Is treatment with a high flow nasal cannula effective in acute viral bronchiolitis? A physiologic study

Purpose

The high flow nasal cannula (HFNC) has recently been proposed to support infants with respiratory syncytial virus (RSV)-related respiratory distress. However, in this disease, no physiologic data are currently available on the effects of this device. We assessed the capacity of HFNC to generate positive airway pressure, as well as the resulting effects on breathing pattern and respiratory effort.

Methods

Twenty-one infants less than 6 months old with acute RSV bronchiolitis were studied prospectively in the pediatric intensive care unit of a university hospital. Pharyngeal pressure (PP) and esophageal pressure (Pes) were measured simultaneously at four increasing flows of 1, 4, 6 and 7 L/min delivered through HFNC.

Results

The PP was correlated with flow rate (r = 0.65, p ≤ 0.0001), reaching mean and end-expiratory values of, respectively, 4 (95% CI 3–5) cmH₂O and 6.5 (95% CI 5–8) cmH₂O at 7 L/min. A flow ≥2 L/kg/min was associated with the generation of a mean pharyngeal pressure ≥4 cmH₂O with a sensitivity of 67 %, a specificity of 96 %, a positive predictive value of 75 %, and a negative predictive value of 94.5%. Only flows ≥6 L/min provided positive PP throughout the respiratory cycle. From baseline to maximal flow rate, breathing frequency (p < 0.01), T _i/T _tot (p < 0.05), Pes swing (p < 0.05) and PTPes_insp/min (p < 0.01), an index of respiratory effort, were reduced.

Conclusions

HFNC with a flow rate equal to or above 2 L/kg/min generated a clinically relevant PP, with improved breathing pattern and rapid unloading of respiratory muscles, in young infants with acute RSV bronchiolitis.     

An optimized set-up for helmet noninvasive ventilation improves pressure support delivery and patient�Cventilator interaction

Objective

To test the effects on mechanical performance of helmet noninvasive ventilation (NIV) of an optimized set-up concerning the ventilator settings, the ventilator circuit and the helmet itself.

Subjects and methods

In a bench study, helmet NIV was applied to a physical model. Pressurization and depressurization rates and minute ventilation (MV) were measured under 24 conditions including pressure support of 10 or 20?cmH₂O, positive end expiratory pressure (PEEP) of 5 or 10?cmH₂O, ventilator circuit with ??high??, ??intermediate?? or ??low?? resistance, and cushion deflated or inflated. In a clinical study pressurization and depressurization rates, MV and patient?Cventilator interactions were compared in six patients with acute respiratory failure during conventional versus an ??optimized?? set-up (PEEP increased to 10?cmH₂O, low resistance circuit and cushion inflated).

Results

In the bench study, all adjustments simultaneously applied (increased PEEP, inflated cushion and low resistance circuit) increased pressurization rate (46.7?±?2.8 vs. 28.3?±?0.6?%, p?<?0.05), depressurization rate (82.9?±?1.9 vs. 59.8?±?1.1?%, p????0.05) and patient MV (8.5?±?3.2 vs. 7.4?±?2.8?l/min, p?<?0.05), and decreased leaks (17.4?±?6.0 vs. 33.6?±?6.0?%, p?<?0.05) compared to the basal set-up. In the clinical study, the optimized set-up increased pressurization rate (51.0?±?3.5 vs. 30.8?±?6.9?%, p?<?0.002), depressurization rate (48.2?±?3.3 vs. 34.2?±?4.6?%, p?<?0.0001) and total MV (27.7?±?7.0 vs. 24.6?±?6.9?l/min, p?<?0.02), and decreased ineffective efforts (3.5?±?5.4 vs. 20.3?±?12.4?%, p?<?0.0001) and inspiratory delay (243?±?109 vs. 461?±?181?ms, p?<?0.005).

Conclusions

An optimized set-up for helmet NIV that limits device compliance and ventilator circuit resistance as much as possible is highly effective in improving pressure support delivery and patient?Cventilator interaction.     

Effect of different seated positions on lung volume and oxygenation in acute respiratory distress syndrome

Rationale

Lung volume available for ventilation is markedly decreased during acute respiratory distress syndrome. Body positioning may contribute to increase lung volume and partial verticalization is simple to perform. This study evaluated whether verticalization had parallel effects on oxygenation and end expiratory lung volume (EELV).

