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Protti A, Tonelli R, Dalla Corte F, Grieco DL, Spinelli E, Spadaro S, Piovani D, Menga LS, Schifino G, Vega Pittao ML, Umbrello M, Cammarota G, Volta CA, Bonovas S, Cecconi M, Mauri T, Clini E. Development of clinical tools to estimate the breathing effort during high-flow oxygen therapy: A multicenter cohort study. Pulmonology 2024:S2531-0437(24)00054-0. [PMID: 38760225 DOI: 10.1016/j.pulmoe.2024.04.008] [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: 03/05/2024] [Revised: 04/11/2024] [Accepted: 04/22/2024] [Indexed: 05/19/2024] Open
Abstract
INTRODUCTION AND OBJECTIVES Quantifying breathing effort in non-intubated patients is important but difficult. We aimed to develop two models to estimate it in patients treated with high-flow oxygen therapy. PATIENTS AND METHODS We analyzed the data of 260 patients from previous studies who received high-flow oxygen therapy. Their breathing effort was measured as the maximal deflection of esophageal pressure (ΔPes). We developed a multivariable linear regression model to estimate ΔPes (in cmH2O) and a multivariable logistic regression model to predict the risk of ΔPes being >10 cmH2O. Candidate predictors included age, sex, diagnosis of the coronavirus disease 2019 (COVID-19), respiratory rate, heart rate, mean arterial pressure, the results of arterial blood gas analysis, including base excess concentration (BEa) and the ratio of arterial tension to the inspiratory fraction of oxygen (PaO2:FiO2), and the product term between COVID-19 and PaO2:FiO2. RESULTS We found that ΔPes can be estimated from the presence or absence of COVID-19, BEa, respiratory rate, PaO2:FiO2, and the product term between COVID-19 and PaO2:FiO2. The adjusted R2 was 0.39. The risk of ΔPes being >10 cmH2O can be predicted from BEa, respiratory rate, and PaO2:FiO2. The area under the receiver operating characteristic curve was 0.79 (0.73-0.85). We called these two models BREF, where BREF stands for BReathing EFfort and the three common predictors: BEa (B), respiratory rate (RE), and PaO2:FiO2 (F). CONCLUSIONS We developed two models to estimate the breathing effort of patients on high-flow oxygen therapy. Our initial findings are promising and suggest that these models merit further evaluation.
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Affiliation(s)
- A Protti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.
| | - R Tonelli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena-Reggio Emilia, Modena, Italy; Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena-Reggio Emilia, Modena, Italy
| | - F Dalla Corte
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - D L Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - E Spinelli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - S Spadaro
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - D Piovani
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - L S Menga
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - G Schifino
- Respiratory and Critical Care Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy; Alma Mater Studiorum, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - M L Vega Pittao
- Respiratory and Critical Care Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy; Alma Mater Studiorum, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - M Umbrello
- SC Rianimazioine e Anestesia, ASST Ovest Milanese, Ospedale Civile di Legnano, Legnano, Milan, Italy
| | - G Cammarota
- Department of Traslational Medicine, Università degli Studi del Piemonte Orientale, Novara, Italy
| | - C A Volta
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - S Bonovas
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - M Cecconi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - T Mauri
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - E Clini
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena-Reggio Emilia, Modena, Italy; Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena-Reggio Emilia, Modena, Italy
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Mohan V, Rathinam C, Yates D, Paungmali A, Boos C. Validity and reliability of outcome measures to assess dysfunctional breathing: a systematic review. BMJ Open Respir Res 2024; 11:e001884. [PMID: 38626928 PMCID: PMC11029193 DOI: 10.1136/bmjresp-2023-001884] [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: 06/23/2023] [Accepted: 03/15/2024] [Indexed: 04/19/2024] Open
Abstract
OBJECTIVE This study aimed to systematically review the psychometric properties of outcome measures that assess dysfunctional breathing (DB) in adults. METHODS Studies on developing and evaluating measurement properties to assess DB were included. The study investigated the empirical research published between 1990 and February 2022, with an updated search in May 2023 in the Cochrane Library database of systematic reviews and the Cochrane Central Register of Controlled Trials, the Ovid Medline (full), the Ovid Excerta Medica Database, the Ovid allied and complementary medicines database, the Ebscohost Cumulative Index to Nursing and Allied Health Literature and the Physiotherapy Evidence Database. The included studies' methodological quality was assessed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) risk of bias checklist. Data analysis and synthesis followed the COSMIN methodology for reviews of outcome measurement instruments. RESULTS Sixteen studies met the inclusion criteria, and 10 outcome measures were identified. The psychometric properties of these outcome measures were evaluated using COSMIN. The Nijmegen Questionnaire (NQ) is the only outcome measure with 'sufficient' ratings for content validity, internal consistency, reliability and construct validity. All other outcome measures did not report characteristics of content validity in the patients' group. DISCUSSION The NQ showed high-quality evidence for validity and reliability in assessing DB. Our review suggests that using NQ to evaluate DB in people with bronchial asthma and hyperventilation syndrome is helpful. Further evaluation of the psychometric properties is needed for the remaining outcome measures before considering them for clinical use. PROSPERO REGISTRATION NUMBER CRD42021274960.
