Noninvasive positive pressure ventilation for the treatment of acute respiratory distress syndrome following esophagectomy for esophageal cancer: a clinical comparative study

Objective

To evaluate the therapeutic efficacy of noninvasive positive pressure ventilation (NPPV) in the treatment of acute respiratory distress syndrome (ARDS) following esophagectomy for esophageal cancer.

Methods

In this retrospective evaluation, we included 64 patients with ARDS following esophagectomy for esophageal cancer between January 2009 and December 2011. The primary evaluations were 28-day fatality and actual fatality. The secondary evaluations were sex, age, onset time, pH value, PaO₂/FiO₂, sequential organ failure assessment (SOFA) score, acute physiology and chronic health evaluation (APACHE-II) score, and presence or absence after surgery of major surgery-related complications such as cardiac arrest, anastomotic fistula, and acute renal dysfunction.

Results

NPPV applied as the first-line intervention for ARDS following esophagectomy for esophageal cancer avoided intubation in 30 patients (30/64, 48.4%). There were no significant differences in gender, age, PaO₂/FiO₂, SOFA score, or APACHE-II score between the NPPV group and the patients who required invasive positive pressure ventilation (IPPV group) (P>0.05) at the time of onset, while differences in the PaO₂/FiO₂ (P<0.05) after 24 h of NPPV and presence of major surgery-related complications were highly significant (P<0.01).

Conclusions

NPPV may be an effective option for the treatment of ARDS/acute lung injury (ALI) following esophagectomy for esophageal cancer. However, conversion to invasive mechanical ventilation should be considered in patients with severe postoperative complications such as acute renal dysfunction and cardiac arrest and in those with PaO₂/FiO₂ <180 after 2 h of NPPV.KEYWORDS : Noninvasive positive pressure ventilation (NPPV), esophagectomy, acute respiratory distress syndrome (ARDS)     

PS联合双水平持续正压通气治疗NRDS早产儿的临床分析

目的分析肺表面活性物质(PS)联合双水平持续气道正压通气(CPAP)治疗新生儿呼吸窘迫综合征(NRDS)早产儿的效果及对患儿肺氧合、肺泡灌洗液B细胞淋巴瘤基因-2(Bcl-2)、半胱氨酸天冬氨酸蛋白酶-3(Caspase-3)、转化生长因子-β1(TGF-β1)的影响。 方法回顾性分析2016年2月至2019年3月医院新生儿重症监护病房(NICU)收治的99例NRDS早产儿的临床资料,按治疗方式分为A组56例(PS+双水平CPAP)、B组43例(PS+常规CPAP),比较两组患儿无创呼吸支持不同时间肺氧合功能的变化,记录无创通气时间、氧支持时间、住院时间、PS应用情况、气管插管率及相关并发症发生情况,测定肺泡灌洗液Bcl-2、Caspase-3、TGF-β1表达情况。 结果A组上机12、24 h动脉血二氧化碳分压(PaCO₂)低于B组,上机12 h动脉血氧分压(PaO₂)高于B组,上机12、24、48 h吸入氧浓度(FiO₂)均低于B组,上机12 h氧合指数(OI)高于B组(P<0.05);A组氧支持时间短于B组,气管插管率、总并发症发生率低于B组(P<0.05);上机48 h,A组Caspase-3、TGF-β1低于B组,Bcl-2高于B组(P<0.05)。 结论PS联合双水平CPAP治疗NRDS早产儿安全有效,可快速改善患儿肺氧合功能,减轻肺泡炎症及氧化损伤,缩短氧暴露时间,降低呼吸机相关并发症发生风险。     

A Randomised Crossover Trial Comparing Volume Assured and Pressure Preset Noninvasive Ventilation in Stable Hypercapnic COPD

