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Westhoff M, Neumann P, Geiseler J, Bickenbach J, Arzt M, Bachmann M, Braune S, Delis S, Dellweg D, Dreher M, Dubb R, Fuchs H, Hämäläinen N, Heppner H, Kluge S, Kochanek M, Lepper PM, Meyer FJ, Neumann B, Putensen C, Schimandl D, Schönhofer B, Schreiter D, Walterspacher S, Windisch W. [Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]. Pneumologie 2024; 78:453-514. [PMID: 37832578 DOI: 10.1055/a-2148-3323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
The guideline update outlines the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.Non-invasive ventilation (NIV) has a high value in therapy of hypercapnic acute respiratory failure, as it significantly reduces the length of ICU stay and hospitalization as well as mortality.Patients with cardiopulmonary edema and acute respiratory failure should be treated with continuous positive airway pressure (CPAP) and oxygen in addition to necessary cardiological interventions. This should be done already prehospital and in the emergency department.In case of other forms of acute hypoxaemic respiratory failure with only mild or moderately disturbed gas exchange (PaO2/FiO2 > 150 mmHg) there is no significant advantage or disadvantage compared to high flow nasal oxygen (HFNO). In severe forms of ARDS NIV is associated with high rates of treatment failure and mortality, especially in cases with NIV-failure and delayed intubation.NIV should be used for preoxygenation before intubation. In patients at risk, NIV is recommended to reduce extubation failure. In the weaning process from invasive ventilation NIV essentially reduces the risk of reintubation in hypercapnic patients. NIV is regarded useful within palliative care for reduction of dyspnea and improving quality of life, but here in concurrence to HFNO, which is regarded as more comfortable. Meanwhile NIV is also recommended in prehospital setting, especially in hypercapnic respiratory failure and pulmonary edema.With appropriate monitoring in an intensive care unit NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency.
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Affiliation(s)
- Michael Westhoff
- Klinik für Pneumologie, Lungenklinik Hemer - Zentrum für Pneumologie und Thoraxchirurgie, Hemer
| | - Peter Neumann
- Abteilung für Klinische Anästhesiologie und Operative Intensivmedizin, Evangelisches Krankenhaus Göttingen-Weende gGmbH
| | - Jens Geiseler
- Medizinische Klinik IV - Pneumologie, Beatmungs- und Schlafmedizin, Paracelsus-Klinik Marl, Marl
| | - Johannes Bickenbach
- Klinik für Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Aachen
| | - Michael Arzt
- Schlafmedizinisches Zentrum der Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg
| | - Martin Bachmann
- Klinik für Atemwegs-, Lungen- und Thoraxmedizin, Beatmungszentrum Hamburg-Harburg, Asklepios Klinikum Harburg, Hamburg
| | - Stephan Braune
- IV. Medizinische Klinik: Akut-, Notfall- und Intensivmedizin, St. Franziskus-Hospital, Münster
| | - Sandra Delis
- Klinik für Pneumologie, Palliativmedizin und Geriatrie, Helios Klinikum Emil von Behring GmbH, Berlin
| | - Dominic Dellweg
- Klinik für Innere Medizin, Pneumologie und Gastroenterologie, Pius-Hospital Oldenburg, Universitätsmedizin Oldenburg
| | - Michael Dreher
- Klinik für Pneumologie und Internistische Intensivmedizin, Uniklinik RWTH Aachen
| | - Rolf Dubb
- Akademie der Kreiskliniken Reutlingen GmbH, Reutlingen
| | - Hans Fuchs
- Zentrum für Kinder- und Jugendmedizin, Neonatologie und pädiatrische Intensivmedizin, Universitätsklinikum Freiburg
| | | | - Hans Heppner
- Klinik für Geriatrie und Geriatrische Tagesklinik Klinikum Bayreuth, Medizincampus Oberfranken Friedrich-Alexander-Universität Erlangen-Nürnberg, Bayreuth
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Matthias Kochanek
- Klinik I für Innere Medizin, Hämatologie und Onkologie, Universitätsklinikum Köln, Köln
| | - Philipp M Lepper
- Klinik für Innere Medizin V - Pneumologie, Allergologie und Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg
| | - F Joachim Meyer
- Lungenzentrum München - Bogenhausen-Harlaching) München Klinik gGmbH, München
| | - Bernhard Neumann
- Klinik für Neurologie, Donauisar Klinikum Deggendorf, und Klinik für Neurologie der Universitätsklinik Regensburg am BKH Regensburg, Regensburg
| | - Christian Putensen
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Bonn
| | - Dorit Schimandl
- Klinik für Pneumologie, Beatmungszentrum, Zentralklinik Bad Berka GmbH, Bad Berka
| | - Bernd Schönhofer
- Klinik für Innere Medizin, Pneumologie und Intensivmedizin, Evangelisches Klinikum Bethel, Universitätsklinikum Ost Westphalen-Lippe, Bielefeld
| | | | - Stephan Walterspacher
- Medizinische Klinik - Sektion Pneumologie, Klinikum Konstanz und Lehrstuhl für Pneumologie, Universität Witten-Herdecke, Witten
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Lehrstuhl für Pneumologie Universität Witten/Herdecke, Köln
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Hughes N, Jia Y, Sujan M, Lawton T, Habli I, McDermid J. Contextual design requirements for decision-support tools involved in weaning patients from mechanical ventilation in intensive care units. APPLIED ERGONOMICS 2024; 118:104275. [PMID: 38574594 DOI: 10.1016/j.apergo.2024.104275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 03/19/2024] [Accepted: 03/21/2024] [Indexed: 04/06/2024]
Abstract
Weaning patients from ventilation in intensive care units (ICU) is a complex task. There is a growing desire to build decision-support tools to help clinicians during this process, especially those employing Artificial Intelligence (AI). However, tools built for this purpose should fit within and ideally improve the current work environment, to ensure they can successfully integrate into clinical practice. To do so, it is important to identify areas where decision-support tools may aid clinicians, and associated design requirements for such tools. This study analysed the work context surrounding the weaning process from mechanical ventilation in ICU environments, via cognitive task and work domain analyses. In doing so, both what cognitive processes clinicians perform during weaning, and the constraints and affordances of the work environment itself, were described. This study found a number of weaning process tasks where decision-support tools may prove beneficial, and from these a set of contextual design requirements were created. This work benefits researchers interested in creating human-centred decision-support tools for mechanical ventilation that are sensitive to the wider work system.
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Affiliation(s)
- Nathan Hughes
- University of York, Deramore Lane, York, YO10 5GH, UK.
| | - Yan Jia
- University of York, Deramore Lane, York, YO10 5GH, UK
| | | | - Tom Lawton
- University of York, Deramore Lane, York, YO10 5GH, UK; Improvement Academy, Bradford Institute for Health Research, Duckworth Lane, Bradford, BD9 6RJ, UK
| | - Ibrahim Habli
- University of York, Deramore Lane, York, YO10 5GH, UK
| | - John McDermid
- University of York, Deramore Lane, York, YO10 5GH, UK
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3
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Zhao F, Wang M, Zhou Q, Du Y, Cheng Q, Sun X, Zhang J, Liang Y, Shen N, Sun Y. Analysis of risk factors for weaning failure from mechanical ventilation in critically ill older patients with coronavirus disease 2019. Heliyon 2024; 10:e32835. [PMID: 38975064 PMCID: PMC11225823 DOI: 10.1016/j.heliyon.2024.e32835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 06/09/2024] [Accepted: 06/10/2024] [Indexed: 07/09/2024] Open
Abstract
Objective This study aimed to investigate the factors influencing weaning failure from invasive mechanical ventilation (IMV) in critically ill older patients with coronavirus disease 2019 (COVID-19). Methods We enrolled critically ill older patients with COVID-19 who were admitted to the medical intensive care unit (ICU) and received IMV between December 2022 and June 2023. Results We included 68 critically ill older patients with COVID-19 (52 male [76.5 %] and 16 female individuals [23.5 %]). The patients' median age (interquartile range) was 75.5 (70.3-82.8) years. The median length of ICU stay was 11.5 (7.0-17.8) days; 34 cases (50.0 %) were successfully weaned from IMV. The successfully weaned group had a higher proportion of underlying chronic obstructive pulmonary disease [6 (17.6 %) vs. 0, P = 0.033] and fewer cases of diabetes [7 (20.6 %) vs. 16 (47.1 %), P = 0.021] compared with the weaning failure group. Serum lactate levels [1.5 (1.2-2.3) vs. 2.6 (1.9-3.1) mmol/L, P < 0.001], blood urea nitrogen [8.2 (6.3-14.4) vs. 11.4 (8.0-21.3) mmol/L, P = 0.033], Acute Physiology and Chronic Health Evaluation (APACHE) II score [19.0 (12.0-23.3) vs. 22.5 (16.0-29.3), P = 0.014], and hospitalization days before endotracheal intubation [1.0 (0.0-5.0) vs. 3.0 (0.0-11.0), P = 0.023] were significantly decreased in the successfully weaned group, whereas PaO2/FiO2 [148.3 (94.6-200.3) vs. 101.1 (67.0-165.1), P = 0.038] and blood lymphocyte levels [0.6 (0.4-1.0) vs. 0.5 (0.2-0.6) 109/L, P = 0.048] were significantly increased, compared with the weaning failure group. Multivariate logistic regression analysis showed that diabetes (OR= 3.413, 95 %CI 1.029-11.326), P = 0.045), APACHE II Score (OR = 1.089, 95 % CI 1.008-1.175), P = 0.030), and hospitalization days before endotracheal intubation (OR = 1.137, 95 % CI 1.023-1.264), P = 0.017) were independent risk factors for weaning failure. Conclusion In critically ill older patients with COVID-19 with diabetes, higher APACHE II Score, and longer hospitalization days before endotracheal intubation, weaning from IMV was more challenging. The study could help develop strategies for improving COVID-19 treatment.
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Affiliation(s)
- Feifan Zhao
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, 100191, China
| | - Meng Wang
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, 100191, China
| | - Qingtao Zhou
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, 100191, China
| | - Yipeng Du
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, 100191, China
| | - Qin Cheng
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, 100191, China
| | - Xiaoyan Sun
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, 100191, China
| | - Jing Zhang
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, 100191, China
| | - Ying Liang
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, 100191, China
| | - Ning Shen
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, 100191, China
| | - Yongchang Sun
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, 100191, China
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4
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Rodriguez P, Hernández G. Weaning from mechanical ventilation: Speed it up and make it safe. Med Intensiva 2024; 48:356-359. [PMID: 38493060 DOI: 10.1016/j.medine.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 02/20/2024] [Indexed: 03/18/2024]
Affiliation(s)
| | - Gonzalo Hernández
- Complejo Hospitalario Universitario de Toledo, Toledo, Spain; Grupo de Investigación en Disfunción y Fallo Orgánico en la Agresión (IdiPAZ), Madrid, Spain; Ciber Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
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5
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Kosuta I, Premkumar M, Reddy KR. Review article: Evaluation and care of the critically ill patient with cirrhosis. Aliment Pharmacol Ther 2024; 59:1489-1509. [PMID: 38693712 DOI: 10.1111/apt.18016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/21/2024] [Accepted: 04/12/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND The increase in prevalence of liver disease globally will lead to a substantial incremental burden on intensive care requirements. While liver transplantation offers a potential life-saving intervention, not all patients are eligible due to limitations such as organ availability, resource constraints, ongoing sepsis or multiple organ failures. Consequently, the focus of critical care of patients with advanced and decompensated cirrhosis turns to liver-centric intensive care protocols, to mitigate the high mortality in such patients. AIM Provide an updated and comprehensive understanding of cirrhosis management in critical care, and which includes emergency care, secondary organ failure management (mechanical ventilation, renal replacement therapy, haemodynamic support and intensive care nutrition), use of innovative liver support systems, infection control, liver transplantation and palliative and end-of life care. METHODS We conducted a structured bibliographic search on PubMed, sourcing articles published up to 31 March 2024, to cover topics addressed. We considered data from observational studies, recommendations of society guidelines, systematic reviews, and meta-analyses, randomised controlled trials, and incorporated our clinical expertise in liver critical care. RESULTS Critical care management of the patient with cirrhosis has evolved over time while mortality remains high despite aggressive management with liver transplantation serving as a crucial but not universally available resource. CONCLUSIONS Implementation of organ support therapies, intensive care protocols, nutrition, palliative care and end-of-life discussions and decisions are an integral part of critical care of the patient with cirrhosis. A multi-disciplinary approach towards critical care management is likely to yield better outcomes.
