The level of discomfort during the use of different circuits of the mechanical ventilator.

Objectives: Endotracheal tube (ETT) intubation is a life-saving procedure in patients with respiratory failure. However, the presence of an ETT can cause significant discomfort. A tracheostomy tube is used to administer a mechanical ventilator, resulting in a more stable airway and fewer serious injuries. Noninvasive ventilators (NIPPVs) administer ventilation through masks and must be tightly fixed to the face. ETT, tracheostomy, and NIPPV are the most common methods of ventilator maintenance. However, these interventions often cause discomfort to patients. This study aimed to compare discomfort associated with ETT, tracheostomy, and NIPPV. Materials and Methods: Forty-nine conscious patients with postextubation NIPPV and eight conscious patients who underwent postextubation tracheotomy were evaluated for discomfort. A questionnaire survey on discomfort was performed before and after NIPPV or tracheostomy. These patients reported their level of discomfort on a visual analog scale. Results: The levels of sore throat, nasal pain, body pain, activity limitation, respiratory discomfort, oral discomfort, difficulty coughing sputum, worry about respiratory tube disconnection, back pain, anxiety, worry about long-term admission, sleep disturbance, and general discomfort during ETT intubation were higher than during tracheostomy or NIPPV (all P < 0.05). The mean level of discomfort was approximately 5-6 points (moderate) in patients with ETT and 2-3 points (mild) in patients with NIPPV or tracheostomy. Conclusion: The level of discomfort was higher in patients who underwent ETT intubation than in those who underwent NIPPV or tracheostomy. However, the level of discomfort was similar between the patients with NIPPV and those who underwent tracheostomy.

The Impact of PEEP on Ventilation Distribution in ARDS.

BACKGROUND: The first aim of this study was to evaluate the capacity of electrical impedance tomography (EIT) to identify the effect of PEEP on regional ventilation distribution and the regional risk of collapse, overdistention, hypoventilation, and pendelluft in mechanically ventilated patients. The second aim was to evaluate the feasibility of EIT for estimating airway opening pressure (AOP). METHODS: The EIT signal was recorded both during baseline cyclic ventilation and slow insufflation for one breath for 9 subjects with moderate-to-severe ARDS. From these data, the AOP and volumes insufflated to lung regions with or without the risk of either collapse, overdistention, hypoventilation, or pendelluft were assessed at 3 PEEP levels (5, 10, and 15 cm H2O). PEEP levels were compared by Friedman analysis of variance and the AOP measured by EIT evaluated using an F-test and the Bland and Altman method. RESULTS: The volume for which there was no specific risk significantly decreased at the highest PEEP from 55 ± 31% tidal volume (VT) at PEEP 5 or 82 ± 18% VT at PEEP 10 to 10 ± 30% VT at PEEP 15 (P = .038 between PEEP 5 vs PEEP 15; P = .01 between PEEP 10 vs PEEP 15). The volume associated with overdistention significantly increased with increasing PEEP, whereas that associated with atelectrauma significantly decreased. Pendelluft significantly decreased with increasing PEEP: VT of 8.9 ± 18.6%, 3.6 ± 7.0%, and 3.2 ± 7.1% for PEEP 5, PEEP 10, and PEEP 15, respectively. The center of ventilation tended to increase in the dependent direction with higher PEEP. The AOPs assessed by EIT and from the pressure-volume curve were in good agreement (bias 0.48 cm H2O). CONCLUSIONS: Our results suggest that EIT could aid clinicians in making personalized and reasoned choices in setting the PEEP for subjects with ARDS.

Comparison of leak fraction between the laryngeal mask airway and endotracheal tube during anesthesia: a single-center retrospective study.

The use of the laryngeal mask airway (LMA), which offers the benefits of ease in insertion and prevention of tracheal damage, is associated with a risk of flow leakage. This study analyzed our extensive database to compare leakage associated with the use of LMA and endotracheal tube (ETT). Adult patients who underwent chest wall, abdominal wall, inguinal region, limb, transurethral, or transvaginal surgery and received either LMA or ETT between January 2007 and March 2020 were included. The leak fraction was calculated as (inspiratory tidal volume-expiratory tidal volume)/(inspiratory tidal volume) × 100% every minute during intraoperative stable positive pressure ventilation. The median leak fraction was calculated for each case. The leak fraction in the LMA group demonstrated a left-skewed distribution with a larger proportion of excessive leak fraction. The leak fraction in the LMA group (median, 7.9%; interquartile range, 4.8-11.4%) was significantly lower than that in the ETT group (median, 9.1%; interquartile range: 5.5-12.4%; P < 0.001). This tendency was consistent across subgroups divided by sex, age, type of surgery, and ventilation mode. We propose that LMA provides leakage comparable to or less than ETT in most cases if stable positive pressure ventilation is achieved.

