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Randhawa VK, Lee R, Alviar CL, Rali AS, Arias A, Vaidya A, Zern EK, Fagan A, Proudfoot AG, Katz JN. Extra-cardiac management of cardiogenic shock in the intensive care unit. J Heart Lung Transplant 2024; 43:1051-1058. [PMID: 38823968 DOI: 10.1016/j.healun.2024.03.017] [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: 12/30/2023] [Revised: 03/23/2024] [Accepted: 03/25/2024] [Indexed: 06/03/2024] Open
Abstract
Cardiogenic shock (CS) is a heterogeneous clinical syndrome characterized by low cardiac output leading to end-organ hypoperfusion. Organ dysoxia ranging from transient organ injury to irreversible organ failure and death occurs across all CS etiologies but differing by incidence and type. Herein, we review the recognition and management of respiratory, renal and hepatic failure complicating CS. We also discuss unmet needs in the CS care pathway and future research priorities for generating evidence-based best practices for the management of extra-cardiac sequelae. The complexity of CS admitted to the contemporary cardiac intensive care unit demands a workforce skilled to care for these extra-cardiac critical illness complications with an appreciation for how cardio-systemic interactions influence critical illness outcomes in afflicted patients.
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Affiliation(s)
- Varinder K Randhawa
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Division of Cardiology, St Michael's Hospital, and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ran Lee
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Sections of Critical Care Cardiology and Advanced Heart Failure and Transplant Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Carlos L Alviar
- The Leon H Charney Division of Cardiovascular Medicine, NYU Langone Medical Center, New York, New York
| | - Aniket S Rali
- Department of Internal Medicine, Division of Cardiovascular Diseases, and Department of Anesthesiology, Division of Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexandra Arias
- Instituto Nacional de Cardiologia Ignacio Chavez, Mexico City, Mexico
| | - Anjali Vaidya
- Pulmonary Hypertension, Right Heart Failure, and CTEPH Program, Division of Cardiology, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Emily K Zern
- Department of Cardiology, Keck School of Medicine of University of Southern California, Los Angeles General Medicine Center, Los Angeles General Medical Center, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Andrew Fagan
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alastair G Proudfoot
- Department of Perioperative Medicine, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Jason N Katz
- Division of Cardiology, NYU Grossman School of Medicine and Bellevue Hospital Center, New York, New York.
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2
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Karvellas CJ, Bajaj JS, Kamath PS, Napolitano L, O'Leary JG, Solà E, Subramanian R, Wong F, Asrani SK. AASLD Practice Guidance on Acute-on-chronic liver failure and the management of critically ill patients with cirrhosis. Hepatology 2024; 79:1463-1502. [PMID: 37939273 DOI: 10.1097/hep.0000000000000671] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/01/2023] [Indexed: 11/10/2023]
Affiliation(s)
- Constantine J Karvellas
- Division of Gastroenterology (Liver Unit), Department of Critical Care Medicine, University of Alberta, Edmonton, Canada
| | - Jasmohan S Bajaj
- Virginia Commonwealth University, Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
| | - Patrick S Kamath
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | | | - Jacqueline G O'Leary
- Department of Medicine, Dallas Veterans Medical Center, University of Texas Southwestern Medical Center Dallas, Texas, USA
| | - Elsa Solà
- Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine, Stanford, California, USA
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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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McCormick G, Mohr NM, Ablordeppey E, Stephens RJ, Fuller BM, Roberts BW. Partial pressure of carbon dioxide/pH interaction and its association with mortality among patients mechanically ventilated in the emergency department. Am J Emerg Med 2024; 79:105-110. [PMID: 38417220 DOI: 10.1016/j.ajem.2024.02.025] [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: 10/10/2023] [Revised: 01/29/2024] [Accepted: 02/18/2024] [Indexed: 03/01/2024] Open
Abstract
OBJECTIVES There is currently conflicting data as to the effects of hypercapnia on clinical outcomes among mechanically ventilated patients in the emergency department (ED). These conflicting results may be explained by the degree of acidosis. We sought to test the hypothesis that hypercapnia is associated with increased in-hospital mortality and decreased ventilator-free days at lower pH, but associated with decreased in-hospital mortality and increased ventilator-free days at higher pH, among patients requiring mechanical ventilation in the emergency department (ED). METHODS Secondary analysis of patient level data from prior clinical trials and cohort studies that enrolled adult patients who required mechanical ventilation in the ED. Patients who had a documented blood gas while on mechanical ventilation in the ED were included in these analyses. The primary outcome was in-hospital mortality, and secondary outcome was ventilator-free days. Mixed-effects logistic, linear, and survival-time regression models were used to test if pH modified the association between partial pressure of carbon dioxide (pCO2) and outcome measures. RESULTS Of the 2348 subjects included, the median [interquartile range (IQR)] pCO2 was 43 (35-54) and pH was 7.31 (7.22-7.39). Overall, in-hospital mortality was 27%. We found pH modified the association between pCO2 and outcomes, with higher pCO2 associated with increased probability of in-hospital mortality when pH is below 7.00, and decreased probability of in-hospital mortality when pH is above 7.10. These results remained consistent across multiple sensitivity and subgroup analyses. A similar relationship was found with ventilator-free days. CONCLUSIONS Higher pCO2 is associated with decreased mortality and greater ventilator-free days when pH is >7.10; however, it is associated with increased mortality and fewer ventilator-free days when the pH is below 7.00. Targeting pCO2 based on pH in the ED may be a potential intervention target for future clinical trials to improve clinical outcomes.
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Affiliation(s)
- Gregory McCormick
- The Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesia, Division of Critical Care Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, United States of America
| | - Enyo Ablordeppey
- Departments of Emergency Medicine and Anesthesia, Division of Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Robert J Stephens
- Department of Medicine, Division of Critical Care, University of Maryland School of Medicine, United States of America
| | - Brian M Fuller
- Departments of Emergency Medicine and Anesthesia, Division of Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Brian W Roberts
- The Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States of America.
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Bluth T, Güldner A, Spieth PM. [Ventilation concepts under extracorporeal membrane oxygenation (ECMO) in acute respiratory distress syndrome (ARDS)]. DIE ANAESTHESIOLOGIE 2024; 73:352-362. [PMID: 38625538 DOI: 10.1007/s00101-024-01407-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
Extracorporeal membrane oxygenation (ECMO) is often the last resort for escalation of treatment in patients with severe acute respiratory distress syndrome (ARDS). The success of treatment is mainly determined by patient-specific factors, such as age, comorbidities, duration and invasiveness of the pre-existing ventilation treatment as well as the expertise of the treating ECMO center. In particular, the adjustment of mechanical ventilation during ongoing ECMO treatment remains controversial. Although a reduction of invasiveness of mechanical ventilation seems to be reasonable due to physiological considerations, no improvement in outcome has been demonstrated so far for the use of ultraprotective ventilation regimens.
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Affiliation(s)
- Thomas Bluth
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - Andreas Güldner
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - Peter M Spieth
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland.
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Bhadra K, Baleeiro C, Patel S, Condra W, Bader BA, Setser RM, Youngblood S. High Tidal Volume, High Positive End Expiratory Pressure and Apneic Breath Hold Strategies (Lung Navigation Ventilation Protocol) With Cone Beam Computed Tomography Bronchoscopic Biopsy of Peripheral Lung Lesions: Results in 100 Patients. J Bronchology Interv Pulmonol 2024; 31:105-116. [PMID: 37459049 PMCID: PMC10984636 DOI: 10.1097/lbr.0000000000000938] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/31/2023] [Indexed: 04/04/2024]
Abstract
BACKGROUND A dedicated anesthesia protocol for bronchoscopic lung biopsy-lung navigation ventilation protocol (LNVP)-specifically designed to mitigate atelectasis and reduce unnecessary respiratory motion, has been recently described. LNVP demonstrated significantly reduced dependent ground glass, sublobar/lobar atelectasis, and atelectasis obscuring target lesions compared with conventional ventilation. METHODS In this retrospective, single-center study, we examine the impact of LNVP on 100 consecutive patients during peripheral lung lesion biopsy. We report the incidence of atelectasis using cone beam computed tomography imaging, observed ventilatory findings, anesthesia medications, and outcomes, including diagnostic yield, radiation exposure, and complications. RESULTS Atelectasis was observed in a minority of subjects: ground glass opacity atelectasis was seen in 30 patients by reader 1 (28%) and in 18 patients by reader 2 (17%), with good agreement between readers (κ = 0.78). Sublobar/lobar atelectasis was observed in 23 patients by reader 1 and 26 patients by reader 2, also demonstrating good agreement (κ = 0.67). Atelectasis obscured target lesions in very few cases: 0 patients (0%, reader 1) and 3 patients (3%, reader 2). Diagnostic yield was 85.9% based on the AQuIRE definition. Pathology demonstrated 57 of 106 lesions (54%) were malignant, 34 lesions (32%) were benign, and 15 lesions (14%) were nondiagnostic. CONCLUSION Cone beam computed tomography images confirmed low rates of atelectasis, high tool-in-lesion confirmation rate, and high diagnostic yield. LNVP has a similar safety profile to conventional bronchoscopy. Most patients will require intravenous fluid and vasopressor support. Further study of LNVP and other ventilation protocols are necessary to understand the impact of ventilation protocols on bronchoscopic peripheral lung biopsy.
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Affiliation(s)
| | | | | | | | | | | | - Sloan Youngblood
- American Anesthesia of Tennessee, CHI Memorial Hospital, Chattanooga, TN
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Szafran JC, Patel BK. Invasive Mechanical Ventilation. Crit Care Clin 2024; 40:255-273. [PMID: 38432695 DOI: 10.1016/j.ccc.2024.01.003] [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
Invasive mechanical ventilation allows clinicians to support gas exchange and work of breathing in patients with respiratory failure. However, there is also potential for iatrogenesis. By understanding the benefits and limitations of different modes of ventilation and goals for gas exchange, clinicians can choose a strategy that provides appropriate support while minimizing harm. The ventilator can also provide crucial diagnostic information in the form of respiratory mechanics. These, and the mechanical ventilation strategy, should be regularly reassessed.
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Affiliation(s)
- Jennifer C Szafran
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA.
| | - Bhakti K Patel
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA
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Seitz KP, Lloyd BD, Wang L, Shotwell MS, Qian ET, Richardson RK, Rooks JC, Hennings-Williams V, Sandoval CE, Richardson WD, Morgan T, Thompson AN, Hastings PG, Ring TP, Stollings JL, Talbot EM, Krasinski DJ, Decoursey B, Gibbs KW, Self WH, Mixon AS, Rice TW, Semler MW, Casey JD. Protocol and Statistical Analysis Plan for the Mode of Ventilation During Critical Illness (MODE) Trial. CHEST CRITICAL CARE 2024; 2:100033. [PMID: 38742219 PMCID: PMC11090486 DOI: 10.1016/j.chstcc.2023.100033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
BACKGROUND For every critically ill adult receiving invasive mechanical ventilation, clinicians must select a mode of ventilation. The mode of ventilation determines whether the ventilator directly controls the tidal volume or the inspiratory pressure. Newer hybrid modes allow clinicians to set a target tidal volume; the ventilator controls and adjusts the inspiratory pressure. A strategy of low tidal volumes and low plateau pressure improves outcomes, but the optimal mode to achieve these targets is not known. RESEARCH QUESTION Can a cluster-randomized trial design be used to assess whether the mode of mandatory ventilation affects the number of days alive and free of invasive mechanical ventilation among critically ill adults? STUDY DESIGN AND METHODS The Mode of Ventilation During Critical Illness (MODE) trial is a cluster-randomized, multiple-crossover pilot trial being conducted in the medical ICU at an academic center. The MODE trial compares the use of volume control, pressure control, and adaptive pressure control. The study ICU is assigned to a single-ventilator mode (volume control vs pressure control vs adaptive pressure control) for continuous mandatory ventilation during each 1-month study block. The assigned mode switches every month in a randomly generated sequence. The primary outcome is ventilator-free days to study day 28, defined as the number of days alive and free of invasive mechanical ventilation from the final receipt of mechanical ventilation to 28 days after enrollment. Enrollment began November 1, 2022, and will end on July 31, 2023. RESULTS This manuscript describes the protocol and statistical analysis plan for the MODE trial of ventilator modes comparing volume control, pressure control, and adaptive pressure control. INTERPRETATION Prespecifying the full statistical analysis plan prior to completion of enrollment increases rigor, reproducibility, and transparency of the trial results. CLINICAL TRIAL REGISTRATION The trial was registered with clinicaltrials.gov on October 3, 2022, before initiation of patient enrollment on November 1, 2022 (ClinicalTrials.gov identifier: NCT05563779).
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Affiliation(s)
- Kevin P Seitz
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Bradley D Lloyd
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Li Wang
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Matthew S Shotwell
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Edward T Qian
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Roger K Richardson
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Jeffery C Rooks
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Vanessa Hennings-Williams
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Claire E Sandoval
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Whitney D Richardson
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Tracy Morgan
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Amber N Thompson
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Pamela G Hastings
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Terry P Ring
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Joanna L Stollings
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Erica M Talbot
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - David J Krasinski
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Bailey Decoursey
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Kevin W Gibbs
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Wesley H Self
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Amanda S Mixon
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Todd W Rice
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Matthew W Semler
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
| | - Jonathan D Casey
- Department of Medicine (K. P. S., E. T. Q., T. W. R., M. W. S., and J. D. C.), Division of Allergy, Pulmonary and Critical Care Medicine; the Department of Emergency Medicine (B. D. L. and W. H. S.); the Department of Biostatistics (L. W. and M. S. S.); the Department of Respiratory Care (R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. M., A. N. T., P. G. H., and T. P. R.); the Department of Pharmaceutical Services (J. L. S.); the Department of Medicine (E. M. T., D. J. K., and B. D.), Vanderbilt University Medical Center, Nashville, TN; the Section on Pulmonary, Critical Care, Allergy, and Immunology (K. W. G.), Wake Forest School of Medicine, Winston-Salem, NC; the Vanderbilt Institute for Clinical and Translational Research (W. H. S.), Vanderbilt University Medical Center, Nashville, TN; the Department of Medicine, Division of General Internal Medicine and Public Health (A. S. M.), Vanderbilt University Medical Center, Nashville, TN; and the VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center (A. S. M.), Nashville, TN
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von Wedel D, Redaelli S, Suleiman A, Wachtendorf LJ, Fosset M, Santer P, Shay D, Munoz-Acuna R, Chen G, Talmor D, Jung B, Baedorf-Kassis EN, Schaefer MS. Adjustments of Ventilator Parameters during Operating Room-to-ICU Transition and 28-Day Mortality. Am J Respir Crit Care Med 2024; 209:553-562. [PMID: 38190707 DOI: 10.1164/rccm.202307-1168oc] [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: 07/09/2023] [Accepted: 01/08/2024] [Indexed: 01/10/2024] Open
Abstract
Rationale: Lung-protective mechanical ventilation strategies have been proven beneficial in the operating room (OR) and the ICU. However, differential practices in ventilator management persist, often resulting in adjustments of ventilator parameters when transitioning patients from the OR to the ICU. Objectives: To characterize patterns of ventilator adjustments during the transition of mechanically ventilated surgical patients from the OR to the ICU and assess their impact on 28-day mortality. Methods: Hospital registry study including patients undergoing general anesthesia with continued, controlled mechanical ventilation in the ICU between 2008 and 2022. Ventilator parameters were assessed 1 hour before and 6 hours after the transition. Measurements and Main Results: Of 2,103 patients, 212 (10.1%) died within 28 days. Upon OR-to-ICU transition, VT and driving pressure decreased (-1.1 ml/kg predicted body weight [IQR, -2.0 to -0.2]; P < 0.001; and -4.3 cm H2O [-8.2 to -1.2]; P < 0.001). Concomitantly, respiratory rates increased (+5.0 breaths/min [2.0 to 7.5]; P < 0.001), resulting overall in slightly higher mechanical power (MP) in the ICU (+0.7 J/min [-1.9 to 3.0]; P < 0.001). In adjusted analysis, increases in MP were associated with a higher 28-day mortality rate (adjusted odds ratio, 1.10; 95% confidence interval, 1.06-1.14; P < 0.001; adjusted risk difference, 0.7%; 95% confidence interval, 0.4-1.0, both per 1 J/min). Conclusion: During transition of mechanically ventilated patients from the OR to the ICU, ventilator adjustments resulting in higher MP were associated with a greater risk of 28-day mortality.
