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OBJECTIVES Obesity is a serious disorder that may lead to numerous difficulties in endotracheal tube (ETT) management. This study investigated the potential of tracheal ultrasound (TUS) for the accurate confirmation of the ETT position in obese patients. METHODS A total of 68 obese patients undergoing tracheal intubation were enrolled in this study from January 2017 to June 2018. All patients received auscultation and TUS to evaluate the ETT position, which was ultimately verified by bronchoscopy. A correct position of the ETT was defined as placement at the trachea, whereas placement at the right/left main bronchus was classified as an incorrect position. RESULTS We found 58 correct placements of the ETT at the trachea, 8 incorrect placements at the right main bronchus, and 2 incorrect placements at the left main bronchus. Compared with auscultation, TUS showed higher accuracy (85.29% versus 67.65%; P = .005), sensitivity (84.48% versus 67.24%; P = .005), and specificity (90.00% versus 70.00%; P

Background: Fine particulate matter (PM2.5) exacerbates airway inflammation and hyperreactivity in patients with asthma, but the mechanism remains unclear. The aim of this study was to observe the effects of prolonged exposure to high concentrations of PM2.5 on the pathology and airway hyperresponsiveness (AHR) of BALB/c mice undergoing sensitization and challenge with ovalbumin (OVA) and to observe the effects of apoptosis and T-cell immunoglobulin and mucin domain 1 (TIM-1) in this process. Methods: Forty female BALB/c mice were divided into four groups: control group, OVA group, OVA/PM group, and PM group (n = 10 in each group). Mice in the control group were exposed to filtered clean air. Mice in the OVA group were sensitized and challenged with OVA. Mice in the OVA/PM group were sensitized and challenged as in the OVA group and then exposed to PM2.5 for 4 h per day and 5 days per week for a total of 8 weeks using a nose-only "PM2.5 online enrichment system" in The Second Hospital of Hebei Medical University. Mice in the PM group were exposed to the PM2.5 online enrichment system only. AHR was detected. Bronchoalveolar lavage fluid (BALF) was collected for cell classification. The levels of interleukin-4 (IL-4), IL-5, and IL-33 in BALF were measured using enzyme-linked immunosorbent assay. Changes in histological structures were examined by light microscopy, and changes in ultramicrostructures were detected by electron microscopy. Apoptosis was determined by terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling (TUNEL) assay in the lung tissues. Western blotting and immunohistochemistry were utilized to analyze the expression of Bcl-2, Bax, and TIM-1 in the lungs. Results: The results showed that AHR in the OVA/PM group was significantly more severe than that in the OVA and PM groups (P < 0.05). AHR in the PM group was also considerably more severe than that in the control group (P < 0.05). The BALF of OVA/PM group (28.00 ± 6.08 vs. 12.33 ± 4.51, t = 4.631, P = 0.002) and PM group (29.00 ± 3.00 vs. 12.33 ± 4.51, t = 4.927, P = 0.001) had more lymphocytes than the BALF of the control group. The number of neutrophils in the BALF of the OVA/PM group (6.67 ± 1.53 vs. 3.33 ± 1.53, t = 2.886, P = 0.020) and PM group (6.67 ± 1.53 vs. 3.33 ± 1.53, t = 2.886, P = 0.020) was much higher than those in the BALF of OVA group (P < 0.05). TUNEL assays showed that the number of apoptotic cells in the OVA/PM group was significantly higher than that in the OVA group (Tunel immunohistochemical scores [IHS%], 1.20 ± 0.18 vs. 0.51 ± 0.03, t = 8.094, P < 0.001) and PM group (Tunel IHS%, 1.20 ± 0.18 vs. 0.51 ± 0.09, t = 8.094, P < 0.001), and that the number of apoptotic cells in the PM group was significantly higher than that in the control group (Tunel IHS%, 0.51 ± 0.09 vs. 0.26 ± 0.03, t = 2.894, P = 0.020). The concentrations of IL-4 (77.44 ± 11.19 vs. 48.02 ± 10.02 pg/ml, t = 4.595, P = 0.002) and IL-5 (15.65 ± 1.19 vs. 12.35 ± 0.95 pg/ml, t = 3.806, P = 0.005) and the Bax/Bcl-2 ratio (1.51 ± 0.18 vs. 0.48 ± 0.10, t = 9.654, P < 0.001) and TIM-1/β-actin ratio (0.78 ± 0.11 vs. 0.40 ± 0.06, t = 6.818, P < 0.001) in the OVA/PM group were increased compared to those in the OVA group. The concentrations of IL-4 (77.44 ± 11.19 vs. 41.47 ± 3.40 pg/ml, t = 5.617, P = 0.001) and IL-5 (15.65 ± 1.19 vs. 10.99 ± 1.40 pg/ml, t = 5.374, P = 0.001) and the Bax/Bcl-2 ratio (1.51 ± 0.18 vs. 0.97 ± 0.16, t = 5.000, P = 0.001) and TIM-1/β-actin ratio (0.78 ± 0.11 vs. 0.31 ± 0.06, t = 8.545, P < 0.001) in the OVA/PM group were increased compared to those in the PM group. The concentration of IL-4 (41.47 ± 3.40 vs. 25.46 ± 2.98 pg/ml, t = 2.501, P = 0.037) and the Bax/Bcl-2 ratio (0.97 ± 0.16 vs. 0.18 ± 0.03, t = 7.439, P < 0.001) and TIM-1/β-actin ratio (0.31 ± 0.06 vs. 0.02 ± 0.01, t = 5.109, P = 0.001) in the PM group were also higher than those in the control group. Conclusions: Exacerbated AHR associated with allergic asthma caused by PM2.5 is related to increased apoptosis and TIM-1 activation. These data might provide insights into therapeutic targets for the treatment of acute exacerbations of asthma induced by PM2.5. Key words: Apoptosis; Asthma; Fine Particulate Matter; T-cell Immunoglobulin and Mucin Domain 1

