Search

Purpose: The triglyceride-glucose (TyG) index is a surrogate biomarker of insulin resistance which has been widely used in intensive care unit (ICU) to predict prognosis. However, its role in critically ill acute exacerbation of COPD (AECOPD) patients remains largely unknown., Material and Methods: A total of 645 AECOPD patients were induced in this retrospective cohort study, which extracted data from the eICU Collaborative Research Database (eICU-CRD). The TyG index was calculated as Ln (fasting triglycerides (mg/dL) × fasting plasma glucose (mg/dL)/2). The primary endpoint includes in-hospital mortality and ICU mortality. The secondary endpoint was sepsis, acute kidney injury (AKI), and acute respiratory failure (ARF)., Results: Multivariable Cox regression analysis revealed that the TyG index was independently associated with an increased risk of in-hospital mortality (hazard ratio, HR: 1.45, 95% CI: 1.04-2.01, P = 0.028) and ICU mortality (HR: 2.13, 95% CI: 1.28-3.54, P = 0.004). Moreover, the TyG index was independently associated with an increased risk of sepsis (odds ratio, OR: 1.54, 95% CI: 1.24-1.93, P < 0.001), AKI (OR: 1.57, 95% CI: 1.26-2.02, P < 0.001) and ARF (OR: 1.50, 95% CI: 1.20-1.87, P < 0.001). Kaplan-Meier survival analysis revealed that higher TyG indexes were also related to increased in-hospital mortality and ICU mortality. In addition, the restricted cubic splines regression model demonstrated that the in-hospital mortality and ICU mortality increased linearly with increasing TyG index (P for non-linearity = 0.897, P for non-linearity = 0.897, respectively)., Conclusion: Elevated TyG index was independently associated with an increased risk of poor clinical outcomes in critically ill AECOPD patients. A prospective study to define TyG as a biomarker for prognosis prediction in critically ill AECOPD patients is warranted., Competing Interests: The authors declare that they have no conflict of interest., (© 2024 Wang et al.)

Diseases associated with chronic respiratory failure have a negative impact on quality of life and life expectancy, notably through a reduction in patients' functional capacity. Assessing balance, coordination, muscular strength and endurance, as well as exercise tolerance, is therefore an important component of the evaluation of individuals with chronic respiratory failure. This evaluation can be made easier by using simple tools such as sit-to-stand tests. This review presents the main sit-to-stand tests that have been described and that can be used in everyday practice. The aim is to provide information to the clinician on the contribution of each test, and to identify the extent to which and the purpose for which these tests can be incorporated into a routine pulmonology and/or respiratory rehabilitation evaluation. Because of their inherently functional nature, these tests could help to identify the indications and/or the effects of respiratory rehabilitation., (Copyright © 2024 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

X-linked myotubular myopathy (XLMTM) is a rare, life-threatening congenital myopathy. Most (80%) children with XLMTM have profound muscle weakness and hypotonia at birth resulting in severe respiratory insufficiency, the inability to sit up, stand or walk, and early mortality. At birth, 85-90% of children with XLMTM require mechanical ventilation, with more than half requiring invasive ventilator support. Historically, ventilator-dependent children with neuromuscular-derived respiratory failure of this degree and nature, static or progressive, are not expected to achieve complete independence from mechanical ventilator support. In the ASPIRO clinical trial (NCT03199469), participants receiving a single intravenous dose of an investigational gene therapy (resamirigene bilparvovec) started showing significant improvements in daily hours of ventilation support compared with controls by 24 weeks post-dosing, and 16 of 24 dosed participants achieved ventilator independence between 14 and 97 weeks after dosing. At the time, there was no precedent or published guidance for weaning chronically ventilated children with congenital neuromuscular diseases off mechanical ventilation. When the first ASPIRO participants started showing dramatically improved respiratory function, the investigators initiated efforts to safely wean them off ventilator support, in parallel with primary protocol respiratory outcome measures. A group of experts in respiratory care and physiology and management of children with XLMTM developed an algorithm to safely wean children in the ASPIRO trial off mechanical ventilation as their respiratory muscle strength increased. The algorithm developed for this trial provides recommendations for assessing weaning readiness, a stepwise approach to weaning, and monitoring of children during and after the weaning process., (© 2024. The Author(s).)

Background: Opioid overdose is a global health crisis, affecting over 27 million individuals worldwide, with more than 100,000 drug overdose deaths in the United States in 2022-2023. This protocol outlines the development of the PneumoWave chest biosensor, a wearable device being designed to detect respiratory depression in real time through chest motion measurement, intending to enhance early intervention and thereby reduce fatalities., Objective: The study aims to (1) differentiate opioid-induced respiratory depression (OIRD) from nonfatal opioid use patterns to develop and refine an overdose detection algorithm and (2) examine participants' acceptability of the chest biosensor., Methods: The study adopts an observational design over a 6-month period. The biosensor, a small device, will be worn by consenting participants during injecting events to capture chest motion data. Safe injecting facilities (SIF) in Melbourne, Victoria (site 1), and Sydney, New South Wales (site 2), which are legally sanctioned spaces where individuals can use preobtained illicit drugs under medical supervision. Each site is anticipated to recruit up to 100 participants who inject opioids and attend the SIF. Participants will wear the biosensor during supervised injecting events at both sites. The biosensor will attempt to capture data on an anticipated 40 adverse drug events. The biosensor's ability to detect OIRD will be compared to the staff-identified events that use standard protocols for managing overdoses. Measurements will include (1) chest wall movement measured by the biosensor, securely streamed to a cloud, and analyzed to refine an overdose detection algorithm and (2) acute events or potential overdose identified by site staff. Acceptability will be measured by a feedback questionnaire as many times as the participant is willing to throughout the study., Results: As of April 2024, a total of 47 participants have been enrolled and data from 1145 injecting events have already been collected, including 10 overdose events. This consists of 17 females and 30 males with an average age of 45 years. Data analysis is ongoing., Conclusions: This protocol establishes a foundation for advancing wearable technology in opioid overdose prevention within SIFs. The study will provide chest wall movement data and associated overdose data that will be used to train an algorithm that allows the biosensor to detect an overdose. The study will contribute crucial insights into OIRD, emphasizing the biosensor's potential step forward in real-time intervention strategies., International Registered Report Identifier (irrid): DERR1-10.2196/57367., (©Basak Tas, Will Lawn, Marianne Jauncey, Mark Bartlett, Paul Dietze, Daniel O'Keefe, Nico Clark, Bruce Henderson, Catriona Cowan, Osian Meredith, John Strang. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 10.09.2024.)

Background: Identification of hypoxaemia and hypercapnia is essential for the diagnosis and treatment of acute respiratory failure. While arterial blood gas (ABG) analysis is standard for PO 2 and PCO 2 measurement, venous blood gas (VBG) analysis is increasingly used as an alternative. Previous systematic reviews established that VBG reporting of PO 2 and PCO 2 is less accurate, but the impacts on clinical management and patient outcomes are unknown., Aims: This study aimed to systematically review available evidence of the clinical impacts of using ABGs or VBGs and examine the arteriovenous difference in blood gas parameters., Methods: A comprehensive search of the MEDLINE, Embase and Cochrane Library databases since inception was conducted. Included studies were prospective or cross-sectional studies comparing peripheral ABG to peripheral VBG in adult non-critical care inpatients presenting with respiratory symptoms., Results: Of 15 119 articles screened, 15 were included. No studies were found that examined clinical impacts resulting from using VBG compared to ABG. Included studies focused on the agreement between ABG and VBG measurements of pH, PO 2 , PCO 2 and HCO 3 - . Due to the heterogeneity of the included studies, qualitative evidence synthesis was performed. While the arteriovenous difference in pH and HCO 3 - was generally predictable, the difference in PO 2 and PCO 2 was more significant and less predictable., Conclusions: Our study reinforces the notion that VBG is not comparable to ABG for physiological measurements. However, a key revelation from our research is the significant lack of data regarding the clinical implications of using VBG instead of ABG, a common scenario in clinical practice. This highlights a critical knowledge gap., (© 2024 The Author(s). Internal Medicine Journal published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Physicians.)

