ContextHypoxemia complicates the recovery of 30% to 50% of patients after abdominal
surgery; endotracheal intubation and mechanical ventilation may be required
in 8% to 10% of cases, increasing morbidity and mortality and prolonging intensive
care unit and hospital stay.ObjectiveTo determine the effectiveness of continuous positive airway pressure
compared with standard treatment in preventing the need for intubation and
mechanical ventilation in patients who develop acute hypoxemia after elective
major abdominal surgery.Design and SettingRandomized, controlled, unblinded study with concealed allocation conducted
between June 2002 and November 2003 at 15 intensive care units of the Piedmont
Intensive Care Units Network in Italy.PatientsConsecutive patients who developed severe hypoxemia after major elective
abdominal surgery. The trial was stopped for efficacy after 209 patients had
been enrolled.InterventionsPatients were randomly assigned to receive oxygen (n = 104)
or oxygen plus continuous positive airway pressure (n = 105).Main Outcome MeasuresThe primary end point was incidence of endotracheal intubation; secondary
end points were intensive care unit and hospital lengths of stay, incidence
of pneumonia, infection and sepsis, and hospital mortality.ResultsPatients who received oxygen plus continuous positive airway pressure
had a lower intubation rate (1% vs 10%; P = .005;
relative risk [RR], 0.099; 95% confidence interval [CI], 0.01-0.76) and had
a lower occurrence rate of pneumonia (2% vs 10%, RR, 0.19; 95% CI, 0.04-0.88; P = .02), infection (3% vs 10%, RR, 0.27; 95%
CI, 0.07-0.94; P = .03), and sepsis (2%
vs 9%; RR, 0.22; 95% CI, 0.04-0.99; P = .03)
than did patients treated with oxygen alone. Patients who received oxygen
plus continuous positive airway pressure also spent fewer mean (SD) days in
the intensive care unit (1.4 [1.6] vs 2.6 [4.2], P = .09)
than patients treated with oxygen alone. The treatments did not affect the
mean (SD) days that patients spent in the hospital (15 [13] vs 17 [15], respectively; P = .10). None of those treated with oxygen plus
continuous positive airway pressure died in the hospital while 3 deaths occurred
among those treated with oxygen alone (P = .12).ConclusionContinuous positive airway pressure may decrease the incidence of endotracheal
intubation and other severe complications in patients who develop hypoxemia
after elective major abdominal surgery.

https://jamanetwork.com/journals/jama/articlepdf/200264/jce40057.pdf

Continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial

Objective: In randomized studies of heterogeneous patients with hypoxemic acute respiratory failure, noninvasive positive pressure ventilation (NPPV) was associated with a significant reduction in endotracheal intubation. The role of NPPV in patients with acute respiratory distress syndrome (ARDS) is still unclear. The objective was to investigate the application of NPPV as a first-line intervention in patients with early ARDS, describing what happens in everyday clinical practice in centers having expertise with NPPV. Design: Prospective, multiple-center cohort study. Setting: Three European intensive care units having expertise with NPPV. Patients: Between March 2002 and April 2004, 479 patients with ARDS were admitted to the intensive care units. Three hundred and thirty-two ARDS patients were already intubated, so 147 were eligible for the study. Interventions: Application of NPPV. Measurements and Main Results: NPPV improved gas exchange and avoided intubation in 79 patients (54%). Avoidance of intubation was associated with less ventilator-associated pneumonia (2% vs. 20%; p 34 and a PaO2/FIO2 34 and the inability to improve PaO2/FIO2 after 1 hr of NPPV were predictors of failure. (Crit Care Med 2007; 35:18‐25)

/pdf/a-multiple-center-survey-on-the-use-in-clinical-practice-of-3zmxsf5be9.pdf

A multiple-center survey on the use in clinical practice of noninvasive ventilation as a first-line intervention for acute respiratory distress syndrome*

