Effects of non-invasive respiratory support in post-operative patients: a systematic review and network meta-analysis.

BACKGROUND: Re-intubation secondary to post-extubation respiratory failure in post-operative patients is associated with increased patient morbidity and mortality. Non-invasive respiratory support (NRS) alternative to conventional oxygen therapy (COT), i.e., high-flow nasal oxygen, continuous positive airway pressure, and non-invasive ventilation (NIV), has been proposed to prevent or treat post-extubation respiratory failure. Aim of the present study is assessing the effects of NRS application, compared to COT, on the re-intubation rate (primary outcome), and time to re-intubation, incidence of nosocomial pneumonia, patient discomfort, intensive care unit (ICU) and hospital length of stay, and mortality (secondary outcomes) in adult patients extubated after surgery. METHODS: A systematic review and network meta-analysis of randomized and non-randomized controlled trials. A search from Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, and Web of Science from inception until February 2, 2024 was performed. RESULTS: Thirty-three studies (11,292 patients) were included. Among all NRS modalities, only NIV reduced the re-intubation rate, compared to COT (odds ratio 0.49, 95% confidence interval 0.28; 0.87, p = 0.015, I2 = 60.5%, low certainty of evidence). In particular, this effect was observed in patients receiving NIV for treatment, while not for prevention, of post-extubation respiratory failure, and in patients at high, while not low, risk of post-extubation respiratory failure. NIV reduced the rate of nosocomial pneumonia, ICU length of stay, and ICU, hospital, and long-term mortality, while not worsening patient discomfort. CONCLUSIONS: In post-operative patients receiving NRS after extubation, NIV reduced the rate of re-intubation, compared to COT, when used for treatment of post-extubation respiratory failure and in patients at high risk of post-extubation respiratory failure.

Multidrug-Resistant and Extended-Spectrum ß-Lactamase Gram-Negative Bacteria in Bilateral Lung Transplant Recipients: Incidence, Risk Factors, and In-Hospital Mortality.

BACKGROUND: In recent decades, the incidence of multidrug-resistant (MDR) and extended-spectrum ß-lactamase (ESBL) gram-negative (GN) bacteria has increased progressively among lung transplantation (LT) recipients. A prompt diagnosis, prevention, and management of these pathogens remain the cornerstone for successful organ transplantation. RESEARCH QUESTION: What are the incidence of MDR and ESBL GN bacteria within the first 30 days after LT and related risk of in-hospital mortality? What are the potential clinical predictors of isolation of MDR and ESBL GN bacteria? STUDY DESIGN AND METHODS: All consecutive LT recipients admitted to the ICU of the University Hospital of Padua (February 2016-December 2021) were screened retrospectively. Only adult patients undergoing the first bilateral LT and not requiring invasive mechanical ventilation, extracorporeal membrane oxygenation, or both before surgery were included. MDR and ESBL GN bacteria were identified using in vitro susceptibility tests and were isolated from the respiratory tract, blood, urine, rectal swab, or surgical wound or drainage according to a routine protocol. RESULTS: One hundred fifty-three LT recipients were screened, and 132 were considered for analysis. Median age was 52 years (interquartile range, 41-60 years) and 46 patients (35%) were women. MDR and ESBL GN bacteria were identified in 45 patients (34%), and 60% of patients demonstrated clinically relevant infection. Pseudomonas aeruginosa (n = 22 [49%]) and Klebsiella pneumoniae (n = 17 [38%]) were frequently isolated after LT from the respiratory tract (n = 21 [47%]) and multiple sites (n = 18 [40%]). Previous recipient-related colonization (hazard ratio [HR], 2.48 [95% CI, 1.04-5.90]; P = .04) and empirical exposure to broad-spectrum antibiotics (HR, 6.94 [95% CI, 2.93-16.46]; P < .01) were independent predictors of isolation of MDR and ESBL GN bacteria. In-hospital mortality of the MDR and ESBL group was 27% (HR, 6.38 [95% CI, 1.98-20.63]; P < .01). INTERPRETATION: The incidence of MDR and ESBL GN bacteria after LT was 34%, and in-hospital mortality was six times greater. Previous recipient-related colonization and empirical exposure to broad-spectrum antibiotics were clinical predictors of isolation of MDR and ESBL GN bacteria.

