Hello, and welcome to today's Journal Club Critical Care Medicine webcast. This webcast, hosted and supported by the Society of Critical Care Medicine, is part of the Journal Club Critical Care Medicine series. In today's webcast, we feature two articles from Critical Care Medicine. This webcast will be available to registrants on demand within five business days. Simply just log in to mysccm.org and navigate to the My Learning tab. My name is Tony Gerlach, and I'm a clinical pharmacist at The Ohio State University Medical Center here in Columbus, Ohio, and I will be moderating today's webcast. Thank you all for joining us and just a few housekeeping items before we get started. First, during the presentation, you will have the opportunity to participate in several interactive polls. When you see a poll, simply click on the bubble next to your choice. Second, there will be a question and answer or Q&A session at the conclusion of the presentation. To submit a question throughout the presentation, type it into the question box located on your control panel. Third, if you have a comment to share during the presentation, you may use the question box for that as well. And finally, everyone joining us today for the webcast will receive a follow-up email that will include an evaluation. Please take five minutes or so to complete the evaluation. Your feedback is always greatly appreciated. Please note, this presentation is for educational purposes only. The material presented is intended to represent an approach, view, statement, or opinion of the presenter, which may be helpful to others. The views and opinions expressed herein are those of the presenters and do not necessarily reflect the opinion or views of SCCM. SCCM does not recommend or endorse any specific test, physician, product, procedure, opinion, or other information that may be mentioned. And now I would like to introduce today's presenters. First is Dr. Ranier Gedet, who is an adjunctive professor of pediatrics at the Medical College of Wisconsin and the Associate Chief Medical Officer of Pediatric Critical Care Physicians at the Children's Hospital of Wisconsin in Milwaukee. Dr. Gedet is active in research. Along with him is Dr. Whitney Kopp, who recently completed her Pediatric Critical Care Fellowship at the Medical College of Wisconsin Children's Hospital of Wisconsin in Milwaukee. And she's now a pediatric intensivist at Sacred Heart Children's Hospital in Spokane, Washington. Her research interests include respiratory support in children with ARDS. Dr. Joseph Lugon is a nephrologist and director of the Dialysis Center at the Hospital Universario Antonio Pedro in Niterói, Rio de Janeiro, Brazil, and he's the coordinator of the Postgraduate in Medicine Science Program at the Fluminese Federal University, which is also in Brazil. Finally, we have Dr. Leonardo Codera de Souza, who has a master's and a PhD degree in medical science from the Fluminese Federal University in Brazil. He is a physiotherapy manager at the Hospital Ecaria and Sé Gonçalo Hospital and scientific director of the Study Center at the Hospital Ecaria, as well as a professor of physiotherapy at Estacio de Sao University, all of which are in Rio de Janeiro, Brazil. Thank you all for joining us today. Before we begin, does anyone have any disclosures to know? Not so. If I hear all none, thank you very much. And now I'm going to turn things over to our first presenters, Dr. Gaudet and Dr. Kopp. Thank you very much. Good afternoon, and thank you for giving us the opportunity to present our work. We'll be presenting our paper on the impact of pre-intubation non-invasive ventilation on outcomes in pediatric ARDS. Non-invasive ventilation is commonly used in adults and has been increasing in its use within the pediatric population. In the adult population, multiple studies cite decreased length of stay, reduction in intubations, and decreased hospital costs with its use. The Japanese and European respiratory societies have published guidelines for its use. Both recommend against non-invasive ventilation use in acute respiratory distress syndrome. Within the pediatric population, there have been small studies looking at non-invasive ventilation and respiratory failure. Few focus specifically on its use in pediatric ARDS and utilized non-pediatric definitions for ARDS and acute lung injury. And in the SCARF trial, early non-invasive ventilation was shown to be associated with worse outcomes. In 2015, a Pediatric Acute Lung Injury Consensus Conference published definitions and recommendations for management and future research for pediatric ARDS. The recommendations include criteria for defining pediatric ARDS when using non-invasive ventilation. The non-invasive ventilation definition included CPAP or BIPAP, as well as P to F and SF ratios. However, no specific risk stratification exists for pediatric ARDS and non-invasive ventilation. In the consensus conference document, non-invasive ventilation is recommended in mild pediatric ARDS, but not in severe. It concludes that patients with severe hypoxemia in the first few hours of non-invasive ventilation are likely to require intubation. Pediatric ARDS severity is determined based on the oxygenation index or the oxygen saturation index and is broken into categories. There is an at-risk category that has specific criteria as well and can be defined as non-invasive ventilation, this including nasal cannula or high-flow nasal cannula, as well as invasive ventilation. Our hypothesis of this