High flow biphasic positive airway pressure by helmet – effects on pressurization, tidal volume, carbon dioxide accumulation and noise exposure

Abstract INTRODUCTION: Non-invasive ventilation (NIV) with a helmet device is often associated with poor patient-ventilator synchrony and impaired carbon dioxide (CO2) removal, which might lead to failure. A possible solution is to use a high free flow system in combination with a time-cycled pressure valve placed into the expiratory circuit (HF-BiPAP). This system would be independent from triggering while providing a high flow to eliminate CO2. METHODS: Conventional pressure support ventilation (PSV) and time-cycled biphasic pressure controlled ventilation (BiVent) delivered by an Intensive Care Unit ventilator were compared to HF-BiPAP in an in vitro lung model study. Variables included delta pressures of 5 and 15 cmH2O, respiratory rates of 15 and 30 breaths/min, inspiratory efforts (respiratory drive) of 2.5 and 10 cmH2O) and different lung characteristics. Additionally, CO2 removal and noise exposure were measured. RESULTS: Pressurization during inspiration was more effective with pressure controlled modes compared to PSV (P < 0.001) at similar tidal volumes. During the expiratory phase, BiVent and HF-BiPAP led to an increase in pressure burden compared to PSV. This was especially true at higher upper pressures (P < 0.001). At high level of asynchrony both HF-BiPAP and BiVent were less effective. Only HF-BiPAP ventilation effectively removed CO2 (P < 0.001) during all settings. Noise exposure was higher during HF-BiPAP (P < 0.001). CONCLUSIONS: This study demonstrates that in a lung model, the efficiency of NIV by helmet can be improved by using HF-BiPAP. However, it imposes a higher pressure during the expiratory phase. CO2 was almost completely removed with HF-BiPAP during all settings

Evolution of Noninvasive Mechanical Ventilation Use: A Cohort Study Among Italian PICUs

To assess how clinical practice of noninvasive ventilation has evolved in the Italian PICUs

A year in review in Minerva Anestesiologica 2019. Anesthesia, analgesia, and perioperative medicine

Innovations in anesthesia and perioperative pain management have animated the debate the last year

The Importance of Mortality Risk Assessment: Validation of the Pediatric Index of Mortality 3 Score

Objective: To evaluate the performance of the newest version of the Pediatric Index of Mortality 3 score and compare it with the Pediatric Index of Mortality 2 in a multicenter national cohort of children admitted to PICU. Design: Retrospective, prospective cohort study. Setting: Seventeen Italian PICUs. Patients: All children 0 to 15 years old admitted in PICU from January 2010 to October 2014. Interventions: None. Measurement and main results: Eleven thousand one hundred nine children were enrolled in the study. The mean Pediatric Index of Mortality 2 and 3 values of 4.9 and 3.9, respectively, differed significantly (p &lt; 0.05). Overall mortality rate was 3.9%, and the standardized mortality ratio was 0.80 for Pediatric Index of Mortality 2 and 0.98 for Pediatric Index of Mortality 3 (p &lt; 0.05). The area under the curve of the receiver operating characteristic curves was similar for Pediatric Index of Mortality 2 and Pediatric Index of Mortality 3. The Hosmer-Lemeshow test was not significant for Pediatric Index of Mortality 3 (p = 0.21) but was highly significant for Pediatric Index of Mortality 2 (p &lt; 0.001), which overestimated death mainly in high-risk categories. Conclusions: Mortality indices require validation in each country where it is used. The new Pediatric Index of Mortality 3 score performed well in an Italian population. Both calibration and discrimination were appropriate, and the score more accurately predicted the mortality risk than Pediatric Index of Mortality 2

Long-term home ventilation of children in Italy: A national survey.

