Search

Background: Acute Respiratory Distress Syndrome (ARDS) has a high morbidity and mortality. One therapy that can decrease mortality is ventilation in the prone position (PP). Patients undergoing PP are amongst the sickest, and there is a need for early identification of patients at particularly high risk of death. These patients may benefit from an in-depth review of treatment or consideration of rescue therapies. We report the development of a machine learning model trained to predict early mortality in patients undergoing prone positioning as part of the management of their ARDS. Methods: Prospectively collected clinical data were analysed retrospectively from a single tertiary ICU. The records of patients who underwent an initial session of prone positioning whilst receiving invasive mechanical ventilation were identified (n = 131). The decision to perform prone positioning was based on the criteria in the PROSEVA study. A C5.0 classifier algorithm with adaptive boosting was trained on data gathered before, during, and after initial proning. Data was split between training (85% of data) and testing (15% of data). Hyperparameter tuning was achieved through a grid-search using a maximal entropy configuration. Predictions for 7-day mortality after initial proning session were made on the training and testing data. Results: The model demonstrated good performance in predicting 7-day mortality (AUROC: 0.89 training, 0.78 testing). Seven variables were used for prediction. Sensitivity was 0.80 and specificity was 0.67 on the testing data set. Patients predicted to survive had 13.3% mortality, while those predicted to die had 66.67% mortality. Among patients in whom the model predicted patient would survive to day 7 based on their response, mortality at day 7 was 13.3%. Conversely, if the model predicted the patient would not survive to day 7, mortality was 66.67%. Conclusions: This proof-of-concept study shows that with a limited data set, a C5.0 classifier can predict 7-day mortality from a number of variables, including the response to initial proning, and identify a cohort at significantly higher risk of death. This can help identify patients failing conventional therapies who may benefit from a thorough review of their management, including consideration of rescue treatments, such as extracorporeal membrane oxygenation. This study shows the potential of a machine learning model to identify ARDS patients at high risk of early mortality following PP. This information can guide clinicians in tailoring treatment strategies and considering rescue therapies. Further validation in larger cohorts is needed. [ABSTRACT FROM AUTHOR]

Liquid-like protein condensates are ubiquitous in cellular system and are increasingly recognized for their roles in physiological processes. Condensed phase harbors distinctive chemical microenvironment, markedly different than dilute aqueous phase. Herein, we demonstrate chemoselective modification pattern of nucleophilic canonical amino acid sidechains (namely – cysteine, tyrosine and lysine) of the protein towards 4-chloro-7-nitrobenzofurazan in the dilute and condensed phase. We also delineate how the effect of nucleotides and their in situ enzymatic dissociation temporally modulate the protein condensate's pH and the protein's corresponding chemoselective modification. We have shown that the pH of the condensate decreases in the presence of nucleoside triphosphate, whereas it increases in the presence of nucleoside monophosphates or phosphate ion. For instance, we find lysine-specific modification gets inhibited in the presence of adenosine triphosphate (ATP), but significantly enhanced in the presence of monophosphates. This feature enables us to gain temporal control over dynamic change in protein functionalization via enzymatic ATP hydrolysis. Overall, this work substantiates the alteration in pH-responsiveness of Brønsted basicity of a protein's ε-amine in the condensed phase. Furthermore, this environment sensitivity in chemoselective protein functionalization in condensed phase will be important in adaptable protein engineering to the chemical biology of protein phase separation. Liquid-like protein condensates are ubiquitous in cellular systems and play key roles in physiological processes, with the condensed phase harboring a distinctive chemical microenvironment. Here, the authors systematically investigate how the local chemical environment within protein condensates impacts chemical reactivity, demonstrating nucleotide-mediated modulation of chemoselective protein functionalization. [ABSTRACT FROM AUTHOR]

Background: Right ventricle impairment (RVI) is common during acute respiratory distress syndrome (ARDS) in adults and children, possibly mediated by the level of transpulmonary pressure (PL). We sought to investigate the impact of the level of PL on ARDS-associated right ventricle impairment (RVI). Methods: Adults and children (> 72 h of life) were included in this two centers prospective study if they were ventilated for a new-onset ARDS or pediatric ARDS, without spontaneous breathing and contra-indication to esophageal catheter. Serial measures of static lung, chest wall, and respiratory mechanics were coupled to critical care echocardiography (CCE) for 3 days. Mixed-effect logistic regression models tested the impact of lung stress (ΔPL) along with age, lung injury severity, and carbon dioxide partial pressure, on RVI using two definitions: acute cor pulmonale (ACP), and RV dysfunction (RVD). ACP was defined as a dilated RV with septal dyskinesia; RVD was defined as a composite criterion using tricuspid annular plane systolic excursion, S wave velocity, and fractional area change. Results: 46 patients were included (16 children, 30 adults) with 106 CCE (median of 2 CCE/patient). At day one, 19% of adults and 4/7 children > 1 year exhibited ACP, while 59% of adults and 44% of children exhibited RVD. In the entire population, ACP was present on 17/75 (23%) CCE. ACP was associated with an increased lung stress (mean ΔPL of 16.2 ± 6.6 cmH2O in ACP vs 11.3 ± 3.6 cmH2O, adjusted OR of 1.33, CI95% [1.11–1.59], p = 0.002) and being a child. RVD was present in 59/102 (58%) CCE and associated with lung stress. In children > 1 year, PEEP was significantly lower in case of ACP (9.3 [8.6; 10.0] cmH2O in ACP vs 15.0 [11.9; 16.3] cmH2O, p = 0.03). Conclusion: Lung stress was associated with RVI in adults and children with ARDS, children being particularly susceptible to RVI. Trial registration Clinical trials identifier: NCT0418467. [ABSTRACT FROM AUTHOR]

Background: Improvements in oxygenation and lung mechanics with prone position (PP) in patients with acute respiratory distress syndrome (ARDS) are inconstant. The objectives of the study were (i) to identify baseline variables, including the recruitment-to-inflation ratio (R/I), associated with a positive response to PP in terms of oxygenation (improvement of the ratio of arterial oxygen partial pressure over the inspired oxygen fraction (PaO2/FiO2) ≥ 20 mmHg) and lung mechanics; (ii) to evaluate whether the response to the previous PP session is associated with the response to the next session. Methods: In this prospective, observational, single-center study in patients who underwent PP for ARDS due to COVID-19, respiratory variables were assessed just before PP and at the end of the session. Respiratory variables included mechanical ventilation settings and respiratory mechanics variables, including R/I, an estimate of the potential for lung recruitment compared to lung overinflation. Results: In 50 patients, 201 PP sessions lasting 19 ± 3 h were evaluated. Neuromuscular blockades were used in 116 (58%) sessions. The PaO2/FiO2 ratio increased from 109 ± 31 mmHg to 165 ± 65 mmHg, with an increase ≥ 20 mmHg in 142 (71%) sessions. In a mixed effect logistic regression, only pre-PP PaO2/FiO2 (OR 1.12 (95% CI [1.01–1.24])/every decrease of 10 mmHg, p = 0.034) in a first model and improvement in oxygenation at the previous PP session (OR 3.69 (95% CI [1.27–10.72]), p = 0.017) in a second model were associated with an improvement in oxygenation with PP. The R/I ratio (n = 156 sessions) was 0.53 (0.30–0.76), separating lower- and higher-recruiters. Whereas PaO2/FiO2 improved to the same level in both subgroups, driving pressure and respiratory system compliance improved only in higher-recruiters (from 14 ± 4 to 12 ± 4 cmH2O, p = 0.027, and from 34 ± 11 to 38 ± 13 mL/cmH2O, respectively, p = 0.014). Conclusions: A lower PaO2/FiO2 at baseline and a positive O2-response at the previous PP session are associated with a PP-induced improvement in oxygenation. In higher-recruiters, lung mechanics improved along with oxygenation. Benefits of PP could thus be greater in these patients. [ABSTRACT FROM AUTHOR]

Copyright of Somnologie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Food rheology is key to manage the swallowing safety of people affected by swallowing disorders (dysphagia). Simple approaches to assess the flow properties of texture-modified drinks are widely used, but relatively poorly understood. This study focuses on the International Dysphagia Diet Standardisation Initiative (IDDSI) flow test, adopted by caregivers worldwide. This test considers the gravity-driven flow in a vertical syringe. Newtonian liquids and non-Newtonian fluids obtained using a commercial starch-based thickener were considered in this study. An accurate theoretical description of the flow is proposed for Newtonian and power-law fluids considering the effect of fluid properties and of the syringe geometry. A rheological map is proposed, based on the results of several thousand simulations, to capture quantitatively the effect of rheological properties and density on the IDDSI classification, highlighting the important effect of the fluid density which is usually ignored. The sensitivity of the IDDSI results with respect to the syringe outlet diameter is discussed, as well as the different average shear rates at which different IDDSI levels are tested. The rheological map also shows quantitatively that different combinations of the fluid rheological properties and density can result in the same IDDSI classification, suggesting interesting directions for future clinical research. [ABSTRACT FROM AUTHOR]

