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da Silva PB, Fernandes SES, Gomes M, da Silveira CDG, Amorim FFP, de Aquino Carvalho AL, Shintaku LS, Miazato LY, Amorim FFP, Maia MDO, Neves FDAR, Amorim FF. Hyperoxemia Induced by Oxygen Therapy in Nonsurgical Critically Ill Patients. Am J Crit Care 2024; 33:82-92. [PMID: 38424024 DOI: 10.4037/ajcc2024723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND Hyperoxemia, often overlooked in critically ill patients, is common and may have adverse consequences. OBJECTIVE To evaluate the incidence of hyperoxemia induced by oxygen therapy in nonsurgical critically ill patients at intensive care unit (ICU) admission and the association of hyperoxemia with hospital mortality. METHODS This prospective cohort study included all consecutive admissions of nonsurgical patients aged 18 years or older who received oxygen therapy on admission to the Hospital Santa Luzia Rede D'Or São Luiz adult ICU from July 2018 through June 2021. Patients were categorized into 3 groups according to Pao2 level at ICU admission: hypoxemia (Pao2<60 mm Hg), normoxemia (Pao2= 60-120 mm Hg), and hyperoxemia (Pao2 >120 mm Hg). RESULTS Among 3088 patients, hyperoxemia was present in 1174 (38.0%) and was independently associated with hospital mortality (odds ratio [OR], 1.32; 95% CI, 1.04-1.67; P=.02). Age (OR, 1.02; 95% CI, 1.02-1.02; P<.001) and chronic kidney disease (OR, 1.55; 95% CI, 1.02-2.36; P=.04) were associated with a higher rate of hyperoxemia. Factors associated with a lower rate of hyperoxemia were Sequential Organ Failure Assessment score (OR, 0.88; 95% CI, 0.83-0.93; P<.001); late-night admission (OR, 0.80; 95% CI, 0.67-0.96; P=.02); and renal/metabolic (OR, 0.22; 95% CI, 0.13-1.39; P<.001), neurologic (OR, 0.02; 95% CI, 0.01-0.05; P<.001), digestive (OR, 0.23; 95% CI, 0.13-0.41; P<.001), and soft tissue/skin/orthopedic (OR, 0.32; 95% CI, 0.13-0.79; P=.01) primary reasons for hospital admission. CONCLUSION Hyperoxemia induced by oxygen therapy was common in critically ill patients and was linked to increased risk of hospital mortality. Health care professionals should be aware of this condition because of its potential risks and unnecessary costs.
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Affiliation(s)
- Priscilla Barbosa da Silva
- Priscilla Barbosa da Silva is a master's student, Graduate Program in Health Sciences, Escola Superior de Ciências da Saúde (ESCS), Brasília, Federal District, Brazil, and a staff nurse, intensive care unit, Hospital Santa Luzia Rede D'Or São Luiz, Brasília
| | | | - Maura Gomes
- Maura Gomes is a staff nurse, intensive care unit, Hospital Santa Luzia Rede D'Or São Luiz
| | - Carlos Darwin Gomes da Silveira
- Carlos Darwin Gomes da Silveira is a professor, Medical School, ESCS, and a professor, Medical School, Centro Universitário do Planalto Central, Brasília
| | - Flávio Ferreira Pontes Amorim
- Flávio Ferreira Pontes Amorim is an undergraduate student, Medical School, Universidade Católica de Brasília, Brasília
| | - André Luiz de Aquino Carvalho
- André Luiz de Aquino Carvalho is a master's student, Graduate Program in Health Sciences, ESCS, and a professor, Medical School, ESCS
| | | | | | | | - Marcelo de Oliveira Maia
- Marcelo de Oliveira Maia is a master's student, Graduate Program in Health Sciences, ESCS, and an intensivist, intensive care unit, Hospital Santa Luzia Rede D'Or São Luiz
| | | | - Fábio Ferreira Amorim
- Fábio Ferreira Amorim is a professor, Graduate Program in Health Sciences, ESCS, and a professor, Graduate Program in Health Sciences, Universidade de Brasília
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Bernhard M, Keymel S, Krüger S, Pin M. [Acute dyspnea]. Dtsch Med Wochenschr 2023; 148:253-267. [PMID: 36848889 DOI: 10.1055/a-1817-7578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
ACUTE DYSPNEA The leading symptom "acute dyspnea" and the causal underlying diseases have a high risk potential for an unfavorable course of treatment with a high letality. This overview of possible causes, diagnostic procedures and guideline-based therapy is intended to help implement a targeted and structured emergency medical care in the emergency department. The leading symptom "acute dyspnea" is present in 10% of prehospital and 4-7% of patients in the emergency department. The most common conditions in the emergency department with the leading symptom "acute dyspnea" are heart failure in 25%, COPD in 15%, pneumonia in 13%, respiratory disorders in 8%, and pulmonary embolism in 4%. In 18% of cases, the leading symptom "acute dyspnea" is sepsis. The in-hospital letality is high and amounts to 9%. In critically ill patients in the non-traumatologic resuscitation room, respiratory disorders (B-problems) are present in 26-29%. In addition to cardiovascular disease, noncardiovascular disease may underlie "acute dyspnea" and requires differential diagnostic consideration. A structured approach can contribute to a high degree of certainty in the clarification of the leading symptom "acute dyspnea".