Background: Over the past decade, noninvasive positive-pressure ventilation (NPPV) in the setting of acute exacerbations of chronic obstructive pulmonary disease (COPD) has increased in popularity. Although several trials have been published on the relative effectiveness of this treatment, apparent inconsistencies in study results remain. Purpose: To assess the effect of NPPV on rate of endotracheal intubation, length of hospital stay, and in-hospital mortality rate in patients with an acute exacerbation of COPD and to determine the effect of exacerbation severity on these outcomes. Data Sources: MEDLINE (1966 to 2002) and EMBASE (1990 to 2002). Additional data sources included the Cochrane Library, personal files, abstract proceedings, reference lists of selected articles, and expert contact. There were no language restrictions. Study Selection: The researchers selected randomized, controlled trials that 1) examined patients with acute exacerbation of COPD; 2) compared noninvasive ventilation and standard therapy with standard therapy alone; and 3) included need for endotracheal intubation, length of hospital stay, or hospital survival as an outcome. Data Extraction: Methodologic quality and results were abstracted independently and in duplicate. Data Synthesis: The addition of NPPV to standard care in patients with an acute exacerbation of COPD decreased the rate of endotracheal intubation (risk reduction, 28% [95% CI, 15% to 40%]), length of hospital stay (absolute reduction, 4.57 days [CI, 2.30 to 6.83 days]), and in-hospital mortality rate (risk reduction, 10% [CI, 5% to 15%]). However, subgroup analysis showed that these beneficial effects occurred only in patients with severe exacerbations, not in those with milder exacerbations. Conclusions: Patients with severe exacerbations of COPD benefit from the addition of NPPV to standard therapy. However, NPPV has not been shown to benefit hospitalized patients with milder COPD exacerbations.

Which patients with acute exacerbation of chronic obstructive pulmonary disease benefit from noninvasive positive-pressure ventilation: a systematic review of the literature

Inspiratory pressure support prevents diaphragmatic fatigue during weaning from mechanical ventilation.

### Principles of mechanical ventilation

#### Modes of mechanical ventilation

Recommendation 

1. Pressure-targeted ventilators are the devices of choice for acute NIV (Grade B).

Good practice points 

#### Choice of interface for NIV

Recommendation 

2. A full face mask (FFM) should usually be the first type of interface used (Grade D).

Good practice points 

#### Indications for and contra-indications to NIV in AHRF

Recommendation 

3. The presence of adverse features increase the risk of NIV failure and should prompt consideration of placement in high dependency unit (HDU)/intensive care unit (ICU) (Grade C).

Good practice points 

#### Monitoring during NIV

Good practice points 

#### Supplemental oxygen therapy with NIV

Recommendations 

4. Oxygen enrichment should be adjusted to achieve SaO2 88–92% in all causes of acute hypercapnic respiratory failure (AHRF) treated by NIV (Grade A).

5. Oxygen should be entrained as close to the patient as possible (Grade C).

Good practice points

https://thorax.bmj.com/content/thoraxjnl/71/Suppl_2/ii1.full.pdf

BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults

Background: Noninvasive positive pressure ventilation (NPPV) with a facemask (FM) is effective in patients with acute exacerbation of their chronic obstructive pulmonary disease. Whether it is feasible to treat these patients with NPPV delivered by a helmet is not known. Methods: Over a 4-month period, the authors studied 33 chronic obstructive pulmonary disease patients with acute exacerbation who were admitted to four intensive care units and treated with helmet NPPV. The patients were compared with 33 historical controls treated with FM NPPV, matched for simplified acute physiologic score (SAPS II), age, Paco 2 , pH, and Pao 2 : fractional inspired oxygen tension. The primary endpoints were the feasibility of the technique, improvement of gas exchange, and need for intubation. Results: The baseline characteristics of the two groups were similar. Ten patients in the helmet group and 14 in the FM group (P = 0.22) were intubated. In the helmet group, no patients were unable to tolerate NPPV, whereas five patients required intubation in the FM group (P = 0.047). After 1 h of treatment, both groups had a significant reduction of Paco 2 with improvement of pH; Paco 2 decreased less in the helmet group (P = 0.01). On discontinuing support, Paco 2 was higher (P = 0.002) and pH lower (P = 0.02) in the helmet group than in the control group. One patient in the helmet group, and 12 in the FM group, developed complications related to NPPV (P < 0.001). Length of intensive care unit stay, intensive care unit, and hospital mortality were similar in both groups. Conclusions: Helmet NPPV is feasible and can be used to treat chronic obstructive pulmonary disease patients with acute exacerbation, but it does not improve carbon dioxide elimination as efficiently as does FM NPPV.

/pdf/noninvasive-positive-pressure-ventilation-using-a-helmet-in-150yl58v0y.pdf

Noninvasive positive pressure ventilation using a helmet in patients with acute exacerbation of chronic obstructive pulmonary disease: a feasibility study.

