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

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

Sedation and analgesia strategies for non-invasive mechanical ventilation: A systematic review and meta-analysis.

BACKGROUND: The use of sedative and analgesic drugs during non-invasive ventilation (NIV) in patients with acute respiratory failure (ARF) is controversial. OBJECTIVES: To assess the clinical effectiveness of sedative and analgesic medications used during NIV for patients with ARF to no sedation or analgesia. In addition, to investigate the characteristics of dexmedetomidine in comparison to other medications. METHODS: PubMed, Embase, Web of Science, Cochrane Library and China National Knowledge Infrastructure (CNKI) were searched. Mean differences (MDs) or pooled risk ratios (RRs) were computed using random-effects models. We applied the Cochrane risk-of-bias assessment tool 2.0 to assess the methodological quality of eligible studies and the GRADE approach to evaluate the evidence certainty. RESULTS: Twenty-one studies were selected. Whether in Group A (using sedative and analgesic drugs vs. nonuse) or Group B (using dexmedetomidine vs. other drugs), the rates of tracheal intubation and delirium, the length of NIV, and the length of stay in the intensive care unit (ICU LOS) all decreased in both experimental groups (P < 0.05). And there were no significant differences in all-cause mortality and the incidence of hypotension between the two groups (P > 0.05), while both Group A and Group B's experimental groups had greater incidences of bradycardia. CONCLUSIONS: Administering sedative and analgesic medications during NIV can reduce the risk of tracheal intubation and delirium. Additionally, dexmedetomidine outperformed other sedative medications in terms of these clinical outcomes, making it the better option when closely monitoring patients' vital signs.

Métodos no invasivos de oxigenación en pacientes con COVID-19 / Non-invasive oxygenation methods in patients with COVID-19

Resumen: Desde el inicio de la pandemia por COVID-19, dentro de las complicaciones más frecuentes de esta infección se encuentran la neumonía y el síndrome de dificultad respiratoria aguda. La hipoxemia y el aumento del trabajo respiratorio son determinantes para adoptar diversas estrategias terapéuticas de oxigenación no invasiva en pacientes con COVID-19. Es importante conocer y describir las diferentes modalidades de oxigenoterapia no invasiva, con la finalidad de preservar la oxigenación y un adecuado trabajo respiratorio, las estrategias descritas en la literatura abarcan: cánulas nasales convencionales, cánulas nasales de alto flujo y ventilación mecánica no invasiva, aunado a otras medidas de soporte como posición prono, administración de esquemas con esteroide, inmunomoduladores y óxido nítrico inhalado. Las estrategias no invasivas de oxigenación por diferentes métodos son herramientas indispensables para el tratamiento de pacientes con neumonía por COVID-19 moderada-grave. Es necesario evaluar el dispositivo a emplear, ya que esta enfermedad tiene características heterogéneas de acuerdo con gravedad y el tiempo de evolución.

Abstract: Since the start of the COVID-19 pandemic, the most frequent complications of this infection include pneumonia and Acute Respiratory Distress Syndrome. Hypoxemia and increased work of breathing are determining factors in adopting various non-invasive oxygenation therapeutic strategies in patients with COVID-19. It is important to know and describe the different modalities of non-invasive oxygen therapy, in order to preserve oxygenation and adequate respiratory work, the strategies described in the literature include: conventional nasal cannulas, high-flow nasal cannulas and non-invasive mechanical ventilation coupled with other support measures such as prone position, administration of schemes with steroids, immunomodulators and inhaled nitric oxide. Non-invasive oxygenation strategies by different methods are essential tools for the treatment of patients with moderate-severe COVID-19 pneumonia. It is necessary to evaluate the device to be used, since this disease has heterogeneous characteristics according to severity and time of evolution.

Efficacy of high-flow nasal cannula in patients with acute heart failure: a systematic review and meta-analysis.

