Acute hypoxemic respiratory failure(AHRF)refers to“de novo”respiratory failure,excluding cardiogenic pulmonary edema or exacerbation of chronic lung diseases.AHRF can be defined as the arterial pressure of oxygen/in...Acute hypoxemic respiratory failure(AHRF)refers to“de novo”respiratory failure,excluding cardiogenic pulmonary edema or exacerbation of chronic lung diseases.AHRF can be defined as the arterial pressure of oxygen/inspiratory fraction of oxygen(PaO_(2)/FiO_(2))≤300 mmHg in patients receiving oxygen therapy.[1]Whereas FiO_(2)cannot be measured under a standard oxygen mask,it can be best estimated using the following formula:FiO_(2)(%)=flow of oxygen(L/min)×3+21%.[2]Several oxygenation strategies can be proposed as an alternative to standard oxygen in patients with AHRF,including highflow nasal cannula oxygen(HFNC),continuous positive airway pressure(CPAP),and noninvasive ventilation(NIV).展开更多
Acute hypoxemic respiratory failure(AHRF)is the leading cause of intensive care unit(ICU)admissions.Of patients with AHRF,40%–50%will require invasive mechanical ventilation during their stay in the ICU,and 30%–80%w...Acute hypoxemic respiratory failure(AHRF)is the leading cause of intensive care unit(ICU)admissions.Of patients with AHRF,40%–50%will require invasive mechanical ventilation during their stay in the ICU,and 30%–80%will meet the Berlin Criteria for Acute Respiratory Distress Syndrome(ARDS).Rapid identification of the underlying cause of AHRF is necessary before initiating targeted treatment.Almost 10%of patients with ARDS have no identified classic risk factors however,and the precise cause of AHRF may not be identified in up to 15%of patients,particularly in cases of immunosuppression.In these patients,a multidisciplinary,comprehensive,and hierarchical diagnostic work-up is mandatory,including a detailed history and physical examination,chest computed tomography,extensive microbiological investigations,bronchoalveolar lavage fluid cytological analysis,immunological tests,and investigation of the possible involvement of pneumotoxic drugs.展开更多
In patients with hypoxemic acute respiratory failure(ARF),the first-line treatment is oxygen therapy,which may include the administration of high-flow nasal oxygen(HFNO),noninvasive ventilation(NIV),or continuous posi...In patients with hypoxemic acute respiratory failure(ARF),the first-line treatment is oxygen therapy,which may include the administration of high-flow nasal oxygen(HFNO),noninvasive ventilation(NIV),or continuous positive airway pressure(CPAP).In addition to improving oxygenation,HFNO and NIV reduce the work of breathing as compared to standard oxygen,while CPAP does not.However,tolerance to NIV and CPAP is clinically challenging,resulting in treatment interruption in 10%-20%of cases.Compared to standard oxygen,HFNO has been shown to reduce the risk of intubation,while the benefits of NIV or CPAP,even when delivered via a helmet,require further evaluation.Although evidence for the efficacy of HFNO in reducing mortality remains inconclusive,HFNO has emerged as the reference treatment and is recommended for patients with hypoxemic ARF given its benefit in reducing the risk of intubation.展开更多
Background:Awake prone positioning(APP)can reportedly reduce the need for intubation and help improve prognosis of patients with acute hypoxemic respiratory failure(AHRF)infected with COVID-19.However,its physiologica...Background:Awake prone positioning(APP)can reportedly reduce the need for intubation and help improve prognosis of patients with acute hypoxemic respiratory failure(AHRF)infected with COVID-19.However,its physiological mechanism remains unclear.In this study,we evaluated the effect of APP on lung ventilation in patients with moderate-to-severe AHRF to better understand the effects on ventilation distribution and to prevent intubation in non-intubated patients.Methods:The prospective study was performed in the Department of Critical Care Medicine at Shanghai General Hospital,China,from January 2021 to November 2022.The study included patients with AHRF(partial pressure of oxygen[PaO_(2)]/inspired oxygen concentration[FiO_(2)]<200 mmHg or oxygen saturation[SpO_(2)]/FiO_(2)<235]treated with high-flow nasal oxygen.Electrical impedance tomography(EIT)measurements including center of ventilation(COV),global inhomogeneity(GI)index,and regional ventilation delay(RVD)index were performed in the supine position(To),30 min after the start of APP(Ti),and 30 min returning to supine position after the APP(T2).Clinical parameters like SpO_(2),respiratory rate(RR),FiO_(2),heart