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Revue Des Maladies Respiratoires Jan 2020Cocaine can be responsible for many psychiatric and/or somatic disorders. The aim of this systematic literature review of data was to expose relations between cocaine...
Cocaine can be responsible for many psychiatric and/or somatic disorders. The aim of this systematic literature review of data was to expose relations between cocaine use and pulmonary complications. Cocaine can be responsible for acute respiratory symptoms (cough, black sputum, hemoptysis, dyspnea, wheezing, chest pain) and for various pulmonary disorders including barotrauma (pneumothorax, pneumomediastinum, subcutaneous emphysema, pneumopericardium), airway damage, asthma, bronchiolitis obliterans with organizing pneumonia, acute pulmonary edema, alveolar hemorrhage, alveolar pneumonia with carbonaceous material, bullous emphysema, acute eosinophilic pneumonia, pulmonary granulomatosis caused by talc or cellulose, interstitial pneumonitis and pulmonary fibrosis, vasculitis, pulmonary hypertension, pulmonary embolism and pulmonary infarction, mycotic pulmonary arterial aneurysms, septic emboli, aspiration pneumonia, community-acquired pneumonia, HIV-related opportunistic infections, latent tuberculosis infection, pulmonary tuberculosis, lung cancer and crack lung. Some of these complications are serious and may have a fatal outcome. Pulmonary function tests, thoracic tomodensitometry, bronchial fibroscopy with bronchoalveolar lavage and lung scintigraphy may be an aid to the diagnosis of these pulmonary compications. Cocaine use must be sought in case of respiratory symptoms in young persons.
Topics: Cocaine; Cocaine-Related Disorders; Drug Users; Humans; Lung Diseases
PubMed: 31883817
DOI: 10.1016/j.rmr.2019.11.641 -
Critical Care Medicine Dec 2019To evaluate the efficacy and safety of airway pressure release ventilation in critically ill adults with acute hypoxemic respiratory failure. (Meta-Analysis)
Meta-Analysis
OBJECTIVES
To evaluate the efficacy and safety of airway pressure release ventilation in critically ill adults with acute hypoxemic respiratory failure.
DATA SOURCES
A systematic literature search of MEDLINE via PUBMED, EMBASE, the Cochrane Library, published conference proceedings and abstracts, reference lists of eligible studies and review articles, and hand searches of relevant journals and trial registers.
STUDY SELECTION
Eligible studies included randomized controlled trials published between years 2000 and 2018, comparing airway pressure release ventilation to any ventilation mode, in critically ill adults with acute hypoxemic respiratory failure and reporting at least one mortality outcome.
DATA EXTRACTION
Screened citations were reviewed and extracted independently by two investigators onto a prespecified proforma.
DATA SYNTHESIS
There were 412 patients from seven randomized controlled trials included in the qualitative and quantitative data synthesis. Airway pressure release ventilation was associated with a significant mortality benefit (relative risk, 0.67; 95% CI, 0.48-0.94; I < 0.1%; p = 0.97) and improvement in day 3 PaO2/FIO2 ratio (weighted mean difference, 60.4; 95% CI, 10.3-110.5). There was no significant difference in requirement to initiate rescue treatments including inhaled pulmonary vasodilators, prone positioning, or extracorporeal membrane oxygenation (relative risk, 0.51; 95% CI, 0.22-1.21; I = 64.7%; p = 0.04). The risk of barotrauma was only reported in three studies and did not differ between groups (relative risk, 0.39; 95% CI, 0.12-1.19; I < 0.1%; p = 0.99).
CONCLUSIONS
In adult patients requiring mechanical ventilation for acute hypoxic respiratory failure, airway pressure release ventilation is associated with a mortality benefit and improved oxygenation when compared with conventional ventilation strategies. Given the limited number of patients enrolled in the available studies, larger multicenter studies are required to validate these findings.
Topics: Acute Disease; Adult; Continuous Positive Airway Pressure; Humans; Hypoxia; Randomized Controlled Trials as Topic; Respiratory Insufficiency
PubMed: 31517696
DOI: 10.1097/CCM.0000000000003972 -
JAMA Network Open Jul 2019A number of interventions are available to manage patients with moderate to severe acute respiratory distress syndrome (ARDS). However, the associations of currently... (Meta-Analysis)
Meta-Analysis
Assessment of Therapeutic Interventions and Lung Protective Ventilation in Patients With Moderate to Severe Acute Respiratory Distress Syndrome: A Systematic Review and Network Meta-analysis.
