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1.
Ned Tijdschr Geneeskd ; 1652021 04 01.
Artigo em Holandês | MEDLINE | ID: mdl-33793126

RESUMO

Extracorporeal CO2 removal is a low-flow technique in which a pump, a membrane lung and sweepgas, remove CO2 from a patient. This facilitates protective, invasive ventilation in patients with severe hypercapnia, for example in ARDS. Although the physiological concept has been proven many times, the indication area has remained limited to only seriously ill, highly complex patients. Because of this and the relatively high number of contraindications and complications, the use of this technique is limited to Intensive Care.


Assuntos
Dióxido de Carbono/sangue , Cuidados Críticos , Oxigenação por Membrana Extracorpórea/métodos , Hipercapnia/terapia , Seleção de Pacientes , Respiração Artificial/métodos , Humanos
2.
Rev Mal Respir ; 37(9): 756-765, 2020 Nov.
Artigo em Francês | MEDLINE | ID: mdl-33169687

RESUMO

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality, especially in cases of chronic hypercapnic respiratory failure. Following a prolonged debate, the indication and benefits of noninvasive ventilation (NIV) have been recently established. Although improved ventilation and reduction in hyperinflation appear to underlie the positive effect on NIV in COPD, only a few studies have focused on specific ventilatory algorithms for improving PaCO2. METHODS: The main objective of this study is to analyze the impact of Löwenstein's ventilatory algorithms, supposed to allow a better management of hyperinflation and its consequences on alveolar ventilation and blood gas parameters. This is an interventional study in routine care, prospective, single blind, randomized with cross over. The primary endpoint will be the transcutaneous partial pressure of nocturnal carbon dioxide. Secondary endpoints will be: abnormal respiratory events occurring during nocturnal NIV; the objective quality of sleep via polysomnography; the tolerance of ventilation and the subjective quality of sleep evaluated by auto questionnaires. EXPECTED RESULTS: The results of this study will clarify whether is it necessary to explore more the impact of the ventilatory modes developed by Löwenstein, dedicated to hypercapnic COPD patients, requiring a long-term NIV.


Assuntos
Algoritmos , Hipercapnia/terapia , Ventilação não Invasiva , Doença Pulmonar Obstrutiva Crônica/terapia , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Dióxido de Carbono/análise , Dióxido de Carbono/sangue , Estudos Cross-Over , Serviços de Assistência Domiciliar , Humanos , Hipercapnia/complicações , Hipercapnia/patologia , Monitorização Fisiológica/métodos , Monitorização Fisiológica/normas , Ventilação não Invasiva/métodos , Seleção de Pacientes , Polissonografia , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/complicações , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/patologia , Ensaios Clínicos Controlados Aleatórios como Assunto/normas , Projetos de Pesquisa , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/patologia , Insuficiência Respiratória/terapia , Tamanho da Amostra , Índice de Gravidade de Doença , Método Simples-Cego , Sono/fisiologia
3.
Medicine (Baltimore) ; 99(42): e22796, 2020 Oct 16.
Artigo em Inglês | MEDLINE | ID: mdl-33080752

RESUMO

BACKGROUND: Respiratory distress syndrome (RDS) is a common neonatal condition in premature infants. Its treatment often requires the use of surfactants. The administration of surfactants has evolved to less invasive surfactant administration (LISA) methods in recent years. Nasal high frequency oscillatory ventilation (nHFOV) is also a good new technology for respiratory support. The use of LISA combined with nHFOV for RDS has not been reported. CASE SUMMARY: A 970 g male infant who was born at 29 weeks of gestational age suffered progressive dyspnea immediately after birth. DIAGNOSIS: According to his clinical symptoms, X-ray, and blood gas analysis results, the extremely low birth weight infant was diagnosed with RDS and deep hypercapnic acidosis. INTERVENTIONS: Less invasive surfactant administration combined with nasal high frequency oscillatory ventilation was utilized in the infant. The mean airway pressure (Paw) was set at 7 cm H2O, amplitude (ΔP) was set at grade 5.5 (level set according to the perception of vibration of the chest wall), frequency was set at 8 Hz, inspiratory time (Ti) was set at 33%, and FiO2 was set at 0.30. OUTCOMES: The patient's pCO2 dropped to 90.9 mm Hg in 2 hours and to 57.8 mm Hg in the following 4.5 hours; the patient was weaned from nHFOV after 12 hours. On day 61, the patient was discharged and free of respiratory symptoms. CONCLUSION: We speculate that less invasive surfactant administration combined with nasal high frequency oscillatory ventilation may be useful in the treatment of RDS with deep hypercapnia to avoid intubation.


