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Wang L, Zhang Q, Guo D, Pu Z, Li L, Fang Z, Liu X, Jia P. Construction of an extubation protocol for adult tracheal intubation patients in the intensive care unit: A Delphi study. Aust Crit Care 2024:S1036-7314(24)00248-0. [PMID: 39304402 DOI: 10.1016/j.aucc.2024.08.007] [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: 04/21/2024] [Revised: 08/20/2024] [Accepted: 08/21/2024] [Indexed: 09/22/2024] Open
Abstract
OBJECTIVE The objective of this study was to develop an extubation practice protocol for adult intensive care unit (ICU) patients who underwent endotracheal intubation, providing theoretical guidance for clinical extubation procedures in the ICU. METHODS A research team was established consisting of medical, nursing, anaesthesia, and respiratory therapy professionals; the multidisciplinary team systematically searched domestic and foreign literature, summarised the best evidence, and combined it with clinical practice experience to preliminarily develop an extubation protocol for adult ICU patients who underwent endotracheal intubation. Seventeen experts in critical care medicine, intensive care nursing, clinical anaesthesia, and respiratory therapy were invited to participate in a Delphi expert consultation to screen and modify the draft protocol. RESULTS The response rates of the two Delphi expert enquiries were 100% and 94.1%, with expert authority coefficients of 0.94 and 0.93, respectively, and Kendall's concordance coefficients were 0.152 and 0.198, respectively, indicating statistically significant differences (p < 0.001). The final protocol included three level I indicators, 14 level II indicators, and 34 level III indicators, covering extubation evaluation, implementation, and postextubation management. CONCLUSION The extubation protocol for adult tracheal intubation patients in the ICU constructed in this study is scientific, practical, and reliable. This study can provide theoretical guidance for extubation in ICU patients who have undergone endotracheal intubation.
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Affiliation(s)
- Li Wang
- Department of Neurosurgery Nursing, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, PR China
| | - Qin Zhang
- Department of General Ward Nursing, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, PR China
| | - Danyang Guo
- University of Electronic Science and Technology of China, PR China
| | - Zaichun Pu
- University of Electronic Science and Technology of China, PR China
| | - Lele Li
- University of Electronic Science and Technology of China, PR China
| | - Ziji Fang
- University of Electronic Science and Technology of China, PR China
| | - Xiaoli Liu
- Department of ICU, Deyang People's Hospital, Deyang Sichuan, PR China.
| | - Ping Jia
- Department of Neurosurgery Nursing, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, PR China.
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Schäfer H, Edel J, Martinez C, Wallenhorst C, Hellstern A. [Role of red blood cell (RBC) transfusions in patients with prolonged mechanical ventilation during weaning process]. Pneumologie 2024. [PMID: 39288903 DOI: 10.1055/a-2368-3815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2024]
Abstract
AIM Patients undergoing long-term ventilation often show anemia. The aim of the study was to investigate the duration and success of weaning from mechanical ventilation in patients with RBC transfusion. METHODS A retrospective analysis of patient data from a weaning unit was performed. Transfused and non-transfused patients were matched using a propensity score. Of the 249 patients in the database, 31 transfused and the same number of non-transfused cases with similar disease severity as measured by the Simplified Acute Physiology Score (SAPS) could be analyzed. Additional sensitivity analyses were performed. RESULTS In the group of transfused patients, the difference in weaning duration was longer than in non-transfused patients (1.35 days and 3.26 days, respectively). Weaning success also varied. The risk of weaning failure was twice as high in the group of transfused patients. The groups also differed in terms of mortality, 25.8% of the transfused patients died, while in the non-transfused patients the mortality rate was 6.5%. The risk of death was increased in patients who received RBC transfusion. The differences were not statistically significant. CONCLUSION A high proportion of patients with prolonged mechanical ventilation have anemia. RBC transfusion does not improve their prognosis. The need for transfusion is associated with higher mortality and longer duration of weaning in this population. The indication for RBC transfusion should therefore be restrictive.
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Affiliation(s)
- Henry Schäfer
- Pneumologie, Kardiologie und Beatmungsmedizin, Gastroenterologie, Bürgerhospital Frankfurt, Frankfurt, Deutschland
| | - Jan Edel
- Pneumologie, Kardiologie und Beatmungsmedizin, Gastroenterologie, Bürgerhospital Frankfurt, Frankfurt, Deutschland
| | - Carlos Martinez
- Frankfurt, Institute for Epidemiology, Statistics and Informatics GmbH, Frankfurt am Main, Deutschland
| | - Christopher Wallenhorst
- Frankfurt, Institute for Epidemiology, Statistics and Informatics GmbH, Frankfurt am Main, Deutschland
| | - Alfred Hellstern
- Pneumologie, Kardiologie und Beatmungsmedizin, Gastroenterologie, Bürgerhospital Frankfurt, Frankfurt, Deutschland
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3
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Balzani E, Murgolo F, Pozzi M, Di Mussi R, Bartolomeo N, Simonetti U, Brazzi L, Spadaro S, Bellani G, Grasso S, Fanelli V. Respiratory Drive, Effort, and Lung-Distending Pressure during Transitioning from Controlled to Spontaneous Assisted Ventilation in Patients with ARDS: A Multicenter Prospective Cohort Study. J Clin Med 2024; 13:5227. [PMID: 39274439 PMCID: PMC11396025 DOI: 10.3390/jcm13175227] [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: 07/22/2024] [Revised: 08/22/2024] [Accepted: 08/28/2024] [Indexed: 09/16/2024] Open
Abstract
Objectives: To investigate the impact of patient characteristics and treatment factors on excessive respiratory drive, effort, and lung-distending pressure during transitioning from controlled to spontaneous assisted ventilation in patients with acute respiratory distress syndrome (ARDS). Methods: Multicenter cohort observational study of patients with ARDS at four academic intensive care units. Respiratory drive (P0.1), diaphragm electrical activity (EAdi), inspiratory effort derived from EAdi (∆PmusEAdi) and from occlusion of airway pressure (∆Pocc) (PmusΔPocc), and dynamic transpulmonary driving pressure (ΔPL,dyn) were measured at the first transition to assisted spontaneous breathing. Results: A total of 4171 breaths were analyzed in 48 patients. P0.1 was >3.5 cmH2O in 10%, EAdiPEAK > 15 µV in 29%, ∆PmusEAdi > 15 cmH2O in 28%, and ΔPL,dyn > 15 cmH2O in 60% of the studied breaths. COVID-19 etiology of ARDS was the strongest independent risk factor for a higher proportion of breaths with excessive respiratory drive (RR 3.00 [2.43-3.71], p < 0.0001), inspiratory effort (RR 1.84 [1.58-2.15], p < 0.0001), and transpulmonary driving pressure (RR 1.48 [1.36-1.62], p < 0.0001). The P/F ratio at ICU admission, days of deep sedation, and dose of steroids were additional risk factors for vigorous inspiratory effort. Age and dose of steroids were risk factors for high transpulmonary driving pressure. Days of deep sedation (aHR 1.15 [1.07-1.24], p = 0.0002) and COVID-19 diagnosis (aHR 6.96 [1-48.5], p = 0.05) of ARDS were independently associated with composite outcome of transitioning from light to deep sedation (RASS from 0/-3 to -4/-5) or return to controlled ventilation within 48 h of spontaneous assisted breathing. Conclusions: This study identified that specific patient characteristics, including age, COVID-19-related ARDS, and P/F ratio, along with treatment factors such as the duration of deep sedation and the dosage of steroids, are independently associated with an increased likelihood of assisted breaths reaching potentially harmful thresholds of drive, effort, and lung-distending pressure during the initial transition to spontaneous assisted breathing. It is noteworthy that patients who were subjected to prolonged deep sedation under controlled mechanical ventilation, as well as those with COVID-19, were more susceptible to failing the transition from controlled to assisted breathing.