ABSTRACT

Recent randomised controlled trials suggest non-invasive ventilation may offer benefit in the long-term management of ventilatory failure in stable COPD. The best mode of ventilation is unknown and newer volume assured modes may offer advantages by optimising ventilation overnight when treatment is delivered. This study compares volume assured with pressure preset non-invasive ventilation. Randomised crossover trial including twenty five subjects previously established on long-term non-invasive ventilation to manage COPD with chronic ventilatory failure. Two 8-week treatment periods of volume assured and pressure preset non-invasive ventilation. The primary outcomes were daytime arterial blood gas tensions and mean nocturnal oxygen saturation. Secondary outcomes included lung function, exercise capacity, mean nocturnal transcutaneous carbon dioxide, health status and compliance. No significant differences were seen in primary or secondary outcomes following 8 weeks of treatment when comparing volume assured and pressure preset ventilation. Primary outcomes assessed: mean (standard deviation) PaO₂ 7.8 (1.2) vs 8.1(1) kPa, PaCO₂ 6.7 (1.1) vs 6.3 (1.2) kPa and mean nocturnal oxygenation 90 (4) vs 91 (3)% volume assured versus pressure preset, respectively. Volume assured and pressure preset non-invasive ventilation appear equally effective in the long-term management of ventilatory failure associated with stable COPD.     

Initial synchronized intermittent mandatory ventilation versus assist/control ventilation in treatment of moderate acute respiratory distress syndrome: a prospective randomized controlled trial

Background

Assist/control (A/C) ventilation may induce delirium in patients with acute respiratory distress syndrome (ARDS). We conducted a trial to determine whether initial synchronized intermittent mandatory ventilation with pressure support (SIMV + PS) could improve clinical outcomes in these patients.

Methods

Intubated patients with moderate ARDS were enrolled and we compared SIMV + PS with A/C. Identical sedation, analgesia and ventilation strategies were performed. The co-primary outcomes were early (≤72 h) partial pressure of arterial oxygen to fraction of inspired oxygen (PaO₂/FiO₂) and incidence of delirium. The secondary outcomes were all-cause in-hospital mortality, dosages of analgesics and sedatives, incidence of patient-ventilator asynchrony, and duration of mechanical ventilation and hospital stay.

Results

We screened 2,684 patients and 40 patients were enrolled in our study. In SIMV + PS, early (≤72 h) PaO₂/FiO₂ was greater improved than that at baseline and that in A/C (P<0.05) with lower positive end-expiratory pressure (PEEP) (8.7±3.0 vs. 10.3±3.2, P<0.001) and FiO₂ (58%±18% vs. 67%±19%, P<0.001). We found more SIMV + PS success (defined as SIMV + PS successfully applied without switching to A/C) (100.0% vs. 16.7%, P<0.001), less male (46.3% vs. 85.7%, P=0.015) and pulmonary etiology of ARDS (53.8% vs. 92.9%, P=0.015), and lower PEEP (9.1±3.1 vs. 10.3±3.3, P=0.004) and FiO₂ (58%±19% vs. 71%±19%, P<0.001) in survival patients. However, there were no significant differences in incidence of delirium and mortality, dosages of analgesics and sedatives, incidence of patient-ventilator asynchrony, duration of mechanical ventilation and hospital stay (P>0.05).

Conclusions

In patients with moderate ARDS, SIMV + PS can safely and effectively improve oxygenation, but does not decrease mortality, incidence of delirium and patient-ventilator asynchrony, dosages of analgesics and sedatives, and duration of mechanical ventilation and hospital stay.     

Comparison of the Sensormedics® 3100A and Bronchotron® transporter in a neonatal piglet ARDS model

The Sensormedics® 3100A (Cardinal Health, Dublin, OH) (HFOV) and the Bronchotron® (Percussionaire, Sandpoint, ID) (HFPV) are high‐frequency ventilation devices used to support neonatal respiratory failure; however, a comparison of the devices, with respect to gas exchange at similar ventilator settings, has not been previously studied. Thus, we compared the ability of HFOV to that of HFPV to provide oxygenation and ventilation during acute lung injury in a newborn animal model. Using a saline lung lavage model, 12 neonatal piglets were randomized to initial support with either the HFOV or HFPV with settings adjusted to achieve PaCO₂ of 45–60 mmHg. After stabilization, ventilator settings and arterial blood gases were serially recorded for 30 min. Animals were then crossed over to the alternative device set to deliver the same V_t, MAP, and F for an additional 30 min with the same parameters recorded. We found that the ΔP needed to generate adequate V_t on HFPV (35 ± 7 cmH₂O) trended higher versus HFOV (31 ± 7 cmH₂O P = 0.09) when the devices were matched for V_t, F, and MAP. No significant differences in ventilation (PaCO₂ = 50 ± 10.7 mmHg vs. 46 ± 10 mmHg, P = 0.22) or oxygenation (PaO₂ = 150 ± 76 mmHg vs. 149 ± 107 mmHg, P = 0.57) between the devices were found. We conclude that HFPV ventilates and oxygenates as well as HFOV at equivalent ventilator settings. HFPV may require larger ΔP's to generate equivalent V_t. Pediatr Pulmonol. 2009; 44:693–700. © 2009 Wiley‐Liss, Inc.     

