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Cinotti R, Mijangos JC, Pelosi P, Haenggi M, Gurjar M, Schultz MJ, Kaye C, Godoy DA, Alvarez P, Ioakeimidou A, Ueno Y, Badenes R, Suei Elbuzidi AA, Piagnerelli M, Elhadi M, Reza ST, Azab MA, McCredie V, Stevens RD, Digitale JC, Fong N, Asehnoune K. Extubation in neurocritical care patients: the ENIO international prospective study. Intensive Care Med 2022; 48:1539-1550. [PMID: 36038713 DOI: 10.1007/s00134-022-06825-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 07/12/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Neurocritical care patients receive prolonged invasive mechanical ventilation (IMV), but there is poor specific information in this high-risk population about the liberation strategies of invasive mechanical ventilation. METHODS ENIO (NCT03400904) is an international, prospective observational study, in 73 intensive care units (ICUs) in 18 countries from 2018 to 2020. Neurocritical care patients with a Glasgow Coma Score (GCS) ≤ 12, receiving IMV ≥ 24 h, undergoing extubation attempt or tracheostomy were included. The primary endpoint was extubation failure by day 5. An extubation success prediction score was created, with 2/3 of patients randomly allocated to the training cohort and 1/3 to the validation cohort. Secondary endpoints were the duration of IMV and in-ICU mortality. RESULTS 1512 patients were included. Among the 1193 (78.9%) patients who underwent an extubation attempt, 231 (19.4%) failures were recorded. The score for successful extubation prediction retained 20 variables as independent predictors. The area under the curve (AUC) in the training cohort was 0.79 95% confidence interval (CI95) [0.71-0.87] and 0.71 CI95 [0.61-0.81] in the validation cohort. Patients with extubation failure displayed a longer IMV duration (14 [7-21] vs 6 [3-11] days) and a higher in-ICU mortality rate (8.7% vs 2.4%). Three hundred and nineteen (21.1%) patients underwent tracheostomy without extubation attempt. Patients with direct tracheostomy displayed a longer duration of IMV and higher in-ICU mortality than patients with an extubation attempt (success and failure). CONCLUSIONS In neurocritical care patients, extubation failure is high and is associated with unfavourable outcomes. A score could predict extubation success in multiple settings. However, it will be mandatory to validate our findings in another prospective independent cohort.
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Affiliation(s)
- Raphaël Cinotti
- Department of Anaesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel Dieu, 44000, Nantes, France.,UMR 1246 SPHERE "MethodS in Patients-Centered Outcomes and HEalth Research", University of Nantes, University of Tours, INSERM, IRS2 22 Boulevard Benoni Goulin, 44200, Nantes, France
| | - Julio Cesar Mijangos
- Hospital Civil de Guadalajara "Fray Antonio Alcalde", Hospital No. 278, Col. El Retiro 44280, Guadalajara, Mexico.,División de Disciplinas Clínicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Sierra Mojada 950, Col. Independencia, 44340, Guadalajara, Jalisco, Mexico
| | - Paolo Pelosi
- IRCCS for Oncology and Neurosciences, San Martino Policlinico Hospital, Largo Rosanna Benzi 10, 16100, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Matthias Haenggi
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, 226014, India
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', 1105 AZ, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, OX3 7LG, UK
| | - Callum Kaye
- Aberdeen Royal Infirmary, Foresterhill, Aberdeen, AB25 2ZN, UK
| | | | - Pablo Alvarez
- Hospital Maciel, ASSE, Street 25 de Mayo 174, 11000, Montevideo, Uruguay
| | - Aikaterini Ioakeimidou
- Department of Critical Care Medicine of Asklepieio G.H.A, V.Paulou 1, 16673, Athens, Greece
| | - Yoshitoyo Ueno
- Tokushima University Hospital, 2-50-1, Kuramotocho, Tokushima, 7700042, Japan
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Department of Surgery, Hospital Clínico Universitario Valencia, University of Valencia, Valencia, Spain
| | | | - Michaël Piagnerelli
- CHU Charleroi-Hôpital Civil Marie-Curie, Université libre de Bruxelles, 140 Chaussée de Bruxelles, Lodelinsart, 6042, Charleroi, Belgium
| | - Muhammed Elhadi
- Faculty of Medicine, University of Tripoli, Furnaj, University Road, 13275, Tripoli, Libya
| | - Syed Tariq Reza
- Department of Anaesthesia, Analgesia, Palliative and Intensive Care, Dhaka Medical College Hospital, Dhaka, 1000, Bangladesh
| | | | - Victoria McCredie
- Toronto Western Hospital-University Health Network, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada
| | - Robert D Stevens
- Department of Anesthesiology and Critical Care, John Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD, 21205, USA
| | - Jean Catherine Digitale
- Department of Epidemiology and Biostatistics, University of California, UCSF, 550 16th St, San Francisco, CA, 94158, USA
| | - Nicholas Fong
- Department of Anesthesia and Perioperative Care, University of California, UCSF, 1001 Potrero Ave, San Francisco, CA, 94110, USA
| | - Karim Asehnoune
- Department of Anaesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel Dieu, 44000, Nantes, France.
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Noninvasive Respiratory Support Does Not Prevent Extubation Failure in High-Risk Norwood Patients. Crit Care Explor 2022; 4:e0782. [PMID: 36311558 PMCID: PMC9605742 DOI: 10.1097/cce.0000000000000782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This study aims to determine whether bilevel positive airway pressure (BiPAP) and continuous positive airway pressure (CPAP) effectively mitigate the risk of extubation failure in children status post-Norwood procedure. DESIGN Single-center, retrospective analysis. Extubation events were collected from January 2015 to July 2021. Extubation failure was defined as the need for reintubation within 48 hours of extubation. Demographics, clinical characteristics, and ventilatory settings were compared between successful and failed extubations. SETTING Pediatric cardiovascular ICU. PATIENTS Neonates following Norwood procedure. INTERVENTIONS Extubation following the Norwood procedure. MEASUREMENTS AND MAIN RESULTS The analysis included 311 extubations. Extubation failure occurred in 31 (10%) extubation attempts within the first 48 hours. On univariate analysis, higher rate of extubation failure was observed when patients were extubated to CPAP/BiPAP relative to patients who were extubated to either high-flow nasal cannula (HFNC) or nasal cannula (NC) (16% vs 7.8%; p = 0.027). On multivariable analysis, the presence of vocal cord anomaly (odds ratio, 3.08; p = 0.005) and lower pre-extubation end-tidal co2 (odds ratio, 0.91; p = 0.006) were simultaneously associated with extubation failure while also controlling for the post-extubation respiratory support (CPAP/BiPAP/HFNC vs NC). CONCLUSIONS Clinicians should not rely on CPAP or BiPAP as the only supportive measure for a patient at increased risk of extubation failure. CPAP or BiPAP do not mitigate the risk of extubation failure in the Norwood patients. A multisite study is needed to generalize these conclusions.
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Celik NB, Tanyildiz M, Yetimakman F, Kesici S, Bayrakci B. Comparison of high flow oxygen therapy versus noninvasive mechanical ventilation for successful weaning from invasive ventilation in children: An observational study. Medicine (Baltimore) 2022; 101:e30889. [PMID: 36181066 PMCID: PMC9524993 DOI: 10.1097/md.0000000000030889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Post-extubation respiratory failure is associated with a poor prognosis due to increased ventilator-associated pneumonia, and longer length of stay in the ICU and hospital. In this study, we aimed to evaluate the efficacy of high-flow nasal cannula (HFNC) and noninvasive mechanical ventilation (NIMV) on extubation success in children. A total of 48 patients, aged between 1 month and 18 years, who were weaned to either NIMV or HFNC were included. Patients who had tracheostomy or were not weaned and underwent unplanned extubation were excluded. Age, gender, anthropometric parameters, Pediatric Risk of Mortality and Pediatric Logistic Organ Dysfunction scores, oxygenation index, mechanical ventilation length of stay (LOS), HFNC/NIMV LOS, Modified Downes-Silverman score (MDS), and venous blood gas parameters, pediatric intensive care unit (PICU) LOS were recorded. 24 patients were extubated to NIMV, and 24 patients to HFNC. HFNC LOS and NIMV LOS were similar (P = .621). The failure rates at the 48th hour of HFNC and NIMV were 33% (n = 8), and 33% respectively (n = 8) (P = 1.0). PICU LOS and mortality rate was also similar (P = .06, P = .312 respectively). MDS decreased significantly in both groups (P < .001, P = .02 respectively). Changes in blood gas parameters and MDS within the first 48-hour of device application were similar between the 2 groups. HFNC is not inferior to NIMV in patients with extubation difficulty or those expected to have such difficulty in terms of treatment success, PICU LOS, and mortality. Therefore, HFNC appears to be a weaning technique alternative to NIMV after extubation.
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Affiliation(s)
- Nur Berna Celik
- Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Murat Tanyildiz
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Filiz Yetimakman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Selman Kesici
- Department of Pediatric Critical Care Medicine, Life Support Practice and Research Center, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Benan Bayrakci
- Department of Pediatric Critical Care Medicine, Life Support Practice and Research Center, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Zeng Z, Tang X, Liu Y, He Z, Gong X. Interpretable recurrent neural network models for dynamic prediction of the extubation failure risk in patients with invasive mechanical ventilation in the intensive care unit. BioData Min 2022; 15:21. [PMID: 36163063 PMCID: PMC9513908 DOI: 10.1186/s13040-022-00309-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 09/19/2022] [Indexed: 11/10/2022] Open
Abstract
Background Clinical decision of extubation is a challenge in the treatment of patient with invasive mechanical ventilation (IMV), since existing extubation protocols are not capable of precisely predicting extubation failure (EF). This study aims to develop and validate interpretable recurrent neural network (RNN) models for dynamically predicting EF risk. Methods A retrospective cohort study was conducted on IMV patients from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Time series with a 4-h resolution were built for all included patients. Two types of RNN models, the long short-term memory (LSTM) and the gated recurrent unit (GRU), were developed. A stepwise logistic regression model was used to select key features for developing light-version RNN models. The RNN models were compared to other five non-temporal machine learning models. The Shapley additive explanations (SHAP) value was applied to explain the influence of the features on model prediction. Results Of 8,599 included patients, 2,609 had EF (30.3%). The area under receiver operating characteristic curve (AUROC) of LSTM and GRU showed no statistical difference on the test set (0.828 vs. 0.829). The light-version RNN models based on the 26 features selected out of a total of 89 features showed comparable performance as their corresponding full-version models. Among the non-temporal models, only the random forest (RF) (AUROC: 0.820) and the extreme gradient boosting (XGB) model (AUROC: 0.823) were comparable to the RNN models, but their calibration was deviated. Conclusions The RNN models have excellent predictive performance for predicting EF risk and have potential to become real-time assistant decision-making systems for extubation. Supplementary Information The online version contains supplementary material available at 10.1186/s13040-022-00309-7.
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Affiliation(s)
- Zhixuan Zeng
- Department of Emergency Medicine, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Xianming Tang
- Department of Emergency Medicine, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Yang Liu
- Department of Rehabilitation, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Zhengkun He
- School of Computer Science and Engineering, Central South University, Changsha, China
| | - Xun Gong
- Department of Emergency Medicine, The Second Xiangya Hospital of Central South University, Changsha, China.
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55
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Hernández G, Vaquero C, Ortiz R, Colinas L, de Pablo R, Segovia L, Rodriguez ML, Villasclaras A, Muñoz-Moreno JF, Suarez-Sipmann F, Canabal A, Cuena R, Roca O. Benefit with preventive noninvasive ventilation in subgroups of patients at high-risk for reintubation: a post hoc analysis. J Intensive Care 2022; 10:43. [PMID: 36089625 PMCID: PMC9465935 DOI: 10.1186/s40560-022-00635-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 09/02/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
High-flow nasal cannula (HFNC) was shown to be non-inferior to noninvasive ventilation (NIV) for preventing reintubation in a general population of high-risk patients. However, some subgroups of high-risk patients might benefit more from NIV. We aimed to determine whether the presence of many risk factors or overweight (body mass index (BMI) ≥ 25 kg/m2) patients could have different response to any preventive therapy, NIV or HFNC in terms of reduced reintubation rate.
Methods
Not pre-specified post hoc analysis of a multicentre, randomized, controlled, non-inferiority trial comparing NFNC and NIV to prevent reintubation in patients at risk for reintubation. The original study included patients with at least 1 risk factor for reintubation.
Results
Among 604 included in the original study, 148 had a BMI ≥ 25 kg/m2. When adjusting for potential covariates, patients with ≥ 4 risk factors (208 patients) presented a higher risk for reintubation (OR 3.4 [95%CI 2.16–5.35]). Patients with ≥ 4 risk factors presented lower reintubation rates when treated with preventive NIV (23.9% vs 45.7%; P = 0.001). The multivariate analysis of overweight patients, adjusted for covariates, did not present a higher risk for reintubation (OR 1.37 [95%CI 0.82–2.29]). However, those overweight patients presented an increased risk for reintubation when treated with preventive HFNC (OR 2.47 [95%CI 1.18–5.15]).
Conclusions
Patients with ≥ 4 risk factors for reintubation may benefit more from preventive NIV. Based on this result, HFNC may not be the optimal preventive therapy in overweight patients. Specific trials are needed to confirm these results.
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56
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Ohnstad MO, Stensvold HJ, Pripp AH, Tvedt CR, Jelsness-Jørgensen LP, Astrup H, Eriksen BH, Klingenberg C, Mreihil K, Pedersen T, Rettedal S, Selberg TR, Solberg R, Støen R, Rønnestad AE. Predictors of extubation success: a population-based study of neonates below a gestational age of 26 weeks. BMJ Paediatr Open 2022; 6:10.1136/bmjpo-2022-001542. [PMID: 36053650 PMCID: PMC9367191 DOI: 10.1136/bmjpo-2022-001542] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 07/19/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE The aim of the study was to investigate first extubation attempts among extremely premature (EP) infants and to explore factors that may increase the quality of clinical judgement of extubation readiness. DESIGN AND METHOD A population-based study was conducted to explore first extubation attempts for EP infants born before a gestational age (GA) of 26 weeks in Norway between 1 January 2013 and 31 December 2018. Eligible infants were identified via the Norwegian Neonatal Network database. The primary outcome was successful extubation, defined as no reintubation within 72 hours after extubation. RESULTS Among 482 eligible infants, 316 first extubation attempts were identified. Overall, 173 (55%) infants were successfully extubated, whereas the first attempt failed in 143 (45%) infants. A total of 261 (83%) infants were extubated from conventional ventilation (CV), and 55 (17%) infants were extubated from high-frequency oscillatory ventilation (HFOV). In extubation from CV, pre-extubation fraction of inspired oxygen (FiO2) ≤0.35, higher Apgar score, higher GA, female sex and higher postnatal age were important predictors of successful extubation. In extubation from HFOV, a pre-extubation FiO2 level ≤0.35 was a relevant predictor of successful extubation. CONCLUSIONS The correct timing of extubation in EP infants is important. In this national cohort, 55% of the first extubation attempts were successful. Our results suggest that additional emphasis on oxygen requirement, sex and general condition at birth may further increase extubation success when clinicians are about to extubate EP infants for the first time.
