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Respiratory Care Jan 2021Studies evaluating neuromuscular blocking agents (NMBAs) in the management of ARDS have produced inconsistent results in terms of their effect on mortality. The purpose... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Studies evaluating neuromuscular blocking agents (NMBAs) in the management of ARDS have produced inconsistent results in terms of their effect on mortality. The purpose of this systematic review and meta-analysis was to evaluate differences in mortality comparing subjects with ARDS who received NMBA to those who received placebo or usual care.
METHODS
We searched Ovid, MEDLINE, Embase, CINAHL, Cochrane, Scopus, and Web of Science for randomized controlled trials evaluating administration of NMBAs in subjects with ARDS.
RESULTS
We included 6 studies ( = 1,558 subjects) from 1,814 abstracts identified by our search strategy. The use of early, continuous-infusion NMBAs reduces the risk of short-term (ie, 21-28-d) mortality (relative risk 0.71 [95% CI 0.52-0.98], = .030, = 60%) in subjects with ARDS but does not reduce the risk of long-term (ie, 90-d) mortality (relative risk 0.81 [95% CI 0.64-1.04], = .10, = 54%). NMBAs decreased the risk of barotrauma (relative risk 0.55 [95% CI 0.35-0.85], = .008, = 0%) and pneumothorax (relative risk 0.46 [95% CI 0.28-0.77], = .003, = 0%) compared to control.
CONCLUSIONS
In subjects with ARDS, early use of NMBAs improves oxygenation, reduces the incidence of ventilator-induced lung injury, and decreases 21-28-d mortality, but it does not improve 90-d mortality. NMBAs should be considered for select patients with moderate-to-severe ARDS for short durations.
Topics: Barotrauma; Humans; Lung; Neuromuscular Blocking Agents; Respiration, Artificial; Respiratory Distress Syndrome; Time Factors
PubMed: 32843506
DOI: 10.4187/respcare.07849 -
European Archives of... Feb 2022Tympanic membrane retraction (TMR) is a relatively common otological finding. However, no consensus on its management exists. We are looking especially for a treatment...
IMPORTANCE
Tympanic membrane retraction (TMR) is a relatively common otological finding. However, no consensus on its management exists. We are looking especially for a treatment strategy in the military population who are unable to attend frequent follow-up visits, and who experience relatively more barotrauma at great heights and depths and easily suffer from otitis externa from less hygienic circumstances.
OBJECTIVE
To assess and summarize the available evidence for the effectiveness of surgical interventions and watchful waiting policy in patients with a tympanic membrane retraction.
EVIDENCE REVIEW
The protocol for this systematic review was published at Prospero (207859). PubMed, Embase, and the Cochrane Database of Systematic Reviews were systematically searched from inception up to September 2020 for published and unpublished studies. We included randomized trials and observational studies that investigated surgical interventions (tympanoplasty, ventilation tube insertion) and wait-and-see policy. The primary outcomes of this study were clinical remission of the tympanic membrane retraction, tympanic membrane perforations and cholesteatoma development.
FINDINGS
In total, 27 studies were included, consisting of 1566 patients with TMRs. We included data from 2 randomized controlled trials (76 patients) and 25 observational studies (1490 patients). Seven studies (329 patients) investigated excision of the TMR with and without ventilation tube placement, 3 studies (207 patients) investigated the wait-and-see policy and 17 studies (1030 patients) investigated tympanoplasty for the treatment of TMRs.
CONCLUSIONS AND RELEVANCE
This study provides all the studies that have been published on the surgical management and wait-and-policy for tympanic membrane retractions. No high level of evidence comparative studies has been performed. The evidence for the management of tympanic membrane retractions is heterogenous and depends on many factors such as the patient population, location and severity of the TMR and presence of other ear pathologies (e.g., perforation, risk of cholesteatoma and serous otitis media).
