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High Flow Nasal Cannula therapy (HFNC) is a form of respiratory support for bronchiolitis. Recent evidence confirms HFNC reduces the risk of treatment escalation by nearly half (45%) compared to standard oxygen therapy (SOT), although most patients (75%) with mild-moderate respiratory distress manage well on SOT. The majority of children (60%) failing SOT respond well to HFNC making rescue use of HFNC a more cost-effective approach compared to its first-line use. HFNC is compared to CPAP in the setting of moderate to severe bronchiolitis. Patients on HFNC have a slightly elevated risk of treatment failure especially in severe bronchiolitis, but this does not translate to a significant difference in patient or healthcare centred outcomes. HFNC has improved tolerance, a lower complication rate and is more easily available in peripheral hospitals. It is therefore the preferred first line option followed by rescue CPAP. HFNC is clinically effective and safe to use in bronchiolitis of all severities. [ABSTRACT FROM AUTHOR]

In patients undergoing invasive thoracic procedures, what are the effects of prophylactic non-invasive positive pressure ventilation (NIV)? Systematic review with meta-analysis of randomised trials. Methodological quality was assessed using the PEDro scale and the certainty of evidence with the GRADE approach. Patients undergoing invasive thoracic procedures. Continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP). Length of hospital stay, postoperative pulmonary complications, need for tracheal intubation, mortality, hypoxaemia, pulmonary function and adverse events. Meta-analysis was performed for all outcomes. Subgroup analyses estimated the effects of CPAP and BIPAP independently. Sixteen trials with 1,814 participants were included. The average quality of the included studies was fair. Moderate certainty evidence indicated that NIV reduces postoperative pulmonary complications (RD –0.09, 95% CI –0.15 to –0.04) without increasing the rate of adverse events (RD 0.01, 95% CI –0.02 to 0.04). Low certainty evidence indicated that NIV reduces length of hospital stay (MD –1.4 days, 95% CI –2.2 to –0.5) compared with usual care. The effects on intubation and mortality rates were very close to no effect, indicating that NIV is safe. Subgroup analyses showed that the evidence for CPAP had more precise estimates that that for BiPAP. NIV reduces postoperative pulmonary complications and length of stay after invasive chest procedures without increasing the risk of adverse events. PROSPERO CRD42015019004. [ABSTRACT FROM AUTHOR]

The use of high-flow nasal cannula (HFNC) oxygen therapy is gaining popularity for the treatment of acute respiratory failure (ARF). However, limited evidence exists regarding the effectiveness of HFNC for hypoxemic ARF in patients with blunt chest trauma (BCT). This retrospective analysis focused on BCT patients with mild-moderate hypoxemic ARF who were treated with either HFNC or non-invasive ventilation (NIV) in the emergency medicine department from January 2021 to December 2022. The primary endpoint was treatment failure, defined as either invasive ventilation, or a switch to the other study treatment (NIV for patients in the NFNC group, and vice-versa). A total of 157 patients with BCT (72 in the HFNC group and 85 in the NIV group) were included in this study. The treatment failure rate in the HFNC group was 11.1% and 16.5% in the NIV group - risk difference of 5.36% (95% CI, −5.94–16.10%; P = 0.366). The most common cause of failure in the HFNC group was aggravation of respiratory distress. While in the NIV group, the most common reason for failure was treatment intolerance. Treatment intolerance in the HFNC group was significantly lower than that in the NIV group (1.4% vs 9.4%, 95% CI 0.40–16.18; P = 0.039). Univariate logistic regression analysis showed that chronic respiratory disease, abbreviated injury scale score (chest) (≥3), Acute Physiology and Chronic Health Evaluation II score (≥15), partial arterial oxygen tension /fraction of inspired oxygen (≤200) at 1 h of treatment and respiratory rate (≥32 /min) at 1 h of treatment were risk factors associated with HFNC failure. In BCT patients with mild-moderate hypoxemic ARF, the usage of HFNC did not lead to higher rate of treatment failure when compared to NIV. HFNC was found to offer better comfort and tolerance than NIV, suggesting it may be a promising new respiratory support therapy for BCT patients with mild-moderate ARF. [ABSTRACT FROM AUTHOR]

• Infants with BPD receiving higher levels of respiratory support on discharge from hospital is associated with poorer NDI. • Understanding the relative risks of NDI may facilitate better-informed counselling of parents regarding outcomes at age 3 years. • Subclassifying BPD infants based on levels of respiratory support received at home is a pragmatic way to predict outcome. The reader will come to appreciate that: • The likelihood of infants with BPD developing poorer childhood neurodevelopmental outcomes is associated with the level of respiratory support provided on discharge from hospital. • Understanding the relative risks of neurodevelopmental impairment may facilitate better-informed counselling of parents regarding clinical outcomes at age 3 years. To investigate the neurodevelopmental outcomes for preterm infants born < 29 weeks gestation with/without bronchopulmonary dysplasia (BPD). Preterm infants < 29 weeks' gestation born 2007–2018 in New South Wales and the Australian Capital Territory, Australia, were included. Infants who died < 36 weeks' postmenstrual age and those with major congenital anomalies were excluded. Subjects were assessed at 18–42 months corrected age using the Bayley Scales of Infant Development, 3rd edition. 1436 infants without BPD (non-BPD) and 1189 infants with BPD were followed. The BPD group, 69 % infants were discharged without respiratory support (BPD1), 29 % on oxygen (BPD2) and 2 % on pressure support/tracheostomy (BPD3). Moderate neurodevelopmental impairment (NDI) was evident in 5.7 % of non-BPD infants, 11 % BPD1, 15 % BPD2, 15 % BPD3 infants. Severe NDI was seen in 1.7 % non-BPD infants, 3.4 % BPD1, 7.3 % BPD2, 35 % BPD3 infants. After adjusting for confounders, infants with BPD2 (OR 2.24, 99.9 % CI 1.25 to 5.77) or BPD3 (OR 5.99, 99.9 % CI 1.27 to 46.77) were more likely to have moderate-severe NDI compared to non-BPD infants. The majority of infants with BPD were discharged home without respiratory support and had better neurocognitive outcomes in early childhood compared to those that required home-based oxygen or respiratory support. [ABSTRACT FROM AUTHOR]

The anatomically complex craniofacial skeleton demands special consideration when caring for cases of polytrauma or medically compromised patients with craniofacial fractures. This paper utilises a systematic review and multidisciplinary opinions to create an algorithm for the hospital-based care of patients with craniofacial fractures (base of skull, orbit, paranasal sinus, and mandible) who require non-invasive ventilation (NIV). Each fracture location has a unique predisposition to a different type of emphysema and associated morbidity. The risk of developing emphysema, combined with its potential severity, is stratified against the harm of not providing NIV for the holistic care of the patient. The aim of this paper is to synthesise evidence from a systematic review of existing literature with multidisciplinary opinions to develop a concise algorithm that outlines the optimal treatment of patients with craniofacial fractures who require NIV. [ABSTRACT FROM AUTHOR]