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Affiliation(s)
- Mari Oma Ohnstad
- Department for Postgraduate Studies, Lovisenberg Diaconal University College, Oslo, Norway .,Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
| | - Hans Jørgen Stensvold
- Department of Neonatal Intensive Care, Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.,Norwegian Neonatal Network, Oslo University Hospital, Oslo, Norway
| | - Are Hugo Pripp
- Oslo Centre of Biostatistics and Epidemiology, Research Support Services, Oslo, Norway.,Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Christine Raaen Tvedt
- Department for Postgraduate Studies, Lovisenberg Diaconal University College, Oslo, Norway
| | - Lars-Petter Jelsness-Jørgensen
- Department for Postgraduate Studies, Lovisenberg Diaconal University College, Oslo, Norway.,Department of Health and Welfare, Østfold University College, Halden, Norway.,Department of Internal Medicine, Østfold Hospital Trust, Kalnes, Norway
| | - Henriette Astrup
- Department of Pediatric and Adolescent Medicine, Sorlandet Hospital Trust, Kristiansand, Norway
| | - Beate Horsberg Eriksen
- Department of Paediatrics, Møre og Romsdal Hospital Trust, Alesund, Norway.,Clinical Research Unit, Norwegian University of Science and Technology, Trondheim, Norway
| | - Claus Klingenberg
- Faculty of Health Sciences, University of Tromsø, Tromso, Norway.,Department of Pediatrics, University Hospital of North Norway, Tromso, Norway
| | - Khalaf Mreihil
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Lorenskog, Norway
| | - Tanja Pedersen
- Neonatal Intensive Care Unit, Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Siren Rettedal
- Department of Paediatrics, Stavanger University Hospital, Stavanger, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Terje Reidar Selberg
- Department of Pediatric and Adolescent Medicine, Ostfold County Hospital, Gralum, Norway
| | - Rønnaug Solberg
- Department of Paediatrics, Vestfold Hospital Trust, Tonsberg, Norway.,Department of Paediatric Research, Oslo University Hospital, Oslo, Norway
| | - Ragnhild Støen
- Department of Paediatrics, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway.,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Arild E Rønnestad
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway.,Department of Neonatal Intensive Care, Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.,Norwegian Neonatal Network, Oslo University Hospital, Oslo, Norway.,Research group for clinical neonatal medicine and epidemiology, Institute of clinical medicine, Oslo, Norway
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Chaudhuri S, Gupta N, Adhikari SD, Todur P, Maddani SS, Rao S. Utility of the One-time HACOR Score as a Predictor of Weaning Failure from Mechanical Ventilation: A Prospective Observational Study. Indian J Crit Care Med 2022; 26:900-905. [PMID: 36042760 PMCID: PMC9363817 DOI: 10.5005/jp-journals-10071-24280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim To determine the utility of the HACOR score in predicting weaning failure in resource-limited settings. Objectives The primary objective was to determine a cut-off value of the HACOR score, sensitivity, and specificity to predict failed weaning. The secondary objective was to determine which out of five components of the score was significantly different between the successful weaning and the failed weaning groups. Introduction Most weaning indices are either inaccurate or are dependent on complex ventilatory parameters, which are difficult to measure in resource-limited settings. This study aimed to determine the utility of the HACOR score consisting of heart rate, acidosis, consciousness level, oxygenation, and respiratory rate as a predictor of weaning in the intensive care unit. Materials and methods It was a prospective observational study on 120 patients between 18 and 90 years. The HACOR score was evaluated at 30 minutes of spontaneous breathing trial (SBT). The total duration of SBT was 120 minutes. Results Out of 120 patients, 83 (69.2%) had successful weaning, whereas 37 (30.8%) had weaning failure. The median and interquartile range (IQR) of the HACOR score in the successful weaning group was 2 (0–3) and 6 (5–8) in the failed weaning group (p-value <0.001). There was a significant difference in each of the five components of the HACOR score between the successful and failed weaning groups (p <0.05). HACOR score ≥5 predicted failed weaning, sensitivity 83.8%, specificity 96.4%, area under the curve (AUC) 0.950, and 95% confidence interval (CI) [0.907–0.993], p <0.001. Multivariable logistic regression analysis showed that HACOR score ≥5 is an independent predictor of weaning failure [p <0.001, 95% CI (1.9–4.2), adjusted odds ratio 2.82]. Conclusion A HACOR score ≥5 is an excellent predictor of weaning failure. This score may be useful as a weaning strategy in the intensive care unit. How to cite this article Chaudhuri S, Gupta N, Adhikari SD, Todur P, Maddani SS, Rao S. Utility of the One-time HACOR Score as a Predictor of Weaning Failure from Mechanical Ventilation: A Prospective Observational Study. Indian J Crit Care Med 2022;26(8):900–905. Ethical approval Prior to the commencement of the study, Institutional Ethics Committee permission was obtained (IEC: 197/2021) and Clinical Trial Registry of India (CTRI) registration was done before recruitment (CTRI/2021/07/035139). We obtained written informed consent from the legally authorized representative prior to recruiting patients for the study.
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Affiliation(s)
- Souvik Chaudhuri
- Department of Critical Care Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Nitin Gupta
- Department of Infectious Diseases, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shreya Das Adhikari
- Department of Anaesthesia, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Pratibha Todur
- Department of Respiratory Therapy, Manipal College of Health Professionals, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Sagar Shanmukhappa Maddani
- Department of Critical Care Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shwethapriya Rao
- Department of Critical Care Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
- Shwethapriya Rao, Department of Critical Care Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India, Phone: +91 9964668404, e-mail:
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Pande RK, Sharma J. Heart Rate, Acidosis, Consciousness, Oxygenation, and Respiratory Rate: A Perfect Weaning Index or Just a New Kid on the Block. Indian J Crit Care Med 2022; 26:887-888. [PMID: 36042771 PMCID: PMC9363811 DOI: 10.5005/jp-journals-10071-24290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Successful weaning is when spontaneous breathing is sustained for more than 48 hours after extubation. Despite a plethora of individual and composite weaning indices being available, most indices have not found much clinical utility, and weaning continues to be largely based on clinical assessment. Heart rate, acidosis, consciousness, oxygenation, and respiratory rate (HACOR) is a new score for prediction of failure of noninvasive ventilation (NIV) in hypoxemic patients receiving NIV. The present study explores its utilization in weaning from invasive ventilation.
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Affiliation(s)
- Rajesh Kumar Pande
- Department of Critical Care, BLK-MAX Super Speciality Hospital, New Delhi, India
- Rajesh Kumar Pande, Department of Critical Care, BLK-MAX Super Speciality Hospital, New Delhi, India, Phone: +91 9810536268, e-mail:
| | - Jitin Sharma
- Department of Critical Care, BLK-MAX Super Speciality Hospital, New Delhi, India
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59
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Cao J, Wang B, Zhu L, Song L. Pooled Analysis of Central Venous Pressure and Brain Natriuretic Peptide Levels in Patients With Extubation Failure. Front Physiol 2022; 13:858046. [PMID: 35910563 PMCID: PMC9335353 DOI: 10.3389/fphys.2022.858046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 06/09/2022] [Indexed: 12/29/2022] Open
Abstract
Purpose: Cardiac insufficiency has been considered to be a common cause of extubation failure. Some studies have shown that central venous pressure (CVP) and brain natriuretic peptide (BNP) are able to predict extubation outcomes. Therefore, we conducted a pooled analysis to evaluate the potential of CVP and BNP levels as predictors of extubation outcomes, using a cohort of critically ill patients who were on mechanical ventilation (MV). Methods: We searched three online electronic databases up to October 2021. All data were analyzed using Review Manager 5.4. For each study, the analysis was performed using standardized mean differences (SMD) with 95% confidence intervals (CI). Results: The pooled analysis of seven studies on CVP levels and extubation outcomes showed that elevated CVP levels were significantly associated with extubation failure (SMD:0.47, 95% CI: 0. 43–0.51, p < 0.00001). This association also appeared before extubation (SMD:0.47, 95% CI: 0. 43–0.51, p < 0.00001), but it did not appear after extubation (SMD: 0.63, 95% CI: −0.05–1.31, p=0.07). Similarly, pooled analysis of eight studies on BNP levels and extubation outcomes showed that increased BNP levels are closely related to extubation failure (SMD:0.68, 95% CI: 0.49–0.86, p < 0.00001). This relationship also occurs before (SMD: 0.57, 95% CI: 0.35–0.79, p < 0.00001) and after (SMD: 0.91, 95% CI: 0.59–1.23, p < 0.00001) extubation. Conclusions: This study showed that elevated CVP and BNP levels are associated with extubation failure in critically ill patients. However, BNP levels are more valuable than CVP levels in predicting extubation outcomes.
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Affiliation(s)
- Jianghong Cao
- Department of Intensive Care Unit, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Beibei Wang
- Department of Cardiology, The First People's Hospital of Jinzhong, Jinzhong, China
| | - Lili Zhu
- Department of Intensive Care Unit, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Lu Song
- Department of Intensive Care Unit, Shanxi Provincial People's Hospital, Taiyuan, China
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60
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Nutritional support for successful weaning in patients undergoing prolonged mechanical ventilation. Sci Rep 2022; 12:12044. [PMID: 35835785 PMCID: PMC9283331 DOI: 10.1038/s41598-022-15917-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/01/2022] [Indexed: 11/13/2022] Open
Abstract
Successful weaning from ventilators not only improves the quality of life of patients, but also reduces medical expenses. The aim of this study was to explore the association between nutritional provision and successful ventilator weaning. In this retrospective study data from the Respiratory Care Center of Chung Shan Medical University Hospital between October, 2017 and July, 2019 on patient characteristics, amount of nutrition delivered, and clinical outcomes were retrieved. A total of 280 ventilated patients were enrolled and divided into successful extubation and failed weaning groups. There were 178 males (63.6%) and 102 females (36.4%) with a mean age of 67.3 ± 16.9 years. The successful extubation group consisted of patients who tended towards ideal body weight during the weaning process (BMI 23.9 ± 5.0 versus 22.7 ± 4.8 kg/m2, p < 0.001). Patients from both groups initially received the same nutritional intervention, while patients of successful extubation received significantly more calories and protein after weaning (23.8 ± 7.8 kcal versus 27.8 ± 9.1 kcal, p < 0.001 and 0.97 ± 0.36 g versus 1.14 ± 0.42 g, p < 0.001). Successful weaning was associated with higher survival rate (p = 0.016), shortened hospital stay (p = 0.001), and reduced medical costs (p < 0.001). Overall, nutritional support with high calories and protein was associated with the probability of successful ventilator weaning in patients undergoing prolonged mechanical ventilation. Adequate nutrition is a determinant of successful ventilator weaning.
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61
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ECONOMIC FEASIBILITY OF A NOVEL TOOL TO ASSIST EXTUBATION DECISION-MAKING: AN EARLY HEALTH ECONOMIC MODELLING. Int J Technol Assess Health Care 2022; 38:e66. [PMID: 35811412 DOI: 10.1017/s0266462322000472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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62
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Ohchi Y, Kuribayashi Y, Makino T, Yasuda N, Kitano T. Nasal pillow noninvasive ventilation versus high-flow nasal therapy after extubation in surgical intensive care patients: A propensity-matched cohort study. J Int Med Res 2022; 50:3000605221112777. [PMID: 35866425 PMCID: PMC9310252 DOI: 10.1177/03000605221112777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objective To evaluate the tolerability and efficacy of nasal pillow-noninvasive ventilation (NP-NIV) compared with high-flow nasal therapy (HFNT) in postsurgical patients. Methods This propensity score-matched retrospective study enrolled postoperative patients that received NP-NIV (NP-NIV group) or HFNT (HFNT group) in the intensive care unit. Data were collected from their medical records and the tolerability and respiratory status before and after extubation were compared between the two groups. Results The study enrolled 83 patients in the NP-NIV group and 27 patients in the HFNT group. After propensity score matching, there were 19 patients in each group. After matching, there were no significant differences in the baseline demographic and clinical characteristics before extubation. The tolerability was similar in both groups. When the NP-NIV group was compared with the HFNT group, the respiratory rate was significantly lower (median 16 [interquartile range, 14–17] versus median 19 [interquartile range, 18–26], respectively) and the partial pressure of arterial oxygen/fraction of inspired oxygen ratio was significantly higher (median 205 [174–256] versus median 155 [130–192], respectively) at 1 h after extubation. Conclusion NP-NIV was equally well tolerated and provided better respiratory support than HFNT in postsurgical patients.
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Affiliation(s)
- Yoshifumi Ohchi
- Department of Anaesthesiology and Intensive Care, Faculty of Medicine, Oita University, Yufu, Japan
| | - Yoshihide Kuribayashi
- Department of Anaesthesiology and Intensive Care, Faculty of Medicine, Oita University, Yufu, Japan
| | - Takenori Makino
- Department of Anaesthesiology and Intensive Care, Faculty of Medicine, Oita University, Yufu, Japan
| | - Norihisa Yasuda
- Department of Anaesthesiology and Intensive Care, Faculty of Medicine, Oita University, Yufu, Japan
| | - Takaaki Kitano
- Department of Anaesthesiology and Intensive Care, Faculty of Medicine, Oita University, Yufu, Japan
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63
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Li T, Zhou D, Zhao D, Lin Q, Wang D, Wang C. Association between fluid intake and extubation failure in intensive care unit patients with negative fluid balance: a retrospective observational study. BMC Anesthesiol 2022; 22:170. [PMID: 35650538 PMCID: PMC9158150 DOI: 10.1186/s12871-022-01708-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 05/19/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Negative fluid balance (NFB) is associated with reduced extubation failure. However, whether achieving more NFB can further improve extubation outcome has not been investigated. This study aimed to investigate whether more NFB and restricted fluid intake were associated with extubation success. METHODS We performed a retrospective study of adult patients with mechanical ventilation (MV) admitted to Medical Information Mart for Intensive Care (MIMIC-III) from 2001 to 2012. Patients with duration of MV over 24 hours and NFB within 24 hours before extubation were included for analysis. The primary outcome was extubation failure, defined as reintubation within 72 hours after extubation. Association between fluid balance or fluid intake and extubation outcome were investigated with multivariable logistic models. RESULTS A total of 3433 extubation events were recorded. 1803 with NFB were included for the final analysis, of which 201(11.1%) were extubation failure. Compared with slight NFB (- 20 to 0 ml/kg), more NFB were not associated improved extubation outcome. Compared with moderate fluid intake (30 to 60 ml/kg), lower (< 30 ml/kg, OR 0.75, 95% CI [0.54, 1.05], p = 0.088) or higher (> 60 ml/kg, OR 1.63, 95% CI [0.73, 3.35], p = 0.206) fluid intake was not associated with extubation outcome. Duration of MV, chronic obstructive pulmonary disease (COPD), hypercapnia, use of diuretics, and SAPSIIscore were associated with extubation failure. CONCLUSIONS More NFB or restricted fluid intake were not associated with reduced extubation failure in patients with NFB. However, for COPD patients, restricted fluid intake was associated with extubation success.
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Affiliation(s)
- Tong Li
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China.
| | - Dawei Zhou
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Dong Zhao
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Qing Lin
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Dija Wang
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Chao Wang
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
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64
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Watanabe A. Concordance Between Outcomes Associated With Withholding Extubation and Extubation Failure After Successful Spontaneous Breathing Trial. Crit Care Med 2022; 50:e589. [PMID: 35612445 DOI: 10.1097/ccm.0000000000005481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Atsuyuki Watanabe
- Division of Hospital Medicine, University of Tsukuba Hospital, Tsukuba, Japan
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65
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The Contribution of Chest X-Ray to Predict Extubation Failure in Mechanically Ventilated Patients Using Machine Learning-Based Algorithms. Crit Care Explor 2022; 4:e0718. [PMID: 35702351 PMCID: PMC9191311 DOI: 10.1097/cce.0000000000000718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To evaluate the contribution of a preextubation chest X-ray (CXR) to identify the risk of extubation failure in mechanically ventilated patients.
