Non-invAsive VentIlation for early General wArd respiraTory failurE (NAVIGATE): A multicenter randomized controlled study. Protocol and statistical analysis plan.

OBJECTIVE: Few randomized trials have evaluated the use of non-invasive ventilation (NIV) for early acute respiratory failure (ARF) in non-intensive care unit (ICU) wards. The aim of this study is to test the hypothesis that early NIV for mild-moderate ARF in non-ICU wards can prevent development of severe ARF. DESIGN: Pragmatic, parallel group, randomized, controlled, multicenter trial. SETTING: Non-intensive care wards of tertiary centers. PATIENTS: Non-ICU ward patients with mild to moderate ARF without an established indication for NIV. INTERVENTIONS: Patients will be randomized to receive or not receive NIV in addition to best available care. MEASUREMENTS AND MAIN RESULTS: We will enroll 520 patients, 260 in each group. The primary endpoint of the study will be the development of severe ARF. Secondary endpoints will be 28-day mortality, length of hospital stay, safety of NIV in non-ICU environments, and a composite endpoint of all in-hospital respiratory complications. CONCLUSIONS: This trial will help determine whether the early use of NIV in non-ICU wards can prevent progression from mild-moderate ARF to severe ARF.

Early non-invasive ventilation treatment for respiratory failure due to severe community-acquired pneumonia.

BACKGROUND AND AIMS: Severe community-acquired pneumonia (sCAP) have been as defined pneumonia requiring admission to the intensive care unit or carrying a high risk of death. Currently, the treatment of sCAP consists of antibiotic therapy and ventilator support. The use of invasive ventilation causes several complications as does admission to ICU. For this reason, non-invasive ventilation (NIV) has been used for acute respiratory failure to avoid endotracheal intubation. However, few studies have currently assessed the usefulness of NIV in sCAP. METHODS: We prospectively assessed 127 patients with sCAP and severe acute respiratory failure [oxygen arterial pressure/oxygen inspiratory fraction ratio (PaO2/FiO2) <250]. We defined successful NIV as avoidance of intubation and the achievement of PaO2/FiO2 >250 with spontaneous breathing. We assessed predictors of NIV failure and hospital mortality using univariate and multivariate analyses. RESULTS: NIV failed in 32 patients (25.1%). Higher chest X-ray score at admission, chest X-ray worsening, and a lower PaO2/FiO2 and higher alveolar-arteriolar gradient (A-aDO2) after 1 h of NIV all independently predicted NIV failure. Higher lactate dehydrogenase and confusion, elevated blood urea, respiratory rate, blood pressure plus age ≥65 years at admission, higher A-aDO2, respiratory rate and lower PaO2/FiO2 after 1 h of NIV and intubation rate were directly related to hospital mortality. CONCLUSIONS: Successful treatment is strongly related to less severe illness as well as to a good initial and sustained response to medical therapy and NIV treatment. Constant monitoring of these patients is mandatory.

Impact of oxy-fuel combustion gases on mercury retention in activated carbons from a macroalgae waste: effect of water.

The aim of this study is to understand the different sorption behaviors of mercury species on activated carbons in the oxy-fuel combustion of coal and the effect of high quantities of water vapor on the retention process. The work evaluates the interactions between the mercury species and a series of activated carbons prepared from a macroalgae waste (algae meal) from the agar-agar industry in oxy-combustion atmospheres, focussing on the role that the high concentration of water in the flue gases plays in mercury retention. Two novel aspects are considered in this work (i) the impact of oxy-combustion gases on the retention of mercury by activated carbons and (ii) the performance of activated carbons prepared from biomass algae wastes for this application. The results obtained at laboratory scale indicate that the effect of the chemical and textural characteristics of the activated carbons on mercury capture is not as important as that of reactive gases, such as the SOx and water vapor present in the flue gas. Mercury retention was found to be much lower in the oxy-combustion atmosphere than in the O2+N2 (12.6% O2) atmosphere. However, the oxidation of elemental mercury (Hg0) to form oxidized mercury (Hg2+) amounted to 60%, resulting in an enhancement of mercury retention in the flue gas desulfurization units and a reduction in the amalgamation of Hg0 in the CO2 compression unit. This result is of considerable importance for the development of technologies based on activated carbon sorbents for mercury control in oxy-combustion processes.

Noninvasive ventilation for hypercapnic exacerbation of chronic obstructive pulmonary disease: factors related to noninvasive ventilation failure.

INTRODUCTION: Noninvasive ventilation (NIV) has changed the prognosis of patients with chronic obstructive pulmonary disease (COPD) suffering from hypercapnic exacerbations. OBJECTIVES: The aim of the study was to evaluate the mortality rate and need for intubation of patients with during hypercapnic COPD exacerbation treated with NIV and to estimate factors related to either success or failure of NIV in a real-life setting. PATIENTS AND METHODS: In a multicenter prospective study conducted over a period of 10 years (2002-2012), we assessed 1809 patients with COPD with hypercapnic exacerbation on admission who were treated with NIV. The primary outcomes were the intubation rate and hospital mortality. RESULTS: In all patients, NIV was conducted by experienced specialists. The intubation rate was 6.6% and the mortality rate was 5.3%. The severity of exacerbations, defined by pH and the Simplified Acute Physiology Score (SAPS II) on admission, worsened during the study period. The presence of comorbidities, SAPS II, pH, the ratio of oxygen arterial pressure to oxygen inspiratory fraction on admission, and, above all, no increase in pH after 1 hour of NIV were closely related to hospital mortality. CONCLUSIONS: Team expertise in NIV and identification of the risk factors for NIV failure may allow to treat patients with more severe hypercapnic exacerbations of COPD during and improve treatment success rates.

