HFNC can provide adequate oxygenation for many patients with hypoxemic respiratory failure and may be an alternative to NIV for DNI patients.

The association of home noninvasive positive pressure ventilation (NIPPV) with outcomes in chronic obstructive pulmonary disease (COPD) and hypercapnia is uncertain.OBJECTIVE To evaluate the association of home NIPPV via bilevel positive airway pressure (BPAP) devices and noninvasive home mechanical ventilator (HMV) devices with clinical outcomes and adverse events in patients with COPD and hypercapnia.

BackgroundCoronavirus disease 2019 (COVID-19) is a disease caused by severe acute respiratory syndrome-coronavirus-2. Consensus suggestions can standardise care, thereby improving outcomes and facilitating future research.MethodsAn International Task Force was composed and agreement regarding courses of action was measured using the Convergence of Opinion on Recommendations and Evidence (CORE) process. 70% agreement was necessary to make a consensus suggestion.ResultsThe Task Force made consensus suggestions to treat patients with acute COVID-19 pneumonia with remdesivir and dexamethasone but suggested against hydroxychloroquine except in the context of a clinical trial; these are revisions of prior suggestions resulting from the interim publication of several randomised trials. It also suggested that COVID-19 patients with a venous thromboembolic event be treated with therapeutic anticoagulant therapy for 3 months. The Task Force was unable to reach sufficient agreement to yield consensus suggestions for the post-hospital care of COVID-19 survivors. The Task Force fell one vote shy of suggesting routine screening for depression, anxiety and post-traumatic stress disorder.ConclusionsThe Task Force addressed questions related to pharmacotherapy in patients with COVID-19 and the post-hospital care of survivors, yielding several consensus suggestions. Management options for which there is insufficient agreement to formulate a suggestion represent research priorities.

Objectives In the Fluid and Catheter Treatment Trial (FACTT) of the National Institutes of Health Acute Respiratory Distress Syndrome Network, a conservative fluid protocol (FACTT Conservative) resulted in a lower cumulative fluid balance and better outcomes than a liberal fluid protocol (FACTT Liberal). Subsequent Acute Respiratory Distress Syndrome Network studies used a simplified conservative fluid protocol (FACTT Lite). The objective of this study was to compare the performance of FACTT Lite, FACTT Conservative, and FACTT Liberal protocols. Design Retrospective comparison of FACTT Lite, FACTT Conservative, and FACTT Liberal. Primary outcome was cumulative fluid balance over 7 days. Secondary outcomes were 60-day adjusted mortality and ventilator-free days through day 28. Safety outcomes were prevalence of acute kidney injury and new shock. Setting ICUs of Acute Respiratory Distress Syndrome Network participating hospitals. Patients Five hundred three subjects managed with FACTT Conservative, 497 subjects managed with FACTT Liberal, and 1,124 subjects managed with FACTT Lite. Interventions Fluid management by protocol. Measurements and Main Results Cumulative fluid balance was 1,918 ± 323 mL in FACTT Lite, −136 ±491 mL in FACTT Conservative, and 6,992 ± 502 mL in FACTT Liberal (p < 0.001). Mortality was not different between groups (24% in FACTT Lite, 25% in FACTT Conservative and Liberal, p = 0.84). Ventilator-free days in FACTT Lite (14.9 ±0.3) were equivalent to FACTT Conservative (14.6±0.5) (p = 0.61) and greater than in FACTT Liberal (12.1 ±0.5, p < 0.001 vs Lite). Acute kidney injury prevalence was 58% in FACTT Lite and 57% in FACTT Conservative (p = 0.72). Prevalence of new shock in FACTT Lite (9%) was lower than in FACTT Conservative (13%) (p = 0.007 vs Lite) and similar to FACTT Liberal (11%) (p = 0.18 vs Lite). Conclusions FACTT Lite had a greater cumulative fluid balance than FACTT Conservative but had equivalent clinical and safety outcomes. FACTT Lite is an alternative to FACTT Conservative for fluid management in Acute Respiratory Distress Syndrome.

