1
|
Shaikh H, Ionita R, Khan U, Park Y, Jubran A, Tobin MJ, Laghi F. Effect of Atypical Sleep EEG Patterns on Weaning From Prolonged Mechanical Ventilation. Chest 2024; 165:1111-1119. [PMID: 38211699 DOI: 10.1016/j.chest.2024.01.005] [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: 06/12/2023] [Revised: 12/22/2023] [Accepted: 01/03/2024] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Approximately one-third of acute ICU patients display atypical sleep patterns that cannot be interpreted by using standard EEG criteria for sleep. Atypical sleep patterns have been associated with poor weaning outcomes in acute ICUs. RESEARCH QUESTION Do patients being weaned from prolonged mechanical ventilation experience atypical sleep EEG patterns, and are these patterns linked with weaning outcomes? STUDY DESIGN AND METHODS EEG power spectral analysis during wakefulness and overnight polysomnogram were performed on alert, nondelirious patients at a long-term acute care facility. RESULTS Forty-four patients had been ventilated for a median duration of 38 days at the time of the polysomnogram study. Eleven patients (25%) exhibited atypical sleep EEG. During wakefulness, relative EEG power spectral analysis revealed higher relative delta power in patients with atypical sleep than in patients with usual sleep (53% vs 41%; P < .001) and a higher slow-to-fast power ratio during wakefulness: 4.39 vs 2.17 (P < .001). Patients with atypical sleep displayed more subsyndromal delirium (36% vs 6%; P = .027) and less rapid eye movement sleep (4% vs 11% total sleep time; P < .02). Weaning failure was more common in the atypical sleep group than in the usual sleep group: 91% vs 45% (P = .013). INTERPRETATION This study provides the first evidence that patients in a long-term acute care facility being weaned from prolonged ventilation exhibit atypical sleep EEG patterns that are associated with weaning failure. Patients with atypical sleep EEG patterns had higher rates of subsyndromal delirium and slowing of the wakeful EEG, suggesting that these two findings represent a biological signal for brain dysfunction.
Collapse
Affiliation(s)
- Hameeda Shaikh
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital and Loyola University of Chicago Stritch School of Medicine, Hines, IL
| | - Ramona Ionita
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital and Loyola University of Chicago Stritch School of Medicine, Hines, IL
| | - Usman Khan
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital and Loyola University of Chicago Stritch School of Medicine, Hines, IL
| | - Youngsook Park
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital and Loyola University of Chicago Stritch School of Medicine, Hines, IL
| | - Amal Jubran
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital and Loyola University of Chicago Stritch School of Medicine, Hines, IL; RML Specialty Hospital, Hinsdale, IL
| | - Martin J Tobin
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital and Loyola University of Chicago Stritch School of Medicine, Hines, IL.
| | - Franco Laghi
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital and Loyola University of Chicago Stritch School of Medicine, Hines, IL; RML Specialty Hospital, Hinsdale, IL
| |
Collapse
|
2
|
Burns KEA, Rochwerg B, Seely AJE. Ventilator Weaning and Extubation. Crit Care Clin 2024; 40:391-408. [PMID: 38432702 DOI: 10.1016/j.ccc.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Increasing evidence supports specific approaches to liberate patients from invasive ventilation including the use of liberation protocols, inspiratory assistance during spontaneous breathing trials (SBTs), early extubation of patients with chronic obstructive pulmonary disease to noninvasive ventilation, and prophylactic use of noninvasive support strategies after extubation. Additional research is needed to elucidate the best criteria to identify patients who are ready to undergo an SBT and to inform optimal screening frequency, the best SBT technique and duration, extubation assessments, and extubation decision-making. Additional clarity is also needed regarding the optimal timing to measure and report extubation success.
Collapse
Affiliation(s)
- Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Medicine and Division of Critical Care, Unity Health Toronto, St. Michaels Hospital, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, Unity Health Toronto, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, Hamilton Health Sciences, Juravinski Hospital, Hamilton, Ontario, Canada; Department of Critical Care, Hamilton Health Sciences, Juravinski Hospital, Hamilton, Ontario, Canada. https://twitter.com/Bram_Rochwerg
| | - Andrew J E Seely
- Department of Critical Care, Ottawa Hospital, Ottawa, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
3
|
Sankar K, Gould MK, Prescott HC. Psychological Morbidity After COVID-19 Critical Illness. Chest 2023; 163:139-147. [PMID: 36202259 PMCID: PMC9528063 DOI: 10.1016/j.chest.2022.09.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/12/2022] [Accepted: 09/26/2022] [Indexed: 11/05/2022] Open
Abstract
Survivors of ICU hospitalizations often experience severe and debilitating symptoms long after critical illness has resolved. Many patients experience notable psychiatric sequelae such as depression, anxiety, and posttraumatic stress disorder (PTSD) that may persist for months to years after discharge. The COVID-19 pandemic has produced large numbers of critical illness survivors, warranting deeper understanding of psychological morbidity after COVID-19 critical illness. Many patients with critical illness caused by COVID-19 experience substantial post-ICU psychological sequelae mediated by specific pathophysiologic, iatrogenic, and situational risk factors. Existing and novel interventions focused on minimizing psychiatric morbidity need to be further investigated to improve critical care survivorship after COVID-19 illness. This review proposes a framework to conceptualize three domains of risk factors (pathophysiologic, iatrogenic, and situational) associated with psychological morbidity caused by COVID-19 critical illness: (1) direct and indirect effects of the COVID-19 virus in the brain; (2) iatrogenic complications of ICU care that may disproportionately affect patients with COVID-19; and (3) social isolation that may worsen psychological morbidity. In addition, we review current interventions to minimize psychological complications after critical illness.
Collapse
Affiliation(s)
- Keerthana Sankar
- Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Michael K Gould
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Hallie C Prescott
- Department of Pulmonary/Critical Care Medicine, University of Michigan, Ann Arbor, MI
| |
Collapse
|
4
|
Bickenbach J, Fritsch S. [Weaning from invasive ventilation : Challenges in the clinical routine]. DIE ANAESTHESIOLOGIE 2022; 71:910-920. [PMID: 36418440 DOI: 10.1007/s00101-022-01219-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/14/2022] [Indexed: 06/16/2023]
Abstract
Modern intensive care medicine is caught between the conflicting demands of an efficient but also increasingly more technical intensive care treatment with numerous therapeutic options and, at the same time, an ageing society with increasing morbidity. This is reflected, among other things, in an increasing number of ventilated patients in intensive care units and an increasing proportion of patients for whom ventilation cannot easily be discontinued. Weaning from a ventilator, which can account for more than 50% of the total ventilation time, therefore plays a central role in this process. This main topic article presents the need for strategically wise and holistic actions to minimize the consequences of invasive mechanical ventilation for patients. An attempt is made to shed more light on individual aspects of the ventilation weaning process with high relevance for clinical practice. Especially for prolonged weaning from ventilation, many more concepts are needed than simply ending ventilation.
Collapse
Affiliation(s)
- Johannes Bickenbach
- Klinik für Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.
| | - Sebastian Fritsch
- Klinik für Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| |
Collapse
|
5
|
Obed D, Schroeter A, Gruber L, Salim M, Krezdorn N, Vogt PM. Outcomes following burn injury in intensive care patients with major psychiatric disorders. Burns 2022; 49:830-837. [PMID: 35817650 DOI: 10.1016/j.burns.2022.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/14/2022] [Accepted: 06/27/2022] [Indexed: 11/02/2022]
Abstract
AIMS Patients with psychiatric comorbidity have been shown to experience high rates of burn injury. Burn epidemiology, etiology, and outcomes have been sparsely documented for patients with major psychiatric disorders. The aim of this study was to analyze the epidemiologic characteristics and outcomes in intensive care burn patients with pre-existing and acute major psychiatric disorders . METHODS A retrospective study was performed including intensive care burn patients admitted between March 2007 and December 2020. Demographic, clinical and epidemiological data were collected and analyzed. Major psychiatric co-morbidities were collected according to ICD-9 and ICD-10 classifications. Patients were stratified according to F-diagnoses. RESULTS A total of 1325 patients were included. 16.6 % of all patients had one or more major psychiatric disorders- 9.3 % with anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders, 9.2 % with mood (affective) disorders, 3.5 % with schizophrenia and other non-mood psychotic disorders, and 1.8 % with disorders of adult personality and behavior. Patients with major psychiatric disorders presented with significantly higher burn severity, reflected by higher abbreviated burn severity index (ABSI) scores (5.9 vs. 5.3, p < 0.001) and larger total body surface area (TBSA) affected (15.9 vs. 12.5 %, p = 0.002). Burned TBSA ≥ 30 and inhalation injuries were observed more frequently in patients with MDP, however without statistical significance. They also experienced prolonged hospital length-of-stay (LOS) (25.5 vs. 16.3 days, p < 0.001), prolonged intensive care unit LOS (14.8 vs. 7.7 days, p < 0.001), underwent surgical interventions (3.5 vs. 2.3, p < 0.001) and mechanical ventilation more frequently (34.1 % vs. 16.5 %, p = 0.43) and had significantly longer ventilation durations (73.5 vs. 31.2 h, p = 0.002). Mortality rates were lower compared to patients without major psychiatric disorders (5.9 vs. 8.1, p < 0.001). CONCLUSIONS The prevalence of major psychiatric disorders in burn patients is considerably high. Patients with psychiatric comorbidities were found to have greater burn severity, prolonged total hospital and ICU LOS, underwent surgical interventions and mechanical ventilation more frequently and had prolonged ventilation duration. Our results highlight the importance of identifying burn patients with major psychiatric disorders who may necessitate additional resources and require extensive inpatient psychiatric care and counseling.
Collapse
Affiliation(s)
- Doha Obed
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany.
| | - Andreas Schroeter
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany
| | - Lisa Gruber
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany
| | - Mustafa Salim
- Department of Human Genetics, Hannover Medical School, Hannover, Germany
| | - Nicco Krezdorn
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany
| | - Peter M Vogt
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany
| |
Collapse
|
6
|
Burns KEA, Agarwal A, Bosma KJ, Chaudhuri D, Girard TD. Liberation from Mechanical Ventilation: Established and New Insights. Semin Respir Crit Care Med 2022; 43:461-470. [PMID: 35760299 DOI: 10.1055/s-0042-1747929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
A substantial proportion of critically ill patients require ventilator support with the majority requiring invasive mechanical ventilation. Timely and safe liberation from invasive mechanical ventilation is a critical aspect of patient care in the intensive care unit (ICU) and is a top research priority for patients and clinicians. In this article, we discuss how to (1) identify candidates for liberation from mechanical ventilation, (2) conduct spontaneous breathing trials (SBTs), and (3) optimize patients for liberation from mechanical ventilation. We also discuss the roles for (4) extubation to noninvasive ventilation and (5) newer modes of mechanical ventilation during liberation from mechanical ventilation. We conclude that, though substantial progress has been made in identifying patients who are likely to be liberated (e.g., through the use of SBTs) and management strategies that speed liberation from the ventilator (e.g., protocolized SBTs, lighter sedation, and early mobilization), many important questions regarding liberation from mechanical ventilation in clinical practice remain unanswered.
Collapse
Affiliation(s)
- Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Departments of Critical Care and Medicine, Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Arnav Agarwal
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Division of General Internal Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Karen J Bosma
- Division of Critical Care Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, and London Health Sciences Centre, London, Ontario, Canada
| | - Dipayan Chaudhuri
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Departments of Critical Care Medicine and Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Timothy D Girard
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| |
Collapse
|
7
|
Shibata M, Miyamoto K, Shima N, Nakashima T, Kunitatsu K, Yonemitsu T, Kawabata A, Kishi Y, Kato S. Activities of daily living and psychiatric symptoms after intensive care unit discharge among critically ill patients with or without tracheostomy: a single center longitudinal study. Acute Med Surg 2022; 9:e753. [PMID: 35592703 PMCID: PMC9092286 DOI: 10.1002/ams2.753] [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: 01/10/2022] [Accepted: 04/20/2022] [Indexed: 11/16/2022] Open
Abstract
Aim Tracheostomy is widely performed in critically ill patients who require prolonged mechanical ventilation. Long-term morbidity (post-intensive care syndrome) in tracheostomized patients is not widely reported, however, so we evaluate it here. Methods This is a sub-analysis of a single center prospective longitudinal study, which assessed activities of daily living (ADL) and psychiatric symptoms in adult patients emergently admitted to the intensive care unit (ICU). We evaluated association between these symptoms and tracheostomy by posting questionnaires at 3 and 12 months after ICU discharge. Results We analyzed 107 patients (15 patients with tracheostomy) at 3 months and 74 patients (13 patients with tracheostomy) at 12 months after ICU discharge. ADL tended to be lower in patients with tracheostomy than in those without tracheostomy at 3 months after ICU discharge (65 [10-100] versus 95 [59-100]; P = 0.28, 7/15 [47%] versus 30/102 [30%] Barthel Index scored ≤ 60; P = 0.23), however there were no significant differences. Psychiatric symptoms were not different between the groups at 3 months and again at 12 months. Conclusion Activities of daily living disability and psychiatric symptoms were not significantly worse in patients with tracheostomy at 3 and 12 months from ICU discharge compared with patients without tracheostomy. Despite the limited number in our cohort, our study may inform shared decision making concerning tracheostomy for critically ill patients and their families.
