Search

BACKGROUND: Home noninvasive ventilation (NIV) may improve chronic hypercarbia in COPD and patient-important outcomes. The efficacy of home high-flow nasal cannula (HFNC) as an alternative is unclear. METHODS: We searched MEDLINE, Embase, Cochrane CENTRAL, Scopus, and ClinicalTrials.gov for randomized trials of subjects from inception to March 31, 2023, and updated the search on July 14, 2023. We performed a frequentist network meta-analysis and assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We analyzed randomized controlled trials (RCTs) comparing NIV, HFNC, or standard care in adult subjects with COPD with chronic hypercapnic respiratory failure. Outcomes included mortality, COPD exacerbations, hospitalizations, and quality of life (St George Respiratory Questionnaire [SGRQ]). RESULTS: We analyzed 24 RCTs (1,850 subjects). We found that NIV may reduce the risk of death compared to standard care (relative risk 0.82 [95% CI 0.66-1.00]) and probably reduces exacerbations (relative risk 0.71 [95% CI 0.58-0.87]). HFNC probably reduces exacerbations compared to standard care (relative risk 0.77 [0.68-0.88]), but its effect on mortality is uncertain (relative risk 1.20 [95% CI 0.63-2.28]). HFNC probably improves SGRQ scores (mean difference -7.01 [95% CI -12.27 to -1.77]) and may reduce hospitalizations (relative risk 0.87 [0.69-1.09]) compared to standard care. No significant difference was observed between HFNC and NIV in reducing exacerbations. CONCLUSIONS: Both NIV and HFNC reduce exacerbation risks in subjects with COPD compared to standard care. HFNC may offer advantages in improving quality of life. [ABSTRACT FROM AUTHOR]

AbstractObjective: Noninvasive ventilation (NIV) is the primary treatment for respiratory insufficiency in neuromuscular disease. NIV implementation is usually conducted within hospitals; however, in-home implementation with intensive follow-up is an effective alternative. This pilot study aimed to assess model feasibility, acceptability, and NIV usage at 12-weeks after a single visit in-home implementation of NIV with remote monitoring follow-up (NIV@Home) compared to an in-hospital day admission NIV initiation plus planned polysomnography (Usual care). Methods: A single-blinded randomized controlled trial (www.anzctr.org.au ACTRN12620000682943) of adults with neuromuscular disease referred for NIV implementation. Participants were stratified by disease (MND or Other diagnoses) and bulbar symptoms before randomization to NIV@Home or Usual care, with follow-up at 12-weeks. The primary outcome was NIV usage. Secondary outcomes included feasibility, health-related quality of life, symptoms, carer burden, and NIV experience (semi-structured qualitative interviews). Results: Twenty-three participants (MND bulbar = 9, MND non-bulbar = 11, Other = 3) were randomized (NIV@Home = 9). No statistical differences were observed in the percentage of MND participants using NIV for >4 hours/day (NIV@Home = 33% vs. Usual care = 60%, p = 0.370), average use (NIV@Home = 2.4 [1.5–9.3] vs. 5.3 [1.8–7.0] hours/day, p = 0.568), or secondary outcomes. In-home NIV implementation was feasible and safe but took more therapist time (NIV@Home = 278 [270–305] vs. 172 [130–200] minutes, p < 0.001). Participants in the NIV@Home group reported substantial advantages to receiving care in home. Conclusion: In-home NIV implementation is feasible and acceptable to people with MND but requires more therapist time. Larger studies are required to determine whether there are clinically important differences between this model of NIV initiation and a traditional hospital-based model. [ABSTRACT FROM AUTHOR]

Rationale: Guidelines recommend systemic corticosteroids and inhaled β-agonists for patients with severe asthma exacerbation who are admitted to intensive care units. The benefits and utilization of adjunct treatments after guideline-recommended first-line treatments have been initiated are unclear. Objectives: Examine practice patterns of adjunct interventions in US intensive care units (ICUs) and their associations with outcomes for adults with severe asthma exacerbations. Methods: Using the multicenter PINC AI Healthcare Database of Premier Inc. (2016–2022), we sought to explore the use of adjunct interventions (medications [e.g., magnesium, leukotriene inhibitors, terbutaline, heliox] and procedures [e.g., invasive and noninvasive mechanical ventilation]) for adult patients admitted to U.S. ICUs with acute asthma exacerbations. We used hierarchical generalized linear models to calculate risk-adjusted rates of adjunct interventions and quantified between-hospital variation in adjunct interventions using the intraclass correlation coefficient (ICC; higher values correspond to higher between-hospital variation). We then used K-means clustering to identify groups of hospitals with similar risk-adjusted practice profiles of all adjunct treatments and examined associations between identified hospital clusters and patient outcomes. Results: We identified 62,392 patients from 961 hospitals for inclusion. Adjunct interventions with the highest between-hospital variation after risk adjustment were heliox (ICC, 91%), inhaled steroids (ICC, 23%), invasive mechanical ventilation (ICC, 21%), terbutaline (ICC, 22%), paralytics (ICC, 16%), and noninvasive ventilation (ICC, 15%). K-means clustering identified two distinct hospital clusters: Patients who were admitted to Cluster 1 hospitals (399 hospitals) had higher risk-adjusted rates of noninvasive ventilation (51% vs. 33%), compared with patients who were admitted to Cluster 2 hospitals (234 hospitals), which had higher risk-adjusted rates of invasive mechanical ventilation (63% vs. 30%). Cluster 2 was associated with fewer hospital-free days (β = −0.75 d; 95% confidence interval [CI] = −0.95, −0.55) and increased in-hospital mortality (adjusted odds ratio, 1.28; 95% CI = 1.17, 1.40). Conclusions: The use of adjunct interventions for patients with severe asthma exacerbations vary widely across U.S. hospitals; however, hospitals generally fall into two clusters differentiated primarily by the use of invasive or noninvasive mechanical ventilation. The cluster favoring noninvasive mechanical ventilation was associated with improved outcomes. Our results help to inform usual-care arms of future comparative effectiveness studies and efforts to standardize asthma practice. [ABSTRACT FROM AUTHOR]

