Noninvasive Ventilation Coupled With Nebulization During Asthma Crises: A Randomized Controlled Trial

 

Valdecir C Galindo-Filho, Daniella C Branda˜o, Rita de Ca´ssia S Ferreira, Maria Jose´ C Menezes, Paulo Almeida-Filho, Veroˆnica F Parreira, Tayse N Silva, Maria da Glo´ria Rodrigues-Machado, Elizabeth Dean, and Arme`le Dornelas de Andrade

 

報告者：王貞慧

報告日期：102.10.23

 

BACKGROUND:

Despite the clinical improvements attributed to noninvasive ventilation (NIV) during asthma crises, and the well established effects of nebulization, there are few studies on the effects of these interventions together. We hypothesized that nebulization coupled to NIV should raise radio-aerosol pulmonary deposition in asthmatics. The aims of this study were to assess the effects of coupling b-agonist nebulization and NIV during asthma exacerbations on radio-aerosol pulmonary deposition, using scintigraphy and cardiopulmonary parameters, to correlate pulmonary function with radio-aerosol deposition index, radio-aerosol penetration index, and pulmonary clearance.

 

METHODS:

In this controlled trial, 21 adults with moderate to severe asthma attack were randomized to a control group (n = 11) or experimental group (NIV+ nebulizer group, n =10). All subjects inhaled bronchodilators for 9 minutes, and after particles were counted with a gamma camera to analyze regions of interest and pulmonary clearance at 0, 15, 30, 45, and 60 min.

 

RESULTS:

Breathing frequency (P =< .001) and minute ventilation (P = .01) were reduced, and tidal volume was increased (P =.01) in the NIV+ nebulizer group, compared with the control group. The NIV + nebulizer group had improvement from baseline values, compared to the control group in the following parameters: FEV1 46.7 ± 0.5% of predicted vs 29.8 ±8.9% of predicted, P =.02), FVC (41.2± 1.5% of predicted vs 23.2 ±7.1% of predicted, P=.02), peak expiratory flow (67.3 ±38.3% of predicted vs 26.9 ±12.1% of predicted, P= .01), and inspiratory capacity (54.9 ±28.8% of predicted vs 31.2 ±9.1% of predicted, P = .01). No differences were observed between groups regarding radio-aerosol deposition index or pulmonary clearance. Negative correlations were found between FEV1, forced expiratory flow during the middle half of the FVC maneuver (FEF25–75%), inspiratory capacity, and radio-aerosol penetration index.

 

CONCLUSIONS:

Coupling nebulization and NIV during asthma exacerbation did not improve radio-aerosol pulmonary deposition, but we observed clinical improvement of pulmonary function in these subjects.

(ClinicalTrials.gov registration NCT01012050)

Key words: noninvasive ventilation; asthma; nebulization; pulmonary scintigraphy; radio-aerosol; pulmonary function. [Respir Care 2013;58(2):241–249]

 

 

 
 

 

 

Medical Research Council dyspnea score

Simplified Acute Physiologic Score II

Score 0-162 points

Types of ICU outcome scoring systems

Specific

a. head injury Glasgow coma score

b. burns % + age ~ mortality

c. trauma injury severity score (ISS)

trauma score

d. IHD NYHA / AHA classification

e. pancreatitis Ranson’s scoring criteria

f. liver failure Child’s classification General

1. Anatomical – e.g. Injury Severity Score

• Useful for trauma audits and research

2. Therapeutic – e.g. Therapeutic Intervention Scoring System (TISS)

• Sum of weighted scores of therapeutic interventions

• Correlates well with outcome

• Wide applicability

3. Physiological – e.g. APACHE – Acute physiology and chronic health evaluation

• Designed for quality review rather than prognosis

Specific models

First generation: Second generation

APACHE I APACHE II

SAPS I

MPM I

Third generation Fourth generation

APACHE III APACHE IV

SAPS II SAPS III

MPM II MPM0 III

Knaux Index (according to APACH II)

 

Rescue Therapy  by Switching to Total Face Mask After Failure of  Face Mask-Delivered Noninvasive Ventilation  in Do-Not-Intubate Patients in Acute Respiratory Failure

