Case Report: Respiratory Management With a 47-Day ECMO Support for a Critical Patient With COVID-19

This paper reports a complete case of severe acute respiratory distress syndrome (ARDS) caused by coronavirus disease 2019 (COVID-19), who presented with rapid deterioration of oxygenation during hospitalization despite escalating high-flow nasal cannulation to invasive mechanical ventilation. After inefficacy with lung-protective ventilation, positive end-expiratory pressure (PEEP) titration, prone position, we administered extracorporeal membrane oxygenation (ECMO) as a salvage respiratory support with ultra-protective ventilation for 47 days and finally discharged the patient home with a good quality of life with a Barthel Index Score of 100 after 76 days of hospitalization. The purpose of this paper is to provide a clinical reference for the management of ECMO and respiratory strategy of critical patients with COVID-19-related ARDS.

Bronchopulmonary Dysplasia and Risk of Developmental Delay: An EPIPAGE-2 Cohort Study

<b><i>Background:</i></b> Overall and respiratory management of preterm children are constantly evolving, which might have changed both the pathophysiology and neurodevelopmental consequences of bronchopulmonary dysplasia (BPD). <b><i>Objectives:</i></b> The objective of this study is to determine whether the previously shown association between BPD and risk of developmental delay persists. <b><i>Methods:</i></b> The study population was children born before 32 weeks’ gestation from the French prospective cohort EPIPAGE-2. The exposure was BPD assessed at 36 weeks’ postmenstrual age. The main outcome was risk of developmental delay defined by an Age &amp; Stages Questionnaires (ASQ) score below threshold at 24 months’ corrected age. <b><i>Results:</i></b> The analyzed population included 2,706 children. Among those with available ASQ score, 196/1,587 had BPD and 671/1,587 had an ASQ score below threshold. BPD was associated with an ASQ score below threshold (odds ratio 1.52, 95% confidence interval 1.11–2.08; <i>p</i> = 0.008). <b><i>Conclusions:</i></b> BPD was strongly associated with risk of developmental delay.

Oscillatory mechanics at birth for identifying infants requiring surfactant: a prospective, observational trial

Background Current criteria for surfactant administration assume that hypoxia is a direct marker of lung-volume de-recruitment. We first introduced an early, non-invasive assessment of lung mechanics by the Forced Oscillation Technique (FOT) and evaluated its role in predicting the need for surfactant therapy. Objectives To evaluate whether lung reactance (Xrs) assessment by FOT within 2 h of birth identifies infants who would need surfactant within 24 h; to eventually determine Xrs performance and a cut-off value for early detection of infants requiring surfactant. Methods We conducted a prospective, observational, non-randomized study in our tertiary NICU in Milan. Eligible infants were born between 27+0 and 34+6 weeks’ gestation, presenting respiratory distress after birth. Exclusion criteria: endotracheal intubation at birth, major malformations participation in other interventional trials, parental consent denied. We assessed Xrs during nasal CPAP at 5 cmH2O at 10 Hz within 2 h of life, recording flow and pressure tracing through a Fabian Ventilator for off-line analysis. Clinicians were blinded to FOT results. Results We enrolled 61 infants, with a median [IQR] gestational age of 31.9 [30.3; 32.9] weeks and birth weight 1490 [1230; 1816] g; 2 infants were excluded from the analysis for set-up malfunctioning. 14/59 infants received surfactant within 24 h. Xrs predicted surfactant need with a cut-off − 33.4 cmH2O*s/L and AUC-ROC = 0.86 (0.76–0.96), with sensitivity 0.85 and specificity 0.83. An Xrs cut-off value of − 23.3 cmH2O*s/L identified infants needing surfactant or respiratory support > 28 days with AUC-ROC = 0.89 (0.81–0.97), sensitivity 0.86 and specificity 0.77. Interestingly, 12 infants with Xrs < − 23.3 cmH2O*s/L (i.e. de-recruited lungs) did not receive surfactant and subsequently required prolonged respiratory support. Conclusion Xrs assessed within 2 h of life predicts surfactant need and respiratory support duration in preterm infants. The possible role of Xrs in improving the individualization of respiratory management in preterm infants deserves further investigation.

