Respiratory insufficiency

Down syndrome is associated with a significant health burden, which is particularly apparent in young children who will frequently present with cardiac and respiratory problems. Respiratory presentations include problems related to structural abnormalities of the airways and lungs, glue ears, recurrent lower respiratory tract infections and obstructive sleep apnoea. These conditions are readily identifiable and able to be treated. An awareness of the breadth of respiratory problems and a plan to monitor patients with Down syndrome for their development has the potential to improve outcomes.

To identify prenatal risk factors for chronic lung disease (CLD) at 36 weeks postmenstrual age in very preterm infants. Population: Data were collected prospectively as part of the ongoing audit of the Australian and New Zealand Neonatal Network (ANZNN) of all infants born at less than 32 weeks gestation admitted to all tertiary neonatal intensive care units in Australia and New Zealand. Methods: Prenatal factors up to 1 minute of age were examined in the subset of infants born at gestational ages 22-31 weeks during 1998-2001, and who survived to 36 weeks postmenstrual age (n = 11 453). Factors that were significantly associated with CLD at 36 weeks were entered into a multivariate logistic regression model. Results: After adjustment, low gestational age was the dominant risk factor, with an approximate doubling of the odds with each week of decreasing gestational age from 31 to less than 25 weeks (trend p,0.0001). Birth weight for gestational age also had a dose-response effect: the lower the birth weight for gestational age, the greater the risk, with infants below the third centile having 5.67 times greater odds of CLD than those between the 25th and 75th centile (trend p,0.0001). There was also a significantly increased risk for male infants (odds ratio 1.51 (95% confidence interval 1.36 to 1.68), p,0.0001). Conclusions: These population based data show that the prenatal factors low gestational age, low birth weight for gestational age, and male sex significantly predict the development of chronic respiratory insufficiency in very preterm infants and may assist clinical decision about delivery.

Binder phenotype, or maxillonasal dysostosis, is a distinctive pattern of facial development characterized by a short nose with a flat nasal bridge, an acute nasolabial angle, a short columella, a convex upper lip, and class III malocclusion. We report 3 cases of prenatally diagnosed Binder phenotype associated with perinatal respiratory impairment.

The tropical mangosteen fruit has long been prized in Southeast Asia for its traditional healing properties. Mangosteen fruit juice is now available in the United States and marketed for its purported health benefits. We describe a case of severe lactic acidosis associated with the use of mangosteen juice as a dietary supplement.

Objective: To determine the incidence and mortality rates and predictors of death in myasthenia gravis (MG) and MG crisis in a large US cohort. Methods: Our cohort was identified from the Nationwide Inpatient Sample database for the years 2000 through 2005 using ICD-9-CM codes. MG crisis was identified by the principal diagnosis code or by the presence of respiratory failure. The incidence of MG was stratified by age, ethnicity, and gender. Multivariate logistic regression analysis was used to identify predictors of mortality in MG. For trend analyses of immune intervention, we used the Cochrane-Armitage test. Results: After data cleansing, 5,502 patients with MG were included. In women, the incidence of admission was two to three times higher during the first 5 decades. In men, the incidence of admission was higher during the sixth, seventh, and eighth decades. The annual incidence rate of MG was higher in black women (0.01 per 1,000 persons/year) compared to white women and white and black men (0.009, 0.008, and 0.007 per 1,000 persons/year). The overall in-hospital mortality rate was 2.2%, being higher in MG crisis (4.47%). Older age and respiratory failure were the predictors of death, with adjusted odds ratios of 9.28 (95% confidence interval [CI], 3.31, 26.0) and 3.58 (95% CI, 2.01, 6.38). The trend of IV immunoglobulin utilization has increased compared to plasma exchange and thymectomy (p Ͻ 0.0001). Conclusion: Myasthenia gravis (MG) is still a disease of young women and old men, as reflected by the hospital admission rates. In-hospital mortality of MG is low. Hospital utilization of IV immunoglobulin has significantly increased compared to plasma exchange and thymectomy.

This is a unique state of the art review written by a group of 21 international recognized experts in the field that gathered during a meeting organized by the European Neuromuscular Centre (ENMC) in Naarden, March 2017. It systematically reports the entire evidence base for airway clearance techniques (ACTs) in both adults and children with neuromuscular disorders (NMD). We not only report randomised controlled trials, which in other systematic reviews conclude that there is a lack of evidence base to give an opinion, but also include case series and retrospective reviews of practice. For this review, we have classified ACTs as either proximal (cough augmentation) or peripheral (secretion mobilization). The review presents descriptions; standard definitions; the supporting evidence for and limitations of proximal and peripheral ACTs that are used in patients with NMD; as well as providing recommendations for objective measurements of efficacy, specifically for proximal ACTs. This s...

