scholarly journals Non-invasive ventilation in the treatment of severe polymicrobial community-acquired pneumonia

2017 ◽  
Vol 11 (1) ◽  
pp. 57
Author(s):  
Enrico Cinque ◽  
Ines Maria Grazia Piroddi ◽  
Cornelius Barlascini ◽  
Alessandro Perazzo ◽  
Antonello Nicolini
Keyword(s):  
Mechanical Ventilation ◽  
Severe Disease ◽  
Invasive Mechanical Ventilation ◽  
Clinical Signs ◽  
Case Series ◽  
Community Acquired Pneumonia ◽  
Invasive Ventilation ◽  
Non Invasive ◽  
Non Invasive Ventilation ◽  
Increased Risk

Polymicrobial pneumonia may be caused by the combination of respiratory viruses, bacteria and fungi in a host. Colonization by <em>Streptococcus pneumoniae</em> was associated with increased risk of Intensive Care Unit admission or death in the setting of influenza infection, whereas the colonization by methicillin sensible <em>Staphylococcus aureus</em> co-infection was associated with severe disease and death in adults and children. The principal association of pathogens in community-acquired pneumonia (CAP) is bacteria and viral co-infection, and accounts approximately for 39% of microbiological diagnosed cases of CAP. The differential clinical diagnosis between a viral and a bacterial CAP is not easy: no clinical signs or radiological findings help the clinician to suspect to the diagnosis. Patients with polymicrobial infections are more likely to have underlying medical conditions and have more severe outcome. Severe respiratory failure and need of mechanical ventilation occur in several cases. Non invasive ventilation (NIV) use aims to avoid invasive mechanical ventilation. NIV treatment is controversial owing to high reported treatment failure. In this case series we report three cases of severe polymicrobial CAP: all of them required NIV with a good outcome.

scholarly journals Extracorporeal carbon dioxide removal for treatment of exacerbated chronic obstructive pulmonary disease (ORION): study protocol for a randomised controlled trial

Trials ◽  
2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Tommaso Tonetti ◽  
Lara Pisani ◽  
Irene Cavalli ◽  
Maria Laura Vega ◽  
Elisa Maietti ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Controlled Trial ◽  
Invasive Mechanical Ventilation ◽  
Chronic Obstructive ◽  
Invasive Ventilation ◽  
Obstructive Pulmonary Disease ◽  
Non Invasive ◽  
Non Invasive Ventilation ◽  
Acute Exacerbations

Abstract Background Hypercapnic exacerbations are severe complications of chronic obstructive pulmonary disease (COPD), characterized by negative impact on prognosis, quality of life and healthcare costs. The present standard of care for acute exacerbations of COPD is non-invasive ventilation; when it fails, the use of invasive mechanical ventilation is inevitable, but is associated with extremely poor prognosis. Extracorporeal circuits designed to remove CO2 (ECCO2R) may enhance the efficacy of NIV to remove CO2 and avoid the worsening of respiratory acidosis, which inevitably leads to failure of non-invasive ventilation. Although the use of ECCO2R for acute exacerbations of COPD is steadily increasing, solid evidence on its efficacy and safety is scarce, thus the need for a randomized controlled trial. Methods multicenter randomized controlled unblinded clinical trial including 284 (142 per arm) patients with acute hypercapnic respiratory failure caused by exacerbation of COPD, requiring respiratory support with NIV. The primary outcome is event free survival at 28 days, a composite outcome defined by survival in absence of prolonged mechanical ventilation, severe hypoxemia, septic shock and second episode of COPD exacerbation. Secondary outcomes are incidence of endotracheal intubation and tracheostomy, intensive care and hospital length-of-stay and 90-day mortality. Discussion Acute exacerbations of COPD represent a significant burden in terms of prognosis, quality of life and healthcare costs. Lack definite evidence despite increasing use of ECCO2R justifies a randomized trial to evaluate whether patients with acute hypercapnic acidosis not responsive to NIV should undergo invasive mechanical ventilation (with all serious related risks) or be treated with ECCO2R to avoid invasive ventilation but be exposed to possible adverse events of ECCO2R. Owing to its pragmatic nature, sample size and composite primary outcome, this trial aims at providing valuable answers to relevant questions for clinical treatment of acute exacerbations of COPD. Trial registration ClinicalTrials.gov, NCT04582799. Registered 12 October 2020, .