Acute cardiogenic pulmonary oedema (ACPO) is a common indication for non-invasive ventilation (NIV) in the emergency department (ED). HACOR score of >5 is used to predict NIV failure. The predictive ability of HACOR may be affected by altered physiological parameters in ACPO patients due to medications or comorbidities. To validate the HACOR scale in predicting NIV failure among acute cardiogenic pulmonary oedema (ACPO) patients. This is a prospective, observational study of consecutive ACPO patients requiring NIV admitted to the ED. Primary outcome was the ability of the HACOR score to predict NIV failure. Clinical, physiological, and HACOR score at baseline and at 1 h, 12 h and 24 h were analysed. Other potential predictors were assessed as secondary outcomes. A total of 221 patients were included in the analysis. Fifty-four (24.4%) had NIV failure. Optimal HACOR score was >5 at 1 h after NIV initiation in predicting NIV failure (AUC 0.73, sensitivity 53.7%, specificity 83.2%). As part of the HACOR score, respiratory rate and heart rate were not found to be significant predictors. Other significant predictors of NIV failure in ACPO patients were acute coronary syndrome, acute kidney injury, presence of congestive heart failure as a comorbid, and the ROX index. The HACOR scale measured at 1 h after NIV initiation predicts NIV failure among ACPO patients with acceptable accuracy. The cut-off level > 5 could be a useful clinical decision support tool in ACPO patient. However, clinicians should consider other factors such as the acute coronary and acute kidney diagnosis at presentation, presence of underlying congestive heart failure and the ROX index when clinically deciding on timely invasive mechanical ventilation. [ABSTRACT FROM AUTHOR]

The objective of this study was to report outcomes of early cleft palate repair in infants born with Robin sequence (RS). A retrospective case series in a tertiary referral paediatric hospital was carried out, examining a consecutive series of 69 infants born with RS and cleft palate. A minimally invasive approach was taken to upper airway obstruction, with liberal nasopharyngeal airway (NPA) and non-invasive ventilation (NIV) use, guided by sleep studies. The palate was repaired between 6 and 9 months with a modified Malek technique. The most frequently used airway adjunct (59.4% of patients) was an NPA and the median duration of use was 5.6 months. All patients underwent a modified Malek cleft palate repair at a median of 7 months of age. Overnight oximetry demonstrated higher mean oxygen saturation (SpO 2) across the group from initial neonatal admission to discharge (median 96.5% (interquartile range [IQR] 95–98%) vs 97.45% (IQR 96.5–98%) (P = 0.2, N = 34). Of those with a cardiorespiratory polysomnogram, the obstructive apnoea-hypopnea index (OAHI) was significantly lower postoperatively (5.9 vs 2.8, P = 0.028). This study supports the use of non-surgical airway strategies and early cleft palate repair in infants born with RS and cleft palate. [ABSTRACT FROM AUTHOR]

• Respiratory function is relatively frequently impaired in adult SMA patients. • Respiratory dysfunction correlates with worse motor function and disease severity. • Respiratory function appears to stabilize in adulthood, except for walking patients. • Disease duration and age do not correlate with respiratory dysfunction. Due to poor data in literature, we aimed to investigate the respiratory function in a large cohort of naïve Italian adult (≥18 years) SMA patients in a multi-centric cross-sectional study. The following respiratory parameters were considered: forced vital capacity (FVC), forced expiratory volume in one second (FEV1) and need for non-invasive ventilation (NIV). We included 145 treatment-naïve adult patients (SMA2=18, SMA3=125; SMA4=2), 58 females (40 %), with median age at evaluation of 37 years (range 18–72). Fifty-six (37 %) and 41 (31 %) patients had abnormal (<80 %) values of FVC and FEV1, respectively. Fourteen (14 %) patients needed NIV, started at median age of 21 (range 4–68). Motor function, measured by Hammersmith Functional Motor Scale Expanded and Revised Upper Limb Module as well as SMA2, loss of walking ability, surgery for scoliosis, use of NIV, and cough assisting device (CAD) were all significantly associated to lower FVC and FEV1 values, while no association with age at baseline, disease duration, gender or 6 min walking test was observed, except for a correlation between FVC and age in SMA3 walkers (p < 0.05). In conclusion, respiratory function in adult SMA patients is relatively frequently impaired, substantially stable, and significantly correlated with motor function and disease severity. [ABSTRACT FROM AUTHOR]

High flow nasal cannula (HFNC) is used to prevent invasive ventilation in COVID-19-associated hypoxemia. The respiratory rate‑oxygenation (ROX) index has been reported to predict failure of HFNC in patients with COVID-19 pneumonia during the intensive care unit stay when measured in first hours of therapy. However, the clinical course of ICU patients may change substantially in the first days of admission. The objective of this study was to investigate whether ROX index obtained in the first four days of ICU admission could predict the need for invasive respiratory support within the next 24 h of measurements. A retrospective cross-sectional study was performed using a database that included adult patients with COVID-19 pneumonia treated in the ICU. Patients were followed from ICU admission and ROX index was calculated daily on HFNC. Receiver operating characteristics curves (ROCs) were performed. Two hundred forty-nine patients were enrolled, 48% of whom require mechanical ventilation (MV). The area under the ROC of the pooled 4-day values of the ROX index as a predictor of transition from HFNC to MV within 24 h of measurements was 0.86 (95%CI 0.83 to 0.88, P < 0.001) with a cutoff point of 4.06. In COVID-19 patients in high flow nasal cannula, daily ROX index measurements successfully predicted transition to mechanical ventilation within the next 24 h. [ABSTRACT FROM AUTHOR]

The choice of correct interface for the right patient is crucial for the success of non-invasive ventilation (NIV) therapy. Helmet CPAP is a type of interface used to deliver NIV. Helmet CPAP improves oxygenation by keeping the airway open throughout the breathing cycle with positive end-expiratory pressure (PEEP). This narrative review describes the technical aspects and clinical indications of helmet continuous positive airway pressure (CPAP). In addition, we explore the advantages and challenges faced using this device at the Emergency Department (ED). Helmet CPAP is tolerable than other NIV interfaces, provides a good seal and has good airway stability. During Covid-19 pandemic, there are evidences it reduced the risk of aerosolization. The potential clinical benefit of helmet CPAP is demonstrated in acute cardiogenic pulmonary oedema (ACPO), Covid-19 pneumonia, immunocompromised patient, acute chest trauma and palliative patient. Compare to conventional oxygen therapy, helmet CPAP had been shown to reduce intubation rate and decrease mortality. Helmet CPAP is one of the potential NIV interface in patients with acute respiratory failure presenting to the emergency department. It is better tolerated for prolonged usage, reduced intubation rate, improved respiratory parameters, and offers protection against aerosolization in infectious diseases. [ABSTRACT FROM AUTHOR]

Currently, evidence-based guidelines about cleaning positive airway pressure devices for maintenance or reprocessing for a new user do not exist. There is no strong evidence of harm caused by contaminated positive airway pressure equipment. Future research opportunities exist to streamline cleaning processes, assure hygiene, and reduce waste. [ABSTRACT FROM AUTHOR]

• Dyspnea scores are low in myotonic dystrophy type 1 (DM1) patients. • A mMRC score ≥ 2 (dyspnea in daily living) is associated with lower vital capacity. • A mMRC score ≥ 2 is associated with a lower six-minute walking test distance. • A mMRC score ≥ 2 is associated with more severe motor handicap. • The mMRC scale might be an useful tool to assess dyspnea in daily living in DM1. In myotonic mystrophy type 1 (DM1), combining respiratory symptom screening and respiratory function testing, is crucial to identify the appropriate time for ventilatory support initiation. Dyspnea has been little investigated in DM1. To provide a multidimensional description of dyspnea, questionnaires assessing dyspnea were administered to 34 consecutive adult patients with DM1 (median (25th-75th centile) age of 36 (28–49), Vital Capacity (VC) of 74 (64–87)% of predicted value). Dyspnea scores were low whatever the questionnaire used: Multidimensional Dyspnea Profile score of 2(0–4.7)/50 for dyspnea sensory descriptor and of 0 (0–4.7)/60 for the emotional descriptor, Visual Analogue Scale score of 0 (0–0)/10 in sitting and supine position and Borg score after six-minute walk test (6MWT) of 2.2 (1.8–4.2)/10. Eleven patients (32%) reported disabling dyspnea in daily living (modified Medical Research Council (mMRC) score ≥ 2). In comparison with patients with mMRC score < 2, patients with mMRC score ≥ 2 had a more severe motor handicap (Muscular Impairment Rating score of 4.0 (4.0–4.0) vs 3.0 (2.0–3.5), p <0.01), a lower 6MWT distance (373 (260–424) vs 436 (346–499)m, p = 0.03) and a lower VC (64 (48–74)% vs 75 (69–89)%, p = 0.02). These data suggest that the mMRC scale might be an easy-to-use and useful tool to assess dyspnea in daily living in DM1 patients. However, the interest of integrating the mMRC dyspnea scale in clinical practice to guide therapeutic management of DM1 patients remains to be assessed in further studies. [ABSTRACT FROM AUTHOR]

