The Effect of Using Different Aerosol Devices and Masks on Aerosol Deposition during Noninvasive Positive Pressure Ventilation in an Adult Lung Model

Introduction: Although patients with an acute increase in airflow resistance may require aerosol therapy and noninvasive positive pressure ventilation (NIPPV), the efficiency of different aerosol devices and masks during NIPPV is not well understood. The purpose of this study was to determine the efficiency of a jet nebulizer (JN), a vibrating mesh nebulizer (VMN) and a pressurized metered-dose inhaler (pMDI) and three different masks during NIPPV. Method: An in vitro lung model consisted of the upper airway of an adult teaching manikin with a collecting filter at the level of the bronchi attached to a passive test lung. NIPPV was administered via full face mask for the first experiment (AF531 oro-nasal) with an IPAP/EPAP of 20/5 cm H2O and a respiratory rate of 15 Breath per minute (BPM). Aerosol generators were placed between the leak in the circuit and the mask. Albuterol sulfate (2.5 mg/ 3 ml) was nebulized with the JN (Micromist) and the VMN (Aeroneb Solo). Four puffs (108 µg/puff) were administered with the pMDI (ProAir HFA) with a spacer (Aerovent) that first was placed in the recommended normal position (pMDI-N) with aerosol plume directed towards patient, and then in the reversed position (pMDI-R), with aerosol directed away from patient (n=3). In the second experiment, three masks were used 1) the Performax mask, 2) the AF531 oro-nasal mask, and 3) the Performa track mask. Performa track mask was tested with only Aeroneb solo while other masks were tested with both Aeroneb solo and NIVO VMNs. In both experiments, filters were eluted with 0.1 HCl and analyzed by a spectrophotometer at 276 nm. Residual volumes were determined gravimetrically. Result: Descriptive statistics, one-way analysis of variance (ANOVA), and independent t tests were used. Statistical significance was set at p\u3c0.05. During NIPPV, inhaled mass (IM) and inhaled mass percent (IM %) varied significantly (p=0.042 and p=0.028, respectively). Aerosol delivery with the JN was the lowest during NIPPV. The VMN has a significantly lower residual volume than the JN (p=0.0001). No statistical difference in efficiency was found between the two pMDI orientations (p=0.253). In the second experiment, oro nasal mask with Aeroneb Solo VMN results in the highest IM which was significant when compared with all other masks(p=0.0001). No statistical difference can be found between other masks. Conclusion: The JN was less efficient than the VMN and the pMDI in either orientation. The type of aerosol device used during NIPPV influenced aerosol delivery in this simulated adult lung model. Oro nasal mask with Aeroneb Solo VMN provided the highest IM

Global Current Practices of Ventilatory Support Management in COVID-19 Patients: An International Survey

Background: As the global outbreak of COVID-19 continues to ravage the world, it is important to understand how frontline clinicians manage ventilatory support and the various limiting factors. / Methods: An online survey composed of 32 questions was developed and validated by an international expert panel. / Results: Overall, 502 respondents from 40 countries across six continents completed the survey. The mean number (±SD) of ICU beds was 64 ± 84. The most popular initial diagnostic tools used for treatment initiation were arterial blood gas (48%) and clinical presentation (37.5%), while the national COVID-19 guidelines were the most used (61.2%). High flow nasal cannula (HFNC) (53.8%), non-invasive ventilation (NIV) (47%), and invasive mechanical ventilation (IMV) (92%) were mostly used for mild, moderate, and severe COVID-19 cases, respectively. However, only 38.8%, 56.6% and 82.9% of the respondents had standard protocols for HFNC, NIV, and IMV, respectively. The most frequently used modes of IMV and NIV were volume control (VC) (36.1%) and continuous positive airway pressure/pressure support (CPAP/PS) (40.6%). About 54% of the respondents did not adhere to the recommended, regular ventilator check interval. The majority of the respondents (85.7%) used proning with IMV, with 48.4% using it for 12– 16 hours, and 46.2% had tried awake proning in combination with HFNC or NIV. Increased staff workload (45.02%), lack of trained staff (44.22%) and shortage of personal protective equipment (PPE) (42.63%) were the main barriers to COVID-19 management. / Conclusion: Our results show that general clinical practices involving ventilatory support were highly heterogeneous, with limited use of standard protocols and most frontline clinicians depending on isolated and varied management guidelines. We found increased staff workload, lack of trained staff and shortage of PPE to be the main limiting factors affecting global COVID-19 ventilatory support management

