Timely intubation with early prediction of respiratory exacerbation in acute traumatic cervical spinal cord injury

Background Early routine intubation in motor-complete cervical spinal cord injury (CSCI) above the C5 level is a conventional protocol to prevent unexpected respiratory exacerbation (RE). However, in the context of recent advances in multidisciplinary respiratory management, the absolute indication for intubation in patients with CSCI based on initial neurologic assessment is controversial because of the drawbacks of intubation. This study aimed to redetermine the most important predictor of RE following CSCI after admission without routine intubation among patients admitted with motor-complete injury and/or injury above the C5 level to ensure timely intubation. Methods We performed a retrospective review of patients with acute traumatic CSCI admitted to our hospital without an initial routine intubation protocol from January 2013 to December 2017. CSCI patients who developed RE (defined as unexpected emergent intubation for respiratory resuscitation) were compared with those who did not. Baseline characteristics and severity of trauma data were collected. Univariate analyses were performed to compare treatment data and clinical outcomes between the two groups. Further, multivariate logistic regression was performed with clinically important independent variables: motor-complete injury, neurologic level above C5, atelectasis, and copious airway secretion (CAS). Results Among 58 patients with CSCI, 35 (60.3%) required post-injury intubation and 1 (1.7%) died during hospitalization. Thirteen (22.4%) had RE 3.5 days (mean) post-injury; 3 (37.5%) of eight patients with motor-complete CSCI above C5 developed RE. Eleven of the 27 (40.7%) patients with motor-complete injury and five of the 22 (22.7%) patients with neurologic injury above C5 required emergency intubation at RE. Three of the eight CSCI patients with both risk factors (motor-complete injury above C5) resulted in emergent RE intubation (37.5%). CAS was an independent predictor for RE (odds ratio 7.19, 95% confidence interval 1.48–42.72, P = 0.0144) in multivariate analyses. Conclusion Timely intubation post-CSCI based on close attention to CAS during the acute 3-day phase may prevent RE and reduce unnecessary invasive airway control even without immediate routine intubation in motor-complete injury above C5.

Do COVID-19 Pandemic-Related Behavior Changes Affect Perioperative Respiratory Adverse Events in Children Undergoing Cardiac Interventional Catheterization?

Background: The Novel Coronavirus Disease (COVID-19) pandemic-related behavior changes could affect the perioperative respiratory adverse events in children with congenital heart disease (CHD). This study was designed to compare the incidence of perioperative respiratory adverse events (PRAEs) in children with and without upper respiratory infection (URI) undergoing the cardiac catheterization before and during COVID-19 pandemic.Methods：COVID-19 was outbreak in January 2020 in China. 260 pediatric patients scheduled for elective therapeutic cardiac catheterization were included from January 2019 to March 2021 and 154 were completed during the pandemic. Recent URI was diagnosed by the attending anesthesiologist owing to different PRAEs incidence in non-URI and URI children. The overall incidence of PRAEs (laryngospasm, bronchospasm, coughing, airway secretion, airway obstruction, and oxygen desaturation) in non-URI and URI children undergoing the elective cardiac catheterization were compared before and during the COVID-19 pandemic. Logistic regression model was fitted to identify the potential risk factors associated with PRAEs.Results: Of 564 children enrolled, 359 completed the study and was analyzed finally. URI incidence decreased substantially during the COVID-19 pandemic (14% vs. 41%, P<0.001). Meanwhile, the overall PRAEs also significantly declined no matter whether or not the child had recent URI (22.3% vs. 42.3%, P=0.001 for non-URI and 29.2% vs. 58.7%, P=0.012 for URI respectively). Post-operative agitation in non-URI children occurred less frequently during the pandemic than before (2.3% vs. 16.2%, P=0.001). Behaviors before the COVID-19 pandemic (odd ratio=2.84, 95%CI 1.76 to 4.58) and recent URI (odd ratio =1.79, 95%CI 1.09 to 2.92) were associated with the PRAEs.Conclusions: COVID-19 pandemic-related behavior changes were associated with the reduction of PRAEs in non-URI and URI children undergoing elective therapeutic cardiac catheterization.