Collapse
Affiliation(s)
- Mami Shibata
- Department of Emergency and Critical Care MedicineWakayama Medical UniversityWakayamaJapan
| | - Kyohei Miyamoto
- Department of Emergency and Critical Care MedicineWakayama Medical UniversityWakayamaJapan
| | - Nozomu Shima
- Department of Emergency and Critical Care MedicineWakayama Medical UniversityWakayamaJapan
| | - Tsuyoshi Nakashima
- Department of Emergency and Critical Care MedicineWakayama Medical UniversityWakayamaJapan
| | - Kosei Kunitatsu
- Department of Emergency and Critical Care MedicineWakayama Medical UniversityWakayamaJapan
| | - Takafumi Yonemitsu
- Department of Emergency and Critical Care MedicineWakayama Medical UniversityWakayamaJapan
| | - Atsumi Kawabata
- Department of NursingWakayama Medical University HospitalWakayamaJapan
| | - Yutsuki Kishi
- Department of NursingWakayama Medical University HospitalWakayamaJapan
| | - Seiya Kato
- Department of Emergency and Critical Care MedicineWakayama Medical UniversityWakayamaJapan
| |
Collapse
|
8
|
Arboleda A, Amado L, Rodriguez J, Naranjo F, Giraldo BF. A new protocol to compare successful versus failed patients using the electromyographic diaphragm signal in extubation process. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2021; 2021:5646-5649. [PMID: 34892403 DOI: 10.1109/embc46164.2021.9629815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
In clinical practice, when a patient is undergoing mechanical ventilation, it is important to identify the optimal moment for extubation, minimizing the risk of failure. However, this prediction remains a challenge in the clinical process. In this work, we propose a new protocol to study the extubation process, including the electromyographic diaphragm signal (diaEMG) recorded through 5-channels with surface electrodes around the diaphragm muscle. First channel corresponds to the electrode on the right. A total of 40 patients in process of withdrawal of mechanical ventilation, undergoing spontaneous breathing tests (SBT), were studied. According to the outcome of the SBT, the patients were classified into two groups: successful (SG: 19 patients) and failure (FG: 21 patients) groups. Parameters extracted from the envelope of each channel of diaEMG in time and frequency domain were studied. After analyzing all channels, the second presented maximum differences when comparing the two groups of patients, with parameters related to root mean square (p = 0.005), moving average (p = 0.001), and upward slope (p = 0.017). The third channel also presented maximum differences in parameters as the time between maximum peak (p = 0.004), and the skewness (p = 0.027). These results suggest that diaphragm EMG signal could contribute to increase the knowledge of the behaviour of respiratory system in these patients and improve the extubation process.Clinical Relevance-This establishes the characterization of success and failure patients in the extubation process.
Collapse
|
9
|
Burns KEA, Stevenson J, Laird M, Adhikari NKJ, Li Y, Lu C, He X, Wang W, Liang Z, Chen L, Zhang H, Friedrich JO. Non-invasive ventilation versus invasive weaning in critically ill adults: a systematic review and meta-analysis. Thorax 2021; 77:752-761. [PMID: 34716282 DOI: 10.1136/thoraxjnl-2021-216993] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 09/15/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Extubation to non-invasive ventilation (NIV) has been investigated as a strategy to wean critically ill adults from invasive ventilation and reduce ventilator-related complications. METHODS We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, proceedings of four conferences and bibliographies (to June 2020) for randomised and quasi-randomised trials that compared extubation with immediate application of NIV to continued invasive weaning in intubated adults and reported mortality (primary outcome) or other outcomes. Two reviewers independently screened citations, assessed trial quality and abstracted data. RESULTS We identified 28 trials, of moderate-to-good quality, involving 2066 patients, 44.6% with chronic obstructive pulmonary disease (COPD). Non-invasive weaning significantly reduced mortality (risk ratio (RR) 0.57, 95% CI 0.44 to 0.74; high quality), weaning failures (RR 0.59, 95% CI 0.43 to 0.81; high quality), pneumonia (RR 0.30, 95% CI 0.22 to 0.41; high quality), intensive care unit (ICU) (mean difference (MD) -4.62 days, 95% CI -5.91 to -3.34) and hospital stay (MD -6.29 days, 95% CI -8.90 to -3.68). Non-invasive weaning also significantly reduced the total duration of ventilation, duration of invasive ventilation and duration of ventilation related to weaning (MD -0.57, 95% CI -1.08 to -0.07) and tracheostomy rate. Mortality, pneumonia, reintubation and ICU stay were significantly lower in trials enrolling COPD (vs mixed) populations. CONCLUSION Non-invasive weaning significantly reduced mortality, pneumonia and the duration of ventilation related to weaning, particularly in patients with COPD. Beneficial effects are less clear (or more careful patient selection is required) in non-COPD patients. PROSPERO REGISTRATION NUMBER CRD42020201402.
Collapse
Affiliation(s)
- Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada .,Departments of Critical Care and Medicine, Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada.,The Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.,Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - James Stevenson
- The School of Medicine, Royal College of Surgeons, Dublin, Ireland
| | - Matthew Laird
- The School of Medicine, Royal College of Surgeons, Dublin, Ireland
| | - Neill K J Adhikari
- Interdepartmental Division of Critical Care Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,The Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Yuchong Li
- Departments of Critical Care and Medicine, Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada.,Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Cong Lu
- Departments of Critical Care and Medicine, Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada.,Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Xiaolin He
- Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Wentao Wang
- The State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhenting Liang
- The Department of Critical Care Medicine, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lu Chen
- Departments of Critical Care and Medicine, Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada.,Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Haibo Zhang
- Interdepartmental Division of Critical Care Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Departments of Critical Care and Medicine, Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada.,Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Anesthesia and Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Jan O Friedrich
- Interdepartmental Division of Critical Care Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Departments of Critical Care and Medicine, Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada.,The Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| |
Collapse
|
10
|
Xu SX, Wu CS, Liu SY, Lu X. High-flow nasal cannula oxygen therapy and noninvasive ventilation for preventing extubation failure during weaning from mechanical ventilation assessed by lung ultrasound score: A single-center randomized study. World J Emerg Med 2021; 12:274-280. [PMID: 34512823 DOI: 10.5847/wjem.j.1920-8642.2021.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 06/26/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND We sought to demonstrate the superiority of a targeted therapy strategy involving high-flow nasal cannula oxygen (HFNCO2) therapy and noninvasive ventilation (NIV) using lung ultrasound score (LUS) in comparison with standard care among patients in the intensive care unit (ICU) who undergo successful weaning to decrease the incidence of extubation failure at both 48 hours and seven days. METHODS During the study period, 98 patients were enrolled in the study, including 49 in the control group and 49 in the treatment group. Patients in the control group and patients with an LUS score <14 points (at low risk of extubation failure) in the treatment group were extubated and received standard preventive care without NIV or HFNCO2. Patients with an LUS score ≥14 points (at high risk of extubation failure) in the treatment group were extubated with a second review of the therapeutic optimization to identify and address any persisting risk factors for postextubation respiratory distress; patients received HFNCO2 therapy combined with sessions of preventive NIV (4-8 hours per day for 4-8 sessions total) for the first 48 hours after extubation. RESULTS In the control group, 13 patients had the LUS scores ≥14 points, while 36 patients had scores <14 points. In the treatment group, 16 patients had the LUS scores ≥14 points, while 33 patients had scores <14 points. Among patients with the LUS score ≥14 points, the extubation failure rate within 48 hours was 30.8% in the control group and 12.5% in the treatment group, constituting a statistically significant difference (P<0.05). Conversely, among patients with an LUS score <14 points, 13.9% in the control group and 9.1% in the treatment group experienced extubation failure (P=0.61). The length of ICU stay (9.4±3.1 days vs. 7.2±2.4 days) was significantly different and the re-intubation rate (at 48 hours: 18.4% vs. 10.2%; seven days: 22.4% vs. 12.2%) significantly varied between the two groups (P<0.05). There was no significant difference in the 28-day mortality rate (6.1% vs. 8.2%) between the control and treatment groups. CONCLUSIONS Among high-risk adults being weaned from mechanical ventilation and assessed by LUS, the NIV+HFNCO2 protocol does not lessen the mortality rate but reduce the length of ICU stay, the rate of extubation failure at both 48 hours and seven days.
Collapse
Affiliation(s)
- Shan-Xiang Xu
- Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Chun-Shuang Wu
- Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Shao-Yun Liu
- Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Xiao Lu
- Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| |
Collapse
|
11
|
Albaiceta GM, Brochard L, Dos Santos CC, Fernández R, Georgopoulos D, Girard T, Jubran A, López-Aguilar J, Mancebo J, Pelosi P, Skrobik Y, Thille AW, Wilcox ME, Blanch L. The central nervous system during lung injury and mechanical ventilation: a narrative review. Br J Anaesth 2021; 127:648-659. [PMID: 34340836 DOI: 10.1016/j.bja.2021.05.038] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/03/2021] [Accepted: 05/24/2021] [Indexed: 11/26/2022] Open
Abstract
Mechanical ventilation induces a number of systemic responses for which the brain plays an essential role. During the last decade, substantial evidence has emerged showing that the brain modifies pulmonary responses to physical and biological stimuli by various mechanisms, including the modulation of neuroinflammatory reflexes and the onset of abnormal breathing patterns. Afferent signals and circulating factors from injured peripheral tissues, including the lung, can induce neuronal reprogramming, potentially contributing to neurocognitive dysfunction and psychological alterations seen in critically ill patients. These impairments are ubiquitous in the presence of positive pressure ventilation. This narrative review summarises current evidence of lung-brain crosstalk in patients receiving mechanical ventilation and describes the clinical implications of this crosstalk. Further, it proposes directions for future research ranging from identifying mechanisms of multiorgan failure to mitigating long-term sequelae after critical illness.
Collapse
Affiliation(s)
- Guillermo M Albaiceta
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Oviedo, Spain; Departamento de Biología Funcional, Instituto Universitario de Oncología del Principado de Asturias, Universidad de Oviedo, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain; Centro de Investigación Biomédica en Red-Enfermedades Respiratorias (CIBER)-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.
| | - Laurent Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Claudia C Dos Santos
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Rafael Fernández
- Centro de Investigación Biomédica en Red-Enfermedades Respiratorias (CIBER)-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Critical Care Department, Althaia Xarxa Assistencial Universitaria de Manresa, Universitat Internacional de Catalunya, Manresa, Spain
| | - Dimitris Georgopoulos
- Intensive Care Medicine Department, University Hospital of Heraklion, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Timothy Girard
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Amal Jubran
- Division of Pulmonary and Critical Care Medicine, Hines VA Hospital, Hines, IL, USA; Loyola University of Chicago, Stritch School of Medicine, Maywood, IL, USA
| | - Josefina López-Aguilar
- Centro de Investigación Biomédica en Red-Enfermedades Respiratorias (CIBER)-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Jordi Mancebo
- Servei Medicina Intensiva, University Hospital Sant Pau, Barcelona, Spain
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy; Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Yoanna Skrobik
- Department of Medicine, McGill University, Regroupement de Soins Critiques Respiratoires, Réseau de Soins Respiratoires FRQS, Montreal, QC, Canada
| | - Arnaud W Thille
- CHU de Poitiers, Médecine Intensive Réanimation, Poitiers, France; INSERM CIC 1402 ALIVE, Université de Poitiers, Poitiers, France
| | - Mary E Wilcox
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, Division of Respirology (Critical Care Medicine), University Health Network, Toronto, ON, Canada
| | - Lluis Blanch
- Centro de Investigación Biomédica en Red-Enfermedades Respiratorias (CIBER)-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| |
Collapse
|
12
|
Lersritwimanmaen P, Rittayamai N, Tscheikuna J, J Brochard L. High-Flow Oxygen Therapy in Tracheostomized Subjects With Prolonged Mechanical Ventilation: A Randomized Crossover Physiologic Study. Respir Care 2021; 66:806-813. [PMID: 33653909 PMCID: PMC9994105 DOI: 10.4187/respcare.08585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND High-flow oxygen therapy via tracheostomy (HFT) can be used in tracheostomized patients during ventilator disconnection. The physiologic effects of this technique are unknown. We hypothesized that HFT would reduce inspiratory effort and improve breathing pattern compared to conventional oxygen therapy via T-tube. This study aimed to evaluate the physiologic effects of HFT compared to conventional O2 in patients with prolonged mechanical ventilation. METHODS A randomized crossover physiologic study was conducted in adult tracheostomized patients who experienced temporary periods of ventilator disconnection. Subjects were ventilated with pressure support ventilation (PSV) for 15 min and were then randomly assigned to HFT or conventional O2 via T-tube for 30 min. After a washout period, subjects were switched to the other system. Esophageal pressure (Pes), breathing frequency, blood pressure, heart rate, [Formula: see text], and transcutaneously measured pressure of carbon dioxide ([Formula: see text]) were recorded. The primary outcome was inspiratory effort as determined by the simplified esophageal pressure-time product (sPTPes). Secondary outcomes were Pes swing, breathing frequency, heart rate, mean arterial pressure, [Formula: see text], and [Formula: see text] between groups. RESULTS Twenty-two subjects were enrolled: sPTPes per minute was significantly higher with HFT and conventional O2 compared to PSV (153.5 ± 97.9, 163.5 ± 111.3, and 86.8 ± 51.1 cm H2O × s/min, respectively, P = .001), but it was not different between HFT and conventional O2 (P = .72). Breathing frequency increased significantly after switching from PSV to HFT and conventional O2 (23 ± 4 vs 26 ± 6 and 23 ± 4 vs 27 ± 5 breaths/min, respectively, P = .001). [Formula: see text] was higher with conventional O2 compared to HFT (P = .02). No differences in [Formula: see text], mean arterial pressure, or heart rate were observed between HFT and conventional O2. CONCLUSIONS Inspiratory effort and breathing frequency increased significantly during unassisted breathing compared to PSV in tracheostomized subjects, but HFT via tracheostomy provided no measurable additional physiologic benefit compared to O2 therapy via T-tube.
