Keyvan Razazi

High-Flow Oxygen through Nasal Cannula in Acute Hypoxemic Respiratory Failure

BACKGROUNDnWhether noninvasive ventilation should be administered in patients with acute hypoxemic respiratory failure is debated. Therapy with high-flow oxygen through a nasal cannula may offer an alternative in patients with hypoxemia.nnnMETHODSnWe performed a multicenter, open-label trial in which we randomly assigned patients without hypercapnia who had acute hypoxemic respiratory failure and a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen of 300 mm Hg or less to high-flow oxygen therapy, standard oxygen therapy delivered through a face mask, or noninvasive positive-pressure ventilation. The primary outcome was the proportion of patients intubated at day 28; secondary outcomes included all-cause mortality in the intensive care unit and at 90 days and the number of ventilator-free days at day 28.nnnRESULTSnA total of 310 patients were included in the analyses. The intubation rate (primary outcome) was 38% (40 of 106 patients) in the high-flow-oxygen group, 47% (44 of 94) in the standard group, and 50% (55 of 110) in the noninvasive-ventilation group (P=0.18 for all comparisons). The number of ventilator-free days at day 28 was significantly higher in the high-flow-oxygen group (24±8 days, vs. 22±10 in the standard-oxygen group and 19±12 in the noninvasive-ventilation group; P=0.02 for all comparisons). The hazard ratio for death at 90 days was 2.01 (95% confidence interval [CI], 1.01 to 3.99) with standard oxygen versus high-flow oxygen (P=0.046) and 2.50 (95% CI, 1.31 to 4.78) with noninvasive ventilation versus high-flow oxygen (P=0.006).nnnCONCLUSIONSnIn patients with nonhypercapnic acute hypoxemic respiratory failure, treatment with high-flow oxygen, standard oxygen, or noninvasive ventilation did not result in significantly different intubation rates. There was a significant difference in favor of high-flow oxygen in 90-day mortality. (Funded by the Programme Hospitalier de Recherche Clinique Interrégional 2010 of the French Ministry of Health; FLORALI ClinicalTrials.gov number, NCT01320384.).

Risk factors for and prediction by caregivers of extubation failure in ICU patients: a prospective study.

Objective:The influence of delirium, ICU-acquired paresis, and cardiac performance on extubation outcome has never been evaluated together. We aimed to assess the respective role of these factors on the risk of extubation failure and to assess the predictive accuracy of caregivers. Design and Setting:Prospective observational study of all planned extubations in a 13-bed medical ICU of a teaching hospital. Interventions:On the day of extubation, muscle strength of the four limbs, criteria for delirium, cardiac performance, cough strength, and the risk of extubation failure predicted by caregivers were prospectively assessed. Extubation failure was defined as the need for reintubation within the following 7 days. Measurements and Main Results:Over the 18-month study period, 533 patients required intubation. Among the 225 patients intubated for more than 24 hours who experienced a planned extubation attempt, 31 patients (14%) required reintubation within the 7 days following extubation. In multivariate analysis, duration of mechanical ventilation more than 7 days prior to extubation, ineffective cough, and severe systolic left ventricular dysfunction were the three independent factors associated with extubation failure. Although patients considered at high risk for extubation failure had higher reintubation rate, prediction of extubation failure by caregivers at time of extubation had high specificity but low sensitivity. Conclusions:An ineffective cough, a prior duration of mechanical ventilation more than 7 days, and severe systolic left ventricular dysfunction were stronger predictors of extubation failure than delirium or ICU-acquired weakness. Only one-third patients who required reintubation were considered at high risk for extubation failure by caregivers.

Delayed hemolytic transfusion reaction in adult sickle-cell disease: presentations, outcomes, and treatments of 99 referral center episodes.

