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Byline: Antoine Cuvelier (1,2), Wilfried Pujol (1), Stephanie Pramil (1), Luis Carlos Molano (1), Catherine Viacroze (1), Jean-Francois Muir (1) Keywords: Noninvasive ventilation; Facial mask; Acute respiratory failure; Cephalic mask Abstract: Objective Compared to oronasal interfaces, a cephalic mask has a larger inner volume, covers the entire anterior surface of the face and limits the risk of deleterious cutaneous side effects during noninvasive ventilation (NIV). The present clinical study aimed to compare the clinical efficacy of a cephalic mask versus an oronasal mask in patients with acute hypercapnic respiratory failure (AHRF). Design and setting Randomized controlled study in a Respiratory Intermediate Care Unit. Patients All consecutive patients admitted for AHRF were randomly assigned to receive bilevel NIV either with a cephalic mask (n = 17) or an oronasal mask (n = 17) during the first 48 h. Measurements The main outcome criterion was the improvement of arterial pH, 24 h after NIV initiation. Secondary criteria included PaCO.sub.2 and physiological parameters. Results Compared to values at inclusion, pH, PaCO.sub.2, encephalopathy score, respiratory distress score and respiratory frequency improved significantly and similarly with both masks. None of these parameters showed statistically significant differences between the masks at each time point throughout the study period. Mean delivered inspiratory and expiratory pressures were similar in both patient groups. Tolerance of the oronasal mask was improved at 24 h and further. One patient with the cephalic mask suffered from claustrophobia that did not lead to premature study interruption. Conclusions In spite of its larger inner volume, the cephalic mask has the same clinical efficacy and requires the same ventilatory settings as the oronasal mask during AHRF. Author Affiliation: (1) Pulmonary and Intensive Care Department, Rouen University Hospital & UPRES EA 3830 (IFR MP23), Institute for Biomedical Research, University of Rouen, Rouen, France (2) Service de Pneumologie et Unite de Soins Intensifs Respiratoires, CHU de Rouen, 76031, Rouen Cedex, France Article History: Registration Date: 02/10/2008 Received Date: 12/07/2007 Accepted Date: 16/09/2008 Online Date: 15/10/2008

Byline: Theodoros Vassilakopoulos (1) Keywords: Mechanical ventilation; Complications; Disuse atrophy; Weaning; Diaphragm Abstract: Experimental evidence suggests that controlled mechanical ventilation (CMV) can induce dysfunction of the diaphragm, resulting in an early-onset and progressive decrease in diaphragmatic force-generating capacity, called ventilator-induced diaphragmatic dysfunction (VIDD). The mechanisms of VIDD are not fully elucidated, but include muscle atrophy (resulting from lysosomal, calpain, caspase and proteasome activation), oxidative stress, structural injury (disrupted myofibrils, increased numbers of lipid vacuoles, and abnormally small and disrupted mitochondria), myofiber remodeling and mitochondrial dysfunction. The major clinical implication of the VIDD is to limit the use of CMV to the extent possible. Partial (assisted) modes of ventilatory support should be used whenever feasible, since these modes attenuate the deleterious effects of mechanical ventilation on respiratory muscles. Author Affiliation: (1) Critical Care Department, Evangelismos Hospital, 45--47 Ipsilandou Str, 10675, Athens, Greece Article History: Registration Date: 05/09/2007 Received Date: 01/07/2006 Accepted Date: 28/08/2007 Online Date: 11/10/2007 Article note: Electronic supplementary material The online version of this article (doi: 10.1007/s00134-007-0866-x) contains supplementary material, which is available to authorized users.