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Affiliation(s)
- Dario von Wedel
- Department of Anesthesia, Critical Care and Pain Medicine
- Center for Anesthesia Research Excellence, and
| | - Simone Redaelli
- Department of Anesthesia, Critical Care and Pain Medicine
- Center for Anesthesia Research Excellence, and
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Aiman Suleiman
- Department of Anesthesia, Critical Care and Pain Medicine
- Center for Anesthesia Research Excellence, and
- Department of Anesthesia and Intensive Care, Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Luca J Wachtendorf
- Department of Anesthesia, Critical Care and Pain Medicine
- Center for Anesthesia Research Excellence, and
| | - Maxime Fosset
- Department of Anesthesia, Critical Care and Pain Medicine
- Center for Anesthesia Research Excellence, and
- Medical Intensive Care Unit and PhyMedExp, Institut National de la Santé et de la Recherche Médicale, Montpellier University Hospital, Montpellier, France
| | - Peter Santer
- Department of Anesthesia, Critical Care and Pain Medicine
- Center for Anesthesia Research Excellence, and
| | - Denys Shay
- Department of Anesthesia, Critical Care and Pain Medicine
- Center for Anesthesia Research Excellence, and
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; and
| | - Ricardo Munoz-Acuna
- Department of Anesthesia, Critical Care and Pain Medicine
- Center for Anesthesia Research Excellence, and
| | - Guanqing Chen
- Department of Anesthesia, Critical Care and Pain Medicine
- Center for Anesthesia Research Excellence, and
| | - Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine
| | - Boris Jung
- Department of Anesthesia, Critical Care and Pain Medicine
- Center for Anesthesia Research Excellence, and
- Department of Pulmonary, Critical Care & Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Medical Intensive Care Unit and PhyMedExp, Institut National de la Santé et de la Recherche Médicale, Montpellier University Hospital, Montpellier, France
| | - Elias N Baedorf-Kassis
- Department of Pulmonary, Critical Care & Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care and Pain Medicine
- Center for Anesthesia Research Excellence, and
- Department of Anesthesiology, Düsseldorf University Hospital, Dusseldorf, Germany
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10
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Piriyapatsom A, Trisukhonth A, Chintabanyat O, Chaiwat O, Kongsayreepong S, Thanakiattiwibun C. Adherence to lung protective mechanical ventilation in patients admitted to a surgical intensive care unit and the associated increased mortality. Heliyon 2024; 10:e26220. [PMID: 38404779 PMCID: PMC10884462 DOI: 10.1016/j.heliyon.2024.e26220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 02/05/2024] [Accepted: 02/08/2024] [Indexed: 02/27/2024] Open
Abstract
Background The adherence rate to the lung protective ventilation (LPV) strategy, which is generally accepted as a standard practice in mechanically ventilated patients, reported in the literature is approximately 40%. This study aimed to determine the adherence rate to the LPV strategy, factors associated with this adherence, and related clinical outcomes in mechanically ventilated patients admitted to the surgical intensive care unit (SICU). Methods This prospective observational study was conducted in the SICU of a tertiary university-based hospital between April 2018 and February 2019. Three hundred and six adult patients admitted to the SICU who required mechanical ventilation support for more than 12 h were included. Ventilator parameters at the initiation of mechanical ventilation support in the SICU were recorded. The LPV strategy was defined as ventilation with a tidal volume of equal or less than 8 ml/kg of predicted body weight plus positive end-expiratory pressure of at least 5 cm H2O. Demographic and clinical data were recorded and analyzed. Results There were 306 patients included in this study. The adherence rate to the LPV strategy was 36.9%. Height was the only factor associated with adherence to the LPV strategy (odds ratio for each cm, 1.10; 95% confidence interval (CI), 1.06-1.15). Cox regression analysis showed that the LPV strategy was associated with increased 90-day mortality (hazard ratio, 1.73; 95% CI, 1.02-2.94). Conclusion The adherence rate to the LPV strategy among patients admitted to the SICU was modest. Further studies are warranted to explore whether the application of the LPV strategy is simply a marker of disease severity or a causative factor for increased mortality.
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Affiliation(s)
- Annop Piriyapatsom
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 10700, Thailand
| | - Ajana Trisukhonth
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 10700, Thailand
| | - Ornin Chintabanyat
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 10700, Thailand
| | - Onuma Chaiwat
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 10700, Thailand
| | - Suneerat Kongsayreepong
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 10700, Thailand
| | - Chayanan Thanakiattiwibun
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 10700, Thailand
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11
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Seri A, Rabadi A, Baral N, Andi K, Hussain B, Bansal M, Mehta A, Vallabhajosyula S. Prevalence of respiratory failure and use of mechanical ventilation in heart failure patients undergoing left atrial appendage occlusion device implantation. Int J Cardiol 2024; 396:131552. [PMID: 37871662 DOI: 10.1016/j.ijcard.2023.131552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 10/10/2023] [Accepted: 10/19/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND We sought to evaluate respiratory complications in heart failure patients undergoing left atrial appendage occlusion (LAAO) for stroke prevention in atrial fibrillation. METHODS Adult admissions (>18 years) undergoing LAAO during 2016-2020 were identified from the National Inpatient Sample. Heart failure (HF) was stratified into systolic (SHF) and diastolic heart failure (DHF) and were compared to those without HF. Outcomes of interested included acute respiratory failure, use of non-invasive and invasive mechanical ventilation, and in-hospital mortality. RESULTS Of 74,440 admissions for atrial fibrillation undergoing LAAO, SHF and DHF were noted in 8335 (11.2%) and 10,925 (14.7%), respectively. The SHF cohort was predominantly male (78%) whereas DHF cohort were female (53%). Compared to those without HF, presence of SHF (2.3% vs. 0.6%; adjusted odds ratio [OR] 1.61 [95% confidence interval {CI} 1.10-2.36]; p = 0.01) and DHF (2.8% vs. 0.6%; adjusted OR 2.20 [95% CI 1.58-3.06]; p < 0.001) were associated with higher rates of acute respiratory failure. SHF (1.7% vs. 0.6%; adjusted OR 1.70 [95% CI 1.07-2.71]; p = 0.02) group but not DHF (1.2% vs. 0.6%; adjusted OR 1.21 [95% CI 0.78-1.89]; p = 0.39) was associated with higher rates of non-invasive ventilation, whereas the DHF group (0.9% vs. 0.2%; adjusted OR 1.91 [95% CI 1.08-3.34]; p = 0.02) but not SHF (0.8% vs. 0.2%; adjusted OR 1.54 [95% CI 0.83-2.84]; p = 0.17) was associated with higher rates of invasive mechanical ventilation use. In-hospital mortality was comparable between cohorts. CONCLUSION Compared to those without HF, atrial fibrillation admissions with HF undergoing LAAO had higher rates of acute respiratory failure and mechanical ventilation rates without differences in in-hospital mortality.
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Affiliation(s)
- Amith Seri
- Department of Medicine, McLaren Health Care/Michigan State University, Flint, MI, United States of America
| | - Alexander Rabadi
- Department of Medicine, McLaren Health Care/Michigan State University, Flint, MI, United States of America
| | - Nischit Baral
- Department of Medicine, McLaren Health Care/Michigan State University, Flint, MI, United States of America
| | - Kartik Andi
- Section of Cardiovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, United States of America
| | - Bilal Hussain
- Department of Medicine, Brooklyn Medical Center, Brooklyn, NY, United States of America
| | - Mridul Bansal
- Department of Medicine, East Carolina University Brody School of Medicine, Greenville, NC, United States of America
| | - Aryan Mehta
- Department of Medicine, University of Connecticut School of Medicine, Farmington, CT, United States of America
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, United States of America.
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Battaglini D, Delpiano L, Masuello D, Leme Silva P, Rocco PRM, Matta B, Pelosi P, Robba C. Effects of positive end-expiratory pressure on brain oxygenation, systemic oxygen cascade and metabolism in acute brain injured patients: a pilot physiological cross-sectional study. J Clin Monit Comput 2024; 38:165-175. [PMID: 37453007 DOI: 10.1007/s10877-023-01042-0] [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: 04/26/2023] [Accepted: 06/02/2023] [Indexed: 07/18/2023]
Abstract
Patients with acute brain injury (ABI) often require the application of positive end-expiratory pressure (PEEP) to optimize mechanical ventilation and systemic oxygenation. However, the effect of PEEP on cerebral function and metabolism is unclear. The primary aim of this study was to evaluate the effects of PEEP augmentation test (from 5 to 15 cmH2O) on brain oxygenation, systemic oxygen cascade and metabolism in ABI patients. Secondary aims include to determine whether changes in regional cerebral oxygenation are reflected by changes in oxygenation cascade and metabolism, and to assess the correlation between brain oxygenation and mechanical ventilation settings. Single center, pilot cross-sectional observational study in an Academic Hospital. Inclusion criteria were: adult (> 18 y/o) patients with ABI and stable intracranial pressure, available gas exchange and indirect calorimetry (IC) monitoring. Cerebral oxygenation was monitored with near-infrared spectroscopy (NIRS) and different derived parameters were collected: variation (Δ) in oxy (O2)-hemoglobin (Hb) (ΔO2Hbi), deoxy-Hb(ΔHHbi), total-Hb(ΔcHbi), and total regional oxygenation (ΔrSO2). Oxygen cascade and metabolism were monitored with arterial/venous blood gas analysis [arterial partial pressure of oxygen (PaO2), arterial saturation of oxygen (SaO2), oxygen delivery (DO2), and lactate], and IC [energy expenditure (REE), respiratory quotient (RQ), oxygen consumption (VO2), and carbon dioxide production (VCO2)]. Data were measured at PEEP 5 cmH2O and 15 cmH2O and expressed as delta (Δ) values. Ten patients with ABI [median age 70 (IQR 62-75) years, 6 (60%) were male, median Glasgow Coma Scale at ICU admission 5.5 (IQR 3-8)] were included. PEEP augmentation from 5 to 15 cmH2O did not affect cerebral oxygenation, systemic oxygen cascade parameters, and metabolism. The arterial component of cerebral oxygenation was significantly correlated with DO2 (ΔO2HBi, rho = 0.717, p = 0.037). ΔrSO2 (rho = 0.727, p = 0.032), ΔcHbi (rho = 0.797, p = 0.013), and ΔHHBi (rho = 0.816, p = 0.009) were significantly correlated with SaO2, but not ΔO2Hbi. ΔrSO2 was significantly correlated with VCO2 (rho = 0.681, p = 0.049). No correlation between brain oxygenation and ventilatory parameters was found. PEEP augmentation test did not affect cerebral and systemic oxygenation or metabolism. Changes in cerebral oxygenation significantly correlated with DO2, SaO2, and VCO2. Cerebral oxygen monitoring could be considered for individualization of mechanical ventilation setting in ABI patients without high or instable intracranial pressure.
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Affiliation(s)
| | - Lara Delpiano
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genoa, Italy
| | - Denise Masuello
- Hospital Donaciòn Francisco Santojanni, Buenos Aires, Argentina
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Centro de Ciências da Saúde, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Centro de Ciências da Saúde, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Rio de Janeiro Network on Neuroinflammation, Carlos Chagas Filho Foundation for Supporting Research in the State of Rio de Janeiro (FAPERJ), Rio de Janeiro, Brazil
| | - Basil Matta
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Paolo Pelosi
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genoa, Italy
| | - Chiara Robba
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genoa, Italy
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13
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Nam KH, Phua J, Du B, Ohshimo S, Kim HJ, Lim CM, Myatra SN, Adib NABN, Arabi YM, Chan MC, Faruq MO, Redjeki IS, Son DN, Nafees KMK, Priyankara D, Patjanasoontorn B, Palo JE, Konkayev A, Shrestha GS, Koh Y. Mechanical ventilation practices in Asian intensive care units: A multicenter cross-sectional study. J Crit Care 2024; 79:154452. [PMID: 37948944 DOI: 10.1016/j.jcrc.2023.154452] [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: 02/16/2023] [Revised: 07/24/2023] [Accepted: 10/15/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE This study investigated current practices of mechanical ventilation in Asian intensive care units, focusing on tidal volume, plateau pressure, and positive end-expiratory pressure (PEEP). MATERIALS AND METHODS In this multicenter cross-sectional study, data on mechanical ventilation and clinical outcomes were collected. Predictors of mortality were analyzed by univariate and multivariable logistic regression. A scoring system was generated to predict 28-day mortality. RESULTS A total of 1408 patients were enrolled. In 138 patients with acute respiratory distress syndrome (ARDS), 65.9% were on a tidal volume ≤ 8 ml/kg predicted body weight (PBW), and 71.3% were on sufficient PEEP. In 1270 patients without ARDS, 88.8% were on a tidal volume ≤ 10 ml/kg PBW. A plateau pressure < 30 cmH2O was measured in 92.2% of patients. Mortality rates increased from 13% to 74% as the generated predictive score increased from 5 to ≥8.5. Income classification, age, SOFA score, PaO2/FiO2 ratio, plateau pressure, number of vasopressors, and steroid use were associated with mortality. CONCLUSIONS In Asia, low tidal volume ventilation and sufficient PEEP were underused in patients with ARDS. The majority of patients without ARDS were on intermediate tidal volumes. Country income, age, and severity of illness were associated with mortality.