Topics: Humans; Middle Ear Ventilation; Otitis Media with Effusion; Tympanic Membrane; Tympanoplasty
PubMed: 33689022
DOI: 10.1007/s00405-021-06719-3 -
Journal of Oral and Maxillofacial... May 2023E-cigarettes have become increasingly popular devices used to consume nicotine in recent years. There is a growing body of evidence regarding the risk of spontaneous...
PURPOSE
E-cigarettes have become increasingly popular devices used to consume nicotine in recent years. There is a growing body of evidence regarding the risk of spontaneous explosion of these devices causing burn and projectile injuries. The primary purpose of this review was to summarize all injuries to the oral and maxillofacial region secondary to explosion of e-cigarettes. The secondary purpose was to propose an initial management algorithm for such injuries based on the findings in the literature. This review also aims to test the hypothesis that e-cigarette explosive injuries to the oral region were associated with an increased risk of intubation and surgery and examine whether any other injury pattern was associated with an increased risk of intubation or surgery.
METHODS
A cohort study based on identifying cases in the literature was conducted to summarize injuries to the oral and maxillofacial region and examine the associations between injury types and location and management. A literature search of the major biomedical databases was conducted in September 2022 using terms such as e-cigarette, explosion, blast, trauma, and burn, among others, which yielded 922 studies. Nonclinical studies, review articles, and studies without injuries to the facial region were excluded. Study subjects were recorded for demographics, device characteristics, injury mechanism, injury location, management, and complications. Chi-squared analysis was used to determine if the predictor variables of type of injury (burn or projectile) and its associated location (ocular, facial, or intraoral for burns and facial thirds for projectile) were associated with the outcomes of intubation and surgical management. The collected data were then used as a guide to propose an initial management algorithm for these injuries.
RESULTS
Twenty eight studies, including 20 case reports and 8 case series met the inclusion criteria. A total of 32 explosions of e-cigarettes to 32 patients caused 105 recorded injuries to the facial region. Projectile injuries made up 73.3% (n = 77) of all facial injuries, while burn injuries made up of 26.7% (n = 28). There were 14 (43.8%) patients who suffered both projectile and burn injuries. Burn injuries mostly involved the face (64.3%, n = 18), oral cavity (25%, n = 7), and eye (10.7%, n = 7). The majority (81.8%, n = 63) of projectile injuries occurred in the lower facial third. There were 20 (62.5%) patients who suffered a bone or tooth fracture. Management of injuries involved surgery in 62.5% (n = 20) of patients, which included open reduction and internal fixation of fractures, dental extraction, bone and skin grafts, and ocular surgery. A complication rate of 44.4% (n = 8) was observed across studies that reported on follow-up. There was no statistically significant association between explosive injury to the oral region and intubation or surgical management. There was also no other statistically significant association between any other injury type and location with intubation or surgical management.
CONCLUSIONS
E-cigarettes are at risk for spontaneous combustion that can cause serious oral and maxillofacial injuries, particularly to the lower facial third and commonly requiring surgical management. Safety of these devices should be improved through increased user education and regulation.
Topics: Humans; Electronic Nicotine Delivery Systems; Cohort Studies; Burns; Maxillofacial Injuries; Explosions; Blast Injuries; Retrospective Studies
PubMed: 36806607
DOI: 10.1016/j.joms.2023.01.009 -
Critical Care Medicine Mar 2022There are concerns of a high barotrauma rate in coronavirus disease 2019 patients with acute respiratory distress syndrome receiving invasive mechanical ventilation.... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
There are concerns of a high barotrauma rate in coronavirus disease 2019 patients with acute respiratory distress syndrome receiving invasive mechanical ventilation. However, a few studies were published, and reported rates were highly variable. We performed a systematic literature review to identify rates of barotrauma, pneumothorax, and pneumomediastinum in coronavirus disease 2019 acute respiratory distress syndrome patients receiving invasive mechanical ventilation.
DATA SOURCE
PubMed and Scopus were searched for studies reporting barotrauma event rate in adult coronavirus disease 2019 patients receiving invasive mechanical ventilation.