Mechanical ventilation is a crucial supportive intervention that allows time to facilitate investigations and provide definitive treatment in critically unwell patients. This article focuses on the various modes of respiratory support available, and the mechanical ventilation strategies used in specific disease processes. It also highlights the possible complications associated with mechanical ventilation and the adjuncts that can be used to aid oxygenation. [ABSTRACT FROM AUTHOR]

The prevalence of asthma and chronic obstructive pulmonary disease is increasing worldwide. Patients who require intensive care management for acute exacerbations of these conditions represent a particular challenge. The requirement for invasive mechanical ventilation is associated with many pitfalls, as evidenced by the higher mortality rate of patients undergoing this intervention. This article describes the initial management, as well as escalating respiratory support and advanced pharmacological therapies, and the current evidence supporting these. In particular, the concept of dynamic hyperinflation is addressed as well as ventilation strategies that should be employed to prevent the development of complications. [ABSTRACT FROM AUTHOR]

Survival of preterm infants has increased steadily over recent decades, primarily due to improved outcomes for those born before 28 weeks of gestation. However, this has not been matched by similar improvements in longer-term morbidity. One of the key long-term sequelae of preterm birth remains bronchopulmonary dysplasia (also called chronic lung disease of prematurity), contributed primarily by the effect of early pulmonary inflammation superimposed on immature lungs. Non-invasive modes of respiratory support have been rapidly introduced providing modest success in reducing the incidence of bronchopulmonary dysplasia when compared with invasive mechanical ventilation, and improved clinical practice has been reported from population-based studies. We present a comprehensive review of the key modes of non-invasive respiratory support currently used in preterm infants, including their mechanisms of action and evidence of benefit from clinical trials. [ABSTRACT FROM AUTHOR]

Awake prone positioning is studied extensively during Covid-19 pandemic, but there is very limited evidence on its utility in acute hypoxic respiratory failure caused by bacterial infections or other causes. The aim of our research is to evaluate the impact of awake prone positioning on outcomes in non-intubated adult patients with acute non-Covid19 hypoxemic respiratory failure. This is a multi-center randomized controlled trial (RCT) with a parallel-group design and a 1:1 allocation ratio. Adult patients, admitted to ICU and diagnosed with hypoxemic respiratory failure will be randomly allocated into intervention (awake prone position (APP)) or control group. Our hypothesis is that addition of awake prone positioning to standard oxygen, high flow oxygen therapy and non-invasive ventilation may reduce the need for mechanical ventilation in adult patients diagnosed with acute hypoxemic respiratory failure. Primary outcome is rate of endotracheal intubation; secondary outcomes include intensive care and hospital mortality, duration of mechanical ventilation, length of intensive care and hospital stay and health related quality of life post hospital discharge. Primary and secondary outcomes will be assessed at hospital discharge, 30, 90 days and 1 year following randomisation. The Hyper-AP study will assess the superiority of awake prone positioning versus standard treatment in spontaneously breathing ICU patients diagnosed with hypoxaemic respiratory failure. [ABSTRACT FROM AUTHOR]

Noninvasive positive-pressure ventilation (NPPV) emerged as an efficient tool for treatment of COVID-19 pneumonia. The factors influencing NPPV failure still are elusive. The aim of the study was to investigate the relationships between semiquantitative chest computed tomography (CT) scoring and NPPV failure and mortality in patients with COVID-19. Observational study. Nonintensive care setting. A total of 112 patients consecutively admitted for COVID-19 pneumonia. Usual care including various degrees of respiratory support. The semiquantitative CT score was calculated at hospital admission. Subgroups were identified according to the ventilation strategy used (oxygen delivered by Venturi mask n = 53; NPPV-responder n = 38; NPPV-failure n = 21). The study's primary endpoint was the use of NPPV. The secondary endpoints were NPPV failure and in-hospital death, respectively. CT score progressively increased among groups (six v nine v 14, p < 0.05 among all). CT score was an independent predictor of all study endpoints (primary endpoint: 1.25 [95% confidence interval {CI} 1.1-1.4], p = 0.001; NPPV failure: 1.41 [95% CI 1.18-1.69], p < 0.001; in-hospital mortality: 1.21 [95% CI 1.07-1.38], p = 0.003). According to receiver operator characteristics curve analysis, CT score was the most accurate variable for prediction of NPPV failure (area under the curve 0.862 with p < 0.001; p < 0.05 v other variables). The authors reported the common and effective use of NPPV in patients with COVID-19 pneumonia. In the authors' population, a semiquantitative chest CT analysis at hospital admission accurately identified those patients responding poorly to NPPV. [ABSTRACT FROM AUTHOR]

• Respiratory failure in the course of SARS-COV-2 infection is a complex and pathophysiology has not yet fully understood. • In the more severe form of COVID-19, the variable association between viral alveolitis and impaired pulmonary perfusion constitutes main mechanism underlying onset of hypoxemia in most cases. • The immunological derangement triggered by virus-host interactions may promote development of acute neuromuscular diseases, or it can exacerbate already existing conditions, causing weakness of respiratory muscles and alveolar hypoventilation. • Non-invasive monitoring of respiratory muscles is very challenging, but could be essential to diagnose onset of respiratory muscle dysfunction in patients with suspected or pre-existing neuromuscular disorders. Coronavirus disease 2019 (COVID-19), a disease caused by the novel betacoronavirus SARS-COV-2, has become a global pandemic threat. SARS- COV-2 is structurally similar to SARS-COV, and both bind to the angiotensin-converting enzyme 2 (ACE2) receptor to enter human cells. While patients typically present with fever, shortness of breath, sore throat, and cough, in some cases neurologic manifestations occur due to both direct and indirect involvement of the nervous system. Case reports include anosmia, ageusia, central respiratory failure, stroke, acute necrotizing hemorrhagic encephalopathy, toxic-metabolic encephalopathy, headache, myalgia, myelitis, ataxia, and various neuropsychiatric manifestations. Some patients with COVID-19 may present with concurrent acute neuromuscular syndromes such as myasthenic crisis (MC), Guillain–Barré syndrome (GBS) and idiopathic inflammatory myopathies (IIM); these conditions coupled with respiratory failure could trigger a life-threatening condition. Here, we review the current state of knowledge on acute neuromuscular syndromes with respiratory failure related to COVID-19 infection in an attempt to clarify and to manage the muscle dysfunction overlapping SARS-COV-2 infection. [ABSTRACT FROM AUTHOR]

