151
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Vivier E, Muller M, Thille AW. Response. Chest 2019; 156:1268-1269. [DOI: 10.1016/j.chest.2019.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 07/18/2019] [Indexed: 10/25/2022] Open
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152
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Navalesi P, Bruni A, Garofalo E, Biamonte E, Longhini F, Frigerio P. Weaning off mechanical ventilation: much less an art, but not yet a science. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S353. [PMID: 32016071 DOI: 10.21037/atm.2019.09.83] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Paolo Navalesi
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy.,Unit of Anesthesia and Intensive Care, University Hospital Mater Domini, Catanzaro, Italy
| | - Andrea Bruni
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy.,Unit of Anesthesia and Intensive Care, University Hospital Mater Domini, Catanzaro, Italy
| | - Eugenio Garofalo
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy.,Unit of Anesthesia and Intensive Care, University Hospital Mater Domini, Catanzaro, Italy
| | - Eugenio Biamonte
- Unit of Anesthesia and Intensive Care, University Hospital Mater Domini, Catanzaro, Italy
| | - Federico Longhini
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy.,Unit of Anesthesia and Intensive Care, University Hospital Mater Domini, Catanzaro, Italy
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153
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Evaluation of diaphragm ultrasound in predicting extubation outcome in mechanically ventilated patients with COPD. Ir J Med Sci 2019; 189:661-668. [PMID: 31691888 PMCID: PMC7223179 DOI: 10.1007/s11845-019-02117-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/09/2019] [Indexed: 12/17/2022]
Abstract
Background To explore the value of the right hemi-diaphragmatic excursion (DE) and its variation in predicting extubation outcome in mechanically ventilated patients with COPD. Methods All included patients with COPD received mechanical ventilation (MV) and were ready to wean from MV. After patients passed the 30 min spontaneous breathing trail (SBT), extubation was considered to be feasible, and the right DE measured by ultrasound at 0 min, 5 min, and 30 min of SBT were named as DE0, DE5, and DE30, respectively. Results Twenty-five patients succeeded extubation; 12 patients failed. The area under receiver operator characteristic curve (AUCROC) of DE30 and ΔDE30−5 (the variation between 30 and 5 min) were 0.762 and 0.835; a cutoff value of DE30 > 1.72 cm and ΔDE30−5 > 0.16 cm were associated with a successful extubation with a sensitivity of 76% and 84%, a specificity of 75% and 83.3%, respectively. The predictive probability equation of the DE30 plus ∆DE30−5 was P = 1/[1 + e−(−5.625+17.689×∆DE30−5+1.802×DE30)], a cutoff value of P > 0.626 was associated with a successful extubation with the AUCROC of 0.867, a sensitivity of 92%, and a specificity of 83.3%. Conclusion The combination of DE30 and ∆DE30−5 could improve the predictive value and could be used as the predictor of extubation outcome in mechanically ventilated patients with COPD.
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154
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Tsai TL, Huang MH, Lee CY, Lai WW. Data Science for Extubation Prediction and Value of Information in Surgical Intensive Care Unit. J Clin Med 2019; 8:E1709. [PMID: 31627316 PMCID: PMC6833107 DOI: 10.3390/jcm8101709] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/03/2019] [Accepted: 10/14/2019] [Indexed: 12/05/2022] Open
Abstract
Besides the traditional indices such as biochemistry, arterial blood gas, rapid shallow breathing index (RSBI), acute physiology and chronic health evaluation (APACHE) II score, this study suggests a data science framework for extubation prediction in the surgical intensive care unit (SICU) and investigates the value of the information our prediction model provides. A data science framework including variable selection (e.g., multivariate adaptive regression splines, stepwise logistic regression and random forest), prediction models (e.g., support vector machine, boosting logistic regression and backpropagation neural network (BPN)) and decision analysis (e.g., Bayesian method) is proposed to identify the important variables and support the extubation decision. An empirical study of a leading hospital in Taiwan in 2015-2016 is conducted to validate the proposed framework. The results show that APACHE II and white blood cells (WBC) are the two most critical variables, and then the priority sequence is eye opening, heart rate, glucose, sodium and hematocrit. BPN with selected variables shows better prediction performance (sensitivity: 0.830; specificity: 0.890; accuracy 0.860) than that with APACHE II or RSBI. The value of information is further investigated and shows that the expected value of experimentation (EVE), 0.652 days (patient staying in the ICU), is saved when comparing with current clinical experience. Furthermore, the maximal value of information occurs in a failure rate around 7.1% and it reveals the "best applicable condition" of the proposed prediction model. The results validate the decision quality and useful information provided by our predicted model.
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Affiliation(s)
- Tsung-Lun Tsai
- Institute of Manufacturing Information and Systems, National Cheng Kung University, Tainan 701, Taiwan.
| | - Min-Hsin Huang
- Department of Surgery, National Cheng Kung University Hospital, Tainan 701, Taiwan.
| | - Chia-Yen Lee
- Institute of Manufacturing Information and Systems, National Cheng Kung University, Tainan 701, Taiwan.
| | - Wu-Wei Lai
- Department of Surgery, National Cheng Kung University Hospital, Tainan 701, Taiwan.
- College of Medicine, National Cheng Kung University, Tainan 701, Taiwan.
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155
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Telias I, Ferguson ND. Added Benefit of Noninvasive Ventilation to High-Flow Nasal Oxygen to Prevent Reintubation in Higher-Risk Patients. JAMA 2019; 322:1455-1457. [PMID: 31577031 DOI: 10.1001/jama.2019.14609] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Irene Telias
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network, Sinai Health System, Toronto, Ontario, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network, Sinai Health System, Toronto, Ontario, Canada
- Departments of Medicine and Physiology, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
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156
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Thille AW, Muller G, Gacouin A, Coudroy R, Decavèle M, Sonneville R, Beloncle F, Girault C, Dangers L, Lautrette A, Cabasson S, Rouzé A, Vivier E, Le Meur A, Ricard JD, Razazi K, Barberet G, Lebert C, Ehrmann S, Sabatier C, Bourenne J, Pradel G, Bailly P, Terzi N, Dellamonica J, Lacave G, Danin PÉ, Nanadoumgar H, Gibelin A, Zanre L, Deye N, Demoule A, Maamar A, Nay MA, Robert R, Ragot S, Frat JP. Effect of Postextubation High-Flow Nasal Oxygen With Noninvasive Ventilation vs High-Flow Nasal Oxygen Alone on Reintubation Among Patients at High Risk of Extubation Failure: A Randomized Clinical Trial. JAMA 2019; 322:1465-1475. [PMID: 31577036 PMCID: PMC6802261 DOI: 10.1001/jama.2019.14901] [Citation(s) in RCA: 157] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
IMPORTANCE High-flow nasal oxygen may prevent postextubation respiratory failure in the intensive care unit (ICU). The combination of high-flow nasal oxygen with noninvasive ventilation (NIV) may be an optimal strategy of ventilation to avoid reintubation. OBJECTIVE To determine whether high-flow nasal oxygen with prophylactic NIV applied immediately after extubation could reduce the rate of reintubation, compared with high-flow nasal oxygen alone, in patients at high risk of extubation failure in the ICU. DESIGN, SETTING, AND PARTICIPANTS Multicenter randomized clinical trial conducted from April 2017 to January 2018 among 641 patients at high risk of extubation failure (ie, older than 65 years or with an underlying cardiac or respiratory disease) at 30 ICUs in France; follow-up was until April 2018. INTERVENTIONS Patients were randomly assigned to high-flow nasal oxygen alone (n = 306) or high-flow nasal oxygen alternating with NIV (n = 342) immediately after extubation. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of patients reintubated at day 7; secondary outcomes included postextubation respiratory failure at day 7, reintubation rates up until ICU discharge, and ICU mortality. RESULTS Among 648 patients who were randomized (mean [SD] age, 70 [10] years; 219 women [34%]), 641 patients completed the trial. The reintubation rate at day 7 was 11.8% (95% CI, 8.4%-15.2%) (40/339) with high-flow nasal oxygen and NIV and 18.2% (95% CI, 13.9%-22.6%) (55/302) with high-flow nasal oxygen alone (difference, -6.4% [95% CI, -12.0% to -0.9%]; P = .02). Among the 11 prespecified secondary outcomes, 6 showed no significant difference. The proportion of patients with postextubation respiratory failure at day 7 (21% vs 29%; difference, -8.7% [95% CI, -15.2% to -1.8%]; P = .01) and reintubation rates up until ICU discharge (12% vs 20%, difference -7.4% [95% CI, -13.2% to -1.8%]; P = .009) were significantly lower with high-flow nasal oxygen and NIV than with high-flow nasal oxygen alone. ICU mortality rates were not significantly different: 6% with high-flow nasal oxygen and NIV and 9% with high-flow nasal oxygen alone (difference, -2.4% [95% CI, -6.7% to 1.7%]; P = .25). CONCLUSIONS AND RELEVANCE In mechanically ventilated patients at high risk of extubation failure, the use of high-flow nasal oxygen with NIV immediately after extubation significantly decreased the risk of reintubation compared with high-flow nasal oxygen alone. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03121482.
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Affiliation(s)
- 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
| | - Grégoire Muller
- Groupe Hospitalier Régional d’Orléans, Médecine Intensive Réanimation, Orléans, France
| | - Arnaud Gacouin
- Centre Hospitalier Universitaire de Rennes, Hôpital Ponchaillou, Service des Maladies Infectieuses et Réanimation Médicale, Rennes, France
| | - Rémi Coudroy
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers, France
- INSERM Centre d’Investigation Clinique 1402 ALIVE, Université de Poitiers, Poitiers, France
| | - Maxens Decavèle
- Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), AP-HP, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Paris, France
| | - Romain Sonneville
- Hôpital Bichat–Claude Bernard, Médecine Intensive Réanimation, AP-HP, Université Paris Diderot, Paris, France
| | - François Beloncle
- Centre Hospitalier Universitaire d’Angers, Département de Médecine Intensive Réanimation, Université d’Angers, Angers, France
| | - Christophe Girault
- Centre Hospitalier Universitaire de Rouen, Hôpital Charles Nicolle, Département de Réanimation Médicale, Normandie Université, UNIROUEN, EA3830-GRHV, Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France
| | - Laurence Dangers
- Centre Hospitalier Universitaire Félix Guyon, Service de Réanimation Polyvalente, Saint Denis de la Réunion, France
| | - Alexandre Lautrette
- Centre Hospitalier Universitaire de Clermont-Ferrand, Hôpital Gabriel Montpied, Service de Réanimation Médicale, Clermont-Ferrand, France
| | - Séverin Cabasson
- Centre Hospitalier de La Rochelle, Service de Réanimation, La Rochelle, France
| | - Anahita Rouzé
- Centre Hospitalier Universitaire de Lille, Centre de Réanimation, Université de Lille, Lille, France
| | - Emmanuel Vivier
- Hôpital Saint-Joseph Saint-Luc, Réanimation Polyvalente, Lyon, France
| | - Anthony Le Meur
- Centre Hospitalier Universitaire de Nantes, Médecine Intensive Réanimation, Nantes, France
| | - Jean-Damien Ricard
- Hôpital Louis Mourier, Réanimation Médico-Chirurgicale, AP-HP, INSERM, Université Paris Diderot, UMR IAME 1137, Sorbonne Paris Cité, Colombes, France
| | - Keyvan Razazi
- Hôpitaux universitaires Henri Mondor, Service de Réanimation Médicale DHU A-TVB, AP-HP, Créteil, France
| | - Guillaume Barberet
- Groupe Hospitalier Régional Mulhouse Sud Alsace, site Emile Muller, Service de Réanimation Médicale, Mulhouse, France
| | - Christine Lebert
- Centre Hospitalier Départemental de Vendée, Service de Médecine Intensive Réanimation, La Roche Sur Yon, France
| | - Stephan Ehrmann
- Centre Hospitalier Régional Universitaire de Tours, Médecine Intensive Réanimation, CIC 1415, Réseau CRICS-Trigger SEP, Centre d'étude des pathologies respiratoires, INSERM U1100, Université de Tours, Tours, France
| | | | - Jeremy Bourenne
- 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, Service de Réanimation, Aurillac, France
| | - Pierre Bailly
- Centre Hospitalier Universitaire de Brest, Médecine Intensive Réanimation, Brest, France
| | - Nicolas Terzi
- Centre Hospitalier Universitaire Grenoble Alpes, Médecine Intensive Réanimation, INSERM, Université Grenoble-Alpes, U1042, HP2, Grenoble, France
| | - Jean Dellamonica
- Centre Hospitalier Universitaire de Nice, Médecine Intensive Réanimation, Archet 1, Université Cote d’Azur, Nice, France
| | - Guillaume Lacave
- Centre Hospitalier de Versailles, Service de Réanimation Médico-Chirurgicale, Le Chesnay, France
| | - Pierre-Éric Danin
- Centre Hospitalier Universitaire de Nice, Réanimation Médico-Chirurgicale Archet 2, INSERM U 1065, Nice, France
| | - Hodanou Nanadoumgar
- Centre Hospitalier Universitaire de Poitiers, Réanimation Chirurgicale, Poitiers, France
| | - Aude Gibelin
- Hôpital Tenon, Réanimation et USC médico-chirurgicale, CARMAS, AP-HP, Faculté de médecine Sorbonne Université, Collegium Galilée, Paris, France
| | - Lassane Zanre
- Centre Hospitalier Emile Roux, Service de Réanimation, Le Puy en Velay, France
| | - Nicolas Deye
- Hôpital Lariboisière, Réanimation Médicale et Toxicologique, AP-HP, INSERM UMR-S 942, Paris, France
| | - Alexandre Demoule
- Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), AP-HP, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Paris, France
| | - Adel Maamar
- Centre Hospitalier Universitaire de Rennes, Hôpital Ponchaillou, Service des Maladies Infectieuses et Réanimation Médicale, Rennes, France
| | - Mai-Anh Nay
- Groupe Hospitalier Régional d’Orléans, Médecine Intensive Réanimation, Orléans, France
| | - René Robert
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers, France
- INSERM Centre d’Investigation Clinique 1402 ALIVE, Université de Poitiers, Poitiers, France
| | - Stéphanie Ragot
- INSERM Centre d’Investigation Clinique 1402 ALIVE, Université de Poitiers, Poitiers, France
| | - Jean-Pierre Frat
- Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers, France
- INSERM Centre d’Investigation Clinique 1402 ALIVE, Université de Poitiers, Poitiers, France
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157
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Burns KEA, Rizvi L, Cook DJ, Seely AJE, Rochwerg B, Lamontagne F, Devlin JW, Dodek P, Mayette M, Tanios M, Gouskos A, Kay P, Mitchell S, Kiedrowski KC, Hill NS. Frequency of Screening and SBT Technique Trial - North American Weaning Collaboration (FAST-NAWC): a protocol for a multicenter, factorial randomized trial. Trials 2019; 20:587. [PMID: 31604480 PMCID: PMC6787986 DOI: 10.1186/s13063-019-3641-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 08/08/2019] [Indexed: 11/10/2022] Open
Abstract
RATIONALE In critically ill patients receiving invasive mechanical ventilation (MV), research supports the use of daily screening to identify patients who are ready to undergo a spontaneous breathing trial (SBT) followed by conduct of an SBT. However, once daily (OD) screening is poorly aligned with the continuous care provided in most intensive care units (ICUs) and the best SBT technique for clinicians to use remains controversial. OBJECTIVES To identify the optimal screening frequency and SBT technique to wean critically ill adults in the ICU. METHODS We aim to conduct a multicenter, factorial design randomized controlled trial with concealed allocation, comparing the effect of both screening frequency (once versus at least twice daily [ALTD]) and SBT technique (Pressure Support [PS] + Positive End-Expiratory Pressure [PEEP] vs T-piece) on the time to successful extubation (primary outcome) in 760 critically ill adults who are invasively ventilated for at least 24 h in 20 North American ICUs. In the OD arm, respiratory therapists (RTs) will screen study patients between 06:00 and 08:00 h. In the ALTD arm, patients will be screened at least twice daily between 06:00 and 08:00 h and between 13:00 and 15:00 h with additional screens permitted at the clinician's discretion. When the SBT screen is passed, an SBT will be conducted using the assigned technique (PS + PEEP or T-piece). We will follow patients until successful extubation, death, ICU discharge, or until day 60 after randomization. We will contact patients or their surrogates six months after randomization to assess health-related quality of life and functional status. RELEVANCE The around-the-clock availability of RTs in North American ICUs presents an important opportunity to identify the optimal SBT screening frequency and SBT technique to minimize patients' exposure to invasive ventilation and ventilator-related complications. TRIAL REGISTRATION Clinical Trials.gov, NCT02399267 . Registered on Nov 21, 2016 first registered.