Timely Intubation With Early Prediction of Respiratory Exacerbation in Acute Traumatic Cervical Spinal Cord Injury

Background: Early routine intubation in motor-complete cervical spinal cord injury (CSCI) above the C5 level is a conventional protocol to prevent unexpected respiratory exacerbation (RE). However, in context of the recent advances in multidisciplinary respiratory management, the absolute indication for intubation in CSCI patients based on initial neurologic assessment is controversial because of the drawbacks of intubation. This study aimed to redetermine the most important predictor of RE following CSCI after admission without routine intubation among patients admitted with motor-complete injury and/or injury above the C5 level to ensure timely intubation. Methods: We performed a retrospective review of patients with acute traumatic CSCI admitted to our hospital without an initial routine intubation protocol from January 2013 to December 2017. CSCI patients who developed RE (defined as unexpected emergent intubation for respiratory resuscitation) were compared with those who did not. Baseline characteristics and severity of trauma data were collected. Univariate analyses were performed to compare treatment data and clinical outcomes between the two groups. Further, multivariate logistic regressions were performed with clinically important independent variables: motor-complete injury, neurologic level above C5, atelectasis, and copious airway secretion (CAS). Results: Among the analyzed 58 patients with CSCI, 35 (60.3%) required post-injury intubation and 1 (1.7%) died during hospitalization. Thirteen (22.4%) had RE in 3.5 days (mean) post-injury; 3 (37.5%) of eight motor-complete CSCI patients above C5 developed RE. Eleven of the 27 (40.7%) patients with motor-complete injury and five of the 22 (22.7%) patients with neurologic injury above C5 required emergency intubation at RE. Three of the eight CSCI patients with both risk factors (motor-complete injury above C5) resulted in emergent RE intubation (37.5%). CAS was an independent predictor for RE (odds ratio 7.19, 95% confidence interval 1.48–42.72, P=0.0144) in multivariate analyses. Conclusion: Timely intubation post-CSCI based on close attention to CAS during the acute 3-day phase may prevent RE and reduce unnecessary invasive airway control even without immediate routine intubation in motor-complete injury above C5.

Secretion management in patients with ineffective airway clearance with non-invasive mechanical ventilation use: Expert guidance for clinical practice

Non-invasive ventilation (NIV) is a mainstay of management of chronic respiratory failure in many disorders which are known to cause abnormal airway secretion clearance. Currently, there is no guidance regarding either the secretion handling during NIV use or the role of NIV in secretion management in these patients. The aim of this document was to provide an overview of the various techniques available in the management of respiratory secretions and their use in conjunction with NIV. Literature search was performed using the keywords, “(secretion OR secretions) AND (noninvasive ventilation OR NIV)” on PubMed and EMBASE. The search yielded 1681 and 509 titles from PubMed and EMBASE, respectively. After screening, 19 articles were included in this review. Suggestions of the expert panel were formulated by mutual consensus after reviewing the relevant literature. The draft of the expert panel’s suggestions was circulated among all authors via electronic mail for comments. Any conflicts were resolved by mutual discussion to achieve agreement. The final document was approved by all. This document by the International Network for Airway Secretions Management in NIV describes various airway secretion clearance techniques. It provides the expert panel’s suggestions for the use of these techniques in conjunction with NIV for patients with muco-obstructive and neuromuscular disorders.

Airway Remodeling Factors During Early-Life Rhinovirus Infection and the Effect of Premature Birth

Background: Early rhinovirus (RV) infection is a strong risk factor for asthma development. Airway remodeling factors play a key role in the progression of the asthmatic condition. We hypothesized that RV infection in young children elicits the secretion of growth factors implicated in airway remodeling and asthma progression.Methods: We examined the nasal airway production of remodeling factors in children ( ≤ 2 years old) hospitalized due to PCR-confirmed RV infection. Airway remodeling proteins included: MMP-1, MMP-2, MMP-7, MMP-9, MMP-10, TIMP-1, TIMP-2, EGF, Angiopoietin-2, G-CSF, BMP-9, Endoglin, Endothelin-1, Leptin, FGF-1, Follistatin, HGF, HB-EGF, PLGF, VEGF-A, VEGF-C, VEGF-D, FGF-2, TGF-β1, TGF-β2, TGF-β3, PDGF AA, PDGF BB, SPARC, Periostin, OPN, and TGF-α.Results: A total of 43 young children comprising RV cases (n = 26) and uninfected controls (n = 17) were included. Early RV infection was linked to (1) enhanced production of several remodeling factors (e.g., HGF, TGFα), (2) lower MMP-9/TIMP-2 and MMP-2/TIMP-2 ratios, and (3) increased MMP-10/TIMP-1 ratios. We also found that relative to term infants, severely premature children had reduced MMP-9/TIMP-2 ratios at baseline.Conclusion: RV infection in young children elicits the airway secretion of growth factors implicated in angiogenesis, fibrosis, and extracellular matrix deposition. Our results highlight the potential of investigating virus-induced airway remodeling growth factors during early infancy to monitor and potentially prevent chronic progression of respiratory disorders in all ages.

