Regional Anesthesia for Abdominal Surgery in a Patient with Severe Chronic Respiratory Failure: A Case Report

General anesthesia is associated with a risk for postoperative pulmonary complications. The risk is even higher in patients with chronic respiratory failure, and postoperative mortality rates are high. Proper perioperative anesthetic management is important in such patients. Therefore, it is essential to optimize the patient’s physical status before anesthesia and to determine the optimal anesthesia technique based on the pre-anesthesia evaluation of the patient’s pulmonary function. We successfully performed abdominal surgery under spinal anesthesia in a patient with severe chronic respiratory failure.

Impact of HACOR Score on Noninvasive Ventilation Failure in Non-COPD Patients with Acute-on-Chronic Respiratory Failure

Background. A rating scale that takes into account heart rate, acidosis, consciousness, oxygenation, and respiratory rate (the HACOR score) has been used to predict noninvasive ventilation (NIV) failure in patients with chronic obstructive pulmonary disease (COPD). However, the HACOR score has not been used to predict NIV failure in non-COPD patients with acute-on-chronic respiratory failure. Methods. This study was performed in the respiratory intensive care unit of a teaching hospital. Data had been collected prospectively between June 2011 and January 2019. We enrolled non-COPD patients who received NIV due to acute-on-chronic respiratory failure, pH < 7.35, and PaCO2 >45 mmHg. NIV failure was defined as requiring intubation or dying during NIV. The HACOR score was determined at initiation and after 1-2, 12, and 24 h of NIV. Scores can range from 0 to 27, with higher scores indicating a higher risk of NIV failure. Results. A total of 148 patients were enrolled in the study, 52 with sleep apnea-hypopnea syndrome, 34 with chronic thoracic sequelae, 31 with bronchiectasis, 14 with chest wall deformity, 5 with obesity-hypoventilation syndrome, and 12 with other conditions. Of the patients, 19 (13%) experienced NIV failure. From initiation to 24 h of NIV, the HACOR scores of patients who experienced NIV failure were much higher than those of patients who received successful NIV. The area under the receiver operating characteristic curve was 0.69, 0.91, 0.91, and 0.94 when the HACOR score was tested at initiation and after 1-2, 12, and 24 h of NIV, respectively. To obtain the best sensitivity and specificity, the cutoff value at initiation was 7 with a sensitivity of 68% and a specificity of 61%. After 1-2 h of NIV, it was 5 with a sensitivity of 90% and a specificity of 85%. After 12 h of NIV, it was 4 with a sensitivity of 82% and a specificity of 91%. After 24 h of NIV, it was 2 with a sensitivity of 100% and a specificity of 76%. Conclusions. The HACOR score has high sensitivity and specificity for predicting NIV failure among non-COPD patients who receive NIV due to acute-on-chronic respiratory failure with respiratory acidosis.

Role of esophageal manometry in polysomnography of patients with chronic respiratory failure

Esophageal pressure (Pes) monitoring is performed during polysomnography (PSG) with a thin, water-filled catheter connected to a transducer. The resulting quantitative assessment of respiratory effort can aid in the accurate diagnosis of sleep-related breathing disorders. This was a prospective observational study using Pes in PSG for thirty patients with chronic respiratory failure (CRF) conducted in the Department of Pulmonary, Critical Care and Sleep Medicine at a tertiary care center of North India. Sleep Scoring was done by conventional method and using esophageal manometry and compared- Polysomnography normal without esophageal manometry recording (PSGN) and polysomnography with esophageal manometry scoring (PSGE). AHI index was similar in both groups. However, RERAs were diagnosed easily using Pes resulting in significant increase in RDI and even reclassification in terms of severity of sleep apnea. Besides, Pes was also useful to distinguish obstructive from central hypopnea which cannot be distinguished by routine PSG which can help guide therapy particularly in chronic respiratory failure patients with hypoventilation. Such patients with hypoventilation often require bilevel positive airway pressure as ventilatory support. Central hypopneas and apneas with hypercapnia may require a higher-pressure support, a backup rate or even advanced volume assured modes of ventilation. Thus, it can be concluded that Pes in PSG remains a safe and generally well-tolerated procedure. Use of Pes aids to detect RERA and thereby respiratory disturbance index (RDI); a better marker of Sleep related breathing disorder rather than AHI. It also helps in differentiate between obstructive and central hypopnea.

PH, CRP as Prognostic Indicators for the Success of Treatment with Non-invasive Ventilation in Patients with Chronic Respiratory Failure Type II

Background: Non-invasive mechanical ventilation (NIMV) provides an alternative option to the initiation of invasive mechanical ventilation in patients with acute respiratory failure, avoiding the associated adverse events. Objective: the present study aimed to assess the outcome of the patients who were initially treated with NIMV and identify the prognostic predictive value of PH and CRP for NIMV failure. Materials and methods: This was observational analytical study conducted in the Department of Pulmonology in Tishreen University Hospital –Lattakia- Syria from January 2019 to January 2020. Adult patients with the diagnosis of acute on chronic respiratory failure type 2 were enrolled in the study. Results: A total of 67 patients with acute on chronic respiratory failure type 2 were included in the study. The median age was 63 years and 62.7% were male. The patients in the PH group (7.20-7.25) presented higher rates of mortality and admission to intensive care unit (ICU) which represented 25% and 50% respectively. The NIMV failure rate was 22.4%. Frequency of patients with PH≤ 7.31, ΔPH ≤ 0.04, or CRP ≥53.5 were higher in NIMV failure group; (33.3% vs. 3.8%, p: 0.001), (46.7% vs. 23.1% -, p: 0.03), and (53.3% vs. 32.7%, p: 0.04) respectively. Independent predictors for NIMV failure were: PH≤ 7.31(OR 3.3[0.6-7.8], p:0.01) and ΔPH ≤ 0.04(OR 2.1[1.1-3.9], p: 0.02). Conclusion: NIMV is an effective treatment for hypercapnic respiratory failure. Identification independent predictors for NIMV failure may be useful to avoid the possible complications.