Nasal High Flow Oxygen in Respiratory Failure

High flow nasal cannula system or nasal high flow oxygen is an oxygen delivery device which administers heated, humidified high flow oxygen with concentrations from 21% to 100% and with a flow rate up to 60 L/min in adults. It generates many physiologic effects to respiratory system with a lot of clinical applications. Indeed, greater comfort and tolerance, more effective oxygenation, and improved breathing pattern with increased tidal volume and decreased respiratory rate and dyspnea has constantly been detected. Therefore, it can be used to improve cardiogenic pulmonary edema and hypoxemic respiratory failure of any cause, postoperatively, during post-extubation, as well as for palliative car

Personalized mechanical ventilation guided by ultrasound in patients with acute respiratory distress syndrome (PEGASUS): study protocol for an international randomized clinical trial

: Background : Acute respiratory distress syndrome (ARDS) is a frequent cause of hypoxemic respiratory failure with a mortality rate of approximately 30%. Identifying ARDS subphenotypes based on “focal” or “non-focal” lung morphology has the potential to better target mechanical ventilation strategies of individual patients. However, classifying morphology through chest radiography or computed tomography is either inaccurate or impractical. Lung ultrasound (LUS) is a non-invasive bedside tool that can accurately distinguish “focal” from “non-focal” lung morphology. We hypothesize that LUS-guided personalized mechanical ventilation in ARDS patients leads to a reduction in 90-day mortality compared to conventional mechanical ventilation. Methods: The Personalized Mechanical Ventilation Guided by UltraSound in Patients with Acute Respiratory Distress Syndrome (PEGASUS) study is an investigator-initiated, international, randomized clinical trial (RCT) that plans to enroll 538 invasively ventilated adult intensive care unit (ICU) patients with moderate to severe ARDS. Eligible patients will receive a LUS exam to classify lung morphology as “focal” or “non-focal”. Thereafter, patients will be randomized within 12 h after ARDS diagnosis to receive standard care or personalized ventilation where the ventilation strategy is adjusted to the morphology subphenotype, i.e., higher positive end-expiratory pressure (PEEP) and recruitment maneuvers for “non-focal” ARDS and lower PEEP and prone positioning for “focal” ARDS. The primary endpoint is all-cause mortality at day 90. Secondary outcomes are mortality at day 28, ventilator-free days at day 28, ICU length of stay, ICU mortality, hospital length of stay, hospital mortality, and number of complications (ventilator-associated pneumonia, pneumothorax, and need for rescue therapy). After a pilot phase of 80 patients, the correct interpretation of LUS images and correct application of the intervention within the safe limits of mechanical ventilation will be evaluated. Discussion: PEGASUS is the first RCT that compares LUS-guided personalized mechanical ventilation with conventional ventilation in invasively ventilated patients with moderate and severe ARDS. If this study demonstrates that personalized ventilation guided by LUS can improve the outcomes of ARDS patients, it has the potential to shift the existing one-size-fits-all ventilation strategy towards a more individualized approach. Trial registration: The PEGASUS trial was registered before the inclusion of the first patient, https://clinicaltrials.gov/ (ID: NCT05492344)

High-flow nasal cannulae for respiratory support in adult intensive care patients

