Airway Reactance Predicts Static Lung Hyperinflation in Severe Asthma.

BACKGROUND AND OBJECTIVES: Background: Static lung hyperinflation (SLH) measured using body plethysmography in patients with asthma is associated with poor outcomes. The severity of SLH may be associated with small airway dysfunction (SAD), which can be measured using impulse oscillometry (IOS). Objective: This study aims to determine the correlation between SLH and SAD in patients with severe asthma and assess the improvement in SLH and SAD with treatment. METHODS: We analyzed data from patients who were enrolled in the Taiwan Severe Asthma Registry, which comprises a prospective observational cohort. Plethysmography and IOS were performed regularly. The relationship between spirometry and IOS parameters was determined. Changes in the clinical outcomes in response to treatment were analyzed. RESULTS: Of 107 patients with severe asthma, 83 (77.6%) had SLH based on an increased residual volume to total lung capacity ratio (RV/ TLC). Most patients were older women with worse pulmonary function and SAD than those without SLH. SAD, defined as increased airway resistance/reactance, was significantly correlated with SLH. Airway reactance at 5 Hz (X5) ≤-0.21 kPa/(L/s) detected SLH with an area under the receiver operating characteristic curve of 0.84 (P<.0001; sensitivity, 85.2%; and specificity, 83.3%). After 12 months, patients who received add-on biologics (vs those who did not) had significantly reduced exacerbations, fractional exhaled nitric oxide level, and blood eosinophil counts, as well as improved forced expiratory volume in the first second, X5, and a trend toward reduced RV/TLC ratio. CONCLUSIONS: In severe asthma, airway reactance (X5) could be a novel parameter for assessing SLH.

Airway Reactance Predicts Static Lung Hyperinflation in Severe Asthma

Background: Static lung hyperinflation (SLH) measured using body plethysmography in patients with asthma is associated with poor outcomes. The severity of SLH may be associated with small airway dysfunction (SAD), which can be measured using impulse oscillometry (IOS). Objective: This study aims to determine the correlation between SLH and SAD in patients with severe asthma and assess the improvement in SLH and SAD with treatment. Methods: We analyzed data from patients who were enrolled in the Taiwan Severe Asthma Registry, which comprises a prospective observational cohort. Plethysmography and IOS were performed regularly. The relationship between spirometry and IOS parameters was determined. Changes in the clinical outcomes in response to treatment were analyzed. Results: Of 107 patients with severe asthma, 83 (77.6%) had SLH based on an increased residual volume to total lung capacity ratio (RV/TLC). Most patients were older women with worse pulmonary function and SAD than those without SLH. SAD, defined as increased airway resistance/reactance, was significantly correlated with SLH. Airway reactance at 5 Hz (X5) ≤−0.21 kPa/(L/s) detected SLH with an area under the receiver operating characteristic curve of 0.84 (P<.0001; sensitivity, 85.2%; and specificity, 83.3%). After 12 months, patients who received add-on biologics (vs those who did not) had significantly reduced exacerbations, fractional exhaled nitric oxide level, and blood eosinophil counts, as well as improved forced expiratory volume in the first second, X5, and a trend toward reduced RV/TLC ratio. Conclusion: In severe asthma, airway reactance (X5) could be a novel parameter for assessing SLH. (AU)

Antecedentes: En el asma bronquial, la hiperinsuflación pulmonar estática (SLH) medida mediante pletismografía corporal (Pleth) se asocia a un peor pronóstico. La gravedad de la SLH podría estar asociada con la disfunción de las vías respiratorias pequeñas (SAD), que puede medirse mediante la oscilometría de impulsos (IOS). Objetivo: Este estudio pretende determinar la correlación entre el SLH y la SAD en pacientes con asma grave, y la mejora de ambos parámetros en respuesta al tratamiento. Métodos: Se analizaron los datos de los pacientes que se inscribieron en el Registro de Asma Grave de Taiwán, una cohorte observacional prospectiva. Se realizaron periódicamente mediciones de Pleth e IOS. Se determinó la relación entre los parámetros espirométricos e IOS. Se analizaron los cambios en los parámetros clínicos y funcionales en respuesta al tratamiento. Resultados: De una muestra de 107 pacientes con asma grave, 83 (77,6%) presentaban SLH, definida mediante una relación volumen residual/capacidad pulmonar total (VR/CTP) aumentada. La mayoría de los pacientes eran mujeres de edad avanzada con peor función pulmonar y SAD, en comparación con los que no tenían SLH. El SAD por aumento de la resistencia/reactancia de las vías respiratorias se correlacionó significativamente con el SLH. La reactancia de las vías respiratorias a 5 Hz (X5) ≤-0,21 [kPa/(L/s)] detectó el SLH con un área bajo la curva ROC de 0,84 (p < 0,0001, sensibilidad = 85,2% y especificidad = 83,3%). Después de 12 meses, los pacientes que recibieron tratamiento biológico adicional presentaron una reducción significativa de las exacerbaciones, del nivel de óxido nítrico exhalado, del recuento de eosinófilos en sangre, una mejora del volumen espiratorio forzado en el primer segundo, de la X5, y una tendencia a la reducción del cociente RV/TLC en comparación con los que no recibieron tratamiento biológico... (AU)

Interventional treatment of bleeding complications due to percutaneous cannulation for peripheral extracorporeal membrane oxygenation.

