Response to the prone position in spontaneously breathing patients with hypoxemic respiratory failure

OBJECTIVES: The prone position is used for intubated patients with adult respiratory distress syndrome (ARDS) and acute lung injury (ALI). The physiological changes associated with the prone position in nonintubated patients may be even more favorable than in intubated patients. We examined the effect of the prone position on arterial blood gases and patient compliance in four awake, nonintubated patients with hypoxemic respiratory failure. DESIGN: We present four consecutive cases of hypoxemic respiratory failure, in which mechanical ventilation was indicated. An attempt was made to avoid assisted ventilation by placing patients in the prone position, while breathing spontaneously. The effect on the clinical condition and the changes in blood gases were registered. RESULTS: We found good patient tolerance. A rapid increase in PaO2 was found, and intubation was avoided in all patients. No significant complications were registered. CONCLUSION: The prone position may prove beneficial in some cases of hypoxemic respiratory failure, even in awake patients, by avoiding mechanical ventilation and ventilator-associated complications.     

Successful mobile extracorporeal membrane oxygenator for COVID-19 severe respiratory failure

High volume extracorporeal membrane oxygenation (ECMO) centers have developed mobile ECMO programs in recent years to facilitate the implementation of ECMO support at hospitals with lower capabilities, and transfer these patients for further care. We report a case of mobile ECMO on a patient with coronavirus disease 2019-related acute respiratory distress syndrome, and discuss the potential application in the current severe acute respiratory syndrome coronavirus 2 pandemic.     

ALI/ARDS患者俯卧位与仰卧位通气的Meta分析

目的比较俯卧位通气与仰卧位通气在急性肺损伤或急性呼吸窘迫综合征(ALI/ARDS)患者中的有效性及安全性。方法计算机检索Pubmed、EMBASE、Cochrane图书馆、CINAHL、CBM、VIP、CNKI和万方数据库,查找所有比较俯卧位通气与仰卧位通气治疗ALI/ARDS患者的随机对照试验(RCT),检索时限均为建库至2015年6月31日。同时手动检索纳入文献的参考文献和灰色文献。由两人独立按照纳入和排除标准进行文献筛选、质量评价、资料提取后,使用RevMan5.0软件进行数据分析。结果共纳入11篇RCT文献,纳入的研究对象共2 268例。Meta分析结果显示,在病死率方面,当俯卧位通气时间大于12h/d时,患者30d病死率较仰卧位通气低(RR=0.70,95%CI 0.58~0.85,P0.01);对于氧合指数(PaO2/FiO2)≤100mmHg组和100mmHgPaO2/FiO2≤200mmHg组的患者,使用俯卧位通气的患者病死率低于使用仰卧位通气的患者(RR=0.70,95%CI0.56~0.89,P0.01)、(RR=0.69,95%CI0.50~0.94,P0.05);当呼气末正压通气(PEEP)≥10cmH2O时,俯卧位通气患者的60d病死率较仰卧位通气低(RR=0.81,95%CI0.67~0.97,P0.05),10cmH2OPEEP≤13cmH2O时,俯卧位通气患者90d病死率较仰卧位低(RR=0.57,95%CI0.43~0.74,P0.01);在并发症的发生方面,俯卧位通气患者的压疮新发病率和静脉通路脱出发生率高于仰卧位通气患者(RR=1.26,95%CI1.11~1.42,P0.01),(RR=1.70,95%CI1.01~2.86,P0.05);而其他并发症如心血管意外、气管内插管移位、呼吸机相关性肺炎、静脉通路脱落、气胸发生率无统计学意义。结论俯卧位通气与仰卧位通气相比,可以降低重症患者的病死率,且俯卧位时间越长,生存率越高;但俯卧位通气可能会增加压疮和静脉通路脱出的发生率,临床上应注意预防。     

Evaluation of conventional weaning criteria in patients with acute respiratory failure