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Affiliation(s)
- Iva Kosuta
- Department of Intensive Care Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Madhumita Premkumar
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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6
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Varón-Vega F, Rincón A, Giraldo-Cadavid LF, Tuta-Quintero E, Palacios J, Crevoisier S, Duarte DC, Poveda M, Cucunubo L, Monedero P. Assessing the reproducibility and predictive value of objective cough measurement for successful withdrawal of invasive ventilatory support in adult patients. BMC Pulm Med 2024; 24:218. [PMID: 38698348 PMCID: PMC11067300 DOI: 10.1186/s12890-024-03033-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 04/23/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Utilizing clinical tests, such as objective cough measurement, can assist in predicting the success of the weaning process in critically ill patients. METHODS A multicenter observational analytical study was conducted within a prospective cohort of patients recruited to participate in COBRE-US. We assessed the capability of objective cough measurement to predict the success of the spontaneous breathing trial (SBT) and extubation. Intra- and inter-observer reproducibility of the cough test and was evaluated using the intraclass correlation coefficient (ICC) and Cohen's weighted kappa. We used receiver operating characteristic curves (ROC-curve) to evaluate the predictive ability of objective cough measurement. RESULTS We recruited 367 subjects who were receiving invasive mechanical ventilation. A total of 451 objective cough measurements and 456 SBTs were conducted. A significant association was found between objective cough measurement and successful SBT (OR: 1.68; 95% CI 1.48-1.90; p = 0.001). The predictive capability of the objective cough test for SBT success had a ROC-curve of 0.58 (95% CI: 0.56-0.61). Objective cough measurement to predict successful extubation had a ROC-curve of 0.61 (95% CI: 0.56-0.66). The intraobserver reproducibility exhibited an ICC of 0.94 (95% CI: 0.89-0.96; p < 0.001), while the interobserver reproducibility demonstrated an ICC of 0.72 (95% CI: 0.51-0.85; p < 0.001). The intraobserver agreement, assessed using Cohen's weighted kappa was 0.94 (95% CI: 0.93-0.99; p < 0.001), whereas the interobserver agreement was 0.84 (95% CI: 0.67 - 0.10; p < 0.001). CONCLUSIONS The objective measurement of cough using the method employed in our study demonstrates nearly perfect intra-observer reproducibility and agreement. However, its ability to predict success or failure in the weaning process is limited.
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Affiliation(s)
- Fabio Varón-Vega
- Critical Care and Lung transplantation Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Bogotá, Colombia.
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Cra. 13b #161 - 85., Bogotá, 110131, Colombia.
| | - Adriana Rincón
- Critical Care and Lung transplantation Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Bogotá, Colombia
- Master's Candidate in Epidemiology, Universidad de La Sabana, Chía, Colombia
| | - Luis F Giraldo-Cadavid
- Facultad de Medicina, Universidad de La Sabana, Chía, Colombia
- Interventional Pulmonology Service, Fundación Neumológica Colombiana, Bogotá, Colombia
| | | | - Jonathan Palacios
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Cra. 13b #161 - 85., Bogotá, 110131, Colombia
| | - Stephanie Crevoisier
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Cra. 13b #161 - 85., Bogotá, 110131, Colombia
| | - Diana C Duarte
- Critical Care and Lung transplantation Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Bogotá, Colombia
| | - Marcela Poveda
- Critical Care Service, Fundación Clínica Shaio, Bogotá, Colombia
| | - Laura Cucunubo
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Cra. 13b #161 - 85., Bogotá, 110131, Colombia
| | - Pablo Monedero
- School of Medicine, Universidad de Navarra, Pamplona, España
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Burns KEA, Rochwerg B, Seely AJE. Ventilator Weaning and Extubation. Crit Care Clin 2024; 40:391-408. [PMID: 38432702 DOI: 10.1016/j.ccc.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Increasing evidence supports specific approaches to liberate patients from invasive ventilation including the use of liberation protocols, inspiratory assistance during spontaneous breathing trials (SBTs), early extubation of patients with chronic obstructive pulmonary disease to noninvasive ventilation, and prophylactic use of noninvasive support strategies after extubation. Additional research is needed to elucidate the best criteria to identify patients who are ready to undergo an SBT and to inform optimal screening frequency, the best SBT technique and duration, extubation assessments, and extubation decision-making. Additional clarity is also needed regarding the optimal timing to measure and report extubation success.
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Affiliation(s)
- Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Medicine and Division of Critical Care, Unity Health Toronto, St. Michaels Hospital, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, Unity Health Toronto, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, Hamilton Health Sciences, Juravinski Hospital, Hamilton, Ontario, Canada; Department of Critical Care, Hamilton Health Sciences, Juravinski Hospital, Hamilton, Ontario, Canada. https://twitter.com/Bram_Rochwerg
| | - Andrew J E Seely
- Department of Critical Care, Ottawa Hospital, Ottawa, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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8
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Hernández Martínez G, Rodriguez P, Soto J, Caritg O, Castellví-Font A, Mariblanca B, García AM, Colinas L, Añon JM, Parrilla-Gomez FJ, Silva-Obregón JA, Masclans JR, Propin A, Cuadra A, Dalorzo MG, Rialp G, Suarez-Sipmann F, Roca O. Effect of aggressive vs conservative screening and confirmatory test on time to extubation among patients at low or intermediate risk: a randomized clinical trial. Intensive Care Med 2024; 50:258-267. [PMID: 38353714 DOI: 10.1007/s00134-024-07330-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/19/2024] [Indexed: 03/03/2024]
Abstract
PURPOSE This study aimed to determine the best strategy to achieve fast and safe extubation. METHODS This multicenter trial randomized patients with primary respiratory failure and low-to-intermediate risk for extubation failure with planned high-flow nasal cannula (HFNC) preventive therapy. It included four groups: (1) conservative screening with ratio of partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2) ≥ 150 and positive end-expiratory pressure (PEEP) ≤ 8 cmH2O plus conservative spontaneous breathing trial (SBT) with pressure support 5 cmH2O + PEEP 0 cmH2O); (2) screening with ratio of partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2) ≥ 150 and PEEP ≤ 8 plus aggressive SBT with pressure support 8 + PEEP 5; (3) aggressive screening with PaO2/FiO2 > 180 and PEEP 10 maintained until the SBT with pressure support 8 + PEEP 5; (4) screening with PaO2/FiO2 > 180 and PEEP 10 maintained until the SBT with pressure support 5 + PEEP 0. Primary outcomes were time-to-extubation and simple weaning rate. Secondary outcomes included reintubation within 7 days after extubation. RESULTS Randomization to the aggressive-aggressive group was discontinued at the interim analysis for safety reasons. Thus, 884 patients who underwent at least 1 SBT were analyzed (conservative-conservative group, n = 256; conservative-aggressive group, n = 267; aggressive-conservative group, n = 261; aggressive-aggressive, n = 100). Median time to extubation was lower in the groups with aggressive screening (p < 0.001). Simple weaning rates were 45.7%, 76.78% (205 patients), 71.65%, and 91% (p < 0.001), respectively. Reintubation rates did not differ significantly (p = 0.431). CONCLUSION Among patients at low or intermediate risk for extubation failure with planned HFNC, combining aggressive screening with preventive PEEP and a conservative SBT reduced the time to extubation without increasing the reintubation rate.
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Affiliation(s)
- Gonzalo Hernández Martínez
- Complejo Hospitalario Universitario de Toledo, Toledo, Spain.
- Grupo de Investigación en Disfunción y Fallo Orgánico en La Agresión (IdiPAZ), Madrid, Spain.
- Ciber Enfermedades Respiratorias (CIBERES), Health Institute Carlos III, Madrid, Spain.
| | | | - Jesus Soto
- Hospital Universitario La Paz, Madrid, Spain
| | - Oriol Caritg
- Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Vall d'Hebron Institut de Reserca (VHIR), Barcelona, Spain
| | - Andrea Castellví-Font
- Hospital del Mar, Barcelona, Spain
- Grupo de Investigación del Paciente Crítico (GREPAC), Institut Hospital del Mar d´Investigacions Mèdiques (IMIM), Barcelona, Spain
| | | | | | - Laura Colinas
- Complejo Hospitalario Universitario de Toledo, Toledo, Spain
| | - Jose Manuel Añon
- Hospital Universitario La Paz, Madrid, Spain
- Grupo de Investigación en Disfunción y Fallo Orgánico en La Agresión (IdiPAZ), Madrid, Spain
| | - Francisco Jose Parrilla-Gomez
- Hospital del Mar, Barcelona, Spain
- Grupo de Investigación del Paciente Crítico (GREPAC), Institut Hospital del Mar d´Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Jose Alberto Silva-Obregón
- Hospital Universitario de Guadalajara, Guadalajara, Spain
- Grupo de Investigación del Paciente Hematológico, Instituto de Investigación Sanitaria Hospital Universitario La Paz (IdiPAZ), Madrid, Spain
| | - Joan Ramon Masclans
- Hospital del Mar, Barcelona, Spain
- Grupo de Investigación del Paciente Crítico (GREPAC), Institut Hospital del Mar d´Investigacions Mèdiques (IMIM), Barcelona, Spain
- MELIS, Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | | | - Alicia Cuadra
- Complejo Hospitalario Universitario de Toledo, Toledo, Spain
| | | | - Gemma Rialp
- Hospital Universitario Son Llàtzer, Palma, Spain
| | | | - Oriol Roca
- Parc Taulí Hospital Universitari, Institut de Investigació i Innovació Parc Taulí (I3PT-CERCA), Sabadell, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
- Ciber Enfermedades Respiratorias (CIBERES), Health Institute Carlos III, Madrid, Spain
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Varón-Vega F, Giraldo-Cadavid LF, Uribe AM, Rincón A, Palacios J, Crevoisier S, Tuta-Quintero E, Ordoñez L, Boada N, Rincón P, Poveda M, Monedero P. Utilization of spontaneous breathing trial, objective cough test, and diaphragmatic ultrasound results to predict extubation success: COBRE-US trial. Crit Care 2023; 27:414. [PMID: 37908002 PMCID: PMC10617213 DOI: 10.1186/s13054-023-04708-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/24/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND The results of clinical and weaning readiness tests and the spontaneous breathing trial (SBT) are used to predict the success of the weaning process and extubation. METHODS We evaluated the capacity of the cuff leak test, rate of rapid and shallow breathing, cough intensity, and diaphragmatic contraction velocity (DCV) to predict the success of the SBT and extubation in a prospective, multicenter observational study with consecutive adult patients admitted to four intensive care units. We used receiver operating characteristic (ROC) curves to assess the tests' predictive capacity and built predictive models using logistic regression. RESULTS We recruited 367 subjects who were receiving invasive mechanical ventilation and on whom 456 SBTs were performed, with a success rate of 76.5%. To predict the success of the SBT, we derived the following equation: (0.56 × Cough) - (0.13 × DCV) + 0.25. When the cutoff point was ≥ 0.83, the sensitivity was 91.5%, the specificity was 22.1%, and the overall accuracy was 76.2%. The area under the ROC curve (AUC-ROC) was 0.63. To predict extubation success, we derived the following equation: (5.7 × SBT) + (0.75 × Cough) - (0.25 × DCV) - 4.5. When the cutoff point was ≥ 1.25, the sensitivity was 96.8%, the specificity was 78.4%, and the overall accuracy was 91.5%. The AUC-ROC of this model was 0.91. CONCLUSION Objective measurement of cough and diaphragmatic contraction velocity could be used to predict SBT success. The equation for predicting successful extubation, which includes SBT, cough, and diaphragmatic contraction velocity values, showed excellent discriminative capacity.
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Affiliation(s)
- Fabio Varón-Vega
- Critical Care and Lung Transplantation Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Bogotá, Colombia.