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Affiliation(s)
- Kyung Hun Nam
- Department of Critical Care Medicine, Seongnam Citizens Medical Center, Seongnam, South Korea
| | - Jason Phua
- FAST and Chronic Programmes, Alexandra Hospital, National University Health System, Singapore; Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore
| | - Bin Du
- State Key Laboratory of Complex, Severe, and Rare Diseases, Medical ICU, Peking Union Medical College Hospital, Beijing, China
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hwa Jung Kim
- Department of Clinical Epidemiology and Biostatistics, ASAN Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | | | - Yaseen M Arabi
- King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Ming-Cheng Chan
- Division of Critical Care and Respiratory Therapy, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; National Chung Hsing University, Taichung, Taiwan
| | - Mohammad Omar Faruq
- Critical Care Medicine and Emergency Medicine, United Medical College and United Hospital, Dhaka 1212, Bangladesh
| | - Ike Sri Redjeki
- Faculty of Medicine, Department of Anesthesiology and Intensive Care, Padjadjaran University, Dr. Hasan Sadikin National Referral Hospital Bandung, Bandung, Indonesia
| | - Do Ngoc Son
- Center for Critical Care Medicine, Bach Mai Hospital, University of Medicine and Pharmacy, Hanoi National University, Viet Nam
| | | | | | - Boonsong Patjanasoontorn
- Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Jose Emmanuel Palo
- Acute and Critical Care Institute, The Medical City, Pasig City, Philippines
| | - Aidos Konkayev
- Anaesthesia and ICU Department, Astana Medical University, Institution of Traumatology and Orthopedics, Nur-Sultan, Kazakhstan
| | - Gentle Sunder Shrestha
- Department of Critical Care Medicine Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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14
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Pisani L, Schultz MJ. The Significance of Sizes: Which Matters Most? Chest 2024; 165:233-235. [PMID: 38336431 DOI: 10.1016/j.chest.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/01/2023] [Indexed: 02/12/2024] Open
Affiliation(s)
- Luigi Pisani
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy; Nuffield Department of Medicine, Center for Tropical Medicine and Global Health, Oxford, England; Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.
| | - Marcus J Schultz
- Nuffield Department of Medicine, Center for Tropical Medicine and Global Health, Oxford, England; Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand; Department of Intensive Care, Amsterdam University Medical Centers; Department of Anesthesia, General Intensive Care and Pain Management, Division of Cardiothoracic and Vascular Anesthesia & Critical Care Medicine, University of Vienna, Vienna, Austria
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15
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Tongyoo S, Viarasilpa T, Deawtrakulchai P, Subpinyo S, Suppasilp C, Permpikul C. Comparison of limited driving pressure ventilation and low tidal volume strategies in adults with acute respiratory failure on mechanical ventilation: a randomized controlled trial. Ther Adv Respir Dis 2024; 18:17534666241249152. [PMID: 38726850 PMCID: PMC11088295 DOI: 10.1177/17534666241249152] [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: 01/06/2024] [Accepted: 04/04/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Ventilator-induced lung injury (VILI) presents a grave risk to acute respiratory failure patients undergoing mechanical ventilation. Low tidal volume (LTV) ventilation has been advocated as a protective strategy against VILI. However, the effectiveness of limited driving pressure (plateau pressure minus positive end-expiratory pressure) remains unclear. OBJECTIVES This study evaluated the efficacy of LTV against limited driving pressure in preventing VILI in adults with respiratory failure. DESIGN A single-centre, prospective, open-labelled, randomized controlled trial. METHODS This study was executed in medical intensive care units at Siriraj Hospital, Mahidol University, Bangkok, Thailand. We enrolled acute respiratory failure patients undergoing intubation and mechanical ventilation. They were randomized in a 1:1 allocation to limited driving pressure (LDP; ⩽15 cmH2O) or LTV (⩽8 mL/kg of predicted body weight). The primary outcome was the acute lung injury (ALI) score 7 days post-enrolment. RESULTS From July 2019 to December 2020, 126 patients participated, with 63 each in the LDP and LTV groups. The cohorts had the mean (standard deviation) ages of 60.5 (17.6) and 60.9 (17.9) years, respectively, and they exhibited comparable baseline characteristics. The primary reasons for intubation were acute hypoxic respiratory failure (LDP 49.2%, LTV 63.5%) and shock-related respiratory failure (LDP 39.7%, LTV 30.2%). No significant difference emerged in the primary outcome: the median (interquartile range) ALI scores for LDP and LTV were 1.75 (1.00-2.67) and 1.75 (1.25-2.25), respectively (p = 0.713). Twenty-eight-day mortality rates were comparable: LDP 34.9% (22/63), LTV 31.7% (20/63), relative risk (RR) 1.08, 95% confidence interval (CI) 0.74-1.57, p = 0.705. Incidences of newly developed acute respiratory distress syndrome also aligned: LDP 14.3% (9/63), LTV 20.6% (13/63), RR 0.81, 95% CI 0.55-1.22, p = 0.348. CONCLUSIONS In adults with acute respiratory failure, the efficacy of LDP and LTV in averting lung injury 7 days post-mechanical ventilation was indistinguishable. CLINICAL TRIAL REGISTRATION The study was registered with the ClinicalTrials.gov database (identification number NCT04035915).
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Affiliation(s)
- Surat Tongyoo
- Faculty of Medicine, Siriraj Hospital, Mahidol University, 2, Prannok Road, Bangkok Noi, Bangkok 10700, Thailand
| | - Tanuwong Viarasilpa
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Phitphiboon Deawtrakulchai
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Subdivision of Critical Care, Division of Internal Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Santi Subpinyo
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chaiyawat Suppasilp
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chairat Permpikul
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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16
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Shin Y, Kim YJ, Jin J, Lee SB, Kim HS, Kim YG. Machine learning model for predicting immediate postoperative desaturation using spirometry signal data. Sci Rep 2023; 13:21881. [PMID: 38072984 PMCID: PMC10711018 DOI: 10.1038/s41598-023-49062-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/04/2023] [Indexed: 12/18/2023] Open
Abstract
Postoperative desaturation is a common post-surgery pulmonary complication. The real-time prediction of postoperative desaturation can become a preventive measure, and real-time changes in spirometry data can provide valuable information on respiratory mechanics. However, there is a lack of related research, specifically on using spirometry signals as inputs to machine learning (ML) models. We developed an ML model and postoperative desaturation prediction index (DPI) by analyzing intraoperative spirometry signals in patients undergoing laparoscopic surgery. We analyzed spirometry data from patients who underwent laparoscopic, robot-assisted gynecologic, or urologic surgery, identifying postoperative desaturation as a peripheral arterial oxygen saturation level below 95%, despite facial oxygen mask usage. We fitted the ML model on two separate datasets collected during different periods. (Datasets A and B). Dataset A (Normal 133, Desaturation 74) was used for the entire experimental process, including ML model fitting, statistical analysis, and DPI determination. Dataset B (Normal 20, Desaturation 4) was only used for verify the ML model and DPI. Four feature categories-signal property, inter-/intra-position correlation, peak value/interval variability, and demographics-were incorporated into the ML models via filter and wrapper feature selection methods. In experiments, the ML model achieved an adequate predictive capacity for postoperative desaturation, and the performance of the DPI was unbiased.
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Affiliation(s)
- Youmin Shin
- Department of Transdisciplinary Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
- Interdisciplinary Program in Bio-engineering, Seoul National University, Seoul, Republic of Korea
| | - Yoon Jung Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, College of Medicine, Seoul National University, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Juseong Jin
- Interdisciplinary Program in Bio-engineering, Seoul National University, Seoul, Republic of Korea
- Integrated Major in Innovative Medical Science, Seoul National University, Seoul, Republic of Korea
| | - Seung-Bo Lee
- Department of Medical Informatics, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, College of Medicine, Seoul National University, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea.
| | - Young-Gon Kim
- Department of Transdisciplinary Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea.
- Department of Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
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17
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Lockstone J, Love A, Chian K, Garnham K, Brumby S, Parry SM. Benefits and risks of ventilator hyperinflation in mechanically ventilated intensive care patients: A systematic review and meta-analysis. Aust Crit Care 2023; 36:1150-1158. [PMID: 36822978 DOI: 10.1016/j.aucc.2023.01.005] [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: 08/11/2022] [Revised: 12/14/2022] [Accepted: 01/08/2023] [Indexed: 02/25/2023] Open
Abstract
OBJECTIVES Patients requiring mechanical ventilation in the intensive care unit (ICU) have diminished respiratory defences and are at high risk of respiratory compromise, leading to an increased risk of pulmonary infection and prolonged ventilation. Ventilator hyperinflation (VHI) is an airway clearance technique used by physiotherapists and is suggested to improve respiratory mechanics. The objective of this study was to review the evidence for the benefits and risks of VHI in intubated and mechanically ventilated patients in the ICU. REVIEW METHOD USED We conducted a systematic review. DATA SOURCES We searched PubMed, Embase, CINAHL, CENTRAL, and Scopus from inception to 31st May 2022 for all randomised control trials evaluating VHI in intubated and mechanically ventilated adults in the ICU. REVIEW METHODS Two authors independently performed study selection and data extraction. Individual study risk of bias was assessed using the Physiotherapy Evidence Database scale, and certainty in outcomes was assessed using the Grading of Recommendations, Assessment, Development and Evaluations framework. RESULTS We included 10 studies enrolling 394 patients. Compared to standard care, VHI had significant effects on sputum clearance (Standardise mean difference: 0.36, 95% confidence interval [CI]: 0.12 to 0.61; very low certainty), static pulmonary compliance (mean difference [MD]: 4.77, 95% CI: 2.40 to 7.14; low certainty), dynamic pulmonary compliance (MD: 1.59, 95% CI: 0.82 to 2.36; low certainty) and oxygenation (MD: 0.28, 95% CI: 0.01 to 0.55; low certainty). No significant adverse events or immediate side effects relating to VHI were reported. There is a paucity of data available on the effects of VHI on clinical outcomes including mechanical ventilation duration, ICU length of stay, and mortality. CONCLUSIONS Our findings suggest VHI has potential short-term respiratory benefits including increased secretion clearance, pulmonary compliance, and oxygenation, with no immediate adverse effects in intubated and mechanically ventilated ICU patients. However, there remains limited data on the longer term influence of VHI on clinical outcomes, and further research to inform clinical practice is needed. REGISTRATION This study is registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD42022341421).
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Affiliation(s)
- Jane Lockstone
- Physiotherapy Department, Launceston General Hospital, TAS, Australia.
| | - Annabel Love
- Physiotherapy Department, Launceston General Hospital, TAS, Australia
| | - Kimberly Chian
- Allied Health Department, Royal Melbourne Hospital, VIC, Australia
| | | | - Susan Brumby
- Physiotherapy Department, Launceston General Hospital, TAS, Australia
| | - Selina M Parry
- Physiotherapy Department, The University of Melbourne, VIC, Australia. https://twitter.com/selina_parry
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18
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Andrea L, Moskowitz A, Chen JT, Fein DG. Decreased Utilization of Low Tidal Volume Ventilation Outside of the Intensive Care Unit as Compared to Inside. J Intensive Care Med 2023; 38:949-956. [PMID: 37226439 DOI: 10.1177/08850666231175646] [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: 05/26/2023]
Abstract
Background: Investigations into the use of low tidal volume ventilation (LTVV) have been performed for patients in emergency departments (EDs) or intensive care units (ICUs). Practice differences between the ICU and non-ICU care areas have not been described. We hypothesized that the initial implementation of LTVV would be better inside ICUs than outside. Methods: This is a retrospective observational study of patients initiated on invasive mechanical ventilation (IMV) between January 1, 2016, and July 17, 2019. Initial recorded tidal volumes after intubation were used to compare the use of LTVV between care areas. Low tidal volume was considered 6.5 cc/kg of ideal body weight (IBW) or less. The primary outcome was the initiation of low tidal volume. Sensitivity analyses used a tidal volume of 8 cc/kg of IBW or less, and direct comparisons were performed between the ICU, ED, and wards. Results: There were 6392 initiations of IMV: 2217 (34.7%) in the ICU and 4175 (65.3%) outside. LTVV was more likely to be initiated in the ICU than outside (46.5% vs 34.2%; adjusted odds ratio [aOR] 0.62, 95% confidence interval [CI] 0.56-0.71, P < .01). The ICU also had more implementation when PaO2/FiO2 ratio was less than 300, (48.0% vs 34.6%; aOR 0.59, 95% CI 0.48-0.71, P < .01). When comparing individual locations, wards had lower odds of LTVV than the ICU (aOR 0.82, 95% CI 0.70-0.96, P = .02), the ED had lower odds than the ICU (aOR 0.55, 95% CI 0.48-0.63, P < .01), and the ED had lower odds than the wards (aOR 0.66, 95% CI 0.56-0.77, P < .01). Interpretation: Initial low tidal volumes were more likely to be initiated in the ICU than outside. This finding remained when examining only patients with a PaO2/FiO2 ratio less than 300. Care areas outside of the ICU do not employ LTVV as often as ICUs and are, therefore, a possible target for process improvement.
