Respiratory care最新文献

Effective airway clearance is essential for persons with neuromuscular disease. Airway clearance prevents infection and optimizes respiratory function and ventilation. The use of mechanical insufflation-exsufflation (MI-E) to promote airway clearance in persons with neuromuscular disorders is well documented. The aim of this scoping review was to identify and map the available evidence relating to physiological effects of MI-E in patients with neuromuscular disease. Electronic databases, including MEDLINE, CINAHL, EMBASE, EMCARE, SCOPUS, COCHRANE, and Web of Science, were searched from inception to November 2024. Inclusion criteria were studies involving spontaneous breathing, adult or pediatric participants with a neuromuscular diagnosis, English/translated to English articles, full-text articles, and studies involving MI-E with clear strategies. Data were extracted by 2 authors using a bespoke extraction form. A Mixed Methods Appraisal Tool was used to assess quality. Of 1,176 abstracts identified, 25 records were included. The review data suggested MI-E was well tolerated in persons with neuromuscular disease and proposed improved cough compared with participants' baseline. Studies predominately used cough peak flow to assess MI-E effectiveness, with emerging evidence looking at upper airway dynamics. Studies specifically focused on a pediatric neuromuscular cohort are vital, as this remains an under-researched area.

Background: Mechanical ventilation following pediatric liver transplant remains common and extends weaning duration. The aim of this study was to identify the risk factors for delayed extubation in children following liver transplantation, focusing on respiratory mechanics. We also compared respiratory morbidity and mortality according to the extubation status.

Methods: In this retrospective, monocentric cohort study, children under 18 years were included if they underwent primary liver transplant. The primary end point was delayed extubation, defined as any extubation 48 hours after transplantation. Preoperative graft and subject characteristics, as well as intra- and postoperative ventilatory and hemodynamic parameters, were tested to assess their association with delayed extubation in univariate then multivariate analyses, using 2 logistic regression models ("intra-operative model" and "pediatric intensive care unit [PICU] model").

Results: Ninety-six subjects were included, among whom 46 (47%) had delayed extubation. In the operating room, independent risk factors for delayed extubation were the amount of transfusions (odds ratio [OR] 2.77, 95% CI, 1.19-9.04, P = .045) and maximal blood lactatemia (OR 1.62, 95% CI, 1.15-2.53, P = .01). In the PICU, driving pressure (ΔP) 12 hours after the surgery and the presence of a postoperative complication (any graft vessel thrombosis, severe bleeding, and/or surgical revision) were independently associated with delayed extubation (OR 1.31, 95% CI, 1.05-1.70, P = .03 for ΔP, and OR 14.55, 95% CI, 2.83-181.29, P = .004 for any complication). When excluding 28 children with surgical revision, ΔP remained associated with delayed extubation, whereas complications were not.

Conclusions: A higher ΔP in the early hours following pediatric liver transplantation was associated with prolonged mechanical ventilation, along with hyperlactatemia and transfusions during surgery, and postoperative complications.

Background: Mechanical insufflation-exsufflation (MI-E) consists of increasing expiratory air flow, thereby promoting an increase in cough peak flow (CPF) and secretion clearance. Respiratory impairment, characterized by reduced lung volumes and ineffective cough, is the major cause of morbidity and mortality in patients with amyotrophic lateral sclerosis (ALS). This study aimed to assess the acute effects of MI-E on CPF and chest wall compartmental and operational volumes in patients with ALS.

Methods: Ten ALS subjects (6 males) were studied by optoelectronic plethysmography (OEP) to assess the immediate effects of MI-E on CPF, chest wall volume variations and their distribution in the chest wall compartments, breathing pattern, and shortening velocity of the respiratory muscles before, during, and after the application of MI-E.

Results: No differences were observed in the CPF analysis between time points (pre, MI-E, post). A significant increase in CPF (P = .01) was obtained immediately after the application of MI-E in subjects with spinal-onset ALS (n = 7). No significant differences in total and compartmental lung volumes and chest wall operational volumes were observed between pre MI-E (quiet breathing), during MI-E (after coughs 1, 2, and 3), and post MI-E time points.

Conclusions: The application of the MI-E technique may increase CPF in individuals with spinal ALS. However, no significant changes in total thoracic volumes, total and compartmental chest wall volumes, or changes in breathing patterns in the participants in our sample after the application of the technique were observed.

Background: Children with cardiac disease liberated from mechanical ventilation often receive noninvasive respiratory support (NRS) postextubation via high-flow nasal cannula, CPAP, or noninvasive ventilation. Predicting the type and duration of postextubation NRS can be challenging due to a lack of objective tools to guide decision-making. The dead space to tidal volume ratio (V_D/V_T) is a potential tool to guide this decision. We hypothesized that an elevated V_D/V_T would be associated with longer duration and higher level of NRS following extubation in children with cardiac disease.

Methods: We conducted a retrospective cohort study of mechanically ventilated patients admitted to our pediatric cardiac intensive care unit between March 2019 and July 2021 with at least one V_D/V_T recorded before extubation. Subjects were dichotomized a priori into two groups V_D/V_T < 0.30 and V_D/V_T ≥ 0.30. We recorded the type of NRS at 24 hours, 48 hours, 72 hours, 7 days, and 14 days after extubation.

Results: We included 226 subjects. Median (IQR) weight was 4.1 (3.3-6.6) kg, 47% were female, 47% had cyanotic heart disease, and 90% were mechanically ventilated for respiratory failure or cardiac surgery. Subjects with V_D/V_T ≥ 0.30 experienced longer postextubation NRS (4 [1.9-9.1] vs 3 [1.2-5.3] days, P = .001) and were more likely to receive high-flow nasal cannula (67% vs 45%, P = .02) 24 hours following extubation. NRS modality immediately postextubation and reintubtion rates were similar between groups. Subjects with V_D/V_T ≥ 0.30 were younger (1.2 [0.1-3.6] vs 4.8 [1.2-30] months, P < .001) and more likely to have cyanotic congenital heart disease (59% vs 26%, P < .001). After adjusting for demographic and clinical characteristics, V_D/V_T was not associated with NRS use.

Conclusions: V_D/V_T was not associated with the length of NRS after extubation or re-intubation after controlling for demographic and clinical differences.

Background: Secretion accumulation in patients undergoing mechanical ventilation impairs ventilatory mechanics and gas exchange, which may prolong hospital stay and increase the risk of respiratory infections. Manual chest compression (MCC) and ventilator hyperinflation (VHI) are techniques used for airway clearance, but there are no studies comparing the effect of these two techniques. The aim of this study was to compare the effects of VHI and MCC on secretion clearance in mechanically ventilated patients.

Method: This randomized crossover clinical trial enrolled 44 adult ICU subjects on mechanical ventilation. Each participant received both interventions in random order, separated by a 4-hour washout period. The primary outcome was the amount of sputum removed. Secondary outcomes included peak expiratory flow (PEF), flow bias, dynamic lung compliance, and hemodynamic parameters.

Results: The results showed that although VHI significantly increased PEF (P = .007) and expiratory flow bias (P < .001) compared with MCC, there was no statistically significant difference in the amount of sputum removed between the two methods (P = .51). Furthermore, there was no difference in the effects on blood pressure, heart rate, peripheral O₂ saturation, and compliance between the two maneuvers.

Conclusions: VHI was noninferior to MCC in promoting airway clearance and offers additional advantages, including enhanced flow dynamics and reduced physical strain on physiotherapists. These findings suggest that VHI may be a practical, safe, and efficient alternative for airway clearance therapy in critically ill, mechanically ventilated patients.

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.