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Cra. 13B #161 - 85, 110131, Bogotá, Colombia.
| | - Luis F Giraldo-Cadavid
- Interventional Pulmonology Service, Fundación Neumológica Colombiana, Bogotá, Colombia
- School of Medicine, Universidad de La Sabana, Chía, Colombia
| | - Ana María Uribe
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Cra. 13B #161 - 85, 110131, Bogotá, Colombia
| | - Adriana Rincón
- Critical Care and Lung Transplantation Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Bogotá, Colombia
| | - Jonathan Palacios
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Cra. 13B #161 - 85, 110131, Bogotá, Colombia
| | - Stephanie Crevoisier
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Cra. 13B #161 - 85, 110131, Bogotá, Colombia
| | | | - Lina Ordoñez
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Cra. 13B #161 - 85, 110131, Bogotá, Colombia
| | - Natalia Boada
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Cra. 13B #161 - 85, 110131, Bogotá, Colombia
- Critical Care Service, Fundación Clínica Shaio, Bogotá, Colombia
| | - Paola Rincón
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Cra. 13B #161 - 85, 110131, Bogotá, Colombia
- Critical Care Service, Fundación Clínica Shaio, Bogotá, Colombia
| | - Marcela Poveda
- Critical Care Service, Fundación Clínica Shaio, Bogotá, Colombia
| | - Pablo Monedero
- School of Medicine, Universidad de Navarra, Pamplona, Spain
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10
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Tanaka A, Shimomura Y, Uchiyama A, Tokuhira N, Kitamura T, Iwata H, Hashimoto H, Ishigaki S, Enokidani Y, Yamashita T, Koyama Y, Iguchi N, Yoshida T, Fujino Y. Time definition of reintubation most relevant to patient outcomes in critically ill patients: a multicenter cohort study. Crit Care 2023; 27:378. [PMID: 37777790 PMCID: PMC10544149 DOI: 10.1186/s13054-023-04668-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 09/27/2023] [Indexed: 10/02/2023] Open
Abstract
BACKGROUND Reintubation is a common complication in critically ill patients requiring mechanical ventilation. Although reintubation has been demonstrated to be associated with patient outcomes, its time definition varies widely among guidelines and in the literature. This study aimed to determine the association between reintubation and patient outcomes as well as the consequences of the time elapsed between extubation and reintubation on patient outcomes. METHODS This was a multicenter retrospective cohort study of critically ill patients conducted between April 2015 and March 2021. Adult patients who underwent mechanical ventilation and extubation in intensive care units (ICUs) were investigated utilizing the Japanese Intensive Care PAtient Database. The primary and secondary outcomes were in-hospital and ICU mortality. The association between reintubation and clinical outcomes was studied using Cox proportional hazards analysis. Among the patients who underwent reintubation, a Cox proportional hazard analysis was conducted to evaluate patient outcomes according to the number of days from extubation to reintubation. RESULTS Overall, 184,705 patients in 75 ICUs were screened, and 1849 patients underwent reintubation among 48,082 extubated patients. After adjustment for potential confounders, multivariable analysis revealed a significant association between reintubation and increased in-hospital and ICU mortality (adjusted hazard ratio [HR] 1.520, 95% confidence interval [CI] 1.359-1.700, and adjusted HR 1.325, 95% CI 1.076-1.633, respectively). Among the reintubated patients, 1037 (56.1%) were reintubated within 24 h after extubation, 418 (22.6%) at 24-48 h, 198 (10.7%) at 48-72 h, 111 (6.0%) at 72-96 h, and 85 (4.6%) at 96-120 h. Multivariable Cox proportional hazard analysis showed that in-hospital and ICU mortality was highest in patients reintubated at 72-96 h (adjusted HR 1.528, 95% CI 1.062-2.197, and adjusted HR 1.334, 95% CI 0.756-2.352, respectively; referenced to reintubation within 24 h). CONCLUSIONS Reintubation was associated with a significant increase in in-hospital and ICU mortality. The highest mortality rates were observed in patients who were reintubated between 72 and 96 h after extubation. Further studies are warranted for the optimal observation of extubated patients in clinical practice and to strengthen the evidence for mechanical ventilation.
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Affiliation(s)
- Aiko Tanaka
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan.
- Department of Intensive Care, University of Fukui Hospital, Yoshida, Fukui, Japan.
| | - Yoshimitsu Shimomura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Department of Hematology, Kobe City Hospital Organization Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Akinori Uchiyama
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Natsuko Tokuhira
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hirofumi Iwata
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Haruka Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Suguru Ishigaki
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yusuke Enokidani
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Tomonori Yamashita
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yukiko Koyama
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Naoya Iguchi
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Takeshi Yoshida
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yuji Fujino
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
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11
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Tinoco HA, Perdomo-Hurtado L, Henao-Cruz JA, Escobar-Serna JF, Jaramillo-Robledo O, Aguirre-Ospina OD, Hurtado-Hernández M, Lopez-Guzman J. Evaluation and Performance of a Positive Airway Pressure Device (CPAP-AirFlife™): A Randomized Crossover Non-Inferiority Clinical Study in Normal Subjects. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1372. [PMID: 37629662 PMCID: PMC10456951 DOI: 10.3390/medicina59081372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/21/2023] [Accepted: 07/21/2023] [Indexed: 08/27/2023]
Abstract
Background and Objectives: During the COVID-19, the demand for non-invasive ventilatory support equipment significantly increased. In response, a novel non-invasive ventilatory support model called CPAP-AirFlife™ was developed utilizing existing technologies. This model offers technological advantages, including an aerosol-controlled helmet suitable for high-risk environments such as ambulances. Additionally, it is cost-effective and does not require medical air, making it accessible for implementation in low-level hospitals, particularly in rural areas. This study aimed to assess the efficacy of CPAP-AirFlife™ by conducting a non-inferiority comparison with conventional ventilation equipment used in the Intensive Care Unit. Materials and Methods: A clinical study was conducted on normal subjects in a randomized and sequential manner. Parameters such as hemoglobin oxygen saturation by pulse oximetry, exhaled PCO2 levels, vital signs, and individual tolerance were compared between the CPAP-AirFlife™ and conventional equipment. The study population was described in terms of demographic characteristics and included in the analysis. Results: It was shown that the CPAP-AirFlife™ was not inferior to conventional equipment in terms of efficacy or tolerability. Hemoglobin oxygen saturation levels, exhaled PCO2 levels, vital signs, and individual tolerance did not significantly differ between the two models. Conclusions: The findings suggest that CPAP-AirFlife™ is a practical and cost-effective alternative for non-invasive ventilatory support. Its technological advantages, including the aerosol-controlled helmet, make it suitable for high-risk environments. The device's accessibility and affordability make it a promising solution for implementation in low-level hospitals, particularly in rural areas. This study supports using CPAP-AirFlife™ as a practical option for non-invasive ventilatory support, providing a valuable contribution to respiratory care during the COVID-19 pandemic and beyond.
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Affiliation(s)
- Héctor A. Tinoco
- Experimental and Computational Mechanics Laboratory, Universidad Autónoma de Manizales, Antigua Estación del Ferrocarril, Edificio Fundadores, Manizales-Caldas 170001, Colombia
| | - Luis Perdomo-Hurtado
- Experimental and Computational Mechanics Laboratory, Universidad Autónoma de Manizales, Antigua Estación del Ferrocarril, Edificio Fundadores, Manizales-Caldas 170001, Colombia
| | | | | | | | | | - Mateo Hurtado-Hernández
- Experimental and Computational Mechanics Laboratory, Universidad Autónoma de Manizales, Antigua Estación del Ferrocarril, Edificio Fundadores, Manizales-Caldas 170001, Colombia
| | - Juliana Lopez-Guzman
- Experimental and Computational Mechanics Laboratory, Universidad Autónoma de Manizales, Antigua Estación del Ferrocarril, Edificio Fundadores, Manizales-Caldas 170001, Colombia
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12
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Nicolotti D, Grossi S, Nicolini F, Gallingani A, Rossi S. Difficult Respiratory Weaning after Cardiac Surgery: A Narrative Review. J Clin Med 2023; 12:jcm12020497. [PMID: 36675426 PMCID: PMC9867514 DOI: 10.3390/jcm12020497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/28/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023] Open
Abstract
Respiratory weaning after cardiac surgery can be difficult or prolonged in up to 22.7% of patients. The inability to wean from a ventilator within the first 48 h after surgery is related to increased short- and long-term morbidity and mortality. Risk factors are mainly non-modifiable and include preoperative renal failure, New York Heart Association, and Canadian Cardiac Society classes as well as surgery and cardio-pulmonary bypass time. The positive effects of pressure ventilation on the cardiovascular system progressively fade during the progression of weaning, possibly leading to pulmonary oedema and failure of spontaneous breathing trials. To prevent this scenario, some parameters such as pulmonary artery occlusion pressure, echography-assessed diastolic function, brain-derived natriuretic peptide, and extravascular lung water can be monitored during weaning to early detect hemodynamic decompensation. Tracheostomy is considered for patients with difficult and prolonged weaning. In such cases, optimal patient selection, timing, and technique may be important to try to reduce morbidity and mortality in this high-risk population.
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Affiliation(s)
- Davide Nicolotti
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
- Correspondence: ; Tel.: +39-0521-703286
| | - Silvia Grossi
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Francesco Nicolini
- Department of Cardiac Surgery, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Alan Gallingani
- Department of Cardiac Surgery, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Sandra Rossi
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
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13
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The predictive value of lung ultrasound combined with central venous oxygen saturation variations in the outcome of ventilator weaning in patients after thoracic surgery. Am J Transl Res 2022; 14:8621-8631. [PMID: 36628206 PMCID: PMC9827289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 11/02/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To evaluate the predictive value of lung ultrasound score (LUS) combined with central venous oxygen saturation variations (ΔScvO2) in the outcome of ventilator weaning in patients after thoracic surgery. METHODS The clinical data of 60 patients who received tracheal intubation ventilator-assisted breathing after thoracic surgery were retrospectively analyzed, and they were divided into successful (n = 35) and failed (n = 25) groups according to the postoperative weaning outcomes. The factors influencing the failure of weaning in patients after thoracic surgery were compared and analyzed, and the values of LUS, ΔScvO2 as well as the combination of both were calculated to predict the failure of weaning in patients after thoracic surgery. RESULTS The results of logistic regression analysis showed that LUS, ΔScvO2, and partial pressure of carbon dioxide (PaCO2) may be risk factors influencing weaning failure in patients after thoracic surgery (OR = 1.844, 4.006, 1.271, P < 0.001 for all), while diaphragm thickening fraction (DTF) and partial pressure of oxygen (PaO2) may be protective factors (OR = 0.852, 0.674, P = 0.002 for all). Receiver operator characteristic (ROC) curve showed that area under the curves (AUCs) of LUS, ΔScvO2, and the combination of the two was 0.865 (95% CI: 0.766-0.964), 0.874 (95% CI: 0.781-0.967), and 0.925 (95% CI: 0.860-0.990), respectively, in predicting failure of weaning in patients after thoracic surgery. CONCLUSION LUS and ΔScvO2 were closely related to chest ultrasound index and arterial blood gas index in patients after thoracic surgery, both of which may be risk factors for weaning failure in patients after thoracic surgery, and their combination can effectively predict the occurrence of weaning failure.
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14
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Zhang JB, Li LH, Zhu JQ, Zhou SF, Ma JH, Li ZQ, Jin XH, Lin XQ. Application of improved Glasgow coma scale score as switching point for sequential invasive-noninvasive mechanical ventilation on chronic obstructive pulmonary disease (COPD) with respiratory failure. Medicine (Baltimore) 2022; 101:e31857. [PMID: 36401492 PMCID: PMC9678540 DOI: 10.1097/md.0000000000031857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND To compare the efficacy and feasibility of using a modified Glasgow coma scale (GCS) score of 13 or 15 as the criterion for switching chronic obstructive pulmonary disease (COPD) patients with respiratory failure to sequential invasive-noninvasive ventilation. METHODS COPD patients with respiratory failure who had undergone endotracheal intubation and invasive mechanical ventilation (IMV) between June 2017 and June 2020 at 4 different hospitals in China were included. A total of 296 patients were randomly divided into 2 groups. In group A, the patients were extubated and immediately placed on noninvasive ventilation (NIV) when the modified GCS score reached 13. In group B, the same was done when the modified GCS score reached 15. RESULTS No significant differences in the mean blood pressure, oxygenation index, arterial partial pressure of oxygen, and arterial partial pressure of carbon dioxide were seen between groups A and B before extubation and 3 hours after NIV. The re-intubation times were also similar in the 2 groups. Compared to group B, the length of hospital stay, incidence of ventilator associated pneumonia, and time of invasive ventilation were all significantly lower in group A (P = .041, .001, <.001). CONCLUSION Using a modified GCS score of 13 as the criterion for switching from IMV to NIV can significantly reduce the duration of IMV, length of hospital stay, and incidence of ventilator associated pneumonia in COPD patients with respiratory failure.
