Indications and techniques of non-invasive ventilation (NIV) in neuromuscular diseases.

The neuromuscular patients may experience the need for respiratory support due to the onset of respiratory failure. Some skills are essential to achieve therapeutic success. In addition to technical knowledge, it is essential to have knowledge relating to individual neuromuscular diseases. The availability of alternative respiratory supports and various interfaces can be a valuable weapon at different moments in the course of the neuromuscular disease. Furthermore, the doctor-patient relationship plays a key role as does taking care of the patient's psychological sphere.

Nutrition therapy in non-intubated patients with acute respiratory failure: a narrative review.

Objectives: Non-invasive ventilation use is increasing in patients from acute respiratory failure. However, nutritional assessment and medical nutritional therapy are often missed and patients may be frequently underfed. This review evaluates the tools for nutritional screening and assessment, assesses the use of medical nutritional therapy in various techniques of non invasive ventilation and suggested tools to improve this therapy. Methods, results: A review of the literature was performed to evaluate the tools available to define malnutrition and determine the energy needs of patients requiring non invasive ventilation. Energy and protein intake was assessed in 16 recent papers. High Flow Nasal Cannula Oxygen therapy and non invasive ventilation using mask were described and nutritional therapy determined in each condition.The Global Leadership International Malnutrition Assessment seems to be the best assessment to be recommended. Energy expenditure is optimally obtained by indirect calorimetry. Patients with Non invasive ventilation are even more underfed than patients receiving High Flow Nasal Cannula Oxygen therapy. Conclusions: A better determination of malnutrition, a more adequate energy requirement and an improved energy and protein administration are required in patients with acute respiratory failure treated with non invasive ventilation.

Practical recommendations for swallowing and speaking during NIV in people with neuromuscular disorders.

Objectives: The functions of eating, drinking, speaking, and breathing demand close coordination of the upper airway musculature which may be challenged by the long-term use of daytime non-invasive ventilation (NIV). This rapid review explores the challenges and practicalities of these interactions in people with neuromuscular disorders. Methods: A search was performed on PubMed (period 2000-2023) using generic terms to refer to eating, drinking, and speaking related to people with neuromuscular disorders on NIV. A narrative approach was used to summarize the available literature. Results: Our review shows only a small number of studies exist exploring the use of NIV on swallowing and speaking in people with neuromuscular disorders. We summarize study findings and provide practical advice on eating, drinking and speaking with NIV. Conclusions: By understanding breathing, NIV mechanics and upper airway interactions, it is possible to optimize swallowing and speaking whilst using NIV. There is a lack of specific guidelines, and concerns regarding aspiration warrant further research and guideline development.

Enhancing respiratory function in neuromuscular disease: the role of non-invasive ventilation. A narrative review.

Neuromuscular diseases (NMDs) comprise a heterogeneous group of conditions characterized by extreme progressive muscle weakness leading to respiratory failure. Noninvasive mechanical ventilation (NIV) has emerged as a cornerstone in the management of respiratory complications associated with NMDs. This review aims to elucidate the role of NMV in respiratory function, improving quality of life, and prolonging survival in individuals with NMD. The physiological basis of respiratory impairment in NMDs, principles of NMV application, evidence supporting its efficacy, patient selection criteria, and potential challenges in its application are discussed.

Effect of noninvasive ventilation on mortality and clinical outcomes among patients with severe hypoxemic COVID-19 pneumonia after high-flow nasal oxygen failure: a multicenter retrospective French cohort with propensity score analysis.

