Neumonía asociada a la ventilación mecánica

Clinical Challenges in Pediatric Ventilation Liberation: A Meta-Narrative Review

OBJECTIVES

To map the evidence for ventilation liberation practices in pediatric respiratory failure using the Realist And MEta-narrative Evidence Syntheses: Evolving Standards publication standards.

DATA SOURCES

CINAHL, MEDLINE, COCHRANE, and EMBASE. Trial registers included the following: ClinicalTrials.gov, European Union clinical trials register, International Standardized Randomized Controlled Trial Number register.

STUDY SELECTION

Abstracts were screened followed by review of full text. Articles published in English language incorporating a heterogeneous population of both infants and older children were assessed.

DATA EXTRACTION

None.

DATA SYNTHESIS

Weaning can be considered as the process by which positive pressure is decreased and the patient becomes increasingly responsible for generating the energy necessary for effective gas exchange. With the growing use of noninvasive respiratory support, extubation can lie in the middle of the weaning process if some additional positive pressure is used after extubation, while for some extubation may constitute the end of weaning. Testing for extubation readiness is a key component of the weaning process as it allows the critical care practitioner to assess the capability and endurance of the patient's respiratory system to resume unassisted ventilation. Spontaneous breathing trials (SBTs) are often seen as extubation readiness testing (ERT), but the SBT is used to determine if the patient can maintain adequate spontaneous ventilation with minimal ventilatory support, whereas ERT implies the patient is ready for extubation.

CONCLUSIONS

Current literature suggests using a structured approach that includes a daily assessment of patient's readiness to extubate may reduce total ventilation time. Increasing evidence indicates that such daily assessments needs to include SBTs without added pressure support. Measures of elevated load as well as measures of impaired respiratory muscle capacity are independently associated with extubation failure in children, indicating that these should also be assessed as part of ERT.

Prevalencia y factores asociados a neumonía nosocomial en la unidad de cuidado intensivo

Introducción. La neumonía nosocomial o neumonía adquirida en el hospital, es una causa importante de infección intrahospitalaria que conlleva una alta morbimortalidad. Ocurre a una tasa de 5 a 10 por cada 1,000 ingresos hospitalarios y se considera la causa más común de infección intrahospitalaria en Europa y Estados Unidos. Más del 90% de los episodios de neumonía que se desarrollan en las unidades de cuidados intensivos (UCI) ocurren en pacientes ventilados. El objetivo del presente estudio es describir la prevalencia y los factores asociados como estancia hospitalaria en UCI, enfermedades concomitantes y situaciones en pacientes mayores de 18 años con neumonía nosocomial con estancia en unidad de cuidados intensivos en una clínica de tercer nivel de la ciudad de Cali, en el periodo enero 2015 y enero 2016. Metodología. Estudio observacional de corte transversal con componente analítico. Se revisaron 353 historias clínicas enfocadas en los factores asociados de neumonía nosocomial en la UCI, con una estancia mayor o igual a 48 horas. El análisis estadístico se realizó con Epi Info versión 7. Resultados. La edad promedio de los casos estudiados fue de 55.17 años. La prevalencia estimada para neumonía nosocomial fue de 26%, con un promedio de estancia en UCI de 9.94 días, una desviación estándar de 8.30 días y días de ventilación mecánica invasiva de 4.27, con una desviación estándar de 7.38 días, en la cual el 26.35% (IC 95%: 22.0-31.1) adquirió neumonía nosocomial en UCI, el 43.06%: (IC 95%: 38.0-48.2) fueron mujeres, requiriendo de ventilación mecánica invasiva el 37.68% (IC 95%: 32.7-42.8). Como antecedentes patológicos de importancia se observó una asociación entre las variables con respecto a la neumonía nosocomial evidenciándose una relación significativa con diabetes mellitus (OR: 25.6; IC: 95% 13.4-48.7), enfermedad renal crónica (OR: 8.4; IC 95%: 4.49-16.0), enfermedad pulmonar obstructiva crónica (OR: 22.2; IC 95% 11.7-42.1), antecedente patológico de sinusitis (OR: 30.9; IC 95%: 7-46.2), utilización de sonda nasogástrica (OR: 13; IC 95%: 5-32) y, finalmente, al correlacionar la mortalidad con este tipo de infección pulmonar (OR: 26.1; IC 95%: 13-49.1), evidenciando una relación entre las variables. Discusión. Los hallazgos muestran alta frecuencia de esta patología, lo que conlleva múltiples implicaciones en los pacientes como estancia prolongada y mortalidad, las cuales son condiciones que han sido identificadas por diferentes autores. Conclusiones. La neumonía nosocomial es un proceso infeccioso frecuente en la UCI, que tiene una alta morbimortalidad, relacionándose con los días de estancia y ventilación mecánica invasiva. 