scholarly journals Management of Acute Respiratory Failure Due to Community-Acquired Pneumonia: A Systematic Review

2019 ◽  
Vol 7 (1) ◽  
pp. 10 ◽  
Author(s):  
Nicolò Maria Vanoni ◽  
Manuela Carugati ◽  
Noemi Borsa ◽  
Giovanni Sotgiu ◽  
Laura Saderi ◽  
...  
Keyword(s):  
Systematic Review ◽  
Respiratory Failure ◽  
Acute Respiratory Failure ◽  
Community Acquired Pneumonia ◽  
Invasive Ventilation ◽  
Non Invasive ◽  
Non Invasive Ventilation ◽  
Increased Risk ◽  
Severity Scores ◽  
Ventilatory Management

Community-acquired pneumonia (CAP) is a leading cause of mortality worldwide. CAP mortality is driven by the development of sepsis and acute respiratory failure (ARF). We performed a systematic review of the available English literature published in the period 1 January 1997 to 31 August 2017 and focused on ARF in CAP. The database searches identified 189 articles—of these, only 29 were retained for data extraction. Of these 29 articles, 12 addressed ARF in CAP without discussing its ventilatory management, while 17 evaluated the ventilatory management of ARF in CAP. In the studies assessing the ventilatory management, the specific treatments addressed were: high-flow nasal cannula (HFNC) (n = 1), continuous positive airway pressure (n = 2), non-invasive ventilation (n = 9), and invasive mechanical ventilation (n = 5). When analyzed, non-invasive ventilation (NIV) success rates ranged from 20% to 76% and they strongly predicted survival, while NIV failure led to an increased risk of adverse outcome. In conclusion, ARF in CAP patients may require both ventilatory and non-ventilatory management. Further research is needed to better evaluate the use of NIV and HFNC in those patients. Alongside the prompt administration of antimicrobials, the potential use of steroids and the implementation of severity scores should also be considered.

scholarly journals Protocolized Post-Extubation Respiratory Support to prevent reintubation: protocol and statistical analysis plan for a clinical trial

BMJ Open ◽  
2019 ◽  
Vol 9 (8) ◽  
pp. e030476 ◽  
Author(s):  
Jonathan Dale Casey ◽  
Erin R Vaughan ◽  
Bradley D Lloyd ◽  
Peter A Bilas ◽  
Eric J Hall ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Usual Care ◽  
Invasive Mechanical Ventilation ◽  
High Flow ◽  
Respiratory Support ◽  
Invasive Ventilation ◽  
High Flow Nasal Cannula ◽  
Non Invasive ◽  
Non Invasive Ventilation ◽  
Risk Patients

IntroductionFollowing extubation from invasive mechanical ventilation, nearly one in seven critically ill adults requires reintubation. Reintubation is independently associated with increased mortality. Postextubation respiratory support (non-invasive ventilation or high-flow nasal cannula applied at the time of extubation) has been reported in small-to-moderate-sized trials to reduce reintubation rates among hypercapnic patients, high-risk patients without hypercapnia and low-risk patients without hypercapnia. It is unknown whether protocolised provision of postextubation respiratory support to every patient undergoing extubation would reduce the overall reintubation rate, compared with usual care.Methods and analysisThe Protocolized Post-Extubation Respiratory Support (PROPER) trial is a pragmatic, cluster cross-over trial being conducted between 1 October 2017 and 31 March 2019 in the medical intensive care unit of Vanderbilt University Medical Center. PROPER compares usual care versus protocolized post-extubation respiratory support (a respiratory therapist-driven protocol that advises the provision of non-invasive ventilation or high-flow nasal cannula based on patient characteristics). For the duration of the trial, the unit is divided into two clusters. One cluster receives protocolised support and the other receives usual care. Each cluster crosses over between treatment group assignments every 3 months. All adults undergoing extubation from invasive mechanical ventilation are enrolled except those who received less than 12 hours of mechanical ventilation, have ‘Do Not Intubate’ orders, or have been previously reintubated during the hospitalisation. The anticipated enrolment is approximately 630 patients. The primary outcome is reintubation within 96 hours of extubation.Ethics and disseminationThe trial was approved by the Vanderbilt Institutional Review Board. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences.Trial registration numberNCT03288311.

scholarly journals Disease Risk and Mortality Prediction in Intensive Care Patients with Pneumonia. Australian and New Zealand Practice in Intensive Care (ANZPIC II)