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Westhoff M. [Exacerbation of COPD and pharmacological therapy]. MMW Fortschr Med 2023; 165:56-64. [PMID: 36759478 DOI: 10.1007/s15006-022-2243-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Affiliation(s)
- Michael Westhoff
- Klinik für Pneumologie, Schlaf- und Beatmungsmedizin, Lungenklinik Hemer, Theo-Funccius-Str. 1, 58675, Hemer, Deutschland.
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Hohmann F, Wedekind L, Grundeis F, Dickel S, Frank J, Golinski M, Griesel M, Grimm C, Herchenhahn C, Kramer A, Metzendorf MI, Moerer O, Olbrich N, Thieme V, Vieler A, Fichtner F, Burns J, Laudi S. Early spontaneous breathing for acute respiratory distress syndrome in individuals with COVID-19. Cochrane Database Syst Rev 2022; 6:CD015077. [PMID: 35767435 PMCID: PMC9242537 DOI: 10.1002/14651858.cd015077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) represents the most severe course of COVID-19 (caused by the SARS-CoV-2 virus), usually resulting in a prolonged stay in an intensive care unit (ICU) and high mortality rates. Despite the fact that most affected individuals need invasive mechanical ventilation (IMV), evidence on specific ventilation strategies for ARDS caused by COVID-19 is scarce. Spontaneous breathing during IMV is part of a therapeutic concept comprising light levels of sedation and the avoidance of neuromuscular blocking agents (NMBA). This approach is potentially associated with both advantages (e.g. a preserved diaphragmatic motility and an optimised ventilation-perfusion ratio of the ventilated lung), as well as risks (e.g. a higher rate of ventilator-induced lung injury or a worsening of pulmonary oedema due to increases in transpulmonary pressure). As a consequence, spontaneous breathing in people with COVID-19-ARDS who are receiving IMV is subject to an ongoing debate amongst intensivists. OBJECTIVES To assess the benefits and harms of early spontaneous breathing activity in invasively ventilated people with COVID-19 with ARDS compared to ventilation strategies that avoid spontaneous breathing. SEARCH METHODS We searched the Cochrane COVID-19 Study Register (which includes CENTRAL, PubMed, Embase, Clinical Trials.gov WHO ICTRP, and medRxiv) and the WHO COVID-19 Global literature on coronavirus disease to identify completed and ongoing studies from their inception to 2 March 2022. SELECTION CRITERIA Eligible study designs comprised randomised controlled trials (RCTs) that evaluated spontaneous breathing in participants with COVID-19-related ARDS compared to ventilation strategies that avoided spontaneous breathing (e.g. using NMBA or deep sedation levels). Additionally, we considered controlled before-after studies, interrupted time series with comparison group, prospective cohort studies and retrospective cohort studies. For these non-RCT studies, we considered a minimum total number of 50 participants to be compared as necessary for inclusion. Prioritised outcomes were all-cause mortality, clinical improvement or worsening, quality of life, rate of (serious) adverse events and rate of pneumothorax. Additional outcomes were need for tracheostomy, duration of ICU length of stay and duration of hospitalisation. DATA COLLECTION AND ANALYSIS We followed the methods outlined in the Cochrane Handbook for Systematic Reviews of Interventions. Two review authors independently screened all studies at the title/abstract and full-text screening stage. We also planned to conduct data extraction and risk of bias assessment in duplicate. We planned to conduct meta-analysis for each prioritised outcome, as well as subgroup analyses of mortality regarding severity of oxygenation impairment and duration of ARDS. In addition, we planned to perform sensitivity analyses for studies at high risk of bias, studies using NMBA in addition to deep sedation level to avoid spontaneous breathing and a comparison of preprints versus peer-reviewed articles. We planned to assess the certainty of evidence using the GRADE approach. MAIN RESULTS We identified no eligible studies for this review. AUTHORS' CONCLUSIONS We found no direct evidence on whether early spontaneous breathing in SARS-CoV-2-induced ARDS is beneficial or detrimental to this particular group of patients. RCTs comparing early spontaneous breathing with ventilatory strategies not allowing for spontaneous breathing in SARS-CoV-2-induced ARDS are necessary to determine its value within the treatment of severely ill people with COVID-19. Additionally, studies should aim to clarify whether treatment effects differ between people with SARS-CoV-2-induced ARDS and people with non-SARS-CoV-2-induced ARDS.
