RESUMEN
X-linked myotubular myopathy (XLMTM) is a rare, life-threatening congenital myopathy. Most (80%) children with XLMTM have profound muscle weakness and hypotonia at birth resulting in severe respiratory insufficiency, the inability to sit up, stand or walk, and early mortality. At birth, 85-90% of children with XLMTM require mechanical ventilation, with more than half requiring invasive ventilator support. Historically, ventilator-dependent children with neuromuscular-derived respiratory failure of this degree and nature, static or progressive, are not expected to achieve complete independence from mechanical ventilator support. In the ASPIRO clinical trial (NCT03199469), participants receiving a single intravenous dose of an investigational gene therapy (resamirigene bilparvovec) started showing significant improvements in daily hours of ventilation support compared with controls by 24 weeks post-dosing, and 16 of 24 dosed participants achieved ventilator independence between 14 and 97 weeks after dosing. At the time, there was no precedent or published guidance for weaning chronically ventilated children with congenital neuromuscular diseases off mechanical ventilation. When the first ASPIRO participants started showing dramatically improved respiratory function, the investigators initiated efforts to safely wean them off ventilator support, in parallel with primary protocol respiratory outcome measures. A group of experts in respiratory care and physiology and management of children with XLMTM developed an algorithm to safely wean children in the ASPIRO trial off mechanical ventilation as their respiratory muscle strength increased. The algorithm developed for this trial provides recommendations for assessing weaning readiness, a stepwise approach to weaning, and monitoring of children during and after the weaning process.
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Algoritmos , Terapia Genética , Miopatías Estructurales Congénitas , Respiración Artificial , Humanos , Miopatías Estructurales Congénitas/terapia , Miopatías Estructurales Congénitas/genética , Miopatías Estructurales Congénitas/diagnóstico , Masculino , Respiración Artificial/métodos , Terapia Genética/métodos , Terapia Genética/tendencias , Preescolar , Niño , Lactante , Desconexión del Ventilador/métodos , Resultado del Tratamiento , Insuficiencia Respiratoria/terapia , Insuficiencia Respiratoria/diagnóstico , Adolescente , Privación de Tratamiento/tendenciasRESUMEN
BACKGROUND: Opioid overdose is a global health crisis, affecting over 27 million individuals worldwide, with more than 100,000 drug overdose deaths in the United States in 2022-2023. This protocol outlines the development of the PneumoWave chest biosensor, a wearable device being designed to detect respiratory depression in real time through chest motion measurement, intending to enhance early intervention and thereby reduce fatalities. OBJECTIVE: The study aims to (1) differentiate opioid-induced respiratory depression (OIRD) from nonfatal opioid use patterns to develop and refine an overdose detection algorithm and (2) examine participants' acceptability of the chest biosensor. METHODS: The study adopts an observational design over a 6-month period. The biosensor, a small device, will be worn by consenting participants during injecting events to capture chest motion data. Safe injecting facilities (SIF) in Melbourne, Victoria (site 1), and Sydney, New South Wales (site 2), which are legally sanctioned spaces where individuals can use preobtained illicit drugs under medical supervision. Each site is anticipated to recruit up to 100 participants who inject opioids and attend the SIF. Participants will wear the biosensor during supervised injecting events at both sites. The biosensor will attempt to capture data on an anticipated 40 adverse drug events. The biosensor's ability to detect OIRD will be compared to the staff-identified events that use standard protocols for managing overdoses. Measurements will include (1) chest wall movement measured by the biosensor, securely streamed to a cloud, and analyzed to refine an overdose detection algorithm and (2) acute events or potential overdose identified by site staff. Acceptability will be measured by a feedback questionnaire as many times as the participant is willing to throughout the study. RESULTS: As of April 2024, a total of 47 participants have been enrolled and data from 1145 injecting events have already been collected, including 10 overdose events. This consists of 17 females and 30 males with an average age of 45 years. Data analysis is ongoing. CONCLUSIONS: This protocol establishes a foundation for advancing wearable technology in opioid overdose prevention within SIFs. The study will provide chest wall movement data and associated overdose data that will be used to train an algorithm that allows the biosensor to detect an overdose. The study will contribute crucial insights into OIRD, emphasizing the biosensor's potential step forward in real-time intervention strategies. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/57367.
