INTRODUCTION High-flow nasal cannula (HFNC) provides benefits to patients undergoing flexible bronchoscopy (FOB). We compared the effects of HFNC versus standard therapy (ST) on gas exchange, lung volume and diaphragm function in patients undergoing FOB for bronchoalveolar lavage (BAL). METHODS 36 outpatients were randomised to ST or HFNC. Arterial blood gases, episodes of severe desaturation, changes of end-expiratory lung impedance (ΔEELI), diaphragm ultrasound were recorded. Measurements were done at baseline (T0), after bronchoscope insertion (T1), at the end of the procedure (T2) and 10 min afterwards (T3). RESULTS Arterial partial oxygen pressure (PaO2) was not different between T0 (10.8 (95% CI 8.7 to 12.0) kPa and T2 (11.1 (95% CI 10.4 to 12.0) kPa) with HFNC, while decreased from 11.1 (95% CI 10.5 to 12.1) to 9.1 (95% CI 8.4 to 9.8) kPa with ST. At T2, PaO2 was significantly higher with HFNC than with ST (p<0.001). Also, with HFNC, compared with ST, fewer desaturations occurred (11% vs 56%; p<0.01). ΔEELI was no different at the different time points with HFNC, while with ST there was a significant decrease at T1 (-170 (95% CI -382 to -32) mL, p=0.003), T2 (-211 (95% CI -425 to -148) mL, p<0.001) and T3 (-213 (95% CI -398 to -81) mL, p<0.001), as opposed to T0. EELI was lower with ST than HFNC at T1 (p=0.006), T2 (p=0.001) and T3 (p=0.002). Diaphragm displacement was no different between groups (p=0.748), while the thickening fraction significantly increased at T1 and T2 with ST only (p<0.01). CONCLUSIONS During FOB for BAL, HFNC improves gas exchange, avoiding loss of end-expiratory lung volume and preventing increase of diaphragm activation. TRIAL REGISTRATION NUMBER NCT04016480.

High-flow nasal cannula oxygen therapy for outpatients undergoing flexible bronchoscopy: a randomised controlled trial.

Electrical impedance tomography: A compass for the safe route to optimal PEEP.

Electrical impedance tomography as a tool for monitoring mechanical ventilation. An introduction to the technique.

Diaphragm dysfunction and weaning-induced pulmonary oedema are commonly involved during weaning failure, but their physiological interactions have been poorly reported. Our hypothesis was that diaphragm dysfunction is not particularly associated with weaning-induced pulmonary oedema. It was a single-centre and physiological study conducted in patients who had failed a first spontaneous breathing trial and who underwent a second trial. The diaphragm function was evaluated by measuring the tracheal pressure generated in response to a bilateral magnetic phrenic nerves stimulations. Weaning-induced pulmonary oedema was diagnosed in case of failure of the spontaneous breathing trial if patients exhibited signs of plasma concentration or echocardiographic diagnosis of pulmonary artery occlusion pressure elevation. Fifty-three patients were included and 31/53 (58%) failed the spontaneous breathing trial, including 24/31 (77%) patients with weaning-induced pulmonary oedema. Diaphragm dysfunction was present in 33/53 (62%) patients. Diaphragm dysfunction or weaning-induced pulmonary oedema were present in 26/31 (84%) of the patients who failed the spontaneous breathing trial. Weaning-induced pulmonary oedema occurred in 20/33 (61%) patients with a diaphragm dysfunction and in 4/20 (20%) patients without (p = 0.005). Weaning-induced pulmonary oedema was three times more frequent in case of diaphragm dysfunction. Even in case of diaphragm dysfunction, physicians might be encouraged to investigate the presence of weaning-induced pulmonary oedema during weaning failure.

/pdf/diaphragm-dysfunction-lung-aeration-loss-and-weaning-induced-379du57nsn.pdf

Diaphragm dysfunction, lung aeration loss and weaning-induced pulmonary oedema in difficult-to-wean patients.

BACKGROUND Readiness for mechanical ventilation (MecV) weaning and extubation is usually assessed clinically with the use of a spontaneous breathing trial (SBT), but its accuracy is limited, and the pathophysiology of weaning failure not completely elucidated. The purpose of the present study was to describe the physiological behavior of electrical impedance tomography parameters during SBT and to propose additional variables that could be helpful in defining weaning/extubation outcome. METHODS From December 2015 to January 2017, all subjects who remained under MecV with an orotracheal tube for more than 24 hours and who were submitted to SBT both in pressure-support ventilation (PSV) or T-tube were included in the study. Both clinical and impedance parameters were collected immediately before as well as during SBT. RESULTS Forty-two subjects were included in the final analysis. For subjects submitted to SBT in PSV, none of the impedance parameters added significant information regarding weaning outcomes. For subjects submitted to a T-tube SBT, a significant and progressive decrease in end-expiratory lung impedance (dEELI) was observed, which was more prominent in subjects who clinically failed the SBT. These subjects had a significant rapid shallow breathing index at the end of SBT. CONCLUSIONS dEELI was a potentially useful parameter in the evaluation of MecV weaning outcome when abrupt lung depressurization was induced during SBT in our study. The degree of dEELI decrease was probably related to the magnitude of lung derecruitment, which seems to play a key role in the MecV weaning outcome.