In December 2019, a series of patients with severe pneumonia were identified in Wuhan, Hubei province, China, who progressed to severe acute respiratory syndrome and acute respiratory distress syndrome. Subsequently, COVID-19 was attributed to a new betacoronavirus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Approximately 20% of patients diagnosed as COVID-19 develop severe forms of the disease, including acute hypoxemic respiratory failure, severe acute respiratory syndrome, acute respiratory distress syndrome and acute renal failure and require intensive care. There is no randomized controlled clinical trial addressing potential therapies for patients with confirmed COVID-19 infection at the time of publishing these treatment recommendations. Therefore, these recommendations are based predominantly on the opinion of experts (level C of recommendation).

BACKGROUND: Tracheostomy practice in patients with acute respiratory failure (ARF) varies greatly among institutions. This variability has the potential to be reflected in the resources expended providing care. In various healthcare environments, increased resource expenditure has been associated with a favorable effect on outcome. OBJECTIVE: To examine the association between institutional resource expenditure and mortality in ARF patients managed with tracheostomy. METHODS: We developed analytic models employing the University Health Systems Consortium (Oakbrook, Illinois) database. Administrative coding data were used to identify patients with the principal diagnosis of ARF, procedures, complications, post-discharge destination, and survival. Mean resource intensity of participating academic medical centers was determined using risk-adjusted estimates of costs. Mortality risk was determined using a multivariable approach that incorporated patient-level demographic and clinical variables and institution-level resource intensity. RESULTS: We analyzed data from 44,124 ARF subjects, 4,776 (10.8%) of whom underwent tracheostomy. Compared to low-resource-intensity settings, treatment in high-resource-intensity academic medical centers was associated with increased risk of mortality (odds ratio 1.11, 95% CI 1.05-1.76), including those managed with tracheostomy (odds ratio high-resource-intensity academic medical center with tracheostomy 1.10, 95% CI 1.04-1.17). We examined the relationship between complication development and outcome. While neither the profile nor number of complications accumulated differed comparing treatment environments (P > .05 for both), mortality for tracheostomy patients experiencing complications was greater in high-resource-intensity (95/313, 30.3%) versus low-resource-intensity (552/2,587, 21.3%) academic medical centers (P < .001). CONCLUSIONS: We were unable to demonstrate a positive relationship between resource expenditure and outcome in ARF patients managed with tracheostomy.

Much of the common practice in paediatric mechanical ventilation is based on personal experiences and what paediatric critical care practitioners have adopted from adult and neonatal experience. This presents a barrier to planning and interpretation of clinical trials on the use of specific and targeted interventions. We aim to establish a European consensus guideline on mechanical ventilation of critically children. Methods: The European Society for Paediatric and Neonatal Intensive Care initiated a consensus conference of international European experts in paediatric mechanical ventilation to provide recommendations using the Research and Development/University of California, Los Angeles, appropriateness method. An electronic literature search in PubMed and EMBASE was performed using a combination of medical subject heading terms and text words related to mechanical ventilation and disease-specific terms. Results: The Paediatric Mechanical Ventilation Consensus Conference (PEMVECC) consisted of a panel of 15 experts who developed and voted on 152 recommendations related to the following topics: (1) general recommendations, (2) monitoring, (3) targets of oxygenation and ventilation, (4) supportive measures, (5) weaning and extubation readiness, (6) normal lungs, (7) obstructive diseases, (8) restrictive diseases, (9) mixed diseases, (10) chronically ventilated

Fernando Frutos-Vivar, MD; Andrés Esteban, MD, PhD; Carlos Apezteguía, MD; Antonio Anzueto, MD; Peter Nightingale, MD; Marco González, MD; Luis Soto, MD; Carlos Rodrigo, MD; Jean Raad, MD; Cide M. David, MD; Dimitros Matamis, MD; Gabriel D&#x27; Empaire, MD; ...

Purpose: Much of the common practice in paediatric mechanical ventilation is based on personal experiences and what paediatric critical care practitioners have adopted from adult and neonatal experience. This presents a barrier to planning and interpretation of clinical trials on the use of specific and targeted interventions. We aim to establish a European consensus guideline on mechanical ventilation of critically children.

One hundred sixty cases of self-poisoning of patients aged 15 years and older were treated on the wards of the four community hospitals of Lansing, Michigan, in 1981. Most cases (91 percent) were intentional and represented suicide attempts. The complication rate was 13.8 percent and the overdose-related mortality rate 0.6 percent. Aspiration pneumonia was the most common complication, followed by respiratory failure and seizures. No patient with a level of consciousness stage 0 or 1 in the emergency room had a major overdose-related complication with permanent sequelae, and this group represented 80 percent of the cases. One possible guideline for managing the self-poisoner is level of consciousness in the emergency room.

