Mechanical ventilation is controlled by volume or pressure during neurosurgery. Is there an advantage?

Background. One of the main technologies of modern anesthesiology is mechanical ventilation (MV). At present, the protective technology of MV is widely recognized. The feasibi-lity of using this technology in the operating room, especially in patients with intact lungs, is not so obvious. Most of the scientific sources that cover this problem relate to patients with abdominal pathology, and less coverage remains in patients with neurosurgical pathology. However, patients who are operated on for neurosurgical pathology belong to the group of patients of high surgical risk, which forced us to conduct this study. The study was aimed to examine the feasibility of using protective MV during surgery in neurosurgical patients. Materials and methods. We examined 46 patients who were hospitalized in KNP 8 MKL in Lviv for spinal pathology and who underwent surgery for vertebroplasty with spondylodesis. Patients were divided into two groups: in the first group (34 patients), MV was performed by S-IPPV technology — synchronized intermittent positive pressure ventilation with volume control; and in the second group (12 patients), MV was performed by PCV technology — controlled ventilation pressure. Results. We retrospectively determined the incidence of post-operative pulmonary complications (POPC) in patients of the first and second groups. Of the 34 patients of the first group, the signs of POPC were detected in 17 patients (50 %), and of 12 patients of the second group, POPC were detected in 4 patients (33.3 %). It should be noted that MV in patients of both groups did not differ in such parameters as respiratory rate, end-alveolar pressure, and the fraction of oxygen in the respiratory mixture. Conclusions. A relatively small number of patients clearly do not allow the conclusions to be drawn, but it should be noted that MV (especially volume-controlled) contributes to postoperative pulmonary complications in patients with intact lungs in the preoperative period. And pressure-controlled MV tends to reduce the incidence of postoperative pulmonary complications in the postoperative period. Given that respiration rate, end-alveolar expiratory pressure and oxygen fraction in the respiratory mixture were comparable in patients of both groups, it can be assumed that the factor influencing the incidence of POPC is the mechanics of pulmonary ventilation.

Single versus continuous sustained inflations during chest compressions and physiological-based cord clamping in asystolic lambs

BackgroundThe feasibility and benefits of continuous sustained inflations (SIs) during chest compressions (CCs) during delayed cord clamping (physiological-based cord clamping; PBCC) are not known. We aimed to determine whether continuous SIs during CCs would reduce the time to return of spontaneous circulation (ROSC) and improve post-asphyxial blood pressures and flows in asystolic newborn lambs.MethodsFetal sheep were surgically instrumented immediately prior to delivery at ~139 days’ gestation and asphyxia induced until lambs reached asystole. Lambs were randomised to either immediate cord clamping (ICC) or PBCC. Lambs then received a single SI (SIsing; 30 s at 30 cmH2O) followed by intermittent positive pressure ventilation, or continuous SIs (SIcont: 30 s duration with 1 s break). We thus examined 4 groups: ICC +SIsing, ICC +SIcont, PBCC +SIsing, and PBCC +SIcont. Chest compressions and epinephrine administration followed international guidelines. PBCC lambs underwent cord clamping 10 min after ROSC. Physiological and oxygenation variables were measured throughout.ResultsThe time taken to achieve ROSC was not different between groups (mean (SD) 4.3±2.9 min). Mean and diastolic blood pressure was higher during chest compressions in PBCC lambs compared with ICC lambs, but no effect of SIs was observed. SIcont significantly reduced pulmonary blood flow, diastolic blood pressure and oxygenation after ROSC compared with SIsing.ConclusionWe found no significant benefit of SIcont over SIsing during CPR on the time to ROSC or on post-ROSC haemodynamics, but did demonstrate the feasibility of continuous SIs during advanced CPR on an intact umbilical cord. Longer-term studies are recommended before this technique is used routinely in clinical practice.

Specific Cytokine Profiles Predict the Severity of Influenza A Pneumonia: A Prospectively Multicenter Pilot Study