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66
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Arrivé F, Rodriguez M, Frat JP, Thille A. Place de l’oxygénothérapie à haut débit en post-extubation. Rev Mal Respir 2022; 39:469-476. [DOI: 10.1016/j.rmr.2022.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 03/02/2022] [Indexed: 11/16/2022]
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67
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Wang H, Gauda EB, Chiu PPL, Moore AM. Risk factors for prolonged mechanical ventilation in neonates following gastrointestinal surgery. Transl Pediatr 2022; 11:617-624. [PMID: 35685067 PMCID: PMC9173873 DOI: 10.21037/tp-22-14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 03/02/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Prolonged mechanical ventilation (MV) should be avoided in neonates. Noninvasive ventilation (NIV) can facilitate weaning from MV but has risks for patients immediately following foregut surgery due to the potential risk of anastomotic leak. We evaluated the risk factors for prolonged MV following intestinal surgery in neonates. METHODS We retrospectively reviewed 253 neonates undergoing intestinal surgery in 2017-2018 to identify risk factors for prolonged MV, and determine the correlation between NIV and anastomotic leak in a tertiary neonatal intensive care unit that performs the greatest number of neonatal surgeries in Ontario. RESULTS The most common diagnoses were necrotizing enterocolitis/spontaneous intestinal perforation (NEC/SIP) 21%, intestinal atresia 16%, esophageal atresia/tracheoesophageal fistula 14%, ano-rectal malformation 13%, malrotation/volvulus 11%, gastroschisis 9% and omphalocele 4%. The median (IQR) duration of MV post-surgery was 3 (1-8) days with 25.7 % (n=65) of neonates on MV for >7 days. Compared to infants on MV post-surgery for ≤7 days, those with MV>7 days were of lower gestational age, birth weight and weight at surgery, but a higher proportion underwent stoma creation, had a longer duration of opioid administration and higher rates of moderate to severe bronchopulmonary dysplasia (BPD) and mortality (P<0.05). Generalized linear regression analysis showed lower gestational age (GA) and longer opioid administration were associated with longer duration of MV (P<0.001), but indication for surgery, weight at surgery and stoma creation didn't correlate with longer duration of MV (P>0.05). Of the 122 patients handled by one-stage resection with primary anastomosis, 22.1% (n=27) received NIV with 74.1% (n=20) commenced on NIV after 7 days post-surgery, anastomotic leak was detected in 2.5 % (3/122) patients and didn't correlate with NIV. CONCLUSIONS Lower GA and longer opioid administration were risk factors for prolonged MV in neonates following intestinal surgery. Further research is needed to investigate modifiable practices around pain assessment/ventilation in these patients, and the correlation between NIV and anastomotic leak.
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Affiliation(s)
- Huanhuan Wang
- Division of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Estelle B Gauda
- Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Priscilla P L Chiu
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Aideen M Moore
- Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada
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68
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Tanaka A, Kabata D, Hirao O, Kosaka J, Furushima N, Maki Y, Uchiyama A, Egi M, Shintani A, Morimatsu H, Mizobuchi S, Kotake Y, Fujino Y. Prediction Model of Extubation Outcomes in Critically Ill Patients: A Multicenter Prospective Cohort Study. J Clin Med 2022; 11:jcm11092520. [PMID: 35566646 PMCID: PMC9102390 DOI: 10.3390/jcm11092520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 04/24/2022] [Accepted: 04/25/2022] [Indexed: 02/05/2023] Open
Abstract
Liberation from mechanical ventilation is of great importance owing to related complications from extended ventilation time. In this prospective multicenter study, we aimed to construct a versatile model for predicting extubation outcomes in critical care settings using obtainable physiological predictors. The study included patients who had been extubated after a successful 30 min spontaneous breathing trial (SBT). A multivariable logistic regression model was constructed to predict extubation outcomes (successful extubation without reintubation and uneventful extubation without reintubation or noninvasive respiratory support) using eight parameters: age, heart failure, respiratory disease, rapid shallow breathing index (RSBI), PaO2/FIO2, Glasgow Coma Scale score, fluid balance, and endotracheal suctioning episodes. Of 499 patients, 453 (90.8%) and 328 (65.7%) achieved successful and uneventful extubation, respectively. The areas under the curve for successful and uneventful extubation in the novel prediction model were 0.69 (95% confidence interval (CI), 0.62−0.77) and 0.70 (95% CI, 0.65−0.74), respectively, which were significantly higher than those in the conventional model solely using RSBI (0.58 (95% CI, 0.50−0.66) and 0.54 (95% CI, 0.49−0.60), p = 0.004 and <0.001, respectively). The model was validated using a bootstrap method, and an online application was developed for automatic calculation. Our model, which is based on a combination of generally obtainable parameters, established an accessible method for predicting extubation outcomes after a successful SBT.
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Affiliation(s)
- Aiko Tanaka
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita 565-0871, Japan; (A.U.); (Y.F.)
- Correspondence: ; Tel.: +81-6-6879-5820; Fax: +81-6-6879-5823
| | - Daijiro Kabata
- Department of Medical Statistics, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan; (D.K.); (A.S.)
| | - Osamu Hirao
- Department of Anesthesiology, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka 558-8558, Japan;
| | - Junko Kosaka
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan; (J.K.); (H.M.)
| | - Nana Furushima
- Department of Anesthesiology and Intensive Care Medicine, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan; (N.F.); (M.E.); (S.M.)
| | - Yuichi Maki
- Department of Anesthesiology, Toho University Ohashi Medical Center, 2-22-36 Ohashi, Meguro-ku, Tokyo 153-8515, Japan; (Y.M.); (Y.K.)
| | - Akinori Uchiyama
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita 565-0871, Japan; (A.U.); (Y.F.)
| | - Moritoki Egi
- Department of Anesthesiology and Intensive Care Medicine, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan; (N.F.); (M.E.); (S.M.)
| | - Ayumi Shintani
- Department of Medical Statistics, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan; (D.K.); (A.S.)
| | - Hiroshi Morimatsu
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan; (J.K.); (H.M.)
| | - Satoshi Mizobuchi
- Department of Anesthesiology and Intensive Care Medicine, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan; (N.F.); (M.E.); (S.M.)
| | - Yoshifumi Kotake
- Department of Anesthesiology, Toho University Ohashi Medical Center, 2-22-36 Ohashi, Meguro-ku, Tokyo 153-8515, Japan; (Y.M.); (Y.K.)
| | - Yuji Fujino
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita 565-0871, Japan; (A.U.); (Y.F.)
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69
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Xie Z, Liu J, Yang Z, Tang L, Wang S, Du Y, Yang L. Risk Factors for Post-operative Planned Reintubation in Patients After General Anesthesia: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2022; 9:839070. [PMID: 35355600 PMCID: PMC8959864 DOI: 10.3389/fmed.2022.839070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 02/09/2022] [Indexed: 11/13/2022] Open
Abstract
Background The occurrence of postoperative reintubation (POR) in patients after general anesthesia (GA) is often synonymous with a poor prognosis in patients. This is the first review analyzing scientific literature to identify risk factors of POR after general anesthesia. The purpose of this study was to collect currently published studies to determine the most common and consistent risk factors associated with POR after GA. Methods We have retrieved all relevant research published before April 2021 from PubMed, Embase, Web of Science, and the Cochrane Library electronic databases. These studies were selected according to the inclusion and exclusion criteria. The Z test determined the combined odds ratio (OR) of risk factors. We used OR and its corresponding 95% confidence interval (CI) to identify significant differences in risk factors. The quality of the study was evaluated with the NOS scale, and meta-analysis was carried out with Cochrane Collaboration's Revman 5.0 software. Results A total of 10 studies were included, with a total of 7,789 recipients of POR. We identified 7 risk factors related to POR after GA: ASA ≥ 3 (OR = 3.58), COPD (OR = 2.09), thoracic surgery (OR = 17.09), airway surgery (OR = 9.93), head-and-neck surgery (OR = 3.49), sepsis (OR = 3.50), DVT (OR = 4.94). Conclusion Our meta-analysis showed that ASA ≥ 3, COPD, thoracic surgery, airway surgery, head-and-neck surgery, sepsis and DVT were associated with POR after GA. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?, Identifier: CRD42021252466.
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Affiliation(s)
- Zhiqin Xie
- Department of Nursing, First Affiliated Hospital of Nanchang University, Nanchang, China.,School of Nursing, Nanchang University, Nanchang, China
| | - Jiawen Liu
- School of Nursing, Nanchang University, Nanchang, China
| | - Zhen Yang
- Department of Nursing, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Liping Tang
- Department of Nursing, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Shuilian Wang
- Department of Nursing, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yunyu Du
- School of Nursing, Nanchang University, Nanchang, China
| | - Lina Yang
- School of Nursing, Nanchang University, Nanchang, China
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70
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Outcomes in Temporary ICUs Versus Conventional ICUs: An Observational Cohort of Mechanically Ventilated Patients With COVID-19–Induced Acute Respiratory Distress Syndrome. Crit Care Explor 2022; 4:e0668. [PMID: 35372841 PMCID: PMC8963854 DOI: 10.1097/cce.0000000000000668] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Throughout the COVID-19 pandemic, thousands of temporary ICUs have been established worldwide. The outcomes and management of mechanically ventilated patients in these areas remain unknown.
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71
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Sakuraya M, Douno E, Iwata W, Takaba A, Hadama K, Kawamura N, Maezawa T, Iwamoto K, Yoshino Y, Yoshida K. Accuracy evaluation of mainstream and sidestream end-tidal carbon dioxide monitoring during noninvasive ventilation: a randomized crossover trial (MASCAT-NIV trial). J Intensive Care 2022; 10:17. [PMID: 35303968 PMCID: PMC8932153 DOI: 10.1186/s40560-022-00603-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 02/24/2022] [Indexed: 12/02/2022] Open
Abstract
Background The end-tidal partial pressure of carbon dioxide (PETCO2) can be used to estimate the arterial partial pressure of carbon dioxide (PaCO2) in patients who undergo mechanical ventilation via endotracheal intubation. However, no reliable method for measuring PETCO2 during noninvasive ventilation (NIV) has been established. The purpose of this study was to evaluate the correlation and agreement between PaCO2 and PETCO2 measured by these two methods and to compare them in patients who underwent NIV after extubation. Methods This study was a randomized, open-label, crossover trial in a mixed intensive care unit. We included patients who were planned for NIV after extubation and for whom the difference between PETCO2 and PaCO2 was ≤ 5 mmHg. We compared mainstream capnography using an inner cup via face mask (the novel method) with sidestream capnography (the previous method) during NIV. The relationships between PaCO2 and PETCO2 were evaluated by computing the Pearson correlation coefficient, and the agreement between PaCO2 and PETCO2 was estimated using the Bland–Altman method. Results From April 2020 to October 2021, 60 patients were included to the study. PaCO2 and PETCO2 were well correlated in both methods (the novel methods: r = 0.92, P < 0.001; the previous method: r = 0.79, P < 0.001). Mean bias between PaCO2 and PETCO2 measured using the novel method was 2.70 (95% confidence interval [CI], 2.15–3.26) mmHg with 95% limits of agreement (LoA) ranging from − 1.61 to 7.02 mmHg, similar to the result of measurement during SBT (mean bias, 2.51; 95% CI, 2.00–3.02; 95% LoA, − 1.45 to 6.47 mmHg). In contrast, measurement using the previous method demonstrated a larger difference (mean bias, 6.22; 95% CI, 5.22–7.23; 95% LoA, − 1.54 to 13.99 mmHg). Conclusion The current study demonstrated that the novel PETCO2 measurement was superior to the previous method for PaCO2 prediction. During NIV, the novel method may collect as sufficient exhalation sample as during intubation. Continuous PETCO2 measurement combined with peripheral oxygen saturation monitoring is expected to be useful for early recognition of respiratory failure among high-risk patients after extubation. Trial registration UMIN-CTR UMIN000039459. Registered February 11, 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s40560-022-00603-w.
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Affiliation(s)
- Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Jigozen 1-3-3, Hatsukaichi, Hiroshima, 738-8503, Japan.
| | - Eri Douno
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Jigozen 1-3-3, Hatsukaichi, Hiroshima, 738-8503, Japan.,Department of Emergency and Critical Care Medicine, Urasoe General Hospital, Okinawa, Japan
| | - Wakana Iwata
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Jigozen 1-3-3, Hatsukaichi, Hiroshima, 738-8503, Japan
| | - Akihiro Takaba
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Jigozen 1-3-3, Hatsukaichi, Hiroshima, 738-8503, Japan
| | - Kosuke Hadama
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Jigozen 1-3-3, Hatsukaichi, Hiroshima, 738-8503, Japan
| | - Natsuki Kawamura
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Jigozen 1-3-3, Hatsukaichi, Hiroshima, 738-8503, Japan
| | - Toshinori Maezawa
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Jigozen 1-3-3, Hatsukaichi, Hiroshima, 738-8503, Japan
| | - Kei Iwamoto
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Jigozen 1-3-3, Hatsukaichi, Hiroshima, 738-8503, Japan.,Critical Care Medical Center, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Yuya Yoshino
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Jigozen 1-3-3, Hatsukaichi, Hiroshima, 738-8503, Japan.,Emergency and Critical Care Center, Kurashiki Central Hospital, Okayama, Japan
| | - Kenichi Yoshida
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Jigozen 1-3-3, Hatsukaichi, Hiroshima, 738-8503, Japan
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72
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Bansal V, Smischney NJ, Kashyap R, Li Z, Marquez A, Diedrich DA, Siegel JL, Sen A, Tomlinson AD, Venegas-Borsellino CP, Freeman WD. Reintubation Summation Calculation: A Predictive Score for Extubation Failure in Critically Ill Patients. Front Med (Lausanne) 2022; 8:789440. [PMID: 35252224 PMCID: PMC8891541 DOI: 10.3389/fmed.2021.789440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/28/2021] [Indexed: 11/13/2022] Open
Abstract
Objective To derive and validate a multivariate risk score for the prediction of respiratory failure after extubation. Patients and methods We performed a retrospective cohort study of adult patients admitted to the intensive care unit from January 1, 2006, to December 31, 2015, who received mechanical ventilation for ≥48 h. Extubation failure was defined as the need for reintubation within 72 h after extubation. Multivariate logistic regression model coefficient estimates generated the Re-Intubation Summation Calculation (RISC) score. Results The 6,161 included patients were randomly divided into 2 sets: derivation (n = 3,080) and validation (n = 3,081). Predictors of extubation failure in the derivation set included body mass index <18.5 kg/m2 [odds ratio (OR), 1.91; 95% CI, 1.12–3.26; P = 0.02], threshold of Glasgow Coma Scale of at least 10 (OR, 1.68; 95% CI, 1.31–2.16; P < 0.001), mean airway pressure at 1 min of spontaneous breathing trial <10 cmH2O (OR, 2.11; 95% CI, 1.68–2.66; P < 0.001), fluid balance ≥1,500 mL 24 h preceding extubation (OR, 2.36; 95% CI, 1.87–2.96; P < 0.001), and total mechanical ventilation days ≥5 (OR, 3.94; 95% CI 3.04–5.11; P < 0.001). The C-index for the derivation and validation sets were 0.72 (95% CI, 0.70–0.75) and 0.72 (95% CI, 0.69–0.75). Multivariate logistic regression demonstrated that an increase of 1 in RISC score increased odds of extubation failure 1.6-fold (OR, 1.58; 95% CI, 1.47–1.69; P < 0.001). Conclusion RISC predicts extubation failure in mechanically ventilated patients in the intensive care unit using several clinically relevant variables available in the electronic medical record but requires a larger validation cohort before widespread clinical implementation.