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Affiliation(s)
- K E A Burns
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada.
- Department of Medicine, Division of Critical Care Medicine, St Michael's Hospital, 30 Bond Street, Office 4-045 Donnelly Wing, Toronto, ON, M5B 1W8, Canada.
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Office 4-045 Donnelly Wing, Toronto, ON, M5B 1W8, Canada.
| | - Leena Rizvi
- Department of Medicine, Division of Critical Care Medicine, St Michael's Hospital, 30 Bond Street, Office 4-045 Donnelly Wing, Toronto, ON, M5B 1W8, Canada
| | - Deborah J Cook
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Andrew J E Seely
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Francois Lamontagne
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, MA, USA
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA, USA
| | - Peter Dodek
- Centre for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada
- University of British Columbia, Vancouver, BC, Canada
| | - Michael Mayette
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Maged Tanios
- Critical Care Medicine, Longbeach Memorial, Longbeach, CA, USA
| | - Audrey Gouskos
- Patient and Family Advisory Committee Member, FAST - NAWC Trial, Toronto, Canada
| | - Phyllis Kay
- Patient and Family Advisory Committee Member, FAST - NAWC Trial, Toronto, Canada
| | - Susan Mitchell
- Patient and Family Advisory Committee Member, FAST - NAWC Trial, Toronto, Canada
| | - Kenneth C Kiedrowski
- Patient and Family Advisory Committee Member, FAST - NAWC Trial, Toronto, Canada
| | - Nicholas S Hill
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA, USA
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158
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Fernando SM, McIsaac DI, Rochwerg B, Bagshaw SM, Muscedere J, Munshi L, Ferguson ND, Seely AJE, Cook DJ, Dave C, Tanuseputro P, Kyeremanteng K. Frailty and invasive mechanical ventilation: association with outcomes, extubation failure, and tracheostomy. Intensive Care Med 2019; 45:1742-1752. [PMID: 31595352 DOI: 10.1007/s00134-019-05795-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 09/22/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE Invasive mechanical ventilation is a common form of life support provided to critically ill patients. Frailty is an emerging prognostic factor for poor outcome in the Intensive Care Unit (ICU); however, its association with adverse outcomes following invasive mechanical ventilation is unknown. We sought to evaluate the association between frailty, defined by the Clinical Frailty Scale (CFS), and outcomes of ICU patients receiving invasive mechanical ventilation. METHODS We performed a retrospective analysis (2011-2016) of a prospectively collected registry from two hospitals of consecutive ICU patients ≥ 18 years of age receiving invasive mechanical ventilation. CFS scores were based on recorded pre-admission function at the time of hospital admission. The primary outcome was hospital mortality. Secondary outcomes included discharge to long-term care, extubation failure at time of first liberation attempt, and tracheostomy. RESULTS We included 8110 patients, and 2529 (31.2%) had frailty (CFS ≥ 5). Frailty was associated with increased odds of hospital death (adjusted odds ratio [aOR]: 1.24 [95% confidence interval [CI] 1.10-1.40) and discharge to long-term care (aOR 1.21 [95% CI 1.13-1.35]). As compared to patients without frailty, patients with frailty had increased odds of extubation failure (aOR 1.17 [95% CI 1.04-1.37]), hospital death following extubation failure (aOR 1.18 [95% CI 1.07-1.28]), tracheostomy (aOR 1.17 [95% CI 1.01-1.36]), and hospital death following tracheostomy (aOR 1.14 [95% CI 1.03-1.25]). CONCLUSIONS The presence of frailty among patients receiving mechanical ventilation is associated with increased odds of hospital mortality, discharge to long-term care, extubation failure, and need for tracheostomy.
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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.
| | - Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine, 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
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - John Muscedere
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Andrew J E Seely
- Division of Critical Care, Department of Medicine, 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.,Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Deborah J Cook
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Chintan Dave
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Peter Tanuseputro
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyere Research Institute, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kwadwo Kyeremanteng
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Institut du Savoir Montfort, Ottawa, ON, Canada
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159
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Ibrahim AS, Aly MG, Abdel-Rahman KA, Mohamed MA, Mehany MM, Aziz EM. Semi-quantitative Cough Strength Score as a Predictor for Extubation Outcome in Traumatic Brain Injury: A Prospective Observational Study. Neurocrit Care 2019; 29:273-279. [PMID: 29644564 DOI: 10.1007/s12028-018-0539-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Between 25 and 40% of extubated patients with traumatic brain injury (TBI) in the intensive care unit at our hospital (Assiut University Hospital-Assiut-Egypt) require reintubation. This reflects the importance of developing better criteria for predicting successful extubation in TBI. We evaluated the accuracy of semi-quantitative cough strength score (SCSS) and Glasgow coma scale (GCS) in predicting extubation outcomes in TBI. METHODS This prospective observational study included patients (18-65 years), with TBI on mechanical ventilation more than 24 h who were ready to be weaned off. Three tools were used. Tool I: Patient assessment sheet, this tool used to assess socio-demographic and clinical data of patients. Tool II: Semi-quantitative cough strength score (0-5). Tool III: Factors affecting successful extubation, this tool used to confirm the presence or absence of factors that can interfere with the results of extubation outcomes. After extubation, patient was followed up for 72 h to check for extubation success. Multivariate logistic binary regression test was used to calculate odds ratio for different clinical data collected before extubation as independent factors and successful extubation as a dependent factor. RESULTS Among 80 patients of mean age 40.6 (± 16.1), 34% were female, median admission GCS was 8 (4-13), extubation occurred on mean post-injury day 6.5 (± 4), and 46.3% required reintubation. Successfully extubated patients had higher semi-quantitative cough scores and GCS. 81.3% patients with SCSS 5 were successfully extubated, while all patients with SCSS 0 were reintubated. All patients with GCS 15 were successfully extubated, and all patients with GCS < 12 required intubation. CONCLUSION SCSS has shown promise in predicting successful extubation in TBI.
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Affiliation(s)
- Abdelrady S Ibrahim
- Anaesthesia and ICU Department, Faculty of Medicine, Assiut University Hospital, Assiut City, 7111, Egypt.
| | - Mohamed G Aly
- Anaesthesia and ICU Department, Faculty of Medicine, Assiut University Hospital, Assiut City, 7111, Egypt
| | - Khaled A Abdel-Rahman
- Anaesthesia and ICU Department, Faculty of Medicine, Assiut University Hospital, Assiut City, 7111, Egypt
| | - Mona A Mohamed
- Critical Care and Emergency Nursing Department, Faculty of Nursing, Assiut University, Assiut, Egypt
| | - Mogedda M Mehany
- Critical Care and Emergency Nursing Department, Faculty of Nursing, Assiut University, Assiut, Egypt
| | - Eman M Aziz
- Critical Care and Emergency Nursing Department, Faculty of Nursing, Assiut University, Assiut, Egypt
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Liang J, Li Z, Dong H, Xu C. Prognostic factors associated with mortality in mechanically ventilated patients in the intensive care unit: A single-center, retrospective cohort study of 905 patients. Medicine (Baltimore) 2019; 98:e17592. [PMID: 31626132 PMCID: PMC6824683 DOI: 10.1097/md.0000000000017592] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Data on outcomes of patients receiving mechanical ventilation (MV) in China are scarce.To investigate factors associated with the prognosis of patients given MV in the intensive care unit (ICU).A 12-year (January 1, 2006-December 31, 2017) retrospective cohort study.ICU of Beijing Geriatric Hospital, China.A total of 905 patients aged ≥16 years given MV during the study period.None.Among 905 patients included (610 men; median age, 78 years; Acute Physiology and Chronic Health Evaluation [APACHE]-II score, 27.3 ± 8.9), 585 survived (388 men; median age, 77 years; average APACHE-II score, 25.6 ± 8.4), and 320 died in the ICU (222 men; median age, 78 years; APACHE-II score, 30.6 ± 8.9). All-cause ICU mortality was 35.4%. In patients aged <65 years, factors associated with ICU mortality were APACHE-II score (odds ratio [OR], 1.108; 95% confidence interval [95% CI], 1.021-1.202; P = .014), nosocomial infection (OR, 6.618; 95% CI, 1.065-41.113; P = .043), acute kidney injury (OR, 17.302; 95% CI, 2.728-109.735; P = .002), invasive hemodynamic monitoring (OR, 10.051; 95% CI, 1.362-74.191; P = .024), MV for cardiopulmonary resuscitation (OR, 0.122; 95% CI, 0.016-0.924; P = .042), duration of MV (OR, 0.993; 95% CI, 0.988-0.998; P = .008), successful weaning from MV (OR, 0.012; 95% CI, 0.002-0.066; P < .001), and renal replacement therapy (OR, 0.039; 95% CI, 0.005-0.324; P = .003). In patients aged ≥65 years, factors associated with mortality were APACHE-II score (OR, 1.062; 95% CI, 1.030-1.096; P < .001), nosocomial infection (OR, 2.427; 95% CI, 1.359-4.334; P = .003), septic shock (OR, 2.017; 95% CI, 1.153-3.529; P = .014), blood transfusion (OR, 1.939; 95% CI, 1.174-3.202; P = .010), duration of MV (OR, 0.999; 95% CI, 0.999-1.000; P = .043), and successful weaning from MV (OR, 0.027; 95% CI, 0.015-0.047; P < .001).APACHE-II score, successful weaning, and nosocomial infection in the ICU are independently associated with the prognosis of patients given MV in the ICU.
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161
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Rodriguez M, Thille AW, Boissier F, Veinstein A, Chatellier D, Robert R, Le Pape S, Frat JP, Coudroy R. Predictors of successful separation from high-flow nasal oxygen therapy in patients with acute respiratory failure: a retrospective monocenter study. Ann Intensive Care 2019; 9:101. [PMID: 31511996 PMCID: PMC6738360 DOI: 10.1186/s13613-019-0578-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 09/05/2019] [Indexed: 01/04/2023] Open
Abstract
Background High-flow nasal oxygen therapy (HFOT) is a promising first-line therapy for acute respiratory failure. However, its weaning has never been investigated and could lead to unnecessary prolonged intensive-care unit (ICU) stay. The aim of this study is to assess predictors of successful separation from HFOT in critically ill patients. We performed a retrospective monocenter observational study over a 2-year period including all patients treated with HFOT for acute respiratory failure in the ICU. Those who died or were intubated without prior HFOT separation attempt, who were treated with non-invasive ventilation at the time of HFOT separation, or who received HFOT as a preventive treatment during the post-extubation period were excluded. Results From the 190 patients analyzed, 168 (88%) were successfully separated from HFOT at the first attempt. Patients who failed separation from HFOT at the first attempt had longer ICU length of stay than those who succeeded: 10 days (7–12) vs. 5 (4–8), p < 0.0001. Fraction of inspired oxygen (FiO2) ≤ 40% and a respiratory rate-oxygenation (ROX) index (calculated as the ratio of SpO2/FiO2 to the respiratory rate) ≥ 9.2 predicted successful separation from HFOT with sensitivity of 85% and 84%, respectively. Conclusions FiO2 ≤ 40% and ROX index ≥ 9.2 were two predictors of successful separation from HFOT at the bedside. Prospective multicenter studies are needed to confirm these results.
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Affiliation(s)
- Maeva Rodriguez
- Médecine Intensive et Réanimation, CHU de Poitiers, 2 rue de la Milétrie, 86000, Poitiers, France
| | - Arnaud W Thille
- Médecine Intensive et Réanimation, CHU de Poitiers, 2 rue de la Milétrie, 86000, Poitiers, France.,INSERM CIC 1402, ALIVE Group, Université de Poitiers, Poitiers, France
| | - Florence Boissier
- Médecine Intensive et Réanimation, CHU de Poitiers, 2 rue de la Milétrie, 86000, Poitiers, France.,INSERM CIC 1402, ALIVE Group, Université de Poitiers, Poitiers, France
| | - Anne Veinstein
- Médecine Intensive et Réanimation, CHU de Poitiers, 2 rue de la Milétrie, 86000, Poitiers, France
| | - Delphine Chatellier
- Médecine Intensive et Réanimation, CHU de Poitiers, 2 rue de la Milétrie, 86000, Poitiers, France
| | - René Robert
- Médecine Intensive et Réanimation, CHU de Poitiers, 2 rue de la Milétrie, 86000, Poitiers, France.,INSERM CIC 1402, ALIVE Group, Université de Poitiers, Poitiers, France
| | - Sylvain Le Pape
- Médecine Intensive et Réanimation, CHU de Poitiers, 2 rue de la Milétrie, 86000, Poitiers, France.,INSERM CIC 1402, ALIVE Group, Université de Poitiers, Poitiers, France
| | - Jean-Pierre Frat
- Médecine Intensive et Réanimation, CHU de Poitiers, 2 rue de la Milétrie, 86000, Poitiers, France.,INSERM CIC 1402, ALIVE Group, Université de Poitiers, Poitiers, France
| | - Remi Coudroy
- Médecine Intensive et Réanimation, CHU de Poitiers, 2 rue de la Milétrie, 86000, Poitiers, France. .,INSERM CIC 1402, ALIVE Group, Université de Poitiers, Poitiers, France.