2005 ◽  
Vol 33 (1) ◽  
pp. 101-111 ◽  
Author(s):  
R. J. Boots ◽  
J. Lipman ◽  
R. Bellomo ◽  
D. Stephens ◽  
R. F. Heller
Keyword(s):  
Intensive Care ◽  
New Zealand ◽  
Clinical Signs ◽  
Community Acquired Pneumonia ◽  
Ventilator Associated Pneumonia ◽  
Invasive Ventilation ◽  
Non Invasive ◽  
Non Invasive Ventilation ◽  
Hospital Acquired Pneumonia ◽  
Hospital Acquired

This study of ventilated patients investigated pneumonia risk factors and outcome predictors in 476 episodes of pneumonia (48% community-acquired pneumonia, 24% hospital-acquired pneumonia, 28% ventilator-associated pneumonia) using a prospective survey in 14 intensive care units within Australia and New Zealand. For community acquired pneumonia, mortality increased with immunosuppression (OR 5.32, CI 95% 1.58–17.99, P<0.01), clinical signs of consolidation (OR 2.43, CI 95% 1.09–5.44, P=0.03) and Sepsis-Related Organ Failure Assessment (SOFA) scores (OR 1.19, CI 95% 1.08–1.30, P<0.001) but improved if appropriate antibiotic changes were made within three days of intensive care unit admission (OR 0.42, CI 95% 0.20–0.86, P=0.02). For hospital-acquired pneumonia, immunosuppression (OR 6.98, CI 95% 1.16–42.2, P=0.03) and non-metastatic cancer (OR 3.78, CI 95% 1.20–11.93, P=0.02) were the principal mortality predictors. Alcoholism (OR 7.80, CI 95% 1.20–17.50, P<0.001), high SOFA scores (OR 1.44, CI 95% 1.20–1.75, P=0.001) and the isolation of “high risk” organisms including Pseudomonas aeruginosa, Acinetobacter spp, Stenotrophomonas spp and methicillin resistant Staphylococcus aureus (OR 4.79, CI 95% 1.43–16.03, P=0.01), were associated with increased mortality in ventilator-associated pneumonia. The use of non-invasive ventilation was independently protective against mortality for patients with community-acquired and hospital-acquired pneumonia (OR 0.35, CI 95% 0.18–0.68, P=0.002). Mortality was similar for patients requiring both invasive and non-invasive ventilation and non-invasive ventilation alone (21% compared with 20% respectively, P=0.56). Pneumonia risks and mortality predictors in Australian and New Zealand ICUs vary with pneumonia type. A history of alcoholism is a major risk factor for mortality in ventilator-associated pneumonia, greater in magnitude than the mortality effect of immunosuppression in hospital-acquired pneumonia or community-acquired pneumonia. Non-invasive ventilation is associated with reduced ICU mortality. Clinical signs of consolidation worsen, while rationalising antibiotic therapy within three days of ICU admission improves mortality for community-acquired pneumonia patients.

Incidence, predictors and prognosis of respiratory support in non-ST segment elevation myocardial infarction

2020 ◽  
pp. 204887262091994
Author(s):  
Thomas Metkus ◽  
P Elliott Miller ◽  
Carlos L Alviar ◽  
Jacob C Jentzer ◽  
Sean van Diepen ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Mechanical Ventilation ◽  
Invasive Mechanical Ventilation ◽  
Respiratory Support ◽  
Invasive Ventilation ◽  
St Segment Elevation ◽  
Non Invasive ◽  
Segment Elevation Myocardial Infarction ◽  
Non Invasive Ventilation ◽  
St Segment

