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BMJ Global Health Dec 2021Increasing access to oxygen services may improve outcomes among children with pneumonia living in low-resource settings. We conducted a systematic review to estimate the... (Meta-Analysis)
Meta-Analysis
Oxygen systems strengthening as an intervention to prevent childhood deaths due to pneumonia in low-resource settings: systematic review, meta-analysis and cost-effectiveness.
OBJECTIVES
Increasing access to oxygen services may improve outcomes among children with pneumonia living in low-resource settings. We conducted a systematic review to estimate the impact and cost-effectiveness of strengthening oxygen services in low-income and middle-income countries with the objective of including oxygen as an intervention in the Lives Saved Tool.
DESIGN
We searched EMBASE and PubMed on 31 March 2021 using keywords and MeSH terms related to 'oxygen', 'pneumonia' and 'child' without restrictions on language or date. The risk of bias was assessed for all included studies using the quality assessment tool for quantitative studies, and we assessed the overall certainty of the evidence using Grading of Recommendations, Assessment, Development and Evaluations. Meta-analysis methods using random effects with inverse-variance weights was used to calculate a pooled OR and 95% CIs. Programme cost data were extracted from full study reports and correspondence with study authors, and we estimated cost-effectiveness in US dollar per disability-adjusted life-year (DALY) averted.
RESULTS
Our search identified 665 studies. Four studies were included in the review involving 75 hospitals and 34 485 study participants. We calculated a pooled OR of 0.52 (95% CI 0.39 to 0.70) in favour of oxygen systems reducing childhood pneumonia mortality. The median cost-effectiveness of oxygen systems strengthening was $US62 per DALY averted (range: US$44-US$225). We graded the risk of bias as moderate and the overall certainty of the evidence as low due to the non-randomised design of the studies.
CONCLUSION
Our findings suggest that strengthening oxygen systems is likely to reduce hospital-based pneumonia mortality and may be cost-effective in low-resource settings. Additional implementation trials using more rigorous designs are needed to strengthen the certainty in the effect estimate.
Topics: Child; Cost-Benefit Analysis; Humans; Oxygen; Pneumonia
PubMed: 34930758
DOI: 10.1136/bmjgh-2021-007468 -
BMJ Global Health Nov 2021Acute fever is a common presenting symptom in low/middle-income countries (LMICs) and is strongly associated with sepsis. Hypoxaemia predicts disease severity in such...
BACKGROUND
Acute fever is a common presenting symptom in low/middle-income countries (LMICs) and is strongly associated with sepsis. Hypoxaemia predicts disease severity in such patients but is poorly detected by clinical examination. Therefore, including pulse oximetry in the assessment of acutely febrile patients may improve clinical outcomes in LMIC settings.
METHODS
We systematically reviewed studies of any design comparing one group where pulse oximetry was used and at least one group where it was not. The target population was patients of any age presenting with acute febrile illness or associated syndromes in LMICs. Studies were obtained from searching PubMed, EMBASE, CABI Global Health, Global Index Medicus, CINAHL, Cochrane CENTRAL, Web of Science and DARE. Further studies were identified through searches of non-governmental organisation websites, snowballing and input from a Technical Advisory Panel. Outcomes of interest were diagnosis, management and patient outcomes. Study quality was assessed using the Cochrane Risk of Bias 2 tool for Cluster Randomised Trials and Risk of Bias in Non-randomized Studies of Interventions tools, as appropriate.
RESULTS
Ten of 4898 studies were eligible for inclusion. Their small number and heterogeneity prevented formal meta-analysis. All studies were in children, eight only recruited patients with pneumonia, and nine were conducted in Africa or Australasia. Six were at serious risk of bias. There was moderately strong evidence for the utility of pulse oximetry in diagnosing pneumonia and identifying severe disease requiring hospital referral. Pulse oximetry used as part of a quality-assured facility-wide package of interventions may reduce pneumonia mortality, but studies assessing this endpoint were at serious risk of bias.
CONCLUSIONS
Very few studies addressed this important question. In LMICs, pulse oximetry may assist clinicians in diagnosing and managing paediatric pneumonia, but for the greatest impact on patient outcomes should be implemented as part of a health systems approach. The evidence for these conclusions is not widely generalisable and is of poor quality.