Impact of extended lung protection during mechanical ventilation on lung recovery in patients with COVID-19 ARDS: a phase II randomized controlled trial.

BACKGROUND: Protective ventilation seems crucial during early Acute Respiratory Distress Syndrome (ARDS), but the optimal duration of lung protection remains undefined. High driving pressures (ΔP) and excessive patient ventilatory drive may hinder lung recovery, resulting in self-inflicted lung injury. The hidden nature of the ΔP generated by patient effort complicates the situation further. Our study aimed to assess the feasibility of an extended lung protection strategy that includes a stepwise protocol to control the patient ventilatory drive, assessing its impact on lung recovery. METHODS: We conducted a single-center randomized study on patients with moderate/severe COVID-19-ARDS with low respiratory system compliance (CRS < 0.6 (mL/Kg)/cmH2O). The intervention group received a ventilation strategy guided by Electrical Impedance Tomography aimed at minimizing ΔP and patient ventilatory drive. The control group received the ARDSNet low-PEEP strategy. The primary outcome was the modified lung injury score (mLIS), a composite measure that integrated daily measurements of CRS, along with oxygen requirements, oxygenation, and X-rays up to day 28. The mLIS score was also hierarchically adjusted for survival and extubation rates. RESULTS: The study ended prematurely after three consecutive months without patient enrollment, attributed to the pandemic subsiding. The intention-to-treat analysis included 76 patients, with 37 randomized to the intervention group. The average mLIS score up to 28 days was not different between groups (P = 0.95, primary outcome). However, the intervention group showed a faster improvement in the mLIS (1.4 vs. 7.2 days to reach 63% of maximum improvement; P < 0.001), driven by oxygenation and sustained improvement of X-ray (P = 0.001). The intervention group demonstrated a sustained increase in CRS up to day 28 (P = 0.009) and also experienced a shorter time from randomization to room-air breathing (P = 0.02). Survival at 28 days and time until liberation from the ventilator were not different between groups. CONCLUSIONS: The implementation of an individualized PEEP strategy alongside extended lung protection appears viable. Promising secondary outcomes suggested a faster lung recovery, endorsing further examination of this strategy in a larger trial. Clinical trial registration This trial was registered with ClinicalTrials.gov (number NCT04497454) on August 04, 2020.

Outcomes after delivery room positive pressure ventilation in late preterm and term infants.

Objectives: Characterize short-term outcomes of late preterm and term infants who received positive pressure ventilation in the delivery room and compare these with infants who did not receive resuscitation at birth. Study Design: Single center retrospective cohort study of infants born between 35 0/7 and 41 6/7 weeks' gestation in 2019. Baseline characteristics and outcomes of infants who received positive pressure ventilation were compared with controls who did not receive delivery room ventilation. The primary outcome was neonatal intensive care unit admission; secondary outcomes included multiple hospital morbidities and interventions. Results: Among 202 infants who received delivery room positive pressure ventilation, 77 (38.1%) received ≤1 min, and 125 (61.9%) received >1 min of positive pressure ventilation. Neonatal intensive care unit admission directly following resuscitation was more common in the ventilation cohort (33%) compared with controls (1.5%), p ≤ 0.0001. After initial admission to the newborn nursery, intensive care unit transfer rates were similar in the positive pressure ventilation cohort (4%) and controls (5%). Antibiotic exposure, hypoxic ischemic encephalopathy, respiratory support in the neonatal intensive care unit, and pneumothorax were more common in the ventilation cohort. The composite outcome of any post-delivery complication occurred in 45% of positive pressure ventilation-exposed infants, compared to 15.8% of control infants (<0.0001); this was more common following >1 min (52.8%) than ≤1 min positive pressure ventilation (32.5%), p = 0.002. Conclusion: Post-delivery complications are common following delivery room positive pressure ventilation, emphasizing the need for post-resuscitation monitoring in either the neonatal intensive care unitor newborn nursery setting.

Impact of the COVID-19 pandemic on management and outcomes of patients with acute heart failure.

