This month’s Editor’s Choice by Villarroel and colleagues details factors associated with accidental decannulation in children with a tracheostomy. Over a 5-year time frame they performed a case-control study of tracheostomy subjects with and without an accidental decannulation event. The majority of subjects (84%) were receiving mechanical ventilation and the primary cause of decannulation was self-decannulation. Risks were highest in children who reached midline in the sitting position and those with smaller tube sizes (<4.0 mm ID). Lower staff to patient ratios were also associated with more frequent decannulation. Awad and Berlinski provide commentary, highlighting the importance of devices to secure tubes, supports for ventilator circuits, and staff coverage. They also note that mortality in this population following accidental decannulation is low, owing to patient tolerance and effective tube replacement.
Coppadoro et al describe a recirculation system to reduce oxygen use during helmet or mask CPAP with a Venturi-based, constant flow CPAP generator. This bench study directed exhaled gas through a CO2 absorber and back to the entrainment port of the CPAP generator, allowing a reduction in the set FIO2. They report an 80% reduction in oxygen use over 10 hours using a single soda lime cannister. The system also nearly tripled inspired humidity. Lipnick and others opine that CO2 absorbent is often a more limited resource than oxygen and that high flow CPAP systems are not always supported by oxygen systems in low- and middle-income countries. They suggest the system described is better suited in more advanced health systems if oxygen conservation is a priority.
Scaramuzzo and co-workers describe the impact of PEEP on respiratory mechanics, ventilation perfusion ratio (V̇/Q̇), and gas exchange in a small group of subjects with COVID-19 and ARDS. At variable PEEP levels they evaluated data from subjects with low and high compliance, often called H and L phenotypes. They report that shunt, low V̇/Q̇, high V̇/Q̇, and alveolar dead space were not significantly influenced, on average, by PEEP. In the two phenotypes, PEEP had opposite effects on shunt, with a decrease in phenotype L and an increase in phenotype H. Cortes-Puentes and colleagues provide commentary, expertly reviewing the impact of PEEP on recruitment, cardiac output, and the role of elastance. They suggest a ‘best PEEP’ approach that is personalized for each patient, balancing the time-dependent changes in lung mechanics with gas exchange while minimizing PEEP-related complications.
Baedorf Kassis et al retrospectively reviewed the Medical Information Mart for Intensive Care IV database to estimate the effects of modifying ventilator settings on driving pressure (ΔP) and mechanical power (MP). Specifically, they evaluated adjustments of PEEP, breathing frequency, and tidal volume (VT). They found that reductions in VT resulted in a more pronounced effect on ΔP and MP and might be the preferred approach to minimize MP.
Azevedo and others contribute a cross-sectional study of subjects with COPD receiving long term oxygen therapy (LTOT) evaluating life-space mobility. Mobility restriction was identified in 90% of participants and was related to exercise capacity and dyspnea. The authors suggest that interventions to reduce these factors should be prioritized to improve patient quality of life.
Abou Nader et al performed a retrospective review of respiratory complications in children requiring veno-arterial extracorporeal membrane oxygenation (ECMO) for cardiac indications. This single center trial studied subjects over a 5-year time frame evaluating chest radiographs for lobar atelectasis. They found multi-lobar atelectasis occurred in 30% of subjects, primarily in the left lung. They concluded that multi-lobar atelectasis was common and associated with worse outcomes. Mechanical ventilation for > 12 h before ECMO appeared to be protective.
Algarni and others describe burnout in respiratory therapists (RTs) working in Saudi Arabia. Using a cross-sectional survey of 100 RTs they found that respondents reported high burnout levels in the 3 domains: 77% reported emotional exhaustion, 98% reported depersonalization, and 73% reported low personal achievement. These findings are similar to data in the United States. They recommend further research focusing on techniques and strategies to alleviate burnout.
Magdy and Metwally performed a randomized controlled trial in obese subjects receiving either high-flow nasal cannula (HFNC) or noninvasive ventilation (NIV) immediately following extubation. Sixty subjects were enrolled in each group. There were no differences in reintubation rates, ICU length of stay, hospital length of stay, or mortality. Reintubation was associated with morbid obesity, comorbidities, greater severity of illness, and hypercapnia.
Wu and others performed a randomized trial of 96 infants following cardiac surgery who received nasal CPAP in either the prone or supine position. Subjects in the prone position group had a 7-fold decrease in extubation failure and had improved oxygenation. Prone position was also associated with reduced duration of nasal CPAP and hospital length of stay.
Al-Subu et al performed a retrospective chart review of patients with spinal muscle atrophy (SMA) admitted to the pediatric ICU for mechanical ventilation. They evaluated 137 subjects with 300 hospital admissions. Half of the subjects were intubated during their stay and 90% were extubated to NIV on the first attempt. Only 4% received tracheostomy. Invasive ventilation was associated with increased ICU and hospital length of stay. The authors conclude that NIV and aggressive airway clearance can support management of SMA patients.
Malkoc and colleagues retrospectively reviewed subjects who were intubated and required bronchoscopy and tracheostomy during their hospital stay. They evaluated 192 subjects over 16 years and found posterior vocal cord ulcers in 80%. Vocal cord ulcers were associated with a median duration of ventilatory support 50% greater than in those without ulcers. The authors conclude that earlier tracheostomy might prevent these complications.
Dorado and colleagues offer a short report demonstrating that monitoring ΔP during PEEP titration provides a better method for choosing PEEP than oxygenation in obese subjects. Jung and others contribute a short report on analyzing morphologic differences in facial soft tissue of subjects with ALS requiring NIV. They demonstrate areas of excess pressure and propose mitigation strategies. Goelzer and others offer a short report on the impact of an expiratory positive airway pressure device on tolerance of high-intensity exercise in subjects with COPD.
Denise Willis contributes a Year in Review of mechanical insufflation-exsufflation, highlighting sentinel papers published in 2022.
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