Collapse
Affiliation(s)
- Patharapan Lersritwimanmaen
- Division of Respiratory Diseases and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nuttapol Rittayamai
- Division of Respiratory Diseases and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Jamsak Tscheikuna
- Division of Respiratory Diseases and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Laurent J Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| |
Collapse
|
13
|
Howard AF, Crowe S, Choroszewski L, Kovatch J, Haynes AJ, Ford J, Beck S, Haljan GJ. Health-related expectations of the chronically critically ill: a multi-perspective qualitative study. BMC Palliat Care 2021; 20:3. [PMID: 33397361 PMCID: PMC7781403 DOI: 10.1186/s12904-020-00696-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 12/11/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Those who survive critical illness only to become chronically critically ill (CCI) experience a high symptom burden, repeat episodes of illness exacerbation, communication barriers, and poor health outcomes. Yet, it is unclear how CCI individuals and their family understand their health and the importance of prognostic information following hospitalization. The research purpose was to examine expectations about health and disease prognosis of CCI residents in long-term care from the perspectives of the CCI themselves and their family members, as well as to describe healthcare provider (HCP) interpretations of, and reactions to, these health-related expectations. METHODS In this qualitative interpretive descriptive study, conducted in British Columbia, Canada, 38 semi-structured interviews were conducted (6 CCI residents, 11 family members, and 21 HCPs) and inductively analyzed using thematic and constant comparative techniques. RESULTS There was divergence in CCI resident, family and HCP expectations about health and the importance of disease prognosis, which contributed to conflict. CCI residents and family viewed conflict with HCPs in relation to their day-to-day care needs, while HCPs viewed this as arising from the unrealistically high expectations of residents and family. The CCI residents and family focussed on the importance of maintaining hope, and the HCPs highlighted the complexity of end-of-life decisions in conjunction with the high expectations and hopes of family. CONCLUSIONS The emotional and ongoing process of formulating health-related expectations points to the need for future research to inform the development and/or adapting of existing communication, psychosocial and health services interventions to ease the burden experienced by those who are CCI.
Collapse
Affiliation(s)
- A Fuchsia Howard
- School of Nursing, The University of British Columbia, T201 - 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada.
- Fraser Health Authority, Surrey, British Columbia, Canada.
| | - Sarah Crowe
- School of Nursing, The University of British Columbia, T201 - 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
- Fraser Health Authority, Surrey, British Columbia, Canada
| | | | - Joe Kovatch
- Fraser Health Authority, Surrey, British Columbia, Canada
| | | | - Joan Ford
- Patient Partner, Vancouver, British Columbia, Canada
| | - Scott Beck
- School of Nursing, The University of British Columbia, T201 - 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
| | - Gregory J Haljan
- Fraser Health Authority, Surrey, British Columbia, Canada
- Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
14
|
Lee HW, Cho YJ. The Impact of Mechanical Ventilation Duration on the Readmission to Intensive Care Unit: A Population-Based Observational Study. Tuberc Respir Dis (Seoul) 2020; 83:303-311. [PMID: 32819076 PMCID: PMC7515670 DOI: 10.4046/trd.2020.0024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 08/20/2020] [Indexed: 11/24/2022] Open
Abstract
Background If the duration of mechanical ventilation (MV) is related with the intensive care unit (ICU) readmission must be clarified. The purpose of this study was to elucidate if prolonged MV duration increases ICU readmission rate. Methods The present observational cohort study analyzed national healthcare claims data from 2006 to 2015. Critically ill patients who received MV in the ICU were classified into five groups according to the MV duration: MV for <7 days, 7–13 days, 14–20 days, 21–27 days, and ≥28 days. The rate and risk of the ICU readmission were estimated according to the MV duration using the unadjusted and adjusted analyses. Results We found that 12,929 patients had at least one episode of MV in the ICU. There was a significant linear relationship between the MV duration and the ICU readmission (R2=0.85, p=0.025). The total readmission rate was significantly higher as the MV duration is prolonged (MV for <7 days, 13.9%; for 7–13 days, 16.7%; for 14–20 days, 19.4%; for 21–27 days, 20.4%; for ≥28 days, 35.7%; p<0.001). The analyses adjusted by covariables and weighted with the multinomial propensity scores showed similar results. In the adjusted regression analysis with a Cox proportional hazards model, the MV duration was significantly related to the ICU readmission (hazard ratio, 1.058 [95% confidence interval, 1.047–1.069], p<0.001). Conclusion The rate of readmission to the ICU was significantly higher in patients who received longer durations of the MV in the ICU. In the clinical setting, closer observation of patients discharged from the ICU after prolonged periods of MV is required.
Collapse
Affiliation(s)
- Hyun Woo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| |
Collapse
|
15
|
Worraphan S, Thammata A, Chittawatanarat K, Saokaew S, Kengkla K, Prasannarong M. Effects of Inspiratory Muscle Training and Early Mobilization on Weaning of Mechanical Ventilation: A Systematic Review and Network Meta-analysis. Arch Phys Med Rehabil 2020; 101:2002-2014. [PMID: 32750371 DOI: 10.1016/j.apmr.2020.07.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 06/26/2020] [Accepted: 07/02/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To compare the effectiveness and rank order of physical therapy interventions, including conventional physical therapy (CPT), inspiratory muscle training (IMT), and early mobilization (EM) on mechanical ventilation (MV) duration and weaning duration. DATA SOURCES PubMed, The Cochrane Library, Scopus, and CINAHL complete electronic databases were searched through August 2019. STUDY SELECTION Randomized controlled trials (RCTs) investigating the effect of IMT, EM, or CPT on MV duration and the weaning duration in patients with MV were included. Studies that were determined to meet the eligibility criteria by 2 independent authors were included. A total of 6498 relevant studies were identified in the search, and 18 RCTs (934 participants) were included in the final analysis. DATA EXTRACTION Data were extracted independently by 2 authors and assessed the study quality by the Cochrane risk-of-bias tool. The primary outcomes were MV duration and weaning duration. DATA SYNTHESIS Various interventions of physical therapy were identified in the eligible studies, including IMT, IMT+CPT, EM, EM+CPT, and CPT. The data analysis demonstrated that compared with CPT, IMT+CPT significantly reduced the weaning duration (mean difference; 95% confidence interval) (-2.60; -4.76 to -0.45) and EM significantly reduced the MV duration (-2.01; -3.81 to -0.22). IMT+CPT and EM had the highest effectiveness in reducing the weaning duration and MV duration, respectively. CONCLUSION IMT or EM should be recommended for improving the weaning outcomes in mechanically ventilated patients. However, an interpretation with caution is required due to the heterogeneity.
Collapse
Affiliation(s)
- Salinee Worraphan
- Department of Physical Therapy, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai
| | - Attalekha Thammata
- Department of Physical Therapy, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai
| | | | - Surasak Saokaew
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao; Unit of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao; Unit of Excellence on Herbal Medicine, School of Pharmaceutical Sciences, University of Phayao, Phayao; Division of Pharmacy Practice, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | - Kirati Kengkla
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao; Unit of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao
| | - Mujalin Prasannarong
- Department of Physical Therapy, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai.
| |
Collapse
|
16
|
Coppadoro A, Grassi A, Giovannoni C, Rabboni F, Eronia N, Bronco A, Foti G, Fumagalli R, Bellani G. Occurrence of pendelluft under pressure support ventilation in patients who failed a spontaneous breathing trial: an observational study. Ann Intensive Care 2020; 10:39. [PMID: 32266600 PMCID: PMC7138895 DOI: 10.1186/s13613-020-00654-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 03/23/2020] [Indexed: 11/23/2022] Open
Abstract
Background Pendelluft, the movement of gas within different lung regions, is present in animal models of assisted mechanical ventilation and associated with lung overstretching. Due to rebreathing of CO2 as compared to fresh gas, pendelluft might reduce ventilatory efficiency possibly exacerbating patient’s respiratory workload during weaning. Our aim was to measure pendelluft by electrical impedance tomography (EIT) in patients who failed a spontaneous breathing trial (SBT). Methods This is an observational study conducted in a general intensive care unit of a tertiary-level teaching hospital. EIT signal was recorded in 20 patients while pressure support (PS) ventilation was progressively reduced from clinical level (baseline) to 2 cmH2O, as in an SBT; four ventral-to-dorsal lung regions of interest were identified for pendelluft measurement. A regional gas movement (> 6 mL) occurring in a direction opposite to the global EIT signal was considered diagnostic for high pendelluft. Results Eight patients out of 20 (40%) were classified as high-pendelluft; baseline clinical characteristics did not differ between high- and low-pendelluft patients. At PS reduction, pendelluft and EtCO2 increased more in the high-pendelluft group (p < .001 and .011, respectively). The volume of gas subject to pendelluft moved almost completely from the ventral towards the dorsal lung regions, while the opposite movement was minimal (16.3 [10:32.8] vs. 0 [0:1.8] mL, p = .001). In a subgroup of patients, increased pendelluft volumes positively correlated with markers of respiratory distress such as increased respiratory rate, p0.1, and EtCO2. Conclusions Occult pendelluft can be measured by EIT, and is frequently present in patients failing an SBT. When present, pendelluft increases with the reduction of ventilator support and is associated with increased EtCO2, suggesting a reduction of the ability to eliminate CO2.
Collapse
Affiliation(s)
- Andrea Coppadoro
- Department of Anesthesia and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Alice Grassi
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Cecilia Giovannoni
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Francesca Rabboni
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Nilde Eronia
- Department of Anesthesia and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Alfio Bronco
- Department of Anesthesia and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Giuseppe Foti
- Department of Anesthesia and Intensive Care, San Gerardo Hospital, Monza, Italy.,School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Roberto Fumagalli
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Giacomo Bellani
- Department of Anesthesia and Intensive Care, San Gerardo Hospital, Monza, Italy. .,School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.
| |
Collapse
|
17
|
Jubran A, Grant BJB, Duffner LA, Collins EG, Lanuza DM, Hoffman LA, Tobin MJ. Long-Term Outcome after Prolonged Mechanical Ventilation. A Long-Term Acute-Care Hospital Study. Am J Respir Crit Care Med 2020; 199:1508-1516. [PMID: 30624956 DOI: 10.1164/rccm.201806-1131oc] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Rationale: Patients managed at a long-term acute-care hospital (LTACH) for weaning from prolonged mechanical ventilation are at risk for profound muscle weakness and disability. Objectives: To investigate effects of prolonged ventilation on survival, muscle function, and its impact on quality of life at 6 and 12 months after LTACH discharge. Methods: This was a prospective, longitudinal study conducted in 315 patients being weaned from prolonged ventilation at an LTACH. Measurements and Main Results: At discharge, 53.7% of patients were detached from the ventilator and 1-year survival was 66.9%. On enrollment, maximum inspiratory pressure (Pimax) was 41.3 (95% confidence interval, 39.4-43.2) cm H2O (53.1% predicted), whereas handgrip strength was 16.4 (95% confidence interval, 14.4-18.7) kPa (21.5% predicted). At discharge, Pimax did not change, whereas handgrip strength increased by 34.8% (P < 0.001). Between discharge and 6 months, handgrip strength increased 6.2 times more than did Pimax. Between discharge and 6 months, Katz activities-of-daily-living summary score improved by 64.4%; improvement in Katz summary score was related to improvement in handgrip strength (r = -0.51; P < 0.001). By 12 months, physical summary score and mental summary score of 36-item Short-Form Survey returned to preillness values. When asked, 84.7% of survivors indicated willingness to undergo mechanical ventilation again. Conclusions: Among patients receiving prolonged mechanical ventilation at an LTACH, 53.7% were detached from the ventilator at discharge and 1-year survival was 66.9%. Respiratory strength was well maintained, whereas peripheral strength was severely impaired throughout hospitalization. Six months after discharge, improvement in muscle function enabled patients to perform daily activities, and 84.7% indicated willingness to undergo mechanical ventilation again.
