Physiopathological rationale of using high-flow nasal therapy in the acute and chronic setting: A narrative review

Chronic lung disease and admissions due to acute respiratory failure (ARF) are becoming increasingly common. Consequently, there is a growing focus on optimizing respiratory support, particularly non-invasive respiratory support, to manage these conditions. High flow nasal therapy (HFNT) is a noninvasive technique where humidified and heated gas is delivered through the nose to the airways via small dedicated nasal prongs at flows that are higher than the rates usually applied during conventional oxygen therapy. HFNT enables to deliver different inspired oxygen fractions ranging from 0.21 to 1. Despite having only recently become available, the use of HFNT in the adult population is quite widespread in several clinical settings. The respiratory effects of HNFT in patients with respiratory failure may be particularly relevant for clinicians. In this narrative review, we discuss the main pathophysiological mechanism and rationale for using HFNT in the acute and chronic setting

What Healthcare Workers Should Know about Environmental Bacterial Contamination in the Intensive Care Unit

Intensive care unit- (ICU-) acquired infections are a major health problem worldwide. Inanimate surfaces and equipment contamination may play a role in cross-transmission of pathogens and subsequent patient colonization or infection. Bacteria contaminate inanimate surfaces and equipment of the patient zone and healthcare area, generating a reservoir of potential pathogens, including multidrug resistant species. Traditional terminal cleaning methods have limitations. Indeed patients who receive a bed from prior patient carrying bacteria are exposed to an increased risk (odds ratio 2.13, 95% confidence intervals 1.62\u20132.81) of being colonized and potentially infected by the same bacterial species of the previous patient. Biofilm formation, even on dry surfaces, may play a role in reducing the efficacy of terminal cleaning procedures since it enables bacteria to survive in the environment for a long period and provides increased resistance to commonly used disinfectants. No-touch methods (e.g., UV-light, hydrogen peroxide vapour) are under investigation and further studies with patient-centred outcomes are needed, before considering them the standard of terminal cleaning in ICUs. Healthcare workers should be aware of the role of environmental contamination in the ICU and consider it in the broader perspective of infection control measures and stewardship initiatives

Efficacy and Safety of Using High-Flow Nasal Oxygenation in Patients Undergoing Rapid Sequence Intubation.

Objective: To assess the efficacy and safety of high-flow nasal oxygen (HFNO) therapy in patients undergoing rapid sequence intubation (RSI) for emergency abdominal surgery. Methods: HFNO of 60 L.min\ue2\u88\u921at an inspiratory oxygen fraction of 1 was delivered 4 min before laryngoscopy and maintained until the patient was intubated, and correct intubation was verified by the appearance of the end-tidal CO2(EtCO2) waveform. Transcutaneous oxygenation (SpO2), heart rate and non-invasive mean arterial pressure were monitored at baseline (T0), after 4 min on HFNO (T1) and at the time of laryngoscopy (T2) and endotracheal intubation (ETI) (T3). An SpO2of <3% from baseline was recorded at any sampled time. The value of EtCO2at T3 was registered after two mechanical breaths. The apnoea time was defined as the time from the end of propofol injection to ETI. RSI was performed with propofol, fentanyl and rocuronium. Results: Forty-five patients were enrolled. SpO2levels showed a statistically significant increase at T1, T2 and T3 compared with those at T0 (p<0.05); median SpO2% (interquartile range) was 97% (range, 96%-99%) at T0, 99% (range, 99%-100%) at T1, 99% (range, 99%-100%) at T2 and 99% (range, 99%-100%) at T3. Minimal SpO2was 96%; no patient showed an SpO2of <3% from baseline; mean EtCO2at the time of ETI was 36\uc2\ub14 mmHg. Maximum apnoea time was 12 min. Conclusion: HFNO is an effective and safe technique for pre-oxygenation in patients undergoing rapid sequence induction of general anaesthesia for emergency surgery

