BACKGROUND: For patients with sepsis receiving non-invasive ventilation (NIV), early rehabilitation is crucial. The Sitting Baduanjin (SBE) is an efficient early rehabilitation exercise suitable for bed patients. There is no consensus about the effect of SBE on the early rehabilitation of septic patients with NIV. This study focused on how the SBE affected the early rehabilitation of sepsis patients with NIV.
METHODS: 96 sepsis patients with NIV were randomly assigned to either an Baduanjin group that received the SBE based on the routine rehabilitation exercise (n = 48) or a control group (n = 48) that received routine rehabilitation exercise. The primary outcome was the Medical Research Council(MRC)score, and the Barthel Index score, the duration of NIV, length of ICU stay, length of total stay, hospitalization expense as secondary outcomes.
RESULTS: A total of 245 sepsis patients were screened, with 96 randomly assigned. The study was completed by 90 patients out of the 96 participants.Results revealed that the MRC score increased in both groups, but the improvement of muscle strength in Baduanjin group was more obvious, with statistical significance (p < 0.001).There was statistically significantly difference between the two groups in Barthel Index at the day of transfer out of ICU(P = 0.028).The patients in the Baduanjin group had an average reduction of 24.09 h in the duration of NIV and 3.35 days in total length of hospital stay compared with the control group (p < 0.05).Of note, the Baduanjin group had significantly reduction the total hospitalization expense. No serious adverse events occurred during the intervention period.
CONCLUSIONS: In patients with sepsis, the SBE appears to improve muscle strength and activities of daily living (ADL), and lowed the duration of NIV, the length of the total stay, and the hospitalization expense.
BACKGROUND: The study registered on the Chinese Clinical Trial Registry ( www.chictr.org.cn ), Clinical Trials identifier ChiCTR1800015011 (28/02/2018).

BACKGROUND: Use of high-flow nasal cannula (HFNC) and non-invasive ventilation (NIV) in the intensive care unit (ICU) is increasing, yet reporting of nutrition intake, muscle thickness, or recovery outcomes in this population is limited.
OBJECTIVE: The objective of this study was to quantify muscle thickness, nutrition intake, and functional recovery outcomes for patients receiving HFNC/NIV within the ICU.
METHODS: A single-centre, prospective, observational study in adult ICU patients recruited within 48 hrs of commencing HFNC/NIV. Change in quadriceps muscle layer thickness using ultrasound (primary outcome) and 24 hr nutrition intake from study inclusion to day 7 (D7), functional capacity (Barthel Index), and quality of life (EuroQol five-dimension five-level utility index) at D90 were assessed. Data are n (%), mean ± standard deviation or median [interquartile range], are compared using paired sample t-test, and a P value of <0.05 was considered significant.
RESULTS: Primary outcome data were available for n = 28/42: 64 ± 13 y, 61% male, body mass index: 29.1 ± 9.0 kg/m2, and Acute Physiology and Chronic Health Evaluation II score: 17 ± 5. Quadriceps muscle layer thickness reduced from 2.41 ± 0.87 to 2.12 ± 0.73 cm; mean difference: -0.29 cm (95% confidence interval: -0.44, -0.13). Nutrition intake increased from study inclusion to D7: 1735 ± 1283 to 5448 ± 2858 kJ and 17.4 ± 16.6 to 60.9 ± 36.8g protein. Barthel Index was 87 ± 20 at baseline and 91 ± 15 at D90 (out of 100). Quality of life was impaired at D90: 0.64 ± 0.23 (health = 1.0).
CONCLUSIONS: Critically ill patients receiving HFNC/NIV experienced muscle loss and impaired quality of life.

