High-flow oxygen therapy versus noninvasive ventilation: a randomised physiological crossover study of alveolar recruitment in acute respiratory failure.

High-flow nasal cannula (HFNC) oxygen therapy has recently shown clinical benefits in hypoxaemic acute respiratory failure (ARF) patients, while the value of noninvasive ventilation (NIV) remains debated. The primary end-point was to compare alveolar recruitment using global end-expiratory electrical lung impedance (EELI) between HFNC and NIV. Secondary end-points compared regional EELI, lung volumes (global and regional tidal volume variation (V (T))), respiratory parameters, haemodynamic tolerance, dyspnoea and patient comfort between HFNC and NIV, relative to face mask (FM). A prospective randomised crossover physiological study was conducted in patients with hypoxaemic ARF due to pneumonia. They received alternately HFNC, NIV and FM. 16 patients were included. Global EELI was 4083 with NIV and 2921 with HFNC (p=0.4). Compared to FM, NIV and HFNC significantly increased global EELI by 1810.5 (95% CI 857-2646) and 826 (95% CI 399.5-2361), respectively. Global and regional V (T) increased significantly with NIV compared to HFNC or FM, but not between HFNC and FM. NIV yielded a significantly higher pulse oxygen saturation/inspired oxygen fraction ratio compared to HFNC (p=0.03). No significant difference was observed between HFNC, NIV and FM for dyspnoea. Patient comfort score with FM was not significantly different than with HFNC (p=0.1), but was lower with NIV (p=0.001). This study suggests a potential benefit of HFNC and NIV on alveolar recruitment in patients with hypoxaemic ARF. In contrast with HFNC, NIV increased lung volumes, which may contribute to overdistension and its potentially deleterious effect in these patients

Evaluation of non-nutritional calories in intensive care patients with acute respiratory distress syndrome due to coronavirus disease-19: a retrospective observational study

Summary: Background &amp; Aims: Nutrition therapy is a critical component of care for critically ill patients in the intensive care unit (ICU). Caloric intake can be provided by artificial nutrition and also by some treatments providing non-nutritional calories (NNCs). The aim of this study was to assess the contribution of NNCs from propofol and dextrose infusions to daily caloric intake. Methods: A retrospective observational study was carried out in three ICUs of a university hospital. Mechanically ventilated patients admitted to ICU for acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19) were included. Daily caloric intake, including NNCs from propofol and dextrose infusions, and calories from artificial nutrition was assessed over the initial seven days of ICU admission. Results: A total of 157 patients were included in the analysis. During the early phase of ICU admission, NNCs constituted all the proportion of caloric intake (Day 1: 100% [100–100], Day 2: 100% [100–100], Day 3: 100% [63–100]). This dominance gradually decreased with the introduction of artificial nutrition after a median of 4 days [3–5]. Propofol contributed significantly to NNCs, constituting a median of 26.6% [15.5–54.0] of total daily caloric intake and 66.2% [53.0–76.4] of daily NNCs intake in patients receiving propofol. By Day 7, only 47.3% of patients had reached their caloric target, while 45.8% remained below target and 6.9% were above target. The instances of overnutrition were minimal and were often associated with NNCs, particularly propofol. Mortality at Day 28 in patients who received propofol during the first 7 days was 32/117 (27%) versus 23/40 (57%) in those who did not (P < 0.001). Conclusions: Our study emphasizes the significant role of NNCs in the early nutritional intake of ICU patients suffering from ARDS due to COVID-19. These findings highlight the need for careful nutritional management in these patients, with particular consideration given to NNCs. Future research should investigate strategies to optimize nutritional support in this specific population

Characteristics, management, and prognosis of elderly patients with COVID-19 admitted in the ICU during the first wave: insights from the COVID-ICU study