Background The incidences of invasive mechanical ventilation and non-invasive ventilation among patients with non-ST segment elevation myocardial infarction and associated prognosis are not well characterized. Methods We conducted a retrospective cohort study of patients with admission diagnosis of non-ST segment elevation myocardial infarction using the US National Inpatient Sample database between 2002–2014. The exposure variable was invasive mechanical ventilation or non-invasive ventilation within 24 h of admission, compared to no respiratory support. The primary outcome was in-hospital mortality. We determined the association between respiratory support and mortality using Cox proportional hazard models. Results A total of 4,152,421 non-ST segment elevation myocardial infarction hospitalizations were identified, among whom 1.3% required non-invasive ventilation and 1.9% required invasive mechanical ventilation. Non-invasive ventilation use increased over time (0.4% in 2002 to 2.4% in 2014, p<0.001) while there was no definite trend in invasive mechanical ventilation use. Revascularization was lower for non-ST segment elevation myocardial infarction hospitalizations including invasive mechanical ventilation (23.9%) and non-invasive ventilation (14.5%) compared to 36.5% of those without respiratory support ( p<0.001). In-hospital mortality was 3.1% for non-ST segment elevation myocardial infarction without respiratory support compared to 9.2% with non-invasive ventilation (adjusted hazard ratio 1.86, 95% confidence interval 1.74–1.98) and 37.2% with invasive mechanical ventilation (adjusted hazard ratio 3.03, 95% confidence interval 2.88–3.19). Mortality for non-ST segment elevation myocardial infarction-non-invasive ventilation is improving over time while mortality for non-ST segment elevation myocardial infarction-invasive mechanical ventilation is increasing over time. Conclusion Mechanical respiratory support in non-ST segment elevation myocardial infarction is used in an important minority of cases, is increasing and is independently associated with mortality. Studies of the optimal management of acute coronary syndrome complicated by respiratory failure are needed to improve outcomes.

scholarly journals Diabetes and Overweight/Obesity Are Independent, Nonadditive Risk Factors for In-Hospital Severity of COVID-19: An International, Multicenter Retrospective Meta-analysis

2021 ◽  
Author(s):  
Danielle K. Longmore ◽  
Jessica E. Miller ◽  
Siroon Bekkering ◽  
Christoph Saner ◽  
Edin Mifsud ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Hospital Mortality ◽  
Subgroup Analysis ◽  
Meta Analysis ◽  
Invasive Mechanical Ventilation ◽  
Invasive Ventilation ◽  
Site Specific ◽  
Non Invasive ◽  
Obesity And Diabetes ◽  
Non Invasive Ventilation

<a><b>OBJECTIVE</b><b> </b></a> <p>Obesity is an established risk factor for severe coronavirus disease 2019 (COVID-19) but the contribution of overweight and/or diabetes remain unclear. In a multi-center international study, we investigated if overweight, obesity and diabetes were independently associated with COVID-19 severity, and whether the body mass index (BMI)-associated risk was increased among those with diabetes. </p> <p> </p> <p><b>RESEARCH DESIGN & METHODS </b><b></b></p> <p>We retrospectively extracted data from health care records and regional databases of hospitalized adult patients with COVID-19 from 18 sites in 11 countries. We used standardized definitions and analyses to generate site-specific estimates, modelling the odds of each outcome (supplemental oxygen/non-invasive ventilation, invasive mechanical ventilation, and in-hospital mortality) by BMI category (reference, overweight, obese) adjusting for age, sex, and pre-specified co-morbidities. Subgroup analysis was performed on patients with pre-existing diabetes. Site-specific estimates were combined in a meta-analysis. </p> <p><u> </u></p> <p><b>RESULTS</b><b></b></p> <p>Among 7244 patients (65.6% overweight/obese), those with overweight were more likely to require oxygen/non-invasive ventilation (random effects adjusted odds ratio [aOR] 1.44 [95% CI 1.15-1.80]) and invasive mechanical ventilation (aOR 1.22 [CI 1.03-1.46]). There was no association between overweight and in-hospital mortality (aOR 0.88 [CI 0.74-1.04]). Similar effects were observed in patients with obesity or diabetes. In the subgroup analysis, the aOR for any outcome was not additionally increased in those with diabetes and overweight or obesity. </p> <p> </p> <p><b>CONCLUSIONS</b><b></b></p> <p>In adults hospitalized with COVID-19, overweight as well as obesity and diabetes were associated with increased odds of respiratory support but not mortality. In patients with diabetes, the odds of severe COVID-19 were not increased above the BMI-associated risk. </p>

scholarly journals Diabetes and Overweight/Obesity Are Independent, Nonadditive Risk Factors for In-Hospital Severity of COVID-19: An International, Multicenter Retrospective Meta-analysis

2021 ◽  
Author(s):  
Danielle K. Longmore ◽  
Jessica E. Miller ◽  
Siroon Bekkering ◽  
Christoph Saner ◽  
Edin Mifsud ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Hospital Mortality ◽  
Subgroup Analysis ◽  
Meta Analysis ◽  
Invasive Mechanical Ventilation ◽  
Invasive Ventilation ◽  
Site Specific ◽  
Non Invasive ◽  
Obesity And Diabetes ◽  
Non Invasive Ventilation

