Comparison of efficacy between sequential ventilation and conventional invasive mechanical ventilation in the treatment of pulmonary hypertension complicated with respiratory failure.

OBJECTIVE: Pulmonary hypertension (PAH) is a serious progressive and fatal pulmonary disease characterized by elevated pulmonary artery pressure. Mechanical sequential ventilation has been gradually applied in the treatment of patients with PAH complicated with RF, which can effectively reduce the incidence of VAP and better promote the recovery of respiratory function. This study is aimed to determine the efficacy of sequential ventilation and conventional invasive mechanical ventilation in the treatment of pulmonary hypertension (PAH) complicated with respiratory failure (RF). METHODS: A total of 198 patients with both PAH and RF admitted to our hospital were enrolled. Among them, 102 patients were treated with sequential ventilation as a study group (stu group), and 96 patients were treated with conventional invasive mechanical ventilation as a control group (con group). Then the two groups were compared in efficacy and related indexes before and after treatment. RESULTS: The stu group experienced significantly shorter invasive ventilation time, total mechanical ventilation time, and hospitalization time than the con group (all P<0.05), and showed a significantly lower complication rate than the con group (P<0.05). The reintubation rate, weaning failure rate, and ventilator-associated pneumonia (VAP) rate of the stu group were all significantly lower than those of the con group (all P<0.05), and the stu group showed significantly higher pondus hydrogenii (pH) and arterial partial pressure of oxygen (PaO2) and significantly lower arterial carbondioxide partial pressure (PaCO2) than the con group after treatment (all P<0.05). Additionally, after treatment, the level of brain natriuretic peptide (BNP) and pulmonary artery pressure in both groups declined significantly (P<0.05), and the decline of them in the stu group was more significant than that in the con group (P<0.05). Moreover, after treatment, endothelin (ET) and angiotensin II (Ang II) in both groups declined significantly, and the decline of them in the stu group was also more significant than that in the con group (P<0.05). CONCLUSION: Compared with conventional invasive mechanical ventilation, sequential ventilation can effectively minimize the treatment time of patients with PAH complicated with RF, reduce the incidences of adverse events and complications in them, and significantly improve the blood gas analysis indexes and BNP in them, so it is worthy of clinical promotion.

Successful management of seven cases of critical COVID-19 with early noninvasive-invasive sequential ventilation algorithm and bundle pharmacotherapy.

We report the clinical and laboratory findings and successful management of seven patients with critical coronavirus disease 2019 (COVID-19) requiring mechanical ventilation (MV). The patients were diagnosed based on epidemiological history, clinical manifestations, and nucleic acid testing. Upon diagnosis with COVID-19 of critical severity, the patients were admitted to the intensive care unit, where they received early noninvasive-invasive sequential ventilation, early prone positioning, and bundle pharmacotherapy regimen, which consists of antiviral, anti-inflammation, immune-enhancing, and complication-prophylaxis medicines. The patients presented fever (n = 7, 100%), dry cough (n = 3, 42.9%), weakness (n = 2, 28.6%), chest tightness (n = 1, 14.3%), and/or muscle pain (n = 1, 14.3%). All patients had normal or lower than normal white blood cell count/lymphocyte count, and chest computed tomography scans showed bilateral patchy shadows or ground glass opacity in the lungs. Nucleic acid testing confirmed COVID-19 in all seven patients. The median MV duration and intensive care unit stay were 9.9 days (interquartile range, 6.5-14.6 days; range, 5-17 days) and 12.9 days (interquartile range, 9.7-17.6 days; range, 7-19 days), respectively. All seven patients were extubated, weaned off MV, transferred to the common ward, and discharged as of the writing of this report. Thus, we concluded that good outcomes for patients with critical COVID-19 can be achieved with early noninvasive-invasive sequential ventilation and bundle pharmacotherapy.

Invasive-noninvasive Sequential Ventilation for the Treatment of Acute Exacerbation of Chronic Obstructive Pulmonary Disease.