rate(HR),and ROX(the ratio of SpO_(2) as measured by pulse oximetry/FiO_(2) to RR)were also recorded simultaneously at To,Ti,and T2.To evaluate the effect of the time points on the variables,Mauchly's test was performed for sphericity and repeated measures analysis of variance was applied with Bonferroni's post hoc multiple comparisons.Results:Ten patients were enrolled.The Pa02/FiO_(2) ratio was(111.4±33.4)mmHg at the time of recruitment.ROX showed a significant increase after initiation of APP(median(interquartile range[IQR)):To:7.5(6.0-10.1)vs.Ti:7.6(6.4-9.3)vs.T2:8.3(7.2-11.0),P=0.043).RR(P=0.409),HR(P=0.417),and SpO_(2)/FiO_(2)(P=0.262)did not change significantly during prone positioning(PP).The CoV moved from the ventral area to the dorsal area(To:48.8%±6.2%vs.T:54.8%±6.8%vs.T2:50.3%±6.1%,P=0.030)after APP.The GI decreased significantly after APP(To:median=42.7%,[IQR:38.3%-47.5%]vs.Ti:median=38.2%,[IQR:34.6%-50.7%]vs.T2:median=37.4%,[IQR:34.2%-41.4%],P=0.049).RVD(P=0.794)did not change after APP.Conclusions:APP can improve ventilation distribution and homogeneity of lung ventilation as assessed by EIT in non-intubated patients with AHRF.Trail Registration Chinese Clinical Trial Registry Identifier:ChiCTR2000035895.展开更多
De novo acute hypoxemic respiratory failure(AHRF)remains one of the leading causes of intensive care unit(ICU)admission and is still associated with high rates of intubation and mortality.Developing effective strategi...De novo acute hypoxemic respiratory failure(AHRF)remains one of the leading causes of intensive care unit(ICU)admission and is still associated with high rates of intubation and mortality.Developing effective strategies to prevent intubation and its associated complications remains a critical objective in this population.Noninvasive ventilation(NIV)has been proposed as a potential alternative to invasive ventilation in AHRF.However,no clear clinical benefit has been consistently demonstrated to date.The lack of definitive evidence has left experts unable to provide recommendations for the use of NIV in AHRF.Several factors may account for the inconsistencies in the literature and merit further investigation.Identifying early predictive criteria for NIV failure could be essential in determining which patients are most likely to benefit from this intervention.In addition,the approach to NIV settings may require reconsideration,particularly regarding the level of assistance.Efforts to reduce tidal volume,while aiming to minimize ventilator-induced lung injury,may have inadvertently resulted in insufficient support,amplifying the harmful effects of excessive inspiratory effort.The choice of interface may also significantly influence the physiological effects and outcomes and warrants further exploration.Finally,the frugal nature of noninvasive techniques makes them well-suited for the universal management of AHRF,regardless of constraints.This highlights the need for future developments aimed at optimizing oxygen and energy efficiency,enhancing the ease of use and robustness of NIV devices,and evaluating the effectiveness of NIV under high-constraint conditions,such as in low-and middle-income countries.This review addresses these critical questions.展开更多
Background Hypoxemic respiratory failure （HRF） is one of the most common causes for neonatal infants requiring aggressive respiratory support. Inhaled nitric oxide （iNO） has been established routinely as an adjunc...Background Hypoxemic respiratory failure （HRF） is one of the most common causes for neonatal infants requiring aggressive respiratory support. Inhaled nitric oxide （iNO） has been established routinely as an adjunct to conventional respiratory support in developed countries. The aim of this study was to investigate effects of iNO in neonates with HRF in resource limited condition with no or limited use of surfactant, high frequency oscillatory ventilation （HFOV） and extracorporeal membrane oxygenation.Methods A non-randomized, open, controlled study of efficacy of iNO was conducted over 18 months. Eligible term and near-term neonates from 28 hospitals with HRF （oxygenation index ＞15） were enrolled prospectively into two groups as either iNO or control. Oxygenation improvement and mortality as primary endpoint were determined in relation with dosing and timing of iNO, severity of underlying diseases, complications and burden. Intention-to-treat principle was adopted for outcome assessment. Response to iNO at 10 or 20 parts per million （ppm） was determined by oxygenation in reference to the control （between-group） and the baseline （within-group）.Results Compared to 93 controls, initial dose of iNO at 10 ppm in 107 treated infants significantly improved oxygenation from first hour （P=0.046）, with more partial- and non-responders improved oxygenation with subsequent 20ppm NO （P=0.018）. This effect persisted on days 1 and 3, and resulted in relatively lower mortalities （11.2% vs. 15%）whereas fewer were treated with surfactant （10% vs. 27%）,HFOV （＜5%） or postnatal corticosteroids （＜10%） in both groups. The overall outcomes at 28 days of postnatal life in the iNO-treated was not related to perinatal asphyxia,underlying diseases, severity of hypoxemia, or complications,but to the early use of iNO. The cost of hospital stay was not significantly different in both groups.Conclusions With relatively limited use of surfactant and/or HFOV in neonatal HRF, significantly more responders were found in the iNO-treated patients as reflected by improved oxygenation in the first three days over the baseline level. It warrants a randomized, controlled trial for assessment of appropriate timing and long-term outcome of iNO.展开更多
Optimal initial non-invasive management of acute hypoxemic respiratory failure(AHRF),of both coronavirus disease 2019(COVID-19)and non-COVID-19 etiologies,has been the subject of significant discussion.Avoidance of en...Optimal initial non-invasive management of acute hypoxemic respiratory failure(AHRF),of both coronavirus disease 2019(COVID-19)and non-COVID-19 etiologies,has been the subject of significant discussion.Avoidance of endotracheal intubation reduces related complications,but maintenance of spontaneous breathing with intense respiratory effort may increase risks of patients’self-inflicted lung injury,leading to delayed intubation and worse clinical outcomes.High-flow nasal oxygen is currently recommended as the optimal strategy for AHRF management for its simplicity and beneficial physiological effects.Non-invasive ventilation(NIV),delivered as either pressure support or continuous positive airway pressure via interfaces like face masks and helmets,can improve oxygenation and may be associated with reduced endotracheal intubation rates.However,treatment failure is common and associated with poor outcomes.Expertise and knowledge of the specific features of each interface are necessary to fully exploit their potential benefits and minimize risks.Strict clinical and physiological monitoring is necessary during any treatment to avoid delays in endotracheal intubation and protective ventilation.In this narrative review,we analyze the physiological benefits and risks of spontaneous breathing in AHRF,and the characteristics of tools for delivering NIV.The goal herein is to provide a contemporary,evidence-based overview of this highly relevant topic.展开更多
Objective： To investigate the therapeutic effect of acupuncture plus hyperbaric oxygen in treating hypoxemic infantile encephalopathy （HIE）. Methods： Fifty-nine HIE children were divided into treatment （33 cases...Objective： To investigate the therapeutic effect of acupuncture plus hyperbaric oxygen in treating hypoxemic infantile encephalopathy （HIE）. Methods： Fifty-nine HIE children were divided into treatment （33 cases） and control （26 cases） groups. Both groups were treated by basic therapy of removing acidosis, controlling cerebral edema and convulsion, and intravenous drip of cerebrolysin or citicoline. The treatment group was treated by acupuncture plus hyperbaric oxygen and the control group was treated by hyperbaric oxygen only. Results： The total effective rate was 97.0% in the treatment group and 73.1% in the control group. Statistical analysis showed a highly significant difference （P〈0.01）. Conclusion： Acupuncture plus hyperbaric oxygen was better than simple hyperbaric oxygen in treating HIE. Its main manifestations were shortening the course of disease, increasing cure rate, decreasing death rate and reducing the occurrence of sequelae. HIE children should be treated as early as possible.展开更多