We evaluated the reliability of conventional weaning criteria from a ventilator during 33 weaning trials on 25 patients with acute respiratory failure (ARF). Of 13 criteria, a ratio of maximal voluntary ventilation to minute ventilation (MV) 2, a vital capacity 12ml·kg^–1, a spontaneous respiratory rate 25 breaths·min^–1, and a MV 10l·min^–1 appeared to be useful for predicting successful weaning outcome. However, even using those criteria, there were many falsely-negative cases. The alveolar-arterial P_{O 2} gradient 350mmHg at an Fi _{O 2} 1.0 was not useful as a predictor of weaning outcome. The present study demonstrates that conventional criteria are frequently inaccurate for predicting weaning outcomes and suggests that the use of some of these criteria may unnecessarily prolong the length of ventilator support. Since ventilation of most patients with poor oxygenation can be successfully discontinued by placing them on a continuous positive airway pressure system, these results suggest that the improvement of oxygenation is not an indispensable prerequisite for weaning from mechanical ventilators.(Okamoto K, Iwamasa H, Dogomori H, et al.: Evaluation of conventional weaning criteria in patients with acute respiratory failure. J Anesth 4: 213–218, 1990)     

No early respiratory benefit with CVVHDF in patients with acute renal failure and acute lung injury.

BACKGROUND: There is debate as to whether, in patients with acute lung injury, continuous renal replacement therapy has beneficial effects on pulmonary gas exchange by mechanisms other than fluid removal. Because continuous renal replacement therapy is associated with potential morbidity and mortality, it seems unethical to perform a randomized trial in patients with acute lung injury without renal failure. Therefore, the effects of continuous venovenous haemodiafiltration with zero volume balance on gas exchange were evaluated in patients with acute renal failure and acute lung injury. Because haemofilter conditions should be comparable between patients, we opted for an evaluation of the effects during a 24-h period. Results of this trial can guide future studies in non-renal patients with acute lung injury. METHODS: In all 37 patients with acute renal failure and acute lung injury, treated with continuous venovenous haemodiafiltration with zero fluid balance during a 1 year period, ventilatory and haemodynamic parameters were measured every 8 h during the 24 h preceding therapy and during the first 24 h of therapy. RESULTS: We found a slight, although not statistically significant, increase in the PaO(2)/FIO(2) ratio and the oxygenation index, in the total group of patients, and in the subgroups of patients with acute lung injury of extrapulmonary and pulmonary causes. CONCLUSIONS: During the first 24 h of treatment, continuous venovenous haemodiafiltration with zero volume balance did not result in a significant improvement of the respiratory status in patients with acute renal failure and acute lung injury, nor in the subgroups of patients with acute lung injury with extrapulmonary causes.     

Non-invasive ventilation (NIV) in surgical patients with post-operative acute respiratory failure

Non-invasive ventilation (NIV) is a technique developed to assist patients with acute respiratory failure (ARF) of different origins, which avoids endotracheal intubation. NIV has already been demonstrated to be a useful alternative to invasive mechanical ventilation in patients with acute exacerbation of COPD, cardiogenic pulmonary oedema and other causes of hypoxemic ARF, avoiding several complications directly related to the presence of an endotracheal tube, such as the increased risk for nosocomial pneumonia.Few studies have evaluated the possible role for NIV in patients developing post-operative acute respiratory failure: this chapter will review the possible indications and the clinical results obtained by applying NIV in patients developing ARF after thoracic and abdominal surgery. The role of different interfaces is also discussed.     

Nitric oxide treatment for acute respiratory failure in children

Summary
We have used nitric oxide in the treatment of four children admitted to the paediatric intensive care unit with acute, severe respiratory failure. Administration resulted in an improvement in arterial oxygenation range 1.3–18.4 kPa (9.9–140 mmHg): mean 6.7 kPa (51 mmHg) and a reduction in arterial carbon dioxide tension range 0.6–1.2 kPa (4.5–9 mmHg): mean 0.9 kPa (6.8 mmHg). No adverse effects were encountered following administration for a duration of 3–12 days at a dose of 40–64 parts per million.     

Foot manifestations in a patient with COVID-19 and Epstein-Barr virus: A case study

SARS-CoV-2 (COVID-19) is highly-contagious. It can lead to respiratory distress—and in some cases—death. Recent reports and observations have identified an association between COVID-19 and manifestations in the feet. However, there are very few reports that describe the course of these foot manifestations in any detail. The authors present a case study chronicling the progression of foot issues in a COVID-19 positive patient who also was positive for the Epstein-Barr virus.     