Non-Invasive Mechanical Ventilation Versus Continuous Positive Airway Pressure Relating to Cardiogenic Pulmonary Edema in an Intensive Care Unit

BackgroundTo compare the application of non-invasive ventilation (NIV) versus continuous positive airway pressure (CPAP) in the treatment of patients with cardiogenic pulmonary edema (CPE) admitted to an intensive care unit (ICU).MethodsIn a prospective, randomized, controlled study performed in an ICU, patients with CPE were assigned to NIV (n=56) or CPAP (n=54). Primary outcome was intubation rate. Secondary outcomes included duration of ventilation, length of ICU and hospital stay, improvement of gas exchange, complications, ICU and hospital mortality, and 28-day mortality. The outcomes were analyzed in hypercapnic patients (PaCO₂ > 45 mmHg) with no underlying chronic lung disease.ResultsBoth devices led to similar clinical and gas exchange improvement; however, in the first 60 min of treatment a higher PaO₂/FiO₂ ratio was observed in the NIV group (205±112 in NIV vs. 150±84 in CPAP, P=.02). The rate of intubation was similar in both groups (9% in NIV vs. 9% in CPAP, P=1.0). There were no differences in duration of ventilation, ICU and length of hospital stay. There were no significant differences in ICU, hospital and 28-d mortality between groups. In the hypercapnic group, there were no differences between NIV and CPAP.ConclusionsEither NIV or CPAP are recommended in patients with CPE in the ICU. Outcomes in the hypercapnic group with no chronic lung disease were similar using NIV or CPAP.     

Transcutaneous monitors during one-lung ventilation: Are they reliable?

During one-lung ventilation, levels of oxygen and carbon dioxide in the blood are commonly assessed by intermittent blood gas sampling. Transcutaneous PO₂ (tcPO₂) and transcutaneous PCO₂ (tCPCO₂) have been reported to accurately reflect arterial PO₂ (PaO₂) and arterial PCO₂ (PaCO₂) in hemodynamically stable patients. Transcutaneous monitors appear to be ideal for detecting trends toward hypoxia and hypercarbia, conditions that may not be evident when using intermittent blood gas sampling, while pulse oximetry, since it reflects saturation, may not detect hypoxia until it has already occurred. Thirtyone patients undergoing one-lung ventilation were monitored using both transcutaneous electrodes applied to the upper arm (group 1) or chest (group 2) and arterial blood gas sampling. Arterial blood gases were sampled while tCPO₂ and tCPCO₂ values were being recorded. Regression, correlation, and covariance analyses were performed. Correlation coefficients of Pa0₂ to tCPO₂ varied from .05 to .99 for each patient. The slopes of individual regression lines varied from 0.03 to 1.16. Correlation coefficients of PaCO₂ to tCPCO₂ varied from .01 to .99, while the slopes of individual regression lines ranged from 0.02 to 5.89. Covariance analyses revealed considerable variation in PaO₂ to tcPO₂ and PaCO₂ to tcPCO₂ in individual patients even under stable hemodynamic conditions. Analysis of covariance also demonstrated that in group 2 the slopes comparing arterial and transcutaneous values were significantly different for PaO₂ < 100 mmHg and PaO₂ > 200 mmHg. In group 1, for PaO₂ < 100 mmHg, there was no difference in slopes but y-intercepts were significantly different (P < .05). However, transcutaneous indices were significantly different in both groups for PaO₂ < 100 mmHg and PaO₂ > 200 mmHg It is concluded that transcutaneous monitoring is useful to indicate trends in arterial values in some patients, but blood gas analysis is still necessary to verify the reliability of such monitoring.     