IMPORTANCE
A number of interventions are available to manage patients with moderate to severe acute respiratory distress syndrome (ARDS). However, the associations of currently available ventilatory strategies and adjunctive therapies with mortality are uncertain.
OBJECTIVES
To compare and rank different therapeutic strategies to identify the best intervention associated with a reduction in mortality in adult patients with moderate to severe ARDS.
DATA SOURCES
An electronic search of MEDLINE, MEDLINE In-Process/ePubs Ahead of Print, Embase, Cochrane Controlled Clinical Trial Register (Central), PubMed, and CINAHL was conducted, from database inception to May 29, 2019.
STUDY SELECTION
Randomized clinical trials of interventions for adults with moderate to severe ARDS that used lung protective ventilation. No language restrictions were applied.
DATA EXTRACTION AND SYNTHESIS
Data were independently extracted by 2 reviewers and synthesized with Bayesian random-effects network meta-analyses.
MAIN OUTCOMES AND MEASURES
The primary outcome was 28-day mortality. Barotrauma was a secondary outcome.
RESULTS
Among 25 randomized clinical trials evaluating 9 interventions, 2686 of 7743 patients (34.6%) died within 28 days. Compared with lung protective ventilation alone, prone positioning and venovenous extracorporeal membrane oxygenation were associated with significantly lower 28-day mortality (prone positioning: risk ratio, 0.69; 95% credible interval, 0.48-0.99; low quality of evidence; venovenous extracorporeal membrane oxygenation: risk ratio, 0.60; 95% credible interval, 0.38-0.93; moderate quality of evidence). These 2 interventions had the highest ranking probabilities, although they were not significantly different from each other. Among 18 trials reporting on barotrauma, 448 of 6258 patients (7.2%) experienced this secondary outcome. No intervention was superior to any other in reducing barotrauma, and each represented low to very low quality of evidence.
CONCLUSIONS AND RELEVANCE
This network meta-analysis supports the use of prone positioning and venovenous extracorporeal membrane oxygenation in addition to lung protective ventilation in patients with ARDS. Moreover, venovenous extracorporeal membrane oxygenation may be considered as an early strategy for adults with severe ARDS receiving lung protective ventilation.
Topics: Adult; Aged; Bayes Theorem; Extracorporeal Membrane Oxygenation; Female; Humans; Male; Middle Aged; Network Meta-Analysis; Patient Positioning; Respiration, Artificial; Respiratory Distress Syndrome
PubMed: 31365111
DOI: 10.1001/jamanetworkopen.2019.8116 -
Therapeutic Advances in Respiratory... 2019Setting a positive end-expiratory pressure (PEEP) on patients with acute respiratory distress syndrome (ARDS) receiving mechanical ventilation has been an issue of great... (Comparative Study)
Comparative Study Meta-Analysis
Effect of lung recruitment and titrated positive end-expiratory pressure (PEEP) low PEEP on patients with moderate-severe acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials.
BACKGROUND
Setting a positive end-expiratory pressure (PEEP) on patients with acute respiratory distress syndrome (ARDS) receiving mechanical ventilation has been an issue of great contention. Therefore, we aimed to determine effects of lung recruitment maneuver (RM) and titrated PEEP low PEEP on adult patients with moderate-severe ARDS.
METHODS
Data sources and study selection proceeded as follows: PubMed, Ovid, EBSCO, and Cochrane Library databases were searched from 2003 to May 2018. Original clinical randomized controlled trials which met the eligibility criteria were included. To compare the prognosis between the titrated PEEP and low PEEP groups on patients with moderate-severe ARDS (PaO/FiO < 200 mmHg). Heterogeneity was quantified through the statistic. Egger's test and funnel plots were used to assess publication bias.
RESULTS
No difference was found in 28-day mortality and ICU mortality (OR = 0.97, 95% CI (0.61-1.52), = 0.88; OR = 1.14, 95% CI (0.91-1.43), = 0.26, respectively). Only ventilator-free days, length of stay in the ICU, length of stay in hospital, and incidence of barotrauma could be systematically reviewed owing to bias and extensive heterogeneity.
CONCLUSION
No difference was observed in the RM between the titrated PEEP and the low PEEP in 28-day mortality and ICU mortality on patients with moderate-severe ARDS.