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Affiliation(s)
- Eleonora Balzani
- Department of Surgical Sciences, University of Turin, 10126 Turin, Italy
| | - Francesco Murgolo
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", 70010 Bari, Italy
| | - Matteo Pozzi
- Department of Emergency and Intensive Care, IRCCS San Gerardo dei Tintori Foundation, 20900 Monza, Italy
| | - Rossella Di Mussi
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", 70010 Bari, Italy
| | - Nicola Bartolomeo
- Interdisciplinary Department of Medicine, University of Bari Aldo Moro, 70121 Bari, Italy
| | - Umberto Simonetti
- Department of Anesthesia, Critical Care and Emergency, Città della Salute e della Scienza Hospital, University of Turin, 10126 Turin, Italy
| | - Luca Brazzi
- Department of Surgical Sciences, University of Turin, 10126 Turin, Italy
- Department of Anesthesia, Critical Care and Emergency, Città della Salute e della Scienza Hospital, University of Turin, 10126 Turin, Italy
| | - Savino Spadaro
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy
- Azienda Ospedaliera-Universitaria di Ferrara, 44122 Ferrara, Italy
| | - Giacomo Bellani
- Centre for Medical Sciences-CISMed, University of Trento, 38122 Trento, Italy
- Department of Anesthesia and Intensive Care, Santa Chiara Hospital, 38122 Trento, Italy
| | - Salvatore Grasso
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", 70010 Bari, Italy
| | - Vito Fanelli
- Department of Surgical Sciences, University of Turin, 10126 Turin, Italy
- Department of Anesthesia, Critical Care and Emergency, Città della Salute e della Scienza Hospital, University of Turin, 10126 Turin, Italy
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4
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Müller-Wirtz LM, O'Gara B, Gama de Abreu M, Schultz MJ, Beitler JR, Jerath A, Meiser A. Volatile anesthetics for lung- and diaphragm-protective sedation. Crit Care 2024; 28:269. [PMID: 39217380 PMCID: PMC11366159 DOI: 10.1186/s13054-024-05049-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Accepted: 07/30/2024] [Indexed: 09/04/2024] Open
Abstract
This review explores the complex interactions between sedation and invasive ventilation and examines the potential of volatile anesthetics for lung- and diaphragm-protective sedation. In the early stages of invasive ventilation, many critically ill patients experience insufficient respiratory drive and effort, leading to compromised diaphragm function. Compared with common intravenous agents, inhaled sedation with volatile anesthetics better preserves respiratory drive, potentially helping to maintain diaphragm function during prolonged periods of invasive ventilation. In turn, higher concentrations of volatile anesthetics reduce the size of spontaneously generated tidal volumes, potentially reducing lung stress and strain and with that the risk of self-inflicted lung injury. Taken together, inhaled sedation may allow titration of respiratory drive to maintain inspiratory efforts within lung- and diaphragm-protective ranges. Particularly in patients who are expected to require prolonged invasive ventilation, in whom the restoration of adequate but safe inspiratory effort is crucial for successful weaning, inhaled sedation represents an attractive option for lung- and diaphragm-protective sedation. A technical limitation is ventilatory dead space introduced by volatile anesthetic reflectors, although this impact is minimal and comparable to ventilation with heat and moisture exchangers. Further studies are imperative for a comprehensive understanding of the specific effects of inhaled sedation on respiratory drive and effort and, ultimately, how this translates into patient-centered outcomes in critically ill patients.
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Affiliation(s)
- Lukas M Müller-Wirtz
- Department of Anesthesiology, Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA
- Department of Anesthesiology, Intensive Care and Pain Therapy, Faculty of Medicine, Saarland University Medical Center and Saarland University, Homburg, Saarland, Germany
- Department of Anesthesiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, University Hospital Erlangen, Erlangen, Germany
| | - Brian O'Gara
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Marcelo Gama de Abreu
- Department of Anesthesiology, Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA
- Division of Intensive Care and Resuscitation, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Jeremy R Beitler
- Columbia Respiratory Critical Care Trials Group, New York-Presbyterian Hospital and Columbia University, New York, NY, USA
| | - Angela Jerath
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Andreas Meiser
- Department of Anesthesiology, Intensive Care and Pain Therapy, Faculty of Medicine, Saarland University Medical Center and Saarland University, Homburg, Saarland, Germany.
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Mazeraud A, Sivanandamoorthy S, Mancusi R, Clair B, Friedman D, Fadel F, Maxime V, Legouy C, Orlikowski D, Sharshar T, Heming N, Annane D. Weaning from mechanical ventilation during myasthenic crisis, a monocentric retrospective study. Sci Rep 2024; 14:19523. [PMID: 39174610 PMCID: PMC11341545 DOI: 10.1038/s41598-024-70373-y] [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: 04/23/2024] [Accepted: 08/16/2024] [Indexed: 08/24/2024] Open
Abstract
Mechanical ventilation in myasthenic crisis is not standardized and is at high risk of failure. We investigated liberation from mechanical ventilation during myasthenic crisis using a prolonged spontaneous breathing trials (SBT) and sequential pulmonary function tests (PFT). In this retrospective monocenter study, we included patients admitted for a first episode of myasthenic crisis between January 2001 and January 2018. The primary outcome was the incidence of weaning failure upon first extubation in our cohort of patients with MC. Secondary objectives were to determine risk factors and outcome associated with weaning failure upon first extubation in MC. We also compared the characteristics of patients with prolonged weaning. 126 episodes of MC were analyzed. Patient's age was 64 [42-76] years with 72/126 (56.5%) being women. The median delay between weaning initiation and first extubation was 6 [3-10] days and the median total length of MV was 14 [10-23] days. 118/126 (93.7%) patients underwent prolonged SBT of 8 h or more prior to first extubation. The overall weaning failure rate was 18/126 (14.3%). Extubation was more often successful when the factor precipitating the myasthenic crisis was identified (86/108 (79.6%) vs. 8/18 (44.4%); p = 0.004), whereas PFT was similar in failure or successes. Most weaning failures upon first extubation attempt (11/18; 61%) were attributed to an insufficient stabilization of myasthenia gravis. Duration of mechanical ventilation, an infectious trigger and maximal inspiratory pressure upon intubation were independent risk factors for prolonged weaning. In myasthenic crisis, a standardized protocol including prolonged SBT and respiratory function tests might improve the success of first extubation without prolonging mechanical ventilation. The results of this single center study warrant further evaluation in interventional trials.
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Affiliation(s)
- Aurélien Mazeraud
- Université Paris Cité, Paris, France.
- GHU Paris Psychiatrie et Neurosciences, Pole Neuro, Service d'anesthésie Réanimation, Paris, France.