Methods

Prospective multicenter study in 40 mechanically ventilated patients with ALI/ARDS in five university hospital MICUs. We evaluated four 45-min successive trunk position epochs (supine slightly elevated at 15°; semi recumbent with trunk elevated at 45°; seated with trunk elevated at 60° and legs down at 45°; back to supine). Arterial blood gases, EELV measured using the nitrogen washin/washout, and static compliance were measured. Responders were defined by a PaO₂/FiO₂ increase >20 % between supine and seated position. Results are median [25th–75th percentiles].

Results

With median PEEP = 10 cmH₂O, verticalization increased lung volume but only responders (13 patients, 32 %) had a significant increase in EELV/PBW (predicted body weight) compared to baseline. This increase persisted at least partially when patients were positioned back to supine. Responders had a lower EELV/PBW supine [14 mL/kg (13–15) vs. 18 mL/kg (15–27) (p = 0.005)] and a lower compliance [30 mL/cmH₂O (22–38) vs. 42 (30–46) (p = 0.01)] than non-responders. Strain decreased with verticalization for responders. EELV/PBW increase and PaO₂/FiO₂ increase were not correlated.

Discussion

Verticalization is easily achieved and improves oxygenation in approximately 32 % of the patients together with an increase in EELV. Nonetheless, effect of verticalization on EELV/PBW is not predictable by PaO₂/FiO₂ increase, its monitoring may be helpful for strain optimization.     

Effects of preserved spontaneous breathing activity during mechanical ventilation in experimental intra-abdominal hypertension

Purpose

Ventilation problems are common in critically ill patients with intra-abdominal hypertension. The aim of this study was to investigate the effects of preserved spontaneous breathing during mechanical ventilation on hemodynamics, gas exchange, respiratory function and lung injury in experimental intra-abdominal hypertension.

Methods

Twenty anesthetized pigs were intubated and ventilated for 24 h with biphasic positive airway pressure without (BIPAP_PC) or with additional, unsynchronized spontaneous breathing (BIPAP_SB). In 12 animals, intra-abdominal pressure was increased to 30 mmHg for two 9 h periods followed by a 3 h pressure relief each. Eight animals served as controls and were ventilated for 24 h. Hemodynamics, gas exchange and respiratory mechanics were measured and lung injury was determined histologically.

Results

Intra-abdominal hypertension caused significant impairment of hemodynamics and respiratory mechanics in both modes. In the presence of intra-abdominal hypertension, BIPAP_SB did not demonstrate superior respiratory mechanics and cardiovascular stability as compared to BIPAP_PC. Although the decrease of dynamic compliance and the increase of airway pressures were mitigated, BIPAP_SB failed to lower pulmonary vascular resistance and caused increased dead space ventilation (p = 0.007). Blood pressures and cardiac output increased in BIPAP_SB, caused by an increase in heart rate (p < 0.001), but not in stroke volume (p = 0.06). BIPAP_SB was associated with an increased breathing effort, decreased transpulmonary pressure during inspiration and lower lobe diffuse alveolar damage (p = 0.002).

Conclusions

In the presence of severe intra-abdominal hypertension, the addition of unsupported spontaneous breaths to BIPAP did not improve hemodynamic and respiratory function and caused greater histopathologic damage to the lungs.     

Physiological comparison of three spontaneous breathing trials in difficult-to-wean patients

Purpose

To compare cardiovascular and respiratory responses to different spontaneous breathing trials (SBT) in difficult-to-wean patients using T-piece and pressure support ventilation (PSV) with or without positive end-expiratory pressure (PEEP).

Methods

Prospective physiological study. Fourteen patients who were monitored with a Swan-Ganz catheter and had failed a previous T-piece trial were studied. Three SBTs were performed in random order in all patients: PSV with PEEP (PSV-PEEP), PSV without PEEP (PSV-ZEEP), and T-piece. PSV level was 7 cmH₂O, and PEEP was 5 cmH₂O. Inspiratory muscle effort was calculated, and hemodynamic parameters were measured using standard methods.