BackgroundMethodsResultsConclusionsAutosomal dominant neovascular inflammatory vitreoretinopathy (NIV), formerly called “ADNIV,” is a rare autoinflammatory condition mainly of adulthood caused by mutations in calcium-activated calpain-5 protease (CAPN5). Our aim is to report the treatment and visual outcomes of children newly diagnosed with NIV after systemic treatment.We reviewed charts of patients ≤18 years old with CAPN5 gene mutation, ocular findings consistent with NIV, and treated with systemic immunosuppression for a minimum of 6 months. Treatment response was based on ophthalmic examination, ultra-widefield fluorescein-angiography (UWFFA), and optical coherence tomography (OCT).Eight children (16 eyes) were diagnosed with NIV at a median age of 14 (Range [R] 9–16) years, with a median follow-up of 18 months (R6–20). At diagnosis, one patient had impaired visual acuity (VA > 0.4), eight had vascular leakage, two had neovascularization, and three had macular edema. All responded to oral or local glucocorticoids but was not sustained. Systemic immunosuppression was started in seven patients with methotrexate and infliximab after a median time from diagnosis of 1.5 months (R0.5–2) and 3.2 months (R2.5–3.1), respectively. Infliximab was discontinued in all after a median time of 7 months (R3.5–10) for ineffectiveness, and 5/7 switched to tocilizumab and 1 to adalimumab. Five failed to respond (4 tocilizumab, 1 adalimumab) and one had a minimal response to tocilizumabWe report on the systemic treatment response of seven children with ADNIV treated with methotrexate, infliximab, and tocilizumab. None were able to control disease. Further studies are needed to understand long-term outcomes and the utility of systemic immunosuppression. [ABSTRACT FROM AUTHOR]

Noninvasive ventilation (NIV) has rapidly expanded as the principle respiratory support strategy in a variety of disease states ultimately resulting in respiratory insufficiency including COPD, overlap syndrome (COPD + comingled sleep disordered breathing), obesity hypoventilation syndrome (OHS), motor neuron diseases, such as amyotrophic lateral sclerosis (ALS), as well as various muscular dystrophies to list just a few examples. In recent years, NIV technology and algorithms have experienced rapid development aimed at improving performance, reliability, comfort, portability, titration efficiency, and treatment outcomes. One specific algorithmic advancement of NIV has been the development of volume targeting algorithms and the creation of new, hybrid modes of NIV. The fundamental feature of volume targeted algorithms is the automation of the inspiratory positive airway pressure (IPAP) or pressure support (PS). In recent years, volume targeted modes have grown in popularity and often are the preferred method of implementing NIV in the home. There are important differences between manufacturer’s proprietary algorithms that should be understood by the clinician when implementing NIV or when evaluating patient response to NIV. This article will identify some of the unique characteristics of commercially available volume targeted modes and will provide an overview of recent findings in specific cohorts.

Background: A few months after the COVID-19 pandemic onset, knowledge of SARS-CoV-2 infection and outcomes and treatments blew up. This paper aimed to evaluate the features of a Tuscany COVID-19 hospitalized cohort and to identify risk factors for COVID-19 severity. Methods: This retrospective observational COVID-19 cohort study (1 March 2020–1 March 2021) was conducted on patients ≥ 18 years old, admitted to Tuscany Hospital, and subjected to follow-up within 12 months after discharge. Patients were enrolled at Pisana, Senese and Careggi University Hospitals, and South East, North West, and Center Local Hospitals. Results: 2888 patients (M = 58.5%, mean age = 66.2 years) were enrolled, of whom 14.3% (N = 413) were admitted to an intensive care unit. Smokers were 25%, and overweight and obese 65%. The most used drugs were corticosteroids, antacids, antibiotics, and antithrombotics, all antiviral drugs, with slight differences between 2020 and 2021. A strong association was found between outcomes of evolution towards critical COVID-19 (non-invasive mechanical ventilation (NIV) and/or admission to intensive care) and smoking (RR = 4.91), ex-smoking (RR = 3.48), overweight (RR = 1.30), obese subjects (RR = 1.62), comorbidities (aRR = 1.38). The alteration of liver enzymes (aspartate aminotransferase, alanine aminotransferase, or gamma-glutamyl transpeptidase) was associated with NIV (aOR = 2.28). Conclusions: Our cohort, characterized by patients with a mean age of 66.2 years, showed 65% of patients were overweight and obese. Smoking/ex-smoking, overweight/obesity, and other comorbidities were associated with COVID-19 adverse outcomes. The findings also demonstrated that alterations in liver enzymes were associated with worse outcomes. [ABSTRACT FROM AUTHOR]