BACKGROUND: We assessed the effect of noninvasive ventilation (NIV) on mortality and length of stay after high flow nasal oxygenation (HFNO) failure among patients with severe hypoxemic COVID-19 pneumonia. METHODS: In this multicenter, retrospective study, we enrolled COVID-19 patients admitted in intensive care unit (ICU) for severe COVID-19 pneumonia with a HFNO failure from December 2020 to January 2022. The primary outcome was to compare the 90-day mortality between patients who required a straight intubation after HFNO failure and patients who received NIV after HFNO failure. Secondary outcomes included ICU and hospital length of stay. A propensity score analysis was performed to control for confounding factors between groups. Exploratory outcomes included a subgroup analysis for 90-day mortality. RESULTS: We included 461 patients with HFNO failure in the analysis, 233 patients in the straight intubation group and 228 in the NIV group. The 90-day mortality did not significantly differ between groups, 58/228 (25.4%) int the NIV group compared with 59/233 (25.3%) in the straight intubation group, with an adjusted hazard ratio (HR) after propensity score weighting of 0.82 [95%CI, 0.50-1.35] (p = 0.434). ICU length of stay was significantly shorter in the NIV group compared to the straight intubation group, 10.0 days [IQR, 7.0-19.8] versus 18.0 days [IQR,11.0-31.0] with a propensity score weighted HR of 1.77 [95%CI, 1.29-2.43] (p < 0.001). A subgroup analysis showed a significant increase in mortality rate for intubated patients in the NIV group with 56/122 (45.9%), compared to 59/233 (25.3%) for patients in the straight intubation group (p < 0.001). CONCLUSIONS: In severely hypoxemic COVID-19 patients, no significant differences were observed on 90-day mortality between patients receiving straight intubation and those receiving NIV after HFNO failure. NIV strategy was associated with a significant reduction in ICU length of stay, despite an increase in mortality in the subgroup of patients finally intubated.

High-flow nasal oxygen therapy compared with conventional oxygen therapy in hospitalised patients with respiratory illness: a systematic review and meta-analysis.

BACKGROUND: High-flow nasal oxygen therapy (HFNO) is used in diverse hospital settings to treat patients with acute respiratory failure (ARF). This systematic review aims to summarise the evidence regarding any benefits HFNO therapy has compared with conventional oxygen therapy (COT) for patients with ARF. METHODS: Three databases (Embase, Medline and CENTRAL) were searched on 22 March 2023 for studies evaluating HFNO compared with COT for the treatment of ARF, with the primary outcome being hospital mortality and secondary outcomes including (but not limited to) escalation to invasive mechanical ventilation (IMV) or non-invasive ventilation (NIV). Risk of bias was assessed using the Cochrane risk-of-bias tool (randomised controlled trials (RCTs)), ROBINS-I (non-randomised trials) or Newcastle-Ottawa Scale (observational studies). RCTs and observational studies were pooled together for primary analyses, and secondary analyses used RCT data only. Treatment effects were pooled using the random effects model. RESULTS: 63 studies (26 RCTs, 13 cross-over and 24 observational studies) were included, with 10 230 participants. There was no significant difference in the primary outcome of hospital mortality (risk ratio, RR 1.08, 95% CI 0.93 to 1.26; p=0.29; 17 studies, n=5887) between HFNO and COT for all causes ARF. However, compared with COT, HFNO significantly reduced the overall need for escalation to IMV (RR 0.85, 95% CI 0.76 to 0.95 p=0.003; 39 studies, n=8932); and overall need for escalation to NIV (RR 0.70, 95% CI 0.50 to 0.98; p=0.04; 16 studies, n=3076). In subgroup analyses, when considering patients by illness types, those with acute-on-chronic respiratory failure who received HFNO compared with COT had a significant reduction in-hospital mortality (RR 0.58, 95% CI 0.37 to 0.91; p=0.02). DISCUSSION: HFNO was superior to COT in reducing the need for escalation to both IMV and NIV but had no impact on the primary outcome of hospital mortality. These findings support recommendations that HFNO may be considered as first-line therapy for ARF. PROSPERO REGISTRATION NUMBER: CRD42021264837.

Racial Differences in Accuracy of Predictive Models for High-Flow Nasal Cannula Failure in COVID-19.