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Affiliation(s)
- Luke Andrea
- Department of Critical Care Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Ari Moskowitz
- Department of Critical Care Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Jen-Ting Chen
- Department of Critical Care Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Daniel G Fein
- Department of Critical Care Medicine, Montefiore Medical Center, Bronx, NY, USA
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19
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Gibbs KW, Forbes JL, Harrison KJ, Krall JT, Isenhart AA, Taylor SP, Martin RS, O'Connell NS, Bakhru RN, Palakshappa JA, Files DC. A Pragmatic Pilot Trial Comparing Patient-Triggered Adaptive Pressure Control to Patient-Triggered Volume Control Ventilation in Critically Ill Adults. Respir Care 2023; 68:1331-1339. [PMID: 36944477 PMCID: PMC10506635 DOI: 10.4187/respcare.10803] [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: 12/13/2022] [Accepted: 03/14/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Patient-triggered adaptive pressure control (APC) continuous mandatory ventilation (CMV) (APC-CMV) has been widely adopted as an alternative ventilator mode to patient-triggered volume control (VC) CMV (VC-CMV). However, the comparative effectiveness of the 2 ventilator modes remains uncertain. We sought to explore clinical and implementation factors pertinent to a future definitive randomized controlled trial assessing APC-CMV versus VC-CMV as an initial ventilator mode strategy. The research objectives in our pilot trial tested clinician adherence and explored clinical outcomes. METHODS In a single-center pragmatic sequential cluster crossover pilot trial, we enrolled all eligible adults with acute respiratory failure requiring mechanical ventilation admitted during a 9-week period to the medical ICU. Two-week time epochs were assigned a priori in which subjects received either APC-CMV or VC-CMV The primary outcome of the trial was feasibility, defined as 80% of subjects receiving the assigned mode within 1 h of initiation of ICU ventilation. The secondary outcome was proportion of the first 24 h on the assigned mode. Finally, we surveyed clinician stakeholders to understand potential facilitators and barriers to conducting a definitive randomized trial. RESULTS We enrolled 137 subjects who received 152 discreet episodes of mechanical ventilation during time epochs assigned to APC-CMV (n = 61) and VC-CMV (n = 91). One hundred and thirty-one episodes were included in the prespecified primary outcome. One hundred and twenty-six (96%) received the assigned mode within the first hour of ICU admission (60 of 61 subjects assigned APC-CMV and 66 of 70 assigned VC-CMV). VC-CMV subjects spent a lower proportion of first 24 h (84% [95% CI 78-89]) on the assigned mode than APC-CMV recipients (95% [95% CI 91-100]). Mixed-methods analyses identified preconceived perceptions of subject comfort by clinicians and need for real-time education to address this concern. CONCLUSIONS In this pilot pragmatic, sequential crossover trial, unit-wide allocation to a ventilator mode was feasible and acceptable to clinicians.
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Affiliation(s)
- Kevin W Gibbs
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Winston-Salem, North Carolina; and Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina.
| | - Jonathan L Forbes
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Kelsey J Harrison
- Department of Respiratory Care, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Jennifer Tw Krall
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Aubrae A Isenhart
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Stephanie P Taylor
- Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina; and Department of Internal Medicine, Wake Forest School of Medicine, Charlotte, North Carolina
| | - R Shayn Martin
- Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina; and Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, North Carolina
| | - Nathaniel S O'Connell
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Rita N Bakhru
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Winston-Salem, North Carolina; and Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jessica A Palakshappa
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Winston-Salem, North Carolina; and Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - D Clark Files
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Winston-Salem, North Carolina; and Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina
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20
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Burša F, Oczka D, Jor O, Sklienka P, Frelich M, Stigler J, Vodička V, Ekrtová T, Penhaker M, Máca J. The Impact of Mechanical Energy Assessment on Mechanical Ventilation: A Comprehensive Review and Practical Application. Med Sci Monit 2023; 29:e941287. [PMID: 37669252 PMCID: PMC10492505 DOI: 10.12659/msm.941287] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/28/2023] [Indexed: 09/07/2023] Open
Abstract
Mechanical ventilation (MV) provides basic organ support for patients who have acute hypoxemic respiratory failure, with acute respiratory distress syndrome as the most severe form. The use of excessive ventilation forces can exacerbate the lung condition and lead to ventilator-induced lung injury (VILI); mechanical energy (ME) or power can characterize such forces applied during MV. The ME metric combines all MV parameters affecting the respiratory system (ie, lungs, chest, and airways) into a single value. Besides evaluating the overall ME, this parameter can be also related to patient-specific characteristics, such as lung compliance or patient weight, which can further improve the value of ME for characterizing the aggressiveness of lung ventilation. High ME is associated with poor outcomes and could be used as a prognostic parameter and indicator of the risk of VILI. ME is rarely determined in everyday practice because the calculations are complicated and based on multiple equations. Although low ME does not conclusively prevent the possibility of VILI (eg, due to the lung inhomogeneity and preexisting damage), individualization of MV settings considering ME appears to improve outcomes. This article aims to review the roles of bedside assessment of mechanical power, its relevance in mechanical ventilation, and its associations with treatment outcomes. In addition, we discuss methods for ME determination, aiming to propose the most suitable method for bedside application of the ME concept in everyday practice.
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Affiliation(s)
- Filip Burša
- Department of Anesthesiology and Intensive Care, University Hospital Ostrava, Ostrava, Czech Republic
| | - David Oczka
- Department of Cybernetics and Biomedical Engineering, Faculty of Electrical Engineering and Computer Science,VSB – Technical University of Ostrava, Ostrava, Czech Republic
| | - Ondřej Jor
- Department of Anesthesiology and Intensive Care, University Hospital Ostrava, Ostrava, Czech Republic
| | - Peter Sklienka
- Department of Anesthesiology and Intensive Care, University Hospital Ostrava, Ostrava, Czech Republic
| | - Michal Frelich
- Department of Anesthesiology and Intensive Care, University Hospital Ostrava, Ostrava, Czech Republic
| | - Jan Stigler
- Department of Anesthesiology and Intensive Care, University Hospital Ostrava, Ostrava, Czech Republic
| | - Vojtech Vodička
- Department of Anesthesiology and Intensive Care, University Hospital Ostrava, Ostrava, Czech Republic
| | - Tereza Ekrtová
- Department of Anesthesiology and Intensive Care, University Hospital Ostrava, Ostrava, Czech Republic
| | - Marek Penhaker
- Department of Cybernetics and Biomedical Engineering, Faculty of Electrical Engineering and Computer Science,VSB – Technical University of Ostrava, Ostrava, Czech Republic
| | - Jan Máca
- Department of Anesthesiology and Intensive Care, University Hospital Ostrava, Ostrava, Czech Republic
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21
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Renard Triché L, Futier E, De Carvalho M, Piñol-Domenech N, Bodet-Contentin L, Jabaudon M, Pereira B. Sample size estimation in clinical trials using ventilator-free days as the primary outcome: a systematic review. Crit Care 2023; 27:303. [PMID: 37528425 PMCID: PMC10394791 DOI: 10.1186/s13054-023-04562-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 07/04/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Ventilator-free days (VFDs) are a composite endpoint increasingly used as the primary outcome in critical care trials. However, because of the skewed distribution and competitive risk between components, sample size estimation remains challenging. This systematic review was conducted to systematically assess whether the sample size was congruent, as calculated to evaluate VFDs in trials, with VFDs' distribution and the impact of alternative methods on sample size estimation. METHODS A systematic literature search was conducted within the PubMed and Embase databases for randomized clinical trials in adults with VFDs as the primary outcome until December 2021. We focused on peer-reviewed journals with 2021 impact factors greater than five. After reviewing definitions of VFDs, we extracted the sample size and methods used for its estimation. The data were collected by two independent investigators and recorded in a standardized, pilot-tested forms tool. Sample sizes were calculated using alternative statistical approaches, and risks of bias were assessed with the Cochrane risk-of-bias tool. RESULTS Of the 26 clinical trials included, 19 (73%) raised "some concerns" when assessing risks of bias. Twenty-four (92%) trials were two-arm superiority trials, and 23 (89%) were conducted at multiple sites. Almost all the trials (96%) were unable to consider the unique distribution of VFDs and death as a competitive risk. Moreover, significant heterogeneity was found in the definitions of VFDs, especially regarding varying start time and type of respiratory support. Methods for sample size estimation were also heterogeneous, and simple models, such as the Mann-Whitney-Wilcoxon rank-sum test, were used in 14 (54%) trials. Finally, the sample sizes calculated varied by a factor of 1.6 to 17.4. CONCLUSIONS A standardized definition and methodology for VFDs, including the use of a core outcome set, seems to be required. Indeed, this could facilitate the interpretation of findings in clinical trials, as well as their construction, especially the sample size estimation which is a trade-off between cost, ethics, and statistical power. Systematic review registration PROSPERO ID: CRD42021282304. Registered 15 December 2021 ( https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021282304 ).
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Affiliation(s)
- Laurent Renard Triché
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France. lrenard--
| | - Emmanuel Futier
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | | | | | - Laëtitia Bodet-Contentin
- Medical Intensive Care Unit, CHRU de Tours, Tours, France
- INSERM, SPHERE, UMR1246, Université de Tours et Nantes, Tours et Nantes, France
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics Unit, Department of Clinical Research, and Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
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22
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Seitz KP, Lloyd BD, Wang L, Shotwell MS, Qian ET, Richardson RK, Rooks JC, Hennings-Williams V, Sandoval CE, Richardson WD, Morgan T, Thompson AN, Hastings PG, Ring TP, Stollings JL, Talbot EM, Krasinski DJ, Decoursey B, Gibbs KW, Self WH, Mixon AS, Rice TW, Semler MW, Casey JD. Protocol and statistical analysis plan for the Mode of Ventilation During Critical IllnEss (MODE) trial. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.07.21.23292998. [PMID: 37546787 PMCID: PMC10402229 DOI: 10.1101/2023.07.21.23292998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Introduction For every critically ill adult receiving invasive mechanical ventilation, clinicians must select a mode of ventilation. The mode of ventilation determines whether the ventilator directly controls the tidal volume or the inspiratory pressure. Newer hybrid modes allow clinicians to set a target tidal volume, for which the ventilator controls and adjusts the inspiratory pressure. A strategy of low tidal volumes and low plateau pressure improves outcomes, but the optimal mode to achieve these targets is not known. Methods and analysis The Mode of Ventilation During Critical Illness (MODE) trial is a cluster-randomized, multiple-crossover pilot trial being conducted in the medical intensive care unit (ICU) at an academic center. The MODE trial compares the use of volume control, pressure control, and adaptive pressure control. The study ICU is assigned to a single ventilator mode (volume control versus pressure control versus adaptive pressure control) for continuous mandatory ventilation during each 1-month study block. The assigned mode switches every month in a randomly generated sequence. The primary outcome is ventilator-free days (VFDs) to study day 28, defined as the number of days alive and free of invasive mechanical ventilation from the final receipt of mechanical ventilation to 28 days after enrollment. Enrollment began November 1, 2022 and will end on July 31, 2023. Ethics and dissemination The trial was approved by the Vanderbilt University Medical Center institutional review board (IRB# 220446). Results of this study will be submitted to a peer-reviewed journal and presented at scientific conferences. Trial registration number The trial was registered with clinicaltrials.gov on October 3, 2022, prior to initiation of patient enrollment on November 1, 2022 (ClinicalTrials.gov identifier: NCT05563779).
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Affiliation(s)
- Kevin P. Seitz
- Vanderbilt University Medical Center, Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Nashville, TN
| | - Bradley D. Lloyd
- Vanderbilt University Medical Center, Department of Emergency Medicine, Nashville, TN
| | - Li Wang
- Vanderbilt University Medical Center, Department of Biostatistics, Nashville, TN
| | - Matthew S. Shotwell
- Vanderbilt University Medical Center, Department of Biostatistics, Nashville, TN
| | - Edward T. Qian
- Vanderbilt University Medical Center, Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Nashville, TN
| | - Roger K. Richardson
- Vanderbilt University Medical Center, Department of Respiratory Care, Nashville, TN
| | - Jeffery C. Rooks
- Vanderbilt University Medical Center, Department of Respiratory Care, Nashville, TN
| | | | - Claire E. Sandoval
- Vanderbilt University Medical Center, Department of Respiratory Care, Nashville, TN
| | | | - Tracy Morgan
- Vanderbilt University Medical Center, Department of Respiratory Care, Nashville, TN
| | - Amber N. Thompson
- Vanderbilt University Medical Center, Department of Respiratory Care, Nashville, TN
| | - Pamela G. Hastings
- Vanderbilt University Medical Center, Department of Respiratory Care, Nashville, TN
| | - Terry P. Ring
- Vanderbilt University Medical Center, Department of Respiratory Care, Nashville, TN
| | - Joanna L. Stollings
- Vanderbilt University Medical Center, Department of Pharmaceutical Services, Nashville, TN
| | - Erica M. Talbot
- Vanderbilt University Medical Center, Department of Medicine, Nashville, TN
| | - David J. Krasinski
- Vanderbilt University Medical Center, Department of Medicine, Nashville, TN
| | - Bailey Decoursey
- Vanderbilt University Medical Center, Department of Medicine, Nashville, TN
| | - Kevin W. Gibbs
- Section on Pulmonary, Critical Care, Allergy, and immunology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Wesley H. Self
- Vanderbilt University Medical Center, Department of Emergency Medicine, Nashville, TN
- Vanderbilt University Medical Center, Vanderbilt Institute for Clinical and Translational Research, Nashville, TN
| | - Amanda S. Mixon
- Vanderbilt University Medical Center, Department of Medicine, Division of General Internal Medicine and Public Health, Nashville, TN
- VA Tennessee Valley Healthcare System, Geriatric Research, Education, and Clinical Center, Nashville, TN
| | - Todd W. Rice
- Vanderbilt University Medical Center, Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Nashville, TN
| | - Matthew W. Semler
- Vanderbilt University Medical Center, Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Nashville, TN
| | - Jonathan D. Casey
- Vanderbilt University Medical Center, Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Nashville, TN
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23
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Karvellas CJ, Gustot T, Fernandez J. Management of the acute on chronic liver failure in the intensive care unit. Liver Int 2023. [PMID: 37365997 DOI: 10.1111/liv.15659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/01/2023] [Accepted: 06/15/2023] [Indexed: 06/28/2023]
Abstract
Acute on chronic liver failure (ACLF) reflects the development of organ failure(s) in a patient with cirrhosis and is associated with high short-term mortality. Given that ACLF has many different 'phenotypes', medical management needs to take into account the relationship between precipitating insult, organ systems involved and underlying physiology of chronic liver disease/cirrhosis. The goals of intensive care management of patients suffering ACLF are to rapidly recognize and treat inciting events (e.g. infection, severe alcoholic hepatitis and bleeding) and to aggressively support failing organ systems to ensure that patients may successfully undergo liver transplantation or recovery. Management of these patients is complex since they are prone to develop new organ failures and infectious or bleeding complications. ICU therapy parallels that applied in the general ICU population in some complications but differs in others. Given that liver transplantation in ACLF is an emerging and evolving field, multidisciplinary teams with expertise in critical care and transplant medicine best accomplish management of the critically ill ACLF patient. The focus of this review is to identify the common complications of ACLF and to describe the proper management in critically ill patients awaiting liver transplantation in our centres, including organ support, prognostic assessment and how to assess when recovery is unlikely.
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Affiliation(s)
- Constantine J Karvellas
- Department of Critical Care Medicine, University of Alberta, Edmonton, Canada
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada
| | - Thierry Gustot
- Department of Gastroenterology, Hepato-Pancreatology and Digestive Oncology, H.U.B., CUB Hôpital Erasme, Brussels, Belgium
| | - Javier Fernandez
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Barcelona, Spain
- EF CLIF, EASL-CLIF Consortium, Barcelona, Spain
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24
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Frisvold S, Coppola S, Ehrmann S, Chiumello D, Guérin C. Respiratory challenges and ventilatory management in different types of acute brain-injured patients. Crit Care 2023; 27:247. [PMID: 37353832 PMCID: PMC10290317 DOI: 10.1186/s13054-023-04532-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 06/15/2023] [Indexed: 06/25/2023] Open
Abstract
Acute brain injury (ABI) covers various clinical entities that may require invasive mechanical ventilation (MV) in the intensive care unit (ICU). The goal of MV, which is to protect the lung and the brain from further injury, may be difficult to achieve in the most severe forms of lung or brain injury. This narrative review aims to address the respiratory issues and ventilator management, specific to ABI patients in the ICU.