Undiagnosed chronic hypercapnic respiratory failure may be encountered during the evaluation of sleep-related breathing disorders at the sleep clinic. This article reviews the mechanism of chronic hypercapnic respiratory failure and the systematic approach to the assessment of specific sleep disorders associated with nocturnal hypoventilation encountered in clinical practice., Competing Interests: Disclosure The authors have no conflict of interest to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Competing Interests: The authors report no conflicts of interest.

Background: In amyotrophic lateral sclerosis (ALS) prognosis is poor due to progressive weakening of the respiratory muscles. Survival and quality of life can be improved by noninvasive ventilation (NIV), which is initially applied while sleeping. The indication for NIV is based on pulmonary function testing (PFT) and polysomnography (PSG) with capnography (tCO 2 ). While it is desirable to predict nocturnal ventilation by waking PFT in ALS, the parameters suited for reliable predictions remain elusive., Methods: We retrospectively analyzed parameters derived from PFT (spirometry, body plethysmography, diffusion capacity, respiratory muscle testing) and blood gas analysis, PSG and tCO 2 in 42 patients with ALS (27 men, 15 women, age 69 ± 12.1 years) and performed Spearman's correlation analysis of daytime waking parameters and nighttime sleep parameters., Results: 28 patients (66.7%) showed restrictive impairment of ventilation and 15 patients (48.3%) showed insufficiency of the respiratory musculature. There was no obstructive impairment of ventilation. We did not observe any significant correlations between any single daytime PFT parameter with nocturnal pCO 2 . However, there were significant correlations between the ratios PIF/PEF, MEF50/MIF50, DLCO/VA as well as FEV 1 /FVC and nocturnal pCO 2 . Highly normal FEV 1 /FVC and Krogh-Factor (DLCOc/VA) indicated nocturnal hypercapnia. Furthermore, waking hypercapnia, concentrations of bicarbonate and base excess were each positively correlated with nocturnal hypercapnia., Conclusions: Waking PFT is not a good predictor of nocturnal ventilation. Inspiratory parameters as well as the ratios FEV 1 /FVC and DLCO/VA performed best and should be included in the interpretation. Our analyses confirm the relevance of inspiratory muscle weakness in ALS. PSG and tCO 2 remain the gold standard for the assessment of nocturnal ventilation., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

A 13-day-old, late preterm male, born appropriate for gestational age, presented to the pediatric clinic for his routine 2-week well visit with less than 1-day history of decreased oral intake and lethargy. During the baby's well exam, he acutely decompensated and required resuscitation and transfer to the emergency department, where he was intubated for frequent apneic events. He was admitted to the NICU for management and further workup. Physical examination and initial laboratory tests were unremarkable. An EEG demonstrated electrographic and clinical seizures. His initial MRI was unremarkable, and infection studies revealed the diagnosis. We review the patient's initial presentation, evaluation, hospital course, and the long-term implications of his diagnosis., (Copyright © 2024 by the American Academy of Pediatrics.)

Purpose: Identifying thresholds at which the ROX index would satisfactorily predict HFNC failure across heterogenous resourced contexts is necessary for clinical use., Methods: Patients ≥18 years admitted to 30 diverse ICUs across 10 states in India who required HFNC for respiratory support were retrospectively included in this study. Patient data and hourly ROX indices were then analyzed and contextualized to clinical outcomes as well as with ROX index thresholds in other regions of the world., Measurements and Main Results: Among the 614 patients included, 276 (44.9%) required respiratory escalation. Pneumonia was the most common diagnosis on admission. Receiver operating characteristic curve analysis revealed that a baseline ROX score of 7.86 was similar to 4.88 in other populations which was confirmed by Kaplan-Mier curves (hazard ratio,3.58 (2.72-4.69, p < 0.001)). ROX scores at 11.84 or 5.89 had roles in screening and confirming HFNC failure. The index performed poorly in a subset of patients who died without respiratory escalation. The ROX index was most predictive in the initial hours of ICU admission and a longer duration of HFNC was associated with more severe outcomes., Conclusions: When optimally calibrated this index can using a method that can reliably predict the risk of HFNC failure among ICU patients from diverse settings., Competing Interests: Declaration of competing interest The authors have not conflicts of interest to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Goal: Analysis of the results of thrombectomy from the arteries of the lower extremities in patients with COVID-19 against the background of different severity of respiratory failure., Materials and Methods: This retrospective, cohort, comparative study for the period from 05/01/2022 to 20/07/2022 included 305 patients with acute thrombosis of the arteries of the lower extremities against the background of the course of COVID-19 (SARS-CoV-2 Omicron variant). Depending on the type of oxygen support, 3 groups of patients were formed: group 1 ( n = 168) - oxygen insufflation through nasal cannulas; group 2 ( n = 92) - non-invasive lung ventilation; and group 3 ( n = 45) - artificial lung ventilation., Results: Myocardial infarction and ischemic stroke were not detected in the total sample. The highest number of deaths (group 1: 5.3%, n = 9; group 2: 72.8%, n = 67; group 3: 100%, n = 45; p < 0.0001), rethrombosis (group 1 : 18.4%, n = 31; group 2: 69.5%, n = 64; group 3: 91.1%, n = 41; p < 0.0001), and limb amputations (group 1: 9.5%, n = 16; group 2: 56.5%, n = 52; group 3: 91.1%, n = 41; p < 0.0001) was recorded in group 3 (ventilated) patients., Conclusion: In patients infected with COVID-19 and on artificial lung ventilation, a more aggressive course of the disease is noted, expressed in an increase in laboratory parameters (C-reactive protein, ferritin, interleukin-6, and D-dimer) of the degree of pneumonia (CT-4 in overwhelming number) and localization of thrombosis of the arteries of the lower extremities, mainly in the tibial arteries., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Extracorporeal membrane oxygenation (ECMO) is a type of circulatory life support for patients with severe lung failure. The use of ECMO has increased worldwide since the pandemic of H1N1 in 2009 and more recently SARS-CoV-2 in 2020 both of which caused severe respiratory failure. ECMO patients experience both increased risk of bleeding and thrombosis. This is due to the pathological insult that damages the lungs, the ECMO circuit, coagulopathy, inflammation and anticoagulation. ECMO presents unique demands on the coagulation laboratory both in tests required to manage the patients and result interpretation. This is a personal opinion of 20 years ECMO experience as a clinical scientist and a short current review of the literature. It will focus on the laboratory coagulation tests used to manage ECMO patients, including different anticoagulants used, testing frequency and interpretation of the results., (© 2024 John Wiley & Sons Ltd.)