STUDY SELECTION
We included all studies investigating adult patients with coronavirus disease 2019 acute respiratory distress syndrome requiring mechanical ventilation. Case reports, studies performed outside ICU setting, and pediatric studies were excluded. Two investigators independently screened and selected studies for inclusion.
DATA EXTRACTION
Two investigators abstracted data on study characteristics, rate of pneumothorax, pneumomediastinum and overall barotrauma events, and mortality. When available, data from noncoronavirus disease 2019 acute respiratory distress syndrome patients were also collected. Pooled estimates for barotrauma, pneumothorax, and pneumomediastinum were calculated.
DATA SYNTHESIS
A total of 13 studies with 1,814 invasively ventilated coronavirus disease 2019 patients and 493 noncoronavirus disease 2019 patients were included. A total of 266/1,814 patients (14.7%) had at least one barotrauma event (pooled estimates, 16.1% [95% CI, 11.8-20.4%]). Pneumothorax occurred in 132/1,435 patients (pooled estimates, 10.7%; 95% CI, 6.7-14.7%), whereas pneumomediastinum occurred in 162/1,432 patients (pooled estimates, 11.2%; 95% CI, 8.0-14.3%). Mortality in coronavirus disease 2019 patients who developed barotrauma was 111/198 patients (pooled estimates, 61.6%; 95% CI, 50.2-73.0%). In noncoronavirus disease 2019 acute respiratory distress syndrome patients, barotrauma occurred in 31/493 patients (6.3%; pooled estimates, 5.7%; 95% CI, -2.1% to 13.5%).
CONCLUSIONS
Barotrauma occurs in one out of six coronavirus disease 2019 acute respiratory distress syndrome patients receiving invasive mechanical ventilation and is associated with a mortality rate of about 60%. Barotrauma rate may be higher than noncoronavirus disease 2019 controls.
Topics: Barotrauma; COVID-19; Humans; Mediastinal Emphysema; Pneumothorax; Respiration, Artificial; SARS-CoV-2
PubMed: 34637421
DOI: 10.1097/CCM.0000000000005283 -
Diving and Hyperbaric Medicine Dec 2021Inner ear barotrauma (IEBt) and inner ear decompression sickness (IEDCS) are the two dysbaric inner ear injuries associated with diving. Both conditions manifest as... (Review)
Review
INTRODUCTION
Inner ear barotrauma (IEBt) and inner ear decompression sickness (IEDCS) are the two dysbaric inner ear injuries associated with diving. Both conditions manifest as cochleovestibular symptoms, causing difficulties in differential diagnosis and possibly delaying (or leading to inappropriate) treatment.
METHODS
This was a systematic review of IEBt and IEDCS cases aiming to define diving and clinical variables that help differentiate these conditions. The search strategy consisted of a preliminary search, followed by a systematic search covering three databases (PubMed, Medline, Scopus). Studies were included when published in English and adequately reporting one or more IEBt or IEDCS patients in diving. Concerns regarding missing and duplicate data were minimised by contacting original authors when necessary.
RESULTS
In total, 25 studies with IEBt patients (n = 183) and 18 studies with IEDCS patients (n = 397) were included. Variables most useful in differentiating between IEBt and IEDCS were dive type (free diving versus scuba diving), dive gas (compressed air versus mixed gas), dive profile (mean depth 13 versus 43 metres of seawater), symptom onset (when descending versus when ascending or surfacing), distribution of cochleovestibular symptoms (vestibular versus cochlear) and absence or presence of other DCS symptoms. Symptoms of difficult middle ear equalisation or findings consistent with middle ear barotrauma could not be reliably assessed in this context, being insufficiently reported in the IEDCS literature.
CONCLUSIONS
There are multiple useful variables to help distinguish IEBt from IEDCS. Symptoms of difficult middle ear equalisation or findings consistent with middle ear barotrauma require further study as means of distinguishing IEBt and IEDCS.