Topics: Africa; Child; Developing Countries; Humans; Income; Oximetry
PubMed: 34824136
DOI: 10.1136/bmjgh-2021-007282 -
European Journal of Vascular and... Nov 2021Carotid endarterectomy is recommended for the prevention of ischaemic stroke due to carotid stenosis. However, the risk of stroke after carotid endarterectomy has been... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Carotid endarterectomy is recommended for the prevention of ischaemic stroke due to carotid stenosis. However, the risk of stroke after carotid endarterectomy has been estimated at 2% - 5%. Monitoring intra-operative cerebral oxygenation with near infrared spectroscopy (NIRS) has been assessed as a strategy to reduce intra- and post-operative complications. The aim was to summarise the diagnostic accuracy of NIRS to detect intra-operative ischaemic events, the values associated with ischaemic events, and the relative contribution of external carotid contamination to the NIRS signal in adults undergoing carotid endarterectomy.
DATA SOURCES
EMBASE, MEDLINE, Cochrane Centre Register of Controlled Trials, and reference lists through May 2019 were searched.
REVIEW METHODS
Non-randomised and randomised studies assessing NIRS as an intra-operative monitoring tool in carotid endarterectomy were included. Studies using NIRS as the reference were excluded. Risk of bias was assessed using the Newcastle Ottawa Scale, RoB-2, and QUADAS-2.
RESULTS
Seventy-six studies were included (n = 8 480), under local (n = 1 864) or general (n = 6 582) anaesthesia. Seven studies were eligible for meta-analysis (n = 524). As a tool for identifying intra-operative ischaemia, specificity increased with more stringent NIRS thresholds, while there was unpredictable variation in sensitivity across studies. A Δ20% threshold under local anaesthesia resulted in pooled estimates for sensitivity and specificity of 70.5% (95% confidence interval, CI, 54.1 - 82.9) and 92.4% (95% CI 85.5 - 96.1) compared with awake neurological monitoring. These studies had low or unclear risk of bias. NIRS signal consistently dropped across clamping and recovered to pre-clamp values upon de-clamp in most studies, and larger decreases were observed in patients with ischaemic events. The contribution of extracranial signal to change in signal across clamp varied from 3% to 50%.
CONCLUSION
NIRS has low sensitivity and high specificity to identify intra-operative ischaemia compared with awake monitoring. Extracranial signal contribution was highly variable. Ultimately, data from high quality studies are desperately needed to determine the utility of NIRS.
Topics: Carotid Stenosis; Endarterectomy, Carotid; Humans; Monitoring, Intraoperative; Sensitivity and Specificity; Spectroscopy, Near-Infrared
PubMed: 34627675
DOI: 10.1016/j.ejvs.2021.08.022 -
Journal of Clinical Monitoring and... Feb 2022The objective of this systematic review and meta-analysis was to analyze the effectiveness of contactless vital sign monitors that utilize a consumer-friendly camera... (Meta-Analysis)
Meta-Analysis Review
The objective of this systematic review and meta-analysis was to analyze the effectiveness of contactless vital sign monitors that utilize a consumer-friendly camera versus medical grade instruments. A multiple database search was conducted from inception to September 2020. Inclusion criteria were as follows: studies that used a consumer-grade camera (smartphone/webcam) to examine contactless vital signs in adults; evaluated the non-contact device against a reference medical device; and used the participants' face for measurement. Twenty-six studies were included in the review of which 16 were included in Pearson's correlation and 14 studies were included in the Bland-Altman meta-analysis. Twenty-two studies measured heart rate (HR) (92%), three measured blood pressure (BP) (12%), and respiratory rate (RR) (12%). No study examined blood oxygen saturation (SpO). Most studies had a small sample size (≤ 30 participants) and were performed in a laboratory setting. Our meta-analysis found that consumer-grade contactless vital sign monitors were accurate in comparison to a medical device in measuring HR. Current contactless monitors have limitations such as motion, poor lighting, and lack of automatic face tracking. Currently available consumer-friendly contactless monitors measure HR accurately compared to standard medical devices. More studies are needed to assess the accuracy of contactless BP and RR monitors. Implementation of contactless vital sign monitors for clinical use will require validation in a larger population, in a clinical setting, and expanded to encompass other vital signs including BP, RR, and SpO.
Topics: Adult; Heart Rate; Humans; Monitoring, Physiologic; Oximetry; Respiratory Rate; Vital Signs
PubMed: 34240262
DOI: 10.1007/s10877-021-00734-9 -
Korean Journal of Anesthesiology Oct 2021Prophylaxis for cerebral desaturation events (CDEs) during anesthesia in the beach chair position (BCP) for shoulder surgeries has not been evaluated. We systematically... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Prophylaxis for cerebral desaturation events (CDEs) during anesthesia in the beach chair position (BCP) for shoulder surgeries has not been evaluated. We systematically analyzed the effectiveness of various prophylactic measures used in this clinical setting.