Study Objectives: Venous blood gases (VBGs) are not consistently considered suitable surrogates for arterial blood gases (ABGs) in assessing acute respiratory failure due to variable measurement error. The physiological stability of patients with chronic ventilatory failure may lead to improved agreement in this setting., Methods: Adults requiring ABGs for sleep or ventilation titration studies had VBGs drawn before or after each ABG, in a randomized order. Veno-arterial correlation and agreement were examined for carbon dioxide tension (PCO 2 ), pH, oxygen tension (PO 2 ), and oxygen saturation (SO 2 )., Results: We analyzed 115 VBG-ABG pairs from 61 patients. Arterial and venous measures were correlated ( P < .05) for PCO 2 ( r = .84) and pH ( r = .72), but not for PO 2 or SO 2 . Adjusted mean veno-arterial differences (95% limits of agreement) were +5.0 mmHg (-4.4 to +14.4) for PCO 2 ; -0.02 (-0.09 to +0.04) for pH; -34.3 mmHg (-78.5 to +10.0) for PO 2 ; and -23.9% (-61.3 to +13.5) for SO 2 . VBGs obtained from the dorsal hand demonstrated a lower mean PCO 2 veno-arterial difference ( P < .01). A venous PCO 2 threshold of ≥ 45.8 mmHg was > 95% sensitive for arterial hypercapnia, so measurements below this can exclude the diagnosis without an ABG. A venous PCO 2 threshold of ≥ 53.7 mmHg was > 95% specific for arterial hypercapnia, so such readings can be assumed diagnostic. The area under the receiver operating characteristic curve of 0.91 indicated high discriminatory capacity., Conclusions: A venous PCO 2 < 45.8 mmHg or ≥ 53.7 mmHg would exclude or diagnose hypercapnia, respectively, in patients referred for sleep studies, but VBGs are poor surrogates for ABGs where precision is important., Clinical Trial Registration: Registry: Australian New Zealand Clinical Trials Register; Name: A comparison of arterial and blood gas analyses in sleep studies; URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372717; Identifier: ACTRN12617000562370., Citation: Lindstrom SJ, McDonald CF, Howard ME, et al. Venous blood gases in the assessment of respiratory failure in patients undergoing sleep studies: a randomized study. J Clin Sleep Med . 2024;20(8):1259-1266., (© 2024 American Academy of Sleep Medicine.)

Background: The assessment of technical and nontechnical skills in emergency medicine requires reliable and usable tools. Three Acute Care Assessment Tools (ACATs) have been developed to assess medical learners in their management of cardiac arrest (ACAT-CA), coma (ACAT-coma) and acute respiratory failure (ACAT-ARF)., Objective: This study aims to analyze the reliability and usability of the three ACATs when used for in situ (bedside) simulation., Methods: This prospective multicenter validation study tested ACATs using interprofessional in situ simulations in seven emergency departments and invited training residents to participate in them. Each session was rated by two independent raters using ACAT. Intraclass correlation coefficients (ICC) were used to assess interrater reliability, and Cronbach's alpha coefficient was used to assess internal consistency for each ACAT. The correlation between ACATs' scores and the learners' level of performance was also assessed. Finally, a questionnaire and two focus groups were used to assess the usability of the ACATs., Results: A total of 104 in situ simulation sessions, including 85 residents, were evaluated by 37 raters. The ICC for ACAT-CA, ACAT-coma and ACAT-ARF were 0.95 [95% confidence interval (CI), 0.93-0.98], 0.89 (95% CI, 0.77-0.95) and 0.92 (95%CI 0.83-0.96), respectively. The Cronbach's alphas were 0.79, 0.80 and 0.73, respectively. The ACAT-CA and ARF showed good construct validity, as third-year residents obtained significantly higher scores than first-year residents ( P  < 0.001; P  < 0.019). The raters supported the usability of the tools, even though they expressed concerns regarding the use of simulations in a summative way., Conclusion: This study reported that the three ACATs showed good external validity and usability., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Systemic sclerosis (SSc) can lead to dyspnea and respiratory failure through multiple mechanisms, making a precise diagnosis particularly challenging, especially amid the current COVID-19 pandemic. In this report, we present a case involving a 26-year-old female who had previously undiagnosed SSc. She experienced acute respiratory failure necessitating orotracheal intubation. Following an extensive evaluation, the patient exhibited skin thickening, kidney failure, thrombocytopenia, microangiopathic anemia, and an antinuclear antibody with a nuclear fine speckled pattern at a titer of 1:320. A diagnosis of SSc complicated by scleroderma renal crisis (SRC) was established. The patient's condition improved after undergoing hemodialysis, receiving an angiotensin-converting enzyme inhibitor, and undergoing cyclophosphamide treatment. Subsequently, she demonstrated sustained improvement during a follow-up period of 20 months., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Morphine relieves dyspnea in various clinical circumstances. Whether or not this applies to patients admitted to intensive care units (ICUs) for acute respiratory failure (ARF) is unknown. We evaluated the efficacy and safety of low-dose morphine on dyspnea in patients admitted to the ICU for ARF., Methods: In this single-center, double-blind, phase 2, randomized, controlled trial, we assigned non-intubated adults admitted to the ICU for ARF with severe dyspnea, defined by a visual analog scale for dyspnea (dyspnea-VAS) from zero (no dyspnea) to 100 mm (worst imaginable dyspnea) ≥40 mm, to receive a low dose of Morphine Hydrochloride (intravenous titration followed by subcutaneous relay) or Placebo. All patients received standard therapy, including etiological treatment and non-invasive respiratory support., Results: Twenty-two patients were randomized, 11 in each group. The average dyspnea (median [interquartile range]) over 24 hours did not significantly differ between the two groups (40 [25 - 43] mm in the Morphine group vs. 40 [36 - 49] mm in the Placebo group, p=0.411). Dyspnea-VAS was lower in the Morphine group than in the Placebo group at the end of intravenous titration (30 [11 - 30] vs. 35 [30 - 44], p=0.044) and four hours later (18 [10 - 29] vs. 50 [30 - 60], p=0.043). The cumulative probability of intubation was higher in the Morphine group than in the Placebo group (p=0.046) CONCLUSION: In this phase 2 pilot trial, morphine did not improve 24-hour average dyspnea in adult patients with ARF, even though it had a statistically significant immediate effect. Of concern, Morphine use was associated with a higher intubation rate., Trial Registration: The protocol was declared on the ClinicalTrial.gov database (no. NCT04358133) and was published in September 2022., (© 2024. The Author(s).)

Gastroenterology nurses working across a variety of clinical settings are responsible for periprocedural monitoring during moderate to deep procedural sedation and analgesia (PSA) to identify signs of respiratory compromise and intervene to prevent cardiorespiratory events. Pulse oximetry is the standard of care for respiratory monitoring, but it may delay or fail to detect abnormal ventilation during PSA. Continuous capnography, which measures end-tidal CO2 as a marker of alveolar ventilation, has been endorsed by a number of clinical guidelines. Large clinical trials have demonstrated that the addition of continuous capnography to pulse oximetry during PSA for various gastroenterological procedures reduces the incidence of hypoxemia, severe hypoxemia, and apnea. Studies have shown that the cost of adding continuous capnography is offset by the reduction in adverse events and hospital length of stay. In the postanesthesia care unit, continuous capnography is being evaluated for monitoring opioid-induced respiratory depression and to guide artificial airway removal. Studies are also examining the utility of continuous capnography to predict the risk of opioid-induced respiratory depression among patients receiving opioids for primary analgesia. Continuous capnography monitoring has become an essential tool to detect early signs of respiratory compromise in patients receiving PSA during gastroenterological procedures. When combined with pulse oximetry, it can help reduce cardiorespiratory adverse events, improve patient outcomes and safety, and reduce health care costs., (Copyright © 2024 Society of Gastroenterology Nurses and Associates.)