International audienceAbstract Background The COVID-19 pandemic is a heavy burden in terms of health care resources. Future decision-making policies require consistent data on the management and prognosis of the older patients (> 70 years old) with COVID-19 admitted in the intensive care unit (ICU). Methods Characteristics, management, and prognosis of critically ill old patients (> 70 years) were extracted from the international prospective COVID-ICU database. A propensity score weighted-comparison evaluated the impact of intubation upon admission on Day-90 mortality. Results The analysis included 1199 (28% of the COVID-ICU cohort) patients (median [interquartile] age 74 [72–78] years). Fifty-three percent, 31%, and 16% were 70–74, 75–79, and over 80 years old, respectively. The most frequent comorbidities were chronic hypertension (62%), diabetes (30%), and chronic respiratory disease (25%). Median Clinical Frailty Scale was 3 (2–3). Upon admission, the PaO 2 /FiO 2 ratio was 154 (105–222). 740 (62%) patients were intubated on Day-1 and eventually 938 (78%) during their ICU stay. Overall Day-90 mortality was 46% and reached 67% among the 193 patients over 80 years old. Mortality was higher in older patients, diabetics, and those with a lower PaO 2 /FiO 2 ratio upon admission, cardiovascular dysfunction, and a shorter time between first symptoms and ICU admission. In propensity analysis, early intubation at ICU admission was associated with a significantly higher Day-90 mortality (42% vs 28%; hazard ratio 1.68; 95% CI 1.24–2.27; p < 0·001). Conclusion Patients over 70 years old represented more than a quarter of the COVID-19 population admitted in the participating ICUs during the first wave. Day-90 mortality was 46%, with dismal outcomes reported for patients older than 80 years or those intubated upon ICU admission

Skin biopsy in adult patients with meningococcal purpura fulminans: a multicenter retrospective cohort study

Abstract Background Neisseria meningitidis is the leading responsible bacterium of Purpura Fulminans (PF) accounting for two thirds of PF. Skin biopsy is a simple and minimally invasive exam allowing to perform skin culture and polymerase chain reaction (PCR) to detect Neisseria meningitidis. We aimed to assess the sensitivity of skin biopsy in adult patients with meningococcal PF. Methods A 17-year multicenter retrospective cohort study including adult patients admitted to the ICU for a meningococcal PF in whom a skin biopsy with conventional and/or meningococcal PCR was performed. Results Among 306 patients admitted for PF, 195 had a meningococcal PF (64%) with a skin biopsy being performed in 68 (35%) of them. Skin biopsy was performed in median 1 day after the initiation of antibiotic therapy. Standard culture of skin biopsy was performed in 61/68 (90%) patients and grew Neisseria meningitidis in 28 (46%) of them. Neisseria meningitidis PCR on skin biopsy was performed in 51/68 (75%) patients and was positive in 50 (98%) of them. Among these 50 positive meningococcal PCR, five were performed 3 days or more after initiation of antibiotic therapy. Finally, skin biopsy was considered as contributive in 60/68 (88%) patients. Identification of the meningococcal serogroup was obtained with skin biopsy in 48/68 (71%) patients. Conclusions Skin biopsy with conventional culture and meningococcal PCR has a global sensitivity of 88% and should be systematically considered in case of suspected meningococcal PF even after the initiation of antimicrobial treatment

Additional file 1 of ROX index performance to predict high-flow nasal oxygen outcome in Covid-19 related hypoxemic acute respiratory failure

Additional file 1: Figure S1. Receiver operating characteristic curves for HFNO failure within 28 days at different times after HFNO initiation. HFNO: high-flow nasal oxygen therapy; ROC: receiver operating characteristic; H0: ROC curve at the time of HFNO initiation; H12:12 hours after HFNO initiation; H18: 18 hours after HFNO initiation; H24:24 hours after HFNO initiation. Figure S2. Rox index performance to predict the risk of HFNO failure at different times after HFNO initiation. HFNO: high-flow nasal oxygen therapy; red line gives proportion of patients in the HFNO failure group with a ROX index ≤ a chosen cut-off value; black line gives proportion of patients in the HFNO success group with a ROX index ≤ a chosen cut-off value. For example: at H6, using a Rox index of ≤8.50 as cut-off would identify 90% of patients with HFNO failure after H6, whereas this cut-off would identify only 38% of patients with HFNO success after H6, avoiding intubation. Figure S3. Incidence of HFNO failure within 7 days after HFNO initiation. HFNO: high-flow nasal oxygen therapy. Table S4. Conditions of intubation and clinical respiratory parameters in all intubated patients and according to hemodynamic status. HFNO: high-flow nasal oxygen therapy; FiO2: fraction of inspired oxygen; SpO2: pulse oxygen saturation; RR: respiratory rate; values are expressed as n (%) or median (Q1-Q3). Table S5. Rox index at H0, HFNO outcome and duration according to each ICU center. HFNO: high-flow nasal oxygen therapy; ICU: intensive care unit; values are expressed as n (%) or median (Q1-Q3); *= logistic regression unless stated otherwise; **= Kruskall-Wallis’s test

