Respiratory Rehabilitation
RCT: High-Intensity NPPV Reduced Criteria for Intubation in Acute COPD Exacerbations
16 Sep, 2024 | 16:50h | UTCBackground: Acute exacerbations of chronic obstructive pulmonary disease (COPD) often lead to hypercapnic respiratory failure requiring ventilatory support. Noninvasive positive pressure ventilation (NPPV) is standard care, commonly delivered at low intensity with lower inspiratory pressures. However, approximately 15% of patients still require endotracheal intubation despite low-intensity NPPV. High-intensity NPPV, using higher inspiratory pressures to achieve greater reductions in PaCO₂, has shown benefits in stable hypercapnic COPD patients, but its effect during acute exacerbations is unclear.
Objective: To determine whether high-intensity NPPV reduces the need for endotracheal intubation in patients with acute COPD exacerbations and persistent hypercapnia compared to low-intensity NPPV.
Methods: In a multicenter, randomized clinical trial conducted at 30 respiratory wards in China from January 2019 to January 2022, 300 patients with acute COPD exacerbations and PaCO₂ greater than 45 mm Hg after 6 hours of low-intensity NPPV were enrolled. Participants were randomized 1:1 to receive either high-intensity NPPV (inspiratory positive airway pressure [IPAP] adjusted to achieve tidal volumes of 10–15 mL/kg predicted body weight, typically IPAP 20–30 cm H₂O) or to continue low-intensity NPPV (IPAP adjusted for tidal volumes of 6–10 mL/kg, maximum IPAP 20 cm H₂O). Patients in the low-intensity group meeting prespecified criteria for intubation were allowed to crossover to high-intensity NPPV. The primary outcome was the need for endotracheal intubation during hospitalization, defined by prespecified clinical and gas exchange criteria. Secondary outcomes included actual endotracheal intubation rates, mortality, length of hospital stay, and adverse events.
Results: Of the 300 patients (mean age 73 years; 68% male), the primary outcome occurred in 4.8% of the high-intensity group versus 13.7% of the low-intensity group (absolute difference –9.0%; 95% CI, –15.4% to –2.5%; one-sided P = .004; adjusted risk ratio [RR], 0.35; 95% CI, 0.14–0.76). However, actual endotracheal intubation rates did not differ significantly between groups (3.4% vs 3.9%; absolute difference –0.5%; 95% CI, –4.8% to 3.7%; P = .81). The high-intensity group had greater reductions in PaCO₂ levels over 72 hours (mean PaCO₂ at 72 hours: 53 mm Hg vs 64 mm Hg; P < .001) and higher rates of achieving normocapnia (21.8% vs 4.6%; P < .001). Abdominal distension occurred more frequently in the high-intensity group (37.4% vs 25.5%; absolute difference 11.9%; 95% CI, 1.5%–22.4%; P = .03), but other adverse events and serious adverse events were similar between groups.
Conclusions: High-intensity NPPV reduced the proportion of patients meeting criteria for endotracheal intubation compared to low-intensity NPPV in patients with acute COPD exacerbations and persistent hypercapnia. However, actual intubation rates did not differ, possibly due to crossover from low- to high-intensity NPPV in patients meeting intubation criteria.
Implications for Practice: High-intensity NPPV may be considered for patients with acute COPD exacerbations who remain hypercapnic after initial low-intensity NPPV, as it may reduce progression to severe respiratory failure requiring intubation criteria. Clinicians should monitor for abdominal distension and potential alkalosis, although these did not significantly affect overall tolerance or safety.
Study Strengths and Limitations: Strengths include the multicenter randomized design, clear enrollment criteria, and standardized protocols. Limitations include early trial termination, unblinded interventions, potential bias due to allowed crossover, and lack of power to detect differences in mortality or actual intubation rates.
Future Research: Further large-scale trials are needed to confirm these findings, assess the impact on actual intubation rates and mortality, and explore the efficacy of high-intensity NPPV in different clinical settings and patient populations, including those without prior NPPV exposure or with more severe respiratory distress.
