Observational cohort study of changing trends in non-invasive ventilation in very preterm infants and associations with clinical outcomes.

OBJECTIVE: To determine the change in non-invasive ventilation (NIV) use over time in infants born at <32 weeks' gestation and the associated clinical outcomes. STUDY DESIGN: Retrospective cohort study using routinely recorded data from the National Neonatal Research Database of infants born at <32 weeks admitted to neonatal units in England and Wales from 2010 to 2017. RESULTS: In 56 537 infants, NIV use increased significantly between 2010 and 2017 (continuous positive airway pressure (CPAP) from 68.5% to 80.2% in 2017 and high flow nasal cannula (HFNC) from 14% to 68%, respectively) (p<0.001)). Use of NIV as the initial mode of respiratory support also increased (CPAP, 21.5%-28.0%; HFNC, 1%-7% (p<0.001)).HFNC was used earlier, and for longer, in those who received CPAP or mechanical ventilation. HFNC use was associated with decreased odds of death before discharge (adjusted OR (aOR) 0.19, 95% CI 0.17 to 0.22). Infants receiving CPAP but no HFNC died at an earlier median chronological age: CPAP group, 22 (IQR 10-39) days; HFNC group 40 (20-76) days (p<0.001). Among survivors, HFNC use was associated with increased odds of bronchopulmonary dysplasia (BPD) (aOR 2.98, 95% CI 2.81 to 3.15) and other adverse outcomes. CONCLUSIONS: NIV use is increasing, particularly as initial respiratory support. HFNC use has increased significantly with a sevenfold increase soon after birth which was associated with higher rates of BPD. As more infants survive with BPD, we need robust clinical evidence, to improve outcomes with the use of NIV as initial and ongoing respiratory support.

Temporal trends in respiratory care and bronchopulmonary dysplasia in very preterm infants over a 10-year period in Spain.

OBJECTIVE: To evaluate trends in respiratory care practices and bronchopulmonary dysplasia (BPD) among very preterm infants born in Spain between 2010 and 2019. STUDY DESIGN: This was a retrospective cohort study of data obtained from a national population-based database (SEN1500 network). Changes in respiratory care and BPD-free survival of infants with gestational age (GA) of 230-316 weeks and <1500 g were assessed over two 5-year periods. Temporal trends were examined by joinpoint and Poisson regression models and expressed as the annual per cent change and adjusted relative risk (RR) for the change per year. RESULTS: A total of 17 952 infants were included. In the second period, infants were less frequently intubated in the delivery room and during neonatal intensive care unit stay. This corresponded with an increase in use of non-invasive ventilation techniques. There were no significant differences between the periods in BPD-free survival or survival without moderate-to-severe BPD. After adjusting for covariates, the RR for the change per year was significant for the following variables: never intubated (RR 1.03, 95% CI 1.02 to 1.04); intubation in the delivery room (RR 0.98, 95% CI 0.97 to 0.99); use of nasal intermittent positive pressure ventilation (RR 1.08, 95% CI 1.05 to 1.11); and BPD-free survival (only in the group with the lowest GA; RR 0.98, 95% CI 0.97 to 0.99). CONCLUSION: Our findings reveal significant changes in respiratory care practices between 2009 and 2019. Despite an increase in use of non-invasive respiratory strategies, BPD-free survival did not improve and even worsened in the group with the lowest GA (230-256).

Effect of pressure-controlled inverse ratio ventilation on dead space during robot-assisted laparoscopic radical prostatectomy: A randomised crossover study of three different ventilator modes.