Resumen La sarcoidosis es una enfemedad granulomatosa sistémica que generalmente afecta al pulmón. Las localizaciones extrapulmonares más frecuentes son los ganglios linfáticos, los ojos y la piel, mientras que en la rinofaringe es extremadamente rara. Presentamos un caso de sarcoidosis que fue diagnosticada por su localización en el cavum.

Objectives: To review the first 50 patients to receive extracorporeal membrane oxygenation (ECMO) for respiratoryfailure at Glenfield Hospital,and to compare them with published series of patients receiving positive pressure ventilation. Design: Retrospective chart review. ...

The clinical use of veno-venous extracorporeal membrane oxygenation (VVECMO) in adult patients with respiratory failure is rapidly increasing. However, recirculation of blood oxygenated by ECMO back into the circuit may occur in VVECMO, resulting in insufficient oxygenation. The cannula position and bypass flow rate are two major factors influencing recirculation, but the relationship and ideal configuration of these factors are not fully understood. In the present study, we attempted to clarify these parameters for effective gas exchange. VVECMO was performed in eight adult goats under general anesthesia. The position of the drainage cannula was fixed in the inferior vena cava (IVC), but the return cannula position was varied between the IVC, right atrium (RA), and superior vena cava (SVC). At each position, the recirculation rates calculated, and the adequacy of oxygen delivery by ECMO in supplying systemic oxygen demand was assessed by measuring the arterial oxygen saturation (Sa...

Objectif.-Étudier les répercussions maternelles et néonatales du rémifentanil (REMI) utilisé en anesthésie générale pour césariennes programmées. Patientes et méthodes.-Après accord du comité d'éthique local et un consentement écrit, 40 parturientes à terme (classe ASA I ou II) proposées pour césarienne programmée ont été incluses dans une étude prospective contrôlée. Les parturientes ont été randomisées en deux groupes : G1 : induction (propofol 2 mg/kg, REMI 0,5 μg/kg, suxaméthonium 1 mg/kg), entretien (propofol 100 μg/kg par minute, REMI 0,2 μg/kg par minute en PSE) ; G2 : induction (propofol 2 mg/kg, suxaméthonium 1 mg/kg), entretien (propofol 100 μg/kg par minute, REMI 0,2 μg/kg par minute après clampage du cordon). Nous avons relevé la pression artérielle moyenne (PAM) et la fréquence cardiaque (FC) maternelle après l'induction, la fréquence respiratoire du nouveau-né ainsi que la survenue d'apnée, la gazométrie de l'artère et la veine ombilicale deux minutes après clampage du cordon. Les tests de Student et de Chi 2 ont été utilisés pour les analyses statistiques à l'aide du logiciel SPSS 11 (p < 0,05 est considérée significative). Résultats.-La PAS, la PAM et la FC étaient significativement plus élevées dans le groupe témoin à l'induction. Cinq nouveau-nés parmi les sept ayant présenté une dépression respiratoire ont nécessité une ventilation au masque (deux dans le G1 et trois dans le G2). Conclusion.-Le REMI utilisé au cours d'une anesthésie générale pour césarienne programmée, assure une meilleure stabilité hémodynamique pour la mère, sans vraisemblablement compromettre la sécurité du nouveau-né.

The static pressure volume (PV) curve of the total respiratory system is a well established method to assess pulmonary mechanics during respiratory failure. We have tested the impact of auto-PEEP on the PV curve determination in 16 COPD patients. An isovolumic pressure increment (IPI) was found at the beginning of the curve and a close correlation between IPI and auto-PEEP level (r = 0.962)p<0.001) was observed. The regression equation was not significantly different from the identity line. We conclude that the appearance of IPI in PV curves is largely determined by auto-PEEP and it is a good estimate of the existing auto PEEP level.

Background: Neuromuscular blocking agents (NMBA) are commonly administered to critically ill children in pediatric intensive care units (PICU) in the USA and Europe. Although NMBA are frequently used in PICU patients, their role in the PICU setting has not yet been clearly defined. The aim of this study was to describe the sustained administration of NMBA and its impact on outcome of PICU patients. Methods: A 3-year retrospective cohort study was conducted to compare mechanically-ventilated patients who received NMBA for at least 12 h with patients who did not (control group). Results: A total of 317 consecutive patients were ventilated over 3473 days. Patients were similar in age, weight and severity scores. Thirty-four children (10.7%) received NMBA. Compared with controls, the neuromuscular blockade (NMB) group had a longer duration of mechanical ventilation (13.7 vs 5.5 days, P = 0.000), longer PICU stay (20 vs 11 days, P = 0.000) and increased occurrence of ventilator-associated pneumonia (6.6 vs 4.1/1000 ventilator days, P = 0.010). The NMB use was not associated with higher mortality (8.8% vs 17.6%, P = 0.287) or longer hospital stay (30.5 vs 23 days, P = 0.117). Conclusion: Although the use of NMBA was not associated with greater mortality, we found that sustained use of NMBA is associated with prolonged mechanical ventilation, longer PICU stay and higher incidence of ventilatorassociated pneumonia when compared with controls. Larger studies are necessary to confirm these findings.

