other relevant clinical outcomes including duration of mechanical ventilation, PICU length of stay in survivors, and 90-day in-hospital mortality. Duration of mechanical ventilation was defined as done in RESTORE  with patients assigned 28 days if they remained intubated or were transferred or died prior to day 28, therefore mak- ing this outcome equivalent to ventilator-free days. Evaluation of the impact of the primary diagnosis associ- ated with acuterespiratoryfailure was conducted in two ways. First, diagnostic categories were evaluated based on categories reported in the parent RESTORE trial (bronchiolitis, aspiration, sepsis, pneumonia, asthma, and others). In addition, the primary diagnoses were tricho- tomized into infectious (bronchiolitis, laryngotracheobron- chitis, pertussis, pneumonia, sepsis), non-infectious (thoracic trauma, aspiration, edema, and transfusion-associated), and indeterminant (asthma, chronic lung disease, acute respira- tory failure post bone marrow transplantation, pulmonary hemorrhage, and acute chest syndrome) categories.
Extracorporeal membrane oxygenatioon (ECMO) is a technique for providing life support, in case the natural lungs are failing and are not able to maintain a sufficient oxygenation of the body’s organ systems. ECMO technique was an adaptation of conventional cardiopulmonary bypass technique and introduced into treatment of severe acuterespiratory distress syndrome (ARDS) in the 1970s. The initial reports of the use of ECMO in ARDS patients were quite enthusiastic, however, in the following years it became clear that ECMO was only of benefit in newborns with acuterespiratoryfailure. In neonates treated with ECMO, survival rates of 80% could be achieved. In adult patients with ARDS, two large randomized controlled trials (RCTs) published in 1979 and 1994 failed to show an advantage of ECMO over convential treatment, survival rates were only 10% and 33%, respectively, in the ECMO groups. Since then, ECMO technology as well as conventional treatment of adult ARDS have undergone further improvements. In conventional treatment lung-protective ventilation strategies were introduced and ECMO was made safer by applying heparin-coated equipment, membranes and tubings. Many ECMO centres now use these advanced ECMO technology and report survival rates in excess of 50% in uncontrolled data collections. The question, however, of whether the improved ECMO can really challenge the advanced conventional treatment of adult ARDS is unanswered and will need evaluation by a future RCT.
Abstract: After the institution of positive-pressure ventilation, the use of noninvasive ventilation (NIV) through an interface substantially increased. The first technique was continuous positive airway pressure; but, after the introduction of pressure support ventilation at the end of the 20th century, this became the main modality. Both techniques, and some others that have been recently introduced and which integrate some technological innovations, have extensively demonstrated a faster improvement of acuterespiratoryfailure in different patient populations, avoiding endo- tracheal intubation and facilitating the release of conventional invasive mechanical ventilation. In acute settings, NIV is currently the first-line treatment for moderate-to-severe chronic obstructive pulmonary disease exacerbation as well as for acute cardiogenic pulmonary edema and should be considered in immunocompromised patients with acuterespiratory insufficiency, in difficult weaning, and in the prevention of postextubation failure. Alternatively, it can also be used in the postoperative period and in cases of pneumonia and asthma or as a palliative treatment. NIV is currently used in a wide range of acute settings, such as critical care and emergency departments, hospital wards, palliative or pediatric units, and in pre-hospital care. It is also used as a home care therapy in patients with chronic pulmonary or sleep disorders. The appropriate selection of patients and the adaptation to the technique are the keys to success. This review essentially analyzes the evidence of benefits of NIV in different populations with acuterespiratoryfailure and describes the main modalities, new devices, and some practical aspects of the use of this technique. Keywords: noninvasive ventilation, acuterespiratoryfailure, pressure support ventilation, CPAP, COPD, acute pulmonary edema
