Luis Carlos Molano

Multimodal nutritional rehabilitation improves clinical outcomes of malnourished patients with chronic respiratory failure: a randomised controlled trial

Background In chronic respiratory failure (CRF), body composition strongly predicts survival. Methods A prospective randomised controlled trial was undertaken in malnourished patients with CRF to evaluate the effects of 3u2005months of home rehabilitation on body functioning and composition. 122 patients with CRF on long-term oxygen therapy and/or non-invasive ventilation (mean (SD) age 66 (10)u2005years, 91 men) were included from eight respiratory units; 62 were assigned to home health education (controls) and 60 to multimodal nutritional rehabilitation combining health education, oral nutritional supplements, exercise and oral testosterone for 90u2005days. The primary endpoint was exercise tolerance assessed by the 6-min walking test (6MWT). Secondary endpoints were body composition, quality of life after 3u2005months and 15-month survival. Results Mean (SD) baseline arterial oxygen tension was 7.7 (1.2)u2005kPa, forced expiratory volume in 1u2005s 31 (13)% predicted, body mass index (BMI) 21.5 (3.9)u2005kg/m2 and fat-free mass index (FFMI) 15.5 (2.4)u2005kg/m2. The intervention had no significant effect on 6MWT. Improvements (treatment effect) were seen in BMI (+0.56u2005kg/m2, 95% CI 0.18 to 0.95, p=0.004), FFMI (+0.60u2005kg/m2, 95% CI 0.15 to 1.05, p=0.01), haemoglobin (+9.1u2005g/l, 95% CI 2.5 to 15.7, p=0.008), peak workload (+7.2u2005W, 95% CI 3.7 to 10.6, p<0.001), quadriceps isometric force (+28.3u2005N, 95% CI 7.2 to 49.3, p=0.009), endurance time (+5.9u2005min, 95% CI 3.1 to 8.8, p<0.001) and, in women, Chronic Respiratory Questionnaire (+16.5 units, 95% CI 5.3 to 27.7, p=0.006). In a multivariate Cox analysis, only rehabilitation in a per-protocol analysis predicted survival (HR 0.27, 95% CI 0.07 to 0.95, p=0.042). Conclusions Multimodal nutritional rehabilitation aimed at improving body composition increased exercise tolerance, quality of life in women and survival in compliant patients, supporting its incorporation in the treatment of malnourished patients with CRF. Clinical Trial number NCT00230984.

Cephalic versus oronasal mask for noninvasive ventilation in acute hypercapnic respiratory failure

ObjectiveCompared to oronasal interfaces, a cephalic mask has a larger inner volume, covers the entire anterior surface of the face and limits the risk of deleterious cutaneous side effects during noninvasive ventilation (NIV). The present clinical study aimed to compare the clinical efficacy of a cephalic mask versus an oronasal mask in patients with acute hypercapnic respiratory failure (AHRF).Design and settingRandomized controlled study in a Respiratory Intermediate Care Unit.PatientsAll consecutive patients admitted for AHRF were randomly assigned to receive bilevel NIV either with a cephalic mask (nxa0=xa017) or an oronasal mask (nxa0=xa017) during the first 48xa0h.MeasurementsThe main outcome criterion was the improvement of arterial pH, 24xa0h after NIV initiation. Secondary criteria included PaCO2 and physiological parameters.ResultsCompared to values at inclusion, pH, PaCO2, encephalopathy score, respiratory distress score and respiratory frequency improved significantly and similarly with both masks. None of these parameters showed statistically significant differences between the masks at each time point throughout the study period. Mean delivered inspiratory and expiratory pressures were similar in both patient groups. Tolerance of the oronasal mask was improved at 24xa0h and further. One patient with the cephalic mask suffered from claustrophobia that did not lead to premature study interruption.ConclusionsIn spite of its larger inner volume, the cephalic mask has the same clinical efficacy and requires the same ventilatory settings as the oronasal mask during AHRF.

Altered synchrony of right ventricular contraction in borderline pulmonary hypertension

Imaging studies have shown that pulmonary hypertension (PH) is associated with inhomogenous right ventricular (RV) regional contraction, or dyssynchrony, and that this is of prognostic relevance. This study aimed at the identification and functional significance of RV dyssynchrony in borderline PH defined by a mean pulmonary artery pressure between (mPAP) 20 and 25xa0mmHg. RV dyssynchrony was measured by 2-dimensional speckle tracking echocardiography in 17 patients with pulmonary arterial hypertension (PAH), 13 patients with borderline PH and 14 controls. Dyssynchrony was defined as the R-R interval-corrected standard deviation of the times to peak-systolic strain for the basal and medium segments of the RV. All the PH patients underwent a right heart catheterization. RV dyssynchrony amounted to 69u2009±u200934xa0ms in PAH, 47u2009±u200923xa0ms in borderline PH and 8u2009±u20096xa0ms in controls, all different from each other (pu2009<u20090.05). RV dyssynchrony in borderline PH was the only parameter of RV systolic dysfunction in 11 of 13 (85%) of the patients. RV dyssynchrony was accompanied by postsystolic shortening and correlated to RV fractional area change, not to mPAP or pulmonary vascular resistance. RV dyssynchrony occurs in borderline PH and may reflect early RV-arterial uncoupling.

Survival of patients with chronic respiratory failure on long-term oxygen therapy and or non-invasive ventilation at home.

BACKGROUND & AIMSnChronic respiratory failure (CRF) is the common fate of respiratory diseases where systemic effects contribute to outcomes. In a prospective cohort of home-treated patients with CRF, we looked for predictors of long-term survival including respiratory, nutritional and inflammatory dimensions.nnnMETHODSn637 stable outpatients with CRF, 397 men, 68 ± 11 years, on long-term oxygen therapy and/or non-invasive ventilation from 21 chest clinics were enrolled and followed over 53 ± 31 months. CRF resulted from Chronic Obstructive Pulmonary Disease (COPD) in 48.5%, restrictive disorders 32%, mixed (obstructive and restrictive patterns) respiratory failure 13.5%, bronchiectasis 6%. Demographic characteristics, smoking habits, underlying respiratory diseases, forced expiratory volume in one second (FEV1), forced vital capacity (FVC), arterial blood gases, 6-min walking distance (6MWD), hemoglobin, body mass index (BMI), serum albumin, transthyretin, C-reactive protein (CRP), history of respiratory assistance, antibiotic and oral corticosteroid use during the previous year were recorded.nnnRESULTSn322 deaths occurred during the follow-up. One-, five- and 8-year actuarial survival was 89%, 56% and 47%. By Cox univariate analysis, age, respiratory disease, PaO2, PaCO2, FEV1/FVC, BMI, 6MWD, activity score, type and length of home respiratory assistance, smoking habits, oral corticosteroid and antibiotic uses, albumin, transthyretin, hemoglobin and CRP levels were associated with survival. Multivariate analysis identified eight independent markers of survival: age, FEV1/FVC, PaO2, PaCO2, 6MWD, BMI, serum transthyretin, CRP ≥ 5 mg/l.nnnCONCLUSIONSnIn CRF, whatever the underlying diseases, besides the levels of obstructive ventilatory defect and gas exchange failure, 6MWD, BMI, serum transthyretin and CRP ≥ 5 mg/l predicted long-term survival identifying potential targets for nutritional rehabilitation.