Purpose. Studying the cytokine profiles in influenza A pneumonia could be helpful to better understand the pathogenesis of the disease and predict its prognosis. Patients and Methods. Patients with influenza A pneumonia (including 2009H1N1, H1N1, H3N1, and H7N1) hospitalized in six hospitals from January 2017 to October 2018 were enrolled (ClinicalTrials.gov ID, NCT03093220). Sputum samples were collected within 24 hours after admission and subsequently analyzed for cytokine profiles using a Luminex assay. Results. A total of 35 patients with influenza A pneumonia were included in the study. The levels of IL-6, IFN-γ, and IL-2 were increased in patients with severe influenza A pneumonia (n =10) ( P = 0.002 , 0.009, and 0.008, respectively), while those of IL-5, IL-25, IL-17A, and IL-22 were decreased compared to patients with nonsevere pneumonia ( P = 0.0001 , 0.009, 0.0001, and 0.006, respectively). The levels of IL-2 and IL-6 in the nonsurvivors ( n = 5 ) were significantly higher than those in the survivors ( P = 0.043 and 0.0001, respectively), while the levels of IL-5, IL-17A, and IL-22 were significantly lower ( P = 0.001 , 0.012, and 0.043, respectively). The IL-4/IL-17A ratio has the potential to be a good predictor ( AUC = 0.94 , P < 0.05 , sensitivity = 88.89 % , specificity = 92.31 % ) and an independent risk factor (OR, 95% CI: 3.772, 1.188-11.975; P < 0.05 ) for intermittent positive pressure ventilation (n = 9). Conclusion. Significant dysregulation of cytokine profiles can be observed in patients with severe influenza A pneumonia.

Cardiorespiratory Parameters in Intermittent Positive Pressure Ventilation Versus Spontaneous Ventilation in Under One-Year-Old Pediatrics: A Randomized Trial

Background: Cardiac catheterization is a useful method for determining the anatomy and pressure in cardiac vessels and chambers. The use of anesthesia methods with minimal hemodynamic and respiratory effects can increase diagnostic accuracy. Objectives: Since there are a few exclusive pediatric angiography centers, scarce studies have been done in this area. Accordingly, this study determined the effects of intermittent positive pressure ventilation (IPPV) versus spontaneous ventilation on cardiorespiratory parameters in less than one-year-old pediatric patients undergoing angiography with general anesthesia. Methods: In this interventional study that was performed as a double-blind, randomized clinical trial, 60 children younger than one year were enrolled. The pulmonary, renal, hepatic, and metabolic background diseases, previous cardiac and thoracic surgery, requiring over two ketamine doses, and receiving sedative or anti-convulsant therapeutics were excluded. The patients were randomly assigned to two groups, including IPPV and spontaneous ventilation. Their vital signs were also recorded before and after anesthesia induction and needling, as well as during measurements of pulmonary parameters and systemic blood pressure. All measurements were done by a single operator using the same device for each variable. Results: It was seen that SPO2, as well as PCO2 after anesthesia had significant alterations among the study variables. Nausea and vomiting, pain, and agitation were not different across the groups (P-value > 0.05). Conclusions: In this study, we found that IPPV and spontaneous ventilation have the same effects on respiration. Both techniques can be used in children with different cardiovascular catheterization conditions to increase accuracy and reduce alterations in cardiopulmonary parameters.

Reintubation rates after extubation to different non-invasive ventilation modes in preterm infants

Introduction Respiratory Distress Syndrome (RDS) is a common cause of neonatal morbidity and mortality in premature newborns. In this study, we aim to compare the reintubation rate in preterm babies with RDS who were extubated to Nasal Continuous Positive Airway Pressure (NCPAP) versus those extubated to Nasal Intermittent Positive Pressure Ventilation (NIPPV). Methods This is a retrospective study conducted in the Neonatal Intensive Care Unit (NICU) of Women’s Wellness and Research Center (WWRC), Doha, Qatar. The medical files (n = 220) of ventilated preterm infants with gestational age ranging between 28 weeks 0 days and 36 weeks + 6 days gestation and extubated to non-invasive respiratory support (whether NCPAP, NIPPV, or Nasal Cannula) during the period from January 2016 to December 2017 were reviewed. Results From the study group of 220 babies, n = 97 (44%) babies were extubated to CPAP, n = 77 (35%) were extubated to NIPPV, and n = 46 (21%) babies were extubated to Nasal Cannula (NC). Out of the n = 220 babies, 18 (8.2%) were reintubated within 1 week after extubation. 14 of the 18 (77.8%) were reintubated within 48 h of extubation. Eleven babies needed reintubation after being extubated to NCPAP (11.2%) and seven were reintubated after extubation to NIPPV (9.2%), none of those who were extubated to NC required reintubation (P = 0.203). The reintubation rate was not affected by extubation to any form of non-invasive ventilation (P = 0.625). The mode of ventilation before extubation does not affect the reintubation rate (P = 0.877). The presence of PDA and NEC was strongly associated with reintubation which increased by two and four-folds respectively in those morbidities. There is an increased risk of reintubation with babies suffering from NEC and BPD and this was associated with an increased risk of hospital stay with a P-value ranging (from 0.02–0.003). Using multivariate logistic regression, NEC the NEC (OR = 5.52, 95% CI 1.26, 24.11, P = 0.023) and the vaginal delivery (OR = 0.23, 95% CI 0.07, 0.78, P = 0.018) remained significantly associated with reintubation. Conclusion Reintubation rates were less with NIPPV when compared with NCPAP, however, this difference was not statistically significant. This study highlights the need for further research studies with a larger number of neonates in different gestational ages birth weight categories. Ascertaining this information will provide valuable data for the factors that contribute to re-intubation rates and influence the decision-making and management of RDS patients in the future.