Topics: Barotrauma; Decompression Sickness; Diagnosis, Differential; Diving; Ear, Inner; Humans
PubMed: 34897597
DOI: 10.28920/dhm51.4.328-337 -
Respiratory Medicine 2023Recent studies suggested that Macklin sign is a predictor of barotrauma in patients with acute respiratory distress syndrome (ARDS). We performed a systematic review to... (Review)
Review
INTRODUCTION
Recent studies suggested that Macklin sign is a predictor of barotrauma in patients with acute respiratory distress syndrome (ARDS). We performed a systematic review to further characterize the clinical role of Macklin.
METHODS
PubMed, Scopus, Cochrane Central Register and Embase were searched for studies reporting data on Macklin. Studies without data on chest CT, pediatric studies, non-human and cadaver studies, case reports and series including <5 patients were excluded. The primary objective was to assess the number of patients with Macklin sign and barotrauma. Secondary objectives were: occurrence of Macklin in different populations, clinical use of Macklin, prognostic impact of Macklin.
RESULTS
Seven studies enrolling 979 patients were included. Macklin was present in 4-22% of COVID-19 patients. It was associated with barotrauma in 124/138 (89.8%) of cases. Macklin sign preceded barotrauma in 65/69 cases (94.2%) 3-8 days in advance. Four studies used Macklin as pathophysiological explanation for barotrauma, two studies as a predictor of barotrauma and one as a decision-making tool. Two studies suggested that Macklin is a strong predictor of barotrauma in ARDS patients and one study used Macklin sign to candidate high-risk ARDS patients to awake extracorporeal membrane oxygenation (ECMO). A possible correlation between Macklin and worse prognosis was suggested in two studies on COVID-19 and blunt chest trauma.
CONCLUSIONS
Increasing evidence suggests that Macklin sign anticipate barotrauma in patients with ARDS and there are initial reports on use of Macklin as a decision-making tool. Further studies investigating the role of Macklin sign in ARDS are justified.
Topics: Humans; Child; Thoracic Injuries; COVID-19; Wounds, Nonpenetrating; Respiratory Distress Syndrome; Barotrauma; Respiration, Artificial
PubMed: 36863617
DOI: 10.1016/j.rmed.2023.107178 -
Intensive Care Medicine Experimental Dec 2020In patients with acute respiratory distress syndrome (ARDS), lung recruitment could be maximised with the use of recruitment manoeuvres (RM) or applying a positive... (Review)
Review
Effects of higher PEEP and recruitment manoeuvres on mortality in patients with ARDS: a systematic review, meta-analysis, meta-regression and trial sequential analysis of randomized controlled trials.
PURPOSE
In patients with acute respiratory distress syndrome (ARDS), lung recruitment could be maximised with the use of recruitment manoeuvres (RM) or applying a positive end-expiratory pressure (PEEP) higher than what is necessary to maintain minimal adequate oxygenation. We aimed to determine whether ventilation strategies using higher PEEP and/or RMs could decrease mortality in patients with ARDS.
METHODS
We searched MEDLINE, EMBASE and CENTRAL from 1996 to December 2019, included randomized controlled trials comparing ventilation with higher PEEP and/or RMs to strategies with lower PEEP and no RMs in patients with ARDS. We computed pooled estimates with a DerSimonian-Laird mixed-effects model, assessing mortality and incidence of barotrauma, population characteristics, physiologic variables and ventilator settings. We performed a trial sequential analysis (TSA) and a meta-regression.
RESULTS
Excluding two studies that used tidal volume (V) reduction as co-intervention, we included 3870 patients from 10 trials using higher PEEP alone (n = 3), combined with RMs (n = 6) or RMs alone (n = 1). We did not observe differences in mortality (relative risk, RR 0.96, 95% confidence interval, CI [0.84-1.09], p = 0.50) nor in incidence of barotrauma (RR 1.22, 95% CI [0.93-1.61], p = 0.16). In the meta-regression, the PEEP difference between intervention and control group at day 1 and the use of RMs were not associated with increased risk of barotrauma. The TSA reached the required information size for mortality (n = 2928), and the z-line surpassed the futility boundary.