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Dispositivos Electrónicos Vestibles , Humanos , Masculino , Femenino , Sobredosis de Droga/diagnóstico , Sobredosis de Opiáceos/epidemiología , Sobredosis de Opiáceos/diagnóstico , Adulto , Persona de Mediana Edad , Analgésicos Opioides/efectos adversos , Analgésicos Opioides/administración & dosificación , Técnicas Biosensibles/instrumentación , Técnicas Biosensibles/métodos , Estudios Observacionales como Asunto , Nueva Gales del Sur/epidemiología , Insuficiencia Respiratoria/diagnósticoRESUMEN
Gastroenterology nurses working across a variety of clinical settings are responsible for periprocedural monitoring during moderate to deep procedural sedation and analgesia (PSA) to identify signs of respiratory compromise and intervene to prevent cardiorespiratory events. Pulse oximetry is the standard of care for respiratory monitoring, but it may delay or fail to detect abnormal ventilation during PSA. Continuous capnography, which measures end-tidal CO2 as a marker of alveolar ventilation, has been endorsed by a number of clinical guidelines. Large clinical trials have demonstrated that the addition of continuous capnography to pulse oximetry during PSA for various gastroenterological procedures reduces the incidence of hypoxemia, severe hypoxemia, and apnea. Studies have shown that the cost of adding continuous capnography is offset by the reduction in adverse events and hospital length of stay. In the postanesthesia care unit, continuous capnography is being evaluated for monitoring opioid-induced respiratory depression and to guide artificial airway removal. Studies are also examining the utility of continuous capnography to predict the risk of opioid-induced respiratory depression among patients receiving opioids for primary analgesia. Continuous capnography monitoring has become an essential tool to detect early signs of respiratory compromise in patients receiving PSA during gastroenterological procedures. When combined with pulse oximetry, it can help reduce cardiorespiratory adverse events, improve patient outcomes and safety, and reduce health care costs.
Asunto(s)
Capnografía , Humanos , Capnografía/métodos , Sedación Consciente/métodos , Sedación Consciente/efectos adversos , Insuficiencia Respiratoria/diagnóstico , Monitoreo Fisiológico/métodos , Analgesia/métodos , Analgesia/efectos adversos , Femenino , Masculino , Oximetría/métodos , Diagnóstico PrecozRESUMEN
Undiagnosed chronic hypercapnic respiratory failure may be encountered during the evaluation of sleep-related breathing disorders at the sleep clinic. This article reviews the mechanism of chronic hypercapnic respiratory failure and the systematic approach to the assessment of specific sleep disorders associated with nocturnal hypoventilation encountered in clinical practice.
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Hipercapnia , Insuficiencia Respiratoria , Humanos , Insuficiencia Respiratoria/terapia , Insuficiencia Respiratoria/fisiopatología , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/diagnóstico , Hipercapnia/fisiopatología , Enfermedad CrónicaRESUMEN
BACKGROUND: In amyotrophic lateral sclerosis (ALS) prognosis is poor due to progressive weakening of the respiratory muscles. Survival and quality of life can be improved by noninvasive ventilation (NIV), which is initially applied while sleeping. The indication for NIV is based on pulmonary function testing (PFT) and polysomnography (PSG) with capnography (tCO2). While it is desirable to predict nocturnal ventilation by waking PFT in ALS, the parameters suited for reliable predictions remain elusive. METHODS: We retrospectively analyzed parameters derived from PFT (spirometry, body plethysmography, diffusion capacity, respiratory muscle testing) and blood gas analysis, PSG and tCO2 in 42 patients with ALS (27 men, 15 women, age 69 ± 12.1 years) and performed Spearman's correlation analysis of daytime waking parameters and nighttime sleep parameters. RESULTS: 28 patients (66.7%) showed restrictive impairment of ventilation and 15 patients (48.3%) showed insufficiency of the respiratory musculature. There was no obstructive impairment of ventilation. We did not observe any significant correlations between any single daytime PFT parameter with nocturnal pCO2. However, there were significant correlations between the ratios PIF/PEF, MEF50/MIF50, DLCO/VA as well as FEV1/FVC and nocturnal pCO2. Highly normal FEV1/FVC and Krogh-Factor (DLCOc/VA) indicated nocturnal hypercapnia. Furthermore, waking hypercapnia, concentrations of bicarbonate and base excess were each positively correlated with nocturnal hypercapnia. CONCLUSIONS: Waking PFT is not a good predictor of nocturnal ventilation. Inspiratory parameters as well as the ratios FEV1/FVC and DLCO/VA performed best and should be included in the interpretation. Our analyses confirm the relevance of inspiratory muscle weakness in ALS. PSG and tCO2 remain the gold standard for the assessment of nocturnal ventilation.
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Esclerosis Amiotrófica Lateral , Pruebas de Función Respiratoria , Humanos , Esclerosis Amiotrófica Lateral/fisiopatología , Esclerosis Amiotrófica Lateral/terapia , Esclerosis Amiotrófica Lateral/diagnóstico , Esclerosis Amiotrófica Lateral/complicaciones , Femenino , Masculino , Anciano , Estudios Retrospectivos , Persona de Mediana Edad , Ventilación no Invasiva/métodos , Sensibilidad y Especificidad , Reproducibilidad de los Resultados , Insuficiencia Respiratoria/terapia , Insuficiencia Respiratoria/fisiopatología , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/diagnóstico , Polisomnografía/métodos , Ritmo Circadiano/fisiologíaRESUMEN
A 13-day-old, late preterm male, born appropriate for gestational age, presented to the pediatric clinic for his routine 2-week well visit with less than 1-day history of decreased oral intake and lethargy. During the baby's well exam, he acutely decompensated and required resuscitation and transfer to the emergency department, where he was intubated for frequent apneic events. He was admitted to the NICU for management and further workup. Physical examination and initial laboratory tests were unremarkable. An EEG demonstrated electrographic and clinical seizures. His initial MRI was unremarkable, and infection studies revealed the diagnosis. We review the patient's initial presentation, evaluation, hospital course, and the long-term implications of his diagnosis.