Background High-flow nasal cannulae (HFNC) deliver high flows of blended humidified air and oxygen via wide-bore nasal cannulae and may be useful in providing respiratory support for adult patients experiencing acute respiratory failure in the intensive care unit (ICU). Objectives We evaluated studies that included participants 16 years of age and older who were admitted to the ICU and required treatment with HFNC. We assessed the safety and efficacy of HFNC compared with comparator interventions in terms of treatment failure, mortality, adverse events, duration of respiratory support, hospital and ICU length of stay, respiratory effects, patient-reported outcomes, and costs of treatment. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 3), MEDLINE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Web of Science, proceedings from four conferences, and clinical trials registries; and we handsearched reference lists of relevant studies. We conducted searches from January 2000 to March 2016 and reran the searches in December 2016. We added four new studies of potential interest to a list of ‘Studies awaiting classification' and will incorporate them into formal review findings during the review update. Selection criteria We included randomized controlled studies with a parallel or cross-over design comparing HFNC use in adult ICU patients versus other forms of non-invasive respiratory support (low-flow oxygen via nasal cannulae or mask, continuous positive airway pressure (CPAP), and bilevel positive airway pressure (BiPAP)). Data collection and analysis Two review authors independently assessed studies for inclusion, extracted data, and assessed risk of bias. Main results We included 11 studies with 1972 participants. Participants in six studies had respiratory failure, and in five studies required oxygen therapy after extubation. Ten studies compared HFNC versus low-flow oxygen devices; one of these also compared HFNC versus CPAP, and another compared HFNC versus BiPAP alone. Most studies reported randomization and allocation concealment inadequately and provided inconsistent details of outcome assessor blinding. We did not combine data for CPAP and BiPAP comparisons with data for low-flow oxygen devices; study data were insufficient for separate analysis of CPAP and BiPAP for most outcomes. For the primary outcomes of treatment failure (1066 participants; six studies) and mortality (755 participants; three studies), investigators found no differences between HFNC and low-flow oxygen therapies (risk ratio (RR), Mantel-Haenszel (MH), random-effects 0.79, 95% confidence interval (CI) 0.49 to 1.27; and RR, MH, random-effects 0.63, 95% CI 0.38 to 1.06, respectively). We used the GRADE approach to downgrade the certainty of this evidence to low because of study risks of bias and different participant indications. Reported adverse events included nosocomial pneumonia, oxygen desaturation, visits to general practitioner for respiratory complications, pneumothorax, acute pseudo-obstruction, cardiac dysrhythmia, septic shock, and cardiorespiratory arrest. However, single studies reported adverse events, and we could not combine these findings; one study reported fewer episodes of oxygen desaturation with HFNC but no differences in all other reported adverse events. We downgraded the certainty of evidence for adverse events to low because of limited data. Researchers noted no differences in ICU length of stay (mean difference (MD), inverse variance (IV), random-effects 0.15, 95% CI -0.03 to 0.34; four studies; 770 participants), and we downgraded quality to low because of study risks of bias and different participant indications. We found no differences in oxygenation variables: partial pressure of arterial oxygen (PaO2)/fraction of inspired oxygen (FiO2) (MD, IV, random-effects 7.31, 95% CI -23.69 to 41.31; four studies; 510 participants); PaO2 (MD, IV, random-effects 2.79, 95% CI -5.47 to 11.05; three studies; 355 participants); and oxygen saturation (SpO2) up to 24 hours (MD, IV, random-effects 0.72, 95% CI -0.73 to 2.17; four studies; 512 participants). Data from two studies showed that oxygen saturation measured after 24 hours was improved among those treated with HFNC (MD, IV, random-effects 1.28, 95% CI 0.02 to 2.55; 445 participants), but this difference was small and was not clinically significant. Along with concern about risks of bias and differences in participant indications, review authors noted a high level of unexplained statistical heterogeneity in oxygenation effect estimates, and we downgraded the quality of evidence to very low. Meta-analysis of three comparable studies showed no differences in carbon dioxide clearance among those treated with HFNC (MD, IV, random-effects -0.75, 95% CI -2.04 to 0.55; three studies; 590 participants). Two studies reported no differences in atelectasis; we did not combine these findings. Data from six studies (867 participants) comparing HFNC versus low-flow oxygen showed no differences in respiratory rates up to 24 hours according to type of oxygen delivery device (MD, IV, random-effects -1.51, 95% CI -3.36 to 0.35), and no difference after 24 hours (MD, IV, random-effects -2.71, 95% CI -7.12 to 1.70; two studies; 445 participants). Improvement in respiratory rates when HFNC was compared with CPAP or BiPAP was not clinically important (MD, IV, random-effects -0.89, 95% CI -1.74 to -0.05; two studies; 834 participants). Results showed no differences in patient-reported measures of comfort according to oxygen delivery devices in the short term (MD, IV, random-effects 0.14, 95% CI -0.65 to 0.93; three studies; 462 participants) and in the long term (MD, IV, random-effects -0.36, 95% CI -3.70 to 2.98; two studies; 445 participants); we downgraded the certainty of this evidence to low. Six studies measured dyspnoea on incomparable scales, yielding inconsistent study data. No study in this review provided data on positive end-expiratory pressure measured at the pharyngeal level, work of breathing, or cost comparisons of treatment. Authors' conclusions We were unable to demonstrate whether HFNC was a more effective or safe oxygen delivery device compared with other oxygenation devices in adult ICU patients. Meta-analysis could be performed for few studies for each outcome, and data for comparisons with CPAP or BiPAP were very limited. In addition, we identified some risks of bias among included studies, differences in patient groups, and high levels of statistical heterogeneity for some outcomes, leading to uncertainty regarding the results of our analysis. Consequently, evidence is insufficient to show whether HFNC provides safe and efficacious respiratory support for adult ICU patients