Background:Lung cancer is one of the leading causes of death despite improvement in treatment modalities such as immunotherapy with chemotherapy and precise radiotherapy.NSCLC is a heterogeneous group of diseases that...Background:Lung cancer is one of the leading causes of death despite improvement in treatment modalities such as immunotherapy with chemotherapy and precise radiotherapy.NSCLC is a heterogeneous group of diseases that differs in cytology and includes adenocarcinoma,squamous cell carcinoma,bronchioloalveolar carcinoma,and poorly differentiated carcinoma.Usually,NSCLC,in contrast to SCLC,spreads locally,and the doubling time of squamous cell carcinoma is 133 days which classifies it as a relatively slow-growing tumor.Case presentation:We present the case of a 72-year-old male,recently diagnosed with squamous cell carcinoma in the right upper lobe along with secondary deposits.Few days after diagnosis,the patient had severe respiratory distress.This endobronchial tumor has increased significantly in size upon bronchoscopic visualization causing a complete obstruction of his right main bronchus and hypoxemic respiratory failure requiring intubation.Conclusion:To our knowledge,there are few reported cases where lung adenocarcinoma progressed rapidly over days.Squamous cell carcinoma usually takes 3 to 6 months to double in size,but in our case,the progression was very fast.In the last decade,it was confirmed that the doubling time of a tumor is an independent factor in the prognosis of lung cancer patients.On the other hand,further studies are needed to identify genes associated with rapid progression and a worse prognosis for lung squamous cell carcinoma.Hence,this aggressive tumor is a“rapid killer.”展开更多
Helmet continuous positive airway pressure(H-CPAP)is a form of non-invasive respiratory support that improves gas exchange and respiratory mechanics during acute hypoxemic respiratory failure,by maintaining a constant...Helmet continuous positive airway pressure(H-CPAP)is a form of non-invasive respiratory support that improves gas exchange and respiratory mechanics during acute hypoxemic respiratory failure,by maintaining a constant positive endexpiratory pressure(PEEP)and delivering inspiratory oxygen fractions up to 100%.[1]The effect of H-CPAP comprises increasing end-expiratory lung volume,avoiding alveolar collapse,reducing shunt,and enhancing ventilation-perfusion ratios.[2]These effects improve oxygenation and may further reduce the work of breathing because the respiratory system is shifted to a more compliant position on its pressure-volume curve.展开更多
Maximizing preoxygenation is the cornerstone of safe emergency airway management both in the emergency department(ED)and in prehospital settings.Emergency patients are particularly vulnerable to hypoxemic deterioratio...Maximizing preoxygenation is the cornerstone of safe emergency airway management both in the emergency department(ED)and in prehospital settings.Emergency patients are particularly vulnerable to hypoxemic deterioration during apnea due to factors such as impaired lung function,anemia,and/or increased metabolic demands.Preoxygenation aims to extend the safe-apnea time.[1]However,in clinical practice,this critical step is often underemphasized or inadequately performed.展开更多
Background Since the beginning of the coronavirus disease 2019(COVID-19)pandemic,prone positioning has been widely applied for non-intubated,spontaneously breathing patients.However,the efficacy and safety of prone po...Background Since the beginning of the coronavirus disease 2019(COVID-19)pandemic,prone positioning has been widely applied for non-intubated,spontaneously breathing patients.However,the efficacy and safety of prone positioning in non-intubated patients with COVID-19-related acute hypoxemic respiratory failure remain unclear.We aimed to systematically analyze the outcomes associated with awake prone positioning(APP).Methods We conducted a systematic literature search of PubMed/MEDLINE,Cochrane Library,Embase,and Web of Science from January 1,2020,to June 3,2022.This study included adult patients with acute respiratory failure caused by COVID-19.The Preferred Reporting Items for Systematic Reviews and Meta-Analyses(PRISMA)guidelines were followed,and the study quality was assessed using the Cochrane risk-of-bias tool.The primary outcome was the reported cumulative intubation risk across randomized controlled trials(RCTs),and the effect estimates were calculated as risk ratios(RRs;95%confidence interval[CI]).Results A total of 495 studies were identified,of which 10 fulfilled the selection criteria,and 2294 patients were included.In comparison to supine positioning,APP significantly reduced the need for intubation in the overall population(RR=0.84,95%CI:0.74–0.95).The two groups showed no significant differences in the incidence of adverse events(RR=1.16,95%CI:0.48–2.76).The meta-analysis revealed no difference in mortality between the groups(RR=0.93,95%CI:0.77–1.11).Conclusions APP was safe and reduced the need for intubation in patients with respiratory failure associated with COVID-19.However,it did not significantly reduce mortality in comparison to usual care without prone positioning.展开更多
