Association of ROX Index with Mechanical Ventilator Use in Sepsis Patients in the Emergency Department

Detecting sepsis patients who are at a high-risk of mechanical ventilation is important in emergency departments (ED). The respiratory rate oxygenation (ROX) index is the ratio of tissue oxygen saturation/fraction of inspired oxygen to the respiratory rate. This study aimed to investigate whether the ROX index could predict mechanical ventilator use in sepsis patients in an ED. This retrospective observational study included quick sequential organ failure assessment (qSOFA) ≥ 2 sepsis patients that presented to the ED between September 2019 and April 2020. The ROX and ROX-heart rate (HR) indices were significantly lower in patients with mechanical ventilator use within 24 h than in those without the use of a mechanical ventilator (4.0 [3.2–5.4] vs. 10.0 [5.9–15.2], p < 0.001 and 3.9 [2.7–5.8] vs. 10.1 [5.4–16.3], p < 0.001, respectively). The area under the receiver operating characteristic (ROC) curve of the ROX and ROX-HR indices were 0.854 and 0.816 (both p < 0.001). The ROX and ROX-HR indices were independently associated with mechanical ventilator use within 24 h (adjusted hazard ratio = 0.78, 95% CI: 0.68–0.90, p < 0.001 and adjusted hazard ratio = 0.87, 95% CI 0.79–0.96, p = 0.004, respectively). The 28-day mortality was higher in the low ROX and low ROX-HR groups. The ROX and ROX-HR indices were associated with mechanical ventilator use within 24 h in qSOFA ≥ 2 patients in the ED.

Evidence-Based Mechanical Ventilatory Strategies in ARDS

Acute respiratory distress syndrome (ARDS) remains one of the leading causes of morbidity and mortality in critically ill patients despite advancements in the field. Mechanical ventilatory strategies are a vital component of ARDS management to prevent secondary lung injury and improve patient outcomes. Multiple strategies including utilization of low tidal volumes, targeting low plateau pressures to minimize barotrauma, using low FiO2 (fraction of inspired oxygen) to prevent injury related to oxygen free radicals, optimization of positive end expiratory pressure (PEEP) to maintain or improve lung recruitment, and utilization of prone ventilation have been shown to decrease morbidity and mortality. The role of other mechanical ventilatory strategies like non-invasive ventilation, recruitment maneuvers, esophageal pressure monitoring, determination of optimal PEEP, and appropriate patient selection for extracorporeal support is not clear. In this article, we review evidence-based mechanical ventilatory strategies and ventilatory adjuncts for ARDS.

Geo–economic variations in epidemiology, ventilation management and outcome of patients receiving intraoperative ventilation during general anesthesia– posthoc analysis of an observational study in 29 countries

Background The aim of this analysis is to determine geo–economic variations in epidemiology, ventilator settings and outcome in patients receiving general anesthesia for surgery. Methods Posthoc analysis of a worldwide study in 29 countries. Lower and upper middle–income countries (LMIC and UMIC), and high–income countries (HIC) were compared. The coprimary endpoint was the risk for and incidence of postoperative pulmonary complications (PPC); secondary endpoints were intraoperative ventilator settings, intraoperative complications, hospital stay and mortality. Results Of 9864 patients, 4% originated from LMIC, 11% from UMIC and 85% from HIC. The ARISCAT score was 17.5 [15.0–26.0] in LMIC, 16.0 [3.0–27.0] in UMIC and 15.0 [3.0–26.0] in HIC (P = .003). The incidence of PPC was 9.0% in LMIC, 3.2% in UMIC and 2.5% in HIC (P < .001). Median tidal volume in ml kg− 1 predicted bodyweight (PBW) was 8.6 [7.7–9.7] in LMIC, 8.4 [7.6–9.5] in UMIC and 8.1 [7.2–9.1] in HIC (P < .001). Median positive end–expiratory pressure in cmH2O was 3.3 [2.0–5.0]) in LMIC, 4.0 [3.0–5.0] in UMIC and 5.0 [3.0–5.0] in HIC (P < .001). Median driving pressure in cmH2O was 14.0 [11.5–18.0] in LMIC, 13.5 [11.0–16.0] in UMIC and 12.0 [10.0–15.0] in HIC (P < .001). Median fraction of inspired oxygen in % was 75 [50–80] in LMIC, 50 [50–63] in UMIC and 53 [45–70] in HIC (P < .001). Intraoperative complications occurred in 25.9% in LMIC, in 18.7% in UMIC and in 37.1% in HIC (P < .001). Hospital mortality was 0.0% in LMIC, 1.3% in UMIC and 0.6% in HIC (P = .009). Conclusion The risk for and incidence of PPC is higher in LMIC than in UMIC and HIC. Ventilation management could be improved in LMIC and UMIC. Trial registration Clinicaltrials.gov, identifier: NCT01601223.