BACKGROUND: Acute heart failure (AHF) is often associated with diffuse insufficiency and arterial hypoxemia, requiring respiratory support for rapid and effective correction. We aimed to compare the effects of high-flow nasal cannula(HFNC) with those of conventional oxygen therapy(COT) or non-invasive ventilation(NIV) on the prognosis of patients with AHF. METHODS: We performed the search using PubMed, Embase, Web of Science, MEDLINE, the Cochrane Library, CNKI, Wanfang, and VIP databases from the inception to August 31, 2023 for relevant studies in English and Chinese. We included controlled studies comparing HFNC with COT or NIV in patients with AHF. Primary outcomes included the intubation rate, respiratory rate (RR), heart rate (HR), and oxygenation status. RESULTS: From the 1288 original papers identified, 16 studies met the inclusion criteria, and 1333 patients were included. Compared with COT, HFNC reduced the intubation rate (odds ratio [OR]: 0.29, 95% CI: 0.14-0.58, P = 0.0005), RR (standardized mean difference [SMD]: -0.73 95% CI: -0.99 - -0.47, P < 0.00001) and HR (SMD: -0.88, 95% CI: -1.07 - -0.69, P < 0.00001), and hospital stay (SMD: -0.94, 95% CI: -1.76 - -0.12, P = 0.03), and increase arterial oxygen partial pressure (PaO2), (SMD: 0.88, 95% CI: 0.70-1.06, P < 0.00001) and oxygen saturation (SpO2 [%], SMD: 0.70, 95% CI: 0.34-1.06, P = 0.0001). CONCLUSIONS: There were no significant differences in intubation rate, RR, HR, arterial blood gas parameters, and dyspnea scores between the HFNC and NIV groups. Compared with COT, HFNC effectively reduced the intubation rate and provided greater clinical benefits to patients with AHF. However, there was no significant difference in the clinical prognosis of patients with AHF between the HFNC and NIV groups. TRIAL REGISTRATION: PROSPERO (identifier: CRD42022365611).

Wolfram Syndrome: A Curious Case of Repetitive Loss of Consciousness.

Wolfram syndrome is a rare, multisystemic, progressive, and autosomal-recessive genetic disease, characterized by diabetes mellitus and diabetes insipidus, optic nerve atrophy, deafness, and other neurological signs. The diagnosis is usually based on history and clinical manifestations but genetic tests are necessary for confirmation. Currently, there are no treatments available to cure or delay disease progression. This report describes a case of a 23-year-old male diagnosed with Wolfram syndrome who presented to the emergency department with several episodes of loss of consciousness. This case reinforces the need for an early diagnosis of obstructive and central apneas, respiratory failure, and dysphagia, in order to prevent and treat the complications of this disease and to improve patients' quality of life.

High-Flow Oxygen Therapy in the Perioperative Setting and Procedural Sedation: A Review of Current Evidence.

High-flow oxygen therapy (HFOT) is a respiratory support system, through which high flows of humidified and heated gas are delivered to hypoxemic patients. Several mechanisms explain how HFOT improves arterial blood gases and enhances patients' comfort. Some mechanisms are well understood, but others are still unclear and under investigation. HFOT is an interesting oxygen-delivery modality in perioperative medicine that has many clinical applications in the intensive care unit (ICU) and the operating room (OR). The purpose of this article was to review the literature for a comprehensive understanding of HFOT in the perioperative period, as well as its uses in procedural sedation. This review will focus on the HFOT definition, its physiological benefits, and their mechanisms, its clinical uses in anesthesia, and when it is contraindicated.

Uso de la determinación transcutánea de co2 en pacientes con déficit de timidina quinasa 2 y costes de su uso en una consulta de ventilación mecánica no invasiva / Use of transcutaneous co2 determination in patients with thymidine kinase 2 deficit and costs of its use in a noninvasive mechanical ventilation consultation

Objetivo: Describir el uso de la capnografía transcutánea en una población adulta y pediátrica de pacientes con déficit de timidina quinasa 2 y hacer un estudio comparativo de costes de una determinación de gasometría arterial y capnografía en la población de nuestra consulta de VMNI. Metodología: Se realizó una anamnesis y unas pruebas funcionales respiratorias para valorar afectación de la musculatura respiratoria y calidad del sueño. Para determinar la hipoventilación, se midió la pCO2 transcutánea en vigilia y/o durante el sueño. Se realizó un estudio económico para comparar el coste de una determinación de ptcCO2 frente a la determinación mediante GSA. El estudio económico se realizó estimando la población total de pacientes que se valoraba en la consulta de VMNI de manera anual. Resultados: 9 pacientes con déficit de TK2 (4 adultos y 5 niños). A 4 pacientes se les realizó una poligrafía respiratoria basal. A la población pediátrica se les realizó un registro continuo de ptcCO2 con pulsioximetria anual. Se realizaron 4 registros con ptcCO2 y VMNI. Elcoste de la determinación de ptCO2 en comparación con la GSA fue de 6,29 euros frente a 5,37 euros. Conclusiones: La medición de la ptcCO2 es útil en la consulta de VMNI para la realización de medidas puntuales en la consulta como para monitorización continua durante el sueño. Con el uso que realizamos en nuestra consulta de la capnografía transcutánea, la determinación puntual de la pCO2 transcutánea es más económica que la realización de la GSA. (AU)