Trajectories of pulse oxygen saturation(SpO_(2))within the first few days after birth are important to inform the strategy for identifying asymptomatic hypoxemic disease but remain poorly substantiated at higher altit...Trajectories of pulse oxygen saturation(SpO_(2))within the first few days after birth are important to inform the strategy for identifying asymptomatic hypoxemic disease but remain poorly substantiated at higher altitudes.Methods We performed a longitudinal cohort study with consecutive neonates at a local hospital in Luchun County,China,at an altitude of 1650 m between January and July 2020.We repeatedly measured the pre-and post-ductal SpO_(2)values at 6,12,18,24,36,48,and 72 hours after birth for neonates without oxygen supplements.All neonates underwent echocardiography and were followed up to 42 days after discharge.We included neonates without hypoxemic diseases to characterize the trajectories of SpO_(2)over time using a linear mixed model.We considered the 2.5th percentile as the reference value to define hypoxemic conditions.Results A total of 1061 neonates were enrolled.Twenty-five had non-cardiac hypoxemic diseases,with 84%(21/25)presenting with abnormal SpO_(2)within 24 hours.One had tetralogy of Fallot identified by echocardiography.Among the 1035 asymptomatic neonates,SpO_(2)values declined from 6 hours after birth,reached a nadir at 48 hours,and tended to level off thereafter,with identical patterns for both pre-and post-ductal SpO_(2).The reference percentile was 92%for both pre-and post-ductal SpO_(2)and was time independent.Conclusions A decline within 48 hours features SpO_(2)trajectories within the first 72 hours at moderate altitude.Our findings suggest that earlier screening may favorably achieve a benefit–risk balance in identifying asymptomatic hypoxemic diseases in this population.展开更多
文摘Acute hypoxemic respiratory failure(AHRF)refers to“de novo”respiratory failure,excluding cardiogenic pulmonary edema or exacerbation of chronic lung diseases.AHRF can be defined as the arterial pressure of oxygen/inspiratory fraction of oxygen(PaO_(2)/FiO_(2))≤300 mmHg in patients receiving oxygen therapy.[1]Whereas FiO_(2)cannot be measured under a standard oxygen mask,it can be best estimated using the following formula:FiO_(2)(%)=flow of oxygen(L/min)×3+21%.[2]Several oxygenation strategies can be proposed as an alternative to standard oxygen in patients with AHRF,including highflow nasal cannula oxygen(HFNC),continuous positive airway pressure(CPAP),and noninvasive ventilation(NIV).
文摘Acute hypoxemic respiratory failure(AHRF)is the leading cause of intensive care unit(ICU)admissions.Of patients with AHRF,40%–50%will require invasive mechanical ventilation during their stay in the ICU,and 30%–80%will meet the Berlin Criteria for Acute Respiratory Distress Syndrome(ARDS).Rapid identification of the underlying cause of AHRF is necessary before initiating targeted treatment.Almost 10%of patients with ARDS have no identified classic risk factors however,and the precise cause of AHRF may not be identified in up to 15%of patients,particularly in cases of immunosuppression.In these patients,a multidisciplinary,comprehensive,and hierarchical diagnostic work-up is mandatory,including a detailed history and physical examination,chest computed tomography,extensive microbiological investigations,bronchoalveolar lavage fluid cytological analysis,immunological tests,and investigation of the possible involvement of pneumotoxic drugs.
文摘In patients with hypoxemic acute respiratory failure(ARF),the first-line treatment is oxygen therapy,which may include the administration of high-flow nasal oxygen(HFNO),noninvasive ventilation(NIV),or continuous positive airway pressure(CPAP).In addition to improving oxygenation,HFNO and NIV reduce the work of breathing as compared to standard oxygen,while CPAP does not.However,tolerance to NIV and CPAP is clinically challenging,resulting in treatment interruption in 10%-20%of cases.Compared to standard oxygen,HFNO has been shown to reduce the risk of intubation,while the benefits of NIV or CPAP,even when delivered via a helmet,require further evaluation.Although evidence for the efficacy of HFNO in reducing mortality remains inconclusive,HFNO has emerged as the reference treatment and is recommended for patients with hypoxemic ARF given its benefit in reducing the risk of intubation.
基金supported by National Clinical Key Specialty(grant number:Z155080000004))Clinical management optimization project of SHDC(grant number:SHDC22022206).