Background: Adjustment for race is discouraged in lung-function testing, but the implications of adopting race-neutral equations have not been comprehensively quantified., Methods: We obtained longitudinal data from 369,077 participants in the National Health and Nutrition Examination Survey, U.K. Biobank, the Multi-Ethnic Study of Atherosclerosis, and the Organ Procurement and Transplantation Network. Using these data, we compared the race-based 2012 Global Lung Function Initiative (GLI-2012) equations with race-neutral equations introduced in 2022 (GLI-Global). Evaluated outcomes included national projections of clinical, occupational, and financial reclassifications; individual lung-allocation scores for transplantation priority; and concordance statistics (C statistics) for clinical prediction tasks., Results: Among the 249 million persons in the United States between 6 and 79 years of age who are able to produce high-quality spirometric results, the use of GLI-Global equations may reclassify ventilatory impairment for 12.5 million persons, medical impairment ratings for 8.16 million, occupational eligibility for 2.28 million, grading of chronic obstructive pulmonary disease for 2.05 million, and military disability compensation for 413,000. These potential changes differed according to race; for example, classifications of nonobstructive ventilatory impairment may change dramatically, increasing 141% (95% confidence interval [CI], 113 to 169) among Black persons and decreasing 69% (95% CI, 63 to 74) among White persons. Annual disability payments may increase by more than $1 billion among Black veterans and decrease by $0.5 billion among White veterans. GLI-2012 and GLI-Global equations had similar discriminative accuracy with regard to respiratory symptoms, health care utilization, new-onset disease, death from any cause, death related to respiratory disease, and death among persons on a transplant waiting list, with differences in C statistics ranging from -0.008 to 0.011., Conclusions: The use of race-based and race-neutral equations generated similarly accurate predictions of respiratory outcomes but assigned different disease classifications, occupational eligibility, and disability compensation for millions of persons, with effects diverging according to race. (Funded by the National Heart Lung and Blood Institute and the National Institute of Environmental Health Sciences.)., (Copyright © 2024 Massachusetts Medical Society.)

Objective: The current standards of postoperative respiratory monitoring on medical-surgical floors involve spot-pulse oximetry checks every 4-8 h, which can miss the opportunity to detect prolonged hypoxia and acute hypercapnia. Continuous respiratory monitoring can recognize acute respiratory depression episodes; however, the existing evidence is limited. We sought to review the current evidence on the effectiveness of continuous pulse oximetry (CPOX) with and without capnography versus routine monitoring and their effectiveness for detecting postoperative respiratory failure, opioid-induced respiratory depression, and preventing downstream adverse events., Methods: We performed a systematic literature search on Ovid Medline, Embase, and Cochrane Library databases for articles published between 1990 and April 2023. The study protocol was registered in Prospero (ID: 439467), and PRISMA guidelines were followed. The NIH quality assessment tool was used to assess the quality of the studies. Pooled analysis was conducted using the software R version 4.1.1 and the package meta. The stability of the results was assessed using sensitivity analysis., Design: Systematic Review and Meta-Analysis., Setting: Postoperative recovery area., Patients: 56,538 patients, ASA class II to IV, non-invasive respiratory monitoring, and post-operative respiratory depression., Interventions: Continuous pulse oximetry with or without capnography versus routine monitoring., Measurements: Respiratory rate, oxygen saturation, adverse events, and rescue events., Results: 23 studies (17 examined CPOX without capnography and 5 examined CPOX with capnography) were included in this systematic review. CPOX was better at recognizing desaturation (SpO 2  < 90%) OR: 11.94 (95% CI: 6.85, 20.82; p < 0.01) compared to standard monitoring. No significant differences were reported for ICU transfer, reintubation, and non-invasive ventilation between the two groups., Conclusions: Oxygen desaturation was the only outcome better detected with CPOX in postoperative patients in hospital wards. These comparisons were limited by the small number of studies that could be pooled for each outcome and the heterogeneity between the studies., Competing Interests: Declaration of competing interest Roop Kaw consults for Medtronic. Ashish K. Khanna consults for Medtronic, Edwards Life Sciences, Philips Research North America, Baxter, GE Healthcare, Potrero Medical, Retia Medical and Caretaker Medical. He is also funded with a Clinical and Translational Science Institute (CTSI) NIH/NCTAS KL2 TR001421 award for a trial on continuous postoperative hemodynamic and saturation monitoring. The Department of Anesthesiology at Wake Forest School of Medicine is supported by Edwards Lifesciences under a master clinical trial agreement and receives grant funding from Masimo and Medtronic. All other authors have no relevant conflict of interest to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: To develop and validate a nomogram for assessing the risk of developing hypercapnic respiratory failure (HRF) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD)., Patients and Methods: From January 2019 to August 2023, a total of 334 AECOPD patients were enrolled in this research. We employed the Least Absolute Shrinkage and Selection Operator (LASSO) regression and multivariate logistic regression to determine independent predictors and develop a nomogram. This nomogram was appraised by the area under the receiver operating characteristic curve (AUC), calibration curve, Hosmer-Lemeshow goodness-of-fit test (HL test), decision curve analysis (DCA), and clinical impact curve (CIC). The enhanced bootstrap method was used for internal validation., Results: Sex, prognostic nutritional index (PNI), hematocrit (HCT), and activities of daily living (ADL) were independent predictors of HRF in AECOPD patients. The developed nomogram based on the above predictors showed good performance. The AUCs for the training, internal, and external validation cohorts were 0.841, 0.884, and 0.852, respectively. The calibration curves and HL test showed excellent concordance. The DCA and CIC showed excellent clinical usefulness. Finally, a dynamic nomogram was developed (https://a18895635453.shinyapps.io/dynnomapp/)., Conclusion: This nomogram based on sex, PNI, HCT, and ADL demonstrated high accuracy and clinical value in predicting HRF. It is a less expensive and more accessible approach to assess the risk of developing HRF in AECOPD patients, which is more suitable for primary hospitals, especially in developing countries with high COPD-related morbidity and mortality., Competing Interests: The authors report no conflicts of interest in this work., (© 2024 Zhou et al.)

In this Pro-Con commentary article, we discuss use of continuous physiologic monitoring for clinical deterioration, specifically respiratory depression in the postoperative population. The Pro position advocates for 24/7 continuous surveillance monitoring of all patients starting in the postanesthesia care unit until discharge from the hospital. The strongest arguments for universal monitoring relate to inadequate assessment and algorithms for patient risk. We argue that the need for hospitalization in and of itself is a sufficient predictor of an individual's risk for unexpected respiratory deterioration. In addition, general care units carry the added risk that even the most severe respiratory events will not be recognized in a timely fashion, largely due to higher patient to nurse staffing ratios and limited intermittent vital signs assessments (e.g., every 4 hours). Continuous monitoring configured properly using a "surveillance model" can adequately detect patients' respiratory deterioration while minimizing alarm fatigue and the costs of the surveillance systems. The Con position advocates for a mixed approach of time-limited continuous pulse oximetry monitoring for all patients receiving opioids, with additional remote pulse oximetry monitoring for patients identified as having a high risk of respiratory depression. Alarm fatigue, clinical resource limitations, and cost are the strongest arguments for selective monitoring, which is a more targeted approach. The proponents of the con position acknowledge that postoperative respiratory monitoring is certainly indicated for all patients, but not all patients need the same level of monitoring. The analysis and discussion of each point of view describes who, when, where, and how continuous monitoring should be implemented. Consideration of various system-level factors are addressed, including clinical resource availability, alarm design, system costs, patient and staff acceptance, risk-assessment algorithms, and respiratory event detection. Literature is reviewed, findings are described, and recommendations for design of monitoring systems and implementation of monitoring are described for the pro and con positions., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2024 International Anesthesia Research Society.)

Background and Importance: 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., Objectives: To validate the HACOR scale in predicting NIV failure among acute cardiogenic pulmonary oedema (ACPO) patients., Design, Settings and Participants: This is a prospective, observational study of consecutive ACPO patients requiring NIV admitted to the ED., Outcome Measure and Analysis: 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., Main Results: 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., Conclusions: 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., Competing Interests: Declaration of competing interest During the preparation of this work, the authors used Chat GPT 4.0 in order to enhance clarity and readability of selected sentences. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Children with advanced pulmonary disease due to cystic fibrosis (CF) are at risk of acute respiratory failure due to pulmonary exacerbations leading to their admission to pediatric intensive care units (PICU). The objectives of this study were to determine short and medium-term outcomes of children with CF admitted to PICU for acute respiratory failure due to pulmonary exacerbation and to identify prognosis factors., Methods: This retrospective monocentric study included patients less than 18 years old admitted to the PICU of a French university hospital between 2000 and 2020. Cox proportional hazard regression methods were used to determine prognosis factors of mortality or lung transplant., Results: Prior to PICU admission, the 29 patients included (median age 13.5 years) had a severe lung disease (median Forced Expiratory Volume in 1 s percentage predicted at 29%). Mortality rates were respectively 17%, 31%, 34%, 41% at discharge and at 3, 12 and 36 months post-discharge. Survival rates free of lung transplant were 34%, 32%, 24% and 17% respectively. Risk factors associated with mortality or lung transplant using the univariate analysis were female sex and higher pCO2 and chloride levels at PICU admission, and following pre admission characteristics: home respiratory and nutritional support, registration on lung transplant list and Stenotrophomonas Maltophilia bronchial colonization., Conclusion: Children with CF admitted to PICU for acute respiratory failure secondary to pulmonary exacerbations are at high risk of death, both in the short and medium terms. Lung transplant is their main chance of survival and should be considered early., (© 2024. The Author(s).)