OBJECTIVES: To develop and validate machine learning (ML) models to predict high-flow nasal cannula (HFNC) failure in COVID-19, compare their performance to the respiratory rate-oxygenation (ROX) index, and evaluate model accuracy by self-reported race. DESIGN: Retrospective cohort study. SETTING: Four Emory University Hospitals in Atlanta, GA. PATIENTS: Adult patients hospitalized with COVID-19 between March 2020 and April 2022 who received HFNC therapy within 24 hours of ICU admission were included. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Four types of supervised ML models were developed for predicting HFNC failure (defined as intubation or death within 7 d of HFNC initiation), using routine clinical variables from the first 24 hours of ICU admission. Models were trained on the first 60% (n = 594) of admissions and validated on the latter 40% (n = 390) of admissions to simulate prospective implementation. Among 984 patients included, 317 patients (32.2%) developed HFNC failure. eXtreme Gradient Boosting (XGB) model had the highest area under the receiver-operator characteristic curve (AUROC) for predicting HFNC failure (0.707), and was the only model with significantly better performance than the ROX index (AUROC 0.616). XGB model had significantly worse performance in Black patients compared with White patients (AUROC 0.663 vs. 0.808, p = 0.02). Racial differences in the XGB model were reduced and no longer statistically significant when restricted to patients with nonmissing arterial blood gas data, and when XGB model was developed to predict mortality (rather than the composite outcome of failure, which could be influenced by biased clinical decisions for intubation). CONCLUSIONS: Our XGB model had better discrimination for predicting HFNC failure in COVID-19 than the ROX index, but had racial differences in accuracy of predictions. Further studies are needed to understand and mitigate potential sources of biases in clinical ML models and to improve their equitability.

Implications of sedation during the use of noninvasive ventilation in children with acute respiratory failure (SEDANIV Study).

BACKGROUND: The objective of this study was to analyze the effects of sedation administration on clinical parameters, comfort status, intubation requirements, and the pediatric intensive care unit (PICU) length of stay (LOS) in children with acute respiratory failure (ARF) receiving noninvasive ventilation (NIV). METHODS: Thirteen PICUs in Spain participated in a prospective, multicenter, observational trial from January to December 2021. Children with ARF under the age of five who were receiving NIV were included. Clinical information and comfort levels were documented at the time of NIV initiation, as well as at 3, 6, 12, 24, and 48 h. The COMFORT-behavior (COMFORT-B) scale was used to assess the patients' level of comfort. NIV failure was considered to be a requirement for endotracheal intubation. RESULTS: A total of 457 patients were included, with a median age of 3.3 months (IQR 1.3-16.1). Two hundred and thirteen children (46.6%) received sedation (sedation group); these patients had a higher heart rate, higher COMFORT-B score, and lower SpO2/FiO2 ratio than did those who did not receive sedation (non-sedation group). A significantly greater improvement in the COMFORT-B score at 3, 6, 12, and 24 h, heart rate at 6 and 12 h, and SpO2/FiO2 ratio at 6 h was observed in the sedation group. Overall, the NIV success rate was 95.6%-intubation was required in 6.1% of the sedation group and in 2.9% of the other group (p = 0.092). Multivariate analysis revealed that the PRISM III score at NIV initiation (OR 1.408; 95% CI 1.230-1.611) and respiratory rate at 3 h (OR 1.043; 95% CI 1.009-1.079) were found to be independent predictors of NIV failure. The PICU LOS was correlated with weight, PRISM III score, respiratory rate at 12 h, SpO2 at 3 h, FiO2 at 12 h, NIV failure and NIV duration. Sedation use was not found to be independently related to NIV failure or to the PICU LOS. CONCLUSIONS: Sedation use may be useful in children with ARF treated with NIV, as it seems to improve clinical parameters and comfort status but may not increase the NIV failure rate or PICU LOS, even though sedated children were more severe at technique initiation in the present sample.

Update in Noninvasive Home Mechanical Ventilation: A Narrative Review of Indications, Outcomes, and Monitoring.