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Affiliation(s)
- Vikas Bansal
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, United States
- Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN, United States
| | - Nathan J. Smischney
- Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN, United States
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Rahul Kashyap
- Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN, United States
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Zhuo Li
- Biostatistics Unit, Mayo Clinic, Jacksonville, FL, United States
| | - Alberto Marquez
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Daniel A. Diedrich
- Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN, United States
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Jason L. Siegel
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, United States
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States
| | - Ayan Sen
- Department of Critical Care Medicine, Mayo Clinic Hospital, Phoenix, AZ, United States
- Department of Neurologic Surgery, Mayo Clinic Hospital, Phoenix, AZ, United States
| | - Amanda D. Tomlinson
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | | | - William David Freeman
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, United States
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States
- *Correspondence: William David Freeman
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Zarrabian B, Wunsch H, Stelfox HT, Iwashyna TJ, Gershengorn HB. Liberation from Invasive Mechanical Ventilation with Continued Receipt of Vasopressor Infusions. Am J Respir Crit Care Med 2022; 205:1053-1063. [PMID: 35107416 DOI: 10.1164/rccm.202108-2004oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Weaning protocols for discontinuation of invasive mechanical ventilation often mandate resolution of shock. Whether extubation while receiving vasopressors is associated with harm is uncertain. OBJECTIVES To examine whether extubation while still receiving vasopressors is associated with worse outcomes. METHODS We performed a retrospective cohort study of adults in Calgary ICUs who received vasopressors with invasive mechanical ventilation and an extubation attempt. The primary exposure was continued vasopressor use at extubation. The primary outcome was reintubation within 96-hours. Secondary outcomes included in-hospital mortality and ICU/hospital length of stay (LOS). We assessed associations of vasopressor use at extubation with outcomes using multivariable competing-risk (reintubation/LOS) and Cox proportional-hazards (mortality) models. MEASUREMENTS AND MAIN RESULTS Of 6140 patients who received invasive mechanical ventilation while on vasopressors, 721 (11.7%) were extubated while receiving vasopressors and 5419 (88.3%) after discontinuation. Extubation on vasopressors was not, in aggregate, significantly associated with an increased hazard of reintubation (sub-hazard ratio, 1.81 [95% CI: 0.91 - 3.61], P=0.09). Both mortality (HR 1.22 [1.02-1.47], P=0.03) and time to hospital discharge (SHR for remaining hospitalized 0.78 [0.68-0.91], P<0.01) were increased. Extubation on high-dose vasopressors (>0.1 µg/kg/min) was associated with a greater hazard of reintubation (SHR 2.25 [1.01-4.98], P=0.046) compared to extubation after vasopressor discontinuation. Meanwhile, extubation on low-dose vasopressors (≤0.1 µg/kg/min) was associated with a lower mortality (HR 0.69 [0.51-0.91], P=0.01) and a shorter ICU LOS (SHR 1.34 [1.09-1.65], P<0.01), but no difference in reintubation or hospital LOS as compared to those weaned off vasopressors. CONCLUSIONS Extubation while receiving high-dose but not low-dose vasopressors was associated with an increased risk of reintubation.
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Affiliation(s)
- Baharan Zarrabian
- University of Miami Miller School of Medicine, 12235, Department of Medicine, Miami, Florida, United States;
| | - Hannah Wunsch
- Sunnybrook Health Sciences Centre, 71545, Department of Critical Care Medicine, Toronto, Ontario, Canada.,University of Toronto, 7938, Department of Anesthesiology and Critical Care, Toronto, Ontario, Canada
| | - Henry T Stelfox
- University of Calgary Cumming School of Medicine, 70401, Department of Critical Care Medicine, Calgary, Alberta, Canada.,University of Calgary Cumming School of Medicine, 70401, Department of Community Health Sciences, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, 157746, Calgary, Alberta, Canada.,Alberta Health Services, 3146, Edmonton, Alberta, Canada
| | - Theodore J Iwashyna
- University of Michigan, 1259, Department of Internal Medicine, Ann Arbor, Michigan, United States.,VA Ann Arbor Healthcare System, 20034, VA Center for Clinical Management Research, Ann Arbor, Michigan, United States.,University of Michigan, 1259, Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan, United States.,Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor, Michigan, United States
| | - Hayley B Gershengorn
- University of Miami School of Medicine, 12235, Division of Pulmonary, Critical Care, and Sleep Medicine, Miami, Florida, United States.,Albert Einstein College of Medicine, 2006, Division of Critical Care Medicine, Bronx, New York, United States
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Ippolito M, Catalisano G, Iozzo P, Raineri SM, Gregoretti C, Giarratano A, Einav S, Cortegiani A. Association between night-time extubation and clinical outcomes in adult patients: A systematic review and meta-analysis. Eur J Anaesthesiol 2022; 39:152-160. [PMID: 34352806 DOI: 10.1097/eja.0000000000001579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Whether night-time extubation is associated with clinical outcomes is unclear. OBJECTIVE The aim of this systematic review and meta-analysis was to evaluate the association between night-time extubation and the reintubation rate, mortality, ICU and in-hospital length of stay in adult patients, compared with daytime extubation. DESIGN A systematic review and meta-analysis. DATA SOURCES PubMed, EMBASE, CINAHL and Web of Science from inception to 2 January 2021 (PROSPERO registration - CRD42020222812). ELIGIBILITY CRITERIA Randomised, quasi and cluster randomised, and nonrandomised studies describing associations between adult patients' outcomes and time of extubation (daytime/night-time) in intensive care or postanaesthesia care units. RESULTS Seven retrospective studies were included in the systematic review and meta-analysis, for a total of 293 663 patients. All the studies were performed in United States (USA). All the studies were judged at moderate risk of bias for reintubation and mortality. The analyses were conducted with random effects models. The analyses from adjusted estimates demonstrated no association between night-time extubation and increased risk of either reintubation (OR 1.00; 95% CI 0.88 to 1.13; P = 1.00; I2 = 66%; low-certainty evidence) or all-cause mortality at the longest available follow-up (OR 1.11; 95% CI 0.87 to 1.42; P = 0.39; I2 = 79%; low-certainty evidence), in comparison with daytime extubation. Analyses from unadjusted data for reintubation, mortality and ICU or in-hospital length of stay showed no significant association with night-time extubation. Analyses based on type of admission, number of centres or duration of mechanical ventilation showed no significant subgroup effects. CONCLUSION Night-time extubation of adult patients was not associated with higher adjusted risks for reintubation or death, in comparison with daytime extubation, but the certainty of the evidence was low.
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Affiliation(s)
- Mariachiara Ippolito
- From the Department of Surgical, Oncological and Oral Science, University of Palermo (MI, GC, SMR, CG, AG, AC), the Department of Anaesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone (PI, SMR, AG, AC), Fondazione 'Giglio' Cefalù, Palermo, Italy (CG), the Intensive Care Unit of the Shaare Zedek Medical Medical Centre and Hebrew University Faculty of Medicine, Jerusalem, Israel (SE)
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Fernando SM, Tran A, Sadeghirad B, Burns KEA, Fan E, Brodie D, Munshi L, Goligher EC, Cook DJ, Fowler RA, Herridge MS, Cardinal P, Jaber S, Møller MH, Thille AW, Ferguson ND, Slutsky AS, Brochard LJ, Seely AJE, Rochwerg B. Noninvasive respiratory support following extubation in critically ill adults: a systematic review and network meta-analysis. Intensive Care Med 2022; 48:137-147. [PMID: 34825256 DOI: 10.1007/s00134-021-06581-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 11/09/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE Systematic review and network meta-analysis to investigate the efficacy of noninvasive respiratory strategies, including noninvasive positive pressure ventilation (NIPPV) and high-flow nasal cannula (HFNC), in reducing extubation failure among critically ill adults. METHODS We searched databases from inception through October 2021 for randomized controlled trials (RCTs) evaluating noninvasive respiratory support therapies (NIPPV, HFNC, conventional oxygen therapy, or a combination of these) following extubation in critically ill adults. Two reviewers performed screening, full text review, and extraction independently. The primary outcome of interest was reintubation. We used GRADE to rate the certainty of our findings. RESULTS We included 36 RCTs (6806 patients). Compared to conventional oxygen therapy, NIPPV (OR 0.65 [95% CI 0.52-0.82]) and HFNC (OR 0.63 [95% CI 0.45-0.87]) reduced reintubation (both moderate certainty). Sensitivity analyses showed that the magnitude of the effect was highest in patients with increased baseline risk of reintubation. As compared to HFNC, no difference in incidence of reintubation was seen with NIPPV (OR 1.04 [95% CI 0.78-1.38], low certainty). Compared to conventional oxygen therapy, neither NIPPV (OR 0.8 [95% CI 0.61-1.04], moderate certainty) or HFNC (OR 0.9 [95% CI 0.66-1.24], low certainty) reduced short-term mortality. Consistent findings were demonstrated across multiple subgroups, including high- and low-risk patients. These results were replicated when evaluating noninvasive strategies for prevention (prophylaxis), but not in rescue (application only after evidence of deterioration) situations. CONCLUSIONS Our findings suggest that both NIPPV and HFNC reduced reintubation in critically ill adults, compared to conventional oxygen therapy. NIPPV did not reduce incidence of reintubation when compared to HFNC. These findings support the preventative application of noninvasive respiratory support strategies to mitigate extubation failure in critically ill adults, but not in rescue conditions.
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Affiliation(s)
- Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Alexandre Tran
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Behnam Sadeghirad
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Karen E A Burns
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Deborah J Cook
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Robert A Fowler
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Margaret S Herridge
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Pierre Cardinal
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Samir Jaber
- Hôpital Saint-Eloi, Centre Hospitalier Universitaire (CHU) Montpellier, PhyMedExp, INSERM, CNRS, Montpellier, France
- Département de Médecine Intensive et Réanimation, Centre Hospitalier Universitaire (CHU) Montpellier, PhyMedExp, INSERM, CNRS, Montpellier, France
| | | | - Arnaud W Thille
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers, France
- INSERM Centre d'Investigation Clinique 1402, ALIVE, Université de Poitiers, Poitiers, France
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Laurent J Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Andrew J E Seely
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
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Liu W, Tao G, Zhang Y, Xiao W, Zhang J, Liu Y, Lu Z, Hua T, Yang M. A Simple Weaning Model Based on Interpretable Machine Learning Algorithm for Patients With Sepsis: A Research of MIMIC-IV and eICU Databases. Front Med (Lausanne) 2022; 8:814566. [PMID: 35118099 PMCID: PMC8804204 DOI: 10.3389/fmed.2021.814566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 12/13/2021] [Indexed: 11/13/2022] Open
Abstract
BackgroundInvasive mechanical ventilation plays an important role in the prognosis of patients with sepsis. However, there are, currently, no tools specifically designed to assess weaning from invasive mechanical ventilation in patients with sepsis. The aim of our study was to develop a practical model to predict weaning in patients with sepsis.MethodsWe extracted patient information from the Medical Information Mart for Intensive Care Database-IV (MIMIC-IV) and the eICU Collaborative Research Database (eICU-CRD). Kaplan–Meier curves were plotted to compare the 28-day mortality between patients who successfully weaned and those who failed to wean. Subsequently, MIMIC-IV was divided into a training set and an internal verification set, and the eICU-CRD was designated as the external verification set. We selected the best model to simplify the internal and external validation sets based on the performance of the model.ResultsA total of 5020 and 7081 sepsis patients with invasive mechanical ventilation in MIMIC-IV and eICU-CRD were included, respectively. After matching, weaning was independently associated with 28-day mortality and length of ICU stay (p < 0.001 and p = 0.002, respectively). After comparison, 35 clinical variables were extracted to build weaning models. XGBoost performed the best discrimination among the models in the internal and external validation sets (AUROC: 0.80 and 0.86, respectively). Finally, a simplified model was developed based on XGBoost, which included only four variables. The simplified model also had good predictive performance (AUROC:0.75 and 0.78 in internal and external validation sets, respectively) and was developed into a web-based tool for further review.ConclusionsWeaning success is independently related to short-term mortality in patients with sepsis. The simplified model based on the XGBoost algorithm provides good predictive performance and great clinical applicablity for weaning, and a web-based tool was developed for better clinical application.
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Affiliation(s)
- Wanjun Liu
- The 2nd Department of Intensive Care Unit, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
- The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Gan Tao
- The 2nd Department of Intensive Care Unit, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yijun Zhang
- The 2nd Department of Intensive Care Unit, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
- The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Wenyan Xiao
- The 2nd Department of Intensive Care Unit, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
- The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jin Zhang
- The 2nd Department of Intensive Care Unit, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
- The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yu Liu
- Key Laboratory of Intelligent Computing and Signal Processing, Ministry of Education, Anhui University, Hefei, China
| | - Zongqing Lu
- The 2nd Department of Intensive Care Unit, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
- The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Tianfeng Hua
- The 2nd Department of Intensive Care Unit, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
- The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Min Yang
- The 2nd Department of Intensive Care Unit, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
- The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
- *Correspondence: Min Yang
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Li J, Zhang J, Hao Q, Shen Z, Du Y, Chen H, Cheng X. The Impact of Time Interval Between First Extubation and Reintubation on Bronchopulmonary Dysplasia or Death in Very Low Birth Weight Infants. Front Pediatr 2022; 10:867767. [PMID: 35547548 PMCID: PMC9085302 DOI: 10.3389/fped.2022.867767] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/14/2022] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To explore the association between time from first extubation to reintubation and moderate-to-severe bronchopulmonary dysplasia (BPD) or death in very low birth weight infants. STUDY DESIGN Infants weighing <1,500 g at birth, requiring mechanical ventilation, and undergoing their initial extubation were retrospectively included from January 2014 to December 2021. They were divided into the moderate-to-severe BPD/death group and the comparison group according to the incidence of moderate-to-severe BPD or death. We defined time to reintubation as the time interval between first extubation and reintubation. In a stepwise multivariate logistic regression analysis, we examined the association between time to reintubation and moderate-to-severe BPD/death using different observation windows after initial extubation (24-h intervals). RESULTS A total of 244 infants were recruited, including 57 cases in the moderate-severe BPD/death group and 187 cases in the comparison group, and 93 (38.1%) cases were reintubated at least one time after their first extubation. Univariate analysis showed that reintubation rates within different observation windows in the moderate-to-severe BPD/death group were statistically significantly (p < 0.05) higher than those in the comparison group. Multivariate regression analysis showed that reintubation within observation windows 48 h or 72 h post-extubation was an independent risk factor in moderate-to-severe BPD/death and death, but not moderate-to-severe BPD. When the time window was 48 h, the probability of moderate-to-severe BPD/death [odds ratio (OR): 3.778, 95% confidence interval (CI): 1.293-11.039] or death (OR: 4.734, 95% CI: 1.158-19.354) was highest. While after extending the observation window to include reintubations after 72 h from initial extubation, reintubation was not associated with increased risk of moderate-to-severe BPD and/or death. CONCLUSIONS Not all reintubations conferred increased risks of BPD/death. Only reintubation within 72 h from initial extubation was independently associated with increased likelihood of moderate-to-severe BPD/death and death in very low birth weight infants, and reintubation within the first 48 h post-extubation posed the greatest risk.
