Chronic obstructive pulmonary disease (COPD) remains a major public health problem. It is the fourth leading cause of chronic morbidity and mortality in the United States, and is projected to rank fifth in 2020 in burden of disease worldwide, according to a study published by the World Bank/World Health Organization. Yet, COPD remains relatively unknown or ignored by the public as well as public health and government officials. In 1998, in an effort to bring more attention to COPD, its management, and its prevention, a committed group of scientists encouraged the U.S. National Heart, Lung, and Blood Institute and the World Health Organization to form the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Among the important objectives of GOLD are to increase awareness of COPD and to help the millions of people who suffer from this disease and die prematurely of it or its complications. The first step in the GOLD program was to prepare a consensus report, Global Strategy for the Diagnosis, Management, and Prevention of COPD, published in 2001. The present, newly revised document follows the same format as the original consensus report, but has been updated to reflect the many publications on COPD that have appeared. GOLD national leaders, a network of international experts, have initiated investigations of the causes and prevalence of COPD in their countries, and developed innovative approaches for the dissemination and implementation of COPD management guidelines. We appreciate the enormous amount of work the GOLD national leaders have done on behalf of their patients with COPD. Despite the achievements in the 5 years since the GOLD report was originally published, considerable additional work is ahead of us if we are to control this major public health problem. The GOLD initiative will continue to bring COPD to the attention of governments, public health officials, health care workers, and the general public, but a concerted effort by all involved in health care will be necessary.

https://www.who.int/respiratory/copd/GOLD_WR_06.pdf

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary.

Objective:To provide an update to the “Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock,” last published in 2008.Design:A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at ke

Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.

To provide an update to the “Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock,” last published in 2008. A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Recommendations were classified into three groups: (1) those directly targeting severe sepsis; (2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and (3) pediatric considerations. Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 h after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 h of the recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 h of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1B); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients (1C); fluid challenge technique continued as long as hemodynamic improvement is based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥65 mmHg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of (a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or (b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7–9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a Pao
 2/Fio
 2 ratio of ≤100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 h) for patients with early ARDS and a Pao
 2/Fi
 o
 2 180 mg/dL, targeting an upper blood glucose ≤180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 h after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 h of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5–10 min (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven “absolute”’ adrenal insufficiency (2C). Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients.

/pdf/surviving-sepsis-campaign-international-guidelines-for-229kg8suph.pdf

Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock, 2012

tion’, implying that most patients ‘should’ receive a particular action. In contrast, level 2 guidelines are essentially ‘suggestions’ and are deemed to be ‘weak’ or discretionary, recognising that management decisions may vary in different clinical contexts. Each recommendation was further graded from A to D by the quality of evidence underpinning them, with grade A referring to a high quality of evidence whilst grade D recognised a ‘very low’ evidence base. The overall strength and quality of the supporting evidence is summarised in table 1 . The guidelines focused on 4 key domains: (1) AKI definition, (2) prevention and treatment of AKI, (3) contrastinduced AKI (CI-AKI) and (4) dialysis interventions for the treatment of AKI. The full summary of clinical practice statements is available at www.kdigo.org, but a few key recommendation statements will be highlighted here.

/pdf/kdigo-clinical-practice-guidelines-for-acute-kidney-injury-27tybolw7l.pdf

KDIGO clinical practice guidelines for acute kidney injury.

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary.


Objective. To evaluate the feasibility and safety of fiberoptic bronchoscopy (FOB) with bronchoalveolar lavage (BAL) during noninvasive positive pressure ventilation (NPPV) delivered by helmet in patients with acute respiratory failure (ARF) and suspected pneumonia. 
Design and setting. Prospective, clinical investigation in a general intensive care unit (ICU) of a university hospital. 
Patients and participants. Four adult patients with ARF who underwent NPPV via the helmet and required fiberoptic BAL for suspected pneumonia. 
Interventions. NPPV was delivered through the helmet in the pressure support ventilation mode. The specific seal connector placed in the plastic ring of the helmet allowed the passage of the bronchoscope, maintaining assisted ventilation. Arterial blood gas levels, pH, oxygen saturation, respiratory rate, heart rate, and mean arterial blood pressure were monitored during the study. 
Results. Helmet NPPV avoided gas exchanges deterioration during FOB and BAL, with good tolerance. During the procedure heart rate increased by 5% and mean arterial blood pressure by 7% over baseline; these levels returned to prebronchoscopic values immediately after the withdrawal of the bronchoscope. Endotracheal intubation was never required during the 24 h after the procedure. BAL yielded diagnostic information in three of four patients. 
Conclusions. NPPV through the helmet allows a safe diagnostic FOB with BAL in patients with hypoxemic ARF, avoiding gas exchange deterioration, and endotracheal intubation. 
Electronic supplementary material is available if you access this article at http://dx.doi.org/10.1007/s00134-002-1554-5. On that page (frame on the left side), a link takes you directly to the supplementary materials.

Fiberoptic bronchoscopy during noninvasive positive pressure ventilation delivered by helmet.