Background: In recent years, a significant understanding of delivering optimal aerosol therapy and the availability of various drugs and devices have led to an increase in its use in clinical practice. There are only a few studies available regarding their use in critically ill patients from a few parts of the world. We aimed to study the practice pattern of aerosol therapy in critically ill patients from Indian intensive care units (ICUs). Methods: After ethical approval, this multi-centric prospective observational study was performed over a study period of four weeks. Newly admitted adult patients considered who had an artificial airway and/or ventilation (including non-invasive). Patients were followed up for the next 14 days or until ICU discharge/death (whichever came first) for details of each aerosol therapy, including ongoing respiratory support, drug type, and aerosol-generating device. Results: From the nine participating centers across India, 218 patients were enrolled. Of 218 enrolled patients, 72.48% received 4884 aerosols with 30.91 ± 27.15 (95%CI: 26.6-35.1) aerosols per patient over 1108 patient days. Approximately 62.7% during IMV, 30.2% during NIV, 2.3% in spontaneously breathing patients with an artificial airway during weaning, and 4.7% were given without an artificial airway after weaning or decannulation. In 59%, a single drug was used, and bronchodilators were the most frequent. The jet nebulizer was the most common, followed by the ultrasonic and vibrating mesh aerosol generator. The ventilator setting was changed in only 6.6% of the aerosol sessions with IMV and none with NIV. Conclusion: Aerosol therapy is frequently used with a wide variation in practices; bronchodilators are the most commonly used drugs, and jet nebulizers are the most widely used.

Objectives Spontaneous pneumothorax among patients with obstructive sleep apnea treated by nocturnal continuous positive airway pressure (CPAP) has not been well documented. Methods We present three cases of patients on chronic CPAP who experienced spontaneous pneumothorax without clear predisposing factors. Their personal and family medical histories, imaging characteristics, and CPAP settings are reviewed. Results In all three cases, the patients had bullae ipsilateral to the pneumothoraces that either formed (n = 1) or grew significantly (n = 2) after CPAP initiation. No other risk factors for pneumothorax or bullae were identified. Conclusions This case series demonstrates a need for further investigation into a possible connection between spontaneous pneumothorax, bullae development, and CPAP use.

Background: In recent years, a significant understanding of delivering optimal aerosol therapy and the availability of various drugs and devices have led to an increase in its use in clinical practice. There are only a few studies available regarding their use in critically ill patients from a few parts of the world. We aimed to study the practice pattern of aerosol therapy in critically ill patients from Indian intensive care units (ICUs). Methods: After ethical approval, this multi-centric prospective observational study was performed over a study period of four weeks. Newly admitted adult patients considered who had an artificial airway and/or ventilation (including non-invasive). Patients were followed up for the next 14 days or until ICU discharge/death (whichever came first) for details of each aerosol therapy, including ongoing respiratory support, drug type, and aerosol-generating device. Results: From the nine participating centers across India, 218 patients were enrolled. Of 218 enrolled patients, 72.48% received 4884 aerosols with 30.91 ± 27.15 (95%CI: 26.6-35.1) aerosols per patient over 1108 patient days. Approximately 62.7% during IMV, 30.2% during NIV, 2.3% in spontaneously breathing patients with an artificial airway during weaning, and 4.7% were given without an artificial airway after weaning or decannulation. In 59%, a single drug was used, and bronchodilators were the most frequent. The jet nebulizer was the most common, followed by the ultrasonic and vibrating mesh aerosol generator. The ventilator setting was changed in only 6.6% of the aerosol sessions with IMV and none with NIV. Conclusion: Aerosol therapy is frequently used with a wide variation in practices; bronchodilators are the most commonly used drugs, and jet nebulizers are the most widely used. [ABSTRACT FROM AUTHOR]

Abstract Objective To evaluate the efficacy of high-flow nasal cannula oxygenation (HFNC) versus non-invasive ventilation (NIV) in pediatric patients post-congenital heart surgery (CHS) through a meta-analysis. Methods A comprehensive literature search was conducted across the Chinese biomedical literature database, Vip database, CNKI, Wanfang, PubMed, Embase, Cochrane Library, and Web of Science until December 20, 2022. We selected RCTs or cohort studies that met inclusion criteria for a meta-analysis using RevMan 5.4 software. Results Our search yielded five publications, comprised of one randomized controlled trial and four cohort studies. Meta-analysis revealed a significant reduction in reintubation rates in children post-CHS treated with HFNC as compared to NIV [RR = 0.36, 95%CI(0.25 ~ 0.53), P 0.05). Furthermore, both groups showed no significant difference in the duration of extracorporeal circulation [MD = -8.27, 95%CI(-17.16 ~ 0.62), P = 0.07]. Conclusions For pediatric patients post-CHS, HFNC appears to be more effective than NIV in reducing reintubation rates and shortening the CICU stay.