METHODS
We performed a meta-analysis (PROSPERO; no. CRD42020167285) of trials reporting CDEs and regional cerebral oxygen saturation (rSO2) and jugular venous oxygen saturation (SjvO2) values in anesthetized patients undergoing shoulder surgery in BCP. Considering the type of prophylactic measures used (pharmacological or non-pharmacological), a subgroup analysis was planned. Outcomes included (1) rSO2 and SjvO2 data with and without prophylactic measures for CDEs, recorded for different time intervals, and (2) the number of patients experiencing CDEs and hypotension.
RESULTS
Twelve studies (786 patients) were included in the analysis. We observed lower absolute rSO2 values for early and all-time periods for vasoactive agent prophylaxis. The lowest achieved rSO2 values were also lower for vasoactive agent prophylaxis. Risk of CDEs was higher with vasoactive agent prophylaxis. Subgroup analysis identified targeted mild hypercarbia as effective in preserving cerebral oxygenation. Similarly, targeted mild hypercarbia prevented the fall in rSO2 with position change. Meta-regressions revealed statistically significant highest estimates for vasoactive agent prophylaxis in contrast to targeted mild hypercarbia. Likelihood of not developing CDEs was higher for targeted mild hypercarbia. In contrast to rSO2, most prophylactic methods reduced hypotensive episodes.
CONCLUSIONS
Targeted mild hypercarbia can reduce BCP-related CDEs. Evidence does not favor prophylactic use of vasoactive agents for the prevention of cerebral desaturations irrespective of whether their use interferes with cerebral oximetry readings.
Topics: Arthroscopy; Cerebrovascular Circulation; Humans; Oximetry; Oxygen; Patient Positioning; Shoulder
PubMed: 34167290
DOI: 10.4097/kja.21069 -
BMC Pulmonary Medicine Jun 2021Patients undergoing bronchoscopy in spontaneous breathing are prone to hypoxaemia and hypercapnia. Sedation, airway obstruction, and lung diseases impair respiration and...
BACKGROUND
Patients undergoing bronchoscopy in spontaneous breathing are prone to hypoxaemia and hypercapnia. Sedation, airway obstruction, and lung diseases impair respiration and gas exchange. The restitution of normal respiration takes place in the recovery room. Nonetheless, there is no evidence on the necessary observation time. We systematically reviewed current guidelines on bronchoscopy regarding sedation, monitoring and recovery.
METHODS
This review was registered at the PROSPERO database (CRD42020197476). MEDLINE and awmf.org were double-searched for official guidelines, recommendation or consensus statements on bronchoscopy from 2010 to 2020. The PICO-process focussed on adults (Patients), bronchoscopy with maintained spontaneous breathing (Interventions), and recommendations regarding the intra- and postprocedural monitoring and sedation (O). The guideline quality was graded. A catalogue of 54 questions was answered. Strength of recommendation and evidence levels were recorded for each recommendation.
RESULTS
Six guidelines on general bronchoscopy and three expert statements on special bronchoscopic procedures were identified. Four guidelines were evidence-based. Most guidelines recommend sedation to improve the patient's tolerance. Midazolam combined with an opioid is preferred. The standard monitoring consists of non-invasive blood pressure, and pulse oximetry, furthermore electrocardiogram in cardiac patients. Only one guideline discusses hypercapnia and capnometry, but without consensus. Two guidelines discuss a recovery time of two hours, but a recommendation was not given because of lack of evidence.
CONCLUSION
Evidence for most issues is low to moderate. Lung-diseased patients are not represented by current guidelines. Capnometry and recovery time lack evidence. More primary research in these fields is needed so that future guidelines may address these issues, too.
Topics: Adult; Analgesics, Opioid; Blood Gas Monitoring, Transcutaneous; Bronchoscopy; Carbon Dioxide; Conscious Sedation; Guidelines as Topic; Humans; Hypercapnia; Midazolam; Patient Safety
PubMed: 34112130
DOI: 10.1186/s12890-021-01532-4 -
Journal of Clinical Sleep Medicine :... Aug 2021Identifying optimal treatment for infants with Robin sequence (RS) is challenging due to substantial variability in the presentation of upper airway obstruction (UAO) in...