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Affiliation(s)
- Jin-Bo Zhang
- Emergency Intensive Care Unit, Wenling Hospital Affiliated to Wenzhou Medical University, The First People’s Hospital of Wenling, Wenling, Zhejiang, China
| | - Li-Hong Li
- Infection Division, Wenling Hospital Affiliated to Wenzhou Medical University, The First People’s Hospital of Wenling, Wenling, Zhejiang, China
| | - Jin-Qiang Zhu
- Emergency Intensive Care Unit, Wenling Hospital Affiliated to Wenzhou Medical University, The First People’s Hospital of Wenling, Wenling, Zhejiang, China
| | - Shi-Fang Zhou
- Department of Emergency Care, Changsha Central Hospital, Changsha, Hunan, China
| | - Ji-Hong Ma
- Intensive Care Unit, First Affiliated Hospital of Wenzhou Medical University, Wenling, Zhejiang, China
| | - Zhi-Qiang Li
- Intensive Care Unit, The First People’s Hospital of Jingmen, Jingmen, Hubei, China
| | - Xiao-Hong Jin
- Emergency Intensive Care Unit, Wenling Hospital Affiliated to Wenzhou Medical University, The First People’s Hospital of Wenling, Wenling, Zhejiang, China
| | - Xiao-Qin Lin
- Department of Hepatopancreatobiliary Surgery, Wenling Hospital Affiliated to Wenzhou Medical University, The First People’s Hospital of Wenling, Wenling, Zhejiang, China
- * Correspondence: Xiao-Qin Lin, Department of Hepatopancreatobiliary Surgery, Wenling Hospital Affiliated to Wenzhou Medical University, The First People’s Hospital of Wenling, No. 333 Chuan an south Road, Wenling, Zhejiang 317500, China (e-mail: )
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15
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Zhang J, Xu N, Zheng D. Effect of High-Quality Nursing Care on Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease Complicated with Respiratory Failure: An Observational Cohort Study. Appl Bionics Biomech 2022; 2022:9440899. [PMID: 35733447 PMCID: PMC9208997 DOI: 10.1155/2022/9440899] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 05/04/2022] [Accepted: 05/20/2022] [Indexed: 11/24/2022] Open
Abstract
Background To investigate the efficacy of high-quality nursing care on patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) complicated with respiratory failure. Methods A total of 84 AECOPD patients were included in this study. Lung function indexes, nursing satisfaction, and arterial blood gas index were collected to assess the efficacy of high-quality nursing care on patients with acute chronic obstructive pulmonary disease complicated with respiratory failure. Results The level of lung function after treatment had a statistical difference between the two groups (P < 0.05). On other hand, the nursing satisfaction is improved in the observation group. The PaCO2 and PaO2 level was improved after treatment; there was statistical significance (P < 0.05). Conclusion High-quality nursing intervention has good therapeutic effect on acute exacerbation of COPD complicated with respiratory failure.
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Affiliation(s)
- Junhong Zhang
- Department of Hemodialysis, Zouping Central Hospital, Shandong 256212, China
| | - Na Xu
- Department of Internal Medicine, Jinan Municipal Hospital of Traditional Chinese Medicine, Jinan, China
| | - Dahuan Zheng
- Department of Internal Medicine, Zouping Central Hospital, Shandong 250012, China
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16
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Wu X, Chen J, Iroegbu CD, Liu J, Wu M, Xie X, Xiang K, Wu X, Chen W, Huang P, Zhou W, Fan C, Yang J. Individualized Analysis and Treatment of Difficult Weaning From Ventilation Following Open Cardiac Surgery in Young Children With Congenital Heart Disease. Front Cardiovasc Med 2022; 9:768904. [PMID: 35722090 PMCID: PMC9198256 DOI: 10.3389/fcvm.2022.768904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 05/11/2022] [Indexed: 11/13/2022] Open
Abstract
AimsThe study explores the leading causes of postoperative extubation difficulties in pediatric patients (neonates and toddlers) with congenital heart diseases and establishes individualized treatment for different reasons.MethodWe retrospectively analyzed medical records of 4,971 pediatric patients with congenital heart defects treated in three tertiary Congenital Heart Disease Centres in China from January 2005 to December 2020, from whom we selected those with difficulty extubation but successful weaning during the postoperative period. Next, we performed an analysis of risk factors and reported the combined experience of individualized treatment for successful extubation.ResultsSeventy-five pediatric patients were identified in our database, among whom 23 had airway stenosis, 17 had diaphragmatic dysfunction, and 35 had pulmonary infection. The patients were all successfully weaned from the ventilator after an individualized treatment plan. In addition, the intubation time in the airway stenosis group was 17.7 ± 9.0, 33.6 ± 13.9 days in the diaphragmatic dysfunction group, and 11.9 ± 3.8 days in the pulmonary infection group.ConclusionGiven the primary reasons for difficult weaning following open-heart surgery in pediatric patients with congenital heart diseases, an individualized treatment scheme can achieve the ideal therapeutic effect where patients can be weaned faster with a shorter intubation period.
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Affiliation(s)
- Xiaoming Wu
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Jinlan Chen
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Chukwuemeka Daniel Iroegbu
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Jian Liu
- Department of Cardiothoracic Surgery, Hunan Children's Hospital, Changsha, China
| | - Ming Wu
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of the Cardiovascular Surgery of the Hunan Provincial People's Hospital, Changsha, China
| | - Xia Xie
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Kun Xiang
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Xun Wu
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Wangping Chen
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Peng Huang
- Department of Cardiothoracic Surgery, Hunan Children's Hospital, Changsha, China
| | - Wenwu Zhou
- Department of the Cardiovascular Surgery of the Hunan Provincial People's Hospital, Changsha, China
| | - Chengming Fan
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Chengming Fan
| | - Jinfu Yang
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
- Jinfu Yang
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17
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Ramnarayan P, Richards-Belle A, Drikite L, Saull M, Orzechowska I, Darnell R, Sadique Z, Lester J, Morris KP, Tume LN, Davis PJ, Peters MJ, Feltbower RG, Grieve R, Thomas K, Mouncey PR, Harrison DA, Rowan KM. Effect of High-Flow Nasal Cannula Therapy vs Continuous Positive Airway Pressure Following Extubation on Liberation From Respiratory Support in Critically Ill Children: A Randomized Clinical Trial. JAMA 2022; 327:1555-1565. [PMID: 35390113 PMCID: PMC8990361 DOI: 10.1001/jama.2022.3367] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
IMPORTANCE The optimal first-line mode of noninvasive respiratory support following extubation of critically ill children is not known. OBJECTIVE To evaluate the noninferiority of high-flow nasal cannula (HFNC) therapy as the first-line mode of noninvasive respiratory support following extubation, compared with continuous positive airway pressure (CPAP), on time to liberation from respiratory support. DESIGN, SETTING, AND PARTICIPANTS This was a pragmatic, multicenter, randomized, noninferiority trial conducted at 22 pediatric intensive care units in the United Kingdom. Six hundred children aged 0 to 15 years clinically assessed to require noninvasive respiratory support within 72 hours of extubation were recruited between August 8, 2019, and May 18, 2020, with last follow-up completed on November 22, 2020. INTERVENTIONS Patients were randomized 1:1 to start either HFNC at a flow rate based on patient weight (n = 299) or CPAP of 7 to 8 cm H2O (n = 301). MAIN OUTCOMES AND MEASURES The primary outcome was time from randomization to liberation from respiratory support, defined as the start of a 48-hour period during which the child was free from all forms of respiratory support (invasive or noninvasive), assessed against a noninferiority margin of an adjusted hazard ratio (HR) of 0.75. There were 6 secondary outcomes, including mortality at day 180 and reintubation within 48 hours. RESULTS Of the 600 children who were randomized, 553 children (HFNC, 281; CPAP, 272) were included in the primary analysis (median age, 3 months; 241 girls [44%]). HFNC failed to meet noninferiority, with a median time to liberation of 50.5 hours (95% CI, 43.0-67.9) vs 42.9 hours (95% CI, 30.5-48.2) for CPAP (adjusted HR, 0.83; 1-sided 97.5% CI, 0.70-∞). Similar results were seen across prespecified subgroups. Of the 6 prespecified secondary outcomes, 5 showed no significant difference, including the rate of reintubation within 48 hours (13.3% for HFNC vs 11.5 % for CPAP). Mortality at day 180 was significantly higher for HFNC (5.6% vs 2.4% for CPAP; adjusted odds ratio, 3.07 [95% CI, 1.1-8.8]). The most common adverse events were abdominal distension (HFNC: 8/281 [2.8%] vs CPAP: 7/272 [2.6%]) and nasal/facial trauma (HFNC: 14/281 [5.0%] vs CPAP: 15/272 [5.5%]). CONCLUSIONS AND RELEVANCE Among critically ill children requiring noninvasive respiratory support following extubation, HFNC compared with CPAP following extubation failed to meet the criterion for noninferiority for time to liberation from respiratory support. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN60048867.
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Affiliation(s)
- Padmanabhan Ramnarayan
- Section of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, United Kingdom
- Children’s Acute Transport Service, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Alvin Richards-Belle
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Laura Drikite
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Michelle Saull
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Izabella Orzechowska
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Robert Darnell
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Kevin P. Morris
- Birmingham Children’s Hospital, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Lyvonne N. Tume
- School of Health & Society, University of Salford, Salford, United Kingdom
| | - Peter J. Davis
- Paediatric Intensive Care Unit, Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Mark J. Peters
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, United Kingdom
- University College London Great Ormond St Institute of Child Health, London, United Kingdom
| | - Richard G. Feltbower
- Leeds Institute for Data Analytics, School of Medicine, University of Leeds, Leeds, United Kingdom
| | - Richard Grieve
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Karen Thomas
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Paul R. Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - David A. Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Kathryn M. Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
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18
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Horvat CM, Curley MAQ, Girard TD. Selecting Intermediate Respiratory Support Following Extubation in the Pediatric Intensive Care Unit. JAMA 2022; 327:1550-1552. [PMID: 35390115 DOI: 10.1001/jama.2022.4637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Christopher M Horvat
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Martha A Q Curley
- Research Institute, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- School of Nursing, Department of Family and Community Health, University of Pennsylvania, Philadelphia
| | - Timothy D Girard
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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19
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Ippolito M, Catalisano G, Iozzo P, Raineri SM, Gregoretti C, Giarratano A, Einav S, Cortegiani A. Association between night-time extubation and clinical outcomes in adult patients: A systematic review and meta-analysis. Eur J Anaesthesiol 2022; 39:152-160. [PMID: 34352806 DOI: 10.1097/eja.0000000000001579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Whether night-time extubation is associated with clinical outcomes is unclear. OBJECTIVE The aim of this systematic review and meta-analysis was to evaluate the association between night-time extubation and the reintubation rate, mortality, ICU and in-hospital length of stay in adult patients, compared with daytime extubation. DESIGN A systematic review and meta-analysis. DATA SOURCES PubMed, EMBASE, CINAHL and Web of Science from inception to 2 January 2021 (PROSPERO registration - CRD42020222812). ELIGIBILITY CRITERIA Randomised, quasi and cluster randomised, and nonrandomised studies describing associations between adult patients' outcomes and time of extubation (daytime/night-time) in intensive care or postanaesthesia care units. RESULTS Seven retrospective studies were included in the systematic review and meta-analysis, for a total of 293 663 patients. All the studies were performed in United States (USA). All the studies were judged at moderate risk of bias for reintubation and mortality. The analyses were conducted with random effects models. The analyses from adjusted estimates demonstrated no association between night-time extubation and increased risk of either reintubation (OR 1.00; 95% CI 0.88 to 1.13; P = 1.00; I2 = 66%; low-certainty evidence) or all-cause mortality at the longest available follow-up (OR 1.11; 95% CI 0.87 to 1.42; P = 0.39; I2 = 79%; low-certainty evidence), in comparison with daytime extubation. Analyses from unadjusted data for reintubation, mortality and ICU or in-hospital length of stay showed no significant association with night-time extubation. Analyses based on type of admission, number of centres or duration of mechanical ventilation showed no significant subgroup effects. CONCLUSION Night-time extubation of adult patients was not associated with higher adjusted risks for reintubation or death, in comparison with daytime extubation, but the certainty of the evidence was low.
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Affiliation(s)
- Mariachiara Ippolito
- From the Department of Surgical, Oncological and Oral Science, University of Palermo (MI, GC, SMR, CG, AG, AC), the Department of Anaesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone (PI, SMR, AG, AC), Fondazione 'Giglio' Cefalù, Palermo, Italy (CG), the Intensive Care Unit of the Shaare Zedek Medical Medical Centre and Hebrew University Faculty of Medicine, Jerusalem, Israel (SE)
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20
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Burns KEA, Stevenson J, Laird M, Adhikari NKJ, Li Y, Lu C, He X, Wang W, Liang Z, Chen L, Zhang H, Friedrich JO. Non-invasive ventilation versus invasive weaning in critically ill adults: a systematic review and meta-analysis. Thorax 2021; 77:752-761. [PMID: 34716282 DOI: 10.1136/thoraxjnl-2021-216993] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 09/15/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Extubation to non-invasive ventilation (NIV) has been investigated as a strategy to wean critically ill adults from invasive ventilation and reduce ventilator-related complications. METHODS We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, proceedings of four conferences and bibliographies (to June 2020) for randomised and quasi-randomised trials that compared extubation with immediate application of NIV to continued invasive weaning in intubated adults and reported mortality (primary outcome) or other outcomes. Two reviewers independently screened citations, assessed trial quality and abstracted data. RESULTS We identified 28 trials, of moderate-to-good quality, involving 2066 patients, 44.6% with chronic obstructive pulmonary disease (COPD). Non-invasive weaning significantly reduced mortality (risk ratio (RR) 0.57, 95% CI 0.44 to 0.74; high quality), weaning failures (RR 0.59, 95% CI 0.43 to 0.81; high quality), pneumonia (RR 0.30, 95% CI 0.22 to 0.41; high quality), intensive care unit (ICU) (mean difference (MD) -4.62 days, 95% CI -5.91 to -3.34) and hospital stay (MD -6.29 days, 95% CI -8.90 to -3.68). Non-invasive weaning also significantly reduced the total duration of ventilation, duration of invasive ventilation and duration of ventilation related to weaning (MD -0.57, 95% CI -1.08 to -0.07) and tracheostomy rate. Mortality, pneumonia, reintubation and ICU stay were significantly lower in trials enrolling COPD (vs mixed) populations. CONCLUSION Non-invasive weaning significantly reduced mortality, pneumonia and the duration of ventilation related to weaning, particularly in patients with COPD. Beneficial effects are less clear (or more careful patient selection is required) in non-COPD patients. PROSPERO REGISTRATION NUMBER CRD42020201402.