This study was to explore a photoelectric magnifier assessing nasal injury in preterm infants receiving non-invasive ventilation (NIV) treatment, and to describe the occurrence status and risk factors of nasal injuries. A prospective observational study. and setting: Preterm infants admitted from the Second Affiliated Hospital of Wenzhou Medical University between October 2018 and October 2019. A continuously convenient sample of 127 preterm infants was included. When the infants were receiving NIV treatment, nursing staff checked nasal skin and mucosa daily with a photoelectric magnifier to confirm whether nasal injuries occurred. Meanwhile, a self-designed questionnaire was used to collect data. The Chi-square test, t -test, univariate and multiple logistic regression model were applied. A total of 127 preterm infants received 175 times NIV therapy, showing that the incidence of nasal injuries (infants number) was 27.6% (35/127) and the incidence of nasal injuries (ventilation cases) was 21.1% (37/175). Of the 37 cases of nasal injuries, 27 cases were I stage, while Ⅱ stage, Ⅲ stage and mucosa injuries appeared 2 cases, 2 cases and 6 cases. In the multivariate logistic analysis, nasal mask interface and NIV treatment more than seven days were independent risk factors affecting the occurrence of nasal injuries. The premature infants who received nasal NIV treatment were susceptible to nasal injuries, and clinical nurse capable of identifying risk factors and inintervening should be strengthened to prevent the occurrence and progression. • Our study applied a photoelectric magnifier to nasal examination, an innovation in assessment method. • Our study attempted to explore possible factors for nasal injuries in premature infants, thereby forming the basis for early detection and development of care practices to prevent them and/or reduce their severity. [ABSTRACT FROM AUTHOR]

• Survival analysis was conducted for 131 patients with coronavirus disease 2019 (COVID-19) in Somalia. • Interventions to improve outcomes in this low-resource and fragile setting were examined. • Risk factors for deaths included age ≥60 years, cardiovascular disease and use of non-invasive ventilation. • Patients who received oxygen alone were more likely to survive than patients who were ventilated. • Optimizing critical care for patients with COVID-19 in fragile states requires policy discourse. To determine risk factors for death in patients with coronavirus disease 2019 (COVID-19) admitted to the main hospital in Somalia, and identify interventions contributing to improved clinical outcome in a low-resource and fragile setting. A survival analysis was conducted of all patients with COVID-19 admitted to the main hospital in Somalia from 30 March to 12 June 2020. Of the 131 patients admitted to the hospital with COVID-19, 52 (40%) died and 79 (60%) survived. The main factors associated with the risk of in-hospital death were age ≥60 years {survival probability on day 21 was 0.789 [95% confidence interval (CI) 0.658–0.874] in patients aged <60 years vs 0.339 (95% CI 0.205–0.478) in patients aged ≥60 years}, cardiovascular disease [survival probability 0.478 (95% CI 0.332–0.610) in patients with cardiovascular disease vs 0.719 (95% CI 0.601–0.807) in patients without cardiovascular disease] and non-invasive ventilation on admission (patients who were not ventilated but received oxygen were significantly more likely to survive than patients who were ventilated; P <0.001). Considering the risk factors (age ≥60 years, presence of cardiovascular disease and use of non-invasive ventilation) is critical when managing patients with severe COVID-19, especially in low-resource settings where availability of skilled healthcare workers for critical care units is limited. These findings also highlight the importance of use of medical oxygen for severely ill patients, and the critical aspect of deciding whether or not to ventilate critical patients with COVID-19 in order to improve clinical outcome. [ABSTRACT FROM AUTHOR]

• Among 90 patients admitted with myasthenic crisis to Neurological ward in a large University hospital in Modena (Italy) between January 2000 and September 2020 and treated with non-invasive ventilation, only 37.8% required mechanical ventilation (MV). • Males exhibited higher risk of MV than females. • Only 10% of our patients underwent tracheostomy due to weaning failure, which was significantly related to male gender. • Patients who required MV were more often treated with plasma exchanges as first-line therapy. • In patients with MC, the early use of NIV outside ICU setting is feasible, and NIV failure may occur only in a third of cases. About 20% of patients with myasthenia gravis (MG) may develop myasthenic crisis (MC) requiring ventilation, either invasive (MV) or non-invasive (NIV) and intensive unit care (ICU). NIV failure in patients with MC can occur up to 60% of cases admitted to ICU. Moreover it is not known the outcome of MC receiving NIV. Purpose of this study was to identify predictors of outcome in MC who underwent non-invasive ventilator support outside ICU setting. We enrolled 90 patients, 53 females and 37 males admitted to University Hospital of Modena (Italy) between January 2000 and September 2020. Median age at MC was 65 years. Thirty-four patients (37.8%) required MV. Thymectomy was performed in 45 cases, associated with thymoma in 55%, with hyperplastic thymus in 33%. First-line treatment was plasmaexchange (38.8%) or intravenous immunoglobulins (45.6%). Males exhibited higher risk of MV than females.Patients in MV were treated with plasmaexchange as first-line therapy. Our in-hospital mortality rate was low. Nine patients underwent tracheostomy which was significantly related to male gender. Comorbidities had significant effect on length of ICU.Our study confirms as predictors of prognosis in our patients male gender, older age at onset, infections as trigger, pneumonia. [ABSTRACT FROM AUTHOR]

Study Objective: To determine whether non-invasive ventilation (NIV) delivered by helmet continuous positive airway pressure (hCPAP) is non-inferior to facemask continuous positive airway pressure (fCPAP) in patients with acute respiratory failure in the emergency department (ED).Methods: Non-inferiority randomized, clinical trial involving patients presenting with acute respiratory failure conducted in the ED of a local hospital. Participants were randomly allocated to receive either hCPAP or fCPAP as per the trial protocol. The primary endpoint was respiratory rate reduction. Secondary endpoints included discomfort, improvement in Dyspnea and Likert scales, heart rate reduction, arterial blood oxygenation, partial pressure of carbon dioxide (PaCO2), dryness of mucosa and intubation rate.Results: 224 patients were included and randomized (113 patients to hCPAP, 111 to fCPAP). Both techniques reduced respiratory rate (hCPAP: from 33.56 ± 3.07 to 25.43 ± 3.11 bpm and fCPAP: from 33.46 ± 3.35 to 27.01 ± 3.19 bpm), heart rate (hCPAP: from 114.76 ± 15.5 to 96.17 ± 16.50 bpm and fCPAP: from 115.07 ± 14.13 to 101.19 ± 16.92 bpm), and improved dyspnea measured by both the Visual Analogue Scale (hCPAP: from 16.36 ± 12.13 to 83.72 ± 12.91 and fCPAP: from 16.01 ± 11.76 to 76.62 ± 13.91) and the Likert scale. Both CPAP techniques improved arterial oxygenation (PaO2 from 67.72 ± 8.06 mmHg to 166.38 ± 30.17 mmHg in hCPAP and 68.99 ± 7.68 mmHg to 184.49 ± 36.38 mmHg in fCPAP) and the PaO2:FiO2 (Partial pressure of arterial oxygen: Fraction of inspired oxygen) ratio from 113.6 ± 13.4 to 273.4 ± 49.5 in hCPAP and 115.0 ± 12.9 to 307.7 ± 60.9 in fCPAP. The intubation rate was lower with hCPAP (4.4% for hCPAP versus 18% for fCPAP, absolute difference -13.6%, p = 0.003). Discomfort and dryness of mucosa were also lower with hCPAP.Conclusion: In patients presenting to the ED with acute cardiogenic pulmonary edema or decompensated COPD, hCPAP was non-inferior to fCPAP and resulted in greater comfort levels and lower intubation rate. [ABSTRACT FROM AUTHOR]