Byline: Stephane Soubrier (1,2), Fabienne Saulnier (1,2), Herve Hubert (2), Pierre Delour (1), Helene Lenci (1), Thierry Onimus (1,2), Saad Nseir (1,2), Alain Durocher (1,2) Keywords: Fluid responsiveness; Volume expansion; Arterial pulse pressure; Arterial systolic pressure; Preload; Heart--lung interactions Abstract: Objective To investigate whether the respiratory changes in arterial pulse (IPP) and in systolic pressure (ISP) could predict fluid responsiveness in spontaneously breathing (SB) patients. Because changes in intrathoracic pressure during spontaneous breathing (SB) might be insufficient to modify loading conditions of the ventricles, performances of indicators were also assessed during a forced respiratory maneuver. Design Prospective interventional study. Setting A 34-bed university hospital medico-surgical ICU. Patients and participants Thirty-two SB patients with clinical signs of hemodynamic instability. Intervention A 500-ml volume expansion (VE). Measurements and results Cardiac index, assessed using transthoracic echocardiography, increased by at least 15% after VE in 19 patients (responders). At baseline, only dynamic indicators were higher in responders than in nonresponders (13a-+-a-5% vs. 7a-+-a-3%, pa-=a-0.003 for IPP and 10a-+-a-4% vs. 6a-+-a-2%, pa-=a-0.002 for ISP). Moreover, they significantly decreased after VE (11a-+-a-5% to 6a-+-a-4%, pa- Conclusions Due to their lack of sensitivity and their dependence to respiratory status, IPP and ISP are clearly less reliable to predict fluid responsiveness during SB than in mechanically ventilated patients. However, when their baseline value is high without acute right ventricular dysfunction in a participating patient, a positive response to fluid is likely. Author Affiliation: (1) Service de Reanimation Medicale, Hopital Calmette, CHRU, boulevard du Pr Leclercq, 59037, Lille cedex, France (2) EA 3614, Lille II University, 59000, Lille, France Article History: Registration Date: 28/03/2007 Received Date: 13/05/2005 Accepted Date: 27/03/2007 Online Date: 17/05/2007 Article note: This study was presented at the American Thoracic Society international conference, 2005, San Diego, California. This article is discussed in the editorial available at: http://dx.doi.org/10.1007/s00134-007-0645-8.

Byline: Raffaele Scala (1), Sandra Bartolucci (2), Mario Naldi (1), Marcello Rossi (3), Mark W. Elliott (4) Keywords: Co-morbidities; Chronic obstructive pulmonary disease; Acute hypercapnic respiratory failure; Non-invasive positive pressure ventilation; Charlson index Abstract: Objective To assess the prevalence and the impact of chronic and/or acute non-respiratory co-morbidity on short and longer-term outcome of non-invasive positive pressure ventilation (NIPPV) in acute decompensations of chronic obstructive pulmonary disease (COPD) with acute hypercapnic respiratory failure (AHRF). Design and setting An observational study in a three-bed respiratory monitoring unit in a respiratory ward of a non-university hospital. Patients We grouped 120 consecutive COPD patients requiring NIPPV for AHRF (pH 7.28+-0.05, PaO.sub.2/FIO.sub.2 ratio 192+-63, PaCO.sub.2 78.3+-12.3 mmHg) according to whether NIPPV succeeded (n=98) or failed (n=22) in avoiding the need for endotracheal intubation and whether alive (n=77) or dead (n=42) at 6 months. Measurements and results The prevalence of chronic and acute co-morbidity was, respectively, 20% and 41.7% most of the cases were cardiovascular. In-hospital NIPPV failure was greater in patients with than in those without chronic (33.3% vs. 14.6%) or acute co-morbidity (32% vs. 8.6%). Six-month mortality was worse in patients with than in those without chronic (54.2% vs. 30.5%) or more than one acute co-morbidity (66.7% vs. 30.8%). Multiple regression analysis predicted in-hospital NIPPV failure by acute co-morbidity and forced expiratory volume in 1 s, while death at 6 months was predicted by having more than one acute co-morbidity, non-cardiovascular chronic co-morbidity and Activities of Daily Living score. Conclusions Chronic and acute co-morbidities are common in COPD patients with AHRF needing NIPPV and their presence influences short and longer-term outcome. Author Affiliation: (1) U.O. Pneumologia, USL8, Ospedale S. Donato, Via Nenni 20, 52100, Arezzo, Italy (2) U.O. Sistema Informativo, Via Fonte Veneziana 16, 52100, Arezzo, Italy (3) U.O. Fisiopatologia e Riabilitazione Respiratoria, Azienda Ospedaliera Senese, Siena, Italy (4) Department of Respiratory Medicine, St. James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK Article History: Registration Date: 11/06/2004 Received Date: 13/02/2004 Accepted Date: 01/06/2004 Online Date: 17/07/2004