A 2-h T-tube trial of spontaneous breathing was used in selecting patients ready for extubation and discontinuation of mechanical ventilation. However, some doubt remains as to whether it is the most appropriate method of performing a spontaneous breathing trial. We carried out a prospective, randomized, multicenter study involving patients who had received mechanical ventilation for more than 48 h and who were considered by their physicians to be ready for weaning according to clinical criteria and standard weaning parameters. Patients were randomly assigned to undergo a 2-h trial of spontaneous breathing in one of two ways: with a T-tube system or with pressure support ventilation of 7 cm H 2 O. If a patient had signs of poor tolerance at any time during the trial, mechanical ventilation was reinstituted. Patients without these features at the end of the trial were extubated. Of the 246 patients assigned to the T-tube group, 192 successfully completed the trial and were extubated; 36 of them required reintubation. Of the 238 patients in the group receiving pressure support ventilation, 205 were extubated and 38 of them required reintubation. The percentage of patients who remained extubated after 48 h was not different between the two groups (63% T-tube, 70% pressure support ventilation, p ϭ 0.14). The percentage of patients failing the trial was significantly higher when the T-tube was used (22 versus 14%, p ϭ 0.03). Clinical evolution during the trial was not different in patients reintubated and successfully extubated. ICU mortality among reintubated patients was significantly higher than in successfully extubated patients (27 versus 2.6%, p Ͻ 0.001). Spontaneous breathing trials with pressure support or T-tube are suitable methods for successful discontinuation of ventilator support in patients without problems to resume spontaneous breathing. Esteban A,

Respiratory muscle strength is a proven predictor of long-term outcome of neuromuscular disease (NMD), including amyotrophic lateral sclerosis, Duchenne muscular dystrophy, and spinal muscular atrophy. Maximal inspiratory pressure (MIP), a sensitive measure of respiratory muscle strength, one of several useful tests of respiratory muscle strength, is gaining interest as a therapeutic clinical trial endpoint for NMD. In this comprehensive review we investigate the use of MIP as a measure of respiratory muscle strength in clinical trials of therapeutics targeting respiratory muscle, examine the correlation of MIP with survival, quality of life, and other measures of pulmonary function, and outline the role of MIP as a clinically significantly meaningful outcome measure. Our analysis supports the utility of MIP for the early evaluation of respiratory muscle strength, especially of the diaphragm, in patients with NMD and as a surrogate endpoint in clinical trials of therapies for NMD.

The use of non-invasive ventilation in patients with community-acquired pneumonia is controversial since this is associated with high rates of treatment failure, compared with other causes of severe acute respiratory failure. The populations of patients with community-acquired pneumonia who have demonstrated better response to non-invasive ventilation are those with previous cardiac or respiratory disease, particularly chronic obstructive pulmonary disease. By contrast, the use of non-invasive ventilation in patients with communityacquired pneumonia without these pre-existing diseases should be very cautious and under strict monitoring conditions, since there are increasing evidences that the unnecessary delay in intubation of those patients who fail treatment with non-invasive ventilation is associated with lower survival. Pulmonary complications of immunosuppressed patients are associated with high rates of intubation and mortality. The use of non-invasive ventilation in these patients may decrease the need for intubation and improve the poor outcome associated with these complications. Continuous positive airway pressure has been used to treat acute respiratory failure in several conditions characterised by alveolar collapse. While this is extremely useful in patients with acute cardiogenic pulmonary oedema, the efficacy in pneumonia seems limited to immunosuppressed patients with pulmonary complications. Conversely, there are no sufficient evidences on the efficacy of continuous positive airway pressure in immunocompetent patients with pneumonia and severe acute respiratory failure.