investigation is that children who received non-invasive ventilation prior to invasive ventilation will have longer length of stay, longer duration of ventilation, and higher mortality compared to those who received only invasive ventilation. This study was a secondary analysis of the RESTORE data set. RESTORE is a cluster randomized trial conducted in 31 U.S. pediatric ICUs with 17 randomized to the intervention arm. RESTORE tested a nurse-implemented, goal-directed sedation protocol compared to usual care. All patients received invasive mechanical ventilation for acute airways and or Prankmal lung disease. It was conducted from June of 2009 to December of 2013, and both arms collected identical clinical data. For this study, non-invasive ventilation was defined as humidified, high-flow nasal cannula greater than 5, CPAP greater than 5 centimeters of water, and any BiPAP. All patients enrolled in RESTORE were included in the study except for those with tracheostomy since one of our outcomes was based on successful extubation. The remaining patients were broken into two groups, those who received pre-intubation non-invasive ventilation and those who did not. Initiation of invasive ventilation was the time of tracheal intubation, and the end of invasive ventilation with successful extubation, defined as remaining extubated for at least 24 hours. The pediatric ARDS severity categories were those defined by the consensus conference based on oxygenation index and oxygen saturation index collected during the RESTORE study. Pediatric ARDS severity categories were based on the highest OI or OSI on day zero to day one of intubation. Our primary outcomes were duration of mechanical ventilation, PICU length of stay, hospital length of stay, and in-hospital mortality at 28 and 90 days within the two groups. P-values for comparing groups were calculated using linear, logistic, and proportional hazards regression for log-transformed, continuous, binary, and time-to-event variables, respectively. Interclass coefficient was utilized for site variability. Due to the cluster randomized design, regression analyses accounted for PICU as a cluster variable using generalized estimating equations. Risk-adjusted analysis of outcomes was performed using age group, PRISM-3, a 12-hour score, and pediatric outcome performance categories greater than one at enrollment. Multivariable models were used to determine the effect of pre-intubation non-invasive ventilation. Now, Dr. Goddite will discuss the results. All right, thanks, Whitney. So for our study, we included a total of 2,427 patients from the RISD database, and as previously mentioned, 22 patients were excluded due to the presence of tracheostomies. Non-invasive ventilation was used in 995 patients prior to intubation. The median duration of non-invasive ventilation prior to intubation was 6.5 hours with a fairly wide interquartile range. NIV use between sites was moderately variable with NIV use ranging from 16 to 70%. Table 1 shows our patient characteristics and demonstrates that the groups were similar except for pre-intubation NIV group having a lower PRISM-3 score at 12 hours and with a corresponding lower risk of mortality. The pre-intubation NIV group had a risk of mortality of 2.2%, wherein the group that did not receive pre-intubation non-invasive ventilation had a risk of mortality of 4.8%. The pre-intubation NIV group also had a greater proportion of patients with a history of seizures or cancer and also had a larger proportion of patients who were intubated due to bronchiolitis or asthma. There were no differences in cognitive or functional impairment between the groups. When we evaluated patient outcomes according to pre-intubation NIV use, we found that those in the pre-intubation NIV group were more likely to have moderate or severe pediatric ARDS by the end of their first full day of invasive mechanical ventilation than the no-NIV group. And that was 68% of patients in the pre-intubation NIV group and only 60% of patients in the no-NIV group. Also patients with pre-intubation NIV had worse outcomes with longer duration of mechanical ventilation, longer duration of PICU and hospital length of stay, and also higher mortality at 28 and 90 days. There were no differences between cognitive impairment at hospital discharge or new tracheostomies between groups. When we looked at the multivariable analysis, we found that pre-intubation NIV use was associated with longer durations of invasive mechanical ventilation and PICU length of stay as well as a higher risk of mortality with an odds ratio ranging from 1.2 to 2.7. So adjusting for history of seizures, cancer, and primary diagnosis, pre-intubation NIV remained independently associated with worse outcomes. We also compared the effect of pre-intubation NIV stratified by pediatric ARDS severity group based on OI or OSI using the PALICC criteria, and it's summarized here. We have the four groups. We have the at-risk for pediatric ARDS group, a group with mild pediatric ARDS, moderate pediatric ARDS, and then also the severe group. Interestingly, we found that the use of pre-intubation non-invasive ventilation in the at-risk group was associated with the worst outcome. They had longer duration of invasive mechanical ventilation, longer duration of PICU stay, and also a higher in-hospital mortality than the group that did not receive pre-intubation non-invasive ventilation. And this is similar to findings in the severe group. The severe group also had a longer duration of invasive