Respiratory care最新文献

Hypothermia, defined as a core body temperature ≤35°C, significantly increases morbidity and mortality in mechanically ventilated patients across numerous care settings. Physiologically, the upper airway conditions inspired gases to body temperature and humidity, minimizing heat energy loss and preventing mucosal damage. Instrumentation, such as endotracheal intubation, bypasses this natural mechanism, leading to considerable heat and moisture loss, potentially exacerbating hypothermia risks in critically ill patients. Active humidifiers and heat and moisture exchangers represent common strategies to mitigate airway heat loss, yet their effectiveness as a method to assist in whole-body rewarming is controversial. Emerging technologies indicate renewed interest in airway-based warming devices, especially for prehospital and military trauma scenarios, but robust clinical validation remains necessary. This narrative review evaluates the feasibility and effectiveness of airway-based thermoregulation through inhalation of heated, humidified gases.

Background: Atelectasis and hypoxemia may occur in invasively ventilated patients undergoing bronchoscopy. This study aimed to assess the respiratory effects of recruitment maneuver (RM) in these patients and explore the population likely to benefit from RM after bronchoscopy.

Methods: This single-center, prospective, observational study included subjects undergoing bronchoscopy who were invasively ventilated. RM was performed 5 min after bronchoscopy by maintaining breaths at a pressure control of 20 cm H₂O and a PEEP of 20 cm H₂O for 1 min. Lung aeration, monitored using electrical impedance tomography (EIT), was assessed throughout the study. High recruitability was defined as an increase in end-expiratory lung impedance (EELI) greater than 20% relative to its value before RM (△EELI/EELI), along with a decrease in the global inhomogeneity (GI) index due to RM.

Results: Of the 80 subjects who completed the study, 32 met the predefined criteria for high recruitability. Subjects' respiratory-system compliance (C_RS) before bronchoscopy (odds ratio [OR] 0.921 [0.854-0.993], P = .032) and the decrease in the ratio of P_aO2/F_IO2 due to bronchoscopy (OR 0.097 [0.020-0.457], P = .003) were significantly associated with high recruitability. In subjects with high recruitability, significant improvements were observed in C_RS in the dorsal region (15.3 ± 6.3 vs 13.5 ± 6.0, P = .002), center of ventilation (43.8 ± 4.8 vs 43.0 ± 4.8, P = .01), GI index (0.39 ± 0.07 vs 0.44 ± 0.08, P < .001), and P_aO2/F_IO2 (257.1 ± 123.5 vs 212 ± 106.6, P < .001) due to RM after fiberoptic bronchoscopy, while no such benefits were observed in subjects exhibiting low recruitability.

Conclusions: In subjects with lower C_RS before bronchoscopy and a decreased P_aO2/F_IO2 due to bronchoscopy, RM after bronchoscopy improved C_RS in the dorsal regions, promoted more uniform ventilation, and improved oxygenation. These patients are likely to benefit more from post-bronchoscopy RM.

Background: The role of noninvasive ventilation (NIV) and heated humidified high-flow nasal cannula (HFNC) in children with high risk for extubation failure is not established. The objective of our study was to compare the re-intubation rate within 48 h of extubation in high-risk children while receiving HFNC or NIV.

Methods: This open-label, parallel, noninferiority randomized trial was conducted on high-risk cases in a 12-bed quaternary-level pediatric ICU. All patients aged 1 month to 18 years receiving invasive mechanical ventilation through an endotracheal tube for >48 h were screened for eligibility. Criteria for high-risk patients for extubation, spontaneous breathing trial, extubation readiness, and re-intubation were defined a priori. Subjects were randomized immediately prior to extubation to receive NIV or HFNC. F_IO2, NIV settings, and flow setting for HFNC were selected according to a predefined algorithm. All subjects were monitored for hemodynamic instability and increased work of breathing, and the target S_pO2 was 92%.

Results: Intention-to-treat analysis was done with 142 subjects in each group. At baseline, both groups were comparable for severity of disease and organ dysfunction. Re-intubation was required in 15 (10.5%) cases in the NIV and 17 (11.9%) of the HFNC group, with no absolute difference (P = .74). The dosage of dexmedetomidine was significantly lower in the HFNC as compared with the NIV group [(0.85 ± 0.22 versus 1.02 ± 0.13 µg/kg/h; 95% CI 0.12-0.21, P < .001)]. Median (interquartile range) postextubation PICU stay was significantly shorter in HFNC subjects [3 (2-4.75) vs 4 (3-5)] days (P = .02).

Conclusions: HFNC was noninferior to NIV as respiratory support in high-risk children after extubation.

Background: During the COVID-19 pandemic, we implemented the Long-term In-Home Ventilator Engagement (LIVE) intervention to provide virtual specialist care. Using a matched home mechanical ventilation control group, we compared publicly funded health-service utilization and costs for ventilator-dependent children and adults receiving the LIVE eHealth intervention.

Methods: LIVE users were matched to controls on age, sex, ventilation type, years on ventilation, and reason for ventilation. The Ventilator Equipment Pool database was linked to health administrative data, which contains medically necessary health care service information on the entire population. We used analysis of covariance and generalized estimating equations to estimate the effect of the LIVE program on health care utilization and costs, controlling for 12-month prior health care utilization. We used Kaplan-Meier curves to compare survival rates.