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Affiliation(s)
- Vikram Mohan
- Department of Rehabilitation and Sports Sciences, Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, UK
| | - Chandrasekar Rathinam
- University of Birmingham, Birmingham, UK
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Derick Yates
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Aatit Paungmali
- Department of Physical Therapy, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Christopher Boos
- Cardiology Department, University Hospitals Dorset NHS Foundation Trust, Poole, UK
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, UK
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Lin L, Wang P, Zheng H, Zhong Z, Zhuansun Y, Yang Z, Chen R. RESPIRATORY MECHANICS AND NEURAL RESPIRATORY DRIVE OF UNTREATED GASPING DURING CARDIAC ARREST IN A PORCINE MODEL. Shock 2023; 59:948-954. [PMID: 37018832 DOI: 10.1097/shk.0000000000002127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
ABSTRACT Introduction: Although the effects on hemodynamics of gasping during cardiac arrest (CA) have received a lot of attention, less is known about the respiratory mechanics and physiology of respiration in gasping. This study aimed to investigate the respiratory mechanics and neural respiratory drive of gasping during CA in a porcine model. Method: Pigs weighing 34.9 ± 5.7 kg were anesthetized intravenously. Ventricular fibrillation (VF) was electrically induced and untreated for 10 min. Mechanical ventilation (MV) was ceased immediately after the onset of VF. Hemodynamic and respiratory parameters, pressure signals, diaphragmatic electromyogram data, and blood gas analysis data were recorded. Results: Gasping was observed in all the animals at a significantly lower rate (2-5 gaps/min), with higher tidal volume ( VT ; 0.62 ± 0.19 L, P < 0.01), and with lower expired minute volume (2.51 ± 1.49 L/min, P < 0.001) in comparison with the baseline. The total respiratory cycle time and the expiratory time tended to be lengthened. Statistically significant elevations in transdiaphragmatic pressure, the pressure-time product of diaphragmatic pressure, and the mean of root mean square diaphragmatic electromyogram values (RMSmean) were observed ( P < 0.05, P < 0.05, and P < 0.001, respectively); however, VT /RMSmean and transdiaphragmatic pressure/RMSmean were reduced at all time points. The partial pressure of oxygen showed a continuous decline after VF to reach statistical significance in the 10th minute (9.46 ± 0.96 kPa, P < 0.001), whereas the partial pressure of carbon dioxide tended to first rise and then fall. Conclusions: Gasping during CA was characterized by high VT , extremely low frequency, and prolonged expiratory time, which may improve hypercapnia. During gasping, increased work of breathing and insufficient neuromechanical efficacy of neural respiratory drive suggested the necessity of MV and appropriate management strategies for MV during resuscitation after CA.