作者：Malcolm Lemyze; Jihad Mallat; Olivier Nigeon; Stéphanie Barrailler; Florent Pepy; Gaëlle Gasan; Nicolas Vangrunderbeeck; Philippe Grosset; Laurent Tronchon; Didier Thevenin.
報告者：張桂禎
報告日期：102.10.16

Objective:
To evaluate the impact of switching to total face mask in cases where face mask-delivered noninvasive mechanical ventilation
has already failed in do-not-intubate patients in acute respiratory failure.
Design and Setting:
Prospective observational study in an ICU and a respiratory stepdown unit over a 12-month study period.

Intervention:
Switching to total face mask, which covers the entire face, when noninvasive mechanical ventilation using facial mask (oronasal mask) failed to reverse acute respiratory failure. Patients: Seventy-four patients with a do-not-intubate order and treated by noninvasive mechanical ventilation for acute respiratory failure.

Main Results:
Failure of face mask-delivered noninvasive mechanical ventilation was associated with a three-fold increase in in-hospital mortality (36% vs. 10.5%; p = 0.009). Nevertheless, 23 out of 36 patients (64%) in whom face mask-delivered noninvasive mechanical ventilation failed to reverse acute respiratory failure and, therefore, switched to total face mask survived hospital discharge. Reasons for switching from facial mask to total face mask included refractory hypercapnic acute respiratory failure (n = 24, 66.7%), painful skin breakdown or facial mask intolerance (n = 11, 30%), and refractory hypoxemia (n = 1, 2.7%). In the 24 patients switched from facial mask to total face mask because of refractory hypercapnia, encephalopathy score (3 [3–4] vs. 2 [2–3]; p < 0.0001), Paco2 (87 ± 25 mm Hg vs. 70 ± 17 mmHg; p < 0.0001), and pH (7.24 ± 0.1 vs. 7.32 ± 0.09; p < 0.0001) significantly improved after 2 hrs of total face mask-delivered noninvasive ventilation. Patients switched early to total face mask (in the first 12 hrs) developed less pressure sores (n = 5, 24% vs.n = 13, 87%; p = 0.0002), despite greater length of noninvasive mechanical ventilation within the first 48 hrs (44 hrs vs. 34 hrs;p = 0.05) and less protective dressings (n = 2, 9.5% vs. n =8, 53.3%; p = 0.007). The optimal cutoff value for face maskdelivered noninvasive mechanical ventilation duration in predicting facial pressure sores was 11 hrs (area under the receiver operating characteristic curve, 0.86 ± 0.04; 95% confidence interval 0.76–0.93; p < 0.0001; sensitivity, 84%; specificity, 71%).

Conclusion:
In patients in hypercapnic acute respiratory failure,for whom escalation to intubation is deemed inappropriate,switching to total face mask can be proposed as a last resort therapy when face mask-delivered noninvasive mechanical ventilation has already failed to reverse acute respiratory failure. This strategy is particularly adapted to provide prolonged periods of continuous noninvasive mechanical ventilation while preventing facial pressure sores. (Crit Care Med 2013; 41:481–488)

Key Words: acute respiratory failure; chronic obstructive pulmonary disease; do-not-intubate order; noninvasive ventilation; total face
mask

Cardiovasc Ther. 2013 Feb;31(1):38-44. doi: 10.1111/1755-5922.12008.

Rapid transition from inhaled iloprost to inhaled treprostinil in patients with pulmonary arterial hypertension.

Bourge RC, Tapson VF, Safdar Z, Benza RL, Channick RN, Rosenzweig EB, Shapiro S, White RJ, McSwain CS, Gotzkowsky SK, Nelsen AC, Rubin LJ.

Source

University of Alabama at Birmingham, Birmingham, AL 35294, USA. bbourge@uab.edu

Abstract

BACKGROUND:

Inhaled treprostinil is a prostacyclin analog approved for the treatment of pulmonary arterial hypertension (PAH) that may provide a more convenient treatment option for patients receiving inhaled iloprost while maintaining the clinical benefit of inhaled prostacyclin therapy.