Assuntos
Ventilação de Alta Frequência , Hipercapnia/terapia , Recém-Nascido de Peso Extremamente Baixo ao Nascer , Surfactantes Pulmonares/administração & dosagem , Síndrome do Desconforto Respiratório do Recém-Nascido/terapia , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Masculino
4.
Am J Respir Crit Care Med ; 202(4): e74-e87, 2020 08 15.
Artigo em Inglês | MEDLINE | ID: mdl-32795139

RESUMO

Background: Noninvasive ventilation (NIV) is used for patients with chronic obstructive pulmonary disease (COPD) and chronic hypercapnia. However, evidence for clinical efficacy and optimal management of therapy is limited.Target Audience: Patients with COPD, clinicians who care for them, and policy makers.Methods: We summarized evidence addressing five PICO (patients, intervention, comparator, and outcome) questions. The GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach was used to evaluate the certainty in evidence and generate actionable recommendations. Recommendations were formulated by a panel of pulmonary and sleep physicians, respiratory therapists, and methodologists using the Evidence-to-Decision framework.Recommendations: 1) We suggest the use of nocturnal NIV in addition to usual care for patients with chronic stable hypercapnic COPD (conditional recommendation, moderate certainty); 2) we suggest that patients with chronic stable hypercapnic COPD undergo screening for obstructive sleep apnea before initiation of long-term NIV (conditional recommendation, very low certainty); 3) we suggest not initiating long-term NIV during an admission for acute-on-chronic hypercapnic respiratory failure, favoring instead reassessment for NIV at 2-4 weeks after resolution (conditional recommendation, low certainty); 4) we suggest not using an in-laboratory overnight polysomnogram to titrate NIV in patients with chronic stable hypercapnic COPD who are initiating NIV (conditional recommendation, very low certainty); and 5) we suggest NIV with targeted normalization of PaCO2 in patients with hypercapnic COPD on long-term NIV (conditional recommendation, low certainty).Conclusions: This expert panel provides evidence-based recommendations addressing the use of NIV in patients with COPD and chronic stable hypercapnic respiratory failure.


Assuntos
Hipercapnia/terapia , Ventilação não Invasiva/normas , Doença Pulmonar Obstrutiva Crônica/terapia , Doença Crônica , Humanos , Hipercapnia/complicações , Doença Pulmonar Obstrutiva Crônica/complicações , Fatores de Tempo
7.
Am J Respir Crit Care Med ; 201(12): 1525-1535, 2020 06 15.
Artigo em Inglês | MEDLINE | ID: mdl-32251606

RESUMO

Rationale: Large decreases in PaCO2 that occur when initiating extracorporeal membrane oxygenation (ECMO) in patients with respiratory failure may cause cerebral vasoconstriction and compromise brain tissue perfusion.Objectives: To determine if the magnitude of PaCO2 correction upon ECMO initiation is associated with an increased incidence of neurological complications in patients with respiratory failure.Methods: We conducted a multicenter, international, retrospective cohort study using the Extracorporeal Life Support Organization Registry, including adults with respiratory failure receiving ECMO via any mode between 2012 and 2017. The relative change in PaCO2 in the first 24 hours was calculated as (24-h post-ECMO PaCO2 - pre-ECMO PaCO2)/pre-ECMO PaCO2. The primary outcome was the occurrence of neurological complications, defined as seizures, ischemic stroke, intracranial hemorrhage, or brain death.Measurements and Main Results: We included 11,972 patients, 88% of whom were supported with venovenous ECMO. The median relative change in PaCO2 was -31% (interquartile range, -46% to -12%). Neurological complications were uncommon overall (6.9%), with a low incidence of seizures (1.1%), ischemic stroke (1.9%), intracranial hemorrhage (3.5%), and brain death (1.6%). Patients with a large relative decrease in PaCO2 (>50%) had an increased incidence of neurological complications compared with those with a smaller decrease (9.8% vs. 6.4%; P < 0.001). A large relative decrease in PaCO2 was independently associated with neurological complications after controlling for previously described risk factors (odds ratio, 1.7; 95% confidence interval, 1.3 to 2.3; P < 0.001).Conclusions: In patients receiving ECMO for respiratory failure, a large relative decrease in PaCO2 in the first 24 hours after ECMO initiation is independently associated with an increased incidence of neurological complications.