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Affiliation(s)
- Lin Lin
- Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou
| | - Pengfei Wang
- Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou
| | | | - Zheye Zhong
- Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou
| | - Yongxun Zhuansun
- Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou
| | - Zhengfei Yang
- Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou
| | - Rui Chen
- Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou
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Kneyber MCJ, Khemani RG, Bhalla A, Blokpoel RGT, Cruces P, Dahmer MK, Emeriaud G, Grunwell J, Ilia S, Katira BH, Lopez-Fernandez YM, Rajapreyar P, Sanchez-Pinto LN, Rimensberger PC. Understanding clinical and biological heterogeneity to advance precision medicine in paediatric acute respiratory distress syndrome. THE LANCET. RESPIRATORY MEDICINE 2023; 11:197-212. [PMID: 36566767 PMCID: PMC10880453 DOI: 10.1016/s2213-2600(22)00483-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/14/2022] [Accepted: 11/15/2022] [Indexed: 12/24/2022]
Abstract
Paediatric acute respiratory distress syndrome (PARDS) is a heterogeneous clinical syndrome that is associated with high rates of mortality and long-term morbidity. Factors that distinguish PARDS from adult acute respiratory distress syndrome (ARDS) include changes in developmental stage and lung maturation with age, precipitating factors, and comorbidities. No specific treatment is available for PARDS and management is largely supportive, but methods to identify patients who would benefit from specific ventilation strategies or ancillary treatments, such as prone positioning, are needed. Understanding of the clinical and biological heterogeneity of PARDS, and of differences in clinical features and clinical course, pathobiology, response to treatment, and outcomes between PARDS and adult ARDS, will be key to the development of novel preventive and therapeutic strategies and a precision medicine approach to care. Studies in which clinical, biomarker, and transcriptomic data, as well as informatics, are used to unpack the biological and phenotypic heterogeneity of PARDS, and implementation of methods to better identify patients with PARDS, including methods to rapidly identify subphenotypes and endotypes at the point of care, will drive progress on the path to precision medicine.
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Affiliation(s)
- Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands; Critical Care, Anaesthesiology, Peri-operative and Emergency Medicine, University of Groningen, Groningen, Netherlands.
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Paediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Anoopindar Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Paediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Robert G T Blokpoel
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Pablo Cruces
- Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Mary K Dahmer
- Department of Pediatrics, Division of Critical Care, University of Michigan, Ann Arbor, MI, USA
| | - Guillaume Emeriaud
- Department of Pediatrics, CHU Sainte Justine, Université de Montréal, Montreal, QC, Canada
| | - Jocelyn Grunwell
- Department of Pediatrics, Division of Critical Care, Emory University, Atlanta, GA, USA
| | - Stavroula Ilia
- Pediatric Intensive Care Unit, University Hospital, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Bhushan H Katira
- Department of Pediatrics, Division of Critical Care Medicine, Washington University in St Louis, St Louis, MO, USA
| | - Yolanda M Lopez-Fernandez
- Pediatric Intensive Care Unit, Department of Pediatrics, Cruces University Hospital, Biocruces-Bizkaia Health Research Institute, Bizkaia, Spain
| | - Prakadeshwari Rajapreyar
- Department of Pediatrics (Critical Care), Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI, USA
| | - L Nelson Sanchez-Pinto
- Department of Pediatrics (Critical Care), Northwestern University Feinberg School of Medicine and Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Peter C Rimensberger
- Division of Neonatology and Paediatric Intensive Care, Department of Paediatrics, University Hospital of Geneva, University of Geneva, Geneva, Switzerland
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Rogal SS, Hansen L, Patel A, Ufere NN, Verma M, Woodrell CD, Kanwal F. AASLD Practice Guidance: Palliative care and symptom-based management in decompensated cirrhosis. Hepatology 2022; 76:819-853. [PMID: 35103995 PMCID: PMC9942270 DOI: 10.1002/hep.32378] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 01/14/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Shari S. Rogal
- Departments of Medicine and Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare Center, Pittsburgh, Pennsylvania, USA
| | - Lissi Hansen
- School of Nursing, Oregon Health and Science University, Portland, Oregon, USA
