Acute hypoxemic respiratory failure (ARF) is a common cause for hospital admission. High-flow nasal oxygen (HFNO) is increasingly used as a first-line treatment for patients with ARF, including in medical wards. Clinical guidance is crucial when providing HFNO, and health services use local health guidance documents (LHGDs) to achieve this. It is unknown what hospital LHGDs recommend regarding ward administration of HFNO. This study examined Australian hospitals\' LHGDs regarding ward-based HFNO administration to determine content that may affect safe delivery. A scoping review was undertaken on 2 May 2022 and updated on 29 January 2024 to identify public hospitals\' LHGDs regarding delivery of HFNO to adults with ARF in medical wards in two Australian states. Data were extracted and analysed regarding HFNO initiation, monitoring, maintenance and weaning, and management of clinical deterioration. Of the twenty-six included LHGDs, five documents referenced Australian Oxygen Guidelines. Twenty LHGDs did not define a threshold level of hypoxaemia where HFNO use was recommended over conventional oxygen therapy. Thirteen did not provide target oxygen saturation ranges whilst utilising HFNO. Recommendations varied regarding maximal levels of inspired oxygen and flow rates in the medical ward. Eight LHGDs did not specify any system to identify and manage deteriorating patients. Five LHGDs did not provide guidance for weaning patients from HFNO. There was substantial variation in the LHGDs regarding HFNO care for adult patients with ARF in Australian hospitals. These findings have implications for the delivery of high-quality, safe clinical care in hospitals.

BACKGROUND: Adherence with follow-up appointments after a pediatric intensive care unit (PICU) admission is likely a key component in managing post-PICU sequalae. However, prior work on PICU follow-up adherence is limited. The objective of this study is to identify hospitalization characteristics, discharge child health metrics, and follow-up characteristics associated with full adherence with recommended follow-up at a quaternary care center after a PICU admission due to respiratory failure.
METHODS: We conducted a retrospective cohort study of patients ≤ 18 years with respiratory failure admitted between 1/2013-12/2014 to a quaternary care PICU. Post-hospitalization full adherence with recommended follow-up in the two years post discharge (1/2013-3/2017) at the quaternary care center was quantified and compared by demographics, baseline child health metrics, hospitalization characteristics, discharge child health metrics, and follow-up characteristics in bivariate and multivariate analyses. Patients were dichotomized into being non-adherent with follow-up (patients who attended less than 100% of recommended appointments at the quaternary care center) and fully adherent (patients who attended 100% of recommended appointments at the quaternary care center).
RESULTS: Of 155 patients alive at hospital discharge, 140 (90.3%) were recommended to follow-up at the quaternary care center. Of the 140 patients with recommended follow-up at the quaternary care center, 32.1% were non-adherent with follow-up and 67.9% were fully adherent. In a multivariable logistic regression model, each additional recommended unique follow-up appointment was associated with lower odds of being fully adherent with follow-up (OR 0.74, 95% CI 0.60-0.91, p = 0.005), and each 10% increase in the proportion of appointments scheduled before discharge was associated with higher odds of being fully adherent with follow-up (OR 1.02, 95% CI 1.01-1.03, p = 0.004).
CONCLUSIONS: After admission for acute respiratory failure, only two-thirds of children were fully adherent with recommended follow-up at a quaternary care center. Our findings suggest that limiting the recommended follow-up to only key essential healthcare providers and working to schedule as many appointments as possible before discharge could improve follow-up adherence. However, a better understanding of the factors that lead to non-adherence with follow-up appointments is needed to inform broader system-level approaches could help improve PICU follow-up adherence.

BACKGROUND: In the general intensive care unit (ICU) women receive invasive mechanical ventilation (IMV) less frequently than men. We investigated whether sex differences in the use of IMV also exist in the neurocritical care unit (NCCU), where patients are intubated not only due to respiratory failure but also due to neurological impairment.
METHODS: This retrospective single-centre study included adults admitted to the NCCU of the University Hospital Zurich between January 2018 and August 2021 with neurological or neurosurgical main diagnosis. We collected data on demographics, intubation, re-intubation, tracheotomy, and duration of IMV or other forms of respiratory support from the Swiss ICU registry or the medical records. A descriptive statistics was performed. Baseline and outcome characteristics were compared by sex in the whole population and in subgroup analysis.
RESULTS: Overall, 963 patients were included. No differences between sexes in the use and duration of IMV, frequency of emergency or planned intubations, tracheostomy were found. The duration of oxygen support was longer in women (men 2 [2, 4] vs. women 3 [1, 6] days, p = 0.018), who were more often admitted due to subarachnoid hemorrhage (SAH). No difference could be found after correction for age, diagnosis of admission and severity of disease.
CONCLUSIONS: In this NCCU population and differently from the general ICU population, we found no difference by sex in the frequency and duration of IMV, intubation, reintubation, tracheotomy and non-invasive ventilation support. These results suggest that the differences in provision of care by sex reported in the general ICU population may be diagnosis-dependent. The difference in duration of oxygen supplementation observed in our population can be explained by the higher prevalence of SAH in women, where we aim for higher oxygenation targets due to the specific risk of vasospasm.

