Respiratory care最新文献

Background: Exercise-induced bronchoconstriction (EIB) is common in children with asthma, but whether it is a phenomenon of central versus peripheral airway reactivity is unknown. The purpose of this study was to investigate central and peripheral airway responses after an exercise challenge test among children with asthma. Methods: Sixteen children with asthma underwent exercise challenge testing on 2 separate visits: one without any medications (control) and another with pretreatment with 180 µg albuterol (bronchodilator). Central airway EIB was defined as a >10% reduction in FEV₁ after exercise assessed with spirometry. Peripheral airway EIB was assessed as a >40% increase in resistance between 5 Hz and 20 Hz with impulse oscillometry. Spirometry and impulse oscillometry were measured before the condition and periodically for up to 30 min after exercise. Results: Three of 16 children (19%) experienced only central airway EIB. Ten of 16 children (62%), including all 3 who experienced central airway EIB, experienced peripheral airway EIB. Among children who experienced EIB, resistance between 5 Hz and 20 Hz increased by 119.67 ± 102.56% after exercise during the control condition compared with an average decrease of -10.38 ± 34.97% during the bronchodilator condition, which suggests that albuterol was effective in preventing EIB (P = .003, paired t test). Conclusions: Peripheral airway EIB may occur frequently in children with asthma. Spirometry-based testing alone may miss peripheral airway EIB in some children. Impulse oscillometry could be used in conjunction with spirometry to detect peripheral airway EIB in children with asthma.

Background: Spinal muscular atrophy (SMA) is often complicated by respiratory problems. The disease-modifying therapies (DMTs) (nusinersen, onasemnogene abeparvovec, and risdiplam) have improved survival, motor function, and functional muscle strength in patients with SMA, but their effects on lung function and respiratory muscle strength need further clarification. Therefore, we performed a systematic review of studies that documented the effects of DMTs on lung function and respiratory muscle strength in patients with SMA types I, II, III, and IV. Methods: We searched the electronic databases PubMed/MEDLINE, CINAHL, Embase, and Web of Science up to December 2023. We included pre-post studies that determined the effect of DMTs for SMA on lung function or respiratory muscle strength in patients with SMA. Where possible, we performed a meta-analysis using a random-effects model with generic inverse variance weighing. Results: We included 19 studies of 376 identified records (16 longitudinal cohort studies and 3 case series) with 384 participants. Seventeen studies investigated the effect of nusinersen, and two studies investigated the effect of risdiplam. Seventeen studies had a moderate and two had a high risk of bias. Most of these studies did not report statistically significant improvement in lung function or respiratory muscle strength after treatment with nusinersen or risdiplam. A meta-analysis of 13 studies showed no statistically significant improvement in FVC after 2, 6, 10, and > 12 months of treatment with nusinersen. Conclusions: The findings of this review indicate that there is moderate evidence that nusinersen does not improve FVC, FEV₁, peak expiratory flow, or maximum inspiratory pressure in subjects with SMA types I, II, III, or IV. There was no statistically significant decline in lung function and respiratory muscle strength after treatment. This may suggest that nusinersen may have stabilized lung function and respiratory muscle strength.

Background: The 2014 American Academy of Pediatrics recommendation for CPAP as an alternative to mechanical ventilation for treatment of neonatal respiratory distress prompted a rapid shift to noninvasive respiratory support. Since most patients receive nasal bubble CPAP a concomitant increase in nasal pressure injuries followed. This prospective observational study aimed to develop strategies to reduce nasal mask pressure injury in neonates by (1) quantifying CPAP mask-interface pressure and (2) assessing placement variability. Methods: A micro-electromechanical systems pressure sensor was modified for contact pressure measurements with silicone embedding and calibrated. The CPAP generator and interface components were sized for a 24-week neonatal simulator. Thirteen neonatal ICU staff placed the simulator on CPAP at 6 cm H₂O and 8 L/min of flow with no humidification. Pressure was measured at 3 locations (the forehead, nasal bridge, and philtrum) in triplicate (3 measurements/site). Descriptive statistics; a location-specific, one-way analysis of variance with a Tukey post hoc test; and a 2-sample paired t test of the means of the first and last triplicate were performed. Results: Pressure ranged from 12-377.3 mm Hg. The mean [SD] interface pressure at the philtrum was significantly higher than both the nasal bridge and the forehead (philtrum 173.9 [101.3], nasal bridge 67.8 [28.9], and forehead 79.0 [36.9], P < .001). CPAP fixation varied, including bonnet placement, trunk angle, mask compression, use of hook and loop extenders, and level of vigorous bubble feedback achieved. Conclusions: This study developed a modified pressure sensor for quantifying the pressure exerted by a nasal mask on facial skin. Maximum pressures were higher than those previously reported. Inter-individual differences were present in both quantitative and qualitative measures of pressure. Reduction of NIV-associated pressure injuries may be achieved through NIV fixation technique training and improved nasal mask stability and size increments.