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Recien Nacido Prematuro , Humanos , Masculino , Recién Nacido , Enfermedades del Prematuro/diagnóstico , Electroencefalografía , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/terapia , Insuficiencia Respiratoria/diagnósticoRESUMEN
BACKGROUND: Morphine relieves dyspnea in various clinical circumstances. Whether or not this applies to patients admitted to intensive care units (ICUs) for acute respiratory failure (ARF) is unknown. We evaluated the efficacy and safety of low-dose morphine on dyspnea in patients admitted to the ICU for ARF. METHODS: In this single-center, double-blind, phase 2, randomized, controlled trial, we assigned non-intubated adults admitted to the ICU for ARF with severe dyspnea, defined by a visual analog scale for dyspnea (dyspnea-VAS) from zero (no dyspnea) to 100 mm (worst imaginable dyspnea) ≥40 mm, to receive a low dose of Morphine Hydrochloride (intravenous titration followed by subcutaneous relay) or Placebo. All patients received standard therapy, including etiological treatment and non-invasive respiratory support. RESULTS: Twenty-two patients were randomized, 11 in each group. The average dyspnea (median [interquartile range]) over 24 hours did not significantly differ between the two groups (40 [25 - 43] mm in the Morphine group vs. 40 [36 - 49] mm in the Placebo group, p=0.411). Dyspnea-VAS was lower in the Morphine group than in the Placebo group at the end of intravenous titration (30 [11 - 30] vs. 35 [30 - 44], p=0.044) and four hours later (18 [10 - 29] vs. 50 [30 - 60], p=0.043). The cumulative probability of intubation was higher in the Morphine group than in the Placebo group (p=0.046) CONCLUSION: In this phase 2 pilot trial, morphine did not improve 24-hour average dyspnea in adult patients with ARF, even though it had a statistically significant immediate effect. Of concern, Morphine use was associated with a higher intubation rate. TRIAL REGISTRATION: The protocol was declared on the ClinicalTrial.gov database (no. NCT04358133) and was published in September 2022.
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Analgésicos Opioides , Disnea , Morfina , Humanos , Morfina/administración & dosificación , Método Doble Ciego , Disnea/tratamiento farmacológico , Disnea/diagnóstico , Masculino , Femenino , Persona de Mediana Edad , Anciano , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/efectos adversos , Insuficiencia Respiratoria/tratamiento farmacológico , Insuficiencia Respiratoria/diagnóstico , Resultado del Tratamiento , AdultoRESUMEN
BACKGROUND: Adjustment for race is discouraged in lung-function testing, but the implications of adopting race-neutral equations have not been comprehensively quantified. METHODS: We obtained longitudinal data from 369,077 participants in the National Health and Nutrition Examination Survey, U.K. Biobank, the Multi-Ethnic Study of Atherosclerosis, and the Organ Procurement and Transplantation Network. Using these data, we compared the race-based 2012 Global Lung Function Initiative (GLI-2012) equations with race-neutral equations introduced in 2022 (GLI-Global). Evaluated outcomes included national projections of clinical, occupational, and financial reclassifications; individual lung-allocation scores for transplantation priority; and concordance statistics (C statistics) for clinical prediction tasks. RESULTS: Among the 249 million persons in the United States between 6 and 79 years of age who are able to produce high-quality spirometric results, the use of GLI-Global equations may reclassify ventilatory impairment for 12.5 million persons, medical impairment ratings for 8.16 million, occupational eligibility for 2.28 million, grading of chronic obstructive pulmonary disease for 2.05 million, and military disability compensation for 413,000. These potential changes differed according to race; for example, classifications of nonobstructive ventilatory impairment may change dramatically, increasing 141% (95% confidence interval [CI], 113 to 169) among Black persons and decreasing 69% (95% CI, 63 to 74) among White persons. Annual disability payments may increase by more than $1 billion among Black veterans and decrease by $0.5 billion among White veterans. GLI-2012 and GLI-Global equations had similar discriminative accuracy with regard to respiratory symptoms, health care utilization, new-onset disease, death from any cause, death related to respiratory disease, and death among persons on a transplant waiting list, with differences in C statistics ranging from -0.008 to 0.011. CONCLUSIONS: The use of race-based and race-neutral equations generated similarly accurate predictions of respiratory outcomes but assigned different disease classifications, occupational eligibility, and disability compensation for millions of persons, with effects diverging according to race. (Funded by the National Heart Lung and Blood Institute and the National Institute of Environmental Health Sciences.).