Oxygen, like all medicines, is a drug which needs moderation. Hypoxia, as well as excess oxygen supplementation, can be harmful in a patient with chronic obstructive pulmonary disease (COPD). Both the European and the British guidelines recommend a target oxygen saturation of 88-92% in patients with COPD. Hypoxia can result in symptoms, such as restlessness, anxiety, agitation, and headache, while excess oxygen can lead to altered sensorium due to the retention of carbon dioxide (CO2) in patients with COPD. We often come across patients who come with breathlessness and have hypoxia, and the knee-jerk reaction is to start the patient on oxygen support to maintain an oxygen saturation of >95%, and this may result in hypercapnia and type II respiratory failure. Here, we present a descriptive review of the proper application of oxygen therapy in a patient presenting with acute exacerbation of COPD, the rationale behind the target oxygen saturations, and the mechanisms of type II respiratory failure due to hyperoxygenation.

OBJECTIVE: High-flow nasal cannula (HFNO) reduces the need for invasive mechanical ventilation in COVID-19 patients with hypoxemic-respiratory failure. During HFNO entrainment of room air dilutes the delivered fractional inspiratory oxygen (FiO2), thereby preventing improvement in oxygenation. The placement of a mask over HFNO to improve oxygenation has provided conflicting results. We aimed to determine and compare the effect of placing various mask types over HFNO on oxygen saturation (SPO2).
METHODS: In this prospective physiological study 40 patients with COVID-19-associated hypoxemic respiratory failure on HFNO with O2 concentration <92% were included. The effect of placing different masks over HFNO on oxygenation, respiratory rate, heart rate, blood pressure, patient comfort, and partial pressure of carbon dioxide level (pCO2) was recorded after a prespecified time interval.
RESULTS: We observed a significantly higher mean SPO2 and lower mean respiratory rate on using various study masks over HFNO compared to HFNO alone. On comparing various mask types, the use of N95 masks and nonrebreather (NRB) masks with O2 showed a significant increase in O2 concentration and reduction in respiratory rate compared to surgical mask (SM) and NRB without O2. The proportion of patients who achieved SPO2 of >92% was higher with the use of N95 masks (47.5%) or NRB with O2 (45%) over HFNO compared to SM (35%) and NRB without O2 (35%). No significant change was observed in heart rate, blood pressure, and CO2 level with the use of any mask over HFNO.
CONCLUSIONS: This study demonstrates improvement in oxygenation and reduction in respiratory rate with the use of various masks over HFNO in patients of COVID-19-related hypoxemic-respiratory-failure. Significantly greater benefit was achieved with the use of N95 or NRB with O2 compared to SM or NRB without O2.

BACKGROUND: Postoperative pulmonary complications (PPCs) are among the most severe complications following total hip arthroplasty revision (THAR), imposing significant burdens on individuals and society. This study examined the prevalence and risk factors of PPCs following THAR using the NIS database, identifying specific pulmonary complications (SPCs) and their associated risks, including pneumonia, acute respiratory failure (ARF), and pulmonary embolism (PE).
METHODS: The National Inpatient Sample (NIS) database was used for this cross-sectional study. The analysis included patients undergoing THAR based on NIS from 2010 to 2019. Available data include demographic data, diagnostic and procedure codes, total charges, length of stay (LOS), hospital information, insurance information, and discharges.
RESULTS: From the NIS database, a total of 112,735 THAR patients in total were extracted. After THAR surgery, there was a 2.62% overall incidence of PPCs. Patients with PPCs after THAR demonstrated increased LOS, total charges, usage of Medicare, and in-hospital mortality. The following variables have been determined as potential risk factors for PPCs: advanced age, pulmonary circulation disorders, fluid and electrolyte disorders, weight loss, congestive heart failure, metastatic cancer, other neurological disorders (encephalopathy, cerebral edema, multiple sclerosis etc.), coagulopathy, paralysis, chronic pulmonary disease, renal failure, acute heart failure, deep vein thrombosis, acute myocardial infarction, peripheral vascular disease, stroke, continuous trauma ventilation, cardiac arrest, blood transfusion, dislocation of joint, and hemorrhage.
CONCLUSIONS: Our study revealed a 2.62% incidence of PPCs, with pneumonia, ARF, and PE accounting for 1.24%, 1.31%, and 0.41%, respectively. A multitude of risk factors for PPCs were identified, underscoring the importance of preoperative optimization to mitigate PPCs and enhance postoperative outcomes.