PURPOSE: This study aimed to evaluate the safety and effectiveness of interventional techniques as a treatment for bleeding complications secondary to percutaneous cannulation for peripheral extracorporeal membrane oxygenation (PECMO). MATERIALS AND METHODS: Out of 1264 patients who underwent PECMO at our hospital between January 2009 and September 2018, we reviewed the clinical characteristics and outcomes of eight patients (4 men, 4 women; mean age, 54.9 years [range, 31-77 years]) who underwent percutaneous interventional treatment for bleeding complications secondary to percutaneous cannulation for PECMO. RESULTS: Both hemodynamic instability and coagulopathy were present in 7 patients who had direct injury during PECMO insertion and absent in one patient with pseudoaneurysm at the PECMO removal site. Percutaneous ultrasound-guided thrombin injection was performed in three patients with pseudoaneurysm of the common or superficial femoral artery, and adjunctive embolization was combined with microcoils or n-butyl 2-cyanoacrylate in two of them. Stent graft was inserted in four patients with contrast extravasation (n=3) from external iliac artery (n=1) or common femoral or iliac veins (n=2) ruptures or the fistula between the superficial femoral artery and vein (n=1). N-butyl 2-cyanoacrylate and coil embolization was performed for pseudoaneurysm from the internal pudendal artery branch in the remaining one patient. Technical success was achieved in all eight patients. There were no procedure-related complications. There was no rebleeding during the follow-up. CONCLUSION: Interventional treatment is a safe, technically feasible and therapeutically effective modality for treating bleeding complications secondary to a percutaneous cannulation for PECMO.

Methodological investigation of measuring nasopharyngeal temperature as noninvasive brain temperature analogue in the neonate.

OBJECTIVES: (a) To investigate in a newborn animal model whether nasopharyngeal temperature is more closely related to epidural brain temperature than rectal temperature and (b) to investigate in human neonates whether measurement of nasopharyngeal temperature is dependent on the measurement site and other conditions. DESIGN AND SETTING: (a) Animal experiment in newborn piglets, at an institute for surgical research. (b) Prospective study in human neonates, at a neonatal intensive care unit of a tertiary care university hospital. ANIMALS AND PATIENTS: (a) Nineteen tracheostomized ventilated newborn piglets. (b) Twenty-two spontaneously breathing human newborns nursed either in an incubator or a cot. MEASUREMENTS AND RESULTS: (a) In the piglets nasopharyngeal temperature (Tnasoph) measured at the nose-ear distance, defined as distance from the inner brim of the nostril to the tragus and inner rim of the meatus accusticus, most closely reflected epidural temperature (Tepidur) at the epidural surface (r2 = 0.89), followed by skin temperature at the temple, rectal temperature (Trectum) at 2 cm depth, and esophageal temperature (Tesoph) in the middle esophagus. Tnasoph did not significantly differ before and after tracheostomy. (b) In the newborns Tnasoph was significantly lower than Trectum. Measurements of Tnasoph at nose-ear distance within a feeding tube had a high precision and were unaffected by breathing or head turning. A nasopharyngeal probe was imaged by magnetic resonance imaging in four newborns of various body weight; its tip when inserted to a depth equal to nose-ear distance was anatomically closest to the brain base but separated from it by tissue layer 2.2 cm thick. CONCLUSIONS: Tnasoph measured at a position anatomically closest to the brain reflects epidural brain temperature more closely than Trectum. When measured at nose-ear distance it is unaffected by breathing or head turning. Measuring Tnasoph within a feeding tube and standardizing the measuring position is crucial for its use as brain temperature analogue.

Early biochemical indicators of hypoxic-ischemic encephalopathy after birth asphyxia.