Byline: J. Farias (1), I. Alia (2), A. Retta (1), F. Olazarri (1), A. Fernandez (1), A. Esteban (2), K. Palacios (1), L. Di Nunzio (1), G. Fernandez (1), A. Bordon (1), C. Berrondo (1), G. Sheehan (1) Keywords: Weaning Mechanical ventilation Weaning indices Extubation failure Infants Children Abstract: Objective. To assess the accuracy of traditional weaning indices in predicting extubation failure, and to compare their accuracy when indices are measured at the onset of a breathing trial (SBT) and at the end of the SBT before extubation. Design. Prospective study. Setting. Medical-surgical intensive care unit at a tertiary care hospital. Patients. Four hundred eighteen consecutive infants and children who received mechanical ventilation for at least 48 h and were deemed ready to undergo a SBT by their primary physician. Interventions. Respiratory frequency (RR), tidal volume (V.sub.T), maximal inspiratory pressure (P.sub.imax) and frequency-to-tidal volume ratio (f/V.sub.T) were obtained within the first 5 min of breathing through a T-piece. The primary physicians were unaware of those measurements and the decision to extubate a patient was made by them. RR, V.sub.T, f/V.sub.T were remeasured before extubation by the respiratory therapists. Extubation failure was defined as needing re intubation within 48 h after extubation. The area under the receiver operating characteristic (ROC) curve was calculated for each index as a measure of the accuracy in predicting extubation outcome. Measurements and main results. Three hundred twenty-three patients successfully underwent the SBT and were extubated, but 48 of them (14%) required re-intubation. The ROC curve for V.sub.T, RR, P.sub.imax and f/V.sub.T measured within the first 5 min of breathing were 0.54, 0.56, 0.57 and 0.57, respectively. The ROC curve did not increase significantly when the above indices were remeasured before extubation. Conclusions. In a population which had passed SBT, the ability of the traditional weaning indices to discriminate between children successfully extubated and children re-intubated is very poor. Author Affiliation: (1) Unidad de Cuidados Intensivos Pediatricos, Hospital de Ninos Ricardo Gutierrez, Gallo 1330, 1425 Temperley, Buenos Aires, Argentina (2) Unidad de Cuidados Intensivos, Hospital Universitario de Getafe, Getafe, Madrid, Spain (3) Address for reprints: Unidad de Cuidados Intensivos Pediatricos, Hospital de Ninos R Gutierrez, Gallo, 1425, Buenos Aires, Argentina, e-mail: jufarias@intramed.net.ar, Tel.: +54-11-49640100, Fax: +54-11-49640798 Article History: Received Date: 19/09/2001 Accepted Date: 15/03/2002 Article note: Electronic Publication

ABBREVIATIONS. OSAS, obstructive sleep apnea syndrome; WARS, upper airway resistance syndrome; NREM, non-rapid eye movement; EEG, electroencephalographic/electroencephalogram; Pes, esophageal pressure; tcPC[O.sub.2], transcutaneous carbon dioxide pressure; C[O.sub.2], carbon dioxide; EMG, electromyogram; [...]

Introduction Timely treatment of acute lower respiratory tract infections in children relies upon the assessment of clinical findings, especially respiratory rate (RR) and chest indrawing. Elevated RR has been shown [...], In a baseline study for training purposes, two indicators of acute respiratory infections (the respiratory rate (RR) and chest indrawing) were assessed by Ministry of Health physicians in Egypt using a WHO test videotape. Chest indrawing, as defined by the WHO Acute Respiratory Infections (ARI) programme, was not widely recognized by current health personnel. Viewing a WHO training videotape led to significantly more correct assessments of chest indrawing compared with a group that had not viewed this videotape. The accuracy of using a timer versus a watch, and a 30-second versus 60-second counting interval was also evaluated. Rates counted over 60 seconds were more accurate than 30-second counts although the difference between them was not clinically significant. Counting of rates using timers with audible cues was comparable to using watches with second hands. Careful training of primary health workers in the assessment of RR and chest indrawing is essential if these clinical findings are to be used as reliable indicators in pneumonia treatment algorithms.

The major cause of death in burn patients is a damaged respiratory system, which results from inhaling the products of combustion. Recent advances in treating burned body surfaces have now made the extent of respiratory injury a better prognostic factor than the proportion of burned body surface. If the degree of internal inhalation injury could be accurately evaluated early in the recovery process, treatment could be initiated immediately. However, signs of respiratory injury often do not appear until several days after the fire, and it is difficult to distinguish which patients will develop this complication. Burns that appear minor may be associated with major inhalation damage, and no reliable early marker yet exists. Calcitonin, a hormone released by cells in the lung in response to oxygen deprivation, toxic gases, cigarette smoke, and other stimuli, is a substance that seems promising for use as a marker. Detection of high levels of calcitonin in the blood of a burn patient can lead physicians to monitor the patient carefully for respiratory complications. One research study found that the average calcitonin level among burn patients increased dramatically 24 hours after injury, and that levels were significantly lower in patients who survived. No correlation was found between calcitonin levels and area of skin burned. Such an assay could also be used for firefighters or others who are not obviously injured, but who may suffer from inhalation injury. (Consumer Summary produced by Reliance Medical Information, Inc.)