文摘Background:Awake prone positioning(APP)can reportedly reduce the need for intubation and help improve prognosis of patients with acute hypoxemic respiratory failure(AHRF)infected with COVID-19.However,its physiological mechanism remains unclear.In this study,we evaluated the effect of APP on lung ventilation in patients with moderate-to-severe AHRF to better understand the effects on ventilation distribution and to prevent intubation in non-intubated patients.Methods:The prospective study was performed in the Department of Critical Care Medicine at Shanghai General Hospital,China,from January 2021 to November 2022.The study included patients with AHRF(partial pressure of oxygen[PaO_(2)]/inspired oxygen concentration[FiO_(2)]<200 mmHg or oxygen saturation[SpO_(2)]/FiO_(2)<235]treated with high-flow nasal oxygen.Electrical impedance tomography(EIT)measurements including center of ventilation(COV),global inhomogeneity(GI)index,and regional ventilation delay(RVD)index were performed in the supine position(To),30 min after the start of APP(Ti),and 30 min returning to supine position after the APP(T2).Clinical parameters like SpO_(2),respiratory rate(RR),FiO_(2),heart rate(HR),and ROX(the ratio of SpO_(2) as measured by pulse oximetry/FiO_(2) to RR)were also recorded simultaneously at To,Ti,and T2.To evaluate the effect of the time points on the variables,Mauchly's test was performed for sphericity and repeated measures analysis of variance was applied with Bonferroni's post hoc multiple comparisons.Results:Ten patients were enrolled.The Pa02/FiO_(2) ratio was(111.4±33.4)mmHg at the time of recruitment.ROX showed a significant increase after initiation of APP(median(interquartile range[IQR)):To:7.5(6.0-10.1)vs.Ti:7.6(6.4-9.3)vs.T2:8.3(7.2-11.0),P=0.043).RR(P=0.409),HR(P=0.417),and SpO_(2)/FiO_(2)(P=0.262)did not change significantly during prone positioning(PP).The CoV moved from the ventral area to the dorsal area(To:48.8%±6.2%vs.T:54.8%±6.8%vs.T2:50.3%±6.1%,P=0.030)after APP.The GI decreased significantly after APP(To:median=42.7%,[IQR:38.3%-47.5%]vs.Ti:median=38.2%,[IQR:34.6%-50.7%]vs.T2:median=37.4%,[IQR:34.2%-41.4%],P=0.049).RVD(P=0.794)did not change after APP.Conclusions:APP can improve ventilation distribution and homogeneity of lung ventilation as assessed by EIT in non-intubated patients with AHRF.Trail Registration Chinese Clinical Trial Registry Identifier:ChiCTR2000035895.
文摘De novo acute hypoxemic respiratory failure(AHRF)remains one of the leading causes of intensive care unit(ICU)admission and is still associated with high rates of intubation and mortality.Developing effective strategies to prevent intubation and its associated complications remains a critical objective in this population.Noninvasive ventilation(NIV)has been proposed as a potential alternative to invasive ventilation in AHRF.However,no clear clinical benefit has been consistently demonstrated to date.The lack of definitive evidence has left experts unable to provide recommendations for the use of NIV in AHRF.Several factors may account for the inconsistencies in the literature and merit further investigation.Identifying early predictive criteria for NIV failure could be essential in determining which patients are most likely to benefit from this intervention.In addition,the approach to NIV settings may require reconsideration,particularly regarding the level of assistance.Efforts to reduce tidal volume,while aiming to minimize ventilator-induced lung injury,may have inadvertently resulted in insufficient support,amplifying the harmful effects of excessive inspiratory effort.The choice of interface may also significantly influence the physiological effects and outcomes and warrants further exploration.Finally,the frugal nature of noninvasive techniques makes them well-suited for the universal management of AHRF,regardless of constraints.This highlights the need for future developments aimed at optimizing oxygen and energy efficiency,enhancing the ease of use and robustness of NIV devices,and evaluating the effectiveness of NIV under high-constraint conditions,such as in low-and middle-income countries.This review addresses these critical questions.
文摘Background Hypoxemic respiratory failure （HRF） is one of the most common causes for neonatal infants requiring aggressive respiratory support. Inhaled nitric oxide （iNO） has been established routinely as an adjunct to conventional respiratory support in developed countries. The aim of this study was to investigate effects of iNO in neonates with HRF in resource limited condition with no or limited use of surfactant, high frequency oscillatory ventilation （HFOV） and extracorporeal membrane oxygenation.Methods A non-randomized, open, controlled study of efficacy of iNO was conducted over 18 months. Eligible term and near-term neonates from 28 hospitals with HRF （oxygenation index ＞15） were enrolled prospectively into two groups as either iNO or control. Oxygenation improvement and mortality as primary endpoint were determined in relation with dosing and timing of iNO, severity of underlying diseases, complications and burden. Intention-to-treat principle was adopted for outcome assessment. Response to iNO at 10 or 20 parts per million （ppm） was determined by oxygenation in reference to the control （between-group） and the baseline （within-group）.Results Compared to 93 controls, initial dose of iNO at 10 ppm in 107 treated infants significantly improved oxygenation from first hour （P=0.046）, with more partial- and non-responders improved oxygenation with subsequent 20ppm NO （P=0.018）. This effect persisted on days 1 and 3, and resulted in relatively lower mortalities （11.2% vs. 15%）whereas fewer were treated with surfactant （10% vs. 27%）,HFOV （＜5%） or postnatal corticosteroids （＜10%） in both groups. The overall outcomes at 28 days of postnatal life in the iNO-treated was not related to perinatal asphyxia,underlying diseases, severity of hypoxemia, or complications,but to the early use of iNO. The cost of hospital stay was not significantly different in both groups.Conclusions With relatively limited use of surfactant and/or HFOV in neonatal HRF, significantly more responders were found in the iNO-treated patients as reflected by improved oxygenation in the first three days over the baseline level. It warrants a randomized, controlled trial for assessment of appropriate timing and long-term outcome of iNO.