This review, based on relevant published evidence and the authors’ clinical experience, presents how to evaluate a patient with acuterespiratoryfailure re- quiring ventilatory support. This patient must be care- fully evaluated by nurses, physiotherapists, respira- tory care practitioners and physicians regarding the elucidation of the cause of the acute episode of respi- ratory failure by means of physical examination with the measurement of respiratory parameters and as- sessment of arterial blood gases analysis to make a correct respiratory diagnosis. After the initial evalua- tion, the patient must quickly receive adequate oxy- gen and ventilatory support that has to be carefully monitored until its discontinuation. When available, a noninvasive ventilation trial must be done in patients presenting desaturation during oxygen mask and or PaCO 2 retention, especially in cases of cardiogenic
Patients with acuterespiratoryfailure almost always develop gas exchange derange- ments that may result in hypercapnia . Lung-protective ventilation strategies are strongly recommended to prevent additional lung injury [2, 3], but these strategies have a strong potential to increase plasma carbon dioxide levels further. One approach is to accept this, i.e., “permissive hypercapnia,” with the option to correct respiratory acidosis by slow bicarbonate infusion for blood buffering. Extracorporeal decapneiza- tion by utilizing “ extracorporeal CO 2 removal ” (ECCO 2 R) is an appealing alternative
Acuterespiratoryfailure requiring MV continues to be a leading reason for admission to the ICU. In unselected critically ill patients, Mehta et al.  noted a steady increase in the use of IMV in the USA between 1993 and 2009. In this study, the subgroup with heart failure (without CS) was noted to have a relatively steady usage of IMV during the study period. Using a registry of 219 patients, Hongisto et al.  described the use of NIV and IMV in unselected CS. They noted a 12% overall inci- dence of NIV use and 63% IMV use during the 2-year study period. In contrast to these studies, our findings demonstrate an increasing incidence of ARF requiring MV. Furthermore, the use of NIV was noted in only 4.7% of our study population as compared to 12% in the Card- Shock trial . In our study, the use of MV was noted in 43.2% of the population, which was significantly lower than the CardShock and IABP-SHOCK II (Intra-aortic Balloon Pump in Cardiogenic Shock II) cohorts [11, 32]. This can possibly be explained by the vast heterogene- ity in the definition of CS employed in real-world reg- istry data as compared to trial definitions. Additionally, differences in patient acuity and treatment between the USA and European populations may contribute to these differences. Our findings are consistent with data from other epidemiological studies that show greater use of IMV in male patients, non-White race and lower socio- economic status . In a population of 3.2 million non- cardiogenic ARF, Cooke et al. noted consistently higher rates of ARF in non-White patients. The reasons for these disparities are incompletely understood and may be due to decreased access to health care, late presentation,
With advances in intensive care, survival of patients with acuterespiratoryfailure has improved. Functional impairments in these survivors are common and persist up to 5 years after the initial episode of illness . As a result, there is a growing proportion of patients who do not fully recover and remain dependent on hospital resources. These chronically critically ill patients have high mortality, and those who survive have functional and cognitive disabilities [2–4]. The rate of post-acute care admission in survivors of acuterespiratoryfailure continues to rise, with a greater proportion of patients requiring extended treatment in a long-term acute care facility, rehabilitation facility, or skilled nursing facility and fewer patients returning directly home [5, 6]. Unfor- tunately, interventions to treat and improve physical function have had variable efficacy, and to date, random- ized controlled studies of both intensive inpatient and outpatient physical therapy interventions as well as multi- disciplinary approaches designed to increase physical function have not improved long-term physical function [7–12].
