Noninvasive ventilation in acute respiratory failure: which recipe for success?

Noninvasive positive-pressure ventilation (NPPV) to treat acute respiratory failure has expanded tremendously over the world in terms of the spectrum of diseases that can be successfully managed, the locations of its application and achievable goals.The turning point for the successful expansion of NPPV is its ability to achieve the same physiological effects as invasive mechanical ventilation with the avoidance of the life-threatening risks correlated with the use of an artificial airway.Cardiorespiratory arrest, extreme psychomotor agitation, severe haemodynamic instability, nonhypercapnic coma and multiple organ failure are absolute contraindications for NPPV. Moreover, pitfalls of NPPV reduce its rate of success; consistently, a clear plan of what to do in case of NPPV failure should be considered, especially for patients managed in unprotected setting. NPPV failure is likely to be reduced by the application of integrated therapeutic tools in selected patients handled by expert teams.In conclusion, NPPV has to be considered as a rational art and not just as an application of science, which requires the ability of clinicians to both choose case-by-case the best "ingredients" for a "successful recipe" (i.e. patient selection, interface, ventilator, interface, etc.) and to avoid a delayed intubation if the ventilation attempt fails

Extracorporeal carbon dioxide removal for treatment of exacerbated chronic obstructive pulmonary disease (ORION): study protocol for a randomised controlled trial

open8noFunding is provided by the Italian Ministry for University and Research (https://www.prin.miur.it/) through a grant (PRIN2017 – grant no. 2017J4BE7A).Background: Hypercapnic exacerbations are severe complications of chronic obstructive pulmonary disease (COPD), characterized by negative impact on prognosis, quality of life and healthcare costs. The present standard of care for acute exacerbations of COPD is non-invasive ventilation; when it fails, the use of invasive mechanical ventilation is inevitable, but is associated with extremely poor prognosis. Extracorporeal circuits designed to remove CO2 (ECCO2R) may enhance the efficacy of NIV to remove CO2 and avoid the worsening of respiratory acidosis, which inevitably leads to failure of non-invasive ventilation. Although the use of ECCO2R for acute exacerbations of COPD is steadily increasing, solid evidence on its efficacy and safety is scarce, thus the need for a randomized controlled trial. Methods: multicenter randomized controlled unblinded clinical trial including 284 (142 per arm) patients with acute hypercapnic respiratory failure caused by exacerbation of COPD, requiring respiratory support with NIV. The primary outcome is event free survival at 28 days, a composite outcome defined by survival in absence of prolonged mechanical ventilation, severe hypoxemia, septic shock and second episode of COPD exacerbation. Secondary outcomes are incidence of endotracheal intubation and tracheostomy, intensive care and hospital length-of-stay and 90-day mortality. Discussion: Acute exacerbations of COPD represent a significant burden in terms of prognosis, quality of life and healthcare costs. Lack definite evidence despite increasing use of ECCO2R justifies a randomized trial to evaluate whether patients with acute hypercapnic acidosis not responsive to NIV should undergo invasive mechanical ventilation (with all serious related risks) or be treated with ECCO2R to avoid invasive ventilation but be exposed to possible adverse events of ECCO2R. Owing to its pragmatic nature, sample size and composite primary outcome, this trial aims at providing valuable answers to relevant questions for clinical treatment of acute exacerbations of COPD. Trial registration: ClinicalTrials.gov, NCT04582799. Registered 12 October 2020,.openTonetti T.; Pisani L.; Cavalli I.; Vega M.L.; Maietti E.; Filippini C.; Nava S.; Ranieri V.M.Tonetti T.; Pisani L.; Cavalli I.; Vega M.L.; Maietti E.; Filippini C.; Nava S.; Ranieri V.M

Mechanical Ventilation

Mechanical ventilation, ventilator management, and weaning from mechanical ventilation vary based on location within the hospital, type of lung injury, and medical condition of the patient. Understanding the types of lung injury and various methods of achieving ventilation expand the armamentarium of the practitioner and allow for the best management decisions. This book begins with the use of a high-flow nasal cannula (HFNC) and a detailed description of the advanced modes of ventilation. The information on the types of ventilation can then be applied to the ventilation approaches in different populations of patients: the trauma patients, the obese patients, and the patients under neurocritical care. The conclusion contains a discussion of the mechanisms on how to wean from mechanical ventilation and how certain medical conditions affect the weaning process

Extracorporeal CO2 removal in patients with Chronic Obstructive Pulmonary Disease (COPD): a pilot study.