- Memory and Perception Unit, Neurosciences Department, Institut Pasteur, Paris, France.
| | | | - Rossella Mancusi
- GHU Paris Psychiatrie et Neurosciences, Pole Neuro, Service d'anesthésie Réanimation, Paris, France
| | - Bernard Clair
- Department of Intensive Care, Raymond Poincaré Hospital, APHP University Versailles Saint Quentin-University Paris Saclay, Paris, France
| | - Diane Friedman
- Department of Intensive Care, Raymond Poincaré Hospital, APHP University Versailles Saint Quentin-University Paris Saclay, Paris, France
| | - Fouad Fadel
- Department of Intensive Care, Raymond Poincaré Hospital, APHP University Versailles Saint Quentin-University Paris Saclay, Paris, France
| | - Virginie Maxime
- Department of Intensive Care, Raymond Poincaré Hospital, APHP University Versailles Saint Quentin-University Paris Saclay, Paris, France
| | - Camille Legouy
- GHU Paris Psychiatrie et Neurosciences, Pole Neuro, Service d'anesthésie Réanimation, Paris, France
| | - David Orlikowski
- Department of Intensive Care, Raymond Poincaré Hospital, APHP University Versailles Saint Quentin-University Paris Saclay, Paris, France
- Laboratory of Infection & Inflammation-U1173, School of Medicine Simone Veil, University Versailles Saint Quentin-University Paris Saclay, INSERM, Garches, France
- Institut Hospitalo-Universitaire PROMETHEUS, Garches, France
| | - Tarek Sharshar
- Université Paris Cité, Paris, France
- GHU Paris Psychiatrie et Neurosciences, Pole Neuro, Service d'anesthésie Réanimation, Paris, France
- Unité INSERM, Institut Psychiatrie et Neurosciences, Paris, France
| | - Nicholas Heming
- Department of Intensive Care, Raymond Poincaré Hospital, APHP University Versailles Saint Quentin-University Paris Saclay, Paris, France
- Laboratory of Infection & Inflammation-U1173, School of Medicine Simone Veil, University Versailles Saint Quentin-University Paris Saclay, INSERM, Garches, France
- Institut Hospitalo-Universitaire PROMETHEUS, Garches, France
| | - Djillali Annane
- Department of Intensive Care, Raymond Poincaré Hospital, APHP University Versailles Saint Quentin-University Paris Saclay, Paris, France
- Laboratory of Infection & Inflammation-U1173, School of Medicine Simone Veil, University Versailles Saint Quentin-University Paris Saclay, INSERM, Garches, France
- Institut Hospitalo-Universitaire PROMETHEUS, Garches, France
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6
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Tingsvik C, Henricson M, Hammarskjöld F, Mårtensson J. Physicians' decision making when weaning patients from mechanical ventilation: A qualitative content analysis. Aust Crit Care 2024:S1036-7314(24)00206-6. [PMID: 39122604 DOI: 10.1016/j.aucc.2024.06.015] [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: 11/06/2023] [Revised: 06/22/2024] [Accepted: 06/24/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND Weaning from mechanical ventilation is a complex and central intensive care process. This complexity indicates that the challenges of weaning must be explored from different perspectives. Furthermore, physicians' experiences and the factors influencing their decision-making regarding weaning are unclear. OBJECTIVES This study aimed to explore and describe the factors influencing physicians' decision-making when weaning patients from invasive mechanical ventilation in Swedish intensive care units (ICUs). METHODS This qualitative study used an exploratory and descriptive design with qualitative content analysis. Sixteen physicians from five ICUs across Sweden were purposively included and interviewed regarding their weaning experiences. FINDINGS The physicians expressed that prioritising the patient's well-being was evident, and there was agreement that both the physical and mental condition of the patient had a substantial impact on decision-making. Furthermore, there was a lack of agreement on whether patients should be involved in the weaning process and how their resources, needs, and wishes should be included in decision-making. In addition, there were factors not directly linked to the patient but which still influenced decision-making, such as the available resources and teamwork. Sometimes, it was difficult to point out the basis for decisions; in that decisions were made by gut feeling, intuition, or clinical experience. CONCLUSION Physicians' decision-making regarding weaning was a dynamic process influenced by several factors. These factors were related to the patient's condition and the structure for weaning. Increased understanding of weaning from the physicians' and ICU teams' perspectives may improve the weaning process by broadening the knowledge about the aspects influencing the decision-making.
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Affiliation(s)
- Catarina Tingsvik
- Jönköping Academy for Improvement of Health and Welfare, Jönköping University, Jönköping SE-551 11, Sweden; Department of Anaesthesia and Intensive Care Medicine, Ryhov County Hospital, Jönköping SE-55185, Sweden.
| | - Maria Henricson
- Jönköping Academy for Improvement of Health and Welfare, Jönköping University, Jönköping SE-551 11, Sweden; Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås SE-501 90, Sweden.
| | - Fredrik Hammarskjöld
- Department of Anaesthesia and Intensive Care Medicine, Ryhov County Hospital, Jönköping SE-55185, Sweden; Department of Biomedical and Clinical Sciences, Linköping University, Linköping SE-581 83, Sweden.
| | - Jan Mårtensson
- Department of Nursing Science, School of Health and Welfare, Jönköping University, Jönköping SE-551 11, Sweden.
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Macpherson D, Hutchinson A, Bloomer MJ. Factors that influence critical care nurses' management of sedation for ventilated patients in critical care: A qualitative study. Intensive Crit Care Nurs 2024; 83:103685. [PMID: 38493573 DOI: 10.1016/j.iccn.2024.103685] [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: 12/02/2023] [Revised: 03/05/2024] [Accepted: 03/11/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Optimising sedation use is key to timely extubation. Whilst sedation protocols may be used to guide critical care nurses' management of sedation, sedation management and decision-making is complex, influenced by multiple factors related to patients' circumstances, intensive care unit design and the workforce. AIM To explore (i) critical care nurses' experiences managing sedation in mechanically ventilated patients and (ii) the factors that influence their sedation-related decision-making. DESIGN Qualitative descriptive study using semi-structured interviews. Data were analysed using Braun and Clarke's six-step thematic analysis. SETTING AND PARTICIPANTS This study was conducted in a 26-bed level 3 accredited ICU, in a private hospital in Melbourne, Australia. The majority of patients are admitted following elective surgery. Critical care nurses, who were permanently employed as a registered nurse, worked at least 16 h per week, and cared for ventilated patients, were invited to participate. FINDINGS Thirteen critical care nurses participated. Initially, participants suggested their experiences managing sedation were linked to local unit policy and learning. Further exploration revealed that experiences were synonymous with descriptors of factors influencing sedation decision-making according to three themes: (i) Learning from past experiences, (ii) Situational awareness and (iii) Prioritising safety. Nurses relied on their cumulative knowledge from prior experiences to guide decision-making. Situational awareness about other emergent priorities in the unit, staffing and skill-mix were important factors in guiding sedation decision-making. Safety of patients and staff was essential, at times overriding goals to reduce sedation. CONCLUSION Sedation decision making cannot be considered in isolation. Rather, sedation decision making must take into account outcomes of patient assessment, emergent priorities, unit and staffing factors and safety concerns. IMPLICATIONS FOR CLINICAL PRACTICE Opportunities for ongoing education are essential to promote nurses' situational awareness of other emergent unit priorities, staffing and skill-mix, in addition to evidence-based sedation management and decision making.
