Faculty Bibliography

INTRODUCTION:Humidified oxygen via a high flow nasal cannula (HFNC) is a form of supplemental oxygen therapy that has significant theoretical advantages over conventional oxygen therapy (COT). However, the clinical role of HFNC in acute hypoxemic respiratory failure (AHRF) has not been well established. This review compares the efficacy of HFNC with COT and non-invasive ventilation (NIV) in patients with AHRF. METHODS:Studies reviewed were selected based on relevance from a systematic literature search conducted in Medline and EMBASE to include all published original research through May 2016. Twelve studies matched the inclusion criteria. RESULTS:In the majority of the studies, HFNC was associated with superior comfort and patient tolerance as compared to NIV or COT. HFNC was associated with reduced work of breathing in comparison with COT in some, but not all, studies in the review. COT and NIV were associated with a higher 90-day mortality rate compared to HFNC in only one multicenter randomized trial versus no mortality difference reported by others. Three out of four studies demonstrated a decreased need for escalation of oxygen therapy with HFNC. Six out of eight studies demonstrated improved oxygenation with HFNC as compared to COT. Two of three studies revealed worse oxygenation with HFNC as compared to NIV. CONCLUSION:This review suggests that HFNC may be superior to COT in AHRF patients in terms of oxygenation, patient comfort, and work of breathing. It may be reasonable to consider HFNC as an intermediate level of oxygen therapy between COT and NIV.

Introduction: Fragmented sleep and altered circadian rhythm in critically ill patients have been linked to an increased risk of delirium. Modifiable environmental factors such as nighttime noise, light and patient-staff interactions may influence normal sleep architecture. The present study is aimed at evaluating the influence of these factors on the occurrence of delirium and perception of sleep quality in critically ill patients during the postoperative period. Methods: 38 patients admitted to the Surgical ICU were included. Noise levels, light levels and patient-staff interactions were recorded daily between 10PM and 6 AM. Sleep quality was assessed using the Richards Campell Sleep Questionnaire (RCSQ). The Confusion Assessment Method for the ICU (CAM-ICU) was performed daily to evaluate for postoperative delirium. APACHE II scores and length of stay were recorded on all patients. Results: 38 patients were studied for a total 177 patient/nights. Mean length of stay was 4.66 days and mean APACHE II score was 9.89. Patient care interactions occurred on average 16.18 times/night. Mean RCSQ score was rated at 30.67/50. The main factors perceived by patients as sleep disruptors were patient care activities (20.7% patient/nights) and noise (12.14% patient/nights). No patient reported light as a significant disruptor. In 55% of patient/nights recorded, no sleep disruptors were reported. Nighttime light levels averaged 87 Lux and light levels were greater than 100 Lux an average of 85 minutes/night. Noise peaks >80dB occurred on average 1055 times/night. Mean sound level pressure (Leq) was 56.72dBA. 9/38 patients (23.68%) developed postoperative delirium during their ICU stay. A significant correlation between APACHE II scores and occurrence of delirium was observed (p=0.008). Additionally, subjects with higher APACHE scores had greater LOS (r=0.48, p=0.002) and required more patient care activities (r=0.44, p=0.007). However, no correlation was found between the occurrence of delirium and average lux levels, time with light levels >100 lux, number of patient care activities, number of peak noise levels >80dB or Leq (p=0.52, p=0.18, p=0.16, p=0.19 and p=0.18, respectively). Similarly, no correlation was demonstrated between environmental factors and RCSQ scores or between RCSQ scores and the presence of delirium. Conclusions: This study suggests that adopting strategies aimed at limiting noise, diminishing light and regulating patient care activities may have little impact in preventing the occurrence of delirium or in improving patients' perception of sleep quality in the postoperative period. Other factors that modify sleep architecture such as disease severity seem to play a more important role

OBJECTIVE: To evaluate the effect of angiopoietin-1, an angiogenic growth factor, on lung capillary leakage and survival in a murine model of acute lung injury. DESIGN: Laboratory investigation. SETTING: Research laboratory at New York University School of Medicine and Department of Veterans Affairs, NY Harbor Healthcare System. SUBJECTS: C57BL/6 mice weighing 18-20 g, susceptible to endotoxin-induced acute lung injury. INTERVENTIONS: Acute lung injury was induced in C57BL/6 mice by the intraperitoneal administration of endotoxin. The effects of angiopoietin-1, expressed from a nonreplicating E1a-deleted adenovirus containing the angiopoietin-1 complementary DNA (AdAng1), on survival and lung injury were evaluated. An E1a-deleted adenovirus that does not contain a transgene (Ad312) and phosphate-buffered saline were used as controls. MEASUREMENTS AND MAIN RESULTS: Angiopoietin-1 protein was detected by immunoblotting in the serum of mice that received an intraperitoneal injection of AdAng1 but not in mice that received the control virus Ad312. When compared with control groups, mice that received AdAng1 5 days before endotoxin administration had improved survival and significantly less protein leakage from the circulation into the lungs, as detected by quantitative spectrophotometric measurements of Evans blue dye. Furthermore, when compared with controls, histopathology and immunostaining of lungs against CD31 and smooth muscle actin suggested preservation of vascular integrity and decreased tissue damage in mice pretreated with AdAng1. When endotoxin administration preceded infection with AdAng1 by 3 hrs, no benefit was observed. CONCLUSIONS: These data show that adenoviral mediated expression of angiopoietin-1 can protect against the development of lung capillary protein leak and decrease the mortality induced by endotoxin. However, the timing of AdAng1 administration in relation to the onset of lung injury may be critical