Background: The dose level and duration needed for early rehabilitation of mechanically ventilated patients in the ICU need to be characterized. Therefore, this study aimed to assess the association between mobilization level, rehabilitation time, and dose (defined as the mean mobilization quantification score [MQS]) during ICU admission and the end point walking independence at hospital discharge in subjects needing ICU admission. Methods: This prospective, multi-center, cohort study included 9 ICUs. Consecutive subjects admitted to the ICU between September 2022-March 2023 receiving mechanical ventilation for >48 h were included in the study. The mean MQS score, highest ICU mobility score (IMS) during the ICU stay, time to the first mobilization day, ICU rehabilitation time (minutes of each rehabilitation physical activity from start to finish), frequency/d, baseline characteristics, and walking independence at hospital discharge were assessed. Results: Among the 116 subjects, 64 did and 51 did not walk independently at hospital discharge, respectively. Multiple logistic regression analysis revealed that the mean MQS and time to first mobilization were significantly associated with walking independence at hospital discharge. We observed that mean MQS was better than IMS, rehabilitation time, frequency, and time to first mobilization predicted walking independence based on receiver operating characteristic (ROC) curve comparison. Comparison of the mean MQS with that on the first mobilization day revealed superior predicting power of the mean MQS. The ROC curve cutoff value for the mean MQS was 4.0. Conclusions: This study shows that in subjects mechanically ventilated for >48 h the dose of rehabilitation calculated using the mean MQS during ICU was a better predictor of walking independence at hospital discharge than intensity, duration, or frequency of the mobilization therapy. Mean MQS during ICU stay may be used to measure and titrate optimal mobilization therapy.

Background: Personalized education and treatment selection can improve health behaviors and outcomes in patients with COPD. However, many patients with COPD have incomplete knowledge of their disease, which leads to undertreated symptoms. We hypothesized that an interdisciplinary care approach to COPD with respiratory therapists (RTs) integrated in our dedicated clinic will significantly affect care as measured by COPD Assessment Test (CAT) scores, exacerbation rates, and COPD-related hospitalizations. Methods: This study was a retrospective analysis of patients enrolled in the UC Davis Comprehensive COPD Clinic registry. Between January 2018-January 2020, 241 patients were seen. Patients screened (n = 101) had been followed 12 months post initial COPD clinic visit. Two subjects were excluded from analysis due to discrepancies in CAT assessments, leaving 99 subjects in total. The clinic RT provided assessment, education, and treatment recommendations. We collected CAT scores, exacerbation rates, and those that required hospitalization in the 12 months prior to and after the initial COPD clinic visit. Analysis for CAT is reported as median and interquartile range (IQR), with differences determined by Wilcoxon test. Summary data are reported as percentages, 95% CI, and chi-square test. Results: The initial median CAT score was 22 (IQR 7-34), and 2-month follow-up CAT median was 19 (IQR 11-24, P < .001). There were 115 exacerbations in the 12-month period prior to the initial clinic visit and 63 exacerbations in the 12 months post clinic visit (P = .006). In the 12-month period prior to the clinic visit, there were 44 hospital admissions for COPD exacerbations compared to 20 hospital admissions for COPD exacerbations in the 12 months after initial clinic visit (P = .06). Conclusions: Our retrospective study demonstrated significant improvements in symptoms and exacerbation rates and a non-significant reduction in hospitalizations for COPD. This suggests that an RT-facilitated program may improve meaningful clinical outcomes.