Assuntos
Dióxido de Carbono/metabolismo , Oxigenação por Membrana Extracorpórea/métodos , Hipercapnia/terapia , Hemorragias Intracranianas/epidemiologia , Insuficiência Respiratória/terapia , Convulsões/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Morte Encefálica , Estudos de Coortes , Humanos , Hipercapnia/etiologia , Hipercapnia/metabolismo , Incidência , Pressão Parcial , Sistema de Registros , Insuficiência Respiratória/complicações , Insuficiência Respiratória/metabolismo , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Vasoconstrição
8.
BMC Pulm Med ; 20(1): 12, 2020 Jan 13.
Artigo em Inglês | MEDLINE | ID: mdl-31931776

RESUMO

BACKGROUND: Persistent hypercapnia after COPD exacerbation is associated with excess mortality and early rehospitalization. High Flow Nasal cannula (HFNC), may be theoretically an alternative to long-term noninvasive ventilation (NIV), since physiological studies have shown a reduction in PaCO2 level after few hours of treatment. In this clinical study we assessed the acceptability of HFNC and its effectiveness in reducing the level of PaCO2 in patients recovering from an Acute Hypercapnic Respiratory Failure (AHRF) episode. We also hypothesized that the response in CO2 clearance is dependent on baseline level of hypercapnia. METHODS: Fifty COPD patients recovering from an acute exacerbation and with persistent hypercapnia, despite having attained a stable pH (i.e. pH > 7,35 and PaCO2 > 45 mmHg on 3 consecutive measurements), were enrolled and treated with HFNC for at least 8 h/day and during the nighttime RESULTS: HFNC was well tolerated with a global tolerance score of 4.0 ± 0.9. When patients were separated into groups with or without COPD/OSA overlap syndrome, the "pure" COPD patients showed a statistically significant response in terms of PaCO2 decrease (p = 0.044). In addition, the subset of patients with a lower pH at enrolment were those who responded best in terms of CO2 clearance (score test for trend of odds, p = 0.0038). CONCLUSIONS: HFNC is able to significantly decrease the level of PaCO2 after 72 h only in "pure" COPD patients, recovering from AHRF. No effects in terms of CO2 reduction were found in those with overlap syndrome. The present findings will help guide selection of the best target population and allow a sample size calculation for future long-term randomized control trials of HFNC vs NIV. TRIAL REGISTRATION: This study is registered with www. clinicaltrials.gov with identifier number NCT03759457.


Assuntos
Dióxido de Carbono/sangue , Hipercapnia/terapia , Ventilação não Invasiva/instrumentação , Doença Pulmonar Obstrutiva Crônica/complicações , Insuficiência Respiratória/terapia , Idoso , Idoso de 80 Anos ou mais , Cateterismo , Progressão da Doença , Feminino , Humanos , Hipercapnia/etiologia , Masculino , Projetos Piloto , Estudos Prospectivos , Insuficiência Respiratória/sangue , Insuficiência Respiratória/etiologia , Fatores de Tempo
9.
Clin Respir J ; 14(2): 165-172, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31799789

RESUMO

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is not fully reversible disease that is characterized by progressive restricting airflow. Non-invasive mechanical ventilation (NIMV) treatment can be used in COPD patients who had type 2 respiratory failure. This study aimed to determine the effect of BPAP S/T and AVAPS modes on intraocular pressure (IOP), central corneal thickness (CCT) in 40 type 2 respiratory failure patients with COPD. METHODS: Forty patients with type 2 respiratory failure who were hospitalized between June and December 2018 with the diagnosis of COPD exacerbations were included to the study. Patients followed up without NIMV for 12 hours after the end of exacerbations treatments end. After IOP, visual acuity and CCT were measured in all patients at the same time (11.00 am), same NIMV treatment was applied to the patients for 4 hours (AVAPS-BPAP S/T). Then the measurements were repeated. The effects of these NIMV modes on IOP were evaluated. RESULTS: After NIMV treatment, it was observed that the mean IOP increased statistically significantly (13.3 vs 12.3 mm Hg; P = 0.001). After treatment with NIMV, there was a decrease for CCT close to statistical significance (P = 0.057) CONCLUSION: As a result; increased IOP and thinning of CCT after NIMV treatment has been shown. The type of NIMV and the level of inspiratory pressure needed in hypercapnic respiratory failure seem to affect IOP and it should be cautiously used to increase IOP.


Assuntos
Hipercapnia/complicações , Pressão Intraocular/fisiologia , Ventilação não Invasiva/instrumentação , Doença Pulmonar Obstrutiva Crônica/terapia , Insuficiência Respiratória/terapia , Idoso , Feminino , Seguimentos , Humanos , Hipercapnia/fisiopatologia , Hipercapnia/terapia , Masculino , Respiração com Pressão Positiva , Doença Pulmonar Obstrutiva Crônica/complicações , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/fisiopatologia , Estudos Retrospectivos
10.
Respir Care ; 65(1): 45-52, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31551283

