Respiratory care最新文献

Background: Determining which patients with ARDS are most likely to benefit from lung recruitment maneuvers is challenging for physicians. The aim of this study was to assess whether the single-breath simplified decremental PEEP maneuver, which evaluates potential lung recruitment, may predict a subject's response to lung recruitment maneuvers, followed by PEEP titration.

Methods: We conducted a pilot prospective single-center cohort study with a 3-step protocol that defined sequential measurements. First, potential lung recruitment was assessed by the single-breath maneuver in the volume controlled mode. Second, the lung recruitment maneuver was performed in the pressure controlled mode, with a fixed driving pressure of 15 cm H₂O and a maximum PEEP of 30 cm H₂O. Third, the lung recruitment maneuver was followed by decremental PEEP titration to determine the optimal PEEP, defined as the lowest driving pressure. Responders to the lung recruitment maneuver were defined by an improvement in [Formula: see text]/[Formula: see text] > 20% between the baseline state and the end of the PEEP titration phase.

Results: Forty-two subjects with moderate-to-severe ARDS were included. The mean ± SD lung recruitment was 149 ± 104 mL. A threshold lung recruitment of 195 mL (area under the receiver operator characteristic curve 0.62, 95% CI 0.43-0.80) predicted a positive response to the maximal lung recruitment maneuver. The lung recruitment maneuver, followed by PEEP titration, resulted in a modification of PEEP in 74% of the subjects. PEEP was increased in more than two thirds of the responders and decreased in almost half of the non-responders to the lung recruitment maneuver. In addition, a decrease in driving pressure and an increase in respiratory system compliance were reported in 62% and 67% of the subjects, respectively.

Conclusions: The single-breath maneuver for evaluating lung recruitability predicted, with poor accuracy, the subjects who responded to the lung recruitment maneuver based on [Formula: see text]/[Formula: see text] improvement. Nevertheless, the lung recruitment maneuver, followed by PEEP titration, improved ventilator settings and respiratory mechanics in a majority of subjects.

Background: This Population, Intervention, Comparison, and Outcomes-guided systematic review assesses continuous lateral rotation therapy versus conventional position changes in mechanically ventilated critically ill adults, evaluating mortality, ICU length of stay (LOS), and hospital LOS as primary outcomes and respiratory function, mechanical ventilation duration, pulmonary complications, and adverse events as secondary outcomes.

Methods: This systematic review follows Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria (International Prospective Register of Systematic Reviews CRD42022384258). Searches spanned databases MEDLINE/PubMed, Embase, Scopus, ScienceDirect, Cochrane, CINAHL, and Web of Science, without language or publication year restrictions. Inclusion criteria involved randomized controlled trials (RCTs) and quasi-randomized trials, comparing continuous lateral rotation therapy (intervention) with conventional position changes (control). Risk of bias and quality of evidence for RCTs were assessed using the Cochrane Collaboration and Grading of Recommendations Assessment, Development, and Evaluation tools. For the quasi-randomized trials, the Risk of Bias in Non-Randomized Studies-of Interventions tool was used.

Results: In 18 studies with 1,466 participants (intervention, n = 700, 47.7%; control, n = 766, 52.2%), continuous lateral rotation therapy was predominantly used for prophylactic purposes, with protocols varying from 10-24 h/d. Meta-analysis (16 RCTs) favored continuous lateral rotation therapy for reduced mechanical ventilation duration (standardized mean difference [SMD] -0.17 [CI -0.29 to -0.04] d, P = .008) and lower nosocomial pneumonia incidence (odds ratio 0.39 [CI 0.29-0.52], P < .001). Continuous lateral rotation therapy showed no significant impact on mortality (odds ratio 1.04 [CI 0.80-1.34], P = .77), ICU LOS (SMD -0.11 [CI -0.25 to 0.02] d, P = .11), hospital LOS (SMD -0.10 [CI -0.31 to 0.11] d, P = .33), and incidence of pressure ulcers (odds ratio 0.73 [CI 0.34-1.60], P = .44).

Conclusions: Continuous lateral rotation therapy showed no significant difference in primary outcomes (mortality, ICU and hospital LOS) but revealed significant differences in secondary outcomes (consistently reduced nosocomial pneumonia, with a minor effect on mechanical ventilation duration), supported by moderate certainty. Very low certainty for other outcomes highlights the need for current studies in diverse clinical settings and protocols to assess continuous lateral rotation therapy effectiveness.