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162
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Ellens T, Kaur R, Roehl K, Dubosky M, Vines DL. Ventilatory equivalent for oxygen as an extubation outcome predictor: A pilot study. CANADIAN JOURNAL OF RESPIRATORY THERAPY : CJRT = REVUE CANADIENNE DE LA THERAPIE RESPIRATOIRE : RCTR 2019; 55:65-71. [PMID: 31489359 PMCID: PMC6699067 DOI: 10.29390/cjrt-2019-007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Introduction Weaning predictors can help liberate patients in a timely manner from mechanical ventilation. Ventilatory equivalent for oxygen (VEqO2), a surrogate for work of breathing and a measure of the efficiency of breathing, may be an important noninvasive alternative to other weaning predictors. Our study’s purpose was to observe any differences in VEqO2 between extubation outcome groups. Methods Employing a metabolic cart, oxygen consumption (V˙O2), minute volume (VE), tidal volume (VT), and breathing frequency were recorded during a spontaneous breathing trial (SBT) to calculate VEqO2 and the rapid shallow breathing index (RSBI) in 34 adult participants in the intensive care unit. Five-breath means of VEqO2 and the RSBI collected throughout the SBT were examined between SBT pass and fail groups and extubation pass and fail groups using the Mann–Whitney U test with p < 0.05. Results Data from 31 participants were analyzed between SBT outcome groups. Data from 20 participants were examined for extubation outcome after a successful SBT. Median (interquartile range) VEqO2 was not different between extubation groups. Participants who passed the SBT had a higher median VEqO2 than those who did not at the midpoint (25.3 L/L V˙O2 [22–33 L/L V˙O2] vs. 23.7 L/L V˙O2 [18–24 L/L V˙O2], p = 0.035) and at the end (25.5 L/L V˙O2 [23–34 L/L V˙O2] vs. 21.3 L/L V˙O2 [20–24 L/L V˙O2], p = 0.017) of the SBT. Discussion VEqO2 may show differences in SBT outcomes, but not differences between extubation outcomes. VEqO2 may be able to detect differences in work during an SBT, but may not be able to predict change in workload in the respiratory system after extubation. The small sample size may also have prevented any differences in extubation outcomes to be shown. Conclusion VEqO2 was higher in patients that passed their SBT. VEqO2 was not useful in identifying extubation success or failure in adult mechanically ventilated patients.
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Affiliation(s)
- Troy Ellens
- Quality Improvement Systems, James. M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ramandeep Kaur
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL, USA
| | - Kelly Roehl
- Department of Nutrition, Rush University, Chicago, IL, USA
| | - Meagan Dubosky
- Department of Pulmonary and Sleep Medicine, DuPage Medical Group, Chicago, IL, USA
| | - David L Vines
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL, USA
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163
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Om SY, Hyun J, Nam KH, Lee SH, Song SM, Hong JA, Lee SE, Kim MS. Early decongestive therapy versus high-flow nasal cannula for the prevention of adverse clinical events in patients with acute cardiogenic pulmonary edema. J Thorac Dis 2019; 11:3991-3999. [PMID: 31656673 DOI: 10.21037/jtd.2019.08.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Few studies have investigated the role of decongestive therapy and high-flow nasal cannula (HFNC) in preventing reintubation and in-hospital mortality in patients with acute cardiogenic pulmonary edema (ACPE). Methods Data from patients with ACPE who were weaned from mechanical ventilation in the cardiac intensive care unit between January 2013 and December 2017 were retrospectively evaluated. All patients were treated with HFNC or conventional oxygen therapy (COT), such as a nasal cannula or venturi mask, immediately after extubation. Decongestive therapy (intravenous furosemide infusion) was administered at the discretion of the attending physician. Results Of 212 patients treated during the study period, 47 were excluded due to recent open-heart surgery and two, due to insufficient clinical data. The remaining 163 patients had a mean age of 67.4±14.3 years, and 92 (56.4%) were male; 44 patients received HFNC, and 119 COT. Mean weight loss within 72 hours of extubation was -0.86±2.03 kg. A total of 38 patients (23.3%) required reintubation, 21 of whom (12.9%) required reintubation within 72 hours of extubation. In-hospital mortality occurred in 16 patients (9.8%). Multivariate analysis showed that weight increase within 72 hours of extubation was independent determinants of reintubation (OR =1.7; 95% CI: 1.2-2.2; P<0.001) and in-hospital mortality (OR =1.5; 95% CI: 1.1-2.1; P=0.005). The use of HFNC was not associated with reintubation or in-hospital mortality. Conclusions Our findings indicate that early weight loss resulted in reduced reintubation and in-hospital mortality in patients with ACPE. However, HFNC and COT did not differ in the prevention of reintubation and in-hospital mortality. Therefore, aggressive decongestive therapy, rather than HFNC, should be considered early after extubation.
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Affiliation(s)
- Sang Yong Om
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Junho Hyun
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Hun Nam
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sun Hack Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Min Song
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Ae Hong
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Eun Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min-Seok Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Ruggeri P, Profazio C, Esquinas A. Post‐intensive care unit respiratory failure in older patients: Can we predict intensive care unit discharge properly? Geriatr Gerontol Int 2019; 19:838. [DOI: 10.1111/ggi.13720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Paolo Ruggeri
- Pulmonology Unit, Department of Biomedical and Dental Sciences, Morphological and Functional Images (BIOMORF)University of Messina Messina Italy
| | - Claudia Profazio
- Department of NeurosciencesNemo Sud Clinical Center for Neuromuscular Disorders Messina Italy
| | - Antonio Esquinas
- Department of Intensive Care and Noninvasive Vnetilatory UnitIntensive Care Unit, Hospital Morales Meseguer Murcia Murcia Spain
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165
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Casey JD, Vaughan ER, Lloyd BD, Bilas PA, Hall EJ, Toporek AH, Buell KG, Brown RM, Richardson RK, Rooks JC, Wang L, Lindsell CJ, Ely EW, Self WH, Bernard GR, Rice TW, Semler MW. Protocolized Post-Extubation Respiratory Support to prevent reintubation: protocol and statistical analysis plan for a clinical trial. BMJ Open 2019; 9:e030476. [PMID: 31377713 PMCID: PMC6687016 DOI: 10.1136/bmjopen-2019-030476] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/06/2019] [Accepted: 06/21/2019] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Following extubation from invasive mechanical ventilation, nearly one in seven critically ill adults requires reintubation. Reintubation is independently associated with increased mortality. Postextubation respiratory support (non-invasive ventilation or high-flow nasal cannula applied at the time of extubation) has been reported in small-to-moderate-sized trials to reduce reintubation rates among hypercapnic patients, high-risk patients without hypercapnia and low-risk patients without hypercapnia. It is unknown whether protocolised provision of postextubation respiratory support to every patient undergoing extubation would reduce the overall reintubation rate, compared with usual care. METHODS AND ANALYSIS The Protocolized Post-Extubation Respiratory Support (PROPER) trial is a pragmatic, cluster cross-over trial being conducted between 1 October 2017 and 31 March 2019 in the medical intensive care unit of Vanderbilt University Medical Center. PROPER compares usual care versus protocolized post-extubation respiratory support (a respiratory therapist-driven protocol that advises the provision of non-invasive ventilation or high-flow nasal cannula based on patient characteristics). For the duration of the trial, the unit is divided into two clusters. One cluster receives protocolised support and the other receives usual care. Each cluster crosses over between treatment group assignments every 3 months. All adults undergoing extubation from invasive mechanical ventilation are enrolled except those who received less than 12 hours of mechanical ventilation, have 'Do Not Intubate' orders, or have been previously reintubated during the hospitalisation. The anticipated enrolment is approximately 630 patients. The primary outcome is reintubation within 96 hours of extubation. ETHICS AND DISSEMINATION The trial was approved by the Vanderbilt Institutional Review Board. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences. TRIAL REGISTRATION NUMBER NCT03288311.
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Affiliation(s)
- Jonathan Dale Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Erin R Vaughan
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bradley D Lloyd
- Division of Respiratory Care, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Peter A Bilas
- Department of Anesthesiology, University of Florida, Gainesville, Florida, USA
| | - Eric J Hall
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alexandra H Toporek
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kevin G Buell
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ryan M Brown
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Roger K Richardson
- Division of Respiratory Care, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - J Craig Rooks
- Division of Respiratory Care, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christopher J Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Gordon R Bernard
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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166
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Xie J, Cheng G, Zheng Z, Luo H, Ooi OC. To extubate or not to extubate: Risk factors for extubation failure and deterioration with further mechanical ventilation. J Card Surg 2019; 34:1004-1011. [PMID: 31374585 DOI: 10.1111/jocs.14189] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Extubation is a critical step in the intensive care unit (ICU). In this study, we aim to investigate the risk factors for both extubation failure and deterioration with further mechanical ventilation (MV). METHODS Data were collected from a cardiothoracic ICU in a tertiary hospital. The risk factors for extubation failure and deterioration with further MV were investigated by multivariate logistic regression. RESULTS A total of 676 patients were enrolled in the study. Patients with extubation failure had a longer ICU length of stay and a higher mortality rate than patients without extubation failure. An age greater than 65 years, abnormal heart rate, respiratory rate exceeding 20 times/min, arterial pH lower than 7.35, pressure of oxygen in arterial blood (PaO2)/fraction of inspired oxygen (FiO2) ratio lower than 300 mmHg, mean arterial pressure lower than 70 mmHg, duration of MV longer than 12 hours, and high quick Sequential Organ Failure Assessment (qSOFA) score were independent risk factors for extubation failure. Furthermore, we found that a respiratory rate greater than 20 times/min and a PaO2/fraction of Inspired Oxygen FiO2 ratio less than 300 mmHg were protective factors, while a mean arterial pressure lower than 70 mmHg, arterial pH lower than 7.35, and high qSOFA score were risk factors for deterioration on continued MV. CONCLUSIONS Since the duration of MV increases the risk of extubation failure, physicians should consider not only the risk of extubation failure but also the risk of deterioration with further MV.
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Affiliation(s)
- Jingui Xie
- The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China.,School of Management, University of Science and Technology of China, Hefei, China
| | - Guang Cheng
- School of Management, University of Science and Technology of China, Hefei, China
| | - Zhichao Zheng
- Lee Kong Chian School of Business, Singapore Management University, Singapore
| | - Haidong Luo
- Department of Cardiac, Thoracic & Vascular Surgery, National University Hospital, Singapore
| | - Oon Cheong Ooi
- Department of Cardiac, Thoracic & Vascular Surgery, National University Hospital, Singapore
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167
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Patel SR, Barounis DA, Milas A, Nikamal AJ, Estoos E, Anand N, Nitti K, Dodd KW. Outcomes following nighttime extubation in a high-intensity medical intensive care unit. J Crit Care 2019; 54:30-36. [PMID: 31326618 DOI: 10.1016/j.jcrc.2019.06.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/23/2019] [Accepted: 06/26/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Samir R Patel
- Department of Internal Medicine, Advocate Christ Medical Center, United States of America; Department of Emergency Medicine, Advocate Christ Medical Center, United States of America; Department of Internal Medicine, University of Illinois at Chicago, United States of America; Department of Emergency Medicine, University of Illinois at Chicago, United States of America
| | - David A Barounis
- Department of Internal Medicine, Advocate Christ Medical Center, United States of America; Department of Emergency Medicine, Advocate Christ Medical Center, United States of America; Department of Internal Medicine, University of Illinois at Chicago, United States of America; Department of Emergency Medicine, University of Illinois at Chicago, United States of America
| | - Anamaria Milas
- Department of Internal Medicine, Advocate Christ Medical Center, United States of America; Department of Internal Medicine, University of Illinois at Chicago, United States of America.
| | - Arya J Nikamal
- Department of Internal Medicine, Advocate Christ Medical Center, United States of America; Department of Internal Medicine, University of Illinois at Chicago, United States of America
| | - Ethan Estoos
- Department of Emergency Medicine, Advocate Christ Medical Center, United States of America
| | - Neesha Anand
- Department of Internal Medicine, Advocate Christ Medical Center, United States of America; Department of Internal Medicine, University of Illinois at Chicago, United States of America
| | - Kara Nitti
- Department of Research, Advocate Christ Medical Center, United States of America
| | - Kenneth W Dodd
- Department of Internal Medicine, Advocate Christ Medical Center, United States of America; Department of Emergency Medicine, Advocate Christ Medical Center, United States of America; Department of Internal Medicine, University of Illinois at Chicago, United States of America; Department of Emergency Medicine, University of Illinois at Chicago, United States of America
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168
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Maggiore SM, Battilana M, Serano L, Petrini F. Ventilatory support after extubation in critically ill patients. THE LANCET RESPIRATORY MEDICINE 2019; 6:948-962. [PMID: 30629933 DOI: 10.1016/s2213-2600(18)30375-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 09/06/2018] [Accepted: 09/07/2018] [Indexed: 12/29/2022]
Abstract
The periextubation period represents a crucial moment in the management of critically ill patients. Extubation failure, defined as the need for reintubation within 2-7 days after a planned extubation, is associated with prolonged mechanical ventilation, increased incidence of ventilator-associated pneumonia, longer intensive care unit and hospital stays, and increased mortality. Conventional oxygen therapy is commonly used after extubation. Additional methods of non-invasive respiratory support, such as non-invasive ventilation and high-flow nasal therapy, can be used to avoid reintubation. The aim of this Review is to describe the pathophysiological mechanisms of postextubation respiratory failure and the available techniques and strategies of respiratory support to avoid reintubation. We summarise and discuss the available evidence supporting the use of these strategies to achieve a tailored therapy for an individual patient at the bedside.
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Affiliation(s)
- Salvatore Maurizio Maggiore
- University Department of Medical, Oral and Biotechnological Sciences, Gabriele d'Annunzio University of Chieti-Pescara, Chieti, Italy; Clinical Department of Anaesthesiology and Intensive Care Medicine, SS. Annunziata Hospital, Chieti, Italy.
| | - Mariangela Battilana
- University Department of Medical, Oral and Biotechnological Sciences, Gabriele d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Luca Serano
- University Department of Medical, Oral and Biotechnological Sciences, Gabriele d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Flavia Petrini
- University Department of Medical, Oral and Biotechnological Sciences, Gabriele d'Annunzio University of Chieti-Pescara, Chieti, Italy; Clinical Department of Anaesthesiology and Intensive Care Medicine, SS. Annunziata Hospital, Chieti, Italy
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169
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Cork G, Camporota L, Osman L, Shannon H. Physiotherapist prediction of extubation outcome in the adult intensive care unit. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2019; 24:e1793. [PMID: 31237395 PMCID: PMC6852206 DOI: 10.1002/pri.1793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 05/02/2019] [Accepted: 05/17/2019] [Indexed: 11/08/2022]
Abstract
Objective Most patients requiring intubation and mechanical ventilation are extubated successfully at the first attempt; however, a minority experience extubation failure, which is associated with increased risk of ventilator‐associated pneumonia, prolonged intensive care unit (ICU) length of stay and mortality. Physiotherapists have expertise to assess cough strength, work of breathing, respiratory muscle strength, and respiratory secretion load, which are important factors in the outcome of extubation. Accurate prediction of extubation outcome could help to inform management plans pre‐extubation and postextubation. The primary objective of this service evaluation was to report the accuracy of physiotherapists' prediction of extubation outcome in the adult ICU. Methods A single‐centre case note review was undertaken. All subjects who received a physiotherapy assessment of extubation suitability prior to extubation between January and March 2016 in the adult ICU of a large teaching hospital in the United Kingdom were included. Assessment, by both specialist and nonspecialist physiotherapists—which included risk stratification of extubation failure as “high,” “moderate,” or “low”—was undertaken prior to extubation. Logistic regression analysis was performed to determine which pre‐extubation factors were predictive of extubation outcome. Results During the evaluation period, 68 subjects were extubated following a physiotherapy assessment. Physiotherapy risk stratification as “high risk” (OR 4; 95% confidence interval, CI, [1.312]; p=0.009) and “inappropriate” neurological status (OR 3.3; 95% CI [1.0410]; p=0.037) were the only pre‐extubation factors significantly associated with extubation failure. Assessment by specialist physiotherapists demonstrated greater sensitivity (100% vs. 22%) but lower specificity (68% vs. 95%) to detect extubation failure compared with the assessment performed by nonspecialist physiotherapists. Conclusion Patients classified as “high risk” of extubation failure by a physiotherapist are significantly more likely to fail extubation. Specialist physiotherapists should be involved in the decision to extubate patients in the adult ICU.