• NIV is a treatment option for CF patients with type II respiratory failure. • This study examined the impact and outcomes of NIV use in adult CF patients studied over a 9 year period. • NIV use in CF adults with respiratory failure was associated with long term improvements in lung function and BMI and a reduction in carbon dioxide levels. • 25% of patients received lung transplantation and modelling suggests that 50% of patients commenced on NIV will survive for approximately 5 years. Non-invasive ventilation (NIV) is an established treatment option for cystic fibrosis (CF) patients with type 2 respiratory failure but the benefits of this therapy remain unclear. This study examined the long-term outcomes and response to NIV in a large adult CF cohort. All patients attending a UK adult CF Centre receiving NIV as treatment for hypercapnic respiratory failure over a nine-year period were studied prospectively. Detailed clinical data was recorded and longitudinal data measurements were examined for the three years pre and post NIV initiation to assess effect of this intervention. 94 patients, mean age 29.9 (SD 9.7) years, percent predicted FEV 1 21.5 (7.3), received NIV. All patients commenced NIV in a hospital setting. 21 remain alive, 24 received double lung transplant, 49 died without lung transplantation. NIV use was associated with a stabilisation and improvement in both FEV 1 and FVC from NIV set up to three years post follow-up, in addition to an increase in body mass index and attenuation of PCO 2 (all p<0.001). No single parameter was found to predict long-term NIV response but baseline PCO 2 (p=0.005), CRP (p=0.004) and age (p=0.009) were identified as independent predictors of mortality. NIV use in CF adults is associated with improvements in lung function and attenuation of hypercapnia which is maintained for up to three years post NIV initiation. Outcomes for CF patients with severe pulmonary disease commenced on NIV have significantly improved with fifty percent of patients expected to survive for approximately five years. [ABSTRACT FROM AUTHOR]

• Restrictive lung disease due to low lung volumes, chronic immunosuppressive treatment, and obesity are potential risk factors that may contribute to a more severe course COVID-19 disease. • As opposed to adult patients with chronic lung disease and obesity, we did not observe a severe course of disease in young DMD patients. • No significant residual lung disease observed following COVID-19 infection in patients with DMD. Duchenne muscular dystrophy (DMD) is the most common childhood muscular dystrophy. As a result of progressive muscle weakness, pulmonary function decreases during the second decade of life and lung disease contributes significantly to morbidity and mortality in these patients. Corticosteroids are the current standard of care for patients with DMD, despite known adverse effects such as obesity and immunosuppression. Over the past year (2020), the novel coronavirus (COVID-19/SARS-CoV2) outbreak has caused a global pandemic. Restrictive lung disease due to low lung volumes, chronic immunosuppressive treatment with corticosteroids, and obesity are potential risk factors that may contribute to a more severe course of the disease. Out of 116 Duchenne/Becker muscular dystrophy patients treated in our tertiary neuromuscular center, six patients with DMD and one with advanced Becker muscular dystrophy were found to be positive for COVID-19 infection. Two of the DMD patients were admitted for hospitalization, of whom one was dependent on daily nocturnal non-invasive ventilation. All patients recovered without complications despite obesity, steroid treatment and severe restrictive lung disease. [ABSTRACT FROM AUTHOR]

• The "early CPAP" protocol was implemented using intermediate pressures of 6–7 cmH 2 O. • A decrease in intubation rate and days of invasive ventilation were observed. • A reduction of exogenous surfactant use and length of hospital stay were observed. • The protocol used simple and affordable equipment and could be reproduced. The use of continuous positive airway pressure (CPAP) applied early after birth improves several outcomes when compared with intubation and invasive mechanical ventilation. "Early CPAP" protocols vary in relation to the pressure level, type of interface used, and studied sample. This study compared intubation rate, exogenous surfactant use, and hospitalization length (among other variables) prior to and after adopting an "early CPAP" protocol in preterm infants with gestational age between 28 and 32 weeks, using intermediate pressures and short binasal prongs. This was a retrospective study conducted in a public university hospital in Brazil. All preterm infants with gestational age between 28 and 32 weeks were included in the study. The newborns born between January 2011 and December 2012, prior to the protocol being implemented, were considered the historical control group, and those born after implementation, between February 2013 and August 2014 were considered the intervention group. The participants in both groups had similar baseline characteristics (p > 0.05). There were significant reductions in intubation rate (89% versus 73%, p = 0.02), exogenous surfactant use (86% versus 67%, p = 0.02), and median (Q1 - Q3) days of invasive mechanical ventilation [4 (2 - 14) versus 1 (0.15–9), p = 0.01] and length of hospital stay in days [56 (42–77) versus 42 (35–71), p = 0.02]. The findings demonstrate positive outcomes of the early CPAP protocol. This protocol used simple and affordable equipment available in the hospital which could easily be reproduced in other centers, generating better outcomes for preterm infants and reducing hospital expenses. [ABSTRACT FROM AUTHOR]

• The findings may augment knowledge of management strategies for COVID-19. • Developers should follow guideline development standards. • More attention should be paid to the impact of non-invasive ventilation. Guidelines from different regions on the use of non-invasive ventilation in COVID-19 have generally been inconsistent. The aim of this systematic review was to appraise the quality and availability of guidelines, and whether non-invasive ventilation in the early stages of the pandemic is of importance. Databases, including PubMed, Web of Science, and Cochrane Library, as well as websites of international organizations and gray literature, were searched up to June 23, 2020. The reference lists of eligible papers were also hand-searched. A total of 26 guidelines met the inclusion criteria. According to the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, the guidelines' methodological quality was low. Among six domains, Rigour of Development and Editorial Independence were of the lowest quality. Given the lack of evidence from randomized clinical trials and the great variation between different regions, recommendations for non-invasive ventilation have generated considerable debate regarding the early stages of COVID-19. Improving the methodological quality of the guidelines should be a goal with regard to future pandemics. Additionally, better-designed randomized clinical trials are needed to resolve contradictions regarding the impact of non-invasive ventilation. CRD42020198410. [ABSTRACT FROM AUTHOR]

• Evidence is lacking on which is the best respiratory support technique in respiratory failure secondary to Covid-19 pneumonia • Available data indicate that non-invasive CPAP/NIV and HFNC may be effective in up to two thirds of patients • Patient selection and a dedicated environment are key to success • Awake prone-positioning seems a promising tool to optimize non-invasive support • Attention must be paid to the possible dispersion of droplets with these techniques In the last 11 months, the SARS-CoV-2 pandemic has overwhelmed and disrupted the whole world in health, social and economic terms. We are progressively learning more and more about the epidemiological and clinical features that distinguish CoViD-19 from any previous experience in the emergency and critical care setting. Experiences are multiplying with regard to the use of non-invasive respiratory support techniques in the context of acute hypoxemic respiratory failure secondary to CoViD-19-related pneumonia. Doubts still far outweigh certainties, but a growing series of mostly monocentric and retrospective studies are becoming available as concrete decision-making and operational support for healthcare workers. In this review the available studies and experiences about non-invasive respiratory support in the treatment of Covid-19 related respiratory failure, mainly coming from outside the ICU setting, will be discussed. [ABSTRACT FROM AUTHOR]