Family nursing with the assistance of network improves clinical outcome and life quality in patients underwent coronary artery bypass grafting: A consolidated standards of reporting trials-compliant randomized controlled trial

Background:Family nursing with the assistance of network (FNAN) improves nurses’ practice and provides family/community-oriented nursing care. This study aimed to explore the effects of FNAN on the clinical outcome and life quality of coronary atherosclerotic heart disease (CHD) patients underwent coronary artery bypass grafting (CABG).Trial Design:This study is a randomized, placebo-controlled and double-blind trial.Methods:One-hundred and twelve patients underwent CABG were randomly divided into control group (CG, routine family nursing care) and experimental group (EG, FNAN) and the allocation ratio was 1:1. The situation of anxiety and depression were analyzed using the Hamilton Anxiety Scale (HAMA) scale and Hamilton Depression Scale (HAMD). Sleep quality was measured by using Pittsburgh Sleep Quality Index (PSQI). Lung function parameters were measured, including minute ventilation (MVV), partial pressure of oxygen (PaO₂), partial pressure of arterial carbon dioxide (PaCO₂), oxygen saturation measurement by pulse oximetry (SpO₂), forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC). Life quality was measured by using Chronic Obstructive Pulmonary Disease Assessment Test (CAT).Results:After a 3-month intervention, 10 and 6 patients were lost in the CG and EG groups, respectively. The scores of HAMA, HAMD, PSQI and CAT were reduced in the EG group when compared with the CG group (P < .05). The values of MVV, PaO₂, SpO₂, FEV1 and FVC in the EG group was higher than those in the CG group whereas the levels of PaCO₂ in the EG group was lower than those in the CG group (P < .05). PSQI score had a strong relationship with the values of MVV, PaO₂, PaCO₂, SpO₂, FEV1, and FVC.Conclusion:FNAN improves the clinical outcome and life quality in the patients underwent CABG.     

Hospital Mortality and Effect of Adjusting PaO2/FiO2 According to Altitude Above the Sea Level in Acclimatized Patients Undergoing Invasive Mechanical Ventilation. A Multicenter Study

Objective(i) Analyze the effect of altitude above the sea level on the mortality rate in patients undergoing invasive mechanical ventilation. (ii) Validate the traditional equation for adjusting PaO₂/FiO₂ according to the altitude.DesignA prospective, observational, multicenter and international study conducted during August 2016.PatientsInclusion criteria: (i) age between 18 and 90 years old, (ii) admitted to intensive care unit (ICU) situated at the same altitude above the sea level (AASL) in which the patients has stayed, at least, during the previous 40 days and (iii) received invasive MV for at least 12 h.Material and methodsAll variables were registered the day of intubation (day 0). Patients were followed until death, ICU discharge or day 28. PaO₂/FiO₂ ratio was adjusted by the AASL according to: PaO₂/FiO₂ * (barometric pressure/760). Categorical variables were compared with χ² and Cochran–Mantel–Haenszel test. Continuous variables with Mann–Whitney. Correlation between continuous variables was analyzed graphically and analytically. Logistic regression model was constructed to identify factors associated to mortality. Kapplan–Meier method was used to estimate the probability of survival according to the altitude. A 2-side p value <0.05 was consider significant.Results249 patients (<1500 m n = 55; 1500 to <2500 m n = 20; 2500 to <3500 m n = 155 and ≥3500 m n = 19) were included. Adjusted and non-adjusted PaO₂/FiO₂ were correlated with several respiratory and non respiratory variables. None discordances between non adjusted and adjusted PaO₂/FiO₂ were identified. However, several correlations were appreciated only in patients situated <1500 m or in >1500 m. Seventy-nine patients died during the ICU stayed (32%). The mortality curve was not affected by the altitude above the sea level. Variables independently associated to mortality are: PEEP, age, systolic arterial blood pressure, and platelet count. AUROC: 0.72.ConclusionIn acclimatized patients undergoing invasive mechanical ventilation, the traditional equation for adjusting PaO₂/FiO₂ according the elevation above the sea level seems to be inaccurate and the altitude above the sea level does not affect the mortality risk.     

Halothane,an Effective Infrequently Used Drug,in the Treatment of Pediatric Status Asthmaticus: A Case Report

Asthma is the most common chronic disease of childhood. Despite a better understanding of the disease process and its management, status asthmaticus continues to be a life-threatening event. The use of volatile inhaled anesthetics is infrequently reported as adjunctive therapy to conventional treatment of this condition. We report the use of halothane in a mechanically ventilated pediatric patient with life-threatening status asthmaticus who was admitted to the pediatric intensive care unit (PICU) after failing to respond to standard medical therapy and noninvasive positive pressure ventilation. A 12-year-old African American male was seen in the emergency department and treated with intravenous corticosteroids, beta-agonist therapy. He deteriorated rapidly and required endotracheal intubation and mechanical ventilation. Two hours later, the patient developed an acute, severe respiratory acidosis (pH = 6.97, PaCO₂ = 171, PaO₂ = 162, BE = 1.7). Halothane was started at 2% by using the Siemens Servo 900C anesthesia ventilator. Improvement in both arterial blood gases and exhaled tidal volume were noted 30 minutes after initiation of the anesthetic gas. The patient remained on halothane for a total of 36 hours. No adverse effects associated with the use of halothane were noted. The patient was extubated to BiPAP 16/6, FiO₂ = 0.30 at 68 hours and was discharged home 5 days later.     