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Affiliation(s)
- Gabriella Cork
- Department of Physiotherapy, Guy's and St Thomas' NHS Foundation Trust, London, UK.,University College London Institute of Child Health, UCL Great Ormond Street Institute of Child Health, London, UK.,School of Health Sciences, University of Liverpool, Liverpool, UK
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's Health Partners, Division of Asthma, Allergy and Lung Biology, King's College London, London, UK
| | - Leyla Osman
- Department of Physiotherapy, Guy's and St Thomas' NHS Foundation Trust, London, UK.,University College London Institute of Child Health, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Harriet Shannon
- University College London Institute of Child Health, UCL Great Ormond Street Institute of Child Health, London, UK
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170
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Girard TD, Burns KEA. Revisiting, Reframing, and Casting a New Light on Liberation From Mechanical Ventilation. JAMA 2019; 321:2167-2169. [PMID: 31184723 DOI: 10.1001/jama.2019.7364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Timothy D Girard
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Karen E A Burns
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Division of Critical Care Medicine, Department of Medicine, St Michael's Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
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171
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Zhu Y, Yin H, Zhang R, Ye X, Wei J. High-flow nasal cannula oxygen therapy versus conventional oxygen therapy in patients after planned extubation: a systematic review and meta-analysis. Crit Care 2019; 23:180. [PMID: 31101127 PMCID: PMC6525416 DOI: 10.1186/s13054-019-2465-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 05/02/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The effect of high-flow nasal cannula (HFNC) therapy in patients after planned extubation remains inconclusive. We aimed to perform a rigorous and comprehensive systematic meta-analysis to robustly quantify the benefits of HFNC for patients after planned extubation by investigating postextubation respiratory failure and other outcomes. METHOD We searched MEDLINE, EMBASE, Web of Science, and the Cochrane Library from inception to August 2018. Two researchers screened studies and collected the data independently. Randomized controlled trials (RCTs) and crossover studies were included. The main outcome was postextubation respiratory failure. RESULTS Ten studies (seven RCTs and three crossover studies; HFNC group: 856 patients; Conventional oxygen therapy (COT) group: 852 patients) were included. Compared with COT, HFNC may significantly reduce postextubation respiratory failure (RR, 0.61; 95% CI, 0.41, 0.92; z = 2.38; P = 0.02) and respiratory rates (standardized mean differences (SMD), - 0.70; 95% CI, - 1.16, - 0.25; z = 3.03; P = 0.002) and increase PaO2 (SMD, 0.30; 95% CI, 0.04, 0.56; z = 2.23; P = 0.03). There were no significant differences in reintubation rate, length of ICU and hospital stay, comfort score, PaCO2, mortality in ICU and hospital, and severe adverse events between HFNC and COT group. CONCLUSIONS Our meta-analysis demonstrated that compared with COT, HFNC may significantly reduce postextubation respiratory failure and respiratory rates, increase PaO2, and be safely administered in patients after planned extubation. Further large-scale, multicenter studies are needed to confirm our results.
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Affiliation(s)
- Youfeng Zhu
- 0000 0004 1790 3548grid.258164.cDepartment of Intensive Care Unit, Guangzhou Red Cross Hospital, Medical College, Jinan University, Tongfuzhong Road No. 396, Guangzhou, 510220 Guangdong China
| | - Haiyan Yin
- 0000 0004 1790 3548grid.258164.cDepartment of Intensive Care Unit, Guangzhou Red Cross Hospital, Medical College, Jinan University, Tongfuzhong Road No. 396, Guangzhou, 510220 Guangdong China
| | - Rui Zhang
- 0000 0004 1790 3548grid.258164.cDepartment of Intensive Care Unit, Guangzhou Red Cross Hospital, Medical College, Jinan University, Tongfuzhong Road No. 396, Guangzhou, 510220 Guangdong China
| | - Xiaoling Ye
- 0000 0004 1790 3548grid.258164.cDepartment of Intensive Care Unit, Guangzhou Red Cross Hospital, Medical College, Jinan University, Tongfuzhong Road No. 396, Guangzhou, 510220 Guangdong China
| | - Jianrui Wei
- 0000 0004 1790 3548grid.258164.cDepartment of Cardiology, Guangzhou Red Cross Hospital, Medical College, Jinan University, Tongfuzhong Road No. 396, Guangzhou, 510220 Guangdong China
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172
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Mowafy SM, Abdelgalel EF. Diaphragmatic rapid shallow breathing index for predicting weaning outcome from mechanical ventilation: Comparison with traditional rapid shallow breathing index. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2018.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Sherif M.S. Mowafy
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Essam F. Abdelgalel
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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173
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Vivier E, Muller M, Putegnat JB, Steyer J, Barrau S, Boissier F, Bourdin G, Mekontso-Dessap A, Levrat A, Pommier C, Thille AW. Inability of Diaphragm Ultrasound to Predict Extubation Failure: A Multicenter Study. Chest 2019; 155:1131-1139. [PMID: 30910636 DOI: 10.1016/j.chest.2019.03.004] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 02/15/2019] [Accepted: 03/07/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Diaphragmatic dysfunction may promote weaning difficulties in patients who are mechanically ventilated. OBJECTIVE The goal of this study was to assess whether diaphragm dysfunction detected by ultrasound prior to extubation could predict extubation failure in the ICU. METHODS This multicenter prospective study included patients at high risk of reintubation: those aged > 65 years, with underlying cardiac or respiratory disease, or intubated > 7 days. All patients had successfully undergone a spontaneous breathing trial. Diaphragmatic function was assessed by ultrasound prior to extubation while breathing spontaneously on a T-piece. Bilateral diaphragmatic excursion and apposition thickening fraction were measured, and diaphragmatic dysfunction was defined as excursion < 10 mm or thickening < 30%. Cough strength was clinically assessed by physiotherapists. Extubation failure was defined as reintubation or death within the 7 days following extubation. RESULTS Over a 20-month period, 191 at-risk patients were studied. Among them, 33 (17%) were considered extubation failures. The proportion of patients with diaphragmatic dysfunction was similar between those whose extubation succeeded and those whose extubation failed: 46% vs 51% using excursion (P = .55), and 71% vs 68% using thickening (P = .73), respectively. Values of excursion and thickening did not differ between the success and the failure groups: at right, excursion was 14 ± 7 mm vs 11 ± 8 (P = .13), and thickening was 29 ± 29% vs 38 ± 48% (P = .83), respectively. Extubation failure rates were 7%, 22%, and 46% in patients with effective, moderate, and ineffective cough (P < .01). Ineffective cough was the only variable independently associated with extubation failure. CONCLUSIONS Diaphragmatic dysfunction assessed by ultrasound was not associated with an increased risk of extubation failure.
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Affiliation(s)
- Emmanuel Vivier
- Hôpital Saint Joseph Saint Luc, Réanimation Polyvalente, Lyon, France.
| | - Michel Muller
- Centre Hospitalier Annecy Genevoix, Réanimation Polyvalente, Metz-Tessy, France
| | | | - Julie Steyer
- Centre Hospitalier Annecy Genevoix, Réanimation Polyvalente, Metz-Tessy, France
| | - Stéphanie Barrau
- CHU de Poitiers, Médecine Intensive Réanimation, Poitiers, France; INSERM CIC 1402 ALIVE, Université de Poitiers, Faculté de Médecine et de Pharmacie, Poitiers, France
| | - Florence Boissier
- CHU de Poitiers, Médecine Intensive Réanimation, Poitiers, France; INSERM CIC 1402 ALIVE, Université de Poitiers, Faculté de Médecine et de Pharmacie, Poitiers, France
| | - Gaël Bourdin
- Hôpital Saint Joseph Saint Luc, Réanimation Polyvalente, Lyon, France
| | | | - Albrice Levrat
- Centre Hospitalier Annecy Genevoix, Réanimation Polyvalente, Metz-Tessy, France
| | - Christian Pommier
- Hôpital Saint Joseph Saint Luc, Réanimation Polyvalente, Lyon, France
| | - Arnaud W Thille
- CHU de Poitiers, Médecine Intensive Réanimation, Poitiers, France; INSERM CIC 1402 ALIVE, Université de Poitiers, Faculté de Médecine et de Pharmacie, Poitiers, France
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174
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Deschamps J, Webber J, Featherstone R, Sebastianski M, Vandermeer B, Senaratne J, Bagshaw SM. Brain natriuretic peptide to predict successful liberation from mechanical ventilation in critically ill patients: protocol for a systematic review and meta-analysis. BMJ Open 2019; 9:e022600. [PMID: 30760513 PMCID: PMC6377517 DOI: 10.1136/bmjopen-2018-022600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 09/07/2018] [Accepted: 12/07/2018] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Predicting successful liberation from mechanical ventilation (MV) among critically ill patients receiving MV can be challenging. The current parameters used to predict successful extubation have shown variable predictive value. Brain natriuretic peptide (BNP) has been proposed as a novel biomarker to help guide decision-making in readiness for liberation of MV following a spontaneous breathing trial (SBT). Current evidence on the predictive ability of BNP has been uncertain, and BNP has not been integrated into clinical practice guidelines. METHODS AND ANALYSIS We will perform a systematic review and meta-analysis to evaluate the value of BNP during SBT to predict success of liberation from MV. A search strategy will be developed in collaboration with a research librarian, and electronic databases (MEDLINE, EMBASE, Cochrane Library, Web of Science) and additional sources will be searched. Search themes will include: (1) BNP and (2) weaning, extubation and/or liberation from MV. Citation screening, selection, quality assessment and data abstraction will be performed in duplicate. The primary outcome will be liberation from MV; secondary outcomes will include time to reintubation, mortality, MV duration, total and postextubation intensive care unit (ICU) stay, hospitalisation duration, tracheostomy rate, ICU-acquired weakness rate and ventilator-free days. Primary statistical analysis will include predictive value of BNP by receiver operating characteristic curve, sensitivity/specificity and likelihood ratios for combination of BNP and SBT parameters for failure of liberation from MV. Secondary statistical analysis will be performed on individual and combinations of extracted metrics. ETHICS AND DISSEMINATION Our review will add knowledge by mapping the current body of evidence on the value of BNP testing for prediction of successful liberation from MV, and describe knowledge gaps and research priorities. Our findings will be disseminated through peer-reviewed publication, presentation at a scientific congress, through regional/national organisations and social media. Research ethics approval is not required. PROSPERO REGISTRATION NUMBER CRD42018087474.
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Affiliation(s)
- Jean Deschamps
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Jordan Webber
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Robin Featherstone
- Alberta Research Center for Health Evidence (ARCHE), University of Alberta, Edmonton, Canada
- Knowledge Translation Platform, Alberta Strategy for Patient Oriented Research (SPOR) Support unit, Edmonton, Canada
| | - Meghan Sebastianski
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Ben Vandermeer
- Alberta Research Center for Health Evidence (ARCHE), University of Alberta, Edmonton, Canada
- Knowledge Translation Platform, Alberta Strategy for Patient Oriented Research (SPOR) Support unit, Edmonton, Canada
| | - Janek Senaratne
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
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175
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Boyer D, Astier A, Carpentier D, Béduneau G. Comment j’évalue les fonctions des voies aériennes supérieures en périextubation, hors dyspnée laryngée. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2019-0089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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176
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Routsi C, Stanopoulos I, Kokkoris S, Sideris A, Zakynthinos S. Weaning failure of cardiovascular origin: how to suspect, detect and treat-a review of the literature. Ann Intensive Care 2019; 9:6. [PMID: 30627804 PMCID: PMC6326918 DOI: 10.1186/s13613-019-0481-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 01/02/2019] [Indexed: 01/09/2023] Open
Abstract
Among the multiple causes of weaning failure from mechanical ventilation, cardiovascular dysfunction is increasingly recognized as a quite frequent cause that can be treated successfully. In this review, we summarize the contemporary evidence of the most important clinical and diagnostic aspects of weaning failure of cardiovascular origin with special focus on treatment. Pathophysiological mechanisms are complex and mainly include increase in right and left ventricular preload and afterload and potentially induce myocardial ischemia. Patients at risk include those with preexisting cardiopulmonary disease either known or suspected. Clinically, cardiovascular etiology as a predominant cause or a contributor to weaning failure, though critical for early diagnosis and intervention, may be difficult to be recognized and distinguished from noncardiac causes suggesting the need of high suspicion. A cardiovascular diagnostic workup including bedside echocardiography, lung ultrasound, electrocardiogram and biomarkers of cardiovascular dysfunction or other adjunct techniques and, in selected cases, right heart catheterization and/or coronary angiography, should be obtained to confirm the diagnosis. Official clinical practice guidelines that address treatment of a confirmed weaning-induced cardiovascular dysfunction do not exist. As the etiologies of weaning-induced cardiovascular dysfunction are diverse, principles of management depend on the individual pathophysiological mechanisms, including preload optimization by fluid removal, guided by B-type natriuretic peptide measurement, nitrates administration in excessive afterload and/or myocardial ischemia, contractility improvement in severe systolic dysfunction as well as other rational treatment in specific indications in order to lead to successful weaning from mechanical ventilation.
