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1.
Alternative interventions for obstructive sleep apnea.
Waters, T
Cleveland Clinic journal of medicine. 2019;(9 Suppl 1):34-41
Abstract
Positive airway pressure (PAP) therapy is the gold standard treatment for patients with obstructive sleep apnea (OSA) and has been shown to positively impact quality of life and cardiovascular outcomes. However, not all patients with OSA can use or tolerate PAP therapy. Alternative interventions to PAP include lifestyle measures, surgical interventions, hypoglossal nerve stimulation, oral appliance therapy, and expiratory PAP devices for OSA. While these alternative interventions may benefit patients and have demonstrated improvements in OSA and quality-of-life measures, the cardiovascular impact of these interventions is uncertain as data are limited.
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2.
Individualized positive end-expiratory pressure in obese patients during general anaesthesia: a randomized controlled clinical trial using electrical impedance tomography.
Nestler, C, Simon, P, Petroff, D, Hammermüller, S, Kamrath, D, Wolf, S, Dietrich, A, Camilo, LM, Beda, A, Carvalho, AR, et al
British journal of anaesthesia. 2017;(6):1194-1205
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Abstract
BACKGROUND General anaesthesia leads to atelectasis, reduced end-expiratory lung volume (EELV), and diminished arterial oxygenation in obese patients. We hypothesized that a combination of a recruitment manoeuvre (RM) and individualized positive end-expiratory pressure (PEEP) can avoid these effects. METHODS Patients with a BMI ≥35 kg m -2 undergoing elective laparoscopic surgery were randomly allocated to mechanical ventilation with a tidal volume of 8 ml kg -1 predicted body weight and (i) an RM followed by individualized PEEP titrated using electrical impedance tomography (PEEP IND ) or (ii) no RM and PEEP of 5 cm H 2 O (PEEP 5 ). Gas exchange, regional ventilation distribution, and EELV (multiple breath nitrogen washout method) were determined before, during, and after anaesthesia. The primary end point was the ratio of arterial partial pressure of oxygen to inspiratory oxygen fraction ( P aO 2 / F iO 2 ). RESULTS For PEEP IND ( n =25) and PEEP 5 ( n =25) arms together, P aO 2 / F iO 2 and EELV decreased by 15 kPa [95% confidence interval (CI) 11-20 kPa, P <0.001] and 1.2 litres (95% CI 0.9-1.6 litres, P <0.001), respectively, after intubation. Mean ( sd ) PEEP IND was 18.5 (5.6) cm H 2 O. In the PEEP IND arm, P aO 2 / F iO 2 before extubation was 23 kPa higher (95% CI 16-29 kPa; P <0.001), EELV was 1.8 litres larger (95% CI 1.5-2.2 litres; P <0.001), driving pressure was 6.7 cm H 2 O lower (95% CI 5.4-7.9 cm H 2 O; P <0.001), and regional ventilation was more equally distributed than for PEEP 5 . After extubation, however, these differences between the arms vanished. CONCLUSIONS In obese patients, an RM and higher PEEP IND restored EELV, regional ventilation distribution, and oxygenation during anaesthesia, but these differences did not persist after extubation. Therefore, lung protection strategies should include the postoperative period. CLINICAL TRIAL REGISTRATION German clinical trials register DRKS00004199, www.who.int/ictrp/network/drks2/en/ .
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Perioperative positive pressure ventilation: an integrated approach to improve pulmonary care.
Futier, E, Marret, E, Jaber, S
Anesthesiology. 2014;(2):400-8
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Nocturnal non-invasive ventilation for cardio-respiratory disorders in adults.
Wahab, R, Basner, RC
Expert review of respiratory medicine. 2013;(6):615-29
Abstract
Following the classic 'iron lung' non-invasive negative pressure ventilator, non-invasive positive pressure ventilation (NIPPV), particularly used 'nocturnally' has developed a broad role in both the acute hospital setting and domiciliary long-term use for many cardio-respiratory disorders associated with acute and chronic ventilatory failure. This role is based in part upon the perceived relative ease of application and discontinuation of NIPPV, ability to avoid intubation or tracheostomy and their associated morbidities and availability of increasingly portable pressure and volume cycled NIPPV devices. Nevertheless, the many methodologies necessary for optimal NIPPV use are often underappreciated by health care workers and patients alike. This review focuses on the rationale, practice, and future directions for 'nocturnal' use of non-invasive positive pressure ventilation (nNIV) in cardio-respiratory disorders in adults which are commonly associated with sleep-related apnea, hypoventilation and hypoxemia: congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), obesity hypoventilation syndrome (OHS), cystic fibrosis (CF) and neuromuscular disorders.