Chest physiotherapy enhances detection of Pseudomonas aeruginosa in non-expectorating CF children

Lung damage in Cystic Fibrosis (CF) is strongly associated with lower airway infections. Early treatment of Pseudomonas aeruginosa is recommended. Pathogen detection requires sampling of lower airway secretions, which remains a challenge in non-expectorating patients. Our hypothesis was that chest physiotherapy would improve the quality of airway secretion samples and increase the rates of pathogens detected in non-expectorating patients.This prospective multicentre study compared three successive methods for sampling airway secretions applied through a same session: 1) oropharyngeal swab (OP); 2) sputum collected after chest physiotherapy (CP-SP); and 3) oropharyngeal swab 2 performed after chest physiotherapy(CP-SP-CP-OP). Haemophilus influenzae, Staphylococcus aureus and P. aeruginosa (Pa) growth cultures were assessed. Accuracy tests and an equivalence test was performed to compare the three successive methods of collection. Three-hundred non-expectorating children with CF were included. Pa was detected cumulatively in 56 (18.9%) children and according to the collection techniques in 28 (9.8%), 37(12.4%) and 44 (15%) children by using CP-SP and CP-OP, respectively. Compared to OP, the increased detection rate was +22% for CP-OP, p=0029 and +57% for CP-SP, p=0.003. CP-SP had the best positive predictive value (PPV) (86.3%) and negative PV (96%) for Pa compared to the overall detection. The results of this adequately powered study show differences in the rates of pathogens detected according to the sampling method used. Chest physiotherapy enhanced detection of P. aeruginosa in non-expectorating children with CF.

Prone treatment position as a novel option for head and neck cancer patients with unmanageable secretions

Background: Supine orientation is the standard treatment position for radiation therapy for head and neck cancer. Some patients, however, cannot tolerate this due to pooling of secretions and airway concerns, and theoretically, treatment would be better tolerated in a prone position. Here, we described the first prone treatment setup and delivery for a patient with head and neck cancer. Methods: A 68-year-old male patient with inoperable locally advanced, T4aN0M0, squamous cell carcinoma of the maxillary sinus was simulated, planned, and treated in prone position due to sinus congestion. Results: Prone position was well tolerated by the patient, who then did not require daily anaesthesia for airway secretion management. The prone dosimetry demonstrated good target coverage and normal tissue sparing. His treatment setup was found to be reproducible throughout the course of therapy. Conclusions: We successfully demonstrated the feasibility of prone treatment position for patients with head and neck cancer who are unable to tolerate supine position due to unmanageable secretions. Consideration should be given to prone treatment when designing both radiation therapy protocols and individual treatment plans.

Candida tropicalis distribution and drug resistance correlated to ERG11 and UPC2 expression

Objective: This study is to analyze the distribution characteristics and drug resistance of Candida tropicalis, and the relationship between ERG11 and UPC2 expression and the resistance to azole.Methods: The Candida tropicalis were cultured and identified by the Sabouraud Agar Medium, CHROM Agar Candida and France Bio-Mérieux ATB test. The total RNA of the collected strains was extracted, and the ERG11 and UPC2 mRNA expression levels were analyzed by the quantitative real-time PCR. Results: Totally 2872 clinical isolates of Candida, including 319 strains of Candida tropicalis were analyzed herein, which were mainly distributed in the Departments of Respiratory Medicine and ICU. The specimen type was mainly based on the airway secretion, and the detection trend in four years was mainly related to the type of the departments and specimens. The resistance rates of Candida tropicalis to fluconazole, itraconazole and voriconazole have been increasing year by year. The mRNA expression levels of ERG11 and UPC2 in the fluconazole resistant group were significantly higher than the sensitive group. In addition, there was a significant linear positive correlation between these two genes in the fluconazole resistant group.Conclusions: Over-expression of ERG11 and UPC2 genes in Candida tropicalis could increase the resistance to antifungal drugs. The routine detection of ERG11 and UPC2 for high-risk patients in the key departments would provide theoretical basis for the rational application of antifungal drugs.