The traditional ALS multidisciplinary clinical practice of quarterly respiratory assessment may leave some individuals in danger of developing untreated respiratory insufficiency between visits or beginning non-invasive ventilation (NIV) later than would be optimal. Remote, or home-based, pulmonary function testing (rPFT) allows patients with ALS to perform regular respiratory testing at more frequent intervals in the home. The aim of this study was to determine the clinical benefit of weekly rPFT compared to standard, quarterly in-clinic respiratory assessments: the number of individuals with earlier identification of NIV need, the magnitude of this advance notice, and the individual factors predicting benefit. Participants with ALS (n = 39) completed rPFT training via telemedicine and then completed one year of weekly self-guided assessments in the home. Over this period, 17 individuals exhibited remotely-measured FVC dropping below 50% of predicted, the value often used for recommendation of NIV initiation. In 13 individuals with clinical detection of this event, the median and range of advance notice of need for NIV was 53 (-61-294) days. Prescription of NIV occurred for 21 individuals on the study, six of whom began NIV as a result of remote testing, prior to indication of need as determined by in-person assessments. Weekly home assessments appeared to be of greatest clinical value in a subset of patients with low baseline respiratory test values and rapid respiratory decline. This has potential implications for clinical management of ALS as well as the conduct of clinical trials that rely on respiratory endpoints., Competing Interests: Declaration of competing interest Dr. Simmons has received consulting fees from Amylyx, Clene, Biogen, and Corcept Therapeutics, and research funding to his institution from Sanofi, Mitsubishi Tanabe, Cytokinetics, and the ALS Association. All other authors report no financial and personal relationships with other people or organizations that could inappropriately influence this work., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Acute respiratory failure is a common clinical finding caused by insufficient oxygenation (hypoxemia) or ventilation (hypocapnia). Understanding the pathophysiology of acute respiratory failure can help to facilitate recognition, diagnosis, and treatment. The cause of acute respiratory failure can be identified through utilization of physical examination findings, laboratory analysis, and chest imaging., Competing Interests: Disclosure Dr C.R. Rackley reports receiving consulting fees from Select Medical, Roche, and Inspira., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Encephalopathy of different etiologies in infants is often the reason for central respiratory insufficiency which eventually leads patients to the Pediatric Intensive Care Unit. Magnetic resonance imaging (MRI) and brainstem auditory evoked potentials (BAEPs) may be useful to identify brainstem alterations among patients with respiratory insufficiency of central origin. MRI is a compulsory technique to identify brain abnormalities, but may fail to detect brainstem lesions of small dimensions. BAEPs play a highly sensitive role on brainstem dysfunction identification because of the generators of different peaks which are related to specific brainstem structures., Methods: The study included ten infants affected by encephalopathy of different etiologies and early neurological respiratory failure. To evaluate BAEPs, the surface electrodes were placed at the vertex (Cz) and on each mastoid side., Results: All subjects presented alteration of BAEPs. The brain MRI revealed selective injury of the brainstem in four patients and supratentorial alterations in six patients., Conclusions: The early identification of brainstem lesions in mechanically ventilated infants with encephalopathy may reduce the weaning off mechanical ventilation's attempt numbers and provide early informative discussions with families and clinical caregivers about treatment options, such as tracheostomy, long term ventilation and the reduction of their length of PICU stay. Furthermore, this would support the evaluation process concerning the affected children, their families and the needs of other social groups, including health systems.

Mechanical ventilation (MV) is a powerful mean to rescue patients with respiratory failure. In view of the different etiology and basic respiratory function of patients with respiratory failure, weaning failure often occurs. Prolonged MV time is often accompanied by many complications. Thus, deeply understanding the pathophysiological changes of respiratory failure and strengthen monitoring of respiratory mechanics are helpful to optimize MV parameter settings, reduce ventilator-induced lung injury and wean from MV as early as possible. A successful weaning from MV depends on many factors, the most important factors are respiratory muscle strength, respiratory load and respiratory drive. Spontaneous breathing trial (SBT) is an important part of weaning process. The main purpose of implementing SBT is to screen patients and opportunities to weaning from MV, and find reversible reasons for not passing SBT. Because the accuracy of SBT in assessing weaning prognosis is about 85%, it is not adequate for difficult weaning patients. Standardized measurement of weaning indicators for patients with difficulty weaning is conducive to accurate assessment of respiratory muscle strength and improve the success rate of weaning from MV.

Background: Although ROX index is frequently used to assess the efficacy of high-flow nasal cannula treatment in acute hypoxemic respiratory failure (AHRF) patients, the relationship between the ROX index and the mortality remains unclear. Therefore, a retrospective cohort study was conducted to evaluate the ability of the ROX index to predict mortality risk in patients with AHRF., Method: Patients diagnosed with AHRF were extracted from the MIMIC-IV database and divided into four groups based on the ROX index quartiles. The primary outcome was 28-day mortality, while in-hospital mortality and follow-up mortality were secondary outcomes. To investigate the association between ROX index and mortality in AHRF patients, restricted cubic spline curve and COX proportional risk regression were utilized., Result: A non-linear association (L-shaped) has been observed between the ROX index and mortality rate. When the ROX index is below 8.28, there is a notable decline in the 28-day mortality risk of patients as the ROX index increases (HR per SD, 0.858 [95%CI 0.794-0.928] P < 0.001). When the ROX index is above 8.28, no significant association was found between the ROX index and 28-day mortality. In contrast to the Q1 group, the mortality rates in the Q2, Q3, and Q4 groups had a substantial reduction (Q1 vs. Q2: HR, 0.749 [0.590-0.950] P = 0.017; Q3: HR, 0.711 [0.558-0.906] P = 0.006; Q4: HR, 0.641 [0.495-0.830] P < 0.001)., Conclusion: The ROX index serves as a valuable predictor of mortality risk in adult patients with AHRF, and that a lower ROX index is substantially associated with an increase in mortality., (© 2024. The Author(s).)

Extracorporeal membrane oxygenation (ECMO) is a form of organ support which is used for severe, potentially reversible respiratory, cardiac or cardiorespiratory failure. While it is associated with significant risk of intracerebral injury in neonates and children, outcomes can be excellent, and timely referral is associated with improved survival and reduced morbidity. This article provides a concise summary of the technical aspects of ECMO support, indications for referral, complications, outcomes and important considerations for follow-up., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Abstract: Acute respiratory failure (ARF) is common in patients with hematological malignancies notably those with acute leukemia, myelodysplastic syndrome, or allogeneic stem cell transplantation. ARF is the leading reason for intensive care unit (ICU) admission, with a 35% case fatality rate. Failure to identify the ARF cause is associated with mortality. A prompt, well-designed diagnostic workup is crucial. The investigations are chosen according to pretest diagnostic probabilities, estimated by the DIRECT approach: D stands for delay, or time since diagnosis; I for pattern of immune deficiency; R and T for radiological evaluation; E refers to clinical experience, and C to the clinical picture. Thorough familiarity with rapid diagnostic tests helps to decrease the use of bronchoscopy with bronchoalveolar lavage, which can cause respiratory status deterioration in those patients with hypoxemia. A prompt etiological diagnosis shortens the time on unnecessary empirical treatments, decreasing iatrogenic harm and costs. High-quality collaboration between intensivists and hematologists and all crossdisciplinary health care workers is paramount. All oxygen delivery systems should be considered to minimize invasive mechanical ventilation. Treatment of the malignancy is started or continued in the ICU under the guidance of the hematologists. The goal is to use the ICU as a bridge to recovery, with the patient returning to the hematology ward in sufficiently good clinical condition to receive optimal anticancer treatment., (© 2024 American Society of Hematology. Published by Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.)