Collapse
Affiliation(s)
- Amal Jubran
- 1 Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois.,2 Loyola University of Chicago Stritch School of Medicine, Maywood, Illinois.,3 RML Specialty Hospital, Hinsdale, Illinois
| | | | - Lisa A Duffner
- 1 Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois.,2 Loyola University of Chicago Stritch School of Medicine, Maywood, Illinois.,3 RML Specialty Hospital, Hinsdale, Illinois
| | - Eileen G Collins
- 1 Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois.,2 Loyola University of Chicago Stritch School of Medicine, Maywood, Illinois.,3 RML Specialty Hospital, Hinsdale, Illinois.,5 University of Illinois at Chicago, Chicago, Illinois
| | | | | | - Martin J Tobin
- 1 Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois.,2 Loyola University of Chicago Stritch School of Medicine, Maywood, Illinois.,3 RML Specialty Hospital, Hinsdale, Illinois
| |
Collapse
|
18
|
Jin T, Jin Y, Lee SM. Medication Use and Risk of Delirium in Mechanically Ventilated Patients. Clin Nurs Res 2019; 30:474-481. [PMID: 31466469 DOI: 10.1177/1054773819868652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
One of the principal complications in patients in the intensive care unit, particularly in those receiving mechanical ventilation, is medication-induced delirium. The present study aimed to intensively analyze pharmaceutical factors affecting the development of delirium in mechanically ventilated patients using the electronic health records. The present study was designed as a retrospective case-control study. The delirium group included 500 mechanically ventilated patients. The non-delirium group included 2,000 patients who were hospitalized during the same period as the delirium group and received mechanical ventilation. A total of seven types of medications (narcotic analgesics, non-narcotic analgesics, psychopharmaceuticals, sleep aid medications, anticholinergics, steroids, and diuretics), conventionally used to manage mechanical ventilation, were found to be major risk factors associated with the occurrence of delirium. Since these medications are an integral part of managing mechanically ventilated patients, prudent protocol-based medication approaches are essential to decrease the risk of delirium.
Collapse
Affiliation(s)
- Taixian Jin
- The Catholic University of Korea, Seoul, Republic of Korea
| | | | - Sun-Mi Lee
- The Catholic University of Korea, Seoul, Republic of Korea
| |
Collapse
|
19
|
de Haro C, Ochagavia A, López-Aguilar J, Fernandez-Gonzalo S, Navarra-Ventura G, Magrans R, Montanyà J, Blanch L. Patient-ventilator asynchronies during mechanical ventilation: current knowledge and research priorities. Intensive Care Med Exp 2019; 7:43. [PMID: 31346799 PMCID: PMC6658621 DOI: 10.1186/s40635-019-0234-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 03/07/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mechanical ventilation is common in critically ill patients. This life-saving treatment can cause complications and is also associated with long-term sequelae. Patient-ventilator asynchronies are frequent but underdiagnosed, and they have been associated with worse outcomes. MAIN BODY Asynchronies occur when ventilator assistance does not match the patient's demand. Ventilatory overassistance or underassistance translates to different types of asynchronies with different effects on patients. Underassistance can result in an excessive load on respiratory muscles, air hunger, or lung injury due to excessive tidal volumes. Overassistance can result in lower patient inspiratory drive and can lead to reverse triggering, which can also worsen lung injury. Identifying the type of asynchrony and its causes is crucial for effective treatment. Mechanical ventilation and asynchronies can affect hemodynamics. An increase in intrathoracic pressure during ventilation modifies ventricular preload and afterload of ventricles, thereby affecting cardiac output and hemodynamic status. Ineffective efforts can decrease intrathoracic pressure, but double cycling can increase it. Thus, asynchronies can lower the predictive accuracy of some hemodynamic parameters of fluid responsiveness. New research is also exploring the psychological effects of asynchronies. Anxiety and depression are common in survivors of critical illness long after discharge. Patients on mechanical ventilation feel anxiety, fear, agony, and insecurity, which can worsen in the presence of asynchronies. Asynchronies have been associated with worse overall prognosis, but the direct causal relation between poor patient-ventilator interaction and worse outcomes has yet to be clearly demonstrated. Critical care patients generate huge volumes of data that are vastly underexploited. New monitoring systems can analyze waveforms together with other inputs, helping us to detect, analyze, and even predict asynchronies. Big data approaches promise to help us understand asynchronies better and improve their diagnosis and management. CONCLUSIONS Although our understanding of asynchronies has increased in recent years, many questions remain to be answered. Evolving concepts in asynchronies, lung crosstalk with other organs, and the difficulties of data management make more efforts necessary in this field.
Collapse
Affiliation(s)
- Candelaria de Haro
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Spain. .,CIBERES, Instituto de Salud Carlos III, Madrid, Spain.
| | - Ana Ochagavia
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Josefina López-Aguilar
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Sol Fernandez-Gonzalo
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Spain.,CIBERSAM, Instituto de Salud Carlos III, Madrid, Spain
| | - Guillem Navarra-Ventura
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Spain
| | - Rudys Magrans
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Lluís Blanch
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | | |
Collapse
|
20
|
Fisser C, Spoletini G, Soe AK, Livesey A, Schreiber A, Swingwood E, Bos LD, Dreher M, Schultz MJ, Heunks L, Scala R. European Respiratory Society International Congress 2018: highlights from Assembly 2 on respiratory intensive care. ERJ Open Res 2019; 5:00198-2018. [PMID: 30847349 PMCID: PMC6397914 DOI: 10.1183/23120541.00198-2018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 01/28/2019] [Indexed: 12/14/2022] Open
Abstract
The respiratory intensive care Assembly of the European Respiratory Society is proud to present a summary of several important sessions held at the International Congress in Paris in 2018. For the highly esteemed reader who may have missed the Congress, a concise review was written on three topics: the state-of-the-art session on respiratory critical care, hot topics in weaning and the best abstracts in noninvasive ventilation. The respiratory intensive care Assembly of the European Respiratory Society is proud to present a summary of several important sessions from the 2018 #ERSCongress in Parishttp://ow.ly/6Du830nFESK
Collapse
Affiliation(s)
- Christoph Fisser
- Dept of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany.,Dept of Pneumology, Hospital Donaustauf, Donaustauf, Germany
| | - Giulia Spoletini
- Respiratory Dept, St James's University Hospital, Leeds Teaching Hospital NHS Trust, Leeds, UK.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Aung Kyaw Soe
- Dept of Hospital Therapy, Pediatric Faculty, Pirogov Russian National Research Medical University, Moscow, Russian Federation
| | - Alana Livesey
- Heartlands Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Annia Schreiber
- Dept of Medicine, Division of Respirology, University Health Network, Toronto, ON, Canada
| | - Ema Swingwood
- Physiotherapy Dept - Adult Therapy Services, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Lieuwe D Bos
- Dept of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Michael Dreher
- Dept of Pneumology and Intensive Care Medicine, University Hospital Aachen, Germany
| | - Marcus J Schultz
- Dept of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Leo Heunks
- Dept of Intensive Care, Amsterdam UMC, location VUMC, Amsterdam, The Netherlands
| | - Raffaele Scala
- Pulmonology and Respiratory Intensive Care Unit, S. Donato Hospital, Arezzo, Italy
| |
Collapse
|
21
|
The Acute Respiratory Distress Syndrome: Diagnosis and Management. PRACTICAL TRENDS IN ANESTHESIA AND INTENSIVE CARE 2018 2019. [PMCID: PMC7122583 DOI: 10.1007/978-3-319-94189-9_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is characterized by a new acute onset of hypoxemia secondary to a pulmonary edema of non-cardiogenic origin, bilateral lung opacities and reduction in respiratory system compliance after an insult direct or indirect to lungs. Its first description was in 1970s, and then several shared definitions tried to describe this clinical entity; the last one, known as Berlin definition, brought an improvement in predictive ability for mortality. In the present chapter, the diagnostic workup of the syndrome will be presented with particular attention to microbiological investigations which represent a milestone in the diagnostic process and to imaging techniques such as CT scan and lung ultrasound. Despite the treatment is mainly based on supportive strategies, attention should be applied to assure adequate respiratory gas exchange while minimizing the risk of ventilator-induced lung injury (VILI) onset. Therefore will be described several therapeutic approaches to ARDS, including noninvasive mechanical ventilation (NIMV), high-flow nasal cannulas (HFNC) and invasive ventilation with particular emphasis to risks and benefits of mechanical ventilation, PEEP optimization and lung protective ventilation strategies. Rescue techniques, such as permissive hypercapnia, prone positioning, neuromuscular blockade, inhaled vasodilators, corticosteroids, recruitment maneuvers and extracorporeal life support, will also be reviewed. Finally, the chapter will deal with the mechanical ventilation weaning process with particular emphasis on extrapulmonary factors such as neurologic, diaphragmatic or cardiovascular alterations which can lead to weaning failure.
Collapse
|
22
|
Acute Kidney Injury and Delirium: Kidney–Brain Crosstalk. ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2019 2019. [DOI: 10.1007/978-3-030-06067-1_31] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
|
23
|
Simonis FD, Serpa Neto A, Binnekade JM, Braber A, Bruin KCM, Determann RM, Goekoop GJ, Heidt J, Horn J, Innemee G, de Jonge E, Juffermans NP, Spronk PE, Steuten LM, Tuinman PR, de Wilde RBP, Vriends M, Gama de Abreu M, Pelosi P, Schultz MJ. Effect of a Low vs Intermediate Tidal Volume Strategy on Ventilator-Free Days in Intensive Care Unit Patients Without ARDS: A Randomized Clinical Trial. JAMA 2018; 320:1872-1880. [PMID: 30357256 PMCID: PMC6248136 DOI: 10.1001/jama.2018.14280] [Citation(s) in RCA: 168] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE It remains uncertain whether invasive ventilation should use low tidal volumes in critically ill patients without acute respiratory distress syndrome (ARDS). OBJECTIVE To determine whether a low tidal volume ventilation strategy is more effective than an intermediate tidal volume strategy. DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial, conducted from September 1, 2014, through August 20, 2017, including patients without ARDS expected to not be extubated within 24 hours after start of ventilation from 6 intensive care units in the Netherlands. INTERVENTIONS Invasive ventilation using low tidal volumes (n = 477) or intermediate tidal volumes (n = 484). MAIN OUTCOMES AND MEASURES The primary outcome was the number of ventilator-free days and alive at day 28. Secondary outcomes included length of ICU and hospital stay; ICU, hospital, and 28- and 90-day mortality; and development of ARDS, pneumonia, severe atelectasis, or pneumothorax. RESULTS In total, 961 patients (65% male), with a median age of 68 years (interquartile range [IQR], 59-76), were enrolled. At day 28, 475 patients in the low tidal volume group had a median of 21 ventilator-free days (IQR, 0-26), and 480 patients in the intermediate tidal volume group had a median of 21 ventilator-free days (IQR, 0-26) (mean difference, -0.27 [95% CI, -1.74 to 1.19]; P = .71). There was no significant difference in ICU (median, 6 vs 6 days; 0.39 [-1.09 to 1.89]; P = .58) and hospital (median, 14 vs 15 days; -0.60 [-3.52 to 2.31]; P = .68) length of stay or 28-day (34.9% vs 32.1%; hazard ratio [HR], 1.12 [0.90 to 1.40]; P = .30) and 90-day (39.1% vs 37.8%; HR, 1.07 [0.87 to 1.31]; P = .54) mortality. There was no significant difference in the percentage of patients developing the following adverse events: ARDS (3.8% vs 5.0%; risk ratio [RR], 0.86 [0.59 to 1.24]; P = .38), pneumonia (4.2% vs 3.7%; RR, 1.07 [0.78 to 1.47]; P = .67), severe atelectasis (11.4% vs 11.2%; RR, 1.00 [0.81 to 1.23]; P = .94), and pneumothorax (1.8% vs 1.3%; RR, 1.16 [0.73 to 1.84]; P = .55). CONCLUSIONS AND RELEVANCE In patients in the ICU without ARDS who were expected not to be extubated within 24 hours of randomization, a low tidal volume strategy did not result in a greater number of ventilator-free days than an intermediate tidal volume strategy. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02153294.