文摘Optimal initial non-invasive management of acute hypoxemic respiratory failure(AHRF),of both coronavirus disease 2019(COVID-19)and non-COVID-19 etiologies,has been the subject of significant discussion.Avoidance of endotracheal intubation reduces related complications,but maintenance of spontaneous breathing with intense respiratory effort may increase risks of patients’self-inflicted lung injury,leading to delayed intubation and worse clinical outcomes.High-flow nasal oxygen is currently recommended as the optimal strategy for AHRF management for its simplicity and beneficial physiological effects.Non-invasive ventilation(NIV),delivered as either pressure support or continuous positive airway pressure via interfaces like face masks and helmets,can improve oxygenation and may be associated with reduced endotracheal intubation rates.However,treatment failure is common and associated with poor outcomes.Expertise and knowledge of the specific features of each interface are necessary to fully exploit their potential benefits and minimize risks.Strict clinical and physiological monitoring is necessary during any treatment to avoid delays in endotracheal intubation and protective ventilation.In this narrative review,we analyze the physiological benefits and risks of spontaneous breathing in AHRF,and the characteristics of tools for delivering NIV.The goal herein is to provide a contemporary,evidence-based overview of this highly relevant topic.
文摘Objective： To investigate the therapeutic effect of acupuncture plus hyperbaric oxygen in treating hypoxemic infantile encephalopathy （HIE）. Methods： Fifty-nine HIE children were divided into treatment （33 cases） and control （26 cases） groups. Both groups were treated by basic therapy of removing acidosis, controlling cerebral edema and convulsion, and intravenous drip of cerebrolysin or citicoline. The treatment group was treated by acupuncture plus hyperbaric oxygen and the control group was treated by hyperbaric oxygen only. Results： The total effective rate was 97.0% in the treatment group and 73.1% in the control group. Statistical analysis showed a highly significant difference （P〈0.01）. Conclusion： Acupuncture plus hyperbaric oxygen was better than simple hyperbaric oxygen in treating HIE. Its main manifestations were shortening the course of disease, increasing cure rate, decreasing death rate and reducing the occurrence of sequelae. HIE children should be treated as early as possible.
文摘Background:Lung cancer is one of the leading causes of death despite improvement in treatment modalities such as immunotherapy with chemotherapy and precise radiotherapy.NSCLC is a heterogeneous group of diseases that differs in cytology and includes adenocarcinoma,squamous cell carcinoma,bronchioloalveolar carcinoma,and poorly differentiated carcinoma.Usually,NSCLC,in contrast to SCLC,spreads locally,and the doubling time of squamous cell carcinoma is 133 days which classifies it as a relatively slow-growing tumor.Case presentation:We present the case of a 72-year-old male,recently diagnosed with squamous cell carcinoma in the right upper lobe along with secondary deposits.Few days after diagnosis,the patient had severe respiratory distress.This endobronchial tumor has increased significantly in size upon bronchoscopic visualization causing a complete obstruction of his right main bronchus and hypoxemic respiratory failure requiring intubation.Conclusion:To our knowledge,there are few reported cases where lung adenocarcinoma progressed rapidly over days.Squamous cell carcinoma usually takes 3 to 6 months to double in size,but in our case,the progression was very fast.In the last decade,it was confirmed that the doubling time of a tumor is an independent factor in the prognosis of lung cancer patients.On the other hand,further studies are needed to identify genes associated with rapid progression and a worse prognosis for lung squamous cell carcinoma.Hence,this aggressive tumor is a“rapid killer.”
