Nasal intermittent positive pressure ventilation for preterm neonates after extubation | Website Bệnh viện nhi đồng 2 -...
Int. J. Med. Sci. 2009, 6 http://www.medsci.org 72IInntteerrnnaattiioonnaall JJoouurrnnaall ooff MMeeddiiccaall SScciieenncceess 2009; 6(2):72-76 © Ivyspring International Publisher. All rights reserved Research Paper High-intensity non-invasive positive pressure ventilation for stable hypercapnic COPD Wolfram Windisch, Moritz Haenel, Jan H Storre and Michael Dreher Department of Pneumology, University Hospital Freiburg, Germany Correspondence to: Michael Dreher, M.D., Department of Pneumology, University Hospital Freiburg, Killianstrasse 5, D - 79106 Freiburg. Tel.: +49 761 270-3706; Fax.: +49 761 270-3704; e-mail: michael.dreher@uniklinik-freiburg.de Received: 2009.02.03; Accepted: 2009.02.26; Published: 2009.02.27 Abstract Background: The objective of the present analysis is to describe the outcomes of high-intensity non-invasive positive pressure ventilation (NPPV) aimed at maximally de-creasing PaCO2 as an alternative to conventional NPPV with lower ventilator settings in stable hypercapnic COPD patients. Methods: Physiological parameters, exacerbation rates and long-term survival were as-sessed in 73 COPD patients (mean FEV1 30±12 %predicted) who were established on high-intensity NPPV due to chronic hypercapnic respiratory failure between March 1997 and May 2006. Results: Controlled NPPV with breathing frequencies of 21±3 breath/min and mean inspi-ratory/expiratory positive airway pressures of 28±5/5±1 cmH2O led to significant im-provements in blood gases, lung function and hematocrit after two months. Only sixteen patients (22%) required hospitalisation due to exacerbation during the first year, with anaemia increasing the risk for exacerbation. Two- and five-year survival rates of all patients were 82% and 58%, respectively. The five year survival rate was 32% and 83% in patients with low (≤39%) and high (≥55%) hematocrit, respectively. Conclusion: High-intensity NPPV improves blood gases, lung function and hematocrit, and is also associated with low exacerbation rates and a favourable long-term outcome. The current report strongly emphasises the need for randomised controlled trials evaluating the role of high-intensity NPPV in stable hypercapnic COPD patients. Key words: COPD, exacerbation, hematocrit, non-invasive ventilation, survival Introduction The effectiveness of non-invasive positive pres-sure ventilation (NPPV) as a treatment for chronic hypercapnic respiratory failure (HRF) arising from COPD [1] remains debatable. Although long-term NPPV is currently used in the treatment of COPD patients in Europe [2], clinical outcomes such as sur-vival, exacerbation and hospitalization rates have not been clearly established in favor of NPPV [3, 4, 5]. However, most studies have used low levels of in-spiratory support with inspiratory positive airway pressures (IPAP) ranging from 12 to 18cmH2O. These settings have not been shown to significantly improve physiological parameters, particularly elevated PaCO2 levels [3, 4, 6]. In contrast, we have recently shown that NPPV is well tolerated and leads to a substantial improvement in blood gases and alveolar ventilation during spontaneous breathing when ven-tilator settings are markedly increased [7, 8, 9, 10]. Since this approach uses more intense ventilator set-tings, we have labeled this form of treatment Int. J. Med. Sci. 2009, 6 http://www.medsci.org 73“high-intensity NPPV”. The aim of the present report is to describe the physiological and blood gas parameters, hospital admissions and mortality in patients with NASAL INTERMITTENT POSITIVE PRESSURE VENTILATION FOR PRETERM NEONATES AFTER EXTUBATION Neonatal Department Background • Preterm infants experience difficulty with spontaneous breathing • NCPAP have shown to be useful method of respiratory support after extubation 25% failed and require endotracheal reintubation with its risks and expense • NIPPV is a method of augmenting NCPAP by delivering ventilator breaths via nasal prongs Background • IPPV provided by a ventilator or a bilevel device and administered via the nasal route either by short nasal prongs or nasopharyngeal tubes • NIPPV may be synchronised with the infant’s inspiration