Collapse
Affiliation(s)
| | - Fabienne D Simonis
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jan M Binnekade
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Annemarije Braber
- Department of Intensive Care, Gelre Hospitals, Apeldoorn, the Netherlands
| | - Karina C M Bruin
- Department of Intensive Care, Westfriesgasthuis, Hoorn, the Netherlands
| | - Rogier M Determann
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Geert-Jan Goekoop
- Department of Intensive Care, Westfriesgasthuis, Hoorn, the Netherlands
| | - Jeroen Heidt
- Department of Intensive Care Tergooi, Hilversum, the Netherlands
| | - Janneke Horn
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Gerard Innemee
- Department of Intensive Care Tergooi, Hilversum, the Netherlands
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Peter E Spronk
- Department of Intensive Care, Gelre Hospitals, Apeldoorn, the Netherlands
| | | | - Pieter Roel Tuinman
- Department of Intensive Care & REVIVE Research VUmc Intensive Care, VU Medical Center, Amsterdam, the Netherlands
| | - Rob B P de Wilde
- Department of Intensive Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Marijn Vriends
- Department of Intensive Care & REVIVE Research VUmc Intensive Care, VU Medical Center, Amsterdam, the Netherlands
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Genoa, Italy
| | - Marcus J Schultz
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| |
Collapse
|
24
|
Propensity score-matching analyses on the effectiveness of integrated prospective payment program for patients with prolonged mechanical ventilation. Health Policy 2018; 122:970-976. [PMID: 30097352 DOI: 10.1016/j.healthpol.2018.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Revised: 07/09/2018] [Accepted: 07/12/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVES An integrated delivery system with a prospective payment program (IPP) for prolonged mechanical ventilation (PMV) was launched by Taiwan's National Health Insurance (NHI) due to the costly and limited ICU resources. This study aimed to analyze the effectiveness of IPP and evaluate the factors associated with successful weaning and survival among patients with PMV. METHODS Taiwan's NHI Research Database was searched to obtain the data of patients aged ≥17 years who had PMV from 2006 to 2010 (N=50,570). A 1:1 propensity score matching approach was used to compare patients with and without IPP (N=30,576). Cox proportional hazards modeling was used to examine the factors related to successful weaning and survival. RESULTS The related factors of lower weaning rate in IPP participants (hazard ratio [HR]=0.84), were older age, higher income, catastrophic illness (HR=0.87), and higher comorbidity. The effectiveness of IPP intervention for the PMV patients showed longer days of hospitalization, longer ventilation days, higher survival rate, and higher medical costs (in respiratory care center, respiratory care ward). The 6-month mortality rate was lower (34.0% vs. 32.9%). The death risk of IPP patients compared to those non-IPP patients was lower (HR=0.91, P<0.001). CONCLUSIONS The policy of IPP for PMV patients showed higher survival rate although it was costly and related to lower weaning rate.
Collapse
|
25
|
[Prolonged weaning during early neurological and neurosurgical rehabilitation : S2k guideline published by the Weaning Committee of the German Neurorehabilitation Society (DGNR)]. DER NERVENARZT 2018; 88:652-674. [PMID: 28484823 DOI: 10.1007/s00115-017-0332-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Prolonged weaning of patients with neurological or neurosurgery disorders is associated with specific characteristics, which are taken into account by the German Society for Neurorehabilitation (DGNR) in its own guideline. The current S2k guideline of the German Society for Pneumology and Respiratory Medicine is referred to explicitly with regard to definitions (e.g., weaning and weaning failure), weaning categories, pathophysiology of weaning failure, and general weaning strategies. In early neurological and neurosurgery rehabilitation, patients with central of respiratory regulation disturbances (e.g., cerebral stem lesions), swallowing disturbances (neurogenic dysphagia), neuromuscular problems (e.g., critical illness polyneuropathy, Guillain-Barre syndrome, paraplegia, Myasthenia gravis) and/or cognitive disturbances (e.g., disturbed consciousness and vigilance disorders, severe communication disorders), whose care during the weaning of ventilation requires, in addition to intensive medical competence, neurological or neurosurgical and neurorehabilitation expertise. In Germany, this competence is present in centers of early neurological and neurosurgery rehabilitation, as a hospital treatment. The guideline is based on a systematic search of guideline databases and MEDLINE. Consensus was established by means of a nominal group process and Delphi procedure moderated by the Association of the Scientific Medical Societies in Germany (AWMF). In the present guideline of the DGNR, the special structural and substantive characteristics of early neurological and neurosurgery rehabilitation and existing studies on weaning in early rehabilitation facilities are examined.Addressees of the guideline are neurologists, neurosurgeons, anesthesiologists, palliative physicians, speech therapists, intensive care staff, ergotherapists, physiotherapists, and neuropsychologists. In addition, this guideline is intended to provide information to specialists for physical medicine and rehabilitation (PMR), pneumologists, internists, respiratory therapists, the German Medical Service of Health Insurance Funds (MDK) and the German Association of Health Insurance Funds (MDS). The main goal of this guideline is to convey the current knowledge on the subject of "Prolonged weaning in early neurological and neurosurgery rehabilitation".
Collapse
|
26
|
Cox CE, Hough CL, Carson SS, White DB, Kahn JM, Olsen MK, Jones DM, Somers TJ, Kelleher SA, Porter LS. Effects of a Telephone- and Web-based Coping Skills Training Program Compared with an Education Program for Survivors of Critical Illness and Their Family Members. A Randomized Clinical Trial. Am J Respir Crit Care Med 2018; 197:66-78. [DOI: 10.1164/rccm.201704-0720oc] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Christopher E. Cox
- Division of Pulmonary and Critical Care Medicine, Department of Medicine
- Duke Program to Support People and Enhance Recovery
| | - Catherine L. Hough
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Shannon S. Carson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Douglas B. White
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Jeremy M. Kahn
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Maren K. Olsen
- Department of Biostatistics, and
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, North Carolina
| | - Derek M. Jones
- Division of Pulmonary and Critical Care Medicine, Department of Medicine
- Duke Program to Support People and Enhance Recovery
| | - Tamara J. Somers
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina
| | - Sarah A. Kelleher
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina
| | - Laura S. Porter
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina
| |
Collapse
|
27
|
Outcomes after traumatic injury in patients with preexisting psychiatric illness. J Trauma Acute Care Surg 2017; 83:882-887. [PMID: 28538629 DOI: 10.1097/ta.0000000000001588] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients with psychiatric illness have been shown to experience higher rates of traumatic injury. Injury patterns, treatment decisions, and outcomes have not been well characterized in patients with psychiatric illness after injury, in particular those who undergo acute surgical intervention. The purpose of this analysis was to determine mortality, complications, and surgical intervention rates in patients with psychiatric illness after traumatic injury. METHODS This is a retrospective study of trauma patients ≥18 years old admitted to LAC + USC Medical Center between January 2008 and March 2015. Patients with psychiatric diagnoses were identified using ICD-9 diagnosis codes. Multivariate logistic regression analyses taking into account demographic and injury characteristics were used to identify associations between psychiatric comorbidity, injury mechanism, surgical interventions, and outcomes in patients after injury. RESULTS A total of 26,502 patients were analyzed. Of these, 3,040 (11.5%) had a documented psychiatric comorbidity (2.0% depressive disorder, 0.8% bipolar disorder, 1.3% schizophrenia, 0.5% anxiety disorder, 3.2% substance use disorder). Patients with psychiatric illness were significantly older (49.6 years vs. 42.0 years, p < 0.001), had a lower proportion of penetrating injuries (13.8% vs. 18.1%, p < 0.001), and had a higher incidence of self-inflicted injuries (11.6% vs. 0.72%, p < 0.001). No difference in gender distribution was observed (74.2% men vs. 74.4% men, p = 0.80). Overall mortality was similar in both groups (adjusted odds ratio [aOR], 0.73; p = 0.07). Patients with psychiatric illness were significantly less likely to undergo acute surgical intervention within 6 hours of emergency department admission (aOR, 0.64; p < 0.001). Time from ED arrival to consent for acute surgical intervention was similar in both groups (94.8 min vs. 93.0 min, p = 0.84). No significant difference in mortality after acute surgical intervention was observed (aOR, 0.26; p = 0.10). Psychiatric illness was associated with a significantly higher likelihood of developing complications (aOR, 1.90; p < 0.001) and longer hospital lengths of stay (10.6 days vs. 6.2 days, p < 0.001). CONCLUSIONS Trauma patients with comorbid psychiatric illness were observed to have lower rates of acute surgical interventions, higher complication rates, and longer hospital lengths of stay. Further studies are needed to better characterize the causative factors underlying these associations. LEVEL OF EVIDENCE Epidemiological, level III.
Collapse
|
28
|
Chen YJ, Hwang SL, Li CR, Yang CC, Huang KL, Lin CY, Lee CY. Vagal withdrawal and psychological distress during ventilator weaning and the related outcomes. J Psychosom Res 2017; 101:10-16. [PMID: 28867413 DOI: 10.1016/j.jpsychores.2017.07.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 07/25/2017] [Accepted: 07/26/2017] [Indexed: 02/01/2023]
Abstract
OBJECTIVE This study investigated the associations between changes in autonomic nervous system (ANS) function, psychological status during the mechanical ventilation (MV) weaning process, and weaning outcomes. METHODS In this prospective study, we recruited 67 patients receiving MV for >24h at a medical center in northern Taiwan. Patients' ANS function, represented by heart rate variability (HRV), the rapid shallow breathing index (RSBI), anxiety, fear, and dyspnea, was repeatedly measured 10min before and 30min after undergoing a weaning trial. Forty-nine patients capable of sustaining a 2-h weaning trial were successfully weaned. RESULTS Compared with the failed group, the success group showed significantly smaller decreases in high-frequency HRV (HRV-HF) and smaller increases in RSBI (per 10 breaths/min/L), fear, dyspnea, and anxiety in response to the weaning trial (odds ratio [OR]=2.19, 0.81, 0.69, 0.66, and 0.77, respectively; p<0.05). Multivariate analyses revealed that low-frequency HRV before weaning (OR=2.32; 95% confidence interval [CI]=1.13-4.78, p=0.02), changes in HRV-HF (OR=3.33; 95% CI=1.18-9.44, p=0.02), and psychological fear during the weaning process (OR=0.50; 95% CI=0.27-0.92, p=0.03) were three independent factors associated with 2-h T-piece weaning success. CONCLUSIONS ANS responses and psychological distress during weaning were associated with T-piece weaning outcomes and may reflect the need for future studies to utilize these factors to guide weaning processes and examine their impact on outcomes.
Collapse
Affiliation(s)
- Yu-Ju Chen
- School of Nursing, National Defense Medical Center, Taipei, Taiwan.
| | - Shiow-Li Hwang
- Department of Nursing, Asia University, Taichung, Taiwan
| | - Chi-Rong Li
- Department of Teaching and Research, Taichung Hospital, Ministry of Health and Welfare, Taiwan
| | - Chia-Chen Yang
- School of Nursing, National Defense Medical Center, Taipei, Taiwan
| | - Kun-Lun Huang
- Hyperbaric Oxygen Therapy Center, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chih-Yuan Lin
- Department of Surgery, National Defense Medical Center, Division of Cardiovascular Surgery, Tri-Service General Hospital, Taipei, Taiwan
| | - Ching-Yi Lee
- Division of Pulmonary and Critical Care Medicine, Tri-Service General Hospital, Taipei, Taiwan
| |
Collapse
|
29
|
Hashmi AM, Han JY, Demla V. Intensive Care and its Discontents: Psychiatric Illness in the Critically Ill. Psychiatr Clin North Am 2017; 40:487-500. [PMID: 28800804 DOI: 10.1016/j.psc.2017.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Critically ill patients can develop a host of cognitive and psychiatric complaints during their intensive care unit (ICU) stay, many of which persist for weeks or months following discharge from the ICU and can seriously affect their quality of life, including their ability to return to work. This article describes some common psychiatric problems encountered by clinicians in the ICU, including their assessment and management. A comprehensive approach is needed to decrease patient suffering, improve morbidity and mortality, and ensure that critically ill patients can return to the highest quality of life after an ICU stay.