The neutrophil lymphocyte ratio (NLR) and red blood cell distribution width (RDW) have been repeatedly demonstrated to be associated with risk of severity, progression, and prognosis of chronic obstructive pulmonary disease (COPD), but data on respiratory failure (RF) in patients with COPD are very limited. This study aimed to examine the relationship between NLR and RDW and the incident RF in patients with COPD. This is a retrospective study that reviewed data by examining the hospitalization medical records to identify those who were admitted with a diagnosis of COPD. Based on whether RF occurred during index hospitalization, patients were classified as COPD group and COPD combined with RF group. Also, healthy controls of the same age and sex were enrolled in a 1:1 ratio as the COPD group. Univariate comparisons were performed between three groups to examine differences. With the COPD group as reference, multivariable logistic regression was formed to identify the relationship between NLR and RDW and RF, with adjustment for multiple covariates. There were 136 healthy controls, 136 COPD patients and 62 patients with COPD combined with RF included for analysis. There was a significant difference for eight variables, including age, WBC, neutrophil, NLR, RDW, platelet, PLR, and CRP. The Spearman test showed the significant correlation between NLR and WBC (correlation coefficient, 0.38; P = .008), NLR and RDW (correlation coefficient, 0.32; P = .013), and NLR and CRP level (correlation coefficient, 0.54; P < .001). The multivariable logistic regression showed that age (every additional 10 years) (OR, 1.785), NLR (OR, 1.716), RDW (OR, 2.266), and CRP (OR, 1.163) were independently associated with an increased risk of RF. This study demonstrated the independent associative effect of NLR and RDW with RF in patients with COPD, exhibiting the potential clinical role in evaluating the progress of COPD to RF.

UNASSIGNED: Guidelines recommend an analgesia-first strategy for sedation during mechanical ventilation, but associations between opioids provided during mechanical ventilation and posthospitalization opioid-related outcomes are unclear.
UNASSIGNED: To evaluate associations between an intravenous opioid dose received during mechanical ventilation and postdischarge opioid-related outcomes in medical (nonsurgical) patients.
UNASSIGNED: This retrospective cohort study evaluated adults receiving mechanical ventilation lasting 24 hours or more for acute respiratory failure and surviving hospitalization. Participants from 21 Kaiser Permanente Northern California hospitals from January 1, 2012, to December 31, 2019, were included. Data were analyzed from October 1, 2020, to October 31, 2023.
UNASSIGNED: Terciles of median daily intravenous fentanyl equivalents during mechanical ventilation.
UNASSIGNED: The primary outcome was the first filled opioid prescription in 1 year after discharge. Secondary outcomes included persistent opioid use and opioid-associated complications. Secondary analyses tested for interaction between opioid doses during mechanical ventilation, prior opioid use, and posthospitalization opioid use. Estimates were based on multivariable-adjusted time-to-event analyses, with death as a competing risk, and censored for hospice or palliative care referral, rehospitalization with receipt of opioid, or loss of Kaiser Permanente plan membership.
UNASSIGNED: The study included 6746 patients across 21 hospitals (median age, 67 years [IQR, 57-76 years]; 53.0% male). Of the participants, 3114 (46.2%) filled an opioid prescription in the year prior to admission. The median daily fentanyl equivalent during mechanical ventilation was 200 μg (IQR, 40-1000 μg), with terciles of 0 to 67 μg, more than 67 to 700 μg, and more than 700 μg. Compared with patients who did not receive opioids during mechanical ventilation (n = 1013), a higher daily opioid dose was associated with opioid prescriptions in the year after discharge (n = 2942 outcomes; tercile 1: adjusted hazard ratio [AHR], 1.00 [95% CI, 0.85-1.17], tercile 2: AHR, 1.20 [95% CI, 1.03-1.40], and tercile 3: AHR, 1.25 [95% CI, 1.07-1.47]). Higher doses of opioids during mechanical ventilation were also associated with persistent opioid use after hospitalization (n = 1410 outcomes; tercile 3 vs no opioids: odds ratio, 1.44 [95% CI, 1.14-1.83]). No interaction was observed between opioid dose during mechanical ventilation, prior opioid use, and posthospitalization opioid use.
UNASSIGNED: In this retrospective cohort study of patients receiving mechanical ventilation, opioids administered during mechanical ventilation were associated with opioid prescriptions following hospital discharge. Additional studies to evaluate risks and benefits of strategies using lower opioid doses are warranted.