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Affiliation(s)
- Danielle Macpherson
- Intensive Care Unit, Epworth HealthCare Richmond, Victoria, Australia; School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia
| | - Anastasia Hutchinson
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia; Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia; Centre for Quality and Patient Safety Research - Epworth HealthCare Partnership, Richmond, Victoria, Australia
| | - Melissa J Bloomer
- School of Nursing and Midwifery, Griffith University, Nathan, Queensland, Australia; Intensive Care Unit, Princess Alexandra Hospital, Queensland Health, Woolloongabba, Queensland, Australia.
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Finnerty J, Gill SE, Alcock E, Johnson E, Flowers E, Price J, Bentley A, Felton T. Retrospective service evaluation of a specialist weaning unit. J Intensive Care Soc 2024; 25:350-352. [PMID: 39224424 PMCID: PMC11366181 DOI: 10.1177/17511437241257117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
Abstract
Specialist weaning units (SWUs) aim to liberate patients with complex weaning failure from mechanical ventilation and facilitate their discharge from the ICU. This retrospective service evaluation reports the outcomes of a SWU at Wythenshawe Hospital, Manchester between 2017 and 2019. In total, 75.0% (n = 33/44) of patients survived to hospital discharge. Of these patients, 72.7% (n = 24/33) were self-ventilating. Overall, 1-year survival was 68.2% (n = 30/44), whilst 5-year survival was 52.3% (n = 23/44). Whilst this study is relatively small, these findings are encouraging and further support the case for SWUs.
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Affiliation(s)
- John Finnerty
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Sonya E Gill
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Emily Alcock
- Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Emma Flowers
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Jemma Price
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Andrew Bentley
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Tim Felton
- Manchester University NHS Foundation Trust, Manchester, UK
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9
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van den Berg M, Shi Z, Claassen WJ, Hooijman P, Lewis CTA, Andersen JL, van der Pijl RJ, Bogaards SJP, Conijn S, Peters EL, Begthel LPL, Uijterwijk B, Lindqvist J, Langlais PR, Girbes ARJ, Stapel S, Granzier H, Campbell KS, Ma W, Irving T, Hwee DT, Hartman JJ, Malik FI, Paul M, Beishuizen A, Ochala J, Heunks L, Ottenheijm CAC. Super-relaxed myosins contribute to respiratory muscle hibernation in mechanically ventilated patients. Sci Transl Med 2024; 16:eadg3894. [PMID: 39083588 DOI: 10.1126/scitranslmed.adg3894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/12/2024] [Accepted: 07/11/2024] [Indexed: 08/02/2024]
Abstract
Patients receiving mechanical ventilation in the intensive care unit (ICU) frequently develop contractile weakness of the diaphragm. Consequently, they may experience difficulty weaning from mechanical ventilation, which increases mortality and poses a high economic burden. Because of a lack of knowledge regarding the molecular changes in the diaphragm, no treatment is currently available to improve diaphragm contractility. We compared diaphragm biopsies from ventilated ICU patients (N = 54) to those of non-ICU patients undergoing thoracic surgery (N = 27). By integrating data from myofiber force measurements, x-ray diffraction experiments, and biochemical assays with clinical data, we found that in myofibers isolated from the diaphragm of ventilated ICU patients, myosin is trapped in an energy-sparing, super-relaxed state, which impairs the binding of myosin to actin during diaphragm contraction. Studies on quadriceps biopsies of ICU patients and on the diaphragm of previously healthy mechanically ventilated rats suggested that the super-relaxed myosins are specific to the diaphragm and not a result of critical illness. Exposing slow- and fast-twitch myofibers isolated from the diaphragm biopsies to small-molecule compounds activating troponin restored contractile force in vitro. These findings support the continued development of drugs that target sarcomere proteins to increase the calcium sensitivity of myofibers for the treatment of ICU-acquired diaphragm weakness.
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Affiliation(s)
- Marloes van den Berg
- Amsterdam UMC, Location VUmc, Department of Physiology, Amsterdam 1081, HV, Netherlands
- Bispebjerg Hospital, Institute of Sports Medicine, Copenhagen 2400, Denmark
| | - Zhonghua Shi
- Amsterdam UMC, Location VUmc, Department of Physiology, Amsterdam 1081, HV, Netherlands
- Amsterdam UMC, Location VUmc, Department of Intensive Care Medicine, Amsterdam 1081, HV, Netherlands
- Sanbo Brain Hospital, Capital Medical University, Intensive Care Medicine, Beijing 100093, China
| | - Wout J Claassen
- Amsterdam UMC, Location VUmc, Department of Physiology, Amsterdam 1081, HV, Netherlands
| | - Pleuni Hooijman
- Amsterdam UMC, Location VUmc, Department of Physiology, Amsterdam 1081, HV, Netherlands
| | - Christopher T A Lewis
- University of Copenhagen, Department of Biomedical Sciences, Copenhagen 2200, Denmark
- Research and Early Development, Novo Nordisk A/S, Måløv 2760, Denmark
| | - Jesper L Andersen
- Bispebjerg Hospital, Institute of Sports Medicine, Copenhagen 2400, Denmark
| | - Robbert J van der Pijl
- Department of Cellular and Molecular Medicine, University of Arizona, Tucson AZ 85721, USA
| | - Sylvia J P Bogaards
- Amsterdam UMC, Location VUmc, Department of Physiology, Amsterdam 1081, HV, Netherlands
| | - Stefan Conijn
- Amsterdam UMC, Location VUmc, Department of Physiology, Amsterdam 1081, HV, Netherlands
| | - Eva L Peters
- Department of Cellular and Molecular Medicine, University of Arizona, Tucson AZ 85721, USA
| | - Leon P L Begthel
- Amsterdam UMC, Location VUmc, Department of Physiology, Amsterdam 1081, HV, Netherlands
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge CB2 0RE, UK
| | - Bas Uijterwijk
- Amsterdam UMC, Location VUmc, Department of Physiology, Amsterdam 1081, HV, Netherlands
| | - Johan Lindqvist
- Department of Cellular and Molecular Medicine, University of Arizona, Tucson AZ 85721, USA
| | - Paul R Langlais
- Department of Endocrinology, University of Arizona, Tucson, AZ 85721, USA
| | - Armand R J Girbes
- Amsterdam UMC, Location VUmc, Department of Intensive Care Medicine, Amsterdam 1081, HV, Netherlands
| | - Sandra Stapel
- Amsterdam UMC, Location VUmc, Department of Intensive Care Medicine, Amsterdam 1081, HV, Netherlands
| | - Henk Granzier
- Department of Cellular and Molecular Medicine, University of Arizona, Tucson AZ 85721, USA
| | - Kenneth S Campbell
- Division of Cardiovascular Medicine, University of Kentucky College of Medicine, Lexington, KY 40536, USA
| | - Weikang Ma
- BioCAT, Illinois Institute of Technology, Lemont, IL 60439, USA
| | - Thomas Irving
- BioCAT, Illinois Institute of Technology, Lemont, IL 60439, USA
| | - Darren T Hwee
- Research and Early Development, Cytokinetics Inc., South San Francisco, CA 94080, USA
| | - James J Hartman
- Research and Early Development, Cytokinetics Inc., South San Francisco, CA 94080, USA
| | - Fady I Malik
- Research and Early Development, Cytokinetics Inc., South San Francisco, CA 94080, USA
| | - Marinus Paul
- Amsterdam UMC, Location VUmc, Department of Cardiothoracic Surgery, Amsterdam 1081, HV, Netherlands
| | - Albertus Beishuizen
- Medisch Spectrum Twente, Intensive Care Center, Enschede 7511, HN, Netherlands