Effect of pediatric ventilation weaning technique on work of breathing

Background

Ventilator liberation is one of the most challenging aspects in patients with respiratory failure. Most patients are weaned through a transition from full to partial respiratory support, whereas some advocate using a continuous spontaneous ventilation (CSV). However, there is little scientific evidence supporting the practice of pediatric ventilator liberation, including the timing of onset of and the approach to weaning mode. We sought to explore differences in patient effort between a pressure controlled continuous mode of ventilation (PC-CMV) [in this cohort PC assist/control (PC-A/C)] with a reduced ventilator rate and CSV, and to study changes in patient effort with decreasing PS.

Methods

In this prospective physiology cross-over study, we randomized children < 5 years to first PC-A/C with a 25% reduction in ventilator rate, or CSV (continuous positive airway pressure [CPAP] + PS). Patients were then crossed over to the other arm. Patient effort was measured by calculating inspiratory work of breathing (WOB) using the Campbell diagram (WOB_Campbell), and by pressure–rate-product (PRP) and pressure–time-product (PTP). Respiratory inductance plethysmography (RIP) was used to calculate the phase angle. Measurements were obtained at baseline, during PC-A/C and CPAP + PS, and during decreasing set PS (maximum -6 cmH₂O).

Results

Thirty-six subjects with a median age of 4.4 (IQR 1.5–11.9) months and median ventilation time of 4.9 (IQR 3.4–7.0) days were included. Nearly all patients (94.4%) were admitted with primary respiratory failure. WOB_Campbell during baseline [0.67 (IQR 0.38–1.07) Joules/L] did not differ between CSV [0.49 (IQR 0.17–0.83) Joules/L] or PC-A/C [0.47 (IQR 0.17–1.15) Joules/L]. Neither PRP, PTP, ∆Pes nor phase angle was different between the two ventilator modes. Reducing pressure support resulted in a statistically significant increase in patient effort, albeit that these differences were clinically negligible.

Conclusions

Patient effort during pediatric ventilation liberation was not increased when patients were in a CSV mode of ventilation compared to a ventilator mode with a ventilator back-up rate. Reducing the level of PS did not lead to clinically relevant increases in patient effort. These data may aid in a better approach to pediatric ventilation liberation.

Trial registration clinicaltrials.gov NCT05254691. Registered 24 February 2022

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02106-6.

[Critically ill patient isolation: risk or protection?]

INTRODUCTION

Isolation precautions are an effective measure to prevent the spread of multi-resistant microorganisms (MMR). However, its implementation is complex and can increase some risks to the patient. The aim of this study is to determine whether the implementation of isolation precautions increase the risk of patient safety incidents (PSI) in critically ill patients.

MATERIAL AND METHODS

A retrospective observational study was conducted involving patients admitted to the ICU of a University Hospital, and that required isolation for more than 48h. Period of study: two years (from 2013/03/01 to 2015/03/31). Data source was the electronic medical record. The tools for evaluation were the Modular Review Form questionnaires (MRF1 and MRF2). An analysis was made of PSI and adverse events (AEs) during periods with and without isolation precautions, including the PSI type, severity, and preventability.

RESULTS

The study included a total of 76 patients, 74 of whom had at least one PSI. A total of 798 PSI were detected (511 during isolation period), 599 were a No harm incident (NHI) and 199 were adverse AEs. The most frequent PSIs were associated with medication (316) and patient health care (279). Most of them were moderately or highly preventable. The incidence of PSI during periods with and without isolation was 27.3 (SD 33.8) and 29 (39.6) per 100 patient-days, respectively.

CONCLUSIONS

PSIs in ICU are frequent, and the most of them are preventable. The adoption of isolation precautions does not constitute a risk factor for PSI. Improving patient safety culture is essential for an adequate prevention strategy.