STUDY OBJECTIVES
Identifying optimal treatment for infants with Robin sequence (RS) is challenging due to substantial variability in the presentation of upper airway obstruction (UAO) in this population. Objective assessments of UAO and treatments are not standardized. A systematic review of objective measures of UAO was conducted as a step toward evidence-based clinical decision-making for RS.
METHODS
A literature search was performed in the PubMed and Embase databases (1990-2020) following PRISMA guidelines. Articles reporting on RS and UAO treatment were included if the following objective measures were studied: oximetry, polysomnography, and blood gas. Quality was appraised by the methodological index for nonrandomized studies (range: 0-24).
RESULTS
A total of 91 articles met the inclusion criteria. The mean methodological index for nonrandomized studies score was 7.1 (range: 3-14). Polysomnography was most frequently used (76%) followed by oximetry (20%) and blood gas (11%). Sleep position of the infant was reported in 35% of studies, with supine position most frequently, and monitoring time in 42%, including overnight recordings, in more than half. Of 71 studies that evaluated UAO interventions, the majority used polysomnography (90%), of which 61% did not specify the polysomnography technique. Reported polysomnography metrics included oxygen saturation (61%), apnea-hypopnea index (52%), carbon dioxide levels (31%), obstructive apnea-hypopnea index (27%), and oxygen desaturation index (16%). Only 42 studies reported indications for UAO intervention, with oximetry and polysomnography thresholds used equally (both 40%). In total, 34 distinct indications for treatment were identified.
CONCLUSIONS
This systematic review demonstrates a lack of standardization, interpretation, and reporting of assessment and treatment indications for UAO in RS. An international, multidisciplinary consensus protocol is needed to guide clinicians on optimal UAO assessment in RS.
CITATION
Logjes RJH, MacLean JE, de Cort NW, et al. Objective measurements for upper airway obstruction in infants with Robin sequence: what are we measuring? A systematic review. . 2021;17(8):1717-1729.
Topics: Airway Obstruction; Humans; Infant; Oxygen Saturation; Pierre Robin Syndrome; Polysomnography; Sleep
PubMed: 33960296
DOI: 10.5664/jcsm.9394 -
Children (Basel, Switzerland) Apr 2021Continuous monitoring of arterial oxygen saturation by pulse oximetry (SpO2) is the main method to guide respiratory and oxygen support in neonates during postnatal... (Review)
Review
Continuous monitoring of arterial oxygen saturation by pulse oximetry (SpO2) is the main method to guide respiratory and oxygen support in neonates during postnatal stabilization and after admission to neonatal intensive care unit. The accuracy of these devices is therefore crucial. The presence of fetal hemoglobin (HbF) in neonatal blood might affect SpO2 readings. We performed a systematic qualitative review to investigate the impact of HbF on SpO2 accuracy in neonates. PubMed/Medline, Embase, Cumulative Index to Nursing & Allied Health database (CINAHL) and Cochrane library databases were searched from inception to January 2021 for human studies in the English language, which compared arterial oxygen saturations (SaO2) from neonatal blood with SpO2 readings and included HbF measurements in their reports. Ten observational studies were included. Eight studies reported SpO2-SaO2 bias that ranged from -3.6%, standard deviation (SD) 2.3%, to +4.2% (SD 2.4). However, it remains unclear to what extent this depends on HbF. Five studies showed that an increase in HbF changes the relation of partial oxygen pressure (paO2) to SpO2, which is physiologically explained by the leftward shift in oxygen dissociation curve. It is important to be aware of this shift when treating a neonate, especially for the lower SpO2 limits in preterm neonates to avoid undetected hypoxia.
PubMed: 33946236
DOI: 10.3390/children8050361 -
CMAJ : Canadian Medical Association... Apr 2021Cesarean delivery is the most common surgical procedure worldwide. Intrapartum fetal surveillance is routinely offered to improve neonatal outcomes, but the effects of... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Cesarean delivery is the most common surgical procedure worldwide. Intrapartum fetal surveillance is routinely offered to improve neonatal outcomes, but the effects of different methods on the risk of emergency cesarean deliveries remains uncertain. We conducted a systematic review and network meta-analysis to evaluate the effectiveness of different types of fetal surveillance.
METHODS
We searched MEDLINE, Embase and CENTRAL until June 1, 2020, for randomized trials evaluating any intrapartum fetal surveillance method. We performed a network meta-analysis within a frequentist framework. We assessed the quality and network inconsistency of trials. We reported primarily on intrapartum emergency cesarean deliveries and other secondary maternal and neonatal outcomes using risk ratios (RRs) and 95% confidence intervals (CIs).