| | - Julien Ochala
- University of Copenhagen, Department of Biomedical Sciences, Copenhagen 2200, Denmark
| | - Leo Heunks
- Radboud UMC, Department of Intensive Care, Nijmegen 6525, GA, Netherlands
| | - Coen A C Ottenheijm
- Amsterdam UMC, Location VUmc, Department of Physiology, Amsterdam 1081, HV, Netherlands
- Department of Cellular and Molecular Medicine, University of Arizona, Tucson AZ 85721, USA
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10
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Subirà C, Rognoni G, Baquerizo H, García C, Cabañes S, de la Torre M, Quevedo B, Pedrós C, Tizón AI, Murillo N, Parro L, Eiras F, Rialp G, Altaba S, González-Castro A, Pacheco AF, Bayoumi P, Gómez-Medrano N, Vallverdú I, Higón Á, Navarro MD, Falcón A, Keough E, Arizo D, Martínez JF, Durán N, Rodríguez R, Popoviciu-Koborzan MR, Guerrero I, Concha P, Barral P, Batlle M, Cano S, Garcia-Castrillon S, Andorrà X, Tua Y, Arnau A, Fernández R. Effect of lung volume preservation during spontaneous breathing trial on successful extubation in patients receiving mechanical ventilation: protocol for a multicenter clinical trial. Trials 2024; 25:481. [PMID: 39014430 PMCID: PMC11251308 DOI: 10.1186/s13063-024-08297-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 06/27/2024] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND In standard weaning from mechanical ventilation, a successful spontaneous breathing test (SBT) consisting of 30 min 8 cmH2O pressure-support ventilation (PSV8) without positive end-expiratory pressure (PEEP) is followed by extubation with continuous suctioning; however, these practices might promote derecruitment. Evidence supports the feasibility and safety of extubation without suctioning. Ultrasound can assess lung aeration and respiratory muscles. We hypothesize that weaning aiming to preserve lung volume can yield higher rates of successful extubation. METHODS This multicenter superiority trial will randomly assign eligible patients to receive either standard weaning [SBT: 30-min PSV8 without PEEP followed by extubation with continuous suctioning] or lung-volume-preservation weaning [SBT: 30-min PSV8 + 5 cmH2O PEEP followed by extubation with positive pressure without suctioning]. We will compare the rates of successful extubation and reintubation, ICU and hospital stays, and ultrasound measurements of the volume of aerated lung (modified lung ultrasound score), diaphragm and intercostal muscle thickness, and thickening fraction before and after successful or failed SBT. Patients will be followed for 90 days after randomization. DISCUSSION We aim to recruit a large sample of representative patients (N = 1600). Our study cannot elucidate the specific effects of PEEP during SBT and of positive pressure during extubation; the results will show the joint effects derived from the synergy of these two factors. Although universal ultrasound monitoring of lungs, diaphragm, and intercostal muscles throughout weaning is unfeasible, if derecruitment is a major cause of weaning failure, ultrasound may help clinicians decide about extubation in high-risk and borderline patients. TRIAL REGISTRATION The Research Ethics Committee (CEIm) of the Fundació Unió Catalana d'Hospitals approved the study (CEI 22/67 and 23/26). Registered at ClinicalTrials.gov in August 2023. Identifier: NCT05526053.
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Affiliation(s)
- Carles Subirà
- Servei de Medicina Intensiva, Hospital de La Santa Creu I Sant Pau, Barcelona, Spain.
- Grup de Recerca en Malalt Crític (GMC), Institut de Recerca I Innovació en Ciències de La Vida I de La Salut a La Catalunya Central (IRIS-CC), Vic, Spain.
- CIBER Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029, Madrid, Spain.
- Servei de Medicina Intensiva, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain.
| | - Gina Rognoni
- Grup de Recerca en Malalt Crític (GMC), Institut de Recerca I Innovació en Ciències de La Vida I de La Salut a La Catalunya Central (IRIS-CC), Vic, Spain
- Servei de Medicina Intensiva, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain
- Programa de Doctorat en Medicina I Ciències Biomèdiques, Universitat de Vic- Universitat Central de Catalunya (UVIC-UCC), Vic, Spain
| | - Herbert Baquerizo
- Grup de Recerca en Malalt Crític (GMC), Institut de Recerca I Innovació en Ciències de La Vida I de La Salut a La Catalunya Central (IRIS-CC), Vic, Spain
- Servei de Medicina Intensiva, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain
- Programa de Doctorat en Medicina I Ciències Biomèdiques, Universitat de Vic- Universitat Central de Catalunya (UVIC-UCC), Vic, Spain
| | - Carolina García
- Servicio de Medicina Intensiva, Hospital Universitario de Canarias, San Cristóbal de La Laguna, Tenerife, Spain
| | - Sara Cabañes
- Servicio de Medicina Intensiva, Txagorritxu Hospital Universitario Araba, Gasteiz, Spain
| | | | - Beatriz Quevedo
- Servicio de Medicina Intensiva, Hospital Clínico Universitario de Valencia, València, Spain
| | - Cristina Pedrós
- Servei de Medicina Intensiva, Hospital General de Granollers, Granollers, Spain
| | - Ana I Tizón
- Servicio de Medicina Intensiva, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Natalia Murillo
- Servei de Medicina Intensiva, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
| | - Laura Parro
- Servicio de Medicina Intensiva, Hospital Universitario del Henrares, Coslada, Spain
| | - Fernando Eiras
- Servicio de Medicina Intensiva, Hospital Universitario de Pontevedra, Pontevedra, Spain
| | - Gemma Rialp
- Servei de Medicina Intensiva, Hospital Son Llàtzer, Palma de Mallorca, Spain
| | - Susana Altaba
- Servicio Medicina Intensiva, Hospital General Universitario de Castellón, Castelló de La Plana, Spain
| | | | - Andrés F Pacheco
- Servei de Medicina Intensiva, Hospital Universitari de La Vall d'Hebron, Barcelona, Spain
| | - Pablo Bayoumi
- Servicio de Medicina Intensiva, Hospital General Universitario Santa Lucía, Cartagena, Spain
| | - Norma Gómez-Medrano
- Servicio de Medicina Intensiva, Hospital General Universitario de Elche, Elx, Spain
| | - Imma Vallverdú
- Servei de Medicina Intensiva, Hospital Universitari San Joan de Reus, Reus, Spain
| | - Áurea Higón
- Servicio de Medicina Intensiva, Hospital General Universitario Morales Messeguer, Murcia, Spain
| | - María D Navarro
- Servicio de Medicina Intensiva, Hospital Arnau de Vilanova, Valencia, Spain
| | - Alirio Falcón
- Servei de Medicina Intensiva, Hospital Universitari Mútua de Terrassa, Terrassa, Spain
| | - Elena Keough
- Servicio de Medicina Intensiva, Hospital Universitario de La Princesa, Madrid, Spain
| | - David Arizo
- Servicio de Medicina Intensiva, Hospital de Sagunto, Sagunt, Spain
| | - Juan F Martínez
- Servicio de Medicina Intensiva, Hospital Regional Universitario de Málaga, Malaga, Spain
| | - Núria Durán
- Servei de Medicina Intensiva, Hospital Universitari Sagrat Cor, Barcelona, Spain
| | - Raquel Rodríguez
- CIBER Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029, Madrid, Spain
- Servicio de Medicina Intensiva, Hospital Universitario Central de Asturias, Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | | | - Isabel Guerrero
- Servicio de Medicina Intensiva, Hospital Universitario Virgen de Las Nieves, Granada, Spain
| | - Pablo Concha
- Servei de Medicina Intensiva, Hospital Verge de La Cinta, Tortosa, Spain
| | - Patricia Barral
- Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - Montserrat Batlle
- Grup de Recerca en Malalt Crític (GMC), Institut de Recerca I Innovació en Ciències de La Vida I de La Salut a La Catalunya Central (IRIS-CC), Vic, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029, Madrid, Spain