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Affiliation(s)
- Christina Routsi
- First Department of Critical Care, Medical School, National and Kapodistrian University of Athens, “Evangelismos” Hospital, Ipsilantou 45-47, 10676 Athens, Greece
| | - Ioannis Stanopoulos
- Respiratory Failure Unit, Medical School, “G. Papanikolaou” Hospital, Aristotle University, Thessaloníki, Greece
| | - Stelios Kokkoris
- First Department of Critical Care, Medical School, National and Kapodistrian University of Athens, “Evangelismos” Hospital, Ipsilantou 45-47, 10676 Athens, Greece
| | - Antonios Sideris
- Department of Cardiology, “Evangelismos” Hospital, Athens, Greece
| | - Spyros Zakynthinos
- First Department of Critical Care, Medical School, National and Kapodistrian University of Athens, “Evangelismos” Hospital, Ipsilantou 45-47, 10676 Athens, Greece
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177
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Oliveira SMR, Novais RMF, Carvalho AADS. IMPACT OF A VENTILATORY WEANING PROTOCOL IN AN INTENSIVE CARE UNIT FOR ADULTS. TEXTO & CONTEXTO ENFERMAGEM 2019. [DOI: 10.1590/1980-265x-tce-2018-0287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective: to evaluate the impact of a ventilatory weaning protocol on the weaning quality and on the outcomes of the patients. Method: a quasi-experimental quantitative study, consisting of comparing a prospective study with a retrospective study. Data was collected through a weaning log sheet applied between September and December 2015 at an intensive care unit in northern Portugal following the implementation of a weaning protocol and compared with a base-line constituted in the year preceding the implementation of the ventilatory weaning protocol. Results: the experimental group had a score mean of higher overall quality of weaning, with a reduction in the timing for initiating the weaning in 27.3% and the weaning time in 36.6%. Conclusion: the implementation of the ventilatory weaning protocol improved the overall quality of the weaning, facilitating the identification of patients with criteria to initiate the process, starting earlier, resulting in a reduction in ventilatory weaning time.
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178
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Trauma and emergency general surgery patients should be extubated with an open abdomen. J Trauma Acute Care Surg 2018; 85:1043-1047. [DOI: 10.1097/ta.0000000000002064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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179
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Duan J, Bai L, Zhou L, Han X, Huang S. Decreasing re-intubation using prophylactic noninvasive ventilation in elderly patients: A propensity-matched study. J Crit Care 2018; 50:77-81. [PMID: 30500567 DOI: 10.1016/j.jcrc.2018.11.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 10/23/2018] [Accepted: 11/20/2018] [Indexed: 01/19/2023]
Abstract
PURPOSE Prophylactic noninvasive ventilation (NIV) reduces re-intubation in high-risk patients. However, its effects in elderly patients remain unclear. Here, we investigated the efficacy of prophylactic NIV in elderly patients after a planned extubation. MATERIALS AND METHODS From January 2011 to December 2017, patients aged ≥65 years old were enrolled after completing an SBT. After extubation, patients who immediately received NIV were classified as the prophylactic NIV group, and those who did not were classified as the control group. Re-intubation was recorded at postextubation 72 h. RESULTS We enrolled 171 and 120 patients in the NIV and control groups, respectively. Patients in the NIV group had a lower re-intubation rate (6.4% vs. 23.3%, p < 0.01) and lower hospital mortality (22.2% vs. 35.8%, p = 0.01) than controls. In addition, prophylactic NIV was an independent protective factor for re-intubation (OR = 0.15, 95% CI: 0.07-0.34, p < 0.01 for all patients; OR = 0.16, 95% CI: 0.05-0.52, p < 0.01 for AECOPD patients, and OR = 0.17, 95% CI: 0.05-0.62, p < 0.01 for pneumonia/ARDS patients). After completing propensity-matched analyses, prophylactic NIV also reduced re-intubation and hospital mortality. CONCLUSIONS Elderly patients received benefits from prophylactic NIV after a planned extubation.
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Affiliation(s)
- Jun Duan
- Department of Respiratory Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, PR China.
| | - Linfu Bai
- Department of Respiratory Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, PR China
| | - Lintong Zhou
- Department of Respiratory Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, PR China
| | - Xiaoli Han
- Department of Respiratory Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, PR China
| | - Shicong Huang
- Department of Respiratory Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, PR China
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180
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Variation of Risk Factors for Cause-Specific Reintubation: A Preliminary Study. Can Respir J 2018; 2018:3654251. [PMID: 30510604 PMCID: PMC6230426 DOI: 10.1155/2018/3654251] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 09/21/2018] [Accepted: 10/04/2018] [Indexed: 11/17/2022] Open
Abstract
Unexpected reintubation may occur, even if the risk factors are considered and a spontaneous breathing trial is successful. Reintubation is thought to be caused by various factors. Several studies have investigated the risk factors of reintubation, but most did not classify reintubation by cause. We retrospectively classified patients undergoing reintubation at intensive care unit by cause (respiratory insufficiency vs. nonrespiratory insufficiency) to examine the cause-specific risk factors of reintubation. A total of 262 patients were included; reintubation within 48 hours after extubation was performed in 12 patients (reintubation rate, 4.5%). After classification by cause of reintubation, the pressure of arterial oxygen to fractional inspired oxygen concentration (P/F) ratio exhibited a significant association with reintubation only in the respiratory insufficiency group (odds ratio (OR) 0.989, 95% confidence interval (CI) 0.980 to 0.999, p=0.036, and OR 0.989, 95% CI 0.979 to 0.999, p=0.026, in the univariate and multivariate analyses, respectively). In the propensity score analysis, a P/F ratio ≤ 200 may be a risk factor for reintubation in the respiratory insufficiency group (OR 7.811, 95% CI 1.345 to 45.367, p=0.022). In the nonrespiratory insufficiency group, intubation duration was significantly related to reintubation (OR 1.165, 95% CI 1.012 to 1.342, p=0.033, and OR 1.163, 95% CI 1.004 to 1.348, p=0.044, in the univariate and multivariate analyses, respectively). In conclusion, a low P/F ratio at extubation may be a risk factor for reintubation due to respiratory insufficiency. In the nonrespiratory insufficiency group, intubation duration may be significantly related to reintubation. The risk factors for reintubation may differ by the cause of reintubation. Further large-scale randomized controlled trials are required.
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181
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Saiphoklang N, Auttajaroon J. Incidence and outcome of weaning from mechanical ventilation in medical wards at Thammasat University Hospital. PLoS One 2018; 13:e0205106. [PMID: 30286153 PMCID: PMC6171918 DOI: 10.1371/journal.pone.0205106] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 09/16/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Weaning from mechanical ventilation is classified as simple, difficult, or prolonged according to weaning process. Theoretically, simple weaning group usually has better clinical outcomes than non-simple group; however, the results of previous studies were still inconsistent. OBJECTIVES The purpose of the study was to determine the incidence, predictors, and outcomes of ventilator weaning and causes of weaning failure. METHODS A prospective observational study was performed between June and December 2013 in all patients (n = 164) who required mechanical ventilation with endotracheal intubation in medical wards at Thammasat University Hospital, Thailand. Duration of weaning, causes of weaning failure, extubation, reintubation, tracheostomy, number of ventilator-free days within 28 days, length of hospital stay, and hospital mortality were measured. RESULTS 103 patients were eligible for final analysis. Mean ± SD age was 65.1±17.5 years and 55.3% were males. The incidences of simple, difficult and prolonged weaning were 46.6%, 36.9% and 16.5%, respectively. The mortality rates for simple, difficult, and prolonged weaning were 0%, 10.5% and 23.5% (p = 0.006), respectively. The 3 causes of weaning failure in non-simple weaning were bronchospasm, pneumonia, and malnutrition. CONCLUSIONS Non-simple weaning increased mortality. Bronchospasm, pneumonia, and malnutrition were key risk factors for weaning failure. Strategies are needed to minimize their effects.
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Affiliation(s)
- Narongkorn Saiphoklang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
- * E-mail:
| | - Jeerayuth Auttajaroon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
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182
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Jung YT, Kim MJ, Lee JG, Lee SH. Predictors of early weaning failure from mechanical ventilation in critically ill patients after emergency gastrointestinal surgery: A retrospective study. Medicine (Baltimore) 2018; 97:e12741. [PMID: 30290686 PMCID: PMC6200493 DOI: 10.1097/md.0000000000012741] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Mechanical ventilation (MV) is the most common therapeutic modality used for critically ill patients. However, prolonged MV is associated with high morbidity and mortality. Therefore, it is important to avoid both premature extubation and unnecessary prolongation of MV. Although some studies have determined the predictors of early weaning success and failure, only a few have investigated these factors in critically ill surgical patients who require postoperative MV. The aim of this study was to evaluate predictors of early weaning failure from MV in critically ill patients who had undergone emergency gastrointestinal (GI) surgery.The medical records of 3327 adult patients who underwent emergency GI surgery between January 2007 and December 2016 were reviewed retrospectively. Clinical and laboratory parameters before surgery and within 2 days postsurgery were investigated.This study included 387 adult patients who required postoperative MV. A low platelet count (adjusted odds ratio [OR]: 0.995; 95% confidence interval [CI]: 0.991-1.000; P = .03), an elevated delta neutrophil index (DNI; adjusted OR: 1.025; 95% CI: 1.005-1.046; P = .016), a delayed spontaneous breathing trial (SBT; adjusted OR: 14.152; 95% CI: 6.571-30.483; P < .001), and the presence of postoperative shock (adjusted OR: 2.436; 95% CI: 1.138-5.216; P = .022) were shown to predict early weaning failure from MV in the study population.Delayed SBT, a low platelet count, an elevated DNI, and the presence of postoperative shock are independent predictors of early weaning failure from MV in critically ill patients after emergency GI surgery.
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Affiliation(s)
- Yun Tae Jung
- Department of Surgery, Ajou University School of Medicine, Suwon
| | - Myung Jun Kim
- Division of Trauma Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae Gil Lee
- Division of Trauma Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Hwan Lee
- Division of Trauma Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
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183
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Alviar CL, Miller PE, McAreavey D, Katz JN, Lee B, Moriyama B, Soble J, van Diepen S, Solomon MA, Morrow DA. Positive Pressure Ventilation in the Cardiac Intensive Care Unit. J Am Coll Cardiol 2018; 72:1532-1553. [PMID: 30236315 PMCID: PMC11032173 DOI: 10.1016/j.jacc.2018.06.074] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 06/18/2018] [Accepted: 06/19/2018] [Indexed: 12/16/2022]
Abstract
Contemporary cardiac intensive care units (CICUs) provide care for an aging and increasingly complex patient population. The medical complexity of this population is partly driven by an increased proportion of patients with respiratory failure needing noninvasive or invasive positive pressure ventilation (PPV). PPV often plays an important role in the management of patients with cardiogenic pulmonary edema, cardiogenic shock, or cardiac arrest, and those undergoing mechanical circulatory support. Noninvasive PPV, when appropriately applied to selected patients, may reduce the need for invasive mechanical PPV and improve survival. Invasive PPV can be lifesaving, but has both favorable and unfavorable interactions with left and right ventricular physiology and carries a risk of complications that influence CICU mortality. Effective implementation of PPV requires an understanding of the underlying cardiac and pulmonary pathophysiology. Cardiologists who practice in the CICU should be proficient with the indications, appropriate selection, potential cardiopulmonary interactions, and complications of PPV.
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Affiliation(s)
- Carlos L Alviar
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - P Elliott Miller
- Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut; Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Dorothea McAreavey
- Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Jason N Katz
- Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina, Center for Heart and Vascular Care Chapel Hill, Chapel Hill, North Carolina
| | - Burton Lee
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Brad Moriyama
- Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Jeffrey Soble
- Division of Cardiovascular Medicine, Rush University Medical Center, Chicago, Illinois
| | - Sean van Diepen
- Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Michael A Solomon
- Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland; Cardiovascular Branch, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - David A Morrow
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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Jaber S, Quintard H, Cinotti R, Asehnoune K, Arnal JM, Guitton C, Paugam-Burtz C, Abback P, Mekontso Dessap A, Lakhal K, Lasocki S, Plantefeve G, Claud B, Pottecher J, Corne P, Ichai C, Hajjej Z, Molinari N, Chanques G, Papazian L, Azoulay E, De Jong A. Risk factors and outcomes for airway failure versus non-airway failure in the intensive care unit: a multicenter observational study of 1514 extubation procedures. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:236. [PMID: 30243304 PMCID: PMC6151191 DOI: 10.1186/s13054-018-2150-6] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 08/07/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Patients liberated from invasive mechanical ventilation are at risk of extubation failure, including inability to breathe without a tracheal tube (airway failure) or without mechanical ventilation (non-airway failure). We sought to identify respective risk factors for airway failure and non-airway failure following extubation. METHODS The primary endpoint of this prospective, observational, multicenter study in 26 intensive care units was extubation failure, defined as need for reintubation within 48 h following extubation. A multinomial logistic regression model was used to identify risk factors for airway failure and non-airway failure. RESULTS Between 1 December 2013 and 1 May 2015, 1514 patients undergoing extubation were enrolled. The extubation-failure rate was 10.4% (157/1514), including 70/157 (45%) airway failures, 78/157 (50%) non-airway failures, and 9/157 (5%) mixed airway and non-airway failures. By multivariable analysis, risk factors for extubation failure were either common to airway failure and non-airway failure: intubation for coma (OR 4.979 (2.797-8.864), P < 0.0001 and OR 2.067 (1.217-3.510), P = 0.003, respectively, intubation for acute respiratory failure (OR 3.395 (1.877-6.138), P < 0.0001 and OR 2.067 (1.217-3.510), P = 0.007, respectively, absence of strong cough (OR 1.876 (1.047-3.362), P = 0.03 and OR 3.240 (1.786-5.879), P = 0.0001, respectively, or specific to each specific mechanism: female gender (OR 2.024 (1.187-3.450), P = 0.01), length of ventilation > 8 days (OR 1.956 (1.087-3.518), P = 0.025), copious secretions (OR 4.066 (2.268-7.292), P < 0.0001) were specific to airway failure, whereas non-obese status (OR 2.153 (1.052-4.408), P = 0.036) and sequential organ failure assessment (SOFA) score ≥ 8 (OR 1.848 (1.100-3.105), P = 0.02) were specific to non-airway failure. Both airway failure and non-airway failure were associated with ICU mortality (20% and 22%, respectively, as compared to 6% in patients with extubation success, P < 0.0001). CONCLUSIONS Specific risk factors have been identified, allowing us to distinguish between risk of airway failure and non-airway failure. The two conditions will be managed differently, both for prevention and curative strategies. TRIAL REGISTRATION ClinicalTrials.gov, NCT 02450669 . Registered on 21 May 2015.