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Affiliation(s)
- Jing Li
- Department of Neonatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jing Zhang
- Department of Neonatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qingfei Hao
- Department of Neonatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ziyun Shen
- Department of Neonatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yanna Du
- Department of Neonatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Haoming Chen
- Department of Neonatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiuyong Cheng
- Department of Neonatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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The physiological underpinnings of life-saving respiratory support. Intensive Care Med 2022; 48:1274-1286. [PMID: 35690953 PMCID: PMC9188674 DOI: 10.1007/s00134-022-06749-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 05/16/2022] [Indexed: 02/04/2023]
Abstract
Treatment of respiratory failure has improved dramatically since the polio epidemic in the 1950s with the use of invasive techniques for respiratory support: mechanical ventilation and extracorporeal respiratory support. However, respiratory support is only a supportive therapy, designed to "buy time" while the disease causing respiratory failure abates. It ensures viable gas exchange and prevents cardiorespiratory collapse in the context of excessive loads. Because the use of invasive modalities of respiratory support is also associated with substantial harm, it remains the responsibility of the clinician to minimize such hazards. Direct iatrogenic consequences of mechanical ventilation include the risk to the lung (ventilator-induced lung injury) and the diaphragm (ventilator-induced diaphragm dysfunction and other forms of myotrauma). Adverse consequences on hemodynamics can also be significant. Indirect consequences (e.g., immobilization, sleep disruption) can have devastating long-term effects. Increasing awareness and understanding of these mechanisms of injury has led to a change in the philosophy of care with a shift from aiming to normalize gases toward minimizing harm. Lung (and more recently also diaphragm) protective ventilation strategies include the use of extracorporeal respiratory support when the risk of ventilation becomes excessive. This review provides an overview of the historical background of respiratory support, pathophysiology of respiratory failure and rationale for respiratory support, iatrogenic consequences from mechanical ventilation, specifics of the implementation of mechanical ventilation, and role of extracorporeal respiratory support. It highlights the need for appropriate monitoring to estimate risks and to individualize ventilation and sedation to provide safe respiratory support to each patient.
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Yi LJ, Tian X, Chen M, Lei JM, Xiao N, Jiménez-Herrera MF. Comparative Efficacy and Safety of Four Different Spontaneous Breathing Trials for Weaning From Mechanical Ventilation: A Systematic Review and Network Meta-Analysis. Front Med (Lausanne) 2021; 8:731196. [PMID: 34881255 PMCID: PMC8647911 DOI: 10.3389/fmed.2021.731196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 10/19/2021] [Indexed: 12/30/2022] Open
Abstract
Background: Spontaneous breathing trial (SBT) has been used to predict the optimal time of weaning from ventilator. However, it remains controversial which trial should be preferentially selected. We aimed to compare and rank four common SBT modes including automatic tube compensation (ATC), pressure support ventilation (PSV), continuous positive airway pressure (CPAP), and T-piece among critically ill patients receiving mechanical ventilation (MV). Methods: We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) to identify studies that investigated the comparative efficacy and safety of at least two SBT strategies among critically ill patients up to May 17, 2020. We estimated the surface under the cumulative ranking curve (SUCRA) to rank SBT techniques, and determined the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation method. Primary outcome was weaning success. Secondary outcomes were reintubation, SBT success, duration of acute care, and intensive care unit (ICU) mortality. Statistical analysis was conducted by using RevMan 5.4, Stata, and R software. Results: We enrolled 24 trials finally. Extubation success rate was significantly higher in ATC than that in T-piece (OR, 0.28; 95% CI, 0.13–0.64) or PSV (OR, 0.53; 95% CI, 0.32–0.88). For SBT success, ATC was better than other SBT techniques, with a pooled OR ranging from 0.17 to 0.42. For reintubation rate, CPAP was worse than T-piece (OR, 2.76; 95% CI, 1.08 to 7.06). No significant difference was detected between SBT modes for the length of stay in ICU or long-term weaning unit (LWU). Similar result was also found for ICU mortality between PSV and T-piece. Majority direct results were confirmed by network meta-analysis. Besides, ATC ranks at the first, first, and fourth place with a SUCRA of 91.7, 99.7, and 39.9%, respectively in increasing weaning success and SBT success and in prolonging ICU or LWU length of stay among four SBT strategies. The confidences in evidences were rated as low for most comparisons. Conclusion: ATC seems to be the optimal choice of predicting successful weaning from ventilator among critically ill patients. However, randomized controlled trials (RCTs) with high quality are needed to further establish these findings.
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Affiliation(s)
- Li-Juan Yi
- Nursing Department, Hunan Traditional Chinese Medical College, Zhuzhou, China
| | - Xu Tian
- Nursing Department, Universitat Rovira i Virgili, Tarragona, Spain
| | - Min Chen
- Nursing Department, Hunan Traditional Chinese Medical College, Zhuzhou, China
| | - Jin-Mei Lei
- Nursing Department, Hunan Traditional Chinese Medical College, Zhuzhou, China
| | - Na Xiao
- Nursing Department, Hunan Traditional Chinese Medical College, Zhuzhou, China
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Thille AW, Coudroy R, Nay MA, Gacouin A, Decavèle M, Sonneville R, Beloncle F, Girault C, Dangers L, Lautrette A, Levrat Q, Rouzé A, Vivier E, Lascarrou JB, Ricard JD, Mekontso-Dessap A, Barberet G, Lebert C, Ehrmann S, Massri A, Bourenne J, Pradel G, Bailly P, Terzi N, Dellamonica J, Lacave G, Robert R, Frat JP, Ragot S. Beneficial Effects of Non-Invasive Ventilation After Extubation in Obese or Overweight Patients: A Post-Hoc Analysis of a Randomized Clinical Trial. Am J Respir Crit Care Med 2021; 205:440-449. [PMID: 34813391 DOI: 10.1164/rccm.202106-1452oc] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Whereas non-invasive ventilation (NIV) may prevent reintubation in patients at high-risk of extubation failure in intensive care units (ICUs), this oxygenation strategy has not been specifically assessed in obese patients. OBJECTIVES We hypothesized that NIV may decrease the risk of reintubation in obese patients compared with high-flow nasal oxygen (HFNO). METHODS Post-hoc analysis of a multicenter, randomized, controlled trial (not pre-specified) comparing NIV alternating with HFNO versus HFNO alone after extubation, with the aim of assessing NIV effects according to patient body-mass index (BMI). MEASUREMENTS AND MAIN RESULTS Among 623 patients at high-risk of extubation failure, 206 (33%) were obese (BMI≥30 kg/m2), 204 (33%) were overweight (25≤BMI<30), and 213 (34%) were normal or underweight (BMI<25). Significant heterogeneity of NIV effects on the rate of reintubation was found according to BMI (Pinteraction=0.007). Reintubation rates at day 7 were significantly lower with NIV alternating with HFNO than with HFNO alone in obese or overweight patients: 7% (15/204) vs. 20% (41/206); difference, -13%; [95% CI, -19 to -6]; P=0.0002; whereas it did not significantly differ in normal or underweight patients. In-ICU mortality was significantly lower with NIV than with HFNO alone in obese or overweight patients (2% vs. 9%; difference, -6%; [95% CI, -11 to -2]; P=0.006). CONCLUSIONS Prophylactic NIV alternating with HFNO immediately after extubation significantly decreased the risk of reintubation and death as compared with HFNO alone in obese or overweight patients at high-risk of extubation failure. By contrast, NIV was not effective in normal or underweight patients.
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Affiliation(s)
- Arnaud W Thille
- Centre Hospitalier Universitaire de Poitiers, 36655, Médecine Intensive Réanimation, Poitiers, France.,University of Poitiers, 27077, INSERM CIC 1402, ALIVE research group, Poitiers, France;
| | - Rémi Coudroy
- Centre Hospitalier Universitaire de Poitiers, 36655, Médecine Intensive Réanimation, Poitiers, France.,University of Poitiers, 27077, INSERM CIC 1402, ALIVE research group, Poitiers, France
| | - Mai-Anh Nay
- Centre Hospitalier Regional d'Orleans, 52817, Orleans, France
| | - Arnaud Gacouin
- Centre Hospitalier Universitaire de Rennes, 36684, Hôpital Ponchaillou, Service des Maladies Infectieuses et Réanimation Médicale, Rennes, France
| | - Maxens Decavèle
- Groupe Hospitalier La Pitié Salpêtrière-Charles Foix, 55577, Médecine Intensive Réanimation, Paris, France
| | - Romain Sonneville
- APHP, 26930, Hôpital Bichat - Claude Bernard, Médecine Intensive Réanimation, Université Paris Diderot, Paris, France
| | - François Beloncle
- Centre Hospitalier Universitaire d'Angers, 26966, Département de Médecine Intensive Réanimation, Université d'Angers, Angers, France
| | - Christophe Girault
- Centre Hospitalier Universitaire de Rouen, 55052, Médecine Intensive Réanimation, Normandie University, UNIROUEN, EA 3830, Rouen, France
| | - Laurence Dangers
- Centre Hospitalier Universitaire Félix Guyon, 375276, Service de Réanimation Polyvalente, Saint-Denis, Réunion
| | - Alexandre Lautrette
- Centre Hospitalier Universitaire de Clermont-Ferrand, 55174, Hôpital Gabriel Montpied, Service de Réanimation Médicale, Clermont-Ferrand, France
| | - Quentin Levrat
- Centre hospitalier de la Rochelle, 26970, Service de Réanimation, La Rochelle, France
| | - Anahita Rouzé
- Centre Hospitalier Universitaire de Lille, 26902, Centre de Réanimation, Université de Lille, Lille, France
| | - Emmanuel Vivier
- Centre Hospitalier Saint Joseph Saint Luc, 149919, Rhône, Lyon, France
| | | | - Jean-Damien Ricard
- APHP, 26930, Hôpital Louis Mourier, DMU ESPRIT, Service de Médecine Intensive Réanimation,Université de Paris, INSERM, UMR IAME 1137 , Paris, France
| | - Armand Mekontso-Dessap
- APHP, 26930, Hôpitaux universitaires Henri Mondor, Service de Médecine Intensive Réanimation, Université Paris Est Créteil, Groupe de recherche clinique CARMAS, Paris, France
| | - Guillaume Barberet
- Groupe Hospitalier Régional Mulhouse Sud-Alsace, site Emile Muller, Service de Réanimation Médicale, Mulhouse, France
| | - Christine Lebert
- Centre Hospitalier Departemental Vendee, 37092, La Roche-sur-Yon, France
| | - Stephan Ehrmann
- Centre Hospitalier Régional Universitaire de Tours, 26928, Médecine Intensive Réanimation, CIC 1415, Réseau CRICS-Trigger SEP, Centre d'étude des pathologies respiratoires, INSERM U1100, Université de Tours, Tours, France
| | - Alexandre Massri
- Centre Hospitalier de Pau, 37101, Service de Réanimation, Pau, France
| | - Jeremy Bourenne
- APHM, 36900, Centre Hospitalier Universitaire La Timone 2, Médecine Intensive Réanimation, Réanimation des Urgences, Aix-Marseille Université, Marseille, France
| | - Gael Pradel
- Centre Hospitalier Henri Mondor d'Aurillac, 91532, Service de Réanimation, Aurillac, France
| | - Pierre Bailly
- Centre Hospitalier Universitaire de Brest, 26990, Médecine Intensive Réanimation, Brest, France
| | - Nicolas Terzi
- Centre Hospitalier Universitaire Grenoble Alpes, 36724, Médecine Intensive Réanimation, INSERM, Université Grenoble-Alpes, U1042, HP2, Grenoble, France
| | - Jean Dellamonica
- Centre Hospitalier Universitaire de Nice, 37045, Médecine Intensive Réanimation, Archet 1, Université Cote d'Azur, Nice, France
| | - Guillaume Lacave
- Centre Hospitalier de Versailles, 26938, Service de Réanimation Médico-Chirurgicale, Le Chesnay, France
| | - René Robert
- Centre Hospitalier Universitaire de Poitiers, 36655, Médecine Intensive Réanimation, Poitiers, France.,University of Poitiers, 27077, INSERM CIC 1402, ALIVE research group, Poitiers, France
| | - Jean-Pierre Frat
- Centre Hospitalier Universitaire de Poitiers, 36655, Médecine Intensive Réanimation, Poitiers, France.,University of Poitiers, 27077, INSERM CIC 1402, ALIVE research group, Poitiers, France
| | - Stéphanie Ragot
- University of Poitiers, 27077, INSERM CIC 1402, ALIVE research group, Poitiers, France
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Torrini F, Gendreau S, Morel J, Carteaux G, Thille AW, Antonelli M, Mekontso Dessap A. Prediction of extubation outcome in critically ill patients: a systematic review and meta-analysis. Crit Care 2021; 25:391. [PMID: 34782003 PMCID: PMC8591441 DOI: 10.1186/s13054-021-03802-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/24/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Extubation failure is an important issue in ventilated patients and its risk factors remain a matter of research. We conducted a systematic review and meta-analysis to explore factors associated with extubation failure in ventilated patients who passed a spontaneous breathing trial and underwent planned extubation. This systematic review was registered in PROPERO with the Registration ID CRD42019137003. METHODS We searched the PubMed, Web of Science and Cochrane Controlled Register of Trials for studies published from January 1998 to December 2018. We included observational studies involving risk factors associated with extubation failure in adult intensive care unit patients who underwent invasive mechanical ventilation. Two authors independently extracted data and assessed the validity of included studies. RESULTS Sixty-seven studies (involving 26,847 participants) met the inclusion criteria and were included in our meta-analysis. We analyzed 49 variables and, among them, we identified 26 factors significantly associated with extubation failure. Risk factors were distributed into three domains (comorbidities, acute disease severity and characteristics at time of extubation) involving mainly three functions (circulatory, respiratory and neurological). Among these, the physiological respiratory characteristics at time of extubation were the most represented. The individual topic of secretion management was the one with the largest number of variables. By Bayesian multivariable meta-analysis, twelve factors were significantly associated with extubation failure: age, history of cardiac disease, history of respiratory disease, Simplified Acute Physiologic Score II score, pneumonia, duration of mechanical ventilation, heart rate, Rapid Shallow Breathing Index, negative inspiratory force, lower PaO2/FiO2 ratio, lower hemoglobin level and lower Glasgow Coma Scale before extubation, with the latest factor having the strongest association with extubation outcome. CONCLUSIONS Numerous factors are associated with extubation failure in critically ill patients who have passed a spontaneous breathing trial. Robust multiparametric clinical scores and/or artificial intelligence algorithms should be tested based on the selected independent variables in order to improve the prediction of extubation outcome in the clinical scenario.
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Affiliation(s)
- Flavia Torrini
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, AP-HP, 1 rue Gustave Eiffel, 94010, Créteil Cedex, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
| | - Ségolène Gendreau
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, AP-HP, 1 rue Gustave Eiffel, 94010, Créteil Cedex, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
| | - Johanna Morel
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, AP-HP, 1 rue Gustave Eiffel, 94010, Créteil Cedex, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
| | - Guillaume Carteaux
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, AP-HP, 1 rue Gustave Eiffel, 94010, Créteil Cedex, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
- INSERM, IMRB, Univ Paris Est Créteil, 94010, Créteil, France
| | - Arnaud W Thille
- Centre d'Investigation Clinique 1402 ALIVE, Université de Poitiers, Poitiers, France
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | | | - Armand Mekontso Dessap
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, AP-HP, 1 rue Gustave Eiffel, 94010, Créteil Cedex, France.