AIMS:

In this open-label safety study, 73 PAH patients were enrolled with primarily World Health Organization Class II (56%) or III (42%) symptoms. At baseline, most patients (93%) were receiving 5 μg of iloprost per dose but 38% of patients reported a dosing frequency below the labeled rate of 6-9 times daily. Patients initiated inhaled treprostinil at 3 breaths four times daily (qid) at the immediate next scheduled iloprost dose. The primary objective was to assess the safety of rapid transition from iloprost to inhaled treprostinil; clinical status and quality of life were also assessed.

RESULTS:

Most patients (84%) achieved the target treprostinil dose of 9 breaths qid and remained on study until transition to commercial therapy (89%). The most frequent adverse events (AEs) were cough (74%), headache (44%), and nausea (30%), and five patients prematurely discontinued study drug due to AE (n = 3), disease progression (n = 1), or death (n = 1). At week 12, the time spent on daily treatment activities was reduced compared to baseline, with a mean total savings of 1.4 h per day. Improvements were also observed at week 12 for 6-min walk distance (+16.0; P < 0.001), N-terminal pro-B-type natriuretic peptide (-74 pg/mL; P = 0.001), and the Cambridge Pulmonary Hypertension Outcome Review (all domains P < 0.001).

CONCLUSIONS:

Pulmonary arterial hypertension patients can be safely transitioned from inhaled iloprost to inhaled treprostinil while maintaining clinical status.

The value of exhaled nitric oxide to identify asthma in smoking patients with asthma-like symptoms

Respiratory Medicine 2012, 106(6), 794-901
Andrei Malinovschi, Vibeke Backer, Henrik Harving, Celeste Porsbjerg

報告者：戴淑婷 102.07

Background

The fraction of nitric oxide in exhaled air (FeNO) is used in asthma diagnosis and management. Smoking reduces FeNO and 20–35% of asthmatics are smoking. However no guidelines exist on the diagnostic value of FeNO in smokers. Therefore we assessed the value of FeNO to diagnose asthma in a population of subjects with asthma-like symptoms and different smoking habits.

Methods

Measurements of FeNO, lung function, bronchial responsiveness and allergy testing were performed in 282 subjects (108 never-, 62 ex- and 112 current smokers) aged 14–44 years, with symptoms suggestive of asthma. These subjects were a subset of subjects reporting respiratory symptoms (n = 686) in a random population sample (n = 10,400).

Results

A diagnosis of asthma was given to 96 of the 282 subjects. Subjects with asthma had higher FeNO levels than subjects with non-specific asthma symptoms in all three smoking strata (p < 0.001), with a percentual increase of FeNO by 76% in never-, 71% in ex- and 60% in current smokers. The area under the ROC-curve was similar in never-, ex- and current smokers (0.72 vs. 0.74 vs. 0.70). The cut-offs were approximately 30% lower for either 90% specificity (22 vs. 31 ppb) or 90% sensitivity (7 vs. 10 ppb) in current vs. never-smokers.

Conclusions

FeNO could differentiate asthmatic subjects from non-asthmatic subjects with asthma-like symptoms equally well in both never- and current smokers within a random population sample. The FeNO cut-off levels needed in order to achieve high sensitivity or specificity were lower in current smokers.

Central retinal artery occlusion treated with oxygen: A literature review and treatment algorithm

H. Murphy-Lavoie , F. Butler , C. Hagan

UHM 2012, Vol. 39, No. 5:943-953

ABSTRACT

Central retinal artery occlusion (CRAO) is an uncommon eye disorder, but one that typically produces severe and irreversible vision loss in the affected eye. The retina has a dual blood supply, with the retinal circulation supplying the inner layers and the choroidal circulation supplying the outer layers. In CRAO, vision loss results from cell death in the inner retinal layers despite relative sparing of the outer layers.

If supplemental oxygen is provided, however, oxygen from the choroidal circulation may diffuse in adequate quantity to the inner layers of the retina to maintain retinal function and restore vision. In some patients this can be achieved with normobaric hyperoxia; in others, hyperbaric oxygen (HBO2) may be required.