Effectiveness of CPAP vs. Noninvasive Ventilation Based on Disease Severity in Obesity Hypoventilation Syndrome and Concomitant Severe Obstructive Sleep Apnea

RationaleObesity hypoventilation syndrome (OHS) with concomitant severe obstructive sleep apnea (OSA) is treated with CPAP or noninvasive ventilation (NIV) during sleep. NIV is costlier, but may be advantageous because it provides ventilatory support. However, there are no long-term trials comparing these treatment modalities based on OHS severity.ObjectiveTo determine if CPAP have similar effectiveness when compared to NIV according to OHS severity subgroups.MethodsPost hoc analysis of the Pickwick randomized clinical trial in which 215 ambulatory patients with untreated OHS and concomitant severe OSA, defined as apnoea-hypopnea index (AHI) ≥ 30 events/h, were allocated to NIV or CPAP. In the present analysis, the Pickwick cohort was divided in severity subgroups based on the degree of baseline daytime hypercapnia (PaCO₂ of 45–49.9 or ≥50 mmHg). Repeated measures of PaCO₂ and PaO₂ during the subsequent 3 years were compared between CPAP and NIV in the two severity subgroups. Statistical analysis was performed using linear mixed-effects model.Results204 patients, 97 in the NIV group and 107 in the CPAP group were analyzed. The longitudinal improvements of PaCO₂ and PaO₂ were similar between CPAP and NIV based on the PaCO₂ severity subgroups.ConclusionIn ambulatory patients with OHS and concomitant severe OSA who were treated with NIV or CPAP, long-term NIV therapy was similar to CPAP in improving awake hypercapnia, regardless of the severity of baseline hypercapnia. Therefore, in this patient population, the decision to prescribe CPAP or NIV cannot be solely based on the presenting level of PaCO₂.     

A Method for Determining Optimal Mean Airway Pressure in High-Frequency Oscillatory Ventilation

Background

“Optimal” mean airway pressure (MAP) during high-frequency oscillatory ventilation (HFOV) can be defined as the pressure that allows for maximal alveolar recruitment while minimizing alveolar overdistension. Choosing a MAP near or just below the point of maximal curvature (PMC) of the volume–pressure characteristics of the lung can serve as a guide to avoid overdistention during HFOV, while simultaneously preventing derecruitment. The purpose of this study was to assess whether optimal MAP at the PMC can be determined by using measures of PaO₂ in patients with acute respiratory distress syndrome (ARDS) undergoing HFOV.

Methods

We prospectively studied seven patients with ARDS who underwent HFOV after failed conventional ventilation. In addition, 11 healthy subjects were studied to validate measurements of changes in end-expiratory lung volume (?EELV) using magnetometers. Using this validated method, plots of ?EELV and MAP were constructed during decremental changes in MAP following a recruitment maneuver in seven ventilated patients with ARDS. The PMC was defined as the point where the slope of the ?EELV versus MAP curve acutely changed. The MAP at the PMC was compared to that determined from plots of PaO₂ versus MAP.

Results

In the healthy cohort, measurements of ?EELV obtained by magnetometry approximated the line of identity when compared to those obtained by spirometry. The MAP determined using either the ?EELV or PaO₂ techniques were identical in all seven HFOV ventilated patients. Additionally, there was a significant correlation between the MAP associated changes in PaO2 and the MAP associated changes in ?EELV (p < 0.001).

Conclusions

The finding that MAP at the PMC is the same whether determined by measures of ?EELV or PaO₂ suggest that bedside measures PaO₂ may provide an acceptable surrogate for measures of EELV when determining “optimal” MAP during HFOV.     