or delivered independently of the infant’s breathing efforts Background Objective To determine the effect of NIPPV compared with NCPAP in preterm infants having their endotracheal tube removed To compare the rates of gastric distension, gastrointestinal perforation, NEC, CLD and mortality between NIPPV and NCPAP NIPPV versus NCPAP to prevent extubation failure? Preventing extubation failure • trials (N=1316 infants) • NIPPV delivery was synchronised in five trials, one trial used non-synchronised, and another trial used mixed method Preventing extubation failure • Five of the eight trials showed a statistically significant benefit for infants extubated to NIPPV in terms of respiratory failure, 48 hours to seven days post-extubation (typical RR 0.71, 95% CI 0.61 to 0.82; typical RD -0.12, 95% CI -0.17 to -0.07) Preventing extubation failure • Both trials used short binasal prongs and binasopharyngeal prongs were effective • The non-synchronised studies and the one using both methods showed no benefit of NIPPV at preventing extubation failure while the other five studies did • Five of the six trials using a ventilator to generate NIPPV showed a benefit of NIPPV in preventing respiratory failure post-extubation while the two trials that used bilevel or both ventilator and bilevel did not Pulmonary outcomes and mortality • Infants randomised to NIPPV did not have significantly lower rates of CLD compared with infants randomised to NCPAP (typical RR 0.97, 95% CI 0.83 to 1.14; typical RD-0.01, 95%CI 0.07 to 0.05) • The meta-analysis of four trials revealed no difference in mortality between treatment groups (typical RR 0.84, 95% CI 0.56 to1.24) Gastrointestinal complications Outcome No of studies No of participants Statistical method Effect size Abdominal distension leading to cessation of feeds 136 Risk ratio (M-H, fixed, 95% CI) 1.76 [0.77, 4.05] Gastrointestinal perforation 1066 Risk ratio (M-H, fixed, 95% CI) 0.94 [0.60, 1.48] NEC 1147 Risk ratio (M-H, fixed, 95% CI) 0.88 [0.64,1.20] Conclusion • Meta-analysis demonstrated a statistically and clinical significant reduction in the risk of meeting extubation failure criteria and needing reintubation • There was no significant reduction in the rates of chronic lung disease, death or difference in the incidence of NEC Thank you REVIEW Open Access Noninvasive positive pressure ventilation for acute respiratory failure in children: a concise review Abolfazl Najaf-Zadeh 1,2 and Francis Leclerc 1,3* Abstract Noninvasive positive pressure ventilation (NPPV) refers to the delivery of mechanical respiratory support without the use of endotracheal intubation (ETI). The present review focused on the effectiveness of NPPV in children > 1 month of age with acute respiratory failure (ARF) due to different conditions. ARF is the most common cause of cardiac arrest in children. Therefore, prompt recognition and treatment of pediatric patients with pending respiratory failure can be lifesaving. Mechanical respiratory support is a critical intervention in many cases of ARF. In recent years, NPPV has been proposed as a valuable alternative to invasive mechanical ventilation (IMV) in this acute setting. Recent physiological studies have demonstrated benefici al effects of NPPV in children with ARF. Several pediatric clinical studies, the majority of which were noncontrolled or case series and of small size, have suggested the effectiveness of NPPV in the treatment of ARF due to acute airway (upper or lower) obstruction or certain primary parenchymal lung disease, and in specific circumstances, such as postoperative or postextubation ARF, immunocompromised patients with ARF, or as a means to facilitate extubation. NPPV was well tolerated with rare major complications and was associated with improved gas exchange, decreased work of breathing, and ETI avoidance in 22-100% of patients. High FiO 2 needs or high PaCO 2 level on admission or within the first hours after starting NPPV appeared to be the best independent predictive factors for the NPPV failur e in children with ARF. However, many important issues, such as the identification of the patient, the right time for NPPV application, and the appropriate setting, are still lacking. Further randomized, controlled trials that address these