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Affiliation(s)
- S Frisvold
- Department of Anesthesia and Intensive Care, University Hospital of North Norway, Tromso, Norway
- Department of Clinical Medicine, UiT the Arctic University of Norway, Tromso, Norway
| | - S Coppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy
- Department of Health Sciences, University of Milan, Milan, Italy
- Coordinated Research Center On Respiratory Failure, University of Milan, Milan, Italy
| | - S Ehrmann
- CHRU Tours, Médecine Intensive Réanimation, CIC INSERM 1415, CRICS-TriggerSep F-CRIN Research Network, Tours, France
- INSERM, Centre d'étude Des Pathologies Respiratoires, U1100, Université de Tours, Tours, France
| | - D Chiumello
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy
- Department of Health Sciences, University of Milan, Milan, Italy
- Coordinated Research Center On Respiratory Failure, University of Milan, Milan, Italy
| | - Claude Guérin
- Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 8 Avenue Rockefeller, 69008, Lyon, France.
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25
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de Haro C, Neto AS, Gomà G, González ME, Ortega A, Forteza C, Frutos-Vivar F, García R, Simonis FD, Gordo-Vidal F, Suarez D, Schultz MJ, Artigas A. Effect of a low versus intermediate tidal volume strategy on pulmonary complications in patients at risk of acute respiratory distress syndrome-a randomized clinical trial. Front Med (Lausanne) 2023; 10:1172434. [PMID: 37351068 PMCID: PMC10282840 DOI: 10.3389/fmed.2023.1172434] [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: 02/23/2023] [Accepted: 05/02/2023] [Indexed: 06/24/2023] Open
Abstract
Introduction There is no consensus on whether invasive ventilation should use low tidal volumes (VT) to prevent lung complications in patients at risk of acute respiratory distress syndrome (ARDS). The purpose of this study is to determine if a low VT strategy is more effective than an intermediate VT strategy in preventing pulmonary complications. Methods A randomized clinical trial was conducted in invasively ventilated patients with a lung injury prediction score (LIPS) of >4 performed in the intensive care units of 10 hospitals in Spain and one in the United States of America (USA) from 3 November 2014 to 30 August 2016. Patients were randomized to invasive ventilation using low VT (≤ 6 mL/kg predicted body weight, PBW) (N = 50) or intermediate VT (> 8 mL/kg PBW) (N = 48). The primary endpoint was the development of ARDS during the first 7 days after the initiation of invasive ventilation. Secondary endpoints included the development of pneumonia and severe atelectases; the length of intensive care unit (ICU) and hospital stay; and ICU, hospital, 28- and 90-day mortality. Results In total, 98 patients [67.3% male], with a median age of 65.5 years [interquartile range 55-73], were enrolled until the study was prematurely stopped because of slow recruitment and loss of equipoise caused by recent study reports. On day 7, five (11.9%) patients in the low VT group and four (9.1%) patients in the intermediate VT group had developed ARDS (risk ratio, 1.16 [95% CI, 0.62-2.17]; p = 0.735). The incidence of pneumonia and severe atelectasis was also not different between the two groups. The use of a low VT strategy did neither affect the length of ICU and hospital stay nor mortality rates. Conclusions In patients at risk for ARDS, a low VT strategy did not result in a lower incidence of ARDS than an intermediate VT strategy.Clinical Trial Registration: ClinicalTrials.gov, identifier NCT02070666.
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Affiliation(s)
- Candelaria de Haro
- Intensive Care Department, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, Netherlands
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Department of Critical Care Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, VIC, Australia
- Department of Critical Care, Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, Melbourne, VIC, Australia
| | - Gemma Gomà
- Intensive Care Department, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
| | | | - Alfonso Ortega
- Intensive Care Unit, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Catalina Forteza
- Intensive Care Unit, Hospital Son Llàtzer, Palma de Mallorca, Spain
| | | | - Raquel García
- Reanimation Unit, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Fabienne D. Simonis
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, Netherlands
| | - Federico Gordo-Vidal
- Intensive Care Unit, Hospital del Henares, Grupo de Investigación en Patología Crítica de la Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | - David Suarez
- Intensive Care Department, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, Netherlands
- Department of Medical Affairs, Hamilton Medical AG, Bonaduz, Switzerland
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Antonio Artigas
- Intensive Care Department, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
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26
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Asehnoune K, Rooze P, Robba C, Bouras M, Mascia L, Cinotti R, Pelosi P, Roquilly A. Mechanical ventilation in patients with acute brain injury: a systematic review with meta-analysis. Crit Care 2023; 27:221. [PMID: 37280579 PMCID: PMC10242967 DOI: 10.1186/s13054-023-04509-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/25/2023] [Indexed: 06/08/2023] Open
Abstract
OBJECTIVE To describe the potential effects of ventilatory strategies on the outcome of acute brain-injured patients undergoing invasive mechanical ventilation. DESIGN Systematic review with an individual data meta-analysis. SETTING Observational and interventional (before/after) studies published up to August 22nd, 2022, were considered for inclusion. We investigated the effects of low tidal volume Vt < 8 ml/Kg of IBW versus Vt > = 8 ml/Kg of IBW, positive end-expiratory pressure (PEEP) < or > = 5 cmH2O and protective ventilation (association of both) on relevant clinical outcomes. POPULATION Patients with acute brain injury (trauma or haemorrhagic stroke) with invasive mechanical ventilation for ≥ 24 h. MAIN OUTCOME MEASURES The primary outcome was mortality at 28 days or in-hospital mortality. Secondary outcomes were the incidence of acute respiratory distress syndrome (ARDS), the duration of mechanical ventilation and the partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FiO2) ratio. RESULTS The meta-analysis included eight studies with a total of 5639 patients. There was no difference in mortality between low and high tidal volume [Odds Ratio, OR 0.88 (95%Confidence Interval, CI 0.74 to 1.05), p = 0.16, I2 = 20%], low and moderate to high PEEP [OR 0.8 (95% CI 0.59 to 1.07), p = 0.13, I2 = 80%] or protective and non-protective ventilation [OR 1.03 (95% CI 0.93 to 1.15), p = 0.6, I2 = 11]. Low tidal volume [OR 0.74 (95% CI 0.45 to 1.21, p = 0.23, I2 = 88%], moderate PEEP [OR 0.98 (95% CI 0.76 to 1.26), p = 0.9, I2 = 21%] or protective ventilation [OR 1.22 (95% CI 0.94 to 1.58), p = 0.13, I2 = 22%] did not affect the incidence of acute respiratory distress syndrome. Protective ventilation improved the PaO2/FiO2 ratio in the first five days of mechanical ventilation (p < 0.01). CONCLUSIONS Low tidal volume, moderate to high PEEP, or protective ventilation were not associated with mortality and lower incidence of ARDS in patients with acute brain injury undergoing invasive mechanical ventilation. However, protective ventilation improved oxygenation and could be safely considered in this setting. The exact role of ventilatory management on the outcome of patients with a severe brain injury needs to be more accurately delineated.
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Affiliation(s)
- Karim Asehnoune
- Nantes Université, CHU Nantes, Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, 44093, Nantes, France.
- Department of Anaesthesia and Critical Care, Hôtel-Dieu, University Hospital of Nantes, 1 Place Alexis Ricordeau, 44093, Nantes, France.
| | - Paul Rooze
- Nantes Université, CHU Nantes, Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, 44093, Nantes, France
| | - Chiara Robba
- Anesthesia and Critical Care, San Martino Policlinico Hospital, University of Genoa, Genoa, Italy
| | - Marwan Bouras
- Nantes Université, CHU Nantes, Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, 44093, Nantes, France
| | - Luciana Mascia
- Dipartimento di Scienze Biomediche e Neuromotorie, University of Bologna, Bologna, Italy
| | - Raphaël Cinotti
- Nantes Université, CHU Nantes, Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, 44093, Nantes, France
- Nantes Université, Univ Tours, CHU Nantes, CHU Tours, INSERM, MethodS in Patients-Centered Outcomes and HEalth Research, SPHERE, 44000, Nantes, France
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, University of Genoa, Genoa, Italy
| | - Antoine Roquilly
- Nantes Université, CHU Nantes, Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, 44093, Nantes, France
- Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, 44000, Nantes, France
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27
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Giardina A, Cardim D, Ciliberti P, Battaglini D, Ball L, Kasprowicz M, Beqiri E, Smielewski P, Czosnyka M, Frisvold S, Groznik M, Pelosi P, Robba C. Effects of positive end-expiratory pressure on cerebral hemodynamics in acute brain injury patients. Front Physiol 2023; 14:1139658. [PMID: 37200838 PMCID: PMC10185889 DOI: 10.3389/fphys.2023.1139658] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 04/14/2023] [Indexed: 05/20/2023] Open
Abstract
Background: Cerebral autoregulation is the mechanism that allows to maintain the stability of cerebral blood flow despite changes in cerebral perfusion pressure. Maneuvers which increase intrathoracic pressure, such as the application of positive end-expiratory pressure (PEEP), have been always challenged in brain injured patients for the risk of increasing intracranial pressure (ICP) and altering autoregulation. The primary aim of this study is to assess the effect of PEEP increase (from 5 to 15 cmH2O) on cerebral autoregulation. Secondary aims include the effect of PEEP increase on ICP and cerebral oxygenation. Material and Methods: Prospective, observational study including adult mechanically ventilated patients with acute brain injury requiring invasive ICP monitoring and undergoing multimodal neuromonitoring including ICP, cerebral perfusion pressure (CPP) and cerebral oxygenation parameters obtained with near-infrared spectroscopy (NIRS), and an index which expresses cerebral autoregulation (PRx). Additionally, values of arterial blood gases were analyzed at PEEP of 5 and 15 cmH2O. Results are expressed as median (interquartile range). Results: Twenty-five patients were included in this study. The median age was 65 years (46-73). PEEP increase from 5 to 15 cmH2O did not lead to worsened autoregulation (PRx, from 0.17 (-0.003-0.28) to 0.18 (0.01-0.24), p = 0.83). Although ICP and CPP changed significantly (ICP: 11.11 (6.73-15.63) to 13.43 (6.8-16.87) mm Hg, p = 0.003, and CPP: 72.94 (59.19-84) to 66.22 (58.91-78.41) mm Hg, p = 0.004), these parameters did not reach clinically relevant levels. No significant changes in relevant cerebral oxygenation parameters were observed. Conclusion: Slow and gradual increases of PEEP did not alter cerebral autoregulation, ICP, CPP and cerebral oxygenation to levels triggering clinical interventions in acute brain injury patients.
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Affiliation(s)
- Alberto Giardina
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genova, Italy
| | - Danilo Cardim
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, United States
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, TX, United States
| | - Pietro Ciliberti
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genova, Italy
| | | | - Lorenzo Ball
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genova, Italy
- IRCCS Policlinico San Martino, Genova, Italy
| | - Magdalena Kasprowicz
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wroclaw, Poland
| | - Erta Beqiri
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Peter Smielewski
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Shirin Frisvold
- Anesthesia and Intensive Care, University Hospital of Northern Norway, Tromsø, Norway
| | - Matjaž Groznik
- Traumatology Department of the University Clinical Center Ljubljana, Ljubljana, Slovenia
| | - Paolo Pelosi
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genova, Italy
- IRCCS Policlinico San Martino, Genova, Italy
| | - Chiara Robba
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genova, Italy
- IRCCS Policlinico San Martino, Genova, Italy
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Azizi BA, Munoz-Acuna R, Suleiman A, Ahrens E, Redaelli S, Tartler TM, Chen G, Jung B, Talmor D, Baedorf-Kassis EN, Schaefer MS. Mechanical power and 30-day mortality in mechanically ventilated, critically ill patients with and without Coronavirus Disease-2019: a hospital registry study. J Intensive Care 2023; 11:14. [PMID: 37024938 PMCID: PMC10077655 DOI: 10.1186/s40560-023-00662-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 03/31/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND Previous studies linked a high intensity of ventilation, measured as mechanical power, to mortality in patients suffering from "classic" ARDS. By contrast, mechanically ventilated patients with a diagnosis of COVID-19 may present with intact pulmonary mechanics while undergoing mechanical ventilation for longer periods of time. We investigated whether an association between higher mechanical power and mortality is modified by a diagnosis of COVID-19. METHODS This retrospective study included critically ill, adult patients who were mechanically ventilated for at least 24 h between March 2020 and December 2021 at a tertiary healthcare facility in Boston, Massachusetts. The primary exposure was median mechanical power during the first 24 h of mechanical ventilation, calculated using a previously validated formula. The primary outcome was 30-day mortality. As co-primary analysis, we investigated whether a diagnosis of COVID-19 modified the primary association. We further investigated the association between mechanical power and days being alive and ventilator free and effect modification of this by a diagnosis of COVID-19. Multivariable logistic regression, effect modification and negative binomial regression analyses adjusted for baseline patient characteristics, severity of disease and in-hospital factors, were applied. RESULTS 1,737 mechanically ventilated patients were included, 411 (23.7%) suffered from COVID-19. 509 (29.3%) died within 30 days. The median mechanical power during the first 24 h of ventilation was 19.3 [14.6-24.0] J/min in patients with and 13.2 [10.2-18.0] J/min in patients without COVID-19. A higher mechanical power was associated with 30-day mortality (ORadj 1.26 per 1-SD, 7.1J/min increase; 95% CI 1.09-1.46; p = 0.002). Effect modification and interaction analysis did not support that this association was modified by a diagnosis of COVID-19 (95% CI, 0.81-1.38; p-for-interaction = 0.68). A higher mechanical power was associated with a lower number of days alive and ventilator free until day 28 (IRRadj 0.83 per 7.1 J/min increase; 95% CI 0.75-0.91; p < 0.001, adjusted risk difference - 2.7 days per 7.1J/min increase; 95% CI - 4.1 to - 1.3). CONCLUSION A higher mechanical power is associated with elevated 30-day mortality. While patients with COVID-19 received mechanical ventilation with higher mechanical power, this association was independent of a concomitant diagnosis of COVID-19.
