Tissue Doppler sonographic assessment of diaphragmatic excursion kinetics is depicted in Fig. 1. At bedside, with patient in 30°-semi-recumbent position, using an ultrasound machine equipped with a ...sectorial (1.8–4.2 MHz) probe and a dedicated cardiac tissue Doppler application (Xario 200, Canon Medical System, Europe), on the right side, the transducer is positioned between midclavicular and anterior axillary lines, and medially, cranially, and dorsally oriented to fnd the hepatic veins confuence into inferior vena cava.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
In case of adverse evolution of COVID-19 pneumonia and high stress ventilation as for patient-self-inflicted lung-injury induced by vigorous negative pressure developed during spontaneous breathing ...or non-invasively assisted breath, “low” phenotype may worsen in “high” phenotype with low respiratory system compliance, high right-to-left shunt, high lung weight, and good response to lung recruitment. ...while assuring a protective ventilation, a high positive end-expiratory pressure (PEEP) strategy, similar to that employed in managing severe COVID-19-free ARDS, can be pursued when a predominant “high” phenotype is observed 1. ...the assessment of lung recruitment through CT-scan was performed 1 min following the application of 16 cmH2O-PEEP. ...despite promising initial reports, randomized trials failed to show benefits when compared to strategies aiming at maintaining oxygenation with the use of lower PEEP levels 6, 7. ...we believe that the use of higher PEEP and recruitment maneuvers should be limited to selected patients based on clinical and physiological reasoning 7, including in COVID-19 pneumonia. ...we were able to detect a clear recruitment effect in some patients, as illustrated in Fig. 1a, b. On the other hand, patients with low recruitment had either diffuse ground glass opacities with few non-aerated areas (Fig. 1c) or large opacities with early fibrotic progression (Fig. 1d), two conditions which might explain the lack of response to PEEP.
Noninvasive respiratory support (NIRS) has been diffusely employed outside the intensive care unit (ICU) to face the high request of ventilatory support due to the massive influx of patients with ...acute respiratory failure (ARF) caused by coronavirus-19 disease (COVID-19). We sought to summarize the evidence on clinically relevant outcomes in COVID-19 patients supported by NIV outside the ICU.
We searched PUBMED®, EMBASE®, and the Cochrane Controlled Clinical trials register, along with medRxiv and bioRxiv repositories for pre-prints, for observational studies and randomized controlled trials, from inception to the end of February 2021. Two authors independently selected the investigations according to the following criteria: (1) observational study or randomized clinical trials enrolling ≥ 50 hospitalized patients undergoing NIRS outside the ICU, (2) laboratory-confirmed COVID-19, and (3) at least the intra-hospital mortality reported. Preferred Reporting Items for Systematic reviews and Meta-analysis guidelines were followed. Data extraction was independently performed by two authors to assess: investigation features, demographics and clinical characteristics, treatments employed, NIRS regulations, and clinical outcomes. Methodological index for nonrandomized studies tool was applied to determine the quality of the enrolled studies. The primary outcome was to assess the overall intra-hospital mortality of patients under NIRS outside the ICU. The secondary outcomes included the proportions intra-hospital mortalities of patients who underwent invasive mechanical ventilation following NIRS failure and of those with 'do-not-intubate' (DNI) orders.
Seventeen investigations (14 peer-reviewed and 3 pre-prints) were included with a low risk of bias and a high heterogeneity, for a total of 3377 patients. The overall intra-hospital mortality of patients receiving NIRS outside the ICU was 36% 30-41%. 26% 21-30% of the patients failed NIRS and required intubation, with an intra-hospital mortality rising to 45% 36-54%. 23% 15-32% of the patients received DNI orders with an intra-hospital mortality of 72% 65-78%. Oxygenation on admission was the main source of between-study heterogeneity.
During COVID-19 outbreak, delivering NIRS outside the ICU revealed as a feasible strategy to cope with the massive demand of ventilatory assistance.