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Affiliation(s)
- Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada .,Departments of Critical Care and Medicine, Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada.,The Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.,Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - James Stevenson
- The School of Medicine, Royal College of Surgeons, Dublin, Ireland
| | - Matthew Laird
- The School of Medicine, Royal College of Surgeons, Dublin, Ireland
| | - Neill K J Adhikari
- Interdepartmental Division of Critical Care Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,The Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Yuchong Li
- Departments of Critical Care and Medicine, Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada.,Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Cong Lu
- Departments of Critical Care and Medicine, Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada.,Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Xiaolin He
- Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Wentao Wang
- The State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhenting Liang
- The Department of Critical Care Medicine, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lu Chen
- Departments of Critical Care and Medicine, Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada.,Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Haibo Zhang
- Interdepartmental Division of Critical Care Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Departments of Critical Care and Medicine, Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada.,Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Anesthesia and Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Jan O Friedrich
- Interdepartmental Division of Critical Care Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Departments of Critical Care and Medicine, Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada.,The Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
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21
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Puslecki M, Dabrowski M, Ligowski M, Zakhary B, Said AS, Ramanathan K, Cooley E, Puslecki L, Stefaniak S, Ziemak P, Kiel-Puslecka I, Dabrowska A, Klosiewicz T, Sip M, Zalewski R, Ladzinska M, Mrowczynski W, Ladzinski P, Szlanga L, Baumgart K, Kupidlowski P, Szarpak L, Jemielity M, Perek B. Comprehensive assessment of a nationwide simulation-based course for artificial life support. PLoS One 2021; 16:e0257162. [PMID: 34618829 PMCID: PMC8496826 DOI: 10.1371/journal.pone.0257162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 08/24/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Successful implementation of medical technologies applied in life-threatening conditions, including extracorporeal membrane oxygenation (ECMO) requires appropriate preparation and training of medical personnel. The pandemic has accelerated the creation of new ECMO centers and has highlighted continuous training in adapting to new pandemic standards. To reach high standards of patients' care, we created the first of its kind, National Education Centre for Artificial Life Support (NEC-ALS) in 40 million inhabitants' country in the Central and Eastern Europe (CEE). The role of the Center is to test and promote the novel or commonly used procedures as well as to develop staff skills on management of patients needing ECMO. METHOD In 2020, nine approved and endorsed by ELSO courses of "Artificial Life Support with ECMO" were organized. Physicians participated in the three-day high-fidelity simulation-based training that was adapted to abide by the social distancing norms of the COVID-19 pandemic. Knowledge as well as crucial cognitive, behavioral and technical aspects (on a 5-point Likert scale) of management on ECMO were assessed before and after course completion. Moreover, the results of training in mechanical chest compression were also evaluated. RESULTS There were 115 participants (60% men) predominantly in the age of 30-40 years. Majority of them (63%) were anesthesiologists or intensivists with more than 5-year clinical experience, but 54% had no previous ECMO experience. There was significant improvement after the course in all cognitive, behavioral, and technical self-assessments. Among aspects of management with ECMO that all increased significantly following the course, the most pronounced was related to the technical one (from approximately 1.0 to more 4.0 points). Knowledge scores significantly increased post-course from 11.4 ± SD to 13 ± SD (out of 15 points). The quality of manual chest compression relatively poor before course improved significantly after training. CONCLUSIONS Our course confirmed that simulation as an educational approach is invaluable not only in training and testing of novel or commonly used procedures, skills upgrading, but also in practicing very rare cases. The implementation of the education program during COVID-19 pandemic may be helpful in founding specialized Advanced Life Support centers and teams including mobile ones. The dedicated R&D Innovation Ecosystem established in the "ECMO for Greater Poland" program, with developed National Education Center can play a crucial role in the knowledge and know-how transfer but future research is needed.
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Affiliation(s)
- Mateusz Puslecki
- Department of Medical Rescue, Chair of Emergency Medicine, Poznan University of Medical Sciences, Poznan, Poland
- Department of Cardiac Surgery and Transplantology, Chair of Cardiac and Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
- Polish Society of Medical Simulation, Slupca, Poland
- * E-mail:
| | - Marek Dabrowski
- Polish Society of Medical Simulation, Slupca, Poland
- Chair and Department of Medical Education, Poznan University of Medical Sciences, Poznan, Poland
| | - Marcin Ligowski
- Department of Cardiac Surgery and Transplantology, Chair of Cardiac and Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Bishoy Zakhary
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, United States of America
| | - Ahmed S. Said
- Division of Pediatric Critical Care Medicine, Washington University School of Medicine in St Louis and St Louis Children’s Hospital, St. Louis, Missouri, United States of America
| | - Kollengode Ramanathan
- Cardiothoracic Intensive Care Unit, National University Hospital, National University of Singapore, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Bond University, Robina, QLD, Australia
| | - Elaine Cooley
- Extracorporeal Life Support Organization, Ann Arbor, Michigan, United States of America
| | - Lukasz Puslecki
- Department of International Management, Poznan University of Economics and Business, Poznan, Poland
| | - Sebastian Stefaniak
- Department of Cardiac Surgery and Transplantology, Chair of Cardiac and Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Piotr Ziemak
- Center of Medical Simulation, Poznan University of Medical Sciences, Poznan, Poland
| | - Ilona Kiel-Puslecka
- Center of Medical Simulation, Poznan University of Medical Sciences, Poznan, Poland
| | - Agata Dabrowska
- Department of Medical Rescue, Chair of Emergency Medicine, Poznan University of Medical Sciences, Poznan, Poland
- Polish Society of Medical Simulation, Slupca, Poland
| | - Tomasz Klosiewicz
- Department of Medical Rescue, Chair of Emergency Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Maciej Sip
- Department of Medical Rescue, Chair of Emergency Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Radoslaw Zalewski
- Department of Medical Rescue, Chair of Emergency Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Malgorzata Ladzinska
- Department of Cardiac Surgery and Transplantology, Chair of Cardiac and Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Wojciech Mrowczynski
- Department of Pediatric Cardiac Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Piotr Ladzinski
- Department of Pediatric Cardiac Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Lidia Szlanga
- Polish Society of Medical Simulation, Slupca, Poland
| | - Konrad Baumgart
- Department of Cardiac Surgery and Transplantology, Chair of Cardiac and Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Lukasz Szarpak
- Polish Society of Medical Simulation, Slupca, Poland
- Sklodowska-Curie Medical Academy, Warsaw, Poland
- Polish Society of Disaster Medicine, Warsaw, Poland
| | - Marek Jemielity
- Department of Cardiac Surgery and Transplantology, Chair of Cardiac and Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Bartlomiej Perek
- Department of Cardiac Surgery and Transplantology, Chair of Cardiac and Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
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Abstract
Rationale: There are limited data on mechanical discontinuation practices in Asia. Objectives: To document self-reported mechanical discontinuation practices and determine whether there is clinical equipoise regarding protocolized weaning among Asian Intensive Care specialists. Methods: A survey using a validated questionnaire, distributed using a snowball method to Asian Intensive Care specialists. Results: Of the 2,967 invited specialists from 20 territories, 2,074 (69.9%) took part. The majority of respondents (60.5%) were from China. Of the respondents, 42% worked in intensive care units (ICUs) where respiratory therapists were present; 78.9% used a spontaneous breathing trial as the initial weaning step; 44.3% frequently/always used pressure support (PS) alone, 53.4% intermittent spontaneous breathing trials with PS in between, and 19.8% synchronized intermittent mandatory ventilation with PS as a weaning mode. Of the respondents, 56.3% routinely stopped feeds before extubation, 71.5% generally followed a sedation protocol or guideline, and 61.8% worked in an ICU with a weaning protocol. Of these, 78.2% frequently always followed the protocol. A multivariate analysis involving a modified Poisson regression analysis showed that working in an ICU with a weaning protocol and frequently/always following it was positively associated with an upper-middle-income territory, a university-affiliated hospital, or in an ICU that employed respiratory therapists; and negatively with a low-income or lower-middle-income territory or a public hospital. There was no significant association with "in-house" intensivist at night, multidisciplinary ICU, closed ICU, or nurse-patient ratio. There was heterogeneity in agreement/disagreement with the statement, "evidence clearly supports protocolized weaning over nonprotocolized weaning." Conclusions: A substantial minority of Asian Intensive Care specialists do not wean patients in accordance with the best available evidence or current guidelines. There is clinical equipoise regarding the benefit of protocolized weaning.
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23
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Vaschetto R, Pecere A, Perkins GD, Mistry D, Cammarota G, Longhini F, Ferrer M, Pletsch-Assunção R, Carron M, Moretto F, Qiu H, Della Corte F, Barone-Adesi F, Navalesi P. Effects of early extubation followed by noninvasive ventilation versus standard extubation on the duration of invasive mechanical ventilation in hypoxemic non-hypercapnic patients: a systematic review and individual patient data meta-analysis of randomized controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:189. [PMID: 34074314 PMCID: PMC8169383 DOI: 10.1186/s13054-021-03595-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/06/2021] [Indexed: 11/25/2022]
Abstract
Background Usefulness of noninvasive ventilation (NIV) in weaning patients with non-hypercapnic hypoxemic acute respiratory failure (hARF) is unclear. The study aims to assess in patients with non-hypercapnic hARF, the efficacy of NIV after early extubation, compared to standard weaning. Methods In this individual patient data meta-analysis, we searched EMBASE, Medline and Cochrane Central Register of Controlled Trials to identify potentially eligible randomized controlled trials published from database inception to October 2020. To be eligible, studies had to include patients treated with NIV after early extubation and compared to conventional weaning in adult non-hypercapnic hARF patients. Anonymized individual patient data from eligible studies were provided by study investigators. Using one-step and two-step meta-analysis models we tested the difference in total days spent on invasive ventilation. Results We screened 1605 records. Six studies were included in quantitative synthesis. Overall, 459 participants (mean [SD] age, 62 [15] years; 269 [59%] males) recovering from hARF were included in the analysis (233 in the intervention group and 226 controls). Participants receiving NIV had a shorter duration of invasive mechanical ventilation compared to control group (mean difference, − 3.43; 95% CI − 5.17 to − 1.69 days, p < 0.001), a shorter duration of total days spent on mechanical ventilation (mean difference, − 2.04; 95% CI − 3.82 to − 0.27 days, p = 0.024), a reduced risk of ventilatory associated pneumonia (odds ratio, 0.24; 95% CI 0.08 to 0.71, p = 0.014), a reduction of time spent in ICU (time ratio, 0.81; 95% CI 0.68 to 0.96, p = 0.015) and in-hospital (time ratio, 0.81; 95% CI 0.69 to 0.95, p = 0.010), with no difference in ICU mortality. Conclusions Although primary studies are limited, using an individual patient data metanalysis approach, NIV after early extubation appears useful in reducing total days spent on invasive mechanical ventilation. Trial registration The protocol was registered to PROSPERO database on 12/06/2019 and available at PROSPERO website inserting the study code i.e., CRD42019133837. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03595-5.