CONCLUSIONS
At low V, the routine use of higher PEEP and/or RMs did not reduce mortality in unselected patients with ARDS.
TRIAL REGISTRATION
PROSPERO CRD42017082035 .
PubMed: 33336325
DOI: 10.1186/s40635-020-00322-2 -
Intensive Care Medicine Experimental Oct 2020Existing clinical practice guidelines support the use of neuromuscular blocking agents (NMBA) in acute respiratory distress syndrome (ARDS); however, a recent large... (Review)
Review
PURPOSE
Existing clinical practice guidelines support the use of neuromuscular blocking agents (NMBA) in acute respiratory distress syndrome (ARDS); however, a recent large randomized clinical trial (RCT) has questioned this practice. Therefore, we updated a previous systematic review to determine the efficacy and safety of NMBAs in ARDS.
METHODS
We searched MEDLINE, EMBASE (October 2012 to July 2019), the Cochrane (Central) database, and clinical trial registries ( ClinicalTrials.gov , ISRCTN Register, and WHO ICTRP) for RCTs comparing the effects of NMBA as a continuous infusion versus placebo or no NMBA infusion (but allowing intermittent NMBA boluses) on patient-important outcomes for adults with ARDS. Two independent reviewers assessed the methodologic quality of the primary studies and abstracted data.
RESULTS
Seven RCTs, including four new RCTs, met eligibility criteria for this review. These trials enrolled 1598 patients with moderate to severe ARDS at centers in the USA, France, and China. All trials assessed short-term continuous infusions of cisatracurium or vecuronium. The pooled estimate for mortality outcomes showed significant statistical heterogeneity, which was only explained by a subgroup analysis by depth of sedation in the control arm. A continuous NMBA infusion did not improve mortality when compared to a light sedation strategy with no NMBA infusion (relative risk [RR] 0.99; 95% CI 0.86-1.15; moderate certainty; P = 0.93). On the other hand, continuous NMBA infusion reduced mortality when compared to deep sedation with as needed NMBA boluses (RR 0.71; 95% CI 0.57-0.89; low certainty; P = 0.003). Continuous NMBA infusion reduced the rate of barotrauma (RR 0.55; 95% CI 0.35-0.85, moderate certainty; P = 0.008) across eligible trials, but the effect on ventilator-free days, duration of mechanical ventilation, and ICU-acquired weakness was uncertain.
CONCLUSIONS
Inconsistency in study methods and findings precluded the pooling of all trials for mortality. In a pre-planned sensitivity analysis, the impact of NMBA infusion on mortality depends on the strategy used in the control arm, showing reduced mortality when compared to deep sedation, but no effect on mortality when compared to lighter sedation. In both situations, a continuous NMBA infusion may reduce the risk of barotrauma, but the effects on other patient-important outcomes remain unclear. Future research, including an individual patient data meta-analysis, could help clarify some of the observed findings in this updated systematic review.
PubMed: 33095344
DOI: 10.1186/s40635-020-00348-6 -
European Archives of... May 2024Determine the prevalence of otological symptoms and tympanic membrane perforation, healing rates of tympanic membrane perforation with surgical and conservative... (Review)
Review
PURPOSE
Determine the prevalence of otological symptoms and tympanic membrane perforation, healing rates of tympanic membrane perforation with surgical and conservative management, and hearing function in civilian victims of terrorist explosions.
METHODS
A systematic review was conducted with searches on Medline, Embase, EMCare and CINAHL for publications between the 1st January 1945 and 26th May 2023. Studies with quantitative data addressing our aims were included. This review is registered with PROSPERO: CRD42020166768. Among 2611 studies screened, 18 studies comprising prospective and retrospective cohort studies were included.