PROSPERO, https://www.crd.york.ac.uk/prospero/ , CRD42020224788, December 11, 2020.
OBJECTIVES:Evaluating the physiologic effects of varying depths of propofol sedation on patient-ventilator interaction and synchrony during pressure support ventilation and neurally adjusted ...ventilatory assist.
DESIGN:Prospective crossover randomized controlled trial.
SETTING:University hospital ICU.
PATIENTS:Fourteen intubated patients mechanically ventilated for acute respiratory failure.
INTERVENTIONS:Six 25-minute trials randomly performed applying both pressure support ventilation and neurally adjusted ventilatory assist during wakefulness and with two doses of propofol, administered by Target Control Infusion, determining light (1.26 ± 0.35 μg/mL) and deep (2.52 ± 0.71 μg/mL) sedation, as defined by the bispectral index and Ramsay Sedation Scale.
MEASUREMENTS AND MAIN RESULTS:We measured electrical activity of the diaphragm to assess neural drive and calculated its integral over time during 1 minute (∫electrical activity of the diaphragm/min) to estimate diaphragm energy expenditure (effort), arterial blood gases, airway pressure, tidal volume and its coefficient of variation, respiratory rate, neural timing components, and calculated the ineffective triggering index. Increasing the depth of sedation did not cause significant modifications of respiratory timing, while determined a progressive significant decrease in neural drive (with both modes) and effort (in pressure support ventilation only). In pressure support ventilation, the difference in ineffective triggering index between wakefulness and light sedation was negligible (from 5.9% to 7.6%, p = 0.97); with deep sedation, however, ineffective triggering index increased up to 21.8% (p < 0.0001, compared to both wakefulness and light sedation). With neurally adjusted ventilatory assist, ineffective triggering index fell to 0%, regardless of the depth of sedation. With both modes, deep sedation caused a significant increase in PaCO2, which resulted, however, from different breathing patterns and patient-ventilator interactions.
CONCLUSIONS:In pressure support ventilation, deep propofol sedation increased asynchronies, while light sedation did not. Propofol reduced the respiratory drive, while breathing timing was not significantly affected. Gas exchange and breathing pattern were also influenced by propofol infusion to an extent that varied with the depth of sedation and the mode of ventilation.
Awake prone position is an emerging rescue therapy applied in patients undergoing noninvasive ventilation (NIV) for acute hypoxemic respiratory failure (ARF) related to novel coronavirus disease ...(COVID-19). Although applied to stabilize respiratory status, in awake patients, the application of prone position may reduce comfort with a consequent increase in the workload imposed on respiratory muscles. Thus, we primarily ascertained the effect of awake prone position on diaphragmatic thickening fraction, assessed through ultrasound, in COVID-19 patients undergoing NIV.
We enrolled all COVID-19 adult critically ill patients, admitted to intensive care unit (ICU) for hypoxemic ARF and undergoing NIV, deserving of awake prone positioning as a rescue therapy. Exclusion criteria were pregnancy and any contraindication to awake prone position and NIV. On ICU admission, after NIV onset, in supine position, and at 1 h following awake prone position application, diaphragmatic thickening fraction was obtained on the right side. Across all the study phases, NIV was maintained with the same setting present at study entry. Vital signs were monitored throughout the entire study period. Comfort was assessed through numerical rating scale (0 the worst comfort and 10 the highest comfort level). Data were presented in median and 25th-75th percentile range.
From February to May 2021, 20 patients were enrolled and finally analyzed. Despite peripheral oxygen saturation improvement 96 (94-97)% supine vs 98 (96-99)% prone, p = 0.008, turning to prone position induced a worsening in comfort score from 7.0 (6.0-8.0) to 6.0 (5.0-7.0) (p = 0.012) and an increase in diaphragmatic thickening fraction from 33.3 (25.7-40.5)% to 41.5 (29.8-50.0)% (p = 0.025).