- Servei de Medicina Intensiva, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain
| | - Sílvia Cano
- Grup de Recerca en Malalt Crític (GMC), Institut de Recerca I Innovació en Ciències de La Vida I de La Salut a La Catalunya Central (IRIS-CC), Vic, Spain
- Servei de Medicina Intensiva, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain
| | - Silvia Garcia-Castrillon
- Grup de Recerca en Malalt Crític (GMC), Institut de Recerca I Innovació en Ciències de La Vida I de La Salut a La Catalunya Central (IRIS-CC), Vic, Spain
- Servei de Medicina Intensiva, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain
| | - Xavier Andorrà
- Grup de Recerca en Malalt Crític (GMC), Institut de Recerca I Innovació en Ciències de La Vida I de La Salut a La Catalunya Central (IRIS-CC), Vic, Spain
- Servei de Medicina Intensiva, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain
| | - Yenifher Tua
- Grup de Recerca en Malalt Crític (GMC), Institut de Recerca I Innovació en Ciències de La Vida I de La Salut a La Catalunya Central (IRIS-CC), Vic, Spain
- Servei de Medicina Intensiva, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain
| | - Anna Arnau
- Unitat de Recerca I Innovació, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain
- Grup de Recerca en Cronicitat de La Catalunya Central (C3RG), Institut de Recerca I Innovació en Ciències de La Vida I de La Salut a La Catalunya Central (IRIS-CC), Vic, Spain
- Facultat de Medicina, Universitat de Vic-Central de Catalunya (UVIC-UCC), Vic, Spain
| | - Rafael Fernández
- Grup de Recerca en Malalt Crític (GMC), Institut de Recerca I Innovació en Ciències de La Vida I de La Salut a La Catalunya Central (IRIS-CC), Vic, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029, Madrid, Spain
- Servei de Medicina Intensiva, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain
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11
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Ghiani A, Walcher S, Lutfi A, Paderewska J, Jaeger SU, Kneidinger N, Stecher SS, Trudzinski FC, Neurohr C. Mechanical power density, spontaneous breathing indexes, and prolonged weaning failure: a prospective cohort study. Sci Rep 2024; 14:16297. [PMID: 39009821 PMCID: PMC11251183 DOI: 10.1038/s41598-024-67237-w] [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: 12/21/2023] [Accepted: 07/09/2024] [Indexed: 07/17/2024] Open
Abstract
A prospective observational study comparing mechanical power density (MP normalized to dynamic compliance) with traditional spontaneous breathing indexes (e.g., predicted body weight normalized tidal volume [VT/PBW], rapid shallow breathing index [RSBI], or the integrative weaning index [IWI]) for predicting prolonged weaning failure in 140 tracheotomized patients. We assessed the diagnostic accuracy of these indexes at the start and end of the weaning procedure using ROC curve analysis, expressed as the area under the receiver operating characteristic curve (AUROC). Weaning failure occurred in 41 out of 140 patients (29%), demonstrating significantly higher MP density (6156 cmH2O2/min [4402-7910] vs. 3004 cmH2O2/min [2153-3917], P < 0.01), lower spontaneous VT/PBW (5.8 mL*kg-1 [4.8-6.8] vs. 6.6 mL*kg-1 [5.7-7.9], P < 0.01) higher RSBI (68 min-1*L-1 [44-91] vs. 55 min-1*L-1 [41-76], P < 0.01) and lower IWI (41 L2/cmH2O*%*min*10-3 [25-72] vs. 71 L2/cmH2O*%*min*10-3 [50-106], P < 0.01) and at the end of weaning. MP density was more accurate at predicting weaning failures (AUROC 0.91 [95%CI 0.84-0.95]) than VT/PBW (0.67 [0.58-0.74]), RSBI (0.62 [0.53-0.70]), or IWI (0.73 [0.65-0.80]), and may help clinicians in identifying patients at high risk for long-term ventilator dependency.
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Affiliation(s)
- Alessandro Ghiani
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic, affiliated to the Robert-Bosch-Hospital GmbH, Auerbachstrasse 110, 70376, Stuttgart, Germany.
| | - Swenja Walcher
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic, affiliated to the Robert-Bosch-Hospital GmbH, Auerbachstrasse 110, 70376, Stuttgart, Germany
| | - Azal Lutfi
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic, affiliated to the Robert-Bosch-Hospital GmbH, Auerbachstrasse 110, 70376, Stuttgart, Germany
| | - Joanna Paderewska
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic, affiliated to the Robert-Bosch-Hospital GmbH, Auerbachstrasse 110, 70376, Stuttgart, Germany
| | - Simon Ulrich Jaeger
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic, affiliated to the Robert-Bosch-Hospital GmbH, Auerbachstrasse 110, 70376, Stuttgart, Germany
| | - Nikolaus Kneidinger
- Department of Medicine V, LMU University Hospital, LMU Munich, Comprehensive Pneumology Center, Member of the German Center for Lung Research (DZL), Munich, Germany
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | | | - Franziska Christina Trudzinski
- Department of Pneumology and Critical Care Medicine, Thoraxklinik, Translational Lung Research Center Heidelberg (TLRC-H), German Center for Lung Research (DZL), University of Heidelberg, Heidelberg, Germany
| | - Claus Neurohr
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic, affiliated to the Robert-Bosch-Hospital GmbH, Auerbachstrasse 110, 70376, Stuttgart, Germany
- Comprehensive Pneumology Center, Member of the German Center for Lung Research (DZL), Munich, Germany
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12
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Combret Y, Machefert M, Prieur G, Fresnel E, Artaud-Macari E, Lamia B, Lebret M, Medrinal C. Impact of tracheostomy tube modalities on ventilatory mechanics: a bench study. Intensive Care Med Exp 2024; 12:63. [PMID: 38976100 PMCID: PMC11231115 DOI: 10.1186/s40635-024-00648-1] [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: 05/01/2024] [Accepted: 07/01/2024] [Indexed: 07/09/2024] Open
Abstract
PURPOSE Tracheostomized patients often present with muscle weakness, altered consciousness, or swallowing difficulties. Hence, the literature is scarce regarding the challenging management of tracheostomy weaning. There is a need to strengthen the understanding of respiratory mechanisms with the different tracheostomy tube modalities that compose this weaning pathway. We aimed to evaluate the impact of these modalities on the work of breathing (WOB), total positive end-expiratory pressure (PEEPtot), and tidal volume (VT). METHODS With a three-dimensional (3D) printed head mimicking human upper airways, we added a tracheal extension, and pierced to allow insertion of a size 7.0 tracheostomy cannula. The whole was connected to an artificial lung. Three lung mechanics were simulated (normal, obstructive and restrictive). We compared five different tracheostomy tube modalities to a control scenario in which the tube was capped and the cuff was deflated. RESULTS A marginal difference was observed on the WOB within conditions with a slight increase + 0.004 [95% CI (0.003-0.004); p < 0.001] when the cuff was inflated in the normal and restrictive models and a slight decrease in the obstructive model. The highest PEEPtot that was reached was + 1 cmH2O [95% CI (1-1.1); p < 0.001] with high-flow therapy (HFT) with the cuff inflated in the obstructive model. We observed a statistically significant reduction in VT [up to - 57 mL 95% CI (- 60 to - 54); p < 0.001] when the cuff was inflated, in both the normal and obstructive models. CONCLUSIONS Our results support the use of conditions that involve cuff deflation. Intermediate modalities with the cuff deflated produced similar results than cannula capping.