Background: The continuous exposure of blood to a non-biological surface during extracorporeal membrane oxygenation (ECMO) may lead to progressive thrombus formation in the oxygenator, hemolysis and consequently impaired gas exchange. In most centers oxygenator performance is monitored only on a once daily basis. Carboxyhemoglobin (COHb) is generated upon red cell lysis and is routinely measured with any co-oximetry performed to surveille gas exchange and acid–base homeostasis every couple of hours. This retrospective cohort study aims to evaluate COHb in the arterial blood gas as a novel marker of oxygenator dysfunction and its predictive value for imminent oxygenator change. Results: Out of the 484 screened patients on ECMO 89, cumulatively requiring 116 oxygenator changes within 1833 patient days, including 19,692 arterial COHb measurements were analyzed. Higher COHb levels were associated with lower post-oxygenator pO2 (estimate for log(COHb): − 2.176 [95% CI − 2.927, − 1.427], p < 0.0001) and with a shorter time to oxygenator change (estimate for log(COHb): − 67.895 [95% CI − 74.209, − 61.542] hours, p < 0.0001). COHb was predictive of oxygenator change within 6 h (estimate for log(COHb): 5.027 [95% CI 1.670, 15.126], p = 0.004). Conclusion: COHb correlates with oxygenator performance and can be predictive of imminent oxygenator change. Therefore, longitudinal measurements of COHb in clinical routine might be a cheap and more granular candidate for ECMO surveillance that should be further analyzed in a controlled prospective trial design. [ABSTRACT FROM AUTHOR]

Background: Mechanical power (MP) is the energy delivered by the ventilator to the respiratory system and combines factors related to the development of ventilator-induced lung injury (VILI). Flow-controlled ventilation (FCV) is a new ventilation mode using a constant low flow during both inspiration and expiration, which is hypothesized to lower the MP and to improve ventilation homogeneity. Data demonstrating these effects are scarce, since previous studies comparing FCV with conventional controlled ventilation modes in ICU patients suffer from important methodological concerns. Objectives: This study aims to assess the difference in MP between FCV and pressure-controlled ventilation (PCV). Secondary aims were to explore the effect of FCV in terms of minute volume, ventilation distribution and homogeneity, and gas exchange. Methods: This is a physiological study in post-cardiothoracic surgery patients requiring mechanical ventilation in the ICU. During PCV at baseline and 90 min of FCV, intratracheal pressure, airway flow and electrical impedance tomography (EIT) were measured continuously, and hemodynamics and venous and arterial blood gases were obtained repeatedly. Pressure–volume loops were constructed for the calculation of the MP. Results: In 10 patients, optimized FCV versus PCV resulted in a lower MP (7.7 vs. 11.0 J/min; p = 0.004). Although FCV did not increase overall ventilation homogeneity, it did lead to an improved ventilation of the dependent lung regions. A stable gas exchange at lower minute volumes was obtained. Conclusions: FCV resulted in a lower MP and improved ventilation of the dependent lung regions in post-cardiothoracic surgery patients on the ICU. Trial registration Clinicaltrials.gov identifier: NCT05644418. Registered 1 December 2022, retrospectively registered. [ABSTRACT FROM AUTHOR]

Purpose of Review: Cardiac arrests constitute a leading cause of mortality in the adult population and cardiologists are often tasked with the management of patients following cardiac arrest either as a consultant or primary provider in the cardiac intensive care unit. Familiarity with evidence-based practice for post-cardiac arrest care is a requisite for optimizing outcomes in this highly morbid group. This review will highlight important concepts necessary to managing these patients. Recent Findings: Emerging evidence has further elucidated optimal care of post-arrest patients including timing for routine coronary angiography, utility of therapeutic hypothermia, permissive hypercapnia, and empiric aspiration pneumonia treatment. Summary: The complicated state of multi-organ failure following cardiac arrest needs to be carefully optimized by the clinician to prevent further neurologic injury and promote systemic recovery. Future studies should be aimed at understanding if these findings extend to specific patient populations, especially those at the highest risk for poor outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Lung weight is an important study endpoint to assess lung edema in porcine experiments on acute respiratory distress syndrome and ventilatory induced lung injury. Evidence on the relationship between lung–body weight relationship is lacking in the literature. The aim of this work is to provide a reference equation between normal lung and body weight in female domestic piglets. Materials and methods: 177 healthy female domestic piglets from previous studies were included in the analysis. Lung weight was assessed either via a CT-scan before any experimental injury or with a scale after autopsy. The animals were randomly divided in a training (n = 141) and a validation population (n = 36). The relation between body weight and lung weight index (lung weight/body weight, g/kg) was described by an exponential function on the training population. The equation was tested on the validation population. A Bland–Altman analysis was performed to compare the lung weight index in the validation population and its theoretical value calculated with the reference equation. Results: A good fit was found between the validation population and the exponential equation extracted from the training population (RMSE = 0.060). The equation to determine lung weight index from body weight was: LungWeightIndex g kg = 26.26 ∗ 10 - 0.011 ∗ BodyWeight kg . At the Bland and Altman analyses, the mean bias between the real and the expected lung weight index was − 0.26 g/kg (95% CI − 0.96–0.43), upper LOA 3.80 g/kg [95% CI 2.59–5.01], lower LOA − 4.33 g/kg [95% CI = − 5.54–(− 3.12)]. Conclusions: This exponential function might be a valuable tool to assess lung edema in experiments involving 16–50 kg female domestic piglets. The error that can be made due to the 95% confidence intervals of the formula is smaller than the one made considering the lung to body weight as a linear relationship. [ABSTRACT FROM AUTHOR]

The role of awake prone positioning (aPP) in patients with acute hypoxemic respiratory failure is debated. We performed a systematic review and meta-analysis to evaluate the role of aPP in acute respiratory failure related to COronaVIrus Disease-19 (COVID-19). Studies reporting on the clinical course of patients with acute respiratory failure related to COVID-19 treated or not treated by aPP were included in the systematic review and meta-analysis (ProsperoID: CRD42022333211). The primary study outcome was the composite of in-hospital death or orotracheal intubation; the individual components of the primary outcome were secondary study outcomes. The composite of in-hospital death or orotracheal intubation was available for 6 studies (1884 patients), five randomized and one prospective; a significant reduction in the risk of this outcome was observed in patients treated vs. not treated by aPP (33.5% vs. 39.8%; OR 0.73, 95% CI 0.60–0.89; I2 0%). In-hospital death was reported in 34 studies (6808 patients) and occurred in 17.4% vs. 23.5% of patients treated or not treated with aPP (random effect OR 0.60, 95% CI 0.46–0.79; I2 59%); orotracheal intubation was observed in 25.8% vs. 32.7% of patients treated or not treated with aPP (27 studies, 5369 patients; random effect OR 0.85, 95% CI 0.56–1.27; I2 84%). aPP reduces the risk for death or orotracheal intubation in patients with acute respiratory failure related to COVID-19. Further studies should be conducted to confirm the clinical benefit of aPP outside the ICU. Registration Prospero ID: CRD42022333211. [ABSTRACT FROM AUTHOR]

Background: Mechanical power may serve as a valuable parameter for predicting ventilation-induced injury in mechanically ventilated patients. Over time, several equations have been developed to calculate power in both volume control ventilation (VCV) and pressure control ventilation (PCV). Among these equations, the linear model mechanical power equation (MPLM) closely approximates the reference method when applied in PCV. The dynamic mechanical power equation (MPdyn) computes power by utilizing the ventilatory work of breathing parameter (WOBv), which is automatically measured by the mechanical ventilator. In our study, conducted in patients with Covid-19 Acute Respiratory Distress Syndrome (C-ARDS), we calculated mechanical power using both the MPLM and MPdyn equations, employing different inspiratory rise times (Tslope) at intervals of 5%, ranging from 5 to 20% and compared the obtained results. Results: In our analysis, we used univariate linear regression at both I:E ratios of 1:2 and 1:1, considering all Tslope values. These analyses revealed that the MPdyn and MPLM equations exhibited strong correlations, with R2 values exceeding 0.96. Furthermore, our Bland–Altman analysis, which compared the power values derived from the MPdyn and MPLM equations for patient averages and all measurements, revealed a mean difference of −0.42 ± 0.41 J/min (equivalent to 2.6% ± 2.3%, p < 0.0001) and −0.39 ± 0.57 J/min (equivalent to 3.6% ± 3.5%, p < 0.0001), respectively. While there was a statistically significant difference between the equations in both absolute value and relative proportion, this difference was not considered clinically relevant. Additionally, we observed that each 5% increase in Tslope time corresponded to a decrease in mechanical power values by approximately 1 J/min. Conclusions: The differences between mechanical power values calculated using the MPdyn and MPLM equations at various Tslope durations were determined to lack clinical significance. Consequently, for practical and continuous mechanical power estimation in Pressure-Controlled Ventilation (PCV) mode, the MPdyn equation presents itself as a viable option. It is important to note that as Tslope times increased, the calculated mechanical power exhibited a clinically relevant decrease. [ABSTRACT FROM AUTHOR]