Conventional and microwave pyrolysis of a macroalgae waste from the Agar-Agar industry. Prospects for bio-fuel production.

A comparative study of the pyrolysis of a macroalgae industrial solid waste (algae meal) in an electrical conventional furnace and in a microwave furnace has been carried out. It was found that the chars obtained from both pyrolyses are similar and show good properties for performing as a solid bio-fuel and as a precursor of activated carbon. Bio-oils from conventional pyrolysis have a greater number of phenolic, pyrrole and alkane compounds whereas benzene and pyridine compounds are more predominant in microwave pyrolysis with a major presence of light compounds. The bio-gas fraction from microwave pyrolysis presents a much higher syngas content (H2+CO), and a lower CO2 and CH4 proportion than that obtained by conventional pyrolysis. Yields are similar for both treatments with a slightly higher gas yield in the case of microwave pyrolysis due to the fact that microwave heating favors heterogeneous reactions between the gases and the char.

Influenza A (H1N1)-associated pneumonia.

OBJECTIVE: To describe the characteristics of patients with influenza A (H1N1)-associated pneumonia treated at two hospitals in the region of Liguria, Italy, as well as to describe their treatment and outcomes. METHODS: This was a prospective observational study including all patients older than 16 years of age with a confirmed diagnosis of influenza A (H1N1) who were admitted to Villa Scassi Hospital, in the city of Genoa, Italy, or to the Sestri Levante General Hospital, in the city of Sestri Levante, Italy, between September of 2009 and January of 2010. The primary outcome measure was mortality within 60 days after diagnosis. Secondary outcome measures were the need for mechanical ventilation and the length of hospital stay. RESULTS: Of the 40 patients with a confirmed diagnosis of influenza A (H1N1), 27 presented pneumonia during the study period. The mean age of the 27 patients was 42.8 ± 14.8 years, and the mean length of hospital stay was 11.6 ± 8.2 days. Of the 27 patients, 20 had respiratory failure, 4 underwent invasive mechanical ventilation, and 5 underwent noninvasive ventilation. One patient had comorbidities, developed multiple organ failure, and died. CONCLUSIONS: During the influenza A (H1N1) pandemic, the associated mortality rate was lower in Italy than in other countries, and cases reported in the country typically had a milder course than did those reported elsewhere. Nevertheless, 9 of our cases (33%) rapidly evolved to respiratory failure, requiring mechanical ventilation.

Pneumonia associada a influenza A (H1N1) / Influenza A (H1N1)-associated pneumonia

OBJETIVO: Descrever as características dos pacientes com pneumonia associada a influenza A (H1N1) tratados em dois hospitais na região da Ligúria, Itália, e descrever seu tratamento e desfechos. MÉTODOS: Estudo prospectivo observacional que incluiu todos os pacientes com mais de 16 anos de idade e com diagnóstico confirmado de influenza A (H1N1) admitidos no Hospital Villa Scassi, em Gênova, ou no Hospital Geral de Sestri Levante, em Sestri Levante, Itália, entre setembro de 2009 e janeiro de 2010. O desfecho primário foi mortalidade em até 60 dias do diagnóstico, e os desfechos secundários foram necessidade de ventilação mecânica e tempo de hospitalização. RESULTADOS: Durante o período do estudo, dos 40 pacientes com diagnóstico confirmado de influenza A (H1N1), 27 apresentaram pneumonia. A média de idade dos 27 pacientes foi de 42,8 ± 14,8 anos, e o tempo médio de hospitalização foi de 11,6 ± 8,2 dias. Dos 27 pacientes, 20 tiveram insuficiência respiratória, 4 necessitaram de ventilação mecânica invasiva e 5, de ventilação mecânica não invasiva. Somente 1 paciente com várias comorbidades teve falência múltipla de órgãos e faleceu. CONCLUSÕES: Embora a influenza A (H1N1) tenha sido mais branda e com menor incidência de mortalidade na Itália do que em outros países, 9 de nossos pacientes (33 por cento) tiveram evolução rápida para falência respiratória e necessitaram de ventilação mecânica.

OBJECTIVE: To describe the characteristics of patients with influenza A (H1N1)-associated pneumonia treated at two hospitals in the region of Liguria, Italy, as well as to describe their treatment and outcomes. METHODS: This was a prospective observational study including all patients older than 16 years of age with a confirmed diagnosis of influenza A (H1N1) who were admitted to Villa Scassi Hospital, in the city of Genoa, Italy, or to the Sestri Levante General Hospital, in the city of Sestri Levante, Italy, between September of 2009 and January of 2010. The primary outcome measure was mortality within 60 days after diagnosis. Secondary outcome measures were the need for mechanical ventilation and the length of hospital stay. RESULTS: Of the 40 patients with a confirmed diagnosis of influenza A (H1N1), 27 presented pneumonia during the study period. The mean age of the 27 patients was 42.8 ± 14.8 years, and the mean length of hospital stay was 11.6 ± 8.2 days. Of the 27 patients, 20 had respiratory failure, 4 underwent invasive mechanical ventilation, and 5 underwent noninvasive ventilation. One patient had comorbidities, developed multiple organ failure, and died. CONCLUSIONS: During the influenza A (H1N1) pandemic, the associated mortality rate was lower in Italy than in other countries, and cases reported in the country typically had a milder course than did those reported elsewhere. Nevertheless, 9 of our cases (33 percent) rapidly evolved to respiratory failure, requiring mechanical ventilation.