AIMS: Guidelines recommend non-invasive positive pressure ventilation (NPPV) for patients with acute decompensated heart failure (ADHF) with an inadequate response to initial oxygen therapy. During Japan's coronavirus disease 2019 pandemic, NPPV use in emergency departments (EDs) was limited due to aerosol-spreading concerns. This study compared the respiratory management and clinical outcomes of patients with ADHF in EDs before and during the pandemic. METHODS AND RESULTS: This retrospective cohort study was conducted at a single centre in Japan using hospital data from September to November 2019 (before the pandemic) and September to November 2020 (during the pandemic). Patients diagnosed with ADHF were included. Patients not responding to standard oxygen therapy were intubated or started on NPPV therapy. The primary outcome measure was discharge after death. The secondary outcomes were length of hospital stay and medical expenses. The study included 37 patients before the pandemic and 36 during the pandemic. No significant differences were found in vital signs or laboratory data between the groups. NPPV utilization decreased significantly from 26 (70.3%) to 7 (19.4%) (P < 0.01). Two patients required intubation during both periods, with no significant differences (P = 0.98). No significant intergroup disparities were observed in discharge after death (1/36 [2.7%] vs. 1/37 [2.7%]; P = 0.19), length of hospital stay (17.5 vs. 19.0 days; P = 0.65), and medical expenses (57 590 vs. 57 600 yen; P = 0.65). CONCLUSIONS: Despite a large decrease in NPPV use before and during the pandemic, there were no significant differences in discharge after death, hospital stay, or medical expenses.

Clinical efficacy of HI-NPPV in the treatment of AECOPD combined with severe type II respiratory failure. / HI-NPPV治疗AECOPD合并严重II型呼吸衰竭的临床疗效.

OBJECTIVES: Patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) combined with severe type II respiratory failure have a high probability of ventilation failure using conventional non-invasive positive pressure ventilation (NPPV). This study aims to investigate the clinical efficacy of high intensity NPPV (HI-NPPV) for the treatment of AECOPD combined with severe type II respiratory failure. METHODS: The data of patients with AECOPD combined with severe type II respiratory failure (blood gas analysis pH≤7.25) treated with NPPV in the Second Affiliated Hospital of Chongqing Medical University from July 2013 to July 2023 were collected to conduct a retrospective case-control study. The patients were divided into 2 groups according to the inspired positive airway pressure (IPAP) used during the NPPV treatment: a NPPV group (IPAP<20 cmH2O, 1 cmH2O=0.098 kPa) and a HI-NPPV group (20 cmH2O≤IPAP< 30 cmH2O). Ninety-nine and 95 patients were included in the NPPV group and the HI-NPPV group, respectively. A total of 86 pairs of data were matched using propensity score matching (PSM) for data matching. The primary outcome indexes (mortality and tracheal intubation rate) and secondary outcome indexes [blood gas analysis pH, arterial partial pressure of oxygen (PaO2) and arterial partial pressure of carbon dioxide (PaCO2), adverse reaction rate, and length of hospitalization] were compared between the 2 groups. RESULTS: The tracheal intubation rates of the NPPV group and the HI-NPPV group were 6.98% and 1.16%, respectively, and the difference between the 2 groups was statistically significant (χ2=4.32, P<0.05); the mortality of the NPPV group and the HI-NPPV group was 23.26% and 9.30%, respectively, and the difference between the 2 groups was statistically significant (χ2=11.64, P<0.01). The PaO2 at 24 h and 48 h after treatment of the HI-NPPV group was higher than that of the NPPV group, and the PaCO2 of the HI-NPPV group was lower than that of the NPPV group, and the differences were statistically significant (all P<0.05). The differences of pH at 24 h and 48 h after treatment between the 2 groups were not statistically significant (both P>0.05). The differences between the 2 groups in adverse reaction rate and hospitalization length were not statistically significant (both P>0.05). CONCLUSIONS: HI-NPPV can reduce mortality and tracheal intubation rates by rapidly improving the ventilation of patients with AECOPD combined with severe type II respiratory failure. This study provides a new idea for the treatment of patients with AECOPD combined with severe type II respiratory failure.

Expiratory flow limitation during mechanical ventilation: real-time detection and physiological subtypes.