Acuterespiratoryfailure (ARF) is a leading indication for performing critical care ultrasonography (CCUS) which, in these patients, combines critical care echocardiography (CCE) and chest ultrasonography. CCE is ideally suited to guide the diagnostic work-up in patients presenting with ARF since it allows the assessment of left ventricular filling pressure and pulmonary artery pressure, and the identification of a potential underlying cardiopathy. In addition, CCE precisely depicts the consequences of pulmonary vascular lesions on right ventricular function and helps in adjusting the ventilator settings in patients sustaining moderate-to-severe acuterespiratory distress syndrome. Similarly, CCE helps in identifying patients at high risk of ventilator weaning failure, depicts the mechanisms of weaning pulmonary edema in those patients who fail a spontaneous breathing trial, and guides tailored therapeutic strategy. In all these clinical settings, CCE provides unparalleled information on both the efficacy and tolerance of therapeutic changes. Chest ultrasonography provides further insights into pleural and lung abnormalities associated with ARF, irrespective of its origin. It also allows the assessment of the effects of treatment on lung aeration or pleural effusions. The major limitation of lung ultrasonography is that it is currently based on a qualitative approach in the absence of standardized quantification parameters. CCE combined with chest ultrasonography rapidly provides highly relevant information in patients sustaining ARF. A pragmatic strategy based on the serial use of CCUS for the
We used a single-pass multiple tracer technique to measure cardiac output, extravascular lung water (EVLW) and lung vascular [14C]urea permeability-surface area (PSu) in 14 patients with acuterespiratoryfailure and pulmonary edema. All patients had increased EVLW, but EVLW in the 10 surviving patients (0.26 +/- 0.06 SE ml/ml total lung capacity [TLC]) was not significantly different from that in the five patients who died (0.22 +/- 0.05). EVLW did not correlate with intravascular pressures or with alveolar-arterial oxygen
respiratory airway obstruction have suggested that NPPV may improve symptoms and ventilation without significant adverse events and reduce the need for IMV [10-20]. NPPV theoretically improves the respiratory status of patients with lower respiratory airway obstruc- tion by several mechanisms . During acute bronch- ospastic episodes, patients have an increase in airway resistance and expiratory time constant. The combina- tion of prolonged expiratory time constant and prema- ture closure of inflamed airways during exhalation results in dynamic hyperinflation, which causes increased positive pressure in the alveoli at end-expira- tion (auto-PEEP). Because the alveolar pressure must be reduced to subatmospheric levels to initiate the next breath, this auto-PEEP increases the inspiratory load and induces respiratory muscle fatigue. The EPAP deliv- ered by NPPV may help to decrease dynamic hyperinfla- tion by maintaining small airway patency and may reduce the patient’s work of breathing by decreasing the drop in alveolar pressure needed to initiate a breath. In addition, inspiratory support, i.e., IPAP delivered by NPPV, helps to support fatigued respiratory muscles, thereby improving dyspnea and gas exchange. Needle- man et al., in a physiological study, found that the NPPV use in children with status asthmaticus was asso- ciated with a decrease in respiratory rate and fractional inspired time and an improvement of thoracoabdominal synchrony in 80% of patients . A few clinical studies of small size (3-73 patients) reported the use of NPPV for treatment of status asthmaticus in children (Table 1) [10,11,13,14]. NPPV was well tolerated with no major complications and was associated with an improvement of gas exchange and respiratory effort (Table 1).
The low mortality associated with ARF when it presented as a single organ failure was recently documented in a study from Finland , which compared the use of different scoring systems for multiple organ dysfunction. The investigators found the frequency of ARF using the SOFA criteria to be 169/520 (32.5%), with an overall hospital mortality rate of 46%. In those patients with single organ ARF (only 24 patients) the hospital mortality rate was 17%, which is very similar to our findings. In that study, the incidence of ARF was lower than that in the European multicentre study and in our patients, but the overall mortality rate in patients with ARF was higher. One explanation may be the differences in case- mix, because the number of medical admissions was more than twice that in the present study (66%).