Hypercapnic respiratory failure arises due to an imbalance in the load-capacity-drive relationship of the respiratory muscle pump, typically arising in patients with chronic obstructive pulmonary disease, obesity-related respiratory failure, and neuromuscular disease. Patients at risk of developing chronic respiratory failure and those with established disease should be referred to a specialist ventilation unit for evaluation and consideration of home noninvasive ventilation (NIV) initiation. Clinical trials demonstrate that, following careful patient selection, home NIV can improve a range of clinical, patient-reported, and physiological outcomes. This narrative review provides an overview of the pathophysiology of chronic respiratory failure, evidence-based applications of home NIV, and monitoring of patients established on home ventilation and describes technological advances in ventilation devices, interfaces, and monitoring to enhance comfort, promote long-term adherence, and optimise gas exchange.

High flow nasal cannula oxygen therapy versus non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease with acute-moderate hypercapnic respiratory failure: a randomized controlled non-inferiority trial.

BACKGROUND: Although cumulative studies have demonstrated a beneficial effect of high-flow nasal cannula oxygen (HFNC) in acute hypercapnic respiratory failure, randomized trials to compare HFNC with non-invasive ventilation (NIV) as initial treatment in acute exacerbations of chronic obstructive pulmonary disease (AECOPD) patients with acute-moderate hypercapnic respiratory failure are limited. The aim of this randomized, open label, non-inferiority trial was to compare treatment failure rates between HFNC and NIV in such patients. METHODS: Patients diagnosed with AECOPD with a baseline arterial blood gas pH between 7.25 and 7.35 and PaCO2 ≥ 50 mmHg admitted to two intensive care units (ICUs) at a large tertiary academic teaching hospital between March 2018 and December 2022 were randomly assigned to HFNC or NIV. The primary endpoint was the rate of treatment failure, defined as endotracheal intubation or a switch to the other study treatment modality. Secondary endpoints were rates of intubation or treatment change, blood gas values, vital signs at one, 12, and 48 h, 28-day mortality, as well as ICU and hospital lengths of stay. RESULTS: 225 total patients (113 in the HFNC group and 112 in the NIV group) were included in the intention-to-treat analysis. The failure rate of the HFNC group was 25.7%, while the NIV group was 14.3%. The failure rate risk difference between the two groups was 11.38% (95% CI 0.25-21.20, P = 0.033), which was higher than the non-inferiority cut-off of 9%. In the per-protocol analysis, treatment failure occurred in 28 of 110 patients (25.5%) in the HFNC group and 15 of 109 patients (13.8%) in the NIV group (risk difference, 11.69%; 95% CI 0.48-22.60). The intubation rate in the HFNC group was higher than in the NIV group (14.2% vs 5.4%, P = 0.026). The treatment switch rate, ICU and hospital length of stay or 28-day mortality in the HFNC group were not statistically different from the NIV group (all P > 0.05). CONCLUSION: HFNC was not shown to be non-inferior to NIV and resulted in a higher incidence of treatment failure than NIV when used as the initial respiratory support for AECOPD patients with acute-moderate hypercapnic respiratory failure. TRIAL REGISTRATION: chictr.org (ChiCTR1800014553). Registered 21 January 2018, http://www.chictr.org.cn.

Noninvasive high-frequency oscillation ventilation as post- extubation respiratory support in neonates: Systematic review and meta-analysis.