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Affiliation(s)
- Basit A Azizi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Brookline Ave 330, Boston, MA, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ricardo Munoz-Acuna
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Brookline Ave 330, Boston, MA, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Aiman Suleiman
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Brookline Ave 330, Boston, MA, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Elena Ahrens
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Brookline Ave 330, Boston, MA, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Simone Redaelli
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Brookline Ave 330, Boston, MA, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tim M Tartler
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Brookline Ave 330, Boston, MA, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Guanqing Chen
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Boris Jung
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Brookline Ave 330, Boston, MA, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Brookline Ave 330, Boston, MA, USA
| | - Elias N Baedorf-Kassis
- Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Brookline Ave 330, Boston, MA, USA.
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany.
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Blok SG, Mousa A, Brouwer MG, de Grooth HJ, Neto AS, Blans MJ, den Boer S, Dormans T, Endeman H, Roeleveld T, Scholten H, van Slobbe-Bijlsma ER, Scholten E, Touw H, van der Ven FSLIM, Wils EJ, van Westerloo DJ, Heunks LMA, Schultz MJ, Paulus F, Tuinman PR. Effect of lung ultrasound-guided fluid deresuscitation on duration of ventilation in intensive care unit patients (CONFIDENCE): protocol for a multicentre randomised controlled trial. Trials 2023; 24:226. [PMID: 36964614 PMCID: PMC10038369 DOI: 10.1186/s13063-023-07171-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/14/2023] [Indexed: 03/26/2023] Open
Abstract
BACKGROUND Fluid therapy is a common intervention in critically ill patients. It is increasingly recognised that deresuscitation is an essential part of fluid therapy and delayed deresuscitation is associated with longer invasive ventilation and length of intensive care unit (ICU) stay. However, optimal timing and rate of deresuscitation remain unclear. Lung ultrasound (LUS) may be used to identify fluid overload. We hypothesise that daily LUS-guided deresuscitation is superior to deresuscitation without LUS in critically ill patients expected to undergo invasive ventilation for more than 24 h in terms of ventilator free-days and being alive at day 28. METHODS The "effect of lung ultrasound-guided fluid deresuscitation on duration of ventilation in intensive care unit patients" (CONFIDENCE) is a national, multicentre, open-label, randomised controlled trial (RCT) in adult critically ill patients that are expected to be invasively ventilated for at least 24 h. Patients with conditions that preclude a negative fluid balance or LUS examination are excluded. CONFIDENCE will operate in 10 ICUs in the Netherlands and enrol 1000 patients. After hemodynamic stabilisation, patients assigned to the intervention will receive daily LUS with fluid balance recommendations. Subjects in the control arm are deresuscitated at the physician's discretion without the use of LUS. The primary endpoint is the number of ventilator-free days and being alive at day 28. Secondary endpoints include the duration of invasive ventilation; 28-day mortality; 90-day mortality; ICU, in hospital and total length of stay; cumulative fluid balance on days 1-7 after randomisation and on days 1-7 after start of LUS examination; mean serum lactate on days 1-7; the incidence of reintubations, chest drain placement, atrial fibrillation, kidney injury (KDIGO stadium ≥ 2) and hypernatremia; the use of invasive hemodynamic monitoring, and chest-X-ray; and quality of life at day 28. DISCUSSION The CONFIDENCE trial is the first RCT comparing the effect of LUS-guided deresuscitation to routine care in invasively ventilated ICU patients. If proven effective, LUS-guided deresuscitation could improve outcomes in some of the most vulnerable and resource-intensive patients in a manner that is non-invasive, easy to perform, and well-implementable. TRIAL REGISTRATION ClinicalTrials.gov NCT05188092. Registered since January 12, 2022.
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Affiliation(s)
- Siebe G Blok
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands.
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Amsterdam, The Netherlands.
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Leiden, The Netherlands.
| | - Amne Mousa
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Amsterdam, The Netherlands
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Leiden, The Netherlands
- Department of Intensive Care, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan, 1117, Amsterdam, Netherlands
| | - Michelle G Brouwer
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Amsterdam, The Netherlands
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Leiden, The Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan, 1117, Amsterdam, Netherlands
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Michiel J Blans
- Department of Intensive Care, Rijnstate Hospital, Arnhem, Netherlands
| | - Sylvia den Boer
- Department of Intensive Care, Spaarne Gasthuis, Haarlem, Hoofddorp, Netherlands
| | - Tom Dormans
- Department of Intensive Care, Zuyderland Medical Centre, Heerlen, Netherlands
- Department of Intensive Care, Zuyderland Medical Centre, Sittard-Geleen, Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Erasmus MC, Rotterdam, Netherlands
| | - Timo Roeleveld
- Department of Intensive Care, Amstelland Hospital, Amstelveen, Netherlands
| | - Harm Scholten
- Department of Intensive Care, Catharina Hospital, Eindhoven, Netherlands
| | | | - Erik Scholten
- Department of Intensive Care, St. Antonius Hospital, Nieuwegein, Utrecht, Netherlands
| | - Hugo Touw
- Department of Intensive Care, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Fleur Stefanie L I M van der Ven
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
- Department of Intensive Care, Rode Kruis Hospital, Beverwijk, Netherlands
| | - Evert-Jan Wils
- Department of Intensive Care, Franciscus Gasthuis & Vlietland, Rotterdam, Netherlands
| | | | - Leo M A Heunks
- Department of Intensive Care, Erasmus MC, Rotterdam, Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Pieter R Tuinman
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Amsterdam, The Netherlands
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Leiden, The Netherlands
- Department of Intensive Care, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan, 1117, Amsterdam, Netherlands
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Beqiri E, Smielewski P, Guérin C, Czosnyka M, Robba C, Bjertnæs L, Frisvold SK. Neurological and respiratory effects of lung protective ventilation in acute brain injury patients without lung injury: brain vent, a single centre randomized interventional study. Crit Care 2023; 27:115. [PMID: 36941683 PMCID: PMC10026451 DOI: 10.1186/s13054-023-04383-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/25/2023] [Indexed: 03/23/2023] Open
Abstract
INTRODUCTION Lung protective ventilation (LPV) comprising low tidal volume (VT) and high positive end-expiratory pressure (PEEP) may compromise cerebral perfusion in acute brain injury (ABI). In patients with ABI, we investigated whether LPV is associated with increased intracranial pressure (ICP) and/or deranged cerebral autoregulation (CA), brain compensatory reserve and oxygenation. METHODS In a prospective, crossover study, 30 intubated ABI patients with normal ICP and no lung injury were randomly assigned to receive low VT [6 ml/kg/predicted (pbw)]/at either low (5 cmH2O) or high PEEP (12 cmH2O). Between each intervention, baseline ventilation (VT 9 ml/kg/pbw and PEEP 5 cmH2O) were resumed. The safety limit for interruption of the intervention was ICP above 22 mmHg for more than 5 min. Airway and transpulmonary pressures were continuously monitored to assess respiratory mechanics. We recorded ICP by using external ventricular drainage or a parenchymal probe. CA and brain compensatory reserve were derived from ICP waveform analysis. RESULTS We included 27 patients (intracerebral haemorrhage, traumatic brain injury, subarachnoid haemorrhage), of whom 6 reached the safety limit, which required interruption of at least one intervention. For those without intervention interruption, the ICP change from baseline to "low VT/low PEEP" and "low VT/high PEEP" were 2.2 mmHg and 2.3 mmHg, respectively, and considered clinically non-relevant. None of the interventions affected CA or oxygenation significantly. Interrupted events were associated with high baseline ICP (p < 0.001), low brain compensatory reserve (p < 0.01) and mechanical power (p < 0.05). The transpulmonary driving pressure was 5 ± 2 cmH2O in both interventions. Partial arterial pressure of carbon dioxide was kept in the range 34-36 mmHg by adjusting the respiratory rate, hence, changes in carbon dioxide were not associated with the increase in ICP. CONCLUSIONS The present study found that most patients did not experience any adverse effects of LPV, neither on ICP nor CA. However, in almost a quarter of patients, the ICP rose above the safety limit for interrupting the interventions. Baseline ICP, brain compensatory reserve, and mechanical power can predict a potentially deleterious effect of LPV and can be used to personalize ventilator settings. Trial registration NCT03278769 . Registered September 12, 2017.
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Affiliation(s)
- Erta Beqiri
- Department of Clinical Neurosciences, Neurosurgery Department, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Department of Clinical Neurosciences, Neurosurgery Department, University of Cambridge, Cambridge, UK
| | - Claude Guérin
- University of Lyon, Lyon, France
- INSERM955, Créteil, France
| | - Marek Czosnyka
- Department of Clinical Neurosciences, Neurosurgery Department, University of Cambridge, Cambridge, UK
| | - Chiara Robba
- IRCCS for Oncology and Neuroscience, Policlinico San Martino, Genoa, Italy
- Department of Surgical Science Diagnostic and Integrated, University of Genova, Genoa, Italy
| | - Lars Bjertnæs
- Department of Anaesthesia and Intensive Care, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway
| | - Shirin K Frisvold
- Department of Anaesthesia and Intensive Care, University Hospital of North Norway, Tromsø, Norway.
- Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway.
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Effect of mechanical power on mortality in invasively ventilated ICU patients without the acute respiratory distress syndrome: An analysis of three randomised clinical trials. Ugeskr Laeger 2023; 40:21-28. [PMID: 36398740 DOI: 10.1097/eja.0000000000001778] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The mechanical power of ventilation (MP) has an association with outcome in invasively ventilated patients with the acute respiratory distress syndrome (ARDS). Whether a similar association exists in invasively ventilated patients without ARDS is less certain. OBJECTIVE To investigate the association of mechanical power with mortality in ICU patients without ARDS. DESIGN This was an individual patient data analysis that uses the data of three multicentre randomised trials. SETTING This study was performed in academic and nonacademic ICUs in the Netherlands. PATIENTS One thousand nine hundred and sixty-two invasively ventilated patients without ARDS were included in this analysis. The median [IQR] age was 67 [57 to 75] years, 706 (36%) were women. MAIN OUTCOME MEASURES The primary outcome was the all-cause mortality at day 28. Secondary outcomes were the all-cause mortality at day 90, and length of stay in ICU and hospital. RESULTS At day 28, 644 patients (33%) had died. Hazard ratios for mortality at day 28 were higher with an increasing MP, even when stratified for its individual components (driving pressure ( P < 0.001), tidal volume ( P < 0.001), respiratory rate ( P < 0.001) and maximum airway pressure ( P = 0.001). Similar associations of mechanical power (MP) were found with mortality at day 90, lengths of stay in ICU and hospital. Hazard ratios for mortality at day 28 were not significantly different if patients were stratified for MP, with increasing levels of each individual component. CONCLUSION In ICU patients receiving invasive ventilation for reasons other than ARDS, MP had an independent association with mortality. This finding suggests that MP holds an added predictive value over its individual components, making MP an attractive measure to monitor and possibly target in these patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02159196, ClinicalTrials.gov Identifier: NCT02153294, ClinicalTrials.gov Identifier: NCT03167580.
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Amado-Rodríguez L, Rodríguez-Garcia R, Bellani G, Pham T, Fan E, Madotto F, Laffey JG, Albaiceta GM. Mechanical ventilation in patients with cardiogenic pulmonary edema: a sub-analysis of the LUNG SAFE study. J Intensive Care 2022; 10:55. [PMID: 36567347 PMCID: PMC9791731 DOI: 10.1186/s40560-022-00648-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/18/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Patients with acute respiratory failure caused by cardiogenic pulmonary edema (CPE) may require mechanical ventilation that can cause further lung damage. Our aim was to determine the impact of ventilatory settings on CPE mortality. METHODS Patients from the LUNG SAFE cohort, a multicenter prospective cohort study of patients undergoing mechanical ventilation, were studied. Relationships between ventilatory parameters and outcomes (ICU discharge/hospital mortality) were assessed using latent mixture analysis and a marginal structural model. RESULTS From 4499 patients, 391 meeting CPE criteria (median age 70 [interquartile range 59-78], 40% female) were included. ICU and hospital mortality were 34% and 40%, respectively. ICU survivors were younger (67 [57-77] vs 74 [64-80] years, p < 0.001) and had lower driving (12 [8-16] vs 15 [11-17] cmH2O, p < 0.001), plateau (20 [15-23] vs 22 [19-26] cmH2O, p < 0.001) and peak (21 [17-27] vs 26 [20-32] cmH2O, p < 0.001) pressures. Latent mixture analysis of patients receiving invasive mechanical ventilation on ICU day 1 revealed a subgroup ventilated with high pressures with lower probability of being discharged alive from the ICU (hazard ratio [HR] 0.79 [95% confidence interval 0.60-1.05], p = 0.103) and increased hospital mortality (HR 1.65 [1.16-2.36], p = 0.005). In a marginal structural model, driving pressures in the first week (HR 1.12 [1.06-1.18], p < 0.001) and tidal volume after day 7 (HR 0.69 [0.52-0.93], p = 0.015) were related to survival. CONCLUSIONS Higher airway pressures in invasively ventilated patients with CPE are related to mortality. These patients may be exposed to an increased risk of ventilator-induced lung injury. Trial registration Clinicaltrials.gov NCT02010073.
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Affiliation(s)
- Laura Amado-Rodríguez
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Avenida del Hospital Universitario s/n, 33011, Oviedo, Spain
- Instituto Universitario de Oncología del Principado de Asturias, Universidad de Oviedo, Oviedo, Spain
- Centro de Investigación Biomédica en Red (CIBER)-Enfermedades Respiratorias, Madrid, Spain
| | - Raquel Rodríguez-Garcia
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Avenida del Hospital Universitario s/n, 33011, Oviedo, Spain
- Centro de Investigación Biomédica en Red (CIBER)-Enfermedades Respiratorias, Madrid, Spain
| | - Giacomo Bellani
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Tài Pham
- Service de Médecine Intensive-Réanimation, AP-HP, Hôpital de Bicêtre, DMU 4 CORREVE Maladies du Cœur et des Vaisseaux, FHU Sepsis, Groupe de Recherche Clinique CARMAS, Le Kremlin-Bicêtre, France
- Université Paris-Saclay, UVSQ, Inserm U1018, Equipe d'Epidémiologie Respiratoire Intégrative, CESP, 94807, Villejuif, France
| | - Eddy Fan
- Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Fabiana Madotto
- Department of Anesthesia, Critical Care and Emergency' Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - John G Laffey
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, Galway, Ireland
- School of Medicine, Regenerative Medicine Institute at CÚRAM Centre for Research in Medical Devices, University of Galway, Galway, Ireland
| | - Guillermo M Albaiceta
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain.
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Avenida del Hospital Universitario s/n, 33011, Oviedo, Spain.
- Instituto Universitario de Oncología del Principado de Asturias, Universidad de Oviedo, Oviedo, Spain.
