Implementation of High-Flow Nasal Cannula Therapy Outside the Intensive Care Setting.

BACKGROUND: High-flow nasal cannula (HFNC) is an option for respiratory support in patients with acute hypoxic respiratory failure. To improve patient outcomes, reduce ICU-associated costs, and ease ICU bed availability, a multi-phased, comprehensive strategy was implemented to make HFNC available outside the ICU under the supervision of pulmonology or trauma providers in cooperation with a dedicated respiratory therapy team. The purpose of this study was to describe the education and implementation process for initiating HFNC therapy outside the ICU and to convey key patient demographics and outcomes from the implementation period. METHODS: HFNC therapy was implemented at a tertiary hospital in the Midwest, with systematic roll-out to all in-patient floors over a 9-month period. Utilization of the therapy and patient outcomes were tracked to ensure safety and efficacy of the effort. RESULTS: During the implementation period, 346 unique subjects met study inclusion criteria. Median (interquartile range) hospital length of stay was 8 d (4-12), and median duration of HFNC therapy was 44 h (18-90). Two thirds of subjects (n = 238) received the entire course of HFNC therapy outside the ICU, and more than half of subjects (n = 184) avoided the ICU for their entire hospitalization. Moreover, 6% of subjects in the study group escalated from HFNC to noninvasive ventilation, and 5% of subjects escalated from HFNC to mechanical ventilation. CONCLUSIONS: A comprehensive implementation process and a robust therapy protocol were integral to initiating and managing HFNC in all hospital locations. Study findings indicate that patients with acute hypoxic respiratory failure can safely receive HFNC therapy outside the ICU with appropriate patient selection and staff education.

Prevalence of risk for sleep apnea among hospitalized patients who survived a medical emergency team activation.

STUDY OBJECTIVES: Sleep-disordered breathing (SDB) is a common disorder that causes people to stop breathing in their sleep, and obstructive sleep apnea (OSA) is the most common form of SDB in the general population. Because OSA is often undiagnosed and undermanaged, it has been associated with adverse events and morbidity in hospitalized patients. The purpose of the study was to evaluate prevalence of OSA risk in a population of patients who survived a medical emergency team (MET) activation during hospitalization. METHODS: This prospective study was conducted at a hospital in the Midwest in 2014. Patients who survived a MET activation and consented to participate were administered the STOP-Bang questionnaire and asked other health and lifestyle questions. Review of the medical record was conducted to ascertain patient characteristics, comorbidities, and medications. Differences were assessed using Kruskal-Wallis one-way analysis of variance and the chi-square test. RESULTS: Of 148 study patients, median age was 68 years (interquartile range: 55-78) and 15% were morbidly obese (body mass index ≥ 40 kg/m²). Fifty percent of patients (n = 74) were found to be at high risk for OSA, yet only 38% (n = 28) of those patients received a previous diagnosis of OSA. Variables available in the medical record were highly correlated with the overall STOP-Bang score (r =. 75, P < .001). CONCLUSIONS: Half of patients who survived a MET activation during hospitalization screened at high risk for OSA. Standardized screening for risk of sleep apnea, as well as a truncated risk score generated by variables in the medical record, could guide clinical decision making in this at-risk population.

Driving with undiagnosed obstructive sleep apnea (OSA): High prevalence of OSA risk in drivers who experienced a motor vehicle crash.