Background The effect of corticosteroids on influenza A(H1N1)pdm09 viral pneumonia patients remains controversial and the impact of dosage has never been studied. Methods Using data of hospitalized adolescent and adult patients with influenza A(H1N1)pdm09 viral pneumonia, prospectively collected from 407 hospitals in mainland China, the effects of low-to-moderate dose (25-150 mg·day−1) and high-dose (> 150 mg·day−1) corticosteroids on 30-day mortality, 60-day mortality, and nosocomial infection were assessed with multivariate Cox regression and propensity score-matched case-control analysis. Results In total, 2141 patients (median age: 34 y; morality rate: 15.9%) were included. Among them, 1160 (54.2%) had PaO2/FiO2 < 300 mmHg on admission, and 1055 (49.3%) received corticosteroids therapy. Corticosteroids, without consideration of dose, did not influence either 30-day or 60-day mortality. Further analysis revealed that, as compared with the no-corticosteroid group, low-to-moderate dose corticosteroids was related to reduced 30-day mortality (adjusted hazard ratio [aHR] 0.64 [95%CI 0.43-0.96, p=0.033]). In the subgroup analysis among patients with PaO2/FiO2 < 300 mmHg, low-to-moderate dose corticosteroid treatment significantly reduced both 30-day (aHR 0.49 [95%CI 0.32-0.77]) and 60-day mortality (aHR 0.51 [95%CI 0.33-0.78]), while high-dose corticosteroid therapy yielded no difference. For patients with PaO2/FiO2 ≥ 300 mmHg, corticosteroids (irrespective of dose) showed no benefit, and even increased 60-day mortality (aHR 3.02 [95%CI 1.06-8.58]). Results were similar in the propensity model analysis. Conclusions Low-to-moderate dose corticosteroids might reduce mortality of influenza A(H1N1)pdm09 viral pneumonia patients with PaO2/FiO2 < 300 mmHg. Mild patients with PaO2/FiO2 ≥ 300 mmHg could not benefit from corticosteroids therapy. This article is protected by copyright. All rights reserved.