- Centro de Investigación Biomédica en Red (CIBER)-Enfermedades Respiratorias, Madrid, Spain.
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Battaglini D, Pelosi P, Robba C. Ten rules for optimizing ventilatory settings and targets in post-cardiac arrest patients. Crit Care 2022; 26:390. [PMID: 36527126 PMCID: PMC9758928 DOI: 10.1186/s13054-022-04268-7] [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: 10/22/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022] Open
Abstract
Cardiac arrest (CA) is a major cause of morbidity and mortality frequently associated with neurological and systemic involvement. Supportive therapeutic strategies such as mechanical ventilation, hemodynamic settings, and temperature management have been implemented in the last decade in post-CA patients, aiming at protecting both the brain and the lungs and preventing systemic complications. A lung-protective ventilator strategy is currently the standard of care among critically ill patients since it demonstrated beneficial effects on mortality, ventilator-free days, and other clinical outcomes. The role of protective and personalized mechanical ventilation setting in patients without acute respiratory distress syndrome and after CA is becoming more evident. The individual effect of different parameters of lung-protective ventilation, including mechanical power as well as the optimal oxygen and carbon dioxide targets, on clinical outcomes is a matter of debate in post-CA patients. The management of hemodynamics and temperature in post-CA patients represents critical steps for obtaining clinical improvement. The aim of this review is to summarize and discuss current evidence on how to optimize mechanical ventilation in post-CA patients. We will provide ten tips and key insights to apply a lung-protective ventilator strategy in post-CA patients, considering the interplay between the lungs and other systems and organs, including the brain.
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Affiliation(s)
- Denise Battaglini
- grid.410345.70000 0004 1756 7871Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Paolo Pelosi
- grid.410345.70000 0004 1756 7871Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy ,grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Chiara Robba
- grid.410345.70000 0004 1756 7871Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy ,grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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Elevated Driving Pressure and Elastance Does Not Increase In-Hospital Mortality Among Obese and Severely Obese Patients With Ventilator Dependent Respiratory Failure. Crit Care Explor 2022; 4:e0811. [PMID: 36583205 PMCID: PMC9750660 DOI: 10.1097/cce.0000000000000811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Existing recommendations for mechanical ventilation are based on studies that under-sampled or excluded obese and severely obese individuals. Objective To determine if driving pressure (DP) and total respiratory system elastance (Ers) differ among normal/overweight (body mass index [BMI] < 30 kg/m2), obese, and severely obese ventilator-dependent respiratory failure (VDRF) patients and if there any associations with clinical outcomes. Design Setting and Participants Retrospective observational cohort study during 2016-2018 at two tertiary care academic medical centers using electronic health record data from the first 2 full days of mechanical ventilation. The cohort was stratified by BMI classes to measure median DP, time-weighted mean tidal volume, plateau pressure, and Ers for each BMI class. Setting and Participants Mechanically ventilated patients in medical and surgical ICUs. Main Outcomes and Measures Primary outcome and effect measures included relative risk of in-hospital mortality, ventilator-free days, ICU length of stay, and hospital length of stay with multivariable adjustment. Results The cohort included 3,204 patients with 976 (30.4%) and 382 (11.9%) obese and severely obese patients, respectively. Severe obesity was associated with a DP greater than or equal to 15 cm H2O (relative risk [RR], 1.51 [95% CI, 1.26-1.82]) and Ers greater than or equal to 2 cm H2O/(mL/kg) (RR, 1.31 [95% CI, 1.14-1.49]). Despite elevated DP and Ers, there were no differences in in-hospital mortality, ventilator-free days, or ICU length of stay among all three groups. Conclusions and Relevance Despite higher DP and ERS among obese and severely obese VDRF patients, there were no differences in in-hospital mortality or duration of mechanical ventilation, suggesting that DP has less prognostic value in obese and severely obese VDRF patients.
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Airway driving pressure is associated with postoperative pulmonary complications after major abdominal surgery: a multicentre retrospective observational cohort study. BJA OPEN 2022; 4:100099. [PMID: 36687665 PMCID: PMC9853922 DOI: 10.1016/j.bjao.2022.100099] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Background High airway driving pressure is associated with adverse outcomes in critically ill patients receiving mechanical ventilation, but large multicentre studies investigating airway driving pressure during major surgery are lacking. We hypothesised that increased driving pressure is associated with postoperative pulmonary complications in patients undergoing major abdominal surgery. Methods In this preregistered multicentre retrospective observational cohort study, the authors reviewed major abdominal surgical procedures in 11 hospitals from 2004 to 2018. The primary outcome was a composite of postoperative pulmonary complications, defined as postoperative pneumonia, unplanned tracheal intubation, or prolonged mechanical ventilation for more than 48 h. Associations between intraoperative dynamic driving pressure and outcomes, adjusted for patient and procedural factors, were evaluated. Results Among 14 218 qualifying cases, 389 (2.7%) experienced postoperative pulmonary complications. After adjustment, the mean dynamic driving pressure was associated with postoperative pulmonary complications (adjusted odds ratio for every 1 cm H2O increase: 1.04; 95% confidence interval [CI], 1.02-1.06; P<0.001). Neither tidal volume nor PEEP was associated with postoperative pulmonary complications. Increased BMI, shorter height, and female sex were predictors for higher dynamic driving pressure (β=0.35, 95% CI 0.32-0.39, P<0.001; β=-0.01, 95% CI -0.02 to 0.00, P=0.005; and β=0.74, 95% CI 0.63-0.86, P<0.001, respectively). Conclusions Dynamic airway driving pressure, but not tidal volume or PEEP, is associated with postoperative pulmonary complications in models controlling for a large number of risk predictors and covariates. Such models are capable of risk prediction applicable to individual patients.
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Wick KD, Matthay MA, Ware LB. Pulse oximetry for the diagnosis and management of acute respiratory distress syndrome. THE LANCET. RESPIRATORY MEDICINE 2022; 10:1086-1098. [PMID: 36049490 PMCID: PMC9423770 DOI: 10.1016/s2213-2600(22)00058-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/30/2022] [Accepted: 02/10/2022] [Indexed: 02/07/2023]
Abstract
The diagnosis of acute respiratory distress syndrome (ARDS) traditionally requires calculation of the ratio of partial pressure of arterial oxygen to fraction of inspired oxygen (PaO2/FiO2) using arterial blood, which can be costly and is not possible in many resource-limited settings. By contrast, pulse oximetry is continuously available, accurate, inexpensive, and non-invasive. Pulse oximetry-based indices, such as the ratio of pulse-oximetric oxygen saturation to FiO2 (SpO2/FiO2), have been validated in clinical studies for the diagnosis and risk stratification of patients with ARDS. Limitations of the SpO2/FiO2 ratio include reduced accuracy in poor perfusion states or above oxygen saturations of 97%, and the potential for reduced accuracy in patients with darker skin pigmentation. Application of pulse oximetry to the diagnosis and management of ARDS, including formal adoption of the SpO2/FiO2 ratio as an alternative to PaO2/FiO2 to meet the diagnostic criterion for hypoxaemia in ARDS, could facilitate increased and earlier recognition of ARDS worldwide to advance both clinical practice and research.
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Affiliation(s)
- Katherine D Wick
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California, San Francisco, CA, USA
| | - Michael A Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California, San Francisco, CA, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine and Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN, USA.
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Intermediate tidal volume is an acceptable option for ventilated patients with acute respiratory distress syndrome. Med Intensiva 2022; 46:609-618. [PMID: 36313965 PMCID: PMC9597521 DOI: 10.1016/j.medin.2022.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 03/25/2022] [Indexed: 01/05/2023]
Abstract
Objective Evidence only proves low surpasses high tidal volume (V T) for acute respiratory distress syndrome (ARDS). Intermediate V T is a common setting for ARDS patients and has been demonstrated as effective as low V T in non-ARDS patients. The effectiveness of intermediate V T in ARDS has not been studied and is the objective of this study. Design A retrospective cohort study. Setting Five ICUs with their totally 130 beds in Taiwan. Patients or participants ARDS patients under invasive ventilation. Interventions No. Main variables of interest 28-D mortality. Result Totally 382 patients, with 6958 ventilator settings eligible for lung protection, were classified into low (mean V T = 6.7 ml/kg), intermediate (mean V T = 8.9 ml/kg) and high (mean V T = 11.2 ml/kg) V T groups. With similar baseline ARDS and ICU severities, intermediate and low V T groups did not differ in 28-D mortality (47% vs. 63%, P = 0.06) or other outcomes such as 90-D mortality, ventilator-free days, ventilator-dependence rate. Multivariate analysis revealed high V T was independently associated with 28-D and 90-D mortality, but intermediate V T was not significantly associated with 28-D mortality (HR 1.34, CI 0.92-1.97, P = 0.13) or 90-D mortality. When the intermediate and low V T groups were matched in propensity scores (n = 66 for each group), their outcomes were also not significantly different. Conclusion Intermediate V T, with its outcomes similar to small V T, is an acceptable option for ventilated ARDS patients. This conclusion needs verification through clinical trials.
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Manrique S, Ruiz-Botella M, Rodríguez A, Gordo F, Guardiola JJ, Bodí M, Gómez J. Secondary use of data extracted from a clinical information system to assess the adherence of tidal volume and its impact on outcomes. Med Intensiva 2022; 46:619-629. [PMID: 36344013 DOI: 10.1016/j.medine.2022.03.003] [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: 11/04/2021] [Accepted: 03/09/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES To extract data from clinical information systems to automatically calculate high-resolution quality indicators to assess adherence to recommendations for low tidal volume. DESIGN We devised two indicators: the percentage of time under mechanical ventilation with excessive tidal volume (>8mL/kg predicted body weight) and the percentage of patients who received appropriate tidal volume (≤8mL/kg PBW) at least 80% of the time under mechanical ventilation. We developed an algorithm to automatically calculate these indicators from clinical information system data and analyzed associations between them and patients' characteristics and outcomes. SETTINGS This study has been carried out in our 30-bed polyvalent intensive care unit between January 1, 2014 and November 30, 2019. PATIENTS All patients admitted to intensive care unit ventilated >72h were included. INTERVENTION Use data collected automatically from the clinical information systems to assess adherence to tidal volume recommendations and its outcomes. MAIN VARIABLES OF INTEREST Mechanical ventilation days, ICU length of stay and mortality. RESULTS Of all admitted patients, 340 met the inclusion criteria. Median percentage of time under mechanical ventilation with excessive tidal volume was 70% (23%-93%); only 22.3% of patients received appropriate tidal volume at least 80% of the time. Receiving appropriate tidal volume was associated with shorter duration of mechanical ventilation and intensive care unit stay. Patients receiving appropriate tidal volume were mostly male, younger, taller, and less severely ill. Adjusted intensive care unit mortality did not differ according to percentage of time with excessive tidal volume or to receiving appropriate tidal volume at least 80% of the time. CONCLUSIONS Automatic calculation of process-of-care indicators from clinical information systems high-resolution data can provide an accurate and continuous measure of adherence to recommendations. Adherence to tidal volume recommendations was associated with shorter duration of mechanical ventilation and intensive care unit stay.
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Affiliation(s)
- S Manrique
- Intensive Care Unit, Hospital Universitario Joan XXIII, Tarragona, Spain; Instituto de Investigación Sanitaria Pere i Virgili, Rovira i Virgili University, Tarragona, Spain.
| | - M Ruiz-Botella
- Intensive Care Unit, Hospital Universitario Joan XXIII, Tarragona, Spain
| | - A Rodríguez
- Intensive Care Unit, Hospital Universitario Joan XXIII, Tarragona, Spain; Instituto de Investigación Sanitaria Pere i Virgili, Rovira i Virgili University, Tarragona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES). Instituto de Salud Carlos III, Spain
| | - F Gordo
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada, Madrid, Grupo de Investigación en Patología Crítica, Grado de Medicina, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | | | - M Bodí
- Intensive Care Unit, Hospital Universitario Joan XXIII, Tarragona, Spain; Instituto de Investigación Sanitaria Pere i Virgili, Rovira i Virgili University, Tarragona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES). Instituto de Salud Carlos III, Spain
| | - J Gómez
- Intensive Care Unit, Hospital Universitario Joan XXIII, Tarragona, Spain; Instituto de Investigación Sanitaria Pere i Virgili, Rovira i Virgili University, Tarragona, Spain
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Intermediate tidal volume is an acceptable option for ventilated patients with acute respiratory distress syndrome. MEDICINA INTENSIVA (ENGLISH EDITION) 2022; 46:609-618. [PMCID: PMC9633924 DOI: 10.1016/j.medine.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 03/25/2022] [Indexed: 11/06/2022]
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Gibbs KW, Forbes JL, O’Connell NS, Martin RS, Bakhru RN, Palakshappa JA, Files DC. Excess Tidal Volume Ventilation in Critically Ill Adults Receiving Adaptive Pressure Control: A Cohort Study. Ann Am Thorac Soc 2022; 19:1942-1945. [PMID: 35622413 PMCID: PMC9667801 DOI: 10.1513/annalsats.202203-200rl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Kevin W. Gibbs
- Wake Forest School of MedicineWinston-Salem, North Carolina
| | | | | | | | - Rita N. Bakhru
- Wake Forest School of MedicineWinston-Salem, North Carolina
| | | | - D. Clark Files
- Wake Forest School of MedicineWinston-Salem, North Carolina
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41
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Batlle Solà M, Subirà Cuyàs C. Less is not always more. Med Intensiva 2022; 46:607-608. [PMID: 36266186 PMCID: PMC9576258 DOI: 10.1016/j.medine.2022.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/03/2022] [Indexed: 11/06/2022]
Affiliation(s)
- M. Batlle Solà
- Critical Care Department, Althaia Xarxa Assitencial Universitària Manresa, Manresa, Barcelona, Spain
| | - C. Subirà Cuyàs
- Critical Care Department, Althaia Xarxa Assitencial Universitària Manresa, Manresa, Barcelona, Spain,Grupo 33, Centro de Investigaciones Biomédicas en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain,Corresponding author
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Moskowitz A, Shotwell MS, Gibbs KW, Harkins M, Rosenberg Y, Troendle J, Merck LH, Files DC, de Wit M, Hudock K, Thompson BT, Gong MN, Ginde AA, Douin DJ, Brown SM, Rubin E, Joly MM, Wang L, Lindsell CJ, Bernard GR, Semler MW, Collins SP, Self WH. Oxygen-Free Days as an Outcome Measure in Clinical Trials of Therapies for COVID-19 and Other Causes of New-Onset Hypoxemia. Chest 2022; 162:804-814. [PMID: 35504307 PMCID: PMC9055785 DOI: 10.1016/j.chest.2022.04.145] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 04/09/2022] [Accepted: 04/22/2022] [Indexed: 11/21/2022] Open
Abstract
Mortality historically has been the primary outcome of choice for acute and critical care clinical trials. However, undue reliance on mortality can limit the scope of trials that can be performed. Large sample sizes are usually needed for trials powered for a mortality outcome, and focusing solely on mortality fails to recognize the importance that reducing morbidity can have on patients' lives. The COVID-19 pandemic has highlighted the need for rapid, efficient trials to rigorously evaluate new therapies for hospitalized patients with acute lung injury. Oxygen-free days (OFDs) is a novel outcome for clinical trials that is a composite of mortality and duration of new supplemental oxygen use. It is designed to characterize recovery from acute lung injury in populations with a high prevalence of new hypoxemia and supplemental oxygen use. In these populations, OFDs captures two patient-centered consequences of acute lung injury: mortality and hypoxemic lung dysfunction. Power to detect differences in OFDs typically is greater than that for other clinical trial outcomes, such as mortality and ventilator-free days. OFDs is the primary outcome for the Fourth Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV-4) Host Tissue platform, which evaluates novel therapies targeting the host response to COVID-19 among adults hospitalized with COVID-19 and new hypoxemia. This article outlines the rationale for use of OFDs as an outcome for clinical trials, proposes a standardized method for defining and analyzing OFDs, and provides a framework for sample size calculations using the OFD outcome.