RESULTS
The percentage of eardrums perforated in patients admitted to hospital, under ENT follow up and attending the emergency department is 69.0% (CI 55.5-80.5%), 38.7% (CI 19.0-63.0%, I 0.715%) and 21.0% (CI 11.9-34.3%, I 0.718%) respectively. Perforated eardrums heal spontaneously in 62.9% (CI 50.4-73.8%, I 0.687%) of cases and in 88.8% (CI 75.9-96.3%, I 0.500%) of cases after surgery. Common symptoms present within one month of bombings are tinnitus 84.7% (CI 70.0-92.9%, I 0.506%), hearing loss 83.0% (CI 64.5-92.9%, I 0.505%) and ear fullness 59.7% (CI 13.4-93.4%, I 0.719). Symptomatic status between one and six months commonly include no symptoms 57.5% (CI 46.0-68.3%), hearing loss 35.4% (CI 21.8-51.8%, I 0.673%) and tinnitus 15.6% (CI 4.9-40.0%, I 0.500%). Within one month of bombings, the most common hearing abnormality is sensorineural hearing loss affecting 26.9% (CI 16.9-40.1%, I 0.689%) of ears 43.5% (CI 33.4-54.2%, I 0.500) of people.
CONCLUSION
Tympanic membrane perforation, subjective hearing loss, tinnitus, ear fullness and sensorineural hearing loss are common sequelae of civilian terrorist explosions.
Topics: Humans; Tympanic Membrane Perforation; Tinnitus; Explosions; Retrospective Studies; Blast Injuries; Prospective Studies; Hearing Loss; Hearing Loss, Sensorineural; Deafness; Terrorism
PubMed: 38189970
DOI: 10.1007/s00405-023-08393-z -
Diving and Hyperbaric Medicine Jun 2024Inhalation of high concentrations of carbon dioxide (CO₂) at atmospheric pressure can be toxic with dose-dependent effects on the cardiorespiratory system or the... (Review)
Review
INTRODUCTION
Inhalation of high concentrations of carbon dioxide (CO₂) at atmospheric pressure can be toxic with dose-dependent effects on the cardiorespiratory system or the central nervous system. Exposure to both hyperbaric and hypobaric environments can result in decompression sickness (DCS). The effects of CO₂ on DCS are not well documented with conflicting results. The objective was to review the literature to clarify the effects of CO₂ inhalation on DCS in the context of hypobaric or hyperbaric exposure.
METHODS
The systematic review included experimental animal and human studies in hyper- and hypobaric conditions evaluating the effects of CO₂ on bubble formation, denitrogenation or the occurrence of DCS. The search was based on MEDLINE and PubMed articles with no language or date restrictions and also included articles from the underwater and aviation medicine literature.
RESULTS
Out of 43 articles, only 11 articles were retained and classified according to the criteria of hypo- or hyperbaric exposure, taking into account the duration of CO₂ inhalation in relation to exposure and distinguishing experimental work from studies conducted in humans.
CONCLUSIONS
Before or during a stay in hypobaric conditions, exposure to high concentrations of CO₂ favors bubble formation and the occurrence of DCS. In hyperbaric conditions, high CO₂ concentrations increase the occurrence of DCS when exposure occurs during the bottom phase at maximum pressure, whereas beneficial effects are observed when exposure occurs during decompression. These opposite effects depending on the timing of exposure could be related to 1) the physical properties of CO₂, a highly diffusible gas that can influence bubble formation, 2) vasomotor effects (vasodilation), and 3) anti-inflammatory effects (kinase-nuclear factor and heme oxygenase-1 pathways). The use of O₂-CO₂ breathing mixtures on the surface after diving may be an avenue worth exploring to prevent DCS.
Topics: Animals; Humans; Atmospheric Pressure; Carbon Dioxide; Decompression Sickness; Diving
PubMed: 38870953
DOI: 10.28920/dhm54.2.110-119