In our COVID-19 patients assisted by NIV in ICU, the application of awake prone position improved the oxygenation at the expense of a greater diaphragmatic thickening fraction compared to supine position. Trial registration ClinicalTrials.gov, number NCT04904731. Registered on 05/25/2021, retrospectively registered. https://clinicaltrials.gov/ct2/show/NCT04904731 .
During flexible fiberoptic bronchoscopy (FOB) the arterial partial pressure of oxygen can drop, increasing the risk for respiratory failure. To avoid desaturation episodes during the procedure ...several oxygenation strategies have been proposed, including conventional oxygen therapy (COT), high flow nasal cannula (HFNC), continuous positive airway pressure (CPAP) and non-invasive ventilation (NIV). By a review of the current literature, we merely describe the clinical practice of oxygen therapies during FOB. We also conducted a pooled data analysis with respect to oxygenation outcomes, comparing HFNC with COT and NIV, separately. COT showed its benefits in patients undergoing FOB for broncho-alveolar lavage (BAL) or brushing for cytology, in those with peripheral arterial oxyhemoglobin saturation < 93% prior to the procedure or affected by obstructive disorder. HFNC is preferable over COT in patients with mild to moderate acute respiratory failure (ARF) undergoing FOB, by improving oxygen saturation and decreasing the episodes of desaturation. On the opposite, CPAP and NIV guarantee improved oxygenation outcomes as compared to HFNC, and they should be preferred in patients with more severe hypoxemic ARF during FOB.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Noninvasive ventilation (NIV) is generally delivered using pneumatically-triggered and cycled-off pressure support (PS
) through a mask. Neurally adjusted ventilatory assist (NAVA) is the only ...ventilatory mode that uses a non-pneumatic signal, i.e., diaphragm electrical activity (EAdi), to trigger and drive ventilator assistance. A specific setting to generate neurally controlled pressure support (PS
) was recently proposed for delivering NIV by helmet. We compared PS
with PS
and NAVA during NIV using a facial mask, with respect to patient comfort, gas exchange, and patient-ventilator interaction and synchrony.
Three 30-minute trials of NIV were randomly delivered to 14 patients immediately after extubation to prevent post-extubation respiratory failure: (1) PS
, with an inspiratory support ≥8 cmH
O; (2) NAVA, adjusting the NAVA level to achieve a comparable peak EAdi (EAdi
) as during PS
; and (3) PS
, setting the NAVA level at 15 cmH
O/μV with an upper airway pressure (Paw) limit to obtain the same overall Paw applied during PS
. We assessed patient comfort, peak inspiratory flow (PIF), time to reach PIF (PIF
), EAdi
, arterial blood gases, pressure-time product of the first 300 ms (PTP
) and 500 ms (PTP
) after initiation of patient effort, inspiratory trigger delay (Delay
), and rate of asynchrony, determined as asynchrony index (AI%). The categorical variables were compared using the McNemar test, and continuous variables by the Friedman test followed by the Wilcoxon test with Bonferroni correction for multiple comparisons (p < 0.017).
PS
significantly improved patient comfort, compared to both PS
(p = 0.001) and NAVA (p = 0.002), without differences between the two latter (p = 0.08). PIF (p = 0.109), EAdi
(p = 0.931) and gas exchange were similar between modes. Compared to PS
and NAVA, PS
reduced PIF
(p < 0.001), and increased PTP
(p = 0.004) and PTP
(p = 0.001). NAVA and PS
significantly reduced Delay
, as opposed to PS
(p < 0.001). During both NAVA and PS
, AI% was <10% in all patients, while AI% was ≥10% in 7 patients (50%) with PS
(p = 0.023 compared with both NAVA and PS
).
Compared to both PS
and NAVA, PS
improved comfort and patient-ventilator interaction during NIV by facial mask. PS
also improved synchrony, as opposed to PS
only.
ClinicalTrials.gov, NCT03041402 . Registered (retrospectively) on 2 February 2017.