| | - Arpan Patel
- Division of Digestive Diseases, David Geffen School of Medicine at University of California, Los Angeles, California, USA
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Nneka N. Ufere
- Liver Center, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Manisha Verma
- Department of Medicine, Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
| | - Christopher D. Woodrell
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Geriatric Research, Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA
| | - Fasiha Kanwal
- Sections of Gastroenterology and Hepatology and Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
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Web Applications for Teaching the Respiratory System: Content Validation. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12094289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The subject of respiratory mechanics has complex characteristics, functions, and interactions that can be difficult to understand in training and medical education contexts. As such, education strategies based on computational simulations comprise useful tools, but their application in the medical area requires stricter validation processes. This paper shows a statistical and a Delphi validation for two modules of a web application used for respiratory system learning: (I) “Anatomy and Physiology” and (II) “Work of Breathing Indexes”. For statistical validation, population and individual analyses were made using a database of healthy men to compare experimental and model-predicted data. For both modules, the predicted values followed the trend marked by the experimental data in the population analysis, while in the individual analysis, the predicted errors were 9.54% and 25.38% for maximal tidal volume and airflow, respectively, and 6.55%, 9.33%, and 11.77% for rapid shallow breathing index, work of breathing, and maximal inspiratory pressure, respectively. For the Delphi validation, an average higher than 4 was obtained after health professionals evaluated both modules from 1 to 5. In conclusion, both modules are good tools for respiratory system learning processes. The studied parameters behaved consistently with the expressions that describe ventilatory dynamics and were correlated with experimental data; furthermore, they had great acceptance by specialists.
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Ashe WB, Innis SE, Shanno JN, Hochheimer CJ, Williams RD, Ratcliffe SJ, Moorman JR, Gadrey SM. Analysis of respiratory kinematics: a method to characterize breaths from motion signals. Physiol Meas 2022; 43. [PMID: 35045405 DOI: 10.1088/1361-6579/ac4d1a] [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: 09/14/2021] [Accepted: 01/19/2022] [Indexed: 11/12/2022]
Abstract
Breathing motion (respiratory kinematics) can be characterized by the interval and depth of each breath, and by magnitude-synchrony relationships between locations. Such characteristics and their breath-by-breath variability might be useful indicators of respiratory health. To enable breath-by-breath characterization of respiratory kinematics, we developed a method to detect breaths using motion sensors. In 34 volunteers who underwent maximal exercise testing, we used 8 motion sensors to record upper rib, lower rib and abdominal kinematics at 3 exercise stages (rest, lactate threshold and exhaustion). We recorded volumetric air flow signals using clinical exercise laboratory equipment and synchronized them with kinematic signals. Using instantaneous phase landmarks from the analytic representation of kinematic and flow signals, we identified individual breaths and derived respiratory rate (RR) signals at 1Hz. To evaluate the fidelity of kinematics-derived RR, we calculated bias, limits of agreement, and cross-correlation coefficients (CCC) relative to flow-derived RR. To identify coupling between kinematics and flow, we calculated the Shannon entropy of the relative frequency with which flow landmarks were distributed over the phase of the kinematic cycle. We found good agreement in the kinematics-derived and flow-derived RR signals [bias (95% limit of agreement) = 0.1 (± 7) breaths/minute; CCC median (IQR) = 0.80 (0.48 - 0.91)]. In individual signals, kinematics and flow were well-coupled (entropy 0.9-1.4 across sensors), but the relationship varied within (by exercise stage) and between individuals. The final result was that the flow landmarks did not consistently localize to any particular phase of the kinematic signals (entropy 2.2-3.0 across sensors). The Analysis of Respiratory Kinematics method can yield highly resolved respiratory rate signals by separating individual breaths. This method will facilitate characterization of clinically significant breathing motion patterns on a breath-by-breath basis. The relationship between respiratory kinematics and flow is much more complex than expected, varying between and within individuals.