RESUMO

BACKGROUND: To investigate patient-ventilator interaction during different levels of noninvasive proportional assist ventilation (PAV) compared with noninvasive pressure support ventilation (PSV). METHODS: Fifteen subjects with severe COPD and hypercapnia were consecutively recruited. After the baseline assessment of unassisted spontaneous breathing, 3 levels of ventilatory support were applied. The proportional assist (PA) and pressure support (PS) levels were set by subject comfort. PA-, PS- or PA+, PS+ were set at 25% more or less of PA or PS (PA- = 75% PA, PA+ = 125% PA, PS- = 75% PS, PS+ = 125% PS). Each level lasted at least 20 min. To demonstrate the patient-ventilator interaction, the neural respiratory drive, respiratory muscle effort, flow signal, and airway pressure were simultaneously monitored. RESULTS: The expiratory cycle delay (time between the termination of the diaphragm electromyogram [EMGdi] signal and the end of the inspiratory flow) progressively increased with increasing assist level in both modes. However, compared with PSV, the expiratory cycle delay was significantly longer in each assist level during noninvasive PAV. The runaway phenomenon was observed in PA+. The time between the peak EMGdi signal and the maximum value of the flow signal and the time difference between the peak EMGdi signal and the maximum value of inspiratory pressure were significantly increased with the increasing assist level of PAV. CONCLUSIONS: The expiratory cycle delay of noninvasive PAV was significantly longer than that of noninvasive PSV in the subjects with COPD with respiratory failure. During the levels of PAV, the lag time between neural respiratory drive and airway pressurization was significantly increased and the "runaway" phenomenon may be observed. (ClinicalTrials.gov registration NCT01782768.).


Assuntos
Suporte Ventilatório Interativo , Ventilação não Invasiva , Respiração com Pressão Positiva , Doença Pulmonar Obstrutiva Crônica/terapia , Idoso , Humanos , Hipercapnia/terapia , Pessoa de Meia-Idade , Mecânica Respiratória/fisiologia , Músculos Respiratórios/fisiologia , Volume de Ventilação Pulmonar/fisiologia , Trabalho Respiratório
11.
Thorax ; 75(3): 244-252, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31484786

RESUMO

INTRODUCTION: Chronic non-invasive ventilation (NIV) has become evidence-based care for stable hypercapnic COPD patients. While the number of patients increases, home initiation of NIV would greatly alleviate the healthcare burden. We hypothesise that home initiation of NIV with the use of telemedicine in stable hypercapnic COPD is non-inferior to in-hospital NIV initiation. METHODS: Sixty-seven stable hypercapnic COPD patients were randomised to initiation of NIV in the hospital or at home using telemedicine. Primary outcome was daytime arterial carbon dioxide pressure (PaCO2) reduction after 6 months NIV, with a non-inferiority margin of 0.4 kPa. Secondary outcomes were health-related quality of life (HRQoL) and costs. RESULTS: Home NIV initiation was non-inferior to in-hospital initiation (adjusted mean difference in PaCO2 change home vs in-hospital: 0.04 kPa (95% CI -0.31 to 0.38 kPa), with both groups showing a PaCO2 reduction at 6 months compared with baseline (home: from 7.3±0.9 to 6.4±0.8 kPa (p<0.001) and in-hospital: from 7.4±1.0 to 6.4±0.6 kPa (p<0.001)). In both groups, HRQoL improved without a difference in change between groups (Clinical COPD Questionnaire total score-adjusted mean difference 0.0 (95% CI -0.4 to 0.5)). Furthermore, home NIV initiation was significantly cheaper (home: median €3768 (IQR €3546-€4163) vs in-hospital: median €8537 (IQR €7540-€9175); p<0.001). DISCUSSION: This is the first study showing that home initiation of chronic NIV in stable hypercapnic COPD patients, with the use of telemedicine, is non-inferior to in-hospital initiation, safe and reduces costs by over 50%. TRIAL REGISTRATION NUMBER: NCT02652559.


Assuntos
Ventilação não Invasiva/métodos , Cooperação do Paciente , Doença Pulmonar Obstrutiva Crônica/terapia , Insuficiência Respiratória/terapia , Telemedicina , Idoso , Dióxido de Carbono , Doença Crônica , Feminino , Volume Expiratório Forçado , Hospitalização , Hospitais , Humanos , Hipercapnia/etiologia , Hipercapnia/terapia , Masculino , Pessoa de Meia-Idade , Ventilação não Invasiva/economia , Pressão Parcial , Doença Pulmonar Obstrutiva Crônica/complicações , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Troca Gasosa Pulmonar , Qualidade de Vida , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/fisiopatologia , Capacidade Vital
12.
Eur Respir Rev ; 28(154)2019 Dec 31.
Artigo em Inglês | MEDLINE | ID: mdl-31694840

RESUMO

Discharging a chronic critically ill patient is a risky procedure if the clinician does not have full control of his prescription. This is even more important when applying a machine to replace a failing organ, as is the case for home ventilation. Even if modern home ventilators fulfil quality and safety criteria and, 'on paper', ventilators and masks look very similar, performance and scenarios of applicability are not always equivalent. In the case of ventilators, the type of circuit, accessories provided and available modes vary between devices. Bench studies comparing ventilators have shown large differences in triggering, rise time, pressurisation capacities, maximal flow provided, cycling and level of authorised expiratory positive airway pressure. Automated algorithms to deal with leaks also vary and have not been sufficiently evaluated. In the case of interfaces, the choice of mask requires careful evaluation of the underlying disease and of the type of ventilator and circuit, which could have a potentially major impact on patient compliance and clinical effectiveness. This could explain different results in the same clinical situation. The choice of ventilator and type of mask represents a medical prescription and should be respected by the provider and not subject to financial constraints.


