During the new coronavirus disease 2019 (COVID-19) pandemic, there has been controversy over whether emergency surgical management should be performed or not in the patients with COVID-19. Stanford type A aortic dissection is a very urgent life-threatening disease, and guidelines recommend surgical treatment for patients with type A aortic dissection in the first instance. However, intraoperative extracorporeal circulation can be fatal to patients recovering from COVID-19. During the pandemic, extracorporeal membrane oxygenation (ECMO) has played an important role in supporting COVID-19 patients with acute respiratory failure. This article reports a successful V-V ECMO treatment for a Stanford type A aortic dissection patient, who suffered respiratory failure caused by COVID-19 after emergency surgery.
ObjectiveTo explore the risk factors for postoperative respiratory failure (RF) in patients with esophageal cancer, construct a predictive model based on the least absolute shrinkage and selection operator (LASSO)-logistic regression, and visualize the constructed model. MethodsA retrospective analysis was conducted on patients with esophageal cancer who underwent surgical treatment in the Department of Thoracic Surgery, Sun Yat-sen University Cancer Center Gansu Hospital from 2020 to 2023. Patients were divided into a RF group and a non-RF (NRF) group according to whether RF occurred after surgery. Clinical data of the two groups were collected, and LASSO-logistic regression was used to optimize feature selection and construct the predictive model. The model was internally validated by repeated sampling 1000 times based on the Bootstrap method. ResultsA total of 217 patients were included, among which 24 were in the RF group, including 22 males and 2 females, with an average age of (63.33±9.10) years; 193 were in the NRF group, including 161 males and 32 females, with an average age of (62.14±8.44) years. LASSO-logistic regression analysis showed that the percentage of forced expiratory volume in one second/forced vital capacity (FEV1/FVC) to predicted value (FEV1/FVC%pred) [OR=0.944, 95%CI (0.897, 0.993), P=0.026], postoperative anastomotic fistula [OR=4.106, 95%CI (1.457, 11.575), P=0.008], and postoperative lung infection [OR=3.776, 95%CI (1.373, 10.388), P=0.010] were risk factors for postoperative RF in patients with esophageal cancer. Based on the above risk factors, a predictive model was constructed, with an area under the receiver operating characteristic curve of 0.819 [95%CI (0.737, 0.901)]. The Hosmer-Lemeshow test for the calibration curve showed that the model had good goodness of fit (P=0.527). The decision curve showed that the model had good clinical net benefit when the threshold probability was between 5% and 50%. Conclusion FEV1/FVC%pred, postoperative anastomotic fistula, and postoperative lung infection are risk factors for postoperative RF in patients with esophageal cancer. The predictive model constructed based on LASSO-logistic regression analysis is expected to help medical staff screen high-risk patients for early individualized intervention.
ObjectiveTo observe the clinical efficacy of invasive-noninvasive sequential mechanical ventilation in the treatment of chronic obstructive pulmonary disease (COPD) complicated by type Ⅱ respiratory failure. MethodsA total of 100 patients with COPD complicated with type Ⅱ respiratory failure from March 2013 to April 2014 were randomly divided into control group and study group (with 50 patients in each). While the control group was given continuous invasive ventilation treatment, the study group was treated with invasive-noninvasive sequential ventilation. The ventilation time, Intensive Care Unit (ICU) monitoring and hospitalization time, the serum concentrations of C-reactioin protein (CRP) before and after treatment and the ventilator associated pneumonia (VAP) and hospital mortality rate were observed and compared between the two groups. ResultsFor patients in the study group, ICU monitoring time, ventilation time and hospitalization time were (9.4±8.1), (10.3±5.8), and (14.7±8.2) days, respectively, significantly shorter than those in the control group[(17.5±10.8), (15.2±7.7), and (22.8±7.4) days] (P<0.05). The incidence of VAP and nosocomial VAP mortality in the study group were 4.0% and 2.0% respectively, which were significantly lower than those in the control group (22.0% and 20.0%), and the differences were statistically significant (P<0.05). ConclusionIn the clinical treatment of COPD patients with type Ⅱ respiratory failure, invasive-noninvasive sequential ventilation treatment is effective in shortening the duration of ventilation and hospitalization time, controlling the incidence of VAP, and reducing the mortality rate, which is worthy of clinical popularization.