Survival of patients with spinal muscular atrophy type 1

BACKGROUND: Spinal muscular atrophy type 1 (SMA1) is a progressive disease and is usually fatal in the first year of life. METHODS: A retrospective chart review was performed of SMA1 patients and their outcomes according to the following choices: letting nature take its course (NT); tracheostomy and invasive mechanical ventilation (TV); continuous noninvasive respiratory muscle aid (NRA), including noninvasive ventilation; and mechanically assisted cough. RESULTS: Of 194 consecutively referred patients enrolled in this study (103 males, 91 females), NT, TV, and NRA were chosen for 121 (62.3%), 42 (21.7%), and 31 (16%) patients, respectively. Survival at ages 24 and 48 months was higher in TV than NRA users: 95% (95% confidence interval: 81.8%-98.8%) and 67.7% (95% confidence interval: 46.7%-82%) at age 24 months (P < .001) and 89.43% and 45% at age 48 months in the TV and NRA groups, respectively (P < .001). The choice of TV decreased from 50% (1992-1998) to 12.7% (2005-2010) (P < .005) with a nonstatistically significant increase for NT from 50% to 65%. The choice of NRA increased from 8.1% (1999-2004) to 22.7% (2005-2010) (P < .001). CONCLUSIONS: Long-term survival outcome is determined by the choice of the treatment. NRA and TV can prolong survival, with NRA showing a lower survival probability at ages 24 and 48 months. Copyright © 2013 by the American Academy of Pediatrics

Gis-based cell model for simulating debris flow routing and deposition phases on a fan

A GIS-based cell model is proposed for the simulation of the routing and deposition phases of debris flow on a fan. Flow pattern is discretized by square cells, 2m size, which coincide with the DEM cells and the mixture is assumed a monophasic continuum. Flow exchange between adjacent cells is ruled by uniform flow or broad-crested weir laws and by continuity equation. Flow occurs from cells with higher surface to those with lower surface and is simulated by uniform flow law if the elevation of the formers is higher than the latter and by broad-crested weir law otherwise. Erosion and deposition are simulated using the empirical law of Egashira, adjusted for monophasic continuum. The cell model is used to simulate debris flow occurred on Rio Lazer (Dolomites, Eastern Italian Alps) the 4th of November 1966. The same event was also simulated using Flo-2D model for a comparison with a widely used model for debris flow simulation. Results of the two simulations were compared with extension of deposition area and the map of measured depths of deposited sediments. Both the model simulate quite well the extent of deposition area, whereas the deposited debris depths are better simulated by the cell model

Role of physiotherapy for adult patients with critical illness

Turin, Italy, Congresul II Internaţional al Societăţii Anesteziologie Reanimatologie din Republica Moldova 27-30 august 2009Long-term complications of critical illness include intensive care unit (ICU)-acquired weakness and neuropsychiatric disease. Immobilisation secondary to sedation might potentiate these problems. Critical illness can last from hours to months, depending on the underlying pathophysiology and response to treatment. It carries high morbidity and mortality rates, and the associated care is a major determinant of healthcare costs. The evolution of intensive care medicine and integrated team management has greatly improved the survival of critically ill patients. In view of the high costs associated with ICU, every attempt should continue to be made to prevent complications and appropriately treat the primary underlying pathophysiology to minimize length of stay in ICU. There are common complications particularly associated with a prolonged ICU stay, including deconditioning, muscle weakness, dyspnoea, depression and anxiety, and reduced health-related quality of life. Chronic critical illness is associated with prolonged immobility and intensive care unit (ICU) stay and accounts for 5–10% of ICU stays, a proportion that appears to beincreasing . Because of these detrimental sequelae of long-term bed rest, there is a need for rehabilitation throughout the critical illness and thereafter , to address these effects. The amount of rehabilitation rehabilitation performed in ICUs is often inadequate, A strategy for whole-body rehabilitation-consisting of interruption of sedation and physical and occupational therapy in the earliest days of critical illness-was safe and well tolerated, and resulted in better functional outcomes at hospital discharge, a shorter duration of delirium, and more ventilator-free days compared with standard care

