Recent advances in the role of non-invasive ventilation in acute respiratory failure.

Non-invasive positive pressure ventilation (NIPPV) is the technique of delivering mechanical ventilation without endotracheal intubation or tracheostomy. This is increasingly being utilised in both acute and chronic conditions. Strong evidence supports the use of NIPPV for acute respiratory failure (ARF) to prevent endotracheal intubation (ETI) and to facilitate extubation in patients with acute exacerbations of chronic obstructive pulmonary disease, to avoid ETI in acute cardiogenic pulmonary oedema (ACPO), and in immunocompromised patients. Weaker evidence supports the use of NIPPV for patients with ARF due to asthma exacerbations, with postoperative ARF, pneumonia and acute lung injury/acute respiratory distress syndrome. NIPPV should be applied under close monitoring for signs of treatment failure and, in such cases, ETI should be promptly available. A trained team, at an appropriate location, with careful patient selection and optimal choice of devices can optimise the outcome of NIPPV.

Early predictors of success of non-invasive positive pressure ventilation in hypercapnic respiratory failure.

BACKGROUND: Non-invasive positive pressure ventilation (NIPPV) has emerged as a significant advancement in the management of acute hypercapnic respiratory failure. METHOD: Patients with hypercapnic respiratory failure requiring ventilation therapy (respiratory rate [RR] of > 30 breaths per minutes, PaCO2 > 55 mmHg and arterial pH < 7.35) were included in the study. Baseline clinical parameters and arterial blood gas (ABG) were recorded before initiating NIPPV. Clinical parameters including heart rate (HR), RR, oxygen saturation and ABG were revaluated at 1, 4, and 24 hours after initiation of NIPPV. Change in these parameters and need for intubation was evaluated. RESULTS: Of the 100 patients, 76 (76%) showed improvement in clinical parameters and ABG. There was improvement in HR and RR, pH, and PCO2 within the first hour in the success group and these parameters continued to improve even after four and 24 hours of NIPPV treatment. Out of 24 (24%) patients who failed to respond, 13 (54%) needed endotracheal intubation within one hour. The failure group had higher baseline HR than the success group. CONCLUSION: Improvement in HR, RR, pH, and PCO2 one hour after putting the patient on NIPPV predicts success of non-invasive positive pressure ventilation in hypercapnic respiratory failure.

Role of Oral Appliances in the Management of Sleep Disorders.

BACKGROUND: A study was undertaken with the aim to evaluate the therapeutic and clinical efficacy of oral appliances in the management of upper airway sleep disorders like snoring and obstructive sleep apnea (OSA). METHODS: Oral appliances were prescribed in eight cases of non - apneic snoring and 42 polysomnography (PSG) diagnosed cases of OSA. The cases were assessed on Epworth Sleepiness Scale (ESS) and Apnea - Hypopnea Index (AHI). RESULT: 62.5% of the non - apneic snoring cases reported gross reduction/cessation of snoring. In the OSA cases, the mean AHI and ESS scores decreased from 51.48 ± 23.70 to 32.78 ± 18.06 and 12.50 ± 3.57 to 7.20 ± 2.917 respectively. A statistically significant (p<0.0001) improvement in AHI and ESS scores was observed. CONCLUSION: Short term therapeutic efficacy of oral appliances therapy in non-apneic snoring and OSA cases was observed.

BRONCHIAL ARTERIOGRAPHY AND TRANSCATHETER EMBOLIZATION IN MANAGEMENT OF SEVERE HAEMOPTYSIS.

The purpose of this study was to assess the effectiveness of bronchial arteriography and transcatheter embolization in treatment of severe haemoptysis. Forty five patients with severe haemoptysis were evaluated by means of bronchial arteriography and study of non bronchial systemic arteries and underwent transcatheter embolization. Specific causes of haemoptysis were Tuberculosis (n=37), Tuberculosis with Aspergilloma (n=4) and bronchiectasis (n=4). Gel foam pellets and polyvinyl alcohol (PVA) particles were used as embolic material in 36 patients and 9 patients respectively. The angiographic signs of haemorrhage encountered were extravasation of contrast in 2 patients (4.4%), hypervascularisation in 42 (93.3%), broncho-pulmonary shunt in 13 (28.8%) and bronchial artery aneurysm in 1 patient (2.2%). Immediate control of bleeding occurred in 44 (97.7%) of 45 patients after embolization. Recurrent haemoptysis occurred in 4 cases (11.9%) more than 1 month after embolization but bleeding was less severe, than before treatment. This study suggests that bronchial artery embolization is an effective method of managing patients with severe haemoptysis, minor bleeding recurrences appear to be relatively infrequent.

MANAGEMENT OF LUNG ABSCESS WITH PERCUTANEOUS CATHETER DRAINAGE.

Percutaneous catheter drainage was used to treat 12 among 34 cases of lung abscesses, who were refractory to medical therapy, severely ill and high risk cases for surgery. A complete clinical and radiological recovery was achieved in all the cases who underwent catheter drainage, thereby obviating the need for surgery. None of the cases had catheter or procedures related complications. From this study it is inferred that percutaneous transthoracic catheter drainage is a safe and an effective modality of therapy for patients with lung abscess in whom medical therapy has failed and those who are unsuitable for surgery.