Objective To analyze the risk factors of treatment failure by noninvasive positive pressure ventilation (NPPV) in patients with acute respiratory failure (ARF) due to acute exacerbation of chronic obstructive pulmonary disease (AECOPD), and explore the best time that NPPV be replaced by invasive ventilation when NPPV failure occurs. Methods The data of patients with ARF due to AECOPD who were treated with NPPV from January 2013 to December 2015 were retrospectively collected. The patients were divided into two groups: the NPPV success group and the NPPV failure group (individuals who required endotracheal intubation or tracheotomy at any time). The Acute Physiology and Chronic Health Evaluation (APACHE) Ⅱ score was analyzed; the Glasgow Coma Scale score, respiratory rate (RR), pH value, partial pressure of oxygen (PaO2), PaO2/fraction of inspired oxygen (FiO2) ratio, and partial pressure of carbon dioxide were also analyzed at admission, after 2 hours of NPPV, and after 24 hours of NPPV. Results A total of 185 patients with ARF due to AECOPD were included. NPPV failed in 35.1% of the patients (65/185). Multivariate analysis identified the following factors to be independently associated with NPPV failure: APACHEⅡscore≥30 [odds ratio (OR)=20.603, 95% confidence interval (CI) (5.309, 80.525), P<0.001], RR at admission≥35 per minute [OR=3.723, 95%CI (1.197, 11.037), P=0.020], pH value after 2 hours of NPPV<7.25 [OR=2.517, 95%CI (0.905, 7.028), P=0.070], PaO2 after 2 hours of NPPV<60 mm Hg (1 mm Hg=0.133 kPa) [OR=3.915, 95%CI (1.374, 11.508), P=0.010], and PaO2/FiO2 after 2 hours of NPPV<200 mm Hg [OR=4.024, 95%CI (1.542, 11.004), P=0.010]. Conclusion When patients with ARF due to AECOPD have a higher severity score, have a rapid RR at admission, or fail to improve in terms of pH and oxygenation after 2 hours of NPPV, the risk of NPPV failure is higher.
Abstract： Objective To analyze risk factors associated with postoperative respiratory failure in patients with valvular surgery. Methods Between January 2001 and November 2010, clinical data of 618 patients with 339 males and 279 fameles at age of 10-74（44.01±13.95）years,undergoing valvular operations were investigated retrospectively. We divided the patients into two groups according to the presence （74 patients）or absence（544 patients）of postoperative respiratory failure. Its risk factors were evaluated by univariate and multivariate logistic regression analysis. Results The hospital mortality rate of valvular surgery was 6.1%（38/618）.The morbidity rate of respiratory failure was 12.0%（74/618） with hospital mortality rate at 17.6%（13/74） which was significantly higher than those patients without postoperative respiratory failure at 4.6%（25/544, χ2=18.994, P=0.000）. Univariate analysis showed age＞ 65 years（P=0.005）, New York Heart Association（NYHA）classⅣ（P=0.014）, election fraction＜ 50.0%（P=0.003）, cardiopulmonary bypass time＞ 3 h（P=0.001）, aortic cross clamping time＞ 2 h（P=0.008）, concomitant operation（ valvular operation with coronary artery bypass grafting, Bentall or radiofrequency ablation maze operation（P=0.000）, reoperation（P=0.012）, postoperative complications （P=0.000）, and blood transfusion＞ 2 000 ml（P=0.000） were important risk factors for postoperative respiratory failure. Multivariate logistic regression showed that concomitant operation（P=0.003）, reoperation（P=0.010）, postoperative complications（P=0.000）, and blood transfusion＞2 000 ml（P=0.012）were significant independent predictive risk factors. Conclusion This study suggest that patients with predictive risk factors of postoperative respiratory failure need more carefully treated. The morbidity of these patients would be reduced through improving perioperative management, shortening cardiopulmonary bypass time and reducing postoperative complications.