Purpose The objective of our trial was to obtain more comprehensive data on the risks and benefits of kinetic therapy in intensive care patients with intracerebral pathology. Methods Standardized data of prone positioning in our NeuroIntensive Care Unit were collected from 2007 onward. A post hoc analysis of all available data was undertaken, with special consideration given to values of intracranial pressure (ICP), cerebral perfusion pressure (CPP) and oxygenation in correlation to prone (PP), or supine positioning (SP) of patients. Cases were considered eligible if kinetic therapy and ICP were documented. Prone positioning was performed in a 135°position for 8 h per treatment unit. Results A total of 115 patients treated with prone positioning from 2007 to 2013 were identified in our medical records. Of these, 29 patients received ICP monitoring. Overall, 119 treatment units of prone positioning with a mean duration of 2.5 days per patient were performed. The mean baseline ICP in SP was 9.5 ± 5.9 mmHg and was increased significantly during PP (p < 0.0001). There was no significant difference between CPP in SP (82 ± 14.5 mmHg) compared to PP (p > 0.05). ICP values >20 mmHg occurred more often during PP than SP (p < 0.0001) and were associated with significantly more episodes of decreased CPP <70 mmHg (p < 0.0022). The mean paO 2 / FiO 2 ratio (P/F ratio) was increased significantly in prone positioning of patients (p < 0.0001). Conclusions The analyzed data allow a more precise understanding of changes in ICP and oxygenation during prone positioning in patients with acute brain injury and almost normal baseline ICP. Our study shows a moderate, yet significant elevation of ICP during prone positioning. However, the achieved increase of oxygenation by far exceeded the changes in ICP. It is evident that continuous monitoring of cerebral pressure is required in this patient group.

The trachea of a 50 year-old woman was intubated for management of respiratory failure following neurotoxic snake bite. She developed bilateral vocal cord palsy following intubation and was managed with tracheostomy and other supportive measures. Vocal cord palsy is a rare complication of intubation, which, in most situations, is preventable.

This article presents specific uses of the portable chest film. The specific utility, borderline utility, and pitfalls in interpretation of films that are often taken to investigate a number of diagnostic problems common to the practice of emergency medicine are discussed.

The centrilobular liver cell necrosis observed in hypoxic hepatitis is generally attributed to failure of hepatic blood perfusion. Accordingly, this injury of the liver is commonly recognized under the terms "shock liver" or "ischemic hepatitis." During a 10-year period, 142 episodes of hypoxic hepatitis were consecutively identified in the intensive care unit of a general hospital, and the clinical, biological, and hemodynamic parameters were prospectively collected on individual files. We conducted the current study to assess retrospectively the role of the hemodynamic mechanisms of tissue hypoxia: ischemia, passive venous congestion, and hypoxemia. Among the 142 episodes of hypoxic hepatitis, 138 were separated in 4 main groups based on clinical features: decompensated congestive heart failure (80 cases), acute cardiac failure (20 cases), exacerbated chronic respiratory failure (19 cases), and toxic/septic shock (19 cases). An elementary hemodynamic evaluation, including blood pressure, central venous pressure, and arterial blood gas analysis, was carried out in every episode and a more complete hemodynamic assessment through pulmonary artery catheterization was performed in 61 episodes. The hemodynamic mechanisms responsible for hypoxic hepatitis were different in the 4 groups. In congestive heart failure and acute heart failure, the hypoxia of the liver resulted from decreased hepatic blood flow (ischemia) due to left-sided heart failure and from venous congestion secondary to right-sided heart failure. In chronic respiratory failure, liver hypoxia was mainly due to profound hypoxemia. In toxic/septic shock, oxygen delivery to the liver was not decreased but oxygen needs were increased, while the liver was unable to use oxygen properly. In all conditions underlying hypoxic hepatitis, except toxic/septic shock, a shock state was observed in only about 50% of the cases. Therefore, the expressions "shock liver" or "ischemic hepatitis" are misleading and should be replaced by the more general term "hypoxic hepatitis."

ventilation. Sixteen children (47.1%) were on noninvasive mechanical ventilation via nasal mask while 7 (20.6%) used a face mask. Seven (20.6%) patients received ventilatory support for 24 h and 27 (79.4%) patients were supported only during sleep. Twenty-four (70.6%) children received supplemental oxygen in addition to ventilatory support. Three patients successfully came off ventilatory support; 11 patients died during follow-up. None of the patients had home nursing and there were no life-threatening complications. Conclusions: A rapidly rising trend of HMV use in chronic respiratory failure (CRF) has been observed in this study. HMV can be safely applied in selected children with CRF with close monitoring and proper follow-up in developing countries despite the lack of home nursing.