BACKGROUND: The study aimed to evaluate the efficacy and safety of invasivenoninvasive sequential ventilation versus invasive ventilation in the treatment of Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD). METHODS: PubMed, Cochrane, Embase, Wanfang, CNKI, VIP database were searched by the index words to identify the qualified RCTs, and relevant literature sources were also searched. The latest research was conducted in June 2017. Relative Risks (RR), and Mean Difference (MD) along with 95% confidence interval (95% CI) were used to analyze the main outcomes. RESULTS: Twenty-nine RCTs were involved in this analysis of 1061 patients in the invasivenoninvasive sequential ventilation group (In-non group) and 1074 patients in the invasive ventilation group (In group). The results indicated that compared with the invasive ventilation, invasive-noninvasive sequential ventilation would significantly decrease the incidence of VAP (RR:0.20, 95%CI: 0.16-0.26), mortality (RR:0.38, 95%CI: 0.26-0.55), reintubation (RR:0.39, 95%CI: 0.27-0.55); and statistically reduced the duration of invasive ventilation (MD:-9.23, 95%CI: -10.65, -7.82), the total duration of mechanical ventilation (MD:-4.91, 95%CI: -5.99, -3.83), and the length of stay in the ICU (MD:-5.10, 95%CI: -5.43, -4.76). CONCLUSION: The results demonstrated that the application of noninvasive sequential ventilation after invasive ventilation at the pulmonary infection control window has a significant influence on VAP incidence, mortality, and the length of stay in the ICU, but further well-designed, adequately powered RCTs are required to validate the conclusion.

Clinical study of rapid shallow breathing index as the switching point for sequential ventilation for patients with prolonged weaning after thoracolaparotomy / 中华急诊医学杂志

Objective To investigate the influencing factors of successfully switching to sequential ventilation in patients with prolonged weaning due to acute respiratory failure (ARF) after thoracolaparotomy based on the initial rapid shallow breathing index (RSBI) at 60 min after spontaneous breathing trial (SBT), namely, the f/VT optimal value range of 80-120 times/ (min · L), thus providing the basis for determining the ideal timing of weaning in clinical practice.Methods A prospective observational study of sequential ventilation [RSBI during the initial SBT (60 min), 80-120 breaths/ (min · L)] was carried out in 42 patients on mechanical ventilation (≥ 48 h) due to post-thoracolaparotomy ARF in the ICUs.According to the duration of the mechanical ventilation, the patients were divided into 2 groups : successfully prolonged weaning group (≥ 7 days, n =24) and refractory weaning group (＜ 7 days, n =18).The patients with cardiac failure, aged less 18 or over 80, with hepatic dysfunction, or those needing gastrointestinal decompression after esophageal surgery or upper abdomen surgery were excluded.The demographics, APACHE Ⅱ scores and duration of mechanical ventilation of both groups were recorded, and the respiratory work and oxygen metabolism variables before the switch to sequential ventilation (within 24 hours after admission to ICU) and at the time of switching (24 hours in the ICU after admission) were recorded, respectively: clinical puhnonary infection score (CPIS), assessment of cough severity, pH, PaO2, PaCO2 and PaO2/FiO2;hemodynamic and microcirculation-related variables: HR, MAP, fluid balance, BNP and Lac;endocrine and metabolism variables : Hb, ALB and random serum cortisol (COR).The clinical features and the changes of the above-mentioned variables before and at the time of switching were compared between both groups.The independent sample t test was used for the single factor comparison and Mann-Whitney U test was applied to the non-normal distributions.The Fisher exact probability test was used for the single factor comparison of ranked data such as categorical variables.Results There were no significant differences in age, gender and severity of disease between two groups (P ＞ 0.05);the successfully prolonged weaning group had longer duration of invasive mechanical ventilation and ICU stay compared with the refractory weaning group (P ＜ 0.05).There were significant differences in cough severity, PaCO2, pH, HR and fluid balance between two groups before switching (P ＜ 0.05).Compared with those before switching, in the refractory weaning group there were marked decrease in Lac (P ＜ 0.05), obvious increase in cough severity, pH, Hb and ALB (P ＜ 0.05), but there was no significant difference in COR (P ＞ 0.05);while in the successfully delayed weaning group, there were significant decrease in CPIS, PaCO2, HR, MAP, BNP, fluid balance and Lac (P ＜ 0.05), and cough severity, pH, ALB and COR showed an upward trend (P ＜ 0.05).Conclusions The key of successful sequential ventilation is within the values of RSBI ranging from 80 to 120 times/ (min · L) during the initial SBT (60 min) selected as the switching point in patients with prolonged weaning after thoracolaparotomy.The major influencing factors for determining the ideal timing of switching include the matching status between respiratory endurance and respiratory work, the balance between myocardial strength and both cardiac preload and afterload, the severe disease associated with adrenal insufficiency, and malnutrition.