Background: There is an argument whether the delayed intubation aggravate the respiratory failure in Acute respiratory distress syndrome (ARDS) patients with coronavirus disease 2019 (COVID-19). We aimed to investigate the effect of high-flow nasal cannula (HFNC) failure before mechanical ventilation on clinical outcomes in mechanically ventilated patients with COVID-19., Methods: This retrospective cohort study included mechanically ventilated patients who were diagnosed with COVID-19 and admitted to the intensive care unit (ICU) between February 2020 and December 2021 at Asan Medical Center. The patients were divided into HFNC failure (HFNC-F) and mechanical ventilation (MV) groups according to the use of HFNC before MV. The primary outcome of this study was to compare the worst values of ventilator parameters from day 1 to day 3 after mechanical ventilation between the two groups., Results: Overall, 158 mechanically ventilated patients with COVID-19 were included in this study: 107 patients (67.7%) in the HFNC-F group and 51 (32.3%) in the MV group. The two groups had similar profiles of ventilator parameter from day 1 to day 3 after mechanical ventilation, except of dynamic compliance on day 3 (28.38 mL/cmH2O in MV vs. 30.67 mL/H2O in HFNC-F, p = 0.032). In addition, the HFNC-F group (5.6%) had a lower rate of ECMO at 28 days than the MV group (17.6%), even after adjustment (adjusted hazard ratio, 0.30; 95% confidence interval, 0.11-0.83; p = 0.045)., Conclusions: Among mechanically ventilated COVID-19 patients, HFNC failure before mechanical ventilation was not associated with deterioration of respiratory failure., (© 2024. The Author(s).)

Background: Children often experience respiratory illnesses requiring bedside nurses skilled in recognizing respiratory decompensation. Historically, recognizing respiratory distress has relied on teaching during direct patient care. Virtual reality simulation may accelerate such recognition among novice nurses., Objective: To determine whether a virtual reality curriculum improved new nurses' recognition of respiratory distress and impending respiratory failure in pediatric patients based on assessment of physical examination findings and appropriate escalation of care., Methods: New nurses (n = 168) were randomly assigned to complete either an immersive virtual reality curriculum on recognition of respiratory distress (intervention) or the usual orientation curriculum (control). Group differences and changes from 3 months to 6 months after the intervention were examined., Results: Nurses in the intervention group were significantly more likely to correctly recognize impending respiratory failure at both 3 months (23.4% vs 3.0%, P < .001) and 6 months (31.9% vs 2.6%, P < .001), identify respiratory distress without impending respiratory failure at 3 months (57.8% vs 29.6%, P = .002) and 6 months (57.9% vs 17.8%, P < .001), and recognize patients' altered mental status at 3 months (51.4% vs 18.2%, P < .001) and 6 months (46.8% vs 18.4%, P = .006)., Conclusions: Implementation of a virtual reality-based training curriculum was associated with improved recognition of pediatric respiratory distress, impending respiratory failure, and altered mental status at 3 and 6 months compared with standard training approaches. Virtual reality may offer a new approach to nurse orientation to enhance training in pediatrics-specific assessment skills., (©2024 American Association of Critical-Care Nurses.)

Myasthenia gravis (MG) is often complicated by respiratory failure, an exacerbation known as myasthenic crisis. However, most patients with MG develop respiratory symptoms during the late course of the disease. Respiratory failure as an exclusive initial and primary complaint in patients with MG is rare and seldom reported. We herein describe a woman in her late 50s who presented with respiratory failure and was diagnosed with obesity hypoventilation syndrome at a local hospital. Her condition gradually worsened during the next 4 months and became accompanied by dysphagia. After 1 year of medical investigation, she was diagnosed in our hospital. A high level of anti-muscle-specific receptor tyrosine kinase antibody was found in her serum, and stimulation and electromyography results suggested MG. The patient's symptoms were improved by intravenous immunoglobulin and hormone therapy. This case reminds physicians to consider MG when encountering a patient who initially presents with respiratory failure., Competing Interests: Declaration of conflicting interestsThe authors declare that there is no conflict of interest.

