Search Results (147)

Background: The aim of this study was to assess in vitro nebulized drug delivery during invasive and non-invasive ventilation, comparing jet nebulizers (JN) and vibrating mesh nebulizers (VMN) across various pediatric ventilation models. Methods: Drug delivery performance was compared between a continuous output JN (Aquineb) and VMN (Aerogen Solo A-VMN). The non-invasive model simulated a spontaneously breathing 9-month-old child using an anatomically correct upper airway model and breathing simulator. The invasive model used a mechanical ventilator with heated humidifier in a pediatric breathing circuit with an endotracheal tube. Nebulizers were driven with supplemental oxygen at manufacturer-recommended rates and positioned at approved locations. Absolute inhaled dose, delivery rate and residual volume were assessed using face mask, mechanical ventilation, high-flow nasal therapy and blow-by delivery methods. Dose was quantified using spectrophotometric analysis. Results: During spontaneous breathing, A-VMN delivered almost double the dose of the evaluated JN (p < 0.001), with a significantly faster delivery rate (p < 0.001) and lower residual volume (p < 0.0001). During mechanical ventilation, A-VMN demonstrated a greater than 3-fold increase in delivered dose (p < 0.0001) and faster delivery (p < 0.0001), with reduced residual volume (p < 0.001). During high-flow nasal therapy, delivery via nasal cannula was affected by gas flow rate for both devices, with A-VMN consistently delivering greater doses. A-VMN delivered significantly greater salbutamol doses during blow-by delivery. Conclusions: VMN demonstrated significantly superior dose delivery, faster delivery rates and reduced residual volumes compared to the evaluated JN across all tested pediatric respiratory support modalities. These in vitro findings provide important performance data for evidence-based device selection and warrant clinical investigation to determine potential therapeutic benefits in pediatric populations requiring aerosol therapy during respiratory support. Full article

Non-invasive respiratory support (NRS) has become a cornerstone in the management of acute respiratory failure (ARF), offering an alternative or a bridge between conventional oxygen therapy (COT) and invasive mechanical ventilation (iMV). While NRS techniques—including non-invasive ventilation (NIV), continuous positive airway pressure (CPAP), and high-flow nasal oxygen (HFNO)—have demonstrated efficacy in reducing intubation rates and improving outcomes, patient tolerance and synchrony remain critical determinants of success. Analgosedation, the strategic use of analgesics and sedatives, has emerged as an important adjunctive therapy to optimise NRS delivery, reduce patient–ventilator asynchrony, and improve comfort. However, the delicate balance between adequate sedation and the preservation of spontaneous breathing, airway protection, and hemodynamic stability presents unique challenges. This comprehensive narrative review synthesises current evidence on analgosedation strategies during NRS use, examining pharmacological agents, their pharmacokinetic and pharmacodynamic properties, comparative studies, indications, monitoring parameters, clinical settings, and safety considerations. We also review existing guidelines, discuss special considerations in paediatric populations, and propose practical clinical approaches. Understanding the nuanced application of analgosedation is essential for clinicians to maximise therapeutic benefit while minimising risks of NRS treatment failure and adverse outcomes. Full article

Postoperative respiratory failure (PRF) remains a pervasive clinical challenge that substantially contributes to perioperative morbidity, mortality, and prolonged ICU stay. Although conventional oxygen therapy is often sufficient, a significant subset of high-risk patients requires escalation to advanced non-invasive support to avoid reintubation and invasive mechanical ventilation. Evidence from recent randomized trials, including the 2025 RENOVATE and Goret et al. studies, indicates that both non-invasive ventilation (NIV) and high-flow nasal oxygen (HFNO) reduce postoperative pulmonary complications and reintubation in selected high-risk populations. While NIV is preferred for hypercapnic ventilatory failure and is commonly used in selected high-risk cardiac surgery patients, HFNO offers comparable outcomes in pure hypoxemic failure with the added benefits of superior patient tolerance and a lower incidence of interface-related complications. Effective PRF management necessitates an individualized, physiology-based approach. By implementing a phenotype-driven algorithm that aligns device mechanics with the dominant pathophysiology, such as atelectasis versus pump failure, clinicians can optimize patient outcomes while minimizing the specific risks associated with delayed intubation. Full article

