Effects of high-flow nasal cannula in patients with persistent hypercapnia after an acute COPD exacerbation: a prospective pilot study.
高流量鼻导管对 COPD 急性加重后持续性高碳酸血症患者的影响: 一项前瞻性初步研究。
- 作者列表："Pisani L","Betti S","Biglia C","Fasano L","Catalanotti V","Prediletto I","Comellini V","Bacchi-Reggiani L","Fers SN
BACKGROUND:Persistent hypercapnia after COPD exacerbation is associated with excess mortality and early rehospitalization. High Flow Nasal cannula (HFNC), may be theoretically an alternative to long-term noninvasive ventilation (NIV), since physiological studies have shown a reduction in PaCO2 level after few hours of treatment. In this clinical study we assessed the acceptability of HFNC and its effectiveness in reducing the level of PaCO2 in patients recovering from an Acute Hypercapnic Respiratory Failure (AHRF) episode. We also hypothesized that the response in CO2 clearance is dependent on baseline level of hypercapnia. METHODS:Fifty COPD patients recovering from an acute exacerbation and with persistent hypercapnia, despite having attained a stable pH (i.e. pH > 7,35 and PaCO2 > 45 mmHg on 3 consecutive measurements), were enrolled and treated with HFNC for at least 8 h/day and during the nighttime RESULTS: HFNC was well tolerated with a global tolerance score of 4.0 ± 0.9. When patients were separated into groups with or without COPD/OSA overlap syndrome, the "pure" COPD patients showed a statistically significant response in terms of PaCO2 decrease (p = 0.044). In addition, the subset of patients with a lower pH at enrolment were those who responded best in terms of CO2 clearance (score test for trend of odds, p = 0.0038). CONCLUSIONS:HFNC is able to significantly decrease the level of PaCO2 after 72 h only in "pure" COPD patients, recovering from AHRF. No effects in terms of CO2 reduction were found in those with overlap syndrome. The present findings will help guide selection of the best target population and allow a sample size calculation for future long-term randomized control trials of HFNC vs NIV. TRIAL REGISTRATION:This study is registered with www. clinicaltrials.gov with identifier number NCT03759457.
背景: COPD 加重后持续高碳酸血症与超额死亡率和早期再住院相关。高流量鼻导管 (HFNC)，理论上可能是长期无创通气 (NIV) 的替代方案，因为生理研究显示治疗数小时后 PaCO2 水平降低。在这项临床研究中，我们评估了 HFNC 的可接受性及其降低急性高碳酸血症呼吸衰竭 (AHRF) 发作恢复期患者 PaCO2 水平的有效性。我们还假设 CO2 清除的反应取决于高碳酸血症的基线水平。 方法: 50 例 COPD 患者从急性加重期恢复并伴有持续高碳酸血症，尽管已达到稳定的 pH 值 (i。 e. 连续 3 次测量 ph> 7,35 和 PaCO2> 45 mmhg)，入组并接受 HFNC 治疗至少 8 h/天和夜间结果: HFNC 耐受性良好，总体耐受性评分为 4.0 ± 0.9。当将患者分为合并或不合并 COPD/OSA 重叠综合征的组时，“单纯” COPD 患者在 PaCO2 降低方面表现出统计学显著性反应 (p = 0.044)。此外，入组时 pH 值较低的患者亚群是在 CO2 清除率方面反应最好的患者 (赔率趋势评分检验，p = 0.0038)。 结论: HFNC 仅在从 AHRF 恢复的 “纯” COPD 患者中，72 h 后能够显著降低 PaCO2 水平。重叠综合征患者未发现 CO2 减少方面的影响。本研究结果将有助于指导最佳目标人群的选择，并为未来 HFNC vs NIV 的长期随机对照试验提供样本量计算。 试验注册: 本研究在 www 注册。Clinicaltrials.gov，标识符编号为 nct03759457。
METHODS:Background: The hospitalization of patients treated in the intensive care unit (ICU) in 5−15% of cases is associated with the occurrence of a complication in the form of ventilator-associated pneumonia (VAP). Purpose: Retrospective assessment of risk factors of VAP in patients treated at ICUs in the University Hospital in Krakow. Methods: The research involved the medical documentation of 1872 patients treated at the ICU of the University Hospital in Krakow between 2014 and 2017. The patients were mechanically ventilated for at least 48 h. The obtained data were presented by qualitative and quantitative analysis (%). The qualitative variables were compared using the Chi2 test. Statistically significant was the p < 0.05 value. Results: VAP was demonstrated in 23% of all patients treated in ICU during the analyzed period, and this infection occurred in 13% of men and 10% of women. Pneumonia associated with ventilation was found primarily in patients staying in the ward for over 15 days