Topics: Adult; Hospitalization; Humans; Intensive Care Units; Positive-Pressure Respiration; Randomized Controlled Trials as Topic; Respiratory Distress Syndrome; Severity of Illness Index; Treatment Outcome
PubMed: 31269867
DOI: 10.1177/1753466619858228 -
Burns : Journal of the International... Jun 2020Ventilation strategies aiming at prevention of ventilator-induced lung injury (VILI), including low tidal volumes (V) and use of positive end-expiratory pressures (PEEP)...
OBJECTIVE
Ventilation strategies aiming at prevention of ventilator-induced lung injury (VILI), including low tidal volumes (V) and use of positive end-expiratory pressures (PEEP) are increasingly used in critically ill patients. It is uncertain whether ventilation practices changed in a similar way in burn patients. Our objective was to describe applied ventilator settings and their relation to development of VILI in burn patients.
DATA SOURCES
Systematic search of the literature in PubMed and EMBASE using MeSH, EMTREE terms and keywords referring to burn or inhalation injury and mechanical ventilation.
STUDY SELECTION
Studies reporting ventilator settings in adult or pediatric burn or inhalation injury patients receiving mechanical ventilation during the ICU stay.
DATA EXTRACTION
Two authors independently screened abstracts of identified studies for eligibility and performed data extraction.
DATA SYNTHESIS
The search identified 35 eligible studies. V declined from 14 ml/kg in studies performed before to around 8 ml/kg predicted body weight in studies performed after 2006. Low-PEEP levels (<10 cmHO) were reported in 70% of studies, with no changes over time. Peak inspiratory pressure (PIP) values above 35 cmHO were frequently reported. Nevertheless, 75% of the studies conducted in the last decade used limited maximum airway pressures (≤35 cmHO) compared to 45% of studies conducted prior to 2006. Occurrence of barotrauma, reported in 45% of the studies, ranged from 0 to 29%, and was more frequent in patients ventilated with higher compared to lower airway pressures.
CONCLUSION
This systematic review shows noticeable trends of ventilatory management in burn patients that mirrors those in critically ill non-burn patients. Variability in available ventilator data precluded us from drawing firm conclusions on the association between ventilator settings and the occurrence of VILI in burn patients.
Topics: Barotrauma; Burns; Humans; Positive-Pressure Respiration; Respiration, Artificial; Smoke Inhalation Injury; Tidal Volume; Ventilator-Induced Lung Injury
PubMed: 31202528
DOI: 10.1016/j.burns.2019.05.015 -
Diving and Hyperbaric Medicine Jun 2019Physiological changes are induced by immersion, swimming and using diving equipment. Divers must be fit to dive. Using medication may impact the capacity to adapt to...
BACKGROUND
Physiological changes are induced by immersion, swimming and using diving equipment. Divers must be fit to dive. Using medication may impact the capacity to adapt to hyperbaric conditions. The aim of this systematic review is to assess the interaction of diving/hyperbaric conditions and medication and to provide basic heuristics to support decision making regarding fitness to dive in medicated divers.
METHODS
This was a systematic review of human and animal studies of medications in the hyperbaric environment. Studies were subdivided into those describing a medication/hyperbaric environment interaction and those concerned with prevention of diving disorders. Studies without a relation to diving with compressed air, and those concerning oxygen toxicity, hyperbaric oxygen therapy or the treatment of decompression sickness were excluded.
RESULTS
Forty-four studies matched the inclusion criteria. Animal studies revealed that diazepam and valproate gave limited protection against the onset of the high-pressure neurological syndrome. Lithium had a protective effect against nitrogen-narcosis and losartan reduced cardiac changes in repetitive diving. Human studies showed no beneficial or dangerous pressure-related interactions. In prevention of diving disorders, pseudoephedrine reduced otic barotrauma, vitamins C and E reduced endothelial dysfunction after bounce diving and hepatic oxidative stress in saturation diving.
DISCUSSION AND CONCLUSIONS
Animal studies revealed that psycho-pharmaceuticals can limit the onset of neurologic symptoms and cardiovascular protective drugs might add a potential protective effect against decompression sickness. No evidence of significant risks due to changes in pharmacologic mechanisms were revealed and most medication is not a contraindication to diving. For improving decision making in prescribing medicine for recreational and occupational divers and to enhance safety by increasing our understanding of pharmacology in hyperbaric conditions, future research should focus on controlled human studies.