Patients with end-stage lung diseases awaiting lung transplant frequently experience severe hypoxemia, dyspnea, and functional limitations that may compromise survival and transplant eligibility. Optimizing noninvasive respiratory support during the waiting period is crucial to preserve oxygenation, maintain physical conditioning, and avoid escalation to invasive mechanical ventilation, which is associated with poorer transplant outcomes. High-flow nasal cannula therapy has emerged as an important noninvasive respiratory support modality capable of providing physiological and clinical benefits such as precise fractions of inspired oxygen, a low level of positive end-expiratory pressure, dead-space washout, and reduced work of breathing. This review summarizes the pathophysiology of hypoxemia in lung transplant candidates, the mechanisms of action of high-flow nasal cannulas, and the current clinical evidence supporting its use in this population during the pre-transplant period. Available evidence suggests that the use of high-flow nasal cannulas improves oxygenation, relieves dyspnea, enhances exercise tolerance, facilitates participation in pulmonary rehabilitation programs, and may reduce the need for endotracheal intubation, thereby improving the likelihood of survival to transplantation. The review also discusses patient selection, the practical implementation of high-flow nasal cannula therapy, and comparisons with other respiratory support modalities. Although the current evidence is largely observational and heterogenous, high flow appears to be a valuable supportive and bridging therapy for selected patients awaiting lung transplant. Future prospective studies are needed to define standardized protocols and evaluate transplant-specific outcomes. Full article

Emergent tracheal intubation in critically ill patients is a common, yet high-risk, intervention. It is frequently complicated by peri-intubation hypoxemia, hemodynamic instability, and metabolic derangements that increase the risk of arrhythmias, hypotension, cardiac arrest, and death. Because the highest-risk interval often occurs in the minutes surrounding induction, when apnea, derecruitment, and abrupt cardiopulmonary shifts converge, oxygenation failure frequently reflects a mismatch between preoxygenation strategy and the underlying physiology rather than inadequate oxygen delivery alone. This review proposes a phenotype-based approach to peri-intubation oxygenation and focuses on four high-risk phenotypes in whom standard preoxygenation strategies commonly fail: obesity, neuromuscular disease, right ventricular dysfunction or pulmonary hypertension, and post-operative respiratory failure with altered respiratory mechanics or airway anatomy. We summarize the key mechanisms that shorten safe apnea time, including reduced functional residual capacity, intrapulmonary shunt, elevated oxygen consumption, rapid derecruitment after induction, and impaired oxygenation–hemodynamics coupling. We then compare preoxygenation modalities as physiologic tools, including facemask oxygen, high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), and controlled bag-mask ventilation (BMV), and integrate contemporary randomized trial evidence that informs bedside selection and combination of these approaches. Finally, we synthesize these concepts into a practical, physiology-informed framework to guide clinicians in choosing and troubleshooting preoxygenation strategies in high-risk patients undergoing emergent intubation. Full article

Background/Objectives: Myositis-associated interstitial lung disease (ILD) can occasionally present as acute respiratory distress syndrome (ARDS); however, clinical data on this presentation remain limited. This study aimed to describe the clinical characteristics and outcomes of patients with myositis-associated ILD presenting as ARDS. Methods: We conducted a single-center retrospective observational study of patients with myositis-associated ILD who were admitted to the intensive care unit (ICU) for acute hypoxemic respiratory failure. Results: Ten patients positive for myositis-specific antibodies met the new global ARDS definition. The median age was 62 years, and eight patients were male. Antibody profiles included anti-MDA-5 (n = 5), anti-synthetase antibodies (Jo-1 [n = 1], PL-7 [n = 2], EJ [n = 4]), and NXP-2 (n = 1). Fever and cutaneous manifestations were the most common extrapulmonary features. Chest computed tomography demonstrated diffuse alveolar damage patterns in six patients and organizing pneumonia patterns in four. At ICU admission, four patients required mechanical ventilation and six received high-flow nasal cannula, of whom four subsequently progressed to mechanical ventilation. Extracorporeal membrane oxygenation was implemented in three patients. All patients received high-dose corticosteroids, six underwent steroid pulse therapy, and four additionally received immunosuppressive agents. Six patients died during hospitalization. Conclusions: Myositis-associated ILD may present as ARDS and should be considered in patients with ARDS of unclear etiology. Careful physical examination and autoantibody testing may assist in recognizing this condition in the critical care setting. Full article