BACKGROUND: Tidal expiratory flow limitation (EFLT) complicates the delivery of mechanical ventilation but is only diagnosed by performing specific manoeuvres. Instantaneous analysis of expiratory resistance (Rex) can be an alternative way to detect EFLT without changing ventilatory settings. This study aimed to determine the agreement of EFLT detection by Rex analysis and the PEEP reduction manoeuvre using contingency table and agreement coefficient. The patterns of Rex were explored. METHODS: Medical patients ≥ 15-year-old receiving mechanical ventilation underwent a PEEP reduction manoeuvre from 5 cmH2O to zero for EFLT detection. Waveforms were recorded and analyzed off-line. The instantaneous Rex was calculated and was plotted against the volume axis, overlapped by the flow-volume loop for inspection. Lung mechanics, characteristics of the patients, and clinical outcomes were collected. The result of the Rex method was validated using a separate independent dataset. RESULTS: 339 patients initially enrolled and underwent a PEEP reduction. The prevalence of EFLT was 16.5%. EFLT patients had higher adjusted hospital mortality than non-EFLT cases. The Rex method showed 20% prevalence of EFLT and the result was 90.3% in agreement with PEEP reduction manoeuvre. In the validation dataset, the Rex method had resulted in 91.4% agreement. Three patterns of Rex were identified: no EFLT, early EFLT, associated with airway disease, and late EFLT, associated with non-airway diseases, including obesity. In early EFLT, external PEEP was less likely to eliminate EFLT. CONCLUSIONS: The Rex method shows an excellent agreement with the PEEP reduction manoeuvre and allows real-time detection of EFLT. Two subtypes of EFLT are identified by Rex analysis. TRIAL REGISTRATION: Clinical trial registered with www.thaiclinicaltrials.org (TCTR20190318003). The registration date was on 18 March 2019, and the first subject enrollment was performed on 26 March 2019.

Problems of operation of positive pressure ventilators on the basis of surveys of Polish officers of the State Fire Service.

Positive pressure ventilators (PPV) used by 97.7% of officers of the National Fire Service in Poland, are characterized by work that is not in line with the expectations of the firefighters. In order to improve the technical and operational features of these devices, a survey was conducted among 25,000 eligible firefighters, identifying the application of these devices, problems in use and expected development directions. A total of 682 officers voluntarily completed the survey. Based on their findings, it was determined that ventilators are most often used to smoke out buildings after or during a fire. Mentioned problems when using these devices were mainly noise (78.2%), exhaust emissions (68.5%), and impediments to mobility through the device's relatively heavy weight (40.2%). Other inconveniences were mentioned by less than 20% of firefighters. Polish firefighters expect the development of these devices mainly in terms of the above-mentioned features (noise reduction (81.7%) and reduction of the weight and size of the ventilators (about 50%)). Other expectations relate to the improvement of smoke removal in buildings: increasing the efficiency of smoke removal (46.4%) and efficiency regarding the rate of smoke removal in a building by increasing the size of the incoming airflow from the building's surroundings (33.2%). About 15% of firefighters expect changes in the operation of the ventilator itself, that is, an increase in the effective operating time (electric ventilators) and an increase in the device's uptime. The aim of the article is to identify the issues encountered during the operation and to indicate the expected direction of development for PPV by users. This information can be used by engineers to initiate new development work on these devices.

Risk of Transient Tachypnea of the Newborn following Elective Cesarean Section Increases at a Gestational Age of 37 Weeks Compared to That at ≥ 38 Weeks Despite the Exclusion of Pre-Existing Risk Factors for Neonatal Respiratory Disorders.

Background: Elective cesarean sections (ECSs) for early-term pregnancies at 37 weeks of gestational age (GA) aim to reduce the risk of emergency cesarean sections due to the onset of labor or rupture of membranes. However, resultant increases in neonatal respiratory disorders, including transient tachypnea of the newborn (TTN) have been observed. However, few studies have elucidated the associated risk factors. Consequently, we aimed to determine whether differences existed in the clinical outcomes between neonates delivered via ECS at 37 weeks and those delivered at ≥ 38 weeks of GA. Methods: A retrospective analysis was conducted on 259 neonates born via ECS at Tottori University Hospital, between January 2013 and December 2019, with birthweights ≥ 2500 g and GAs > 37 weeks. The neonates were categorized into two cohorts: births at 37 and at ≥ 38 weeks of GA (37-week and 38-week cohorts). The principal clinical outcomes included the appearance, pulse, grimace, activity, and respiration (Apgar) scores, need for positive-pressure ventilation, incidence of TTN, and length of hospital stay. Results: No statistically significant differences were observed in the indications for ECS, sex, or birthweight between the two cohorts. The 37-week cohort exhibited a lower 1-min Apgar score than did the 38-week cohort, with no statistically significant differences between the two cohorts, at 5 min. Statistically significant differences were not observed in the need for positive-pressure ventilation during initial resuscitation or length of hospital stay for patients with TTN between the two cohorts. Notably, the 37-week cohort exhibited a significantly higher incidence of TTN than did the 38-week cohort. Conclusion: ECSs at 37 weeks of GA exhibited an increased risk of TTN than ECSs at ≥ 38 weeks of GA. Strategic neonatal care and adequate preparation can mitigate this risk without affecting the length of hospital stay.