Collapse
Affiliation(s)
- Ali M Hashmi
- Department of Psychiatry and Behavioral Sciences, King Edward Medical University/Mayo Hospital, Neela Gumbad, Lahore-54700, Pakistan.
| | - Jin Y Han
- Menninger Department of Psychiatry and Behavioral Sciences, Department of Family and Community Medicine, Baylor College of Medicine, 1502 Taub Loop NPC 2nd Floor, Houston, TX 77030, USA
| | - Vishal Demla
- Division of Critical Care Medicine, Department of Internal Medicine, University of Texas Health Science Center, 6431 Fannin, MSB 1.150, Houston, TX 77030, USA
| |
Collapse
|
30
|
Using Selective Serotonin Reuptake Inhibitors and Serotonin-Norepinephrine Reuptake Inhibitors in Critical Care: A Systematic Review of the Evidence for Benefit or Harm. Crit Care Med 2017; 45:e607-e616. [PMID: 28338497 DOI: 10.1097/ccm.0000000000002308] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Selective serotonin reuptake inhibitor/serotonin-norepinephrine reuptake inhibitors are among the most commonly prescribed drugs in patients admitted to the ICU. Our objective was to systematically review available literature for evidence of benefit or harm in ICU patients resulting from chronic effects, continued use, or withdrawal. DATA SOURCES Medline, Embase, and Cochrane Central Register of Controlled Trials (1990 to November 2014). STUDY SELECTION We searched for studies of ICU patients with recorded selective serotonin reuptake inhibitor/serotonin-norepinephrine reuptake inhibitor prescription before or during admission, and reporting morbidity, mortality, adverse events, and resource measures like ICU length of stay. We considered all study designs. We excluded studies of deliberate overdose and depression in non-ICU settings. Two authors independently and in duplicate screened citations and reviewed text of studies to apply selection criteria. DATA EXTRACTION Two authors abstracted data on patient characteristics in exposed and control groups; use of selective serotonin reuptake inhibitor/serotonin-norepinephrine reuptake inhibitors previously or during ICU; comparator intervention; and outcomes, and also assessed methodologic quality. DATA SYNTHESIS The database search retrieved 4,172 unique citations, of which 289 were reviewed, and 13 studies representing a total of 20,048 patients met selection criteria. There were five cohort studies, one case series, and seven case reports. Only one case report suggested benefit from selective serotonin reuptake inhibitor/serotonin-norepinephrine reuptake inhibitor use and 11 studies reported morbidity in patients using these medications at admission to ICU. However, due to inadequate drug administration reporting, it was generally unclear if outpatient selective serotonin reuptake inhibitor/serotonin-norepinephrine reuptake inhibitors were continued in ICU, complicating interpretation. CONCLUSIONS There may be excess morbidity in critically ill selective serotonin reuptake inhibitor/serotonin-norepinephrine reuptake inhibitor users, but uncertainty remains whether this is due to chronic effects, ongoing use, or drug withdrawal. Further research with improved standards of drug administration reporting is needed to help clinicians decide when to use selective serotonin reuptake inhibitor/serotonin-norepinephrine reuptake inhibitors in critically ill patients.
Collapse
|
31
|
Opening the Door: The Experience of Chronic Critical Illness in a Long-Term Acute Care Hospital. Crit Care Med 2017; 45:e357-e362. [PMID: 27632675 DOI: 10.1097/ccm.0000000000002094] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Chronically critically ill patients have recurrent infections, organ dysfunction, and at least half die within 1 year. They are frequently cared for in long-term acute care hospitals, yet little is known about their experience in this setting. Our objective was to explore the understanding and expectations and goals of these patients and surrogates. DESIGN We conducted semi-structured interviews with chronically critically ill long-term acute care hospital patients or surrogates. Conversations were recorded, transcribed, and analyzed. SETTING One long-term acute care hospital. SUBJECTS Chronically critically ill patients, defined by tracheotomy for prolonged mechanical ventilation, or surrogates. INTERVENTION Semi-structured conversation about quality of life, expectations, and planning for setbacks. MEASUREMENTS AND MAIN RESULTS A total of 50 subjects (30 patients and 20 surrogates) were enrolled. Thematic analyses demonstrated: 1) poor quality of life for patients; 2) surrogate stress and anxiety; 3) optimistic health expectations; 4) poor planning for medical setbacks; and 5) disruptive care transitions. Nearly 80% of patient and their surrogate decision makers identified going home as a goal; 38% were at home at 1 year. CONCLUSIONS Our study describes the experience of chronically critically ill patients and surrogates in an long-term acute care hospital and the feasibility of patient-focused research in this setting. Our findings indicate overly optimistic expectations about return home and unmet palliative care needs, suggesting the need for integration of palliative care within the long-term acute care hospital. Further research is also needed to more fully understand the challenges of this growing population of ICU survivors.
Collapse
|
32
|
[Depressive, anxiety and posttraumatic stress disorders as long-term sequelae of intensive care treatment]. DER NERVENARZT 2016; 87:253-63. [PMID: 26908007 DOI: 10.1007/s00115-016-0070-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Modern intensive care medicine has led to increased survival rates even after severe life-threatening medical conditions. In self-critical and multidimensional outcome research, however, it must be considered that beyond survival rates treatment on intensive care units (ICU) can also be associated with high long-term rates of depressive, anxiety and posttraumatic stress disorders. Significant correlations with increased somatic morbidity and mortality, persisting cognitive impairments and significant deficits in health-related quality of life must also be taken into consideration. Empirical analysis of the risk factors reveals that a history of premorbid depression, sociodemographic and socioeconomic variables, age, female sex, personality traits, the underlying pathophysiological condition requiring ICU treatment, mode of sedation and analgesia, life support measures, such as mechanical ventilation, manifold traumatic experiences and memories during the stay in the ICU are all of particular pathogenetic importance. In order to reduce principally modifiable risk factors several strategies are illustrated, including well-reflected intensive care sedation and analgesia, special prophylactic medication regarding the major risk of traumatic memories and posttraumatic stress disorder (PTSD), psychological and psychotherapeutic interventions in states of increased acute stress symptoms and aids for personal memories and reorientation.
Collapse
|
33
|
Abstract
PURPOSE OF REVIEW In this review, we discuss the causes for a failed weaning trial and specific diagnostic tests that could be conducted to identify the cause for weaning failure. We briefly highlight treatment strategies that may enhance the chance of weaning success. RECENT FINDINGS Impaired respiratory mechanics, respiratory muscle dysfunction, cardiac dysfunction, cognitive dysfunction, and metabolic disorders are recognized causes for weaning failure. In addition, iatrogenic factors may be at play. Most studies have focused on respiratory muscle dysfunction and cardiac dysfunction. Recent studies demonstrate that both ultrasound and electromyography are valuable tools to evaluate respiratory muscle function in ventilated patients. Sophisticated ultrasound techniques and biomarkers such as B-type natriuretic peptide, are valuable tools to identify cardiac dysfunction as a cause for weaning failure. Once a cause for weaning failure has been identified specific treatment should be instituted. Concerning treatment, both strength training and endurance training should be considered for patients with respiratory muscle weakness. Inotropes and vasodilators should be considered in case of heart failure. SUMMARY Understanding the complex pathophysiology of weaning failure in combination with a systematic diagnostic approach allows identification of the primary cause of weaning failure. This will help the clinician to choose a specific treatment strategy and therefore may fasten liberation from mechanical ventilation.
Collapse
|
34
|
Rojek-Jarmuła A, Hombach R, Krzych ŁJ. Does the APACHE II score predict performance of activities of daily living in patients discharged from a weaning center? KARDIOCHIRURGIA I TORAKOCHIRURGIA POLSKA = POLISH JOURNAL OF CARDIO-THORACIC SURGERY 2016; 13:353-358. [PMID: 28096834 PMCID: PMC5233767 DOI: 10.5114/kitp.2016.64880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 09/09/2016] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Data regarding the functional status of patients after prolonged mechanical ventilation are scarce, and little is known about its clinical predictors. AIM To investigate whether the Acute Physiology and Chronic Health Evaluation (APACHE) II score on admission may predict performance in activities of daily living on discharge from a weaning center. MATERIAL AND METHODS All consecutive patients admitted between January 1, 2012 and December 31, 2013 were enrolled (n = 130). During this period, 15 subjects died, and 115 were successfully discharged (34 women; 81 men). APACHE II was calculated based on the worst values taken during the first 24 hours after admission. On discharge, the Barthel Index (BI) and its extended version, the Early Rehabilitation Barthel Index (ERBI), were assessed. RESULTS Median BI was 20 points (IQR 5; 40), and ERBI was 20 points (-50; 40). There was no correlation between APACHE II and either BI (R = -0.07; p = 0.47) or ERBI (R = -0.07; p = 0.44). APACHE II predicted the need for assistance with bathing (AUROC = 0.833; p < 0.001), grooming (AUROC = 0.823; p < 0.001), toilet use (AUROC = 0.887; p < 0.001), and urination (AUROC = 0.658; p = 0.04). APACHE II had no impact on any ERBI items associated with ventilator weaning, including the need of further mechanical ventilation (AUROC = 0.534; p = 0.65) or tracheostomy (AUROC = 0.544; p = 0.42). CONCLUSIONS Although APACHE II cannot predict the overall functional status in patients discharged from a weaning center, it helps identify subjects who will need support with bathing, grooming, and toilet use. The APACHE II score is inadequate to predict performance in activities associated with further respiratory support.
Collapse
Affiliation(s)
- Anna Rojek-Jarmuła
- Weaning Station, Marienhaus Klinikum Eifel, Neuerburg, Germany
- Department of Anesthesiology and Intensive Care, Marienhaus Klinikum Eifel St. Elizabeth, Gerolstein, Germany
| | - Rainer Hombach
- Weaning Station, Marienhaus Klinikum Eifel, Neuerburg, Germany
| | - Łukasz J. Krzych
- Department of Anesthesiology and Intensive Care, School of Medicine, Medical University of Silesia, Katowice, Poland
| |
Collapse
|
35
|
Jordan J, Rose L, Dainty KN, Noyes J, Blackwood B. Factors that impact on the use of mechanical ventilation weaning protocols in critically ill adults and children: a qualitative evidence-synthesis. Cochrane Database Syst Rev 2016; 10:CD011812. [PMID: 27699783 PMCID: PMC6458040 DOI: 10.1002/14651858.cd011812.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Prolonged mechanical ventilation is associated with a longer intensive care unit (ICU) length of stay and higher mortality. Consequently, methods to improve ventilator weaning processes have been sought. Two recent Cochrane systematic reviews in ICU adult and paediatric populations concluded that protocols can be effective in reducing the duration of mechanical ventilation, but there was significant heterogeneity in study findings. Growing awareness of the benefits of understanding the contextual factors impacting on effectiveness has encouraged the integration of qualitative evidence syntheses with effectiveness reviews, which has delivered important insights into the reasons underpinning (differential) effectiveness of healthcare interventions. OBJECTIVES 1. To locate, appraise and synthesize qualitative evidence concerning the barriers and facilitators of the use of protocols for weaning critically-ill adults and children from mechanical ventilation;2. To integrate this synthesis with two Cochrane effectiveness reviews of protocolized weaning to help explain observed heterogeneity by identifying contextual factors that impact on the use of protocols for weaning critically-ill adults and children from mechanical ventilation;3. To use the integrated body of evidence to suggest the circumstances in which weaning protocols are most likely to be used. SEARCH METHODS We used a range of search terms identified with the help of the SPICE (Setting, Perspective, Intervention, Comparison, Evaluation) mnemonic. Where available, we used appropriate methodological filters for specific databases. We searched the following databases: Ovid MEDLINE, Embase, OVID, PsycINFO, CINAHL Plus, EBSCOHost, Web of Science Core Collection, ASSIA, IBSS, Sociological Abstracts, ProQuest and LILACS on the 26th February 2015. In addition, we searched: the grey literature; the websites of professional associations for relevant publications; and the reference lists of all publications reviewed. We also contacted authors of the trials included in the effectiveness reviews as well as of studies (potentially) included in the qualitative synthesis, conducted citation searches of the publications reporting these studies, and contacted content experts.We reran the search on 3rd July 2016 and found three studies, which are awaiting classification. SELECTION CRITERIA We included qualitative studies that described: the circumstances in which protocols are designed, implemented or used, or both, and the views and experiences of healthcare professionals either involved in the design, implementation or use of weaning protocols or involved in the weaning of critically-ill adults and children from mechanical ventilation not using protocols. We included studies that: reflected on any aspect of the use of protocols, explored contextual factors relevant to the development, implementation or use of weaning protocols, and reported contextual phenomena and outcomes identified as relevant to the effectiveness of protocolized weaning from mechanical ventilation. DATA COLLECTION AND ANALYSIS At each stage, two review authors undertook designated tasks, with the results shared amongst the wider team for discussion and final development. We independently reviewed all retrieved titles, abstracts and full papers for inclusion, and independently extracted selected data from included studies. We used the findings of the included studies to develop a new set of analytic themes focused on the barriers and facilitators to the use of protocols, and further refined them to produce a set of summary statements. We used the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) framework to arrive at a final assessment of the overall confidence of the evidence used in the synthesis. We included all studies but undertook two sensitivity analyses to determine how the removal of certain bodies of evidence impacted on the content and confidence of the synthesis. We deployed a logic model to integrate the findings of the qualitative evidence synthesis with those of the Cochrane effectiveness reviews. MAIN RESULTS We included 11 studies in our synthesis, involving 267 participants (one study did not report the number of participants). Five more studies are awaiting classification and will be dealt with when we update the review.The quality of the evidence was mixed; of the 35 summary statements, we assessed 17 as 'low', 13 as 'moderate' and five as 'high' confidence. Our synthesis produced nine analytical themes, which report potential barriers and facilitators to the use of protocols. The themes are: the need for continual staff training and development; clinical experience as this promotes felt and perceived competence and confidence to wean; the vulnerability of weaning to disparate interprofessional working; an understanding of protocols as militating against a necessary proactivity in clinical practice; perceived nursing scope of practice and professional risk; ICU structure and processes of care; the ability of protocols to act as a prompt for shared care and consistency in weaning practice; maximizing the use of protocols through visibility and ease of implementation; and the ability of protocols to act as a framework for communication with parents. AUTHORS' CONCLUSIONS There is a clear need for weaning protocols to take account of the social and cultural environment in which they are to be implemented. Irrespective of its inherent strengths, a protocol will not be used if it does not accommodate these complexities. In terms of protocol development, comprehensive interprofessional input will help to ensure broad-based understanding and a sense of 'ownership'. In terms of implementation, all relevant ICU staff will benefit from general weaning as well as protocol-specific training; not only will this help secure a relevant clinical knowledge base and operational understanding, but will also demonstrate to others that this knowledge and understanding is in place. In order to maximize relevance and acceptability, protocols should be designed with the patient profile and requirements of the target ICU in mind. Predictably, an under-resourced ICU will impact adversely on protocol implementation, as staff will prioritize management of acutely deteriorating and critically-ill patients.