Coronavirus-related (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) global pandemic has caused significant mortality and morbidity globally in the last 3 years. In the present case report, a 51-year-old man presented in the outdoor unit for shortness of breath on exertion with a history of severe coronavirus disease-2019 (COVID-19) pneumonia resulted in acute respiratory distress syndrome with hospitalisation in the intensive care unit 1 year back and required high-flow nasal cannula (HFNC) with noninvasive ventilatory support (NIV) for 2 weeks. He was offered oxygen supplementation at home with antibiotics for 3 months and there was no requirement of oxygen and some respiratory symptoms even after 1 year. His high-resolution computed tomography thorax documented at 1 year of discharge from the hospital revealed typical interstitial opacities labelled as persistent residual lung abnormalities (RLAs) that are predominantly reticular and linear opacities in peripheral parts of lungs without honeycombing within typical pleural-based areas with parenchymal bands and minimally altered lung architecture and preserved lung volume.

BackgroundWe evaluated in-hospital mortality and outcomes incidence after hospital discharge due to COVID-19 in a Brazilian multicenter cohort.MethodsThis prospective multicenter study (RECOVER-SUS, NCT04807699) included COVID-19 patients hospitalized in public tertiary hospitals in Brazil from June 2020 to March 2021. Clinical assessment and blood samples were performed at hospital admission, with post-hospital discharge remote visits. Hospitalized participants were followed-up until March 31, 2021. The outcomes were in-hospital mortality and incidence of rehospitalization or death after hospital discharge. Kaplan-Meier curves and Cox proportional-hazard models were performed.Findings1589 participants [54.5% male, age=62 (IQR 50-70) years; BMI=28.4 (IQR,24.9-32.9) Kg/m² and 51.9% with diabetes] were included. A total of 429 individuals [27.0% (95%CI,24.8-29.2)] died during hospitalization (median time 14 (IQR,9-24) days). Older age [vs

Objective: To evaluate the efficacy of high-flow nasal cannula oxygenation (HFNC) versus non-invasive ventilation (NIV) in pediatric patients post-congenital heart surgery (CHS) through a meta-analysis. Methods: A comprehensive literature search was conducted across the Chinese biomedical literature database, Vip database, CNKI, Wanfang, PubMed, Embase, Cochrane Library, and Web of Science until December 20, 2022. We selected RCTs or cohort studies that met inclusion criteria for a meta-analysis using RevMan 5.4 software. Results: Our search yielded five publications, comprised of one randomized controlled trial and four cohort studies. Meta-analysis revealed a significant reduction in reintubation rates in children post-CHS treated with HFNC as compared to NIV [RR = 0.36, 95%CI(0.25 ~ 0.53), P < 0.00001]. There was also a notable reduction in the duration of ICU stay [MD = -4.75, 95%CI (-9.38 ~ -0.12), P = 0.04]. No statistically significant differences were observed between HFNC and NIV in terms of duration of mechanical ventilation, 24 h PaO2, and PaCO2 post-treatment (P > 0.05). Furthermore, both groups showed no significant difference in the duration of extracorporeal circulation [MD = -8.27, 95%CI(-17.16 ~ 0.62), P = 0.07]. Conclusions: For pediatric patients post-CHS, HFNC appears to be more effective than NIV in reducing reintubation rates and shortening the CICU stay. [ABSTRACT FROM AUTHOR]

Nipah virus (NiV), a biosafety level 4 agent, was first identified in human clinical cases during an outbreak in 1998 in Malaysia and Singapore. While flying foxes are the primary host and viral vector, the infection is associated with a severe clinical presentation in humans, resulting in a high mortality rate. Therefore, NiV is considered a virus with an elevated epidemic potential which is further underscored by its recent emergence (September 2023) as an outbreak in India. Given the situation, it is paramount to understand the molecular dynamics of the virus to shed more light on its evolution and prevent potential future outbreaks. In this study, we conducted Bayesian phylogenetic analysis on all available NiV complete genomes, including partial N-gene NiV sequences (≥1000 bp) in public databases since the first human case, registered in 1998. We observed the distribution of genomes into three main clades corresponding to the genotypes Malaysia, Bangladesh and India, with the Malaysian clade being the oldest in evolutionary terms. The Bayesian skyline plot showed a recent increase in the viral population size since 2019. Protein analysis showed the presence of specific protein families (Hendra_C) in bats that might keep the infection in an asymptomatic state in bats, which also serve as viral vectors. Our results further indicate a shortage of complete NiV genomes, which would be instrumental in gaining a better understanding of NiV's molecular evolution and preventing future outbreaks. Our investigation also underscores the critical need to strengthen genomic surveillance based on complete NiV genomes that will aid thorough genetic characterization of the circulating NiV strains and the phylogenetic relationships between the henipaviruses. This approach will better prepare us to tackle the challenges posed by the NiV virus and other emerging viruses. [ABSTRACT FROM AUTHOR]