Background: The literature suggests there is variability in the clinical practice of spontaneous breathing trials (SBTs). Evidence-based literature and clinical practice guidelines (CPGs) have been published over time to address various aspects of SBT implementation. It can take many years for evidence-based recommendations to be adopted into clinical practice. The American Association for Respiratory Care recently published a CPG addressing 4 aspects of SBT implementation. Methods: This study evaluated how the clinical practice of SBTs compares to the recommendations of the CPG. An online survey was developed to assess how hospitals with SBT protocols perform different components of SBTs. Descriptive statistics were used in the data analysis. Results: A total of 26 representatives from different health care institutions in the United States met the criteria for data analysis; 61.5% of reported protocols use rapid shallow breathing index, which is not in alignment with the current recommendation; 77% reported the use of pressure support (PS); 11.5% specified the use of a T-piece, and 11% specified the option of either PS or T-piece during the SBT. The responses were 100% in alignment with the current recommendation of performing a SBT with or without support; 73.1% aligned with having a standardized approach to performing SBTs by specifying when the SBT will be initiated; 65.4% perform an SBT during the day, though it was not specified if it occurs before noon each day; 53.8% allow for an increase in F_IO2 during an SBT, which is not in alignment with the current recommendations. Conclusions: The reported hospitals' protocols demonstrated moderate alignment with the 4 CPG recommendations. Identifying current discrepancies between clinical practice and CPGs will allow for the assessment of the adoption of recommendations into clinical practice over time. Further assessment could be performed to determine if there is an impact on patient outcomes.

Background: Dyspnea and desaturation during exercise are essential assessment items for pulmonary rehabilitation. Characterizing patients using these 2 factors may be important for providing more effective pulmonary rehabilitation. This study aimed to categorize subjects with interstitial lung disease (ILD) using dyspnea and desaturation at the end of the 6-min walk test (6MWT). Methods: This was a retrospective study including 230 stable subjects with ILD who underwent 6MWT in our out-patient department at a general hospital in Japan. The modified Borg scale and oxygen saturation determined by S_pO2 at the end of the 6MWT were used for cluster analysis using the k-means method with k = 4. Results: Subjects were classified into 4 characteristic clusters. S_pO2 at the end of the 6MWT was lower in cluster 4 (80.5 ± 3.0%) than in clusters 1 (94.3 ± 2.0%), 2 (94.3 ± 1.9%), and 3 (87.9 ± 1.8%) and was lower in cluster 3 than in clusters 1 and 2. The modified Borg scale score at the end of the 6MWT was higher in clusters 2 (4 [3-8]), 3 (3 [0-9]), and 4 (4 [0-7]) than in cluster 1 (0.5 [0-2.0]) and was higher in cluster 2 than in cluster 3. Conclusions: Subjects with ILD were classified into 4 characteristic clusters using dyspnea and S_pO2 at the end of the 6MWT. The 4 clusters are characterized as follows: Cluster 1 had mild desaturation and mild dyspnea; cluster 2 had mild desaturation and severe dyspnea; cluster 3 had both moderate desaturation and dyspnea, and cluster 4 had both severe desaturation and dyspnea. These classification data offer insight for individualized pulmonary rehabilitation for patients with ILD.

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: The burden of asthma remains steady with no decline observed in the past few decades. Obesity prevalence has been steadily increasing with a rate of 41.9% in the United States between 2017-2020. Obesity is an inflammatory chronic condition that may partially contribute to the burden and severity of asthma. This study aimed to examine whether the association between obesity and asthma varies with the categories of obesity (class I, II, and III) and persistent asthma (mild, moderate, and severe asthma). We hypothesized that subjects with elevated body mass index (BMI) are more likely to be diagnosed with persistent asthma than subjects without obesity with asthma. Methods: As a retrospective and cross-sectional study, this study used a total of 1,977 records of subjects with asthma (age ≥ 19 y) hospitalized in Nevada between 2016-2021. BMI and persistent asthma were evaluated as the main exposure and outcome of interest. Logistic regression was used to estimate the magnitude of the association between obesity and persistent asthma. Results: Among the selected subject records, subjects with obesity were more likely to be diagnosed with persistent asthma compared to subjects without obesity (odds ratio 1.50 [CI 1.10-2.05]). Subgroup analyses revealed that subjects with class III obesity (BMI ≥ 40) were more likely than subjects without obesity to be diagnosed with mild persistent asthma (odds ratio 2.21 [CI 1.18-4.16]) and severe persistent asthma (odds ratio 1.74 [CI 1.12-2.70]). Conclusions: Obesity was identified as a risk factor for persistent asthma, particularly class III obesity. This in turn increases the potential for greater health care utilization and economic burden. Public health and clinical interventions are necessary among those with comorbid asthma and obesity.