consumption (Vo2peak) criteria (n = 13), NIV failed to significantly increase Vo2peak (1.73 ± 0.66 L/min vs 1.78 ± 0.59 L/min); however, the range of responses revealed a correlation between changes in peak alveolar ventilation and Vo2peak (r = 0.89; P < .05). Furthermore, those with higher level injuries and shorter time since injury exhibited the greatest increases in Vo2peak. CONCLUSIONS: Acute NIV can successfully improve ventilatory efficiency during FES exercise in SCI but may not improve Vo2peak in all patients. Those who benefit most seem to be patients with cervical SCI within a shorter time since injury. TRIAL REGISTRY: ClinicalTrials.gov; Nos.: NCT02865343 and NCT03267212; URL: www.clinicaltrials.gov.

Clinical presentation, treatment, and short-term outcomes of lung injury associated with e-cigarettes or vaping: a prospective observational cohort study.

BACKGROUND: An ongoing outbreak of lung injury associated with e-cigarettes or vaping (also known as E-VALI or VALI) started in March, 2019, in the USA. The cause, diagnosis, treatment, and course of this disease remains unknown. METHODS: In this multicentre, prospective, observational, cohort study, we collected data on all patients with lung injury associated with e-cigarettes or vaping seen in Intermountain Healthcare, an integrated health system based in Utah, USA, between June 27 and Oct 4, 2019. Telecritical care, based in Salt Lake City, UT, USA, was used as the central repository for case validation, public reporting, and system-wide dissemination of expertise, which included a proposed diagnosis and treatment guideline for lung injury associated with e-cigarettes or vaping. We extracted data on patient presentation, treatment, and short-term follow-up (2 weeks after discharge) from chart review and interviews with patients undertaken by the Utah Department of Health (Salt Lake City, UT, USA). FINDINGS: 60 patients presented with lung injury associated with e-cigarettes or vaping at 13 hospitals or outpatient clinics in the integrated health system. 33 (55%) of 60 were admitted to an intensive care unit (ICU). 53 (88%) of 60 patients presented with constitutional symptoms, 59 (98%) with respiratory symptoms, and 54 (90%) with gastrointestinal symptoms. 54 (90%) of 60 were given antibiotics and 57 (95%) were given steroids. Six (10%) of 60 patients were readmitted to an ICU or hospital within 2 weeks, three (50%) of whom had relapsed with vaping or e-cigarette use. Of 26 patients who were followed up within 2 weeks, despite clinical and radiographic improvement in all, many had residual abnormalities on chest radiographs (ten [67%] of 15) and pulmonary function tests (six [67%] of nine). Two patients died and lung injury associated with e-cigarettes or vaping was thought to be a contributing factor, but not the cause of death, for both. INTERPRETATION: Lung injury associated with e-cigarettes or vaping is an emerging illness associated with severe lung injury and constitutional and gastrointestinal symptoms. Increased awareness has led to identification of a broad spectrum of severity of illness in patients who were treated with antibiotics and steroids. Despite improvement, at short-term follow-up many patients had residual abnormalities. Lung injury associated with e-cigarettes or vaping remains a clinical diagnosis with symptoms that overlap infectious and other lung diseases. Maintaining a high index of suspicion for this disease is important as work continues in understanding the cause or causes, optimal therapy, and long-term outcomes of these patients. FUNDING: Intermountain Healthcare.