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Affiliation(s)
- Samir Jaber
- PhyMedExp, University of Montpellier, Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Centre Hospitalier Universitaire Montpellier, 34295, Montpellier, cedex 5, France.
| | - Hervé Quintard
- Université Cote d'Azur, CNRS U7275, CHU de Nice, Service réanimation polyvalente et U 7275, IPMC, Nice, France
| | - Raphael Cinotti
- Intensive Care & Anesthesiology Department, University of Nantes, Hotel-Dieu Hospital, Nantes, France
| | - Karim Asehnoune
- Intensive Care & Anesthesiology Department, University of Nantes, Hotel-Dieu Hospital, Nantes, France
| | | | - Christophe Guitton
- Medical Intensive Care Unit, Hôtel-Dieu Teaching Hospital, Nantes, France
| | - Catherine Paugam-Burtz
- Intensive Care & Anesthesiology Department, Univ Paris Diderot, Sorbonne Paris Cité, AP-HP, Hôpital Beaujon, F-75018, Paris, France
| | - Paer Abback
- Intensive Care & Anesthesiology Department, Univ Paris Diderot, Sorbonne Paris Cité, AP-HP, Hôpital Beaujon, F-75018, Paris, France
| | - Armand Mekontso Dessap
- Service de Réanimation Médicale, DHU A-TVB, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Groupe de Recherche Clinique CARMAS, Faculté de Médecine de Créteil, Université Paris Est Créteil, 94010, Créteil Cedex, France
| | - Karim Lakhal
- Intensive Care & Anesthesiology Department, University of Nantes, Laennec Nord Hospital, Nantes, France
| | - Sigismond Lasocki
- Département Anesthésie Réanimation, CHU Angers, 49933, Angers, Cedex 9, France
| | - Gaetan Plantefeve
- Medical-Surgical Intensive Care Unit, General Hospital Centre, Argenteuil, France
| | - Bernard Claud
- Medical-Surgical Intensive Care Unit, General Hospital Centre, Le Puy-en-Velay, France
| | - Julien Pottecher
- Hôpitaux Universitaires de Strasbourg, Pôle Anesthésie Réanimation Chirurgicale SAMU, Hôpital de Hautepierre, Service d'Anesthésie-Réanimation Chirurgicale, Université de Strasbourg, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Faculté de Médecine, Institut de Physiologie, Equipe d'Accueil EA3072 "Mitochondrie, stress oxydant et protection musculaire", Strasbourg, France
| | - Philippe Corne
- Medical Intensive Care Unit, Montpellier University Hospital, Montpellier, France
| | - Carole Ichai
- Université Cote d'Azur, CNRS U7275, CHU de Nice, Service réanimation polyvalente et U 7275, IPMC, Nice, France
| | - Zied Hajjej
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Centre Hospitalier Universitaire Montpellier, 34295, Montpellier, cedex 5, France
| | - Nicolas Molinari
- IMAG, CNRS, Univ Montpellier, CHU Montpellier, Montpellier, France
| | - Gerald Chanques
- PhyMedExp, University of Montpellier, Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Centre Hospitalier Universitaire Montpellier, 34295, Montpellier, cedex 5, France
| | - Laurent Papazian
- APHM, URMITE UMR CNRS 7278, Hôpital Nord, Réanimation des Détresses Respiratoires et Infections Sévères, Aix-Marseille Univ, Marseille, France
| | - Elie Azoulay
- Medical Intensive Care Unit, University of Paris-Diderot, Saint Louis Hospital, Paris, France
| | - Audrey De Jong
- PhyMedExp, University of Montpellier, Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Centre Hospitalier Universitaire Montpellier, 34295, Montpellier, cedex 5, France
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Chittawatanarat K, Orrapin S, Jitkaroon K, Mueakwan S, Sroison U. An Open Label Randomized Controlled Trial to Compare Low Level Pressure Support and T-piece as Strategies for Discontinuation of Mechanical Ventilation in a General Surgical Intensive Care Unit. ACTA ACUST UNITED AC 2018; 72:51-57. [PMID: 29416219 PMCID: PMC5789559 DOI: 10.5455/medarh.2018.72.51-57] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objective The purpose of this study was to compare the efficacy of continuous low pressure support (PSV) and T-piece as strategies for discontinuation of mechanical ventilation and extubation in a surgical ICU. Patients and Methods This was a prospective open label randomized control study in surgical ICU patients who were intubated, mechanically ventilated, and who met criteria for a spontaneous breathing trial. Eligible, enrolled patients were randomized to receive low-level pressure supportup to 7 cmH2O (PSV) or T-piece as the mode of their spontaneous breathing trial. Results A total of 520 patients were randomized (260 in PSV group and 260 in T-piece group). There were no differences between the groups in baseline characteristics except duration of MV before trial was longer in PSV group. There were also no differences in hemodynamic and respiratory measures between groups. The PSV had a significant higher number of SBT attempt before success and extubation. After extubation, the re-intubation within 48 hours had a lower trend in PSV group (PSV vs. T-piece: 10% vs. 14.6%; p=0.11). The pneumonia occurrence, hospital mortality, hospital and ICU length of stay were not significant different between groups. In multivariable analysis, PSV was associated with a lower risk of success at the first SBT (adjusted relative risk, RR 0.79 [95% confidence interval, CI, 0.70 - 0.88]; p<0.001], and a lower risk of re-intubation within 48 hours after extubation (adjusted RR 0.62 [95%CI 0.40 - 0.98]; p=0.04). There were no differences between groups in pneumonia after extubation and in hospital mortality rate. Conclusion Although PSV needs a higher number of SBT trial before success and extubation, the re-intubation within 48 hours is lower than T piece. However, there were no differences between the groups in term of pneumonia after extubation, hospital mortality as well as ICU and hospital length of stay.
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Affiliation(s)
- Kaweesak Chittawatanarat
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Maharaj Nakorn Chiang Mai Hospital, Sripume district, Chiang Mai, Thailand
| | - Sariphat Orrapin
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Maharaj Nakorn Chiang Mai Hospital, Sripume district, Chiang Mai, Thailand
| | - Karuna Jitkaroon
- Surgical Intensive Care and Critical Care Unit, Division of Surgical Nursing, Faculty of Medicine, Chiang Mai University, Maharaj Nakorn Chiang Mai Hospital, Sripume, Chiang Mai, Thailand
| | - Sirirat Mueakwan
- Surgical Intensive Care and Critical Care Unit, Division of Surgical Nursing, Faculty of Medicine, Chiang Mai University, Maharaj Nakorn Chiang Mai Hospital, Sripume, Chiang Mai, Thailand
| | - Ubolrat Sroison
- Surgical Intensive Care and Critical Care Unit, Division of Surgical Nursing, Faculty of Medicine, Chiang Mai University, Maharaj Nakorn Chiang Mai Hospital, Sripume, Chiang Mai, Thailand
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186
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Thille AW, Muller G, Gacouin A, Coudroy R, Demoule A, Sonneville R, Beloncle F, Girault C, Dangers L, Lautrette A, Cabasson S, Rouzé A, Vivier E, Le Meur A, Ricard JD, Razazi K, Barberet G, Lebert C, Ehrmann S, Picard W, Bourenne J, Pradel G, Bailly P, Terzi N, Buscot M, Lacave G, Danin PE, Nanadoumgar H, Gibelin A, Zanre L, Deye N, Ragot S, Frat JP. High-flow nasal cannula oxygen therapy alone or with non-invasive ventilation during the weaning period after extubation in ICU: the prospective randomised controlled HIGH-WEAN protocol. BMJ Open 2018; 8:e023772. [PMID: 30185583 PMCID: PMC6129104 DOI: 10.1136/bmjopen-2018-023772] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Recent practice guidelines suggest applying non-invasive ventilation (NIV) to prevent postextubation respiratory failure in patients at high risk of extubation failure in intensive care unit (ICU). However, such prophylactic NIV has been only a conditional recommendation given the low certainty of evidence. Likewise, high-flow nasal cannula (HFNC) oxygen therapy has been shown to reduce reintubation rates as compared with standard oxygen and to be as efficient as NIV in patients at high risk. Whereas HFNC may be considered as an optimal therapy during the postextubation period, HFNC associated with NIV could be an additional means of preventing postextubation respiratory failure. We are hypothesising that treatment associating NIV with HFNC between NIV sessions may be more effective than HFNC alone and may reduce the reintubation rate in patients at high risk. METHODS AND ANALYSIS This study is an investigator-initiated, multicentre randomised controlled trial comparing HFNC alone or with NIV sessions during the postextubation period in patients at high risk of extubation failure in the ICU. Six hundred patients will be randomised with a 1:1 ratio in two groups according to the strategy of oxygenation after extubation. The primary outcome is the reintubation rate within the 7 days following planned extubation. Secondary outcomes include the number of patients who meet the criteria for moderate/severe respiratory failure, ICU length of stay and mortality up to day 90. ETHICS AND DISSEMINATION The study has been approved by the ethics committee and patients will be included after informed consent. The results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03121482.
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Affiliation(s)
- Arnaud W Thille
- Department of Réanimation Médicale, CHU de Poitiers, Poitiers, France
- Université de Poitiers, INSERM CIC 1402 ALIVE, Poitiers, France
| | - Grégoire Muller
- Médecine Intensive Réanimation, Groupe Hospitalier Régional d'Orléans, Orléans, France
| | - Arnaud Gacouin
- Service des Maladies Infectieuses et Réanimation Médicale, CHU de Rennes, Hôpital Ponchaillou, Rennes, France
| | - Rémi Coudroy
- Department of Réanimation Médicale, CHU de Poitiers, Poitiers, France
- Université de Poitiers, INSERM CIC 1402 ALIVE, Poitiers, France
| | - Alexandre Demoule
- Service de Pneumologie et Réanimation Médicale du Département R3S, AP-HP, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris, France
| | - Romain Sonneville
- Hôpital Bichat - Claude Bernard, Médecine Intensive Réanimation, AP-HP, Université Paris Diderot, Paris, France
| | - François Beloncle
- Département de Médecine Intensive - Réanimation, Université d'Angers, CHU d'Angers, Angers, France
| | - Christophe Girault
- Département de Réanimation Médicale, Normandie Université, UNIROUEN, EA3830-GRHV, Institute for Research and Innovation in Biomedicine (IRIB), CHU de Rouen, Hôpital Charles Nicolle, Rouen, France
| | - Laurence Dangers
- Service de Réanimation Polyvalente, CHU Félix Guyon, Saint Denis de la Réunion, France
| | - Alexandre Lautrette
- Service de Réanimation Médicale, CHU de Clermont-Ferrand, Hôpital Gabriel Montpied, Clermont-Ferrand, France
| | - Séverin Cabasson
- Service de Réanimation, Centre hospitalier de la Rochelle, La Rochelle, Nouvelle-Aquitaine, France
| | - Anahita Rouzé
- Centre de Réanimation, Université de Lille, CHU de Lille, Lille, France
| | - Emmanuel Vivier
- Reanimation Polyvalente, Hôpital Saint Joseph Saint Luc, Lyon, France
| | - Anthony Le Meur
- Médecine Intensive Réanimation, CHU de Nantes, Nantes, France
| | - Jean-Damien Ricard
- Réanimation Médico-Chirurgicale, AP-HP, INSERM, Université Paris Diderot, UMR IAME 1137, Sorbonne Paris Cité, Hopital Louis-Mourier, Colombes, France
| | - Keyvan Razazi
- Service de Réanimation Médicale DHU A-TVB, AP-HP, Hopitaux Universitaires Henri Mondor, Creteil, Île-de-France, France
| | - Guillaume Barberet
- Service de Réanimation Médicale, Groupe Hospitalier Régional Mulhouse Sud Alsace, Site Emile Muller, Mulhouse, France
| | - Christine Lebert
- Service de Médecine Intensive et Réanimation, Centre Hospitalier Départemental de Vendée, La Roche-sur-Yon, France
| | - Stephan Ehrmann
- CHU de Tours, Médecin Intensive Réanimation, CIC 1415, CRICS-TriggerSEP, Centre d'étude des pathologies respiratoires, INSERM U1100, Université de Tours, Tours, France
| | - Walter Picard
- Service de Réanimation, Centre Hospitalier de Pau, Pau, France
| | - Jeremy Bourenne
- CHU La Timone 2, Médecine Intensive Réanimation, Réanimation des Urgences, Aix-Marseille Université, Marseille, France
| | - Gael Pradel
- Service de Réanimation, Centre Hospitalier Henri Mondor d'Aurillac, Aurillac, France
| | - Pierre Bailly
- Médecine Intensive Réanimation, CHU de Brest, Brest, France
| | - Nicolas Terzi
- Médecine Intensive Réanimation, INSERM, Université Grenoble-Alpes, U1042, HP2, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Matthieu Buscot
- Réanimation Médicale Archet 1, Université Cote d'Azur, CHU de Nice, Nice, France
| | - Guillaume Lacave
- Service de Réanimation Médico-Chirurgicale, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Pierre-Eric Danin
- Réanimation Médico-Chirurgicale Archet 2, INSERM U 1065, CHU de Nice, Nice, France
| | | | - Aude Gibelin
- Réanimation et USC médico-chirurgicale, CARMAS, AP-HP, Faculté de Médecine Sorbonne Université, Collegium Galilée, Hopital Tenon, Paris, France
| | - Lassane Zanre
- Service de Réanimation, Centre Hospitalier Emile Roux, Le Puy-en-Velay, France
| | - Nicolas Deye
- Réanimation Médicale et Toxicologique, AP-HP, INSERM UMR-S 942, Hopital Lariboisiere, Paris, France
| | - Stéphanie Ragot
- Université de Poitiers, INSERM CIC 1402 ALIVE, Poitiers, France
| | - Jean-Pierre Frat
- Department of Réanimation Médicale, CHU de Poitiers, Poitiers, France
- Université de Poitiers, INSERM CIC 1402 ALIVE, Poitiers, France
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Di Mussi R, Spadaro S, Stripoli T, Volta CA, Trerotoli P, Pierucci P, Staffieri F, Bruno F, Camporota L, Grasso S. High-flow nasal cannula oxygen therapy decreases postextubation neuroventilatory drive and work of breathing in patients with chronic obstructive pulmonary disease. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:180. [PMID: 30071876 PMCID: PMC6091018 DOI: 10.1186/s13054-018-2107-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 06/22/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The physiological effects of high-flow nasal cannula O2 therapy (HFNC) have been evaluated mainly in patients with hypoxemic respiratory failure. In this study, we compared the effects of HFNC and conventional low-flow O2 therapy on the neuroventilatory drive and work of breathing postextubation in patients with a background of chronic obstructive pulmonary disease (COPD) who had received mechanical ventilation for hypercapnic respiratory failure. METHODS This was a single center, unblinded, cross-over study on 14 postextubation COPD patients who were recovering from an episode of acute hypercapnic respiratory failure of various etiologies. After extubation, each patient received two 1-h periods of HFNC (HFNC1 and HFNC2) alternated with 1 h of conventional low-flow O2 therapy via a face mask. The inspiratory fraction of oxygen was titrated to achieve an arterial O2 saturation target of 88-92%. Gas exchange, breathing pattern, neuroventilatory drive (electrical diaphragmatic activity (EAdi)) and work of breathing (inspiratory trans-diaphragmatic pressure-time product per minute (PTPDI/min)) were recorded. RESULTS EAdi peak increased from a mean (±SD) of 15.4 ± 6.4 to 23.6 ± 10.5 μV switching from HFNC1 to conventional O2, and then returned to 15.2 ± 6.4 μV during HFNC2 (conventional O2: p < 0.05 versus HFNC1 and HFNC2). Similarly, the PTPDI/min increased from 135 ± 60 to 211 ± 70 cmH2O/s/min, and then decreased again during HFNC2 to 132 ± 56 (conventional O2: p < 0.05 versus HFNC1 and HFNC2). CONCLUSIONS In patients with COPD, the application of HFNC postextubation significantly decreased the neuroventilatory drive and work of breathing compared with conventional O2 therapy.
