Explore the vast range of titles available.

Background Previous studies suggest that prone positioning (PP) can increase PaO 2 /FiO 2 and reduce mortality in moderate to severe acute respiratory distress syndrome (ARDS). The aim of our study was to determine whether the early use of PP combined with non-invasive ventilation (NIV) or high-flow nasal cannula (HFNC) can avoid the need for intubation in moderate to severe ARDS patients. Methods This prospective observational cohort study was performed in two teaching hospitals. Non-intubated moderate to severe ARDS patients were included and were placed in PP with NIV or with HFNC. The efficacy in improving oxygenation with four support methods—HFNC, HFNC+PP, NIV, NIV+PP—were evaluated by blood gas analysis. The primary outcome was the rate of intubation. Results Between January 2018 and April 2019, 20 ARDS patients were enrolled. The main causes of ARDS were pneumonia due to influenza (9 cases, 45%) and other viruses (2 cases, 10%). Ten cases were moderate ARDS and 10 cases were severe. Eleven patients avoided intubation (success group), and 9 patients were intubated (failure group). All 7 patients with a PaO 2 /FiO 2  < 100 mmHg on NIV required intubation. PaO 2 /FiO 2 in HFNC+PP were significantly higher in the success group than in the failure group (125 ± 41 mmHg vs 119 ± 19 mmHg, P  = 0.043). PaO 2 /FiO 2 demonstrated an upward trend in patients with all four support strategies: HFNC < HFNC+PP ≤ NIV < NIV+PP. The average duration for PP was 2 h twice daily. Conclusions Early application of PP with HFNC, especially in patients with moderate ARDS and baseline SpO 2  > 95%, may help avoid intubation. The PP was well tolerated, and the efficacy on PaO 2 /FiO 2 of the four support strategies was HFNC < HFNC+PP ≤ NIV < NIV+PP. Severe ARDS patients were not appropriate candidates for HFNC/NIV+PP. Trial registration ChiCTR, ChiCTR1900023564 . Registered 1 June 2019 (retrospectively registered)

Background Incorporation of heart rate, flow rate, and PaO 2 /FIO 2 (PF) ratio to ROX index has been postulated to better predict high-flow nasal cannula (HFNC) usage outcomes in post-extubation setting. Therefore, we aimed to compare ROX index with new modified indices to predict HFNC outcomes in the post-extubation setting. Methods This single-centre 6-year retrospective study included subjects initiated on HFNC post-extubation. The modified indices (ROX-HR, ROX-HR-Flow and POX-HR-Flow) incorporated HFNC flow rate, heart rate and substituted PF ratio for SF ratio. Evaluation was performed using AUROC and cut-offs assessed for prediction of HFNC outcomes. Results Eighty-one subjects were initiated on HFNC post-extubation, of whom 67 patients (82.7%) had HFNC success. ROX-HR-Flow at 2 h post-HFNC initiation demonstrated the best prediction accuracy (AUROC 0.854, 95% CI 0.756–0.952). A ROX-HR-Flow > 12.25 at 2 h post-HFNC initiation was significantly associated with a lower risk of HFNC failure (Sensitivity 77.6% and Specificity 85.7%). Conclusions Our proposed modified index at 2 h post-HFNC initiation (ROX-HR-Flow), may facilitate early and accurate prediction of HFNC outcomes compared to ROX index among subjects initiated on HFNC in the post-extubation setting.

Obesity is an important risk factor for major complications, morbidity and mortality related to intubation procedures and ventilation in the intensive care unit (ICU). The fall in functional residual capacity promotes airway closure and atelectasis formation. This narrative review presents the impact of obesity on the respiratory system and the key points to optimize airway management, noninvasive and invasive mechanical ventilation in ICU patients with obesity. Non-invasive strategies should first optimize body position with reverse Trendelenburg position or sitting position. Noninvasive ventilation (NIV) is considered as the first-line therapy in patients with obesity having a postoperative acute respiratory failure. Positive pressure pre-oxygenation before the intubation procedure is the method of reference. The use of videolaryngoscopy has to be considered by adequately trained intensivists, especially in patients with several risk factors. Regarding mechanical ventilation in patients with and without acute respiratory distress syndrome (ARDS), low tidal volume (6 ml/kg of predicted body weight) and moderate to high positive end-expiratory pressure (PEEP), with careful recruitment maneuver in selected patients, are advised. Prone positioning is a therapeutic choice in severe ARDS patients with obesity. Prophylactic NIV should be considered after extubation to prevent re-intubation. If obesity increases mortality and risk of ICU admission in the overall population, the impact of obesity on ICU mortality is less clear and several confounding factors have to be taken into account regarding the “obesity ICU paradox”.