The challenge is to provide the supplemental oxygen early enough after the onset of vision loss to prevent irreversible damage to the retina. In experimental models of complete CRAO, the ischemic time window before permanent retinal damage occurs is just over 90 minutes; in the clinical setting where occlusion may be incomplete, return of vision may be achieved even after delays of eight to 24 hours.

In patients with a clinical picture of CRAO who present within 24 hours of vision loss, supplemental oxygen should be started immediately at the highest possible fraction of inspired oxygen (FiO2). If vision is not quickly restored, emergent HBO2 should be undertaken if feasible. If the patient responds to HBO2, follow-up treatment with supplemental oxygen should be customized to maintain retinal viability until the obstructed retinal artery recanalizes, which typically occurs within the first 72 hours. This paper reviews the pertinent literature on CRAO and HBO2 and provides a treatment algorithm.

 

Based on the American Heart Association classification of evidence, treatment of CRAO with hyperbaric oxygen therapy is Level IIb . There is fair to good evidence to support its use with retrospective case series but no prospective randomized controlled trials. It is acceptable, safe, considered efficacious but lacks confirmation of efficacy by Level 1 studies. There is no evidence of harm, and consistently positive results, when HBO2 is started shortly after onset on vision loss. In addition, there are no alternative therapies with similar outcomes, that would present ethical considerations for a proposed randomized trial. The relatively rare incidence of this condition does not lend itself to randomized controlled trials, as evidenced by the paucity of trials for other therapies in treating this condition. As of 2012, a Medline search revealed only four small randomized controlled trials for all of the proposed therapies, none of which revealed clinically positive results. The hopeless and recalcitrant nature of this condition when left untreated mandates we utilize all potentially helpful treatments, including hyperbaric oxygen therapy.

Comparison of therapeutic results in sudden sensorineural hearing loss with/without additional hyperbaric oxygen therapy: a retrospective review of 465 audiologically controlled cases

Liu, S.-C., Kang, B.-H., Lee, J.-C., Lin, Y.-S., Huang, K.-L., Liu, D.-W., Su, W.-F.,

Kao, C.-H., Chu, Y.-H., Chen, H.-C. & Wang, C.-H.
 

Clin. Otolaryngol. 2011, 36, 121–128

 

Objective: To investigate the necessity of routine application of hyperbaric oxygen therapy for sudden sensorineural hearing loss.

Design ⁄ setting and participants: A retrospective chart review looked at 465 patients, with 353 of them receiving pharmacologic treatments alone. Among these patients, 76 underwent systemic steroid treatment only (steroid group) and 277 received systemic steroids and dextran (steroid–dextran group). The remaining 112 patients were treated with hyperbaric oxygen in addition to pharmacologic agents (steroid–dextran–hyperbaric oxygen group).

 

Main outcome measures: The outcome was determined by comparing the difference of pure-tone thresholds and absolute hearing gains after treatment calculated at each audiometric octave frequency or grouped frequencies of audiograms. On the basis of the severity of initial hearing loss, patients were classified at three scales of hearing impairments measured in decibels hearing level (dBHL): ≦70 dBHL, less severe; 71–90 dBHL, severe; and ≧91 dBHL, profound. The outcomes of their hearing recovery were classified into three recovery grades: good, fair and poor.

 

Results:  In those patients with initial hearing loss >90 dBHL, the addition of hyperbaric oxygen to steroid–dextran gave a significant hearing gain difference (P = 0.030) by showing a greater hearing gain of 24.5 ± 2.7 dB compared with steroid only (12.9 ± 3.7 dB) or steroid–dextran (15.6 ± 2.7 dB). This outcome was confirmed when we compared the outcome using the recovery grading; steroid–dextran–hyperbaric oxygen group showed that more patients with initial profound (≧91 dBHL) hearing loss responded to hyperbaric oxygen treatment by exhibiting good and fair recoveries (2% and 70%) as compared with steroid only (0% and 42%) or steroid–dextran (8% and 46%) groups (P = 0.043), while the patients with initial severe (71–90 dBHL) and less severe (≦70 dBHL) hearing loss responded to the addition of hyperbaric oxygen treatment with less favourable recoveries. Furthermore, the addition of dextran in steroid–dextran group showed no significant benefit compared with the steroid group (P =0.435).