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Affiliation(s)
- William Bonner Ashe
- Electrical and Computer Engineering, University of Virginia, Thornton Hall, 351 McCormick Road, Charlottesville, Virginia, 22904, UNITED STATES
| | - Sarah E Innis
- Biomedical Engineering, University of Virginia, Thornton Hall, 351 McCormick Road, Charlottesville, Virginia, 22904, UNITED STATES
| | - Julia N Shanno
- Biomedical Engineering, University of Virginia, Thornton Hall, 351 McCormick Road, Charlottesville, Virginia, 22904, UNITED STATES
| | - Camille J Hochheimer
- Public Health Sciences, University of Virginia, P.O. Box 800717, Charlottesville, Virginia, 22908, UNITED STATES
| | - Ronald Dean Williams
- Electrical and Computer Engineering, University of Virginia, Thornton Hall, 351 McCormick Road, Charlottesville, Virginia, 22904, UNITED STATES
| | - Sarah Jane Ratcliffe
- Public Health Sciences, University of Virginia, P.O. Box 800717, Charlottesville, Virginia, 22908, UNITED STATES
| | - J Randall Moorman
- Department of Medicine, University of Virginia, Division of Cardiovascular Medicine, Charlottesville VA, USA, Charlottesville, 22908, UNITED STATES
| | - Shrirang Mukund Gadrey
- Medicine, University of Virginia, PO box 800901, Charlottesville, Virginia, 22908, UNITED STATES
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Dhala A, Gotur D, Hsu SHL, Uppalapati A, Hernandez M, Alegria J, Masud F. A Year of Critical Care: The Changing Face of the ICU During COVID-19. Methodist Debakey Cardiovasc J 2021; 17:31-42. [PMID: 35855452 PMCID: PMC9244858 DOI: 10.14797/mdcvj.1041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 09/17/2021] [Indexed: 11/10/2022] Open
Abstract
During the SARS-CoV-2 pandemic, admissions to hospital intensive care units (ICUs) surged, exerting unprecedented stress on ICU resources and operations. The novelty of the highly infectious coronavirus disease 2019 (COVID-19) required significant changes to the way critically ill patients were managed. Houston Methodist’s incident command center team navigated this health crisis by ramping up its bed capacity, streamlining treatment algorithms, and optimizing ICU staffing while ensuring adequate supplies of personal protective equipment (PPE), ventilators, and other ICU essentials. A tele–critical-care program and its infrastructure were deployed to meet the demands of the pandemic. Community hospitals played a vital role in creating a collaborative ecosystem for the treatment and referral of critically ill patients. Overall, the healthcare industry’s response to COVID-19 forced ICUs to become more efficient and dynamic, with improved patient safety and better resource utilization. This article provides an experiential account of Houston Methodist’s response to the pandemic and discusses the resulting impact on the function of ICUs.
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Affiliation(s)
- Atiya Dhala
- Houston Methodist Hospital, Houston, Texas, US
| | - Deepa Gotur
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, US
| | - Steven Huan-Ling Hsu
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, US
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Frost DW, Shah R, Melvin L, de Juana MG, MacMillan TE, Abdelhalim T, Lai A, Rawal S, Cavalcanti RB. Principles for clinical care of patients with COVID-19 on medical units. CMAJ 2020; 192:E720-E726. [PMID: 32493744 DOI: 10.1503/cmaj.200855] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- David W Frost