Background High flow nasal cannula (HFNC) is increasingly being used to support patients with acute respiratory failure (ARF) and to avoid need for intubation. However, almost one third of the patients do not respond and require escalation of respiratory support. Previously, ROX index (SpO 2 /FIO 2 [SF] ratio/respiratory rate) has been validated among pneumonia patients to facilitate early recognition of patients likely to fail HFNC and therefore, benefit from timely interventions. However, it has been postulated that incorporation of PaO 2 /FIO 2 (PF) ratio from arterial blood gas (ABG) analysis may better predict the outcome of HFNC compared to indices that utilizes SF ratio. Similarly, heart rate increase after HFNC therapy initiation has been found to be associated with HFNC failure. Therefore, we aimed to compare ROX index with a new modified index to predict HFNC outcomes among ARF patients. Materials and methods This single centre 2-year retrospective study included ARF patients of varying etiologies treated with HFNC. The modified index incorporated heart rate and substituted PF ratio for SF ratio in addition to respiratory rate. We named the index POX-HR and calculated Delta POX-HR index as the difference pre- and post-HFNC initiation POX-HR. We also recorded ROX index at the time when post-HFNC initiation ABG was done (‘post-HFNC initiation ROX’) and calculated Delta ROX. HFNC success was defined as no need of escalation of respiratory support or discharged to ward within 48 h of HFNC initiation, or successful wean off HFNC for at least 12 h. Evaluation was performed using area under the receiver operating characteristic curve (AUROC) and cut-offs assessed for prediction of HFNC outcomes. Results One hundred eleven patients were initiated on HFNC for ARF, of whom 72 patients (64.9%) had HFNC success. Patients with HFNC failure had significantly lower values for all the indices. At median of 3.33 h (IQR 1.48–7.24 h), Delta POX-HR demonstrated the best prediction accuracy (AUROC 0.813, 95% CI 0.726–0.900). A Delta POX-HR > 0.1 was significantly associated with a lower risk of HFNC failure. Conclusions Our proposed modified dynamic index (Delta POX-HR) may facilitate early and accurate prediction of HFNC outcomes compared to ROX index among ARF patients of varied etiologies.

Background High-flow nasal cannula oxygen (HFNC) is a relatively new therapy used in adults with respiratory failure. Whether it is superior to conventional oxygen therapy (COT) or to noninvasive mechanical ventilation (NIV) remains unclear. The aim of the present study was to investigate whether HFNC was superior to either COT or NIV in adult acute respiratory failure patients. Methods A review of the literature was conducted from the electronic databases from inception up to 20 October 2016. Only randomized clinical trials comparing HFNC with COT or HFNC with NIV were included. The intubation rate was the primary outcome; secondary outcomes included the mechanical ventilation rate, the rate of escalation of respiratory support and mortality. Results Eleven studies that enrolled 3459 patients (HFNC, n  = 1681) were included. There were eight studies comparing HFNC with COT, two comparing HFNC with NIV, and one comparing all three. HFNC was associated with a significant reduction in intubation rate (OR 0.52, 95% CI 0.34 to 0.79, P  = 0.002), mechanical ventilation rate (OR 0.56, 95% CI 0.33 to 0.97, P  = 0.04) and the rate of escalation of respiratory support (OR 0.45, 95% CI 0.31 to 0.67, P  < 0.0001) when compared to COT. There was no difference in mortality between HFNC and COT utilization (OR 1.01, 95% CI 0.67 to 1.53, P  = 0.96). When HFNC was compared to NIV, there was no difference in the intubation rate (OR 0.96; 95% CI 0.66 to 1.39, P  = 0.84), the rate of escalation of respiratory support (OR 1.00, 95% CI 0.77 to 1.28, P  = 0.97) or mortality (OR 0.85, 95% CI 0.43 to 1.68, P  = 0.65). Conclusions Compared to COT, HFNC reduced the rate of intubation, mechanical ventilation and the escalation of respiratory support. When compared to NIV, HFNC showed no better outcomes. Large-scale randomized controlled trials are necessary to prove our findings. Trial registration PROSPERO International prospective register of systematic reviews on May 25, 2016 registration no. CRD42016039581 .