Objective: to describe the use of transcutaneous capnography in an adult and pediatric population of patients with Thymidine inase 2 deficiency and to compare the costs between blood gases by arterial gasometry (BGA) and capnography in our population. Material and methods: an anamnesis, and respiratory functional tests to assess respiratory muscle involvement, sleep quality were performed.To assess the presence of alveolar hypoventilation the determination of transcutaneous pCO2while awake and/or during sleepwas performed. An economic study has been done to compare the cost of a determination of ptcCO2 versus the determination by BGA. Results: 9 patients with TK2 deficiency (4 adults and 5 children). 4 patients underwent baseline respiratory polygraphy. The pediatric patients underwent at least one continuous recording of ptcCO2 with pulse oximetry each year.4 studies of ptcCO2 duringNIV were performed. The cost in the adult population of a punctual determination of pCO2 by BGA was 6,29 euros while for capnography was 5,37 euros. Conclusions: the measurement of ptcCO2 is useful in the consultation of NIV for the realization of specific measurements in the consultation as for continuous monitoring of this parameter. In our practice of transcutaneous capnography, the punctual determination of transcutaneous pCO2 is cheaper than the BGA. (AU)

Debilidad pulmonar asociada a COVID-19 (DPAC): revisión sistemática y metaanálisis / COVID-19-associated lung weakness (CALW): Systematic review and meta-analysis

Objetivo: Evaluar la mortalidad y diversos factores clínicos derivados del desarrollo de neumotórax (NTX) y/o neumomediastino (NMD) atraumáticos en pacientes críticos como consecuencia de la debilidad pulmonar asociada a la COVID-19 (DPAC). Diseño: Revisión sistemática con metaanálisis. Ámbito: Unidad de cuidados intensivos (UCI). Participantes: Investigaciones originales en las que se evaluase a pacientes, con o sin necesidad de ventilación mecánica invasiva (VMI), con diagnóstico de COVID-19 que hubiesen desarrollado NTX o NMD atraumáticos al ingreso o durante su estancia hospitalaria. Intervenciones: Se obtuvieron los datos de interés de cada artículo que fueron analizados y evaluados por la Escala Newcastle-Ottawa. El riesgo de las variables de interés principales se evaluó por los datos derivados de los estudios que incluyeron a pacientes que desarrollaron NTX o NMD atraumáticos. Variables de interés principales: Mortalidad, estancia media en la UCI y PaO2/FiO2 media en el momento diagnóstico. Resultados: Se recogieron datos de 12 estudios longitudinales. En el metaanálisis se incluyeron datos de un total de 4.901 pacientes, entre los cuales 1.629 presentaron un episodio de NTX y 253 de NMD atraumáticos. A pesar de encontrar asociaciones significativamente fuertes, la alta heterogeneidad entre los estudios hace que la interpretación de los resultados deba hacerse con cautela. Conclusiones: La mortalidad de los pacientes con COVID-19 fue mayor en los que desarrollaron NTX y/o NMD atraumáticos con respecto a los que no lo hicieron. La media del índice PaO2/FiO2 fue menor en los pacientes que desarrollaron NTX y/o NMD atraumáticos. Proponemos agrupar bajo el término DPAC estos casos. (AU)