<a><b>OBJECTIVE</b><b> </b></a> <p>Obesity is an established risk factor for severe coronavirus disease 2019 (COVID-19) but the contribution of overweight and/or diabetes remain unclear. In a multi-center international study, we investigated if overweight, obesity and diabetes were independently associated with COVID-19 severity, and whether the body mass index (BMI)-associated risk was increased among those with diabetes. </p> <p> </p> <p><b>RESEARCH DESIGN & METHODS </b><b></b></p> <p>We retrospectively extracted data from health care records and regional databases of hospitalized adult patients with COVID-19 from 18 sites in 11 countries. We used standardized definitions and analyses to generate site-specific estimates, modelling the odds of each outcome (supplemental oxygen/non-invasive ventilation, invasive mechanical ventilation, and in-hospital mortality) by BMI category (reference, overweight, obese) adjusting for age, sex, and pre-specified co-morbidities. Subgroup analysis was performed on patients with pre-existing diabetes. Site-specific estimates were combined in a meta-analysis. </p> <p><u> </u></p> <p><b>RESULTS</b><b></b></p> <p>Among 7244 patients (65.6% overweight/obese), those with overweight were more likely to require oxygen/non-invasive ventilation (random effects adjusted odds ratio [aOR] 1.44 [95% CI 1.15-1.80]) and invasive mechanical ventilation (aOR 1.22 [CI 1.03-1.46]). There was no association between overweight and in-hospital mortality (aOR 0.88 [CI 0.74-1.04]). Similar effects were observed in patients with obesity or diabetes. In the subgroup analysis, the aOR for any outcome was not additionally increased in those with diabetes and overweight or obesity. </p> <p> </p> <p><b>CONCLUSIONS</b><b></b></p> <p>In adults hospitalized with COVID-19, overweight as well as obesity and diabetes were associated with increased odds of respiratory support but not mortality. In patients with diabetes, the odds of severe COVID-19 were not increased above the BMI-associated risk. </p>

scholarly journals Observational study of changes in utilization and outcomes in mechanical ventilation in COVID-19

PLoS ONE ◽  
2022 ◽  
Vol 17 (1) ◽  
pp. e0262315
Author(s):  
Christian Karagiannidis ◽  
Corinna Hentschker ◽  
Michael Westhoff ◽  
Steffen Weber-Carstens ◽  
Uwe Janssens ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Hospital Stay ◽  
Invasive Mechanical Ventilation ◽  
Length Of Hospital Stay ◽  
Local Health ◽  
Invasive Ventilation ◽  
Non Invasive ◽  
Non Invasive Ventilation ◽  
Local Health Care ◽  
Overall Mortality

Background The role of non-invasive ventilation (NIV) in severe COVID-19 remains a matter of debate. Therefore, the utilization and outcome of NIV in COVID-19 in an unbiased cohort was determined. Aim The aim was to provide a detailed account of hospitalized COVID-19 patients requiring non-invasive ventilation during their hospital stay. Furthermore, differences of patients treated with NIV between the first and second wave are explored. Methods Confirmed COVID-19 cases of claims data of the Local Health Care Funds with non-invasive and/or invasive mechanical ventilation (MV) in the spring and autumn pandemic period in 2020 were comparable analysed. Results Nationwide cohort of 17.023 cases (median/IQR age 71/61–80 years, 64% male) 7235 (42.5%) patients primarily received IMV without NIV, 4469 (26.3%) patients received NIV without subsequent intubation, and 3472 (20.4%) patients had NIV failure (NIV-F), defined by subsequent endotracheal intubation. The proportion of patients who received invasive MV decreased from 75% to 37% during the second period. Accordingly, the proportion of patients with NIV exclusively increased from 9% to 30%, and those failing NIV increased from 9% to 23%. Median length of hospital stay decreased from 26 to 21 days, and duration of MV decreased from 11.9 to 7.3 days. The NIV failure rate decreased from 49% to 43%. Overall mortality increased from 51% versus 54%. Mortality was 44% with NIV-only, 54% with IMV and 66% with NIV-F with mortality rates steadily increasing from 62% in early NIV-F (day 1) to 72% in late NIV-F (>4 days). Conclusions Utilization of NIV rapidly increased during the autumn period, which was associated with a reduced duration of MV, but not with overall mortality. High NIV-F rates are associated with increased mortality, particularly in late NIV-F.

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