RCT: 24-Hour Oxygen Therapy Does Not Reduce Hospitalization or Mortality Compared to 15-Hour Therapy in Severe Hypoxemia
12 Sep, 2024 | 13:21h | UTCStudy Design and Population: This multicenter, registry-based randomized controlled trial compared the effects of 24-hour versus 15-hour daily oxygen therapy in 241 patients with chronic, severe hypoxemia. Patients, recruited between 2018 and 2022, were assigned to either 24 hours (117 patients) or 15 hours (124 patients) of oxygen therapy daily. The study’s primary outcome was the composite of hospitalization or death from any cause within 1 year.
Main Findings: After 12 months, the results showed no significant difference between the two groups in the primary outcome. The event rates for hospitalization or death were similar in the 24-hour and 15-hour groups (124.7 vs. 124.5 events per 100 person-years, hazard ratio 0.99, 95% CI, 0.72-1.36). Secondary outcomes, including individual rates of hospitalization and mortality, also showed no meaningful differences, and adverse event rates were comparable between groups.
Implications for Practice: These findings suggest that increasing oxygen therapy from 15 to 24 hours per day does not reduce hospitalization or mortality in patients with severe hypoxemia. Therefore, the less burdensome 15-hour regimen may be preferable in clinical practice, as it is equally effective while reducing patient burden.
Meta-Analysis: ERAS Protocols Improve Recovery and Reduce Complications After Emergency Laparotomy – Am J Surg
18 Aug, 2024 | 19:32h | UTCStudy Design and Population: This systematic review and meta-analysis assessed the effects of Enhanced Recovery After Surgery (ERAS) protocols compared to standard care (SC) in patients undergoing emergency laparotomy. The analysis included six randomized clinical trials (RCTs) with a total of 509 patients.
Main Findings: The ERAS group showed a reduction in length of hospital stay (mean difference: -2.92 days) and quicker recovery milestones, such as time to ambulation (mean difference: -1.67 days) and first bowel opening (mean difference: -1.26 days). The ERAS protocols were also associated with lower rates of pulmonary complications (odds ratio [OR]: 0.43) and surgical site infections (OR: 0.33). Mortality rates were similar between the ERAS and SC groups.
Implications for Practice: These findings suggest that ERAS protocols may enhance recovery and reduce complications in patients undergoing emergency laparotomy. Implementation of these protocols could be beneficial in emergency surgical settings, where feasible.
Meta-Analysis: Daily Sedation Interruption Shortens PICU Stay Without Impacting Mortality or Ventilation Duration in Pediatric MV Patients – JAMA Netw Open
11 Aug, 2024 | 13:19h | UTCStudy Design and Population: This systematic review and meta-analysis included six randomized clinical trials (RCTs) involving 2,810 pediatric patients receiving mechanical ventilation (MV) in the pediatric intensive care unit (PICU). The trials compared the effects of daily sedation interruption (DSI) with continuous intravenous (IV) sedation on clinical outcomes such as MV duration and PICU length of stay.
Main Findings: The analysis found that DSI was associated with a significant reduction in the length of PICU stay (mean difference of -1.45 days, p = 0.03). However, there was no significant difference in the duration of MV between DSI and continuous sedation (mean difference of -0.93 days, p = 0.06). Additionally, there were no significant differences in total sedative doses, adverse events, or mortality between the two groups.
Implications for Practice: The findings suggest that DSI may reduce the length of PICU stay without increasing the risk of adverse events, making it a potentially valuable strategy in managing sedation for pediatric patients on MV. However, further research is needed to explore the long-term neurodevelopmental outcomes associated with DSI.
RCT: Lower oxygenation target improves days alive without life support in severe COVID-19 hypoxemia
21 Mar, 2024 | 13:46h | UTCStudy Design and Population: This multicenter randomized clinical trial investigated the impact of different oxygenation targets on the survival of adult patients with COVID-19 and severe hypoxemia in the ICU. Conducted across 11 European ICUs from August 2020 to March 2023, the study involved 726 patients requiring at least 10 L/min of oxygen or mechanical ventilation. Participants were randomly assigned to receive an oxygenation target of either 60 mm Hg (lower oxygenation group, n=365) or 90 mm Hg (higher oxygenation group, n=361) for up to 90 days.