Differential molecular approach and ESBL detection from Klebsiella pneumoniae and Escherichia coli isolated from the supraglottic region of patients undergoing mechanical ventilation in an intensive care unit

Introduction: Given their ability for colonizing the supraglottic region, desiccation tolerance, resistance to β-lactam antibiotics, and adherence to both inert surfaces and epithelial cells, Klebsiella pneumoniae and Escherichia coli are potentially pathogenic microorganisms for patients undergoing mechanical ventilation in an intensive care unit (ICU).Objective: To perform a molecular characterization and detection of extended spectrum β-lactamases (ESBL) in K. pneumoniae and E. coli strains isolated from the supraglottic region of patients undergoing mechanical ventilation in an ICU.Materials and methods: A descriptive study was conducted in 18 isolates. Disk diffusion technique was used for detecting ESBL-producing bacteria. Molecular characterization was made by BOX-PCR technique, while ESBL production was confirmed by testing the isolates against cefotaxime and ceftazidime, alone and in combination with clavulanic acid.Results: a K. pneumoniae strain and another E. coli strain were confirmed as ESBL producers. A divergence greater than 50% was observed in most of the strains; besides non-infectious origin strains resistant to third generation cephalosporins were found.Conclusion: The polyclonality found in this study might indicate that most of the strains belong to each patient’s microbiota.

Diagnostic value of procalcitonin in ventilator-associated pneumonia

BACKGROUND AND OBJECTIVE

Procalcitonin (PCT) can help the early diagnosis of bacterial infections and estimate the response obtained. The objective is to study the value of PCT for the diagnosis of ventilator-associated pneumonia (VAP).

PATIENTS AND METHOD

Prospective and observational study, carried out for 18 months, in a polyvalent Intensive Care Unit (ICU). Those included were over 18 years of age, with suspected pneumonia after 48h of mechanical ventilation (MV). Collected were demographic characteristics; admission pathology; reason for beginning MV; gravity scores (APACHE II, SAPS II and SOFA); C-reactive protein (CRP) and PCT. At the time of suspicion of VAP: early or late, radiological severity, presence of septic shock, SOFA, CRP, PCT and microbiology.

RESULTS

Ninety-one patients with suspected VAP were included. The mean age was 42 (17.76) and that of hospitalisation in the ICU was 18.59 (11.69) days. VAP was confirmed in 74 patients, of which 19 (25.7%) presented septic shock. The mortality was 28.4%. There were no significant differences of the PCT in the patients who presented VAP versus those who did not present VAP (P=.449). When patients without VAP, with VAP and VAP with shock, were compared, the PCT median was 0.38 (CI95%: 0.22-1.90), 0.56 (CI95%: 0.19-1.77) and 1.93 (CI95%: 0.38-10.07), respectively (P=.169).

CONCLUSIONS

In our study, PCT did not prove useful for the diagnosis of VAP.

[Infections in critically ill patients]

Introducción

Las infecciones son muy frecuentes en los pacientes que se encuentran ingresados en los servicios de medicina intensiva, siendo unas veces motivo de ingreso y en otras la infección se adquiere durante el ingreso.

Epidemiologia

Las causas más frecuentes de infección adquirida en la comunidad que precisa ingreso en la UCI son las infecciones respiratorias, infecciones urinarias y las infecciones del sistema nervioso central. Dentro de las infecciones adquiridas en la UCI, las asociadas a dispositivos son las más frecuentes.

Etiología

Los gérmenes más frecuentes en la UCI son los Gram negativos.

Etiopatogenia. En el paciente crítico se aúnan factores, haciéndolos especialmente vulnerables a las infecciones.

Manifestaciones clínicas

Dependerán de la localización de la infección.

Diagnóstico

Debe ser precoz dada su alta mortalidad.

Pronóstico

Las infecciones nosocomiales se asocian con un aumento de la mortalidad y la estancia.

Tratamiento

El retraso en el tratamiento se asocia con un aumento de la mortalidad.

[Prevention of ventilator-associated pneumonia: a comparison of level of knowledge in three critical care units]

OBJECTIVE

To determine the level of knowledge of the prevention of ventilator-associated pneumonia guidelines of nurses working in three intensive care units (ICU) in 3 university hospitals in a Spanish region, and evaluate the relationship between this level of knowledge and years worked in the ICU.