Inhibitory Effect of Nasal Intermittent Positive Pressure Ventilation on Gastroesophageal Reflux

Non-invasive intermittent positive pressure ventilation can lead to esophageal insufflations and in turn to gastric distension. The fact that the latter induces transient relaxation of the lower esophageal sphincter implies that it may increase gastroesophageal refluxes. We previously reported that nasal Pressure Support Ventilation (nPSV), contrary to nasal Neurally-Adjusted Ventilatory Assist (nNAVA), triggers active inspiratory laryngeal closure. This suggests that esophageal insufflations are more frequent in nPSV than in nNAVA. The objectives of the present study were to test the hypotheses that: i) gastroesophageal refluxes are increased during nPSV compared to both control condition and nNAVA; ii) esophageal insufflations occur more frequently during nPSV than nNAVA. Polysomnographic recordings and esophageal multichannel intraluminal impedance pHmetry were performed in nine chronically instrumented newborn lambs to study gastroesophageal refluxes, esophageal insufflations, states of alertness, laryngeal closure and respiration. Recordings were repeated without sedation in control condition, nPSV (15/4 cmH2O) and nNAVA (~ 15/4 cmH2O). The number of gastroesophageal refluxes recorded over six hours, expressed as median (interquartile range), decreased during both nPSV (1 (0, 3)) and nNAVA [1 (0, 3)] compared to control condition (5 (3, 10)), (p < 0.05). Meanwhile, the esophageal insufflation index did not differ between nPSV (40 (11, 61) h-1) and nNAVA (10 (9, 56) h-1) (p = 0.8). In conclusion, nPSV and nNAVA similarly inhibit gastroesophageal refluxes in healthy newborn lambs at pressures that do not lead to gastric distension. In addition, the occurrence of esophageal insufflations is not significantly different between nPSV and nNAVA. The strong inhibitory effect of nIPPV on gastroesophageal refluxes appears identical to that reported with nasal continuous positive airway pressure.

Inhibitory Effect of Nasal Intermittent Positive Pressure Ventilation on Gastroesophageal Reflux

Non-invasive intermittent positive pressure ventilation can lead to esophageal insufflations and in turn to gastric distension. The fact that the latter induces transient relaxation of the lower esophageal sphincter implies that it may increase gastroesophageal refluxes. We previously reported that nasal Pressure Support Ventilation (nPSV), contrary to nasal Neurally-Adjusted Ventilatory Assist (nNAVA), triggers active inspiratory laryngeal closure. This suggests that esophageal insufflations are more frequent in nPSV than in nNAVA. The objectives of the present study were to test the hypotheses that: i) gastroesophageal refluxes are increased during nPSV compared to both control condition and nNAVA; ii) esophageal insufflations occur more frequently during nPSV than nNAVA. Polysomnographic recordings and esophageal multichannel intraluminal impedance pHmetry were performed in nine chronically instrumented newborn lambs to study gastroesophageal refluxes, esophageal insufflations, states of alertness, laryngeal closure and respiration. Recordings were repeated without sedation in control condition, nPSV (15/4 cmH2O) and nNAVA (~ 15/4 cmH2O). The number of gastroesophageal refluxes recorded over six hours, expressed as median (interquartile range), decreased during both nPSV (1 (0, 3)) and nNAVA [1 (0, 3)] compared to control condition (5 (3, 10)), (p < 0.05). Meanwhile, the esophageal insufflation index did not differ between nPSV (40 (11, 61) h-1) and nNAVA (10 (9, 56) h-1) (p = 0.8). In conclusion, nPSV and nNAVA similarly inhibit gastroesophageal refluxes in healthy newborn lambs at pressures that do not lead to gastric distension. In addition, the occurrence of esophageal insufflations is not significantly different between nPSV and nNAVA. The strong inhibitory effect of nIPPV on gastroesophageal refluxes appears identical to that reported with nasal continuous positive airway pressure.