Topics: Animals; Decompression Sickness; Diving; Humans; Hyperbaric Oxygenation; Inert Gas Narcosis; Swimming
PubMed: 31177519
DOI: 10.28920/dhm49.2.127-136 -
Medicine May 2019Traumatic vascular injury is caused by explosions and projectiles (bullets and shrapnel); it may affect the arteries and veins of the limbs, and is common in wartime,...
BACKGROUND
Traumatic vascular injury is caused by explosions and projectiles (bullets and shrapnel); it may affect the arteries and veins of the limbs, and is common in wartime, triggering bleeding, and ischemia. The increasing use of high-energy weapons in modern warfare is associated with severe vascular injuries.
METHODS
To summarize the current evidence of diagnosis and treatment for traumatic vascular injury of limbs, for saving limbs and lives, and put forward some new insights, we comprehensively consulted literatures and analyzed progress in injury diagnosis and wound treatment, summarized the advanced treatments now available, especially in wartime, and explored the principal factors in play in an effort to optimize clinical outcomes.
RESULTS
Extremity vascular trauma poses several difficult dilemmas in diagnosis and treatment. The increasing use of high-energy weapons in modern warfare is associated with severe vascular injuries. Any delay in treatment may lead to loss of limbs or death. The development of diagnose and treat vascular injury of extremities are the clinical significance to the tip of military medicine, such as the use of fast, cheap, low invasive diagnostic methods, repairing severe vascular injury as soon as possible, using related technologies actively (fasciotomy, etc).
CONCLUSION
We point out the frontier of the diagnosis and treatment of traumatic vascular injury, also with a new model of wartime injury treatment in American (forward surgical teams and combat support hospitals), French military surgeons regarding management of war-related vascular wounds and Chinese military ("3 districts and 7 grades" model). Many issues remain to be resolved by further experience and investigation.
Topics: Amputation, Surgical; Ankle Brachial Index; Blast Injuries; Blood Vessel Prosthesis; Decompression, Surgical; Emergency Medicine; Extremities; Fasciotomy; Fractures, Bone; Humans; Military Medicine; Military Personnel; Retrospective Studies; Skin Transplantation; Time Factors; Trauma Severity Indices; United States; Vascular Surgical Procedures; Vascular System Injuries
PubMed: 31045795
DOI: 10.1097/MD.0000000000015406 -
Diabetic Medicine : a Journal of the... Jul 2019To examine the efficacy of hyperbaric oxygen therapy in healing diabetes-related lower limb ulcers through a meta-analysis of randomized clinical trials. (Meta-Analysis)
Meta-Analysis
AIM
To examine the efficacy of hyperbaric oxygen therapy in healing diabetes-related lower limb ulcers through a meta-analysis of randomized clinical trials.
METHODS
A literature search was conducted to identify appropriate clinical trials. Inclusion required randomized study design and reporting of the proportion of diabetes-related lower limb ulcers that healed. A meta-analysis was performed to examine the effect of hyperbaric oxygen therapy on ulcer healing. The secondary outcomes were minor and major amputations.
RESULTS
Nine randomized trials involving 585 participants were included. People allocated to hyperbaric oxygen therapy were more likely to have complete ulcer healing (relative risk 1.95, 95% CI 1.51-2.52; P<0.001), and less likely to require major (relative risk 0.54, 95% CI 0.36-0.81; P=0.003) or minor (relative risk 0.68, 95% CI 0.48-0.98; P=0.040) amputations than control groups. Sensitivity analyses suggested the findings were dependent on the inclusion of one trial. Adverse events included ear barotrauma and a seizure. Many of the trials were noted to have methodological weaknesses including absence of blinding of outcome assessors, lack of a justifiable sample size calculation and limited follow-up.
CONCLUSIONS
This meta-analysis suggests hyperbaric oxygen therapy improves the healing of diabetes-related lower limb ulcers and reduces the requirement for amputation. Confidence in these results is limited by significant design weaknesses of previous trials and inconsistent findings. A more rigorous assessment of the efficacy of hyperbaric the efficacy of hyperbaric oxygen therapy is needed.