Background and Objectives: The use of non-invasive ventilation (NIV) for community-acquired pneumonia (CAP) remains controversial. NIV failure in the setting of acute hypoxemic respiratory failure is associated with increased mortality, highlighting the need for careful patient selection. Methods and Methods: This is a retrospective observational cohort study. We included 140 patients with severe CAP, treated with either NIV or invasive mechanical ventilation (IMV) as their primary oxygenation strategy. Results: The median PaO2/FiO2 ratio and SOFA score upon ICU admission were 151 mmHg and 6, respectively. We managed 76% of patients with NIV initially and report an NIV success rate of 59%. Overall, the 28-day mortality was 25%, whilst for patients with NIV success, the mortality was significantly lower at 13%. In the univariate analysis, NIV failure was associated with the SOFA score (OR 1.33), the HACOR score (OR 1.14) and the presence of septic shock (OR 3.99). The SOFA score has an AUC of 0.75 for NIV failure upon ICU admission, whilst HACOR has an AUC of 0.76 after 2 h of NIV. Conclusions: Our results suggest that a SOFA ≤ 4 and an HACOR ≤ 5 are reasonable thresholds to identify patients with severe CAP likely to benefit from NIV. [ABSTRACT FROM AUTHOR]

Background and Objectives: In patients with COVID-19, high-flow nasal cannula (HFNC) and continuous positive airway pressure (CPAP) are widely applied as initial treatments for moderate-to-severe acute hypoxemic respiratory failure. The aim of the study was to assess which respiratory supports improve 28-day mortality and to identify a predictive index of treatment response. Materials and Methods: This is a single-center retrospective observational study including 159 consecutive adult patients with COVID-19 and moderate-to-severe hypoxemic acute respiratory failure. Results: A total of 159 patients (82 in the CPAP group and 77 in the HFNC group) were included in the study. Mortality within 28 days was significantly lower with HFNC compared to CPAP (16.8% vs. 50%), while ICU admission and tracheal intubation within 28 days were significantly higher with CPAP compared to HFNC treatment (32% vs. 13%). We identified an index for survival in HFNC by including three variables easily available at admission (LDH, age, and respiratory rate) and the PaO2/FiO2 ratio at 48 h. The index showed high discrimination for survival with an AUC of 0.88, a negative predictive value of 86%, and a positive predictive value of 95%. Conclusions: Treatment with HFNC appears to be associated with greater survival and fewer ICU admission than CPAP. LDH, respiratory rate, age, and PaO2/FiO2 at 48 h were independently associated with survival and an index based on these variables allows for the prediction of treatment success and the assessment of patient allocation to the appropriate intensity of care after 48 h. Further research is warranted to determine effects on other outcomes and to assess the performance of the index in larger cohorts. [ABSTRACT FROM AUTHOR]

BACKGROUND: Non-invasive ventilation (NIV) reduces the rate of endotracheal intubation and overall mortality in severe acute exacerbation of COPD (AECOPD) with respiratory failure. However, poor patient selection and ineffective NIV administration lead to higher mortality. We aimed to identify factors that predict the outcome of NIV in AECOPD. METHODOLOGY: We have conducted prospective observational study in the Department of Pulmonary Medicine Government Chest diseases and TB hospital, Hanmakonda, Telangana. between November 2020 to July 2022. Patients who were admitted with AECOPD with increased work of breathing and PaCO2 >45mm Hg were included in this study. COPD was diagnosed with history, clinical examination, chest X-ray PA View and previous spirometry. Blood gas analysis was done to assess PaCO2, PaO2 and PH before and after NIV administration after clinical improvement. RESULTS: Total 40 patients were included in this study of which 12.5% were female and 87.5% were male patients. Out of 40 patients, 37 patients improved with NIV treatment and remaining 3 failed to improve. Duration of NIV treatment depends upon following factors like sputum consistency, current history smoking, respiratory rate at the time of admission, presence of comorbidities (corpulmonale, diabetes) high PaCO2 levels and low PH levels. [ABSTRACT FROM AUTHOR]

Management of nutritional support in patients undergoing noninvasive mechanical ventilation (NIMV) in respiratory intensive care units (r-ICU) is still a challenge and it’s a topic not often discussed among respiratory physician. Our article summarizes the state of the art, with the aim to give the physician a view of the status of the art and some practical advice. In our article, we will discuss energy expenditure, that can be used to assess patient’s nutritional needs, and possible strategies for nutritional support (oral intake, enteral or parenteral nutrition). [ABSTRACT FROM AUTHOR]

This document summarizes the work of the CPAP and bilevel PAP therapy for OSA Technical Expert Panel working group. For positive airway pressure (PAP) therapy, the most pressing current coverage barriers identified were: an insufficient symptom list describing all potential symptoms in patients with mild OSA; the 4 h per night of PAP usage requirement to keep the device; the additional sleep studies requirement to re-qualify for PAP or supplemental oxygen; and the inability to use telehealth visits for follow-up visits. Critical evidence supports changes to current policies and includes: symptom list inadequate to cover all scenarios based on updated clinical practice guidelines; published evidence that 2 h per night of PAP use can result in benefit to quality of life and other metrics; the costs of another sleep study not justified for all nonadherent patients or for supplemental oxygen due to other types of assessment currently available; and the remarkable success and acceptance of telehealth visits. To achieve optimal access for patients on PAP therapy, we make the following key suggestions: removing symptom criteria for mild OSA; reduce continued coverage criteria to > 2 h per night; eliminate the need for a sleep study to re-qualify if nonadherent or for new Centers for Medicare & Medicaid Services beneficiaries already on and adherent to PAP therapy; allow telehealth visits for documenting benefit and adherence; and allow PAP reports and domiciliary oximetry to qualify for supplemental oxygen with PAP if needed. This paper shares our best vision for bringing the right device to the right patient at the right time.