INTRODUCTION: Noninvasive High-Frequency Oscillatory Ventilation (NHFOV) is increasingly being adopted to reduce the need for invasive ventilation after extubation. OBJECTIVES: To evaluate the benefits and harms of NHFOV as post-extubation respiratory support in newborns compared to other non-invasive respiratory support modes. MATERIAL & METHODS: We included randomized controlled trials comparing NHFOV with other non-invasive modes post-extubation in newborns. Data sources were MEDLINE (via Pubmed), Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, WHO international clinical trials registry platform and Clinical Trial Registry, forward and backward citation search. Methodological quality of studies was assessed by Cochrane's Risk of Bias tool 1.0. RESULTS: This systematic review included 21 studies and 3294 participants, the majority of whom were preterm. NHFOV compared to nasal continuous positive airway pressure (NCPAP) reduced reintubation within seven days (RR 0.34, 95% CI 0.22 to 0.53) after extubation. It also reduced extubation failure (RR 0.39, 95% CI 0.30 to 0.51) and reintubation within 72 hrs (RR 0.40, 95% CI 0.31 to 0.53), bronchopulmonary dysplasia (RR 0.59, 95% CI 0.37 to 0.94) and pulmonary air leak (RR 0.46, 95% CI 0.27 to 0.79) compared to NCPAP. The rate of reintubation within seven days (RR 0.62, 95% CI 0.18 to 2.14) was similar whereas extubation failure (RR 0.65, 95% CI 0.50 to 0.83) and reintubation (RR 0.68, 95% CI 0.52 to 0.89) within 72 hrs were lower in NHFOV group compared to nasal intermittent positive pressure ventilation. There was no effect on other outcomes. Overall quality of the evidence was low to very low in both comparisons. CONCLUSIONS: NHFOV may reduce the rate of reintubation and extubation failure post-extubation without increasing complications. Majority of the trials were exclusively done in preterm neonates. Further research with high methodological quality is warranted.

Nutrition during noninvasive respiratory support.

PURPOSE OF REVIEW: The use of noninvasive techniques [noninvasive ventilation (NIV) or high flow nasal cannula (HFNC) oxygen therapy] to support oxygenation and/or ventilation in patients with respiratory failure has become widespread, even more so since the coronavirus disease 2019 pandemic. The use of these modalities may impair the patient's ability to eat. "To breath or to eat" may become a dilemma. In this review, we identify the patients at risk of malnutrition that require medical nutritional therapy and understand the mechanisms of function of the devices to better give adapted nutritional indications for noninvasive ventilation or high flow nasal cannula. RECENT FINDINGS: The Global Leadership Initiative for Malnutrition has been validated in the Intensive Care setting and can be used in patients requiring NIV. Many patients are underfed when receiving noninvasive ventilation therapies. HFNC may impair the swallowing ability and increase dysphagia while NIV may improve the swallowing reflexes. New technology preventing reflux and ensuring enteral feeding efficacy may increase the medical nutrition therapy safety and provide near-target energy and protein provision. SUMMARY: The patient requiring noninvasive ventilation presents one of the most challenging nutritional challenges. The main steps to improve nutrition administration are to assess nutritional status, evaluate the presence of dysphagia, choose the most adequate tool of respiratory support, and adapt nutritional therapy (oral, enteral, or parenteral) accordingly.

Noninvasive Ventilation for Moderate to Severe Acute Respiratory Distress Syndrome Due to COVID-19.

BACKGROUND: Use of noninvasive ventilation in patients with acute respiratory distress syndrome (ARDS) is debated. The COVID-19 pandemic posed challenges due to high patient volumes and worldwide resource strain. OBJECTIVES: To determine associations between use of noninvasive ventilation in adult patients with moderate to severe ARDS due to SARS-CoV-2 pneumonia, progression to intubation, and hospital mortality. METHODS: This retrospective cohort study included patients in an institutional COVID-19 registry. Adult patients were included if they were admitted for COVID-19 between March 1, 2020, and March 31, 2022, and developed moderate to severe ARDS. Primary outcomes were progression to intubation and hospital mortality in patients who received noninvasive ventilation or mechanical ventilation. A secondary outcome was successful treatment with noninvasive ventilation without intubation. RESULTS: Of 823 patients who met inclusion criteria, 454 (55.2%) did not receive noninvasive ventilation and 369 (44.8%) received noninvasive ventilation. Patients receiving noninvasive ventilation were more likely to require mechanical ventilation than were patients not receiving noninvasive ventilation. Among patients requiring endotracheal intubation, those receiving noninvasive ventilation had a higher likelihood of mortality. Patients receiving noninvasive ventilation had lower severity-adjusted odds of survival to discharge without intubation than did patients not receiving noninvasive ventilation. CONCLUSION: Patients with moderate to severe ARDS due to SARS-CoV-2 pneumonia treated with noninvasive ventilation had increased likelihood of progression to endotracheal intubation and hospital mortality.