BACKGROUND: Pressure-controlled inverse inspiratory to expiratory ratio ventilation (PC-IRV) is thought to be beneficial for reducing the dead space volume. OBJECTIVE: To investigate the effects of PC-IRV on the components of dead space during robot-assisted laparoscopic radical prostatectomy (RLRP). DESIGN: A randomised crossover study of three different ventilator modes. SETTING: A single university hospital from September 2014 to April 2015. PATIENTS: Twenty consecutive study participants undergoing RLRP. INTERVENTIONS: Patients were ventilated sequentially with three different modes in random order for 30 min: volume control ventilation (VCV; inspiratory to expiratory ratio 0.5), pressure control ventilation (PCV; inspiratory to expiratory ratio 0.5) and PC-IRV. Inverse inspiratory to expiratory ratio was adjusted individually by observing the expiratory flow-time wave to prevent the risk of dynamic pulmonary hyperinflation. MAIN OUTCOME MEASURES: The primary outcome included physiological dead space (VDphys), airway dead space (VDaw), alveolar dead space (VDalv) and shunt dead space (VDshunt). VDphys was calculated by Enghoff's method. We also analysed respiratory dead space (VDresp) and VDaw using a novel analytical method. Then, VDalv and VDshunt were calculated by VDalv = VDresp - VDaw and VDshunt = VDphys - VDresp, respectively. RESULTS: The VDphys/expired tidal volume (VTE) ratio in PC-IRV (29.2 ±â€Š4.7%) was significantly reduced compared with that in VCV (43 ±â€Š8.5%) and in PCV (35.9 ±â€Š3.9%). The VDshunt/VTE in PC-IRV was significantly smaller than that in VCV and PCV. VDaw/VTE in PC-IRV was also significantly smaller than that in VCV but not that in PCV. There was no significant change in VDalv/VTE. CONCLUSION: PC-IRV with the inspiratory to expiratory ratio individually adjusted by the expiratory flow-time wave decreased VDphys/VTE in patients undergoing RLRP. TRIAL REGISTRATION: University Hospital Medical Information Network in Japan 000014004.

Intubación traqueal «a ciegas» con la mascarilla air-Q ® (ILA-Cookgas). Comparación con la mascarilla laríngea de intubación ILMA-Fastrach™ / Blind tracheal intubation with the air-Q ® (ILA-Cookgas) mask. A comparison with the ILMA-Fastrach™ laryngeal intubation mask

Introducción y objetivos. El uso de los dispositivos supraglóticos en pacientes con dificultades para la intubación y/o ventilación se ha incrementado de manera progresiva tanto en el ámbito de la anestesia como en la medicina de urgencias. Este estudio se diseñó para evaluar la tasa de éxito de intubación «a ciegas» en pacientes sin criterios de vía aérea difícil con la mascarilla air-Q®, comparándola con el dispositivo supraglótico patrón: la mascarilla laríngea de intubación ILMA-Fastrach™. Pacientes y métodos. Se incluyeron 80 pacientes (40 por grupo). La inserción de los dispositivos se realizó de acuerdo con las instrucciones de los fabricantes. Tras la colocación, se realizó un test de fugas (aplicando una presión inspiratoria de 20 cmH2O por el ventilador). Se comprobó posteriormente la visión glótica usando un fibrobroncoscopio pediátrico, y se realizó la inserción de un tubo endotraqueal a través del dispositivo. En aquellos casos en que el intento resultó fallido, se retiró el dispositivo y se repitió nuevamente la secuencia. Se evaluaron, como objetivo primario, el éxito en la intubación, y como objetivos secundarios, la ventilación adecuada, el grado de visión fibrobroncoscópica y las complicaciones observadas tras su uso. Resultados. La ventilación adecuada en el primer intento de colocación fue mayor con ILMA-Fastrach™ que con air-Q® (90 frente a 60%, p = 0,0019), y el éxito global en la ventilación (primer y segundo intentos incluidos) fue mejor con ILMA-Fastrach™ (95 frente a 80%, p = 0,04). El grado de visión glótica de acuerdo con la escala de Brimacombe fue mejor con air-Q® (84,62 frente a 37,50%, p = 0,0017) en el segundo intento, pero no en el primero. No hubo diferencias en el porcentaje de intubación con ambos dispositivos. La incidencia de dolor de garganta fue similar con los 2 dispositivos empleados. Dos pacientes en el grupo de air-Q® presentaron ronquera y desaturación arterial. Conclusiones. Ambos dispositivos fueron igualmente eficaces para conseguir una adecuada intubación «a ciegas», y la incidencia de efectos adversos fue similar también con los 2. La ILMA-Fastrach™ permitió ventilar de forma adecuada a un mayor número de pacientes, pero como no se emplearon en ningún caso maniobras adicionales de recolocación, habrá que confirmar necesariamente estos resultados con futuros estudios (AU)