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Growth-arrest-specific 6 (GAS6) protein in ARDS patients: determination of plasma levels and influence of PEEP setting.
Diehl, JL, Coolen, N, Faisy, C, Osman, D, Prat, G, Sebbane, M, Nieszkowska, A, Gervais, C, Richard, JC, Richecoeur, J, et al
Respiratory care. 2013;(11):1886-91
Abstract
BACKGROUND Growth-arrest-specific protein 6 (GAS6) is a vitamin K-dependent protein expressed by endothelial cells and leukocytes participating in cell survival, migration and proliferation and involved in many pathological situations. The aim of our study was to assess its implication in ARDS and its variation according to PEEP setting, considering that different cyclic stresses could alter GAS6 plasma levels. METHODS Our subjects were enrolled in the ExPress study comparing a minimal alveolar distention (low-PEEP) ventilatory strategy to a maximal alveolar recruitment (high-PEEP) strategy in ARDS. Plasma GAS6, interleukin-8 (IL-8), and vascular endothelial growth factor (VEGF) levels were measured at day 0 and day 3 by enzyme-linked immunosorbent assay in blood samples prospectively collected during the study for a subset of 52 subjects included in 8 centers during year 2005. RESULTS We found that GAS6 plasma level was elevated in the whole population at day 0: median 106 ng/mL IQR 77-139 ng/mL, with significant correlations with IL-8, the Simplified Acute Physiology Score II and the Organ Dysfunction and Infection scores. Statistically significant decreases in GAS6 and IL-8 plasma levels were observed between day 0 and day 3 in the high-PEEP group (P = .02); while there were no differences between day 0 and day 3 in the low-PEEP group. CONCLUSIONS GAS6 plasma level is elevated in ARDS patients. The high-PEEP strategy is associated with a decrease in GAS6 and IL-8 plasma levels at day 3, without significant differences in day 28 mortality between the 2 groups. (Clinicaltrials.gov NCT00188058).
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Iron lung versus mask ventilation in acute exacerbation of COPD: a randomised crossover study.
Corrado, A, Gorini, M, Melej, R, Baglioni, S, Mollica, C, Villella, G, Consigli, GF, Dottorini, M, Bigioni, D, Toschi, M, et al
Intensive care medicine. 2009;(4):648-55
Abstract
OBJECTIVE To compare iron lung (ILV) versus mask ventilation (NPPV) in the treatment of COPD patients with acute on chronic respiratory failure (ACRF). DESIGN Randomised multicentre study. SETTING Respiratory intermediate intensive care units very skilled in ILV. PATIENTS AND METHODS A total of 141 patients met the inclusion criteria and were assigned: 70 to ILV and 71 to NPPV. To establish the failure of the technique employed as first line major and minor criteria for endotracheal intubation (EI) were used. With major criteria EI was promptly established. With at least two minor criteria patients were shifted from one technique to the other. RESULTS On admission, PaO(2)/FiO(2), 198 (70) and 187 (64), PaCO(2), 90.5 (14.1) and 88.7 (13.5) mmHg, and pH 7.25 (0.04) and 7.25 (0.05), were similar for ILV and NPPV groups. When used as first line, the success of ILV (87%) was significantly greater (P = 0.01) than NPPV (68%), due to the number of patients that met minor criteria for EI; after the shift of the techniques; however, the need of EI and hospital mortality was similar in both groups. The total rate of success using both techniques increased from 77.3 to 87.9% (P = 0.028). CONCLUSIONS The sequential use of NPPV and ILV avoided EI in a large percentage of COPD patients with ACRF; ILV was more effective than NPPV on the basis of minor criteria for EI but after the crossover the need of EI on the basis of major criteria and mortality was similar in both groups of patients.
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Positive end-expiratory pressure reduces pneumocephalus in spinal intradural tumor surgery.
Turgut, N, Turkmen, A, Gokkaya, S, Hatiboglu, MA, Iplikcioglu, AC, Altan, A
Journal of neurosurgical anesthesiology. 2007;(3):161-5
Abstract
We tested the hypothesis that 5 cm H2O of positive end-expiratory pressure (PEEP) reduces the incidence of pneumocephalus in patients who undergo spinal intradural tumor surgery. Fifty-three ASA I to III patients who underwent thoracolumbar intradural tumor surgery between the years 2003 and 2006 were included in this study. All patients received propofol, fentanyl, and cisatracurium for induction of the anesthesia. Maintenance was provided by propofol infusion and, oxygen (50%) and air (50%). Group I (n=28) did not receive PEEP whereas group II (n=25) received PEEP as 5 cm H2O. Cranial computerized tomography was taken at 8 hours after the surgery and cases were evaluated for pneumocephalus using BAB Bs200ProP Image System software. Pneumocephalus areas between 0.03 and 4.24 cm2 were observed in 9 patients, 8 in group I and 1 patient in group II at the 8th postoperative hour, at various localizations. There were no neurologic findings in other patients except for 2 patients in group I who presented with headache and mental status change. Although the cerebrospinal fluid leakage is minimal, N2O is not used and the patients are well hydrated, pneumocephalus with neurologic deficits may occur in patients undergoing microsurgical spinal intradural tumor surgery in prone position. In our study, we showed that using 5 cm H2O PEEP perioperatively reduced the risk of pneumocephalus. However, more cases must be studied to support this hypothesis.