Assuntos
Hipercapnia/terapia , Ventilação não Invasiva , Medicina de Precisão , Doença Pulmonar Obstrutiva Crônica/complicações , Doença Pulmonar Obstrutiva Crônica/terapia , Insuficiência Respiratória/terapia , Humanos , Hipercapnia/etiologia , Masculino , Pessoa de Meia-Idade , Insuficiência Respiratória/etiologia , Ventiladores Mecânicos
13.
Int J Chron Obstruct Pulmon Dis ; 14: 2385-2393, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31695358

RESUMO

Background: Patients with Acute Hypercapnic Respiratory Failure (AHRF) are often treated with Noninvasive Positive Pressure Ventilation (NPPV). In this heterogeneous patient group, there is a lack of clinical tools for predicting mortality and outcome. Aims: In order to facilitate the choice of treatment in patients with AHRF we evaluated the protein ST2, an established biomarker for cardiac stress, and its role in predicting mortality in patients with AHRF treated with NPPV. We also examined if ST2 baseline levels and changes during the first 12 hrs of treatment were predictive of treatment outcome. Methods: The study population consisted of 46 patients treated with NPPV for AHRF. Background data and clinical parameters were obtained and blood samples taken at various time points during the treatment. During the follow-up period of 18 months, the prognostic value of ST2 with regards to mortality was evaluated using Cox proportional hazard model. Results: Of the 46 patients, there were 3 subgroups in regards to primary diagnosis: Acute Exacerbation of COPD (n=34), Acute Heart Failure (n=8) and Acute Exacerbation in Obesity Hypoventilation Syndrome (n=4). We found that ST2 was an independent predictor of both short-term and long-term mortality during the follow-up period. The Hazard Ratio (HR) per 1-SD increment of ST2 for 28-day mortality was 11.00 (95% CI 1.8-67.2, p 0.009) and for 18-month mortality 2.11 (95% CI 1.4-3.2, p 0.001). The results seem to be driven by the largest subgroup of patients, with Acute Exacerbation of COPD, and deaths within the first 28 days. Furthermore, changes in ST2 values during the first 12 hrs of treatment were not predictive of treatment outcome. Conclusion: Our results show that ST2 is a target to explore further as a predictor of short-term mortality in patients with AHRF treated with NPPV.


Assuntos
Hipercapnia/sangue , Hipercapnia/mortalidade , Proteína 1 Semelhante a Receptor de Interleucina-1/sangue , Insuficiência Respiratória/sangue , Insuficiência Respiratória/mortalidade , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Feminino , Humanos , Hipercapnia/complicações , Hipercapnia/terapia , Masculino , Pessoa de Meia-Idade , Ventilação não Invasiva , Respiração com Pressão Positiva , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Insuficiência Respiratória/complicações , Insuficiência Respiratória/terapia
14.
Am J Case Rep ; 20: 1619-1622, 2019 Nov 04.
Artigo em Inglês | MEDLINE | ID: mdl-31680117

RESUMO

BACKGROUND Pulmonary barotrauma is considered as complication of the use of positive-pressure ventilations. Nasal high-flow therapy is increasingly being used as an alternative to them. Nasal high-flow therapy rarely causes pulmonary barotrauma probably because airway pressures are lower when compared with invasive mechanical ventilation. Bronchiolitis obliterans syndrome after allogenic hematopoietic stem cell transplantation is triggered by an alloimmune response in the bronchioles and causes obstruction of the bronchioles. However, the threshold of additional positive pressure has not been determined in a patient with bronchiolitis obliterans syndrome. CASE REPORT A 14-year-old female patient with acute myeloid leukemia at high risk of recurrence received an allogeneic hematopoietic stem cell transplantation from an unrelated bone marrow donor. After engraftment, she developed acute graft-versus-host disease, followed by chronic graft-versus-host disease. Ten months post-transplantation, she developed bronchiolitis obliterans syndrome. She continued to receive nasal supplemental oxygen therapy for persistent dyspnea due to bronchiolitis obliterans syndrome. At month +25, hypercapnia was noted. Therefore, we carefully initiated nasal high-flow therapy for dyspnea and adjusted the oxygen dose to maintain 90% SpO2 to avoid life-threatening apnea. The flow rate was as low as 14 to 20 L/min to avoid the risk of barotrauma and the deterioration of air trapping. Unfortunately, she died of respiratory failure at month +31 post-transplantation. A lung autopsy revealed pulmonary barotrauma. CONCLUSIONS Nasal high-flow therapy, even at low flow rates, may cause fatal pulmonary barotrauma in bronchiolitis obliterans syndrome.