Background and objectives. Supraglottic airway devices are increasingly used in anesthesia and emergency medicine as a rescue for intubation and ventilation. This study was designed to investigate the air-Q® supralaryngeal device and compare it with the ILMA-Fastrach™ for airway rescue and intubation. Patients and methods. The devices were inserted in 80 patients (40 patients in each group) according to manufacturer’ instructions. An inspiration pressure of 20 cmH2O was applied through a ventilator for checking air leaks. If no air leak was detected, the glottis status was checked using a pediatric fiberoptic bronchoscope, followed by introducing an endotracheal tube through the supraglottic device. If the first attempt was unsuccessful, the device was removed and a second attempt was made in the same way. The primary outcome was the overall success rate for intubation. Other measurements were: successful ventilation, fiberoptic glottis view and adverse events. Results. Successful first-attempt ventilation was better with the Fastrach™ than with the air-Q® (90 vs. 60%, P = .0019) and overall ventilation success (first plus second attempts) was also better with ILMA-Fastrach™ (95 vs. 80%, P = .04). View of the glottis,according to Brimacombe scale, was better with air-Q® (84.62 vs. 37.50%, P = .0017) at the second, but not at the first, attempt. There were no differences in the percentage of successful intubations between the 2 devices. The incidence of sore throat was similar with both devices. Two patients in the air-Q® group suffered hoarseness and arterial desaturation, but the difference was not statistically significant. Conclusions. Both the ILMA-Fastrach™ and the air-Q® provided a similar rate of successful intubation, but ILMA-Fastrach™ was better for ventilation. The rate of adverse events was similar with both devices. Because no additional maneuver was used to facilitated intubation, there needs to be further studies to confirm these findings (AU)

A historical perspective on expiratory muscle aids and their impact on home care.

Mechanically assisted coughing is the combination of mechanical insufflation-exsufflation to the airways in conjunction with an exsufflation-timed abdominal thrust. It has permitted in-home long-term survival of respirator-dependent users of continuous noninvasive intermittent positive pressure ventilatory support in the United States since shortly after it became available in 1952. By contrast, the first European patients to benefit from continuous noninvasive intermittent positive pressure ventilatory support were not described until institutionalized continuous noninvasive intermittent positive pressure ventilatory support users with Duchenne muscular dystrophy were described in Belgium in 2006, 2 yrs after mechanically assisted coughing was approved for sale by the European Union. Domiciliary management with continuous noninvasive intermittent positive pressure ventilatory support and mechanically assisted coughing has subsequently been described in Europe. This work describes the historical development of mechanically assisted coughing in the framework of aiding the respiratory muscles to prevent respiratory failure and avoid invasive airway intubation. Some current mechanical in-exsufflators include oscillation as a surrogate for physiologic mucociliary transport along with their assisted coughing function. Noninvasive management prolongs life while promoting cost containment and preserving quality-of-life for patients with respiratory muscle impairment.

Use of noninvasive ventilation in patients with amyotrophic lateral sclerosis.

INTRODUCTION: Noninvasive positive pressure ventilation (NIPPV) is associated with improved survival in amyotrophic lateral sclerosis (ALS) and has been widely recommended. The extent of NIPPV use in ALS patients and the factors associated with its use have not been studied. METHODS: A cross-sectional study using the ALS Patient Care Database. Analyses were performed to assess the association of patient and care characteristics with use of ventilatory support. RESULTS: 1458 patients were studied. 15.6% used NIPPV and 2.1% used invasive mechanical ventilation. Patients who used NIPPV were significantly more likely to be male and have higher income than those who did not. They were also more likely to have a gastrostomy tube, lower vital capacity, more severe disease, bulbar involvement and poorer general health status as measured by the SF-12 and Sickness Impact Profile. Multivariate analysis revealed that lower FVC, higher income and use of gastrostomy tube were independently associated with use of NIPPV. CONCLUSIONS: NIPPV is used more than seven times as frequently as invasive ventilation in ALS patients. Patients who use NIPPV have more severe disease than those who do not use any respiratory intervention. Patients with lower income are less likely to use NIPPV, which raises concerns about disparities in the care of patients with ALS.

