The significance of natural ventilation Porteous, Colin
Building research and information : the international journal of research, development and demonstration,
02/2019, Volume:
47, Issue:
2
Journal Article
Non-invasive ventilation (NIV) with bi-level positive airway pressure (BiPAP) is commonly used to treat patients admitted to hospital with acute hypercapnic respiratory failure (AHRF) secondary to an ...acute exacerbation of chronic obstructive pulmonary disease (AECOPD).
To compare the efficacy of NIV applied in conjunction with usual care versus usual care involving no mechanical ventilation alone in adults with AHRF due to AECOPD. The aim of this review is to update the evidence base with the goals of supporting clinical practice and providing recommendations for future evaluation and research.
We identified trials from the Cochrane Airways Group Specialised Register of trials (CAGR), which is derived from systematic searches of bibliographic databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Allied and Complementary Medicine Database (AMED), and PsycINFO, and through handsearching of respiratory journals and meeting abstracts. This update to the original review incorporates the results of database searches up to January 2017.
All randomised controlled trials that compared usual care plus NIV (BiPAP) versus usual care alone in an acute hospital setting for patients with AECOPD due to AHRF were eligible for inclusion. AHRF was defined by a mean admission pH < 7.35 and mean partial pressure of carbon dioxide (PaCO
) > 45 mmHg (6 kPa). Primary review outcomes were mortality during hospital admission and need for endotracheal intubation. Secondary outcomes included hospital length of stay, treatment intolerance, complications, changes in symptoms, and changes in arterial blood gases.
Two review authors independently applied the selection criteria to determine study eligibility, performed data extraction, and determined risk of bias in accordance with Cochrane guidelines. Review authors undertook meta-analysis for data that were both clinically and statistically homogenous, and analysed data as both one overall pooled sample and according to two predefined subgroups related to exacerbation severity (admission pH between 7.35 and 7.30 vs below 7.30) and NIV treatment setting (intensive care unit-based vs ward-based). We reported results for mortality, need for endotracheal intubation, and hospital length of stay in a 'Summary of findings' table and rated their quality in accordance with GRADE criteria.
We included in the review 17 randomised controlled trials involving 1264 participants. Available data indicate that mean age at recruitment was 66.8 years (range 57.7 to 70.5 years) and that most participants (65%) were male. Most studies (12/17) were at risk of performance bias, and for most (14/17), the risk of detection bias was uncertain. These risks may have affected subjective patient-reported outcome measures (e.g. dyspnoea) and secondary review outcomes, respectively.Use of NIV decreased the risk of mortality by 46% (risk ratio (RR) 0.54, 95% confidence interval (CI) 0.38 to 0.76; N = 12 studies; number needed to treat for an additional beneficial outcome (NNTB) 12, 95% CI 9 to 23) and decreased the risk of needing endotracheal intubation by 65% (RR 0.36, 95% CI 0.28 to 0.46; N = 17 studies; NNTB 5, 95% CI 5 to 6). We graded both outcomes as 'moderate' quality owing to uncertainty regarding risk of bias for several studies. Inspection of the funnel plot related to need for endotracheal intubation raised the possibility of some publication bias pertaining to this outcome. NIV use was also associated with reduced length of hospital stay (mean difference (MD) -3.39 days, 95% CI -5.93 to -0.85; N = 10 studies), reduced incidence of complications (unrelated to NIV) (RR 0.26, 95% CI 0.13 to 0.53; N = 2 studies), and improvement in pH (MD 0.05, 95% CI 0.02 to 0.07; N = 8 studies) and in partial pressure of oxygen (PaO
) (MD 7.47 mmHg, 95% CI 0.78 to 14.16 mmHg; N = 8 studies) at one hour. A trend towards improvement in PaCO
was observed, but this finding was not statistically significant (MD -4.62 mmHg, 95% CI -11.05 to 1.80 mmHg; N = 8 studies). Post hoc analysis revealed that this lack of benefit was due to the fact that data from two studies at high risk of bias showed baseline imbalance for this outcome (worse in the NIV group than in the usual care group). Sensitivity analysis revealed that exclusion of these two studies resulted in a statistically significant positive effect of NIV on PaCO
. Treatment intolerance was significantly greater in the NIV group than in the usual care group (risk difference (RD) 0.11, 95% CI 0.04 to 0.17; N = 6 studies). Results of analysis showed a non-significant trend towards reduction in dyspnoea with NIV compared with usual care (standardised mean difference (SMD) -0.16, 95% CI -0.34 to 0.02; N = 4 studies). Subgroup analyses revealed no significant between-group differences.