Assuntos
Barotrauma/etiologia , Bronquiolite Obliterante/terapia , Lesão Pulmonar/etiologia , Oxigenoterapia/efeitos adversos , Oxigenoterapia/métodos , Adolescente , Barotrauma/fisiopatologia , Bronquiolite Obliterante/complicações , Dispneia/terapia , Evolução Fatal , Feminino , Doença Enxerto-Hospedeiro/complicações , Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Humanos , Hipercapnia/terapia , Leucemia Mieloide Aguda , Lesão Pulmonar/fisiopatologia , Insuficiência Respiratória
15.
Pulmonology ; 25(6): 348-354, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31591056

RESUMO

Chronic Obstructive Pulmonary Disease (COPD) history is characterized by episodes of exacerbation of varying severity, featured by acute worsening of respiratory symptoms, commonly precipitated by respiratory tract infection. The recent ERS/ATS clinical practice guidelines strongly recommend the application of non invasive ventilation (NIV) for patients with acute respiratory failure (ARF) leading to acute or acute-on-chronic respiratory acidosis (pH 7.35) and not for those patients with acute exacerbation of COPD (AECOPD) and hypercapnia who are not acidotic. In recent years, High-Flow through Nasal Cannula (HFNC) has been introduced in the clinical practice. We designed the present systematic review of the literature to assess all effects of HFNC use reported in exacerbated COPD patients. In this setting, HFNC is able to keep PaCO2 unmodified, while oxygenation slightly deteriorates as opposed to NIV. Furthermore, the work of breathing is reduced with HFNC by a similar extent to NIV, while it increases by 40-50% during conventional oxygen therapy (COT). HFNC is also reported to be more comfortable than COT and NIV. Despite these results, little and limited evidence for improved clinical outcomes is currently available.


Assuntos
Ventilação não Invasiva/métodos , Doença Pulmonar Obstrutiva Crônica/terapia , Terapia Respiratória/métodos , Acidose Respiratória/terapia , Gasometria , Progressão da Doença , Humanos , Hipercapnia/terapia , Ventilação não Invasiva/instrumentação , Respiração com Pressão Positiva/instrumentação , Respiração com Pressão Positiva/métodos , Doença Pulmonar Obstrutiva Crônica/sangue , Insuficiência Respiratória/complicações , Insuficiência Respiratória/terapia , Taxa Respiratória , Terapia Respiratória/instrumentação , Resultado do Tratamento , Trabalho Respiratório
16.
Eur Respir J ; 54(3)2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31467119

RESUMO

BACKGROUND: While the role of acute non-invasive ventilation (NIV) has been shown to improve outcome in acute life-threatening hypercapnic respiratory failure in COPD, the evidence of clinical efficacy of long-term home NIV (LTH-NIV) for management of COPD is less. This document provides evidence-based recommendations for the clinical application of LTH-NIV in chronic hypercapnic COPD patients. MATERIALS AND METHODS: The European Respiratory Society task force committee was composed of clinicians, methodologists and experts in the field of LTH-NIV. The committee developed recommendations based on the GRADE (Grading, Recommendation, Assessment, Development and Evaluation) methodology. The GRADE Evidence to Decision framework was used to formulate recommendations. A number of topics were addressed under a narrative format which provides a useful context for clinicians and patients. RESULTS: The task force committee delivered conditional recommendations for four actionable PICO (target population-intervention-comparator-outcome) questions, 1) suggesting for the use of LTH-NIV in stable hypercapnic COPD; 2) suggesting for the use of LTH-NIV in COPD patients following a COPD exacerbation requiring acute NIV 3) suggesting for the use of NIV settings targeting a reduction in carbon dioxide and 4) suggesting for using fixed pressure support as first choice ventilator mode. CONCLUSIONS: Managing hypercapnia may be an important intervention for improving the health outcome of COPD patients with chronic respiratory failure. The task force conditionally supports the application of LTH-NIV to improve health outcome by targeting a reduction in carbon dioxide in COPD patients with persistent hypercapnic respiratory failure. These recommendations should be applied in clinical practice by practitioners that routinely care for chronic hypercapnic COPD patients.