Towards a Singing Voice Multi-Sensor Analysis Tool: System Design, and Assessment Based on Vocal Breathiness

Singing voice is a human quality that requires the precise coordination of numerous kinetic functions and results in a perceptually variable auditory outcome. The use of multi-sensor systems can facilitate the study of correlations between the vocal mechanism kinetic functions and the voice output. This is directly relevant to vocal education, rehabilitation, and prevention of vocal health issues in educators; professionals; and students of singing, music, and acting. In this work, we present the initial design of a modular multi-sensor system for singing voice analysis, and describe its first assessment experiment on the ‘vocal breathiness’ qualitative characteristic. A system case study with two professional singers was conducted, utilizing signals from four sensors. Participants sung a protocol of vocal trials in various degrees of intended vocal breathiness. Their (i) vocal output, (ii) phonatory function, and (iii) respiratory behavior-per-condition were recorded through a condenser microphone (CM), an Electroglottograph (EGG), and thoracic and abdominal respiratory effort transducers (RET), respectively. Participants’ individual respiratory management strategies were studied through qualitative analysis of RET data. Microphone audio samples breathiness degree was rated perceptually, and correlation analysis was performed between sample ratings and parameters extracted from CM and EGG data. Smoothed Cepstral Peak Prominence (CPPS) and vocal folds’ Open Quotient (OQ), as computed with the Howard method (HOQ), demonstrated the higher correlation coefficients, when analyzed individually. DECOM method-computed OQ (DOQ) was also examined. Interestingly, the correlation coefficient of pitch difference between estimates from CM and EGG signals appeared to be (based on the Pearson correlation coefficient) statistically insignificant (a result that warrants investigation in larger populations). The study of multi-variate models revealed even higher correlation coefficients. Models studied were the Acoustic Breathiness Index (ABI) and the proposed multiple regression model CDH (CPPS, DOQ, and HOQ), which was attempted in order to combine analysis results from microphone and EGG signals. The model combination of ABI and the proposed CDH appeared to yield the highest correlation with perceptual breathiness ratings. Study results suggest potential for the use of a completed system version in vocal pedagogy and research, as the case study indicated system practicality, a number of pertinent correlations, and introduced topics with further research possibilities.

Efficacy of non-invasive and invasive respiratory management strategies in adult patients with acute hypoxaemic respiratory failure: a systematic review and network meta-analysis

Background Although non-invasive respiratory management strategies have been implemented to avoid intubation, patients with de novo acute hypoxaemic respiratory failure (AHRF) are high risk of treatment failure. In the previous meta-analyses, the effect of non-invasive ventilation was not evaluated according to ventilation modes in those patients. Furthermore, no meta-analyses comparing non-invasive respiratory management strategies with invasive mechanical ventilation (IMV) have been reported. We performed a network meta-analysis to compare the efficacy of non-invasive ventilation according to ventilation modes with high-flow nasal oxygen (HFNO), standard oxygen therapy (SOT), and IMV in adult patients with AHRF. Methods The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Ichushi databases were searched. Studies including adults with AHRF and randomized controlled trials (RCTs) comparing two different respiratory management strategies (continuous positive airway pressure (CPAP), pressure support ventilation (PSV), HFNO, SOT, or IMV) were reviewed. Results We included 25 RCTs (3,302 participants: 27 comparisons). Using SOT as the reference, CPAP (risk ratio [RR] 0.55; 95% confidence interval [CI] 0.31–0.95; very low certainty) was associated significantly with a lower risk of mortality. Compared with SOT, PSV (RR 0.81; 95% CI 0.62–1.06; low certainty) and HFNO (RR 0.90; 95% CI 0.65–1.25; very low certainty) were not associated with a significantly lower risk of mortality. Compared with IMV, no non-invasive respiratory management was associated with a significantly lower risk of mortality, although all certainties of evidence were very low. The probability of being best in reducing short-term mortality among all possible interventions was higher for CPAP, followed by PSV and HFNO; IMV and SOT were tied for the worst (surface under the cumulative ranking curve value: 93.2, 65.0, 44.1, 23.9, and 23.9, respectively). Conclusions When performing non-invasive ventilation among patients with de novo AHRF, it is important to avoid excessive tidal volume and lung injury. Although pressure support is needed for some of these patients, it should be applied with caution because this may lead to excessive tidal volume and lung injury. Trial registration protocols.io (Protocol integer ID 49375, April 23, 2021). 10.17504/protocols.io.buf7ntrn.

Erratum: The role of physiotherapy in the respiratory management of children with neuromuscular diseases: A South African perspective

No abstract available.