Results [median (and interquartile range)]

Most patients succeeded in the PSV-PEEP (11/14) and PSV-ZEEP (8/14) trials, but all failed the T-piece trial. Patient effort was significantly higher during T-piece than during PSV with or without PEEP [esophageal pressure-time product was 292 (238–512), 128 (58–299), and 148 (100–465) cmH₂O·s/min, respectively, p < 0.05]. Left ventricular heart failure was observed in 11 of the 14 patients during the T-piece trial. Pulmonary artery occlusion pressure and respiratory rate were significantly higher during T-piece than with PSV-PEEP [21 (18–24) mmHg versus 17 (14–22) mmHg, p < 0.05 and 27 (21–35) breaths/min versus 19 (16–29) breaths/min, p < 0.05 respectively]. Tidal volume was significantly lower during the T-piece trial.

Conclusion

In this selected population of difficult-to-wean patients, PSV and PSV plus PEEP markedly modified the breathing pattern, inspiratory muscle effort, and cardiovascular response as compared to the T-piece. Caregivers should be aware of these differences in SBT as they may play an important role in weaning decision-making.     

The assessment of transpulmonary pressure in mechanically ventilated ARDS patients

Purpose

The optimal method for estimating transpulmonary pressure (i.e. the fraction of the airway pressure transmitted to the lung) has not yet been established.

Methods

In this study on 44 patients with acute respiratory distress syndrome (ARDS), we computed the end-inspiratory transpulmonary pressure as the change in airway and esophageal pressure from end-inspiration to atmospheric pressure (i.e. release derived) and as the product of the end-inspiratory airway pressure and the ratio of lung to respiratory system elastance (i.e. elastance derived). The end-expiratory transpulmonary pressure was estimated as the product of positive end-expiratory pressure (PEEP) minus the direct measurement of esophageal pressure and by the release method.

Results

The mean elastance- and release-derived transpulmonary pressure were 14.4 ± 3.7 and 14.4 ± 3.8 cmH₂O at 5 cmH₂O of PEEP and 21.8 ± 5.1 and 21.8 ± 4.9 cmH₂O at 15 cmH₂O of PEEP, respectively (P = 0.32, P = 0.98, respectively), indicating that these parameters were significantly related (r ² = 0.98, P < 0.001 at 5 cmH₂O of PEEP; r ² = 0.93, P < 0.001 at 15 cmH₂O of PEEP). The percentage error was 5.6 and 12.0 %, respectively. The mean directly measured and release-derived transpulmonary pressure were ?8.0 ± 3.8 and 3.9 ± 0.9 cmH₂O at 5 cmH₂O of PEEP and ?1.2 ± 3.2 and 10.6 ± 2.2 cmH₂O at 15 cmH₂O of PEEP, respectively, indicating that these parameters were not related (r ² = 0.07, P = 0.08 at 5 cmH₂O of PEEP; r ² = 0.10, P = 0.53 at 15 cmH₂O of PEEP).

Conclusions

Based on our observations, elastance-derived transpulmonary pressure can be considered to be an adequate surrogate of the release-derived transpulmonary pressure, while the release-derived and directly measured end-expiratory transpulmonary pressure are not related.     

The use of end-tidal carbon dioxide monitoring in patients with hypotension in the emergency department

Background

The aim of this study was to determine the usefulness of end tidal carbon dioxide (ETCO₂) monitoring in hypotensive shock patients presenting to the ED.

Methods

This was a prospective observational study in a tertiary ED. One hundred three adults in shock with hypotension presenting to the ED were recruited into the study. They were grouped according to different types of shock, hypovolemic, cardiogenic, septic and others. Vital signs and ETCO₂ were measured on presentation and at 30-min intervals up to 120 min. Blood gases and serum lactate levels were obtained on arrival. All patients were managed according to standard protocols and treatment regimes. Patient survival up to hospital admission and at 30 days was recorded.

Results

Mean ETCO₂ for all patients on arrival was 29.07?±?9.96 mmHg. Average ETCO₂ for patients in hypovolemic, cardiogenic and septic shock was 29.64?±?11.49, 28.60?±?9.87 and 27.81?±?7.39 mmHg, respectively. ETCO₂ on arrival was positively correlated with systolic and diastolic BP, MAP, bicarbonate, base excess and lactate when analyzed in all shock patients. Early ETCO₂ measurements were found to be significantly lower in patients who did not survive to hospital admission (p?=?0.005). All patients who had ETCO₂????12mmHg died in the ED. However, normal ETCO₂ does not ensure patient survival.

Conclusion

The use of ETCO₂ in the ED has great potential to be used as a method of non-invasive monitoring of patients in shock.     