BACKGROUND: Although cumulative studies have demonstrated a beneficial effect of high-flow nasal cannula oxygen (HFNC) in acute hypercapnic respiratory failure, randomized trials to compare HFNC with non-invasive ventilation (NIV) as initial treatment in acute exacerbations of chronic obstructive pulmonary disease (AECOPD) patients with acute-moderate hypercapnic respiratory failure are limited. The aim of this randomized, open label, non-inferiority trial was to compare treatment failure rates between HFNC and NIV in such patients.
METHODS: Patients diagnosed with AECOPD with a baseline arterial blood gas pH between 7.25 and 7.35 and PaCO2 ≥ 50 mmHg admitted to two intensive care units (ICUs) at a large tertiary academic teaching hospital between March 2018 and December 2022 were randomly assigned to HFNC or NIV. The primary endpoint was the rate of treatment failure, defined as endotracheal intubation or a switch to the other study treatment modality. Secondary endpoints were rates of intubation or treatment change, blood gas values, vital signs at one, 12, and 48 h, 28-day mortality, as well as ICU and hospital lengths of stay.
RESULTS: 225 total patients (113 in the HFNC group and 112 in the NIV group) were included in the intention-to-treat analysis. The failure rate of the HFNC group was 25.7%, while the NIV group was 14.3%. The failure rate risk difference between the two groups was 11.38% (95% CI 0.25-21.20, P = 0.033), which was higher than the non-inferiority cut-off of 9%. In the per-protocol analysis, treatment failure occurred in 28 of 110 patients (25.5%) in the HFNC group and 15 of 109 patients (13.8%) in the NIV group (risk difference, 11.69%; 95% CI 0.48-22.60). The intubation rate in the HFNC group was higher than in the NIV group (14.2% vs 5.4%, P = 0.026). The treatment switch rate, ICU and hospital length of stay or 28-day mortality in the HFNC group were not statistically different from the NIV group (all P > 0.05).
CONCLUSIONS: HFNC was not shown to be non-inferior to NIV and resulted in a higher incidence of treatment failure than NIV when used as the initial respiratory support for AECOPD patients with acute-moderate hypercapnic respiratory failure.
BACKGROUND: chictr.org (ChiCTR1800014553). Registered 21 January 2018, http://www.chictr.org.cn.

Home non-invasive ventilation (NIV) is used to treat patients with chronic respiratory failure (CRF). However, knowledge on the prevalence and impact of multimorbid aetiology of CRF, patterns of NIV use, and survival of these patients is limited. Our aim was to analyse the multiple aetiologies of CRF, patterns of NIV use and the outcome of those patients. We conducted a retrospective analysis of 1,281 patients treated with home-NIV between 2004 and 2014 in Turku University Hospital, Finland. The patients were divided into nine disease categories: obstructive airways disease (16 %); obesity hypoventilation syndrome (11 %); neuromuscular disease (10 %); chest wall diseases (4 %); sleep apnoea (26 %); interstitial lung diseases (3 %); malignancy (2 %); other (3 %) and acute (8 %), which refers to the patients who did not fulfil criteria of CRF. In addition, multiple aetiologies of CRF were found in 17 %. Mean adherence to home-NIV was 6.0 ± 4.4 h/d and median treatment duration 410 (120-1021) days. Adherence, treatment duration or survival did not significantly differ between patients with either single or multiple causative diseases leading to CRF. Median survival was 4.5 years (95 % CI 3.6 to 5.4). The main reasons for discontinuing NIV were death (56 %) and lack of motivation (19 %). We conclude that home-NIV is used in a variety of diseases. CRF of multiple aetiologies is prevalent and not limited to chronic obstructive lung disease and obstructive sleep apnoea overlap syndrome. However, the adherence to home-NIV or survival did not differ between patients with a single or multiple diseases causing CRF, but the survival of the home-NIV patients differed according to the underlying aetiology of CRF.

OBJECTIVE: The use of high-flow nasal cannula (HFNC) oxygen therapy is gaining popularity for the treatment of acute respiratory failure (ARF). However, limited evidence exists regarding the effectiveness of HFNC for hypoxemic ARF in patients with blunt chest trauma (BCT).
METHODS: This retrospective analysis focused on BCT patients with mild-moderate hypoxemic ARF who were treated with either HFNC or non-invasive ventilation (NIV) in the emergency medicine department from January 2021 to December 2022. The primary endpoint was treatment failure, defined as either invasive ventilation, or a switch to the other study treatment (NIV for patients in the NFNC group, and vice-versa).
RESULTS: A total of 157 patients with BCT (72 in the HFNC group and 85 in the NIV group) were included in this study. The treatment failure rate in the HFNC group was 11.1% and 16.5% in the NIV group - risk difference of 5.36% (95% CI, -5.94-16.10%; P = 0.366). The most common cause of failure in the HFNC group was aggravation of respiratory distress. While in the NIV group, the most common reason for failure was treatment intolerance. Treatment intolerance in the HFNC group was significantly lower than that in the NIV group (1.4% vs 9.4%, 95% CI 0.40-16.18; P = 0.039). Univariate logistic regression analysis showed that chronic respiratory disease, abbreviated injury scale score (chest) (≥3), Acute Physiology and Chronic Health Evaluation II score (≥15), partial arterial oxygen tension /fraction of inspired oxygen (≤200) at 1 h of treatment and respiratory rate (≥32 /min) at 1 h of treatment were risk factors associated with HFNC failure.
CONCLUSIONS: In BCT patients with mild-moderate hypoxemic ARF, the usage of HFNC did not lead to higher rate of treatment failure when compared to NIV. HFNC was found to offer better comfort and tolerance than NIV, suggesting it may be a promising new respiratory support therapy for BCT patients with mild-moderate ARF.