Background: Despite advancements in cystic fibrosis (CF) therapeutics, the persistence of chronic infections necessitates continued use of nebulized therapies. Though the Cystic Fibrosis Foundation recommends well-defined cleaning and disinfection of nebulizers to mitigate pathogen exposure risks, discrepancies between Cystic Fibrosis Foundation guidelines, manufacturers' instructions, and variability in center recommendations contribute to confusion and non-standardized practices.

Methods: A digital survey was distributed to directors, associate directors, and care coordinators of CF centers across the United States to investigate the methods, frequency, and educational practices surrounding nebulizer care they provide patients. Responses were analyzed using descriptive techniques and chi-square analyses.

Results: Of 855 distributed surveys, 129 respondents provided insights into nebulizer care recommendations. Discrepancies in disinfection frequency were notable, with 18% of respondents recommending disinfecting nebulizers less than daily. Approximately 20% of respondents were unsure if their recommendations aligned with Cystic Fibrosis Foundation guidelines while 73% reported that their recommendations strictly adhered to the published guidelines. Of this 73%, all recommended at least daily cleaning, with 69% specifying cleaning before reuse; and 88% recommended disinfection at least daily, with 36% specifying disinfection before reuse. Only 10% recommended both cleaning and disinfection after every use. Disinfection less than daily was recommended by 11% of the respondents who felt they were strictly following the guidelines. We also highlight respondents who cited barriers to strict adhesion to the published guidelines.

Conclusions: The highlighted variations in CF centers' recommendations for nebulizer care with deviations from Cystic Fibrosis Foundation guidelines underscore the necessity for developing clear and practical guidelines that consider both efficacy and the realities of patient adherence. Collaboration among CF care centers, patients, guideline committees, and other stakeholders is essential to develop recommendations that effectively address the challenges faced by the CF community, ensuring the safe and effective nebulizer use.

COVID-19, caused by SARS-CoV-2 infection, led to a pandemic of acute respiratory illness that is ongoing. High-flow nasal cannula (HFNC) is a commonly used form of respiratory support during acute respiratory distress and is used to treat patients with COVID-19 in many centers. Due to the novel nature of COVID-19 at the onset of the pandemic, evidence to support the use and best practices of HFNC for treating patients with COVID-19 was lacking. This is a review of key peer-reviewed manuscripts from 2022-2023 discussing the efficacy and best practices for using HFNC for patients with COVID-19. Efficacy of HFNC for COVID-19, the use of the respiratory oxygenation index to guide HFNC for COVID-19, and concerns of generated/fugitive aerosols when using HFNC for COVID-19 are emphasized.

Background: The COVID-19 global pandemic dramatically increased our institution's tracheostomy census. Comparing our existing protocols with American Association for Respiratory Care (AARC) January 2021 clinical practice guideline (CPG) relevant to caring for adult patients with tracheostomy in the acute care setting revealed numerous opportunities for improving our care of those patients. We assembled an interdisciplinary tracheostomy team to implement AARC CPG recommendations and manage all patients with tracheostomy in our hospital.

Methods: We examined the effect our interdisciplinary team approach and implementation of AARC CPG recommendations had on the following metrics: average patient length of stay (LOS); ICU LOS; percentage of ventilator days; percentage of tracheostomy mask days; tracheostomy tube changes; decannulations; average time to decannulation; mortality; 30-d readmissions; and consultations for speech-language pathology (SLP), one-way speaking valves, physical therapy, and occupational therapy.

Results: A total of 203 subjects with tracheostomy were followed in a quality improvement study from June 2019-June 2023 (94 in the pre-intervention group, 109 in the post group). There were significant increases between before and after intervention groups in percentage of decannulations in acutely patients with tracheostomy/not present on admission, non-COVID subjects who survived hospitalization (11.8% vs 33.3%, P = .043), percentage of SLP consults (53.2% vs 89.0%, P < .001), and percentage of one-way speaking valve consults (17.0% vs 32.1%, P = .02).

Conclusions: Establishment of an interdisciplinary tracheostomy team and implementation of AARC CPG recommendations for care of adult patients with tracheostomy in the acute care setting resulted in positive, statistically significant outcomes.

Background: A noninvasive ventilation (NIV) mask has been designed to deliver NIV with expiratory washout to improve efficacy of ventilation by optimizing clearance of expired gases from the anatomic dead space. This study compared the performance and comfort of a novel investigational mask with expiratory washout with a conventional mask during NIV therapy.