Electrical impedance tomography monitoring during spontaneous breathing trial: Physiological description and potential clinical utility

This study aims to assess the changes in lung aeration and ventilation during the first spontaneous breathing trial (SBT) and after extubation in a population of patients at risk of extubation failure. We included 78 invasively ventilated patients eligible for their first SBT, conducted with low positive end-expiratory pressure (2 cm H2O) for 30 min. We acquired three 5-min electrical impedance tomography (EIT) records at baseline, soon after the beginning (SBT_0) and at the end (SBT_30) of SBT. In the case of SBT failure, ventilation was reinstituted; otherwise, the patient was extubated and two additional records were acquired soon after extubation (SB_0) and 30 min later (SB_30) during spontaneous breathing. Extubation failure was defined by the onset of post-extubation respiratory failure within 48 h after extubation. We computed the changes from baseline of end-expiratory lung impedance (∆EELI), tidal volume (∆Vt%), and the inhomogeneity index. Arterial blood was sampled for gas analysis. Data were compared between sub-groups stratified for SBT and extubation success/failure. Compared to SBT success (n = 61), SBT failure (n = 17) showed a greater reduction in ∆EELI at SBT_0 (p   0.05 for all comparisons). Compared to SBT success, SBT failure was characterized by more lung de-recruitment and inhomogeneity. Whether EIT may be useful to monitor SBT remains to be determined. No significant changes in lung ventilation, aeration or homogeneity related to extubation outcome occurred up to 30 min after extubation. Trial registration Retrospectively registered on clinicaltrials.gov (Identifier: NCT03894332; release date 27th March 2019).

/pdf/electrical-impedance-tomography-during-spontaneous-breathing-582iwu8a0y.pdf

Electrical impedance tomography during spontaneous breathing trials and after extubation in critically ill patients at high risk for extubation failure: a multicenter observational study

"Diagnosis on the Dock" project: A proactive screening program for diagnosing pulmonary tuberculosis in disembarking refugees and new SEI model.

Introduction: Early assessment of weaning failure and prediction of extubation failure are crucial for management of invasively ventilated patients. Aim: Evaluating whether changes in end-expiratory lung impedance (dEELI) and tidal impedance variation (TIV) by electrical impedance tomography (EIT) may predict weaning failure early in the course of the spontaneous breathing trial (SBT) and extubation failure soon after tube removal. Methods: Multicentre study planning enrolment of 80 invasively ventilated ICU patients. dEELI and TIV are computed averaging 5 consecutive minutes during mechanical ventilation (baseline), at SBT initiation (SBT_0) and end (SBT_30), immediately (SB_0) and 30 minutes after extubation (SB_30). Data comparisons are made between subgroups stratified for weaning and extubation outcome. Results: So far, we enrolled 46 patients. Compared to baseline, patients (n=11) failing SBT, as opposed to those succeeding, show dEELI significantly more negative at SBT_0 (-281 [-1048; -119] vs. -126 [-241; 18] ml, p=0.015) and SBT_30 (-279 [-1396; -156] vs. -73 [-247; 116] ml, p=0.008). No significant loss of dEELI (p= 0.172 at SB_30) was observed in the patients who failed extubation(n=14), compared to those who succeeded (n=21). TIV was no significantly different in any comparisons. Conclusions: While changes in TIV are unhelpful for assessing the risk of both weaning and extubation failure, early fall of dEELI occurs in patients failing SBT, as opposed to those succeeding. The values of dEELI are not significantly different between the patients failing extubation and those succeeding, despite a trend toward a greater reduction in the formers, which makes necessary achieving the planned sample size.

Electric impedance tomography to predict weaning and extubation failure

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Electrical impedance tomography during spontaneous breathing trials and after extubation in critically ill patients at high risk for extubation failure: a multicenter observational study

"Diagnosis on the Dock" project: A proactive screening program for diagnosing pulmonary tuberculosis in disembarking refugees and new SEI model.

Electric impedance tomography to predict weaning and extubation failure