1684 Correspondence / American Journal of Emergency Medicine 38 (2020) 1679-1694

Obesity prevalence: there is no reference to body mass index, which would be very important, since obese patients may present a signif- icant restrictive respiratory mechanical pattern, requiring higher in- sufflation pressures.

Dyspnea/comfort evaluation/measurement. The authors do not use a dyspnea or comfort control scale to objectively compare symp- tom control between the two groups.

Source of support

None.

Declaration of competing interest

None.

Miguel Guia

Pulmonology Department, Hospital Professor Doutor Fernando Fonseca,

IC19, Amadora, 2720-276 Lisbon, Portugal

*Corresponding author at: Rua Tenente General Zeferino Sequeira, n?20,

13?A, Carnaxide, 2790-156 Lisbon, Portugal.

E-mail address: [email protected].

Hilmi Demirkiran Anesthesiology and Reanimation Department, Medical Faculty, Van Yuzuncu Yil University, Tusba, 65080 Van, Turkey

Antonio Esquinas

Intensive Care Unit, Hospital Morales Meseguer, Avenida Marques de Los

Velez s/n, 30500 Murcia, Spain

7 April 2020

https://doi.org/10.1016/j.ajem.2020.04.081

Reference

[1] Ilhan UZ, Kiyan GS, ?zcete E, Yalcinli S, Korgan MB, Altunci YA, et al. Is the flow-safe disposable continuous positive airway pressure (CPAP) system as effective as non- invasive mechanical ventilation (NIMV) in the treatment of acute cardiogenic pulmo- nary oedema? YAJEM-158720. doi:https://doi.org/10.1016/j.ajem.2020.01.034.

Flow-safe disposable CPAP efficiency in cardiogenic pulmonary oedema

Dear Editor,

We are very pleased that our article has been read and evaluated by readers [1]. We would like to answer the questions as follows:

Flow-safe II Disposable CPAP is connected to the gas source by oxy- gen tubing nipple. The pressure setting is done with the connection valve and its change can be monitored with a manometer. It can be adjusted until the desirED flowmeter pressure is obtained. If neces- sary, the flowmeter can be readjusted to obtain desired CPAP pressure.

non-invasive positive pressure ventilation (NPPV) rapidly improves respiratory distress and reduces the need for intubation and even mor- tality in patients with acute cardiogenic pulmonary edema . Therefore, non-invasive mechanical ventilation (NIMV) is indicated as first-line therapy in ACPO. We have written in our article as follows; ‘While NIMV is one of the most preferred modalities in the initial treat- ment of ACPO, the number of devices that can administer NIMV in the

emergency services is limited. For this reason, there may be a need for Alternative devices that can be as effective as NIMV in units with large numbers of patients and with a limited number of devices that can ad- minister NIMV, especially during the pre-hospital period.’

The most important time for the treatment of ACPO is in the emer- gency department time, patients respond dramatically to the NPPV treatment they receive in the first hour. In our study, we consider that we evaluated the response to treatment in the first hour very well.

Chronic obstructive pulmonary disease (COPD) prevalence was higher on NIMV group, we have mentioned it in the limitation section. Nonin- vasive bilevel positive airway pressure support ventilation may be preferable in patients with significant chronic or acute hypercapnia, in- cluding associated COPD. However, we do not think that it is a major concern for mild to moderate hypercapnic patients with pulmonary edema in the use of flow safe CPAP similarly in our study.

Obesity prevalence and body mass index were not recorded in the

study patients since we have a few numbers of morbidly obese pa- tients and usually they applied with other respiratory problems rather than ACPO.

We used a dyspnea scale such as the modified Borg classification to objectively compare symptom control between the two groups.

Ilhan Uz, MD, PhD? Guclu Selahattin Kiyan MD, PhD Enver Ozcete MD, PhD

Sercan Yalcinli MD, PhD Mehmet Birkan Korgan MD, PhD Yusuf Ali Altunci MD, PhD Murat Ersel MD, PhD

Funda Karbek Akarca MD, PhD

Department of Emergency Medicine, Ege University Faculty of Medicine,

Izmir, Turkey

?Corresponding author.

E-mail address: [email protected].

Oguz Yavuzgil MD, PhD

Department of Cardiology, Ege University Faculty of Medicine, Izmir, Turkey

25 April 2020

https://doi.org/10.1016/j.ajem.2020.04.073

References

Uz Ilhan, Kiyan GS, Ozcete E, Yalcinli S, Korgan MB, Altunci YA, et al. 2020. Is the flow-safe disposable Continuous positive airway pressure system as ef- fective as non-invasive mechanical ventilation (NIMV) in the treatment of acute cardiogenic pulmonary oedema? YAJEM-158720https://doi.org/10. 1016/j.ajem.2020.01.034.

Delirium-informed care in emergency departments: Diagnosis and beyond

Delirium, an acute global brain dysfunction, has been reported to af- fect more than 10% of the patients in emergency departments (EDs) [1]. Although patients with delirium are more susceptible to adverse out- comes including mortality and cognitive decline, they are often mis- or under-diagnosed in wards and EDs [2-4]. Additionally, only a limited number of researches have focused on delirium in EDs.

To reduce the burden of delirium among patients in EDs, effective methods for the early detection of delirium and appropriate interven- tion strategies are required [5]. A single validated assessment tool for di- agnosing delirium is desired [5]; however, thus far, not a single stand- alone indicator has fulfilled sufficiently high sensitivity and specificity

Correspondence / American Journal of Emergency Medicine 38 (2020) 1679-1694 1685

in an efficient manner. Therefore, integrated strategies using several in- dicators are a realistic option for diagnosing delirium.