Abstract Background Continuous positive airway pressure (CPAP) has been a key treatment modality for Coronavirus Disease 2019 (COVID-19) worldwide. Globally, the demand for CPAP outstripped the supply during the pandemic. The LeVe CPAP System was developed to provide respiratory support for treatment of COVID-19 and tailored for use in low- and middle-income country (LMIC) settings. Prior to formal trial approval, received in November 2021, these devices were used in extremis to support critically unwell adult patients requiring non-invasive ventilatory support. Methods This is a retrospective descriptive review of adult patients with COVID-19 pneumonitis, who were treated with advanced respiratory support (CPAP and/or high-flow nasal oxygen, HFNO) at Mengo Hospital, Uganda. Patients were treated with the LeVe CPAP System, Elisa CPAP and/or AIRVO™ HFNO. Treatment was escalated per standard local protocols for respiratory failure, and CPAP was the maximum respiratory support available. Data were collected on patient characteristics, length of time of treatment, clinical outcome, and any adverse events. Results Overall 333 patients were identified as COVID-19 positive, 44 received CPAP ± HFNO of which 43 were included in the study. The median age was 58 years (range 28–91 years) and 58% were female. The median duration of advanced respiratory support was 7 days (range 1–18 days). Overall (all device) mortality was 49% and this was similar between those started on the LeVe CPAP System and those started non-LeVe CPAP System devices (50% vs 47%). Conclusions The LeVe CPAP system was the most used CPAP device during the pandemic, bringing the hospital’s number of available HFNO/CPAP devices from two to 14. They were a critical resource for providing respiratory support to the sickest group of patients when no alternative devices were available. The devices appear to be safe and well-tolerated with no serious adverse events recorded. This study is unable to assess the efficacy of the LeVe CPAP System; therefore, formal comparative studies are required to inform further use.

Objectives: We compared the risk of environmental contamination among patients with COVID-19 who received high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), and conventional oxygen therapy (COT) via nasal cannula for respiratory failure. Methods: Air was sampled from the hospital isolation rooms with 12 air changes/hr where 26 patients with COVID-19 received HFNC (up to 60 l/min, n = 6), NIV (n = 6), or COT (up to 5 l/min of oxygen, n = 14). Surface samples were collected from 16 patients during air sampling. Results: Viral RNA was detected at comparable frequency in air samples collected from patients receiving HFNC (3/54, 5.6%), NIV (1/54, 1.9%), and COT (4/117, 3.4%) (P = 0.579). Similarly, the risk of surface contamination was comparable among patients receiving HFNC (3/46, 6.5%), NIV (14/72, 19.4%), and COT (8/59, 13.6%) (P = 0.143). An increment in the cyclic thresholds of the upper respiratory specimen prior to air sampling was associated with a reduced SARS-CoV-2 detection risk in air (odds ratio 0.83 [95% confidence interval 0.69-0.96], P = 0.027) by univariate logistic regression. Conclusion: No increased risk of environmental contamination in the isolation rooms was observed in the use of HFNC and NIV vs COT among patients with COVID-19 with respiratory failure. Higher viral load in the respiratory samples was associated with positive air samples.

Introduction Non-invasive ventilation (NIV) has a significant role in supporting patients with respiratory failure with the goal of avoiding mechanical ventilation. Traditionally, NIV has been applied using dedicated NIV-specific devices but over the last decade, newer generation critical care ventilators have updated their capabilities to include NIV options with improved synchrony and leak compensation. No recent trials have compared the efficacy of new generation critical care ventilators to NIV ventilators. The purpose of this study was to evaluate clinicians attitudes and perceptions toward the use of NIV between the dedicated NIV and critical care ventilators. Methods An online survey of clinicians with seven questions regarding their thoughts and experience in using NIV in acute care settings was posted online and promoted through emails and social media. The survey was anonymous and an exemption of consent was obtained from the Institutional Review Board. Analysis of variants (ANOVA) was done for the total responses in each question, followed by multivariate analysis of variants (MANOVA) for responses per occupation. Results 514 responses from 54 countries were recorded. 151 from North America, 109 from South America, 125 from Europe, 97 from Asia, 21 from Africa, and 11 from Australia. 218 responders were physicians, 218 were respiratory therapists, 28 were nurses, and 50 were reported as other professionals (engineers, biomedical technicians). 346 (67.3%) reported using both types of ventilators for NIV, 91 (17.7%) use only NIV -specific devices, and 77 (15%) only use critical care ventilators (P 0.097), responses per occupation (P < 0.001). 290 (56.4%) have automatic synchronization software on either of their ventilators, 113 (22%) do not, while 111 (21.6%) are unsure if they do (P 0.22), with significant variation by occupation (P 0.008). Regarding synchrony, 233 (45.3%) said NIV ventilators are better, and 165 (32.1%) said critical care ventilators are better, while 116 (22.5%) said both are similar (P 0.59) with significant variation by occupation (P 0.04). Regarding leak compensation, 241 (46.9%) said NIV ventilators are better, and 146 (284%) said critical care ventilators are better, while 127 (24.7%) said both are similar (P 0.6) without significant variation by occupation (P 0.07). Regarding the general opinion of superiority, 273 (53.1%) said NIV ventilators are better, 131 (25.5%) said critical care ventilators are better, and 110 (21.4%) said both are similar (P 0.42) without significant variation by occupation (P 0.098). Conclusion Despite the lack of evidence, there is wide variability in opinion with no clear consensus regarding the clinicians’ attitude towards which ventilators are superior to use during NIV, especially according to surveyed occupation.