mechanical ventilation, longer PICU stay, and a higher in-hospital mortality at 28 days. In the mild group, there were no differences between the groups, and in the cohort of patients with moderate pediatric ARDS, the only difference was the pediatric length of stay. So again, it's interesting finding to see that the patients at the lower and the higher end of disease severity had similar findings. We also evaluated the influence of duration of pre-intubation non-invasive ventilation on outcomes, and here we have four groups. We have the pre-intubation NIV use greater than 24 hours, non-invasive ventilation use between 6 and 24 hours, and then non-invasive ventilation use less than 6 hours, and then also the no pre-intubation non-invasive ventilator use, non-invasive ventilation use. In the cohort, we found that 24% of patients received NIV for greater than 24 hours prior to intubation, and a large proportion of these, 44%, had severe pediatric ARDS by the end of the first full day of invasive mechanical ventilation, and this was higher than all other groups who received pre-intubation NIV, as well as the group that received no pre-intubation non-invasive ventilation. Again, in the severe group, this was 44%, and it was less than 40% in all of the other groups. The group of patients who received non-invasive ventilation for longer than 24 hours also had the longest duration of mechanical ventilation, the longest duration of PICU and hospital length of stay, and higher mortality at 28 and 90 days, and these findings of higher mortality were present despite the pre-intubation NIV scores, and pre-intubation group having lower PRISM scores and a lower risk of mortality. And this can be demonstrated in the table here, where we look at the patient characteristics according to the duration of pre-intubation NIV use. The groups here are the same, and the table, again, has the same categories as we previously described. And in this group, we can see that when we look at the risk of mortality for these groups of patients, the group that received no pre-intubation non-invasive ventilation had a predicted mortality of 4.8%, and we found an actual mortality at 90 days of 5%. In the group receiving NIV for less than 6 hours, the predicted mortality was 3.8%, and the mortality in this study was 6% at 90 days. In the group that received non-invasive ventilation between 6 and 24 hours, the predicted mortality was 1.9%, and the actual mortality was 6%. And the risk of mortality in our group of patients who received non-invasive ventilation greater than 24 hours was low, was 1.3%, and our actual mortality was 15%. So the duration of NIV use was related to a higher than actual predicted mortality. So I'm going to turn it back to Dr. Kopp to go over the next couple of slides. So it's unclear why these patients have worse outcomes, and it's likely multifactorial. Possible reasons include microaspiration, unregulated tidal volumes leading to increased lung trauma while on non-invasive ventilation, as well as suboptimal nutrition. We were very surprised at the significant findings within the at-risk group, as they were quite similar to those who had severe pediatric ARDS, and it's unclear why that is, and definitely an area for possible future research. Great. And obviously, this study does have some limitations. We do not have any data on the severity of respiratory disease prior to the initiation of invasive mechanical ventilation. We could not break out the different forms of non-invasive ventilation that were used. Respiratory failure was not defined primarily in the RESTORE trial, and we did not collect any data on fluid management. And also, the data were collected between 2009 and 2013, and non-invasive ventilation use may have changed over time. However, we do have some significant strengths. This is a large sample of PICU patients that are representative of patients with respiratory failure from 31 pediatric intensive care units. We have a large number of patients exposed to non-invasive ventilation and have multiple analyses showing similar outcomes. And our findings are consistent with current literature with the articles that are listed below. So, in conclusion, we find that in our cohort of patients that there is a fairly wide variability of non-invasive ventilation use between centers, that patients with pediatric ARDS who receive pre-intubation non-invasive ventilation have a longer duration of invasive mechanical ventilation, a longer duration of PICU in hospital stay, and have a higher 28-day and 90-day mortality. And we also found that the duration of pre-intubation non-invasive ventilation is associated with worse outcomes. So, where does this leave us? That leads us to really things we need to do in the future. We need to determine which patients can benefit from non-invasive ventilation, identify high-risk groups where this should not be done. We need to, therefore, determine optimal patient selection, which ones will benefit, which ones won't. Look at markers, early markers of non-invasive ventilation failure, again, because in this population, almost 50% of our patients received NIV for greater than six hours. And we also need to determine the causes of the vulnerability in the at-risk category for pediatric ARDS. What put those patients at a higher risk for worse outcomes when they had the mild lung disease at the beginning of their course? So with that, we need to thank our co-investigators in this study. We thank Lisa Asaro and David Whippy from Boston, Gwen