Ability of pleth variability index to detect hemodynamic changes induced by passive leg raising in spontaneously breathing volunteers

Introduction

Pleth Variability Index (PVI) is a new algorithm that allows continuous and automatic estimation of respiratory variations in the pulse oximeter waveform amplitude. Our aim was to test its ability to detect changes in preload induced by passive leg raising (PLR) in spontaneously breathing volunteers.

Methods

We conducted a prospective observational study. Twenty-five spontaneously breathing volunteers were enrolled. PVI, heart rate and noninvasive arterial pressure were recorded. Cardiac output was assessed using transthoracic echocardiography. Volunteers were studied in three successive positions: baseline (semirecumbent position); after PLR of 45° with the trunk lowered in the supine position; and back in the semirecubent position.

Results

We observed significant changes in cardiac output and PVI during changes in body position. In particular, PVI decreased significantly from baseline to PLR (from 21.5 ± 8.0% to 18.3 ± 9.4%; P < 0.05) and increased significantly from PLR to the semirecumbent position (from 18.3 ± 9.4% to 25.4 ± 10.6 %; P < 0.05). A threshold PVI value above 19% was a weak but significant predictor of response to PLR (sensitivity 82%, specificity 57%, area under the receiver operating characteristic curve 0.734 ± 0.101).

Conclusion

PVI can detect haemodynamic changes induced by PLR in spontaneously breathing volunteers. However, we found that PVI was a weak predictor of fluid responsiveness in this setting.     

Methodological Considerations in Quantification of 3'-Deoxy-3'-[18F]Fluorothymidine Uptake Measured with Positron Emission Tomography in Patients with Non-Small Cell Lung Cancer

Purpose

To investigate the effect of image-derived input functions (IDIF), input function corrections and volume of interest (VOI) size in quantification of [¹⁸F]FLT uptake in non-small cell lung cancer (NSCLC) patients.

Procedures

Twenty-three NSCLC patients were scanned on a HR+ scanner. IDIFs were defined over the aorta and left ventricle. Activity concentration and metabolite fraction were measured in venous blood samples. Venous blood samples at 30, 40 and 60 min after injection were used to calibrate the IDIF time–activity curves. Adaptive thresholds were used for VOI definition. Full kinetic analysis and simplified measures were performed.

Results

Non-linear regression analysis showed better fits for the irreversible model compared to the reversible model in the majority. Calibrated and metabolite corrected plus plasma-to-blood ratio corrected input function resulted in high correlations between SUV and Patlak K _i (Pearson correlation coefficients 0.86–0.96, p value?<?0.001). No significant differences in correlation between SUV and Patlak K _i were observed with variation of IDIF structure or VOI size.

Conclusions

Plasma-to-blood ratio correction, metabolite correction and calibration improved the correlation between SUV and Patlak K _i significantly, indicating the need for these corrections when K _i is used to validate semi-quantitative measures, such as SUV.     

Estimation of mean systemic filling pressure in postoperative cardiac surgery patients with three methods

Purpose

To assess the level of agreement between different bedside estimates of effective circulating blood volume—mean systemic filling pressure (Pmsf), arm equilibrium pressure (Parm) and model analog (Pmsa)—in ICU patients.

Methods

Eleven mechanically ventilated postoperative cardiac surgery patients were studied. Sequential measures were made in the supine position, rotating the bed to a 30° head-up tilt and after fluid loading (500?ml colloid). During each condition four inspiratory hold maneuvers were done to determine Pmsf; arm stop-flow was created by inflating a cuff around the upper arm for 30?s to measure Parm, and Pmsa was estimated from a Guytonian model of the systemic circulation.

Results

Mean Pmsf, Parm and Pmsa across all three states were 20.9?±?5.6, 19.8?±?5.7 and 14.9?±?4.0?mmHg, respectively. Bland-Altman analysis for the difference between Parm and Pmsf showed a non-significant bias of ?1.0?±?3.08?mmHg (p?=?0.062), a coefficient of variation (COV) of 15?%, and limits of agreement (LOA) of ?7.3 and 5.2?mmHg. For the difference between Pmsf and Pmsa we found a bias of ?6.0?±?3.1?mmHg (p?Conclusions Parm and Pmsf are interchangeable in mechanically ventilated postoperative cardiac surgery patients. Changes in effective circulatory volume are tracked well by changes in Parm and Pmsa.     