Delayed hemolytic transfusion reaction (DHTR) is one of the most feared complications of sickle‐cell disease (SCD). We retrospectively analyzed the clinical and biological features, treatments and outcomes of 99 DHTRs occurring in 69 referral center patients over 12 years. The first clinical signs appeared a median of 9.4 [IQR, 3–22] days after the triggering transfusion (TT). The most frequent DHTR‐related clinical manifestation was dark urine/hemoglobinuria (94%). Most patients (89%) had a painful vaso‐occlusive crisis and 50% developed a secondary acute chest syndrome (ACS). The median [IQR] hemoglobin‐concentration nadir was 5.5 [4.5–6.3] g/dL and LDH peak was 1335 [798–2086] IU/L. Overall mortality was 6%. None of the patients had been receiving chronic transfusions. Among these DHTRs, 61% were developed in previously immunized patients, 28% in patients with prior DHTR. Among Abs detected after the TT in 62% of the episodes, half are classically considered potentially harmful. No association could be established between clinical severity and immunohematological profile and/or the type and specificity of Abs detected after the TT. Management consisted of supportive care alone (53%) or with adjunctive measures (47%), including recombinant erythropoietin and sometimes rituximab and/or immunosuppressants. Additional transfusions were either ineffective or worsened hemolysis. In some cases, severe intravascular hemolysis can be likely responsible for the vascular reaction and high rates of ACS, pulmonary hypertension and (multi)organ failure. In conclusion, clinicians and patients must recognize early DHTR signs to avoid additional transfusions. For patients with a history of RBC immunization or DHTR, transfusion indications should be restricted. Am. J. Hematol. 91:989–994, 2016.

Easily identified at-risk patients for extubation failure may benefit from noninvasive ventilation: a prospective before-after study

BackgroundWhile studies have suggested that prophylactic noninvasive ventilation (NIV) could prevent post-extubation respiratory failure in the intensive care unit, they appear inconsistent with regard to reintubation. We assessed the impact of a prophylactic NIV protocol on reintubation in a large population of at-risk patients.MethodsProspective before-after study performed in the medical ICU of a teaching referral hospital. In the control cohort, we determined that patients older than 65 years and those with underlying cardiac or respiratory disease were at high-risk for reintubation. In the interventional cohort, we implemented a protocol using prophylactic NIV in all patients intubated at least 24xa0h and having one of these risk factors. NIV was immediately applied after planned extubation during at least the first 24xa0hours. Extubation failure was defined by the need for reintubation within sevenxa0days following extubation.ResultsWe included 83 patients at high-risk among 132 extubated patients in the control cohort (12-month period) and 150 patients at high-risk among 225 extubated patients in the NIV cohort (18-month period). The reintubation rate was significantly decreased from 28xa0% in the control cohort (23/83) to 15xa0% (23/150) in the NIV cohort (pu2009=u20090.02 log-rank test), whereas the non-at-risk patients did not significantly differ in the two periods (10.2xa0% vs. 10.7xa0%, pu2009=u20090.93). After multivariate logistic-regression analysis, the use of prophylactic NIV protocol was independently associated with extubation success.ConclusionsThe implementation of prophylactic NIV after extubation may reduce the reintubation rate in a large population of patients with easily identified risk factors for extubation failure.

Severe haemoptysis in patients with nonsmall cell lung carcinoma

Severe haemoptysis due to nonsmall cell lung cancer (NSCLC) is considered a grim condition, and there is still scarce data on its characteristics and outcome, despite new imaging and treatment modalities. This retrospective study sought to describe the clinical characteristics, pathophysiology and outcome of NSCLC-related haemoptysis. We included 125 consecutive patients with severe haemoptysis (>100u2009mL) at admission, 65 (52%) exhibiting squamous cell carcinoma. Tumour cavitation/necrosis was reported in 26 (21%) patients. 52 patients had received anticancer treatment, but none had received anti-angiogenic agents. Severe haemoptysis was related mainly to the bronchial artery (82%), and major pulmonary artery involvement was rare (6.4%). Interventional radiology was performed in 102 patients. Bleeding cessation was achieved in 108 (87%) out of 125 patients. The overall in-hospital and 1-year survival rates were 69% and 30%, respectively. Performance status (PS) ≥2 (OR 3.6, 95% CI 1.3–9.6), advanced stage (OR 8.6, 95% CI 2–37) and mechanical ventilation (OR 13, 95% CI 4.5–36) were independent predictors of in-hospital mortality. Performance status ≥2 (hazard ratio (HR) 2.4, 95% CI 1.5–3.7), advanced stage (HR 4, 95% CI 2.1–7.7), cancer progression (HR 2, 95% CI 1.01–2.7) and cavitation/necrosis (HR 1.7, 95% CI 1.21–3.2) were independently associated with 1-year mortality. Management of severe haemoptysis related to NSCLC should be improved, given our observed survival rates after hospital discharge. NSCLC-related haemoptysis should not be considered dismissively; its management is still suboptimal http://ow.ly/CeI3S