Hypoxic-ischemic encephalopathy (HIE) after perinatal asphyxia is a condition in which serum concentrations of brain-specific biochemical markers may be elevated. Neuroprotective interventions in asphyxiated newborns require early indicators of brain damage to initiate therapy. We examined brain-specific creatine kinase (CK-BB), protein S-100, and neuron-specific enolase in cord blood and 2, 6, 12, and 24 h after birth in 29 asphyxiated and 20 control infants. At 2 h after birth, median (quartiles) serum CK-BB concentration was 10.0 U/L (6.0-13.0 U/L) in control infants, 16.0 U/L (13.0-23.5 U/L) in infants with no or mild HIE, and 46.5 U/L (21.4-83.0 U/L) in infants with moderate or severe HIE. Serum protein S-100 was 1.6 microg/L (1.4-2.5 microg/L) in control infants, 2.9 microg/L (1.8-4.7 microg/L) in asphyxiated infants with no or mild HIE, and 17.0 microg/L (3.2-34.1 microg/L) in infants with moderate or severe HIE 2 h after birth. No significant difference was detectable in serum neuron-specific enolase between infants with no or mild and moderate or severe HIE 2 and 6 h after birth. A combination of serum protein S-100 (cutoff value, 8.5 microg/L) and CK-BB (cutoff value, 18.8 U/L) 2 h after birth had the highest predictive value (83%) and specificity (95%) of predicting moderate and severe HIE. Cord blood pH (cutoff value, <6.9) and cord blood base deficit (cutoff value, >17 mM) increase the predictive values of protein S-100 and CK-BB. We conclude that elevated serum concentrations of protein S-100 and CK-BB reliably indicate moderate and severe HIE as early as 2 h after birth.

Propofol versus midazolam for intensive care unit sedation after coronary artery bypass grafting.

OBJECTIVE: To compare the safety and effectiveness of propofol (2,6-diisopropylphenol) to midazolam for sedation of mechanically ventilated patients after coronary artery bypass grafting. DESIGN: Open, randomized, prospective trial. SETTING: Cardiothoracic intensive care unit (ICU), Cleveland Clinic Foundation. PATIENTS: Eighty-four patients with normal or moderately impaired left ventricular function who underwent elective coronary artery bypass graft surgery under high-dose opioid anesthesia. INTERVENTIONS: Patients were randomly selected to receive either propofol (mean loading dose 0.24 mg/kg; mean maintenance dose 0.76 mg/kg/hr) or midazolam (mean loading dose 0.012 mg/kg; mean maintenance dose 0.018 mg/kg/hr). Infusion rates were titrated to keep patients comfortable, drowsy, and responsive to verbal stimulation. Study duration, 8 to 12 hrs; infusions were started in the ICU when patients were awake and hemodynamically stable. MEASUREMENTS AND MAIN RESULTS: During therapy, both groups had lower mean arterial pressures and heart rates compared with baseline measurements; however, the propofol group had significantly lower heart rates than the midazolam group during the first 2 hrs of infusion. The propofol group also had significantly lower blood pressure measurements 5 and 10 mins after the initial dose, although there was no difference during infusion. Baseline cardiac output was measured before starting the infusion, and measurements were repeated during continuous infusion at 4, 8, and 12 hrs. Cardiac output values were similar. Propofol maintenance infusions ranged from 3 to 30 micrograms/kg/min and midazolam infusions ranged from 0.1 to 0.7 micrograms/kg/min. At these infusion rates. both groups had adequate sedation, based on nurse and patient evaluations; however, the propofol group used significantly lower total doses of sodium nitroprusside and supplemental opioids. CONCLUSIONS: Both propofol and midazolam provided safe and effective sedation of coronary artery bypass graft patients recovering from high-dose opioid anesthesia. The reduced need for both antihypertensive medication and opioids seen in the propofol group may be advantageous. However, the hypotension seen after the initial bolus dose of propofol may be a concern. No difference between the two drugs could be demonstrated in time to extubation or ICU discharge, although it is probable that time to extubation was governed more by residual operative opioids than the study agents.

[Monitoring fetal delivery by oxycardiotocography]. / Fetale Geburtsüberwachung durch Oxykardiotokographie (OCTG).

Oxycardiotocography is a combination of cardiotocography and continuous registration of the foetal arterial oxygen saturation (SaO2). In a few cases, the value of this additional information of foetal SaO2 is demonstrated. During uncomplicated deliveries with normal foetal heart rate patterns, the foetal SaO2 usually ranges between 50% and 70%. Uterine hyperactivity with impaired perfusion of the placenta shows besides a changed heart rate patterns, a significant decrease of the foetal oxygen saturation. Conversely, by supplying oxygen to the mother with a mask, the foetal oxygen saturation can be increased by approx. 10%. In case of a breech presentation and application of the sensor to the buttocks, the measured O2-saturation is approx. 10% to 15% below the values usually obtained from the scalp because the tissue there is supplied with mixed blood after the ductus.