The effects of head and neck alignment and pharyngeal anatomy on epiglottic inversion remain unclear. This study investigated the factors involved in epiglottic inversion, including head and neck alignment and pharyngeal anatomy, in patients with dysphagia. Patients with a chief complaint of dysphagia and who underwent videofluoroscopic swallowing study at our hospital from January to July 2022 were enrolled. They were divided into three groups based on the degree of epiglottic inversion as the complete-inversion (CI), partial-inversion (PI), and non-inversion group (NI) groups. Data were compared among the three groups; a total of 113 patients were analyzed. The median age was 72.0 (IQR: 62.0–76.0) years; 41 (36.3%) and 72 (63.7%) were women and men, respectively. There were in 45 (39.8%) patients in the CI, 39 (34.5%) in the PI, and 29 (25.7%) in the NI groups, respectively. Single-variable analysis revealed significant relation to epiglottic inversion of Food Intake LEVEL Scale score, penetration–aspiration score with 3-mL thin liquid bolus, epiglottic vallecula and pyriform sinus residue, hyoid position and displacement during swallowing, pharyngeal inlet angle (PIA), epiglottis to posterior pharyngeal wall distance, and body mass index. Logistic regression analysis with complete epiglottic inversion as the dependent variable revealed the X coordinate at maximum hyoid elevation position during swallowing and PIA as significant explanatory variables. These results suggest that epiglottic inversion is constrained in patients with dysphagia who have poor head and neck alignment or posture and a narrow pharyngeal cavity just before swallowing. [ABSTRACT FROM AUTHOR]

Mechanical ventilation is a life-saving therapy in several clinical situations, promoting gas exchange and providing rest to the respiratory muscles. However, mechanical ventilation may cause hemodynamic instability and pulmonary structural damage, which is known as ventilator-induced lung injury (VILI). The four main injury mechanisms associated with VILI are as follows: barotrauma/volutrauma caused by overstretching the lung tissues; atelectrauma, caused by repeated opening and closing of the alveoli resulting in shear stress; and biotrauma, the resulting biological response to tissue damage, which leads to lung and multi-organ failure. This narrative review elucidates the mechanisms underlying the pathogenesis, progression, and resolution of VILI and discusses the strategies that can mitigate VILI. Different static variables (peak, plateau, and driving pressures, positive end-expiratory pressure, and tidal volume) and dynamic variables (respiratory rate, airflow amplitude, and inspiratory time fraction) can contribute to VILI. Moreover, the potential for lung injury depends on tissue vulnerability, mechanical power (energy applied per unit of time), and the duration of that exposure. According to the current evidence based on models of acute respiratory distress syndrome and VILI, the following strategies are proposed to provide lung protection: keep the lungs partially collapsed (SaO2 > 88%), avoid opening and closing of collapsed alveoli, and gently ventilate aerated regions while keeping collapsed and consolidated areas at rest. Additional mechanisms, such as subject-ventilator asynchrony, cumulative power, and intensity, as well as the damaging threshold (stress–strain level at which tidal damage is initiated), are under experimental investigation and may enhance the understanding of VILI. [ABSTRACT FROM AUTHOR]

This work presents a dataset of human hand kinematics and forearm muscle activation collected during the performance of a wide variety of activities of daily living (ADLs), with tagged characteristics of products and tasks. A total of 26 participants performed 161 ADLs selected to be representative of common elementary tasks, grasp types, product orientations and performance heights. 105 products were used, being varied regarding shape, dimensions, weight and type (common products and assistive devices). The data were recorded using CyberGlove instrumented gloves on both hands measuring 18 degrees of freedom on each and seven surface EMG sensors per arm recording muscle activity. Data of more than 4100 ADLs is presented in this dataset as MATLAB structures with full continuous recordings, which may be used in applications such as machine learning or to characterize healthy human hand behaviour. The dataset is accompanied with a custom data visualization application (ERGOMOVMUS) as a tool for ergonomics applications, allowing visualization and calculation of aggregated data from specific task, product and/or participants' characteristics. [ABSTRACT FROM AUTHOR]

Background: COVID-19 patients with respiratory failure may need intensive care unit (ICU) admission. Prone positioning in mechanically ventilated patients improves oxygenation and reduces mortality in moderate to severe acute respiratory distress syndrome. For better oxygenation and outcomes, awake proning is being tried in non-intubated patients also. Our aim was to investigate advantage of awake self-prone positioning with oxygen therapy using non-rebreathing mask (NRBM) in COVID-19 ICU patients. Results: This prospective observational study was conducted in ICU from 18th November 2020 to 28th February 2021. Sixty COVID-19 cooperative patients with hypoxemia on arrival with hemodynamic stability were included. Patients on NRBM were advised to turn prone for 12–14 h per day. Oxygen saturation (SpO2) was recorded in supine position and 30 min after initiation of prone positioning. Ratio of arterial partial pressure of oxygen and fractional concentration of inspired oxygen (P/F) was recorded in supine and 24 h after initiation of prone position. Primary outcome was improvement in SpO2 > 94%. Secondary outcome was incidence of intubation. Sixty patients were received in ICU with supplemental oxygen, and median SpO2 was 80% (IQR 70–88%). Patients were put on NRBM with median SpO2 in supine position 86% (IQR 76–90). Thirty minutes of proning increased SpO2 to 94% (IQR 89 to 97%). Wilcoxon rank-sum test was used (P = 0.001). Forty-three patients did not require intubation, and seventeen patients needed intubation. Conclusions: Awake self-proning in COVID-19 patients on NRBM improved oxygenation with reduced intubation rate. [ABSTRACT FROM AUTHOR]

Background: in COVID-19 acute respiratory failure, the effects of CPAP and FiO2 on respiratory effort and lung stress are unclear. We hypothesize that, in the compliant lungs of early Sars-CoV-2 pneumonia, the application of positive pressure through Helmet-CPAP may not decrease respiratory effort, and rather worsen lung stress and oxygenation when compared to higher FiO2 delivered via oxygen masks. Methods: In this single-center (S.Luigi Gonzaga University-Hospital, Turin, Italy), randomized, crossover study, we included patients receiving Helmet-CPAP for early (< 48 h) COVID-19 pneumonia without additional cardiac or respiratory disease. Healthy subjects were included as controls. Participants were equipped with an esophageal catheter, a non-invasive cardiac output monitor, and an arterial catheter. The protocol consisted of a random sequence of non-rebreather mask (NRB), Helmet-CPAP (with variable positive pressure and FiO2) and Venturi mask (FiO2 0.5), each delivered for 20 min. Study outcomes were changes in respiratory effort (esophageal swing), total lung stress (dynamic + static transpulmonary pressure), gas-exchange and hemodynamics. Results: We enrolled 28 COVID-19 patients and 7 healthy controls. In all patients, respiratory effort increased from NRB to Helmet-CPAP (5.0 ± 3.7 vs 8.3 ± 3.9 cmH2O, p < 0.01). However, Helmet's pressure decreased by a comparable amount during inspiration (− 3.1 ± 1.0 cmH2O, p = 0.16), therefore dynamic stress remained stable (p = 0.97). Changes in static and total lung stress from NRB to Helmet-CPAP were overall not significant (p = 0.07 and p = 0.09, respectively), but showed high interpatient variability, ranging from − 4.5 to + 6.1 cmH2O, and from − 5.8 to + 5.7 cmH2O, respectively. All findings were confirmed in healthy subjects, except for an increase in dynamic stress (p < 0.01). PaO2 decreased from NRB to Helmet-CPAP with FiO2 0.5 (107 ± 55 vs 86 ± 30 mmHg, p < 0.01), irrespective of positive pressure levels (p = 0.64). Conversely, with Helmet's FiO2 0.9, PaO2 increased (p < 0.01), but oxygen delivery remained stable (p = 0.48) as cardiac output decreased (p = 0.02). When PaO2 fell below 60 mmHg with VM, respiratory effort increased proportionally (p < 0.01, r = 0.81). Conclusions: In early COVID-19 pneumonia, Helmet-CPAP increases respiratory effort without altering dynamic stress, while the effects upon static and total stress are variable, requiring individual assessment. Oxygen masks with higher FiO2 provide better oxygenation with lower respiratory effort. Trial registration Retrospectively registered (13-May-2021): clinicaltrials.gov (NCT04885517), https://clinicaltrials.gov/ct2/show/NCT04885517. [ABSTRACT FROM AUTHOR]

