Respiratory support by neurally adjusted ventilatory assist (NAVA) in severe RSV-related bronchiolitis: a case series report

<p>Abstract</p> <p>Background</p> <p>Neurally adjusted ventilatory assist (NAVA) is a new mode of mechanical ventilation controlled by diaphragmatic electrical signals. The electrical signals allow synchronization of ventilation to spontaneous breathing efforts of a child, as well as permitting pressure assistance proportional to the electrical signal. NAVA provides equally fine synchronization of respiratory support and pressure assistance varying with the needs of the child. NAVA has mainly been studied in children who underwent cardiac surgery during the period of weaning from a respirator.</p> <p>Case presentation</p> <p>We report here a series of 3 children (1 month, 3 years, and 28 days old) with severe respiratory distress due to RSV-related bronchiolitis requiring invasive mechanical ventilation with a high level of oxygen (FiO₂≥50%) for whom NAVA facilitated respiratory support. One of these children had diagnosis criteria for acute lung injury, another for acute respiratory distress syndrome.</p> <p>Establishment of NAVA provided synchronization of mechanical ventilatory support with the breathing efforts of the children. Respiratory rate and inspiratory pressure became extremely variable, varying at each cycle, while children were breathing easily and smoothly. All three children demonstrated less oxygen requirements after introducing NAVA (57 ± 6% to 42 ± 18%). This improvement was observed while peak airway pressure decreased (28 ± 3 to 15 ± 5 cm H₂O). In one child, NAVA facilitated the management of acute respiratory distress syndrome with extensive subcutaneous emphysema.</p> <p>Conclusions</p> <p>Our findings highlight the feasibility and benefit of NAVA in children with severe RSV-related bronchiolitis. NAVA provides a less aggressive ventilation requiring lower inspiratory pressures with good results for oxygenation and more comfort for the children.</p

Pyrogen testing of phage therapeutic products

The use of phage therapeutic products has gained popularity in Belgium these last years, with treatments provided to more than 100 patients, against more than 10 different bacterial species. Therapeutic phage products are produced&nbsp; in a bacterial host strain, hence pyrogen contamination (e.g. cell wall debris) is a major safety concern as these pro-inflammatory agents can cause unwanted clinical reactions with potential detrimental outcome. The most common and potent pyrogens are endotoxins, components of the cell wall of gram-negative bacteria which are released upon bacterial&nbsp;lysis. &nbsp; In our routine phage quality control (QC) workflow, endotoxins are quantified using the Limulus amoebocyte lysate (LAL) assay and the animal-friendly alternative, the recombinant factor C (rFC) test. However, other (non-endotoxin) pyrogenic substances including compounds of the gram-positive bacterial cell wall, flagellin, etc. are not detected by those tests. As phages are being produced in a growing variety of bacterial host strains, including gram-positive bacteria, an expansion of the QC workflow is pivotal to limit the risk of non-endotoxin contamination. These pyrogens can be detected by the monocyte activation test (MAT), which employs human blood cells to quantify pyrogenicity in vitro. In this work, we discuss and compare the applicability of the LAL, rFC and MAT tests for pyrogen testing of clinical grade phage products based on the analysis of various productions manufactured by the Queen Astrid Military Hospital in Brussels. With a few exceptions, the results on different phages demonstrate that in general pyrogenic contamination is low for most&nbsp;samples.</p

Extracorporeal life support for patients with acute respiratory distress syndrome: report of a Consensus Conference

International audienceThe influenza H1N1 epidemics in 2009 led a substantial number of people to develop severe acute respiratory distress syndrome and refractory hypoxemia. In these patients, extracorporeal membrane oxygenation was used as rescue oxygenation therapy. Several randomized clinical trials and observational studies suggested that extracorporeal membrane oxygenation associated with protective mechanical ventilation could improve outcome, but its efficacy remains uncertain. Organized by the Societe de Reanimation de Langue Francaise (SRLF) in conjunction with the Societe Francaise d'Anesthesie et de Reanimation (SFAR), the Societe de Pneumologie de Langue Francaise (SPLF), the Groupe Francophone de Reanimation et d'Urgences Pediatriques (GFRUP), the Societe Francaise de Perfusion (SOFRAPERF), the Societe Francaise de Chirurgie Thoracique et Cardiovasculaire (SFCTV) et the Sociedad Espanola de Medecina Intensiva Critica y Unidades Coronarias (SEMICYUC), a Consensus Conference was held in December 2013 and a jury of 13 members wrote 65 recommendations to answer the five following questions regarding the place of extracorporeal life support for patients with acute respiratory distress syndrome: 1) What are the available techniques?; 2) Which patients could benefit from extracorporeal life support?; 3) How to perform extracorporeal life support?; 4) How and when to stop extracorporeal life support?; 5) Which organization should be recommended? To write the recommendations, evidence-based medicine (GRADE method), expert panel opinions, and shared decisions taken by all the thirteen members of the jury of the Consensus Conference were taken into account