Efficacy and safety of endotracheal instillation of iloprost for persistent pulmonary hypertension of the newborn

Objective: To determine the efficacy and safety of endotracheal instillation of iloprost as a rescue therapy for persistent pulmonary hypertension of the newborn. Methods: Neonates diagnosed with persistent pulmonary hypertension who were unresponsive to standard treatment protocol applied for persistent pulmonary hypertension in our unit, and who were being followed up with mechanical ventilation, were included in the study. Iloprost was instilled endotracheally as a rescue treatment. Systolic pulmonary artery pressure, oxygen saturation index, mean airway pressure, fraction of inspired oxygen, preductal and postductal venous oxygen saturation, heart rate, and blood pressure were recorded before and after 30 minutes of endotracheal iloprost instillation. Adverse events after endotracheal iloprost were recorded. Results: Twenty neonates were included. The median gestational age and birth weight were found to be 37 (30.5-38) weeks and 2975 (2125-3437.5) grams, respectively. When compared to the period before endotracheal iloprost instillation, systolic pulmonary artery pressure, oxygen saturation index, mean airway pressure, and fraction of inspired oxygen values significantly decreased (p < 0.001, p < 0.001, p = 0.021, p = 0.001, respectively), whereas preductal and postductal oxygen saturation values significantly increased 30 minutes after the endotracheal iloprost instillation (p = 0.002, p < 0.001, respectively). There were no significant differences in heart rate and blood pressure values before and after the iloprost administration. No adverse events were observed. Conclusion: Endotracheal instillation of iloprost was found to be an effective and safe therapy for persistent pulmonary hypertension unresponsive to conventional treatment.

Acupuncture Effects on Cerebral Blood Flow during Normoxia and Normobaric Hypoxia: Results from a Prospective Crossover Pilot Study

Cerebral blood flow (CBF) is significantly influenced by exposure to hypoxia, both hypobaric and normobaric. Alterations in cerebral blood flow can play a crucial role in the pathogenesis of acute mountain sickness (AMS) and its symptoms, especially headache, dizziness, and nausea. Acupuncture has been proven to be effective in treating some cerebrovascular disorders and PC6 Nei Guan stimulation seems to enhance cerebral blood flow. Therefore, we have hypothesized that PC6 Nei Guan stimulation could affect CBF in acute hypoxia and could be used to contrast AMS symptoms. We evaluated blood flow in the middle cerebral artery (MCA) in normoxia, after 15 min in normobaric hypoxia (fraction of inspired oxygen (FiO2) 14%, corresponding to 3600 m a.s.l.) in basal conditions, and after PC6 Nei Guan stimulation, both by needle and by pressure. No comparisons with other acupuncture points and sham acupuncture were done. PC6 stimulation seemed to counteract the effects of acute normobaric hypoxia on end-diastolic velocity (EDV) in MCA, especially after acupuncture, and significantly reduced systolic and diastolic blood pressure. A rebalance of CBF could control some AMS symptoms, but further studies are necessary.

Causes and Treatment of Hypoxia during Total Hip Arthroplasty in Elderly Patients: A Case Report

Intraoperative hypoxia occurs in approximately 6.8% of surgeries and requires appropriate management to avoid poor outcomes, such as increased mortality or extended hospitalization. Hypoxia can be caused by a variety of factors, including laryngospasm, inhalational anesthetics, and surgery for abdominal pathology or hip fractures. In particular, elderly patients are more vulnerable to hypoxia due to their existing lung diseases or respiratory muscle weakness. This study presents the cases of two elderly patients who developed hypoxia during total hip arthroplasty under general anesthesia. Positive end expiratory pressure, the recruitment maneuver, and increased fraction of inspired oxygen improved hypoxia only temporarily, and patients’ oxygen saturation level again dropped to 79–80%. We suspected that hypoxia was caused by atelectasis and, therefore, resumed spontaneous respiration. Thereafter, both the patients showed an improvement in hypoxia. Intraoperative hypoxia that is suspected to be caused by atelectasis can be improved by securing sufficient lung volume for respiration through increased muscle tone with spontaneous respiration.

OP339 Virtual COVID Ward: The Use Of Telehealth In The Emergency Response To COVID-19

IntroductionWith unprecedented times, comes accelerated change. Hospitals in our region have begun to facilitate safe discharge for COVID-19 patients in the form of “The virtual COVID ward”. This has enabled patients to be monitored safely in the community using pulse oximetry, Florence (a telehealth mobile app) and remote consultations. Our objective is to expand upon this model by providing home oxygen therapy for these patients facilitated by telemedicine.MethodsPatients were discharged with an oxygen concentrator if they had an oxygen requirement equal to or less than four litres/minute. Fraction of inspired oxygen needed to be stable and an early warning score of less than four was also required. Once admitted, the Florence app and daily remote consultations were crucial to closely monitor the patient's clinical status. The patient was instructed to enter oxygen saturations and heart rate into the app four times daily. The app would then alert our team if any patients observations deteriorate, triggering immediate assessment.ResultsWe have discharged ninety patients to the virtual ward, fifty-six of these with home oxygen. The average age was fifty-seven and the Clinical Frailty Score ranged between one and six. At present, ten patients have been re-admitted, four with increasing oxygen requirements, and six with unrelated symptoms. Two patients had oxygen concentrators installed at home after we were alerted to their desaturation by the Florence App. The re-admission rate is eleven percent, which mirrors that of other virtual wards (who do not provide home oxygen). In total, the ward has saved the trust 627 hospital inpatient ‘days’. Patients report increased satisfaction at playing a meaningful role in monitoring their own healthcare using the app.ConclusionsOur novel model of supported discharge with oxygen therapy using telehealth demonstrates that it is possible to manage such patients, safely, in the community. Other trusts could utilise this model to reduce inpatient bed occupancy. Looking to the future, could telehealth be utilised further to facilitate other “Virtual wards” in the community?