Acute respiratory distress syndrome (ARDS) is a heterogeneous inflammatory lung injury marked by increased alveolar–capillary permeability, reduced respiratory system compliance, and impaired gas exchange. Despite advances in supportive care, ARDS remains associated with high mortality. Lung-protective ventilation with low tidal volumes and prone positioning is the cornerstone of treatment. However, these strategies do not fully account for patient-specific physiological variability. Recent guidelines emphasize a more individualized approach to respiratory support. Key elements include limitation of driving pressure, optimized use of high-flow nasal oxygen, and application of bedside tools such as the SpO₂/FiO₂ ratio and lung ultrasound. These measures improve diagnosis, monitoring, and physiological assessment at the bedside. This narrative review summarizes current evidence supporting contemporary ventilatory and non-invasive strategies in ARDS. It also examines emerging diagnostic and therapeutic approaches that integrate respiratory physiology into clinical decision-making. Finally, we discuss future directions focused on personalized, physiology-guided management to improve outcomes in patients with ARDS. Full article

Cardiogenic pulmonary edema (CPE) is a life-threatening manifestation of acute heart failure characterized by rapid accumulation of fluid in the interstitial and alveolar spaces, leading to severe dyspnea, hypoxemia, and respiratory failure. The condition arises from elevated left-sided filling pressures that increase pulmonary capillary hydrostatic pressure, disrupt alveolo-capillary barrier integrity, and impair gas exchange. Neurohormonal activation further perpetuates congestion and increases myocardial workload, creating a vicious cycle of hemodynamic overload and respiratory compromise. Respiratory support is a cornerstone of management in CPE, aimed at stabilizing oxygenation, reducing the work of breathing, and facilitating ventricular unloading while definitive therapies, such as diuretics, vasodilators, inotropes, or mechanical circulatory support (MCS), address the underlying cause. Among available modalities, non-invasive ventilation (NIV) with continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) has the strongest evidence base in moderate-to-severe CPE, consistently reducing the need for intubation and providing rapid relief of dyspnea. High-flow nasal cannula (HFNC) represents an emerging alternative in patients with moderate hypoxemia or intolerance to mask ventilation, and should be considered an adjunctive option in selected patients with less severe disease or NIV intolerance, although its efficacy in severe presentations remains uncertain. Invasive mechanical ventilation is reserved for refractory cases, while extracorporeal membrane oxygenation (ECMO) and other advanced circulatory support modalities may be necessary in cardiogenic shock. Integration of respiratory strategies with hemodynamic optimization is essential, as positive pressure ventilation favorably modulates preload and afterload, synergizing with pharmacological unloading. Future directions include personalization of ventilatory strategies using advanced monitoring, novel interfaces to improve tolerability, and earlier integration of MCS. In summary, respiratory support in CPE is both a bridge and a decisive therapeutic intervention, interrupting the cycle of hypoxemia and hemodynamic deterioration. A multidisciplinary, individualized approach remains central to improving outcomes in this high-risk population. Full article

Background/Objectives: Flexible bronchoscopy (FB) enables airway exploration and diagnosis of various respiratory pathologies, but the sedation and instrumentation required during the procedure raise oxygen demand while reducing ventilation, which can lead to hypoxemia. Conventional oxygen therapy (COT) may not adequately prevent desaturations in high-risk groups, as patients with moderate respiratory deficiency. High-flow nasal cannula (HFNC) can deliver heated, humidified oxygen at high flow rates, generating low-level positive airway pressure, improving oxygenation, reducing dead-space, and enhancing procedure tolerance. Prior studies have shown that HFNC can improve gas exchange and reduce desaturations during bronchoscopy. However, evidence remains limited for patients with moderate respiratory deficiency, who are particularly vulnerable. Evaluating the feasibility and safety of HFNC in this population is essential to guide safe procedural practice. Methods: A retrospective observational study including patients undergoing FB with HFNC support between January and May 2025. Inclusion criteria were BMI between 18 and 30; age > 18 years old; moderate respiratory dysfunction, defined by pulse oximetry, Pulmonary Functional Tests (PFTs) and Arterial Blood Gas (ABG) analysis. Exclusion criteria were intolerance/contraindication to HFNC. Procedures were performed under basic monitoring. Primary outcome was occurrence of severe hypoxemia (SpO2 < 90%). Secondary outcomes were needed for rescue maneuvers, interruption for conversion to other ventilatory strategies, and hemodynamic instability. Results: No severe desaturations were recorded, all procedures were completed without rescue maneuvers or other ventilatory strategies, and no hypoxemia occurred. Mean duration of the procedure was 9 min. Vital parameters were maintained within the normal ranges, with a mean SpO₂ during bronchoscopy of 98%. Conclusions: HFNC enables oxygenation and ventilation without adverse events in sedations for FB in patients with moderate respiratory deficiency. Full article