We investigated whether machine learning (ML) analysis of ICU monitoring data incorporating volumetric capnography measurements of mean alveolar PCO2 can partition venous admixture (VenAd) into its shunt and low V/Q components without manipulating the inspired oxygen fraction (FiO2). From a 21-compartment ventilation / perfusion (V/Q) model of pulmonary blood flow we generated blood gas and mean alveolar PCO2 data in simulated scenarios with shunt values from 7.3% to 36.5% and a range of FiO2 settings, indirect calorimetry and cardiac output measurements and acid- base and hemoglobin oxygen affinity conditions. A 'deep learning' ML application, trained and validated solely on single FiO2 bedside monitoring data from 14,736 scenarios, then recovered shunt values in 500 test scenarios with true shunt values 'held back'. ML shunt estimates versus true values (n = 500) produced a linear regression model with slope = 0.987, intercept = -0.001 and R2 = 0.999. Kernel density estimate and error plots confirmed close agreement. With corresponding VenAd values calculated from the same bedside data, low V/Q flow can be reported as VenAd—shunt. ML analysis of blood gas, indirect calorimetry, volumetric capnography and cardiac output measurements can quantify pulmonary oxygenation deficits as percentage shunt flow (V/Q = 0) versus percentage low V/Q flow (V/Q > 0). High fidelity reports are possible from analysis of data collected solely at the operating FiO2. [ABSTRACT FROM AUTHOR]

Copyright of Innere Medizin (2731-7080) is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Trunk inclination from semirecumbent head-upright to supine-flat positioning reduces driving pressure and increases respiratory system compliance in patients with acute respiratory distress syndrome (ARDS). These effects are associated with an improved ventilatory ratio and reduction in the partial pressure of carbon dioxide (PaCO2). However, these physiological effects have not been completely studied, and their mechanisms have not yet been elucidated. Therefore, this study aimed to evaluate the effects of a change in trunk inclination from semirecumbent (45°) to supine-flat (10°) on physiological dead space and ventilation distribution in different lung regions. Results: Twenty-two ARDS patients on pressure-controlled ventilation underwent three 60-min steps in which trunk inclination was changed from 45° (baseline) to 10° (intervention) and back to 45° (control) in the last step. Tunk inclination from a semirecumbent (45°) to a supine-flat (10°) position resulted in a higher tidal volume [371 (± 76) vs. 433 (± 84) mL (P < 0.001)] and respiratory system compliance [34 (± 10) to 41 (± 12) mL/cmH2O (P < 0.001)]. The CO2 exhaled per minute improved from 191 mL/min (± 34) to 227 mL/min (± 38) (P < 0.001). Accordingly, Bohr's dead space ratio decreased from 0.49 (± 0.07) to 0.41 (± 0.06) (p < 0.001), and PaCO2 decreased from 43 (± 5) to 36 (± 4) mmHg (p < 0.001). In addition, the impedance ratio, which divides the ventilation activity of the ventral region by the dorsal region ventilation activity in tidal images, dropped from 1.27 (0.83–1.78) to 0.86 (0.51–1.33) (p < 0.001). These results, calculated from functional EIT images, indicated further ventilation activity in the dorsal lung regions. These effects rapidly reversed once the patient was repositioned at 45°. Conclusions: A change in trunk inclination from a semirecumbent (45 degrees) to a supine-flat position (10 degrees) improved Bohr's dead space ratio and reduced PaCO2 in patients with ARDS. This effect is associated with an increase in tidal volume and respiratory system compliance, along with further favourable impedance ventilation distribution toward the dorsal lung regions. This study highlights the importance of considering trunk inclination as a modifiable determinant of physiological parameters. The angle of trunk inclination is essential information that must be reported in ARDS patients. [ABSTRACT FROM AUTHOR]

The kinematic parameters of reach-to-grasp movements are modulated by action intentions. However, when an unexpected change in visual target goal during reaching execution occurs, it is still unknown whether the action intention changes with target goal modification and which is the temporal structure of the target goal prediction. We recorded the kinematics of the pointing finger and wrist during the execution of reaching movements in 23 naïve volunteers where the targets could be located at different directions and depths with respect to the body. During the movement execution, the targets could remain static for the entire duration of movement or shifted, with different timings, to another position. We performed temporal decoding of the final goals and of the intermediate trajectory from the past kinematics exploiting a recurrent neural network. We observed a progressive increase of the classification performance from the onset to the end of movement in both horizontal and sagittal dimensions, as well as in decoding shifted targets. The classification accuracy in decoding horizontal targets was higher than the classification accuracy of sagittal targets. These results are useful for establishing how human and artificial agents could take advantage from the observed kinematics to optimize their cooperation in three-dimensional space. [ABSTRACT FROM AUTHOR]

Dysphagia diets are recommended to prevent choking and aspiration in people with dysphagia; however, rice-porridge and mashed rice-porridge, which are used as staple foods for people with dysphagia in Japan, are time-consuming to prepare. The National Agriculture and Food Research Organization has found jelly-like food products made from high-amylose rice-flour (rice-flour jelly) to be easy to prepare with a texture suitable for dysphagia diets. To investigate the potential of rice-flour jelly for the dysphagia diet, we evaluated the amount of pharyngeal residue after swallowing rice-flour jelly using fiberoptic endoscopic evaluation of swallowing and compared it with those of rice-porridge, mashed rice-porridge, and fruit jelly. We enrolled 70 participants (43 males and 27 females, aged 32–96 years, median 74.5 years) and evaluated their pharyngeal residue using the Yale Pharyngeal Residue Severity Rating Scale which includes five levels from I (none) to V (severe). Statistical analysis showed that level I was more common in fruit jelly for vallecula residue and pyriform sinus residue, and level III (mild) was more common in rice-porridge for vallecula residue (p < 0.05). No differences of pharyngeal residue were found in rice-flour jelly or mashed rice-porridge. No significant difference was observed in the number of participants with laryngeal penetration or aspiration. Therefore, rice-flour jelly is a suitable alternative to rice-porridge as a staple food for people with dysphagia in terms of food texture. [ABSTRACT FROM AUTHOR]

We aimed to assess the potential role of Asymmetric dimethylarginine (ADMA) in conditioning respiratory function and pulmonary vasoregulation during Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2) infection. Within 72 h from admission, samples from 90 COVID-19 patients were assessed for ADMA, SDMA, L-arginine concentrations. In addition to classical statistics, patients were also clustered by a machine learning approach according to similar features. Multivariable analysis showed that C-reactive protein (OR 1.012), serum ADMA (OR 4.652), white blood cells (OR = 1.118) and SOFA (OR = 1.495) were significantly associated with negative outcomes. Machine learning-based clustering showed three distinct clusters: (1) patients with low severity not requiring invasive mechanical ventilation (IMV), (2) patients with moderate severity and respiratory failure whilst not requiring IMV, and (3) patients with highest severity requiring IMV. Serum ADMA concentration was significantly associated with disease severity and need for IMV although less pulmonary vasodilation was observed by CT scan. High serum levels of ADMA are indicative of high disease severity and requirement of mechanical ventilation. Serum ADMA at the time of hospital admission may therefore help to identify COVID-19 patients at high risk of deterioration and negative outcome. [ABSTRACT FROM AUTHOR]

We aimed to assess the potential role of Asymmetric dimethylarginine (ADMA) in conditioning respiratory function and pulmonary vasoregulation during Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2) infection. Within 72 h from admission, samples from 90 COVID-19 patients were assessed for ADMA, SDMA, L-arginine concentrations. In addition to classical statistics, patients were also clustered by a machine learning approach according to similar features. Multivariable analysis showed that C-reactive protein (OR 1.012), serum ADMA (OR 4.652), white blood cells (OR = 1.118) and SOFA (OR = 1.495) were significantly associated with negative outcomes. Machine learning-based clustering showed three distinct clusters: (1) patients with low severity not requiring invasive mechanical ventilation (IMV), (2) patients with moderate severity and respiratory failure whilst not requiring IMV, and (3) patients with highest severity requiring IMV. Serum ADMA concentration was significantly associated with disease severity and need for IMV although less pulmonary vasodilation was observed by CT scan. High serum levels of ADMA are indicative of high disease severity and requirement of mechanical ventilation. Serum ADMA at the time of hospital admission may therefore help to identify COVID-19 patients at high risk of deterioration and negative outcome. [ABSTRACT FROM AUTHOR]