BACKGROUND: Awake prone positioning is studied extensively during Covid-19 pandemic, but there is very limited evidence on its utility in acute hypoxic respiratory failure caused by bacterial infections or other causes. The aim of our research is to evaluate the impact of awake prone positioning on outcomes in non-intubated adult patients with acute non-Covid19 hypoxemic respiratory failure.
METHODS: This is a multi-center randomized controlled trial (RCT) with a parallel-group design and a 1:1 allocation ratio. Adult patients, admitted to ICU and diagnosed with hypoxemic respiratory failure will be randomly allocated into intervention (awake prone position (APP)) or control group. Our hypothesis is that addition of awake prone positioning to standard oxygen, high flow oxygen therapy and non-invasive ventilation may reduce the need for mechanical ventilation in adult patients diagnosed with acute hypoxemic respiratory failure. Primary outcome is rate of endotracheal intubation; secondary outcomes include intensive care and hospital mortality, duration of mechanical ventilation, length of intensive care and hospital stay and health related quality of life post hospital discharge. Primary and secondary outcomes will be assessed at hospital discharge, 30, 90 days and 1 year following randomisation.
CONCLUSIONS: The Hyper-AP study will assess the superiority of awake prone positioning versus standard treatment in spontaneously breathing ICU patients diagnosed with hypoxaemic respiratory failure.

Background: Amyotrophic lateral sclerosis (ALS) is a neuromuscular progressive disorder characterized by limb and bulbar muscle wasting and weakness. A total of 30% of patients present a bulbar onset, while 70% have a spinal outbreak. Respiratory involvement represents one of the worst prognostic factors, and its early identification is fundamental for the early starting of non-invasive ventilation and for the stratification of patients. Due to the lack of biomarkers of early respiratory impairment, we aimed to evaluate the role of chest dynamic MRI in ALS patients. Methods: We enrolled 15 ALS patients and 11 healthy controls. We assessed the revised ALS functional rating scale, spirometry, and chest dynamic MRI. Data were analyzed by using the Mann-Whitney U test and Cox regression analysis. Results: We observed a statistically significant difference in both respiratory parameters and pulmonary measurements at MRI between ALS patients and healthy controls. Moreover, we found a close relationship between pulmonary measurements at MRI and respiratory parameters, which was statistically significant after multivariate analysis. A sub-group analysis including ALS patients without respiratory symptoms and with normal spirometry values revealed the superiority of chest dynamic MRI measurements in detecting signs of early respiratory impairment. Conclusions: Our data suggest the usefulness of chest dynamic MRI, a fast and economically affordable examination, in the evaluation of early respiratory impairment in ALS patients.

BACKGROUND: Non-invasive ventilation (NIV) is a standard of care for hypercapnic chronic respiratory failure (CRF). Obstructive sleep apnea syndrome (OSA) frequently contributes to hypoventilation in CRF patients. CPAP improves hypercapnia in selected COPD and obese patients, like NIV. We aimed to describe the profile of patients switching from NIV to CPAP in a cohort of patients on long-term ventilation and to identify the factors associated with a successful switch.
METHODS: In this case-control study, 88 consecutive patients who were candidates for a NIV-CPAP switch were compared with 266 controls among 394 ventilated patients treated at the Dijon University Hospital between 2015 and 2020. They followed a standardized protocol including a poly(somno)graphy recorded after NIV withdrawal for three nights. CPAP trial was performed if severe OSA was confirmed. Patients were checked for recurrent hypoventilation after 1 and 23[14-46] nights under CPAP.
RESULTS: Patients were 53% males, median age 65 [56-74] years, and median BMI 34 [25-38.5] kg/m2. Sixty four percent of patients were safely switched and remained on long-term CPAP. In multivariate analysis, the probability of a NIV-CPAP switch was correlated to older age (OR: 1.3 [1.01-1.06]), BMI (OR: 1.7 [1.03-1.12]), CRF etiology (OR for COPD: 20.37 [4.2-98,72], OR for obesity: 7.31 [1.58-33.74]), circumstances of NIV initiation (OR for acute exacerbation: 11.64 [2.03-66.62]), lower pressure support (OR: 0.90 [0.73-0.92]), lower baseline PaCO2 (OR: 0.85 [0.80-0.91]) and lower compliance (OR: 0.76 [0.64-0.90]). Among 72 patients who went home under CPAP, pressure support level was the only factor associated with the outcome of the NIV-CPAP switch, even after adjustment for BMI and age (p=0.01) with a non-linear correlation. Etiology of chronic respiratory failure, age, BMI, baseline PaCO2, circumstances of NIV initiation, time under home NIV or NIV compliance were not predictive of the outcome of the NIV-CPAP switch.
CONCLUSIONS: A NIV-CPAP switch is possible in real life conditions in stable obese and COPD patients with underlying OSA.