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Affiliation(s)
- Rosanna Vaschetto
- Azienda Ospedaliero Universitaria "Maggiore della Carità", Anestesia e Terapia Intensiva, Novara, Italy. .,Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, via Solaroli 17, 28100, Novara, Italy.
| | - Alessandro Pecere
- Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, via Solaroli 17, 28100, Novara, Italy
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, Warwick University, Gibbet Hill, Coventry, UK
| | - Dipesh Mistry
- Warwick Clinical Trials Unit, Warwick Medical School, Warwick University, Gibbet Hill, Coventry, UK
| | - Gianmaria Cammarota
- Azienda Ospedaliero Universitaria "Maggiore della Carità", Anestesia e Terapia Intensiva, Novara, Italy
| | - Federico Longhini
- Anestesia e Rianimazione, Dipartimento di Scienze Mediche e Chirurgiche, Università "Magna Graecia", Catanzaro, Italy
| | - Miguel Ferrer
- RIICU, Department of Pneumology, Respiratory Institute, Hospital Clinic of Barcelona, IDIBAPS, CibeRes (CB/06/06/0028), University of Barcelona, Barcelona, Spain
| | - Renata Pletsch-Assunção
- Department of Physiotherapy, Centro Universitário Padre Anchieta, UNIANCHIETA, Jundiaí, SP, Brazil
| | - Michele Carron
- Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care, University of Padua, Padua, Italy
| | - Francesca Moretto
- Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, via Solaroli 17, 28100, Novara, Italy
| | - Haibo Qiu
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Francesco Della Corte
- Azienda Ospedaliero Universitaria "Maggiore della Carità", Anestesia e Terapia Intensiva, Novara, Italy.,Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, via Solaroli 17, 28100, Novara, Italy
| | - Francesco Barone-Adesi
- Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, via Solaroli 17, 28100, Novara, Italy
| | - Paolo Navalesi
- Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care, University of Padua, Padua, Italy
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Jin Y, Di J, Wang X. Early rehabilitation nursing in ICU promotes rehabilitation of patients with respiratory failure treated with invasive mechanical ventilation. Am J Transl Res 2021; 13:5232-5239. [PMID: 34150113 PMCID: PMC8205794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 02/01/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE This paper aimed at exploring the application value of early rehabilitation nursing (ERN) in intensive care unit (ICU) for nursing patients with respiratory failure (RF) treated with invasive mechanical ventilation (IMV). METHODS Admitted to the ICU of our hospital from January 2019 to June 2020, 172 RF patients that was treated with IMV were selected as the research objects. Those in the general group (n=80) received routine nursing in ICU, whereas those in the recovery group (n=92) received ERN on the basis of the general group. The recovery of their vital signs, blood gas functions and pulmonary functions was monitored. Their treatment time in ICU, mechanical ventilation time (MVT), total hospitalization time (THT) and incidence of complications were recorded. Their negative emotions, quality of life (QOL) and nursing satisfaction were assessed. RESULTS After intervention, the body temperature, the respiratory rate and the heart rate in the recovery group were lower than those in the general group (P<0.05). The arterial partial pressure of oxygen (PaO2) and blood oxygen saturation (SpO2) were remarkably higher in the recovery group, while the arterial partial pressure of carbon dioxide (PaCO2) was remarkably lower (P<0.05). One-second forced expiratory volume (FEV1), FEV1/forced vital capacity (FVC) and FEV1% were remarkably higher in the recovery group (P<0.05). The treatment time in ICU, the MVT and the THT were remarkably shorter in the recovery group (P<0.05). During intervention, the total incidence of complications was lower in the recovery group (P<0.05). While after intervention, the scores of the Self-rating Anxiety Scale (SAS), the Self-rating Depression Scale (SDS) and the St. George's Respiratory Questionnaire (SGRQ; symptom, activity, impact) were lower in the recovery group, but the nursing satisfaction was remarkably higher (P<0.05). CONCLUSION During the treatment of RF patients with IMV, ERN can promote their recovery, reduce the incidence of complications, relieve their negative emotions, and improve their QOL and nursing satisfaction. So, this nursing model is worthy of clinical application.
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Affiliation(s)
- Yue Jin
- Intensive Care Unit, Changzhou No.2 People's Hospital, The Affiliated Hospital of Nanjing Medical University Changzhou 213000, Jiangsu Province, China
| | - Jie Di
- Intensive Care Unit, Changzhou No.2 People's Hospital, The Affiliated Hospital of Nanjing Medical University Changzhou 213000, Jiangsu Province, China
| | - Xiaofei Wang
- Intensive Care Unit, Changzhou No.2 People's Hospital, The Affiliated Hospital of Nanjing Medical University Changzhou 213000, Jiangsu Province, China
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Hernandez G, Roca O. Redefining "Minimal Ventilator Settings": Should We Customize the Spontaneous Breathing Trial in the Era of Prevention of Extubation Failure? Chest 2021; 158:1314-1316. [PMID: 33036078 DOI: 10.1016/j.chest.2020.05.578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 05/19/2020] [Indexed: 11/27/2022] Open
Affiliation(s)
- Gonzalo Hernandez
- Department of Critical Care Medicine, University Hospital Virgen de la Salud, Toledo, Spain.
| | - Oriol Roca
- Department of Critical Care Medicine, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain; Ciber Enfermedades Respiratorias (Ciberes), Instituto de Salud Carlos III, Madrid, Spain
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Prediction of weaning from mechanical ventilation using Convolutional Neural Networks. Artif Intell Med 2021; 117:102087. [PMID: 34127233 DOI: 10.1016/j.artmed.2021.102087] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 05/03/2021] [Accepted: 05/03/2021] [Indexed: 10/21/2022]
Abstract
Weaning from mechanical ventilation covers the process of liberating the patient from mechanical support and removing the associated endotracheal tube. The management of weaning from mechanical ventilation comprises a significant proportion of the care of critically ill intubated patients in Intensive Care Units (ICUs). Both prolonged dependence on mechanical ventilation and premature extubation expose patients to an increased risk of complications and increased health care costs. This work aims to develop a decision support model using routinely-recorded patient information to predict extubation readiness. In order to do so, we have deployed Convolutional Neural Networks (CNN) to predict the most appropriate treatment action in the next hour for a given patient state, using historical ICU data extracted from MIMIC-III. The model achieved 86% accuracy and 0.94 area under the receiver operating characteristic curve (AUC-ROC). We also performed feature importance analysis for the CNN model and interpreted these features using the DeepLIFT method. The results of the feature importance assessment show that the CNN model makes predictions using clinically meaningful and appropriate features. Finally, we implemented counterfactual explanations for the CNN model. This can help clinicians understand what feature changes for a particular patient would lead to a desirable outcome, i.e. readiness to extubate.
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Abstract
PURPOSE OF REVIEW Ventilator weaning forms an integral part in critical care medicine and strategies to shorten duration are rapidly evolving alongside our knowledge of the relevant physiological processes. The purpose of the current review is to discuss new physiological and clinical insights in ventilator weaning that help us to fasten liberation from mechanical ventilation. RECENT FINDINGS Several new concepts have been introduced in the field of ventilator weaning in the past 2 years. Approaches to shorten the time until ventilator liberation include frequent spontaneous breathing trials, early noninvasive mechanical ventilation to shorten invasive ventilation time, novel ventilatory modes, such as neurally adjusted ventilatory assist and drugs to enhance the contractile efficiency of respiratory muscles. Equally important, ultrasound has been shown to be a versatile tool to monitor physiological changes of the cardiorespiratory system during weaning and steer targeted interventions to improve extubation outcome. SUMMARY A thorough understanding of the physiological adaptations during withdrawal of positive pressure ventilation is extremely important for clinicians in the ICU. We summarize and discuss novel insights in this field.
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Abstract
PURPOSE OF REVIEW The aim of this study was to review the most recent literature on mechanical ventilation strategies in patients with septic shock. RECENT FINDINGS Indirect clinical trial evidence has refined the use of neuromuscular blocking agents, positive end-expiratory pressure (PEEP) and recruitment manoeuvres in septic shock patients with acute respiratory distress syndrome. Weaning strategies and devices have also been recently evaluated. The role of lung protective ventilation in patients with healthy lungs, while recognized, still needs to be further refined. The possible detrimental effects of spontaneous breathing in patients who develop acute respiratory distress syndrome is increasingly recognized, but clinical trial evidence is still lacking to confirm this hypothesis. A new concept of lung and diaphragm protective is emerging in the critical care literature, but its application will need a complex intervention implementation approach to allow adequate scrutiny of this concept and uptake by clinicians. SUMMARY Many advances in the management of the mechanically ventilated patient with sepsis and septic shock have occurred in recent years, but clinical trial evidence is still necessary to translate new hypotheses to the bedside and find the right balance between benefits and risks of these new strategies.
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Affiliation(s)
- Qi Liu
- Emergency Intensive Care WardFirst Affiliated Hospital of Zhengzhou UniversityZhengzhou, Henan Province, China
| | - Mengtian Shan
- Emergency Intensive Care WardFirst Affiliated Hospital of Zhengzhou UniversityZhengzhou, Henan Province, China
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Khan I, Maredza M, Dritsaki M, Mistry D, Lall R, Lamb SE, Couper K, Gates S, Perkins GD, Petrou S. Is Protocolised Weaning that Includes Early Extubation Onto Non-Invasive Ventilation More Cost Effective Than Protocolised Weaning Without Non-Invasive Ventilation? Findings from the Breathe Study. PHARMACOECONOMICS - OPEN 2020; 4:697-710. [PMID: 32240532 PMCID: PMC7223248 DOI: 10.1007/s41669-020-00210-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Optimising techniques to wean patients from invasive mechanical ventilation (IMV) remains a key goal of intensive care practice. The use of non-invasive ventilation (NIV) as a weaning strategy (transitioning patients who are difficult to wean to early NIV) may reduce mortality, ventilator-associated pneumonia and intensive care unit (ICU) length of stay. OBJECTIVES Our objectives were to determine the cost effectiveness of protocolised weaning, including early extubation onto NIV, compared with weaning without NIV in a UK National Health Service setting. METHODS We conducted an economic evaluation alongside a multicentre randomised controlled trial. Patients were randomised to either protocol-directed weaning from mechanical ventilation or ongoing IMV with daily spontaneous breathing trials. The primary efficacy outcome was time to liberation from ventilation. Bivariate regression of costs and quality-adjusted life-years (QALYs) provided estimates of the incremental cost per QALY and incremental net monetary benefit (INMB) overall and for subgroups [presence/absence of chronic obstructive pulmonary disease (COPD) and operative status]. Long-term cost effectiveness was determined through extrapolation of survival curves using flexible parametric modelling. RESULTS NIV was associated with a mean INMB of £620 ($US885) (cost-effectiveness threshold of £20,000 per QALY) with a corresponding probability of 58% that NIV is cost effective. The probability that NIV is cost effective was higher for those with COPD (84%). NIV was cost effective over 5 years, with an estimated incremental cost-effectiveness ratio of £4618 ($US6594 per QALY gained). CONCLUSIONS The probability of NIV being cost effective relative to weaning without NIV ranged between 57 and 59% overall and between 82 and 87% for the COPD subgroup.
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Affiliation(s)
- Iftekhar Khan
- Warwick Clinical Trials Unit, University of Warwick, Coventry, CV4 7AL UK
- Centre for Statistics in Medicine, University of Oxford, Oxford, OX3 9DU UK
| | - Mandy Maredza
- Warwick Clinical Trials Unit, University of Warwick, Coventry, CV4 7AL UK
| | - Melina Dritsaki
- Centre for Statistics in Medicine, University of Oxford, Oxford, OX3 9DU UK
| | - Dipesh Mistry
- Warwick Clinical Trials Unit, University of Warwick, Coventry, CV4 7AL UK
| | - Ranjit Lall
- Warwick Clinical Trials Unit, University of Warwick, Coventry, CV4 7AL UK
| | - Sarah E. Lamb
- Warwick Clinical Trials Unit, University of Warwick, Coventry, CV4 7AL UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, OX3 9DU UK
| | - Keith Couper
- Warwick Clinical Trials Unit, University of Warwick, Coventry, CV4 7AL UK
| | - Simon Gates
- Warwick Clinical Trials Unit, University of Warwick, Coventry, CV4 7AL UK
| | - Gavin D. Perkins
- Warwick Clinical Trials Unit, University of Warwick, Coventry, CV4 7AL UK
| | - Stavros Petrou
- Warwick Clinical Trials Unit, University of Warwick, Coventry, CV4 7AL UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG UK
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Matsuda W, Uemura T, Yamamoto M, Uemura Y, Kimura A. Impact of frailty on protocol-based weaning from mechanical ventilation in patients with sepsis: a retrospective cohort study. Acute Med Surg 2020; 7:e608. [PMID: 33299566 PMCID: PMC7705235 DOI: 10.1002/ams2.608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 11/02/2020] [Indexed: 12/29/2022] Open
Abstract
Aim Frailty has been shown to be associated with prolonged mechanical ventilation (MV). However, due to limited physiological data, it has been unclear how frailty affects weaning from MV in septic patients subjected to a specific weaning protocol. Methods This was a single‐center retrospective cohort study. The study included patients with sepsis on MV who underwent protocol‐based weaning between August 2015 and December 2018. Frailty was defined as a Clinical Frailty Scale score 4 or more. The association between frailty and weaning was evaluated. Results Ninety‐nine eligible patients were identified and categorized as frail (n = 67) or not frail (n = 32). The duration of MV was significantly longer in the frail group (8 days versus 5 days, P < 0.01). In multivariate analysis, frailty was independently associated with duration of MV (regression coefficient 17.97, 95% confidence interval 1.77–34.17) and successful weaning (hazard ratio 0.60, 95% confidence interval 0.36–1.00). There was no significant between‐group difference in duration until the first separation attempt or reintubation rate. Respiratory failure was significantly more common in the frail group as a cause of weaning failure, whereas airway failure was common in both groups. Conclusion Frailty was independently associated with a longer duration of MV in patients with sepsis who underwent protocol‐based weaning. Frail patients were more likely to fail spontaneous breathing trials than nonfrail patients during the weaning process, although the risk after extubation was similar.