Regional anesthesia results in shrinkage of the primary sensory cortex (S1) representation of the area and the perception that the area is larger than it is. 1 Complex regional pain syndrome type 1 (CRPS1) also involves shrinkage of S1 representation 2 and, anecdotally, the perception of marked swelling when none is apparent. We posited that if a reduced S1 representation of the affected limb is involved in generating a perception that the limb is larger than it really is, then this effect should be present in patients with CRPS1.Methods. Fifty patients diagnosed with CRPS1 3 initiated by wrist or hand fracture and 18 patients with non-CRPS1 hand or wrist pain were eligible (see table E-1 on the Neurology Web site at www.neurology.org). Exclusion criteria were pain elsewhere (five patients with CRPS1), symptoms extending beyond the affected limb (four patients), psychiatric diagnosis (two patients), and unable to understand English (one patient). A 3,000-DPI, 4.8 ϫ 3.2-cm digital photograph was taken of the two hands and distal one-third of the forearms, placed side by side. The image of the affected limb was compressed or expanded in one dimension to 85%, 90%, 95%, 100%, 105%, 110%, or 115% such that an expanded image made the limb look thicker but not longer than it was. Seven 4.2 ϫ 2.8-cm images of the limb pairs (each incorporating one of the thickness manipulations of the affected hand) were positioned randomly on a 19-inch 1,280 ϫ 1,024 resolution color monitor. Patients selected the photograph they believed to be accurate. Pilot data showed that image pair selection is reliable in patients with non-CRPS1 pain (intercorrelation coefficient [ICC] Ͼ0.93). The size of the affected limb was estimated by the ratio between limbs of the mean circumference taken midway along the proximal phalanx of fingers 2 to 4, using hand measuring tape (Beiersdorf-Jobst, Hamburg, Germany). This measure is reproducible (ICC Ͼ0.9). A Mann-Whitney U test was used to test the difference between the perceived sizes of the affected limb selected by subjects and controls. To identify whether the selected image was related to patient characteristics, linear regression between the selected image and finger circumference ratio, mean pain intensity, age of the patient, and duration of symptoms, with correction for multiple measures, was used. Assessors were blinded to the purpose of the study. Logistic regressions were run testing the relationship of the perceived relative size of the affected limb to the presence or absence of each medication, the presence of apparent swelling (to the investigator), and apparent atrophy (to the investigator). Patients gave informed consent. Procedures were approved by the institutional ethics committee and conformed to the Declaration of Helsinki.Results. For patients with CRPS1, the median selection showed that the affected limb expanded to 105% of the actual width. The mean (SD) size of the affected limb in the selected image was 107% (3%). Sixty-three percent of patients with CRPS1 and 17% of the cont...

IntroductionThis small observational study was motivated by our belief that scaling the tidal volume in mechanically ventilated patients to the size of the injured lung is safer and more 'physiologic' than scaling it to predicted body weight, i.e. its size before it was injured. We defined Total Lung Capacity (TLC) as the thoracic gas volume at an airway pressure of 40 cm H2O and tested if TLC could be inferred from the volume of gas that enters the lungs during a brief 'recruitment' maneuver.MethodsLung volume at relaxed end expiration (Vrel) as well as inspiratory capacity (IC), defined as the volume of gas that enters the lung during a 5 second inflation to 40 cm H2O, were measured in 14 patients with respiratory failure. TLC was defined as the sum of IC and Vrel. The dependence of IC and Vrel on body mass index (BMI), respiratory system elastance and plateau airway pressure was assessed.ResultsTLC was reduced to 59 ± 23% of that predicted. Vrel/TLC, which averaged 0.45 ± 0.11, was no different than the 0.47 ± 0.04 predicted during health in the supine posture. The greater than expected variability in observed Vrel/TLC was largely accounted for by BMI. Vrel and IC were correlated (r = 0.76). Taking BMI into account strengthened the correlation (r = 0.92).ConclusionsWe conclude that body mass is a powerful determinant of lung volume and plateau airway pressure. Effective lung size can be easily estimated from a recruitment maneuver derived inspiratory capacity measurement and body mass index.

BackgroundPhysicians require extensive training to achieve proficiency in mechanical ventilator (MV) management of the critically ill patients. Guided self-directed learning (GSDL) is usually the method used to learn. However, it is unclear if this is the most proficient approach to teaching mechanical ventilation to critical care fellows. We, therefore, investigated whether critical care fellows achieve higher scores on standardized testing and report higher satisfaction after participating in a hands-on tutorial combined with GSDL compared to self-directed learning alone.MethodsFirst-year Pulmonary and Critical Care Medicine (PCCM) fellows (n=6) and Critical Care Internal Medicine (CCIM) (n=8) fellows participated. Satisfaction was assessed using the Likert scale. MV knowledge assessment was performed by administering a standardized 25-question multiple choice pre- and posttest. For 2 weeks the CCIM fellows were exposed to GSDL, while the PCCM fellows received hands-on tutoring combined with GSDL.ResultsNinety-three percentage (6 PCCM and 7 CCIM fellows, total of 13 fellows) completed all evaluations and were included in the final analysis. CCIM and PCCM fellows scored similarly in the pretest (64% vs. 52%, p=0.13). Following interventions, the posttest scores increased in both groups. However, no significant difference was observed based on the interventions (74% vs. 77%, p=0.39). The absolute improvement with the hands-on-tutoring and GSDL group was higher than GSDL alone (25% vs. 10%, p=0.07). Improved satisfaction scores were noted with hands-on tutoring.ConclusionsHands-on tutoring combined with GSDL and GSDL alone were both associated with an improvement in posttest scores. Absolute improvement in test and satisfaction scores both trended higher in the hands-on tutorial group combined with GSDL group.

Movement of the mechanically ventilated patient may be for a routine procedure or medical emergency. The risks of transport seem manageable, but the memory of a respiratory-related catastrophe still gives many practitioners pause. The risk/benefit ratio of transport must be assessed before movement. During transport of the ventilated patients, should we always use a transport ventilator? What is the risk of using manual ventilation? How are PEEP and F IO 2 altered? Is there an impact on the ability to trigger during manual ventilation? Is hyperventilation and hypoventilation a common problem? Does hyperventilation or hypoventilation result in complications? Are portable ventilators worth the cost? What about the function of portable ventilators? Can these devices faithfully reproduce ICU ventilator function? The following pro and con discussion will attempt to address many of these issues by reviewing the current evidence on transport ventilation.