Respiratory care最新文献

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 controversial. 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 flow increases. Our data contribute to the difficult interpretation of the existing interrelation between the flow and its effects on the respiratory system.

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: COPD exacerbations are a major cause of morbidity and mortality. Although inhaled corticosteroids (ICS) have a role as long-term treatment, their efficacy in exacerbations, particularly as an adjunct to systemic steroids, remains unclear. Methods: In this retrospective observational study, we analyzed data from 870 subjects admitted with COPD exacerbations to a tertiary medical center in Israel from January 2018-January 2023. We investigated the impact of adding ICS to standard systemic steroid treatment on hospital length of stay, intubation rates, and 30-d mortality using propensity score matching to account for confounders. Results: The cohort, after matching, included 354 subjects treated with systemic steroids and ICS and 121 treated with systemic steroids alone. All characteristics were similar between the groups. Our analysis showed no differences in 30-d mortality (7.1% vs 5.8%, P = .63) or secondary outcomes (intubation, hospital length of stay, and readmission rates) between the groups. Subgroup analyses based on different eosinophil levels did not alter these findings. In multivariate analysis among the general cohort, eosinophil count <150 cells/μL (adjusted odds ratio 0.45 [95% CI 0.21-0.87], P = .02) and high Charlson score (adjusted odds ratio 1.19 [95% CI 1.02-1.37], P = .02) were independent predictors for 30-d mortality. Conclusions: Despite the known benefits of ICS in managing chronic COPD, we did not find an added value of ICS to systemic steroids in exacerbations. These results underscore the necessity for individualized treatment strategies and further research into the role of ICS in COPD exacerbations.

Background: Medication adherence to inhaler therapy is pivotal for optimizing the management of COPD. Individuals with COPD often have suboptimal adherence behaviors to inhaler therapy. Illness perception and beliefs about medicines have been proved to be associated with medication adherence. Nevertheless, the influence of illness perception and medication beliefs on adherence to inhaler therapy among elderly individuals with COPD in China remains unclear. Methods: A cross-sectional study was conducted in 252 elderly subjects with COPD in China from June 2022-September 2023. The Test of Adherence to Inhalers, the Brief Illness Perception Questionnaire, and the Belief About Medicines Questionnaire (BMQ) were utilized. Spearman correlations, regression analysis, and parallel mediation analysis were employed to assess the correlations and mediating effects among beliefs about medicines, illness perception, and medication adherence to inhaler therapy. Results: Medication adherence to inhaler therapy exhibited a negative correlation with concerns beliefs, while showing positive correlations with illness perception, necessity beliefs, and total BMQ scores. Mediating effects of concerns beliefs and necessity beliefs were observed in the relationship between perception of illness and medication adherence to inhaler therapy. Conclusions: This study suggests that essential interventions targeting beliefs about medicines in elderly individuals with COPD should be implemented to optimize the level of their inhaler adherence, particularly in those with low levels of necessity beliefs or high levels of concerns beliefs.

Background: Evidence on quality of care and sociodemographics in patients with COPD needing care during the COVID-19 pandemic is scarce. We aimed to examine indicators of quality and clinical outcomes (eg, readmissions, death) and sociodemographics in patients with COPD in need of hospital care during the COVID-19 pandemic compared to before the pandemic. Methods: This was a nationwide register-based study of subjects with a hospital contact due to COPD from January 1, 2015-December 15, 2021, in Denmark. A generalized linear model using Poisson distribution was used to estimate prevalence ratios (PRs) for variables of interest. Results: During the pandemic, the early average of admissions was 36% lower than before the pandemic; the average number of out-patients was 23% lower. The proportion of readmissions for exacerbation within 30 d of discharge decreased during the pandemic (PR 0.93 [95% CI 0.90-0.96]). The proportion of subjects who died within 30 d of admission remained unchanged (PR 0.98 [0.94-1.03]). Among out-patients, the proportion with 2 or more exacerbations in the preceding year was lower during the pandemic (PR 0.82 [0.80-0.84]). During the pandemic, both in-patients and out-patients were less likely to be younger, to live alone, and to have a lower educational level. Conclusions: In this nationwide study of subjects with COPD, hospital contacts decreased during the pandemic due to lockdowns and isolation, which led to a decrease in infections overall in the society. Meanwhile, in-hospital care remained unaltered. However, concerns are raised about patients with COPD and low educational level and immigrants not seeking relevant health care.

Background: Because alpha-1 antitrypsin deficiency is severely underrecognized and delayed diagnosis is associated with harm, strategies to enhance early detection of alpha-1 antitrypsin deficiency are needed. Methods: The study intervention was placing a reminder to test for alpha-1 antitrypsin deficiency within an electronic medical record health maintenance dashboard that houses prompts to providers to implement guideline-based recommendations. This recommendation was for all patients assigned a diagnosis of COPD based on relevant International Classification of Diseases, Tenth Revision codes. The rate of testing for and detecting individuals with alpha-1 antitrypsin deficiency was assessed in 12 one-month intervals before and after implementing the dashboard. Results: After the prompt, whereas testing was still performed in only a small percentage of guideline-concordant instances, the rate of testing for alpha-1 antitrypsin deficiency increased 3.8-fold (ie, from 1.2% to 4.6%, P < .05). This did not result in detection of new patients with alpha-1 antitrypsin deficiency. The rate of testing increased both for alpha-1 antitrypsin serum levels and genotypes in each month after the intervention, though the rate of genotype testing was 2-5-fold lower than the rate of testing for serum level. Conclusions: The results of this preliminary study of a detection strategy for alpha-1 antitrypsin deficiency show that placing a reminder to test for alpha-1 antitrypsin deficiency when indicated in an electronic medical record health maintenance dashboard significantly increased the frequency of testing. Still, that only 4.6% of those in whom testing for alpha-1 antitrypsin deficiency was indicated were tested in the post-intervention period shows that, as for all other alpha-1 antitrypsin deficiency-targeted detection interventions to date, the impact of the intervention was marginal and that other strategies remain needed to mitigate underrecognition. A focus on combining targeted detection strategies (eg, coupling enhanced awareness with free testing) and population-based screening for alpha-1 antitrypsin deficiency is suggested.