Home non-invasive ventilation (HNIV) during sleep is a standard treatment for chronic hypercapnic respiratory failure (CHRF). The aim of this study was to evaluate the feasibility of the complex overnight assessment of HNIV in adults performed at home and the efficacy of HNIV after one year of treatment. Stable patients with CHRF on HNIV for more than 12 months had unattended polygraphy (PG) with transcutaneous monitoring of PCO 2 (tcPCO 2) at home during one night. The recording quality was regarded as excellent when 100% and good if 80–99% of the analysis time was registered. The following efficacy criteria were approved: (1) SpO 2 <90% for <10% of analysis time, (2) increase in PtcCO 2 ≤7.5 ​mmHg between baseline and average value at night, (3) apnea-hypopnea index (AHI) ≤5/h. Eighteen patients with CHRF (median age 66 [60–74] years, 10 female) were included. The quality of the PG tracings was good to excellent in 16 (89%) patients and the quality of the tcPCO 2 data was good to excellent in 14 (78%) patients. There was no difference in the quality of tcPCO 2 between patients who lived alone and those who lived with family (100 [50–100]% vs. 100 [90–100]% of analysis time, respectively). Only 4 (22%) patients fulfilled all three efficacy criteria. Home-based monitoring using PG and tcPCO 2 is a feasible and adequate tool to assess the efficacy of HNIV. In most of the patients on HNIV for more than 12 months, the treatment was not effective based on the predefined efficacy criteria. [ABSTRACT FROM AUTHOR]

· This meta-analysis showed that HFNC may not increase the risk of intubation or mortality compared to NIV, HFNC may not exacerbate hypercapnia and acidosis in AECOPD patients with hypercapnia and mild acidosis and patients weaned from invasive ventilation. · Compared to COT, HFNC may also not exacerbate hypercapnia and acidosis, but decrease the respiratory rate and diaphragm movement for patients with hypoxemia and patients with mild hypercapnia. The evidence for the safety of high-flow nasal cannula (HFNC) in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients is conflicting. To evaluate the intubation and mortality risks of HFNC compared to non-invasive ventilation (NIV) and conventional oxygen therapy (COT) for AECOPD patients. A search of electronic databases was performed. Studies that used HFNC to treat AECOPD patients were identified. Seven RCTs and one observational study were included. There were no differences in intubation risk (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.49 to 1.78, p = 0.84, very low certainty) and mortality risk (RR 0.91, 95% CI 0.46 to 1.79, p = 0.77, very low certainty) for HFNC compared with NIV. No data were available for intubation or mortality risk for HFNC compared with COT. For AECOPD patients, low-quality evidence indicates that HFNC does not increase intubation and mortality risks compared to NIV. [ABSTRACT FROM AUTHOR]

The treatment applied for children admitted to the pediatric intensive care unit (PICU) for severe acute bronchiolitis may differ from general recommendations. The first objective of our study was to describe the treatments offered to these children in a Spanish tertiary PICU. The second objective was to analyse the changes in management derived from the publication of the American Academy of Pediatrics (AAP) bronchiolitis guideline in 2014. This was a retrospective–prospective observational study conducted during two epidemic waves (2014–2015 and 2015–2016). The AAP guidelines were distributed and taught to PICU staff between both epidemic waves. A total of 138 children were enrolled (78 male). In the first period, 78 children were enrolled. The median age was 1.8 months (IQR 1.1–3.6). There were no differences between the management in the two periods, except for the use of high-flow oxygen therapy (HFOT); its use increased in the second period. Overall, 83% of patients received non-invasive ventilation or HFOT. Children older than 12 months received HFOT exclusively. In comparison, continuous positive airway pressure and bi-level positive airway pressure were used less during the period 2015–2016 (P = 0.036). Regarding pharmacological therapy, 70% of patients received antibiotics, 23% steroids, 33% salbutamol, 31% adrenaline, and 7% hypertonic saline. The mortality rate was zero. Our PICU did not follow the AAP recommendations. There were no differences between the two periods, except in the use of HFOT. All children older than 12 months received HFOT exclusively. The rate of using invasive mechanical ventilation was also low. [ABSTRACT FROM AUTHOR]

• Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes a wide spectrum of clinical manifestations, including acute respiratory distress syndrome (ARDS). • Continuous positive airway pressure (i.e., non-invasive ventilation) and invasive ventilatory support are often required to manage the acute respiratory failure in patients with coronavirus disease 2019 (COVID-19). • Temperature >38 °C, lactate dehydrogenase >250 U/l, and d -dimer >1000 ng/mL were found to be independent risk factors associated with the requirement for non-invasive/invasive ventilator support. • Early inflammatory screening is warranted in order to stratify the illness severity and provide appropriate treatment. To investigate risk factors for non-invasive/invasive ventilatory support (NI/I-VS) in patients with coronavirus disease 2019 (COVID-19). All consecutive patients admitted to the Infectious Diseases Unit and Intensive Care Unit (ICU) of Santa Maria Annunziata Hospital (Florence, Italy), from February 25 to April 25, 2020, with a confirmed COVID-19 diagnosis were enrolled in this retrospective cohort study. NI/I-VS was defined as the need for continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BPAP) (non-invasive ventilation) or mechanical ventilation, not including low-flow systems of oxygen therapy such as the Venturi mask or nasal cannula. Ninety-seven patients were enrolled; 61.9% (60/97) were male and the median patient age was 64 years. The in-hospital mortality was 9.3%. Thirty-five of the 97 patients (36%) required ICU admission and 94.8% (92/97) were prescribed oxygen therapy: 10.8% (10/92) by nasal cannula, 44.5% (41/92) by Venturi mask, 31.5% (29/92) by CPAP, 2.2% (2/92) by BPAP, and 10.8% (10/92) by mechanical ventilation following intubation. On univariate analysis, patients with a body mass index >30, type II diabetes mellitus, and those presenting with dyspnoea, asthenia, SOFA score ≥2 points, PaO 2 /FiO 2 <300, temperature >38 °C, increased levels of lactate dehydrogenase (LDH), alanine aminotransferase, and C-reactive protein, and a d -dimer >1000 ng/mL at admission more frequently underwent NI/I-VS. Multivariate logistic regression analysis confirmed temperature >38 °C (odds ratio (OR) 21.2, 95% confidential interval (95% CI) 3.5–124.5, p = 0.001), LDH >250 U/l (OR 15.2, 95% CI 1.8–128.8, p = 0.012), and d -dimer >1000 ng/mL (OR 4.5, 95% CI 1.2–17.3, p = 0.027) as significantly associated with the requirement for NI/I-VS. A non-significant trend (p = 0.051) was described for PaO 2 /FiO 2 <300. Temperature >38 °C, LDH > 250 U/l, and d -dimer >1000 ng/mL were found to be independent risk factors for NI/I-VS in COVID-19 patients. In order to quickly identify patients likely at risk of developing a critical illness, inflammatory markers should be assessed upon hospital admission. [ABSTRACT FROM AUTHOR]

Objective: Introducing a new, simple and inexpensive portable equipment for lifeguards, consisting of a pre-assembled full-size plastic blanket with a mask and HEPA filter, which could offer significant time-saving advantages to reduce COVID-19 risk transmission in the first few minutes of CPR after water rescue, avoiding the negative impact of delayed ventilation.Method: A pilot study was carried out to determine the feasibility of the pre-assembled kit of face-mask and HEPA filter adapted on a pre-set plastic-blanket. The first step consisted of washing hands, putting on safety glasses and gloves as the first personal protection equipment (PPE) and then covering the victim with an assembled plastic blanket. The second step consisted of 10 min of cardiopulmonary resuscitation (CPR) with PPE and plastic blanket, following the technical recommendations for ventilation during COVID-19.Results: Ten rescuers took part in the pilot study. The average time to wear PPE and place the pre-assembly kit on the victim was 82 s [IC 58-105]. After 10 min the quality of the resuscitation (QCPR) was 91% [87-94]. Quality chest compressions (CC) were 22% better than ventilations (V). Most of the rescuers (60%) thought that placing the plastic blanket on the victim on the beach was somewhat simple or very simple.Conclusions: Resuscitation techniques in COVID-19 era at the beach have added complexities for the correct use of PPE. Plastic blanket plus basic ventilations equipment resource could be a new alternative to be considered for lifeguards to keep ventilation on use while reducing risk transmission. [ABSTRACT FROM AUTHOR]