Background: Durvalumab, a PD-L1 inhibitor used as consolidation therapy after chemoradiation in unresectable stage III non–small cell lung cancer (NSCLC), can induce immune-related adverse events, among which immune-mediated pneumonitis represents one of the most severe. Differentiating checkpoint inhibitor pneumonitis (CIP) from infectious pneumonia is challenging due to overlapping clinical and radiologic findings. Case presentation: We describe a 67-year-old woman with stage III lung adenocarcinoma treated with chemotherapy, radiotherapy, and durvalumab, who presented with progressive dyspnea and extensive bilateral ground-glass opacities on CT imaging. Laboratory tests revealed leukopenia and elevated inflammatory markers. Despite broad-spectrum antibiotic and antiviral therapy, her condition worsened, requiring high-flow nasal cannula oxygen therapy. Multiplex molecular testing on sputum identified human metapneumovirus (HMPV), while blood cultures and urinary antigens for Streptococcus pneumoniae and Legionella pneumophila were negative. A pulmonology consultation raised suspicion for severe durvalumab-induced pneumonitis exacerbated by viral infection. High-dose methylprednisolone (2 mg/kg/day) followed by a four-week taper led to gradual clinical and radiologic resolution. Durvalumab was permanently discontinued. Discussion: To our knowledge, this is the first reported case of HMPV-associated pneumonitis in a patient receiving durvalumab. This case highlights the potential synergistic interplay between viral infection and immune checkpoint blockade, resulting in severe lung injury. Comprehensive microbiologic evaluation, including molecular diagnostics, is essential to guide therapy and distinguish infectious from immune-mediated causes. Conclusions: Early recognition of mixed infectious and immune-mediated pneumonitis, and timely corticosteroid therapy are critical to achieving favorable outcomes and preventing irreversible pulmonary damage. Full article

Background: Use of high-flow nasal cannula (HFNC) expanded from ICUs to internal medicine/respiratory wards during and after the COVID-19 pandemic, but safety and effectiveness in non-ICU settings remain uncertain. Methods: We performed a systematic review and meta-analysis of adults (≥18 years) initiated on HFNC in non-ICU wards. Primary outcomes were in-hospital (or 28-day) mortality and ICU transfer; where available, we compared mortality for HFNC vs. conventional oxygen therapy (COT) in do-not-intubate (DNI) cohorts. Observational studies and trials were eligible. Random-effects models synthesized proportions and risk ratios; risk of bias (ROBINS-I/RoB 2) and certainty (GRADE) were assessed. Results: Ten studies met the inclusion criteria for any-ward HFNC; subsets contributed data to pooled analyses. Across all non-ICU wards (general wards plus step-up IMCU/HDU), pooled mortality was 14.0% (95% CI 4.6–35.5; I² ≈ 92%). Pooled ICU transfer after ward/step-up HFNC start was 20.0% (95% CI 6.3–48.1; I² ≈ 97%). Restricted to internal medicine/respiratory wards, pooled mortality was 19.8% (95% CI 7.1–44.2; I² ≈ 95%) and ICU transfer 31.2% (95% CI 9.9–65.0; I² ≈ 97%). In step-up units (IMCU/HDU), ICU transfer appeared lower and less variable (22.0% [95% CI 16.5–28.8]; I² ≈ 10%), suggesting environment-dependent outcomes. In a multicenter DNI COVID-19 cohort, HFNC vs. COT showed no clear mortality difference (RR ≈ 0.90, 95% CI 0.75–1.08; adjusted OR ≈ 0.72, 95% CI 0.34–1.54). Certainty of evidence for all critical outcomes was very low due to observational design, high inconsistency, and imprecision. Conclusions: HFNC outside the ICU is feasible, but it is related to nontrivial mortality and frequent escalation—particularly on general wards—while step-up units demonstrate more reproducible trajectories. Outcomes appear strongly conditioned by care environment, staffing, monitoring, and escalation pathways. Given very low certainty and substantial heterogeneity, institutions should pair ward HFNC with protocolized reassessment and rapid response/ICU outreach, and future research should prospectively compare ward HFNC pathways against optimized COT/NIV using standardized outcomes. Full article