McLaughlin from Miami, and of course, Martha Curley from Philadelphia, who was the principal investigator for the RESTORAL trial. We also have to thank the RESTORE study investigators who did all the hard work for the primary RESTORE trial, and the pediatric acute lung injury and sepsis investigators who, without their support, we could not have completed this study. So with all that, we will go to our first polling question. So I'll go ahead and read it here. In which clinical situations do you use non-invasive ventilation? So go ahead and choose and see what we think. All right. So, I mean, again, I think looking at these data, I think, again, as we saw from the study, the use of non-invasive ventilation is used in a lot of different patients. Mostly here we can see, you know, all of the above, so people will use it in either primarily, you know, you will use primarily in upper airway or bronchiolitis, but again, as I think most of us use non-invasive ventilation, we use it in many different settings and again, I think it opens up the questions, which are the right patients to use non-invasive ventilation for? Whitney, you got any comments? No. Okay. All right. So, we'll move to polling question number two, which I think is, again, another question that you need to think about in the future is how is non-invasive ventilation, how do we define non-invasive ventilation failure, specifically in lung disease, not in upper airway obstruction or lower airways obstruction, but really how do we define it with lung disease? All right, well this I think this is again a Interesting findings that we see it's mostly scattered It's it's throughout either we can look at it many different ways the oxygen requirements worker breathing co2 Increases in co2 so I think again it defines the need to really determine What are the best methods to determine non-invasive ventilation failure since we do have a you know? Don't don't seem to have a consensus at what that really means So I think again this bodes really for the need for more research in these areas The the only thing I would add to this one. I think the other really kind of big point is timing of failure so How much time do you give? these kids before you kind of say No more increasing the support, and you do call it a failure Yeah, true, that's a great. That's that's another thing. We need to look at you're absolutely right All right So thank you all very much for giving us the time to discuss This work and again. I think it was for me very interesting to look at and Now we'd like to hand it off to Dr.. D'Souza so he can discuss his paper. Thank you very much Hello My name is Leonardo D'Souza I'd like to thank you for the opportunity to share our fight and Say that is a great honor for our team to conduct in this presentation Initially Pimax was the only winning predictor in the intensive care When in the method of where we occlusion for 20 seconds is used They could have values sitting around 30 centimeters of water in This study you can see that the survival rate goes Significantly down when the maximum spiratory pressure is below the 30 centimeters of water It has been clear since then that the measurement of the inspiratory muscle function in Intensive care is very important So in this meta-analysis the resulting suggesting that the inspiratory muscle training can offer Benefits to patients with the winning difficult like here In The same year when comparing the device used for the inspiratory muscle training the electronic devices might have been representing one step ahead as indicating in this study In this meta-analysis of 2018 the inspiratory muscle training was confirmed as a hope to the winning process And now I would like to show you the timeline of the Thai index publication as Can see he our research team has been working in the new approach into evaluating the inspiratory muscle function with the promise results since 2012 And another session point to mention about the Thai index is that the measurement is highly reproducible Like in here in this study and Now we are working to demonstrate that the Thai index can be an acceptable Alternative to spontaneous brief trial as a tool to help the extubation decision provide less patient suffering in this study and Finally In 2020 we publish in a case report to use the inspiratory muscle training with an electronic device and the patient with COVID-19 Like here and this study that we brought for this meeting here So our team become interest to know if It's possible to improve the technique of the measurement of the PI max one crucial question That was what should be the timing required to achieve the maximum inspiratory pressure peak In 2012 we first published in a paper described the use of the digital vacuum meter and the unidirectional valve areas address is such important question The Result have pointed out that when in the airway occlusion lasts longer the absolute values of the inspiratory pressure become progressively higher as You can see here 86% of the participant have reached the maximum pressure after 40 seconds of occlusion Beside his graphs also shows that the usual measurement within the 20 seconds like here describing 997 free in the report in a number of the study Have resulting the values that you'd make in the prediction of the winning outcome very uncertain In 2013 We published in the first paper about the tie index in reach the result present the major accuracy in comparison with the other practicing index So the question is what is the tie