issues in children with ARF are recommended. Introduction Breathing dif ficultie s are common symptoms in children and common reason for v isits to the emergency depart- ment [1]. In United Kingdo m, respiratory illnesses (both acut e and chronic) accounted for 20% of weekly general practitioner consultations, 15% of hospital admissions, and 8% of deaths in childhood in 2001 [2]. Although the great majority of cases are benign and self-limited, requiring no intervention, some patients will require a higher level of respiratory support. Invasive mechanical ventilation (IMV) is a critical intervention in many cases of acute respiratory failure (ARF), but there are definite risks associated w ith endotracheal intubation (ETI) [3]. By providing respiratory support without ETI, non- invasive positive pressure ventilation (NPPV) may be, in appropriately selected patients, an extremely valuable alternative to IMV. It i s generally much safer than IMV and has been shown to decrease resource utilization and to avoid the myriad of complications associated with ETI, including upper airway trauma, laryngeal swelling, postextubation vocal cord dysfunction, and nosocomial infections [3]. NPPV usually refers to continuous posi- tive airway pressure (CPAP) or bilevel respiratory su p- port, including expiratory positive airway pressure (EPAP) and inspiratory positive airway pressure (IPAP), i.e., biphasic positive airway pressure (BIPAP) and bile- vel positive airway pressure (BiPAP), delivered through 400 COPD = chronic obstructive pulmonary disease; ICU = intensive care unit; NPPV = noninvasive positive pressure ventilation. Critical Care December 2003 Vol 7 No 6 Hill In a recent issue of the British Medical Journal, Lightowler and coworkers [1] presented a meta-analysis of seven randomized controlled trials of noninvasive positive pressure ventilation (NPPV) to treat acute respiratory failure caused by chronic obstructive pulmonary disease (COPD) exacerbations as compared with ‘usual care’. Their analysis showed substantial and statistically significant reductions in mortality (relative risk 0.41), intubation (relative risk 0.42) and complications (relative risk 0.32). In addition, respiratory rate, pH, and arterial carbon dioxide tension improved significantly more after the first hour of treatment, and the duration of hospital stay was approximately 3 days shorter among NPPV- treated patients. The authors concluded that ‘NPPV should be considered early’ to treat respiratory failure due to COPD exacerbations. In an accompanying editorial, Babu and Chauhan [2] advocated the ‘timely use of non-invasive ventilation in more severe exacerbations’. The question is at what point does the weight of evidence become sufficient to establish a new standard of care, replacing ‘usual’ care as applied in the control groups of the randomized trials? My opinion is that we now have enough evidence to establish a new standard. The analysis by Lightowler and coworkers did not include several studies that provide further supportive evidence [3,4], and other meta-analyses have drawn similar conclusions [5]. Furthermore, consensus groups of experts advocate the routine use of NPPV for selected patients with COPD exacerbations [6,7]. The question must be asked in arguing this position – are there weaknesses in the evidence base? Lightowler and coworkers acknowledged that meta-analyses are subject to publication bias – that favorable trials are more likely to be published than are unfavorable ones. In addition, all NPPV trials in the acute setting are limited by the problem that complete blinding is virtually impossible. Even if a sham control group were included, which was not the case in any of the trials, it is quite easy for investigators and patients to tell which group they are in. Nonetheless, the consistency of the favorable findings among multiple studies reduces but does not eliminate concern about these kinds of biases. Commentary Noninvasive positive pressure ventilation for respiratory failure caused by exacerbations of chronic obstructive pulmonary disease: a standard of care? Nicholas S Hill Pulmonary, Critical Care and Sleep Division, TUFTS – New England Medical Center, Boston, MA, USA Correspondence: Nicholas S Hill, nhill@tufts-nemc.org