Automated oxygen titration with non-invasive ventilation in hypoxaemic adults with cardiorespiratory disease: a randomised cross-over trial.

BACKGROUND: Closed-loop oxygen control systems automatically adjust the fraction of inspired oxygen (FiO2) to maintain oxygen saturation (SpO2) within a predetermined target range. Their performance with low and high-flow oxygen therapies, but not with non-invasive ventilation, has been established. We compared the effect of automated oxygen on achieving and maintaining a target SpO2 range with nasal high flow (NHF), bilevel positive airway pressure (bilevel) and continuous positive airway pressure (CPAP), in stable hypoxaemic patients with chronic cardiorespiratory disease. METHODS: In this open-label, three-way cross-over trial, participants with resting hypoxaemia (n=12) received each of NHF, bilevel and CPAP treatments, in random order, with automated oxygen titrated for 10 min, followed by 36 min of standardised manual oxygen adjustments. The primary outcome was the time taken to reach target SpO2 range (92%-96%). Secondary outcomes included time spent within target range and physiological responses to automated and manual oxygen adjustments. RESULTS: Two participants were randomised to each of six possible treatment orders. During automated oxygen control (n=12), the mean (±SD) time to reach target range was 114.8 (±87.9), 56.6 (±47.7) and 67.3 (±61) seconds for NHF, bilevel and CPAP, respectively, mean difference 58.3 (95% CI 25.0 to 91.5; p=0.002) and 47.5 (95% CI 14.3 to 80.7; p=0.007) seconds for bilevel and CPAP versus NHF, respectively. Proportions of time spent within target range were 68.5% (±16.3), 65.6% (±28.7) and 74.7% (±22.6) for NHF, bilevel and CPAP, respectively.Manually increasing, then decreasing, the FiO2 resulted in similar increases and then decreases in SpO2 and transcutaneous carbon dioxide (PtCO2) with NHF, bilevel and CPAP. CONCLUSION: The target SpO2 range was achieved more quickly when automated oxygen control was initiated with bilevel and CPAP compared with NHF while time spent within the range across the three therapies was similar. Manually changing the FiO2 had similar effects on SpO2 and PtCO2 across each of the three therapies. TRIAL REGISTRATION NUMBER: ACTRN12622000433707.

Mask-related pressure injury prevention associated with non-invasive ventilation: A systematic review.

Noninvasive ventilation interfaces are one of the main factors contributing to pressure injuries caused by medical devices. Prevention is still the best course of action when discussing noninvasive ventilation-induced pressure injuries. A systematic review was designed to summarize and analyse all published literature on strategies to prevent pressure injuries caused by masks in patients undergoing noninvasive ventilation. The protocol of the systematic review followed the PRISMA guideline. An extensive search from the beginning to May 16, 2023, using current articles in databases such as Web of Science (WOS), Scopus, PubMed, and Cochrane Library was conducted. Medical Subject Headings (MESH) were used as follows: "Pressure Injury," "Noninvasive Ventilation," "Prevention," and "Pressure Sore." Any language-published studies that met the inclusion criteria were included in this review. A risk of bias assessment was conducted using the Joanna Briggs Institute tool, including evaluation methodologies for all studies. Database searches yielded 2546 articles, which were reduced to 23 that met our criteria after reviewing full texts. A narrative synthesis was conducted. As a result, type of interface (14 studies), dressings (4 studies), adjustment of mask leakage (1 study), humidity (1 study), positioning (1 study), and design of personalized masks (2 studies) seem to be a practical approach to prevent pressure injuries caused by masks in patients undergoing noninvasive ventilation. The results of our study show the effectiveness of preventive methods in reducing the incidence of pressure injuries caused by masks. Given the significant occurrence of pressure injury related to noninvasive ventilation and the crucial role of prevention and treatment, it is imperative to conduct more rigorous studies to ascertain the efficacy of each strategy.