Airway pressure release ventilation and prone positioning in severe acute respiratory distress syndrome

BACKGROUND: Implementation of lung protective strategy in the treatment of severe Acute Respiratory Distress Syndrome (ARDS) has been reported to be associated with improved outcome. To fulfil this approach, sedation, neuromuscular blocking agents and full mechanical ventilatory support are often used in critical failure of gas exchange. CASE REPORT: We present a patient who developed multiple organ failure, including severe ARDS, after severe skin injuries and septic shock. Ventilatory strategy consisted of lung protective approach, permissive hypercapnia and prone positioning. Airway pressure release ventilation (APRV) with the patient's superimposed spontaneous breathing was implemented and maintained, also during prone episodes. Improvement of gas exhange occurred after application of combined use of APRV and prone positioning. CONCLUSION: APRV and maintenance of patients' spontaneous ventilation is feasible during prone positioning, and this approach may have beneficial synergistic effects on gas exhange in patients with severe acute lung injury.     

Improved oxygenation using the prone position in patients with ARDS

Background: The prone position is known to increase oxygen uptake in patients with Adult Respiratory Distress Syndrome (ARDS).
Methods: In this clinical study from 1995–96, 14 ARDS patients with severe respiratory failure were treated for at least 1 h in the prone position. Responders, defined as having more than 10% increase in PaO₂/FiO₂ ratio from baseline after 1 h, were treated at least 6 h in the prone position.
Results: 11 patients responded during the first period of the prone position (primary responders). Two of the 3 non-responders were turned prone a second time with increase in the PaO₂FiO₂ ratio (secondary responders). Mean PaO₂FiO₂ ratio (mean±SEM) in the supine position was 11.7±0.8 kPa, increasing to 16.6±1.8 kPa and 18.0±1.4 kPa after 1 and 6 h respectively ( P =0.009). Mean time spent in the prone position was 69 h (range 3–256 h), and mean ventilatory time was 17 d (3–52 d). The mortality in this subgroup of our patients with ARDS was 42%, compared to 58% in 19 patients not turned prone in the same period.
Conclusions: The prone position together with PEEP appears to improve ventilation-perfusion matching. The prone position is simple, effective and readily available and could be used early in most patients with ARDS.     

Progressive dysphonia and acute respiratory failure: revealing a bronchogenic cyst

We report the case of a 17-year old girl presenting a 3-month history of progressive dysphonia, and ultimately acute respiratory failure. CT scan and bronchoscopy showed severe extrinsic compression of the carina and of the left main stem bronchus. Emergency thoracotomy was performed permitting complete resection of an intra mural oesophageal bronchogenic cyst. The post operative course was uneventful except a persistent dysphonia. Dysphonia is an exceptional early symptom of bronchogenic cyst located in the oesophageal wall.     

The use of prone ventilation in acute lung injury and acute respiratory distress syndrome

Prone positioning has been suggested since 1974 as a ventilatory strategy to improve oxygenation and pulmonary mechanics in patients with acute lung injury and acute respiratory distress syndrome. Although this mode of ventilation can improve gas exchange, the optimal role of the prone position is uncertain. The aim of this article is to examine the evidence in support of this mode of ventilation in adult patients with acute lung injury and acute respiratory distress syndrome. Limitations of the currently available evidence upon which the recommendations are made must be recognized. With these limitations in mind, however, the available evidence has been considered and conclusions presented. Considerable clinical experience confirms that prone ventilation can improve oxygenation in the majority of patients. It is difficult to predict which patients will respond. There are few contraindications and with experienced staff it can be achieved safely. Most patients should therefore be considered for a trial of prone positioning. Prolonged and repeated prone ventilation may be more effective. Whether the improvement in physiological parameters translates into improved clinical outcomes is less certain and well-designed randomized controlled trials will be required to address this issue.     

Tubular aggregate myopathy presenting with acute type II respiratory failure and severe orthopnoea

Acute hypercapnic respiratory failure (AHRF) is a common reason for hospital admission. Most patients have an underlying chronic lung disease such as chronic obstructive pulmonary disease. We report the case of a man who presented with AHRF secondary to tubular aggregate myopathy.