Collapse
Affiliation(s)
- Joanne Jordan
- Ulster UniversitySchool of NursingShore RoadNewtownabbeyNorthern IrelandUKBT37 OQB
| | - Louise Rose
- Sunnybrook Health Sciences Centre and Sunnybrook Research InstituteDepartment of Critical Care MedicineTorontoCanada
| | - Katie N Dainty
- St. Michael's HospitalLi Ka Shing Knowledge InstituteTorontoONCanada
| | - Jane Noyes
- Bangor UniversityCentre for Health‐Related Research, Fron HeulogBangorWalesUKLL57 2EF
| | - Bronagh Blackwood
- Queen's University BelfastCentre for Experimental Medicine, School of Medicine, Dentistry and Biomedical SciencesWellcome‐Wolfson Building97 Lisburn RoadBelfastNorthern IrelandUKBT9 7LB
| | | |
Collapse
|
36
|
Chen T, Chen C, Zhang Z, Zou Y, Peng M, Wang Y. Toll-like receptor 4 knockout ameliorates neuroinflammation due to lung-brain interaction in mechanically ventilated mice. Brain Behav Immun 2016; 56:42-55. [PMID: 27067748 DOI: 10.1016/j.bbi.2016.04.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 03/31/2016] [Accepted: 04/08/2016] [Indexed: 02/07/2023] Open
Abstract
Toll-like receptor 4 (TLR4) is a crucial receptor in the innate immune system, and increasing evidence supports its role in inflammation, stress, and tissue injury, including injury to the lung and brain. We aimed to investigate the effects of TLR4 on neuroinflammation due to the lung-brain interaction in mechanically ventilated mice. Male wild-type (WT) C57BL/6 and TLR4 knockout (TLR4 KO) mice were divided into three groups: (1) control group (C): spontaneous breathing; (2) anesthesia group (A): spontaneous breathing under anesthesia; and (3) mechanical ventilation group (MV): 6h of MV under anesthesia. The behavioral responses of mice were tested with fear conditioning tests. The histological changes in the lung and brain were assessed using hematoxylin-eosin (HE) staining. The level of TLR4 mRNA in tissue was measured using reverse transcription-polymerase chain reaction (RT-PCR). The levels of inflammatory cytokines were measured with an enzyme-linked immunosorbent assay (ELISA). Microgliosis, astrocytosis, and the TLR4 immunoreactivity in the hippocampus were measured by double immunofluorescence. MV mice exhibited impaired cognition, and this impairment was less severe in TLR4 KO mice than in WT mice. In WT mice, MV increased TLR4 mRNA expression in the lung and brain. MV induced mild lung injury, which was prevented in TLR4 KO mice. MV mice exhibited increased levels of inflammatory cytokines, increased microglia and astrocyte activation. Microgliosis was alleviated in TLR4 KO mice. MV mice exhibited increased TLR4 immunoreactivity, which was expressed in microglia and astrocytes. These results demonstrate that TLR4 is involved in neuroinflammation due to the lung-brain interaction and that TLR4 KO ameliorates neuroinflammation due to lung-brain interaction after prolonged MV. In addition, Administration of a TLR4 antagonist (100μg/mice) to WT mice also significantly attenuated neuroinflammation of lung-brain interaction due to prolonged MV. TLR4 antagonism may be a new and novel approach for the treatment and management of neuroinflammation in long-term mechanically ventilated patients.
Collapse
Affiliation(s)
- Ting Chen
- Department of Anesthesiology, Zhongnan Hospital, Wuhan University, East Lake Road, Wuhan, Hubei 430071, China.
| | - Chang Chen
- Department of Anesthesiology, Zhongnan Hospital, Wuhan University, East Lake Road, Wuhan, Hubei 430071, China.
| | - Zongze Zhang
- Department of Anesthesiology, Zhongnan Hospital, Wuhan University, East Lake Road, Wuhan, Hubei 430071, China.
| | - Yufeng Zou
- Department of Anesthesiology, Zhongnan Hospital, Wuhan University, East Lake Road, Wuhan, Hubei 430071, China
| | - Mian Peng
- Department of Anesthesiology, Zhongnan Hospital, Wuhan University, East Lake Road, Wuhan, Hubei 430071, China
| | - Yanlin Wang
- Department of Anesthesiology, Zhongnan Hospital, Wuhan University, East Lake Road, Wuhan, Hubei 430071, China
| |
Collapse
|
37
|
Abstract
Mechanical ventilation supports gas exchange and alleviates the work of breathing when the respiratory muscles are overwhelmed by an acute pulmonary or systemic insult. Although mechanical ventilation is not generally considered a treatment for acute respiratory failure per se, ventilator management warrants close attention because inappropriate ventilation can result in injury to the lungs or respiratory muscles and worsen morbidity and mortality. Key clinical challenges include averting intubation in patients with respiratory failure with non-invasive techniques for respiratory support; delivering lung-protective ventilation to prevent ventilator-induced lung injury; maintaining adequate gas exchange in severely hypoxaemic patients; avoiding the development of ventilator-induced diaphragm dysfunction; and diagnosing and treating the many pathophysiological mechanisms that impair liberation from mechanical ventilation. Personalisation of mechanical ventilation based on individual physiological characteristics and responses to therapy can further improve outcomes.
Collapse
Affiliation(s)
- Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Physiology, University of Toronto, Toronto, ON, Canada; Department of Medicine, Division of Respirology, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Physiology, University of Toronto, Toronto, ON, Canada; Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Medicine, Division of Respirology, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
| | - Laurent J Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, ON, Canada.
| |
Collapse
|
38
|
Barbas CSV, Ísola AM, Farias AMDC, Cavalcanti AB, Gama AMC, Duarte ACM, Vianna A, Serpa Neto A, Bravim BDA, Pinheiro BDV, Mazza BF, de Carvalho CRR, Toufen Júnior C, David CMN, Taniguchi C, Mazza DDDS, Dragosavac D, Toledo DO, Costa EL, Caser EB, Silva E, Amorim FF, Saddy F, Galas FRBG, Silva GS, de Matos GFJ, Emmerich JC, Valiatti JLDS, Teles JMM, Victorino JA, Ferreira JC, Prodomo LPDV, Hajjar LA, Martins LC, Malbouisson LMS, Vargas MADO, Reis MAS, Amato MBP, Holanda MA, Park M, Jacomelli M, Tavares M, Damasceno MCP, Assunção MSC, Damasceno MPCD, Youssef NCM, Teixeira PJZ, Caruso P, Duarte PAD, Messeder O, Eid RC, Rodrigues RG, de Jesus RF, Kairalla RA, Justino S, Nemer SN, Romero SB, Amado VM. Brazilian recommendations of mechanical ventilation 2013. Part 2. Rev Bras Ter Intensiva 2016; 26:215-39. [PMID: 25295817 PMCID: PMC4188459 DOI: 10.5935/0103-507x.20140034] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2013] [Indexed: 12/13/2022] Open
Abstract
Perspectives on invasive and noninvasive ventilatory support for critically ill
patients are evolving, as much evidence indicates that ventilation may have positive
effects on patient survival and the quality of the care provided in intensive care
units in Brazil. For those reasons, the Brazilian Association of Intensive Care
Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and
the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e
Tisiologia - SBPT), represented by the Mechanical Ventilation Committee
and the Commission of Intensive Therapy, respectively, decided to review the
literature and draft recommendations for mechanical ventilation with the goal of
creating a document for bedside guidance as to the best practices on mechanical
ventilation available to their members. The document was based on the available
evidence regarding 29 subtopics selected as the most relevant for the subject of
interest. The project was developed in several stages, during which the selected
topics were distributed among experts recommended by both societies with recent
publications on the subject of interest and/or significant teaching and research
activity in the field of mechanical ventilation in Brazil. The experts were divided
into pairs that were charged with performing a thorough review of the international
literature on each topic. All the experts met at the Forum on Mechanical Ventilation,
which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to
collaboratively draft the final text corresponding to each sub-topic, which was
presented to, appraised, discussed and approved in a plenary session that included
all 58 participants and aimed to create the final document.
Collapse
Affiliation(s)
- Carmen Sílvia Valente Barbas
- Corresponding author: Carmen Silvia Valente Barbas, Disicplina de
Pneumologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São
Paulo, Avenida Dr. Eneas de Carvalho Aguiar, 44, Zip code - 05403-900 - São Paulo
(SP), Brazil, E-mail:
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Depressive symptoms and anxiety in intensive care unit (ICU) survivors after ICU discharge. Heart Lung 2016; 45:140-6. [PMID: 26791248 PMCID: PMC4878700 DOI: 10.1016/j.hrtlng.2015.12.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 11/10/2015] [Accepted: 12/08/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND The association between intensive care unit (ICU) survivors' psychological sequelae, individual care needs, and discharge disposition has not been evaluated. OBJECTIVE To describe depressive symptoms and anxiety in ICU survivors and explore these symptoms based on individual care needs and discharge disposition for 4 months post-ICU discharge. METHODS We analyzed data from 39 ICU survivors who self-reported measures of depressive symptoms (Center for Epidemiologic Studies-Depression 10 items [CESD-10]) and anxiety (Shortened Profile of Mood States-Anxiety subscale [POMS-A]). RESULTS A majority of patients reported CESD-10 scores above the cut off (≥ 8) indicating risk for clinical depression. POMS-A scores were highest within 2 weeks post-ICU discharge and decreased subsequently. Data trends suggest worse depressive symptoms and anxiety when patients had moderate to high care needs and/or were unable to return home. CONCLUSION ICU survivors who need caregiver assistance and extended institutional care reported trends of worse depressive symptoms and anxiety.
Collapse
|
40
|
Marchioni A, Fantini R, Antenora F, Clini E, Fabbri L. Chronic critical illness: the price of survival. Eur J Clin Invest 2015; 45:1341-9. [PMID: 26549412 DOI: 10.1111/eci.12547] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Accepted: 10/03/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND The evolution of the techniques used in the intensive care setting over the past decades has led on one side to better survival rates in patients with acute conditions and severely impaired vital functions. On the other side, it has resulted in a growing number of patients who survive an acute event, but who then become dependent on one or more life support techniques. Such patients are called chronically critically ill patients. MATERIALS & METHODS No absolute definition of the disease is currently available, although most patients are characterized by the need for prolonged mechanical ventilation. Mortality rates are still high even after dismissal from intensive care unit (ICU) and transfer to specialized rehabilitation care settings. RESULTS In recent years, some studies have tried to clarify the pathophysiological characteristics underlying chronic critical illness (CCI), a disease that is also characterized by severe endocrine and inflammatory impairments, partly accounting for the almost constant set of symptoms. DISCUSSION Currently, no specific treatment is available. However, a strategic early therapeutic approach on ICU admission might try to prevent the progress of the acute disease towards chronic critical illness.