To explore the disease course and outcomes of severe or critical pregnant women with 2009 pandemic H1N1 (pH1N1) infection in China.A retrospective observational study was conducted for 394 severe or critical pregnant women with pH1N1 influenza admitted into hospital in 27 Chinese provinces from September 1, 2009 to December 31, 2009. Their clinical features in different trimesters were analyzed. The viral infection of pH1N1 was verified by real-time reverse transcription (rRT)-PCR. Severe and critical cases were defined according to the 2009 H1N1 clinical guidelines.Among them, 374 (94.9%) were infected in the second or third trimester. Fever and cough were the most common symptoms in all trimesters. However, hemoptysis, dyspnea and associated pneumonia were likely to occur in the second or third trimester. The ratio of required mechanical ventilation in the second or third trimester (44.7%, 167/374) was significantly higher than that in the first trimester (3/20). Among 77 mortality cases, 72.7% (56/77) died in the third trimester. Pregnancy was terminated after the onset of pH1N1 symptoms in 52.5%(207/394) pregnant women. And 57.0%(118/207) of them had delivery37 weeks and 29.0%(60/207) fetuses deceased.A clinician should be on a high alert for pH1N1 infection in pregnant women, particularly in the second or third trimester.

The 2009 pandemic H1N1 (pH1N1) influenza showed that relatively young adults accounted for the highest rates of hospital admission and death. In preparation for pH1N1, the aim of the study is to identify factors associated with the mortality of patients with 2009 pH1N1 infection, especially for young patients without chronic medical conditions.Retrospective observational study of 2151 severe or critical adult cases (≥ 14 years old) admitted to a hospital with pH1N1 influenza from September 1, 2009 to December 31, 2009 from 426 hospitals of 27 Chinese provinces. A confirmed case was a person whose pH1N1 virus infection was verified by real-time reverse-transcriptase polymerase chain reaction (rRT-PCR). Severe and critical cases were defined according to the H1N1 2009 Clinical guidelines (Third Edition, 2009) released by the Ministry of Health of China.Among the 2151 patients, the mean age was 34.0 years. Two hundred and ninty-three (13.6%) died during hospital stay. One thousand four hundred and forty-two patients (67.0%) had no comorbidities and 189 (13.1%) of them died. Pregnancy (OR 8.03), pneumonia (OR 8.91), dyspnea (OR 3.95), central nervous system (CNS) symptom (OR 1.55), higher APACHE (Acute Physiology and Chronic Health Evaluation) II score (OR 1.06), Alanine aminotransferase (ALT) (OR 1.002), and the lactate dehydrogenase (LDH) level (OR 1.001) were independent risk factors for death among adults without chronic medical conditions. Higher APACHE II score (OR 1.08) and age (OR 1.06) were independent risk factors for death among adults with respiratory diseases. A multivariate analysis showed an association between mortality and CNS symptoms (OR 2.66), higher APACHE II score (OR 1.03), ALT (OR 1.006), and LDH level (OR 1.002) in patients with cardiovascular diseases. Dyspnea (OR 11.32) was an independent risk factor for patient death in patients with diabetes mellitus.Clinical knowledge of identified prognostic factors for mortality may aid in the management of adult influenza infection.

Noninvasive positive pressure ventilation is beneficial for patients with acute respiratory failure. However, its possible benefit for patients with acute lung injury (200 mm HgPaO(2)/FIO(2) ≤300 mm Hg) remains unclear. Our aim was to assess the safety and efficacy of noninvasive positive pressure ventilation for patients with acute lung injury and compare this with high-concentration oxygen therapy.A multicentered randomized controlled trial.Ten multipurpose intensive care units.Forty patients who fulfilled the criteria for acute lung injury were included in this study.Patients were randomly allocated to receive either noninvasive positive pressure ventilation (noninvasive positive pressure ventilation group) or high-concentration oxygen therapy through a Venturi mask (control group).Twenty-one patients were assigned to the noninvasive positive pressure ventilation group and 19 were in the control group. At study entry, the patients' characteristics in the two groups were similar. Noninvasive positive pressure ventilation application decreased the respiratory rate and improved PaO(2)/FIO(2) with time. The proportion of patients requiring intubation and the actual number of intubations in the noninvasive positive pressure ventilation group were significantly less than in the control group (one of 21 vs. seven of 19; p = .02, and one of 21 vs. four of 19; p = .04, respectively). Noninvasive positive pressure ventilation showed a trend for reducing inhospital mortality (one of 21 vs. five of 19; p = .09). The total number of organ failures in the noninvasive positive pressure ventilation group was significantly lower than in the control group (three vs. 14; p.001).Noninvasive positive pressure ventilation is safe for selected patients with acute lung injury. However, a larger randomized trial with need for intubation and mortality as the outcomes of interest is required.