Long-term pneumatic stenting with positive expiratory pressure therapy for severe expiratory central airway collapse.

Expiratory central airway collapse (ECAC) comprising excessive central airway collapse (EDAC) and tracheobronchomalacia. Treatment is challenging for severe cases that are not candidates for surgical management. We report a case of severe ECAC successfully managed with continuous positive airway pressure (CPAP) therapy. A 75-year-old female patient status post right pneumonectomy, presented with chronic cough. Dynamic bronchoscopy evaluation showed severe EDAC which improved with intraprocedural noninvasive positive pressure (NIPPV) therapy. Due to patients' comorbidities, she was not a candidate to surgical tracheobronchoplasty. Therefore, we attempted pneumatic stenting with long-term CPAP therapy resulting in improvement of symptoms and functional capacity. The long-term efficacy of pneumatic stenting has not been clearly established yet. Literature review of management of ECAC with NIPPV consist primarily of case reports and there is only one clinical trial being conducted to assess the efficacy of CPAP therapy in ECAC. While NIPPV arises as a sufficient alternative for management of severe ECAC, larger scale studies are needed to prove the real efficacy of NIPPV in this setting.

Non-invasive versus invasive respiratory support in preterm infants.

Respiratory insufficiency is almost ubiquitous in infants born preterm, with its incidence increasing with lower gestational age. A wide range of respiratory support management strategies are available for these infants, separable into non-invasive and invasive forms of respiratory support. Here we review the history and evolution of respiratory care for the preterm infant and then examine evidence that has emerged to support a non-invasive approach to respiratory management where able. Continuous positive airway pressure (CPAP) is the non-invasive respiratory support mode currently with the most evidence for benefit. CPAP can be delivered safely and effectively and can commence in the delivery room. Particularly in early life, time spent on non-invasive respiratory support, avoiding intubation and mechanical ventilation, affords benefit for the preterm infant by virtue of a lessening of lung injury and hence a reduction in incidence of bronchopulmonary dysplasia. In recent years, enthusiasm for application of non-invasive support has been further bolstered by new techniques for administration of exogenous surfactant. Methods of less invasive surfactant delivery, in particular with a thin catheter, have allowed neonatologists to administer surfactant without resort to endotracheal intubation. The benefits of this approach appear to be sustained, even in those infants subsequently requiring mechanical ventilation. This cements the notion that any reduction in exposure to mechanical ventilation leads to alleviation of injury to the vulnerable preterm lung, with a long-lasting effect. Despite the clear advantages of non-invasive respiratory support, there will continue to be a role for intubation and mechanical ventilation in some preterm infants, particularly for those born <25 weeks' gestation. It is currently unclear what role early non-invasive support has in this special population, with more studies required.

The Outcomes of Preterm Infants with Neonatal Respiratory Distress Syndrome Treated by Minimally Invasive Surfactant Therapy and Non-Invasive Ventilation.

In recent years, the utilization of minimally invasive surfactant therapy (MIST) and Non-invasive ventilation (NIV) as the primary respiratory assistance has become increasingly prevalent among preterm infants with neonatal respiratory distress syndrome (RDS). This study aims to compare the outcomes between MIST administered with nasal continuous positive airway pressure (NCPAP) versus nasal intermittent positive pressure ventilation (NIPPV), with the objective of exploring the respiratory therapeutic benefits of these two approaches. This retrospective study collected data from the neonatal intensive care unit of Kaohsiung Medical University Hospital spanning from January 2016 to June 2021. Infants were divided into two groups based on the type of NIV utilized. The NCPAP group comprised 32 infants, while the NIPPV group comprised 22 infants. Statistical analysis revealed significant differences: the NIPPV group had a smaller gestational age, lower birth weight, higher proportion of female infants, and earlier initiation of MIST. Additionally, the NIPPV group exhibited higher incidence rates of retinopathy of prematurity, longer respiratory support duration, prolonged hospitalization, and mortality. However, upon adjustment, these differences were not statistically significant. Analysis of venous blood gas and respiratory parameter changes indicated that both the NCPAP and NIPPV groups experienced improvements in oxygenation and ventilation following MIST.