Objectives: To assess mortality and different clinical factors derived from the development of atraumatic pneumothorax (PNX) and/or pneumomediastinum (PNMD) in critically ill patients as a consequence of COVID-19-associated lung weakness (CALW). Design: Systematic review with meta-analysis. Setting: Intensive care unit (ICU). Participants: Original research evaluating patients, with or without the need for protective invasive mechanical ventilation (IMV), with a diagnosis of COVID-19 who had developed atraumatic PNX or PNMD on admission or during their hospital stay. Interventions: Data of interest were obtained from each article and analysed and assessed by the Newcastle-Ottawa Scale. The risk of the variables of interest was assessed by data derived from studies including patients who developed atraumatic PNX or PNMD. Main variables of interest: Mortality, mean ICU length of stay and mean PaO2/FiO2 at diagnosis. Results: Data were collected from 12 longitudinal studies. Data from a total of 4,901 patients were included in the meta-analysis. A total of 1,629 patients had an episode of atraumatic PNX and 253 patients had an episode of atraumatic PNMD. Despite finding significantly strong associations, the high heterogeneity between studies means that interpretation of the results should be made with caution. Conclusions: Mortality of COVID-19 patients was higher in those who developed atraumatic PNX and/or PNMD compared to those who did not. The mean PaO2/FiO2 index was lower in patients who developed atraumatic PNX and/or PNMD. We propose to group these cases under the term CAPD. (AU)

Psychological Factors Influencing Adherence to NIV in Neuromuscular Patients Dependent on Non Invasive Mechanical Ventilation: Preliminary Results.

BACKGROUND: Non-invasive ventilation (NIV) is associated with improvement of both morbility and mortality in patients affected by neuromuscular diseases with chronic respiratory failure. Several studies have also shown that long-term NIV positively impacts the patient's quality of life and perception of disease status. Its effectiveness is likely related to the adherence to NIV. Several factors, patient- and not patient-related, may compromise adherence to NIV, such as physical, behavioral, familiar, and social issues. Few data are currently available on the role of psychological factors in influencing NIV adherence. MATERIALS AND METHODS: In this pilot study, we evaluated the adherence to NIV in a group of 15 adult patients with neuromuscular diseases (Duchenne muscular dystrophy, myotonic dystrophy, and amyotrophic lateral sclerosis) in relation to their grade of depression assessed by the Beck Depression Inventory (BDI) questionnaire. Other data were collected, such as clinical features (age and sex), use of anxiolytic drugs, the presence of a family or professional caregiver, the quality of patient-physician relationship, the beginning of psychological support after BDI screening, and the family acceptance of NIV. NIV adherence was definied as the use of NIV for at least 4 h per night on 70% of nights in a month. RESULTS: The overall rate of NIV adherence was 60%. Based on the BDI questionnaire, patients who were non-adherent to NIV had a higher rate of depression, mainly observed in the oldest patients. The acceptance of NIV by the family and positive physician-patient interaction seem to favor NIV adherence. CONCLUSION: Depression can interfere with NIV adherence in patients with neuromuscolar diseases.

The Use of High-Flow Nasal Cannula and Non-Invasive Mechanical Ventilation in the Management of COVID-19 Patients: A Prospective Study.

High-flow nasal cannula (HFNC) and ventilator-delivered non-invasive mechanical ventilation (NIV) were used to treat acute respiratory distress syndrome (ARDS) due to COVID-19 pneumonia, especially in low- and middle-income countries (LMICs), due to lack of ventilators and manpower resources despite the paucity of data regarding their efficacy. This prospective study aimed to analyse the efficacy of HFNC versus NIV in the management of COVID-19 ARDS. A total of 88 RT-PCR-confirmed COVID-19 patients with moderate ARDS were recruited. Linear regression and generalized estimating equations (GEEs) were used for trends in vital parameters over time. A total of 37 patients were on HFNC, and 51 were on NIV. Patients in the HFNC group stayed slightly but not significantly longer in the ICU as compared to their NIV counterparts (HFNC vs. NIV: 8.00 (4.0-12.0) days vs. 7.00 (2.0-12.0) days; p = 0.055). Intubation rates, complications, and mortality were similar in both groups. The switch to HFNC from NIV was 5.8%, while 37.8% required a switch to NIV from HFNC. The resolution of respiratory alkalosis was better with NIV. We conclude that in patients with COVID-19 pneumonia with moderate ARDS, the duration of treatment in the ICU, intubation rate, and mortality did not differ significantly with the use of HFNC or NIV for respiratory support.

Effects of Different Anticoagulation Doses on Moderate-to-Severe COVID-19 Pneumonia With Hypoxemia.