Creation of an institutional preoperative checklist to support clinical risk assessment in patients with ulcerative colitis (UC) considering ileoanal pouch surgery

Background: Total proctocolectomy with ileal pouch–anal anastomosis (IPAA) is the most established restorative operative approach for patients with ulcerative colitis. It has associated morbidity and the potential for major repercussions on quality of life. As such, patient selection is crucial to its success. The main aim of this paper is to present an institutional preoperative checklist to support clinical risk assessment and patient selection in those considering IPAA. Methods: A literature review was performed to identify the risk factors associated with surgical complications, decreased functional outcomes/quality of life, and pouch failure after IPAA. Based on this, a preliminary checklist was devised and modified through an iterative process. This was then evaluated by a consensus group comprising the pouch multidisciplinary team (MDT) core members. Results: The final preoperative checklist includes assessment for risk factors such as gender, advanced age, obesity, comorbidities, sphincteric impairment, Crohn’s disease and pelvic radiation therapy. In addition, essential steps in the decision-making process, such as pouch nurse counselling and discussion regarding surgical alternatives, are also included. The last step of the checklist is discussion at a dedicated pouch-MDT. Discussion: A preoperative checklist may support clinicians with the selection of patients that are suitable for pouch surgery. It also serves as a useful tool to inform the discussion of cases at the MDT meeting

Substance Use and Misuse among Adults with Chronic Obstructive Pulmonary Disease in the United States, 2015–2019: Prevalence, Association, and Moderation

Background: Despite the advancements in chronic obstructive pulmonary disease (COPD) treatment, complications related to COPD exacerbation remain challenging. One associated factor is substance use/misuse among adults with COPD. Fewer studies, however, examined the prevalence and association between COPD and substance use and misuse. In addition, limited knowledge existed about the moderation effects of serious psychological distress and gender among adults with COPD and substance use/misuse. We aimed, therefore, to measure such prevalence, association, and moderation from nationally representative samples in the United States. Method: Data were drawn from the 2015–2019 National Survey on Drug Use and Health. Weighted logistic regressions were used to measure the associations of last-month tobacco (cigarettes, cigars, pipe, and smokeless tobacco products), other licit and illicit substance use (alcohol, marijuana, cocaine, crack, heroin, hallucinogens, and inhalants), and substance misuse (pain relievers, tranquilizers, stimulants, and sedatives) among adults with COPD. Serious psychological distress and gender were tested as moderators in the association between COPD and substance use/misuse. Results: The findings revealed that adults with COPD [Weighted N = 53,115,718) revealed greater odds of cigarettes [adjusted odds ratio (aOR) = 2.48 (95%CI = 1.80–3.42)) and smokeless tobacco (aOR = 3.65 (95%CI = 1.75–7.65)). However, they were less likely to use alcohol (aOR = 0.61 (95%CI = 0.45–0.84)). Adults with COPD who had serious psychological distress were more likely to use pipe tobacco and alcohol; however, they were less likely to use hallucinogens and inhalants. Finally, males compared to females with COPD were less likely to use smokeless tobacco. Conclusion: Adults with COPD in the United States were more likely to use tobacco products and less likely to use alcohol. In addition, serious psychological distress and gender were moderators in associations between COPD and substance use but not in substance misuse. Future studies should longitudinally assess the factors that may contribute to the initiation and progression of substance use and misuse among adults with COPD