Published online: 30 May 2003 Critical Care 2003, 7:400-401 (DOI 10.1186/cc2335) This article is online at http://ccforum.com/content/7/6/400 © 2003 BioMed Central Ltd (Print ISSN 1364-8535; Online ISSN 1466-609X) Abstract This editorial comments on a meta-analysis of the use of noninvasive positive pressure ventilation to treat patients with acute respiratory failure caused by chronic obstructive pulmonary disease (COPD) exacerbations published in the British Medical Journal earlier this year. Based on its analysis of seven randomized controlled trials that met pre-specified criteria, the meta-analysis demonstrated highly significant benefits of noninvasive positive pressure ventilation in COPD patients, including a reduction in a combined end-point consisting of death and endotracheal intubation. The editorial argues that, based on the strength of this and other evidence, noninvasive positive pressure ventilation to treat selected patients with acute respiratory failure due to COPD exacerbations should now be considered a standard of care. Keywords acute respiratory failure, chronic obstructive pulmonary disease, COPD exacerbation, mechanical ventilation, noninvasive ventilation 401 Available ORIGINAL RESEARCH Open AccessEmergency intraosseous access in a helicopteremergency medical service: a retrospective studyGeir A Sunde1,2*, Bård E Heradstveit1,2, Bjarne H Vikenes1,2, Jon K Heltne1,2,3AbstractBackground: Intraosseous access (IO) is a method for providing vascular access in out-of-hospital resuscitation ofcritically ill and injured patients when traditional intravenous access is difficult or impossible. Different intraosseoustechniques have been used by our Helicopter Emergency Medical Services (HEMS) since 2003. Few articlesdocument IO use by HEMS physicians. The aim of this study was to evaluate the use of intraosseous access in pre-hospital emergency situations handled by our HEMS.Methods: We reviewed all medical records from the period May 2003 to April 2010, and compared three differenttechniques: Bone Injection Gun (B.I.G® - Waismed), manual bone marrow aspiration needle (Inter V - Medical DeviceTechnologies) and EZ-IO® (Vidacare), used on both adults and paediatric patients.Results: During this seven-year period, 78 insertion attempts were made on 70 patients. Overall success rates were50% using the manual needle, 55% using the Bone Injection Gun, and 96% using the EZ-IO®. Rates of success onfirst attempt were significantly higher using the EZ-IO® compared to the manual needle/Bone Injection Gun (p <0.01/p < 0.001). Fifteen failures were due to insertion-related problems (19.2%), with four technical problems (5.1%)and three extravasations (3.8%) being the most frequent causes. Intraosseous access was primarily used inconnection with 53 patients in cardiac arrest (75.7%), including traumatic arrest, drowning and SIDS. Otherdiagnoses were seven patients with multi-trauma (10.0%), five with seizures/epilepsy (7.1%), three with respiratoryfailure (4.3%) and two others (2.9%). Nearly one third of all insertions (n = 22) were made in patients younger thantwo years. No cases of osteomyelitis or other serious complications were documented on the follow-up.Conclusions: Newer intraosseous techniques may enable faster and more reliable vascular access, and this canlower the threshold for intraosseous access on both adult and paediatric patients in critical situations. We believethat all emergency services that handle critically ill or injured paediatric and adult patients should be familiar withintraosseous techniques.BackgroundVascular access is important in the resuscitation of criti-cally ill or injured adult and paediatric patients [1,2]. Itcan be challenging to obtain vascular access, especiallyin the resuscitation of small children in emergencysituations [3-5]. The European Resuscitation Council2005 guidelines [6] and International Liaison Committeeon Resuscitation guidelines [4] recommend intraosseousaccess during resuscitation if intravenous access provesto be difficult or impossible. Despite these recommenda-tions, intraosseous techniques appear to be rarely used[7]. While numerous reports have been published aboutthe use of different intraosseous devices in emergencypatients, they are primarily from