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Effective and safe practices during extracorporeal membrane oxygenation (ECMO) including infection precautions and securement of lines (cannulas and circuits) are critical to prevent life-threatening patient complications, yet little is known about the practices of bedside clinicians and data to support best practice is lacking. Therefore, the aim of this study was to identify and describe common line-related practices for patients supported by peripheral ECMO worldwide and to highlight any gaps for further investigation. An electronic survey was conducted to examine common line practices for patients managed on peripheral ECMO. Responses were obtained from 45 countries with the majority from the United States (n = 181) and United Kingdom (n = 32). Standardised infection precautions including hand hygiene, maximal barrier precautions and skin antisepsis were commonplace for cannulation. The most common antisepsis strategies included alcohol-based chlorhexidine gluconate (CHG) for cannula insertion (53%) and maintenance (54%), isopropyl alcohol on circuit access ports (39%), and CHG-impregnated dressings to cover insertion sites (36%). Adverse patient events due to line malposition or dislodgement were reported by 34% of respondents with most attributable to ineffective securement. Centres 'always' suturing peripheral cannula sites were more likely to experience a cannula adverse event than centres that 'never' sutured (35% [95% CI 30, 41] vs 0% [95% CI 0, 28]; Chi-square 4.40; p = 0.04) but this did not meet the a priori significance level of <0.01. An evidence-based guideline would be beneficial to improve ECMO line management according to 78% of respondents. Evidence gaps were identified for antiseptic agents, dressing products and regimens, securement methods, and needleless valves. Future research addressing these areas may provide opportunities for consensus guideline development and practice improvement.

AbstractPatients with COPD using long-term oxygen therapy (LTOT) over 15 h per day have improved outcomes. As inhalation of dry cold gas is detrimental to mucociliary clearance, humidified nasal high flow (NHF) oxygen may reduce frequency of exacerbations, while improving lung function and quality of life in this cohort. In this randomised crossover study, we assessed short-term physiological responses to NHF therapy in 30 males chronically treated with LTOT. LTOT (2–4 L/min) through nasal cannula was compared with NHF at 30 L/min from an AIRVO through an Optiflow nasal interface with entrained supplemental oxygen. Comparing NHF with LTOT: transcutaneous carbon dioxide (TcCO2) (43.3 vs 46.7 mm Hg, p<0.001), transcutaneous oxygen (TcO2) (97.1 vs 101.2 mm Hg, p=0.01), I:E ratio (0.75 vs 0.86, p=0.02) and respiratory rate (RR) (15.4 vs 19.2 bpm, p<0.001) were lower; and tidal volume (Vt) (0.50 vs 0.40, p=0.003) and end-expiratory lung volume (EELV) (174% vs 113%, p<0.001) were higher. EELV is expressed as relative change from baseline (%Δ). Subjective dyspnoea and interface comfort favoured LTOT. NHF decreased TcCO2, I:E ratio and RR, with a concurrent increase in EELV and Vt compared with LTOT. This demonstrates a potential mechanistic rationale behind the improved outcomes observed in long-term treatment with NHF in oxygen-dependent patients.Trial registration numberACTRN12613000028707.