Collapse
Affiliation(s)
- Alessandro Marchioni
- Respiratory Disease Clinic Department of Oncology, Haematology and Respiratory Disease, University of Modena and Reggio Emilia, Modena, Italy
| | - Riccardo Fantini
- Respiratory Disease Clinic Department of Oncology, Haematology and Respiratory Disease, University of Modena and Reggio Emilia, Modena, Italy
| | - Federico Antenora
- Respiratory Disease Clinic Department of Oncology, Haematology and Respiratory Disease, University of Modena and Reggio Emilia, Modena, Italy
| | - Enrico Clini
- Respiratory Disease Clinic Department of Oncology, Haematology and Respiratory Disease, University of Modena and Reggio Emilia, Modena, Italy
| | - Leonardo Fabbri
- Respiratory Disease Clinic Department of Oncology, Haematology and Respiratory Disease, University of Modena and Reggio Emilia, Modena, Italy
| |
Collapse
|
41
|
Dessap AM, Roche-Campo F, Launay JM, Charles-Nelson A, Katsahian S, Brun-Buisson C, Brochard L. Delirium and Circadian Rhythm of Melatonin During Weaning From Mechanical Ventilation. Chest 2015; 148:1231-1241. [DOI: 10.1378/chest.15-0525] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
|
42
|
Jordan J, Rose L, Dainty KN, Noyes J, Blackwood B. Factors that impact on the use of mechanical ventilation weaning protocols in critically ill adults and children: a qualitative evidence-synthesis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd011812] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
43
|
Jordan J, Rose L, Dainty KN, Noyes J, Clarke S, Blackwood B. Factors that impact on the use of mechanical ventilation weaning protocols in critically ill adults and children: a qualitative evidence-synthesis. Hippokratia 2015. [DOI: 10.1002/14651858.cd009851.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Joanne Jordan
- Ulster University; School of Nursing; Shore Road Newtownabbey Northern Ireland UK BT37 OQB
| | - Louise Rose
- University of Toronto; Lawrence S. Bloomberg Faculty of Nursing; 155 College St Toronto ON Canada M5T 1P8
| | - Katie N Dainty
- St. Michael's Hospital; Li Ka Shing Knowledge Institute; Toronto ON Canada
| | - Jane Noyes
- Bangor University; Centre for Health-Related Research, Fron Heulog; Bangor Wales UK LL57 2EF
| | - Sean Clarke
- University of Toronto; Lawrence S. Bloomberg Faculty of Nursing; 155 College St Toronto ON Canada M5T 1P8
| | - Bronagh Blackwood
- Queen's University Belfast; Centre for Infection and Immunity, School of Medicine, Dentistry and Biomedical Sciences; Health Sciences Building, Room: 111 97 Lisburn Road Belfast Northern Ireland UK BT9 7AE
| |
Collapse
|
44
|
Simonis FD, Binnekade JM, Braber A, Gelissen HP, Heidt J, Horn J, Innemee G, de Jonge E, Juffermans NP, Spronk PE, Steuten LM, Tuinman PR, Vriends M, de Vreede G, de Wilde RB, Serpa Neto A, Gama de Abreu M, Pelosi P, Schultz MJ. PReVENT--protective ventilation in patients without ARDS at start of ventilation: study protocol for a randomized controlled trial. Trials 2015; 16:226. [PMID: 26003545 PMCID: PMC4453265 DOI: 10.1186/s13063-015-0759-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 05/14/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND It is uncertain whether lung-protective mechanical ventilation using low tidal volumes should be used in all critically ill patients, irrespective of the presence of the acute respiratory distress syndrome (ARDS). A low tidal volume strategy includes use of higher respiratory rates, which could be associated with increased sedation needs, a higher incidence of delirium, and an increased risk of patient-ventilator asynchrony and ICU-acquired weakness. Another alleged side-effect of low tidal volume ventilation is the risk of atelectasis. All of these could offset the beneficial effects of low tidal volume ventilation as found in patients with ARDS. METHODS/DESIGN PReVENT is a national multicenter randomized controlled trial in invasively ventilated ICU patients without ARDS with an anticipated duration of ventilation of longer than 24 hours in 5 ICUs in The Netherlands. Consecutive patients are randomly assigned to a low tidal volume strategy using tidal volumes from 4 to 6 ml/kg predicted body weight (PBW) or a high tidal volume ventilation strategy using tidal volumes from 8 to 10 ml/kg PBW. The primary endpoint is the number of ventilator-free days and alive at day 28. Secondary endpoints include ICU and hospital length of stay (LOS), ICU and hospital mortality, the incidence of pulmonary complications, including ARDS, pneumonia, atelectasis, and pneumothorax, the cumulative use and duration of sedatives and neuromuscular blocking agents, incidence of ICU delirium, and the need for decreasing of instrumental dead space. DISCUSSION PReVENT is the first randomized controlled trial comparing a low tidal volume strategy with a high tidal volume strategy, in patients without ARDS at onset of ventilation, that recruits a sufficient number of patients to test the hypothesis that a low tidal volume strategy benefits patients without ARDS with regard to a clinically relevant endpoint. TRIAL REGISTRATION The trial is registered at www.clinicaltrials.gov under reference number NCT02153294 on 23 May 2014.
Collapse
Affiliation(s)
- Fabienne D Simonis
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - Jan M Binnekade
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - Annemarije Braber
- Department of Intensive Care, Gelre Hospitals, Apeldoorn, The Netherlands.
| | - Harry P Gelissen
- Department of Intensive Care & REVIVE Research VUmc Intensive Care, VU Medical Center, Amsterdam, The Netherlands.
| | - Jeroen Heidt
- Department of Intensive Care, Tergooi, Hilversum, The Netherlands.
| | - Janneke Horn
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - Gerard Innemee
- Department of Intensive Care, Tergooi, Hilversum, The Netherlands.
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands.
| | - Nicole P Juffermans
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - Peter E Spronk
- Department of Intensive Care, Gelre Hospitals, Apeldoorn, The Netherlands.
| | - Lotte M Steuten
- Department of Health Technology and Services Research, Twente University, Enschede, The Netherlands.
| | - Pieter Roel Tuinman
- Department of Intensive Care & REVIVE Research VUmc Intensive Care, VU Medical Center, Amsterdam, The Netherlands.
| | - Marijn Vriends
- Department of Intensive Care, Tergooi, Hilversum, The Netherlands.
| | | | - Rob B de Wilde
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands.
| | - Ary Serpa Neto
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care, University Hospital Carl Gustav Carus, Dresden, Germany.
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS San Martino IST, University of Genoa, Genoa, Italy.
| | - Marcus J Schultz
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| |
Collapse
|
45
|
Winck J, Camacho R, Ambrosino N. Multidisciplinary rehabilitation in ventilator-dependent patients: Call for action in specialized inpatient facilities. REVISTA PORTUGUESA DE PNEUMOLOGIA 2015; 21:S2173-5115(15)00083-4. [PMID: 25963388 DOI: 10.1016/j.rppnen.2015.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 03/24/2015] [Indexed: 10/23/2022] Open
Abstract
The numbers of patients needing prolonged mechanical ventilation are growing. The rehabilitation programs to be implemented in specialized inpatient facilities are ill defined. There is a clear need to establish guidelines to define the optimal rehabilitation program in this setting. In this article we review the current evidence and propose some guidance.
Collapse
Affiliation(s)
- J Winck
- Department of Pulmonology, Faculdade de Medicina, Universidade do Porto, Portugal & Linde Healthcare, Pullach, Germany.
| | | | - N Ambrosino
- Weaning and Rehabilitation Unit, Auxilium Vitae Rehabilitation Center, Volterra, Italy
| |
Collapse
|
46
|
Abstract
OBJECTIVE Mortality on medical intensive care units (ICU) is approximately 25%. It is associated with age, severity of illness, and comorbidities. Preexisting depression is a risk factor for worse outcome in many diseases. The impact of depression on outcome of ICU patients has not been investigated. We assessed a possible association between mortality and preexisting depressive mood at the time of ICU admission. The primary end point was 28-day mortality. METHODS This single-center cohort study was conducted in a tertiary medical ICU. Two hundred patients were evaluated for preexisting depressive mood at ICU admission, determined by Hospital Anxiety and Depression Scale (HADS) score ≥8 in the depression dimension in patients with appropriate cognitive function. Patients with insufficient cognitive function were assessed using observer rating by next of kin by Hammond scale (cutoff ≥4) and/or a modified version of the Hospital Anxiety and Depression Scale for observer rating (cutoff ≥10). RESULTS In total, 66 (33%) of 200 patients were classified with preexisting depressive mood. Forty-nine (24.5%) of 200 patients had died by day 28. Of these, 23 (47%) had preexisting depressive mood as compared with 43 of 151 (29%) 28-day survivors (p = .017). Multiple logistic regression analysis revealed that preexisting depressive mood at the time of ICU admission is an independent risk factor for 28-day (odds ratio = 2.2, 95% confidence interval = 1.08-4.5, p = .030) and in-hospital mortality (median time till death = 20.5 [2-186] days, odds ratio = 2.58, 95% confidence interval = 1.31-5.1, p = .006). CONCLUSION Preexisting depressive mood might be an independent risk factor for 28-day mortality in medical ICU patients. This could have diagnostic and therapeutic implications for critically ill patients.
Collapse
|
47
|
Karnatovskaia LV, Johnson MM, Benzo RP, Gajic O. The spectrum of psychocognitive morbidity in the critically ill: A review of the literature and call for improvement. J Crit Care 2015; 30:130-7. [DOI: 10.1016/j.jcrc.2014.09.024] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 09/07/2014] [Accepted: 09/29/2014] [Indexed: 10/24/2022]
|
48
|
Massanet PL, Petit L, Louart B, Corne P, Richard C, Preiser JC. Nutrition rehabilitation in the intensive care unit. JPEN J Parenter Enteral Nutr 2015; 39:391-400. [PMID: 25587007 DOI: 10.1177/0148607114567901] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 11/24/2014] [Indexed: 11/17/2022]
Abstract
The maintenance of homeostasis after severe injury requires the restoration of the physiological regulation of food intake. A wide array of functional alterations can hinder the intake of adequate amounts of nutrients to support the recovery from critical illness. These alterations encompass changes in the preprandial phase, reflected by a loss of appetite; changes in the prandial phase, yielding swallowing disorders; and changes in the postprandial phase, including impairments of gastric emptying, gut motility, and satiety. This tutorial aims to review these often overlooked features and to suggest recommendations for the nutrition rehabilitation of the critically ill.
Collapse
Affiliation(s)
| | - Laurent Petit
- Surgical and Trauma Intensive Care Unit, Pellegrin University Hospital, Bordeaux, France
| | - Benjamin Louart
- Medical Intensive Care Unit, Nimes University Hospital, Nimes, France
| | | | - Celine Richard
- Clinical Dietitian Department, Gui De Chauliac Hospital, Montpellier, France
| | | |
Collapse
|
49
|
Filières de soins après la réanimation : identifier les besoins pour mieux prendre en charge. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-015-1075-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
50
|
Abstract
OBJECTIVES Palliative care is an interprofessional specialty as well as an approach to care by all clinicians caring for patients with serious and complex illness. Unlike hospice, palliative care is based not on prognosis but on need and is an essential component of comprehensive care for critically ill patients from the time of ICU admission. In this clinically focused article, we review evidence of opportunities to improve palliative care for critically ill adults, summarize strategies for ICU palliative care improvement, and identify resources to support implementation. DATA SOURCES We searched the MEDLINE database from inception through January 2014. We also searched the Reference Library of The Improving Palliative Care in the ICU Project website sponsored by the National Institutes of Health and the Center to Advance Palliative Care, which is updated monthly. We hand-searched reference lists and author files. STUDY SELECTION Selected studies included all English-language articles concerning adult patients using the search terms 'intensive care' or 'critical care' with 'palliative care,' 'supportive care,' 'end-of-life care,' or 'ethics.' DATA EXTRACTION : After examination of peer-reviewed original scientific articles, consensus statements, guidelines, and reviews resulting from our literature search, we made final selections based on author consensus. DATA SYNTHESIS Existing evidence is organized to address: 1) opportunities to alleviate physical and emotional symptoms, improve communication, and provide support for patients and families; 2) models and specific interventions for improving ICU palliative care; 3) available resources for ICU palliative care improvement; and 4) ongoing challenges and targets for future research. Key domains of ICU palliative care have been defined and operationalized as measures of quality. There is increasing recognition that effective integration of palliative care during acute and chronic critical illness may help patients and families face challenges after discharge from intensive care. CONCLUSIONS Palliative care is increasingly accepted as an essential component of comprehensive care for critically ill patients, regardless of diagnosis or prognosis. A variety of strategies to improve ICU palliative care appear to be effective, and resources including technical assistance and tools are available to support improvement efforts. As the longer-term impact of intensive care on those surviving acute critical illness is increasingly documented, palliative care can help prepare and support patients and families for challenges after ICU discharge. Further research is needed to inform efforts to integrate palliative care with intensive care more effectively and efficiently in and after the ICU and to document improvement using valid and responsive outcome measures.
Collapse
Affiliation(s)
- Rebecca A Aslakson
- 1Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, MD. 2The Palliative Care Program at the Kimmel Cancer Center at Johns Hopkins, The Johns Hopkins School of Medicine, Baltimore, MD. 3Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, WA. 4Division of Pulmonary, Critical Care and Sleep Medicine and Hertzberg Palliative Care Institute, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | |
Collapse
|