Negative Pressure Wound Therapy-A Vacuum-Mediated Positive Pressure Wound Therapy and a Closer Look at the Role of the Laser Doppler.

Background: Negative pressure wound therapy (NPWT) is an intensely investigated topic, but its mechanism of action accounts for one of the least understood ones in the area of wound healing. Apart from a misleading nomenclature, by far the most used diagnostic tool to investigate NPWT, the laser Doppler, also has its weaknesses regarding the detection of changes in blood flow and velocity. The aim of the present study is to explain laser Doppler readings within the context of NPWT influence. Methods: The cutaneous microcirculation beneath an NPWT system of 10 healthy volunteers was assessed using two different laser Dopplers (O2C/Rad-97®). This was combined with an in vitro experiment simulating the compressing and displacing forces of NPWT on the arterial and venous system. Results: Using the O2C, a baseline value of 194 and 70 arbitrary units was measured for the flow and relative hemoglobin, respectively. There was an increase in flow to 230 arbitrary units (p = 0.09) when the NPWT device was switched on. No change was seen in the relative hemoglobin (p = 0.77). With the Rad-97®, a baseline of 92.91% and 0.17% was measured for the saturation and perfusion index, respectively. No significant change in saturation was noted during the NPWT treatment phase, but the perfusion index increased to 0.32% (p = 0.04). Applying NPWT compared to the arteriovenous-vessel model resulted in a 28 mm and 10 mm increase in the venous and arterial water column, respectively. Conclusions: We suspect the vacuum-mediated positive pressure of the NPWT results in a differential displacement of the venous and arterial blood column, with stronger displacement of the venous side. This ratio may explain the increased perfusion index of the laser Doppler. Our in vitro setup supports this finding as compressive forces on the bottom of two water columns within a manometer with different resistances results in unequal displacement.

The Effect of Guided Imagery and Progressive Muscle Relaxation on Sedation in Patients Undergoing Noninvasive Mechanical Ventilation.

Mental imagery and relaxation are noninvasive methods and can easily be used by the patient. Accordingly, this study aimed to detect the effect of guided mental imagery (GI) and progressive muscle relaxation (PMR) on sedation in patients undergoing noninvasive mechanical ventilation (NIV). This clinical trial study was carried out in the Shahid Modarres Hospital in 2022 and encompassed 80 patients with COVID-19 undergoing NIV, who were assigned to two intervention and control groups. The sedation survey scale was used to collect the required data. Before the intervention, the two groups completed the questionnaires, and then the relaxation program was presented during four sessions for the intervention group. This study included 80 patients with a mean age (± SD) of 59.59 ± 9.27 years. The Quade nonparametric ANCOVA revealed the significant impact of intervention on the post values of Total score (p-value < 0.001), Tolerance (p-value < 0.001), Calmness (p-value < 0.001), Ventilator synchrony (p-value < 0.001), face relaxation (p-value < 0.001), Consciousness (p-value = 0.009) and Awakeness (p-value = 0.020). The study findings demonstrated the effectiveness of relaxation program in promoting sedation in patients undergoing NIV. Accordingly, intensive care unit (ICU) nurses at our institution are encouraged to use PMR and GI to sedation of patients under NIV.

Pulmonary strain and end-expiratory lung volume during apnea test: a comparative analysis using electrical impedance tomography.

The apnea test, employed for brain death assessment, aims to demonstrate the absence of respiratory drive due to hypercapnia. The tracheal oxygen insufflation apnea test mode (I-AT) involves disconnecting the patient from invasive mechanical ventilation (iMV) for approximately 8 minutes while maintaining oxygenation. This test supports the diagnosis of brain death based on a specified increase in PaCO2. Common complications include hypoxemia and hemodynamic instability, and lung collapse-induced reduction in end-expiratory lung volume (EELV). In our case series utilizing electrical impedance tomography (EIT), we observed that continuous positive airway pressure during the apnea test (CPAP-AT) effectively mitigated lung collapse. This resulted in improved pulmonary strain compared to the disconnection of iMV. These findings suggest the potential benefits of routine CPAP-AT, particularly for potential lung donors, emphasizing the relevance of our study in providing quantitative insights into EELV loss and its association with pulmonary strain and potential lung injury.