La Broncopneumopatia Cronica Ostruttiva (BPCO) è una delle principali cause di morbilità in tutto il mondo con un conseguente peso sociale ed economico che è consistente ed in aumento. La caratteristica principale della BPCO è la presenza di ostruzione bronchiale cronica che è, per definizione, sostanzialmente irreversibile. Quando lo squilibrio tra la capacità dei muscoli respiratori e l’aumento del carico di lavoro diventa grave, si verifica una riacutizzazione e l’ipercapnia si associa ad acidosi respiratoria. La ventilazione meccanica non invasiva (NIV) è il trattamento di scelta nei pazienti con insufficienza respiratoria acuta ipercapnica secondaria a BPCO riacutizzata. Inoltre, alcuni studi riportano effetti positivi della NIV anche in pazienti con BPCO stabile. In entrambi i casi, il miglioramento clinico è stato correlato all'efficacia della NIV nel rimuovere l'eccesso di anidride carbonica (CO2). Recentemente, la rimozione extracorporea di anidride carbonica (ECCO2R), tecnica che si riferisce ad un circuito extracorporeo in grado di estrarre selettivamente la CO2 dal sangue facendolo passare attraverso una membrana, è stata implementata utilizzando sistemi veno-venosi minimamente invasivi. Le caratteristiche principali di questi sistemi sono un basso flusso ematico extracorporeo e l'utilizzo di cateteri a doppio lume di piccole dimensioni. L'infusione continua di eparina è comunque necessaria. Scopo di questa tesi è stato quello di valutare l’efficacia e la fattibilità della decapneizzazione in tre diversi scenari e con altrettanti diversi scopi: 1. nei pazienti BPCO affetti da insufficienza respiratoria acuta ipercapnica e a rischio di fallire con il trattamento ventilatorio non invasivo per evitare l’intubazione; 2. nei pazienti ipercapnici intubati per un episodio di riacutizzazione al fine di favorire lo svezzamento dalla ventilazione meccanica invasiva; 3. nei pazienti BPCO stabili non responsivi alla NIV domiciliare per valutare l’efficacia del trattamento extracorporeo in termini di modificazione dei valori emogasanalitici e dei segni vitali.Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of morbidity worldwide resulting in a social and economical burden that is substantial and increasing. The major characteristic of COPD is the presence of chronic airflow limitation that is, by definition, largely irreversible. When the unbalance between capacity of the respiratory muscles and increase in respiratory workload becomes severe, acute decompensation occurs and hypercapnia is associated to respiratory acidosis. Non-invasive ventilation (NIV) has been consistently shown to be effective to reduce mortality in patients with acute exacerbations of COPD. In addition, some studies report positive effects of NIV in patients with stable COPD. In both cases, the improvement in outcome has been related to the effectiveness of NIV to remove the excess of carbon dioxide (CO2). Recently, extracorporeal carbon dioxide removal (ECCO2R) technique, that refers to an extracorporeal circuit that is able to selectively extract CO2 from the blood by passing it through a membrane lung, was implemented using a minimally invasive system based on a modified continuous veno-venous hemofiltration device. The main features of this system are a low extracorporeal blood flow and the use of small double-lumen catheters. However, full anticoagulation is required. The present thesis was focused on the efficacy and safety of ECCO2R in three different scenarios and with different purpose: 1. to reduce the need of endotracheal intubation in COPD patients with acute hypercapnic respiratory failure in whom NIV is at risk of failure; 2. to facilitate weaning in mechanically COPD ventilated hypercapnic patients; 3. to evaluate the effects of ECCO2R in terms of arterial blood gas and vital signs modifications in stable COPD patients not responsive to chronic NIV

Lund Concept for De-airing of the Left Heart. Clinical Evaluation.