Electrical impedance tomography: A compass for the safe route to optimal PEEP.

Setting the proper level of positive end-expiratory pressure (PEEP) is a cornerstone of lung protective ventilation. PEEP keeps the alveoli open at the end of expiration, thus reducing atelectrauma and shunt. However, excessive PEEP may contribute to alveolar overdistension. Electrical impedance tomography (EIT) is a non-invasive bedside tool that monitors in real-time ventilation distribution. Aim of this narrative review is summarizing the techniques for EIT-guided PEEP titration, while providing useful insights to enhance comprehension on advantages and limits of EIT for current and future users. EIT detects thoracic impedance to alternating electrical currents between pairs of electrodes and, through the analysis of its temporal and spatial variation, reconstructs a two-dimensional slice image of the lung depicting regional variation of ventilation and perfusion. Several EIT-based methods have been proposed for PEEP titration. The first described technique estimates the variations of regional lung compliance during a decremental PEEP trial, after lung recruitment. The optimal PEEP value is represented by the best compromise between lung collapse and overdistension. Later on, a second technique assessing alveolar recruitment by variation of the end-expiratory lung impedance was validated. Finally, the global inhomogeneity index and the regional ventilation delay, two EIT-derived parameters, showed promising results selecting the optimal PEEP value as the one that presents the lowest global inhomogeneity index or the lowest regional ventilation delay. In conclusion EIT represents a promising technique to individualize PEEP in mechanically ventilated patients. Whether EIT is the best technique for this purpose and the overall influence of personalizing PEEP on clinical outcome remains to be determined.

Prediction of difficult tracheal intubations in thyroid surgery. Predictive value of neck circumference to thyromental distance ratio.

INTRODUCTION: Difficult tracheal intubation (DTI) contributes to perioperative morbidity and mortality. There are conflicting study results about the most predictive DTI risk criteria in patients undergoing thyroid surgery. MATERIALS AND METHODS: We conducted a prospective observational study on 500 consecutive patients aged ≥18 years to identify predictors for DTI. Body weight, body mass index (BMI), inability to prognath, head movement, mouth opening, Mallampati score, neck circumference (NC), thyromental distance (TMD), neck circumference to thyromental distance ratio (NC/TMD), tracheal deviation apparent on chest x-ray, mediastinal goiter, histology and history of DTI were measured as possible predictors of DTI. Spearman's rank correlation test and multiple logistic regression analysis were performed. RESULTS: DTI was observed in 9.6% of all patients. Compared with the group of patients without DTI, the group of patients with DTI had significantly greater median values for body weight, BMI, NC, NC/TMD, Mallampati score, el-Ganzouri score, incidence of mediastinal goiter, and had reduced TMD and mouth opening. Significant correlations between BMI ≥30 kg/m2 and the Mallampati score ≥3 (R = 0.124, p = 0.00541), Cormack-Lehane ≥3 (R = 0.128, p = 0.00409), NC ≥40 cm (R = 0.376, p<0.001), and NC/TMD ≥5 (R = 0.103, p = 0.0207) were found. The logistic regression analysis revealed that an NC ≥40 cm at the goiter level, but not an NC/TMD ratio ≥5, was the strongest predictor of DTI (p<0.001). The area under the receiver operating characteristic curve for NC/TMD was better than the curve for NC. The sensitivity and specificity of NC/TMD were also greater, compared with NC. An NC of 40.00 cm and an NC/TMD of 5.85 were the estimated cut-off points. DISCUSSION: This study found that NC was a strong predictor of DTI. The results also suggested that NC/TMD could be used as a measure to stratify the risk of DTI in patients undergoing thyroid surgery.