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Affiliation(s)
- Rosa Di Mussi
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Ospedale Policlinico, Università degli Studi di Bari "Aldo Moro", Piazza Giulio Cesare 11, Bari, Italy
| | - Savino Spadaro
- Dipartimento di Morfologia, Chirurgia e Medicina Sperimentale, Sezione di Anestesiologia e Terapia Intensiva Universitaria, Università degli studi di Ferrara, Ferrara, Italy
| | - Tania Stripoli
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Ospedale Policlinico, Università degli Studi di Bari "Aldo Moro", Piazza Giulio Cesare 11, Bari, Italy
| | - Carlo Alberto Volta
- Dipartimento di Morfologia, Chirurgia e Medicina Sperimentale, Sezione di Anestesiologia e Terapia Intensiva Universitaria, Università degli studi di Ferrara, Ferrara, Italy
| | - Paolo Trerotoli
- Dipartimento di Scienze Biomediche ed Oncologia Umana, Cattedra di Statistica Medica, Università degli Studi Aldo Moro, Bari, Italy
| | - Paola Pierucci
- Dipartimento di Medicina Respiratoria e del Sonno, Università degli Studi di Bari "Aldo Moro", Bari, Italy
| | - Francesco Staffieri
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Chirurgia Veterinaria, Università degli Studi di Bari "Aldo Moro", Bari, Italy
| | - Francesco Bruno
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Ospedale Policlinico, Università degli Studi di Bari "Aldo Moro", Piazza Giulio Cesare 11, Bari, Italy
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, and Division of Centre of Human Applied Physiological Sciences, King's College London, London, UK
| | - Salvatore Grasso
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Ospedale Policlinico, Università degli Studi di Bari "Aldo Moro", Piazza Giulio Cesare 11, Bari, Italy.
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188
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Lung-thorax compliance measured during a spontaneous breathing trial is a good index of extubation failure in the surgical intensive care unit: a retrospective cohort study. J Intensive Care 2018; 6:44. [PMID: 30083347 PMCID: PMC6069862 DOI: 10.1186/s40560-018-0313-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 07/18/2018] [Indexed: 01/27/2023] Open
Abstract
Background Extubation failure is associated with mortality and morbidity in the intensive care unit. Ventilator weaning protocols have been introduced, and extubation is conducted based on the results of a spontaneous breathing trial. Room for improvement still exists in extubation management, and additional objective indices may improve the safety of the weaning and extubation process. Static lung-thorax compliance reflects lung expansion difficulty that is caused by several conditions, such as atelectasis, fibrosis, and pleural effusion. Nevertheless, it is not used commonly in the weaning and extubation process. In this study, we investigated whether lung-thorax compliance is a good index of extubation failure in adults even when patients pass a spontaneous breathing trial. Methods In a single-center, retrospective cohort study, patients over 18 years of age were mechanically ventilated, weaned with proportional assist ventilation, and underwent a spontaneous breathing trial process in surgical intensive care units of Kagawa University Hospital from July 2014 to June 2016. Extubation failure was the outcome measure of the study. We defined extubation failures as when patients were reintubated or underwent non-invasive positive-pressure ventilation within 24 h after extubation. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the clinical involvement of several parameters. The area under the curve (AUC) was calculated to assess the discriminative power of the parameters. Results We analyzed 173 patients and compared the success and failure groups. Most patients (162, 93.6%) were extubated successfully, and extubation failed in 11 patients (6.4%). The averages of lung-thorax compliance values in the success and failure groups were 71.9 ± 23.0 and 43.3 ± 14.6 mL/cmH2O, respectively, and were significantly different (p < 0.0001). In the ROC curve analysis, the AUC was highest for lung-thorax compliance (0.862), followed by the respiratory rate (0.821), rapid shallow breathing index (0.781), Acute Physiology and Chronic Health Evaluation II score (0.72), heart rate (0.715), and tidal volume (0.695). Conclusions Lung-thorax compliance measured during a spontaneous breathing trial is a potential indicator of extubation failure in postoperative patients.
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189
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Hu X, Zhang Y, Cao Y, Huang G, Hu Y, McArthur A. Prevention of neonatal unplanned extubations in the neonatal intensive care unit: a best practice implementation project. ACTA ACUST UNITED AC 2018; 15:2789-2798. [PMID: 29135753 DOI: 10.11124/jbisrir-2016-003249] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Adverse events of mechanically ventilated neonates such as unplanned extubations may be associated with serious negative outcomes. Unplanned extubation rates have been monitored by many neonatal intensive care units as a quality of care metric. OBJECTIVES The objective was to implement evidence-based best practice and assess the effects of these strategies on minimizing unplanned extubation in the neonatal intensive care unit in a large tertiary children's hospital. METHODS Evidence-based audit criteria were used to conduct an audit in the neonatal intensive care unit, Children's Hospital of Fudan University, Shanghai. The program included three phases and was conducted from May 2016 to October 2016. The Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice audit tools for promoting change in health practice were used to ascertain compliance with the criteria before and after the implementation of best practice. RESULTS Compared with the baseline audit, the follow-up audit results demonstrated increased compliance rates for securement procedures, documentation of position and security of the endotracheal tube. Compliance for standardized care practice documentation increased from 0% to 100%; compliance for standard care practice implementation increased from 0% to 54.9%; and compliance for staff education increased from 66.7% to 100%. The neonatal intensive care unit also achieved the benchmark of less than one UE per 100 intubation days. CONCLUSIONS This implementation project achieved a significant improvement in establishing evidence-based prevention of unplanned extubations in the neonatal intensive care unit of Children's Hospital of Fudan University, China. Standardizing the procedures represented an important step toward refining the quality improvement process.
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Affiliation(s)
- Xiaojing Hu
- 1Children's Hospital of Fudan University, Shanghai, P.R. China 2Fudan University Centre for Evidence-based Nursing: a Joanna Briggs Institute Centre of Excellence 3The Joanna Briggs Institute, Faculty of Health and Medical Sciences, The University of Adelaide, Australia
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Attaallah AF, Vallejo MC, Elzamzamy OM, Mueller MG, Eller WS. Perioperative risk factors for postoperative respiratory failure. J Perioper Pract 2018; 29:49-53. [PMID: 30035690 DOI: 10.1177/1750458918788978] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The study aimed to identify the risk factors for respiratory failure after surgery. Postoperative respiratory failure (PRF) was defined as prolonged intubation after surgery or reintubation after unsuccessful extubation. We conducted a retrospective analysis of the following risk factors: age, obesity as reflected by body mass index (BMI), gender, patient admitted to hospital (in-patient status) vs. outpatient surgery, smoking, hypertension, chronic obstructive pulmonary disease (COPD), diabetes, abnormal liver function, anaemia, respiratory infection, physical condition as reflected by ASA class, case type (elective or emergency), anaesthesia type, and surgical duration. The incidence of PRF was found to be 2.4%. Independent risk factors were older age, inpatient status, hypertension, COPD, elective procedure, surgical duration >2 hours, and ASA class ≥3. The study concludes that PRF results in significant postoperative complications. Minimising these risks is essential in improving PRF and subsequently surgical outcomes.
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Affiliation(s)
| | - Manuel C Vallejo
- 2 Departments of Medical Education and Anesthesiology, School of Medicine, West Virginia University, Morgantown, WV
| | - Osama M Elzamzamy
- 3 Clinical and Translational Sciences Institute, West Virginia University, Morgantown, WV
| | - Michael G Mueller
- 4 Department of Health Policy, School of Public Health, West Virginia University, Management, and Leadership, Morgantown, WV
| | - Warren S Eller
- 4 Department of Health Policy, School of Public Health, West Virginia University, Management, and Leadership, Morgantown, WV
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FRIEND or FOE: A prospective evaluation of risk factors for reintubation in surgical and trauma patients. Am J Surg 2018; 216:1056-1062. [PMID: 30017306 DOI: 10.1016/j.amjsurg.2018.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 06/28/2018] [Accepted: 07/06/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND A Form for Re-Intubation Evaluation by Nurses and Doctors (FRIEND) was used to prospectively collect pre-extubation data, to determine failure of extubation (FOE) risk. METHODS FRIENDs, including airway, breathing, and neurologic variables, were completed before extubation on trauma & surgical patients in one ICU from 1/1/16 to 5/31/17. Those with failed vs. successful extubation were compared. We excluded those with tracheostomy, comfort measures, or death before extubation. RESULTS There were 464 eligible extubations in 436 patients. Thirty five reintubations (7.9% FOE rate) occurred in 32 patients within 96 h of extubation. FOE patients had higher ICU days (6 d vs. 2 d), ventilator days (6 d vs. 2 d), and mortality (15.6% vs. 2.7%) [all p < 0.001] compared to those without FOE. Odds of FOE (OR [CI]) increased with age (1.03, [1, 1.06]), delirium (3, [1.16, 7.76]), moderate/copious secretions (3.95, [1.46, 10.66]), and enteral opioid use (4.23, [1.28, 14.02]). CONCLUSIONS Several characteristics present at the time of extubation were risk factors for FOE in trauma and surgical patients. Patients with FOE had higher mortality.
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192
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Tenza-Lozano E, Llamas-Alvarez A, Jaimez-Navarro E, Fernández-Sánchez J. Lung and diaphragm ultrasound as predictors of success in weaning from mechanical ventilation. Crit Ultrasound J 2018; 10:12. [PMID: 29911284 PMCID: PMC6004341 DOI: 10.1186/s13089-018-0094-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Accepted: 05/02/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Lung and diaphragm ultrasound methods have recently been introduced to predict the outcome of weaning from mechanical ventilation (MV). The aim of this study is to assess the reliability and accuracy of these techniques for predicting successful weaning in critically ill adults. METHODS We conducted two studies: a cross-sectional interobserver agreement study between two sonographers and a prospective cohort study to assess the accuracy of lung and diaphragm ultrasound for predicting weaning and extubation outcome. For the interobserver agreement study, we included 50 general critical care patients who were consecutively admitted to the ICU. For the predictive accuracy study, we included consecutively 69 patients on MV who were ready for weaning. We assessed interobserver agreement of ultrasound measurements, using the weighted kappa coefficient for LUSm score (modified lung ultrasound score) and the intraclass correlation coefficient (ICC) and Bland-Altman method for TI (diaphragm thickening index). We assessed the predictive value of LUSm and TI in weaning outcome by plotting the corresponding ROC curves. RESULTS We found adequate interobserver agreement for both LUSm (weighted kappa 0.95) and TI (ICC 0.78, difference according to Bland-Altman analysis ± 12.5%). LUSm showed good-moderate discriminative power for successful weaning and extubation (area under the ROC curve (AUC) for successful weaning 0.80, and sensitivity and specificity at optimal cut-off point 0.76 and 0.73, respectively; AUC for successful extubation 0.78, and optimal sensitivity and specificity 0.76 and 0.47, respectively. TI was more sensitive but less specific for predicting successful weaning (AUC 0.71, optimal sensitivity and specificity 0.93 and 0.48) and successful extubation (AUC 0.76, optimal sensitivity and specificity 0.93 and 0.58). The area under the ROC curve for predicting weaning success was 0.83 for both ultrasound measurements together. CONCLUSIONS Interobserver agreement was excellent for LUSm and moderate-good for TI. A low TI value or high LUSm value indicates high risk of weaning failure.
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Affiliation(s)
- Eva Tenza-Lozano
- Intensive Care Unit, Department of Intensive Care Medicine, Elche General University Hospital, Camino de la Almazara 11, 03203, Elche, Spain.
| | - Ana Llamas-Alvarez
- Intensive Care Unit, Department of Intensive Care Medicine, Elche General University Hospital, Camino de la Almazara 11, 03203, Elche, Spain
| | - Enrique Jaimez-Navarro
- Intensive Care Unit, Department of Intensive Care Medicine, Elche General University Hospital, Camino de la Almazara 11, 03203, Elche, Spain
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193
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Abbas A, Embarak S, Walaa M, Lutfy SM. Role of diaphragmatic rapid shallow breathing index in predicting weaning outcome in patients with acute exacerbation of COPD. Int J Chron Obstruct Pulmon Dis 2018; 13:1655-1661. [PMID: 29849456 PMCID: PMC5967374 DOI: 10.2147/copd.s161691] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background The diaphragmatic rapid shallow breathing index (D-RSBI), which is the ratio between respiratory rate (RR) and the ultrasonographic evaluation of diaphragmatic displacement (DD), is a new and promising tool to predict weaning outcome. Its accuracy in predicting weaning failure, in ready-to-wean acute exacerbation COPD (AECOPD) patients, needs to be evaluated. Patients and methods A prospective observational study was carried out on ready-to-wean AECOPD patients. During a T-tube spontaneous breathing trial (SBT) evaluation of the right hemidiaphragm displacement (ie, DD), M-mode ultrasonography to calculate the D-RSBI, as well as the RSBI (RR/tidal volume [VT]) were carried out simultaneously. Outcome of the weaning trial was recorded. Receiver operating characteristic (ROC) curves were used to evaluate the diagnostic accuracy of D-RSBI and RSBI. Results A total of 50 AECOPD patients requiring mechanical ventilation for more than 48 h who were ready to perform a SBT were included. Of these, 37 (74%) were successfully liberated from mechanical ventilation. Among the 13 patients who failed the weaning trial, 8 (62%) failed the SBT and reconnected to the ventilator, 2 (15%) were reintubated within 48 h of extubation and 3 (23%) required NIV support within 48 h of extubation. The areas under the ROC curves for D-RSBI and RSBI were 0.97 (p<0.001) and 0.67 (p<0.06), respectively. Conclusion D-RSBI (RR/DD) is superior to the traditional RSBI (RR/VT) in predicting weaning outcome in AECOPD patients.
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Affiliation(s)
- Ahmad Abbas
- Chest Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Sameh Embarak
- Chest Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Mohammad Walaa
- Chest Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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194
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Kim M, Rhim SC, Roh SW, Jeon SR. Analysis of the Risk Factors Associated with Prolonged Intubation or Reintubation after Anterior Cervical Spine Surgery. J Korean Med Sci 2018; 33:e77. [PMID: 29686594 PMCID: PMC5909108 DOI: 10.3346/jkms.2018.33.e77] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 12/12/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Standardized postoperative airway management is essential for patients undergoing anterior cervical spine surgery (ACSS). The paucity of clinical series evaluating these airway complications after ACSS has been resulted in a significant limitation in statistical analyses. METHODS A retrospective cohort study was performed regarding airway distress (intubation for more than 24 hours or unplanned reintubation within 7 days of operation) developed after ACSS. If prevertebral soft tissue swelling was evident after the operation, patients were managed with prolonged intubation (longer than 24 hours). Preoperative and intraoperative patient data, and postoperative outcome (time to extubation and reintubation) were analyzed. RESULTS Between 2008 and 2016, a total of 400 ACSS were performed. Of them, 389 patients (97.25%) extubated within 24 hours of surgery without airway complication, but 11 patients (2.75%) showed postoperative airway compromise; 7 patients (1.75%) needed prolonged intubation, while 4 patients (1.00%) required unplanned reintubation. The mean time for extubation were 2.75 hours (range: 0-23 hours) and 50.55 hours (range: 0-250 hours), respectively. Age (P = 0.015), diabetes mellitus (P = 0.003), operative time longer than 5 hours (P = 0.048), and estimated blood loss (EBL) greater than 300 mL (P = 0.042) were associated with prolonged intubation or reintubation. In prolonged intubation group, all patients showed no airway distress after extubation. CONCLUSION In ACSS, postoperative airway compromise is related to both patients and operative factors. We recommend a prolonged intubation for patients who are exposed to these risk factors to perform a safe and effective extubation.