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France.
- INSERM, IMRB, Univ Paris Est Créteil, 94010, Créteil, France.
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82
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Milne B. Role of Early Extubation After Orthotopic Liver Transplant. EXP CLIN TRANSPLANT 2021; 20:108-111. [PMID: 34775935 DOI: 10.6002/ect.2021.0281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Benjamin Milne
- From the Department of Anaesthesia, King's College Hospital, London, United Kingdom
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83
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Ultrasound Assessment in Cardiogenic Shock Weaning: A Review of the State of the Art. J Clin Med 2021; 10:jcm10215108. [PMID: 34768629 PMCID: PMC8585073 DOI: 10.3390/jcm10215108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/26/2021] [Accepted: 10/29/2021] [Indexed: 12/23/2022] Open
Abstract
Cardiogenic shock (CS) is associated with a high in-hospital mortality despite the achieved advances in diagnosis and management. Invasive mechanical ventilation and circulatory support constitute the highest step in cardiogenic shock therapy. Once established, taking the decision of weaning from such support is challenging. Intensive care unit (ICU) bedside echocardiography provides noninvasive, immediate, and low-cost monitoring of hemodynamic parameters such as cardiac output, filling pressure, structural disease, congestion status, and device functioning. Supplemented by an ultrasound of the lung and diaphragm, it is able to provide valuable information about signs suggesting a weaning failure. The aim of this article was to review the state of the art taking into account current evidence and knowledge on ICU bedside ultrasound for the evaluation of weaning from mechanical ventilation and circulatory support in cardiogenic shock.
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84
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Ju TR, Wang E, Castaneda C, Rathod A, Abe O. Superficial placement of endotracheal tubes associated with unplanned extubation: A case-control study. J Crit Care 2021; 67:39-43. [PMID: 34649093 DOI: 10.1016/j.jcrc.2021.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 08/01/2021] [Accepted: 09/24/2021] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Unplanned extubations (UEs) refer to the inadvertent removal of endotracheal tubes (ETTs). Superficially placed ETTs anecdotally increases the risk of UEs. This study aims to assess the impact of ETT position as well as other factors that could be associated with risk of UEs. METHOD A retrospective case-control study was conducted at NewYork-Presbyterian Queens Hospital from January 2017 to February 2020. All adults admitted to intensive care units (ICUs) who received mechanical ventilation (MV) through ETTs were screened to identify UEs. For each case with UE, two controls with planned extubation were identified. A multivariate logistic regression was conducted to identify risk factors associated with UEs. RESULTS 1100 patients received MV through ETTs during the time period. The incidence of UE was 4.9%. 53 patients with UEs and 106 patients with planned extubation were included for statistical analysis. Overall, patients with UE had higher in-hospital mortality rates (26.4% versus 11.3%, P = 0.02) and reintubation rates (28.3% versus 6.6%, P < 0.001). Within the UE group, patients who required reintubation had significantly higher in-hospital mortality rates than those who did not require reintubation (53.3% versus 15.8%, P = 0.005). Multivariate logistic regression showed higher APACHE II scores (Odds ratios (OR) 1.07; 95% Confidence interval (CI), 1 to 1.13), distance of ETT tips to carina ≥6 cm (OR 6.41; 95% CI, 1.1 to 37.3), physical restraint use (OR 2.98; 95% CI, 1.28 to 6.95) and continuous infusions of sedatives and/or analgesics (OR 10.72, 95% CI, 4.19 to 27.43) were associated with UE. CONCLUSION UE and the need for reintubation is associated with worse outcomes. Distance of ETT tips to carina ≥6 cm may be associated with higher risks of UE. Further prospective studies are needed to establish the optimal position of ETT to prevent UE.
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Affiliation(s)
- Teressa Reanne Ju
- Department of Medicine, NewYork-Presbyterian Queens Hospital, Flushing, NY, USA.
| | - Emily Wang
- Department of Medicine, NewYork-Presbyterian Queens Hospital, Flushing, NY, USA
| | - Christian Castaneda
- Department of Medicine, Division of Pulmonary and Critical Care, NewYork-Presbyterian Queens Hospital, Flushing, NY, USA
| | - Anisha Rathod
- Department of Respiratory Therapy, NewYork-Presbyterian Queens Hospital, Flushing, NY, USA
| | - Olumayowa Abe
- Department of Medicine, Division of Pulmonary and Critical Care, NewYork-Presbyterian Queens Hospital, Flushing, NY, USA; Weill Cornell Medical College, Cornell University, NY, New York, United States of America
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85
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Cottereau G, Messika J, Megarbane B, Guérin L, da Silva D, Bornstain C, Santos M, Ricard JD, Sztrymf B. Handgrip strength to predict extubation outcome: a prospective multicenter trial. Ann Intensive Care 2021; 11:144. [PMID: 34601639 PMCID: PMC8487340 DOI: 10.1186/s13613-021-00932-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 09/23/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND ICU-acquired weakness (ICUAW) has been shown to be associated with prolonged duration of mechanical ventilation and extubation failure. It is usually assessed through Medical Research Council (MRC) score, a time-consuming score performed by physiotherapists. Handgrip strength (HG) can be monitored very easily at the bedside. It has been shown to be a reproducible and reliable marker of global muscular strength in critical care patients. We sought to test if muscular weakness, as assessed by handgrip strength, was associated with extubation outcome. METHODS Prospective multicenter trial over an 18 months period in six mixed ICUs. Adults receiving mechanical ventilation for at least 48 h were eligible. Just before weaning trial, HG, Maximal Inspiratory Pressure (MIP), Peak Cough Expiratory Flow (PCEF) and Medical Research Council (MRC) score were registered. The attending physicians were unaware of the tests results and weaning procedures were conducted according to guidelines. Occurrence of unscheduled reintubation, non-invasive ventilation (NIV) or high-flow nasal continuous oxygen (HFNC) because of respiratory failure within 7 days after extubation defined extubation failure. The main outcome was the link between HG and extubation outcome. RESULTS 233 patients were included. Extubation failure occurred in 51 (22.5%) patients, 39 (17.2%) required reintubation. Handgrip strength was 12 [6-20] kg and 12 [8-20] kg, respectively, in extubation success and failure (p = 0.85). There was no association between extubation outcome and MRC score, MIP or PCEF. Handgrip strength was well correlated with MRC score (r = 0.718, p < 0.0001). ICU and hospital length of stay were significantly higher in the subset of patients harboring muscular weakness as defined by handgrip performed at the first weaning trial (respectively, 15 [10-25] days vs. 11 [7-17] days, p = 0.001 and 34 [19-66] days vs. 22 [15-43] days, p = 0.002). CONCLUSION No association was found between handgrip strength and extubation outcome. Whether this was explained by the appropriateness of the tool in this specific setting, or by the precise impact of ICUAW on extubation outcome deserves to be further evaluated. Trial registration Clinical Trials; NCT02946502, 10/27/2016, URL: https://clinicaltrials.gov/ct2/results?cond=&term=gripwean&cntry=&state=&city=&dist=.
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Affiliation(s)
- Guillaume Cottereau
- AP-HP, Service de Rééducation Fonctionnelle et Kinésithérapie, Hôpital Antoine Béclère, 92140, Clamart, France
| | - Jonathan Messika
- AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Service de Médecine Intensive Réanimation, Université de Paris, 92700, Colombes, France
- PHERE UMRS 1152, Université de Paris, 75018, Paris, France
| | - Bruno Megarbane
- Réanimation Médicale et Toxicologique, Fédération de toxicologie, Hôpital Lariboisière, Université Paris-Diderot, Inserm UMRS 1144, 2, rue Ambroise-Paré, 75010, Paris, France
| | - Laurent Guérin
- AP-HP, Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service de Réanimation Médicale, 78, Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
- Faculté de Médecine Paris-Sud, Univ Paris-Sud, Inserm UMR_S 999, 94270, Le Kremlin-Bicêtre, France
| | - Daniel da Silva
- Réanimation Polyvalente, Hôpital Delafontaine, 93200, Saint-Denis, France
| | - Caroline Bornstain
- Réanimation Polyvalente, Hôpital Intercommunal de Montfermeil, 93370, Montfermeil, France
| | - Matilde Santos
- AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Service de Médecine Intensive Réanimation, Université de Paris, 92700, Colombes, France
| | - Jean-Damien Ricard
- AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Service de Médecine Intensive Réanimation, Université de Paris, 92700, Colombes, France
- PHERE UMRS 1152, Université de Paris, 75018, Paris, France
| | - Benjamin Sztrymf
- AP-HP, Service de réanimation polyvalente et surveillance continue, Hôpital Antoine Béclère, 157 rue de la porte de Triveaux, 92140, Clamart, France.
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Stocker B, Byskosh A, Weiss H, Devin CL, Weingarten N, Masteller M, Johnston A, Posluszny J. A Multifaceted Extubation Protocol to Reduce Reintubation Rates in the Surgical ICU. Jt Comm J Qual Patient Saf 2021; 48:81-91. [PMID: 34756824 DOI: 10.1016/j.jcjq.2021.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 09/16/2021] [Accepted: 09/16/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Reintubation is associated with significant morbidity and mortality. The reintubation rate in surgical ICUs (SICUs) is ∼10% nationally but was 17.0% in our SICU. The objective of this study was to determine if the reintubation rate could be reduced with a protocol for extubation assessment and post-extubation care consisting of standardized extubation criteria and targeted interventions for patients at high risk for reintubation. METHODS Standardized extubation criteria for all SICU patients were identified via literature review and best-practice guidelines. High reintubation risk criteria were identified (age ≥ 65 years, chronic cardiopulmonary disease, ≥ 4 days intubated, emergency intubation, and fluid balance ≥ 5 liters) through a literature review and 13-month retrospective review of reintubations in our institution's SICU. Patients meeting at least one criterion putting them at higher risk for reintubation received interventions including post-extubation high-flow nasal cannula for 24 hours and algorithm-guided respiratory therapy. RESULTS During the 12-month period following protocol implementation, 36 of 402 extubations resulted in reintubations (9.0% vs. 17.0% preintervention, p < 0.001). Among all extubations, 305 (75.9%) were identified as high risk. Among reintubated patients, 34 (94.4%) met high-risk criteria. The mortality rate for reintubated patients was 40.0%, compared to 3.3% in those not reintubated (p < 0.001). The high-risk screening tool had a negative predictive value of 98%. CONCLUSION A multifaceted and pragmatic extubation and post-extubation care protocol significantly reduced one SICU's reintubation rate. This protocol can be easily implemented in any SICU to improve patient outcomes following extubation.
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87
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Tongyoo S, Tantibundit P, Daorattanachai K, Viarasilpa T, Permpikul C, Udompanturak S. High-flow nasal oxygen cannula vs. noninvasive mechanical ventilation to prevent reintubation in sepsis: a randomized controlled trial. Ann Intensive Care 2021; 11:135. [PMID: 34523035 PMCID: PMC8439370 DOI: 10.1186/s13613-021-00922-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/22/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND High-flow nasal oxygen cannula (HFNC) and noninvasive mechanical ventilation (NIV) can prevent reintubation in critically ill patients. However, their efficacy in post-extubated sepsis patients remains unclear. The objective of this study was to compare the efficacy of HFNC vs. NIV to prevent reintubation in post-extubated sepsis patients. METHODS We conducted a single-centre, prospective, open-labelled, randomised controlled trial at the medical intensive care unit of Siriraj Hospital, Mahidol University, Bangkok, Thailand. Sepsis patients who had been intubated, recovered, and passed the spontaneous breathing trial were enrolled and randomly assigned in a 1:1 ratio to receive either HFNC or NIV support immediately after extubation. The primary outcome was rate of reintubation at 72 h after extubation. RESULTS Between 1st October 2017 and 31st October 2019, 222 patients were enrolled and 112 were assigned to the HFNC group and 110 to the NIV group. Both groups were well matched in baseline characteristics. The median [IQR] age of the HFNC group was 66 [50-77] vs. 65.5 [54-77] years in the NIV group. The most common causes of intubation at admission were shock-related respiratory failure (57.1% vs. 55.5%) and acute hypoxic respiratory failure (34.8% vs. 40.9%) in the HFNC and NIV groups, respectively. The duration of mechanical ventilation before extubation was 5 [3-8] days in the HFNC group vs. 5 [3-9] days in the NIV group. There was no statistically significant difference in the primary outcome: 20/112 (17.9%) in the HFNC group required reintubation at 72 h compared to 20/110 (18.2%) in the NIV group [relative risk (RR) 0.99: 95% confidence interval (CI) (0.70-1.39); P = 0.95]. The 28-day mortality was not different: 8/112 (7.1%) with HFNC vs. 10/110 (9.1%) with NIV (RR 0.88: 95% CI (0.57-1.37); P = 0.59). CONCLUSIONS Among sepsis patients, there was no difference between HFNC and NIV in the prevention of reintubation at 72 h after extubation. Clinical Trial Registration ClinicalTrials.gov Identifier: NCT03246893; Registered 11 August 2017; https://clinicaltrials.gov/ct2/show/NCT03246893?term=surat+tongyoo&draw=2&rank=3.
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Affiliation(s)
- Surat Tongyoo
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, No. 2, Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand.
| | - Porntipa Tantibundit
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, No. 2, Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand.,Department of Emergency Medicine, Khon Kaen Hospital, Khon Kaen, Thailand
| | - Kiattichai Daorattanachai
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, No. 2, Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand.,Department of Emergency Medicine, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Tanuwong Viarasilpa
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, No. 2, Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Chairat Permpikul
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, No. 2, Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Suthipol Udompanturak
- Office of Research and Development, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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The authors reply. Crit Care Med 2021; 49:e557-e558. [PMID: 33653977 DOI: 10.1097/ccm.0000000000004960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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89
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Ravi C, Gang M, Sugalski G, Kenyon V, Nelson L. Extubating trauma patients in the emergency department. Am J Emerg Med 2021; 50:289-293. [PMID: 34419710 DOI: 10.1016/j.ajem.2021.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Trauma patients often require endotracheal intubation for urgent or emergent airway protection or to allow expeditious imaging when they cannot cooperate with the needed evaluation. These patients may occasionally be extubated in the emergency department (ED) when the trauma workup is negative for consequential injuries and eventually discharged from the ED. The timing and safety of discharging these patients is unclear. OBJECTIVE The objective of this study was to identify the adverse outcomes and evaluate the safety of extubating trauma patients who are clinically well following evaluation in the ED. METHODS Records of trauma patients who were intubated and then extubated in the ED at a single level 1 trauma referral center during the 4-year study period (Jan 2014 - Dec 2017) were retrospectively abstracted. The primary outcome was the incidence of a post-extubation complication, including desaturation, emesis, aspiration, need for sedative administration, or unplanned reintubation. Additional outcome measures included final disposition, duration of observation following extubation, ED length of stay and return to the hospital within 72 h. RESULTS There were 59 eligible patients identified over the study period, of whom 95% presented following blunt trauma. One patient (1.7%; 95% confidence interval 0-9) required unplanned reintubation and developed aspiration pneumonia following re-extubation. Forty-two (71%) of the patients were discharged from the ED following extubation and a period of post-extubation observation with a mean of 5.8 h (0.6-16.7 h). None of the patients who were discharged returned to the ED within 72 h with complications related to extubation (0%; 95% confidence interval 0-6%). CONCLUSIONS Patients presenting to the ED with possible acute traumatic injuries who are intubated and then extubated after trauma evaluation and resolution of the indication for intubation appear to have a low incidence of complication or return visit when discharged from the ED after a brief period of observation. Specific extubation and discharge criteria should be developed to ensure the safety of this practice. Further validation is required in the form of larger and prospective studies.
