The Editor's Choice for December is a study on noninvasiveventilation (NIV) device-related pressure injuries in children byLauderbaugh and colleagues. They performed a retrospectivereview of 225 subjects with 343 episodes of NIV use, and foundpressure injuries in 7% of cases. Characteristics associated withpressure injuries included older age, excessive leak, maximuminspiratory pressure, and NIV duration. Multivariate analysisidentified excessive mask leak as the primary factor associatedwith pressure injury. Visscher contributes an accompanyingeditorial that describes some advanced techniques for assessingmask fit and reducing pressure injury. Both author and editorialistagree that reducing leaks through improved mask fit is key toreducing injuries.
Children requiring home mechanical ventilation and admittedto the hospital for exacerbation of their illnesses are at risk forpoor outcomes. Kun et al retrospectively evaluated rapid responseand code events and found that these events were 2–6 times more frequent in subjects admitted following ventilation at home. Children preparing for initial hospital discharge had the mostfrequent events. Ventilator setting adjustments and tracheostomy-related interventions were the most prevalent interventions. LopezDomowicz and Cheifetz comment that this population continuesto increase and represents a significant financial burden to thehealthcare system. They encourage further research to identifymethods to reduce re-admissions and control costs.
Cammarota and others describe the use of diaphragmaticultrasound in the emergency department to evaluate response toNIV. Diaphragmatic excursion, thickness, and thickening fractionhave been suggested as predictors of early NIV failure. In 22subjects they found that diaphragmatic excursion was greater inNIV success than NIV failure, while diaphragmatic thickenessand thickening fraction were similar. Shaikh and Laghi commentthat while ultrasound may be helpful in determining NIV success,NIV failure has many components including interface intolerance,deterioration in hemodynamics, and psychological distress. Theyastutely note that few endeavors in critical care are more dependenton diagnostic acumen and individualized care than care of COPD patients requiring NIV.
Lu et al describe lung aeration in subjects supported withvenovenous extracorporeal membrane oxygenation (VV-ECMO). In a retrospective study of 50 subjects they report that the lungultrasound aeration score increased during VV-ECMO in survivors compared to non-survivors. They concluded that there was a significant improvement in lung aeration in survivors, while a severeloss of lung aeration persisted in non-survivors. These data suggest a role for the use of ultrasound in monitoring patients requiringVV-ECMO.
Expiratory flow limitation represents a classic pathophysiologicfinding in COPD. Frohlich and others describe tidal flow-volumeloop ‘enveloping’ occurring in COPD subjects at rest and duringexercise. In 37 COPD subjects they reported that tidal flow-volumeloop enveloping at rest was associated with increased dyspneaburden and exercise intolerance. They suggest monitoring couldbe used to determine functional assessments in COPD patients.
Kuhn Kambestad and colleagues provide a 4-year prospectivestudy evaluating unplanned extubations (UE) in the neonatal ICU.They identified 134 UE events, after which half of subjects weregiven a trial of extubation with 63% remaining extubated. CPR wasrequired in 13% of subjects post-UE, and following re-intubationsubjects had higher airway pressures and oxygen requirements. Insubjects requiring CPR, development of sepsis was significantlyincreased. Agitation was the most common known cause of UE.
Sarhan et al describe the use of a holding chamber designed foruse with a mesh nebulizer during oxygen supplementation. This bench evaluation measured particle size and included subjectevaluation assessing aerosol delivery by using urinary salbutamollevels. They report that holding chamber use increased the total inhalable dose as determined by urinary salbutamol levels. Addition of oxygen to the holding chamber reduced aerosoldelivery.
Pazzianotto-Forti and colleagues evaluated the use of inspiratory exercises with linear and nonlinear loads on diaphragmdysfunction and atelectasis in a group of postoperative subjectsfollowing bariatric surgery for morbid obesity. On the second postoperative day, nasal inspiratory pressure and sustained maximal inspiratory pressure measurements were determined anddegree of atelectasis on radiograph evaluated. They report that both groups were able to maintain respiratory muscle endurance after bariatric surgery and that inspiratory muscle exercise reduced atelectasis.
Zampogna and others studied a pulmonary rehabilitation (PR) program in subjects with asthma. They retrospectively reviewed a 3-week PR program that included educational support, endurance training, respiratory exercises, and airway clearance techniques. In over 500 subjects they measured exercise tolerance, asthmaseverity, oxygen saturation, and 6MWT. They found that subjects at any GINA step seemed to benefit from the PR program, with younger subjects, those with a smoking history and poor baseline exercise performance deriving the most benefit.
Pulmonary embolism (PE) is a common complication in patients with an exacerbation of COPD. Fekih Hassen et aldetermined the incidence, risk factors and impact of PE duringCOPD exacerbation requiring mechanical ventilation. In a cohort of 131 COPD subjects admitted to the ICU the incidence of PE was 14%. They concluded that PE was a common etiology of COPD exacerbation leading to high mortality. Age, invasivemechanical ventilation, and immobilization were identified asprimary risk factors for PE.
Reychler and colleagues evaluated the impact of subjectposition on aerosol deposition. In healthy volunteers, theymeasured regional lung deposition in sitting and lateral decubitus positions using radiolabeled aerosol. They report that the total amount of drug delivered to the lungs decreased in the left lateraldecubitus posture. Deposition of particles in the dependent lungwas not improved by the lateral decubitus posture.
Chebib and others report their experience providing ventilatory support in the ICU in subjects with obesity-hypoventilationsyndrome (OHS). They performed a retrospective study of OHS in 4 ICUs over a 4-year period. They identified 115 subjects with OHS, of whom 37 required ICU admission and 36 of these receivedNIV. NIV was successful in 33 subjects and ICU mortality was low (3%). They concluded that hypoxemic respiratory failure in subjects with OHS was responsive to NIV.
Daoud et al used a lung model to evaluate the accuracy ofrespiratory mechanics displayed by a ventilator in both activeand passive conditions. Using respiratory mechanics settingsto simulate normal, COPD, and ARDS patients they altered simulated muscle pressure from 0 to -15 cm H2O. Automated dynamic calculations of compliance and resistance were thencompared based on the clinical scenarios. They found that automated displayed calculations of respiratory mechanics werenot dependable or accurate in the active breathing conditions,while the calculations improved in passive scenarios.
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