Background COVID-19 is a prothrombotic disease that can cause thromboembolism and microthrombi, which could lead to multiorgan failure and death. Since COVID-19 is a relatively new disease, there are guidelines for anticoagulation dosing for COVID-19 patients without consensus on the dosing. We studied the effects of different doses of anticoagulation in hospitalized patients with COVID-19 pneumonia and hypoxemia on any differences in need for high-flow oxygen, mechanical ventilation, and mortality. We also analyzed the patient population who benefited most from anticoagulation. Methodology We performed a retrospective chart review of all patients who were admitted with the diagnosis of COVID-19 infection with positive polymerase chain reaction, pneumonia (confirmed either by chest X-ray or CT chest), and hypoxemia (oxygen saturation of <94%, while on room air). These patients were studied for outcomes (the need for high-flow oxygen, the requirement for mechanical ventilation, and overall mortality) for different doses of anticoagulation (prophylactic, escalated, and therapeutic). Results The sample consists of 132 subjects, predominantly males (116, 87%), with a mean age of 59 years and a standard deviation of 15. About one-third of the participants had diabetes, and more than 50% had hypertension. Additionally, 27 (20.3%) had a history of heart disease, and 70 (53%) of the subjects were admitted to the intensive care unit (ICU) at some point during the study. Among those admitted to the ICU, about 11 (8%) subjects required mechanical ventilation and 16 (12%) passed away during the study. Those who died had higher use of high-flow oxygen, noninvasive mechanical ventilation, and invasive mechanical ventilation and had a longer stay on mechanical ventilation. There was no significant difference in mortality or need for mechanical ventilation for any strategy of anticoagulation. Conclusions Different doses of anticoagulation did not show any statistically significant relationship between the need for mechanical ventilation and mortality. More patients on high-flow oxygen had received escalated doses of anticoagulation as compared to those who were not on high-flow oxygen. Anticoagulation levels did not have any statistically significant effect on overall survival of patients.

COVID-19-associated lung weakness (CALW): Systematic review and meta-analysis.

OBJECTIVES: To assess mortality and different clinical factors derived from the development of atraumatic pneumothorax (PNX) and/or pneumomediastinum (PNMD) in critically ill patients as a consequence of COVID-19-associated lung weakness (CALW). DESIGN: Systematic review with meta-analysis. SETTING: Intensive Care Unit (ICU). PARTICIPANTS: Original research evaluating patients, with or without the need for protective invasive mechanical ventilation (IMV), with a diagnosis of COVID-19, who developed atraumatic PNX or PNMD on admission or during hospital stay. INTERVENTIONS: Data of interest were obtained from each article and analyzed and assessed by the Newcastle-Ottawa Scale. The risk of the variables of interest was assessed with data derived from studies including patients who developed atraumatic PNX or PNMD. MAIN VARIABLES OF INTEREST: Mortality, mean ICU stay and mean PaO2/FiO2 at diagnosis. RESULTS: Information was collected from 12 longitudinal studies. Data from a total of 4901 patients were included in the meta-analysis. A total of 1629 patients had an episode of atraumatic PNX and 253 patients had an episode of atraumatic PNMD. Despite the finding of significantly strong associations, the great heterogeneity between studies implies that the interpretation of results should be made with caution. CONCLUSIONS: Mortality among COVID-19 patients was higher in those who developed atraumatic PNX and/or PNMD compared to those who did not. The mean PaO2/FiO2 index was lower in patients who developed atraumatic PNX and/or PNMD. We propose grouping these cases under the term COVID-19-associated lung weakness (CALW).

[COVID-19-associated lung weakness (CALW): Systematic review and meta-analysis]. / Debilidad pulmonar asociada a COVID-19 (DPAC): revisión sistemática y metaanálisis.