文摘Helmet continuous positive airway pressure(H-CPAP)is a form of non-invasive respiratory support that improves gas exchange and respiratory mechanics during acute hypoxemic respiratory failure,by maintaining a constant positive endexpiratory pressure(PEEP)and delivering inspiratory oxygen fractions up to 100%.[1]The effect of H-CPAP comprises increasing end-expiratory lung volume,avoiding alveolar collapse,reducing shunt,and enhancing ventilation-perfusion ratios.[2]These effects improve oxygenation and may further reduce the work of breathing because the respiratory system is shifted to a more compliant position on its pressure-volume curve.
文摘Maximizing preoxygenation is the cornerstone of safe emergency airway management both in the emergency department(ED)and in prehospital settings.Emergency patients are particularly vulnerable to hypoxemic deterioration during apnea due to factors such as impaired lung function,anemia,and/or increased metabolic demands.Preoxygenation aims to extend the safe-apnea time.[1]However,in clinical practice,this critical step is often underemphasized or inadequately performed.
基金supported by the Clinical Research Plan of SHDC (grant number:SHDC2020CR2013A)the Clinical Research Plan of SHDC (grant number:SHDC2020CR5010-003).
文摘Background Since the beginning of the coronavirus disease 2019(COVID-19)pandemic,prone positioning has been widely applied for non-intubated,spontaneously breathing patients.However,the efficacy and safety of prone positioning in non-intubated patients with COVID-19-related acute hypoxemic respiratory failure remain unclear.We aimed to systematically analyze the outcomes associated with awake prone positioning(APP).Methods We conducted a systematic literature search of PubMed/MEDLINE,Cochrane Library,Embase,and Web of Science from January 1,2020,to June 3,2022.This study included adult patients with acute respiratory failure caused by COVID-19.The Preferred Reporting Items for Systematic Reviews and Meta-Analyses(PRISMA)guidelines were followed,and the study quality was assessed using the Cochrane risk-of-bias tool.The primary outcome was the reported cumulative intubation risk across randomized controlled trials(RCTs),and the effect estimates were calculated as risk ratios(RRs;95%confidence interval[CI]).Results A total of 495 studies were identified,of which 10 fulfilled the selection criteria,and 2294 patients were included.In comparison to supine positioning,APP significantly reduced the need for intubation in the overall population(RR=0.84,95%CI:0.74–0.95).The two groups showed no significant differences in the incidence of adverse events(RR=1.16,95%CI:0.48–2.76).The meta-analysis revealed no difference in mortality between the groups(RR=0.93,95%CI:0.77–1.11).Conclusions APP was safe and reduced the need for intubation in patients with respiratory failure associated with COVID-19.However,it did not significantly reduce mortality in comparison to usual care without prone positioning.
基金supported by the National Key Research and Development Program of China(2021YFC2701004 and 2016YFC1000506)the Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences(2019-I2M-5-002).
文摘Trajectories of pulse oxygen saturation(SpO_(2))within the first few days after birth are important to inform the strategy for identifying asymptomatic hypoxemic disease but remain poorly substantiated at higher altitudes.Methods We performed a longitudinal cohort study with consecutive neonates at a local hospital in Luchun County,China,at an altitude of 1650 m between January and July 2020.We repeatedly measured the pre-and post-ductal SpO_(2)values at 6,12,18,24,36,48,and 72 hours after birth for neonates without oxygen supplements.All neonates underwent echocardiography and were followed up to 42 days after discharge.We included neonates without hypoxemic diseases to characterize the trajectories of SpO_(2)over time using a linear mixed model.We considered the 2.5th percentile as the reference value to define hypoxemic conditions.Results A total of 1061 neonates were enrolled.Twenty-five had non-cardiac hypoxemic diseases,with 84%(21/25)presenting with abnormal SpO_(2)within 24 hours.One had tetralogy of Fallot identified by echocardiography.Among the 1035 asymptomatic neonates,SpO_(2)values declined from 6 hours after birth,reached a nadir at 48 hours,and tended to level off thereafter,with identical patterns for both pre-and post-ductal SpO_(2).The reference percentile was 92%for both pre-and post-ductal SpO_(2)and was time independent.Conclusions A decline within 48 hours features SpO_(2)trajectories within the first 72 hours at moderate altitude.Our findings suggest that earlier screening may favorably achieve a benefit–risk balance in identifying asymptomatic hypoxemic diseases in this population.