index the tie index is calculated as the ratio of the PI max registered after the first 30-second of the observation by the Correspondent time to reach it Arrest keeping the airway occlusion within a unidirectional valve for up to 60 seconds We found that the value of the one or more was highly predictable of successful in Here you can follow two examples of the tie index calculation In the first in gray the PI max was 65 centimeters of water regions at the 54 seconds and the result in the tie index 1.2 centimeters of water per second within the predictor successful winning and the second in black The PI max was 22 centimeters of water Richard in the same time and the calculated time was 0.41 predicting winning failure One more question, is it possible to improve the prolong the winning outcome? In In this our first report of not successful in a patient on prolonging the winning in 2014 The patient was the first managing by the inspiratory muscle training problem with the electronic device Guided by the time effort to reach it the real PI max This Is a second case in 2016 the patient has been a control ventilation for 26 days in the deployed in a severe myopathy the first figure here Shows that at this stage when in the patient was unable to cooperate Within the session of the inspiratory muscle training program in the second figure after two weeks of training the patient read show a total control during the inspiratory muscle training session and the achieved the PI max of this 15 centimeters of water And This was the result and the gain of the 87% in the strength using the electronic device for the inspiratory muscle training problem guided by the time index This happened despite the initial impossibility of the patient to collaborate So Here's some lessons about the time index the time index incorporates the dominion of time to the inspiratory pressure measurement is fast simple reproducible in the safe Exhibit better overall performance Then that the simple measurement the maximum inspiratory pressure portrays the better performance as to the predictor of successful winning and The time index can help guide the inspiratory muscle train problems with an electronic resistive load device So He is the highlights of this talk our recent indicate that the inspiratory muscle train problem with an electronic resistive load device there's helping prolonging the winning outcome in randomized controlled trial fashion Here are the inclusive criteria for the present study And show here the exclusion ones The Criterion to interrupt the period of the spontaneous ventilation in tp's trial in both group Were these in here? The formation the agitation and Dinary Less-than the saturation and the other end once So four important points about the procedures I highlight here for the eating patients the time index and the PI max were measurement at the beginning of the winning process and Repeating on the seven-day base The last measurement of was obtaining the weekend before ventilatory Independence death or the end of the follow-up the performance of the alert in no alert participants were Attended by the layout changes in the screen of the user specific software The training session were stopping the following the same criteria used for the interruption of the tp's trial He He is the muscle training protocol for the present study the protocol Consisting often the inspiratory load for the 60 breath in the two sets of 30 breaths each After the resting period of the two minutes like here Each Set was composed the three subsets of 10 breaths each In The each subsets the load increase progressively until the target loading was heated In the end of the each training session patient were returning to the mechanical ventilation the press support Ventilation mode for two hours to rest afterward They wonder when they have tp's trial rose landing. They intended to be increasing the each train session The values of the target load for the inspiratory muscle training was adjusted every seven days base on the current PI max of each patients So the characteristics of the participant in this study as present in the table one the only statistical difference was found between the alert and start in the favor of The interventional groups in the second line here And the table two you can see that the interventional group Tended to have a long period of the mechanical ventilation before the randomization But statistical significance was not found The inspiratory muscle training was associating with the significant gain in the muscle strength as Demonstrated by the higher and the statistical difference in the medial final values of the tie index and the PI max In the interventional group like here and here for the P values here The frequency of two or more interruptions During the winning trial was higher in the control group You So At Cox proportional regression modes the inspiratory muscle train was strongly and positively positively associated with the successful winning As Expected successful winning was negatively associated with the duration of the mechanical ventilation before the randomization In addition there was a trend for negative association with with eight But statistical significance was not found in the age A more prolonged duration of the mechanical ventilation before randomization and senescence are widely recognized and predisposing factors to the ventilatory diaphragm dysfunction I'd like to show you the flowcharts and the outcome in both groups you can see that the Intervention