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Affiliation(s)
- Ari Moskowitz
- Department of Medicine, Montefiore Medical Center, The Bronx, NY
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Kevin W Gibbs
- Department of Medicine, Wake Forest University, Winston-Salem, NC
| | - Michelle Harkins
- Department of Medicine, University of New Mexico, Albuquerque, NM
| | | | | | - Lisa H Merck
- Department of Emergency Medicine, Virginia Commonwealth University, Richmond, VA
| | - D Clark Files
- Department of Medicine, Wake Forest University, Winston-Salem, NC
| | - Marjolein de Wit
- Department of Medicine, Virginia Commonwealth University, Richmond, VA
| | - Kristin Hudock
- Department of Medicine, University of Cincinnati, Cincinnati, OH
| | | | - Michelle N Gong
- Department of Medicine, Montefiore Medical Center, The Bronx, NY
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - David J Douin
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO
| | - Samuel M Brown
- Department of Medicine, Intermountain Medical Center, Murray, UT; Office of Research, Intermountain Medical Center, Murray, UT
| | | | - Meghan Morrison Joly
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | | | - Gordon R Bernard
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew W Semler
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Sean P Collins
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN; Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN
| | - Wesley H Self
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN; Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN.
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Walsh SP, Shaz D, Amar D. Ventilation during Lung Resection and Critical Care: Comparative Clinical Outcomes. Anesthesiology 2022; 137:473-483. [PMID: 35993993 PMCID: PMC11210714 DOI: 10.1097/aln.0000000000004325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Recent evidence suggests that outcomes do not meaningfully differ between thoracic surgery patients who are ventilated with a low or higher tidal volume and the effects of low versus higher positive end-expiratory pressure are unclear.
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Affiliation(s)
- Spencer P. Walsh
- Department of Anesthesiology, Weill Cornell Medical College, New York, New York
| | - David Shaz
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
| | - David Amar
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, and Weill Cornell Medical College, New York, New York
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Malnoske ML, Quill CM, Barwise AK, Pietropaoli AP. Disparities in Lung-Protective Ventilation in the United States. Cureus 2022; 14:e29834. [PMID: 36337793 PMCID: PMC9625078 DOI: 10.7759/cureus.29834] [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] [Accepted: 10/02/2022] [Indexed: 06/16/2023] Open
Abstract
Background The objective of our study was to determine whether disparities exist in the use of lung-protective ventilation for critically ill mechanically ventilated patients in the United States based on gender, race/ethnicity, or insurance status. Methods This was a secondary data analysis of a prospective multicenter cohort study conducted from 2010 to 2012. The outcome of interest was the proportion of patients receiving tidal volume > 8 mL/kg predicted body weight (PBW). Results There were 1,595 patients in our primary analysis (710 women, 885 men). Women were more likely to receive tidal volumes > 8 mL/kg PBW than men (odds ratio [OR] = 3.42, 95% confidence interval [CI] = 2.67-4.40), a finding largely but not completely explained by gender differences in height. The underinsured were significantly more likely to receive tidal volume > 8 mL/kg PBW than the insured in multivariable analysis (OR = 1.54, 95% CI = 1.16-2.04). The prescription of > 8 mL/kg PBW tidal volume did not differ by racial or ethnic categories. Conclusions In this prospective nationwide cohort of critically ill mechanically ventilated patients, women and the underinsured were less likely than their comparators to receive lung-protective ventilation, with no apparent differences based on race/ethnicity alone.
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Affiliation(s)
- Michelle L Malnoske
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, USA
| | - Caroline M Quill
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, USA
| | - Amelia K Barwise
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, USA
| | - Anthony P Pietropaoli
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, USA
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Oliveira DSD, Firmo RC, Silva Júnior JRD. Comparação da Mortalidade entre Pacientes com Neoplasias submetidos à Ventilação Invasiva e não Invasiva: Estudo de Coorte Retrospectiva. REVISTA BRASILEIRA DE CANCEROLOGIA 2022. [DOI: 10.32635/2176-9745.rbc.2022v68n3.2466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Introdução: O paciente com câncer apresenta alta prevalência de insuficiência respiratória aguda (IRpA) relacionada a complicações do tratamento oncológico. O suporte ventilatório mecânico e a principal terapêutica para resolução dessas complicações. No entanto, tal recurso pode aumentar a mortalidade. Objetivo: Verificar a taxa de mortalidade e os fatores intervenientes de pacientes oncológicos com IRpA expostos a ventilação mecânica invasiva (VMI) e não invasiva (VNI). Método: Estudo de coorte retrospectiva. Foram incluídos 121 pacientes oncológicos em ventilação mecânica separados em grupos: neoplasias hematológicas em VMI (HVMI, n=17), neoplasias hematológicas em VNI (HVNI, n=36), neoplasias solidas em VMI (SVMI, n=39) e neoplasias solidas em VNI (SVNI, n=29). Os desfechos avaliados foram: taxa de mortalidade, tempo de internamento, tempo de exposição a ventilação mecânica, taxa de falha da VNI e fatores relacionados a falha da VNI. Resultados: A taxa de mortalidade geral foi de 47,9%, distribuídos em HVMI (82,4%), HVNI (27,8%), SVMI (69,2%) e SVNI (24,1%). O escore APACHE III elevado foi associado a uma maior taxa de mortalidade. A taxa de mortalidade associada a falha da VNI foi de 71,4% HVNI e 77,8% SVNI. As variáveis associadas a maior taxa de falha da VNI foram o APACHE III>7 e o tempo de exposição a VNI>72 horas. Conclusão: A taxa de mortalidade de pacientes com neoplasia hematológica e solida em IRpA mostrou-se menor em pacientes expostos a VNI.
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Robba C, Badenes R, Battaglini D, Ball L, Brunetti I, Jakobsen JC, Lilja G, Friberg H, Wendel-Garcia PD, Young PJ, Eastwood G, Chew MS, Unden J, Thomas M, Joannidis M, Nichol A, Lundin A, Hollenberg J, Hammond N, Saxena M, Annborn M, Solar M, Taccone FS, Dankiewicz J, Nielsen N, Pelosi P. Ventilatory settings in the initial 72 h and their association with outcome in out-of-hospital cardiac arrest patients: a preplanned secondary analysis of the targeted hypothermia versus targeted normothermia after out-of-hospital cardiac arrest (TTM2) trial. Intensive Care Med 2022; 48:1024-1038. [PMID: 35780195 PMCID: PMC9304050 DOI: 10.1007/s00134-022-06756-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 05/24/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE The optimal ventilatory settings in patients after cardiac arrest and their association with outcome remain unclear. The aim of this study was to describe the ventilatory settings applied in the first 72 h of mechanical ventilation in patients after out-of-hospital cardiac arrest and their association with 6-month outcomes. METHODS Preplanned sub-analysis of the Target Temperature Management-2 trial. Clinical outcomes were mortality and functional status (assessed by the Modified Rankin Scale) 6 months after randomization. RESULTS A total of 1848 patients were included (mean age 64 [Standard Deviation, SD = 14] years). At 6 months, 950 (51%) patients were alive and 898 (49%) were dead. Median tidal volume (VT) was 7 (Interquartile range, IQR = 6.2-8.5) mL per Predicted Body Weight (PBW), positive end expiratory pressure (PEEP) was 7 (IQR = 5-9) cmH20, plateau pressure was 20 cmH20 (IQR = 17-23), driving pressure was 12 cmH20 (IQR = 10-15), mechanical power 16.2 J/min (IQR = 12.1-21.8), ventilatory ratio was 1.27 (IQR = 1.04-1.6), and respiratory rate was 17 breaths/minute (IQR = 14-20). Median partial pressure of oxygen was 87 mmHg (IQR = 75-105), and partial pressure of carbon dioxide was 40.5 mmHg (IQR = 36-45.7). Respiratory rate, driving pressure, and mechanical power were independently associated with 6-month mortality (omnibus p-values for their non-linear trajectories: p < 0.0001, p = 0.026, and p = 0.029, respectively). Respiratory rate and driving pressure were also independently associated with poor neurological outcome (odds ratio, OR = 1.035, 95% confidence interval, CI = 1.003-1.068, p = 0.030, and OR = 1.005, 95% CI = 1.001-1.036, p = 0.048). A composite formula calculated as [(4*driving pressure) + respiratory rate] was independently associated with mortality and poor neurological outcome. CONCLUSIONS Protective ventilation strategies are commonly applied in patients after cardiac arrest. Ventilator settings in the first 72 h after hospital admission, in particular driving pressure and respiratory rate, may influence 6-month outcomes.
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Affiliation(s)
- Chiara Robba
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy. .,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Viale Benedetto XV 16, Genoa, Italy.
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínic Universitari de Valencia, Valencia, Spain.,Department of Surgery, University of Valencia, Valencia, Spain
| | - Denise Battaglini
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Lorenzo Ball
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Viale Benedetto XV 16, Genoa, Italy
| | - Iole Brunetti
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Getingevägen 4, 222 41, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences Lund, Anesthesia and Intensive Care, Lund University, Lund, Sweden
| | - Pedro D Wendel-Garcia
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Paul J Young
- Medical Research Institute of New Zealand, Private Bag 7902, Wellington, 6242, New Zealand.,Intensive Care Unit, Wellington Regional Hospital, Wellington, New Zealand.,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Department of Critical Care, University of Melbourne, Parkville, VIC, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Johan Unden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.,Department of Operation and Intensive Care, Lund University, Hallands Hospital Halmstad, Halland, Sweden
| | - Matthew Thomas
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | | | - Andreas Lundin
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 423 45, Gothenburg, Sweden
| | - Jacob Hollenberg
- Department of Medicine, Centre for Resuscitation Science, Karolinska Institutet, Södersjukhuset Sjukhusbacken 10, Solna, 118 83, Stockholm, Sweden
| | - Naomi Hammond
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Critical Care Division, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, Australia
| | - Manoj Saxena
- Intensive Care Unit, St George Hospital, Sydney, Australia
| | - Martin Annborn
- Department of Clinical Medicine, Anaesthesiology and Intensive Care, Lund University, Lund, Sweden
| | - Miroslav Solar
- Department of Internal Medicine, Faculty of Medicine in Hradec Králové, Charles University, Hradec Králové, Czech Republic.,Department of Internal Medicine-Cardioangiology, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Fabio S Taccone
- Department of Intensive Care Medicine, Université Libre de Bruxelles, Hopital Erasme, Brussels, Belgium
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care and Clinical Sciences Helsingborg, Helsingborg Hospital, Lund University, Lund, Sweden
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Viale Benedetto XV 16, Genoa, Italy
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Modeling surgical patients’ tidal volumes set by anesthesiologists – A successful regression approach based on 6 body parameters. Biomed Signal Process Control 2022. [DOI: 10.1016/j.bspc.2022.103801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Biselli PJC, Degobbi Tenorio Quirino Dos Santos Lopes F, Righetti RF, Moriya HT, Tibério IFLC, Martins MA. Lung Mechanics Over the Century: From Bench to Bedside and Back to Bench. Front Physiol 2022; 13:817263. [PMID: 35910573 PMCID: PMC9326096 DOI: 10.3389/fphys.2022.817263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 06/17/2022] [Indexed: 11/13/2022] Open
Abstract
Lung physiology research advanced significantly over the last 100 years. Respiratory mechanics applied to animal models of lung disease extended the knowledge of the workings of respiratory system. In human research, a better understanding of respiratory mechanics has contributed to development of mechanical ventilators. In this review, we explore the use of respiratory mechanics in basic science to investigate asthma and chronic obstructive pulmonary disease (COPD). We also discuss the use of lung mechanics in clinical care and its role on the development of modern mechanical ventilators. Additionally, we analyse some bench-developed technologies that are not in widespread use in the present but can become part of the clinical arsenal in the future. Finally, we explore some of the difficult questions that intensive care doctors still face when managing respiratory failure. Bringing back these questions to bench can help to solve them. Interaction between basic and translational science and human subject investigation can be very rewarding, as in the conceptualization of “Lung Protective Ventilation” principles. We expect this interaction to expand further generating new treatments and managing strategies for patients with respiratory disease.
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Affiliation(s)
- Paolo Jose Cesare Biselli
- Intensive Care Unit, University Hospital, University of Sao Paulo, Sao Paulo, Brazil
- *Correspondence: Paolo Jose Cesare Biselli,
| | | | - Renato Fraga Righetti
- Laboratory of Experimental Therapeutics, Department of Clinical Medicine, School of Medicine, University of Sao Paulo, Sao Paulo, Brazil
- Hospital Sírio-Libanês, Serviço de Reabilitação, São Paulo, Brazil
| | - Henrique Takachi Moriya
- Biomedical Engineering Laboratory, Escola Politecnica, University of Sao Paulo, Sao Paulo, Brazil
| | - Iolanda Fátima Lopes Calvo Tibério
- Laboratory of Experimental Therapeutics, Department of Clinical Medicine, School of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - Milton Arruda Martins
- Laboratory of Experimental Therapeutics, Department of Clinical Medicine, School of Medicine, University of Sao Paulo, Sao Paulo, Brazil
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Ward J, Noel C. Basic Modes of Mechanical Ventilation. Emerg Med Clin North Am 2022; 40:473-488. [DOI: 10.1016/j.emc.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Airway Pressure Release Ventilation. Emerg Med Clin North Am 2022; 40:489-501. [DOI: 10.1016/j.emc.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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