The Effects of Withdrawing Long-Term Nocturnal Non-Invasive Ventilation in COPD Patients

ABSTRACT

Patients with ventilatory failure due to chronic obstructive pulmonary disease (COPD) are increasingly managed with long-term non-invasive positive pressure ventilation (NIPPV) and this may improve survival. NIPPV can frequently be interrupted but there are few data detailing the short-term effects and none on the longer-term consequences of treatment withdrawal. Ten patients withdrew from NIPPV for 1 week and were randomised to restart NIPPV or to continued withdrawal for up to 6 months. Outcomes assessed included daytime blood gases, nocturnal ventilation, lung function, exercise capacity and health status. After 1 week of withdrawal PaO₂, PaCO₂, nocturnal oximetry, lung function and exercise capacity did not change, but mean nocturnal transcutaneous CO₂ (6.3 (1) vs. 7.6 (1.1) kPa p = 0.04) and daytime blood gas bicarbonate (30.3 (4.5) vs. 31.2 (3.9) mmol/L p = 0.04) rose. During a 6-month period of withdrawal of nocturnal NIPPV, daytime PaCO₂ (6 (1.1) vs. 7.5 (1.3) kPa p = 0.002) increased and health status (total St George's Respiratory Questionnaire score 55.5 (6.3) vs. 65.6 (10) p = 0.006) worsened. Three out of five patients met a priori criteria to restart NIPPV in the continued withdrawal group. Short interruptions to domiciliary NIPPV used to manage chronic ventilatory failure as a consequence of COPD do not cause a rapid clinical deterioration but nocturnal ventilation worsens and daytime bicarbonate levels increase following 1 week's cessation. Thereafter, daytime PaCO₂ rises and health status worsens, supporting the role of long-term NIPPV in the management of such patients.     

High-Frequency Oscillatory Ventilation in Pediatric Acute Hypoxemic Respiratory Failure: Disease-Specific Morbidity Survival Analysis

Background

Multiple ventilatory strategies for acute hypoxemic respiratory failure (AHRF) in children have been advocated, including high-frequency oscillatory ventilation (HFOV). Despite the frequent deployment of HFOV, randomized controlled trials remain elusive and currently there are no pediatric trials looking at its use. Our longitudinal study analyzed the predictive clinical outcome of HFOV in pediatric AHRF given disease-specific morbidity.

Methods

A retrospective 8-year review on pediatric intensive care unit admissions with AHRF ventilated by HFOV was performed. Primary outcomes included survival, morbidity, length of stay (LOS), and factors associated with survival or mortality.

Results

A total of 102 patients underwent HFOV with a 66?% overall survival rate. Survivors had a greater LOS than nonsurvivors (p?=?0.001). Mortality odds ratio (OR) for patients without bronchiolitis was 8.19 (CI?=?1.02, 65.43), and without pneumonia it was 3.07 (CI?=?1.12, 8.39). A lower oxygenation index (OI) after HFOV commencement and at subsequent time points analyzed predicted survival. After 24?h, mortality was associated with an OI?>?35 [OR?=?31.11 (CI?=?3.25, 297.98)]. Sepsis-related mortality was associated with a higher baseline FiO₂ (0.88 vs. 0.65), higher OI (42 vs. 22), and augmented metabolic acidosis (pH of 7.25 vs. 7.32) evaluated 4?h on HFOV (p?<?0.05).

Conclusion

High-frequency oscillatory ventilation may be safely utilized. It has a 66?% overall survival rate in pediatric AHRF of various etiologies. Patients with morbidity limited to the respiratory system and optimized oxygenation indices are most likely to survive on HFOV.     

Effect of Intensity of Home Noninvasive Ventilation in Individuals With Neuromuscular and Chest Wall Disorders: A Systematic Review and Meta-Analysis of Individual Participant Data