[Predictive value of a risk prediction model guided by the ratio of respiratory rate to diaphragmatic thickening fraction for the timing of noninvasive-invasive mechanical ventilation transition in patients with acute exacerbation of chronic obstructive pulmonary disease].

OBJECTIVE: To evaluate the predictive value of a risk prediction model guided by the ratio of respiratory rate to diaphragm thickening fraction (RR/DTF) for noninvasive-invasive mechanical ventilation transition timing in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD), through ultrasound evaluation of diaphragm movement indicators. METHODS: Sixty-four patients diagnosed with AECOPD and undergoing non-invasive ventilation (NIV), who were admitted to the department of critical care medicine of the First Affiliated Hospital of Jinzhou Medical University from January 2022 to July 2023 were enrolled. They were divided into NIV successful group and NIV failure group based on the outcome of NIV within 24 hours. Clinical indicators such as RR/DTF, diaphragmatic excursion (DE), tidal volume (VT), respiratory rate (RR), pH value, partial pressure of carbon dioxide (PaCO2), and sputum excretion disorder were compared between the two groups after 2 hours of NIV. The factors influencing NIV failure were included in binary Logistic regression analysis, and an RR/DTF oriented risk prediction model was established. Receiver operator characteristic curve (ROC curve) analysis was used to assess the predictive value of this model for the timing of noninvasive-invasive mechanical ventilation transition in AECOPD patients. RESULTS: Among 64 patients with AECOPD, with 43 in the NIV successful group and 21 in the NIV failure group. There were no statistically significant differences in baseline data such as age, gender, body mass index (BMI), oxygenation index (P/F), smoking history, and acute physiological and chronic health evaluation II (APACHE II) between the two groups of patients, indicating comparability. Compared to the NIV successful group, the NIV failure group showed a significantly increase in RR/DTF, RR, PaCO2, and sputum retention, while VT and DE were significantly decreased [RR/DTF (%): 1.00±0.18 vs. 0.89±0.22, RR (bpm): 21.64±3.13 vs. 19.62±2.98, PaCO2 (mmHg, 1 mmHg ≈ 0.133 kPa): 70.82±8.82 vs. 65.29±9.47, sputum retention: 57.1% vs. 30.2%, VT (mL): 308.09±14.89 vs. 324.48±23.82, DE (mm): 19.91±2.94 vs. 22.05±3.30, all P < 0.05]. Binary Logistic regression analysis showed that RR/DTF [odds ratio (OR) = 147.989, 95% confidence interval (95%CI) was 3.321-595.412, P = 0.010], RR (OR = 1.296, 95%CI was 1.006-1.670, P = 0.045), VT (OR = 0.966, 95%CI was 0.935-0.999, P = 0.044), PaCO2 (OR = 1.086, 95%CI was 1.006~1.173, P = 0.035), and sputum retention (OR = 4.533, 95%CI was 1.025-20.049, P = 0.046) were independent risk factors for predicting NIV failure in AECOPD patients. ROC curve analysis showed that the area under the curve (AUC) of 0.713 with a 95%CI of 0.587-0.839 (P = 0.005). The sensitivity was 72.73%, the specificity was 88.10%, the Youden index was 0.394, and the optimal cut-off value was 0.87. CONCLUSIONS: The RR/DTF risk prediction model has good predictive value for the timing of noninvasive-invasive mechanical ventilation transition in AECOPD patients.

Effects of Non-Invasive Ventilation with different modalities in patients undergoing heart surgery: Protocol for a randomized controlled clinical trial.