The aim of the present study is to evaluate the impact of Land Use Land Cover (LULC) changes induced by urbanization on the hydrological response of the Wadi Koriche and Wadi Kniss watersheds, located in the urban area of Algiers (the capital of Algeria). Three land use scenarios were established by processing aerial and satellite images in three different periods (1959–1984–2019). These three scenarios were simulated with the flood of November 10, 2001, under the hydrological model Hydrologic Engineering Center-Hydrologic Modeling System. The results of this work show an increase in the built environment of 38% between 1959 and 2019 and a reduction in vegetation cover of 63%, accompanied by an increase in impervious surfaces of 48%, with an increase in runoff coefficients, a reduction in response times and water concentration times of the two watersheds, as well as an increase in peak flows of 30 m3/s and runoff volumes of more than 400,000 m3 between 1959 and 2019. The results indicate that LULC changes significantly impact the hydrological response of watersheds. They reduce infiltration and significantly increase runoff along the two wadis, causing flooding in the downstream parts of the studied watersheds. [ABSTRACT FROM AUTHOR]

Veno-venous extracorporeal membrane oxygenation (V–V ECMO) has an established evidence base in acute respiratory distress syndrome (ARDS) and has seen exponential growth in its use over the past decades. However, there is a paucity of evidence regarding the approach to weaning, with variation of practice and outcomes between centres. Preconditions for weaning, management of patients' sedation and mechanical ventilation during this phase, criteria defining success or failure, and the optimal duration of a trial prior to decannulation are all debated subjects. Moreover, there is no prospective evidence demonstrating the superiority of weaning the sweep gas flow (SGF), the extracorporeal blood flow (ECBF) or the fraction of oxygen of the SGF (FdO2), thereby a broad inter-centre variability exists in this regard. Accordingly, the aim of this review is to discuss the required physiological basis to interpret different weaning approaches: first, we will outline the physiological changes in blood gases which should be expected from manipulations of ECBF, SGF and FdO2. Subsequently, we will describe the resulting adaptation of patients' control of breathing, with special reference to the effects of weaning on respiratory effort. Finally, we will discuss pertinent elements of the monitoring and mechanical ventilation of passive and spontaneously breathing patients during a weaning trial. Indeed, to avoid lung injury, invasive monitoring is often required in patients making spontaneous effort, as pressures measured at the airway may not reflect the degree of lung strain. In the absence of evidence, our approach to weaning is driven largely by an understanding of physiology. Take home message: Successful weaning from veno-venous ECMO requires understanding and consideration of the complex physiological interactions between the native and the extracorporeal lung. We describe our understanding of the physiological adaptations of the patient as extracorporeal support is weaned and outline the implications for clinical practice. [ABSTRACT FROM AUTHOR]

Patients with traumatic brain injury (TBI) frequently require invasive mechanical ventilation and admission to an intensive care unit. Ventilation of patients with TBI poses unique clinical challenges, and careful attention is required to ensure that the ventilatory strategy (including selection of appropriate tidal volume, plateau pressure, and positive end-expiratory pressure) does not cause significant additional injury to the brain and lungs. Selection of ventilatory targets may be guided by principles of lung protection but with careful attention to relevant intracranial effects. In patients with TBI and concomitant acute respiratory distress syndrome (ARDS), adjunctive strategies include sedation optimization, neuromuscular blockade, recruitment maneuvers, prone positioning, and extracorporeal life support. However, these approaches have been largely extrapolated from studies in patients with ARDS and without brain injury, with limited data in patients with TBI. This narrative review will summarize the existing evidence for mechanical ventilation in patients with TBI. Relevant literature in patients with ARDS will be summarized, and where available, direct data in the TBI population will be reviewed. Next, practical strategies to optimize the delivery of mechanical ventilation and determine readiness for extubation will be reviewed. Finally, future directions for research in this evolving clinical domain will be presented, with considerations for the design of studies to address relevant knowledge gaps. [ABSTRACT FROM AUTHOR]

Using computer simulation we investigated whether machine learning (ML) analysis of selected ICU monitoring data can quantify pulmonary gas exchange in multi-compartment format. A 21 compartment ventilation/perfusion (V/Q) model of pulmonary blood flow processed 34,551 combinations of cardiac output, hemoglobin concentration, standard P50, base excess, VO2 and VCO2 plus three model-defining parameters: shunt, log SD and mean V/Q. From these inputs the model produced paired arterial blood gases, first with the inspired O2 fraction (FiO2) adjusted to arterial saturation (SaO2) = 0.90, and second with FiO2 increased by 0.1. 'Stacked regressor' ML ensembles were trained/validated on 90% of this dataset. The remainder with shunt, log SD, and mean 'held back' formed the test-set. 'Two-Point' ML estimates of shunt, log SD and mean utilized data from both FiO2 settings. 'Single-Point' estimates used only data from SaO2 = 0.90. From 3454 test gas exchange scenarios, two-point shunt, log SD and mean estimates produced linear regression models versus true values with slopes ~ 1.00, intercepts ~ 0.00 and R2 ~ 1.00. Kernel density and Bland–Altman plots confirmed close agreement. Single-point estimates were less accurate: R2 = 0.77–0.89, slope = 0.991–0.993, intercept = 0.009–0.334. ML applications using blood gas, indirect calorimetry, and cardiac output data can quantify pulmonary gas exchange in terms describing a 20 compartment V/Q model of pulmonary blood flow. High fidelity reports require data from two FiO2 settings. [ABSTRACT FROM AUTHOR]

Dysphagia in People with Parkinson's Disease (PWPD) is expected to occur in most individuals. The manifestation of dysphagia and its salient swallow dysfunction characteristics leading to decreased airway safety are not well understood. The aim of this study was to quantify dysphagia presentation and severity, examine contributors to airway invasion, and explore gender differences in dysphagia manifestation in PWPD. 60 PWPD in clinical, healthcare settings underwent a Videofluoroscopic Swallow Study (VFSS) after referral for complaints of dysphagia. VFSS records and videos were analyzed to obtain dysphagia diagnosis, Videofluoroscopic Dysphagia Scale (VDS) scores, laryngeal vestibule kinematic timings, and Penetration-Aspiration Scale scores. Frequencies of VDS component and PAS scores were examined. MANOVA and logistic regression analyses were used to identify predictors of penetration and aspiration. Pharyngeal stage dysphagia was prevalent throughout PWPD and presented more frequently than oral stage dysphagia. Pharyngeal residue was a significant predictor for aspiration events. Laryngeal vestibule closure reaction time (LVCrt) and duration time (LVCd) were significant predictors of airway invasion, as were bolus consistency and volume. LVCrt, LVCd, and pharyngeal stage VDS scores were significantly altered in men compared to women in PWPD. A broad clinical sample of PWPD displayed atypical frequencies of airway invasion and frequent atypical scores of oral and pharyngeal stage physiologies. Thicker and smaller bolus consistencies significantly reduced the odds of airway invasion. Men and women presented with significantly different swallow physiology including prolonged LVCrt, LVCd, and more frequent atypical scores of pharyngeal residue and laryngeal elevation.Journal instruction requires a country for affiliations; however, these are missing in affiliation [1, 2]. Please verify if the provided country are correct and amend if necessary.Yes, USA is correct as the provided country. [ABSTRACT FROM AUTHOR]

Gattinoni's equation, MP rs = 0.098 × RR × V T 2 1 2 E rs + RR × 1 + I : E 60 × I : E × R aw + V T × PEEP , now commonly used to calculate the mechanical power (MP) of ventilation. However, it calculates only inspiratory MP. In addition, the inclusion of PEEP in Gattinoni's equation raises debate because PEEP does not produce net displacement or contribute to MP. Measuring the area within the pressure–volume loop accurately reflects the MP received in a whole ventilation cycle and the MP thus obtained is not influenced by PEEP. The MP of 25 invasively ventilated patients were calculated by Gattinoni's equation and measured by integration of the areas within the pressure–volume loops of the ventilation cycles. The MP obtained from both methods were compared. The effects of PEEPs on MP were also evaluated. We found that the MP obtained from both methods were correlated by R2 = 0.75 and 0.66 at PEEP 5 and 10 cmH2O, respectively. The biases of the two methods were 3.13 (2.03 to 4.23) J/min (P < 0.0001) and − 1.23 (− 2.22 to − 0.24) J/min (P = 0.02) at PEEP 5 and 10 cmH2O, respectively. These P values suggested that both methods were significantly incongruent. When the tidal volume used was 6 ml/Kg, the MP by Gattinoni's equation at PEEP 5 and 10 cmH2O were significantly different (4.51 vs 7.21 J/min, P < 0.001), but the MP by PV loop area was not influenced by PEEPs (6.46 vs 6.47 J/min, P = 0.331). Similar results were observed across all tidal volumes. We conclude that the Gattinoni's equation is not accurate in calculating the MP of a whole ventilatory cycle and is significantly influenced by PEEP, which theoretically does not contribute to MP. [ABSTRACT FROM AUTHOR]