- Department of Medicine (Abdelhalim, Cavalcanti, Frost, Lai, MacMillan, Melvin, Rawal, Shah), University of Toronto; Division of General Internal Medicine (Abdelhalim, Cavalcanti, Frost, MacMillan, Melvin, Rawal, Shah), University Health Network; HoPingKong Centre for Excellence in Education and Practice, Centre for Innovation in Complex Care (Abdelhalim, Cavalcanti, Frost, Lai, MacMillan, Melvin, Rawal, Shah), University Health Network, Toronto, Ont.; Department of Internal Medicine (Galán de Juana), Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Rupal Shah
- Department of Medicine (Abdelhalim, Cavalcanti, Frost, Lai, MacMillan, Melvin, Rawal, Shah), University of Toronto; Division of General Internal Medicine (Abdelhalim, Cavalcanti, Frost, MacMillan, Melvin, Rawal, Shah), University Health Network; HoPingKong Centre for Excellence in Education and Practice, Centre for Innovation in Complex Care (Abdelhalim, Cavalcanti, Frost, Lai, MacMillan, Melvin, Rawal, Shah), University Health Network, Toronto, Ont.; Department of Internal Medicine (Galán de Juana), Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Lindsay Melvin
- Department of Medicine (Abdelhalim, Cavalcanti, Frost, Lai, MacMillan, Melvin, Rawal, Shah), University of Toronto; Division of General Internal Medicine (Abdelhalim, Cavalcanti, Frost, MacMillan, Melvin, Rawal, Shah), University Health Network; HoPingKong Centre for Excellence in Education and Practice, Centre for Innovation in Complex Care (Abdelhalim, Cavalcanti, Frost, Lai, MacMillan, Melvin, Rawal, Shah), University Health Network, Toronto, Ont.; Department of Internal Medicine (Galán de Juana), Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Miguel Galán de Juana
- Department of Medicine (Abdelhalim, Cavalcanti, Frost, Lai, MacMillan, Melvin, Rawal, Shah), University of Toronto; Division of General Internal Medicine (Abdelhalim, Cavalcanti, Frost, MacMillan, Melvin, Rawal, Shah), University Health Network; HoPingKong Centre for Excellence in Education and Practice, Centre for Innovation in Complex Care (Abdelhalim, Cavalcanti, Frost, Lai, MacMillan, Melvin, Rawal, Shah), University Health Network, Toronto, Ont.; Department of Internal Medicine (Galán de Juana), Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Thomas E MacMillan
- Department of Medicine (Abdelhalim, Cavalcanti, Frost, Lai, MacMillan, Melvin, Rawal, Shah), University of Toronto; Division of General Internal Medicine (Abdelhalim, Cavalcanti, Frost, MacMillan, Melvin, Rawal, Shah), University Health Network; HoPingKong Centre for Excellence in Education and Practice, Centre for Innovation in Complex Care (Abdelhalim, Cavalcanti, Frost, Lai, MacMillan, Melvin, Rawal, Shah), University Health Network, Toronto, Ont.; Department of Internal Medicine (Galán de Juana), Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Tarek Abdelhalim
- Department of Medicine (Abdelhalim, Cavalcanti, Frost, Lai, MacMillan, Melvin, Rawal, Shah), University of Toronto; Division of General Internal Medicine (Abdelhalim, Cavalcanti, Frost, MacMillan, Melvin, Rawal, Shah), University Health Network; HoPingKong Centre for Excellence in Education and Practice, Centre for Innovation in Complex Care (Abdelhalim, Cavalcanti, Frost, Lai, MacMillan, Melvin, Rawal, Shah), University Health Network, Toronto, Ont.; Department of Internal Medicine (Galán de Juana), Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Alison Lai
- Department of Medicine (Abdelhalim, Cavalcanti, Frost, Lai, MacMillan, Melvin, Rawal, Shah), University of Toronto; Division of General Internal Medicine (Abdelhalim, Cavalcanti, Frost, MacMillan, Melvin, Rawal, Shah), University Health Network; HoPingKong Centre for Excellence in Education and Practice, Centre for Innovation in Complex Care (Abdelhalim, Cavalcanti, Frost, Lai, MacMillan, Melvin, Rawal, Shah), University Health Network, Toronto, Ont.; Department of Internal Medicine (Galán de Juana), Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Shail Rawal