Topics: Amputation, Surgical; Clinical Trials as Topic; Diabetes Mellitus; Diabetic Foot; Humans; Hyperbaric Oxygenation; Treatment Outcome; Ulcer; Wound Healing
PubMed: 31002414
DOI: 10.1111/dme.13975 -
Annals of Intensive Care Apr 2019Airway pressure release ventilation (APRV) has been considered a tempting mode of ventilation during acute respiratory failure within the concept of open lung...
BACKGROUND
Airway pressure release ventilation (APRV) has been considered a tempting mode of ventilation during acute respiratory failure within the concept of open lung ventilation. We performed a systematic review and meta-analysis to verify whether adult patients with hypoxemic respiratory failure have a higher number of ventilator-free days at day 28 when ventilated in APRV compared to conventional ventilation strategy. Secondary outcomes were difference in PaO/FiO at day 3, ICU length of stay (LOS), ICU and hospital mortality, mean arterial pressure (MAP), risk of barotrauma and level of sedation. We searched MEDLINE, Scopus and Cochrane Central Register of Controlled Trials database until December 2018.
RESULTS
We considered five RCTs for the analysis enrolling a total of 330 patients. For ventilatory-free day at day 28, the overall mean difference (MD) between APRV and conventional ventilation was 6.04 days (95%CI 2.12, 9.96, p = 0.003; I = 65%, p = 0.02). Patients treated with APRV had a lower ICU LOS than patients treated with conventional ventilation (MD 3.94 days [95%CI 1.44, 6.45, p = 0.002; I = 37%, p = 0.19]) and a lower hospital mortality (RD 0.16 [95%CI 0.02, 0.29, p = 0.03; I = 0, p = 0.5]). PaO/FiO at day 3 was not different between the two groups (MD 40.48 mmHg [95%CI - 25.78, 106.73, p = 0.23; I = 92%, p < 0.001]). MAP was significantly higher during APRV (MD 5 mmHg [95%CI 1.43, 8.58, p = 0.006; I = 0%, p = 0.92]). Then, there was no difference regarding the onset of pneumothorax under the two ventilation strategies (RR 1.94 [95%CI 0.54, 6.94, p = 0.31; I = 0%, p = 0.74]). ICU mortality and sedation level were not included into quantitative analysis.
CONCLUSION
This study showed a higher number of ventilator-free days at 28 day and a lower hospital mortality in acute hypoxemic patients treated with APRV than conventional ventilation, without any negative hemodynamic impact or higher risk of barotrauma. However, these results need to be interpreted with caution because of the low-quality evidence supporting them and the moderate heterogeneity found. Other well-designed RCTs need to be conducted to confirm our findings.
PubMed: 30949778
DOI: 10.1186/s13613-019-0518-7 -
Aerospace Medicine and Human Performance Feb 2019Barodontalgia, barometric pressure-induced dental pain, may jeopardize diving/flight safety. The aim of this systematic review was to investigate the rate of...
Barodontalgia, barometric pressure-induced dental pain, may jeopardize diving/flight safety. The aim of this systematic review was to investigate the rate of barodontalgia among military and civilian divers and aircrews based on previous reports. We analyzed the data of 4894 aircrew/divers reported in the literature. Barodontalgia rates (flight vs. diving, military vs. civilian, pressurized vs. non-pressurized aircrafts) were analyzed. The Chi-squared test was used to compare between groups. Of the 4894 individuals, 402 (8.2%) suffered from barodontalgia. Divers (9.8%) were more vulnerable than aircrews (5.8%). Barodontalgia experience rate was 5.4% and 6.5% in military and civilian aircrews, respectively, and 7.3% and 12.8% in military and civilian scuba divers, respectively. Barodontalgia was more common among aircrews of pressurized than non-pressurized aircrafts (7.3% vs. 3.2%, respectively). The greater amplitude of barometric pressure changes explains the higher rate of barodontalgia in divers than aircrew. The higher rate during pressurized flights is possibly because intracabin pressure in the pressurized cabin is still routinely higher than in nonpressurized aircrafts. Improved oral care and mandatory annual dental checkups may be the reason for the significantly lower rate of barodontalgia experienced among military aircrews and divers compared to their civilian counterparts. These results emphasize the essential role of atmospheric pressure change in the generation of pain during flight or diving and the importance of proper dental care.
Topics: Aerospace Medicine; Atmospheric Pressure; Barotrauma; Diving; Humans; Military Personnel; Pilots; Toothache
PubMed: 30670123
DOI: 10.3357/AMHP.5183.2019