ObjectiveTo systematically evaluate the effect of high-flow nasal cannula in immunocompromised patients with acute respiratory failure.MethodsRandomized controlled trials (RCT) or cohort studies on the efficacy of high-flow oxygen therapy in immunocompromised patients with acute respiratory failure were reviewed by computer in PubMed, EMBASE, Cochrane Library, and China Knowledge Network, Wanfang and VIP databases. The group used HFNC and the control group used a mask or a nasal catheter to give oxygen-based conventional oxygen therapy (COT) or noninvasive ventilation (NIV). Two investigators conducted quality assessments and data extractions based on the Cochrane Collaboration Risk Assessment Manual and the Newcastle-Ottawa Scale. Meta analysis was performed using RevMan 5.3 software. The main outcome measures included tracheal intubation rate, and intensive care unit (ICU) mortality. The secondary outcomes included ICU hospitalization time.ResultsThe study included 13 articles (4 RCTs, 9 cohort studies), a total of 1133 subjects, with 583 in the HFNC group and 550 in the control group (280 in the COT and 270 in the NIV). Meta-analysis showed that HFNC was significantly different from COT in reducing tracheal intubation rate in immunocompromised patients with respiratory failure (OR=0.49, 95%CI 0.33 - 0.72, P=0.0003), but no statistical significance compared with NIV (OR=0.73, 95%CI 0.52 - 1.02, P=0.07); two-combination analysis showed that HFNC had a significant advantage in reducing tracheal intubation rate compared with COT/NIV (combined OR=0.61, 95%CI 0.47 - 0.79, P=0.0002). In terms of ICU mortality, there was a statistically significant difference between HFNC and COT (OR=0.59, 95%CI 0.35 - 1.01, P=0.05) or NIV (OR=0.63, 95%CI 0.44 - 0.91, P=0.01). The results of the two subcombinations and analysis did not change (combined OR=0.62, 95%CI 0.46 - 0.83, P=0.002). In terms of ICU hospital stay, there was no statistically significant difference between HFNC and COT (MD=−4.52, 95%CI −9.43 - 0.39, P=0.07), but the difference was statistically significant compared with NIV (MD=−1.46, 95%CI −2.41 - −0.51, P =0.003); the two sub-combinations and analysis results showed significant difference (combined MD=−3.41, 95%CI −6.16 - −0.66, P=0.01). According to different research types, after subgroup analysis, the analysis results were not different from the combined results. Sensitivity analysis revealed that HFNC could significantly reduce the patient's ICU hospital stay compared with the control group oxygen therapy. The results of the funnel chart analysis show that there were publication offsets in the studies on tracheal intubation rate and ICU mortality included in the literature; studies on ICU hospital stays had a smaller publication offset.ConclusionsCompared with COT, HFNC can reduce the tracheal intubation rate of patients, but there is no significant difference compared with NIV; HFNC can reduce the ICU mortality of patients compared with COT/NIV. However, due to the high heterogeneity between the studies, whether HFNC can reduce ICU hospital stay remains to be further explored.
As an extracorporeal life support technology, veno-venous extracorporeal membrane oxygenation (VV-ECMO) has been demonstrated its role in the treatment of patients with severe respiratory failure. Its main advantages include the ability to maintain adequate oxygenation and remove excess CO2, increase oxygen delivery, improve tissue perfusion and metabolism, and implement lung protection strategies. Clinicians should accurately assess and identify the patient's condition, timely and accurately carry out VV-ECMO operation and management. This article will review the patient selection, cannulation strategy, anticoagulation, clinical management and weaning involved in the application of VV-ECMO.
ObjectiveTo evaluate the safety and efficacy of non-invasive positive pressure ventilation (NIPPV) combined with fiberoptic bronchoscopy(FB) on acute exacerbation of chronic obstructive puhmonary disease (AECOPD) patients with acute respiratory failure. MethodsA prospective study was conducted on the AECOPD patients with respiratory failure in respiratory intensive care unit of Tangdu Hospital of Fourth Military Medicine University from February 2010 to February 2011.They were randomly divided into a case group and a control group.The case group was administrated FB and lavage after one hour of NIPPV treatment.The control group was administrated NIPPV without FB and lavage.Other treatment regimen was the same in two groups. ResultsThere were 51 subjects recruited in the study, 25 subjects in the case group and 26 subjects in the control group.All variables at baseline were matched (P > 0.05).All variables improved after one hour of NIPPV before FB, without significant difference between two groups (P > 0.05).During the period of FB, heart rate in the case group was faster than that in the control group (P < 0.05), and other variables were not significantly different between two groups (P > 0.05).Both groups received NIPPV for one hour after FB, the variables including heart rate, respiratory rate, pH, PaO2, PaCO2 were statistically significant between two groups(P < 0.05).At the time of 24 hours after FB, the variables including mean arterial pressure, heart rate, respiratory rate, pH, PaO2 and PaCO2 in the case group were nearly recovered, and differences between two groups were significant (P < 0.05).The positive rate of sputum culture was significantly higher in the case group than that in the control group[88.0%(22/25) vs.58.6%(14/26)].Success rate in the case group were obviously superior to that in control group.The cases of failure, death and refusing in the case group were lower than those in the control group.Complications in two groups had no significant difference (P > 0.05).There was not serious complication such as hear arrest, hemoptysis and apnea during the process of NIPPV combined with early FB. Conclusion It deserves to be used in clinic because of the safety, efficacy and feasible for most of AECOPD patients through NIPPV combined with early FB.