Objectives: To assess mortality and different clinical factors derived from the development of atraumatic pneumothorax (PNX) and/or pneumomediastinum (PNMD) in critically ill patients as a consequence of COVID-19-associated lung weakness (CALW). Design: Systematic review with meta-analysis. Setting: Intensive care unit (ICU). Participants: Original research evaluating patients, with or without the need for protective invasive mechanical ventilation (IMV), with a diagnosis of COVID-19 who had developed atraumatic PNX or PNMD on admission or during their hospital stay. Interventions: Data of interest were obtained from each article and analysed and assessed by the Newcastle-Ottawa Scale. The risk of the variables of interest was assessed by data derived from studies including patients who developed atraumatic PNX or PNMD. Main variables of interest: Mortality, mean ICU length of stay and mean PaO2/FiO2 at diagnosis. Results: Data were collected from 12 longitudinal studies. Data from a total of 4,901 patients were included in the meta-analysis. A total of 1,629 patients had an episode of atraumatic PNX and 253 patients had an episode of atraumatic PNMD. Despite finding significantly strong associations, the high heterogeneity between studies means that interpretation of the results should be made with caution. Conclusions: Mortality of COVID-19 patients was higher in those who developed atraumatic PNX and/or PNMD compared to those who did not. The mean PaO2/FiO2 index was lower in patients who developed atraumatic PNX and/or PNMD. We propose to group these cases under the term CAPD.

Uso de cánula nasal de alto flujo artesanal como oxigenoterapia en insuficiencia respiratoria por COVID-19 / Use of artisanal high flow nasal cannula as oxygen therapy in respiratory failure due to COVID-19

Los riesgos asociados a la neumonía por (SARS-CoV-2) es la generación de insuficiencia respiratoria secundaria que en algunos casos desencadenara al tan temido síndrome de distres respiratorio (SDRA); Informes sobre atención clínica, indican que tiene una incidencia (SDRA) de 3-10 % con necesidad de Asistencia Respiratoria Mecánica (ARM) en pacientes hospitalizados; por lo que dispositivos de oxigenación no invasivos siguen siendo una opción atractiva, de forma inicial. Caso clínico: mujer de 47 años con insuficiencia respiratoria secundario a neumonía por COVID-19, por la gravedad se indica su ingreso a terapia intensiva, pero por razones de falta de unidad es manejada en unidad respiratoria, con el uso de dispositivos de oxigenación de armado ARTESAL, de manera exitosa, con la utilización de CNAF-artesanal, se pretende mejorar el trabajo respiratorio, índices de oxigenación, mientras se da tratamiento a la infección por el COVID-19; el objetivo del presente caso es reportar el presente caso con evolución favorable a la literatura disponible. Discusión: El uso de terapia de oxigenación con dispositivo de Cánula Nasal de Alto Flujo, aún no ha sido normatizado en pacientes con COVID-19, pero existe evidencia clínica sobre los efectos beneficiosos en la insuficiencia respiratoria en neonatos mas no en adultos. Conclusión: El uso temprano de la CNAF-artesanal en la insuficiencia respiratoria resulta muy atractivo, más aún con dispositivo de confección artesanal, da una opción más al paciente fuera de UTI, pudiendo apoyar en evitar la intubación y su ingreso a ventilación mecánica.

The risks associated with pneumonia (SARS-CoV-2) is the generation of secondary respiratory failure that in some cases will trigger the much feared respiratory distress syndrome (ARDS); Reports on clinical care indicate that it has an incidence (ARDS) of 3-10% with the need for Mechanical Respiratory Assistance (ARM) in hospitalized patients; so non-invasive oxygenation devices remain an attractive option, initially. Clinical case: a 47-year-old woman with respiratory failure secondary to covid-19 pneumonia. Due to the severity, her admission to intensive care is indicated, but for reasons of lack of unity, she is managed in a common room, with the use of high-pressure oxygenation devices. ARTISAL assembly, successfully, with the use of CNAF-artisanal, is intended to improve the work of breathing, and oxygenation indices, while treating the infection by COVID-19; The objective of this case is to report the present case with a favorable evolution based on the available literature. Discussion: The use of oxygenation therapy with a High Flow Nasal Cannula device has not yet been standardized in patients with COVID-19, but there is clinical evidence on the beneficial effects in respiratory failure in neonates but not in adults. Conclusion: The early use of the artisan HFNC in respiratory failure is very attractive, even more so with an artisanal device, it gives the patient another option outside the ICU, being able to help avoid intubation and admission to mechanical ventilation.

The role of prone positioning in patients with SARS-CoV-2-related respiratory failure in non-intensive care unit.