RESULTS
We included 33 trials (118 863 patients) evaluating intermittent auscultation with Pinard stethoscope/handheld Doppler (IA), cardiotocography (CTG), computerized cardiotocography (cCTG), CTG with fetal scalp lactate (CTG-lactate), CTG with fetal scalp pH analysis (CTG-FBS), CTG with fetal pulse oximetry (FPO-CTG), CTG with fetal heart electrocardiogram (CTG-STAN) and their combinations. Intermittent auscultation reduced the risk of emergency cesarean deliveries compared with other types of surveillance (IA v. CTG: RR 0.83, 95% CI 0.72-0.97; IA v. CTG-FBS: RR 0.71, 95% CI 0.63-0.80; IA v.CTG-lactate: RR 0.77, 95% CI 0.64-0.92; IA v. FPO-CTG: RR 0.75, 95% CI 0.65-0.87; IA v.FPO-CTG-FBS: RR 0.81, 95% CI 0.67-0.99; cCTG-FBS v. IA: RR 1.21, 95% CI 1.04-1.42), except STAN-CTG-FBS (RR 1.17, 95% CI 0.98-1.40). There was a similar reduction observed for emergency cesarean deliveries for fetal distress. None of the evaluated methods was associated with a reduced risk of neonatal acidemia, neonatal unit admissions, Apgar scores or perinatal death.
INTERPRETATION
Compared with other types of fetal surveillance, intermittent auscultation seems to reduce emergency cesarean deliveries in labour without increasing adverse neonatal and maternal outcomes.
Topics: Cesarean Section; Female; Fetal Monitoring; Humans; Pregnancy; Pregnancy Outcome; Randomized Controlled Trials as Topic
PubMed: 33824144
DOI: 10.1503/cmaj.202538 -
Systematic Reviews Mar 2021Even when resting pulse oximetry is normal in the patient with acute Covid-19, hypoxia can manifest on exertion. We summarise the literature on the performance of...
BACKGROUND
Even when resting pulse oximetry is normal in the patient with acute Covid-19, hypoxia can manifest on exertion. We summarise the literature on the performance of different rapid tests for exertional desaturation and draw on this evidence base to provide guidance in the context of acute Covid-19.
MAIN RESEARCH QUESTIONS
1. What exercise tests have been used to assess exertional hypoxia at home or in an ambulatory setting in the context of Covid-19 and to what extent have they been validated? 2. What exercise tests have been used to assess exertional hypoxia in other lung conditions, to what extent have they been validated and what is the applicability of these studies to acute Covid-19?
METHOD
AMED, CINAHL, EMBASE MEDLINE, Cochrane and PubMed using LitCovid, Scholar and Google databases were searched to September 2020. Studies where participants had Covid-19 or another lung disease and underwent any form of exercise test which was compared to a reference standard were eligible. Risk of bias was assessed using QUADAS 2. A protocol for the review was published on the Medrxiv database.
RESULTS
Of 47 relevant papers, 15 were empirical studies, of which 11 described an attempt to validate one or more exercise desaturation tests in lung diseases other than Covid-19. In all but one of these, methodological quality was poor or impossible to fully assess. None had been designed as a formal validation study (most used simple tests of correlation). Only one validation study (comparing a 1-min sit-to-stand test [1MSTST] with reference to the 6-min walk test [6MWT] in 107 patients with interstitial lung disease) contained sufficient raw data for us to calculate the sensitivity (88%), specificity (81%) and positive and negative predictive value (79% and 89% respectively) of the 1MSTST. The other 4 empirical studies included two predictive studies on patients with Covid-19, and two on HIV-positive patients with suspected pneumocystis pneumonia. We found no studies on the 40-step walk test (a less demanding test that is widely used in clinical practice to assess Covid-19 patients). Heterogeneity of study design precluded meta-analysis.
DISCUSSION
Exertional desaturation tests have not yet been validated in patients with (or suspected of having) Covid-19. A stronger evidence base exists for the diagnostic accuracy of the 1MSTST in chronic long-term pulmonary disease; the relative intensity of this test may raise safety concerns in remote consultations or unstable patients. The less strenuous 40-step walk test should be urgently evaluated.
Topics: COVID-19; Dyspnea; Exercise; Exercise Test; Humans; Hypoxia; Lung Diseases; Oxygen; Physical Exertion; Predictive Value of Tests; SARS-CoV-2; Sensitivity and Specificity
PubMed: 33726854
DOI: 10.1186/s13643-021-01620-w