Objectives: Neuromuscular disorders could have respiratory involvement early or late into illness. Rarely, patients may present with a hypercapnic respiratory failure (with minimal motor signs) unmasking an underlying disease. There are hardly any studies which have addressed the spectrum and challenges involved in management of this subset, especially in the real-world scenario., Methods: A retrospective study comprising consecutive patients hospitalized with hypercapnic respiratory failure as the sole/dominant manifestation. The clinical-electrophysiological spectrum, phrenic conductions, diaphragm thickness, and outcomes were analyzed., Results: Twenty-seven patients were included, the mean age was 47.29 (SD 15.22) years, and the median duration of respiratory symptoms was 2 months (interquartile range [IQR] 1-4). Orthopnea was present in 23 patients (85.2%) and encephalopathy in 8 patients (29.6%). Phrenic nerve latencies and amplitudes were abnormal in 83.3% and 95.6%, respectively. Abnormal diaphragm thickness was noted in 78.5%. Based on a comprehensive electrophysiological strategy and paraclinical tests, an etiology was established in all. Reversible etiologies were identified in 17 patients (62.9%). These included myasthenia gravis (anti-AChR and MuSK), inflammatory myopathy, riboflavin transporter deficiency neuronopathy, Pompe disease, bilateral phrenic neuritis, and thyrotoxicosis. Respiratory onset motor neuron disease was diagnosed in 8 patients (29.6%). Despite diaphragmatic involvement, a functional respiratory recovery was noted at discharge (45%) and last follow-up (60%). Predictors for good outcomes included female sex, normal nerve conductions, and recent-onset respiratory symptoms., Discussion: A good functional recovery was noted in most of the patients including respiratory onset motor neuron disease. A systematic algorithmic approach helps in proper triaging, early diagnosis, and treatment. Clinical and electrodiagnostic challenges and observations from a tertiary care referral center are discussed., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Dexmedetomidine sedation has advantages, such as low incidence of respiratory depression and prolonged block duration, but also significant disadvantages, such as slow onset, high rate of sedation failure, and a long context-sensitive half-life. Remimazolam provides rapid sedation and recovery, high sedation efficacy and has minimal hemodynamic effects. We hypothesized that patients who received remimazolam would require less rescue midazolam than dexmedetomidine., Methods: Patients (n=103) scheduled for surgery under spinal anesthesia were randomized to receive dexmedetomidine (DEX group) or remimazolam (RMZ group) targeting a Modified Observer's Assessment of Alertness/Sedation score of 3 or 4. Rescue midazolam was administered if the patient failed to be sedated after the initial loading dose or despite infusion rate adjustment., Results: Rescue midazolam administration was significantly higher in the DEX group (0% vs 39.2%; p<0.001). Patients in the RMZ group reached the target sedation level more rapidly. The incidences of bradycardia (0% vs 25.5%; p<0.001) and hypertension (0% vs 21.6%; p<0.001) were higher in the DEX group. Respiratory depression occurred at a higher rate in the RMZ group (21.2% vs 2.0%; p=0.002), but no patients required manual ventilation. Patients in the RMZ group recovered faster, had a shorter PACU stay and higher satisfaction scores. Hypotensive episodes in the PACU were more frequent in the DEX group (1.9% vs 29.4%; p<0.001)., Conclusions: Remimazolam showed excellent sedation efficacy, minimal hemodynamic effects, and fewer adverse events in the PACU than dexmedetomidine. However, it is important to note that respiratory depression was more frequent with the use of remimazolam., Trial Registration Number: NCT05447507., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Non-invasive and invasive ventilation have become essential for therapy in acute and chronic respiratory failure. More than one-third of patients in intensive care units receive invasive ventilation, and the number of ventilated patients in out-of-hospital care is also steadily increasing. While normalization of blood gases was considered the most significant goal in past decades, and the idea that mechanical ventilation also poses dangers played little role, the dominant thought at present is the application of ventilation from the most protective point of view possible. Because fundamental change in equipment technology is likely to be difficult, improvement of protective ventilation and further development of understanding of pathophysiologic processes in acute and chronic respiratory failure will continue to be of great importance in the future. This article summarizes different aspects of the technical basis of noninvasive and invasive ventilation and their practical implementation., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: We sought to evaluate respiratory complications in heart failure patients undergoing left atrial appendage occlusion (LAAO) for stroke prevention in atrial fibrillation., Methods: Adult admissions (>18 years) undergoing LAAO during 2016-2020 were identified from the National Inpatient Sample. Heart failure (HF) was stratified into systolic (SHF) and diastolic heart failure (DHF) and were compared to those without HF. Outcomes of interested included acute respiratory failure, use of non-invasive and invasive mechanical ventilation, and in-hospital mortality., Results: Of 74,440 admissions for atrial fibrillation undergoing LAAO, SHF and DHF were noted in 8335 (11.2%) and 10,925 (14.7%), respectively. The SHF cohort was predominantly male (78%) whereas DHF cohort were female (53%). Compared to those without HF, presence of SHF (2.3% vs. 0.6%; adjusted odds ratio [OR] 1.61 [95% confidence interval {CI} 1.10-2.36]; p = 0.01) and DHF (2.8% vs. 0.6%; adjusted OR 2.20 [95% CI 1.58-3.06]; p < 0.001) were associated with higher rates of acute respiratory failure. SHF (1.7% vs. 0.6%; adjusted OR 1.70 [95% CI 1.07-2.71]; p = 0.02) group but not DHF (1.2% vs. 0.6%; adjusted OR 1.21 [95% CI 0.78-1.89]; p = 0.39) was associated with higher rates of non-invasive ventilation, whereas the DHF group (0.9% vs. 0.2%; adjusted OR 1.91 [95% CI 1.08-3.34]; p = 0.02) but not SHF (0.8% vs. 0.2%; adjusted OR 1.54 [95% CI 0.83-2.84]; p = 0.17) was associated with higher rates of invasive mechanical ventilation use. In-hospital mortality was comparable between cohorts., Conclusion: Compared to those without HF, atrial fibrillation admissions with HF undergoing LAAO had higher rates of acute respiratory failure and mechanical ventilation rates without differences in in-hospital mortality., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Introduction: Nirmatrelvir-ritonavir (NMV-r) and molnupiravir (MOL) were developed as out-patient anti-viral for mild COVID-19. There was limited data on their role in treating COVID-19 for hospitalized patients, especially among adult patients who are unvaccinated and had chronic respiratory diseases., Methods: A territory-wide retrospective study was conducted in Hong Kong to compare the efficacy of NMV-r and MOL against COVID-19 in unvaccinated adult patients with asthma, chronic obstructive pulmonary disease, bronchiectasis and interstitial lung diseases presenting with moderate COVID-19 from 16th February 2022 to 15th March 2023., Results: A total of 1354 patients were included, 738 received NMV-r and 616 received MOL. NMV-r was more effective in reducing 90-day mortality with adjusted hazard ratios (aHR) of 0.508 (95% confidence interval [CI] = 0.314-0.822, p = 0.006). Patients who received NMV-r also had significantly shorter length of stay (LOS) than those receiving MOL, with median LOS of 4 (Interquartile range [IQR] = 2-7) for NMV-r and 6 (IQR = 3-10) for MOL (p-value < 0.001). There was no statistically significant difference in the development of respiratory failure and severe respiratory failure in the two groups., Discussion: NMV-r was more effective than MOL among unvaccinated adults with chronic respiratory diseases who were hospitalized for moderate COVID-19 without hypoxaemia on admission., Competing Interests: All authors report no conflicts of interest in this work., (© 2024 Kwok et al.)

Objectives: The Berlin definition of acute respiratory distress syndrome (ARDS) was constructed for patients receiving invasive mechanical ventilation (IMV) with consideration given to issues related to reliability, feasibility, and validity. Notwithstanding, patients with acute respiratory failure (ARF) may be treated with high-flow nasal oxygen (HFNO) and may not fall within the scope of the original definition. We aimed to evaluate the predictive validity of the Berlin definition in HFNO-treated patients with COVID-19-related respiratory failure who otherwise met ARDS criteria., Design: Multicenter, prospective cohort study., Setting: Five ICUs of five centers in Argentina from March 2020 to September 2021., Patients: We consecutively included HFNO-treated patients older than 18 years with confirmed COVID-19-related ARF, a Pa o2 /F io2 of less than 300 mm Hg, bilateral infiltrates on imaging, and worsening respiratory symptoms for less than 1 week., Interventions: None., Measurements and Main Results: We evaluated the predictive validity of mortality at day 28 using the area under the receiver operating characteristics curve (AUC), compared the predictive validity across subgroups, and characterized relevant clinical outcomes. We screened 1,231 patients and included 696 ARDS patients [30 (4%) mild, 380 (55%) moderate, and 286 (41%) severe]. For the study cohort, the AUC for mortality at day 28 was 0.606 (95% CI, 0.561-0.651) with the AUC for subgroups being similar to that of the overall cohort. Two hundred fifty-six patients (37%) received IMV. By day 28, 142 patients (21%) had died, of whom 81 (57%) had severe ARDS. Mortality occurred primarily in patients who were transitioned to IMV., Conclusions: The predictive validity of the Berlin ARDS definition was similar for HFNO-treated patients as compared with the original population of invasively ventilated patients. Our findings support the extension of the Berlin definition to HFNO-treated patients with ARDS., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Background: This study aimed to assess the validity of the oxygenation saturation index (OSI) and the ratio of oxygen saturation to the fraction of inspired oxygen (F I O 2 ) (S/F ratio) with percutaneous oxygen saturation (OSI SpO2 and the S p /F ratio) and to evaluate the correlation between these values and the oxygen index (OI). It also determined their cut-off values for predicting OI in accordance with neonatal hypoxic respiratory failure severity., Methods: We reviewed the data of 77 neonates (gestational age 31.7 ± 6.1 weeks; birthweight, 1768 ± 983 g) requiring invasive mechanical ventilation between 2013 and 2020, 1233 arterial blood gas samples in total. We calculated the OI, OSI SpO2 , OSI with arterial oxygen saturation (SaO 2 ) (OSI SaO2 ), S p /F ratio, and the ratio of SaO 2 to F I O 2 (S a /F ratio)., Results: The regression and Bland-Altman analysis showed good agreement between OSI SpO2 or the S p /F ratio and OSI SaO2 or the S a /F ratio. Although a significant positive correlation was found between OSI SpO2 and OI, OSI SpO2 was overestimated in SpO 2  > 98% with a higher slope of the fitted regression line than that below 98% of SpO 2 . Furthermore, receiver-operating characteristic curve analysis using only SpO 2  ≤ 98% samples showed that the optimal cut-off points of OSI SpO2 and the S p /F ratio for predicting OI were: OI 5, 3.0 and 332; OI 10, 5.3 and 231; OI 15, 7.7 and 108; OI 20, 11.0 and 149; and OI 25, 17.1 and 103, respectively., Conclusion: The cut-off OSI SpO2 and S p /F ratio values could allow continuous monitoring for oxygenation changes in neonates with the potential for wider clinical applications., (© 2024 Japan Pediatric Society.)