This study has focused on the transmission dynamics of the Nipah Virus (NiV) and its controlling system. In this respect, we have developed a virus transmission model based on several compartments and discussed the model's basic reproduction number and stability analysis at disease-free equilibrium (DFE) and endemic equilibrium (EE) points. It is observed that the model is locally and globally asymptotically stable at DFE and EE for the basic reproduction number R01, respectively. We have also solved the model equations numerically using the Runge-Kutta (RK-45) method to investigate the effect of disease parameters. In the calculation, some parameter values are taken from several references. Lastly, the calculated results show that the infection rate of the exposed individuals highly influences the disease compartments. Furthermore, drug resistance is observed to be less effective than the treatment rate. In addition, it is found that the number of infected people is reducing with the increasing treatment rate.

Non-invasiv ventilasjonsbehandling (NIV) er en behandlingsform som kan gjennomføres på sengepost med intermediærstue og er et tiltak som kan avlaste intensivavdelinger. Hensikten med denne studien var å belyse hva sykepleiere vurderer som viktige forutsetninger for vellykket oppstart av NIV-behandling på sengepost med intermediærstue. En kvalitativ metode med et eksplorerende og beskrivende design ble valgt. Det ble gjennomført individuelle, semistrukturerte intervjuer med syv sykepleiere. Datamaterialet ble analysert ved bruk av systematisk tekstkondensering. Sykepleierne vurderte at det å skape en trygg relasjon på pasientens premisser gjennom tilstedeværelse og oppmerksomhet og tilstrekkelig NIV-kompetanse hos sykepleierne som forutsetninger for vellykket oppstart av NIV-behandling. Videre vurderte sykepleierne at vellykket oppstart av NIV-behandling forutsetter at sykepleiere er i stand til å utføre et bredt spekter av kliniske og etiske vurderinger for å vurdere pasientens behov og effekt av NIVbehandlingen. Det som er nytt med denne studien er at den beskriver oppstart av NIV-behandling på sengepost med intermediærstue.

The use of the Ratio of Oxygen Saturation (ROX) index to predict the success of high-flow nasal oxygenation (HFNO) is well established. The ROX can also predict the need for intubation, mortality, and is easier to calculate compared with APACHE II. In this prospective study, the primary aim is to compare the ROX (easily administered in resource limited setting) to APACHE II for clinically relevant outcomes such as mortality and the need for intubation. Our secondary aim was to identify thresholds for the ROX index in predicting outcomes such as the length of ICU stay and failure of non-invasive respiratory support therapies and to assess the effectiveness of using the ROX (day 1 at admission, day 2, and day 3) versus Acute physiology and chronic health evaluation (APACHE) II scores (at admission) in patients with Coronavirus Disease 2019 (COVID-19) pneumonia and Acute Respiratory Distress Syndrome (ARDS) to predict early, late, and non-responders. After screening 208 intensive care unit patients, a total of 118 COVID-19 patients were enrolled, who were categorized into early (n = 38), late (n = 34), and non-responders (n = 46). Multinomial logistic regression, receiver operating characteristic (ROC), Multivariate Cox regression, and Kaplan–Meier analysis were conducted. Multinomial logistic regressions between late and early responders and between non- and early responders were associated with reduced risk of treatment failures. ROC analysis for early vs. late responders showed that APACHE II on admission had the largest area under the curve (0.847), followed by the ROX index on admission (0.843). For responders vs. non-responders, we found that the ROX index on admission had a slightly better AUC than APACHE II on admission (0.759 vs. 0.751). A higher ROX index on admission [HR (95% CI): 0.29 (0.13–0.52)] and on day 2 [HR (95% CI): 0.55 (0.34–0.89)] were associated with a reduced risk of treatment failure. The ROX index can be used as an independent predictor of early response and mortality outcomes to HFNO and NIV in COVID-19 pneumonia, especially in low-resource settings, and is non-inferior to APACHE II. [ABSTRACT FROM AUTHOR]