Personalized mechanical ventilation guided by ultrasound in patients with acute respiratory distress syndrome (PEGASUS): study protocol for an international randomized clinical trial

background acute respiratory distress syndrome (ARDS) is a frequent cause of hypoxemic respiratory failure with a mortality rate of approximately 30%. Identifying ARDS subphenotypes based on "focal" or "non-focal" lung morphology has the potential to better target mechanical ventilation strategies of individual patients. however, classifying morphology through chest radiography or computed tomography is either inaccurate or impractical. Lung ultrasound (LUS) is a non-invasive bedside tool that can accurately distinguish "focal" from "non-focal" lung morphology. We hypothesize that LUS-guided personalized mechanical ventilation in ARDS patients leads to a reduction in 90-day mortality compared to conventional mechanical ventilation. methods the personalized mechanical ventilation guided by ultrasound in patients with acute respiratory distress syndrome (PEGASUS) study is an investigator-initiated, international, randomized clinical trial (RCT) that plans to enroll 538 invasively ventilated adult intensive care unit (ICU) patients with moderate to severe ARDS. eligible patients will receive a LUS exam to classify lung morphology as "focal" or "non-focal". thereafter, patients will be randomized within 12 h after ARDS diagnosis to receive standard care or personalized ventilation where the ventilation strategy is adjusted to the morphology subphenotype, i.e., higher positive end-expiratory pressure (PEEP) and recruitment maneuvers for "non-focal" ARDS and lower PEEP and prone positioning for "focal" ARDS. the primary endpoint is all-cause mortality at day 90. secondary outcomes are mortality at day 28, ventilator-free days at day 28, ICU length of stay, ICU mortality, hospital length of stay, hospital mortality, and number of complications (ventilator-associated pneumonia, pneumothorax, and need for rescue therapy). after a pilot phase of 80 patients, the correct interpretation of LUS images and correct application of the intervention within the safe limits of mechanical ventilation will be evaluated. discussion PEGASUS is the first RCT that compares LUS-guided personalized mechanical ventilation with conventional ventilation in invasively ventilated patients with moderate and severe ARDS. If this study demonstrates that personalized ventilation guided by LUS can improve the outcomes of ARDS patients, it has the potential to shift the existing one-size-fits-all ventilation strategy towards a more individualized approach. trial registration the PEGASUS trial was registered before the inclusion of the first patient, https://clinicaltrials.gov/ (ID: NCT05492344)

Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine

[This corrects the article DOI: 10.1186/s13054-016-1208-6.]

Smoking and depression: Is smoking cessation effective?