BACKGROUND: Prone positioning (PP) is an established and commonly used lung recruitment method for intubated patients with severe acute respiratory distress syndrome, with potential benefits in clinical outcome. The role of PP outside the intensive care unit (ICU) setting is debated. OBJECTIVES: We aimed at assessing the role of PP in death and ICU admission in non-intubated patients with acute respiratory failure related to COronaVIrus Disease-19 (COVID-19) pneumonia. DESIGN: This is a retrospective analysis of a collaborative multicenter database obtained by merging local non-interventional cohorts. METHODS: Consecutive adult patients with COVID-19-related respiratory failure were included in a collaborative cohort and classified based on the severity of respiratory failure according to the partial arterial oxygen pressure to fraction of inspired oxygen ratio (PaO2/FiO2) and on clinical severity by the quick Sequential Organ Failure Assessment (qSOFA) score. The primary study outcome was the composite of in-hospital death or ICU admission within 30 days from hospitalization. RESULTS: PP was used in 114 of 536 study patients (21.8%), more commonly in patients with lower PaO2/FiO2 or receiving non-invasive ventilation and less commonly in patients with known comorbidities. A primary study outcome event occurred in 163 patients (30.4%) and in-hospital death in 129 (24.1%). PP was not associated with death or ICU admission (HR 1.17, 95% CI 0.78-1.74) and not with death (HR 1.01, 95% CI 0.61-1.67) at multivariable analysis; PP was an independent predictor of ICU admission (HR 2.64, 95% CI 1.53-4.40). The lack of association between PP and death or ICU admission was confirmed at propensity score-matching analysis. CONCLUSION: PP is used in a non-negligible proportion of non-intubated patients with COVID-19-related severe respiratory failure and is not associated with death but with ICU admission. The role of PP in this setting merits further evaluation in randomized studies.

Non-invasive Ventilation Failure - Predict and Protect.

Modified heart rate, acidosis, consciousness, oxygenation and respiratory rate (HACOR) score takes into consideration pneumonia, cardiogenic pulmonary edema, pulmonary acute respiratory distress syndrome (ARDS), immunosuppression, septic shock, and the sequential organ failure assessment (SOFA) score prior to non-invasive mechanical ventilation (NIV) that would impact the success of NIV and are commonly seen in patients presenting to the emergency. Propensity score matching could have been done for similar distribution of baseline characteristics. Specific objective criteria are needed to define respiratory failure requiring intubation. How to cite this article: Pratyusha K, Jindal A. Non-invasive Ventilation Failure - Predict and Protect. Indian J Crit Care Med 2023;27(2):149.

Inspiratory Effort and Respiratory Mechanics in Patients with Acute Exacerbation of Idiopathic Pulmonary fibrosis: A Preliminary Matched Control Study.

BACKGROUND: Patients with acute exacerbation of idiopathic pulmonary fibrosis (AE-IPF) may experience severe acute respiratory failure, even requiring ventilatory assistance. Physiological data on lung mechanics during these events are lacking. METHODS: Patients with AE-IPF admitted to Respiratory Intensive Care Unit to receive non-invasive ventilation (NIV) were retrospectively analyzed. Esophageal pressure swing (ΔPes) and respiratory mechanics before and after 2 hours of NIV were collected as primary outcome. The correlation between positive end-expiratory pressure (PEEP) levels and changes of in dynamic compliance (dynCRS) and PaO2/FiO2 ratio was assessed. Further, an exploratory comparison with a historical cohort of ARDS patients matched 1:1 by age, sequential organ failure assessment score, body mass index and PaO2/FiO2 level was performed. RESULTS: At baseline, AE-IPF patients presented a high respiratory drive activation with ΔPes = 27 (21-34) cmH2O, respiratory rate (RR) = 34 (30-39) bpm and minute ventilation (VE) = 21 (20-26) L/min. Two hours after NIV application, ΔPes, RR and VE values showed a significant reduction (16 [14-24] cmH2O, p<0.0001, 27 [25-30] bpm, p=0.001, and 18 [17-20] L/min, p=0.003, respectively) while no significant change was found in dynamic transpulmonary pressure, expiratory tidal volume (Vte), dynCRS and dynamic mechanical power. PEEP levels negatively correlated with PaO2/FiO2 ratio and dynCRS (r=-0.67, p=0.03 and r=-0.27, p=0.4, respectively). When compared to AE-IPF, ARDS patients presented lower baseline ΔPes, RR, VE and dynamic mechanical power. Differently from AE-IPF, in ARDS both Vte and dynCRS increased significantly following NIV (p=0.01 and p=0.004 respectively) with PEEP levels directly associated with PaO2/FiO2 ratio and dynCRS (r=0.24, p=0.5 and r=0.65, p=0.04, respectively). CONCLUSIONS: In this study, patients with AE-IPF showed a high inspiratory effort, whose intensity was reduced by NIV application without a significant improvement in respiratory mechanics. In an exploratory analysis, AE-IPF patients showed a different mechanical behavior under spontaneous unassisted and assisted breathing compared with ARDS patients of similar severity.

