ERS International Congress 2023: highlights from the Respiratory Intensive Care Assembly.

Early career members of Assembly 2 (Respiratory Intensive Care) attended the 2023 European Respiratory Society International Congress in Milan, Italy. The conference covered acute and chronic respiratory failure. Sessions of interest to our assembly members and to those interested in respiratory critical care are summarised in this article and include the latest updates in respiratory intensive care, in particular acute respiratory distress syndrome and mechanical ventilation.

Peri-operative outcomes of bariatric surgery in obstructive sleep apnoea: a single-centre cohort study.

Background: The prevalence of obstructive sleep apnoea (OSA) is increasing worldwide. Bariatric surgery is an option where conventional measures to achieve weight loss fail. We compared peri-operative outcomes in patients living with obesity with and without OSA undergoing bariatric surgery. Methods: Retrospective cohort study of consecutive patients undergoing bariatric surgery at a tertiary referral centre. Data were extracted from electronic patient records. Primary outcomes were the rate of peri-operative complications and level of respiratory support. Secondary outcomes were length of stay (LOS), and the highest level of care required. Results: A total of 302 patients underwent surgery [age 47 (±11.6) years, 238 (78.8%) female, body mass index (BMI) 48.1 (±7.8) kg/m2]. A total of 101 (33.4%) patients had moderate or severe OSA, or mild OSA with significant sleepiness, and were prescribed continuous positive airway pressure (CPAP), whilst 201 (66.6%) had mild OSA without symptoms or no OSA and weren't. Patients requiring CPAP were more obese (BMI 50.2 vs. 47.0 kg/m2, P=0.002). Complications were analysed individually and according to the Clavien-Dindo classification. The incidence of each individual complication did not differ between groups. When grouped into Clavien-Dindo grades, only grade I complications differed: CPAP 9% vs. non-CPAP 2.6%, P=0.02). LOS was longer in the CPAP group [3 (1.5) vs. 2 (1.0) days, P=0.002]. Conclusions: The rate of peri-operative complications in patients with OSA undergoing bariatric surgery is low and can be addressed by the provision of CPAP therapy in most cases. However, a longer LOS and more frequent Grade I complications requires selection of appropriate post-operative monitoring.

Pulmonary function, computerized tomography features and six-minute walk test at three months in severe COVID-19 patients treated with intravenous pulsed methylprednisolone: a preliminary report.

COVID-19 acute respiratory distress syndrome (ARDS) has a high mortality and few therapeutic options. We present a preliminary report on our experience using high-dose pulsed methylprednisolone in COVID-19 ARDS and three-month outcomes. We performed a retrospective analysis of all patients treated with high-dose methylprednisolone for COVID-19 ARDS and three-month lung function, 6-minutes walking test (6MWT), and computerized tomography (CT) findings. Fifteen patients were treated of which 10 survived to discharge. Reduced diffusion capacity for carbon monoxide (DLCO) was the commonest abnormality in lung function tests and had the lowest mean value. Parenchymal bands were the commonest CT finding and 50% of patients had fibrosis at three months. Mean 6-minutes walk distance (6MWD) was 65.4% predicted and was abnormal in 62.5% of patients. In this cohort of patients with COVID-19 ARDS treated with high-dose methylprednisolone pulses, CT, lung function, and 6MWT abnormalities were unsurprisingly common at three months, although all 10 patients treated early in their disease course survived, a possible therapeutic effect. Further randomised controlled trials are needed to assess the benefits of this treatment.

A one-year cost-utility analysis of REBOA versus RTACC for non-compressible torso haemorrhage.

INTRODUCTION: Major trauma is a leading cause of death and disability in young adults, especially from massive non-compressible torso haemorrhage. The standard technique to control distal haemorrhage and maximise central perfusion is resuscitative thoracotomy with aortic cross-clamping (RTACC). More recently, the minimally invasive technique of resuscitative endovascular balloon occlusion of the aorta (REBOA) has been developed to similarly limit distal haemorrhage without the morbidity of thoracotomy; cost-utility studies on this intervention, however, are still lacking. The aim of this study was to perform a one-year cost-utility analysis of REBOA as an intervention for patients with major traumatic non-compressible abdominal haemorrhage, compared to RTACC within the U.K.'s National Health Service. METHODS: A retrospective analysis of the outcomes following REBOA and RTACC was conducted based on the published literature of survival and complication rates after intervention. Utility was obtained from studies that used the EQ-5D index and from self-conducted surveys. Costs were calculated using 2016/2017 National Health Service tariff data and supplemented from further literature. A cost-utility analysis was then conducted. RESULTS: A total of 12 studies for REBOA and 20 studies for RTACC were included. The mean injury severity scores for RTACC and REBOA were 34 and 39, and mean probability of death was 9.7 and 54%, respectively. The incremental cost-effectiveness ratio of REBOA when compared to RTACC was £44,617.44 per quality-adjusted life year. The incremental cost-effectiveness ratio, by exceeding the National Institute for Health and Clinical Effectiveness's willingness-to-pay threshold of £30,000/quality-adjusted life year, suggests that this intervention is not cost-effective in comparison to RTACC. However, REBOA yielded a 157% improvement in utility with a comparatively small cost increase of 31.5%. CONCLUSION: Although REBOA has not been found to be cost-effective when compared to RTACC, ultimately, clinical experience and expertise should be the main factor in driving the decision over which intervention to prioritise in the emergency context.

Does medical school lung function teaching need an update?

This article highlights the importance of teaching up-to-date diagnostic criteria for lung function in medical school as it becomes relevant to clinical practice http://ow.ly/CBhj30i5nbT.

Differential effects of different vitamin D replacement strategies in patients with diabetes.

BACKGROUND: The optimal treatment regimen for correcting vitamin D insufficiency in diabetic patients has not been established. METHODS: Two hundred and forty four adult diabetic patients with vitamin D insufficiency were enrolled to receive: Ergocalciferol (D2) 50,000 IU daily over 10 days (500,000 IU) followed by Calcichew D3 (calcium carbonate/Cholecalciferol) BID (~24,000 IU cholecalciferol/month) (ECC) (n=53); Cholecalciferol (D3) 40,000 IU daily over 10 days (400,000 IU) followed by Calcichew D3 BID (~24,000 IU cholecalciferol/month) (CCC) (n=94) or Cholecalciferol 40,000 IU daily over 10 days (400,000 IU) followed by Cholecalciferol 40,000 IU monthly (CC) (n=97). The 25(OH)D, HbA1c, lipids, blood pressure and eGFR were assessed at baseline and after a mean follow up of 8.0±4.0 months. RESULTS: Treatment increased 25(OH)D concentrations significantly in ECC (17.4±13.8 vs 29.9±9.6 ng/ml, P<0.0001), CCC (14.2±6.6 vs 30.9±13.1 ng/ml, p<0.0001) and CC (13.5±8.4 vs 33.9±14.4 ng/ml, P<0.0001). The relative increase in 25(OH)D was significantly lower with ECC compared to CC (+14.6±12.2 vs +20.6±15.0, P=0.01) and the majority of subjects in the ECC group (63%) remained vitamin D deficient (25(OH)D <30 ng/ml) compared to CCC (46%) and CC (36%) (P=0.0005). CONCLUSION: This study demonstrates that relatively aggressive treatment regimens of both vitamin D2 and D3 increase 25(OH)D concentrations in diabetic patients, but the ability to raise 25(OH)D status to 'sufficient' levels is inadequate in a large proportion of individuals.