Flood is the most ubiquitous environmental hazard on the earth perhaps because rivers are the most dominant geomorphic agent in the present geological epoch. The actual process of flooding is the outcome of a complex set of control factors where nature and humans play a conjoint role. Unpredictable climate change with its weather phenomena increases the chances of disastrous events like floods, so it is a need to undertake in depth study using advanced techniques like GIS and remote sensing with accurate methods, including appropriate basin factors. The present study has identified the flood hazard zones of the Kasari River catchment, located in the Kolhapur District of Maharashtra. Remote sensing (RS) and geographic information system (GIS) techniques have been used for the attempted research work. Analytic hierarchy process (AHP) and weighted overlay analysis are the multi-criteria decision-making tools that have been used for preparing the flood hazard zone map of the Kasari River basin. A number of popular approaches to flood hazard mapping use DEMs, discharge data, and flood frequency data such as remote sensing, GIS, and hydrological data. As a phenomenon, flood is complex—caused by a multiplicity of factors—thus, this often overlooks its multidimensionality. This study used a multi-criteria decision-making tool, such as AHP, which has the added advantage of analyzing a large number of input parameters and their comparative analysis; this led to the identification of factors of relative importance. In order to create the map, twelve control parameters were calculated, viz. elevation, slope, distance from the river, flow accumulation, drainage density, topographical wetness index (TWI), stream power index (SPI), curvature, rainfall, land use/land cover, geomorphology, and geology. Among these parameters, elevation is the dominant factor that influences floods, followed by distance from the river. Both factors show a strong negative correlation of r = − 0.81 and r = − 0.70, respectively. Flooding is directly related to the drainage density of a river basin. High drainage density is directly associated with a higher probability of disastrous floods since it indicates high runoff from the surface. The stream network was extracted from the ASTER DEM and a drainage density map was created using the spatial analyst ArcGIS (10.8). This drainage density ranges from 2.2 to 3.8 km/ km2 in the middle and downstream parts of the study area, which are more likely to cause flooding. Zones of very high flood vulnerability are located in the downstream region, i.e., in the eastern part of the basin. More than 50% of agricultural land and 16% of the settlement areas come under the zone of very high flood vulnerability. The high and moderate flood hazard zone affected areas are 23.05 and 32.11 percent, respectively, which is a cause for concern. [ABSTRACT FROM AUTHOR]

Background: For mechanically ventilated critically ill COVID-19 patients, prone positioning has quickly become an important treatment strategy, however, prone positioning is labor intensive and comes with potential adverse effects. Therefore, identifying which critically ill intubated COVID-19 patients will benefit may help allocate labor resources. Methods: From the multi-center Dutch Data Warehouse of COVID-19 ICU patients from 25 hospitals, we selected all 3619 episodes of prone positioning in 1142 invasively mechanically ventilated patients. We excluded episodes longer than 24 h. Berlin ARDS criteria were not formally documented. We used supervised machine learning algorithms Logistic Regression, Random Forest, Naive Bayes, K-Nearest Neighbors, Support Vector Machine and Extreme Gradient Boosting on readily available and clinically relevant features to predict success of prone positioning after 4 h (window of 1 to 7 h) based on various possible outcomes. These outcomes were defined as improvements of at least 10% in PaO2/FiO2 ratio, ventilatory ratio, respiratory system compliance, or mechanical power. Separate models were created for each of these outcomes. Re-supination within 4 h after pronation was labeled as failure. We also developed models using a 20 mmHg improvement cut-off for PaO2/FiO2 ratio and using a combined outcome parameter. For all models, we evaluated feature importance expressed as contribution to predictive performance based on their relative ranking. Results: The median duration of prone episodes was 17 h (11–20, median and IQR, N = 2632). Despite extensive modeling using a plethora of machine learning techniques and a large number of potentially clinically relevant features, discrimination between responders and non-responders remained poor with an area under the receiver operator characteristic curve of 0.62 for PaO2/FiO2 ratio using Logistic Regression, Random Forest and XGBoost. Feature importance was inconsistent between models for different outcomes. Notably, not even being a previous responder to prone positioning, or PEEP-levels before prone positioning, provided any meaningful contribution to predicting a successful next proning episode. Conclusions: In mechanically ventilated COVID-19 patients, predicting the success of prone positioning using clinically relevant and readily available parameters from electronic health records is currently not feasible. Given the current evidence base, a liberal approach to proning in all patients with severe COVID-19 ARDS is therefore justified and in particular regardless of previous results of proning. [ABSTRACT FROM AUTHOR]

Background: Celiac disease requires appropriate management and support, both medically and psychologically. This is especially important for adolescents, who may benefit from relevant peer interactions. Objective: This study evaluated the effects of interactive peer support on quality of life, friendship relations, and coping levels among adolescents with celiac disease. Method: This was a randomized controlled trial in which 36 adolescents (13–18 years of age) with celiac disease were equally divided into study and control groups. The study group was exposed to six interactive peer group sessions that were held every other week for 3 months under the supervision of nurses, while the control group was not exposed to any sessions, training, or consulting. All were assessed at baseline and post-intervention via the Pediatric Quality of Life Inventory, Friendship Qualities Scale, and KIDCOPE scale. Results: Several changes were detected upon final assessment. First, the mean scores for the PedsQL and FSS were significantly higher in the study group when compared to the control group. Second, the study group had higher mean scores for active coping and avoidance coping when compared to baseline. Third, the study group had significantly lower mean scores for negative coping when compared to the control group. Conclusions: Under the supervision of nurses, participants who were exposed to the peer support group showed improved quality of life, decreased social isolation, and enhanced positive coping strategies when dealing with celiac disease. ClinicalTrials.gov Identifier NCT04533776. [ABSTRACT FROM AUTHOR]

Some patients affected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) experience acute hypoxemic respiratory failure progressing toward atypical acute respiratory distress syndrome (ARDS). The aim of the study is to evaluate whether a correlation between ratio of peripheral saturation of oxygen (SpO2) and fraction of inspired oxygen (S/F) and ratio of arterial partial pressure of oxygen and fraction of inspired oxygen (P/F) exists in COVID-19-related ARDS as already known in classical ARDS. In this multicenter, retrospective, observational study, consecutive, adult (≥ 18 years) patients with symptomatic coronavirus disease 2019 (COVID-19) admitted to different COVID-19 divisions in Italy between March and December 2020 were included. Patients with SpO2 > 97% or missing information were excluded. We included 1,028 patients (median age 72 years, prevalence of males [62.2%]). A positive correlation was found between P/F and S/F (r = 0.938, p < 0.0001). A receiver operating characteristic (ROC) curve analysis showed that S/F accurately recognizes the presence of ARDS (P/F ≤ 300 mmHg) in COVID-19 patients, with a cut-off of ≤ 433% showing good sensitivity and specificity. S/F was also tested against P/F values ≤ 200 and ≤ 100 mmHg (suggestive for moderate and severe ARDS, respectively), the latter showing great accuracy for S/F ≤ 178%. S/F was accurate in predicting ARDS for SpO2 ≥ 92%. In conclusion, our findings support the routine use of S/F as a reliable surrogate of P/F in patients with COVID-19-related ARDS. [ABSTRACT FROM AUTHOR]

One of the most helpful strategies to deal with ongoing coronavirus pandemics is to use some prudence when treating patients infected with SARS-CoV-2. We aimed to evaluate the clinical, demographic, and laboratory parameters that might have predictive value for in-hospital mortality and the need for intensive care and build a model based on them. This study was a prospective, observational, single-center study including non-critical patients admitted to COVID-19 wards. Besides classical clinic-demographic features, basic laboratory parameters obtained on admission were tested, and then new models for each outcome were developed built on the most significant variables. Receiver operating characteristics (ROC) analyses were performed by calculating each model's probability. A total of 368 non-critical hospitalized patients were recruited, the need for ICU care was observed in 70 patients (19%). The total number of patients who died in either ICU or wards was 39 (10.6%). The first two models (based on clinical features and demographics) were developed to predict ICU and death, respectively; older age, male sex, active cancer, and low baseline saturation were noted to be independent predictors. The area under the curve values of the first two models were noted 0.878 and 0.882 (p <.001; confidence interval [CI] 95% [0.837–0.919], p <.001; CI 95% [0.844–0.922]). Following two models, the third and fourth were based on laboratory parameters with clinic-demographic features. Initial lower sodium and lower albumin levels were determined as independent factors in predicting the need for ICU care; higher blood urea nitrogen and lower albumin were independent factors in predicting in-hospital mortality. The area under the curve values of the third and fourth model was noted 0.938 and 0.929, respectively (p <.001; CI 95% [0.912–0.965], p <.001; CI 95% [0.895–962]). By integrating the widely available blood tests results with simple clinic demographic data, non-critical patients can be stratified according to their risk level. Such stratification is essential to filter the patients' non-critical underlying diseases and conditions that can obfuscate the physician's predictive capacity. [ABSTRACT FROM AUTHOR]