Venous admixture (Qva/Q) and true shunt (Qs/Qt) in ARF patients: Effects of PEEP at constant FIO2

Venous admixture (Qva/Q) in ARF patients is due to both true right to left shunt (Qs/Qt: perfusion of truly unventilated areas) and to maldistribution ((Qva-Qs)/Qt: effects of unevenness of ventilation/perfusion ratio). Using the retention rate of sulphur hexafluoride we determined the effects of PEEP on Qs/Qt and (Qva-Qs)/Qt at a constant F_IO₂ for each patient (0.57±0.19 SD, range 0.4–0.95). Eleven patients with ARF (treated either by CPPV or CPAP) were studied on 16 occasions. Each measurement was repeated at two levels of PEEP, 5 cm H₂O below and 5 cm H₂O above the patient's clinically determined PEEP level. The increase in PEEP resulted in: — a decrease in Qva/Q (from 0.37±0.13 to 0.27±0.12,p<0.01); — a parallel decrease in Qs/Qt (from 0.29±0.16 to 0.22±0.14,p<0.01); there was a positive correlation between Qva/Q and Qs/Qt changes (r=0.53,p<0.05). No significant variation was demonstrated in (Qva-Qs)/Qt (from 0.074±0.045 to 0.054±0.048). On the other hand there was a negative correlation between the fraction of Qva/Q due to the maldistribution and F_IO₂: (Qva-Qs)/Qva=0.75–0.86 F_IO₂ (r=0.74,p<0.01). We conclude that: PEEP decreased Qva/Q mainly through changes in Qs/Qt but did not have a definite effect on (Qva-Qs)/Qt. Maldistribution was responsible for a significant portion of Qva/Q in those ARF patients tolerating a relatively low F_IO₂ (0.4–0.6).     

Pediatric extubation readiness tests should not use pressure support

Purpose

Pressure support is often used for extubation readiness testing, to overcome perceived imposed work of breathing from endotracheal tubes. We sought to determine whether effort of breathing on continuous positive airway pressure (CPAP) of 5 cmH₂O is higher than post-extubation effort, and if this is confounded by endotracheal tube size or post-extubation noninvasive respiratory support.

Methods

Prospective trial in intubated children. Using esophageal manometry we compared effort of breathing with pressure rate product under four conditions: pressure support 10/5 cmH₂O, CPAP 5 cmH₂O (CPAP), and spontaneous breathing 5 and 60 min post-extubation. Subgroup analysis excluded post-extubation upper airway obstruction (UAO) and stratified by endotracheal tube size and post-extubation noninvasive respiratory support.

Results

We included 409 children. Pressure rate product on pressure support [100 (IQR 60, 175)] was lower than CPAP [200 (120, 300)], which was lower than 5 min [300 (150, 500)] and 60 min [255 (175, 400)] post-extubation (all p < 0.01). Excluding 107 patients with post-extubation UAO (where pressure rate product after extubation is expected to be higher), pressure support still underestimated post-extubation effort by 126–147 %, and CPAP underestimated post-extubation effort by 17–25 %. For all endotracheal tube subgroups, ≤3.5 mmID (n = 152), 4–4.5 mmID (n = 102), and ≥5.0 mmID (n = 48), pressure rate product on pressure support was lower than CPAP and post-extubation (all p < 0.0001), while CPAP pressure rate product was not different from post-extubation (all p < 0.05). These findings were similar for patients extubated to noninvasive respiratory support, where pressure rate product on pressure support before extubation was significantly lower than pressure rate product post-extubation on noninvasive respiratory support (p < 0.0001, n = 81).

Conclusions

Regardless of endotracheal tube size, pressure support during extubation readiness tests significantly underestimates post-extubation effort of breathing.

     

Acute respiratory failure in the elderly: etiology, emergency diagnosis and prognosis

Introduction

Our objectives were to determine the causes of acute respiratory failure (ARF) in elderly patients and to assess the accuracy of the initial diagnosis by the emergency physician, and that of the prognosis.