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8.
[Non-invasive positive pressure ventilation for neuromuscular diseases. Practice guidelines].
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Revue des maladies respiratoires. 2006;(5 Pt 4):14S15-14S40
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9.
Acute effects of tidal volume strategy on hemodynamics, fluid balance, and sedation in acute lung injury.
Cheng, IW, Eisner, MD, Thompson, BT, Ware, LB, Matthay, MA, ,
Critical care medicine. 2005;(1):63-70; discussion 239-40
Abstract
OBJECTIVE To examine the effects of mechanical ventilation with a tidal volume of 6 mL/kg compared with 12 mL/kg predicted body weight on hemodynamics, vasopressor use, fluid balance, diuretics, sedation, and neuromuscular blockade within 48 hrs in patients with acute lung injury and acute respiratory distress syndrome. DESIGN Retrospective analysis of a previously conducted randomized, clinical trial. SETTING Two adult intensive care units at a tertiary university medical center and a large county hospital. PATIENTS One hundred eleven patients who were enrolled in the National Institutes of Health ARDS Network trial at the University of California, San Francisco. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Compared with 12 mL/kg predicted body weight, treatment with a tidal volume of 6 mL/kg predicted body weight had no adverse effects on hemodynamics. There were also no differences in the need for supportive therapies, including vasopressors, intravenous fluids, or diuretics. In addition, there were no differences in body weight, urine output, and fluid balance. Finally, there was no difference in the need for sedation or neuromuscular blockade between the two tidal volume protocols. CONCLUSIONS When compared with ventilation with 12 mL/kg predicted body weight, patients treated with the lung-protective 6 mL/kg predicted body weight tidal volume protocol had no difference in their supportive care requirements. Therefore, concerns regarding potential adverse effects of this protocol should not preclude its use in patients with acute lung injury or the acute respiratory distress syndrome.
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10.
A randomized controlled trial of sodium bicarbonate in neonatal resuscitation-effect on immediate outcome.
Lokesh, L, Kumar, P, Murki, S, Narang, A
Resuscitation. 2004;(2):219-23
Abstract
UNLABELLED Very little evidence is available that supports or disproves the use of medications in neonatal resuscitation. In this randomized controlled trial, we evaluated the effect of sodium bicarbonate given during neonatal resuscitation, on survival and neurological outcome at discharge. SUBJECTS AND METHODS Consecutively born asphyxiated neonates continuing to need positive pressure ventilation at 5min of life received either sodium bicarbonate or 5% dextrose. The study group was given intravenous sodium bicarbonate solution 4ml/kg (1.8meq./kg) over 3-5min. This solution was prepared by diluting 7.5% sodium bicarbonate (0.9meq./ml) with distilled water in a 1:1 ratio. The placebo group received 4ml/kg of undiluted 5% dextrose at a similar rate. The surviving neonates were evaluated for their neurological status at discharge. Primary outcome variable: Death or abnormal neurological examination at discharge. Secondary outcome variables: Encephalopathy, multi-organ dysfunction, intraventricular haemorrhage (IVH) and arterial pH at 6h. RESULTS Twenty-seven babies were randomized to receive sodium bicarbonate (bicarb group) and 28 to receive 5% dextrose. Eighteen of the 27 (66.7%) babies in the bicarb group and 19 of the 28 babies (68%) in the dextrose group survived to discharge ( P=0.84 ). Twenty-eight percent of the survivors in the bicarb group and 32% of the survivors in the dextrose group were neurologically abnormal at discharge ( P=0.10 ). The composite primary outcome of death or abnormal neurological examination at discharge was similar in both groups (52% versus 54%, P=0.88 ). The incidence of encephalopathy (74% versus 63%), cerebral oedema (52% versus 30%), need for inotropic support (44% versus 29%), intraventricular haemorrhage (IVH) and the mean arterial pH at 6hrs were similar between the two groups. CONCLUSION Administration of sodium bicarbonate during neonatal resuscitation did not help to improve survival or immediate neurological outcome.