While plateau airway pressure alone is an unreliable estimate of lung overdistension inspiratory transpulmonary pressure (PL) is an important parameter to reflect it in patients with ARDS and there is no concensus about which computation method should be used to calculate it. Recent studies suggest that different formulas may lead to different tidal volume and PEEP settings. The aim of this study is to compare 3 different inspiratory PL measurement method; direct measurement (PLD), elastance derived (PLE) and release derived (PLR) methods in patients with multiple mechanical abnormalities. 34 patients were included in this prospective observational study. Measurements were obtained during volume controlled mechanical ventilation in sedated and paralyzed patients. During the study day airway and eosephageal pressures, flow, tidal volume were measured and elastance, inspiratory PLE, PLD and PLR were calculated. Mean age of the patients was 67 ± 15 years and APACHE II score was 27 ± 7. Most frequent diagnosis of the patients were pneumonia (71%), COPD exacerbation(56%), pleural effusion (55%) and heart failure(50%). Mean plateau pressure of the patients was 22 ± 5 cmH2O and mean respiratory system elastance was 36.7 ± 13 cmH2O/L. EL/ERS% was 0.75 ± 0.35%. Mean expiratory transpulmonary pressure was 0.54 ± 7.7 cmH2O (min: − 21, max: 12). Mean PLE (18 ± 9 H2O) was significantly higher than PLD (13 ± 9 cmH2O) and PLR methods (11 ± 9 cmH2O). There was a good aggreement and there was no bias between the measurements in Bland–Altman analysis. The estimated bias was similar between the PLD and PLE (− 3.12 ± 11 cmH2O) and PLE and PLR (3.9 ± 10.9 cmH2O) measurements. Our results suggest that standardization of calculation method of inspiratory PL is necessary before using it routinely to estimate alveolar overdistension. [ABSTRACT FROM AUTHOR]

Dysphagia, a serious health issue, is common in healthcare residents and the elderly. Food thickening agents, including starch- and gum-based thickeners, have been widely used in the treatment and nursing of patients with dysphagia and can effectively reduce the risk of aspiration. In order to provide a reference for medical staff in clinical use, the dietary grades of eating disorders in multiple countries, the rheological parameters, types, characteristics and the latest research of common food thickeners were summarized in this review. Furthermore, the sensory attributes, rheological properties, dysphagic patients' preference and risks of accidental aspiration were also compared between starch- and gum-thickened foods. [ABSTRACT FROM AUTHOR]

Infant dysphagia is commonly managed using thickened formulas. Substantial research investigates thickening of a variety of beverages for adults and children, yet few studies address the unique considerations of thickened formula for infants. Understanding the consistency and behaviour of thickened formula will guide clinicians and parents to make informed decisions to minimise risk of aspiration. To investigate the effect of time and storage temperature on the flow properties of thickened formula, four formulas and two thickeners currently utilised at a major metropolitan children's hospital in Australia were tested in combinations, at refrigerated and room temperatures. Their flow properties were measured at three time-points (baseline, 1 h, 24 h) using the International Dysphagia Diet Standardisation Initiative (IDDSI) Flow Test, the current clinical standard for classifying drinks based on flow properties. A combination of paired t tests, Wilcoxon Signed-Rank tests, repeated measures analysis of variance (ANOVA) and Cohen's d was used to statistically compare flow properties and determine the significance of the observed data. At baseline, 98% (n = 48) of the thickened formula bottles were measured as thinner than the "mildly thick" IDDSI category to which they were prepared. Conversely, at 24 h, 17% were measured thicker than "mildly thick" whilst 10% measured too thin for the category "mildly thick". Refrigerated samples increased in thickness more significantly over time compared to those stored at room temperature. Two of the formulas, when thickened, resulted in a foamy mixture non-compatible with IDDSI Flow Test measurement. As a result, these two formulas were not subjected to further testing. All the tested commercial products behaved differently to each other and were unstable over varying times and temperatures. This finding indicates the need for improved guidelines regarding preparation and storage of thickened fluids. Further investigation is recommended into the chemical processes underlying the observed deviations. [ABSTRACT FROM AUTHOR]

Severe COVID-19-related acute respiratory distress syndrome (C-ARDS) requires mechanical ventilation. While this intervention is often performed in the prone position to improve oxygenation, the underlying mechanisms responsible for the improvement in respiratory function during invasive ventilation and awake prone positioning in C-ARDS have not yet been elucidated. In this prospective observational trial, we evaluated the respiratory function of C-ARDS patients while in the supine and prone positions during invasive (n = 13) or non-invasive ventilation (n = 15). The primary endpoint was the positional change in lung regional aeration, assessed with electrical impedance tomography. Secondary endpoints included parameters of ventilation and oxygenation, volumetric capnography, respiratory system mechanics and intrapulmonary shunt fraction. In comparison to the supine position, the prone position significantly increased ventilation distribution in dorsal lung zones for patients under invasive ventilation (53.3 ± 18.3% vs. 43.8 ± 12.3%, percentage of dorsal lung aeration ± standard deviation in prone and supine positions, respectively; p = 0.014); whereas, regional aeration in both positions did not change during non-invasive ventilation (36.4 ± 11.4% vs. 33.7 ± 10.1%; p = 0.43). Prone positioning significantly improved the oxygenation both during invasive and non-invasive ventilation. For invasively ventilated patients reduced intrapulmonary shunt fraction, ventilation dead space and respiratory resistance were observed in the prone position. Oxygenation is improved during non-invasive and invasive ventilation with prone positioning in patients with C-ARDS. Different mechanisms may underly this benefit during these two ventilation modalities, driven by improved distribution of lung regional aeration, intrapulmonary shunt fraction and ventilation-perfusion matching. However, the differences in the severity of C-ARDS may have biased the sensitivity of electrical impedance tomography when comparing positional changes between the protocol groups. Trial registration: ClinicalTrials.gov (NCT04359407) and Registered 24 April 2020, https://clinicaltrials.gov/ct2/show/NCT04359407. [ABSTRACT FROM AUTHOR]

Purpose: Oropharyngeal dysphagia (OD) is a common phenomenon in otorhinolaryngology and phoniatrics. As both sub-disciplines have a strong tradition and clinical experience in endoscopic assessment of the upper aerodigestive tract, the implementation of fiberoptic endoscopic evaluation of swallowing (FEES) was an almost self-evident evolution. This review aims to provide an update on FEES and the role of phoniatricians and otorhinolaryngologists using FEES in Europe. Methods: A narrative review of the literature was performed by experts in the field of FEES both in the clinical context and in the field of scientific research. Results: FEES is the first-choice OD assessment technique for both phoniatricians and otorhinolaryngologists. FEES is becoming increasingly popular because of its usefulness, safety, low costs, wide applicability, and feasibility in different clinical settings. FEES can be performed by health professionals of varying disciplines, once adequate knowledge and skills are acquired. FEES aims to determine OD nature and severity and can provide diagnostic information regarding the underlying etiology. The direct effect of therapeutic interventions can be evaluated using FEES, contributing to design the OD management plan. Standardization of FEES protocols and metrics is still lacking. Technological innovation regarding image resolution, frame rate frequency, endoscopic light source specifications, and endoscopic rotation range has contributed to an increased diagnostic accuracy. Conclusion: The rising number of phoniatricians and otorhinolaryngologists performing FEES contributes to the early detection and treatment of OD in an aging European population. Nevertheless, a multidisciplinary approach together with other disciplines is crucial for the success of OD management. [ABSTRACT FROM AUTHOR]

Children with dysphagia, or swallowing disorder, are at an increased risk for developing respiratory compromise, failure to thrive, and aversion. Thickened liquids can be recommended for children with dysphagia, if shown to be effective on instrumental examination and if strategies/interventions with thin liquids are not successful. Thickened liquids have many benefits, including creating a more cohesive bolus, slowing oropharyngeal transit time, and reducing aspiration. However, preparing thickened liquids with commercially available thickeners can result in poor compliance due to concerns regarding taste, texture, accessibility, cost, thickness variability, and potential negative impact of these substances on a child's immature digestive tract. The purpose of this study was to determine if liquids could be successfully thickened with widely available, commercial pureed foods, and to assess how these mixtures compare to starch and gum based thickening agents. The International Dysphagia Diet Standardisation Initiative (IDDSI) flow test was performed for each sample of puree thickened liquids, gum based thickened water, and cornstarch based thickened water. In addition, rheology testing was performed on each category of the samples to measure viscosity at various shear rates and temperatures, and to assess the presence of yield stress. Results revealed that liquids thickened with smooth textured purees were comparable to commercial starch and gum based thickeners, and may be offered as a viable alternative. [ABSTRACT FROM AUTHOR]