IntroductionHome noninvasive ventilation (NIV), targeting a reduction of carbon dioxide with a combination of sufficient inspiratory support and backup-rate improves outcomes in patients with chronic obstructive pulmonary disease. The aim of this systematic review with individual participant data (IPD) meta-analysis was to evaluate the effects of intensity of home NIV on respiratory outcomes in individuals with slowly progressive neuromuscular (NMD) or chest-wall disorders (CWD).MethodsControlled, non-controlled and cohort studies indexed between January-2000 and December-2020 were sought from Medline, Embase and the Cochrane Central Register. Outcomes were diurnal PaCO₂, PaO₂, daily NIV usage, and interface type (PROSPERO-CRD 42021245121). NIV intensity was defined according to the Z-score of the product of pressure support (or tidal volume) and backup-rate.Results16 eligible studies were identified; we obtained IPD for 7 studies (176 participants: 113-NMD; 63-CWD). The reduction in PaCO₂ was greater with higher baseline PaCO₂. NIV intensity per se was not associated with improved PaCO₂ except in individuals with CWD and the most severe baseline hypercapnia. Similar results were found for PaO₂. Daily NIV usage was associated with improvement in gas exchange but not with NIV intensity. No association between NIV intensity and interface type was found.ConclusionFollowing home NIV initiation in NMD or CWD patients, no relationship was observed between NIV intensity and PaCO₂, except in individuals with the most severe CWD. The amount of daily NIV usage, rather than intensity, is key to improving hypoventilation in this population during the first few months after introduction of therapy.     

Early versus late surfactant replacement therapy in severe respiratory distress syndrome

26 preterm infants with severe respiratory distress syndrome (RDS) have been treated at different ages with a single dose of natural porcine surfactant (Curosurf, 200 mg/kg). Criteria for treatment included clinical and radiological signs of severe RDS (grade III–IV), requirement of artificial ventilation and an FiO₂ ≥0.6. Nineteen neonates have been subjected to early treatment (2–15 h of age, mean birth weight SD: 1201 ± 387 g) and 7 patients to late treatment (> 15 h to 48 h of age, birth weight SD 1624 ± 649 g). Average FiO₂ before treatment was 0.88 in early-treated patients and 0.8 in late-treated patients, age at treatment was 4.6 h and 36 h, respectively (median). Both early- and late-treated infants exhibited an improvement in oxygenation (more than twofold increase of the PaO₂/FiO₂ ratio) within 5 minutes after initiation of therapy. Average duration of intermittent pressure ventilation was 15 days in the early treatment group and 19 days in the late treatment group. Total exposition to >21% oxygen was 21 days in early-treated and 48 days in late-treated infants. Pneumothorax occurred in none of the patients. All early treated infants survived without signs of severe bronchopulmonary dysplasia (BPD>21%O₂, >90 days plus radiological changes). However, two out of seven late-treated infants developed severe BPD; one patient died as a consequence of cardiopulmonary deterioration. Two patients in the early treatment group died of nonpulmonary complications. We conclude that surfactant replacement therapy should probably be initiated as soon as possible after manifestation of severe RDS.     

Ventilación mecánica no invasiva en pacientes con síndrome de obesidad-hipoventilación. Evolución a largo plazo y factores pronósticos

IntroductionObesity is associated with 2 closely related respiratory diseases: obesity hypoventilation syndrome (OHS) and obstructive sleep apnea-hypopnea syndrome (OSAHS). It has been shown that noninvasive ventilation during sleep produces clinical and functional improvement in these patients. The long-term survival rate with this treatment, and the difference in clinical progress in OHS patients with and without OSAHS are analyzed.MethodologyLongitudinal, observational study with a cohort of patients diagnosed with OHS, included in a home ventilation program over a period of 12 years, divided into 2 groups: pure OHS and OSAHS-associated OHS. Bi-level positive airway pressure ventilation was administered. During the follow-up period, symptoms, exacerbations and hospitalizations, blood gas tests and pulmonary function tests, and survival rates were monitored and compared.ResultsEighty-three patients were eligible for analysis, 60 women (72.3%) and 23 men (27.7%), with a mean survival time of 8.47 years. Fifty patients (60.2%) were included in the group without OSAHS (OHS) and 33 (39.8%) in the OSAHS-associated OHS group (OHS-OSAHS). PaCO₂ in the OHS group was significantly higher than in the OHS-OSAHS group (P < .01). OHS patients also had a higher hospitalization rate (P < .05). There was a significant improvement in both groups in FEV₁ and FVC, and no differences between groups in PaCO₂ and PaO₂ values. There were no differences in mortality between the 2 groups, but low FVC values were predictive of mortality.ConclusionsThe use of mechanical ventilation in patients with OHS, with or without OSAHS, is an effective treatment for the correction of blood gases and functional alterations and can achieve prolonged survival rates.     