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Affiliation(s)
- Moinay Kim
- Department of Neurological Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seung Chul Rhim
- Department of Neurological Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sung Woo Roh
- Department of Neurological Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sang Ryong Jeon
- Department of Neurological Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Jeong BH, Nam J, Ko MG, Chung CR, Suh GY, Jeon K. Impact of limb weakness on extubation failure after planned extubation in medical patients. Respirology 2018; 23:842-850. [PMID: 29641839 DOI: 10.1111/resp.13305] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 03/14/2018] [Accepted: 03/15/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Limb muscle weakness is associated with difficult weaning. However, there are limited data on extubation failure. The objective of this cohort study was to evaluate the association between limb muscle weakness according to the Medical Research Council (MRC) scale and extubation failure rates among patients in a medical intensive care unit (ICU). METHODS All consecutive medical ICU patients who were mechanically ventilated for more than 24 h and who were weaned according to protocol were prospectively registered, and limb muscle weakness was assessed using the MRC scale on the day of planned extubation. Association of limb muscle weakness with extubation failure within 48 h following planned extubation was evaluated with logistic regression analysis. RESULTS Over the study period, 377 consecutive patients underwent planned extubation through a standardized weaning process. Extubation failure occurred in 106 (28.1%) patients. Median scores on the MRC scale for four limbs were lower in patients with extubation failure (14, interquartile range (IQR) 12-16) than in patients without extubation failure (16, IQR 12-18; P = 0.024). In addition, extubation failure rates decreased significantly with increasing quartiles of MRC scores (P for trend <0.001). In multivariable analysis, MRC scores ≤10 points were independently associated with extubation failure within 48 h (adjusted OR 2.131, 95% CI: 1.071-4.240, P = 0.031). CONCLUSION Limb muscle weakness assessed on the day of extubation was found to be independently associated with higher extubation failure rates within 48 h following planned extubation in medical patients.
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Affiliation(s)
- Byeong-Ho Jeong
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jimyoung Nam
- Intensive Care Unit Nursing Department, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Myeong Gyun Ko
- Intensive Care Unit Nursing Department, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gee Young Suh
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyeongman Jeon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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196
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Dres M, Demoule A. Diaphragm dysfunction during weaning from mechanical ventilation: an underestimated phenomenon with clinical implications. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:73. [PMID: 29558983 PMCID: PMC5861656 DOI: 10.1186/s13054-018-1992-2] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2018. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2018. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
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Affiliation(s)
- Martin Dres
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France. .,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département ″R3S″), Paris, France.
| | - Alexandre Demoule
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département ″R3S″), Paris, France
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Thille AW, Reynaud F, Marie D, Barrau S, Rousseau L, Rault C, Diaz V, Meurice JC, Coudroy R, Frat JP, Robert R, Drouot X. Impact of sleep alterations on weaning duration in mechanically ventilated patients: a prospective study. Eur Respir J 2018. [DOI: 10.1183/13993003.02465-2017] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Sleep is markedly altered in intensive care unit (ICU) patients and may alter respiratory performance. Our objective was to assess the impact of sleep alterations on weaning duration.We conducted a prospective physiological study at a French teaching hospital. ICU patients intubated for at least 24 h and difficult to wean were included. Complete polysomnography (PSG) was performed after the first spontaneous breathing trial failure. Presence of atypical sleep, duration of sleep stages, particularly rapid eye movement (REM) sleep, and electroencephalogram (EEG) reactivity at eyes opening were assessed by a neurologist.20 out of 45 patients studied (44%) had atypical sleep that could not be classified according to the standard criteria. Duration of weaning between PSG and extubation was significantly longer in patients with atypical sleep (median (interquartile range) 5 (2–8) versus 2 (1–2) days; p=0.001) and in those with no REM sleep compared with the others. Using multivariate logistic regression analysis, atypical sleep remained independently associated with prolonged weaning (>48 h after PSG). Altered EEG reactivity at eyes opening was a good predictor of atypical sleep.Our results suggest for the first time that brain dysfunction may have an influence on the ability to breathe spontaneously.
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198
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Yoo JW, Lee SJ, Lee JD, Kim HC. Comparison of clinical utility between diaphragm excursion and thickening change using ultrasonography to predict extubation success. Korean J Intern Med 2018; 33:331-339. [PMID: 29050461 PMCID: PMC5840594 DOI: 10.3904/kjim.2016.152] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 08/03/2016] [Accepted: 10/13/2016] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND/AIMS Both diaphragmatic excursion and change in muscle thickening are measured using ultrasonography (US) to assess diaphragm function and mechanical ventilation weaning outcomes. However, which parameter can better predict successful extubation remains to be determined. The aim of this study was to compare the clinical utility of these two diaphragmatic parameters to predict extubation success. METHODS This study included patients subjected to extubation trial in the medical or surgical intensive care unit of a university-affiliated hospital from May 2015 through February 2016. Diaphragm excursion and percent of thickening change (Δtdi%) were measured using US within 24 hours before extubation. RESULTS Sixty patients were included, and 78.3% (47/60) of these patients were successfully extubated, whereas 21.7% (13/60) were not. The median degree of excursion was greater in patients with extubation success than in those with extubation failure (1.65 cm vs. 0.8 cm, p < 0.001). Patients with extubation success had a greater Δtdi% than those with extubation failure (42.1% vs. 22.5%, p = 0.03). The areas under the receiver operating curve for excursion and Δtdi% were 0.836 (95% confidence interval [CI], 0.717 to 0.919) and 0.698 (95% CI, 0.566 to 0.810), respectively (p = 0.017). CONCLUSIONS Diaphragm excursion seems more accurate than a change in the diaphragm thickness to predict extubation success.
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Affiliation(s)
- Jung-Wan Yoo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Seung Jun Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Jong Deog Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Ho Cheol Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Korea
- Correspondence to Ho Cheol Kim, M.D. Department of Internal Medicine, Gyeongsang National University Hospital, 79 Gangnam-ro, Jinju 52727, Korea Tel: +82-55-750-8684 Fax: +82-55-750-8618 E-mail:
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Terzi N, Lofaso F, Masson R, Beuret P, Normand H, Dumanowski E, Falaize L, Sauneuf B, Daubin C, Brunet J, Annane D, Parienti JJ, Orlikowski D. Physiological predictors of respiratory and cough assistance needs after extubation. Ann Intensive Care 2018; 8:18. [PMID: 29404723 PMCID: PMC5799095 DOI: 10.1186/s13613-018-0360-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 01/23/2018] [Indexed: 12/13/2022] Open
Abstract
Background Identifying patients at high risk of post-extubation acute respiratory failure requiring respiratory or mechanical cough assistance remains challenging. Here, our primary aim was to evaluate the accuracy of easily collected parameters obtained before or just after extubation in predicting the risk of post-extubation acute respiratory failure requiring, at best, noninvasive mechanical ventilation (NIV) and/or mechanical cough assistance and, at worst, reintubation after extubation.
Methods We conducted a multicenter prospective, open-label, observational study from April 2012 through April 2015. Patients who passed a weaning test after at least 72 h of endotracheal mechanical ventilation (MV) were included. Just before extubation, spirometry and maximal pressures were measured by a technician. The results were not disclosed to the bedside physicians. Patients were followed until discharge or death.
Results Among 3458 patients admitted to the ICU, 730 received endotracheal MV for longer than 72 h and were then extubated; among these, 130 were included. At inclusion, the 130 patients had mean ICU stay and endotracheal MV durations both equal to 11 ± 4.2 days. After extubation, 36 patients required curative NIV, 7 both curative NIV and mechanical cough assistance, and 8 only mechanical cough assistance; 6 patients, all of whom first received NIV, required reintubation within 48 h. The group that required NIV after extubation had a significantly higher proportion of patients with chronic respiratory disease (P = 0.015), longer endotracheal MV duration at inclusion, and lower Medical Research Council (MRC) score (P = 0.02, P = 0.01, and P = 0.004, respectively). By multivariate analysis, forced vital capacity (FVC) and peak cough expiratory flow (PCEF) were independently associated with (NIV) and/or mechanical cough assistance and/or reintubation after extubation. Areas under the ROC curves for pre-extubation PCEF and FVC were 0.71 and 0.76, respectively. Conclusion In conclusion, FVC measured before extubation correlates closely with FVC after extubation and may serve as an objective predictor of post-extubation respiratory failure requiring NIV and/or mechanical cough assistance and/or reintubation in heterogeneous populations of medical ICU patients. ClinicalTrials.gov as #NCT01564745 Electronic supplementary material The online version of this article (10.1186/s13613-018-0360-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nicolas Terzi
- INSERM, Université Grenoble-Alpes, U1042, HP2, 38000, Grenoble, France. .,CHU Grenoble Alpes, Service de réanimation médicale, 38000, Grenoble, France. .,Service de réanimation médicale, Centre Hospitalier Universitaire Grenoble - Alpes, CS10217, Grenoble Cedex 09, France.
| | - Frédéric Lofaso
- Université de Versailles Saint Quentin en Yvelines, INSERM U1179, Garches, France.,CIC 1429, INSERM, AP-HP, Hôpital Raymond Poincaré, 92380, Garches, France.,Service d'Explorations Fonctionnelles Respiratoires, AP-HP, Hôpital Raymond Poincaré, 92380, Garches, France
| | - Romain Masson
- Service de réanimation médicale, Centre Hospitalier Universitaire Grenoble - Alpes, CS10217, Grenoble Cedex 09, France
| | - Pascal Beuret
- Service de Réanimation, Centre Hospitalier de Roanne, 42300, Roanne, France
| | - Hervé Normand
- INSERM, U1075, 14000, Caen, France.,Université de Caen, 14000, Caen, France.,CHRU Caen, Service d'Explorations Fonctionnelles Respiratoire, 14000, Caen, France
| | - Edith Dumanowski
- CHRU Caen, Service d'Explorations Fonctionnelles Respiratoire, 14000, Caen, France
| | - Line Falaize
- INSERM U 1179, Université de Versailles-Saint Quentin en Yvelines, 104 Bd Raymond Poincaré, 92380, Garches, France.,CIC 1429, Inserm-APHP, Hôpital Raymond Poincaré, 104 Bd Raymond Poincaré, 92380, Garches, France
| | - Bertrand Sauneuf
- Service de réanimation médicale, Centre Hospitalier Universitaire Grenoble - Alpes, CS10217, Grenoble Cedex 09, France.,Service de Réanimation Médicale Polyvalente, Centre Hospitalier Public du Cotentin, BP 208, 50102, Cherbourg-en-Cotentin, France
| | - Cédric Daubin
- Service de réanimation médicale, Centre Hospitalier Universitaire Grenoble - Alpes, CS10217, Grenoble Cedex 09, France
| | - Jennifer Brunet
- Service de réanimation médicale, Centre Hospitalier Universitaire Grenoble - Alpes, CS10217, Grenoble Cedex 09, France
| | - Djillali Annane
- General Intensive Care Unit, Raymond Poincaré Hospital (AP-HP), Laboratory of Inflammation and Infection, U1173, INSERM and University of Versailles SQY, 92380, Garches, France
| | - Jean-Jacques Parienti
- Unité de Biostatistique et de Recherche Clinique, Centre Hospitalier Universitaire de Caen, Avenue de la Côte de Nacre, 14033, Caen, France
| | - David Orlikowski
- Université de Versailles Saint Quentin en Yvelines, INSERM U1179, Garches, France.,CIC 1429, INSERM, AP-HP, Hôpital Raymond Poincaré, 92380, Garches, France.,Pôle de ventilation à domicile, AP-HP, Hôpital Raymond Poincaré, 92380, Garches, France.,Service de Santé Publique, AP-HP, Hôpital Raymond Poincaré, 92380, Garches, France
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200
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Palkar A, Narasimhan M, Greenberg H, Singh K, Koenig S, Mayo P, Gottesman E. Diaphragm Excursion-Time Index: A New Parameter Using Ultrasonography to Predict Extubation Outcome. Chest 2018; 153:1213-1220. [PMID: 29353023 DOI: 10.1016/j.chest.2018.01.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 11/11/2017] [Accepted: 01/02/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The diaphragmatic response to increased mechanical load following withdrawal of mechanical ventilation is critical in determining the outcome of extubation. Using ultrasonography, we aimed to evaluate the performance of the excursion-time (E-T) index-a product of diaphragm excursion and inspiratory time, to predict the outcome of extubation. METHODS Right hemidiaphragm excursion, inspiratory time, and E-T index were measured by ultrasonography during mechanical ventilation: (1) on assist-control (A/C) mode during consistent patient-triggered ventilation, (2) following 30 min during a spontaneous breathing trial (SBT), and (3) between 4 and 24 h following extubation. These measurements were correlated with the outcome of extubation. Patients in the "failure" group required reintubation or noninvasive ventilation within 48 h of extubation. RESULTS Of the 73 patients studied, 20 patients failed extubation. During SBT, diaphragm excursion was 1.65 ± 0.82 and 2.1 ± 0.9 cm (P = .06), inspiratory time was 0.89 ± 0.30 and 1.11 ± 0.39 s (P = .03), and the E-T index was 1.64 ± 1.19 and 2.42 ± 1.55 cm-s (P < .03) in the "failure" and "success" groups, respectively. The mean change in E-T index between A/C and SBT was -3.9 ± 57.8% in the failure group and 59.4 ± 74.6% in the success group (P < .01). A decrease in diaphragmatic E-T index less than 3.8% between A/C and SBT had a sensitivity of 79.2% and a specificity of 75%, to predict successful extubation. CONCLUSIONS Diaphragm E-T index measured during SBT may help predict the outcome of extubation. Maintenance or increase in diaphragm E-T index between A/C and SBT increases the likelihood of successful extubation.
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Affiliation(s)
- Atul Palkar
- Pulmonary Physicians of Norwich, Norwich, CT.
| | - Mangala Narasimhan
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Hofstra-Northwell School of Medicine, New Hyde Park, NY
| | - Harly Greenberg
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Hofstra-Northwell School of Medicine, New Hyde Park, NY
| | - Karan Singh
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Hofstra-Northwell School of Medicine, New Hyde Park, NY
| | - Seth Koenig
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Hofstra-Northwell School of Medicine, New Hyde Park, NY
| | - Paul Mayo
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Hofstra-Northwell School of Medicine, New Hyde Park, NY
| | - Eric Gottesman
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Hofstra-Northwell School of Medicine, New Hyde Park, NY
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