Bilateral Vocal Cord Palsy Secondary to Rheumatoid Arthritis.

Rheumatoid arthritis (RA) can cause a number of laryngeal manifestations; however, most of these do not cause an airway emergency. Airway obstruction due to vocal cord fixation of one or both vocal cords occurs late in the disease process of RA and can present as an inspiratory stridor. We report the case of an elderly lady who presented with acute stridor secondary to RA-induced bilateral vocal cord palsy and describe the various management options that were considered.

Combining four screening tools for cost effective screening of OSA in train drivers: A UK experience.

Background: Obstructive sleep apnoea (OSA) in drivers/workers has been implicated in railway and road traffic safety incidents; however, there are insufficient data on its prevalence and cost-effective screening methods.

Aim: This pragmatic study examines four OSA screening tools: the Epworth sleepiness scale (ESS), the STOP-Bang (SB), the adjusted neck circumference (ANC) and the body mass index (BMI), exploring their suitability and effectiveness separately and in combination.

Method: Using all four tools, 292 train drivers were opportunistically screened between 2016 and 2017.

Therapeutic educational workshops for caregivers of patients with severe acquired brain injury.

Severe acquired brain injury (sABI) leads to a wide range of functional limitations in cognitive, moto and behavioural abilities. These changes impact the patient's family in terms of the feeling of emotional and physical health, social life and financial condition. Caregivers are often intensely involved in the patient's management exposing them to negative effects of caregiving including stress, mood disorders and decreased quality of life.

Patient-reported outcome measures following maxillomandibular advancement surgery in patients with obstructive sleep apnoea syndrome.

Maxillomandibular advancement (MMA) is an effective treatment for obstructive sleep apnoea syndrome (OSAS) that is refractory to conventional treatment. However, it is a highly invasive procedure with several recognised side effects, and we know of few data on its effect on important patient-reported outcome measures (PROMS). Here we describe a case series of patients selected for MMA through our joint respiratory/maxillofacial surgery clinic, detailing the effect of MMA on objective physiological measurements and important PROMS.

The variation of FiO with circuit type and peak inspiratory flow rate during non-invasive respiratory support using domiciliary ventilators and its significance during the COVID-19 pandemic.

Background: The COVID-19 pandemic has resulted in increased admissions with respiratory failure and there have been reports of oxygen failure and shortages of machines to deliver ventilation and Continuous Positive Airway Pressure (CPAP). Domiciliary ventilators which entrain room air have been widely used during the pandemic. Poor outcomes reported with non-invasive respiratory support using ventilators which lack an oxygen blender could be related to an unreliable Fraction of inspired O (FiO).

How to eat, drink and speak on non-invasive ventilation.

We report our observations on six individuals with non-bulbar neuromuscular disorders using non-invasive ventilation (NIV), who were able to maintain adequate hydration and nutrition orally despite being ventilator-dependant. All had severe respiratory muscle weakness, with a vital capacity less than 500 mL and cough peak flow rate less than 250 L/min. Their median (range) age was 49 (23-64) years; they had been on NIV for 8 (2-24) years.

Spot the Pneumothorax.

Subcutaneous emphysema (SE) and pneumomediastinum are commonly associated with critically ill patients with blunt or penetrating trauma, in particular lower rib fractures. It however rarely needs urgent intervention, and routine use of chest tube tracheostomy or mediastinal drains is not recommended as the patients do not go on to develop a respiratory compromise. Our case is novel as it describes a case of subcutaneous emphysema with acute upper airway compromise and respiratory distress requiring urgent bilateral wide bore subcutaneous drains and thoracic drain insertion.

A retrospective cohort study of idiopathic diaphragmatic palsy: a diagnostic triad, natural history and prognosis.

Background: Isolated diaphragmatic palsy in the absence of progressive neuromuscular disease is uncommon. It poses diagnostic challenges and limited data are available regarding prognosis. We present retrospective cohort data from two large teaching hospitals in the United Kingdom.

A Case Report of Acute Flaccid Paralysis Caused by Enterovirus D68 Infection: The Beginning of a Polio-Like Epidemic?

Enterovirus D68 (EV-D68) is a non-polio enterovirus that occasionally causes respiratory illnesses. EV-D68 infections have occurred over the last couple of years and have a high prevalence worldwide. This virus has recently been linked to acute flaccid paralysis and particularly affects children.

Long-Term Survival on Noninvasive Ventilation in Adults With Thoracic Scoliosis.