Background: Residual air accumulated air in the pulmonary veins constitutes a challenge to achievment of complete de-airing in open left heart surgery. To adress this problem, a conceptual method for de-airing was developed in Lund comprising bilateral opening of the pleurae to induce pulmonary collapse and a strategy with gradual pulmonary reperfusion and ventilation at weaning from cardiopulmonary bypass (CPB). Aim: To evaluate effectiveness and safety aspects of the Lund concept for de-airing. Methods and results: In the first paper a randomized controlled study was conducted comparing the Lund method to a standardized carbon dioxide (CO2) insufflation technique in twenty patients undergoing open left heart surgery. The number of cerebral microembolic signals (MES) was monitored by transcranial Doppler sonography (TCD) during de-airing and in the first ten minutes after CPB. Residual intracardiac air during the first ten minutes after CPB was graded by transesophageal echocardiography (TEE). The frequency of reopenings of the left ventricular (LV) vent during the first ten minutes after CPB was registered as well as the duration of the de-airing procedure. Compared to the CO2 insufflation technique, the Lund method resulted in fewer MES during de-airing (p6 kPa) despite compensational higher gas flows in the oxygenator at 30 minutes of CPB (p<0.001) and acidosis (pH<7.35) already at 15 min of CPB, (p<0.01). CO2 production (VCO2 mL/min) increased during CPB as did the respiratory quotient (RQ; p<0.001) secondary to the extraneously supplied CO2. The mean blood flow velocities in both MCAs increased secondary to increasing PaCO2 (p<0.001 at 45 and 60 minutes of CPB). rSo2 measured by near-infrared spectroscopy (NIRS) were also found higher at 30, 45 and 60 minutes of CPB (p<0.05, p<0.01 and p<0.01, respectively). Scanning electron microscope imaging the cardiotomy suction and LV vent line tubing showed a higher fraction of morphologically changed red blood cells in the CO2 insufflation group. In the third paper we aimed to study the contribution of each component constituting the Lund concept. In a randomized controlled study of twenty patients undergoing open left heart surgery, we compared a group with open pleurae and conventional pulmonary reperfusion and ventilation to a group with intact pleurae combined with staged pulmonary reperfusion and ventilation. During de-airing and in the first ten minutes after CPB, there was a lower number of MES in the group with open pleurae (p<0.05, p<0.01, respectively). A lower amount of residual intracardiac air was also registered in the group with open pleurae in up to six minutes after CPB (p<0.01). The LV vent was reopened fewer times in the group with open pleurae (p<0.001). De-airing time was also shorter in the group with open pleurae, 9 vs 14 minutes (p<0.05). In the fourth paper we studied the impact of single right pulmonary collapse on effectiveness of the Lund method and the effectiveness of a right superior pulmonary vein vent (RSPV). Twenty patients in two prospective cohorts with right pleura open and RSPV respectively, were compared to a historical control cohort from the first paper with bilateral open pleurae and left ventricular apical vent (LVAV). We found a higher number of MES after CPB in the group with single right pulmonary collapse and in the group with RSPV compared to bilateral pulmonary collapse and LVAV (p<0.001, p<0.01, respectively) but no differences in residual intracardiac air graded by TEE or in de-airing times. Conclusion: The Lund concept for de-airing was demonstrated to be an effective and safe alternative to the CO2 insufflation technique. The effectiveness of the Lund method depends primarily on bilateral pulmonary collapse and it may preferably be combined with a left ventricular apical vent

Mechanical Ventilation

The therapeutic alliance has been found to predict psychotherapy outcome in numerous studies. However, critics maintain that the therapeutic alliance is a by-product of prior symptomatic improvements. Moreover, almost all alliance research to date has used differences between patients in alliance as predictor of outcome, and results of such analyses do not necessarily mean that improving the alliance with a given patient will improve outcome (i.e., a within-patient effect). In a sample of 646 patients (76% women, 24% men) in primary care psychotherapy, the effect of working alliance on next session symptom level was analyzed using multilevel models. The Clinical Outcomes in Routine Evaluation–Outcome Measure was used to measure symptom level, and the patient version of the Working Alliance Inventory–Short form revised (Hatcher &amp; Gillaspy, 2006) was used to measure alliance. There was evidence for a reciprocal causal model, in which the alliance predicted subsequent change in symptoms while prior symptom change also affected the alliance. The alliance effect varied considerably between patients. This variation was partially explained by patients with personality problems showing stronger alliance effect. These results indicate that the alliance is not just a by-product of prior symptomatic improvements, even though improvement in symptoms is likely to enhance the alliance. Results also point to the importance of therapists paying attention to ruptures and repair of the therapy alliance. Generalization of results may be limited to relatively brief primary care psychotherapy