 

Conclusions: When applied as an adjuvant to pharmacologic agents, hyperbaric oxygen benefits patients with initial profound sudden sensorineural hearing loss. Therefore, we recommend the routine application of hyperbaric oxygen in conjunction with pharmacologic agents for those patients. The addition of dextran to steroid has no benefit and cannot be recommended.

Hyperbaric oxygen for idiopathic sudden sensorineural hearing loss and tinnitus

Michael H Bennett1, Tom Kertesz2, Matthias Perleth3, Philip Yeung2, Jan P Lehm4

Cochrane Database of Systematic Reviews 2012, Issue 10.

Copyright © 2012 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.

A B S T R A C T

Background

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 1, 2005 and previously updated in 2007 and 2009. Idiopathic sudden sensorineural hearing loss (ISSHL) is common and has a significant effect on quality of life. Hyperbaric oxygen therapy (HBOT) may improve oxygen supply to the inner ear and result in an improvement in hearing.

Objectives

To assess the benefits and harms of HBOT for treating ISSHL and/or tinnitus.

Search methods

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; Database of Randomised Trials in HyperbaricMedicine (DORCTHIM); CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 2 May 2012, following previous searches in 2009, 2007 and 2004.

Selection criteria

Randomised studies comparing the effect on ISSHL and tinnitus of HBOT and alternative therapies.

Data collection and analysis

Three authors evaluated the quality of trials using the ’Risk of bias’ tool and extracted data from the included trials.

Main results

Seven trials contributed to this review (392 participants). The studies were small and of generally poor quality. Pooled data from two trials did not show any significant improvement in the chance of a 50% increase in hearing threshold on pure-tone average with HBOT (risk ratio (RR) with HBOT 1.53, 95% confidence interval (CI) 0.85 to 2.78, P = 0.16), but did show a significantly increased chance of a 25% increase in pure-tone average (RR 1.39, 95% CI 1.05 to 1.84, P = 0.02). There was a 22% greater chance of improvement with HBOT, and the number needed to treat (NNT) to achieve one extra good outcome was 5 (95% CI 3 to 20). There was also an absolute improvement in average pure-tone audiometric threshold following HBOT (mean difference (MD) 15.6 dB greater with HBOT, 95% CI 1.5 to 29.8, P = 0.03). The significance of any improvement in tinnitus could not be assessed. There were no significant improvements in hearing or tinnitus reported for chronic presentation (sixmonths) of ISSHL and/or tinnitus.

Authors’ conclusions

For people with acute ISSHL, the application of HBOT significantly improved hearing, but the clinical significance remains unclear. We could not assess the effect of HBOT on tinnitus by pooled analysis. In view of the modest number of patients, methodological shortcomings and poor reporting, this result should be interpreted cautiously. An appropriately powered trial is justified to define those patients (if any) who can be expected to derive most benefit from HBOT. There is no evidence of a beneficial effect of HBOT on chronic ISSHL or tinnitus and we do not recommend the use of HBOT for this purpose.

Central retinal artery occlusion treated with oxygen: A literature review and treatment algorithm

UHM 2012, Vol. 39, NO. 5:943-953

The retina has a dual blood supply, with the retinal circulation supplying the inner layers and
the choroidal circulation supplying the outer layers. In CRAO. vision loss results from cell death
in the inner retinal layers despite relative sparing of the outer layers.
O2 from the choroidal circulation may diffuse in adequate quantity to the inner layers of the retina to maintain retinal function and restore vision.
In some patients this can be achieved with normobaric hyperopia, in others, HBO2 may be required.
In experimental models of complete CRAO, the ischemic time window before permanent retinal damage occurs is just over 90 mins; in the clinical setting where occlusion may be incomplete, return of vision may be achieved even after delays of 8 to 24 hours.

NRM(high FiO2) -＞vision not restored->HBO2-＞until the obstructed retinal artery recanalizes, which typically occurs within 72 hours.