and subjected to intratracheal intubation (17%). A statistically significant was found between VAP and co-morbidities, e.g., chronic obstructive pulmonary disease, diabetes, alcoholism, obesity, the occurrence of VAP and multi-organ trauma, hemorrhage/hemorrhagic shock, and fractures as the reasons for admitting ICU patients. Conclusions: Patients with comorbidities such as chronic obstructive pulmonary disease, obesity, diabetes, and alcoholism are a high-risk group for VAP. Particular attention should be paid to patients admitted to the ICU with multi-organ trauma, fractures, and hemorrhage/hemorrhagic shock as patients predisposed to VAP. There is a need for further research into risk factors for non-modifiable VAP such as comorbidities and reasons for ICU admission in order to allow closer monitoring of these patients for VAP.
METHODS::Backgroud Severe pneumonia is one of the most common causes for mechanical ventilation. We aimed to early identify severe pneumonia patients with high risk of extubation failure in order to improve prognosis. Methods From April 2014 to December 2015, medical records of intubated patients with severe pneumonia in intensive care unit were retrieved from database. Patients were divided into extubation success and failure groups, and multivariate logistic regressions were performed to identify independent predictors for extubation failure. Results A total of 125 eligible patients were included, of which 82 and 43 patients had extubation success and failure, respectively. APACHE II score (odds ration (OR) 1.141, 95% confident interval (CI) 1.022-1.273, P = 0.019, cutoff at 17.5), blood glucose (OR 1.122, 95%CI 1.008-1.249, P = 0.035, cutoff at 9.87mmol/L), dose of fentanyl (OR 3.010, 95%CI 1.100-8.237, P = 0.032, cutoff at 1.135mg/d), and the need for red blood cell (RBC) transfusion (OR 2.774, 95%CI 1.062-7.252, P = 0.037) were independent risk factors for extubation failure. Conclusions In patients with severe pneumonia, APACHE II score > 17.5, blood glucose > 9.87mmol/L, fentanyl usage > 1.135mg/d, and the need for RBC transfusion might be associated with higher risk of extubation failure.
METHODS:PURPOSE:To assess the association between the duration of mechanical ventilation during post resuscitation care and 30-day survival after cardiac arrest. METHODS:We conducted a retrospective observational study using data from two national registries. Comatose cardiac arrest patients admitted to general intensive care in Swedish hospitals between 2011 and 2016 were eligible. Based on the median duration of mechanical ventilation for patients who did not survive to hospital discharge, used as a proxy for the endurance of post resuscitation care, the hospitals were divided into four ordered groups for which association with 30-day survival was analyzed. RESULTS:In total, 5.113 patients in 56 hospitals were included. Median duration of mechanical ventilation for patients who did not survive to hospital discharge ranged from 17 hours in hospital group 1 to 51 hours in hospital group 4. After adjustment for baseline characteristics, 30-day survival in the entire cohort was positively and independently associated with ordered hospital group: (adjusted odds ratio (95%CI); 1.12 (1.02,1.23); p = 0.02). Thus, hospitals with a longer duration of mechanical ventilation among non-survivors had better survival rate among patients admitted to ICU after a cardiac arrest. However, in a secondary analysis restricted to patients with length of stay in the intensive care unit ≥ 48 hours, there was no significant association between 30-day survival and ordered hospital group. CONCLUSION:A tendency for longer duration of post resuscitation care in the ICU was associated with higher 30-day survival in comatose patients admitted to intensive care after cardiac arrest.