Patients with depression tend to have a higher rate of smoking and an increased severity of nicotine dependence. It seems that common genetic and environmental factors may influence the bimodal relationship between smoking and depression. Nicotine has some positive reinforcing/rewarding effects that may affect people with mood disorders and smoking is also used as a ‘relief medication’ in order to ameliorate symptoms of depression, as it is already known that nicotine, which is the major psychoactive ingredient in tobacco, may act as an antidepressant. To date, the data regarding the difficulty in smoking cessation in depressed smokers are conflicting. Low confidence and self-esteem among this group of smokers are significant predictors of failure during smoking cessation attempt. In the most recently published guidelines for smokers with psychiatric comorbidities the suggestion is for combination treatment (counseling and pharmaceutical treatment) and prolongation of a therapeutic approach. © 2009, SAGE Publications. All rights reserved

Body weight and systemic consequences in COPD

COPD primarily affects the lungs but also produces systemic consequences that are not reflected by the recent staging according to Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Body mass index (BMI) and fat-free mass index (FFMI) represent different aspects of nutrition abnormalities in COPD. We investigated whether BMI and FFMI could be related to parameters expressing airflow obstruction and limitation, exercise capacity, and quality of life, and whether they would reflect the GOLD staging of the disease.Methods: 112 patients with clinically stable COPD were classified into the four stages of the disease according to GOLD staging. Furthermore, 36 smokers with cough and sputum production but with normal spirometric values were classified as “on risk” or stage 0. All of the participants were evaluated for their nutritional status (BMI, FFMI measured by bioelectrical impedance analysis), airway obstruction and hyperinflation (FEV1, FEV1/FVC, inspiratory capacity), exercise capacity (6-min walk distance [6MWD], Borg scale before and after 6MWD]), chronic dyspnea using the Medical Research Council (MRC) scale, and quality of life (emotional part of the chronic respiratory disease questionnaire).Results: FFMI is a stronger predictor of exercise capacity of COPD patients related to BMI. FFMI is significantly associated with MRC, IC and ΔBorg No association was observed between the two nutritional indexes. BMI was not statistically different among patients in the four stages of COPD, while FFMI reflected the staging of the disease, presenting the minimal values in stage 0.Conclusions: Nutritional status is mainly related to exercise capacity. FFMI seems to be more accurate in expressing variables of disease severity, as well as the current staging compared to BMI.Η ΧΑΠ δεν αποτελεί πάθηση μόνο των πνευμόνων αλλά χαρακτηρίζεται και από σημαντικές συστηματικές εκδηλώσεις από εξωπνευμονικά όργανα και οι οποίες δεν αντανακλώνται από την υπάρχουσα σταδιοποίησή της GOLD. Ο δείκτης μάζας σώματος (ΒΜΙ) και ο δείκτης μάζας ελεύθερης λίπους (FFMI) αντιπροσωπεύουν διαφορετικές όψεις της θρεπτικής κατάστασης των ασθενών με ΧΑΠ. Στη παρούσα μελέτη διερευνάτε το κατά πόσο οι δύο αυτοί δείκτες θρέψης μπορούν να συσχετιστούν με παραμέτρους που εκφράζουν απόφραξη των αεραγωγών και περιορισμό της ροής του αέρα, ικανότητα για άσκηση, δύσπνοια και ποιότητα ζωής. Επίσης μελετάται η συσχέτισή τους με την κλασσική κατά GOLD σταδιοποίηση της νόσου.Μέθοδος: 112 ασθενείς με κλινικά σταθερή ΧΑΠ ταξινομήθηκαν στα τέσσερα στάδια της νόσου βάση της σταδιοποίησης GOLD. Επιπλέον 36 καπνιστές με συμπτώματα χρόνιου βήχα και απόχρεμψης και φυσιολογική σπιρομέτρηση χαρακτηρίστηκαν ως «καπνιστές με κίνδυνο εμφάνισης ΧΑΠ» ή αλλιώς ως στάδιο 0. Σε όλους τους συμμετέχοντες στη μελέτη εκτιμήθηκε η θρεπτική τους κατάσταση (BMI, FFMI με τη μέθοδο Bioelectican Impedance Analysis), η απόφραξη των αεραγωγών και η υπερδιάταση των πνευμόνων (FEV1, FEV1/FVC, εισπνευστική χωρητικότητα-IC), η ικανότητα για άσκηση (δοκιμασία βάδισης των 6 λεπτών-6MWD και οπτική κλίμακα δύσπνοιας Borg πριν και μετά τη δοκιμασία-ΔBorg), η χρόνια δύσπνοια (κλίμακα MRC) και η ποιότητα ζωής (συναισθηματικό μέρος του ερωτηματολογίου για τις χρόνιες αναπνευστικές παθήσεις, CRQ)Αποτελέσματα: Ο δείκτης FMMI είναι πολύ ισχυρότερος προβλεπτικός παράγοντας της ικανότητας για άσκηση στους ασθενείς με ΧΑΠ σε σχέση με το ΒΜΙ. Επίσης το FFMI σχετίζεται σημαντικά με τις παραμέτρους MRC, IC και ΔBorg. Δε βρέθηκε συσχέτιση μεταξύ των δύο δεικτών θρέψης. Ο δείκτης ΒΜΙ δε διαφέρει σημαντικά μεταξύ των διαφόρων σταδίων της ΧΑΠ ενώ αντίθετα ο δείκτης FFMI είναι μικρότερος σε ασθενείς με ΧΑΠ σταδίου 4 σε σχέση με άλλα στάδια.Συμπέρασμα: Η θρεπτική κατάσταση σχετίζεται κυρίως με την ικανότητα για άσκηση. Ο δείκτης FFMI φαίνεται ότι είναι πιο ακριβής στην έκφραση παραμέτρων σοβαρότητας της νόσου αλλά και στη συσχέτισή του με τη σύγχρονη σταδιοποίηση της ΧΑΠ σε σχέση με το ΒΜΙ