BACKGROUND: Improved technology, as well as professional and parental awareness, enable many ventilator-dependent children to live at home. However, the profile of this growing population, the quality and adequacy of home care, and patients' needs still require thorough assessment. OBJECTIVES: To define the characteristics of Italian children receiving long-term home mechanical ventilation (HMV) in Italy. METHODS: A detailed questionnaire was sent to 302 National Health Service hospitals potentially involved in the care of HVM in children (aged <17 years). Information was collected on patient characteristics, type of ventilation, and home respiratory care. RESULTS: A total of 362 HMV children was identified. The prevalence was 4.2 per 100,000 (95% CI: 3.8-4.6), median age was 8 years (interquartile range 4-14), median age at starting mechanical ventilation was 4 years (1-11), and 56% were male. The most frequent diagnostic categories were neuromuscular disorders (49%), lung and upper respiratory tract diseases (18%), hypoxic (ischemic) encephalopathy (13%), and abnormal ventilation control (12%). Medical professionals with nurses (for 62% of children) and physiotherapists (20%) participated in the patients' discharge from hospital, though parents were the primary care giver, and in 47% of cases, the sole care giver. Invasive ventilation was used in 41% and was significantly related to young age, southern regional residence, longer time spent under mechanical ventilation, neuromuscular disorders, or hypoxic (ischemic) encephalopathy. CONCLUSIONS: Care and technical assistance of long-term HMV children need assessment, planning, and resources. A wide variability in pattern of HMV was found throughout Italy. An Italian national ventilation program, as well as a national registry, could be useful in improving the care of these often critically ill children

Recommendations for mechanical ventilation of critically ill children from the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC)

Purpose: Much of the common practice in paediatric mechanical ventilation is based on personal experiences and what paediatric critical care practitioners have adopted from adult and neonatal experience. This presents a barrier to planning and interpretation of clinical trials on the use of specific and targeted interventions. We aim to establish a European consensus guideline on mechanical ventilation of critically children. Methods: The European Society for Paediatric and Neonatal Intensive Care initiated a consensus conference of international European experts in paediatric mechanical ventilation to provide recommendations using the Research and Development/University of California, Los Angeles, appropriateness method. An electronic literature search in PubMed and EMBASE was performed using a combination of medical subject heading terms and text words related to mechanical ventilation and disease-specific terms. Results: The Paediatric Mechanical Ventilation Consensus Conference (PEMVECC) consisted of a panel of 15 experts who developed and voted on 152 recommendations related to the following topics: (1) general recommendations, (2) monitoring, (3) targets of oxygenation and ventilation, (4) supportive measures, (5) weaning and extubation readiness, (6) normal lungs, (7) obstructive diseases, (8) restrictive diseases, (9) mixed diseases, (10) chronically ventilated patients, (11) cardiac patients and (12) lung hypoplasia syndromes. There were 142 (93.4%) recommendations with "strong agreement". The final iteration of the recommendations had none with equipoise or disagreement. Conclusions: These recommendations should help to harmonise the approach to paediatric mechanical ventilation and can be proposed as a standard-of-care applicable in daily clinical practice and clinical research

Search for dark matter produced in association with bottom or top quarks in √s = 13 TeV pp collisions with the ATLAS detector

A search for weakly interacting massive particle dark matter produced in association with bottom or top quarks is presented. Final states containing third-generation quarks and miss- ing transverse momentum are considered. The analysis uses 36.1 fb−1 of proton–proton collision data recorded by the ATLAS experiment at √s = 13 TeV in 2015 and 2016. No significant excess of events above the estimated backgrounds is observed. The results are in- terpreted in the framework of simplified models of spin-0 dark-matter mediators. For colour- neutral spin-0 mediators produced in association with top quarks and decaying into a pair of dark-matter particles, mediator masses below 50 GeV are excluded assuming a dark-matter candidate mass of 1 GeV and unitary couplings. For scalar and pseudoscalar mediators produced in association with bottom quarks, the search sets limits on the production cross- section of 300 times the predicted rate for mediators with masses between 10 and 50 GeV and assuming a dark-matter mass of 1 GeV and unitary coupling. Constraints on colour- charged scalar simplified models are also presented. Assuming a dark-matter particle mass of 35 GeV, mediator particles with mass below 1.1 TeV are excluded for couplings yielding a dark-matter relic density consistent with measurements