BACKGROUND: The severe acute respiratory syndrome Coronarovirus-2 associated still causes a significant number of deaths and hospitalizations mainly by the development of respiratory failure. We aim to validate lung ultrasound score in order to predict mortality and the severity of the clinical course related to the need of respiratory support.
METHODS: In this prospective multicenter hospital-based cohort study, all adult patients with diagnosis of SARS-CoV-2 infection, performed by real-time reverse transcription polymerase chain reaction were included. Upon admission, all patients underwent blood gas analysis and lung ultrasound by expert operators. The acquisition of ultrasound scan was performed on 12 peculiar anatomic landmarks of the chest. Lung ultrasound findings were classified according to a scoring method, ranging 0 to 3: Score 0: normal A-lines. Score 1: multiple separated B-lines. Score 2: coalescent B-lines, alteration of pleural line. Score 3: consolidation area.
RESULTS: One thousand and seven patients were included in statistical analysis (male 62.4 %, mean age 66.3). Oxygen support was needed in 811 (80.5 %) patients. The median ultrasound score was 24 and the risk of having more invasive respiratory support increased in relation to higher values score computed. Lung ultrasound score showed negative strong correlation (rho: -0.71) with the P/F ratio and a significant association with in-hospital mortality (OR 1.11, 95 %CI 1.07-1.14; p < 0.001), even after adjustment with the following variables (age, sex, P/F ratio, SpO2, lactate, hypertension, chronic renal failure, diabetes, and obesity).
CONCLUSIONS: The novelty of this research corroborates and validates the 12-field lung ultrasound score as tool for predicting mortality and severity clinical course in COVID-19 patients. Baseline lung ultrasound score was associated with in-hospital mortality and requirement of intensive respiratory support and predict the risk of IOT among COVID-19 patients.

The aim of this study is to study cardio-respiratory effects of nasal high-frequency oscillatory ventilation (NHFOV) vs. NCPAP as an initial mode of ventilation in moderate-late-preterm infants. A randomized controlled trial was conducted in NICU of Alexandria University Maternity Hospital (AUMH). One-hundred late-moderate-preterm infants were randomly assigned to either NHFOV-group (n = 50) or NCPAP-group (n = 50). For both groups, functional echocardiography was performed in the first 24 h to detect hemodynamic changes and respiratory outcome was monitored throughout the hospital stay. The main outcomes were hemodynamic measurements and myocardial function using functional echocardiography of those infants along with the respiratory outcome and complications. Kaplan-Meier survival plot was used representing time course of NCPAP and NHFOV failure. Left ventricular output values were not significantly different in both groups with median 202 ml/kg /min and IQR (176-275) in NCPAP-group and 226 ml/kg/min with IQR (181-286) in NHFOV group. Nevertheless, ejection fraction and fractional shortening were significantly higher in NHFOV-group with P 0.001. The time to weaning, the time to reach 30%-FIO2, the need for invasive ventilation, oxygen support duration, and maximal-FIO2 were significantly more in NCAPAP group.     Conclusion: NHFOV is an effective and promising tool of non-invasive-ventilation which can be used as a primary modality of respiratory support in preterm infants with variable forms of respiratory distress syndrome without causing detrimental effect on hemodynamics or significant respiratory complications.     Trial registration: NCT05706428 (registered on January 21, 2023). What is Known: • NHFOV might be beneficial as a secondary mode of ventilation and might have an impact on hemodynamics. What is New: • NHFOV can be used as an initial mode of ventilation with CDP beyond the reported pressure limits of CPAP without causing neither CO2 retention nor adverse hemodynamic consequences.