Smoking and depression: is smoking cessation effective?

Patients with depression tend to have a higher rate of smoking and an increased severity of nicotine dependence. It seems that common genetic and environmental factors may influence the bimodal relationship between smoking and depression. Nicotine has some positive reinforcing/rewarding effects that may affect people with mood disorders and smoking is also used as a `relief medication' in order to ameliorate symptoms of depression, as it is already known that nicotine, which is the major psychoactive ingredient in tobacco, may act as an antidepressant. To date, the data regarding the difficulty in smoking cessation in depressed smokers are conflicting. Low confidence and self-esteem among this group of smokers are significant predictors of failure during smoking cessation attempt. In the most recently published guidelines for smokers with psychiatric comorbidities the suggestion is for combination treatment (counseling and pharmaceutical treatment) and prolongation of a therapeutic approach

Nasal high flow therapy: A novel treatment rather than a more expensive oxygen device

Nasal high flow is a promising novel oxygen delivery device, whose mechanisms of action offer some beneficial effects over conventional oxygen systems. The administration of a high flow of heated and humidified gas mixture promotes higher and more stable inspiratory oxygen fraction values, decreases anatomical dead space and generates a positive airway pressure that can reduce the work of breathing and enhance patient comfort and tolerance. Nasal high flow has been used as a prophylactic tool or as a treatment device mostly in patients with acute hypoxaemic respiratory failure, with the majority of studies showing positive results. Recently, its clinical indications have been expanded to post-extubated patients in intensive care or following surgery, for pre- and peri-oxygenation during intubation, during bronchoscopy, in immunocompromised patients and in patients with “do not intubate” status. In the present review, we differentiate studies that suggest an advantage (benefit) from other studies that do not suggest an advantage (no benefit) compared to conventional oxygen devices or noninvasive ventilation, and propose an algorithm in cases of nasal high flow application in patients with acute hypoxaemic respiratory failure of almost any cause. © ERS 2017