Antiplatelet Drugs and Risk of Bleeding After Bedside Pleural Procedures: A National Multicenter Cohort Study

International audienceBackground: The decision-making on antiplatelet drug withdrawal or continuation before performing a pleural procedure is based on the balance between the risk of bleeding associated with the antiplatelet therapy and the risk of arterial thrombosis due to its interruption. Knowledge on antiplatelet therapy-associated risk of bleeding after pleural procedures is lacking.Research question: Is the risk of bleeding associated with antiplatelet drugs increased in patients undergoing pleural procedures?Study design and methods: We conducted a French multicenter cohort study in 19 centers. The main outcome was the occurrence of bleeding, defined as hematoma, hemoptysis, or hemothorax, during the 24 h following a pleural procedure. Serious bleeding events were defined as bleeding requiring blood transfusion, respiratory support, endotracheal intubation, embolization, or surgery, or as death.Results: A total of 1,124 patients was included (men, 66%; median age, 62.6 ± 27.7 years), of whom 182 were receiving antiplatelet therapy and 942 were not. Fifteen patients experienced a bleeding event, including eight serious bleeding events. The 24-h incidence of bleeding was 3.23% (95% CI, 1.08%-5.91%) in the antiplatelet group and 0.96% (95% CI, 0.43%-1.60%) in the control group. The occurrence of bleeding events was significantly associated with antiplatelet therapy in univariate analysis (OR, 3.44; 95% CI, 1.14-9.66; P = .021) and multivariate analysis (OR, 4.13; 95% CI, 1.01-17.03; P = .044) after adjusting for demographic data and the main risk factors for bleeding. Likewise, antiplatelet therapy was significantly associated with serious bleeding in univariate analysis (OR, 8.61; 95% CI, 2.09-42.3; P = .003) and multivariate analysis (OR, 7.27; 95% CI, 1.18-56.1; P = .032) after adjusting for the number of risk factors for bleeding.Interpretation: Antiplatelet therapy was associated with an increased risk of post-pleural procedure bleeding and serious bleeding. Future guidelines should take into account these results for patient safety

High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure

BACKGROUND: Whether noninvasive ventilation should be administered in patients with acute hypoxemic respiratory failure is debated. Therapy with high-flow oxygen through a nasal cannula may offer an alternative in patients with hypoxemia. METHODS: We performed a multicenter, open-label trial in which we randomly assigned patients without hypercapnia who had acute hypoxemic respiratory failure and a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen of 300 mm Hg or less to high-flow oxygen therapy, standard oxygen therapy delivered through a face mask, or noninvasive positive-pressure ventilation. The primary outcome was the proportion of patients intubated at day 28; secondary outcomes included all-cause mortality in the intensive care unit and at 90 days and the number of ventilator-free days at day 28. RESULTS: A total of 310 patients were included in the analyses. The intubation rate (primary outcome) was 38% (40 of 106 patients) in the high-flow-oxygen group, 47% (44 of 94) in the standard group, and 50% (55 of 110) in the noninvasive-ventilation group (P = 0.18 for all comparisons). The number of ventilator-free days at day 28 was significantly higher in the high-flow-oxygen group (24±8 days, vs. 22±10 in the standard-oxygen group and 19±12 in the noninvasive-ventilation group; P = 0.02 for all comparisons). The hazard ratio for death at 90 days was 2.01 (95% confidence interval [CI], 1.01 to 3.99) with standard oxygen versus high-flow oxygen (P = 0.046) and 2.50 (95% CI, 1.31 to 4.78) with noninvasive ventilation versus high-flow oxygen (P = 0.006). CONCLUSIONS: In patients with nonhypercapnic acute hypoxemic respiratory failure, treatment with high-flow oxygen, standard oxygen, or noninvasive ventilation did not result in significantly different intubation rates. There was a significant difference in favor of high-flow oxygen in 90-day mortality. (Funded by the Programme Hospitalier de Recherche Clinique Interrégional 2010 of the French Ministry of Health; FLORALI ClinicalTrials.gov number, NCT01320384.