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Affiliation(s)
- Wataru Matsuda
- Department of Emergency Medicine and Critical Care Center Hospital of the National Center for Global Health and Medicine Tokyo Japan
| | - Tatsuki Uemura
- Department of Emergency Medicine and Critical Care Center Hospital of the National Center for Global Health and Medicine Tokyo Japan
| | - Makiko Yamamoto
- Department of Emergency Medicine and Critical Care Center Hospital of the National Center for Global Health and Medicine Tokyo Japan
| | - Yukari Uemura
- Biostatistics Section Department of Data Science Center for Clinical Science National Center for Global Health and Medicine Tokyo Japan
| | - Akio Kimura
- Department of Emergency Medicine and Critical Care Center Hospital of the National Center for Global Health and Medicine Tokyo Japan
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Ten tips to optimize weaning and extubation success in the critically ill. Intensive Care Med 2020; 46:2461-2463. [PMID: 33104823 PMCID: PMC7585833 DOI: 10.1007/s00134-020-06300-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 10/13/2020] [Indexed: 12/16/2022]
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Silva LCRD, Tonelli IS, Oliveira RCC, Lemos PL, Matos SSD, Chianca TCM. Clinical study of Dysfunctional Ventilatory Weaning Response in critically ill patients. Rev Lat Am Enfermagem 2020; 28:e3334. [PMID: 32813785 PMCID: PMC7426140 DOI: 10.1590/1518-8345.3522.3334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 04/16/2020] [Indexed: 11/22/2022] Open
Abstract
Objective: to clinically validate the nursing diagnosis of Dysfunctional Ventilatory Weaning Response in adult patients admitted to Intensive Care Units. Method: a concurrent cohort performed with 93 patients admitted to Intensive Care Units. The incidence and incidence density of the diagnosis were estimated, its related factors were identified based on bivariate analysis and clinical indicators for determining its occurrence, according to the global and temporal presentation. Results: the overall incidence of the diagnosis was 44.09% and the incidence density was 14.49 occurrences for every 100 extubations/day. The factors related to the diagnosis were the following: age, clinical severity, fluid balance, oliguria, hemodialysis, edema in upper/lower limbs, anasarca, number of antibiotics, hypothermia, hyperthermia, amount of secretion, muscle retraction, anxiety score, heart rate, use of vasopressors and non-invasive ventilation after extubation. The clinical indicators most frequently identified for determining the diagnosis were the following: tachypnea, drop of saturation and tachycardia. Temporal progression in the severity of these manifestations was found. Conclusion: the Dysfunctional Ventilatory Weaning Response is a common finding in critically ill patients. Some components of the diagnosis of the NANDA-International (2018) version could be clinically validated. It is noteworthy that there are variables not yet described in the taxonomy, demonstrating the need to review this nursing diagnosis.
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Affiliation(s)
| | | | | | - Patricia Lage Lemos
- Hospital Risoleta Tolentino Neves, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
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Zhang JB, Zhu JQ, Cao LX, Jin XH, Chen LL, Song YK, Zhou SF, Ma JH, Fu H, Xu JZ, Dong MP, Yan LC, Wu XD, Wang HP, Zhou JY, Wang YQ. Use of the modified Glasgow Coma Scale score to guide sequential invasive-noninvasive mechanical ventilation weaning in patients with AECOPD and respiratory failure. Exp Ther Med 2020; 20:1441-1446. [PMID: 32742377 PMCID: PMC7388266 DOI: 10.3892/etm.2020.8884] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 05/07/2020] [Indexed: 12/16/2022] Open
Abstract
Sequential invasive-noninvasive ventilation (NIV) improves the outcomes of patients with respiratory failure caused by acute exacerbation of chronic obstructive pulmonary disease (AECOPD); however, there is no clear consensus on the optimal timing of the switch to sequential invasive-NIV in these patients. In the present study, a potential role for the modified Glasgow Coma Scale (GCS) score to guide sequential weaning was investigated. Patients with AECOPD and respiratory failure were prospectively recruited from three study centers (Wenling Hospital Affiliated to Wenzhou Medical University, the First Affiliated Hospital of Wenzhou Medical University and Changsha Central Hospital) between January 1st 2016 and December 31st 2018. Patients were randomly assigned to group A and B, with the switching point for sequential weaning strategy in the two groups being a modified GCS score ≥13 and 10 points, respectively. Each group included 240 patients. Baseline demographic characteristics were comparable in the two groups. The duration of invasive mechanical ventilation (IMV) in group A was significantly shorter than that in group B. However, there were no significant between-group differences with respect to the incidence of re-intubation, ventilator-associated pneumonia, in-hospital mortality or the length of hospital stay. Use of a modified GCS score ≥13 as the switching point for sequential invasive-NIV may help decrease the duration of IMV in patients with AECOPD and respiratory failure.
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Affiliation(s)
- Jin-Bo Zhang
- Emergency Intensive Care Unit, Wenling Hospital Affiliated to Wenzhou Medical University, The First People's Hospital of Wenling, Wenling, Zhejiang 317500, P.R. China
| | - Jin-Qiang Zhu
- Emergency Intensive Care Unit, Wenling Hospital Affiliated to Wenzhou Medical University, The First People's Hospital of Wenling, Wenling, Zhejiang 317500, P.R. China
| | - Lie-Xiang Cao
- Emergency Intensive Care Unit, Wenling Hospital Affiliated to Wenzhou Medical University, The First People's Hospital of Wenling, Wenling, Zhejiang 317500, P.R. China
| | - Xiao-Hong Jin
- Emergency Intensive Care Unit, Wenling Hospital Affiliated to Wenzhou Medical University, The First People's Hospital of Wenling, Wenling, Zhejiang 317500, P.R. China
| | - Li-Li Chen
- Emergency Intensive Care Unit, Wenling Hospital Affiliated to Wenzhou Medical University, The First People's Hospital of Wenling, Wenling, Zhejiang 317500, P.R. China
| | - Yu-Kang Song
- Emergency Intensive Care Unit, Wenling Hospital Affiliated to Wenzhou Medical University, The First People's Hospital of Wenling, Wenling, Zhejiang 317500, P.R. China
| | - Shi-Fang Zhou
- Department of Emergency Care, Changsha Central Hospital, Changsha, Hunan 410004, P.R. China
| | - Ji-Hong Ma
- Intensive Care Unit, First Affiliated Hospital of Wenzhou Medical University, Wenling, Zhejiang 325000, P.R. China
| | - Hui Fu
- Emergency Intensive Care Unit, Wenling Hospital Affiliated to Wenzhou Medical University, The First People's Hospital of Wenling, Wenling, Zhejiang 317500, P.R. China
| | - Jin-Zhong Xu
- Emergency Intensive Care Unit, Wenling Hospital Affiliated to Wenzhou Medical University, The First People's Hospital of Wenling, Wenling, Zhejiang 317500, P.R. China
| | - Mei-Ping Dong
- Emergency Intensive Care Unit, Wenling Hospital Affiliated to Wenzhou Medical University, The First People's Hospital of Wenling, Wenling, Zhejiang 317500, P.R. China
| | - Lai-Chao Yan
- Emergency Intensive Care Unit, Wenling Hospital Affiliated to Wenzhou Medical University, The First People's Hospital of Wenling, Wenling, Zhejiang 317500, P.R. China
| | - Xian-Dan Wu
- Emergency Intensive Care Unit, Wenling Hospital Affiliated to Wenzhou Medical University, The First People's Hospital of Wenling, Wenling, Zhejiang 317500, P.R. China
| | - Hui-Ping Wang
- Emergency Intensive Care Unit, Wenling Hospital Affiliated to Wenzhou Medical University, The First People's Hospital of Wenling, Wenling, Zhejiang 317500, P.R. China
| | - Jun-Yang Zhou
- Emergency Intensive Care Unit, Wenling Hospital Affiliated to Wenzhou Medical University, The First People's Hospital of Wenling, Wenling, Zhejiang 317500, P.R. China
| | - Yan-Qiu Wang
- Emergency Intensive Care Unit, Wenling Hospital Affiliated to Wenzhou Medical University, The First People's Hospital of Wenling, Wenling, Zhejiang 317500, P.R. China
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Nam H, Cho JH, Park TS, Kim SW, Kang HK, Shin YM, Hwang JJ, Lee K, Ha JH, Lee YS, Chang Y, Park S. Non-invasive ventilation for acute respiratory failure: pressure support ventilation vs. pressure-controlled ventilation. J Thorac Dis 2020; 12:2553-2562. [PMID: 32642163 PMCID: PMC7330335 DOI: 10.21037/jtd.2020.03.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background The best ventilator mode for patients receiving non-invasive ventilation (NIV) has not been clarified. This study compared the effectiveness of two pressure-targeted modes, i.e., pressure support ventilation (PSV) and pressure-controlled ventilation (PCV), in patients receiving NIV. Methods This was a prospective multicentre observational study of NIV use for acute respiratory failure (ARF) in adult patients. We compared the two pressure-targeted modes in terms of NIV success and complication rates. Results Among 176 patients receiving NIV, 88 patients were included in the study (PCV mode, n=29; PSV mode, n=59). The study population had a median age of 73.0 years and median body mass index of 20.8 kg/m2. The applied inspiratory positive airway pressure (IPAP) was higher in patients with PCV than in those with PSV [18.0 cmH2O (15.0–20.5 cmH2O) vs. 15.0 cmH2O (12.0–17.0 cmH2O), respectively, P=0.001]. More patients with PCV received sedatives and experienced dry mouth than those with PSV; however, the incidences of large leaks were low in both groups (n=5 vs. n=2, respectively). With regard to NIV outcomes, 24 (27.2%) patients experienced NIV failure and 13 (14.8%) died in hospital. PSV mode was a significant factor for NIV success [odds ratio (OR), 2.303; 95% confidence interval (CI), 1.216 to 4.360] in multivariate analyses and this association remained significant in a 1:1 matched cohort (n=29 per group). Conclusions In contrast to PCV mode, PSV mode was significantly associated with NIV success in the intensive care unit setting, particularly when large leaks were not a major concern. Nevertheless, further well-designed multicenter, protocol-driven randomized controlled trials are warranted.