OBJECTIVE
Perioperative management of glucose levels remains challenging. We aimed to assess whether fully closed-loop subcutaneous insulin delivery would improve glycemic control compared with standard insulin therapy in insulin-requiring patients undergoing elective surgery.


RESEARCH DESIGN AND METHODS
We performed a single-center, open-label, randomized controlled trial. Patients with diabetes (other than type 1) undergoing elective surgery were recruited from various surgical units and randomly assigned using a minimization schedule (stratified by HbA1c and daily insulin dose) to fully closed-loop insulin delivery with fast-acting insulin aspart (closed-loop group) or standard insulin therapy according to local clinical practice (control group). Study treatment was administered from hospital admission to discharge (for a maximum of 20 days). The primary end point was the proportion of time with sensor glucose in the target range (5.6-10.0 mmol/L).


RESULTS
Forty-five patients were enrolled and assigned to the closed-loop (n = 23) or the control (n = 22) group. One patient (closed-loop group) withdrew from the study before surgery and was not analyzed. Participants underwent abdominal (57%), vascular (23%), orthopedic (9%), neuro (9%), or thoracic (2%) surgery. The mean proportion of time that sensor glucose was in the target range was 76.7 ± 10.1% in the closed-loop and 54.7 ± 20.8% in the control group (mean difference 22.0 percentage points [95% CI 11.9; 32.0%]; P < 0.001). No episodes of severe hypoglycemia (<3.0 mmol/L) or hyperglycemia with ketonemia or any study-related adverse events occurred in either group.


CONCLUSIONS
In the context of mixed elective surgery, the use of fully closed-loop subcutaneous insulin delivery improves glucose control without a higher risk of hypoglycemia.

Perioperative Fully Closed-Loop Insulin Delivery in Patients Undergoing Elective Surgery: An Open-Label, Randomized Controlled Trial.

Background and Aims: Pancreatic surgery challenges perioperative glucose management by abrupt changes in endogenous insulin stores, surgical stress, medication and nutritional support. We hypothesize that fully closed-loop (CL) insulin delivery, compared to usual care, may better accomodate the complex needs of this population.
 Methods: In this subpopulation analysis of a randomized controlled trial (NCT04361799) we compared the CamAPS HX fully CL system using subcutaneous faster insulin aspart (CL) with standard insulin treatment (control) in patients undergoing pancreatic surgery. Glucose control was assessed using the Dexcom G6 continuous glucose monitoring (blinded in the control group) from hospital admission to discharge (max 20 days) .
 Results: Twelve patients (6 per group, 58% female, mean±SD age 69±18 years, BMI 27.3±3.9 kg/m2, HbA1C 7.8±2.0 %, 66 % total pancreatectomy) were analyzed. Median [IQR] %time in target glucose range (5.6-10.0mmol/L) was 76.5 [75.3; 80.3] % with CL vs. 45.6 [24.1; 55.5] % with control (P=0.005) . Time in hypoglycemia (<3.9mM and <3.0mM) did not differ between groups (P=0.81 and P=0.46) . No study-related serious adverse events occurred in either group.
 Conclusions: Perioperative fully CL in patients undergoing partial or total pancreatectomy improves glucose control compared to standard insulin therapy without a higher risk of hypoglycemia.
 
 
 
 D.Herzig: None. R.Hovorka: Advisory Panel; Eli Lilly and Company, Other Relationship; CamDiab Ltd., Research Support; Abbott Diabetes, Dexcom, Inc., Medtronic, Speaker's Bureau; Dexcom, Inc., Eli Lilly and Company, Novo Nordisk. A.Vogt: None. L.Bally: None. S.Suhner: None. L.Cecchini: None. J.L.Roos: None. D.Schürch: None. C.Nakas: None. G.Beldi: None. B.Gloor: None. M.E.Wilinska: Consultant; CamDiab Ltd.
 
 
 
 Swiss Helmut Horten Foundation;Swiss Foundation for Anaesthesiology and Intensive Care;Product support by Dexcom Inc.;


Luca Cecchini

Papers

Noninvasive positive pressure ventilation using a helmet in patients with acute exacerbation of chronic obstructive pulmonary disease: a feasibility study.

Perioperative Fully Closed-Loop Insulin Delivery in Patients Undergoing Elective Surgery: An Open-Label, Randomized Controlled Trial.

757-P: Perioperative Fully Closed-Loop vs. Standard Insulin Therapy in Adults Undergoing Pancreatic Surgery