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Affiliation(s)
- Yann Combret
- Université Paris-Saclay, UVSQ, Erphan, 78000, Versailles, France
- Intensive Care Unit Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France
- Pulmonology Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France
| | - Margaux Machefert
- Université Paris-Saclay, UVSQ, Erphan, 78000, Versailles, France
- Physiotherapy Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France
| | - Guillaume Prieur
- Université Paris-Saclay, UVSQ, Erphan, 78000, Versailles, France
- Intensive Care Unit Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France
- Pulmonology Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France
| | - Emeline Fresnel
- Kernel Biomedical, 18 Rue Marie Curie Bâtiment ANIDER, 76000, Rouen, France
| | - Elise Artaud-Macari
- UR3830 GRHVN, Institute for Research and Innovation in Biomedicine (IRIB), Normandie Univ, UNIROUEN, 76000, Rouen, France
- Department of Pulmonary, Thoracic Oncology and Respiratory Intensive Care, CHU Rouen, 76000, Rouen, France
| | - Bouchra Lamia
- UR3830 GRHVN, Institute for Research and Innovation in Biomedicine (IRIB), Normandie Univ, UNIROUEN, 76000, Rouen, France
- Pulmonology, Respiratory Department, Rouen University Hospital, Rouen, France
| | - Marius Lebret
- Kernel Biomedical, 18 Rue Marie Curie Bâtiment ANIDER, 76000, Rouen, France
| | - Clément Medrinal
- Intensive Care Unit Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France.
- Pulmonology Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France.
- UR3830 GRHVN, Institute for Research and Innovation in Biomedicine (IRIB), Normandie Univ, UNIROUEN, 76000, Rouen, France.
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13
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Hughes N, Jia Y, Sujan M, Lawton T, Habli I, McDermid J. Contextual design requirements for decision-support tools involved in weaning patients from mechanical ventilation in intensive care units. APPLIED ERGONOMICS 2024; 118:104275. [PMID: 38574594 DOI: 10.1016/j.apergo.2024.104275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 03/19/2024] [Accepted: 03/21/2024] [Indexed: 04/06/2024]
Abstract
Weaning patients from ventilation in intensive care units (ICU) is a complex task. There is a growing desire to build decision-support tools to help clinicians during this process, especially those employing Artificial Intelligence (AI). However, tools built for this purpose should fit within and ideally improve the current work environment, to ensure they can successfully integrate into clinical practice. To do so, it is important to identify areas where decision-support tools may aid clinicians, and associated design requirements for such tools. This study analysed the work context surrounding the weaning process from mechanical ventilation in ICU environments, via cognitive task and work domain analyses. In doing so, both what cognitive processes clinicians perform during weaning, and the constraints and affordances of the work environment itself, were described. This study found a number of weaning process tasks where decision-support tools may prove beneficial, and from these a set of contextual design requirements were created. This work benefits researchers interested in creating human-centred decision-support tools for mechanical ventilation that are sensitive to the wider work system.
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Affiliation(s)
- Nathan Hughes
- University of York, Deramore Lane, York, YO10 5GH, UK.
| | - Yan Jia
- University of York, Deramore Lane, York, YO10 5GH, UK
| | | | - Tom Lawton
- University of York, Deramore Lane, York, YO10 5GH, UK; Improvement Academy, Bradford Institute for Health Research, Duckworth Lane, Bradford, BD9 6RJ, UK
| | - Ibrahim Habli
- University of York, Deramore Lane, York, YO10 5GH, UK
| | - John McDermid
- University of York, Deramore Lane, York, YO10 5GH, UK
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14
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Karagiannidis C, Krause F, Bentlage C, Wolff J, Bein T, Windisch W, Busse R. In-hospital mortality, comorbidities, and costs of one million mechanically ventilated patients in Germany: a nationwide observational study before, during, and after the COVID-19 pandemic. THE LANCET REGIONAL HEALTH. EUROPE 2024; 42:100954. [PMID: 39070745 PMCID: PMC11281923 DOI: 10.1016/j.lanepe.2024.100954] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/17/2024] [Accepted: 05/21/2024] [Indexed: 07/30/2024]
Abstract
Background Even more than hospital care in general, intensive care and mechanical ventilation capacities and its utilization in terms of rates, indications, ventilation types and outcomes vary largely among countries. We analyzed complete and nationwide data for Germany, a country with a large intensive care sector, before, during and after the COVID-19 pandemic. Methods Analysis of administrative claims data, provided by the German health insurance, from all hospitals for all individual patients who were mechanically ventilated between 2019 and 2022. The data included age, sex, diagnoses, length of stay, procedures (e.g., form and duration of mechanical ventilation), outcome (dead vs. alive) and costs. We included all patients who were at least 18 years old at the time of discharge from January 1st, 2019 to December 31st, 2022. Patients were grouped according to year, age group and the form of mechanical ventilation. We further analyzed subgroups of patients being resuscitated and those being COVID-19 positive (vs. negative). Findings During the four years, 1,003,882 patients were mechanically ventilated in 1395 hospitals. Rates per 100,000 inhabitants varied across age groups from 110 to 123 (18-59 years) to 1101-1275 (>80 years). The top main diagnoses were other forms of heart diseases, pneumonia, chronic obstructive pulmonary disease (COPD), ischemic heart diseases and cerebrovascular diseases. 43.3% (437,031/1,003,882) of all mechanically ventilated patients died in hospital with a remarkable increase in mortality with age and from 2019 to 2022 by almost 5%-points. The in-hospital mortality of ventilated COVID-19 patients was 53.7% (46,553/86,729), while it was 42.6% (390,478/917,153) in non-COVID patients. In-hospital mortality varied from 27.0% in non-invasive mechanical ventilation (NIV) only to 53.4% in invasive mechanical ventilation only cases, 59.4% with early NIV failure, 68.6% with late NIV failure, to 74.0% in patients receiving VV-ECMO and 80.0% in VA-ECMO. 17.5% of mechanically ventilated patients had been resuscitated before, of whom 78.2% (153,762/196,750) died. Total expenditure was around 6 billion Euros per year, i.e. 0.17% of the German GDP. Interpretation Mechanical ventilation was widely used, before, during and after the COVID-19 pandemic in Germany, reaching more than 1000 patients per 100,000 inhabitants per year in the age over 80 years. In-hospital mortality rates in this nationwide and complete cohort exceeded most of the data known by far. Funding This research did not receive any dedicated funding.