Method

In this prospective observational study, patients were included if they were admitted to our emergency department, aged 65 years or more with dyspnea, and fulfilled at least one of the following criteria of ARF: respiratory rate at least 25 minute^-1; arterial partial pressure of oxygen (PaO₂) 70 mmHg or less, or peripheral oxygen saturation 92% or less in breathing room air; arterial partial pressure of CO₂ (PaCO₂) ≥ 45 mmHg, with pH ≤ 7.35. The final diagnoses were determined by an expert panel from the completed medical chart.

Results

A total of 514 patients (aged (mean ± standard deviation) 80 ± 9 years) were included. The main causes of ARF were cardiogenic pulmonary edema (43%), community-acquired pneumonia (35%), acute exacerbation of chronic respiratory disease (32%), pulmonary embolism (18%), and acute asthma (3%); 47% had more than two diagnoses. In-hospital mortality was 16%. A missed diagnosis in the emergency department was noted in 101 (20%) patients. The accuracy of the diagnosis of the emergency physician ranged from 0.76 for cardiogenic pulmonary edema to 0.96 for asthma. An inappropriate treatment occurred in 162 (32%) patients, and lead to a higher mortality (25% versus 11%; p < 0.001). In a multivariate analysis, inappropriate initial treatment (odds ratio 2.83, p < 0.002), hypercapnia > 45 mmHg (odds ratio 2.79, p < 0.004), clearance of creatinine < 50 ml minute^-1 (odds ratio 2.37, p < 0.013), elevated NT-pro-B-type natriuretic peptide or B-type natriuretic peptide (odds ratio 2.06, p < 0.046), and clinical signs of acute ventilatory failure (odds ratio 1.98, p < 0.047) were predictive of death.

Conclusion

Inappropriate initial treatment in the emergency room was associated with increased mortality in elderly patients with ARF.     

AV interval optimization using pressure volume loops in dual chamber pacemaker patients with maintained systolic left ventricular function

Background

Atrioventricular (AV) interval optimization is often deemed too time-consuming in dual-chamber pacemaker patients with maintained LV function. Thus the majority of patients are left at their default AV interval.

Objective

To quantify the magnitude of hemodynamic improvement following AV interval optimization in chronically paced dual chamber pacemaker patients.

Patients and methods

A pressure volume catheter was placed in the left ventricle of 19 patients with chronic dual chamber pacing and an ejection fraction >45?% undergoing elective coronary angiography. AV interval was varied in 10?ms steps from 80 to 300?ms, and pressure volume loops were recorded during breath hold.

Results

The average optimal AV interval was 152?±?39?ms compared to 155?±?8?ms for the average default AV interval (range 100–240?ms). The average improvement in stroke work following AV interval optimization was 935?±?760?mmHg/ml (range 0–2,908; p?p?=?0.01).

Conclusion

The overall hemodynamic effect of AV interval optimization in patients with maintained LV function is in the same range as for patients undergoing cardiac resynchronization therapy for several parameters. The positive effect of AV interval optimization also applies to patients who have been chronically paced for years.     

Value of the swimming position and arm traction in visualizing the cervicothoracic junction over the standard lateral cervical X-ray

Background

The cervicothoracic junction (CTJ) is often inadequately visualized on lateral cervical X-rays due to anatomic variations and technical factors.

Aims

The aim of this study was to investigate whether the swimmer’s view and arm traction could enhance the image field on the standard lateral cervical (SLC) X-ray.

Methods

The study was conducted in a university hospital in October 2007 with 40 volunteers. SLC X-ray, lateral cervical X-ray in the swimming position, and lateral cervical X-ray with arm traction were performed in the supine position. The enhancements in the image fields were analyzed.

Results

There was a statistically significant difference for the increases in the view of cervical spines between SLC X-ray (12.60?±?7.48) and either lateral cervical X-ray with arm traction (21.73?±?9.78; p?=?0.000) or in the swimming position (21.20?±?14.19; p?=?0.001). Both arm traction and swimming position increased the field of view by approximately 9 mm. Increased visualization of the cervical spine occurred for 24 of the 40 participants using the arm traction view (60.0%) and 23 participants (57.5%) using the swimming position view—results found to be statistically similar according to the?≥?1/3 caudal vertebral height visualized (p?=?0.902). Using the lateral cervical X-ray view, the number of cervical vertebrae visualized differed according to body mass index (BMI)—seven cervical vertebrae were visualized in participants with a BMI?p?=?0.007).