Study of timing of invasive and noninvasive sequential ventilation in patients with acute respiratory distress syndrome / 中华危重病急救医学

Objective To investigate the timing and value of noninvasive ventilation (NIV) as a weaning tool immediately after early extubation in patients with acute respiratory distress syndrome (ARDS).Methods A prospective randomized controlled trial was conducted.The ARDS patients with surgical diseases admitted to Department of Respiratory Intensive Care Unit (RICU) of the First Affiliated Hospital of Xinjiang Medical University were enrolled.The patients were randomly divided into sequential group and control group.All patients underwent endotracheal intubation and were mechanically ventilated.Every 12 hours during the first 3 days,the lung recruitment maneuver was performed during pressure control ventilation (PCV).After lung recruitment,all patients were ventilated with synchronized intermittent mandatory ventilation (SIMV) + pressure support ventilation (PSV) + positive end-expiratory pressure (PEEP) or assistant/control ventilation (A/C).The objects in sequential group who met the following criteria including those with oxygen index (PaO2/FiO2) reaching 200-250 mmHg (1 mmHg=0.133 kPa) under PEEP of 8 cmH2O (1 cmH2O =0.098 kPa),and pressure support of 12 cmH2O,and most acute infiltrating lesions having resolved on chest imaging,received noninvasive ventilation (NIV) immediately after extubation,and patients in control group continued to have invasive mechanical ventilation via intubation or tracheostomy with an endotracheal tube.The baseline data in both groups and the number of re-intubation in the sequential group were recorded.The duration of invasive mechanical ventilation and total duration of mechanical ventilation,ICU length of stay,the incidence of ventilator-associated pneumonia (VAP),and mortality rate were compared between the two groups.Results 53 consecutive adult patients were enrolled,including 26 in sequential group and 27 cases in control group.The period of endotracheal intubation was 7.0 (6.8,9.5) days,and 7.7％ (2/26) patients underwent re-intubation in sequential group.There were significant difference in respiratory and circulatory indicators before extubation spontaneous breathing trial (SBT) ≤10 minutes in sequential group,indicating that the patients were still in the early stage of extubation sequential NIV.There was no significant difference in indices reflecting respiratory function and circulation between the two groups,except that respiratory rate at 1 hour was slightly increased in sequential group as compared with that of control group,indicating that sequential NIV could maintain invasive ventilation function.There was significant difference in duration of invasive mechanical ventilation [days:7.0 (6.8,9.5) vs.21.0 (17.0,25.0),Z=-6.048,P=0.000],duration of total mechanical ventilation (days:18.0 ± 4.1 vs.22.0 ± 7.3,t=-2.805,P=0.008),and length of ICU stay (days:21.0 ± 4.1 vs.28.0 ± 8.1,t=-4.012,P=0.000) between sequential group and control group,but there was no significant differences in the incidence of VAP [15.4％ (4/26) vs.29.6 (8/27),x2=1.535,P=0.215] and mortality rate [7.7％ (2/26) vs.18.5％ (5/27),P=0.420].Conclusion When PaO2/FiO2 reached 200-250 mmHg under the condition of low ventilation,sequential NIV facilitates the early discontinuation of mechanical ventilation in ARDS patients with surgical diseases,with shortening of duration of invasive mechanical ventilation,total mechanical ventilation,and the length of ICU stay.