Early High-Dose Erythropoietin Therapy After Out-of-Hospital Cardiac Arrest: A Multicenter, Randomized Controlled Trial.

BACKGROUNDnPreliminary data suggested a clinical benefit in treating out-of-hospital cardiac arrest (OHCA) patients with a high dose of erythropoietin (Epo) analogs.nnnOBJECTIVESnThe authors aimed to evaluate the efficacy of epoetin alfa treatment on the outcome of OHCA patients in a phase 3 trial.nnnMETHODSnThe authors performed a multicenter, single-blind, randomized controlled trial. Patients still comatose after a witnessed OHCA of presumed cardiac origin were eligible. In the intervention group, patients received 5 intravenous injections spaced 12 h apart during the first 48 h (40,000 units each, resulting in a maximal dose of 200,000 total units), started as soon as possible after resuscitation. In the control group, patients received standard care without Epo. The main endpoint was the proportion of patients in each group reaching level 1 on the Cerebral Performance Category (CPC) scale (survival with no or minor neurological sequelae) at day 60. Secondary endpoints included all-cause mortality rate, distribution of patients in CPC levels at different time points, and side effects.nnnRESULTSnIn total, 476 patients were included in the primary analysis. Baseline characteristics were similar in the 2 groups. At day 60, 32.4% of patients (76 of 234) in the intervention group reached a CPC 1 level, as compared with 32.1% of patients (78 of 242) in the control group (odds ratio: 1.01; 95% confidence interval: 0.68 to 1.48). The mortality rate and proportion of patients in each CPC level did not differ at any time points. Serious adverse events were more frequent in Epo-treated patients as compared with controls (22.6% vs. 14.9%; pxa0= 0.03), particularly thrombotic complications (12.4% vs. 5.8%; pxa0= 0.01).nnnCONCLUSIONSnIn patients resuscitated from an OHCA of presumed cardiac cause, early administration of erythropoietin plus standard therapy did not confer a benefit, and was associated with a higher complication rate. (High Dose ofxa0Erythropoietin Analogue After Cardiac Arrest [Epo-ACR-02]; NCT00999583).

Shock complicating successful bronchial artery embolization for severe hemoptysis.

Bronchial artery embolization (BAE) complications are uncommon. We describe three patients who had a shock related to splenic infarction after a successful BAE.

High-flow nasal oxygen for bronchoalveolar lavage in acute respiratory failure patients

Fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) holds significant risks of oxygenation deterioration [1]. Among various means to improve oxygenation during BAL, noninvasive positive pressure ventilation (NPPV) has received the greatest attention [2, 3]. However, NPPV is a time-consuming and very demanding technique. High-flow nasal cannula oxygen therapy (HFNC) has emerged as a technique for noninvasive respiratory management of hypoxaemic patients [4]. In patients with acute respiratory failure (ARF), its beneficial effects have been shown in various populations [5], and its effectiveness and superiority over NPPV and conventional oxygenation recently demonstrated [6]. Its use has also been described during bronchoscopy in non-hypoxaemic [7] and in hypoxaemic patients in comparison with NPPV [8]. However, bronchoscopy was performed with an open mouth in both studies, which considerably reduces HFNC efficacy [9]. Thus, we aimed to determine HFNCs effectiveness during nasal bronchoscopy with BAL in patients with ARF along with BALs feasibility and yield. HFNC is an effective and safe method of oxygenation during nasal bronchoscopy with BAL in hypoxaemic ARF patients http://ow.ly/XAmtZ

A Multicenter Randomized Trial Assessing the Efficacy of Helium/Oxygen in Severe Exacerbations of Chronic Obstructive Pulmonary Disease