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Affiliation(s)
- Chandni Ravi
- Department of Emergency Medicine, Rutgers New Jersey Medical School, 185 South Orange Ave, MSB E609, Newark, NJ 07103,.
| | - Maureen Gang
- Department of Emergency Medicine, Rutgers New Jersey Medical School, 185 South Orange Ave, MSB E609, Newark, NJ 07103
| | - Gregory Sugalski
- Department of Emergency Medicine, Rutgers New Jersey Medical School, 185 South Orange Ave, MSB E609, Newark, NJ 07103
| | - Van Kenyon
- Department of Emergency Medicine, Rutgers New Jersey Medical School, 185 South Orange Ave, MSB E609, Newark, NJ 07103
| | - Lewis Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, 185 South Orange Ave, MSB E609, Newark, NJ 07103,.
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90
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Wang TH, Wu CP, Wang LY. Impact of peripheral muscle strength on prognosis after extubation and functional outcomes in critically ill patients: a feasibility study. Sci Rep 2021; 11:16082. [PMID: 34373543 PMCID: PMC8352971 DOI: 10.1038/s41598-021-95647-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/20/2021] [Indexed: 02/07/2023] Open
Abstract
The influence of peripheral muscle strength on prognosis after extubation and subsequent functional outcomes is not evident. The objectives of this study were to determine (1) whether peripheral muscle strength can be used as a predictor for patients' prognoses after extubation, and (2) whether the peripheral muscle strength before extubation is correlated with patients' subsequent ambulation ability and in-hospital mortality. This study was a prospective observational cohort study. A hand-held dynamometer was used for evaluated the muscle strength of the biceps and quadriceps right before extubation. Besides, after the patients had been transferred from the ICU to the general ward, a 2-minute walk test was performed. A total of 52 patients were enrolled in this study, and the rate of extubation failure was 15%. The muscle strength of the quadriceps was significantly correlated with the prognosis after extubation, 48% of the patients were able to ambulate after being transferred to the general ward. The overall mortality rate was 11%, and there was a significant correlation between the biceps muscle strength and in-hospital mortality. Peripheral muscle strength may serve as an important predictor of a patients' prognoses after extubation. Poor peripheral muscle strength is indicative of not only a higher risk of re-intubation but also higher in-hospital mortality and poorer functional outcomes.Trial registration: ISRCTN16370134. Registered 30 May 2019, prospectively registered. https://www.isrctn.com/ISRCTN16370134 .
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Affiliation(s)
- Tsung-Hsien Wang
- grid.19188.390000 0004 0546 0241School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan ,Departments of Critical Care Medicine, Landseed International Hospital, Taoyuan, Taiwan
| | - Chin-Pyng Wu
- Departments of Critical Care Medicine, Landseed International Hospital, Taoyuan, Taiwan
| | - Li-Ying Wang
- grid.19188.390000 0004 0546 0241School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan
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91
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Armañac-Julián P, Hernando D, Lázaro J, de Haro C, Magrans R, Morales J, Moeyersons J, Sarlabous L, López-Aguilar J, Subirà C, Fernández R, Orini M, Laguna P, Varon C, Gil E, Bailón R, Blanch L. Cardiopulmonary coupling indices to assess weaning readiness from mechanical ventilation. Sci Rep 2021; 11:16014. [PMID: 34362950 PMCID: PMC8346488 DOI: 10.1038/s41598-021-95282-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 07/20/2021] [Indexed: 02/07/2023] Open
Abstract
The ideal moment to withdraw respiratory supply of patients under Mechanical Ventilation at Intensive Care Units (ICU), is not easy to be determined for clinicians. Although the Spontaneous Breathing Trial (SBT) provides a measure of the patients' readiness, there is still around 15-20% of predictive failure rate. This work is a proof of concept focused on adding new value to the prediction of the weaning outcome. Heart Rate Variability (HRV) and Cardiopulmonary Coupling (CPC) methods are evaluated as new complementary estimates to assess weaning readiness. The CPC is related to how the mechanisms regulating respiration and cardiac pumping are working simultaneously, and it is defined from HRV in combination with respiratory information. Three different techniques are used to estimate the CPC, including Time-Frequency Coherence, Dynamic Mutual Information and Orthogonal Subspace Projections. The cohort study includes 22 patients in pressure support ventilation, ready to undergo the SBT, analysed in the 24 h previous to the SBT. Of these, 13 had a successful weaning and 9 failed the SBT or needed reintubation -being both considered as failed weaning. Results illustrate that traditional variables such as heart rate, respiratory frequency, and the parameters derived from HRV do not differ in patients with successful or failed weaning. Results revealed that HRV parameters can vary considerably depending on the time at which they are measured. This fact could be attributed to circadian rhythms, having a strong influence on HRV values. On the contrary, significant statistical differences are found in the proposed CPC parameters when comparing the values of the two groups, and throughout the whole recordings. In addition, differences are greater at night, probably because patients with failed weaning might be experiencing more respiratory episodes, e.g. apneas during the night, which is directly related to a reduced respiratory sinus arrhythmia. Therefore, results suggest that the traditional measures could be used in combination with the proposed CPC biomarkers to improve weaning readiness.
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Affiliation(s)
- Pablo Armañac-Julián
- Biomedical Signal Interpretation and Computational Simulation (BSICoS) group at the Aragón Institute of Engineering Research (I3A), IIS Aragón, University of Zaragoza, Zaragoza, Spain.
- CIBER de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Instituto de Salud Carlos III, Madrid, Spain.
| | - David Hernando
- Biomedical Signal Interpretation and Computational Simulation (BSICoS) group at the Aragón Institute of Engineering Research (I3A), IIS Aragón, University of Zaragoza, Zaragoza, Spain
- CIBER de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Instituto de Salud Carlos III, Madrid, Spain
| | - Jesús Lázaro
- Biomedical Signal Interpretation and Computational Simulation (BSICoS) group at the Aragón Institute of Engineering Research (I3A), IIS Aragón, University of Zaragoza, Zaragoza, Spain
- CIBER de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Instituto de Salud Carlos III, Madrid, Spain
| | - Candelaria de Haro
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació Parc Taulí I3PT, Universitat Autónoma de Barcelona, Sabadell, Spain
- CIBER de Enfermedades Respiratorias (CIBER-ES), Instituto de Salud Carlos III, Madrid, Spain
| | | | - John Morales
- Department of Electrical Engineering-ESAT, STADIUS Center for Dynamical Systems, Signal Processing and Data Analytics, KU Leuven, Leuven, Belgium
| | - Jonathan Moeyersons
- Department of Electrical Engineering-ESAT, STADIUS Center for Dynamical Systems, Signal Processing and Data Analytics, KU Leuven, Leuven, Belgium
| | - Leonardo Sarlabous
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació Parc Taulí I3PT, Universitat Autónoma de Barcelona, Sabadell, Spain
| | - Josefina López-Aguilar
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació Parc Taulí I3PT, Universitat Autónoma de Barcelona, Sabadell, Spain
- CIBER de Enfermedades Respiratorias (CIBER-ES), Instituto de Salud Carlos III, Madrid, Spain
| | - Carles Subirà
- Department of Intensive Care, Fundació Althaia, Universitat Internacional de Catalunya, Manresa, Spain
| | - Rafael Fernández
- CIBER de Enfermedades Respiratorias (CIBER-ES), Instituto de Salud Carlos III, Madrid, Spain
- Department of Intensive Care, Fundació Althaia, Universitat Internacional de Catalunya, Manresa, Spain
| | - Michele Orini
- Institute of Cardiovascular Science, University College London, London, UK
- Barts Heart Centre, St Bartholomews Hospital, University College London, London, UK
| | - Pablo Laguna
- Biomedical Signal Interpretation and Computational Simulation (BSICoS) group at the Aragón Institute of Engineering Research (I3A), IIS Aragón, University of Zaragoza, Zaragoza, Spain
- CIBER de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Instituto de Salud Carlos III, Madrid, Spain
| | - Carolina Varon
- Department of Electrical Engineering-ESAT, STADIUS Center for Dynamical Systems, Signal Processing and Data Analytics, KU Leuven, Leuven, Belgium
- Circuits and Systems (CAS) group, Delft University of Technology, Delft, The Netherlands
| | - Eduardo Gil
- Biomedical Signal Interpretation and Computational Simulation (BSICoS) group at the Aragón Institute of Engineering Research (I3A), IIS Aragón, University of Zaragoza, Zaragoza, Spain
- CIBER de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Instituto de Salud Carlos III, Madrid, Spain
| | - Raquel Bailón
- Biomedical Signal Interpretation and Computational Simulation (BSICoS) group at the Aragón Institute of Engineering Research (I3A), IIS Aragón, University of Zaragoza, Zaragoza, Spain
- CIBER de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Instituto de Salud Carlos III, Madrid, Spain
| | - Lluís Blanch
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació Parc Taulí I3PT, Universitat Autónoma de Barcelona, Sabadell, Spain
- CIBER de Enfermedades Respiratorias (CIBER-ES), Instituto de Salud Carlos III, Madrid, Spain
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92
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Casey JD, Vaughan EM, Lloyd BD, Billas PA, Jackson KE, Hall EJ, Toporek AH, Buell KG, Brown RM, Richardson RK, Rooks JC, Buie RB, Wang L, Lindsell CJ, Ely EW, Self WH, Bernard GR, Rice TW, Semler MW. Protocolized Postextubation Respiratory Support to Prevent Reintubation: A Randomized Clinical Trial. Am J Respir Crit Care Med 2021; 204:294-302. [PMID: 33794131 DOI: 10.1164/rccm.202009-3561oc] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Respiratory support (noninvasive ventilation or high-flow nasal cannula) applied at the time of extubation has been reported to reduce reintubation rates, but concerns regarding effectiveness have limited uptake into practice.Objectives: To determine if providing postextubation respiratory support to all patients undergoing extubation in a medical ICU would decrease the incidence of reintubation.Methods: We conducted a pragmatic, two-armed, cluster-crossover trial of adults undergoing extubation from invasive mechanical ventilation between October 1, 2017, and March 31, 2019, in the medical ICU of an academic medical center. Patients were assigned to either protocolized postextubation respiratory support (a respiratory therapist-driven protocol in which patients with suspected hypercapnia received noninvasive ventilation and patients without suspected hypercapnia received high-flow nasal cannula) or usual care (postextubation management at the discretion of treating clinicians). The primary outcome was reintubation within 96 hours of extubation.Measurements and Main Results: A total of 751 patients were enrolled. Of the 359 patients assigned to protocolized support, 331 (92.2%) received postextubation respiratory support compared with 66 of 392 patients (16.8%) assigned to usual care, a difference driven by differential use of high-flow nasal cannula (74.7% vs. 2.8%). A total of 57 patients (15.9%) in the protocolized support group experienced reintubation compared with 52 patients (13.3%) in the usual care group (odds ratio, 1.23; 95% confidence interval, 0.82 to 1.84; P = 0.32).Conclusions: Among a broad population of critically ill adults undergoing extubation from invasive mechanical ventilation at an academic medical center, protocolized postextubation respiratory support, primarily characterized by an increase in the use of high-flow nasal cannula, did not prevent reintubation compared with usual care.Clinical trial registered with www.clinicaltrials.gov (NCT0328831).
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Affiliation(s)
| | - Erin M Vaughan
- Division of Allergy, Pulmonary, and Critical Care Medicine
| | | | - Peter A Billas
- Department of Anesthesiology, University of Florida, Gainesville, Florida
| | | | | | | | | | - Ryan M Brown
- Division of Allergy, Pulmonary, and Critical Care Medicine
| | | | | | - Reagan B Buie
- Vanderbilt Institute for Clinical and Translational Research
| | | | | | - E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine.,Critical Illness, Brain Dysfunction, and Survivorship Center.,Tennessee Valley Veterans Affairs Geriatric Research Education Clinical Center, and
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | | | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine
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93
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Weber Y, Epstein D, Miller A, Segal G, Berger G. Association of Low Alanine Aminotransferase Values with Extubation Failure in Adult Critically Ill Patients: A Retrospective Cohort Study. J Clin Med 2021; 10:jcm10153282. [PMID: 34362065 PMCID: PMC8348471 DOI: 10.3390/jcm10153282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 07/21/2021] [Accepted: 07/23/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Liberation from mechanical ventilation is a cardinal landmark during hospitalization of ventilated patients. Decreased muscle mass and sarcopenia are associated with a high risk of extubation failure. A low level of alanine aminotransferase (ALT) is a known biomarker of sarcopenia. This study aimed to determine whether low levels of ALT are associated with increased risk of extubation failure among critically ill patients. Methods: This was a retrospective single-center cohort study of mechanically ventilated patients undergoing their first extubation. The study’s outcome was extubation failure within 48 h and 7 days. Multivariable logistic and Cox regression were performed to determine whether ALT was an independent predictor of these outcomes. Results: The study included 329 patients with a median age of 62.4 years (IQR 48.1–71.2); 210 (63.8%) patients were at high risk for extubation failure. 66 (20.1%) and 83 (25.2%) failed the extubation attempt after 48 h and 7 days, respectively. Low ALT values were more common among patients requiring reintubation (80.3–61.5% vs. 58.6–58.9%, p < 0.002). Multivariable logistic regression analysis identified ALT as an independent predictor of extubation failure at 48 h and 7 days. ALT ≤ 21 IU/L had an adjusted hazard ratio (HR) of 2.41 (95% CI 1.31–4.42, p < 0.001) for extubation failure at 48 h and ALT ≤ 16 IU/L had adjusted HR of 1.94 (95% CI 1.25–3.02, p < 0.001) for failure after 7 days. Conclusions: Low ALT, an established biomarker of sarcopenia and frailty, is an independent risk factor for extubation failure among hospitalized patients. This simple laboratory parameter can be used as an effective adjunct predictor, along with other weaning parameters, and thereby facilitate the identification of high-risk patients.
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Affiliation(s)
- Yoav Weber
- Department of Internal Medicine “B”, Rambam Health Care Campus, Haifa 3109601, Israel; (D.E.); (G.B.)
- Correspondence: ; Tel.: +972-054-9249749
| | - Danny Epstein
- Department of Internal Medicine “B”, Rambam Health Care Campus, Haifa 3109601, Israel; (D.E.); (G.B.)
- Critical Care Division, Rambam Health Care Campus, Haifa 3109601, Israel
| | - Asaf Miller
- Medical Intensive Care Unit, Rambam Health Care Campus, Haifa 3109601, Israel;
| | - Gad Segal
- Department of Internal Medicine “T”, Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan 6971039, Israel;
- Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv 6997801, Israel
| | - Gidon Berger
- Department of Internal Medicine “B”, Rambam Health Care Campus, Haifa 3109601, Israel; (D.E.); (G.B.)
- Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3109601, Israel
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94
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Raventós AA, Serpa Neto A. Biomarkers to Guide Ventilation Management and Readiness for Extubation. Am J Respir Crit Care Med 2021; 203:1211-1212. [PMID: 33503397 PMCID: PMC8456467 DOI: 10.1164/rccm.202101-0093ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre Monash University Melbourne, Victoria, Australia.,Data Analytics Research and Evaluation Centre Austin Hospital Heidelberg, Victoria, Australia.,Department of Critical Care University of Melbourne Heidelberg, Victoria, Australia and.,Department of Critical Care Medicine Hospital Israelita Albert Einstein São Paulo, Brazil
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95
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Baldomero AK, Melzer AC, Greer N, Majeski BN, MacDonald R, Linskens EJ, Wilt TJ. Effectiveness and Harms of High-Flow Nasal Oxygen for Acute Respiratory Failure: An Evidence Report for a Clinical Guideline From the American College of Physicians. Ann Intern Med 2021; 174:952-966. [PMID: 33900793 PMCID: PMC8292205 DOI: 10.7326/m20-4675] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Use of high-flow nasal oxygen (HFNO) for treatment of adults with acute respiratory failure (ARF) has increased. PURPOSE To assess HFNO versus noninvasive ventilation (NIV) or conventional oxygen therapy (COT) for ARF in hospitalized adults. DATA SOURCES English-language searches of MEDLINE, Embase, CINAHL, and Cochrane Library from January 2000 to July 2020; systematic review reference lists. STUDY SELECTION 29 randomized controlled trials evaluated HFNO versus NIV (k = 11) or COT (k = 21). DATA EXTRACTION Data extraction by a single investigator was verified by a second, 2 investigators assessed risk of bias, and evidence certainty was determined by consensus. DATA SYNTHESIS Results are reported separately for HFNO versus NIV, for HFNO versus COT, and by initial or postextubation management. Compared with NIV, HFNO may reduce all-cause mortality, intubation, and hospital-acquired pneumonia and improve patient comfort in initial ARF management (low-certainty evidence) but not in postextubation management. Compared with COT, HFNO may reduce reintubation and improve patient comfort in postextubation ARF management (low-certainty evidence). LIMITATIONS Trials varied in populations enrolled, ARF causes, and treatment protocols. Trial design, sample size, duration of treatment and follow-up, and results reporting were often insufficient to adequately assess many outcomes. Protocols, clinician and health system training, cost, and resource use were poorly characterized. CONCLUSION Compared with NIV, HFNO as initial ARF management may improve several clinical outcomes. Compared with COT, HFNO as postextubation management may reduce reintubations and improve patient comfort; HFNO resulted in fewer harms than NIV or COT. Broad applicability, including required clinician and health system experience and resource use, is not well known. PRIMARY FUNDING SOURCE American College of Physicians. (PROSPERO: CRD42019146691).
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Affiliation(s)
- Arianne K Baldomero
- Minneapolis Veterans Affairs Health Care System and University of Minnesota, Minneapolis, Minnesota (A.K.B., A.C.M.)
| | - Anne C Melzer
- Minneapolis Veterans Affairs Health Care System and University of Minnesota, Minneapolis, Minnesota (A.K.B., A.C.M.)
| | - Nancy Greer
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota (N.G., B.N.M., R.M., E.J.L.)
| | - Brittany N Majeski
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota (N.G., B.N.M., R.M., E.J.L.)
| | - Roderick MacDonald
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota (N.G., B.N.M., R.M., E.J.L.)
| | - Eric J Linskens
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota (N.G., B.N.M., R.M., E.J.L.)
| | - Timothy J Wilt
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, and University of Minnesota, Minneapolis, Minnesota (T.J.W.)
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96
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Ferreira NDA, Ferreira ADS, Guimarães FS. Cough peak flow to predict extubation outcome: a systematic review and meta-analysis. Rev Bras Ter Intensiva 2021; 33:445-456. [PMID: 35107557 PMCID: PMC8555400 DOI: 10.5935/0103-507x.20210060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 01/20/2021] [Indexed: 11/23/2022] Open
Abstract
Objetivo Avaliar a utilidade do pico de fluxo da tosse para predizer o desfecho da
extubação em pacientes que obtiveram sucesso no teste de
respiração espontânea. Métodos A busca cobriu as bases de dados científicos MEDLINE®,
Lilacs, Ibecs, Cinahl, SciELO, Cochrane, Scopus, Web of Science e literatura
cinzenta. Utilizaram-se os critérios Quality Assessment of Diagnostic
Accuracy Studies para avaliar a qualidade da metodologia e o risco de
viés dos estudos. A heterogeneidade estatística da
razão de verossimilhança (LR) e razão de chance
diagnóstica (RCD) do diagnóstico foram avaliadas com
utilização de gráficos em floresta, teste Q de Cochran
e um gráfico crosshair summary Receiver Operating Characteristic,
utilizando um modelo com múltiplos pontos de corte. Resultados Inicialmente obteve-se, nas bases de dados, um total de 3.522
referências; dentre estas, selecionaram-se para análise
qualitativa 12 estudos que incluíram 1.757 participantes. Muitos
estudos apresentavam um risco de viés incerto em termos da
seleção de pacientes e do fluxo e tempo. Dentre os 12 estudos
incluídos, sete tinham alto risco e cinco risco incerto para o item
padrão de referência. O desempenho diagnóstico do pico
de fluxo da tosse para o resultado da extubação foi baixo a
moderado quando se consideram os resultados de todos os estudos
incluídos, com +LR de 1,360 (IC95% 1,240 - 1,530), -LR de 0,218
(IC95% 0,159 - 0,293) e razão de chance diagnóstica de 6,450
(IC95% 4,490 - 9,090). Uma análise de subgrupos que incluiu somente
estudos com valores de corte entre 55 e 65 L/minuto demonstrou desempenho
ligeiramente melhor, porém ainda moderado. Conclusão A avaliação do pico de fluxo da tosse, considerando valor de
corte entre 55 e 65 L/minuto, pode ser útil como medida complementar
antes da extubação. São necessários estudos com
melhor delineamento para elucidar o melhor método e equipamento para
registrar o pico de fluxo da tosse, assim como o melhor ponto de corte.
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Affiliation(s)
- Natália de Araújo Ferreira
- Programa de Pós-Graduação em Ciências da Reabilitação, Centro Universitário Augusto Motta - Rio de Janeiro (RJ), Brasil
| | - Arthur de Sá Ferreira
- Programa de Pós-Graduação em Ciências da Reabilitação, Centro Universitário Augusto Motta - Rio de Janeiro (RJ), Brasil
| | - Fernando Silva Guimarães
- Departamento de Fisioterapia Cardiorrespiratória e Musculoesquelética, Faculdade de Fisioterapia, Universidade Federal do Rio de Janeiro - Rio de Janeiro (RJ), Brasil
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97
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Gupta D, Greenberg RG, Natarajan G, Jani S, Sharma A, Cotten M, Thomas R, Chawla S. Respiratory setback associated with extubation failure in extremely preterm infants. Pediatr Pulmonol 2021; 56:2081-2086. [PMID: 33819392 DOI: 10.1002/ppul.25387] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 03/07/2021] [Accepted: 03/10/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND AND OBJECTIVES Extubation failure in preterm infants is associated with an increased risk of mortality and morbidity. There is limited evidence to suggest if the increased morbidities are due to inherent differences among infants who fail or succeed; or whether these are due to a true respiratory setback among those who fail extubation. The aim of this study was to evaluate the respiratory status of infants who fail extubation and to assess the time taken for these infants to achieve pre-extubation respiratory status. METHODS This was a retrospective study of infants with birth weight ≤ 1250 g who were born between January 2009 and December 2016. Infants were eligible if they failed first elective extubation. Extubation failure was defined as need for re-intubation within 5 days of extubation. Ventilator settings, blood gas parameters, respiratory severity score (RSS), and ventilation index (VI) were used to assess the respiratory status of infants. RESULTS Out of 384 infants, 76% were successful and 24% failed extubation. Among those who failed extubation 91%, 77%, and 56% infants remained intubated at 24 h, 72 h, and 7 days, respectively. Respiratory status was worse at 24 and 72 h after re-intubation when compared to pre-extubation levels. The median times for RSS and VI to reach pre-extubation levels were 4 and 7 days, respectively. CONCLUSION Among preterm infants, failed elective extubation is associated with a significant setback in the respiratory status. Infants who fail an extubation attempt may not achieve pre-extubation respiratory status for many days after reintubation.
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Affiliation(s)
- Dhruv Gupta
- Department of Pediatrics, Wayne State University, Detroit, Michigan, USA
| | | | - Girija Natarajan
- Department of Pediatrics, Central Michigan University, Detroit, Michigan, USA
| | - Sanket Jani
- Department of Pediatrics, Central Michigan University, Detroit, Michigan, USA
| | - Amit Sharma
- Department of Pediatrics, Wayne State University, Detroit, Michigan, USA
| | - Michael Cotten
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - Ronald Thomas
- Department of Pediatrics, Central Michigan University, Detroit, Michigan, USA
| | - Sanjay Chawla
- Department of Pediatrics, Central Michigan University, Detroit, Michigan, USA
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Discordances Between Factors Associated With Withholding Extubation and Extubation Failure After a Successful Spontaneous Breathing Trial. Crit Care Med 2021; 49:2080-2089. [PMID: 34259451 DOI: 10.1097/ccm.0000000000005107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To identify whether factors associated with withholding extubation in the ICU also predict the risk of extubation failure. DESIGN Retrospective cohort study. SETTING Eight medical-surgical ICUs in Toronto. PATIENTS Adult patients receiving invasive mechanical ventilation, with a first successful spontaneous breathing trial within 28 days of initial ICU admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary end point had three mutually exclusive levels, including: 1) withholding extubation after a successful spontaneous breathing trial, 2) extubation failure within 48 hours, and 3) successful extubation. Among 9,910 patients, 38% of patients were not extubated within 24 hours of their first successful spontaneous breathing trial. A total of 12.9% of patients who were promptly extubated failed within the next 48 hours. Several discrepancies were evident in the association of factors with risk of withholding extubation and extubation failure. Specifically, both age and female sex were associated with withholding extubation (odds ratio, 1.07; 95% CI, 1.03-1.11; and odds ratio, 1.13; 95% CI, 1.02-1.26, respectively) but not a higher risk of failed extubation (odds ratio, 0.99; 95% CI, 0.93-1.05; and odds ratio, 0.93; 95% CI, 0.77-1.11, respectively). Conversely, both acute cardiovascular conditions and intubation for hypoxemic respiratory failure were associated with a higher risk of failed extubation (odds ratio, 1.32; 95% CI, 1.06-1.66; and odds ratio, 1.46; 95% CI, 1.16-1.82, respectively) but not a higher odds of a withheld extubation attempt (odds ratio, 0.79; 95% CI, 0.68-0.91; and odds ratio, 1.07; 95% CI, 0.93-1.23, respectively). CONCLUSIONS Several factors showed discordance between the decision to withhold extubation and the risk of extubation failure. This discordance may lead to longer duration of mechanical ventilation or higher reintubation rates. Improving the decision-making behind extubation may help to reduce both exposure to invasive mechanical ventilation and extubation failure.
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Thille AW, Wairy M, Pape SL, Frat JP. Oxygenation strategies after extubation of critically ill and postoperative patients. JOURNAL OF INTENSIVE MEDICINE 2021; 1:65-70. [PMID: 36788799 PMCID: PMC9923965 DOI: 10.1016/j.jointm.2021.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/10/2021] [Accepted: 05/17/2021] [Indexed: 10/21/2022]
Abstract
In intensive care units (ICUs), the decision to extubate is a critical one because mortality is particularly high in case of reintubation. Around 15% of patients ready to be weaned off a ventilator experience extubation failure leading to reintubation. The use of high-flow nasal oxygen and non-invasive ventilation are two alternatives of standard oxygen supplementation that may help to prevent reintubation. High-flow nasal oxygen and non-invasive ventilation, may be used to prevent reintubation in patients with low (e.g., patients without comorbidities and with short durations of mechanical ventilation) and high risk (e.g., patients >65 years and those with underlying cardiac disease, chronic respiratory disorders, and/or hypercapnia at the time of extubation) of reintubation, respectively. However, non-invasive ventilation used as a rescue therapy to treat established post-extubation respiratory failure could increase mortality by delaying reintubation, and should therefore be used very carefully in this setting. The oxygenation strategy to be applied in postoperative patients is different from the patients who are extubated in the ICUs. Standard oxygen after a surgical procedure is adequate, even following major abdominal or cardiothoracic surgery, but should probably be switched to high-flow nasal oxygen in patients with hypoxemic. Unlike in patients experiencing post-extubation respiratory failure in ICUs wherein non-invasive ventilation may have deleterious effects, it may actually improve the outcomes in postoperative patients with respiratory failure. This review discusses the different clinical situations with the aim of choosing the most effective oxygenation strategy to prevent post-extubation respiratory failure and to avoid reintubation.
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Affiliation(s)
- Arnaud W. Thille
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers 86021, France,ALIVE Research group, INSERM CIC 1402, University of Poitiers, Poitiers 86021, France,Corresponding author: Arnaud W. Thille, Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, 2 rue la Milétrie, Poitiers Cedex 86021, France.
| | - Mathilde Wairy
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers 86021, France,ALIVE Research group, INSERM CIC 1402, University of Poitiers, Poitiers 86021, France
| | - Sylvain Le Pape
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers 86021, France,ALIVE Research group, INSERM CIC 1402, University of Poitiers, Poitiers 86021, France
| | - Jean-Pierre Frat
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers 86021, France,ALIVE Research group, INSERM CIC 1402, University of Poitiers, Poitiers 86021, France
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Association of baseline diaphragm, rectus femoris and vastus intermedius muscle thickness with weaning from mechanical ventilation. Respir Med 2021; 185:106503. [PMID: 34166958 DOI: 10.1016/j.rmed.2021.106503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 05/27/2021] [Accepted: 06/03/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND To determine whether baseline diaphragm (Tdi), rectus femoris (RF) and vastus intermedius (VI) muscle thickness (TRF and TRF + VI) are associated with weaning success. MATERIAL AND METHODS Right Tdi, TRF and TRF + VI were measured by ultrasonography within 36 h of intubation and diaphragmatic excursion (DE) was evaluated at the first spontaneous breathing trial in adult critically-ill patients. Reintubation or death within 7 days after extubation was defined as weaning failure. Weaning failure and success groups were compared in terms of ultrasonographic measurements and clinical features. RESULTS Thirty-eight patients were assessed for weaning, 15 (39.4%) being in the weaning failure group. The median body mass index (BMI) was lower while the median clinical frailty scale (CFS), vasopressor use, duration of mechanical ventilation, intensive care and hospital mortality rate were higher in the weaning failure group, and the median TRF + VI (14.0 [12.3-26.2] vs 23.6 [21.3-27.1] mm, p = 0.03) and median DE (19.4 [14.6-24.0] vs 25.9 [19.3-38.5] mm, p = 0.045) were lower. The median Tdi was similar in two groups (1.9 [1.5-2.3] vs 2.0 [1.7-2.4] mm, p = 0.26). In ROC analysis, area under the curve for TRF + VI was 0.71 (95% CI: 0.51-0.90; p = 0.035), with 21 mm cut-off having sensitivity of 82% and specificity of 57%. Binary logistic regression analysis revealed TRF + VI < 21 mm as the only predictor of weaning failure with an odds ratio of 10.5 (95% CI: 1.1-97.8, p = 0.038) after adjusting for age, sex, BMI and CFS. CONCLUSIONS TRF + VI lower than 21 mm, measured by ultrasonography within 36 h of intubation, was associated with weaning failure among critically-ill patients.
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