group on the right Had the hand successful winning and the survival rates with the compare for the control group And finally there was a significant difference in survival rates Favoring the interventional group like here in this curve and the cumulative rates of successful winning Was also higher intervention group to like here However some limitations need to be considered and the first Blinding was not possible in the present study Annotation should be exercised especially regarding external validity and the negative finds interpretation Seeing a center future of the research and the small sample size The definition used for successful winning was not the recent introduced one Which was not available By the time this study was designed and registered the prevalence of the alertness Was high in the intervention group Something that could weaken our conclusion hopefully the post hoc analysis suggesting that the difference did not jeopardize our conclusions and Finally most extensive X studies were needed to confirm our finds Some conclusion our finds have shown that the use of the inspiratory muscle training program with an electronically resistive load device was associated with the substantial improvement of the following outcomes the muscle exchange gain Successful winning rates and the more important result in the survival rates He was some patient to illustrate in this history And I want to thank my team and the special professor Lugon my mentor and Thank to our search in this meeting with the opportunity to share our fights Thank you, and now it's time for the question the answer that Tony will moderate Thank you very much to everyone those were some great presentations as Always for everyone who is in the audience. Feel free to use the questions tab to submit on questions And I'll get to them as best I can and I have one and this is for dr. Good diet and dr. Kopp and it was for their paper on pediatric ARDS and non-invasive ventilation They were wondering why the propensity scores were not chosen for the statistical analysis All right, yes Yeah, thanks for that question. It's a good one again We just we didn't have all the data that we needed to do propensity scoring again. This was a secondary analysis The restore database so we did not have all the information we needed to in order to do the propensity scoring So that would have would have would have helped in In the better defining the results here. So that's something though again look at in the future but again, I think the the The strength of the study really is I think in the numbers that are there And in the analyses that we could do so, thanks for that question Thanks for that answer and then just a follow-up study since You didn't have all the data at that time Where do you guys really see the place of therapy and non-invasive ventilation and pediatric ARDS? Whitney you want to take that or Sure, so Tony you said where can you just repeat it really quick Sure, no problem. Where is there a place and if there is a place of non-invasive ventilation What do you guys think it might be? So I definitely think there there is a place for it and many publications have looked at Trying to determine the factors for non-invasive ventilation failure Such as our polling question alluded to like respiratory rate work of breathing heart rate and so on Respiratory rate work of breathing heart rate and how the P to F and S to F ratios are changing So I think it's gonna take more investigation into that and seeing Kind of where the patients how the patients are tolerating tolerating the non-invasive ventilation and I think you know after You know looking at these and other data, I think again there is there is a role for it I think again, we don't have the data on those who You know successfully Did not require intubation after non-invasive ventilation use but I think you know looking at personally in my own practice this has really changed the way I look at things and looking at things more rapidly looking really that that Somewhere between you know, one in six hours or two and six hours is really looking for that improvement If that patient doesn't improve then go ahead and Go ahead and intubate those patients, but I think again it also Brings to the question of you know, how long do you do non-invasive ventilation which? You know which can interfere with other things such as you know Good nutritional support those types of things that are required for recovery So I think you know, it's a question of not only you know, how do you decide? Failure, but how do you decide success and how long is success? Is this a patient who who will get better quickly or will you keep somebody on non-invasive ventilation or two three four five days? As they kind of plateau so I think it's difficult right now and I think we really do need Trials to really think about which patients Will benefit from non-invasive ventilation and what are parameters for success? What are parameters for failure? So I think these are all very very important things to look at No, I would agree Completely there. I think I mean you still have some of those same issues and adults that I typically practice with as well as children So I think you brought up some very good points. Now. The next question is for dr. D'Souza and dr. Lugon and it's really about Using and I think your study was unique with having a device to help with inspiratory muscle training versus just trying to do Trials on yourself, but with your device, is there any special training