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Pruebas de Función Respiratoria , Insuficiencia Respiratoria , Adolescente , Adulto , Anciano , Niño , Femenino , Humanos , Masculino , Persona de Mediana Edad , Adulto Joven , Enfermedades Pulmonares/diagnóstico , Enfermedades Pulmonares/economía , Enfermedades Pulmonares/etnología , Enfermedades Pulmonares/terapia , Trasplante de Pulmón/estadística & datos numéricos , Encuestas Nutricionales/estadística & datos numéricos , Enfermedad Pulmonar Obstructiva Crónica/diagnóstico , Enfermedad Pulmonar Obstructiva Crónica/economía , Enfermedad Pulmonar Obstructiva Crónica/etnología , Enfermedad Pulmonar Obstructiva Crónica/terapia , Grupos Raciales , Pruebas de Función Respiratoria/clasificación , Pruebas de Función Respiratoria/economía , Pruebas de Función Respiratoria/normas , Espirometría , Estados Unidos/epidemiología , Insuficiencia Respiratoria/diagnóstico , Insuficiencia Respiratoria/economía , Insuficiencia Respiratoria/etnología , Insuficiencia Respiratoria/terapia , Negro o Afroamericano/estadística & datos numéricos , Blanco/estadística & datos numéricos , Evaluación de la Discapacidad , Ayuda a Lisiados de Guerra/clasificación , Ayuda a Lisiados de Guerra/economía , Ayuda a Lisiados de Guerra/estadística & datos numéricos , Personas con Discapacidad/clasificación , Personas con Discapacidad/estadística & datos numéricos , Enfermedades Profesionales/diagnóstico , Enfermedades Profesionales/economía , Enfermedades Profesionales/etnología , Financiación Gubernamental/economía , Financiación Gubernamental/estadística & datos numéricosRESUMEN
Purpose: To develop and validate a nomogram for assessing the risk of developing hypercapnic respiratory failure (HRF) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Patients and Methods: From January 2019 to August 2023, a total of 334 AECOPD patients were enrolled in this research. We employed the Least Absolute Shrinkage and Selection Operator (LASSO) regression and multivariate logistic regression to determine independent predictors and develop a nomogram. This nomogram was appraised by the area under the receiver operating characteristic curve (AUC), calibration curve, Hosmer-Lemeshow goodness-of-fit test (HL test), decision curve analysis (DCA), and clinical impact curve (CIC). The enhanced bootstrap method was used for internal validation. Results: Sex, prognostic nutritional index (PNI), hematocrit (HCT), and activities of daily living (ADL) were independent predictors of HRF in AECOPD patients. The developed nomogram based on the above predictors showed good performance. The AUCs for the training, internal, and external validation cohorts were 0.841, 0.884, and 0.852, respectively. The calibration curves and HL test showed excellent concordance. The DCA and CIC showed excellent clinical usefulness. Finally, a dynamic nomogram was developed (https://a18895635453.shinyapps.io/dynnomapp/). Conclusion: This nomogram based on sex, PNI, HCT, and ADL demonstrated high accuracy and clinical value in predicting HRF. It is a less expensive and more accessible approach to assess the risk of developing HRF in AECOPD patients, which is more suitable for primary hospitals, especially in developing countries with high COPD-related morbidity and mortality.
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Progresión de la Enfermedad , Hipercapnia , Nomogramas , Valor Predictivo de las Pruebas , Enfermedad Pulmonar Obstructiva Crónica , Insuficiencia Respiratoria , Humanos , Enfermedad Pulmonar Obstructiva Crónica/diagnóstico , Enfermedad Pulmonar Obstructiva Crónica/fisiopatología , Enfermedad Pulmonar Obstructiva Crónica/complicaciones , Masculino , Femenino , Anciano , Hipercapnia/diagnóstico , Hipercapnia/fisiopatología , Insuficiencia Respiratoria/diagnóstico , Insuficiencia Respiratoria/fisiopatología , Insuficiencia Respiratoria/etiología , Medición de Riesgo , Factores de Riesgo , Persona de Mediana Edad , Reproducibilidad de los Resultados , Pronóstico , Evaluación Nutricional , Anciano de 80 o más Años , Hematócrito , Estudios Retrospectivos , Factores Sexuales , Técnicas de Apoyo para la Decisión , Actividades Cotidianas , Estado NutricionalAsunto(s)
Neumonía , Toxoplasma , Toxoplasmosis , Zoonosis , Femenino , Humanos , Broncoscopía , Ácidos Nucleicos Libres de Células/sangre , Infecciones Comunitarias Adquiridas/sangre , Infecciones Comunitarias Adquiridas/diagnóstico , Infecciones Comunitarias Adquiridas/etiología , Infecciones Comunitarias Adquiridas/terapia , ADN Protozoario/sangre , ADN Protozoario/aislamiento & purificación , Hipoxia/sangre , Hipoxia/diagnóstico , Hipoxia/etiología , Hipoxia/terapia , Inmunocompetencia , Anamnesis , Neumonía/sangre , Neumonía/diagnóstico , Neumonía/etiología , Neumonía/terapia , Insuficiencia Respiratoria/sangre , Insuficiencia Respiratoria/diagnóstico , Insuficiencia Respiratoria/terapia , Toxoplasma/aislamiento & purificación , Toxoplasmosis/sangre , Toxoplasmosis/diagnóstico , Toxoplasmosis/etiología , Toxoplasmosis/terapia , Resultado del Tratamiento , Zoonosis/sangre , Zoonosis/diagnóstico , Zoonosis/etiología , Zoonosis/terapia , Ciervos/parasitologíaRESUMEN
Mechanical ventilation (MV) is a powerful mean to rescue patients with respiratory failure. In view of the different etiology and basic respiratory function of patients with respiratory failure, weaning failure often occurs. Prolonged MV time is often accompanied by many complications. Thus, deeply understanding the pathophysiological changes of respiratory failure and strengthen monitoring of respiratory mechanics are helpful to optimize MV parameter settings, reduce ventilator-induced lung injury and wean from MV as early as possible. A successful weaning from MV depends on many factors, the most important factors are respiratory muscle strength, respiratory load and respiratory drive. Spontaneous breathing trial (SBT) is an important part of weaning process. The main purpose of implementing SBT is to screen patients and opportunities to weaning from MV, and find reversible reasons for not passing SBT. Because the accuracy of SBT in assessing weaning prognosis is about 85%, it is not adequate for difficult weaning patients. Standardized measurement of weaning indicators for patients with difficulty weaning is conducive to accurate assessment of respiratory muscle strength and improve the success rate of weaning from MV.