Abstract
Background
Besides airway suctioning, patients undergoing invasive mechanical ventilation (iMV) benefit of different combinations of chest physiotherapy techniques, to improve mucus removal. ...To date, little is known about the clearance effects of oscillating devices on patients with acute respiratory failure undergoing iMV. This study aimed to assess (1) the effects of high-frequency chest wall oscillation (HFCWO) on lung aeration and ventilation distribution, as assessed by electrical impedance tomography (EIT), and (2) the effect of the association of HFCWO with recruitment manoeuvres (RM).
Methods
Sixty critically ill patients, 30 classified as normosecretive and 30 as hypersecretive, who received ≥ 48 h of iMV, underwent HFCWO; patients from both subgroups were randomized to receive RM or not, according to two separated randomization sequences. We therefore obtained four arms of 15 patients each. After baseline record (T0), HFCWO was applied for 10 min. At the end of the treatment (T1) or after 1 (T2) and 3 h (T3), EIT data were recorded. At the beginning of each step, closed tracheobronchial suctioning was performed. In the RM subgroup, tracheobronchial suctioning was followed by application of 30 cmH
2
O to the patient’s airway for 30 s. At each step, we assessed the change in end-expiratory lung impedance (ΔEELI) and in tidal impedance variation (ΔTIV), and the center of gravity (COG) through EIT. We also analysed arterial blood gases (ABGs).
Results
ΔTIV and COG did not differ between normosecretive and hypersecretive patients. Compared to T0, ΔEELI significantly increased in hypersecretive patients at T2 and T3, irrespective of the RM; on the contrary, no differences were observed in normosecretive patients. No differences of ABGs were recorded.
Conclusions
In hypersecretive patients, HFCWO significantly improved aeration of the dorsal lung region, without affecting ABGs. The application of RM did not provide any further improvements.
Trial registration
Prospectively registered at the Australian New Zealand Clinical Trial Registry (
www.anzctr.org.au
; number of registration: ACTRN12615001257550; date of registration: 17th November 2015).
OBJECTIVES:The value of visual inspection of ventilator waveforms in detecting patient–ventilator asynchronies in the intensive care unit has never been systematically evaluated. This study aims to ...assess intensive care unit physiciansʼ ability to identify patient–ventilator asynchronies through ventilator waveforms.
DESIGN:Prospective observational study.
SETTING:Intensive care unit of a University Hospital.
PATIENTS:Twenty-four patients receiving mechanical ventilation for acute respiratory failure.
INTERVENTION:Forty-three 5-min reports displaying flow-time and airway pressure-time tracings were evaluated by 10 expert and 10 nonexpert, i.e., residents, intensive care unit physicians. The asynchronies identified by experts and nonexperts were compared with those ascertained by three independent examiners who evaluated the same reports displaying, additionally, tracings of diaphragm electrical activity.
MEASUREMENTS AND MAIN RESULTS:Data were examined according to both breath-by-breath analysis and overall report analysis. Sensitivity, specificity, and positive and negative predictive values were determined. Sensitivity and positive predictive value were very low with breath-by-breath analysis (22% and 32%, respectively) and fairly increased with report analysis (55% and 44%, respectively). Conversely, specificity and negative predictive value were high with breath-by-breath analysis (91% and 86%, respectively) and slightly lower with report analysis (76% and 82%, respectively). Sensitivity was significantly higher for experts than for nonexperts for breath-by-breath analysis (28% vs. 16%, p < .05), but not for report analysis (63% vs. 46%, p = .15). The prevalence of asynchronies increased at higher ventilator assistance and tidal volumes (p < .001 for both), whereas it decreased at higher respiratory rates and diaphragm electrical activity (p < .001 for both). At higher prevalence, sensitivity decreased significantly (p < .001).
CONCLUSIONS:The ability of intensive care unit physicians to recognize patient–ventilator asynchronies was overall quite low and decreased at higher prevalence; expertise significantly increased sensitivity for breath-by-breath analysis, whereas it only produced a trend toward improvement for report analysis.
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