To evaluate the etiology and drug resistance of biofilms in endotracheal tubes in respiratory intensive care unit (RICU).A prospective cohort study was conducted. The biofilms were observed by scanning electron microscopy at different times of ventilation. The pathogens were identified and their resistance to antibiotics were analyzed.Twenty one VAP cases were identified in 39 mechanically ventilated patients (53.85%). Patchy biofilms were observed 2 d to 7 d after the initiation of ventilation. After 7 d to 10 d, 87.5% of the endotracheal tubes were covered by biofilms. Biofilms were identified in all the tubes longer than 10 d.The incidence of VAP increased with prolonged mechanical ventilation. Meanwhile the antibiotic resistance rate increased and more pathogens isolated were consistent with those in the biofilms.

To evaluate the effectiveness of de-escalation therapy (DET) in patients with severe lower airway infection in the respiratory care unit.Sixty-seven cases of severe lower airway infection (SLAI) were divided into two groups: a DET group (n = 29), and a non-DET group (NDET, n = 38). Samples of lower airway secretions were collected by blinded protected specimen brush for culture and Gram stain. The clinical data were compared between the DET group and the NDET group, including the time of mechanical ventilation, time of stay in hospital, APACHE-II score, treatment responses and outcome, cost of antibiotics and total cost in the hospital.There were significant differences in time in hospital (14 +/- 8; 19 +/- 12), the time of mechanical ventilation (22 +/- 16; 32 +/- 16) and the total cost in-hospital (52 871 +/- 54 457; 82 913 +/- 49 564. t = 2.195, 2.449, 2.354, all P0.05), while there was no significant difference in the cost on antibiotics between the DET group (7896 +/- 4718) and the NDET group (8490 +/- 5786. t = 0.449, P0.05). The mortality and inappropriate antibiotic therapy rate of the DET group (13.8%, 27.6%) were lower than those of the NDET group (36.8%, 60.5%; chi(2) = 4.45, 7.18, all P0.05).The mortality of SLAI was significantly decreased by DET. DET also led to shorter time of mechanical ventilation, shorter course of therapy and less total cost of therapy.

To evaluate the efficacy and safety of tulobuterol tape in mild and moderate persistent asthma patients.A multicenter, randomized, controlled, open label study was performed. A total of 233 adult patients with mild and moderate persistent asthma were enrolled, and 115 patients were treated with tulobuterol tape and 118 with tulobuterol tablet.After 4 weeks of treatment, the morning peak expiratory flow (PEF) and evening PEF and the percent change in the tulobuterol tape group were increased significantly as compared to the tulobuterol tablet group (P0.05). The rate of improvement in morning PEF with the tape group and the tablet group were 9.1 (0.38 approximately 19.4)% and 4.2 (-6.4 approximately 18.3)%, respectively. The pulmonary function, variation rate of PEF, asthma score and usage of short-acting beta(2) agonist were improved after 4 weeks of treatment, but the differences were not significant between the two groups. The incidence of adverse reactions including palpitations and tremor in the tulobuterol tape group was significantly lower than that in the tablet group (chi(2) = 7.0919, P = 0.0077), and the incidence of local skin adverse reactions in tape group was 2.6%.Tulobuterol tape is a newly formulated, effective and safe medication for the treatment of asthma.