Background: Spontaneous breathing trials (SBT) can be exhausting, but the preventive role of rest has never been studied. This study aimed to evaluate whether reconnection to mechanical ventilation (MV) for 1 h after the effort of a successful SBT could reduce the need for reintubation in critically ill patients. Methods: Randomized multicenter trial conducted in 17 Spanish medical-surgical intensive care units (Oct 2013-Jan 2015). Patients under MV for longer than 12 h who fulfilled criteria for planned extubation were randomly allocated after a successful SBT to direct extubation (control group) or reconnection to the ventilator for a 1-h rest before extubation (rest group). The primary outcome was reintubation within 48 h. Analysis was by intention to treat. Results: We recruited 243 patients randomized to the control group and 227 to the rest group. Median time from intubation to SBT did not differ between groups [5.5 (2.7, 9.6) days in the control group vs. 5.7 (2.7, 10.6) in the rest group; p = 0.85]. Reintubation within 48 h after extubation was more common in the control than in the rest group [35 (14%) vs. 12 (5%) patients; OR 0.33; 95% CI 0.16-0.65; p < 0.001]. A multivariable regression model demonstrated that the variables independently associated with reintubation were rest [OR 0.34 (95%CI 0.17-0.68)], APACHE II [OR 1.04 (1.002-1.077)], and days of MV before SBT [OR 1.04 (1.001-1.073)], whereas age, reason for admission, and type and duration of SBT were not. Conclusion: One-hour rest after a successful SBT reduced the rates of reintubation within 48 h after extubation in critically ill patients. Trial registration Clinicaltrials.gov identifier NCT01915563.

Invasive ventilation is associated with both pulmonary and non-pulmonary complications. There has been a renewed interest in the use of negative pressure ventilation (NPV) for various medical conditions to minimise the complications associated with positive pressure ventilation. The routine use of NPV in an ICU setting still requires further studies and research. In this article, the authors review the clinical applications of NPV together with associated risks and limitations. Case reports of patients with cardiac, neuromuscular, and respiratory diseases managed with NPV on our unit are described. NPV improved the clinical condition in each of these patients and decreased the requirement for invasive therapy.

Increasing numbers of patients are surviving episodes of prolonged mechanical ventilation or benefitting from the recent availability of userfriendly noninvasive ventilators. Although many publications pertaining to specific aspects of home mechanical ventilation (HMV) exist, very few comprehensive guidelines that bring together all of the current literature on patients at risk for or using mechanical ventilatory support are available. The Canadian Thoracic Society HMV Guideline Committee has reviewed the available English literature on topics related to HMV in adults, and completed a detailed guideline that will help standardize and improve the assessment and management of individuals requiring noninvasive or invasive HMV. The guideline provides a disease-specific review of illnesses including amyotrophic lateral sclerosis, spinal cord injury, muscular dystrophies, myotonic dystrophy, kyphoscoliosis, post-polio syndrome, central hypoventilation syndrome, obesity hypoventilation syn...

Spinal cord injuries (SCIs) often lead to impairment of the respiratory system and, consequently, restrictive respiratory changes. Paresis or paralysis of the respiratory muscles can lead to respiratory insufficiency, which is dependent on the level and completeness of the injury. Respiratory complications include hypoventilation, a reduction in surfactant production, mucus plugging, atelectasis, and pneumonia. Vital capacity (VC) is an indicator of overall pulmonary function; patients with severely impaired VC may require assisted ventilation. It is best to proceed with intubation under controlled circumstances rather than waiting until the condition becomes an emergency. Mechanical ventilation can adversely affect the structure and function of the diaphragm. Early tracheostomy following short orotracheal intubation is probably beneficial in selected patients. Weaning should start as soon as possible, and the best modality is progressive ventilator-free breathing (PVFB). Appropriat...

Experience with prolonged mechanical ventilation has improved over recent years. Retrospective analysis of the records of 104 patients older than 16 years of age who were mechanically ventilated for more than 29 days over a 29month period from May 1986 to October 1988 revealed the following findings. The mean patient age was 66.3 ± 15.7 years (SD). The mean number ofin-hospital ventilator days was 59.9 ± 36.7 days (range, 29 to 247 days). The mean number of days of oral or nasal endotracheal intubation prior to tracheostomy (96 patients) was 21.5± Receive free e-mail alerts when new articles cite this article. To sign up, select the "Services" link to Citation Alerts slide format. See any online figure for directions. articles can be downloaded for teaching purposes in PowerPoint CHEST Figures that appear in Images in PowerPoint format

BackgroundAmyotrophic lateral sclerosis (ALS) is a neurodegenerative disease resulting in death, usually from respiratory failure, within 2–3 years of symptom onset. Non-invasive ventilation (NIV) is a treatment that when given to patients in respiratory failure leads to improved survival and quality of life. Diaphragm pacing (DP), using the NeuRx/4®diaphragm pacing system (DPS)™ (Synapse Biomedical, Oberlin, OH, USA), is a new technique that may offer additional or alternative benefits to patients with ALS who are in respiratory failure.ObjectiveThe Diaphragm Pacing in patients with Amyotrophic Lateral Sclerosis (DiPALS) trial evaluated the effect of DP on survival over the study duration in patients with ALS with respiratory failure.DesignThe DiPALS trial was a multicentre, parallel-group, open-label, randomised controlled trial incorporating health economic analyses and a qualitative longitudinal substudy.ParticipantsEligible participants had a diagnosis of ALS (ALS laboratory-su...