UNASSIGNED: Extracorporeal membrane oxygenation (ECMO) use in peripartum patients is rare, and there is a gap in the literature on the outcomes and guidance on using ECMO in peripartum patients. This study describes ECMO strategies our institution uses for peripartum patients and reports outcomes of ECMO use in peripartum patients with respiratory and/or cardiac failure.
UNASSIGNED: A case series of all peripartum patients, defined as pregnant or up to 6 weeks after delivery of an infant >20 weeks gestation, from 2018 to 2023 from a single center requiring ECMO support. Patients were included if ECMO was initiated in the setting of cardiac, pulmonary, or combined failure. Patient demographics, operative details, ECMO data, and adverse outcomes for maternal, fetus, and neonates were all collected.
UNASSIGNED: Eighteen patients met the inclusion criteria. The cohort had a mean maternal age of 30.7 years old and was racially diverse. A majority of this cohort tested positive for COVID-19 (n = 10, 55%). ECMO was a bridge to recovery for all patients, of whom 14 (78%) were discharged out of the hospital alive. No patients received transplantation or a durable mechanical device. The most common complications were infection (25%) and postpartum hemorrhage (22%).
UNASSIGNED: ECMO use in peripartum patients in a single tertiary center was associated with a high survival rate. Furthermore, a strong multidisciplinary team, careful reevaluation of clinical trajectory, and consideration of complications and risks associated with using ECMO in peripartum patients are possible frameworks to use when challenged with critically ill peripartum patients.

UNASSIGNED: Partial carbondioxide pressure of the arterial blood (PaCO2) is used to evaluate alveolar ventilation. Transcutaneous carbon dioxide pressure (TcCO2) monitoring has been developed as a non-invasive (NIV) alternative to arterial blood gas analysis (ABG). Studies have shown that decreased tissue perfusion leads to increased carbondioxide (CO2). The use of transcutaneous capnometry may be unreliable in patients with perfusion abnormalities. In this study, we aimed to evaluate the relation between TcCO2-PaCO2 and lactate level which is recognized as a marker of hypoperfusion.
UNASSIGNED: In this prospective cohort study in critical care patients with hypercapnic respiratory failure (PaCO2 ≥45 mmHg) who received NIV between April 2019 and January 2020 in the intensive care unit were enrolled in the study. Patients\' simultaneously measured TcCO2 and PaCO2 values of hypercapnic patients were recorded. Each paired measurement was categorized into two groups; normal lactate (<2 mmol/L) and increased lactate (≥2 mmol/L).
UNASSIGNED: A total of 116 paired TcCO2 and PaCO2 measurements of 29 patients were recorded. Bland-Altman analysis showed the mean bias between the TcCO2 and PaCO2 and 95% limits of agreement (LOA) in all measurements (1.75 mmHg 95% LOA -3.67 to 7.17); in the normal lactate group (0.66 mmHg 95% LOA -1.71 to 3.03); and in the increased lactate group (5.17 mmHg 95% LOA -1.63 to 11.97). The analysis showed a correlation between lactate level and the difference between TcCO2 and PaCO2 (r= 0.79, p< 0.001) and a negative correlation between mean blood pressure and the difference between TcCO2 and PaCO2 (r= -0.54, p= 0.001). Multiple regression analysis results showed that lactate level was independently associated with increased differences between TcCO2 and PaCO2 (Beta= 0.875, p< 0.001).
UNASSIGNED: TcCO2 monitoring may not be reliable in patients with increased lactate levels. TcCO2 levels should be checked by ABG analysis in these patients.