Use of inflammatory markers as predictor for mechanical ventilation in COVID-19 patients with stages IIIb-V chronic kidney disease?

BACKGROUND: Studies have shown elevated C-reactive protein (CRP) to predict mechanical ventilation (MV) in patients with coronavirus disease 2019 (COVID-19). Its utility is unknown in patients with chronic kidney disease (CKD), who have elevated baseline CRP levels due to chronic inflammation and reduced renal clearance. AIM: To assess whether an association exists between elevated inflammatory markers and MV rate in patients with stages IIIb-V CKD and COVID-19. METHODS: We conducted a retrospective cohort study on patients with COVID-19 and stages IIIb-V CKD. The primary outcome was the rate of invasive MV, the rate of noninvasive MV, and the rate of no MV. Statistical analyses used unpaired t-test for continuous variables and chi-square analysis for categorical variables. Cutoffs for variables were CRP: 100 mg/L, ferritin: 530 ng/mL, D-dimer: 0.5 mg/L, and lactate dehydrogenase (LDH): 590 U/L. RESULTS: 290 were screened, and 118 met the inclusion criteria. CRP, D-dimer, and ferritin were significantly different among the three groups. On univariate analysis for invasive MV (IMV), CRP had an odds ratio (OR)-5.44; ferritin, OR-2.8; LDH, OR-7.7; D-dimer, OR-3.9, (P < 0.05). The admission CRP level had an area under curve-receiver operator characteristic (AUROC): 0.747 for the IMV group (sensitivity-80.8%, specificity-50%) and 0.663 for the non-IMV (NIMV) group (area under the curve, sensitivity-69.2%, specificity-53%). CONCLUSION: Our results demonstrate a positive correlation between CRP, ferritin, and D-dimer levels and MV and NIMV rates in CKD patients. The AUROC demonstrates a good sensitivity for CRP levels in detecting the need for MV in patients with stages IIIb-V CKD. This may be because of the greater magnitude of increased inflammation due to COVID-19 itself compared with increased inflammation and reduced clearance due to CKD alone.

Influence of Non-invasive Ventilation in an Adult Patient With Acute Epiglottitis: A Case Report.

Adult acute epiglottitis is a rare, life-threatening disease that requires prompt airway management, resuscitation, and stabilization. This case report discusses a patient with type ΙΙ respiratory failure due to acute epiglottitis, which was managed successfully with non-invasive positive-pressure ventilation in the emergency department. We report a case of a male patient in his 30s who arrived at the emergency department complaining of sore throat, cough, and shortness of breath. He was found to be in severe respiratory distress. The patient's condition improved dramatically after non-invasive positive-pressure ventilation, which prevented the need for endotracheal intubation. He was admitted to the ICU and discharged without complications five days later. Non-invasive positive-pressure ventilation may help manage moderate cases of acute epiglottitis with partial airway obstruction as a bridging therapy until other treatments have decreased edema, thus preventing the need for endotracheal intubation.

Inhaled Nitric Oxide (iNO) With a Massive Pulmonary Embolism: A Case Report.

Massive pulmonary embolism (PE) is a type of complication related to the migration of deep venous thrombi clot to the lungs. Massive PE is associated with a high level of morbidity and mortality due to elevated pulmonary vascular resistance that can cause right ventricular failure, cardiogenic shock, and hypoxemia. This report aims to explain to the readers the efficacy of applying inhaled nitric oxide (iNO) to patients with a massive PE. It also aims to evaluate iNO's pulmonary vasodilator efficacy for acute PE.