[Artificial respiration at home seen in a 5-year perspective. Established treatment, but remarkable differences among the counties]. / Hemrespiratorbehandling i ett femårsperspektiv. Etablerad behandling, men anmärkningsvärda skillnader mellan landstingen.

The Swedish prevalence of home mechanical ventilation is 8.2 per 100.000 with 10% annual increase. There is a large span (20 vs 2 per 100.000) between "top level" and "low level" counties, in spite of Sweden's homogeneous publicly financed system for provision of health care. The largest prevalence difference was found in patients with obstructive sleep apnoea syndrome (Pickwickian type), but their blood gas and lung function data were identical in top-level vs low-level counties. These data refute the hypothesis of overprescription in top-level counties. We conclude that the most probable explanation is under-recognition of patients in low-level counties.

[Invasive and non-invasive home ventilation--changes between 1982 and 1996]. / Invasive und nichtinvasive intermittierende Selbstbeatmung--Wandel zwischen 1982 und 1996.

PATIENTS AND METHODS: In our centre, 111 patients with chronic ventilatory insufficiency (33 females, 78 males, age 48 +/- 18 years, range 3 to 76 years) were treated by intermittent positive pressure ventilation between 1982 and 1996. Underlying diseases were neuromuscular diseases in 29%, sleep-related hypoventilation in 26%, kyphoscoliosis in 15%, chronic obstructive airway disease in 15%, and post-tuberculosis syndromes in 12%. Singular indications were 1 bronchiectasis, 1 lung fibrosis and 1 cystic fibrosis. RESULTS: Until 1991, most patients were ventilated via tracheostoma (10 of 16), in the following years 87 of 95 patients could be ventilated via a nasal or facial mask. Ventilation mode was a controlled one in 80 patients and an assisted one in 31 patients, average ventilation time during night was 6 to 8 hours. In the majority of patients hypercapnia was not only removed during ventilation but also at daytime as an indicator of improvement of ventilatory insufficiency accomplished by a clearly better quality of life and daytime activity. Ten patients (9%) died due to their underlying diseases, 5 of them in the first year of intermittent ventilation.

The protracted demise of medical technology. The case of intermittent positive pressure breathing.

In this study, the effects of hospital, staff, and patient characteristics on the rates of use and abandonment of an outmoded medical technology, intermittent positive pressure breathing (IPPB) are analyzed. The study focuses specifically on the use of IPPB to treat inpatients with chronic obstructive pulmonary disease in a national sample of more than 500 community hospitals from 1980 to 1987. Cross-sectionally, hospitals with shorter case-mix-adjusted lengths of stay, private nonprofit or investor-owned hospitals, and hospitals located outside of the north central United States were more likely to abandon IPPB by 1980. Teaching status, location, ownership, volume, and source of payment all appeared to affect rates of IPPB use in 1980. The longitudinal analysis examines both the probability a hospital abandoned IPPB and declines in rates of IPPB use over the study period, conditioned on the availability of IPPB in 1980. The results show that changes in the characteristics of hospitals, patients, and physicians all help to explain variations in the abandonment of IPPB. These findings contrast with previous studies of technological change, which find hospital size to be the most important variable. Size is important in explaining the rate of use in 1980, but it has no effect on the rate of decline in use or abandonment after 1980. In general, the analysis demonstrates that a combination of factors, economic incentives as well as information, contribute to the abandonment of outmoded medical technologies. Given the surprisingly long time periods required for this process to occur, the analysis underscores the need to strengthen financial incentives that encourage appropriate medical decisions and to disseminate information about the efficacy of specific procedures more widely and effectively.