Main Findings: The primary outcome was the number of days alive without life support at 90 days post-intervention. Patients in the lower oxygenation group achieved a median of 80.0 days alive without life support compared to 72.0 days in the higher oxygenation group, a difference that was statistically significant (P=0.009). Although there was a slight reduction in mortality at 90 days in the lower oxygenation group (30.2% vs 34.7% in the higher group), this was not statistically significant. No significant differences were observed in the proportion of patients with serious adverse events or the number of days alive and out of hospital.
Implications for Practice: Targeting a lower Pao2 of 60 mm Hg in ICU patients with COVID-19 and severe hypoxemia appears to increase the days alive without life support compared to a higher target of 90 mm Hg, without increasing serious adverse events. This finding suggests that a lower oxygenation target could be more beneficial for this patient population, potentially guiding clinical practice in managing oxygen therapy for severe COVID-19 cases.
Reference
Reference: Nielsen FM et al. (2024). Randomized Clinical Trial: Effect of Oxygenation Targets on Survival Without Life Support in COVID-19 Patients with Severe Hypoxemia. JAMA, Published online March 19, 2024. DOI: 10.1001/jama.2024.2934. Access the study here: [Link]
Survival ≠ Recovery | A narrative review of post-intensive care syndrome
11 Aug, 2023 | 15:11h | UTCSurvival ≠ Recovery: A Narrative Review of Post-Intensive Care Syndrome – CHEST Critical Care
Review | Pulmonary rehabilitation and physical interventions
21 Jun, 2023 | 13:11h | UTCPulmonary rehabilitation and physical interventions – European Respiratory Review
Commentary on Twitter
ERR: Pulmonary rehabilitation that includes individualised exercise training is effective in patients with stable COPD and those who have suffered an exacerbation. Remaining challenges are to increase uptake and access to and personalisation of programmes. https://t.co/NSoASus6TW pic.twitter.com/JRl7dCOZrm
— ERS publications (@ERSpublications) June 12, 2023
ATS Report | Rehabilitation for people with respiratory disease and frailty
16 Jun, 2023 | 13:51h | UTC
ERS statement on airway clearance techniques in adults with bronchiectasis
12 May, 2023 | 13:42h | UTC
M-A | Effects of different types of early rehabilitation on ventilator weaning among patients in the ICU
10 May, 2023 | 15:34h | UTC
What’s new in reducing the impact of tracheostomy on communication and swallowing in the ICU
4 May, 2023 | 13:34h | UTC
Commentary on Twitter
? Tracheostomy? Profound impact on functional communication, swallowing/oral intake & other comorbidities in #ICU. Early strategies to restore laryngo‑pharyngeal airflow/subglottic P likely to ⬇️ negative impact ⬆️ short/longer-term sequelae.#ICUrehab
?️ https://t.co/Jslkv04Djf pic.twitter.com/YKLNKYvabC— Intensive Care Medicine (@yourICM) April 23, 2023
SR | Exercise‐based rehabilitation programs for pulmonary hypertension
17 Apr, 2023 | 12:44h | UTCExercise‐based rehabilitation programmes for pulmonary hypertension – Cochrane Library
Summary: Exercise-based rehabilitation in pulmonary hypertension – Cochrane Library
Review | Managing respiratory muscle weakness during weaning from invasive ventilation
11 Apr, 2023 | 14:12h | UTC
M-A | Noninvasive respiratory support after extubation
11 Apr, 2023 | 14:03h | UTC
Review | Post-COVID syndrome
6 Apr, 2023 | 13:21h | UTCPost-COVID Syndrome – Deutsches Ärzteblatt International
Related:
Long COVID: major findings, mechanisms and recommendations – Nature Reviews Microbiology
RCT | Effect of non-invasive ventilation after extubation in critically ill patients with obesity
17 Feb, 2023 | 13:10h | UTCEffect of non-invasive ventilation after extubation in critically ill patients with obesity in France: a multicentre, unblinded, pragmatic randomised clinical trial – The Lancet Respiratory Medicine (link to abstract – $ for full-text)