METHOD

A descriptive, prospective, cross-sectional, multicentre study was conducted using a validated and reliable questionnaire, made up by 9 questions with closed answers drawn from the EVIDENCE study. A total of 98 questionnaires were collected from ICU nurses of the three university hospitals (A, B, and C) from January to April 2014. The sample from hospital A responded the most, in contrast with the sample from hospital B, which was the one with the less participation. The Pearson correlation was calculated in order to determine the relationship between nurse years worked in ICU and level of knowledge.

RESULTS

Hospital A obtained in the best mean score in the questionnaire, 6.33 (SD 1.4) points, followed by hospital C with 6.21 (SD 1.4), and finally, the hospital B with 6.06 (SD 1.5) points. A p=.08 was obtained on relating years worked with the level of knowledge.

CONCLUSION

The results showed a high level of knowledge compared other studies. There was a tendency between the years worked in the unit and the level of knowledge in ventilator-associated pneumonia prevention.

[Nosocomial pneumonia in ICU CHU Hassan II of Fez]

L'objectif principal de notre étude était d'identifier les bactéries incriminées dans la pneumopathie nosocomiale (PN) au service de réanimation A1 du CHU Hassan II de Fès, en vue d'en améliorer la prise en charge et de diminuer la morbi-mortalité associée. Il s'agit d'une étude rétrospective et descriptive, menée du 1er janvier 2012 au 31 décembre 2013. Seules les infections pulmonaires survenant au-delà de 48 heures de l'admission du patient au service de réanimation ont été incluses. L'incidence de la PN était de 11,2%. Les Bacilles à Gram négatif (BGN) étaient retrouvés dans 48,5% des cas, le Staphylocoque Aureus dans 21,21% des cas et le Klebsiella Pneumoniae était dans 10,7% des cas. Le taux de mortalité était de 48,33%. L’âge, la gravité de la pathologie sous jacente et le retard de l'instauration d'une antibiothérapie adaptée étaient considérées comme facteurs de mauvais pronostic. L’étude de la résistance aux antibiotiques, montre une multirésistance surtout pour les BGN, dont il faut tenir compte en mettant en place une stratégie de prévention active.

Evaluation of head-of-bed elevation compliance in critically ill patients under mechanical ventilation in a polyvalent intensive care unit

OBJECTIVES

To evaluate head-of-bed elevation (HOBE) compliance in mechanically ventilated (MV) patients during different time periods, in order to identify factors that may influence compliance and to compare direct-observation compliance with checklist-reported compliance.

DESIGN AND SETTING

A prospective observational study was carried out in a polyvalent Intensive Care Unit.

PATIENTS

All consecutive patients with MV and no contraindication for semi-recumbency were studied.

INTERVENTION AND VARIABLES

HOBE was observed during four periods of one month each for one year, the first period being blinded. HOBE was measured with an electronic device three times daily. Main variables were HOBE, type of airway device, type of bed, nursing shift, day of the week and checklist-reported compliance. No patient characteristics were collected.

RESULTS

During the four periods, 2639 observations were collected. Global HOBE compliance was 24.0%, and the median angle head-of-bed elevation (M-HOBE) was 24.0° (IQR 18.8-30.0). HOBE compliance and M-HOBE by periods were as follows: blinded period: 13.8% and 21.1° (IQR 16.3-24.4); period 1: 25.5% and 24.3° (IQR 18.8-30.2); period 2: 22.7% and 24.4° (IQR 18.9-29.6); and period 3: 31.4% and 26.7° (IQR 21.3-32.6) (p<0.001). An overestimation of 50-60% was found when comparing self-reported compliance using a checklist versus direct-observation compliance (p<0.001). Multivariate logistic regression analysis found the presence of an endotracheal tube (ET) and bed without HOBE measuring device to be independently associated to greater compliance (p<0.05).

CONCLUSIONS

Although compliance increased significantly during the study period, it was still not optimal. Checklist-reported compliance significantly overestimated HOBE compliance. The presence of an ET and a bed without HOBE measuring device was associated to greater compliance.