- Department of Medicine (Abdelhalim, Cavalcanti, Frost, Lai, MacMillan, Melvin, Rawal, Shah), University of Toronto; Division of General Internal Medicine (Abdelhalim, Cavalcanti, Frost, MacMillan, Melvin, Rawal, Shah), University Health Network; HoPingKong Centre for Excellence in Education and Practice, Centre for Innovation in Complex Care (Abdelhalim, Cavalcanti, Frost, Lai, MacMillan, Melvin, Rawal, Shah), University Health Network, Toronto, Ont.; Department of Internal Medicine (Galán de Juana), Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Rodrigo B Cavalcanti
- Department of Medicine (Abdelhalim, Cavalcanti, Frost, Lai, MacMillan, Melvin, Rawal, Shah), University of Toronto; Division of General Internal Medicine (Abdelhalim, Cavalcanti, Frost, MacMillan, Melvin, Rawal, Shah), University Health Network; HoPingKong Centre for Excellence in Education and Practice, Centre for Innovation in Complex Care (Abdelhalim, Cavalcanti, Frost, Lai, MacMillan, Melvin, Rawal, Shah), University Health Network, Toronto, Ont.; Department of Internal Medicine (Galán de Juana), Hospital Universitario Fundación Alcorcón, Madrid, Spain
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Finette BA, McLaughlin M, Scarpino SV, Canning J, Grunauer M, Teran E, Bahamonde M, Quizhpe E, Shah R, Swedberg E, Rahman KA, Khondker H, Chakma I, Muhoza D, Seck A, Kabore A, Nibitanga S, Heath B. Development and Initial Validation of a Frontline Health Worker mHealth Assessment Platform (MEDSINC ®) for Children 2-60 Months of Age. Am J Trop Med Hyg 2020; 100:1556-1565. [PMID: 30994099 PMCID: PMC6553915 DOI: 10.4269/ajtmh.18-0869] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Approximately 3 million children younger than 5 years living in low- and middle-income countries (LMICs) die each year from treatable clinical conditions such as pneumonia, dehydration secondary to diarrhea, and malaria. A majority of these deaths could be prevented with early clinical assessments and appropriate therapeutic intervention. In this study, we describe the development and initial validation testing of a mobile health (mHealth) platform, MEDSINC®, designed for frontline health workers (FLWs) to perform clinical risk assessments of children aged 2–60 months. MEDSINC is a web browser–based clinical severity assessment, triage, treatment, and follow-up recommendation platform developed with physician-based Bayesian pattern recognition logic. Initial validation, usability, and acceptability testing were performed on 861 children aged between 2 and 60 months by 49 FLWs in Burkina Faso, Ecuador, and Bangladesh. MEDSINC-based clinical assessments by FLWs were independently and blindly correlated with clinical assessments by 22 local health-care professionals (LHPs). Results demonstrate that clinical assessments by FLWs using MEDSINC had a specificity correlation between 84% and 99% to LHPs, except for two outlier assessments (63% and 75%) at one study site, in which local survey prevalence data indicated that MEDSINC outperformed LHPs. In addition, MEDSINC triage recommendation distributions were highly correlated with those of LHPs, whereas usability and feasibility responses from LHP/FLW were collectively positive for ease of use, learning, and job performance. These results indicate that the MEDSINC platform could significantly increase pediatric health-care capacity in LMICs by improving FLWs’ ability to accurately assess health status and triage of children, facilitating early life-saving therapeutic interventions.