Objective: Treatment of severe asthma exacerbation could be challenging, especially in the initial hours of acute attack when systemic corticosteroid is yet to take effect. In spite of using inhaled agents, the role of non-invasive ventilation (NIV), including Bilevel Positive Airway Pressure (BiPAP), had been addressed recently.Methods: We reviewed 5-year experience in our hospital for records of patients who were admitted to pediatric intensive care unit because of severe asthma attack. The included admission records from 2012 to 2017 were grouped according to BiPAP use (Yes/No). Clinical parameters (heart rate (HR), respiratory rate (RR), SpO2 and serum pCO2) at selected time intervals of treatment were collected for both groups and analyzed.Results: We included data of 46 admissions from 33 different patients (24 with BiPAP and 21 without BiPAP.) The BiPAP group had significantly higher initial RR as well as higher severity scores compared with the other group (p < 0.001). The RR improved significantly in the following time intervals in BiPAP group. There was no significant difference in HR between groups in any of the time intervals. The serum pCO2 levels decreased significantly after initiation of ventilation support in the BiPAP group, and SpO2 levels improved significantly for both groups.Conclusion: BiPAP seemed efficient in improving respiratory rate and oxygenation in our study. It does not seem to cause additional irritation regarding that HR was not increased in BiPAP group compared with non-BiPAP group. Overall, BiPAP ventilation is safe and efficient in treating children with severe asthma attack. [ABSTRACT FROM AUTHOR]

• The Respicheck questionnaire looks for symptoms of respiratory involvement in DM1. • The higher the scores on the Respicheck the worst is the respiratory impairment. • A cut-off of 2 discriminates patients with respiratory impairment. • Patients with the higher scores have a higher risk of respiratory involvement. • Patients with scores below 2 have a lower risk of respiratory involvement. Symptoms of respiratory involvement are frequently present but overlooked by patients with Myotonic Dystrophy type 1 (DM1). A respiratory symptom checklist was designed to test whether a DM-specifically designed checklist to detect symptoms of respiratory involvement (The Respicheck Questionnaire) could help patients be more aware of their respiratory problems, if any, and help clinicians in identifying potential candidates for intervention. The Respicheck questionnaire was administered to 58 consecutive adult-onset patients with genetically determined DM1 who did not complain of respiratory involvement per history at enrollment. Based on respiratory function test results patients were divided into 3 groups: A, (n = 17) having no signs of respiratory involvement; B (n = 13), patients having borderline results on respiratory assessments and having no need for respiratory intervention; C, (n = 28) patients having respiratory impairment requiring intervention. Respiratory test results and Respicheck scores were analyzed. Respicheck total score and subscales correlated positively with global respiratory impairment. Respicheck appears to be able to discriminate between patients having a higher level of respiratory dysfunction from those having a lower risk of respiratory involvement. This might allow to better target efforts and resources in respiratory management in DM1. [ABSTRACT FROM AUTHOR]

The recent introduction of different non-invasive ventilation modes for preterm has decreased the need for intubation, invasive ventilation and sedation. However, specific guidelines for each non-invasive mode are still lacking. This paper reviews available evidence for each of the commonly used noninvasive mode. Electronic search was carried out as a step forward towards a more comprehensive and detailed neonatal noninvasive ventilation guideline. [ABSTRACT FROM AUTHOR]

More children with chronic and complex care needs are transitioned to adulthood due to advancements in medical technology including the use of non-invasive ventilation [NIV] at home and innovative medical therapies. Sleep medicine is becoming a common and at times vital component of the management plan. Various challenges are experienced in transitioning sleep patients depending on the underlying condition. These include the direct conflict between the desires of a young person for independence and their declining ability to provide self-care in neuromuscular patients, the behavioural challenges inherent in the management of children with various syndromes and the funding of equipment, care needs and multidisciplinary team input in an already resource limited adult setting. These patients should be transitioned in an early and coordinated approach following core principles of transition. Ongoing advocacy is required to raise awareness of the increased trend for technology supported young people being transitioned. Further research is required to track and assess the transition process in patients with various sleep conditions. [ABSTRACT FROM AUTHOR]

Extracellular fluid retained in the lungs lead to respiratory distress in both late preterm (LP) and term neonates. The relationship between urine parameters toward the diuresis and the duration of ventilation postnatally is unknown. To find the correlation between the diuretic phase with urine parameters in the first 4 days after birth and the duration of non-invasive ventilation (NIV). Serial measurements of urine osmolality (Uosm), urine sodium (U Na), and urine output (U/O) in neonates were collected at 5 time periods (T1:0–12 postnatal hours, T2:12–24 postnatal hours, T3:24–48 postnatal hours, T4:48–72 postnatal hours, T5:72–96 postnatal hours) were recorded. The correlations were analyzed in late preterm and term neonates. Ninety-seven neonates were included. Negative correlation between Uosm and U/O were observed. LP neonates (n=26) and term neonates (n=71) had differences with Uosm at T2, U Na at T4, T5, and U/O at T2, T3. Factors of U/O < 1 ml/kg/hr at T1 (odds ratio (OR) = 20.0; 95% confidence interval (CI) 1.796-222.776; p = 0.015) or Uosm > 273 mOsm/L at T1 (OR = 9.0; 95% CI 1.031-78.574; p = 0.047) in LP neonates and U Na > 26.5 mEq/L at T5 (OR = 23.625; 95% CI 2.683-79.276; p < 0.01) in term neonates were associated with prolonged NIV use (> 120 hours). We speculate the significant correlation between Uosm/U Na and the diuretic phase. The LP neonates acquire earlier diuretic phase than the term neonates. The Uosm/U Na in the first few postnatal days had the correlation with the duration of NIV support. [ABSTRACT FROM AUTHOR]

The selection of the mask interface for non-invasive ventilation (NIV) is recognized to be an essential part for therapy success. While nasal masks are the first recommended option in children and adults, there are indications for other mask types such as intolerance or complications from nasal masks. Evidence comparing performance, adherence and complication risk among mask interfaces in pediatrics is, however, scarce and information is often extrapolated from adult studies. Given this gap in knowledge and the lack of guidelines on NIV initiation in children, mask selection often relies on the clinicians' knowledge and expertise. Careful mask selection, a well-fitting headgear and time investment for mask desensitization are some important recommendations for adequate mask adaptation in children. Frequent mask-related complications include nasal symptoms, unintentional leak, mask displacement, skin injury, and midface hypoplasia. Close monitoring and a pro-active approach may help to minimize complications and promote the optimal use of home NIV. [ABSTRACT FROM AUTHOR]

Non-invasive ventilation (NIV) for respiratory failure and airway clearance is an established intervention in cystic fibrosis (CF), but its therapeutic benefit on lung function and survival remains under-investigated. Using data from the UK CF Registry between 2007 and 2015, we explored the patterns of NIV use, and assessed changes in mean percent predicted FEV 1 (ppFEV 1) prior to and after NIV use, and the survival of patients on NIV. Among 11,079 patients, 1107 had at least one record of NIV treatment. Incidence and prevalence of NIV was lower in children and followed non-linear temporal patterns. Adjusting for other risk factors, ppFEV 1 rose by 0.70 (95%CI: -0.83, 2.24) after first NIV use in children. In adults with a low ppFEV 1 (<40%) at initiation of treatment, NIV increased mean ppFEV 1 by 2.60 (95% CI: 0.93, 4.27). Our analysis showed that NIV initiation is associated with an increased risk of death/transplant in both children (HR = 2.47; 95%CI: 1.20–5.08) and adults (HR = 1.96; 95% CI: 1.63–2.36) but effect was attenuated in children with low ppFEV 1 (<40%). NIV usage in CF improves spirometric values but does not benefit survival. Further studies are required to better understand survival outcomes and ultimately improve NIV outcomes in CF. • Incidence and prevalence of NIV use in children did not follow a linear pattern and was lower than that of adults. • We found an increase in ppFEV 1 by 0.70 after NIV was first introduced in children. • Adults starting with low ppFEV 1 had an increase in mean ppFEV1 following treatment by 2.60 (95% CI: 0.93, 4.27). • Adults and children on NIV had increased risk for death/transplant even when confined to severe cases. • The risk remained in adults after confining analysis to those with a low ppFEV1 (> 40%), and attenuated in children. [ABSTRACT FROM AUTHOR]