Methods: In this pilot crossover study, participants with severe stable COPD attended a single visit to receive bi-level NIV through 2 masks; the investigational mask with expiratory washout and a conventional mask. The order of mask use was randomly allocated, and each mask was used for 60 min with a 30-60-min washout in between. The primary outcome was transcutaneous carbon dioxide at 60 min. Other physiologic and NIV device variables were also assessed.

Results: The mean difference (95% CI) in the transcutaneous carbon dioxide between the investigational and conventional masks at 60 min, adjusted for baseline, was -0.74 mm Hg, 95% CI -2.81 to 1.33 mm Hg (P = .45). The investigational mask with expiratory washout elicited a lower tidal volume (-128.7 mL, 95% CI -190.0 to -67.3 mL; P < .001) and minute ventilation (-2.28 L/min,^, 95% CI -3.12 to -1.43 L/min; P < .001), and a higher leak (7.96 L/min, 95% CI 4.39-11.54 L/min; P < .001) than the conventional mask. There were no differences in other physiologic responses or ratings of dyspnea or comfort.

Conclusions: NIV therapy delivered by using a novel mask with expiratory washout was similarly effective at reducing transcutaneous carbon dioxide, whereas the delivered tidal volume and minute ventilation were significantly lower when compared with a conventional mask in participants with severe COPD.

Background: Lung-protective ventilation is a standard intervention for mitigating ventilator-induced lung injury in patients with ARDS. Despite its efficacy, adherence to contemporary evidence-based guidelines remains suboptimal. We aimed to identify factors that affect the adherence of staff to applying lung-protective ventilation guidelines by analyzing real-time, continuously monitored ventilation data over a 5-year longitudinal period.

Methods: We conducted retrospective cohort and qualitative studies. Subjects with billing code J80 who survived at least 48 h of continuous mandatory ventilation with volume control in critical care settings between January 1, 2018, and December 31, 2022, were eligible. Tidal volume was measured dynamically (1-min resolution) and averaged hourly. The lung-protective ventilation setting studied was ≤ 6 mL/kg predicted body weight. A subgroup analysis was conducted by considering COVID-19 status. Focus groups of critical-care providers were convened to investigate the possible reasons for the non-utilization of lung-protective ventilation.

Results: Among 1,055 subjects, 42.4% were on lung-protective ventilation settings at 48 h. Male sex was correlated with lung-protective ventilation (odds ratio [OR] 1.63, 95% CI 1.08-2.47), whereas age ≥ 60 y was associated with no lung-protective ventilation use (OR 0.61, 95% CI 0.39-0.94] in the subjects with non-COVID-19 etiologies. Improved staff adherence was observed in the subjects with COVID-19 early in the pandemic when COVID-19 (OR 1.48, 95% CI 1.07-2.04), male sex (OR 2.42, 95% CI 1.79-3.29), and neuromuscular blocking agent use within 48 h (OR 1.69, 95% CI 1.25-2.29) were correlated with staff placing subjects on lung-protective ventilation. However, lung-protective ventilation use occurred less frequently by staff managing subjects with cancer (OR 0.59, 95% CI 0.35-0.99) and hypertension (OR 0.62, 95% CI 0.45-0.85). Focus groups supported these findings and highlighted the need for an accurate height measurement on unit admission to determine the appropriate target tidal volume.

Conclusions: Staff are not yet universally adherent to lung-protective ventilation best practices. Strategies, for example, continuous monitoring, with frequent feedback to clinical teams may help.

Background: The understanding of how pharyngeal pressure is transmitted to the trachea with high-flow nasal cannula (HFNC) implementation and the behavior of tracheal pressure in the presence of mouth leaks remains limited. This study aimed to assess the impact of HFNC administration on tracheal pressure by comparing measurements taken with open and closed mouth with varying flows.

Methods: A crossover study was conducted between March 2019 and June 2023. Subjects age > 18 years, with a tracheostomy and who were in the process of decannulation were included. Tracheal and pharyngeal pressures were measured by using specific devices, with different HFNC flows and mouth conditions.

Results: Nine subjects were assessed: 77% women, with an average age of 60.5 years. Tracheal pressure was significantly higher than pharyngeal pressure only in baseline conditions (P = .03). With regard to the rest of the scenarios, there were no significant differences between both pressures. Tracheal pressure was higher than the baseline condition both with an open mouth and a closed mouth (P = .02). The tracheal pressure at 60 L/min with an open mouth was higher than at 40 L/min (P = .042). The median pharyngeal pressure with a closed mouth was higher than with an open mouth, both with 40 and 60 L/min of flow (P = .048 and P < .001, respectively). Pharyngeal pressure at 60 L/min with an open mouth was higher than both baseline condition and at 40 L/min (P = .002 and P = .043, respectively). However, pharyngeal pressure with the closed mouth was significantly higher than with the open mouth both with 40 and 60 L/min of flow (P = .031 and P = .02 respectively).