高频振荡通气治疗重症新生儿胎粪吸入综合征的临床疗效探讨

目的：探讨高频振荡通气（ HFOV）与常频机械通气（ CMV）治疗重症新生儿胎粪吸入综合征（ MAS）的临床疗效。方法将60例重症MAS患儿随机分为CMV组与HFOV组各30例,动态监测两组患儿48 h 内的pH 值、氧气分压（PaO2）、二氧化碳分压（PaCO2）、吸入氧浓度（FiO2）、氧合指数（OI）等变化情况,比较两组患儿的并发症及临床转归。结果两组患儿上机前（0 h）的pH 值、PaO2、PaCO2、FiO2、OI 差异均无统计学意义（P ＞0.05）,上机后在2、12、24、48 h 时间点上,差异均有统计学意义（P 均＜0.05）;两组患儿在平均上机时间比较差异有统计学意义（t ＝3.197,P ＝0.002）;两组患儿上机后的并发症比较差异有统计意义（χ2＝4.043,P ＝0.044）;两组患儿的治愈率比较差异有统计学意义（χ2＝4.320,P ＝0.038）。结论 HFOV 治疗重症MAS 安全、有效。     

Combined APACH II score and arterial blood lactate clearance rate to predict the prognosis of ARDS patients

ObjectiveTo explore the easily applicable indicators of practical value to evaluate the prognosis of acute respiratory distress syndrome (ARDS).MethodsBlood and biochemical tests and blood-gas analyses were performed upon entry into the ICUs, 12 h, 24 h, 48 h and 72 h after that in 72 ARDS patients (who were admitted to the ICUs of our hospital from January 2000 to December 2009). Then APACHE Π scores were achieved by combining relevant physiological parameters and laboratory results.ResultsThere was a statistical difference between the death group and survival group at different time points upon entering the ICUs in terms of APACHE Π score, alveolar-arterial oxygen difference and arterial blood lactate clearance rate. PaO₂/FiO₂ values were recorded to be statistically different between the death group and survival group 24 h, 48 h and 72 h, respectively after entry into the ICUs. In addition, registered linear regression existed between APACHE Π score, alveolar-arterial oxygen difference or PaO₂/FiO₂ value and time. APACHE Π score 24 h and 72 h after entering ICUs predicted mortality with an area under the ROC curve (AUC) standing respectively at 0.919 and 0.955. Arterial blood lactate clearance rate 12 h, 24 h, 48 h and 72 h after entering ICUs predicted mortality with an area under the ROC curve (AUC) at 0.918, 0.918, 0.909 and 0.991, respectively.ConclusionsAPACHE Π score applied in combination with arterial blood lactate clearance rate is of clinical significance in assessing the prognosis of ARDS patients.     

容量控制和压力控制通气模式在开腹手术老年患者中的比较

目的比较压力控制(PCV)模式和容量控制(VCV)模式肺通气策略对老年全身麻醉腹部开放手术患者术中及术后的影响。方法入选解放军总医院接受腹部开放手术的老年患者70例,男性39例,女性31例,年龄65~82岁。采用随机数字表法分为PCV组和VCV组,每组35例。记录插管前(T_0)、插管机械通气3 min(T_1)、手术开始后(T_2)、手术2 h(T_3)、手术结束(T_4)和拔管后5 min(T_5)时间点的心率(HR)、血压(BP)、平均动脉压(MAP)、气道峰压(Ppeak)、气道平均压(Pmean)、潮气量(VT)和呼吸频率(RR),并在T_0、T_1、T_3和T_5时间点采取桡动脉血行血气分析,并记录患者住院期间并发症。结果有8例患者被剔除,共62例患者纳入研究,PCV组30例,VCV组32例。PCV组患者T_2、T_3、T_4时间点Ppeak显著低于VCV组(P0.05)。手术开始后HR、MAP呈下降趋势,相比VCV组,PCV组患者T_2、T_3、T_4时间点MAP较高,T4时间点最高,T_3时间点乳酸水平较低,差异有统计学意义(P0.05)。相比T_0时间点,T_5时间点两组患者pH、PaO_2和氧合指数(OI)均明显下降(P0.05)。PCV组和VCV组患者住院时间差异有统计学意义(18.3±5.3vs15.6±4.5,P=0.045)。PCV组患者术后2例(6.7%)转入重症监护病房(ICU),VCV组患者9例(28.1%)转入ICU,差异有统计学意义(P0.05)。结论老年开腹手术患者利用PCV模式的保护性肺通气策略可在术中以更低的气道压水平获得相似的OI及PaO_2,提示PCV模式保护性肺通气策略可更利于老年全身麻醉下的开腹手术患者。