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Affiliation(s)
- Friedrich Hohmann
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
| | - Lisa Wedekind
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
- Institute of Medical Statistics, Computer and Data Sciences, University Hospital Jena, Jena, Germany
| | - Felicitas Grundeis
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
| | - Steffen Dickel
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Goettingen, Goettingen, Germany
| | - Johannes Frank
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
| | - Martin Golinski
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Goettingen, Goettingen, Germany
| | - Mirko Griesel
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
| | - Clemens Grimm
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Goettingen, Goettingen, Germany
| | - Cindy Herchenhahn
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
| | - Andre Kramer
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
| | - Maria-Inti Metzendorf
- Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Onnen Moerer
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Goettingen, Goettingen, Germany
| | - Nancy Olbrich
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
| | - Volker Thieme
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
| | - Astrid Vieler
- Medicine and Sciences Library, Leipzig University, Leipzig, Germany
| | - Falk Fichtner
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
| | - Jacob Burns
- Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Chair of Public Health and Health Services Research, LMU Munich, Munich, Germany
| | - Sven Laudi
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
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Kluge S. In Reply. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:439. [PMID: 36178314 PMCID: PMC9549894 DOI: 10.3238/arztebl.m2022.0143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Stefan Kluge
- *Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Grensemann J, Mader MMD, Westphal M, Kluge S, Czorlich P. Hyperoxia is Dose-Dependently Associated with an Increase of Unfavorable Outcomes in Ventilated Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Cohort Study. Neurocrit Care 2022; 37:523-530. [PMID: 35672497 PMCID: PMC9519732 DOI: 10.1007/s12028-022-01534-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 05/05/2022] [Indexed: 11/05/2022]
Abstract
Background Adequate oxygenation in patients with aneurysmal subarachnoid hemorrhage (SAH) is imperative. However, hyperoxia increases formation of reactive oxygen species and may be associated with a dose-dependent toxicity. We postulated a threshold for arterial partial pressure of oxygen (paO2) above which toxicity effects precipitate and sought to study the effects on 30-day mortality, favorable outcome at discharge and at 3 months, and delayed cerebral ischemia. Methods In this retrospective single-center cohort study, patients with SAH and mechanical ventilation > 72 h were included. Oxygen integrals were calculated above the following thresholds: 80, 100, 120, and 150 mm Hg and time-weighted mean paO2. All calculations were done from admission to end of day 1, day 3, and day 14. We conducted multivariable logistic regression analyses adjusted for age, sex, duration of ventilation, and Hunt and Hess grade. Time-weighted mean paO2 was categorized by quartiles. Favorable outcome was defined as Glasgow Outcome Scale scores of 4 and 5. Results From November 2010 to February 2021, 282 of 549 patients fulfilled the inclusion criteria. Odds ratios for 30-day mortality increased dose dependently and were as follows: 1.07 (95% confidence interval [CI] 1.03–1.11; p = 0.001) for each 1 mm Hg per day above 80 mm Hg; 1.16 (95% CI 1.07–1.27), above 100 mm Hg; 1.36 (95% CI 1.15–1.61), above 120 mm Hg; and 1.59 (95% CI 1.22–2.08), above 150 mm Hg (all p < 0.001) at day 14. For favorable outcome at 3 months, odds ratios were 0.96 (95% CI 0.92–0.99) for each 1 mm Hg per day above 80 mm Hg; 0.90 (95% CI 0.84–0.98), above 100 mm Hg; 0.83 (95% CI 0.72–0.97), above 120 mm Hg; and 0.77 (95% CI 0.61–0.97), above 150 mm Hg (all p < 0.05). For time-weighted mean paO2, lowest 30-day mortality and highest favorable outcome at 3 months were found in the second quartile (78–85 mm Hg). Thirty-day mortality increased above 93 mm Hg (fourth quartile), with an odds ratio of 3.4 (95% CI 1.4–8.4, p = 0.007). Odds ratios for favorable outcome at 3 months were 0.28 (95% CI 0.12–0.69), 0.27 (95% CI 0.11–0.67), and 0.24 (95% CI 0.10–0.59) for the first, third, and fourth quartiles, respectively (all p < 0.01). No significant association was found at day 1 and day 3, for favorable outcome at discharge, or for delayed cerebral ischemia. Conclusions Integrals above the defined paO2 thresholds were dose-dependently associated with an increase in mortality in ventilated patients with SAH. When we considered time-weighted mean paO2, unfavorable outcomes and 30-day mortality were more frequent both below and above a certain range. Unfavorable outcomes increased in paO2 ranges usually defined as normoxia. This emphasizes the necessity to further characterize oxygenation thresholds in ventilated patients with SAH in prospective clinical studies. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-022-01534-y.
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Liberale Sauerstoffgabe bei kritisch Kranken: Doch unschädlich? Dtsch Med Wochenschr 2022. [DOI: 10.1055/a-1653-9026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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