Assuntos
Ventilação não Invasiva/normas , Respiração com Pressão Positiva/normas , Doença Pulmonar Obstrutiva Crônica/terapia , Pneumologia/normas , Progressão da Doença , Europa (Continente) , Medicina Baseada em Evidências , Serviços de Assistência Domiciliar , Humanos , Hipercapnia/terapia , Guias de Prática Clínica como Assunto , Insuficiência Respiratória/terapia , Resultado do Tratamento
17.
J Pak Med Assoc ; 69(8): 1146-1149, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31431769

RESUMO

OBJECTIVE: The aim was to access the effectiveness of Bilevel Positive Airway Pressure (BiPAP) in patients with type II respiratory failure secondary to Post Tuberculosis (TB) sequelae and determine the factors that can predict its success. PostTB pulmonary sequelae are complications after healing of TB and type II respiratory failure is frequently encountered in this group. . METHODS: This prospective study was carried out in the department of Chest Medicine, Jinnah Postgraduate Medical Center Karachi. (JPMC) Total 78 patients, between 20-80 years of age having hypercapnic respiratory failure, were included. Patients were given BiPAP along with standard treatment. RESULTS: Among 78 patients, 45 (56.3%) were males and 33 (43.7%) were females. Patients mean age was 50.6 } 15.76 years. The BiPAP success rate was 70.5% (55/78). There is significant difference in age (p=0.008), duration of disease (p=0.021), baseline pH (p=0.00), PaCO2 (p=0.004), Glasgow Coma Score (p=0.031), Chest X-ray (p<0.05) and systolic blood pressure (p=0.007) between responders and non-responders. Improvement in Abgs and vitals was observed among responders following 3 hours of therapy while pH drops significantly at 3 hours in non-responders. CONCLUSIONS: This study reveals that BiPAP is also efficacious method in patients with Type II respiratory failure post TB sequelae. Potential non responders can be identified relatively early in course of treatment and considered for ventilator.


Assuntos
Pressão Positiva Contínua nas Vias Aéreas/métodos , Hipercapnia/terapia , Ventilação não Invasiva/métodos , Insuficiência Respiratória/terapia , Tuberculose Pulmonar/complicações , Adulto , Fatores Etários , Idoso , Gasometria , Pressão Sanguínea , Feminino , Escala de Coma de Glasgow , Humanos , Concentração de Íons de Hidrogênio , Hipercapnia/etiologia , Masculino , Pessoa de Meia-Idade , Pressão Parcial , Prognóstico , Radiografia Torácica , Insuficiência Respiratória/sangue , Insuficiência Respiratória/diagnóstico por imagem , Insuficiência Respiratória/etiologia , Fatores de Tempo
18.
Trials ; 20(1): 465, 2019 Jul 30.
Artigo em Inglês | MEDLINE | ID: mdl-31362776

RESUMO

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a common cause of chronic respiratory failure and its course is punctuated by a series of acute exacerbations which commonly lead to hospital admission. Exacerbations are managed through the application of non-invasive ventilation and, when this fails, tracheal intubation and mechanical ventilation. The need for mechanical ventilation significantly increases the risk of death. An alternative therapy, extracorporeal carbon dioxide removal (ECCO2R), has been shown to be efficacious in removing carbon dioxide from the blood; however, its impact on respiratory physiology and patient outcomes has not been explored. METHODS/DESIGN: A randomised controlled open label trial of patients (12 in each arm) with acute exacerbations of COPD at risk of failing conventional therapy (NIV) randomised to either remaining on NIV or having ECCO2R added to NIV with a primary endpoint of time to cessation of NIV. The change in respiratory physiology following the application of ECCO2R and/or NIV will be measured using electrical impedance tomography, oesophageal pressure and parasternal electromyography. Additional outcomes, including patient tolerance, outcomes, need for readmission, changes in blood gases and biochemistry and procedural complications, will be measured. Physiological changes will be compared within one patient over time and between the two groups. Healthcare costs in the UK system will also be compared between the two groups. DISCUSSION: COPD is a common disease and exacerbations are a leading cause of hospital admission in the UK and worldwide, with a sizeable mortality. The management of patients with COPD consumes significant hospital and financial resources. This study seeks to understand the feasibility of a novel approach to the management of patients with acute exacerbations of COPD as well as to understand the underlying physiological changes to explain why the approach does or does not assist this patient cohort. Detailed respiratory physiology has not been previously undertaken using this technique and there are no other randomised controlled trials currently in the literature. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02086084.