[Nosocomial pneumonia]

The hospital acquired pneumonia (HAP) is one of the most common infections acquired among hospitalised patients. Within the HAP, the ventilator-associated pneumonia (VAP) is the most common nosocomial infection complication among patients with acute respiratory failure. The VAP and HAP are associated with increased mortality and increased hospital costs. The rise in HAP due to antibiotic-resistant bacteria also causes an increase in the incidence of inappropriate empirical antibiotic therapy, with an associated increased risk of hospital mortality. It is very important to know the most common organisms responsible for these infections in each hospital and each Intensive Care Unit, as well as their antimicrobial susceptibility patterns, in order to reduce the incidence of inappropriate antibiotic therapy and improve the prognosis of patients. Additionally, clinical strategies aimed at the prevention of HAP and VAP should be employed in hospital settings caring for patients at risk for these infections.

Weaning from mechanical ventilation in paediatrics. State of the art

Weaning from mechanical ventilation is one of the greatest volume and strength issues in evidence-based medicine in critically ill adults. In these patients, weaning protocols and daily interruption of sedation have been implemented, reducing the duration of mechanical ventilation and associated morbidity. In paediatrics, the information reported is less consistent, so that as yet there are no reliable criteria for weaning and extubation in this patient group. Several indices have been developed to predict the outcome of weaning. However, these have failed to replace clinical judgement, although some additional measurements could facilitate this decision.

[Should the diagnosis of ventilator associated pneumonia be improved?]

Ventilator associated pneumonia (VAP) is the leading nosocomial infection in intensive care. It is associated with increased ICU and hospital stay, an increased use of antibiotics, and greater hospital costs. The recently launched Pneumonia Zero project (NZ) undoubtedly constitutes a challenge for professionals in the ICU, and has been designed to reduce the high incidence rates described. It is necessary to establish the true incidence, and whether the latter is influenced by the diagnostic method employed. The lack of a reference standard for the microbiological diagnosis of VAP has generated controversy over the diagnostic algorithms to be used, with the distinction of two strategies: a noninvasive or clinical strategy based on upper respiratory tract cultures, and an invasive method based on the use of quantitative cultures of samples from the lower respiratory tract obtained by bronchoscopic techniques. Despite the recommendations of scientific societies, which do not justify the use of qualitative tracheal aspirates in the microbiological diagnosis of VAP, this method is still routinely used. This study underscores the need to stop using qualitative tracheal aspirates as a routine diagnostic method for VAP, recommending the use of bronchoscopic techniques or quantitative tracheal aspirates.

[Classification of mental disorders in the Intensive Care Unit]

PURPOSE

To determine the incidence and characteristics of mental disorders (MD) in the Intensive Care Unit (ICU), and to define a classification system adapted to the ICU environment.

DESIGN

A retrospective, descriptive analysis.

SETTING

Intensive Care Unit, Arnau de Vilanova Hospital in Lérida (Spain).

PATIENTS

All patients with MD admitted during 5-year period (January, 1 2004 to December 31, 2008).

MAIN VARIABLES

General variables included clinical-demographic data, diagnostic variables, procedures, severity score, length of stay and mortality. Specific variables included psychiatric history, screening for substance abuse, psychiatric assessment, monitoring and transfer to a psychiatric center. Classification of the MD was as follows: 1) acute substance intoxication (SI); 2) suicide attempts (SA); and 3) MD associated with the main diagnosis (AMD).

RESULTS

A total of 146 patients had MD (7.8%); they were predominantly male (74%) and were younger than the general ICU population (43.9 vs. 55.3 years, p<0.001). The ICU stays of the patients with MDs were shorter (4 days vs. 7 days, p<0.001), and there was less hospital mortality (17.1 vs. 25%, p<0.05). They also showed a higher incidence of pneumonia (19.9 vs. 13.8%, p<0.05), but no differences in the level of severity were observed. The SI group (24.7%) contained the highest number of young people; the SA group (36.3%) showed a predominance of women; and the AMD (39%) group had the longest stays and the highest mortality. Psychiatric consultation was carried out mainly in the SA group (62.3%).

CONCLUSIONS

MD is a relatively common problem in the ICU. Collaboration with the Psychiatry Department seldom occurs, but must be encouraged to develop fully integrated management of critical patients with MD.