Objective: Obstructive sleep apnea (OSA) is a risk factor for motor vehicle crashes (MVC), and patients with diagnosed OSA have a higher likelihood of being involved in a traffic accident. OSA, however, is often underdiagnosed in the general population. The purpose of this study was to assess the risk of undiagnosed OSA among hospitalized patients involved in MVCs.Methods: This is a prospective, observational pilot study of adult trauma patients admitted to a Level 1 trauma center after being the driver in a MVC. Patients were administered the STOP-Bang to assess risk of OSA and were asked questions about the circumstances of the MVC. Patients with a STOP-Bang score 5-8 were considered to be at high risk for OSA. Differences between variables were assessed using independent t-tests and chi-square.Results: Eighty patients participated in the study, and 26% (n = 21) were considered to be at high risk for OSA based on the STOP-Bang score. Compared to patients at low and intermediate risk, patients at high risk for OSA were significantly older (p < .001), had longer hospitalization (p = .06), and were less likely to discharge home from the hospital (p = .01). Patients at moderate and high risk had higher rates of hospital readmission within 1 year of discharge, when compared to the low risk group. Eighty-four percent of all crashes involved a single occupant (driver) in the vehicle, 58% involved only a single vehicle, and 40% occurred on a rural road. There were no significant differences between risk groups for number of vehicles involved in the accident, location of the accident, or number of vehicle occupants.Conclusions: Results of this pilot study suggest that more than one-quarter of drivers hospitalized after motor vehicle crashes were at high risk for OSA. Diagnosed or undiagnosed OSA is a significant public health concern and an established risk factor for motor vehicle accidents. Standardized screening for risk of sleep apnea should be considered by primary care physicians when guiding patients on health and behavior decisions, particularly in regards to driving and road safety.

Role of B-Type Natriuretic Peptide in Predicting In-Hospital Outcomes in Acute Exacerbation of Chronic Obstructive Pulmonary Disease With Preserved Left Ventricular Function: A 5-Year Retrospective Analysis.

BACKGROUND: The role of B-type natriuretic peptide (BNP) is less understood in the risk stratification of patients with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD), especially in patients with normal left ventricular ejection fraction (LVEF). METHODS: This retrospective study from 2008 to 2012 evaluated all adult patients with AECOPD having BNP levels and available echocardiographic data demonstrating LVEF ≥40%. The patients were divided into groups 1, 2, and 3 with BNP ≤ 100, 101 to 500, and ≥501 pg/mL, respectively. A subgroup analysis was performed for patients without renal dysfunction. Outcomes included need for and duration of noninvasive ventilation (NIV) and mechanical ventilation (MV), NIV failure, reintubation at 48 hours, intensive care unit (ICU) and total length of stay (LOS), and in-hospital mortality. Two-tailed P < .05 was considered statistically significant. RESULTS: Of the total 1145 patients, 550 (48.0%) met our inclusion criteria (age 65.1 ± 12.2 years; 271 [49.3%] males). Groups 1, 2, and 3 had 214, 216, and 120 patients each, respectively, with higher comorbidities and worse biventricular function in higher categories. Higher BNP values were associated with higher MV use, NIV failure, MV duration, and ICU and total LOS. On multivariate analysis, BNP was an independent predictor of higher NIV and MV use, NIV failure, NIV and MV duration, and total LOS in groups 2 and 3 compared to group 1. B-type natriuretic peptide continued to demonstrate positive correlation with NIV and MV duration and ICU and total LOS independent of renal function in a subgroup analysis. CONCLUSION: Elevated admission BNP in patients with AECOPD and normal LVEF is associated with worse in-hospital outcomes and can be used to risk-stratify these patients.

Influence of Left Ventricular Hypertrophy on In-Hospital Outcomes in Acute Exacerbation of Chronic Obstructive Pulmonary Disease.

Left ventricular hypertrophy (LVH) is associated with worse outcomes in chronic obstructive pulmonary disease (COPD); however, its role in an acute exacerbation of COPD (AECOPD) has not been reported. This was a retrospective cohort study during 2008-2012 at an academic medical center. AECOPD patients >18 years with available echocardiographic data were included. LVH was defined as LV mass index (LVMI) >95 g/m2 (women) and >115g/m2 (men). Relative wall thickness was used to classify LVH as concentric (>0.42) or eccentric (<0.42). Outcomes included need for and duration of non-invasive ventilation (NIV) and mechanical ventilation (MV), NIV failure, intensive care unit (ICU) and total length of stay (LOS), and in-hospital mortality. Two-tailed p < 0.05 was considered statistically significant. Of 802 patients with AECOPD, 615 patients with 264 (42.9%) having LVH were included. The LVH cohort had higher LVMI (141.1 ± 39.4 g/m2 vs. 79.7 ± 19.1 g/m2; p < 0.001) and lower LV ejection fraction (44.5±21.9% vs. 50.0±21.6%; p ≤ 0.001). The LVH cohort had statistically non-significant longer ICU LOS, and higher NIV and MV use and duration. Of the 264 LVH patients, concentric LVH (198; 75.0%) was predictive of greater NIV use [82 (41.4%) vs. 16 (24.2%), p = 0.01] and duration (1.0 ± 1.9 vs. 0.6 ± 1.4 days, p = 0.01) compared to eccentric LVH. Concentric LVH remained independently associated with NIV use and duration. In-hospital outcomes in patients with AECOPD were comparable in patients with and without LVH. Patients with concentric LVH had higher NIV need and duration in comparison to eccentric LVH.