paramedic-basedambulance services [2,8]. Few comparisons have beenpublished of different IO techniques used by physiciansin emergency departments [7] or in HEMS servicesmanned by physicians/nurses [9,10].Typical HEMS operating conditions make specialdemands on medical equipment such as IO devices.Rain, cold, darkness and non-sterile conditions meanthat such equipment must be durable and simple to usein all conditions. User friendliness is important for res-cuers, both on-scene and in-flight [10].Intravenous access is traditionally regarded as theoptimal route for medication and fluids, and the* Oral Ondansetron for Gastroenteritis in a Pediatric Emergency Department Background BỘ GIÁO DỤC VÀ ĐÀO TẠO TRƯỜNG ĐẠI HỌC DÂN LẬP HẢI PHÒNG ------------------------------- ISO 9001 : 2008 KHÓA LUẬN TỐT NGHIỆP NGÀNH: NGOẠI NGỮ HẢI PHÒNG - 2010 2 HAIPHONG PRIVATE UNIVESITY FOREIGN LANGUAGES DEPARTMENT ----------------------------------- GRADUATION PAPER A STUDY ON TRANSLATION OF ENGLISH - RELATED TERMS IN FINANCE AND BANKING INTO VIETNAMESE By: BUI THI THOM Class: NA 1004 Supervisor: DAO THI LAN HUONG, M.A HAI PHONG - 2010 3 BỘ GIÁO DỤC VÀ ĐÀO TẠO TRƯỜNG ĐẠI HỌC DÂN LẬP HẢI PHÒNG -------------------------------------- Nhiệm vụ đề tài tốt nghiệp Sinh viên: .Mã Số: Lớp: Ngành: Tên đề tài: . . 4 Nhiệm vụ đề tài 1. Nội dung và các yêu cầu cần giải quyết trong nhiệm vụ đề tài tốt nghiệp ( về lý luận, thực tiễn, các số liệu cần tính toán và các bản vẽ). …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… 2. Các số liệu cần thiết để thiết kế, tính toán. …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… Update on mangement of patent ductus arteriosus in preterm infants Dr Trinh Thi Thu Ha Outline Overview of PDA Timing of screening PDA? When to treat PDA? Timing of ductal closure Prenatal MgSO4, tocolytic Postnatal surfactant Early, severe pulmonary hemorrhage is associated with ductal patency at 12 to 18 hours of age, but later pulmonary hemorrhage (after the first week) is not related to persistent ductal patency (Workbook in Practical Neonatology 5th Edition 2015) Diagnosis: In most cases, the clinically silent PDA during the first few days goes undetected unless an echocardiogram is performed Signs of bounding pulses, active precordium, and systolic murmur were of reasonable specificity but very low sensitivity in the first to days of birth for diagnosis of an echocardiographically defined significant PDA Relying on clinical signs alone led to a mean diagnostic delay of days (A blinded comparison of clinical and echocardiographic evaluation of the preterm infant for patent ductus arteriosus.Skelton R1, Evans N, Smythe J JPaediatr Child Health 1994 Oct;30(5):406-11) Ibuprofen Prophylaxis No significant differences in mortality, IVH, or BPD No reduction in IVH, PAL in the treated group Increased risk of gastrointestinal bleeding Prophylactic ibuprofen exposes many infants to renal and gastrointestinal side effects without any important short-term benefits and is not recommended Pre-symptomatic Pharmacologic Treatment No effect on the rate of mortality, BPD, IVH, ROP, or length of ventilation, death, IVH, NEC,… More renal side effect Presymptomatic indomethacin or ibuprofen therapy for PDA in preterm infants is not recommended Conservative Management Fluid restriction Diuretics, avoidance of loop diuretics Maintaining a hematocrit of 35 to 40 percent Increased positive airway pressure Correction of alkalosis Avoidance of pulmonary vasodilators: oxygen or NO Asymptomatic infants with PDAs generally not require medical management or surgical ligation These infants should be monitored for evidence of CHF, failure or renal ... hours to seven days post -extubation (typical RR 0.71, 95% CI 0.61 to 0. 82; typical RD -0 . 12, 95% CI -0 .17 to -0 .07) Preventing extubation failure • Both trials used short binasal prongs and binasopharyngeal... ratio (M-H, fixed, 95% CI) 1.76 [0.77, 4.05] Gastrointestinal perforation 1066 Risk ratio (M-H, fixed, 95% CI) 0.94 [0.60, 1.48] NEC 1147 Risk ratio (M-H, fixed, 95% CI) 0.88 [0.64,1 .20 ] Conclusion... Background • Preterm infants experience difficulty with spontaneous breathing • NCPAP have shown to be useful method of respiratory support after extubation 25 % failed and require endotracheal