臨床處置：當視力突然低於20／200
1.使用血管擴張劑並用眼底鏡觀察。
2.詢問是否產生閃光或有漂浮物，視力喪失，痛，最近創傷／手術史或年齡低於40歲，建議可能其它診斷（如：視網膜剝離或玻璃體出血）。
3.會診眼科醫師。
4.立刻給予O2。
5.測眼壓，升高時給予治療。或予以前腔窒穿刺放液。
6.檢查CBC（有無血小板病變或感染），ESR（檢查有無動脈炎），高凝血物質(fibrinogen, PT/PTT, anti phospholipid antibody), lipid panel, EKG, carotid ultrasound.
7.HBO.
8.若為血管發炎性的CRAO，可用iv的steroid.

氧氣調節：
1.立即給予高濃度氧氣（如：NRM）
2.若對氧有反應，每小時吸15分鐘氧氣，45分鐘空氣。
3.若對氧無反應，給HBO 2ATA, 90分鐘。
4.若無反應，HBO 改為2.4 ATA, 90分鐘。
5.若無反應，HBO 改為2.8 ATA, 90分鐘。

1980 Augsberger and Magargal硏究報告指出：成功組治療延遲時間為21.1小時，失敗組平均為58.6小時。

本篇回顧28篇，均為retrospective studies，樣本數共476人，成功人數為主306人，成功率為65%，但不是meta analysis, 療程也多不一致。

此篇於2012進行midline search 4篇樣本數小的RCT，均無臨床正向效果，因此僅能儘量可能有效的治療，包括HBO2。

A Randomized Controlled Trial of Nebulized Gentamicin in Non–Cystic Fibrosis Bronchiectasis

Authors: Maeve P. Murray, John R. W. Govan, Catherine J. Doherty, et al.

Journal: Am J Respir Crit Care Med Vol 183. pp 491–499, 2011

報告者:孫文娟  呼吸治療師

指導者:鄭瑞駿  臨床組長

報告日期:2012年2月20日

Rationale: Bronchiectasis is a chronic debilitating disease with few evidence-based long-term treatments.

Objectives: A randomized controlled trial assessing the efficacy of nebulized gentamicin therapy over 1 year in patients with non–cystic fibrosis bronchiectasis.

Methods: Sixty-five patients were randomized to either twice-daily nebulized gentamicin, 80 mg, or nebulized 0.9% saline, for 12 months. All were reviewed at three-monthly intervals during treatment and at 3 months’ follow-up. Measurements and Main Results: At each review the following were assessed: quantitative and qualitative sputum bacteriology; sputum purulence and 24-hour volume; FEV1, FVC, and forced expiratory flow, mid expiratory phase; exercise capacity; Leicester Cough Questionnaire and St. George’s Respiratory Questionnaire; and exacerbation frequency. Fifty-seven patients completed the study. At the end of 12 months’ treatment, compared with the saline group, in the gentamicin group there was reduced sputum bacterial density with 30.8% eradication in those infected with Pseudomonas aeruginosa and 92.8% eradication in those infected with other pathogens; less sputum purulence (8.7% vs. 38.5%; P<0.0001); greater exercise capacity (510 [350–690]m vs. 415 [267.5–530]m; P=0.03); and fewer exacerbations (0 [0–1] vs. 1.5 [1–2]; P<0.0001) with increased time to first exacerbation (120 [87–161.5] d vs. 61.5 [20.7–122.7] d; P=0.02). The gentamicin group had greater improvements in Leicester Cough Questionnaire (81.4% vs. 20%; P<0.01) and St. George’s Respiratory Questionnaire (87.5%vs. 19.2%; P<0.004) score. No differences were seen in 24-hour sputum volume, FEV1, FVC, or forced expiratory flow, mid expiratory phase. No P. aeruginosa isolates developed resistance to gentamicin. At follow-up, all outcome measures were similar to baseline.

Conclusions: Regular, long-term nebulized gentamicin is of significant benefit in non–cystic fibrosis bronchiectasis but treatment needs to be continuous for its ongoing efficacy.