Objective To investigate the efficacy and prognostic risk factors of high flow nasal cannula (HFNC) in elderly patients with respiratory failure. Methods Clinical data of 172 elderly patients with respiratory failure admitted to 363 Hospital from April 2020 to August 2022 were retrospectively collected. The patients were divided into an observation group (n=86) and a control group (n=86) according to treatment method. The observation group (54 males, 32 females), mean 68.67±2.36 years old, received HFNC oxygen therapy. The control group (52 males, 34 females), mean 68.12±2.14 years old, received conventional oxygen therapy. According to the prognosis after HFNC treatment, the observation group was subdivided into a poor prognosis group (n=21) and a good prognosis group (n=65). The clinical effects of different treatment methods in the two groups were analyzed, and the risk factors affecting prognosis of elderly patients with respiratory failure treated by HFNC were analyzed by multivariate logistic regression. A line graph model was constructed, and the model was verified by receiver operator characteristic curve and cumulative gain graph. Results Repeated measures ANOVA was conducted on the oxygen therapy indicators of the two groups of patients. The results showed that pH, PaO2, PaCO2, and respiratory rate all have statistical significance in terms of time effect (F=423.25, P<0.001; F=326.25, P<0.001; F=128.79, P<0.001; F=323.16, P<0.001), inter-group effect (F=128.79, P<0.001; F=205.46, P<0.001; F=310.52, P<0.001; F=123.15, P<0.001), and interactive effect (F=111.06, P<0.001; F=198.76, P<0.001; F=134.28, P<0.001; F=112.47, P<0.001). This indicated that the impact of time on pH, PaO2, PaCO2, and respiratory rate differs depending on the treatment method. The scores of acute physiology and chronic health evaluation Ⅱ (APACHEⅡ), the level of brain natriuretic peptide (BNP), the heart rate before treatment, the posterior root of tongue fall, the initial HFNC flow and the duration of HFNC in the poor prognosis group were significantly higher than those in the good prognosis group. Initial PaO2/FiO2 was significantly lower than that in the good prognosis group (P<0.05). Multiple factor analysis showed that APACHEⅡ score>17 points, BNP level>150 ng/L before treatment, heart rate >105 times/min before treatment, posterior root of tongue drop, initial HFNC flow>55 L/min, initial PaO2/FiO2<150 mmHg were independent influencing factors for poor prognosis of elderly patients with respiratory failure treated by HFNC. The histogram model showed that the total score of the above 6 indicators is 284, corresponding to a probability of poor prognosis of 71.6%, which proved that the prediction ability of this model is good. Conclusions The application of HFNC in elderly patients with respiratory failure has a significant effect. APACHEⅡ score, BNP level before treatment, heart rate before treatment, posterior root of tongue fall, initial HFNC flow, initial PaO2/FiO2 are all risk factors affecting the prognosis, which should be paid attention to in clinic to improve the therapeutic effect.
ObjectiveTo explore the value of three brief scales (BAP-65 class, DECAF score, and CAPS) on assessing the severity of acute exacerbation in patients with chronic obstructive pulmonary disease(COPD) complicated by hypercapnic respiratory failure. MethodsTwo hundred and forty-four cases with acute exacerbation of COPD complicated by hypercapnic respiratory failure, admitted in West China Hospital from August 2012 to December 2013, were analyzed retrospectively.The scores of each scale were calculated.The areas under the receiver operating characteristic curves (AUROC) of each scale for hospital mortality, mechanical ventilation use, mortality of patients requiring mechanical ventilation, invasive mechanical use were analyzed and compared. ResultsThe AUROCs of BAP-65 class, DECAF score and CAPS for hospital mortality were 0.731, 0.765, and 0.711; for mechanical ventilation were 0.638, 0.702, and 0.617; for mortality of patients requiring mechanical ventilation were 0.672, 0.707, and 0.677; for invasive mechanical ventilation use were 0.745, 0.732, and 0.627(BAP-65 vs.CAPS, P < 0.05).Mortality and mechanical ventilation use increased as the three scales escalated.In the patients whose BAP-65 or DECAF score were more than 4 points, the hospital mortality was nearly 50%, and about 95% of the patients underwent mechanical ventilation. ConclusionsThe BAP-65 class, DECAF score, and CAPS of patients on admission have predictive values on assessing the severity of acute exacerbation in patients with COPD complicated by hypercapnic respiratory failure, especially the simple and practical BAP-65 class and DECAF score.