Purpose Patients with a body mass index (BMI) ≥30 kg/m 2 experience more severe atelectasis following cardiac surgery than those with normal BMI and its resolution is slower. This study aimed to compare extubation of patients post-cardiac surgery with a BMI ≥30 kg/m 2 onto high-flow nasal cannulae (HFNC) with standard care to determine whether HFNC could assist in minimising post-operative atelectasis and improve respiratory function. Methods In this randomised controlled trial, patients received HFNC or standard oxygen therapy post-extubation. The primary outcome was atelectasis on chest X-ray. Secondary outcomes included oxygenation, respiratory rate (RR), subjective dyspnoea, and failure of allocated treatment. Results One hundred and fifty-five patients were randomised, 74 to control, 81 to HFNC. No difference was seen between groups in atelectasis scores on Days 1 or 5 (median scores = 2, p  = 0.70 and p  = 0.15, respectively). In the 24-h post-extubation, there was no difference in mean PaO 2 /FiO 2 ratio (HFNC 227.9, control 253.3, p  = 0.08), or RR (HFNC 17.2, control 16.7, p  = 0.17). However, low dyspnoea levels were observed in each group at 8 h post-extubation, median (IQR) scores were 0 (0–1) for control and 1 (0–3) for HFNC ( p  = 0.008). Five patients failed allocated treatment in the control group compared with three in the treatment group [Odds ratio 0.53, (95 % CI 0.11, 2.24), p  = 0.40]. Conclusions In this study, prophylactic extubation onto HFNC post-cardiac surgery in patients with a BMI ≥30 kg/m 2 did not lead to improvements in respiratory function. Larger studies assessing the role of HFNC in preventing worsening of respiratory function and intubation are required.

Endotracheal suctioning causes significant lung derecruitment. Closed suction (CS) minimizes lung volume loss during suction, and therefore, volumes are presumed to recover more quickly postsuctioning. Conflicting evidence exists regarding this. We examined the effects of open suction (OS) and CS on lung volume loss during suctioning, and recovery of end-expiratory lung volume (EELV) up to 30 minutes postsuction. Randomized crossover study examining 20 patients postcardiac surgery. CS and OS were performed in random order, 30 minutes apart. Lung impedance was measured during suction, and end-expiratory lung impedance was measured at baseline and postsuctioning using electrical impedance tomography. Oximetry, partial pressure of oxygen in the alveoli/fraction of inspired oxygen ratio and compliance were collected. Reductions in lung impedance during suctioning were less for CS than for OS (mean difference, −905 impedance units; 95% confidence interval [CI], −1234 to –587; P < .001). However, at all points postsuctioning, EELV recovered more slowly after CS than after OS. There were no statistically significant differences in the other respiratory parameters. Closed suctioning minimized lung volume loss during suctioning but, counterintuitively, resulted in slower recovery of EELV postsuction compared with OS. Therefore, the use of CS cannot be assumed to be protective of lung volumes postsuctioning. Consideration should be given to restoring EELV after either suction method via a recruitment maneuver.

Endotracheal suctioning (ES) of mechanically ventilated patients decreases end-expiratory lung volume (EELV). Manual hyperinflation (MHI) and ventilator hyperinflation (VHI) may restore EELV post-ES but it remains unknown which method is most effective. The primary aim was to compare the efficacy of MHI and VHI in restoring EELV post-ES. ES was performed on mechanically ventilated intensive care patients, followed by MHI or VHI, in a randomised crossover design. The washout period between interventions was 1 h. End-expiratory lung impedance (EELI), measured by electrical impedance tomography, was recorded at baseline, during ES, during hyperinflation and 1, 5, 15 and 30 min post-hyperinflation. Nine participants were studied. ES decreased EELI by 1672z (95% CI, 1204 to 2140) from baseline. From baseline, MHI increased EELI by 1154z (95% CI, 977 to 1330) while VHI increased EELI by 769z (95% CI, 457 to 1080). Five minutes post-VHI, EELI remained 528z (95% CI, 4 to 1053) above baseline. Fifteen minutes post-MHI, EELI remained 351z (95% CI, 111 to 592) above baseline. At subsequent time-points, EELI returned to baseline. MHI and VHI effectively restore EELV above baseline post-ES and should be considered post suctioning. •Endotracheal suction is associated with significant end-expiratory lung volume loss.•Manual and ventilator hyperinflation restore lung volume after endotracheal suction.•Both techniques have similar effects on oxygenation and lung compliance.•Ventilator hyperinflation is a safe alternative to manual hyperinflation.