The clinical presentation of AIP, as noted in several case series, has been reported in the literature [3–6]. The onset of the disease is usually abrupt, with a prodromal illness that lasts 1 to 2 weeks prior to presentation [6, 7]. The most common clinical symptoms are fever, cough, and shortness of breath . Further, AIP is characterized by the rapid development of acuterespiratoryfailure in a previously
From 2009 to 2013, three patients were diagnosed with acuterespiratoryfailure secondary to acute toxoplasmo- sis with extensive lung involvement. Two of the patients were female, and one was male; the patients were 38, 56 and 36 years old, respectively. All three patients similarly presented to the emergency department with a two- week febrile illness and progressive dyspnea during the few days before admission without previous respiratory symptoms. The physical examinations revealed crackles in all patients and low oxygen saturation (SpO 2 ) values,
ECLS was initially developed in the 1950s by John Gibbon as a means of oxygenating blood via a membrane oxy- genator during prolonged operations on cardiopulmonary bypass . Given the lack of an open reservoir of blood and extreme anticoagulation required with a traditional cardiopulmonary bypass circuit, ECMO presented a less complex and more sustainable option for treatment of re- fractory cardiovascular and respiratoryfailure outside the operating room. Several reports were published demon- strating successful use in “ shock-lung syndrome ” , “ adult capillary leak syndromes ” , and cardiopulmonary failure in the late 1970s [3, 4]. In 1979, a randomized controlled trial conducted on adult patients with severe acuterespiratoryfailure reported a 90 % mortality rate for patients in both groups . Thus, enthusiasm stalled and over the next 30 years ECMO was used mostly for neonatal and pediatric patients with only a small number of highly spe- cialized centers pursuing ECMO in adult patients.
Notes: Data are presented as mean ± standard deviations, numbers (percentages), or medians (interquartile ranges). CVDs included stroke, ischemic heart disease, valvular heart diseases, and peripheral vascular diseases. CKD was defined as persistent abnormal renal function (serum creatinine . 1.4 mg/dl) for at least 6 months. CPDs included asthma, chronic bronchitis, COPD, and lung fibrosis. Hyperlipidemia was diagnosed by a physician and required regular treatments with antilipidemic agent. Diabetes mellitus was diagnosed by a physician and required regular treatments with antihyperglycemic drugs. Hypertension was defined as blood pressure above 140/90 mmHg based on at least two measurements and regular treatment with an antihypertensive drug. Shock was defined as mean arterial pressure less than 60 mmHg. Acuterespiratoryfailure was defined as acute onset of respiratoryfailure that required ventilator support. AKI was defined as serum creatinine above 2.0 mg/dL and/or daily urine amount less than 500 mL. Bold indicates clinical variables are significant in statistical analysis (P,0.05).
Acuterespiratory distress syndrome (ARDS) is a severe lung disease with a high mortality rate [1-4]. Extracorpor- eal membrane oxygenation (ECMO) can provide gas ex- change independently of mechanical ventilation, either as a rescue intervention or to minimize ventilator-induced lung injury [5-7]. Because of encouraging outcomes from the CESAR trial  and success with ECMO in patients with influenza A (H1N1) and ARDS [8-10], standard veno-venous ECMO has been proposed as the modality of choice for severe acuterespiratoryfailure (ARF) without
The current epidemiological study allows us to further charac- terise the impact of DM on the development of organ dysfunc- tion among patients with sepsis. When compared with patients with severe sepsis and no DM, people with DM are less likely to develop acuterespiratoryfailure. The lower risk of acuterespiratoryfailure among patients with severe sepsis and DM was irrespective of whether the primary source of infection was pulmonary or non-pulmonary. With respect to other organ dysfunctions, people with DM were more likely to develop acute renal failure. The presence of a GU source of infection did not affect the development of acute renal failure among those with DM. The decrease in the frequency of res- piratory failure in people with DM was associated with a signif- icant difference in case fatality.
8. Lemiale V, Mokart D, Mayaux J, Lambert J, Rabbat A, Demoule A, Azoulay E. The effects of a 2-h trial of high-flow oxygen by nasal cannula versus Venturi mask in immunocompromised patients with hypoxemic acuterespiratoryfailure: a multicenter randomized trial. Crit Care. 2015;19:380. 9. Jones PG, Kamona S, Doran O, Sawtell F, Wilsher M. Randomized Controlled