Age, sex, and ethnicity may modify the influence of obesity on inflammation.

OBJECTIVES: Many medical concerns associated with obesity are due to chronic inflammation, but factors underlying the development or maintenance of obesity-associated inflammation remain unclear. This study investigated how age, sex, and ethnicity may modify the interplay of subclinical inflammation and obesity in nationally representative contexts. METHODS: Using National Health and Nutrition Examination Survey data from 1999 to 2008, we assessed the role of these demographic factors on immunological markers of subclinical inflammation (such as total white blood cell counts, white blood cell subpopulation counts, and C-reactive protein [CRP] levels) in both obese and nonobese individuals. Approximately 9756 individuals were included in the analysis after removing individuals with confounding conditions. RESULTS: The CRP levels, total white blood cell count, and white blood cell subpopulation counts increased with increasing body mass index (BMI). After controlling for BMI, female subjects had greater levels of most inflammatory markers compared with male subjects. After controlling for age, sex, and ethnicity, the following inflammatory markers significantly increased with increasing BMI: CRP and white blood cell, lymphocyte, monocyte, and neutrophil counts. Basophil and eosinophil counts also increased with increasing BMI but not significantly. CONCLUSIONS: Factors, such as age, sex, and ethnicity, may modify the influence of obesity on subclinical inflammation at the population level.

Echinacea tennesseensis ethanol tinctures harbor cytokine- and proliferation-enhancing capacities.

BACKGROUND: Members of the genus Echinacea are used medicinally to treat upper respiratory infections such as colds and influenza. The aim of the present investigation was to characterize the phytomedicinal properties of the American federally endangered species Echinacea tennesseensis. METHODS: Fifty-percent ethanol tinctures were prepared from roots, stems, leaves, and flowers and tested separately for their ability to influence production of IL-1beta, IL-2, IL-10, and TNF-alpha as well as proliferation by young human adult peripheral blood mononuclear cells (PMBC) in vitro. Tincture aliquots were stored at three different temperatures (4, -20, and -80 degrees C) for 21h before testing. At 1-month post-extraction, tinctures stored at -20 degrees C were tested again for cytokine modulation. Phytochemical analyses were performed using HPLC. RESULTS: Fresh root, leaf, and flower tinctures stimulated PBMC proliferation. Fresh root tinctures alone stimulated IL-1beta, IL-10, and TNF-alpha production. No tinctures modulated IL-2 production. Stem tinctures showed no activity. Storage temperature did not influence any outcomes. Root tinctures maintained their ability to modulate IL-1beta, IL-10, and TNF-alpha production after 1month of storage at -20 degrees C. CONCLUSIONS: These results suggest E. tennesseensis harbors phytomedicinal properties that vary by plant organ, with roots demonstrating the strongest activities.

Bloodroot (Sanguinaria canadensis L., Papaveraceae) Enhances Proliferation and Cytokine Production by Human Peripheral Blood Mononuclear Cells in an In Vitro Model.