Purpose Nurse navigators (NNs) coordinate patient care, improve care quality and potentially reduce healthcare resource use. The purpose of this paper is to undertake an evaluation of hospitalisation outcomes in a new NN programme in Queensland, Australia. Design/methodology/approach A matched case-control study was performed. Patients under the care of the NNs were randomly selected (n=100) and were matched to historical (n=300) and concurrent (n=300) comparison groups. The key outcomes of interest were the number and types of hospitalisations, length of hospital stay and number of intensive care unit days. Generalised linear and two-part models were used to determine significant differences in resources across groups. Findings The control and NN groups were well matched on socio-economic characteristics, however, groups differed by major disease type and number/type of comorbidities. NN patients had high healthcare needs with 53 per cent having two comorbidities. In adjusted analyses, compared with the control groups, NN patients showed higher proportions of preventable hospitalisations over 12 months, similar days in intensive care and a smaller proportion had overnight stays in hospital. However, the NN patients had significantly more hospitalisations (mean: 6.0 for NN cases, 3.4 for historical group and 3.2 for concurrent group); and emergency visits. Research limitations/implications As many factors will affect hospitalisation rates beyond whether patients receive NN care, further research and longer follow-up is required. Originality/value A matched case-control study provides a reasonable but insufficient design to compare the NN and non-NN exposed patient outcomes.

Purpose: Patients with a body mass index (BMI) greater than or equal to 30 kg/m super(2) experience more severe atelectasis following cardiac surgery than those with normal BMI and its resolution is slower. This study aimed to compare extubation of patients post-cardiac surgery with a BMI greater than or equal to 30 kg/m super(2) onto high-flow nasal cannulae (HFNC) with standard care to determine whether HFNC could assist in minimising post-operative atelectasis and improve respiratory function. Methods: In this randomised controlled trial, patients received HFNC or standard oxygen therapy post-extubation. The primary outcome was atelectasis on chest X-ray. Secondary outcomes included oxygenation, respiratory rate (RR), subjective dyspnoea, and failure of allocated treatment. Results: One hundred and fifty-five patients were randomised, 74 to control, 81 to HFNC. No difference was seen between groups in atelectasis scores on Days 1 or 5 (median scores = 2, p = 0.70 and p = 0.15, respectively). In the 24-h post-extubation, there was no difference in mean PaO sub(2)/FiO sub(2) ratio (HFNC 227.9, control 253.3, p = 0.08), or RR (HFNC 17.2, control 16.7, p = 0.17). However, low dyspnoea levels were observed in each group at 8 h post-extubation, median (IQR) scores were 0 (0-1) for control and 1 (0-3) for HFNC (p = 0.008). Five patients failed allocated treatment in the control group compared with three in the treatment group [Odds ratio 0.53, (95 % CI 0.11, 2.24), p = 0.40]. Conclusions: In this study, prophylactic extubation onto HFNC post-cardiac surgery in patients with a BMI greater than or equal to 30 kg/m super(2) did not lead to improvements in respiratory function. Larger studies assessing the role of HFNC in preventing worsening of respiratory function and intubation are required.

A 54-year-old man presented with severe symptoms of heart failure. An evaluation revealed a wide pulse pressure, displaced cardiac impulse, volume overload, and a diastolic murmur. A chest radiograph showed enlargement of the cardiac silhouette. Additional diagnostic tests were performed.

Prostate cancer is the most commonly diagnosed malignant condition and the second leading cause of cancer-related death in American men. 1 In its early stage the disease is sometimes curable by radical prostatectomy or radiation therapy. However, metastases are common at presentation and they ultimately afflict many patients who were treated with curative intent when they had early-stage disease. The only effective treatment for metastatic prostate cancer is reduction of testosterone and 5α-dihydrotestosterone concentrations (androgen ablation), by either orchiectomy or the administration of an agonist of luteinizing hormone–releasing hormone (LHRH). The rate of response to androgen ablation can be as high . . .