High-flow nasal cannula for respiratory failure in adult patients

The high-flow nasal cannula (HFNC) has been recently used in several clinical settings for oxygenation in adults. In particular, the advantages of HFNC compared with low-flow oxygen systems or non-invasive ventilation include enhanced comfort, increased humidification of secretions to facilitate expectoration, washout of nasopharyngeal dead space to improve the efficiency of ventilation, provision of a small positive end-inspiratory pressure effect, and fixed and rapid delivery of an accurate fraction of inspired oxygen (FiO2) by minimizing the entrainment of room air. HFNC has been successfully used in critically ill patients with several conditions, such as hypoxemic respiratory failure, hypercapneic respiratory failure (exacerbation of chronic obstructive lung disease), post-extubation respiratory failure, pre-intubation oxygenation, and others. However, the indications are not absolute, and much of the proven benefit remains subjective and physiologic. This review discusses the practical application and clinical uses of HFNC in adults, including its unique respiratory physiologic effects, device settings, and clinical indications.

Randomised crossover trial comparing algorithms and averaging times for automatic oxygen control in preterm infants

ObjectiveAutomatic control (SPOC) of the fraction of inspired oxygen (FiO2), based on continuous analysis of pulse oximeter saturation (SpO2), improves the proportion of time preterm infants spend within a specified SpO2-target range (Target%). We evaluated if a revised SPOC algorithm (SPOCnew, including an upper limit for FiO2) compared to both routine manual control (RMC) and the previously tested algorithm (SPOCold, unrestricted maximum FiO2) increases Target%, and evaluated the effect of the pulse oximeter’s averaging time on controlling the SpO2 signal during SPOC periods.DesignUnblinded, randomised controlled crossover study comparing 2 SPOC algorithms and 2 SpO2 averaging times in random order: 12 hours SPOCnew and 12 hours SPOCold (averaging time 2 s or 8 s for 6 hours each) were compared with 6-hour RMC. A generated list of random numbers was used for allocation sequence.SettingUniversity-affiliated tertiary neonatal intensive care unit, GermanyPatientsTwenty-four infants on non-invasive respiratory support with FiO2 >0.21 were analysed (median gestational age at birth, birth weight and age at randomisation were 25.3 weeks, 585 g and 30 days).Main outcome measureTarget%.ResultsMean (SD) [95% CI] Target% was 56% (9) [52, 59] for RMC versus 69% (9) [65, 72] for SPOCold_2s, 70% (7) [67, 73] for SPOCnew_2s, 71% (8) [68, 74] for SPOCold_8s and 72% (8) [69, 75] for SPOCnew_8s.ConclusionsIrrespective of SpO2-averaging time, Target% was higher with both SPOC algorithms compared to RMC. Despite limiting the maximum FiO2, SPOCnew remained significantly better at maintaining SpO2 within target range compared to RMC.Trial registrationNCT03785899

Krebs von den Lungen 6 levels in COVID-19 ICU Patients are Associated with Mortality

Rationale Krebs von den Lungen 6 (KL-6) is a high molecular weight mucin-like glycoprotein produced by type II pneumocytes and bronchial epithelial cells. Elevated circulating levels of KL-6 may denote disorder of the alveolar epithelial lining. Objective Aim of this study was to verify if KL-6 values may help to risk stratify and triage severe COVID-19 patients. Methods We performed a retrospective prognostic study on 110 COVID-19 ICU patients, evaluating the predictive role of KL-6 for mortality. Measurements and Main Results The study sample was divided in two groups related according to the median KL-6 value [Group A (KL-6 lower than the log-transformed median (6.73)) and Group B (KL-6 higher than the log-transformed median)]. In both linear and logistic multivariate analyses, ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (P/F) was significantly and inversely related to KL-6. Death rate was higher in group B than in group A (80.3 versus 45.9%) (p<0.001), Accordingly, the Cox regression analysis showed a significant prognostic role of KL-6 on mortality in the whole sample as well as in the subgroup with SOFA lower than its median value. Conclusions At ICU admission, KL-6 serum level was significantly lower in the survivors group. Our findings shown that, in severe COVID19 patients, elevated KL-6 was strongly associated with mortality in ICU.