Invasive diagnostic strategies in immunosuppressed patients with acute respiratory distress syndrome

Mortality Risk Factors in Patients Admitted with the Primary Diagnosis of Tracheostomy Complications: An Analysis of 8026 Patients

Background: Tracheostomy is a procedure commonly conducted in patients undergoing emergency admission and requires prolonged mechanical ventilation. In the present study, the aim was to determine the prevalence and risk factors of mortality among emergently admitted patients with tracheostomy complications, during the years 2005−2014. Methods: This was a retrospective cohort study. Demographics and clinical data were obtained from the National Inpatient Sample, 2005−2014, to evaluate elderly (65+ years) and non-elderly adult patients (18−64 years) with tracheostomy complications (ICD-9 code, 519) who underwent emergency admission. A multivariable logistic regression model with backward elimination was used to identify the association between predictors and in-hospital mortality. Results: A total of 4711 non-elderly and 3315 elderly patients were included. Females included 44.5% of the non-elderly patients and 47.6% of the elderly patients. In total, 181 (3.8%) non-elderly patients died, of which 48.1% were female, and 163 (4.9%) elderly patients died, of which 48.5% were female. The mean (SD) age of the non-elderly patients was 50 years and for elderly patients was 74 years. The mean age at the time of death of non-elderly patients was 53 years and for elderly patients was 75 years. The odds ratio (95% confidence interval, p-value) of some of the pertinent risk factors for mortality showed by the final regression model were older age (OR = 1.007, 95% CI: 1.001−1.013, p < 0.02), longer hospital length of stay (OR = 1.008, 95% CI: 1.001−1.016, p < 0.18), cardiac disease (OR = 3.21, 95% CI: 2.48−4.15, p < 0.001), and liver disease (OR = 2.61, 95% CI: 1.73−3.93, p < 0.001). Conclusion: Age, hospital length of stay, and several comorbidities have been shown to be significant risk factors in in-hospital mortality in patients admitted emergently with the primary diagnosis of tracheostomy complications. Each year of age increased the risk of mortality by 0.7% and each additional day in the hospital increased it by 0.8%.

Role of bronchoscopy in critically ill patients managed in intermediate care units - indications and complications: A narrative review

Flexible bronchoscopy (FB) has become a standard of care for the triad of inspection, sampling, and treatment in critical care patients. It is an invaluable tool for diagnostic and therapeutic purposes in critically ill patients in intensive care unit (ICU). Less is known about its role outside the ICU, particularly in the intermediate care unit (IMCU), a specialized environment, where an intermediate grade of intensive care and monitoring between standard care unit and ICU is provided. In the IMCU, the leading indications for a diagnostic work-up are: To visualize airway system/obstructions, perform investigations to detect respiratory infections, and identify potential sources of hemoptysis. The main procedures for therapeutic purposes are secretion aspiration, mucus plug removal to solve atelectasis (total or lobar), and blood aspiration during hemoptysis. The decision to perform FB might depend on the balance between potential benefits and risks due to frailty of critically ill patients. Serious adverse events related to FB are relatively uncommon, but they may be due to lack of expertise or appropriate precautions. Finally, nowadays, during dramatic recent coronavirus disease 2019 (COVID-19) pandemic, the exact role of FB in COVID-19 patients admitted to IMCU has yet to be clearly defined. Hence, we provide a concise review on the role of FB in an IMCU setting, focusing on its indications, technical aspects and complications.

The use of bronchoscopy in critically ill patients: considerations and complications

INTRODUCTION

Flexible bronchoscopy has been well established for diagnostic and therapeutic purposes in critically ill patients. Areas covered: This review outlines the clinical evidence of the utility and safety of flexible bronchoscopy in the intensive care unit, as well as specific considerations, including practical points and potential complications, in critically ill patients. Expert commentary: Its ease to learn and perform and its capacity for bedside application with relatively few complications make flexible bronchoscopy an indispensable tool in the intensive care unit setting. The main indications for flexible bronchoscopy in the intensive care unit are the visualization of the airways, sampling for diagnostic purposes and management of the artificial airways. The decision to perform flexible bronchoscopy can only be made by trade-offs between potential risks and benefits because of the fragile nature of the critically ill. Flexible bronchoscopy-associated serious adverse events are inevitable in cases of a lack of expertise or appropriate precautions.