Assuntos
Dióxido de Carbono/sangue , Circulação Extracorpórea , Hipercapnia/terapia , Pulmão/fisiopatologia , Doença Pulmonar Obstrutiva Crônica/terapia , Respiração , Biomarcadores/sangue , Terapia Combinada , Progressão da Doença , Circulação Extracorpórea/efeitos adversos , Humanos , Hipercapnia/sangue , Hipercapnia/diagnóstico , Hipercapnia/fisiopatologia , Londres , Ventilação não Invasiva , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/sangue , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Recuperação de Função Fisiológica , Fatores de Tempo , Resultado do Tratamento
19.
Respiration ; 98(2): 95-110, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31291632

RESUMO

Central sleep apnea (CSA) comprises a variety of breathing patterns and clinical entities. They can be classified into 2 categories based on the partial pressure of carbon dioxide in the arterial blood. Nonhypercapnic CSA is usually characterized by a periodic breathing pattern, while hypercapnic CSA is based on hypoventilation. The latter CSA form is associated with central nervous, neuromuscular, and rib cage disorders as well as obesity and certain medication or substance intake. In contrast, nonhypercapnic CSA is typically accompanied by an overshoot of the ventilation and often associated with heart failure, cerebrovascular diseases, and stay in high altitude. CSA and hypoventilation syndromes are often considered separately, but pathophysiological aspects frequently overlap. An integrative approach helps to recognize underlying pathophysiological mechanisms and to choose adequate therapeutic strategies. Research in the last decades improved our insights; nevertheless, diagnostic tools are not always appropriately chosen to perform comprehensive sleep studies. This supports misinterpretation and misclassification of sleep disordered breathing. The purpose of this article is to highlight unresolved problems, raise awareness for different pathophysiological components and to discuss the evidence for targeted therapeutic strategies.


Assuntos
Hipercapnia/fisiopatologia , Hipoventilação/fisiopatologia , Apneia do Sono Tipo Central/fisiopatologia , Altitude , Analgésicos Opioides/efeitos adversos , Pressão Positiva Contínua nas Vias Aéreas , Insuficiência Cardíaca/complicações , Humanos , Hipercapnia/etiologia , Hipercapnia/terapia , Hipoventilação/etiologia , Hipoventilação/terapia , Obesidade/complicações , Oxigenoterapia , Polissonografia , Apneia do Sono Tipo Central/induzido quimicamente , Apneia do Sono Tipo Central/etiologia , Apneia do Sono Tipo Central/terapia , Acidente Vascular Cerebral/complicações
20.
Trials ; 20(1): 450, 2019 Jul 22.
Artigo em Inglês | MEDLINE | ID: mdl-31331372

RESUMO

BACKGROUND: Noninvasive ventilation (NIV) is indicated to treat respiratory acidosis due to exacerbation of chronic obstructive pulmonary disease (COPD). Recent nonrandomized studies also demonstrated some physiological effects of high-flow nasal therapy (HFNT) in COPD patients. We designed a prospective, unblinded, multicenter, randomized controlled trial to assess the noninferiority of HFNT compared to NIV with respect to the reduction of arterial partial pressure of carbon dioxide (PaCO2) in patients with hypercapnic acute respiratory failure with mild-to-moderate respiratory acidosis. METHODS: We will enroll adult patients with acute hypercapnic respiratory failure, as defined by arterial pH between 7.25 and 7.35 and PaCO2 ≥ 55 mmHg. Patients will be randomly assigned 1:1 to receive NIV or HFNT. NIV will be applied through a mask with a dedicated ventilator in pressure support mode. Positive end-expiratory pressure will be set at 3-5 cmH2O with inspiratory support to obtain a tidal volume between 6 and 8 ml/kg of ideal body weight. HFNT will be initially set at a temperature of 37 °C and a flow of 60 L/min. At 2 and 6 h we will assess arterial blood gases, vital parameters, respiratory rate, treatment intolerance and failure, need for endotracheal intubation, time spent under mechanical ventilation (both invasive and NIV), intensive care unit and hospital length of stay, and hospital mortality. Based on an α error of 5% and a ß error of 80%, with a standard deviation for PaCO2 equal to 15 mmHg and a noninferiority limit of 10 mmHg, we computed a sample size of 56 patients. Considering potential drop-outs and nonparametric analysis, the final computed sample size was 80 patients (40 per group). DISCUSSION: HFNT is more comfortable than NIV in COPD patients recovering from an episode of exacerbation. If HFNT would not be inferior to NIV, HFNT could be considered as an alternative to NIV to treat COPD patients with mild-to-moderate respiratory acidosis. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03370666 . Registered on December 12, 2017.


Assuntos
Hipercapnia/terapia , Pulmão/fisiopatologia , Ventilação não Invasiva , Oxigenoterapia/métodos , Doença Pulmonar Obstrutiva Crônica/terapia , Insuficiência Respiratória/terapia , Doença Aguda , Estudos de Equivalência como Asunto , Humanos , Hipercapnia/diagnóstico , Hipercapnia/fisiopatologia , Itália , Estudos Multicêntricos como Assunto , Ventilação não Invasiva/efeitos adversos , Oxigenoterapia/efeitos adversos , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
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