Commentary on Twitter
NEW Research—Among critically ill adults with obesity undergoing extubation, the use of NIV was effective to reduce treatment-failure within 3 days
Read the RCT from Audrey De Jong & colleagues here: https://t.co/nMB3W8NAYX #SCCM2023 pic.twitter.com/iEHExPEhSN
— The Lancet Respiratory Medicine (@LancetRespirMed) January 21, 2023
RCT | Effect of early mobilization on long-term cognitive impairment in critical illness
17 Feb, 2023 | 13:07h | UTCEffect of early mobilisation on long-term cognitive impairment in critical illness in the USA: a randomised controlled trial – The Lancet Respiratory Medicine (free registration required)
Related:
M-A | The effect of early active mobilization at 6 months after critical illness
Early Active Mobilization during Mechanical Ventilation in the ICU – New England Journal of Medicine (link to abstract – $ for full-text)
Commentary on Twitter
NEW Research—Early mobilisation might improve long-term cognitive impairment in ICU survivors after MV, but the increased risk of adverse events in the intervention group should be noted
Read the RCT from Bhakti Patel & colleagues here: https://t.co/DeqraodGXq #SCCM2023 pic.twitter.com/RMDhE7UxPM
— The Lancet Respiratory Medicine (@LancetRespirMed) January 21, 2023
RCT | Home high-flow nasal cannula oxygen therapy for stable hypercapnic COPD
17 Feb, 2023 | 12:53h | UTC
SR | Inspiratory muscle training, with or without concomitant pulmonary rehabilitation, for COPD
15 Feb, 2023 | 15:42h | UTC
Review | How to optimize extubation?
3 Feb, 2023 | 14:13h | UTCHow to optimize extubation? – Intensive Care Medicine
Commentary on Twitter
How to optimize extubation?
➡️ anticipate cause of failure before extubation
➡️ after extubation: still anticipate to avoid re-intubation
➡️ high risk specific populations: COPD, obesity, brain injury
Free to read #FOAMcc on @yourICM
?️ https://t.co/C1fxrzO6Mf pic.twitter.com/1L4FdsuW6p— Intensive Care Medicine (@yourICM) February 1, 2023
SR | Patient-reported outcomes to assess dyspnea in interstitial lung disease and pulmonary hypertension
27 Jan, 2023 | 12:12h | UTC
M-A | Post-operative outcomes of pre-thoracic surgery respiratory muscle training vs. aerobic exercise training
26 Jan, 2023 | 12:19h | UTCPost-Operative Outcomes of Pre-Thoracic Surgery Respiratory Muscle Training Vs. Aerobic Exercise Training: A Systematic Review and Network Meta-analysis – Archives of Physical Medicine and Rehabilitation (link to abstract – $ for full-text)
M-A | The effect of early active mobilization at 6 months after critical illness
19 Jan, 2023 | 14:21h | UTCThe Effect of Mobilization at 6 Months after Critical Illness — Meta-Analysis – NEJM Evidence
Related:
Early Active Mobilization during Mechanical Ventilation in the ICU – New England Journal of Medicine (link to abstract – $ for full-text)
Commentary on Twitter
In this systemic review and meta-analysis on early mobilization in the ICU, Paton et al. find no significant effect on days alive and out of hospital. However, they find a possibility that it might increase mortality and adverse events. https://t.co/NrzDi7Y5KY#CriticalCare pic.twitter.com/mOW6BF44qx
— NEJM Evidence (@NEJMEvidence) December 20, 2022
Policy Statement | Palliative care early in the care continuum among patients with serious respiratory illness.
7 Dec, 2022 | 14:22h | UTC
Commentary on Twitter
Read "Palliative Care Early in the Care Continuum among Patients with Serious Respiratory Illness: An Official ATS/AAHPM/HPNA/SWHPN Policy Statement" here: https://t.co/vMALIcwp3K pic.twitter.com/lUclouz0Dj
— American Thoracic (@atscommunity) September 26, 2022
RCT | Effects of a physical exercise intervention during vs. after chemotherapy to improve cardiorespiratory fitness.
23 Nov, 2022 | 14:01h | UTCEditorial: Inclusion of Exercise in Cancer Treatment Planning: When Is the Right Time? – JACC: CardioOncology
Commentary: Exercise Intervention During Chemotherapy Beneficial – HealthDay