Physiopathological rationale of using high-flow nasal therapy in the acute and chronic setting: A narrative review

Chronic lung disease and admissions due to acute respiratory failure (ARF) are becoming increasingly common. Consequently, there is a growing focus on optimizing respiratory support, particularly non-invasive respiratory support, to manage these conditions. High flow nasal therapy (HFNT) is a noninvasive technique where humidified and heated gas is delivered through the nose to the airways via small dedicated nasal prongs at flows that are higher than the rates usually applied during conventional oxygen therapy. HFNT enables to deliver different inspired oxygen fractions ranging from 0.21 to 1. Despite having only recently become available, the use of HFNT in the adult population is quite widespread in several clinical settings. The respiratory effects of HNFT in patients with respiratory failure may be particularly relevant for clinicians. In this narrative review, we discuss the main pathophysiological mechanism and rationale for using HFNT in the acute and chronic setting

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016.

OBJECTIVE: To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012." DESIGN: A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS: The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS: The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS: Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality

Reporting quality of music intervention research in healthcare: A systematic review

INTRODUCTION: Concomitant with the growth of music intervention research, are concerns about inadequate intervention reporting and inconsistent terminology, which limits validity, replicability, and clinical application of findings. OBJECTIVE: Examine reporting quality of music intervention research, in chronic and acute medical settings, using the Checklist for Reporting Music-based Interventions. In addition, describe patient populations and primary outcomes, intervention content and corresponding interventionist qualifications, and terminology. METHODS: Searching MEDLINE, PubMed, CINAHL, HealthSTAR, and PsycINFO we identified articles meeting inclusion/exclusion criteria for a five-year period (2010-2015) and extracted relevant data. Coded material included reporting quality across seven areas (theory, content, delivery schedule, interventionist qualifications, treatment fidelity, setting, unit of delivery), author/journal information, patient population/outcomes, and terminology. RESULTS: Of 860 articles, 187 met review criteria (128 experimental; 59 quasi-experimental), with 121 publishing journals, and authors from 31 countries. Overall reporting quality was poor with <50% providing information for four of the seven checklist components (theory, interventionist qualifications, treatment fidelity, setting). Intervention content reporting was also poor with <50% providing information about the music used, decibel levels/volume controls, or materials. Credentialed music therapists and registered nurses delivered most interventions, with clear differences in content and delivery. Terminology was varied and inconsistent. CONCLUSIONS: Problems with reporting quality impedes meaningful interpretation and cross-study comparisons. Inconsistent and misapplied terminology also create barriers to interprofessional communication and translation of findings to patient care. Improved reporting quality and creation of shared language will advance scientific rigor and clinical relevance of music intervention research

Yoga for generalized anxiety disorder: design of a randomized controlled clinical trial.

Generalized anxiety disorder (GAD) is a common disorder associated with significant distress and interference. Although cognitive behavioral therapy (CBT) has been shown to be the most effective form of psychotherapy, few patients receive or have access to this intervention. Yoga therapy offers another promising, yet under-researched, intervention that is gaining increasing popularity in the general public, as an anxiety reduction intervention. The purpose of this innovative clinical trial protocol is to investigate the efficacy of a Kundalini Yoga intervention, relative to CBT and a control condition. Kundalini yoga and CBT are compared with each other in a noninferiority test and both treatments are compared to stress education training, an attention control intervention, in superiority tests. The sample will consist of 230 individuals with a primary DSM-5 diagnosis of GAD. This randomized controlled trial will compare yoga (N=95) to both CBT for GAD (N=95) and stress education (N=40), a commonly used control condition. All three treatments will be administered by two instructors in a group format over 12 weekly sessions with four to six patients per group. Groups will be randomized using permuted block randomization, which will be stratified by site. Treatment outcome will be evaluated bi-weekly and at 6month follow-up. Furthermore, potential mediators of treatment outcome will be investigated. Given the individual and economic burden associated with GAD, identifying accessible alternative behavioral treatments will have substantive public health implications.R01 AT007257 - NCCIH NIH HHS; R01 AT007258 - NCCIH NIH HH

Rationale for Prolonged Glucocorticoid Use in Pediatric ARDS: What the Adults Can Teach Us.

Based on molecular mechanisms and physiologic data, a strong association has been established between dysregulated systemic inflammation and progression of acute respiratory distress syndrome (ARDS). In ARDS patients, glucocorticoid receptor-mediated downregulation of systemic inflammation is essential to restore homeostasis, decrease morbidity and improve survival and can be significantly enhanced with prolonged low-to-moderate dose glucocorticoid treatment. A large body of evidence supports a strong association between prolonged glucocorticoid treatment-induced downregulation of the inflammatory response and improvement in pulmonary and extrapulmonary physiology. The balance of the available data from eight controlled trials (n = 622) provides consistent strong level of evidence for improving patient-centered outcomes and hospital survival. The sizable increase in mechanical ventilation-free days (weighted mean difference, 6.48 days; CI 95% 2.57-10.38, p &lt; 0.0001) and intensive care unit-free days (weighted mean difference, 7.7 days; 95% CI, 3.13-12.20, p &lt; 0.0001) by day 28 is superior to any investigated intervention in ARDS. For treatment initiated before day 14 of ARDS, the increased in hospital survival (70 vs. 52%, OR 2.41, CI 95% 1.50-3.87, p = 0.0003) translates into a number needed to treat to save one life of 5.5. Importantly, prolonged glucocorticoid treatment is not associated with increased risk for nosocomial infections (22 vs. 27%, OR 0.61, CI 95% 0.35-1.04, p = 0.07). Treatment decisions involve a tradeoff between benefits and risks, as well as costs. This low-cost, highly effective therapy is familiar to every physician and has a low risk profile when secondary prevention measures are implemented