Background: Subjects with thoracic scoliosis were an important group in early studies of noninvasive ventilation (NIV). The aim of this study was to describe current rates of initiation of NIV and survival after initiation in this population.

Methods: This study included patients identified as having thoracic scoliosis and established between 1993 and 2018 on home NIV.

The Noninvasive Ventilation Outcomes (NIVO) score: prediction of in-hospital mortality in exacerbations of COPD requiring assisted ventilation.

Introduction: Acute exacerbations of COPD (AECOPD) complicated by acute (acidaemic) hypercapnic respiratory failure (AHRF) requiring ventilation are common. When applied appropriately, ventilation substantially reduces mortality. Despite this, there is evidence of poor practice and prognostic pessimism.

Assessing the impact of posture on diaphragm morphology and function using an open upright MRI system-A pilot study.

Purpose: The diaphragm is the most important muscle of respiration. Disorders of the diaphragm can have a deleterious impact on respiratory function. We aimed to evaluate the use of an open-configuration upright low-field MRI system to assess diaphragm morphology and function in patients with bilateral diaphragm weakness (BDW) and chronic obstructive pulmonary disease (COPD) with hyperinflation.

Non-invasive ventilation during surgery under neuraxial anaesthesia: a pathophysiological perspective on application and benefits and a systematic literature review.

Unlike general anaesthesia, neuraxial anaesthesia (NA) reduces the burden and risk of respiratory adverse events in the post-operative period. However, both patients affected by chronic obstructive pulmonary disease (COPD) and chest wall disorders and/or neuromuscular diseases may experience the development or the worsening of respiratory failure, even during surgery performed under NA; this latter negatively affects the function of accessory respiratory muscles, resulting in a blunted central response to hypercapnia and possibly in an exacerbation of cardiac dysfunction (NA-induced relative hypovolemia). According to European Respiratory Society (ERS) and American Thoracic Society (ATS) guidelines, non-invasive ventilation (NIV) is effective in the post-operative period for the treatment of both impaired pulmonary gas exchange and ventilation, while the intra-operative use of NIV in association with NA is just anecdotally reported in the literature.

Correction of Paradoxical Ribcage Motion in Scoliosis by Noninvasive Ventilation.

Study Design: Observational study of ribcage motion in scoliosis.

Objective: To see whether noninvasive ventilation corrected paradoxical inward motion of the ribs during inspiration.

Summary Of Background Data: Paradoxical inward motion of the ribs is observed after rib fractures, low cervical cord injury, and in chronic obstructive pulmonary disease.

High prevalence of recurrent nocturnal desaturations in systemic AL amyloidosis: a cross-sectional pilot study.

Objectives: Cardiac involvement and/or macroglossia with soft tissue deposits are risk factors for central sleep apnoea (CSA) and obstructive sleep apnoea (OSA), and common features of systemic AL amyloidosis. Little data exist on the occurrence of sleep-disordered breathing (SDB) or recurrent nocturnal hypoxia in amyloidosis, which this study sought to investigate.

Methods: A total of 72 consecutive patients with systemic amyloidosis (mean age 69 years and mean BMI 25) were evaluated for occurrence of SDB, by overnight continuous pulse oximetry, and completed Epworth Sleepiness Score (ESS) and STOPBANG questionnaires.

Effect of expiratory positive airway pressure on tidal volume during non-invasive ventilation.

During non-invasive ventilation (NIV), tidal volume ( V) will depend upon the difference between inspiratory and expiratory positive airway pressure (IPAP and EPAP, respectively), provided the respiratory muscles are relaxed and the lungs and chest wall therefore move along their passive pressure-volume curves. To test this hypothesis, we studied the effect of increasing EPAP during pressure-controlled modes of NIV in 30 long-term ventilator users (10 each with scoliosis, obesity hypoventilation or neuromuscular disorders). While maintaining the same IPAP, addition of 5 cmHO of EPAP reduced mean V by 167 ml; 10 cmHO reduced V by 367 ml.

Long-term non-invasive ventilation in muscular dystrophy.

Long-term non-invasive ventilation (NIV) was introduced in the 1980s, initially mainly for patients with poliomyelitis, muscular dystrophy (MD) or scoliosis. The obesity-hypoventilation syndrome has since become the commonest reason for referral to most centres providing home-NIV. Patients with MD are numerically a much smaller part of the workload, but as their disease progresses the need for ventilatory support changes and they require regular comprehensive assessment of their condition.