The review by Lee et al. [1] narratively summarizes:

• Burden of delirium in ED
• (DSM-based) Pathophysiology
• Definition of delirium
• Clinical phenotypes
• Underlying etiology
• Overview of clinical assessment tools
• Treatment
• Non-pharmacological
• Pharmacological
• Delirium care bundles
• Prevention strategy
• Future directions

Of note, the authors’ group has recently published several important and promising studies [6-8]. They have developed a bispectral electroen- cephalography system, which utilizes only a two-channel patient- and in- vestigator-friendly electroencephalogram -recording system; they have shown that a 10-min bispectral EEG from this system can differenti- ate between admitted patients with and without delirium [6]. Moreover, the bispectral EEG score (calculated by the signal-processing algorithm, followed by the conversion of the bispectral EEG data into spectral density plots using fast Fourier transformation [6,7]) was significantly associated with the patients’ clinical outcomes such as mortality, duration of hospital stay, and discharge disposition [7]. Importantly, the bispectral EEG score predicted mortality better than the clinical delirium status in admitted pa- tients [7]. They have also presented the possibility that the bispectral EEG is applicable to patients in EDs in a pilot study [8].

Fig. 1. Integration of DSM-defined delirium diagnosis and machine-assisted phenotyping. This future direction aims to achieve:

Early diagnosis for general “delirium-informed care”

Subclass stratification for “tailored care”.

Delirium is a heterogeneous syndrome, as observed in patients at the bedside and repeatedly mentioned in previous studies [2,3]. Although DSM has classified delirium into the hyperactive, hypoactive, and mixed subtypes, utilizing novel technologies and methods such as ma- chine learning-based phenotyping [9] and machine-supportED decision making [10] may classify delirium into other subclasses, like the case for sepsis, which is also a heterogenous syndrome; such methods are cur- rently being investigated for sepsis [9,10].

Since “delirium-informed care” may improve the outcomes of ad- mitted patients with delirium [3,11,12], integrating DSM-defined delir- ium diagnosis and machine-assisted phenotyping (Fig. 1) is warranted for both:

early diagnosis for general “delirium-informed care”

subclass stratification for “tailored care”

The future research also requires a viewpoint that considers the pe- culiarity of ED settings, differences in cohort (previous reports have pre- dominantly dealt with white individuals [6] from North America [5]), and external validity. The review published in this issue of the AJEM

[1] provides a useful perspective on the status quo and future directions for delirium-informed care in EDs.

Hidetaka Tamune Department of Cellular Neurobiology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan Department of Neuropsychiatry, Graduate School of Medicine, The

University of Tokyo, Japan Department of Neuropsychiatry, Tokyo Metropolitan Tama Medical Center,

Tokyo, Japan E-mail address: [email protected]. Received 17 September 2019

Accepted 19 September 2019 https://doi.org/10.1016/j.ajem.2019.158460

References

1. AJEM21150. Recognition, prevention, and treatment of delirium in emergency de- partment: An evidence-based narrative review. Am J Emerg Med 2020 Feb;38(2): 349-357.
2. Marcantonio ER. Delirium in hospitalized older adults. N Engl J Med 2017;377(15):1456-66.
3. Oldham MA. Delirium. Perioperative Psychiatry 2019. https://doi.org/10.1007/978- 3-319-99774-2.
4. Tamune H, Yasugi D. How can we identify patients with delirium in the emergency department?: A review of available screening and diagnostic tools. Am J Emerg Med 2017;35(9):1332-4.
5. Barron EA, Holmes J. Delirium within the Emergency care setting, occurrence and detection: A systematic review. Emerg Med J 2013;30(4):263-8.
6. Shinozaki G, Chan AC, Sparr NA, Zarei K, Gaul LN, Heinzman JT, et al. Delirium detec- tion by a novel bispectral electroencephalography device in general hospital. Psychi- atry Clin Neurosci 2018;72(12):856-63.
7. Shinozaki G, Bormann NL, Chan AC, Zarei K, Sparr NA, Klisares MJ, et al. Identification of patients with high mortality risk and prediction of outcomes in delirium by bispectral EEG. J Clin Psychiatry 2019;80(5):4-5.
8. Lee S, Yuki K, Chan A, Cromwell J, Shinozaki G. The point-of-care EEG for delir- ium detection in the emergency department. Am J Emerg Med 2019;37(5): 995-6.
9. Seymour CW, Kennedy JN, Wang S, Chang CH, Elliott CF, Xu Z, et al. Derivation, val- idation, and potential treatment implications of novel clinical phenotypes for sepsis. JAMA 2019;321(20):2003-17.
10. Komorowski M, Celi LA, Badawi O, Gordon AC, Faisal AA. The Artificial intelligence clinician learns Optimal treatment strategies for sepsis in intensive care. Nat Med 2018;24(11):1716-20.
11. Bigatello LM, Amirfarzan H, Haghighi AK, Newhouse B, Del Rio JM, Allen K, et al. Ef- fects of routine monitoring of delirium in a surgical/trauma intensive care unit. J Trauma Acute Care Surg 2013;74(3):876-83.
12. Todd KS, Barry J, Hoppough S, McConnell E. Delirium detection and improved delir- ium management in older patients hospitalized for Hip fracture. Int J Orthop Trauma Nurs 2015;19(4):214-21.