La prueba de apnea es una técnica diagnóstica ampliamente utilizada para la evaluación de la muerte cerebral, con el objetivo de demostrar la ausencia de impulso respiratorio debido a la hipercapnia. La variante de la prueba de apnea con insuflación de oxígeno traqueal (I-AT) implica desconectar al paciente de la ventilación mecánica invasiva (iVM) durante aproximadamente 8 minutos, manteniendo la oxigenación mediante un catéter de insuflación. Esta prueba respalda el diagnóstico de muerte cerebral cuando se determina un aumento de la PaCO 2 superior a 20 mmHg en comparación con el valor inicial o un nivel de PaCO 2 superior a 60 mmHg al final de la prueba. En nuestra serie de casos, la implementación de la tomografía de impedancia eléctrica (EIT) reveló que la prueba de apnea con presión positiva continua (CPAPAT) mitiga eficazmente el colapso pulmonar. Este enfoque resulta en una mejora en la tensión pulmonar en comparación con la desconexión de iMV, demostrando su relevancia en el contexto de potenciales donantes de pulmones.

Non-Invasive Positive Pressure Ventilation Use-Practice Recommendations of the Slovak Society of Pulmonology and Phthisiology.

Non-invasive positive pressure ventilation (NIPPV) is increasingly used as a treatment method for patients with respiratory failure. The first recommendations for the use of NIPPV in Slovakia were developed by the Slovak Society of Pulmonology and Phthisiology in 2007 and were partially revised in 2015. New scientific evidence prompted the present update, which is based on widely accepted international guidelines and was adapted to address local needs. Important features of the present update include a classification of acute indications for NIPPV into three categories based on the level of supporting evidence, namely 1. definite indications for in-hospital use of NIPPV; 2. possible indications for in-hospital use of NIPPV; and 3. disorders and states in which in-hospital use of NIPPV is not recommended. The current update also reflects the importance of comorbid sleep-related breathing disorders and other chronic respiratory conditions, as well as the use and limitations of continuous positive airway pressure therapy. Since oxygen therapy is often administered along with NIPPV, guidance on the safe use of oxygen in NIPPV-treated patients has also been included. Also, the present update extends the range of its users, addressing the needs of specialists in pediatric respiratory medicine as a novelty.

The Diaphragmatic Initiated Ventilatory Assist (DIVA) trial: study protocol for a randomized controlled trial comparing rates of extubation failure in extremely premature infants undergoing extubation to non-invasive neurally adjusted ventilatory assist versus non-synchronized nasal intermittent positive pressure ventilation.

BACKGROUND: Invasive mechanical ventilation contributes to bronchopulmonary dysplasia (BPD), the most common complication of prematurity and the leading respiratory cause of childhood morbidity. Non-invasive ventilation (NIV) may limit invasive ventilation exposure and can be either synchronized or non-synchronized (NS). Pooled data suggest synchronized forms may be superior. Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) delivers NIV synchronized to the neural signal for breathing, which is detected with a specialized catheter. The DIVA (Diaphragmatic Initiated Ventilatory Assist) trial aims to determine in infants born 240/7-276/7 weeks' gestation undergoing extubation whether NIV-NAVA compared to non-synchronized nasal intermittent positive pressure ventilation (NS-NIPPV) reduces the incidence of extubation failure within 5 days of extubation. METHODS: This is a prospective, unblinded, pragmatic, multicenter phase III randomized clinical trial. Inclusion criteria are preterm infants 24-276/7 weeks gestational age who were intubated within the first 7 days of life for at least 12 h and are undergoing extubation in the first 28 postnatal days. All sites will enter an initial run-in phase, where all infants are allocated to NIV-NAVA, and an independent technical committee assesses site performance. Subsequently, all enrolled infants are randomized to NIV-NAVA or NS-NIPPV at extubation. The primary outcome is extubation failure within 5 days of extubation, defined as any of the following: (1) rise in FiO2 at least 20% from pre-extubation for > 2 h, (2) pH ≤ 7.20 or pCO2 ≥ 70 mmHg; (3) > 1 apnea requiring positive pressure ventilation (PPV) or ≥ 6 apneas requiring stimulation within 6 h; (4) emergent intubation for cardiovascular instability or surgery. Our sample size of 478 provides 90% power to detect a 15% absolute reduction in the primary outcome. Enrolled infants will be followed for safety and secondary outcomes through 36 weeks' postmenstrual age, discharge, death, or transfer. DISCUSSION: The DIVA trial is the first large multicenter trial designed to assess the impact of NIV-NAVA on relevant clinical outcomes for preterm infants. The DIVA trial design incorporates input from clinical NAVA experts and includes innovative features, such as a run-in phase, to ensure consistent technical performance across sites. TRIAL REGISTRATION: www. CLINICALTRIALS: gov , trial identifier NCT05446272 , registered July 6, 2022.