Conclusion

Lateral cervical X-rays with arm traction and swimming position enhance the view of SLC X-rays. An initial SLC X-ray including the lower third of the cervical spine (with C7), arm traction, and swimming position may be beneficial in visualizing the CTJ. However, patients with an increased BMI are unlikely to benefit from all three methods.     

Hematopoietic progenitor cell transplantation toxicities in multiple myeloma patients with bisphosphonate-induced osteonecrosis of the jaw: a longitudinal cohort study

Purpose

There is no information regarding the toxicity associated with autologous hematopoietic progenitor cell transplantation (AHPCT) in patients with multiple myeloma (MM) who have bisphosphonate-induced osteonecrosis of the jaw (ONJ). There is also limited information regarding long-term outcome of these patients.

Methods

In this retrospective cohort study, we compared the toxicity after AHPCT in MM patients with and without ONJ. We also analyzed the response rate and overall survival of this population of patients.

Results

During the study period, 176 patients underwent AHPCT at our institution for MM. Ten patients with ONJ prior to AHPCT were matched to 40 control patients without ONJ. The incidence and severity of transplantation-associated toxicities were similar in both groups, including mucositis, 50?% in patients with ONJ vs. 68?% in controls (p?=?0.889) and febrile days, median 1 vs. 3?days, respectively (p?=?0.524). Myeloid engraftment and hospital length of stay were also similar between patients with ONJ and controls. There were significantly more complete remissions in patients with ONJ than in control patients (45?% vs. 15?%, p?=?0.0336), but survival between the groups was not significantly different (log-rank p?=?0.0818).

Conclusions

We conclude that the incidence and severity of transplantation-associated toxicities are similar in MM patients with and without ONJ. Long-term survival was also similar between both groups.     

Lixisenatide Treatment for Older Patients with Type 2 Diabetes Mellitus Uncontrolled on Oral Antidiabetics: Meta-Analysis of Five Randomized Controlled Trials

Aim

Evaluate the efficacy and safety of lixisenatide, a once-daily prandial glucagon-like peptide-1 receptor agonist, in older patients with type 2 diabetes mellitus (T2DM) insufficiently controlled on oral antidiabetics (OADs).

Methods

A meta-analysis was conducted on data from older patients (≥65 years) from five of the GetGoal trials, in which patients with T2DM were treated with lixisenatide 20 µg once daily or placebo, as an add-on to OADs. The primary endpoint in all trials was change from baseline at week 24 in glycated hemoglobin (HbA_1c). Other endpoints included changes in post-prandial plasma glucose (PPG), fasting plasma glucose (FPG) and weight. Composite and safety endpoints were also analyzed.

Results

A total of 501 patients aged ≥65 years were included in this meta-analysis: 304 received lixisenatide plus OADs and 197 received placebo as add-on to OADs. Lixisenatide as an add-on to OADs significantly reduced HbA_1c, PPG, FPG and weight, with placebo-corrected treatment effects at week 24 of ?0.54% (p < 0.0001), ?126 mg/dL (p < 0.0001), ?13 mg/dL (p = 0.0005) and ?0.90 kg (p = 0.0021), respectively. Patients receiving lixisenatide plus OADs were significantly more likely to achieve composite (HbA_1c levels <7%, HbA_1c levels <7% and no symptomatic hypoglycemia, and HbA_1c levels <7%, no weight gain and no symptomatic hypoglycemia) and safety endpoints than those receiving placebo plus OADs. Symptomatic hypoglycemia was experienced by 8.55% and 3.55% of patients in the lixisenatide plus OADs and placebo plus OADs groups, respectively (p = 0.0276), although no serious hypoglycemic episodes were reported.

Conclusions

Lixisenatide plus OADs improved glycemic control in older patients inadequately controlled on OADs compared with placebo plus OADs. Lixisenatide is well tailored to the pathophysiology of T2DM in older patients.     

Effects of the components of positive airway pressure on work of breathing during bronchospasm

Introduction

Partial assist ventilation reduces work of breathing in patients with bronchospasm; however, it is not clear which components of the ventilatory cycle contribute to this process. Theoretically, expiratory positive airway pressure (EPAP), by reducing expiratory breaking, may be as important as inspiratory positive airway pressure (IPAP) in reducing work of breathing during acute bronchospasm.

Method

We compared the effects of 10 cmH₂O of IPAP, EPAP, and continuous positive airwaypressure (CPAP) on inspiratory work of breathing and end-expiratory lung volume (EELV) in a canine model of methacholine-induced bronchospasm.