We present the cases of two patients with Guillain-Barré syndrome and one with myasthenic crisis who developed acute respiratory failure and needed mechanical ventilation in the intensive care unit. All the patients were treated with plasmapheresis, resulting in weaning from mechanical ventilation, and eventually complete functional recovery. Early treatment with plasma exchange shortens the treatment duration, whereas early intubation can prevent life-threatening complications.

Most outcomes do not deeply express the degree of disability in patients with respiratory failure (RF) following inpatient pulmonary rehabilitation (IPR). The aim of our study was to evaluate the efficacy of an IPR in patients with confirmed COPD and RF using functional independence measure (FIM) that determines the degree of disability experienced by patients and the progress they make during rehabilitation. This scale includes several items: self care, mobility, locomotion, communication and social recognition. Twenty-two patients (age 70 AE 2 years, PO 2 58.18 AE 7.63 mmHg, PCO 2 46.82 AE 9.11 mmHg) were prospectively observed and studied. IPR included respiratory and peripheral muscle training, mucus evacuation techniques, and energy conservation techniques. FIM, Medical Research Council dyspnoea scale (MRC), St. George's Respiratory Questionnaire (SGRQ), and 6-min walking distance (6-MWD) were assessed on admission (pre) and discharge (post) from IPR. After IPR there was a statistically significant improvement (p < 0.01) in all the FIM items (total score in self care, mobility, locomotion, social recognition) except for communication. Changes of MRC (pre 4.32 AE 0.84; post 3.00 AE 1.15, p < 0.001), SGRQ (%) (pre 69.86 AE 4.62; post 46.50 AE 11.94, p < 0.001), and 6-MWD (pre 164.54 AE 98.63; post 214.32 AE 97.64, p < 0.001) paralleled those improvements. An inverse correlation between MRC and FIM (r Z À0.5042, p Z 0.016) was observed.

Background: Patients requiring prolonged invasive mechanical ventilation are prone to complications, such as infections, tracheal stenosis and death. It has been proposed that early tracheostomy could have a role in preventing these outcomes, but the proper identification of patients at risk can be difficult. Purpose: The aim of this study was to develop a multivariate model that allows the early detection of patients that will require prolonged ventilatory support. Patients and methods: A retrospective cohort study was undertaken in the intensive care unit of the Hospital Naval Almirante Nef, Chile, between June 2011 and June 2012. The charts of all intubated patients were reviewed in search for early predictors of prolonged intubation (> 7 days). Multivariate logistic regression analysis was used to detect statistically significant associations and to assess potential confounders. Results: A total of 349 patients were admitted to the intensive care unit during the study period and 142 (40.7%) required invasive mechanical ventilation. Most of them were male (60.5%), with a mean age of 65.8 ± 16.7 years. Thirty-five patients (24%) required to be ventilated for 7 days or more, and 16 (46%) were tracheostomized for this reason. The regression model showed that older age (p = 0.026), a Pa/Fi ratio of less than 200 (p = 0.046), and the presence of chronic pulmonary disease (p = 0.035) or hypernatremia (p = 0.012) on intubation day were significantly associated with the requirement of prolonged intubation. Discussion: Invasive mechanical ventilation is a common reason for admittance to the ICU. The abovementioned predictors can be of assistance when selecting patients that could benefit from early tracheostomies, and are in agreement with earlier reports. Although the model's discriminating capacity was good, it is necessary to formally validate it before recommending its widespread use.

Introduction: Respiratory failure following chemical exposure can be fatal and although supraglottic airway devices have been evaluated for use in the management of CBRN casualties' intubation remains the gold standard airway. Methods: This is a randomised cross-over study involving 66 paramedic students utilising the following intubating aids bougie, stylet, McCoy laryngoscope, Airtraq TM , intubating laryngeal mask (ILMA) and standard intubation. Each participant performed intubation with each device while wearing standard uniform and CBRN-PPE. Results: While wearing standard uniform all intubation aids, except the Airtraq TM , resulted in at least a 90% successful intubation rate by 60 s. The use of CBRN-PPE led to significantly longer intubation times (ranging from 14.3 to 20.7 s) depending on intubation aid used (p < 0.001) with a 90% successful intubation rate not being achieved by all devices even by 150 s. While wearing CBRN-PPE standard intubation and intubation with a stylet were the fastest whereas the ILMA was deemed the easiest to use with the highest success rate. A marked deterioration in the number of intubation attempts completed within 30 s was also noted with standard intubation deteriorating by 82%, stylet deteriorating by 96% and the McCoy by 100%. The deterioration in intubation success at 60 s was less marked. Conclusion: In this manikin-based study all intubation aids evaluated while wearing CBRN-PPE were adversely affected by the loss of dexterity associated with wearing Butyl gloves. Standard intubation and intubation utilising a stylet resulted in the fastest intubation times; whereas the ILMA offers the highest intubation success rate and was deemed to be the easiest intubating aid to use. An important consideration with regards future research is the impact of a learning curve with regards to different intubation aids and whether preassembling all the intubation aids prior to the intubation attempt may improve intubation speed. The impact of intubator familiarity with regards to individual intubation aids is also an important consideration but established intubation aids like the Bougie are more difficult to use when dexterity is reduced due to CBRN-PPE.