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Fuerza Muscular , Músculos Respiratorios , Desconexión del Ventilador , Desconexión del Ventilador/métodos , Humanos , Músculos Respiratorios/fisiopatología , Fuerza Muscular/fisiología , Respiración Artificial/métodos , Insuficiencia Respiratoria/terapia , Insuficiencia Respiratoria/diagnósticoRESUMEN
Extracorporeal membrane oxygenation (ECMO) is a type of circulatory life support for patients with severe lung failure. The use of ECMO has increased worldwide since the pandemic of H1N1 in 2009 and more recently SARS-CoV-2 in 2020 both of which caused severe respiratory failure. ECMO patients experience both increased risk of bleeding and thrombosis. This is due to the pathological insult that damages the lungs, the ECMO circuit, coagulopathy, inflammation and anticoagulation. ECMO presents unique demands on the coagulation laboratory both in tests required to manage the patients and result interpretation. This is a personal opinion of 20 years ECMO experience as a clinical scientist and a short current review of the literature. It will focus on the laboratory coagulation tests used to manage ECMO patients, including different anticoagulants used, testing frequency and interpretation of the results.
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COVID-19 , Oxigenación por Membrana Extracorpórea , Humanos , Pruebas de Coagulación Sanguínea/métodos , COVID-19/complicaciones , COVID-19/sangre , Anticoagulantes/uso terapéutico , Coagulación Sanguínea , SARS-CoV-2/aislamiento & purificación , Trombosis/etiología , Trombosis/diagnóstico , Hemorragia/etiología , Insuficiencia Respiratoria/terapia , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/diagnóstico , Insuficiencia Respiratoria/sangreRESUMEN
PURPOSE: Identifying thresholds at which the ROX index would satisfactorily predict HFNC failure across heterogenous resourced contexts is necessary for clinical use. METHODS: Patients ≥18 years admitted to 30 diverse ICUs across 10 states in India who required HFNC for respiratory support were retrospectively included in this study. Patient data and hourly ROX indices were then analyzed and contextualized to clinical outcomes as well as with ROX index thresholds in other regions of the world. MEASUREMENTS AND MAIN RESULTS: Among the 614 patients included, 276 (44.9%) required respiratory escalation. Pneumonia was the most common diagnosis on admission. Receiver operating characteristic curve analysis revealed that a baseline ROX score of 7.86 was similar to 4.88 in other populations which was confirmed by Kaplan-Mier curves (hazard ratio,3.58 (2.72-4.69, p < 0.001)). ROX scores at 11.84 or 5.89 had roles in screening and confirming HFNC failure. The index performed poorly in a subset of patients who died without respiratory escalation. The ROX index was most predictive in the initial hours of ICU admission and a longer duration of HFNC was associated with more severe outcomes. CONCLUSIONS: When optimally calibrated this index can using a method that can reliably predict the risk of HFNC failure among ICU patients from diverse settings.
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Unidades de Cuidados Intensivos , Humanos , India , Masculino , Femenino , Estudios Retrospectivos , Persona de Mediana Edad , Terapia por Inhalación de Oxígeno , Adulto , Curva ROC , Anciano , Insuficiencia Respiratoria/terapia , Insuficiencia Respiratoria/diagnóstico , CalibraciónRESUMEN
BACKGROUND: Children with advanced pulmonary disease due to cystic fibrosis (CF) are at risk of acute respiratory failure due to pulmonary exacerbations leading to their admission to pediatric intensive care units (PICU). The objectives of this study were to determine short and medium-term outcomes of children with CF admitted to PICU for acute respiratory failure due to pulmonary exacerbation and to identify prognosis factors. METHODS: This retrospective monocentric study included patients less than 18 years old admitted to the PICU of a French university hospital between 2000 and 2020. Cox proportional hazard regression methods were used to determine prognosis factors of mortality or lung transplant. RESULTS: Prior to PICU admission, the 29 patients included (median age 13.5 years) had a severe lung disease (median Forced Expiratory Volume in 1 s percentage predicted at 29%). Mortality rates were respectively 17%, 31%, 34%, 41% at discharge and at 3, 12 and 36 months post-discharge. Survival rates free of lung transplant were 34%, 32%, 24% and 17% respectively. Risk factors associated with mortality or lung transplant using the univariate analysis were female sex and higher pCO2 and chloride levels at PICU admission, and following pre admission characteristics: home respiratory and nutritional support, registration on lung transplant list and Stenotrophomonas Maltophilia bronchial colonization. CONCLUSION: Children with CF admitted to PICU for acute respiratory failure secondary to pulmonary exacerbations are at high risk of death, both in the short and medium terms. Lung transplant is their main chance of survival and should be considered early.