Results

Methacholine infusion increased airway resistance and work of breathing. During bronchospasm IPAP and CPAP reduced work of breathing primarily through reductions in transdiaphragmatic pressure per tidal volume (from 69.4 ± 10.8 cmH₂O/l to 45.6 ± 5.9 cmH₂O/l and to 36.9 ± 4.6 cmH₂O/l, respectively; P < 0.05) and in diaphragmatic pressure–time product (from 306 ± 31 to 268 ± 25 and to 224 ± 23, respectively; P < 0.05). Pleural pressure indices of work of breathing were not reduced by IPAP and CPAP. EPAP significantly increased all pleural and transdiaphragmatic work of breathing indices. CPAP and EPAP similarly increased EELV above control by 93 ± 16 ml and 69 ± 12 ml, respectively. The increase in EELV by IPAP of 48 ± 8 ml (P < 0.01) was significantly less than that by CPAP and EPAP.

Conclusion

The reduction in work of breathing during bronchospasm is primarily induced by the IPAP component, and that for the same reduction in work of breathing by CPAP, EELV increases more.     

Central venous-arterial pCO2 difference as a tool in resuscitation of septic patients

Purpose

To investigate the interchangeability of mixed and central venous-arterial carbon dioxide differences and the relation between the central difference (pCO₂ gap) and cardiac index (CI). We also investigated the value of the pCO₂ gap in outcome prediction.

Methods

We performed a post hoc analysis of a well-defined population of 53 patients with severe sepsis or septic shock. Mixed and central venous pCO₂ were determined earlier at a 6 h interval (T = 0 to T = 4) during the first 24 h after intensive care unit (ICU) admittance. The population was divided into two groups based on pCO₂ gap (cut off value 0.8 kPa).

Results

The mixed pCO₂ difference underestimated the central pCO₂ difference by a mean bias of 0.03± 0.32 kPa (95 % limits of agreement: ?0.62–0.58 kPa). We observed a weak relation between pCO₂ gap and CI. The in hospital mortality rate was 21 % (6/29) for the low gap group and 29 % (7/24) for the high gap group; the odds ratio was 1.6 (95 % CI 0.5–5.5), p = 0.53. At T = 4 the odds ratio was 5.3 (95 % CI 0.9–30.7); p = 0.08.

Conclusions

From a practical perspective, the clinical utility of central venous pCO₂ values is of potential interest in determining the venous-arterial pCO₂ difference. The likelihood of a bad outcome seems to be enhanced when a high pCO₂ gap persists after 24 h of therapy.     

Physical exercise and therapy in terminally ill cancer patients: a retrospective feasibility analysis

Purpose

Physical exercise (PE) and/or therapy (PT) shows beneficial effects in advanced cancer patients and is increasingly implemented in hospice and palliative care, although systematic data are rare. This retrospective study systematically evaluated the feasibility of PE/PT in terminally ill cancer patients and of different modalities in correspondence to socio-demographic and disease- and care-related aspects.

Methods

All consecutive terminally ill cancer patients treated in a palliative care inpatient ward during a 3.5-year period were included. The modalities were chosen according to the therapists' and patients' appraisal of current performance status and symptoms.

Results

PE/PT were offered to 572 terminally ill cancer patients, whereof 528 patients (92 %) were able to perform at least one PE/PT unit (average 4.2 units/patient). The most frequently feasible modalities were physical exercises in 50 %, relaxation therapy in 22 %, breathing training in 10 %, and positioning and lymph edema treatment in 6 % each. Physical exercise and positioning treatment were performed significantly more often in older patients (p?=?0.009 and p?=?0.022, respectively), while relaxation (p?=?0.05) and lymph edema treatment (p?=?0.001) were used more frequently in younger. Breathing training was most frequently performed in head and neck cancer (p?=?0.002) and lung cancer (p?=?0.026), positioning treatment in brain tumor patients (p?=?0.021), and lymph edema treatment in sarcoma patients (p?=?0.012).

Conclusions

PE/PT were feasible in >90 % of terminally ill cancer patients to whom PE/PT had been offered. Physical exercises, relaxation therapy, and breathing training were the most frequently applicable methods. Prospective trials are needed to evaluate the efficacy of specific PE/PT programs in terminally ill cancer patients.