Extracorporeal membrane oxygenation (ECMO) is a method of life support to maintain cardiopulmonary function. Its use as a medical application has increased since its inception to treat multiple conditions including acute respiratory distress syndrome, myocardial ischemia, cardiomyopathy, and septic shock. While complications including neurological and renal injury occur in patients on ECMO, bleeding and coagulopathy are most common.

ECMO is associated with an inflammatory response promoting a hypercoagulable state, requiring anticoagulation to avoid thromboembolism originating in the nonendothelial surfaced circuit. However, excessive anticoagulation may result in bleeding complications including intracerebral hemorrhage. ...

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Abnormal vocal cord movement may coexist with asthma and cause additional upper/middle airway obstruction. The condition may be a form of muscular dystonia that could contribute to asthma resistant to optimised treatments. Botulinum toxin causes temporary paralysis of muscle and may be an effective local treatment that improves asthma control.

Methods : In an observational study, we evaluated the benefits of unilateral vocal cord injection with botulinum toxin in 11 patients (total 24 injections). Subjects had asthma resistant to optimised treatment and abnormal vocal cord movement. Responses after botulinum toxin treatment were assessed using asthma control test (ACT) scores, vocal cord narrowing quantified by computerised tomography (CT) of the larynx and spirometry. Side-effects were recorded.

Results : ACT scores improved overall (9.1 ± 2.4 before and 13.5 ± 4.5 after treatment; difference 4.4 ± 4.2; P < 0.001). There was also an improvement in airway size on CT larynx (time below lower limit of normal at baseline 39.4 ± 37.63% and improved to 17.6 ± 25.6% after injection; P = 0.032). Spirometry was not altered. One patient experienced an asthma exacerbation but overall side-effects were moderate, chiefly dysphonia and dysphagia.

Conclusions : Although a placebo effect cannot be ruled out, local injection of botulinum toxin may be an effective treatment for intractable asthma associated with abnormal vocal cord movement. Further mechanistic studies and a double-blind randomised controlled trial of botulinum toxin treatment are merited.

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Effective non-invasive ventilation (NIV) therapy is dependent on optimal ventilator settings to maximize clinical benefit and patient tolerance. Intelligent volume-assured pressure support (iVAPS) is a hybrid mode of servoventilation, providing constant automatic adjustment of pressure support (PS) to achieve a target ventilation determined by the patient's requirements. In a randomized crossover trial, we tested the hypothesis that iVAPS, with automated selection of ventilator settings, was non-inferior to standard PS ventilation, with settings determined by an experienced health-care professional, for controlling nocturnal hypoventilation in patients naive to NIV.

Methods : Eighteen patients referred to a ventilator clinic with chronic obstructive or restrictive lung disease and newly diagnosed nocturnal hypoventilation (10 male, median (interquartile range): age 54(41–61) years, mean daytime PaO2 9.25(8.59–10.31) kPa, -PaCO2 6.38(5.93–6.65) kPa were randomized to iVAPS and standard PS. Polysomnography with transcutaneous CO2 monitoring was performed at baseline and 1 month after each treatment period. Nightly hours of therapy were recorded by the ventilator.

Results : iVAPS delivered a lower median PS compared with standard PS (8.3(5.6–10.4) vs 10.0(9.0–11.4) cmH2O; P = 0.001) for the same ventilatory outcome (mean overnight: SpO2 96(95–98) vs 96(93–97)%; P = 0.13 and PtcCO2 6.5(5.8–6.8) vs 6.2(5.8–6.9); P = 0.54). There was no difference in outcome between ventilator modes for spirometry, respiratory muscle strength, sleep quality, arousals or O2 desaturation index. Adherence was greater with iVAPS (5:40(4:42–6:49) vs 4:20(2:27–6:17) hh:mm/night; P = 0.004).

Conclusions : iVAPS servoventilation with automation of ventilation settings is as effective as PS ventilation initiated by a skilled health-care professional in controlling nocturnal hypoventilation and produced better overnight adherence in patients naive to NIV.

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Background and objective : A number of clinical factors play pivotal roles in weaning and successful extubation of patients requiring long-term mechanical ventilator (LTMV) support. Many patients fail extubation even after passing weaning protocols and spontaneous breathing trials. This study aimed to assess the effectiveness of using a modified Burns Wean Assessment Program (m-BWAP) scoring instrument to predict extubation outcome in patients requiring LTMV.

Methods : All patients with a diagnostic coding for respiratory failure requiring LTMV for longer than 21 days over a 5-year period in a single centre (total 527 patients) were included. Advanced practice nurses trained in the use of the m-BWAP scored the items according to standard definitions. All patients were weaned by pressure support weaning and spontaneous breathing trails. Patients were divided into successful and unsuccessful groups according to the weaning and extubation outcomes. Baseline data, traditional weaning parameters and m-BWAP of the groups were analysed. The sensitivity and specificity of m-BWAP for predicting successful extubation were calculated.

Results : Of the 527 patients included, 145 (27.5%) had successful weaning trials. Of the 130 patients extubated, 102 (78.5%) had successful extubation. The m-BWAP score was higher in the patients with successful weaning trials and successful extubation outcome. Using a cut-off value of 60, the sensitivity and specificity of the m-BWAP to predict successful extubation were 81.4% and 82.1%, respectively. This was better than traditional weaning parameters.

Conclusions : The m-BWAP is a good predictor for weaning and extubation outcome in patients requiring LTMV for longer than 21 days.

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