[This corrects the article DOI: 10.3389/fmed.2025.1594145.].

After the SARS-CoV-2 pandemic, we noticed a marked increase in high-flow nasal cannula use for bronchiolitis. This study aims to report the percentage of children treated with high-flow nasal cannula (HFNC) in various seasons. The secondary outcomes were admissions for bronchiolitis, virological results, hospital burden, and NICU/PICU need. We conducted a retrospective study in four Italian hospitals, examining the medical records of all infants (< 12 months) hospitalized for bronchiolitis in the last four winter seasons (1 September–31 March 2018–2022). In the 2021–2022 winter season, 66% of admitted children received HFNC versus 23%, 38%, and 35% in the previous 3 years. A total of 876 patients were hospitalized in the study periods. In 2021–2022, 300 infants were hospitalized for bronchiolitis, 22 in 2020–2021, 259 in 2019–2020, and 295 in 2018–2019. The percentage of patients needing intensive care varied from 28.7% to 18%, 22%, and 15% in each of the four considered periods ( p  < 0.05). Seventy-seven percent of children received oxygen in the 2021–2022 winter; vs 50%, 63%, and 55% ( p  < 0.01) in the previous 3 years. NIV/CPAP was used in 23%, 9%, 16%, and 12%, respectively. In 2021–2020, 2% of patients were intubated; 0 in 2020–2021, 3% in 2019–2020, and 1% in 2018–2019. Conclusion: This study shows a marked increase in respiratory support and intensive care admissions this last winter. While these severity indexes were all driven by medical choices, more reliable indexes such as intubation rate and length of stay did not change. Therefore, we suggest that there is a more aggressive treatment attitude rather than a more severe disease. What is Known: • COVID-19 pandemic deeply impacted bronchiolitis epidemiology, reducing hospitalizations to onetenth. In the 2021-2022 winter, bronchiolitis resurged to pre-pandemic numbers in Europe. What is New: • Bronchiolitis hospitalization rose much faster in the 2021-2022 winter period, peaking at a higher level. Respiratory supports and high-flow nasal cannula increased significantly compared to the pre-pandemic era.

Continuous positive airway pressure (CPAP) has been used in infants with bronchiolitis for decades. Recently, high flow nasal cannula (HFNC) therapy was introduced. We conducted a trial of 50 children with bronchiolitis who were randomized to treatment with CPAP or HFNC. Objectives were to compare the development in respiratory rate, pCO2, and Modified Woods Clinical Asthma Score (M-WCAS) in young children with bronchiolitis, treated with CPAP or HFNC. Secondarily, to compare Neonatal Infant Pain Score (NIPS), treatment duration, treatment failure, and hospitalization length. Median age at inclusion was 2.8 (CPAP group) vs 2.1 months (HFNC group). Mean baseline pCO2 was 6.7 in both groups and mean respiratory rate was 60 vs 56 in the CPAP and HFNC group respectively. No differences were observed in development of respiratory rate, pCO2, or M-WCAS. NIPS was higher in the CPAP group. Treatment failure was scarce in both groups. No significant differences in treatment duration or length of hospitalization were observed.Conclusion: In infants and young children with bronchiolitis, HFNC may be an effective and pleasant alternative to CPAP. Larger multicenter studies are needed to further explore differences in treatment failure and treatment duration.Trial registration: www.clinicaltrial.gov. id NCT02618213, registration date December 1, 2015.What is Known:• CPAP has been used for many years for respiratory support in infant bronchiolitis. The method requires special staff skills and may be stressful to the child.• HFNC has been introduced as a newer tool.What is New:• In infants with bronchiolitis, HFNC and CPAP were comparable in decreasing respiratory rate, pCO2, and need for oxygen supply.• Pain score during therapy was lower in the HFNC group.