Multisystemic involvement of post-traumatic fat embolism at a Pediatric Trauma Center: a clinical series and literature review

Accidental drowning represents a leading cause of paediatric injury worldwide. Dirty water and sand/mud aspiration during submersion is quite rare though possibly lifethreatening, due to the complex mechanism of asphyxia. Aspiration of particulate matter should be considered in all dirty water drowning, and early bronchoscopy, and/ or airway lavage, should be undertaken when diagnosis is uncertain. Even if the early mechanical consequences of large quantity of contaminated water are overcome1, sand, mud, and a variety of microbes entering into their lower airways pose a significant infectious risk for both pulmonary and extrapulmonary complications.2– 4 Although relatively uncommon, sand and particulate aspiration in the neardrowning child should be excluded because of the associated spectrum of injuries. Acute respiratory failure secondary to inadequate ventilation may develop if the oropharynx and upper airway are partially occluded by sand. Damage to the bronchioles and alveoli can result in significant airway inflammation and acute lung injury requiring prolonged mechanical ventilatory support. Initial Chest XRay is often nonspecific, and sometimes only diffuse atelectatic or an alveolar patchy picture can be seen [Figure 1]. According to some authors, a role for early airway clearance has been suggested,1 possibly preventing further airway damage and barotrauma; moreover, submersion in dirty water makes it necessary for an early bronchoalveolar lavage to remove particulate and, possibly, to reduce the bacterial and fungal load.1,2 Undiagnosed foreign body in the bronchial tree may result in serious longterm sequelae such as recurrent pneumonia, atelectasis, or bronchiectasis.5 Traditionally, clinical outcome in children after neardrowning has been associated with cardiac arrest, a submersion time of >15 min, with no bystander CPR, an extended resuscitation time with the use of epinephrine/profound metabolic acidosis, and deep hypothermia.3 For patients experiencing dirty drowning, the early development of pneumonia is likely if the aspiration into the airway is accompanied by a large inoculum of infectious agents. Therefore, beyond early airway injury and cerebral hypoxia, infectious complications can have a profound influence on the clinical outcome. Late deaths from fungal Central Nervous System (CNS) complications have also been described, underlining the need for early fungal investigations and treatment2,6 A recent review paper regarding neardrowning intensive care7 could not demonstrate a significant advantage when using prophylactic antibiotics in neardrowning patients and highly contaminated submersion water. However, for dirtydrowned children, both antibiotic and antimycotic prophylaxis appear mandatory. We report the ICU management of five children (four male and one female), aged 2– 15 years (median age nine years), who were retrieved by heliambulance after being submersed in dirty water, suffering from asphyxia and aspiration of water contaminated by sand and/or mud. All the patients presented with a severe hypoxemic Acute Respiratory Failure (ARF). Three of them received an emergency intubation on site, while two were intubated at PICU admission. Four of them underwent early airway clearance, that in wo cases was guided by fibrobronchoscopy. The admission blood gas analysis showed in all cases a picture of respiratory acidosis with a reduced P/F. The only patient with further pulmonary complications (bilateral barotrauma, early severe pneumonia, refractory hypoxaemia) did not undergo early intubation and bronchoalveolar lavage. He required invasive ventilation for 26 days, while median invasive mechanical ventilation duration in all patients was five days, and reached a maximum Oxygenation Index (OI) of 35 (median of maximum OI in all patients: 15), also requiring iNO and eventually ExtraCorporeal Membrane Oxygenation. He was also the only patient with late complications (seizures with MRI finding of CNS bleeding) and remained in PICU for 87 days (median PICU stay of all dirty drowning patients was eight days). Main clinical and laboratory findings are illustrated in supporting information Table S1, and admission chest radiograms in Figure 1. This clinical series consists of five chidren admitted to the PICU after being retrieved from neardrowning in “dirty” and possibly contaminated fresh water: available literature mostly depicts isolated case reports or mixed series.6 Drowning in dirty water remains a relatively uncommon occurrence in paediatrics, while it can lead to respiratory failure secondary to inadequate ventilation for occlusive phenomena at onset (mud, sand)1; however, airway inflammation and acute lung injury can develop in the following hours requiring even prolonged mechanical ventilatory support. Inhomogeneous lung damage may facilitate air leaks whenever airway pressure is required to achieve gas exchange. Sequential lung washing followed by exogenous surfactant administration has also been described,1 and it seems reasonable because high amounts of lavage fluids can dilute and remove natural surfactant, possibly increasing the risk of lung atelectasis.

“Dirty drowning” related lung injury in a paediatric intensive care unit

Intrathecal nusinersen administration, a fundamental step in the treatment of spinal muscular atrophy, is challenging in children.

Needleless inhaled anesthesia with sevoflurane: Advantages of a simplified approach for children with spinal muscular atrophy undergoing intrathecal administration of nusinersen

Giorgio Conti

Papers

Fiberoptic bronchoscopy during noninvasive positive pressure ventilation delivered by helmet.

Multisystemic involvement of post-traumatic fat embolism at a Pediatric Trauma Center: a clinical series and literature review

“Dirty drowning” related lung injury in a paediatric intensive care unit

Needleless inhaled anesthesia with sevoflurane: Advantages of a simplified approach for children with spinal muscular atrophy undergoing intrathecal administration of nusinersen

Autonomic dysfunction as first presentation of Glu54Gln transthyretin amyloidosis