or storage or maintenance that's needed for it and who? Specifically profession or discipline were responsible for actually using the device All right, I'll take the question dr. Lugon, okay Well, Tony Learning to use the system takes about four hours We wrote a tutorial To make the life of our team members easier it teaches how to handle the computer system and to customize the software according to the IMT program that we designed The equipment is Stored at room temperature. It does not require special storage conditions We always use the device involved in a plastic wrap in a barrier filter For virus and bacteria to prevent its contamination at the end. It is disinfected with isopropanol The Professional that deals with the device is the physiotherapist But the decision about its use is shared with the doctor responsible for the case Okay Thank you very much. That sounds very good. And my question being since I'm the pharmacist is During the study did anything come up that might affect the training such as the development of Pneumonias between groups and if so, how was this handled and did you guys actually look at any difference in the rates of? Pneumonias between those going the training versus a TP screening protocol No, no, no, it did not In fact more than two interruptions due to worsening of the patient's condition were more common in the control group as You know in the post-operative scenario for instance that are showing that the chance of hospital acquired Pneumonia is indeed lower when an IMT program is used That's That's very very good news and that's what I was kind of hoping to hear the next questions coming through and Once again to everyone in the audience, feel free to use the question and answers tab. I will get to your questions Out there and this is again for dr. Good diet and dr. Cop Were there any difference in the outcomes between the people? The patients the pediatric patients that had high-flow nasal cannula or BiPAP and might that be part of the reason or a difference and Some of these outcomes are seen with non-invasive ventilation and pediatric ARDS So unfortunately just given the nature of the study. We were not able to actually break down The non-invasive ventilation into groups, so there's no way for us to Go back and actually look and see Of the patients who received non-invasive ventilation was it high flow was it CPAP or was it BiPAP? They were all just kind of grouped as one large category. So it's it's completely possible It's one of the things that I've wondered Looking at this research for hours upon hours is of the patients who are in the greater than 24 hours how much of that was escalation of care meaning they started on high flow they went from high flow to CPAP to BiPAP and Was that why it took? Greater than 24 hours because they were just escalating care throughout that whole thing And unfortunately, we just don't have the ability to to look at that Now It sounds like that that might be another study to come up if it was coded in the appropriate way And I'm assuming then then I'm assuming then the next question is we probably didn't have the data either was What sedation during the non-invasive ventilation is that and if there was was there a difference between there? Yeah, so that's another great question that unfortunately we don't have The data here was just being collected after intubation for sedation, however, you know, we know that you know from other publications that you know that that the age groups that you know, some people a lot of Lot of clinicians find difficult using non-invasive ventilation and is that toddler age group because of their anxiety and activity We know that in this group of patients, you know in our patients about 70% of them were under age 6 That's about the only ages we can break down so there was probably a significant number of patients who did receive some sedation and again clinically we utilize that to Facilitate non-invasive ventilation at times. So again, it's probably there probably were a significant number of patients But we don't know how sedation affected this group Well Thank you very much and then one last question for dr. Lugan and dr. De Sousa and it was really based on using your Inspiratory muscle training device. What are some lessons learned that you think the audience and others are out? There should know on how to use it and how to successfully implement it Well, you know Prolonged weaning is problematic Increases the length of stay intensive care the chance of infection complications and costs Our study shows that an IMT program can improve two paramount outcomes in prolonged weaning patients The weaning success rate and the mortality rate So we learned that it seems more than worth Embarking on such a worksome and time-consuming task trying to benefit these Patients. Thank you Well, thank you very much and yet again, I want to thank all of our presenters today and our audience for attending Again, everyone who joined us today for the webcast will receive a follow-up email that includes an evaluation Please take the time and it's only about five minutes or so to complete the evaluation Your feedback is greatly appreciated and then on our final note Please join us for our next journal club on May 27th. This concludes our presentation today Thank you very much

critical care medicine

pre-intubation non-invasive ventilation

pediatric ARDS

RESTORE trial

mechanical ventilation

mortality rate

inspiratory muscle training device

weaning process

patient outcomes