Neonatal respiratory failure (NRF) is an emergency which has not been examined extensively. We critically synthesized the contemporary in-hospital prevalence, mortality rate, predictors, aetiologies, diagnosis and management of NRF to better formulate measures to curb its burden. We searched MEDLINE and Google Scholar from 01/01/1992 to 31/12/2022 for relevant publications. We identified 237 papers from 58 high-income and low-and middle-income countries (LMICs). NRF prevalence ranged from 0.64 to 88.4% with some heterogeneity. The prevalence was highest in Africa, the Middle East and Asia. Globally as well as in Asia and the Americas, respiratory distress syndrome (RDS) was the leading aetiology of NRF. Neonatal sepsis was first aetiology in Africa, whereas in both Europe and the Middle East it was transient tachypnoea of the newborn. Independent predictors of NRF were prematurity, male gender, ethnicity, low/high birth weight, young/advanced maternal age, primiparity/multiparity, maternal smoking, pregestational/gestational diabetes mellitus, infectious anamneses, antepartum haemorrhage, gestational hypertensive disorders, multiple pregnancy, caesarean delivery, antenatal drugs, foetal distress, APGAR score, meconium-stained amniotic fluid and poor pregnancy follow-up. The NRF-related in-hospital mortality rate was 0.21-57.3%, highest in Africa, Asia and the Middle East. This death toll was primarily due to RDS globally and in all regions. Clinical evaluation using the Silverman-Anderson score was widely used and reliable. Initial resuscitation followed by specific management was the common clinical practice., Conclusion: NRF has a high burden globally, driven by RDS, especially in LIMCs where more aggressive treatment and innovations, preferably subsidized, are warranted to curb its alarming burden., What Is Known: • Neonatal respiratory failure is a frequent emergency associated with a significant morbidity and mortality, yet there is no comprehensive research paper summarizing its global burden. • Neonatal respiratory failure needs prompt diagnosis and treatment geared at improving neonatal survival., What Is New: • Neonatal respiratory failure has an alarmingly high global burden largely attributed to Respiratory distress syndrome. Low resource settings are disproportionately affected by the burden of neonatal respiratory failure. • Independent preditors of neonatal respiratory failure are several but can be classified into foetal, maternal and obstetrical factors. An illustrative pedagogical algorithm is provided to facilitate diagnosis and management of neonatal respiratory failure by healthcare providers., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: To evaluate the accuracy of the persistent AKI risk index (PARI) in predicting acute kidney injury within 72 hours after admission to the intensive care unit, persistent acute kidney injury, renal replacement therapy, and death within 7 days in patients hospitalized due to acute respiratory failure., Methods: This study was done in a cohort of diagnoses of consecutive adult patients admitted to the intensive care unit of eight hospitals in Curitiba, Brazil, between March and September 2020 due to acute respiratory failure secondary to suspected COVID-19. The COVID-19 diagnosis was confirmed or refuted by RT-PCR for the detection of SARS-CoV-2. The ability of PARI to predict acute kidney injury at 72 hours, persistent acute kidney injury, renal replacement therapy, and death within 7 days was analyzed by ROC curves in comparison to delta creatinine, SOFA, and APACHE II., Results: Of the 1,001 patients in the cohort, 538 were included in the analysis. The mean age was 62 ± 17 years, 54.8% were men, and the median APACHE II score was 12. At admission, the median SOFA score was 3, and 83.3% had no renal dysfunction. After admission to the intensive care unit, 17.1% had acute kidney injury within 72 hours, and through 7 days, 19.5% had persistent acute kidney injury, 5% underwent renal replacement therapy, and 17.1% died. The PARI had an area under the ROC curve of 0.75 (0.696 - 0.807) for the prediction of acute kidney injury at 72 hours, 0.71 (0.613 - 0.807) for renal replacement therapy, and 0.64 (0.565 - 0.710) for death., Conclusion: The PARI has acceptable accuracy in predicting acute kidney injury within 72 hours and renal replacement therapy within 7 days of admission to the intensive care unit, but it is not significantly better than the other scores.

Importance: Artificial intelligence (AI) could support clinicians when diagnosing hospitalized patients; however, systematic bias in AI models could worsen clinician diagnostic accuracy. Recent regulatory guidance has called for AI models to include explanations to mitigate errors made by models, but the effectiveness of this strategy has not been established., Objectives: To evaluate the impact of systematically biased AI on clinician diagnostic accuracy and to determine if image-based AI model explanations can mitigate model errors., Design, Setting, and Participants: Randomized clinical vignette survey study administered between April 2022 and January 2023 across 13 US states involving hospitalist physicians, nurse practitioners, and physician assistants., Interventions: Clinicians were shown 9 clinical vignettes of patients hospitalized with acute respiratory failure, including their presenting symptoms, physical examination, laboratory results, and chest radiographs. Clinicians were then asked to determine the likelihood of pneumonia, heart failure, or chronic obstructive pulmonary disease as the underlying cause(s) of each patient's acute respiratory failure. To establish baseline diagnostic accuracy, clinicians were shown 2 vignettes without AI model input. Clinicians were then randomized to see 6 vignettes with AI model input with or without AI model explanations. Among these 6 vignettes, 3 vignettes included standard-model predictions, and 3 vignettes included systematically biased model predictions., Main Outcomes and Measures: Clinician diagnostic accuracy for pneumonia, heart failure, and chronic obstructive pulmonary disease., Results: Median participant age was 34 years (IQR, 31-39) and 241 (57.7%) were female. Four hundred fifty-seven clinicians were randomized and completed at least 1 vignette, with 231 randomized to AI model predictions without explanations, and 226 randomized to AI model predictions with explanations. Clinicians' baseline diagnostic accuracy was 73.0% (95% CI, 68.3% to 77.8%) for the 3 diagnoses. When shown a standard AI model without explanations, clinician accuracy increased over baseline by 2.9 percentage points (95% CI, 0.5 to 5.2) and by 4.4 percentage points (95% CI, 2.0 to 6.9) when clinicians were also shown AI model explanations. Systematically biased AI model predictions decreased clinician accuracy by 11.3 percentage points (95% CI, 7.2 to 15.5) compared with baseline and providing biased AI model predictions with explanations decreased clinician accuracy by 9.1 percentage points (95% CI, 4.9 to 13.2) compared with baseline, representing a nonsignificant improvement of 2.3 percentage points (95% CI, -2.7 to 7.2) compared with the systematically biased AI model., Conclusions and Relevance: Although standard AI models improve diagnostic accuracy, systematically biased AI models reduced diagnostic accuracy, and commonly used image-based AI model explanations did not mitigate this harmful effect., Trial Registration: ClinicalTrials.gov Identifier: NCT06098950.

Respiratory failure is a common and potentially life-threatening complication of neuromuscular diseases. Prompt recognition and accurate diagnosis of new or worsening chronic neuromuscular disease have important clinical management and prognostic implications. In this article, we present an approach to the acute presentation of undifferentiated neuromuscular respiratory failure in the ICU and guidance for determination and respiratory management of the underlying disorder., Competing Interests: Financial/Nonfinancial Disclosures The authors have reported to CHEST the following: J. B. C. has a grant from Catalyst Pharmaceuticals Inc and receives clinical trial support from MTB Pharma Inc and Amylyx Pharmaceuticals. The institution receives funding on behalf of D. C. F. from NIH, CDC, and Quantum Leap Healthcare Collaborative. D. C. F. has worked as a consultant for Cytovale and Medpace. None declared (J. T. W. K., A. C.)., (Copyright © 2023. Published by Elsevier Inc.)