To assess the influence of subglottic secretion drainage (SSD) on the morbidity of ventilator-associated pneumonia (VAP) in mechanically ventilated patients.All studied patients who received mechanical ventilation (MV) estimated for more than 48 hours were intubated with a special type endotracheal tube with a small-bore cannula in the wall for SSD. The patients were randomly divided into two groups receiving SSD (group A) and usual care (non-SSD, group B) respectively. Bacterial culture of samples from lower airway secretion taken regularly by Bagpipe Protected specimen brush were performed, and at the same time the subglottic secretion and scraping-pharynx specimen were collected for bacterial quantitative culture and antibiotic sensitivity test. The clinical data were recorded and the duration of MV, the length of stay in hospital and the time of occurrence of ventilator-associated airway infection (VAAI) and VAP were analyzed.(1) In patients with MV5 days: The incidence of VAAI and VAP in group A (VAAI: 8.3% and VAP: 6.0%) was lower than those in group B (VAAI: 24.0% and VAP: 20.0%, P0.05). The onset of VAAI and VAP was delayed in group A [VAAI: (7.4 +/- 3.0) d and VAP: (7.7 +/- 3.2) d] as compared with group B [VAAI: (4.9 +/- 1.4) d and VAP: (4.6 +/- 2.1) d, P0.05]. There were no significantly statistic differences for hospital mortality, overall duration of mechanical ventilation, lengths of stay in the hospital between the two groups (P0.05). (2) The same organism as that previously found from subglottic secretion was isolated by PSB in 21.4% patients. (3) The concentration of bacteria in subglottic secretion from group A was decreased significantly as compared to that of group B. (4) Gram-negative bacilli were the main pathogens in the lower respiratory tract in the two groups. The dominant bacteria cultured in the lower airway secretions were Pseudomonas aeruginosa and Acinetobacter baumanii. There was no significant difference between the two groups in the spectrum of bacteria (P0.05).(1) SSD reduced the incidence of VAAI and VAP in patients with MV5 d. The onset of VAAI and VAP was delayed in group A as compared with group B. The concentration of bacteria in the subglottic secretion was significantly reduced by subglottic secretion drainage. (2) Migration of the dominant bacteria of the subglottic secretion was one of the important factors for VALAI. (3) The dominant cultured bacteria in the lower airway secretion were gram-negative bacilli, most commonly Pseudomonas aeruginosa and Acinetobacter baumanii.

Background 2009 pandemic H1N1 (pH1N1) influenza posed an increased risk of severe illness among pregnant women. Data on risk factors associated with death of pregnant women and neonates with pH1N1 infections are limited outside of developed countries. Methods Retrospective observational study in 394 severe or critical pregnant women admitted to a hospital with pH1N1 influenza from Sep. 1, 2009 to Dec. 31, 2009. rRT-PCR testing was used to confirm infection. In-hospital mortality was the primary endpoint of this study. Univariable logistic analysis and multivariate logistic regression analysis were used to investigate the potential factors on admission that might be associated with the maternal and neonatal mortality. Results 394 pregnant women were included, 286 were infected with pH1N1 in the third trimester. 351 had pneumonia, and 77 died. A PaO2/FiO2 ≤ 200 (odds ratio (OR), 27.16; 95% confidence interval (CI), 2.64-279.70) and higher BMI (i.e. ≥ 30) on admission (OR, 1.26; 95% CI, 1.09 to 1.47) were independent risk factors for maternal death. Of 211 deliveries, 146 neonates survived. Premature delivery (OR, 4.17; 95% CI, 1.19-14.56) was associated neonatal mortality. Among 186 patients who received mechanical ventilation, 83 patients were treated with non-invasive ventilation (NIV) and 38 were successful with NIV. The death rate was lower among patients who initially received NIV than those who were initially intubated (24/83, 28.9% vs 43/87, 49.4%; p = 0.006). Septic shock was an independent risk factor for failure of NIV. Conclusions Severe hypoxemia and higher BMI on admission were associated with adverse outcomes for pregnant women. Preterm delivery was a risk factor for neonatal death among pregnant women with pH1N1 influenza infection. NIV may be useful in selected pregnant women without septic shock.