Deep Sedation (DS) allows for shorter recovery times, reduced complication rates and increased cost-effectiveness compared to general anesthesia. In prolonged DS, High Flow Nasal Oxygen Therapy (HFNOT) ensures adequate oxygenation. Concerns remain regarding potential masking of inadequate ventilation and induction of hyperoxia. In this single-center observational study, we continuously monitored tcPCO₂ and mitoPO₂ in 30 patients using the SenTec Monitoring System and Cellular Oxygen METabolism (COMET^®, Photonics Healthcare, Utrecht, The Netherlands) device to observe the effect of prolonged DS with HFNOT on periprocedural ventilation and oxygenation. Measurements were taken at baseline and 30, 60, 90 and 120 min after starting DS. tcPCO₂ significantly increased after 30 (55.5 (34.5–61.9) mmHg, p < 0.001), 60 (54.8 (52.5–62.2) mmHg, p < 0.001), 90 (56.5 (53.1–69.3), p < 0.001) and 120 (55.8 (50.7–56.6) mmHg, p = 0.02) minutes of DS compared to baseline (37.3 (34.5–45.5) mmHg), surpassing the normal range (35–45 mmHg). mitoPO₂ increased non-significantly from baseline (69.6 (43.9–76.7) mmHg) compared to 30 (80.5 (65.7–98.9) mmHg, p = 0.19), 60 (78.6 (70.3–85.8) mmHg, p = 0.19), 90 (74.4 (52.7–86.3) mmHg, p = 0.38) and 120 (85.6 (82.5–98.0) mmHg, p = 0.38) minutes. We observed increased tcPCO₂ and a non-significant rise in mitoPO₂ over time, without adverse effects. These findings highlight the potential of continuous sensor-based monitoring to improve real-time detection of ventilation and oxygenation. Full article

Background and Clinical Significance: Intermediate-high-risk pulmonary embolism is characterized by right-ventricular dysfunction and positive cardiac biomarkers in the absence of hemodynamic instability. Current guidelines recommend anticoagulation with vigilant monitoring, and reserve systemic fibrinolysis for patients who deteriorate hemodynamically. However, some patients may experience physiologic decompensation manifested by refractory hypoxemia rather than hypotension, despite preserved systemic perfusion and normal lung parenchyma. In such cases, oxygenation failure reflects the severity of perfusion impairment and incipient right-ventricular-circulatory collapse. Whether this scenario justifies systemic fibrinolysis remains uncertain. Case Presentation: We present a 75-year-old man, five days after arthroscopic meniscus repair, presenting with acute dyspnea, tachycardia, and severe respiratory failure despite normal chest radiography. Laboratory findings revealed elevated troponin-I and brain natriuretic peptide, and echocardiography demonstrated marked right-ventricular dilation. Computed tomographic pulmonary angiography confirmed extensive bilateral central emboli with preserved lung parenchyma. Despite high-flow nasal oxygen at 100% fraction of inspired oxygen, respiratory failure worsened, necessitating intubation under lung-protective settings. With catheter-directed therapy unavailable and transfer unsafe, a multidisciplinary team administered staged systemic fibrinolysis with alteplase, pausing heparin during infusion. No bleeding or surgical complications occurred. Oxygenation and right-ventricular indices improved promptly. The patient was extubated on day 2, discharged from intensive care unit on day 7, and remained asymptomatic with normal echocardiography at 3 months. Conclusions: Refractory hypoxemia in intermediate-high-risk, normotensive pulmonary embolism, particularly when parenchymal disease and ventilator confounding are excluded, may represent an early form of circulatory decompensation warranting rescue reperfusion. In the absence of catheter-directed options and with acceptable bleeding risk, staged full-dose systemic fibrinolysis can be life-saving and physiologically justified. This case supports expanding the concept of “clinical deterioration” in intermediate-risk pulmonary embolism to include isolated, unexplained respiratory failure, highlighting the need for future trials to refine individualized reperfusion thresholds. Full article