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Fibrosis Quística , Unidades de Cuidado Intensivo Pediátrico , Insuficiencia Respiratoria , Humanos , Fibrosis Quística/mortalidad , Fibrosis Quística/complicaciones , Fibrosis Quística/diagnóstico , Femenino , Masculino , Estudios Retrospectivos , Niño , Adolescente , Insuficiencia Respiratoria/mortalidad , Insuficiencia Respiratoria/diagnóstico , Insuficiencia Respiratoria/etiología , Unidades de Cuidado Intensivo Pediátrico/estadística & datos numéricos , Factores de Riesgo , Progresión de la Enfermedad , Francia/epidemiología , Preescolar , Resultado del TratamientoRESUMEN
In this Pro-Con commentary article, we discuss use of continuous physiologic monitoring for clinical deterioration, specifically respiratory depression in the postoperative population. The Pro position advocates for 24/7 continuous surveillance monitoring of all patients starting in the postanesthesia care unit until discharge from the hospital. The strongest arguments for universal monitoring relate to inadequate assessment and algorithms for patient risk. We argue that the need for hospitalization in and of itself is a sufficient predictor of an individual's risk for unexpected respiratory deterioration. In addition, general care units carry the added risk that even the most severe respiratory events will not be recognized in a timely fashion, largely due to higher patient to nurse staffing ratios and limited intermittent vital signs assessments (e.g., every 4 hours). Continuous monitoring configured properly using a "surveillance model" can adequately detect patients' respiratory deterioration while minimizing alarm fatigue and the costs of the surveillance systems. The Con position advocates for a mixed approach of time-limited continuous pulse oximetry monitoring for all patients receiving opioids, with additional remote pulse oximetry monitoring for patients identified as having a high risk of respiratory depression. Alarm fatigue, clinical resource limitations, and cost are the strongest arguments for selective monitoring, which is a more targeted approach. The proponents of the con position acknowledge that postoperative respiratory monitoring is certainly indicated for all patients, but not all patients need the same level of monitoring. The analysis and discussion of each point of view describes who, when, where, and how continuous monitoring should be implemented. Consideration of various system-level factors are addressed, including clinical resource availability, alarm design, system costs, patient and staff acceptance, risk-assessment algorithms, and respiratory event detection. Literature is reviewed, findings are described, and recommendations for design of monitoring systems and implementation of monitoring are described for the pro and con positions.
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Fatiga de Alerta del Personal de Salud , Insuficiencia Respiratoria , Humanos , Oximetría , Monitoreo Fisiológico , Examen Físico , Insuficiencia Respiratoria/diagnósticoRESUMEN
BACKGROUND: This study aimed to assess the validity of the oxygenation saturation index (OSI) and the ratio of oxygen saturation to the fraction of inspired oxygen (FIO2) (S/F ratio) with percutaneous oxygen saturation (OSISpO2 and the Sp/F ratio) and to evaluate the correlation between these values and the oxygen index (OI). It also determined their cut-off values for predicting OI in accordance with neonatal hypoxic respiratory failure severity. METHODS: We reviewed the data of 77 neonates (gestational age 31.7 ± 6.1 weeks; birthweight, 1768 ± 983 g) requiring invasive mechanical ventilation between 2013 and 2020, 1233 arterial blood gas samples in total. We calculated the OI, OSISpO2, OSI with arterial oxygen saturation (SaO2) (OSISaO2), Sp/F ratio, and the ratio of SaO2 to FIO2 (Sa/F ratio). RESULTS: The regression and Bland-Altman analysis showed good agreement between OSISpO2 or the Sp/F ratio and OSISaO2 or the Sa/F ratio. Although a significant positive correlation was found between OSISpO2 and OI, OSISpO2 was overestimated in SpO2 > 98% with a higher slope of the fitted regression line than that below 98% of SpO2. Furthermore, receiver-operating characteristic curve analysis using only SpO2 ≤ 98% samples showed that the optimal cut-off points of OSISpO2 and the Sp/F ratio for predicting OI were: OI 5, 3.0 and 332; OI 10, 5.3 and 231; OI 15, 7.7 and 108; OI 20, 11.0 and 149; and OI 25, 17.1 and 103, respectively. CONCLUSION: The cut-off OSISpO2 and Sp/F ratio values could allow continuous monitoring for oxygenation changes in neonates with the potential for wider clinical applications.