Background The benefit of Inhaled nitric oxide (iNO) therapy in the setting of COVID-19-related ARDS is obscure. We performed a multicenter retrospective study to evaluate the impact of iNO on patients with COVID-19 who require respiratory support. Methods This retrospective multicenter study included COVID-19 patients enrolled in the SCCM VIRUS COVID-19 registry who were admitted to different Mayo Clinic sites between March 2020 and June 2022 and required high-flow nasal cannula (HFNC), non-invasive ventilation (NIV), or invasive mechanical ventilation (IMV). Patients were included in the ‘spontaneously breathing’ group if they remained non-intubated or were initiated on an HFNC (± NIV) before intubation. Patients who got intubated without prior use of an HFNC (± NIV) were included in the ‘intubated group.’ They were further divided into categories based on their iNO usage. Propensity score matching (PSM) and inverse propensity of treatment weighting (IPTW) were performed to examine outcomes. Results Among 2767 patients included in our analysis, 1879 belonged to spontaneously breathing (153 received iNO), and 888 belonged to the intubated group (193 received iNO). There was a consistent improvement in FiO2 requirement, P/F ratio, and respiratory rate within 48 h of iNO use among both spontaneously breathing and intubated groups. However, there was no significant difference in intubation risk with iNO use among spontaneously breathing patients (PSM OR 1.08, CI 0.71–1.65; IPTW OR 1.10, CI 0.90–1.33). In a time-to-event analysis using Cox proportional hazard model, spontaneously breathing patients initiated on iNO had a lower hazard ratio of in-hospital mortality (PSM HR 0.49, CI 0.32–0.75, IPTW HR 0.40, 95% CI 0.26–0.62) but intubated patients did not (PSM HR: 0.90; CI 0.66–1.24, IPTW HR 0.98, 95% CI 0.73–1.31). iNO use was associated with longer in-hospital stays, ICU stays, ventilation duration, and a higher incidence of creatinine rise. Conclusions This retrospective propensity-score matched study showed that spontaneously breathing COVID-19 patients on HFNC/ NIV support had a decreased in-hospital mortality risk with iNO use in a time-to-event analysis. Both intubated and spontaneously breathing patients had improvement in oxygenation parameters with iNO therapy but were associated with longer in-hospital stays, ICU stays, ventilation duration, and higher incidence of creatinine rise.

Background To determine whether lung ultrasound (LUS) may early predict the failure of non-invasive respiratory support (high-flow nasal cannula-HFNC, continuous positive airway pressure-CPAP, non-invasive ventilation-NIV) in hypoxemic patients. Methods In this prospective multicenter international observational study, we enrolled patients undergoing non-invasive treatments for hypoxemia (PaO 2 /FiO 2  < 300 mmHg). LUS, PaO 2 /FiO 2 and ROX index were assessed before (baseline) and 2 h after treatment start. Regional/global LUS aeration scores were computed (4 degrees of loss-of-aeration: 0-normal to 3-severe loss of aeration) in 6 regions per hemithorax (2 anterior, 2 lateral, 2 posterior). Failure was defined as need of respiratory support’s escalation within 48 h (HFNC to CPAP to NIV, any support to intubation/ECMO). Results We studied 100 patients (age 70 [57–76] years; female sex 39%; supports: 13 HFNC, 68 CPAP, 19 NIV); the overall rate of treatment failure was 22%. At the baseline, clinical and ultrasound parameters were similar in failing and non-failing patients; after 2 h, failing patients had lower PaO 2 /FiO 2 . (149 mmHg [124–201] vs. 200 [171–243]; p  = 0.001), lower ROX index (7.8 [4.9–9.2] vs. 10.9 [7.9–13.8]; p  = 0.003) and higher lateral (3.0 [1.0–6.0] vs. 1.5 [0.0–3.0]; p  = 0.047), antero-lateral (4.0 [1.0–9.0] vs. 2.0 [0.0–4.0]; p  = 0.027) and global (13.0 [8.0–17.0] vs. 10.0 [7.0–13.0]; p  = 0.036) LUS aeration scores. No improvement in lung aeration was observed in failing patients within the initial 2 h of treatment (global LUS score variations 0.0 [-2.0–1.0] vs. -3.0 [-5.0 – -2.0]; p  < 0.001). ROX index and antero-lateral/global LUS scores’ variations were independent predictors of failure. AUCs for treatment failure were: 2-hour ROX index 0.71 [0.58–0.84], 2-hour PaO 2 /FiO 2 0.73 [0.60–0.85], global LUS score variations 0.73 [0.62–0.89]. A combined clinical-ultrasound score (ROX-US) showed AUC of 0.82 [0.73–0.91]. A ROX-US≥1 identified the success of the treatment with sensitivity 95% and specificity 50%; a ROX-US≥2 identified the success of the treatment with sensitivity 45% and specificity 96%. Conclusions Changes in LUS aeration scores induced by 2 h of non-invasive respiratory support help early predict the risk of treatment failure. LUS score improved only in responders and was an independent predictor of failure.