Purpose: To evaluate and compare the performance of NT-proBNP levels, plasma protein concentration, hematocrit, and fluid balance for the preceding 24 h in predicting the outcome of the two steps of weaning: (1) spontaneous breathing trial (SBT), (2) extubation. Methods: This was a prospective observational study of 143 patients who were mechanically ventilated for more than 48 h (55 % COPD) and were ready to wean. They underwent an SBT and were extubated when they passed the trial. Immediately before the SBT, we measured the evaluated diagnosis tools. Results: Of 143 patients, 80 (56 %) passed the SBT and were extubated. Of these, two were reintubated for laryngeal dyspnea, 57 had no respiratory problem during the next 48 h, and 21 developed post-extubation respiratory distress (26 %). Rescue noninvasive ventilation (NIV) prevented reintubation in 15 (71 %). None of the tested diagnosis tools predicted the outcome of the SBT. Patients who developed post-extubation respiratory distress were older, had lower values of plasma protein concentration and higher values of NT-proBNP than those who did not. Only NT-proBNP was an independent predictor of the occurrence of post-extubation respiratory distress (OR 1.2; 95 % CI 1.09-1.4; p = 0.003); the area under the ROC curve for NT-proBNP to predict post-extubation respiratory distress was 0.78 (95 % CI 0.67-0.89; p = 0.0001). NT-proBNP was more accurate to rule out (negative likelihood ratio 0.09 for a cutoff of no greater than 1,000 pg/ml) than to rule in the risk of post-extubation respiratory distress (positive likelihood ratio 3.45 for a cutoff of at least 2,000 pg/ml). Conclusion: NT-proBNP levels at SBT help in the prediction of post-extubation respiratory distress and could identify the subgroup of extubated patients requiring close observation and/or prophylactic NIV.

To identify the indications for tracheal intubation in the emergency department of the Lagos University Teaching Hospital and problems encountered with the view to improve patient outcome. A one-year prospective observational study of endotracheal intubation in the emergency room (ER) of the Lagos University Teaching Hospital. Data collected included indications, methods, success rates, use of drugs and complications of intubation. Ninety-four patients underwent endotracheal intubation. Indications included severe traumatic brain injury (58.5%) and traumatic brain injury with associated multiple injuries (10.6%). Anaesthetist registrars performed 73.9% of the intubations. Seventy seven patients (81.9%) were successfully intubated at the first attempt. No patient required a surgical airway due to failed intubation. The mean time from a decision to intubate to successful tracheal intubation was 129.90 ± 23.43 mins. 63.8% of the patients were intubated between 4 pm-8 am. Causes of dela...

BACKGROUND: Early enteral nutrition is recommended for mechanically ventilated patients in several studies and guidelines. In contrast, the effects of early enteral nutrition on noninvasive ventilation (NIV) have not been investigated extensively. The lack of an established method of airway protection suggests that enteral nutrition administration to these patients could increase airway complications and worsen outcomes. METHODS: Between January 2007 and January 2015, 150 patients were admitted to our respiratory department for acute respiratory failure and received NIV for >48 h. Of these, 107 subjects incapable of oral intake were retrospectively analyzed. Clinical background and complications were compared in subjects who did and did not receive enteral nutrition. RESULTS: Sixty of the 107 subjects (56%) incapable of oral intake who received NIV also received enteral nutrition. Serum albumin concentration was significantly lower in subjects who received enteral nutrition than in those who did not (mean 2.7 ؎ 0.68 mg/dL vs 3.0 ؎ 0.75 mg/dL, P ‫؍‬ .048). The rate of airway complications was significantly higher (53% [32/60] vs 32% [15/47], P ‫؍‬ .03), and median NIV duration was significantly longer (16 [interquartile range 7-43] d vs 8 [5-20] d, P ‫؍‬ .02) in subjects who received enteral nutrition than in those who did not. Multivariate analysis showed that enteral nutrition was unrelated to in-hospital mortality. CONCLUSIONS: Among subjects receiving NIV, enteral nutrition was associated with increased risk of airway complications but did not affect mortality. Enteral nutrition should be carefully considered in these patients.