Effect of Active Physiotherapy With Positive Airway Pressure on Pulmonary Atelectasis After Cardiac Surgery: A Randomized Controlled Study.

OBJECTIVES: The authors investigated the effect of active work with positive airway pressure (PAP) in addition to chest physiotherapy (CP) on pulmonary atelectasis (PA) in patients undergoing cardiac surgery with cardiopulmonary bypass. DESIGN: A randomized controlled study. SETTING: At a single-center tertiary hospital. PARTICIPANTS: Eighty adult patients undergoing cardiac surgery (coronary artery bypass grafting, valve surgery, or both), and presenting with PA after tracheal extubation on postoperative days 1 or 2, were randomized from November 2014 to September 2016. INTERVENTION: Three days of CP, twice daily, associated with active work with PAP effect (intervention group) versus CP alone (control group). Pulmonary atelectasis was assessed by using the radiologic atelectasis score (RAS) measured from daily chest x-rays. All radiographs were reviewed blindly. MEASUREMENTS AND MAIN RESULTS: Among included patients, 79 (99%) completed the trial. The primary outcome was mean RAS on day 2 after inclusion. It was significantly lower in the intervention group (mean difference and 95% CI: -1.1 [-1.6 to -0.6], p < 0.001). The secondary outcomes were the sniff nasal inspiratory pressure measured before and after CP and clinical variables. Sniff nasal inspiratory pressure was significantly higher in the intervention group on day 2 (7.7 [3.0-12.5] cmH2O, p = 0.002). The respiratory rate was lower in the intervention group (-3.2 [95% CI -4.8 to -1.6] breaths/min, p < 0.001) on day 2. No differences were found between the 2 groups for percutaneous oxygen saturation/oxygen requirement ratio, heart rate, pain, and dyspnea scores. CONCLUSIONS: Active work with the PAP effect, combined with CP, significantly decreased the RAS of patients undergoing cardiac surgery after 2 days of CP, with no differences observed in clinically relevant parameters.

Noninvasive Ventilation in Obese Subjects After Acute Respiratory Failure.

INTRODUCTION: Noninvasive ventilation (NIV) has been widely used to treat acute respiratory failure in obese patients. Criteria that could help clinicians to decide whether they should continue to use NIV after such an initial episode remain unclear. Our retrospective study aims to analyze characteristics of subjects receiving long-term NIV after an initial hospitalization for acute respiratory failure. METHODS: From January 2011 to December 2012, 77 obese adults were admitted in the ICU of the respiratory disease department in Nantes University Hospital in France. After discharge, adherence, body mass index (BMI), and arterial blood gases were assessed or measured at 6 months and 12 months. RESULTS: In all, 53 subjects were analyzed, including 62% who were admitted for idiopathic acute hypercapnic respiratory failure. Mean BMI was 42 ± 11 kg/m2. Failure of NIV occurred in 10% cases in the ICU. At the end of the hospital stay, 34 subjects were discharged with NIV at home. They had higher BMI and higher initial inspiratory positive airway pressure than those who were not ventilated at home. During follow-up, BMI, PaCO2 , and bicarbonate rate significantly decreased. At 12 months, 4 subjects were not ventilated anymore after a mean duration of 6 ± 4.2 months of ventilation. Adherence was correct in 86%, with a mean use of 7 ± 3.1 h/d. Adherent subjects had better adherence at 1 month, a lower forced vital capacity, a higher bicarbonate rate, and a higher NIV breathing frequency when compared to subjects with poor adherence. CONCLUSIONS: Subjects with the most severe obesity or who experienced the most difficult initial ventilation were more likely to receive long-term NIV after initial management of acute respiratory failure in the ICU. In those subjects, long-term NIV at home was effective and well tolerated.

Home Non-Invasive Ventilation Fails to Improve Quality of Life in the Elderly: Results from a Multicenter Cohort Study.

BACKGROUND: Home non-invasive ventilation (NIV) is a widely used treatment for chronic hypoventilation but little is known on its impact in the elderly. In a multicenter prospective cohort study, we studied tolerance and efficacy of domiciliary NIV in patients aged 75 or more compared to younger ones. METHODS AND RESULTS: 264 patients with at least a six-month follow-up were analyzed. Among them, 82 were elderly. In the elderly and the younger, we found an improvement of arterial blood gas, the Epworth sleepiness scale and the Pittsburgh sleep quality index at 6 months. Mean daily use of NIV at 6 months was 7 hours and the rate of non-adherent patients was similar in both group. Health-related quality of life (HRQL) assessed by SF-36 questionnaires did not change significantly after NIV initiation in the elderly whereas HRQL improved in the less than 75. On univariate analysis, we found that diabetes was a predictive factor for non-adherence in the elderly (Odds ratio: 3.95% confidence interval: 1.06-8.52). CONCLUSION: NIV was efficient in the elderly while evaluation at 6 months showed a good adherence but failed to improve HRQL.

Mouth and nasal inspiratory pressure: learning effect and reproducibility in healthy adults.

BACKGROUND: Inspiratory muscle strength measurements have become a cornerstone in monitoring neuromuscular disorders. Usually, sniff nasal inspiratory pressure (SNIP) and maximal inspiratory pressure (MIP) are performed. To our knowledge the session-to-session learning effect has rarely been evaluated for MIP performance and has never been done for SNIP performance. OBJECTIVES: We hypothesized that the sniff manoeuvre was natural and did not need to be learned, whereas the Muller manoeuvre, used for MIP measurement, was an isometric contraction which needed to be learned because it is rarely performed in real life conditions. This hypothesis suggests that from the first session and continuing through a subsequent one, the maximal SNIP value and the number of sniff trials necessary to attain it are more reproducible than the maximal MIP value and the number of Muller manoeuvre trials necessary to attain it. METHODS: Seventy-one healthy subjects were included. SNIP and MIP manoeuvres were repeated 12 and 6 times, respectively, per week during 2 sessions a week apart. RESULTS: We observed a session effect on MIP but not on SNIP. Maximal value for MIP was higher during the second session, whereas SNIP maximal value did not increase during the second session. The number of trials needed to obtain the maximal value for MIP was lower during the second session whereas it was not different for SNIP. CONCLUSIONS: SNIP is less sensitive to a learning effect than is MIP. It requires only a routine warm-up. We suggest that SNIP is preferable to MIP for repeated measurement of inspiratory muscle performance.