INTRODUCTION: The thoracic surgical procedure leads to a reduction in respiratory muscle strength. To restore it, certain strategies must be employed. Physiotherapy utilizes resources and techniques such as deep breathing stimulation, cough stimulation, use of incentive spirometers, mobilization, and ambulation. However, at times these resources and techniques may prove insufficient, and additional measures, such as Non-Invasive Ventilation (NIV), are employed Pieczkoski (2017). Non-Invasive Positive Pressure Ventilation (NPPV) has been utilized to expedite pulmonary function recovery as well as to prevent and treat postoperative pulmonary complications Nasrala 2018. NIV diminishes the risk of ventilator-associated complications due to its non-invasive nature. Consequently, NIV has been adopted to avert post-extubation complications in postoperative patients Liu 2020. The objective of this study is to conduct a randomized clinical trial and assess the efficacy of NIV in comparison to conventional physiotherapy in terms of pulmonary function among patients undergoing cardiac surgery at a selected hospital in Campina Grande, Paraíba, Brazil. METHODS AND ANALYSES: This randomized, controlled, double-blind (patient and analyst) clinical trial will be conducted at Hospital João XXIII in Campina Grande, Paraíba, Brazil. Patients do not know which group they are allocated to. Those in the group that use CPAP or BIPAP will not be able to distinguish one from the other. The data analyst at the end of the collections will also be blinded. Only the health professional who will be applying the protocol cannot be blinded. The sample size, determined via sample calculation, yielded a total of 21 patients per group (63 patients). The patients will be allocated into 3 groups (CPAP group - CPAP + standard physiotherapy, BiPAP group - BiPAP + standard physiotherapy, and Control group - standard physiotherapy) in a 1:1:1 allocation ratio. The control group will receive the usual physiotherapeutic treatment as per the kinesiotherapy protocol. The treatment will be administered twice daily, starting in the ICU and progressing to the ward. In the CPAP group, nasal CPAP at 10cmH2O will be administered for 1 hour, twice daily, using an approved device. In the BiPAP group, nasal BiPAP with an IPAP of 13cmH2O and EPAP of 8cmH2O will be administered for 1 hour, twice daily, using an approved device. The NIV sessions will be conducted over the course of 5 days of hospitalization, both in the ICU and the ward. Assessments will be conducted at two time points: on day 1 preoperatively and on day 5 postoperatively. The following measures will be evaluated: pulmonary function, length of hospital stay, presence of postoperative pulmonary complications, score of the Minnesota Living with Heart Failure Questionnaire (MLHFQ) in its Portuguese version, functional capacity, the Global Perception of Change Scale, and the Functional Independence Measure (MIF). The normality of variables will be assessed using the Shapiro-Wilk test. IBM SPSS Statistics Base 25.0, using the Shapiro-Wilk test for normality and paired Student's t-test for pre-post intervention comparison. They will use linear mixed effects models for longitudinal analysis and GLMMs to compare NIV effects over time between groups. They will employ ITT for missing data, INAR models for time dependence, fixed effects models for endogeneity, and Cohen's d for effect sizes. Parametric model assumptions will be checked, and various models will be considered for data characteristics. PRIMARY OUTCOMES: Pulmonary function, Length of hospital stay. SECOND OUTCOMES: Score of the Minnesota Living with Heart Failure Questionnaire (MLHFQ) in Portuguese version, Funcional capacity, The global perception of change scale, The functional independence measure (MIF), pO2 (partial pressure of oxygen), pCO2 (partial pressure of carbon dioxide), HCO3 (bicarbonate), Arterial Oxygen Saturation (SaO2), Base Excess (BE), Presence of lung complications. OTHER PRE-SPECIFIED OUTCOMES: Duration of cardiopulmonary bypass, type of surgery, personal history, preoperative ejection fraction, previous respiratory complications, body mass index (BMI), gender and age. TRIAL REGISTRATION: Trial register number NCT05966337.