Integration of a respiratory function monitor into newborn positive pressure ventilation training; development of a standardised training intervention.

Objective: One in twenty newborns require resuscitation with positive pressure ventilation (PPV) at birth. Newborn face mask ventilation is often poorly performed. To address this, the potential role of respiratory function monitors (RFM) in newborn resuscitation training has been highlighted. The objective of this study was to develop a standardised training intervention on newborn PPV using an RFM with a simple visual display to identify and correct suboptimal ventilations. Methods: We adapted the framework from a simulation development guideline to create a hands-on intervention on newborn PPV using an RFM with simple visual feedback (Monivent NeoTraining). We enrolled a group of healthcare professionals to a manikin-based pilot study as part of this process, conducting a series of teaching sessions to refine the intervention. Suggested changes were gathered from participants and instructors. Our main objective was to develop a standardised, reproducible training intervention. Results: A standardised training intervention on newborn PPV was systematically developed. Twenty-six healthcare professionals working in tertiary neonatal care participated in a pilot study, consisting of eight training sessions. Each iteration of the intervention was informed by the previous session. Instructions for the delivery of teaching were standardised and a training algorithm was developed. Conclusion: RFM's have been shown to be effective tools in research settings, addressing poor technique and face mask leak. They are not routinely used in newborn resuscitation training. To address this, we developed a standardised training intervention on newborn PPV using an RFM with simple visual feedback.

Internet of things-based management versus standard management of home noninvasive ventilation in COPD patients with hypercapnic chronic respiratory failure: a multicentre randomized controlled non-inferiority trial.

Background: Effective monitoring and management are crucial during long-term home noninvasive positive pressure ventilation (NPPV) in patients with hypercapnic chronic obstructive pulmonary disease (COPD). This study investigated the benefit of Internet of Things (IOT)-based management of home NPPV. Methods: This multicenter, prospective, parallel-group, randomized controlled non-inferiority trial enrolled patients requiring long-term home NPPV for hypercapnic COPD. Patients were randomly assigned (1:1), via a computer-generated randomization sequence, to standard home management or IOT management based on telemonitoring of clinical and ventilator parameters over 12 months. The intervention was unblinded, but outcome assessment was blinded to management assignment. The primary outcome was the between-group comparison of the change in health-related quality of life, based on severe respiratory insufficiency questionnaire scores with a non-inferiority margin of -5. This study is registered with Chinese Clinical Trials Registry (No. ChiCTR1800019536). Findings: Overall, 148 patients (age: 72.7 ± 6.8 years; male: 85.8%; forced expiratory volume in 1 s: 0.7 ± 0.3 L; PaCO2: 66.4 ± 12.0 mmHg), recruited from 11 Chinese hospitals between January 24, 2019, and June 28, 2021, were randomly allocated to the intervention group (n = 73) or the control group (n = 75). At 12 months, the mean severe respiratory insufficiency questionnaire score was 56.5 in the intervention group and 50.0 in the control group (adjusted between-group difference: 6.26 [95% CI, 3.71-8.80]; P < 0.001), satisfying the hypothesis of non-inferiority. The 12-month risk of readmission was 34.3% in intervention group compared with 56.0% in the control group, adjusted hazard ratio of 0.56 (95% CI, 0.34-0.92; P = 0.023). No severe adverse events were reported. Interpretation: Among stable patients with hypercapnic COPD, using IOT-based management for home NPPV improved health-related quality of life and prolonged the time to readmission. Funding: Air Liquide Healthcare (Beijing) Co., Ltd.