Previous studies have suggested that phytomedicinal preparations from bloodroot (Sanguinaria canadensis L.) may harbor immunomodulatory properties. The purpose of this investigation was to determine the effects of alcohol tinctures and water infusions generated from bloodroot flowers, leaves, rhizomes, and roots on human peripheral blood mononuclear cell (PBMC) cytokine production and proliferation in vitro. PBMCs were collected from 16 healthy young adults and cultured with bloodroot extracts or respective controls for interleukins-1ß, -2, -8, -10, interferon-γ, and tumor necrosis factor. Proliferative capabilities of both PBMCs and K562 cells (an immortalized human myelogenous leukemia cell line) following extract treatment were determined. High-pressure liquid chromatography was used to quantify berberine, chelerythrine, and sanguinarine in the extracts and to correlate extract composition with observed effects. Overall, infusions demonstrated greater immunomodulatory capabilities than tinctures, and flower- and root-based extracts showed greater immunomodulatory properties than leaf- or rhizome-based extracts (some effects seen with root-based extracts may be due to endotoxin). Several extracts were able to augment PBMC proliferation and diminish K562 proliferation, suggesting a selective anti-carcinogenic activity. The rhizome alcohol tincture had a markedly stronger effect against K562 cells than other extracts. Chelerythrine, sanguinarine, and endotoxin (but not berberine) sometimes correlated with observed effects. The in vitro activities demonstrated here suggest bloodroot extracts may have potential as therapeutic immunomodulators.

Cytokine- and interferon-modulating properties of Echinacea spp. root tinctures stored at -20 degrees C for 2 years.

Echinacea spp. phytomedicines are popular for treating upper respiratory infections. The purpose of this investigation was to examine the immunomodulatory properties of Echinacea tinctures from seven species after being stored at -20 degrees C for 2 years. Two experimental techniques were employed using human peripheral blood mononuclear cells (PBMC). In the first set of experiments, PBMCs were stimulated in vitro with tinctures alone and assayed for proliferation and production of interleukin-10 (IL-10), IL-12, and tumor necrosis factor-alpha (TNF-alpha). In the second set of experiments, subjects were immunized with influenza vaccine. PBMCs from vaccinated individuals were stimulated in vitro with Echinacea tinctures and influenza virus; cytokine production (IL-2, IL-10, and interferon-gamma [IFN-gamma]) was compared prevaccination and postvaccination. In the first experiments, (1) tinctures from E. angustifolia, E. pallida, E. paradoxa, and E. tennesseensis stimulated proliferation and tended to increase IL-10, (2) E. sanguinea and E. simulata stimulated only proliferation, (3) E. purpurea stimulated only IL-10, and (4) none of the extracts influenced IL-12 or TNF-alpha. In the second experiments, (1) tinctures from E. pallida, E. paradoxa, E. sanguinea, and E. simulata diminished influenza-specific IL-2, and (2) none of the extracts influenced influenza-specific IL-10 or IFN-gamma. For in vitro models using Echinacea, immune response may vary based on stimulus (Echinacea alone vs. Echinacea + recall stimulation with virus).

Changes in immunomodulatory properties of Echinacea spp. root infusions and tinctures stored at 4 degrees C for four days.

BACKGROUND: Phytomedicinal preparations from members of the genus Echinacea are popular worldwide and frequently used to treat upper respiratory infections. With the increasing popularity of herbal medicines, many people are making their own Echinacea extracts at home and storing them at refrigerator (4 degrees C) temperatures. We tested the hypothesis that Echinacea extracts made using homemade methods change in immunomodulatory efficacy with storage at 4 degrees C over a 4-day period. METHODS: Three extract types (50% ethanol tincture, cold water infusion, hot water infusion) from 5 different species (Echinacea angustifolia, E. pallida, E. purpurea, E. sanguinea, E. tennesseensis) were prepared. Four in vitro immune assays (monocyte secretion of TNF-alpha, IL-10, and IL-12; and peripheral blood mononuclear cell proliferation) using human blood were used to test extract efficacy at Days 1 and 4 post-extraction. Two statistical analyses, traditional ANOVA and several statistical models that account for endotoxin effects, were used. RESULTS: Endotoxin was found to significantly impact immune outcomes only in 4-day old cold water infusions and not in all assays. Extracts showed the greatest stimulation in TNF-alpha assays. By extract type, 50% ethanol tinctures produced the most immune stimulation. By species, extracts from E. angustifolia extracts were the most efficacious in our assays; extracts from E. sanguinea showed the least activity overall. CONCLUSIONS: Taken together, these results suggest that: (1) homemade Echinacea extracts are efficacious in modulating immune cell activity in vitro but that their properties change with time during storage at 4 degrees C; and (2) endotoxin effects from extracts may be important considerations in the analysis of immunobiological data.