Results: Of the 250 LIVE users, we were able to 1:1 match 178 with home mechanical ventilation controls. Adjusted rate ratios for most outcomes resulted in elevated costs and utilization in the post period attributable to LIVE; however, most did not reach statistical significance. All-cause in-patient admissions (16%), out-patient pulmonology visits (41%), and general practitioner costs (77%) were significantly elevated in LIVE participants in the post period. There was no statistically significant difference in survival between the groups.

Conclusions: LIVE users had higher rates of out-patient pulmonology visits, in-patient admissions, and general practitioner visit costs, but no difference in overall costs or mortality. This study highlights the limitations of evaluating eHealth interventions through observational research and the need for a randomized controlled trial.

Long-term oxygen therapy (LTOT), that is, home oxygen prescribed for at least 15-18 hours per day, improves survival in patients with COPD and severe hypoxemia. LTOT does not benefit all severely hypoxemic patients, however, a large proportion of patients who receive home oxygen do not benefit from therapy, whereas a number of patients who would benefit from home oxygen are denied therapy because they do not meet the current prescription criteria that are accepted worldwide. To overcome this problem, we suggest that the practice of LTOT prescription be individualized. Biomarkers of cellular or vascular dysfunction should complement the mere measurement of P_aO2 or S_pO2 to decide who should receive LTOT. In this article, we present clinical vignettes to illustrate the application of this proposal and describe a protocol for a clinical trial designed to test its validity.

Background: To investigate obstructive sleep apnea (OSA) prevalence, associated comorbidities, distribution of respiratory events in different sleep states, and body positions in infants. Methods: This was a single-center retrospective study that included infants aged 0 to 12 months who underwent polysomnogram (PSG). OSA severity was categorized by obstructive apnea-hypopnea index (OAHI) as mild (1-4.9 events/h), moderate (5-9.9 events/h), and severe (≥10 events/h). Results: One hundred eighteen infants were included with a median age of 5 months (interquartile range, [IQR] 2.0-9.0) for the OSA group (73/118) and 7 months (IQR 6.0-9.0) for the non-OSA group (45/118) (P = .01). The most common indication for PSG was snoring (57.5%), followed by apneas (41.1%). OSA prevalence was 61.9% (53.4% mild, 17.8% moderate, and 28.8% severe). Gastroesophageal reflux disease (GERD; 32.9%) and 21.9% of craniofacial abnormalities were commonly associated comorbidities. Multivariate binominal regression analysis indicated that infants with a history of craniofacial abnormalities (P = .038) had higher odds of having OSA. There were no significant differences noted in sleep architecture medians, such as total sleep time, sleep efficiency, sleep latency, stage 1, 2, 3, and rapid eye movement (REM) sleep durations, between the OSA and the non-OSA group, except for the median arousal index, which was significantly higher in the OSA group (15.7 [11.9, 24.1] versus 10.6 [9.4, 16.3]; P < .001). Differences in respiratory parameters including apnea hypopnea index (AHI), OAHI, REM AHI, non-REM AHI, S_pO2 nadir and mean, and carbon dioxide mean and peak were significant. In 6-12-month-olds, 32 infants with OSA had REM AHI that was higher than non-REM (AHI: 17.0 [10.9, 33.8] versus 2.3 [0.6, 6.0]; P < .001). Similarly, supine AHI was higher (P < .001) when we compared it with each non-supine positions individually. Conclusions: In infants, OSA was highly prevalent in our cohort; a history of GERD and craniofacial abnormalities were commonly associated comorbidities. Obstructive events occurred predominantly in REM sleep and the supine position.

Background: Arterial puncture for blood gas sampling is a painful procedure, often requiring multiple attempts. At this institution, the current standard of care does not include regular use of analgesics, which may lead to high anxiety and low patient satisfaction. Virtual reality (VR) technology has shown promise in reducing pain and anxiety in various medical procedures, though its use in arterial puncture remains unexplored. This study investigates the effectiveness of VR in reducing pain and anxiety during arterial puncture and its impact on patient satisfaction. Methods: A mixed-method study was conducted at Cedars-Sinai Medical Center's pulmonary function testing lab. Forty-one subjects scheduled for arterial blood sampling were assigned to either VR (21 subjects) or standard care (20 subjects) during the procedure. Remarkable differences in pain, anxiety, and patient satisfaction were evaluated. Additionally, qualitative insights were gathered from interviews with eleven subjects. Results: Quantitative analysis revealed a statistically significant (P < .001) and clinically important reduction in pain within the VR group with a 63% decrease that exceeded the minimum clinically important difference. Anxiety levels also showed a statistically significant (P < .001) and clinically meaningful reduction, with a 16.4-point decrease, surpassing the minimum clinically important difference. Patient satisfaction during the procedure was substantially higher in the VR group (P = .004), though no difference was observed in overall satisfaction (P = .21). Qualitative data indicated that subjects valued VR as a distraction from pain and felt more cared for, contributing positively to the overall patient experience. Conclusions: VR reduced pain and anxiety and enhanced patient satisfaction during arterial puncture. However, limitations such as small sample size and inclusion of only English language-speaking subjects restrict the ability to generalize results. Despite this, VR may show potential as a tool to improve patient experience and care quality.