Multimodal analgesia in trauma patients in ICU

Turin, Italy, Congresul II Internaţional al Societăţii Anesteziologie Reanimatologie din Republica Moldova 27-30 august 2009Treatment of the trauma patient has evolved rapidly in the past decade. Nevertheless, the treatment of pain as part of overall trauma management has been relatively neglected. Although recent publications suggest that the assessment and treatment of pain in trauma have improved, most studies still document inadequate analgesia..Following the initial resuscitation of trauma patients, the pain experienced may be divided into a ‘background’ pain and a ‘breakthrough’ pain associated with painful procedures in ICU (e.g. tracheal suctioning, chest tube positioning, staple removal and wound-dressing, bathing in major burn patients.) Background pain may be treated with intravenous opioids via continuous infusion or patient-controlled analgesia (PCA) and/ or less potent oral opioids, epidural analgesia or with continuous regional blocks, The aim is to reduce patient anxiety, improve analgesia and ensure immobilization when required. Untreated pain and improper sedation may result in psychological distress such as post-traumatic stress disorder, major depression or delirium and activation of inflammatory response During painful procedures the most reliable way to administer drugs is intravenously. Fast-acting opioids can be combined with propofol or benzodiazepines. Adjuvant drugs such as clonidine, low dose ketamine, magnesium and paracetamol (acetaminophen) have also been used to realize a multimodal drugs approach both in the treatment of background pain as well as during procedural pain. Patients in spontaneous breathing may only receive ketamine will usually maintain spontaneous breathing. This is an important feature in patients with heat trauma (major burn) who are continuously turned during wound dressing procedures and where analgo-sedation is often performed by practitioners who are not specialists in anaesthesiology. However, it must bear in mind that trauma patients often show an altered pharmacokinetic and pharmacodynamic response to drugs as a result of altered haemodynamics, protein binding and/or increased extracellular fluid volume, and possible changes in glomerular filtration. Educating the staff to perform early routine assessment of pain and to be familiar with the administration of analgesia are key elements to improved pain management in trauma.. Further developments are needed in order to provide safer and more effective analgesia to the trauma patient

An integrated approach to simulate channalized debris flows from triggering to deposition

The purpose of this study, which is currently underway, is the analysis of debris flows from the lithology of the bedrocks (source rocks) that gives rise to the loose material, through the triggering process, to the routing and deposition phases. In particular three methods of analysis have been linked: a geological model, a triggering model that couples the results of a distributed kinematic hydrological model with a critical discharge relationship and a numerical model based on Cellular Automata for the simulation of debris flow routing and deposition. The geological model concerns the catchment lithology and outlines some links between the main lithology forming a basin bed-rock and the characteristics of debris flow triggering process. The triggering model, computes debris flow hydrogram which is the input of the routing model. The methodology outlined above was successfully applied to debris flows occurred in a basin located in North-western Alps

Grain‐energy release governs mobility of debris flow due to solid–liquid mass release

Debris flows often exhibit high mobility, leading to extensive hazards far from their sources. Although it is known that debris flow mobility increases with initial volume, the underlying mechanism remains uncertain. Here, we reconstruct the mobility–volume relation for debris flows using a recent depth‐averaged two‐phase flow model without evoking a reduced friction coefficient, challenging currently prevailing friction‐reduction hypotheses. Physical experimental debris flows driven by solid–liquid mass release and extended numerical cases at both laboratory and field scales are resolved by the model. For the first time, we probe into the energetics of the debris flows and find that, whilst the energy balance holds and fine and coarse grains play distinct roles in debris flow energetics, the grains as a whole release energy to the liquid due to inter‐phase and inter‐grain size interactions, and this grain‐energy release correlates closely with mobility. Despite uncertainty arising from the model closures, our results provide insight into the fundamental mechanisms operating in debris flows. We propose that debris flow mobility is governed by grain‐energy release, thereby facilitating a bridge between mobility and internal energy transfer. The initial volume of debris flow is inadequate for characterizing debris flow mobility, and a friction‐reduction mechanism is not a prerequisite for the high mobility of debris flows. By contrast, inter‐phase and inter‐grain size interactions play primary roles and should be incorporated explicitly in debris flow models. Our findings are qualitatively encouraging and physically meaningful, providing implications not only for assessing future debris flow hazards and informing mitigation and adaptation strategies, but also for unravelling a spectrum of earth surface processes including heavily sediment‐laden floods, subaqueous debris flows and turbidity currents in rivers, reservoirs, estuaries, and ocean

Choosing a ventilator for home mechanical ventilation

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