Data from good quality randomised controlled trials show that NIV is beneficial as a first-line intervention in conjunction with usual care for reducing the likelihood of mortality and endotracheal intubation in patients admitted with acute hypercapnic respiratory failure secondary to an acute exacerbation of chronic obstructive pulmonary disease (COPD). The magnitude of benefit for these outcomes appears similar for patients with acidosis of a mild (pH 7.30 to 7.35) versus a more severe nature (pH < 7.30), and when NIV is applied within the intensive care unit (ICU) or ward setting.
Außerklinische Beatmung Schäfer, Harald
MMW Fortschritte der Medizin,
04/2020, Volume:
162, Issue:
7
Journal Article
Peer reviewed
Open access
In den letzten Jahren ist eine deutliche und kontinuierliche Zunahme von meist schwerkranken Patienten zu konstatieren, die außerhalb einer Klinik beatmet werden. Diese Patienten stellen eine ...wachsende Herausforderung für alle an der Versorgung Beteiligten dar. In der Regel erfolgt die ärztliche Weiterbetreuung und die Verordnung der benötigten Hilfsmittel durch Hausärzte. In diesem Beitrag lesen Sie, was ein Hausarzt aus dem Bereich der Beatmungsmedizin wissen sollte.
Summary
The effect of intra‐operative mechanical ventilation modes on pulmonary outcomes after thoracic surgery with one‐lung ventilation has not been well established. We evaluated the impact of ...three common ventilation modes on postoperative pulmonary complications in patients undergoing lung resection surgery. In this two‐centre randomised controlled trial, 1224 adults scheduled for lung resection surgery with one‐lung ventilation were randomised to one of three groups: volume‐controlled ventilation; pressure‐controlled ventilation; and pressure‐control with volume guaranteed ventilation. Enhanced recovery after surgery pathways and lung‐protective ventilation protocols were implemented in all groups. The primary outcome was a composite of postoperative pulmonary complications within the first seven postoperative days. The outcome occurred in 270 (22%), with 87 (21%) in the volume control group, 89 (22%) in the pressure control group and 94 (23%) in the pressure‐control with volume guaranteed group (p = 0.831). The secondary outcomes also did not differ across study groups. In patients undergoing lung resection surgery with one‐lung ventilation, the choice of ventilation mode did not influence the risk of developing postoperative pulmonary complications. This is the first randomised controlled trial examining the effect of three ventilation modes on pulmonary outcomes in patients undergoing lung resection surgery.
Energy demand has been increasing worldwide and the building sector represents a large percentage of global energy consumption. Therefore, promoting energy efficiency in buildings is essential. Among ...all building services, Heating, Ventilation and Air Conditioning (HVAC) systems are significantly responsible for building energy use. In HVAC, ventilation is the key issue for providing suitable Indoor Air Quality (IAQ), while it is also responsible for energy consumption in buildings. Thus, improving ventilation systems plays an important role not only in fostering energy efficiency in buildings, but also in providing better indoor climate for the occupants and decreasing the possibility of health issues in consequence. In the last decades, many energy-efficient ventilation methods are developed by researchers to mitigate energy consumption in buildings. This paper reviews scientific research and reports, as well as building regulations and standards, which evaluated, investigated and reported the development of energy-efficient methods for ventilation in buildings. Besides energy-efficient methods such as natural and hybrid ventilation strategies, occupants’ behaviours regarding ventilation, can also affect the energy demand in buildings. Therefore, the influence of occupants’ behaviour on the energy use and the correlation between ventilation and the occupants’ health and productivity were also considered. The review showed that ventilation is interrelated with many factors such as indoor and outdoor conditions, building characteristics, building application as well as users’ behaviour. Thus, it is concluded that many factors must be taken into account for designing energy-efficient and healthy ventilation systems. Moreover, it should be mentioned that utilizing hybrid ventilation in buildings integrated with suitable control strategies, to adjust between mechanical and natural ventilation, leads to considerable energy savings while an appropriate IAQ is maintained.
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