Conclusions: The implementation of HFNC changes airway pressures with values that impact at a tracheal level as the flow used increases. Our data contribute to the difficult interpretation of the existing interrelation between the programmed flow and its effects on the respiratory system.

Background: Mechanical insufflation-exsufflation (MI-E) is crucial to assist patients with impaired cough, especially those with neuromuscular diseases. Despite recent advancements that enable real-time display of peak expiratory flow (PEF) and inspiratory volume, accurately monitoring these parameters with MI-E devices during treatment can still present challenges.

Methods: A bench study that used a mechanical lung connected to 3 MI-E devices (EOVE-70; E-70 and Comfort Cough II) was conducted to evaluate PEF and inspiratory volume monitoring accuracy. Two clinical conditions were tested, low and normal compliance, with 6 different MI-E settings tested: +20/-20, +30/-30, +40/-40, +40/-50, +40/-60, and +40/-70 cm H₂O. PEF (L/min) and inspiratory volume (mL) displayed on the screen were recorded cycle by cycle, while a pneumotachograph connected to the mechanical lung was used to measure the actual PEF and inspiratory volume for data comparison. Flow bias was assessed by calculating the difference (PEF - peak inspiratory flow) and ratio (PEF to peak inspiratory flow) between flows.

Results: All devices systematically underestimated PEF, with device A showing the smallest estimation error (-7.4 [-10.1; -6] %). Devices B and C exhibited larger errors (-26.5 [-29.2; -25.6] and (-29.9 [-30.7; -28.7] %, respectively). All the devices underestimated inspiratory volume, with device B showing the smallest estimation error (-15.1 [-21.2; -12.3] %). Device A exhibited a significantly larger error (-26.9 [-30.3; -24.8] %). The error from device C (-17.7 [-34.5; -13.8] %) was not statistically different from device B. Device type, high pressure settings (> +40/-40 cm H₂O), and a lung model compliance of 60 mL/cm H₂O were the main contributors to error in estimating PEF and inspiratory volume. Finally, we observed differences of PEF-to-peak inspiratory flow ratio and PEF minus peak inspiratory flow differences achieved.

Conclusions: Our study highlighted consistent underestimation of PEF and inspiratory volume across MI-E devices. Improving device monitoring is essential for guiding MI-E therapy and ensuring patient safety.

Background: Assessing respiratory mechanics in patients with acute hypoxemic respiratory failure who are not intubated could provide useful information about illness trajectory. Oscillometry is a respiratory function test used to measure total respiratory impedance during tidal breathing, which reveals resistive and elastic properties of the lung. This study assessed the feasibility of oscillometry in patients with acute hypoxemic respiratory failure and described their respiratory mechanics.

Methods: Adult participants with acute hypoxemic respiratory failure who were receiving noninvasive respiratory support with ${\text{F}}_{{\text{IO}}_{\text{2}}}$ ≥0.4 and flow ≥6 L/min underwent oscillometry at baseline and after resolution of acute hypoxemic respiratory failure. The primary end point was the number of participants who completed the baseline measurement. The feasibility criterion was in obtaining baseline oscillometry measurements in ≥80% of enrolled participants.

Results: Of 183 patients screened between July 2022 and August 2023, 29% were unable to cooperate due to altered mental state, 20% with extreme hypoxemia were excluded because of clinical instability, and 12% declined participation. Of the 10 participants (5.4%) recruited, all tolerated oscillometry measurements. At baseline, the median (minimum, maximum) ${\text{F}}_{{\text{IO}}_{\text{2}}}$ was 0.8 (0.4, 0.8), median oxygen saturation of 94% dropped to a nadir of 82% at the end of oscillometry and recovered within 2 min. Lung reactance was increased, with a reactance area of 25 (15-32) cm H₂O/L. Hypoxemia resolved in 9 participants. After resolution of acute hypoxemic respiratory failure in 8 (6-16) d, the median reactance area dropped to 15 (14-19) cm H₂O/L.

Conclusions: Respiratory mechanics in the participants with acute hypoxemic respiratory failure who were not intubated could be assessed by oscillometry in carefully selected cases.