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Affiliation(s)
- Barry A Finette
- THINKMD, Inc., Burlington, Vermont.,University of Vermont Robert Larner College of Medicine, Vermont Children's Hospital, Burlington, Vermont
| | | | | | | | | | | | | | - Edy Quizhpe
- University of San Francisco de Quito- Ecuador Ministry of Health-Affiliate, Quito, Ecuador
| | - Rashed Shah
- Save the Children - US, Fairfield, Connecticut
| | | | | | | | - Ituki Chakma
- Save the Children - International Bangladesh, Dhaka, Bangladesh
| | | | - Awa Seck
- UNICEF-Burkina Faso, Ouagadougou, Burkina Faso
| | | | | | - Barry Heath
- THINKMD, Inc., Burlington, Vermont.,University of Vermont Robert Larner College of Medicine, Vermont Children's Hospital, Burlington, Vermont
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Ruiz Ferrón F, Serrano Simón J. La monitorización convencional no es suficiente para valorar el esfuerzo respiratorio durante la ventilación asistida. Med Intensiva 2019; 43:197-206. [DOI: 10.1016/j.medin.2018.02.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 01/25/2018] [Accepted: 02/14/2018] [Indexed: 12/28/2022]
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Abstract
OBJECTIVES To derive and validate a score that correlates with an objective measurement of a child's effort of breathing. DESIGN Secondary analysis of a previously conducted observational study. SETTING The pediatric and cardiothoracic ICUs of a quaternary-care children's hospital. PATIENTS Patients more than 37 weeks gestational age to age 18 years who were undergoing extubation. INTERVENTIONS Effort of breathing was measured in patients following extubation using esophageal manometry to calculate pressure rate product. Simultaneously, members of a multidisciplinary team (nurse, physician, and respiratory therapist) assessed respiratory function using a previously validated tool. Elements of the tool that were significantly associated with pressure rate product in univariate analysis were identified and included in a multivariate model. An Effort of Breathing score was derived from the results of the model using data from half of the subjects (derivation cohort) and then validated using data from the remaining subjects (validation cohort) by calculating the area under the receiver operator characteristic curve for pressure rate product greater than 90th percentile and for the need for reintubation. MEASUREMENTS AND MAIN RESULTS Among 409 subjects, the median age was 5 months, and nearly half were cardiac surgery patients (49.1%). Retractions, stridor, and pulsus paradoxus were included in the Simple Score. Area under the receiver operator characteristic curve for pressure rate product greater than 90th percentile was 0.8359 (95% CI, 0.7996-0.8722) in the derivation cohort and 0.7930 (0.7524-0.8337) in the validation cohort. Area under the receiver operator characteristic curve for reintubation was 0.7280 (0.6807-0.7752) when all scores were analyzed individually and was 0.7548 (0.6644-0.8452) if scores from three clinicians from different disciplines were summated. Results were similar regardless of provider discipline or training. CONCLUSIONS A scoring system was derived and validated, performed acceptably to predict increased effort of breathing or need for advanced respiratory support and may function best when used by a team.
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DiapHRaGM: A mnemonic to describe the work of breathing in patients with respiratory failure. PLoS One 2017; 12:e0179641. [PMID: 28671972 PMCID: PMC5495207 DOI: 10.1371/journal.pone.0179641] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Accepted: 06/01/2017] [Indexed: 11/19/2022] Open
Abstract
Background The assessment of the work of breathing in the definitions of respiratory failure is vague and variable. Objective Identify a parsimonious set of signs to describe the work of breathing in hypoxemic, acutely ill patients. Methods We examined consecutive medical ICU patients receiving oxygen with a mask, non-invasive ventilation, or T-piece. A physician inspected each patient for 10 seconds, rated the level of respiratory distress, and then examined the patient for vital signs and 17 other physical signs. We used the rating of distress as a surrogate for measuring the work of breathing, constructed three multivariate models to identify the one with the smallest number of signs and largest explained variance, and validated it with bootstrap analysis. Results We performed 402 observations on 240 patients. Respiratory distress was absent in 78, mild in 157, moderate in 107, and severe in 60. Respiratory rate, hypoxia, heart rate, and frequency of most signs increased as distress increased. Respiratory rate and hypoxia explained 43% of the variance in respiratory distress. Diaphoresis, gasping, and contraction of the sternomastoid explained an additional 28%. Heart rate, blood pressure, alertness, agitation, body posture, nasal flaring, audible breathing, cyanosis, tracheal tug, retractions, paradox, scalene or abdominal muscles contraction did not increase the explained variance in respiratory distress. Conclusion Most of the variance is respiratory distress can be explained by five signs summarized by the mnemonic DiapHRaGM (diaphoresis, hypoxia, respiratory rate, gasping, accessory muscle). This set of signs may allow for efficient, standardized assessments of the work of breathing of hypoxic patients.
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Medical Devices for Pediatric Apnea Monitoring and Therapy: Past and New Trends. IEEE Rev Biomed Eng 2017; 10:199-212. [DOI: 10.1109/rbme.2017.2757899] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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