Asunto(s)
Enfermedades del Recién Nacido , Insuficiencia Respiratoria , Humanos , Recién Nacido , Análisis de los Gases de la Sangre , Hipoxia/diagnóstico , Oximetría , Oxígeno , Insuficiencia Respiratoria/diagnóstico , Insuficiencia Respiratoria/terapiaRESUMEN
Antecedentes y objetivos: En España carecemos de datos poblacionales de hospitalizaciones por insuficiencia cardiaca (IC) según sea sistólica o diastólica. Analizamos las diferencias clínicas, en mortalidad intrahospitalaria y reingresos de causa cardiovascular a los 30 días entre ambos tipos. Métodos: Estudio observacional retrospectivo de pacientes dados de alta con el diagnóstico principal de IC de los hospitales del Sistema Nacional de Salud entre 2016 y 2019, distinguiendo entre IC sistólica y diastólica. La fuente de datos fue el conjunto mínimo básico de datos del Ministerio de Sanidad. Se calcularon las razones de mortalidad intrahospitalaria y de reingreso a los 30 días estandarizadas por riesgo usando sendos modelos de regresión logística multinivel de ajuste de riesgo. Resultados: Se seleccionaron 190.200 episodios de IC. De ellos, 163.727 (86,1%) fueron por IC diastólica y se caracterizaron por presentar mayor edad, mayor proporción de mujeres, de diabetes y de insuficiencia renal que los de IC sistólica. Según los modelos de ajuste de riesgo la IC diastólica, frente a la sistólica, se comportó como un factor protector de mortalidad intrahospitalaria (odds ratio [OR]: 0,79; intervalo de confianza del 95% [IC 95%]: 0,75-0,83; p<0,001) y de reingreso de causa cardiovascular a los 30 días (OR: 0,93; IC 95%: 0,88-0,97; p0,002). Conclusiones: En España, entre 2016 y 2019, los episodios de hospitalización por IC fueron mayoritariamente por IC diastólica. Según los modelos de ajuste de riesgo la IC diastólica, con respecto a la sistólica, fue un factor protector de mortalidad intrahospitalaria y de reingreso de causa cardiovascular a los 30 días.(AU)
Background and purpose: In Spain there is a lack of population data that specifically compare hospitalization for systolic and diastolic heart failure (HF). We assessed clinical characteristics, in-hospital mortality and 30-day cardiovascular readmission rates differentiating by HF type. Methods: We conducted a retrospective observational study of patients discharged with the principal diagnosis of HF from The National Health System acute hospital during 2016-2019, distinguishing between systolic and diastolic HF. The source of the data was the Minimum Basic Data Set. The risk-standardized in-hospital mortality ratio and risk-standardized 30-day cardiovascular readmission ratio were calculated using multilevel risk adjustment models. Results: The 190,200 episodes of HF were selected. Of these, 163,727 (86.1%) were classified as diastolic HF and were characterized by older age, higher proportion of women, diabetes mellitus, dementia and renal failure than those with systolic HF. In the multilevel risk adjustment models, diastolic HF was a protective factor for both in-hospital mortality (odds ratio [OR]: 0.79; 95% confidence interval [CI]: 0.75-0.83; P<.001) and 30-day cardiovascular readmission versus systolic HF (OR: 0.93; 95% CI: 0.88-0.97; P=.002). Conclusions: In Spain, between 2016 and 2019, hospitalization episodes for HF were mostly due to diastolic HF. According to the multilevel risk adjustment models, diastolic HF compared to systolic HF was a protective factor for both in-hospital mortality and 30-day cardiovascular readmission.(AU)
Asunto(s)
Humanos , Masculino , Femenino , Hospitalización/estadística & datos numéricos , Insuficiencia Cardíaca Diastólica/diagnóstico , Insuficiencia Cardíaca Sistólica/diagnóstico , Mortalidad Hospitalaria , Estudios Retrospectivos , Medicina Clínica , España , Insuficiencia Respiratoria/diagnóstico , Insuficiencia Respiratoria/mortalidad , Insuficiencia Cardíaca Diastólica/mortalidad , Insuficiencia Cardíaca Sistólica/mortalidadRESUMEN
BACKGROUND: The assessment of technical and nontechnical skills in emergency medicine requires reliable and usable tools. Three Acute Care Assessment Tools (ACATs) have been developed to assess medical learners in their management of cardiac arrest (ACAT-CA), coma (ACAT-coma) and acute respiratory failure (ACAT-ARF). OBJECTIVE: This study aims to analyze the reliability and usability of the three ACATs when used for in situ (bedside) simulation. METHODS: This prospective multicenter validation study tested ACATs using interprofessional in situ simulations in seven emergency departments and invited training residents to participate in them. Each session was rated by two independent raters using ACAT. Intraclass correlation coefficients (ICC) were used to assess interrater reliability, and Cronbach's alpha coefficient was used to assess internal consistency for each ACAT. The correlation between ACATs' scores and the learners' level of performance was also assessed. Finally, a questionnaire and two focus groups were used to assess the usability of the ACATs. RESULTS: A total of 104 in situ simulation sessions, including 85 residents, were evaluated by 37 raters. The ICC for ACAT-CA, ACAT-coma and ACAT-ARF were 0.95 [95% confidence interval (CI), 0.93-0.98], 0.89 (95% CI, 0.77-0.95) and 0.92 (95%CI 0.83-0.96), respectively. The Cronbach's alphas were 0.79, 0.80 and 0.73, respectively. The ACAT-CA and ARF showed good construct validity, as third-year residents obtained significantly higher scores than first-year residents ( P â <â 0.001; P â <â 0.019). The raters supported the usability of the tools, even though they expressed concerns regarding the use of simulations in a summative way. CONCLUSION: This study reported that the three ACATs showed good external validity and usability.