Ensuring inpatients with dysphagia receive and consume the correct texture-modified diet and thickened fluid prescriptions is challenging, and errors can result in significant complications for patients and increased costs to hospitals. The aim of this study was to investigate underlying factors that help or hinder receipt and consumption of correct dietary prescriptions for people with dysphagia in the hospital setting then implement and evaluate a range of strategies to address identified issues. A mixed-methods study design, using an integrated knowledge translation approach, was conducted in three phases. In Phase 1, clinical incident data (i.e., documented incidents of diet/fluid errors, with errors defined as the provision or consumption of any food/fluid not appropriate for a patient's dietary prescription) were analyzed, and staff, patients, and family members were interviewed using the Theoretical Domains Framework to identify factors contributing to errors. In Phase 2, health professionals assisted with the development and implementation of interventions targeted at micro (patient/family), meso (staff), and macro (organizational) levels to address factors identified in Phase 1. In Phase 3, outcomes including the change in number of dietary clinical incidents pre- to post-intervention, meal accuracy error rates from mealtime audits post-intervention, and follow-up interviews were evaluated using quantitative and qualitative measures. Post-intervention, there was a 50% reduction in clinical incidents, and a 2.3% meal accuracy error rate was observed. Staff reported most interventions were acceptable and feasible within their workload, although some interventions were not well embedded in everyday practice. This study highlights the value in using an integrated knowledge translation approach to inform tailored interventions targeting improved dietary accuracy in the hospital setting. [ABSTRACT FROM AUTHOR]

Background: Mechanical power is a promising new metric to assess energy transfer from a mechanical ventilator to a patient, which combines the contributions of multiple parameters into a single comprehensive value. However, at present, most ventilators are not capable of calculating mechanical power automatically, so there is a need for a simple equation that can be used to estimate this parameter at the bedside. For volume-controlled ventilation (VCV), excellent equations exist for calculating power from basic ventilator parameters, but for pressure-controlled ventilation (PCV), an accurate, easy-to-use equation has been elusive. Results: Here, we present a new power equation and evaluate its accuracy compared to the three published PCV power equations. When applied to a sample of 50 patients on PCV with a non-zero rise time, we found that our equation estimated power within an average of 8.4% ± 5.9% (mean ± standard deviation) of the value obtained by numerical integration of the P–V loop. The other three equations estimated power with an error of 19.4% ± 12.9% (simplified Becher equation), 10.0% ± 6.8% (comprehensive Becher equation), and 16.5% ± 14.6% (van der Meijden equation). Conclusions: Our equation calculates power more accurately than the other three published equations, and is much easier to use than the only previously published equation with similar accuracy. The proposed new mechanical power equation is accurate and simple to use, making it an attractive option to estimate power in PCV cases at the bedside. [ABSTRACT FROM AUTHOR]

Considering that thickened liquids are frequently used for patients with dysphagia, elucidating their impact on laryngeal dynamics is important. Although studies have investigated the impact of thickened liquids on laryngeal movement velocity among healthy young adults, no study has examined the same among patients with dysphagia. We aimed to elucidate the influence of bolus consistency on laryngeal movement velocity and surface electromyographic activity of the suprahyoid muscles in patients with dysphagia. Participants included 18 male, poststroke patients with dysphagia, whereas patients with true bulbar paralysis, head and neck cancer, neuromuscular disease, or recurrent nerve paralysis were excluded. A video fluoroscopic swallowing study (VFSS) was performed while swallowing 3 mL of moderately thick and thin liquids. Quantitative VFSS analysis, including factors such as laryngeal peak velocity, laryngeal mean velocity, laryngeal movement distance, duration of the laryngeal elevation movement, and the temporal location of laryngeal vestibule closure within the laryngeal elevation movement was performed. Muscle activity was evaluated using integrated muscles activity values obtained from electromyography (iEMG) of the suprahyoid muscle during swallowing. VFSS analysis showed that laryngeal peak velocity and laryngeal mean velocity were significantly faster while swallowing moderately thick than while swallowing thin liquids. Laryngeal movement distance was significantly greater while swallowing moderately thick than while swallowing thin liquids. iEMG was significantly higher while swallowing moderately thick liquids than while swallowing thin liquids. Compared to thin liquids, moderately thick induced an increase in laryngeal movement velocity and in suprahyoid muscle activity among patients with dysphagia, a finding consistent with that of a previous study among healthy adults. [ABSTRACT FROM AUTHOR]

Background: SARS-CoV-2 infection, manifesting as COVID-19 pneumonia, constitutes a global pandemic that is disrupting health-care systems. Most patients who are infected are asymptomatic/pauci-symptomatic can safely self-isolate at home. However, even previously healthy individuals can deteriorate rapidly with life-threatening respiratory failure characterized by disproportionate hypoxemic failure compared to symptoms. Ultrasound findings have been proposed as an early indicator of progression to severe disease. Furthermore, ultrasound is a safe imaging modality that can be performed by novice users remotely guided by experts. We thus examined the feasibility of utilizing common household informatic-technologies to facilitate self-performed lung ultrasound. Methods: A lung ultrasound expert remotely mentored and guided participants to image their own chests with a hand-held ultrasound transducer. The results were evaluated in real time by the mentor, and independently scored by three independent experts [planned a priori]. The primary outcomes were feasibility in obtaining good-quality interpretable images from each anatomic location recommended for COVID-19 diagnosis. Results: Twenty-seven adults volunteered. All could be guided to obtain images of the pleura of the 8 anterior and lateral lung zones (216/216 attempts). These images were rated as interpretable by the 3 experts in 99.8% (647/648) of reviews. Fully imaging one's posterior region was harder; only 108/162 (66%) of image acquisitions was possible. Of these, 99.3% of images were interpretable in blinded evaluations. However, 52/54 (96%) of participants could image their lower posterior lung bases, where COVID-19 is most common, with 99.3% rated as interpretable. Conclusions: Ultrasound-novice adults at risk for COVID-19 deterioration can be successfully mentored using freely available software and low-cost ultrasound devices to provide meaningful lung ultrasound surveillance of themselves that could potentially stratify asymptomatic/paucisymptomatic patients with early risk factors for serious disease. Further studies examining practical logistics should be conducted. Trial Registration: ID ISRCTN/77929274 on 07/03/2015. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed at investigating the mechanisms underlying the oxygenation response to proning and recruitment maneuvers in coronavirus disease 2019 (COVID-19) pneumonia. Methods: Twenty-five patients with COVID-19 pneumonia, at variable times since admission (from 1 to 3 weeks), underwent computed tomography (CT) lung scans, gas-exchange and lung-mechanics measurement in supine and prone positions at 5 cmH2O and during recruiting maneuver (supine, 35 cmH2O). Within the non-aerated tissue, we differentiated the atelectatic and consolidated tissue (recruitable and non-recruitable at 35 cmH2O of airway pressure). Positive/negative response to proning/recruitment was defined as increase/decrease of PaO2/FiO2. Apparent perfusion ratio was computed as venous admixture/non aerated tissue fraction. Results: The average values of venous admixture and PaO2/FiO2 ratio were similar in supine-5 and prone-5. However, the PaO2/FiO2 changes (increasing in 65% of the patients and decreasing in 35%, from supine to prone) correlated with the balance between resolution of dorsal atelectasis and formation of ventral atelectasis (p = 0.002). Dorsal consolidated tissue determined this balance, being inversely related with dorsal recruitment (p = 0.012). From supine-5 to supine-35, the apparent perfusion ratio increased from 1.38 ± 0.71 to 2.15 ± 1.15 (p = 0.004) while PaO2/FiO2 ratio increased in 52% and decreased in 48% of patients. Non-responders had consolidated tissue fraction of 0.27 ± 0.1 vs. 0.18 ± 0.1 in the responding cohort (p = 0.04). Consolidated tissue, PaCO2 and respiratory system elastance were higher in patients assessed late (all p < 0.05), suggesting, all together, "fibrotic-like" changes of the lung over time. Conclusion: The amount of consolidated tissue was higher in patients assessed during the third week and determined the oxygenation responses following pronation and recruitment maneuvers. [ABSTRACT FROM AUTHOR]