Pilot Testing Behavior Therapy for Chronic Tic Disorders in Neurology and Developmental Pediatrics Clinics

Comprehensive Behavioral Intervention for Tics (CBIT) is an efficacious treatment with limited regional availability. As neurology and pediatric clinics are often the first point of therapeutic contact for individuals with tics, the present study assessed preliminary treatment response, acceptability, and feasibility of an abbreviated version, modified for child neurology and developmental pediatrics clinics. Fourteen youth (9-17) with Tourette disorder across 2 child neurology clinics and one developmental pediatrics clinic participated in a small case series. Clinician-rated tic severity (Yale Global Tic Severity Scale) decreased from pre- to posttreatment, z = –2.0, P \u3c .05, r = –.48, as did tic-related impairment, z = –2.4, P \u3c .05, r = –.57. Five of the 9 completers (56%) were classified as treatment responders. Satisfaction ratings were high, and therapeutic alliance ratings were moderately high. Results provide guidance for refinement of this modified CBIT protocol

Sleep apnoea and its impact on public health

In 1997 we published a systematic review on the health effects of obstructive sleep apnoea and the effectiveness of treatment with CPAP. This generated much controversy and considerable correspondence. About half the letters received by the authors suggested that the paper was just stating the obvious, the other half that the paper was completely inaccurate. To help clarify our findings this paper will discuss the public health impact of sleep apnoea and the rationale behind systematic reviews

Executive Summary:International Clinical Practice Guidelines for Pediatric Ventilator Liberation, A Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network Document

Rationale: Pediatric-specific ventilator liberation guidelines are lacking despite the many studies exploring elements of extubation readiness testing. The lack of clinical practice guidelines has led to significant and unnecessary variation in methods used to assess pediatric patients’ readiness for extubation. Methods: Twenty-six international experts comprised a multiprofessional panel to establish pediatrics-specific ventilator liberation clinical practice guidelines, focusing on acutely hospitalized children receiving invasive mechanical ventilation for more than 24 hours. Eleven key questions were identified and first prioritized using the Modified Convergence of Opinion on Recommendations and Evidence. A systematic review was conducted for questions that did not meet an a priori threshold of &gt;80% agreement, with Grading of Recommendations, Assessment, Development, and Evaluation methodologies applied to develop the guidelines. The panel evaluated the evidence and drafted and voted on the recommendations. Measurements and Main Results: Three questions related to systematic screening using an extubation readiness testing bundle and a spontaneous breathing trial as part of the bundle met Modified Convergence of Opinion on Recommendations criteria of &gt;80% agreement. For the remaining eight questions, five systematic reviews yielded 12 recommendations related to the methods and duration of spontaneous breathing trials, measures of respiratory muscle strength, assessment of risk of postextubation upper airway obstruction and its prevention, use of postextubation noninvasive respiratory support, and sedation. Most recommendations were conditional and based on low to very low certainty of evidence. Conclusions: This clinical practice guideline provides a conceptual framework with evidence-based recommendations for best practices related to pediatric ventilator liberation.</p

Breathing exercises for dysfunctional breathing/hyperventilation syndrome in adults

Copyright © 2013 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.Background: Dysfunctional breathing/hyperventilation syndrome (DB/HVS) is a respiratory disorder, psychologically or physiologically based, involving breathing too deeply and/or too rapidly (hyperventilation) or erratic breathing interspersed with breath-holding or sighing (DB). DB/HVS can result in significant patient morbidity and an array of symptoms including breathlessness, chest tightness, dizziness, tremor and paraesthesia.DB/HVS has an estimated prevalence of 9.5%in the general adult population, however, there is little consensus regarding the most effective management of this patient group. Objectives: 1) To determine whether breathing exercises in patients with DB/HVS have beneficial effects as measured by quality of life indices. 2) To determine whether there are any adverse effects of breathing exercises in patients with DB/HVS Search methods: We identified trials for consideration using both electronic and manual search strategies. We searched CENTRAL, MEDLINE, EMBASE, and four other databases. The latest search was in February 2013. Selection criteria: We planned to include randomised, quasi-randomised or cluster randomised controlled trials (RCTs) in which breathing exercises, or a combined intervention including breathing exercises as a key component, were compared with either no treatment or another therapy that did not include breathing exercises in patients with DB/HVS. Observational studies, case studies and studies utilising a cross-over design were not eligible for inclusion. We considered any type of breathing exercise for inclusion in this review, such as breathing control, diaphragmatic breathing, yoga breathing, Buteyko breathing, biofeedback-guided breathingmodification, yawn/sigh suppression. Programs where exercises were either supervised or unsupervised were eligible as were relaxation techniques and acute-episode management, as long as it was clear that breathing exercises were a key component of the intervention. We excluded any intervention without breathing exercises or where breathing exercises were not key to the intervention