Asunto(s)
Competencia Clínica , Medicina de Emergencia , Internado y Residencia , Humanos , Estudios Prospectivos , Reproducibilidad de los Resultados , Masculino , Medicina de Emergencia/educación , Femenino , Entrenamiento Simulado/métodos , Adulto , Evaluación Educacional/métodos , Paro Cardíaco/terapia , Coma/diagnóstico , Insuficiencia Respiratoria/terapia , Insuficiencia Respiratoria/diagnósticoRESUMEN
STUDY OBJECTIVES: Venous blood gases (VBGs) are not consistently considered suitable surrogates for arterial blood gases (ABGs) in assessing acute respiratory failure due to variable measurement error. The physiological stability of patients with chronic ventilatory failure may lead to improved agreement in this setting. METHODS: Adults requiring ABGs for sleep or ventilation titration studies had VBGs drawn before or after each ABG, in a randomized order. Veno-arterial correlation and agreement were examined for carbon dioxide tension (PCO2), pH, oxygen tension (PO2), and oxygen saturation (SO2). RESULTS: We analyzed 115 VBG-ABG pairs from 61 patients. Arterial and venous measures were correlated (P < .05) for PCO2 (r = .84) and pH (r = .72), but not for PO2 or SO2. Adjusted mean veno-arterial differences (95% limits of agreement) were +5.0 mmHg (-4.4 to +14.4) for PCO2; -0.02 (-0.09 to +0.04) for pH; -34.3 mmHg (-78.5 to +10.0) for PO2; and -23.9% (-61.3 to +13.5) for SO2. VBGs obtained from the dorsal hand demonstrated a lower mean PCO2 veno-arterial difference (P < .01). A venous PCO2 threshold of ≥ 45.8 mmHg was > 95% sensitive for arterial hypercapnia, so measurements below this can exclude the diagnosis without an ABG. A venous PCO2 threshold of ≥ 53.7 mmHg was > 95% specific for arterial hypercapnia, so such readings can be assumed diagnostic. The area under the receiver operating characteristic curve of 0.91 indicated high discriminatory capacity. CONCLUSIONS: A venous PCO2 < 45.8 mmHg or ≥ 53.7 mmHg would exclude or diagnose hypercapnia, respectively, in patients referred for sleep studies, but VBGs are poor surrogates for ABGs where precision is important. CLINICAL TRIAL REGISTRATION: Registry: Australian New Zealand Clinical Trials Register; Name: A comparison of arterial and blood gas analyses in sleep studies; URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372717; Identifier: ACTRN12617000562370. CITATION: Lindstrom SJ, McDonald CF, Howard ME, et al. Venous blood gases in the assessment of respiratory failure in patients undergoing sleep studies: a randomized study. J Clin Sleep Med. 2024;20(8):1259-1266.
Asunto(s)
Análisis de los Gases de la Sangre , Insuficiencia Respiratoria , Humanos , Masculino , Análisis de los Gases de la Sangre/métodos , Femenino , Insuficiencia Respiratoria/sangre , Insuficiencia Respiratoria/diagnóstico , Persona de Mediana Edad , Dióxido de Carbono/sangre , Polisomnografía/métodos , Adulto , Venas/fisiopatología , Oxígeno/sangre , Anciano , Concentración de Iones de HidrógenoRESUMEN
OBJECTIVES: Neuromuscular disorders could have respiratory involvement early or late into illness. Rarely, patients may present with a hypercapnic respiratory failure (with minimal motor signs) unmasking an underlying disease. There are hardly any studies which have addressed the spectrum and challenges involved in management of this subset, especially in the real-world scenario. METHODS: A retrospective study comprising consecutive patients hospitalized with hypercapnic respiratory failure as the sole/dominant manifestation. The clinical-electrophysiological spectrum, phrenic conductions, diaphragm thickness, and outcomes were analyzed. RESULTS: Twenty-seven patients were included, the mean age was 47.29 (SD 15.22) years, and the median duration of respiratory symptoms was 2 months (interquartile range [IQR] 1-4). Orthopnea was present in 23 patients (85.2%) and encephalopathy in 8 patients (29.6%). Phrenic nerve latencies and amplitudes were abnormal in 83.3% and 95.6%, respectively. Abnormal diaphragm thickness was noted in 78.5%. Based on a comprehensive electrophysiological strategy and paraclinical tests, an etiology was established in all. Reversible etiologies were identified in 17 patients (62.9%). These included myasthenia gravis (anti-AChR and MuSK), inflammatory myopathy, riboflavin transporter deficiency neuronopathy, Pompe disease, bilateral phrenic neuritis, and thyrotoxicosis. Respiratory onset motor neuron disease was diagnosed in 8 patients (29.6%). Despite diaphragmatic involvement, a functional respiratory recovery was noted at discharge (45%) and last follow-up (60%). Predictors for good outcomes included female sex, normal nerve conductions, and recent-onset respiratory symptoms. DISCUSSION: A good functional recovery was noted in most of the patients including respiratory onset motor neuron disease. A systematic algorithmic approach helps in proper triaging, early diagnosis, and treatment. Clinical and electrodiagnostic challenges and observations from a tertiary care referral center are discussed.