Background: There are limited data reporting diagnostic practices, compared to clinical guidelines, for patients with chronic respiratory failure requiring home mechanical ventilation (HMV). There are no data detailing the current use of downloaded physiological monitoring data in day-to-day clinical practice during initiation and follow up of patients on HMV. This survey reports clinicians' practices, with a specific focus on the clinical approaches employed to assess, monitor and manage HMV patients. Methods: A web-based international survey was open between 1 January and 31 March 2023. Results: In total, 114 clinicians responded; 84% of the clinicians downloaded the internal physiological ventilator data when initiating and maintaining HMV patients, and 99% of the clinicians followed up with patients within 3 months. Adherence, leak and the apnea-hypopnea index were the three highest rated items. Oxygen saturation was used to support a diagnosis of nocturnal hypoventilation and was preferred over measurements of carbon dioxide. Furthermore, 78% of the clinicians reviewed data for the assessment of patient ventilator asynchrony (PVA), although the confidence reported in identifying certain PVAs was reported as unconfident or extremely unconfident. Conclusions: This survey confirmed that clinical practice varies and often does not follow the current guidelines. Despite PVA being of clinical interest, its clinical relevance was not clear, and further research, education and training are required to improve clinical confidence. [ABSTRACT FROM AUTHOR]

Background: A Medico-legal case [MLC] is defined as “any case of injury or hurt, which the attending medical officer after complete history taking and examination, considers investigation by the law enforcement agencies necessary, in order to fix responsibility regarding the related injury in accordance with the prevailing laws of the country.” The objective of medico-legal autopsy is to establish the identity of a body, when not known; to find out the cause of death, time since death, nature and manner of death, whether it was homicidal, suicidal or accidental. In addition, the question of live birth and viability assumes the importance in case of infant deaths. Material and Methods: The present study is a retrospective study of medicolegal autopsies performed at Mahatma Gandhi Medical College, Jaipur, India. from period of January 2021 to September 2023. The total no. of medico-legal autopsies performed During the study period were 538. Ethical clearance for this study was obtained by the Institutional Ethical Committee. The identities of the deceased persons whose data was obtained from the medical records has not been revealed in any of the documents related to the study. Results: The distribution of cases with respect to different age group. The most vulnerable study group with respect to all type cases is 21 to 30 years age group, especially the hanging, road traffic accident & railway accident having 69, 38 and 32 cases respectively, are highest in this age group, followed by 31 to 40 and 41 to 50 years age group. The overall most common cause being hanging (131 cases) road traffic accident (112 cases) & railway accident (77 cases). Least number of cases recorded in age group of less than 10 years, with road traffic accident having highest 6 cases. Conclusion: While Road Traffic Accidents seemingly associated with increased vehicular speed, rare use of helmets and seat belts, along with drunken driving, substance abuse, driving while having mental stress and divided lost attention etc. [ABSTRACT FROM AUTHOR]

The less invasive surfactant application (LISA) technology has been widely used to manage breathing in premature infants. Premature infants with respiratory distress syndrome (RDS) were retrospectively analyzed and divided into 2 groups according to the drug delivery methods used: LISA versus traditional pulmonary surfactant injection (INSURE). The decrease of transcutaneous saturation (TcSO2) and heart rate during surfactant delivery in the LISA group was higher than that in the INSURE group (P <.05). Between the 2 groups, there was no significant difference in the change in partial pressure of oxygen/fraction of inspired oxygen value before and after drug delivery; second-use pulmonary surfactant; noninvasive ventilation (NIV) failure rate; incidence of some complications; duration of NIV use; hospitalization time; and mortality (P >.05). However, the incidence of bronchopulmonary dysplasia (BPD) in the LISA group was lower than that in the INSURE group (P <.05). The clinical efficacy of LISA combined with the NIV treatment in premature infants with RDS was clear, and this treatment could reduce the incidence of BPD. [ABSTRACT FROM AUTHOR]

Nighttime and non-working days are characterized by a shortage of dedicated staff and available resources. Previous studies have highlighted that patients admitted during the weekend had higher mortality than patients admitted on weekdays ("weekend effect"). However, most studies have focused on specific conditions and controversial results were reported. We conducted an observational, monocentric, retrospective cohort study, based on data collected prospectively to evaluate the impact of the timing of NIV initiation on clinical outcomes in COPD patients with acute respiratory failure (ARF). A total of 266 patients requiring NIV with a time gap between diagnosis of ARF and NIV initiation <48 h were included. Interestingly, 39% of patients were not acidotic (pH = 7.38 ± 0.09 vs. 7.26 ± 0.05, p = 0.003) at the time of NIV initiation. The rate of NIV failure (need for intubation and/or all-cause in-hospital death) was similar among three different scenarios: "daytime" vs. "nighttime", "working" vs. "non-working days", "nighttime or non-working days" vs. "working days at daytime". Patients starting NIV during nighttime had a longer gap to NIV initiation compared to daytime (219 vs. 115 min respectively, p = 0.01), but this did not influence the NIV outcome. These results suggested that in a training center for NIV management, the failure rate did not increase during the "silent" hours. [ABSTRACT FROM AUTHOR]