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Affiliation(s)
- Hyunseung Nam
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Jae Hwa Cho
- Department Internal Medicine, Gangnam Severance Hospital, College of Medicine, Yonsei University, Seoul, Korea
| | - Tai Sun Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Sei Won Kim
- Department of Pulmonary, Critical Care and Sleep Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyung Koo Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Yoon Mi Shin
- Department of Pulmonary and Critical Care Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Jae Joon Hwang
- Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Kwangha Lee
- Department of Internal Medicine, Pusan National University Hospital, Busan, Korea
| | - Jick Hwan Ha
- Department of Pulmonary and Critical Care Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Inchoen, Korea
| | - Young Seok Lee
- Department of Pulmonary and Critical Care Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Youjin Chang
- Department of Pulmonary and Critical Care Medicine, Inje University Paik Hospital, Seoul, Korea
| | - Sunghoon Park
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
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Which Multicenter Randomized Controlled Trials in Critical Care Medicine Have Shown Reduced Mortality? A Systematic Review. Crit Care Med 2019; 47:1680-1691. [DOI: 10.1097/ccm.0000000000004000] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Li J, Scott JB, Duan J, Liu K, Fink JB. More than just a screen to liberate from mechanical ventilation: treat to keep extubated? ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S338. [PMID: 32016056 DOI: 10.21037/atm.2019.09.100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL, USA
| | - J Brady Scott
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL, USA
| | - Jun Duan
- Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Kai Liu
- Department of Critical Care Medicine, Shanghai Zhongshan Hospital, Fu Dan University, Shanghai 200032, China
| | - James B Fink
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL, USA.,Aerogen Pharma Corp, San Mateo, CA, USA
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Dietrich M, Reuß CJ, Beynon C, Hecker A, Jungk C, Michalski D, Nusshag C, Schmidt K, Bernhard M, Brenner T, Weigand MA. Beatmung und Sauerstofftherapie. Anaesthesist 2019; 68:770-776. [DOI: 10.1007/s00101-019-00640-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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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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40
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Multiorgan Drug Action of Levosimendan in Critical Illnesses. BIOMED RESEARCH INTERNATIONAL 2019; 2019:9731467. [PMID: 31641670 PMCID: PMC6770297 DOI: 10.1155/2019/9731467] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 08/24/2019] [Indexed: 01/13/2023]
Abstract
Cardiotonic drugs mainly include digitalis, catecholamines, phosphodiesterase inhibitors, and calcium sensitizers, which have been successively discovered and applied in clinical practice. However, there are only a few new drugs available in this field, and the selection is very limited. Digitalis, catecholamines, and phosphodiesterase inhibitors increase myocardial contractility by increasing intracellular concentrations of cyclic adenosine monophosphate (cAMP) and Ca2+, and this increase in intracellular calcium ion concentration enhances myocardial oxygen consumption and causes arrhythmia. For these reasons, the research focus on positive inotropic agents has shifted from calcium mobilization to calcium sensitization. Intracellular calcium sensitizers are more effective and safer drugs because they do not increase the intracellular concentration of calcium ions. However, only three calcium sensitizers have been fully developed and used in the past three decades. One of these drugs, levosimendan, has multiple molecular targets and exerts its pharmacological effects by not only increasing myocardial contractility, but also enhancing respiratory muscle function and liver and kidney protection, and it is useful for patients with severe sepsis and septic shock. Recently, more than 60 randomized controlled clinical trials of levosimendan have been reported; however, these clinical trials have occasionally shown different findings. This article reviews the research progress of levosimendan in critical illnesses in recent years.
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41
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Xu L, Ba H, Pei Y, Huang X, Liang Y, Zhang L, Huang H, Zhang C, Tang W. Comprehensive approach to weaning in difficult-to-wean infantile and juvenile-onset glycogen-storage disease type II patients: a case series. Ital J Pediatr 2019; 45:106. [PMID: 31439017 PMCID: PMC6704633 DOI: 10.1186/s13052-019-0692-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 07/30/2019] [Indexed: 12/05/2022] Open
Abstract
Background Glycogen storage disease type II (GSD II) is caused by acid alpha-glucosidase (GAA) deficiency. Both infantile-onset and juvenile-onset GSD II lead to proximal muscle weakness and respiratory insufficiency and require mechanical ventilation. However, GSD II is also independently associated with delayed weaning from mechanical ventilation. This study aimed to describe a comprehensive approach including sequential invasive-noninvasive mechanical ventilation weaning and enzyme replacement therapy (ERT) in patients with weaning difficulties. Case presentation We studied six difficult-to-wean GSD II (three juvenile-onset, three infantile-onset) patients at the First Affiliated Hospital, Sun Yat-sen University from October 2015 to December 2017. Difficulty in weaning was defined as follows: the need for more than three spontaneous breathing trials or more than 1 week to achieve successful weaning. All patients received comprehensive treatment including sequential invasive-noninvasive mechanical ventilation weaning, ERT and general treatment. Recombinant human acid alpha-glucosidase enzyme therapy (20 mg/kg every 14 days) was used after diagnosis, and Patients 1–6 received ERT for 15.5, 4.5, 2, 2.5, 17, and 2 months, respectively. The therapeutic effect of the comprehensive treatment was observed. The patients’ respiratory function and limb muscle strength improved after each ERT session. Patients who successfully completed a spontaneous breathing trial could proceed to extubation, and then start non-invasive ventilation. The patients’ age range at initial mechanical ventilation was 3–47 (median 26.5) months, duration of invasive ventilation was 1–36 (median 2.75) months, and duration of noninvasive ventilation was 0–0.6 (median 0.05) month. The patients’ nutritional status improved after enhanced nutritional support. Patients 2, 3, and 5 were successfully weaned off the ventilator. Patient 1 underwent tracheal intubation after six weaning failures, and Patients 4 and 6 died after therapy was abandoned by their parents. Discussion and conclusions Male sex, GSD II type, and the presence of malnutrition and neurological impairment may predict poor respiratory outcomes. The above-described comprehensive sequential invasive-noninvasive mechanical ventilation weaning strategy may increase the success rate of weaning from mechanical ventilation.
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Affiliation(s)
- Lingling Xu
- Department of PICU, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, Guangdong, 510080, People's Republic of China
| | - Hongjun Ba
- Department of Cardiovascular pediatrics, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, Guangdong, 510080, People's Republic of China
| | - Yuxin Pei
- Department of PICU, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, Guangdong, 510080, People's Republic of China
| | - Xueqiong Huang
- Department of PICU, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, Guangdong, 510080, People's Republic of China
| | - Yujian Liang
- Department of PICU, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, Guangdong, 510080, People's Republic of China
| | - Lidan Zhang
- Department of PICU, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, Guangdong, 510080, People's Republic of China
| | - Huimin Huang
- Department of PICU, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, Guangdong, 510080, People's Republic of China
| | - Cheng Zhang
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, Guangdong, 510080, People's Republic of China
| | - Wen Tang
- Department of PICU, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, Guangdong, 510080, People's Republic of China.
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42
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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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43
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Kemp HI, Laycock H, Costello A, Brett SJ. Chronic pain in critical care survivors: a narrative review. Br J Anaesth 2019; 123:e372-e384. [PMID: 31126622 DOI: 10.1016/j.bja.2019.03.025] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/22/2019] [Accepted: 03/19/2019] [Indexed: 01/28/2023] Open
Abstract
Chronic pain is an important problem after critical care admission. Estimates of the prevalence of chronic pain in the year after discharge range from 14% to 77% depending on the type of cohort, the tool used to measure pain, and the time point when pain was assessed. The majority of data available come from studies using health-related quality of life tools, although some have included pain-specific tools. Nociceptive, neuropathic, and nociplastic pain can occur in critical care survivors, but limited information about the aetiology, body site, and temporal trajectory of pain is currently available. Older age, pre-existing pain, and medical co-morbidity have been associated with pain after critical care admission. No trials were identified of interventions to target chronic pain in survivors specifically. Larger studies, using pain-specific tools, over an extended follow-up period are required to confirm the prevalence, identify risk factors, explore any association between acute and chronic pain in this setting, determine the underlying pathological mechanisms, and inform the development of future analgesic interventions.
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Affiliation(s)
- Harriet I Kemp
- Department of Surgery and Cancer, Imperial College London, London, UK.
| | - Helen Laycock
- Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - Stephen J Brett
- Department of Surgery and Cancer, Imperial College London, London, UK
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44
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Jing G, Li J, Hao D, Wang T, Sun Y, Tian H, Fu Z, Zhang Y, Wang X. Comparison of high flow nasal cannula with noninvasive ventilation in chronic obstructive pulmonary disease patients with hypercapnia in preventing postextubation respiratory failure: A pilot randomized controlled trial. Res Nurs Health 2019; 42:217-225. [PMID: 30887549 DOI: 10.1002/nur.21942] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/11/2019] [Accepted: 02/22/2019] [Indexed: 12/27/2022]
Abstract
High flow nasal cannula (HFNC) has been shown to improve extubation outcomes in patients with hypoxemia, but the role of HFNC in weaning patients with chronic obstructive pulmonary disease (COPD) with hypercapnia from invasive ventilation is unclear. We compared the effects of HFNC to noninvasive ventilation (NIV) on postextubation vital signs and arterial blood gases (ABGs) among patients with COPD. Other outcomes included comfort scores, need for bronchoscopy, use of pulmonary medications, and chest physiotherapy. Forty-two COPD patients who had persistent hypercapnia at extubation were assigned randomly to receive HFNC (22) or NIV (20). Twenty patients in each group were enrolled for per-protocol analysis with regard to primary outcomes. Vital signs and ABGs before extubation were similar between groups. At 3 hr after extubation, pH in the NIV group was lower than HFNC group (7.42 ± 0.06 vs. 7.45 ± 0.05, p = 0.01). At 24 hr after extubation, patients' mean arterial pressure (82.97 ± 9.04 vs. 92.06 ± 11.11 mmHg, p = 0.05) and pH (7.42 ± 0.05 vs. 7.46 ± 0.03, p = 0.05) in the NIV group were lower than in the HFNC group. No significant differences were found at 48 hr after extubation. In the HFNC group, comfort scores were better (3.55 ± 2.01 vs. 5.15 ± 2.28, p = 0.02) and fewer patients needed bronchoscopy for secretion management within 48 hr after extubation (2/22 vs. 9/20, p = 0.03). HFNC is a potential alternative to NIV to wean hypercapnic COPD patients with regard to vital signs and ABGs, HFNC improved patients' comfort and secretion clearance.
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Affiliation(s)
- Guoqiang Jing
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou Medical University, Binzhou, China
| | - Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, Illinois
| | - Dong Hao
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou Medical University, Binzhou, China
| | - Tao Wang
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou Medical University, Binzhou, China
| | - Yunliang Sun
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou Medical University, Binzhou, China
| | - Huanhuan Tian
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou Medical University, Binzhou, China
| | - Zhong Fu
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou Medical University, Binzhou, China
| | - Yuewei Zhang
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou Medical University, Binzhou, China
| | - Xiaozhi Wang
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou Medical University, Binzhou, China
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45
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Arabi YM, Gouda A, Ali YA. 2018 Year in Review in Critical Care. Ann Thorac Med 2019; 14:122-126. [PMID: 31007763 PMCID: PMC6467021 DOI: 10.4103/atm.atm_72_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Yaseen M Arabi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,Department of Intensive Care, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Alaa Gouda
- Department of Intensive Care, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Youssuf A Ali
- Alfaisal University, College of Medicine, Riyadh, Saudi Arabia
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46
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Yeung J, Couper K, Ryan EG, Gates S, Hart N, Perkins GD. Non-invasive ventilation as a strategy for weaning from invasive mechanical ventilation: a systematic review and Bayesian meta-analysis. Intensive Care Med 2018; 44:2192-2204. [PMID: 30382306 PMCID: PMC6280833 DOI: 10.1007/s00134-018-5434-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 10/24/2018] [Indexed: 01/01/2023]
Abstract
PURPOSE A systematic review and meta-analysis was conducted to answer the question 'In adults with respiratory failure requiring invasive ventilation for more than 24 h, does a weaning strategy with early extubation to non-invasive ventilation (NIV) compared to invasive ventilation weaning reduce all-cause hospital mortality?' METHODS We included randomised and quasi-randomised controlled trials that evaluated the use of non-invasive ventilation, compared to invasive ventilation, as a weaning strategy in adults mechanically ventilated for at least 24 h. The EMBASE, MEDLINE and Cochrane Central Register of Controlled Trials (CENTRAL) bibliographic databases were searched from inception to February 2018. Bayesian hierarchical models were used to perform the meta-analysis. The primary outcome was mortality at hospital discharge. Secondary outcomes included mortality (30, 60, 90 and 180 days), quality of life, duration of invasive ventilation, weaning failure, length of stay [intensive care unit (ICU) and hospital] and adverse events. RESULTS Twenty-five relevant studies involving 1609 patients were included in the quantitative analysis. Studies had moderate to high risk of bias due to risk of performance and detection bias. Mortality at hospital discharge was lower in the NIV weaning group compared to the invasive weaning group [pooled odds ratio (OR) 0.58, 95% highest density interval (HDI) 0.29-0.89]. Subgroup analyses showed lower pooled mortality at hospital discharge rates in NIV weaning than those in the control group in chronic obstructive pulmonary disease (COPD) patients (pooled OR 0.43, 95% HDI 0.13-0.81) and the effect is less certain in the mixed ICU population (pooled OR 0.88, 95% HDI 0.25-1.48). NIV weaning reduced the duration of invasive ventilation in patients [standardised mean difference (SMD) - 1.34, 95% HDI - 1.92 to - 0.77] and ICU length of stay (SMD - 0.70, 95% HDI - 0.94 to - 0.46). Reported rates of ventilator associated pneumonia (VAP) were lower in the NIV group. NIV weaning did not reduce overall hospital length of stay or long-term mortality. There were insufficient data to compare other adverse events and health-related quality of life. CONCLUSIONS The use of NIV in weaning from mechanical ventilation decreases hospital mortality, the incidence of VAP and ICU length of stay. NIV as a weaning strategy appears to be most beneficial in patients with COPD.
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Affiliation(s)
- Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK.
- Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK.
| | - Keith Couper
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Elizabeth G Ryan
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Simon Gates
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Nick Hart
- Lane Fox Respiratory Unit, Guy's and St. Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
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