Background: Data on high flow nasal oxygenation (HFNO) efficacy in hypoxia prevention in transcatheter aortic valve replacement (TAVR) are conflictive. We aimed to determine the benefit of HFNO in preventing the occurrence of desaturations during TAVR. Methods: An investigator-initiated, proof of concept, single-centre, randomised, and controlled trial on 132 adult patients who were scheduled to undergo transfemoral TAVR was conducted. Patients were randomised (1:1) to HFNO (H-group) with a flow rate of 50 L min⁻¹ and FiO₂ 0.6 or standard of care oxygen therapy (S-group). The primary endpoint was the number of patients with a desaturation episode (SpO₂ < 93%) for >10 s during TAVR. Secondary outcomes included arterial partial pressure of oxygen (pO₂) 45 min from sedation start and changes in glomerular filtration rate from baseline to 12 h post-procedure. Results: Between 23 November and 24 July, a per-protocol analysis was performed in a total of 125 patients (H-group n = 64; S- group n = 61; 49 females). The number of patients with any desaturation episode was significantly lower in the H-group [13/64 (20%, 95% CI: 12–32%)] than in the S-group [31/61 (51%, 95% CI: 39–63%), RR: 0.39 (95%CI: 0.23–0.68)]. At 45 min, mean (SD) pO₂ was higher in the H-group (24(9.8) kPa vs. 16.7(7.5) kPa; p < 0.005). A significant improvement in delta median (IQR) difference on glomerular filtration rate was observed in the H-group [1.6(−1–7.9) mL min⁻¹ 1.73 m⁻²] with respect to the S-group [0.2(−6.1–3.1) mL min⁻¹ 1.73 m⁻²; p-value: 0.013]. Conclusions: This trial demonstrated that HFNO provides a better oxygenation pattern than standard oxygen therapy during TAVR. Larger studies focusing on long-term clinical outcomes are warranted to evaluate the benefit of HFNO during sedation for TAVR procedures. Full article

Objectives: This study aimed to evaluate how non-invasive ventilation (NIV) and high-flow nasal cannula therapy (HFT) versus conventional oxygen therapy (COT) affect neural ventilatory drive during exercise in patients with severe chronic obstructive pulmonary disease (COPD). Methods: We conducted an experimental, controlled study with one arm and three different conditions for the same cohort. After initial testing on conventional oxygen therapy (COT), patients exercised under NIV and HFT in sequential days and a random order. Participants: Twenty patients (mean age 60 years old (SD 3.9), 6 female) with severe COPD (30% women) on home NIV as a bridge to lung transplantation were enrolled in this study, with a mean FEV₁ of 19.78% predicted and marked hyperinflation. Protocol: Participants performed constant-load cycling exercises at 75% maximum tolerated workload under three conditions: COT, NIV, and HFT. Neuro-respiratory drive (NRD) was measured using surface parasternal and sternocleidomastoid electromyography, and mixed ANOVA was performed to analyze repeated measures across conditions. Results: In total, 20 patients were included in this study. NIV demonstrated superior performance, with 60% lower NRD compared to COT (488.81 µV vs. 1180.63 µV, p < 0.05). HFT showed intermediate effects (807.8 µV). NIV also achieved greater reduction in respiratory rate (4.2 breaths/min), lower perceived exertion (Borg score decrease: 1.8 points), and more pronounced CO₂ reduction (5.3 mmHg) compared to both COT and HFT. Conclusions: NIV significantly reduces NRD during exercise in severe COPD patients compared to HFT and COT. This supports its use as a valuable adjunct to pulmonary rehabilitation in severe COPD. Full article