• Sleep disorders and sleepiness are common in myotonic dystrophy type I (DM1). • 72% of DM1 patients showed nocturnal hypoventilation on transcutaneous capnometry. • Transcutaneous capnometry was superior to oximetry for detecting hypoventilation. • Noninvasive ventilation therapy had beneficial long-term effects on gas exchange. • Adherence to NIV is highly variable in DM1 patients and treatment benefits should be individually assessed. Patients with myotonic dystrophy type I (DM1) may develop nocturnal hypoventilation, requiring non-invasive ventilation. Data on long-term adherence to non-invasive ventilation, or sleep and ventilation outcomes are scarce. We retrospectively collected baseline polysomnography and capnometry results from 36 adult patients with sleep-related symptoms (42.9 ± 12.5 years, 20 female), plus follow-up sleep study records from those treated with non-invasive ventilation. Sleep-disordered breathing was found in 33 patients (91.7%) including 8 (22.2%) with daytime hypercapnia. Twenty-six patients (72.2%) showed nocturnal hypoventilation on transcutaneous capnometry. The sensitivity of oximetry to detect nocturnal hypoventilation was only 0.38. Twenty-eight patients (77.8%) showed sleep apnea, which was predominantly obstructive (n = 8), central (n = 9), or "mixed" (n = 11). Thirty-two patients were initiated on non-invasive ventilation which significantly improved ventilation and oxygenation in the first night of treatment. Follow-up revealed stable normoxia and normocapnia without deterioration of sleep outcomes for up to 52 months. Adherence to treatment was low to moderate, with substantial inter-individual variability. Sleep disordered breathing is highly prevalent in adult DM1 patients complaining of daytime sleepiness, and non-invasive ventilation significantly, rapidly and persistently improves nocturnal gas exchange. Capnometry is superior to oximetry for detection of nocturnal hypoventilation. Adherence to non-invasive ventilation remains a major issue in DM1, and long-term treatment benefits should be individually assessed. [ABSTRACT FROM AUTHOR]

Aim: To highlight Canada's contributions to the assessment and treatment of pediatric obstructive sleep apnea as well as outline the current state of pediatric obstructive sleep apnea in Canada.Methods: A search was conducted in MEDLINE (Ovid) using Medical Subject Headings (MeSH) and free-text terms for 'child' and 'obstructive sleep apnea' with subsequent 'human' limit. The results were reviewed to identify publications where any author's listed a Canadian institution.Results: Canadian contributions to the field of pediatric obstructive sleep apnea have grown over the last 30 years with an increase in number of contributors and centres. Much of the early work stemmed from McGill University with important contributions in examining alternatives to polysomnography and post-adenotonsillectomy respiratory compromise. Today, contributors from centres across the country are engaged in the field and come from a greater diversity of disciplines. With continued challenges and opportunities, Canada will continue to help advance the field of pediatric OSA.Conclusion: Canada has a strong community of people invested in continuing to work to improve the lives of Canadian children with pediatric OSA. [ABSTRACT FROM AUTHOR]

Aims: Evaluation of the efficacy of prehospital non-invasive ventilation (NIV) in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) and cardiogenic pulmonary edema (CPE).Material and Methods: Consecutive patients who were prehospitally treated by Emergency Physicians using NIV were prospectively included. A step-by-step approach escalating NIV-application from continuous positive airway pressure (CPAP) to continuous positive airway pressure supplemented by pressure support (CPAP-ASB) and finally bilevel inspiratory positive airway pressure (BIPAP) was used. Patients were divided into two groups according to the prehospital NIV-treatment-time (NIV-group 1: ≤15 min, NIV-group 2: >15 min). In addition, a historic control group undergoing standard care was created. Endpoints were heart rate, peripheral oxygen saturation, breathing rate, systolic blood pressure, and a dyspnea score.Results: A total of 99 patients were analyzed (NIV-group 1: n = 41, NIV-group 2: n = 58). The control group consisted of 30 patients. The majority of NIV-patients (90%) received CPAP-ASB, while CPAP without ASB was conducted in 8% and BIPAP-ventilation in 2% of all cases. Technical application of NIV lasted 6.1 ± 3.8 min. NIV-treatment-time was as follows: NIV-group 1: 13.1 ± 3.2 min, NIV-group 2: 22.8 ± 5.9 min. Differences between baseline- and hospital admission values of all endpoints showed significantly better improvement in NIV-groups compared to the control group (p < 0.001). The stabilizing effect of NIV in terms of vital parameters was comparable between both NIV-groups, independent of the duration of treatment (n.s.).Conclusion: Prehospital NIV-treatment should be performed in patients with COPD-exacerbation and CPE, even if the distance between emergency scene and hospital is short. [ABSTRACT FROM AUTHOR]

Bronchiolitis is a common viral disease that significantly affects infants less than 12 months of age. The purpose of this review is to present a review of the current knowledge of the uses of respiratory support in the management of infants with bronchiolitis presenting to hospital. We electronically searched MEDLINE, Cochrane, CINAHL and EMBASE (inception to 25th March 2018), to manually search for clinical trials that address the management strategies for respiratory support of infants with bronchiolitis. We identified 120 papers who met the inclusion criteria, of which 33 papers were relevant for this review with only nine randomized controlled trials. This review demonstrated that non-invasive respiratory support reduced the need for escalation of therapy, particularly the proportion of intubations required for infants with bronchiolitis. Additionally, clear economic benefits have been demonstrated when non-invasive ventilation has been used. The potential early use of non-invasive respiratory supports such as nasal high flow therapy and non-invasive ventilation may have an impact on health care costs and reduction in ICU admissions and intubation rates. High-grade evidence demonstrates safety and quality of high flow therapy in general ward settings. [ABSTRACT FROM AUTHOR]

Abstract Objective Few randomized trials have evaluated the use of non-invasive ventilation (NIV) for early acute respiratory failure (ARF) in non-intensive care unit (ICU) wards. The aim of this study is to test the hypothesis that early NIV for mild-moderate ARF in non-ICU wards can prevent development of severe ARF. Design Pragmatic, parallel group, randomized, controlled, multicenter trial. Setting Non-intensive care wards of tertiary centers. Patients Non-ICU ward patients with mild to moderate ARF without an established indication for NIV. Interventions Patients will be randomized to receive or not receive NIV in addition to best available care. Measurements and main results We will enroll 520 patients, 260 in each group. The primary endpoint of the study will be the development of severe ARF. Secondary endpoints will be 28-day mortality, length of hospital stay, safety of NIV in non-ICU environments, and a composite endpoint of all in-hospital respiratory complications. Conclusions This trial will help determine whether the early use of NIV in non-ICU wards can prevent progression from mild-moderate ARF to severe ARF. [ABSTRACT FROM AUTHOR]