Rationale: During noninvasive ventilation (NIV) for chronic obstructive pulmonary disease (COPD) exacerbations, helium/oxygen (heliox) reduces the work of breathing and hypercapnia more than air/O2, but its impact on clinical outcomes remains unknown. Objectives: To determine whether continuous administration of heliox for 72 hours, during and in‐between NIV sessions, was superior to air/O2 in reducing NIV failure (25‐15%) in severe hypercapnic COPD exacerbations. Methods: This was a prospective, randomized, open‐label trial in 16 intensive care units (ICUs) and 6 countries. Inclusion criteria were COPD exacerbations with PaCO2 ≥ 45 mm Hg, pH ≤ 7.35, and at least one of the following: respiratory rate ≥ 25/min, PaO2 ≤ 50 mm Hg, and oxygen saturation (arterial [SaO2] or measured by pulse oximetry [SpO2]) ≤ 90%. A 6‐month follow‐up was performed. Measurements and Main Results: The primary endpoint was NIV failure (intubation or death without intubation in the ICU). The secondary endpoints were physiological parameters, duration of ventilation, duration of ICU and hospital stay, 6‐month recurrence, and rehospitalization rates. The trial was stopped prematurely (445 randomized patients) because of a low global failure rate (NIV failure: air/O2 14.5% [n = 32]; heliox 14.7% [n = 33]; P = 0.97, and time to NIV failure: heliox group 93 hours [n = 33], air/O2 group 52 hours [n = 32]; P = 0.12). Respiratory rate, pH, PaCO2, and encephalopathy score improved significantly faster with heliox. ICU stay was comparable between the groups. In patients intubated after NIV failed, patients on heliox had a shorter ventilation duration (7.4 ± 7.6 d vs. 13.6 ± 12.6 d; P = 0.02) and a shorter ICU stay (15.8 ± 10.9 d vs. 26.7 ± 21.0 d; P = 0.01). No difference was observed in ICU and 6‐month mortality. Conclusions: Heliox improves respiratory acidosis, encephalopathy, and the respiratory rate more quickly than air/O2 but does not prevent NIV failure. Overall, the rate of NIV failure was low. Clinical trial registered with www.clinicaltrials.gov (NCT 01155310).

Prognostic Value of Relative Adrenal Insufficiency During Cardiogenic Shock: A Prospective Cohort Study with Long-Term Follow-Up.

Background: Relative adrenal insufficiency (RAI) is common in intensive care unit patients, particularly during septic shock (SS). Cardiogenic shock (CS) may share some pathophysiological features with SS. The aim of this study was to evaluate the prevalence and long-term prognosis of RAI during CS. Patients and Methods: Prospective observational study conducted in the intensive care and cardiology units in one university hospital in France. Patients meeting the criteria for CS without prior corticosteroid therapy were included. Total blood cortisol levels were assessed immediately before (T0) a short corticotropin stimulation test (0.25u200amg i.v. of tetracosactrin) and 30 and 60 min afterward. &Dgr;max was defined as the difference between the maximal value after the test and T0. Results: Of the 92 patients enrolled, 42 (46%) (95% confidence interval [CI] [36%–56%]) died in hospital and 7 more died during a median follow-up of 616 [57–2,498] days, for an overall mortality rate of 53% (95% CI [43%–63%]). Three groups were identified based on the corticotropin test: group 1 (T0 ⩽798u200anmol/L and &Dgr;max >473u200anmol/L), group 2 ([T0 >798u200anmol/L and &Dgr;max >473u200anmol/L] or [T0 ⩽798u200anmol/L and &Dgr;max ⩽473u200anmol/L]), and group 3 (T0 >798u200anmol/L and &Dgr;max ⩽473u200anmol/L) with an overall survival of 76%, 43%, and 15%, respectively (log rank Pu200a=u200a0.003). In the multivariable analysis, adrenal nonresponse (group 3) was an independent predictor of mortality (Pu200a=u200a0.04), along with left ventricular ejection fraction, Simplified Acute Physiology Score II, and cardiac arrest. Conclusions: These data suggest that a short corticotropin test has a good prognostic value in CS and allows identifying patients at higher risk of death.