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Affiliation(s)
- Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Center, Kliniken der Stadt Köln, Witten/Herdecke University Hospital, Cologne, Germany
| | - Franz Krause
- GKV-Spitzenverband (National Association of Statutory Health Insurance Funds), Germany
| | - Claas Bentlage
- GKV-Spitzenverband (National Association of Statutory Health Insurance Funds), Germany
| | - Johannes Wolff
- GKV-Spitzenverband (National Association of Statutory Health Insurance Funds), Germany
| | | | - Wolfram Windisch
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Center, Kliniken der Stadt Köln, Witten/Herdecke University Hospital, Cologne, Germany
| | - Reinhard Busse
- TU Berlin, Department of Health Care Management, Technische Universität Berlin, Berlin, Germany
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15
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Chen S, Liao SF, Lin YJ, Huang CY, Ho SC, Chang JH. Outcomes of different pulmonary rehabilitation protocols in patients under mechanical ventilation with difficult weaning: a retrospective cohort study. Respir Res 2024; 25:243. [PMID: 38879514 PMCID: PMC11180404 DOI: 10.1186/s12931-024-02866-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 06/04/2024] [Indexed: 06/19/2024] Open
Abstract
BACKGROUND The endeavor of liberating patients from ventilator dependence within respiratory care centers (RCCs) poses considerable challenges. Multiple factors contribute to this process, yet establishing an effective regimen for pulmonary rehabilitation (PR) remains uncertain. This retrospective study aimed to evaluate existing rehabilitation protocols, ascertain associations between clinical factors and patient outcomes, and explore the influence of these protocols on the outcomes of the patients to shape suitable rehabilitation programs. METHODS Conducted at a medical center in northern Taiwan, the retrospective study examined 320 newly admitted RCC patients between January 1, 2015, and December 31, 2017. Each patient received a tailored PR protocol, following which researchers evaluated weaning rates, RCC survival, and 3-month survival as outcome variables. Analyses scrutinized differences in baseline characteristics and prognoses among three PR protocols: protocol 1 (routine care), protocol 2 (routine care plus breathing training), and protocol 3 (routine care plus breathing and limb muscle training). RESULTS Among the patients, 28.75% followed protocol 1, 59.37% protocol 2, and 11.88% protocol 3. Variances in age, body-mass index, pneumonia diagnosis, do-not-resuscitate orders, Glasgow Coma Scale scores (≤ 14), and Acute Physiology and Chronic Health Evaluation II (APACHE) scores were notable across these protocols. Age, APACHE scores, and abnormal blood urea nitrogen levels (> 20 mg/dL) significantly correlated with outcomes-such as weaning, RCC survival, and 3-month survival. Elevated mean hemoglobin levels linked to increased weaning rates (p = 0.0065) and 3-month survival (p = 0.0102). Four adjusted models clarified the impact of rehabilitation protocols. Notably, the PR protocol 3 group exhibited significantly higher 3-month survival rates compared to protocol 1, with odds ratios (ORs) ranging from 3.87 to 3.97 across models. This association persisted when comparing with protocol 2, with ORs between 3.92 and 4.22. CONCLUSION Our study showed that distinct PR protocols significantly affected the outcomes of ventilator-dependent patients within RCCs. The study underlines the importance of tailored rehabilitation programs and identifies key clinical factors influencing patient outcomes. Recommendations advocate prospective studies with larger cohorts to comprehensively assess PR effects on RCC patients.
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Affiliation(s)
- Shiauyee Chen
- Department of Physical Medicine and Rehabilitation, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- School of Respiratory Therapy, College of Medicine, Taipei Medical University, 250 Wuxing Street, Taipei, 11031, Taiwan
| | - Shu-Fen Liao
- Department of Medical Research, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Yun-Jou Lin
- School of Respiratory Therapy, College of Medicine, Taipei Medical University, 250 Wuxing Street, Taipei, 11031, Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Chao-Ying Huang
- School of Respiratory Therapy, College of Medicine, Taipei Medical University, 250 Wuxing Street, Taipei, 11031, Taiwan
- Graduate Institute of Physiology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shu-Chuan Ho
- School of Respiratory Therapy, College of Medicine, Taipei Medical University, 250 Wuxing Street, Taipei, 11031, Taiwan.
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.
| | - Jer-Hwa Chang
- School of Respiratory Therapy, College of Medicine, Taipei Medical University, 250 Wuxing Street, Taipei, 11031, Taiwan.
- Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
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16
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Warnaar RSP, Cornet AD, Beishuizen A, Moore CM, Donker DW, Oppersma E. Advanced waveform analysis of diaphragm surface EMG allows for continuous non-invasive assessment of respiratory effort in critically ill patients at different PEEP levels. Crit Care 2024; 28:195. [PMID: 38851709 PMCID: PMC11162564 DOI: 10.1186/s13054-024-04978-0] [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: 03/01/2024] [Accepted: 06/01/2024] [Indexed: 06/10/2024] Open
Abstract
BACKGROUND Respiratory effort should be closely monitored in mechanically ventilated ICU patients to avoid both overassistance and underassistance. Surface electromyography of the diaphragm (sEMGdi) offers a continuous and non-invasive modality to assess respiratory effort based on neuromuscular coupling (NMCdi). The sEMGdi derived electrical activity of the diaphragm (sEAdi) is prone to distortion by crosstalk from other muscles including the heart, hindering its widespread use in clinical practice. We developed an advanced analysis as well as quality criteria for sEAdi waveforms and investigated the effects of clinically relevant levels of PEEP on non-invasive NMCdi. METHODS NMCdi was derived by dividing end-expiratory occlusion pressure (Pocc) by sEAdi, based on three consecutive Pocc manoeuvres at four incremental (+ 2 cmH2O/step) PEEP levels in stable ICU patients on pressure support ventilation. Pocc and sEAdi quality was assessed by applying a novel, automated advanced signal analysis, based on tolerant and strict cut-off criteria, and excluding inadequate waveforms. The coefficient of variations (CoV) of NMCdi after basic manual and automated advanced quality assessment were evaluated, as well as the effect of an incremental PEEP trial on NMCdi. RESULTS 593 manoeuvres were obtained from 42 PEEP trials in 17 ICU patients. Waveform exclusion was primarily based on low sEAdi signal-to-noise ratio (Ntolerant = 155, 37%, Nstrict = 241, 51% waveforms excluded), irregular or abrupt cessation of Pocc (Ntolerant = 145, 35%, Nstrict = 145, 31%), and high sEAdi area under the baseline (Ntolerant = 94, 23%, Nstrict = 79, 17%). Strict automated assessment allowed to reduce CoV of NMCdi to 15% from 37% for basic quality assessment. As PEEP was increased, NMCdi decreased significantly by 4.9 percentage point per cmH2O. CONCLUSION Advanced signal analysis of both Pocc and sEAdi greatly facilitates automated and well-defined identification of high-quality waveforms. In the critically ill, this approach allowed to demonstrate a dynamic NMCdi (Pocc/sEAdi) decrease upon PEEP increments, emphasising that sEAdi-based assessment of respiratory effort should be related to PEEP dependent diaphragm function. This novel, non-invasive methodology forms an important methodological foundation for more robust, continuous, and comprehensive assessment of respiratory effort at the bedside.
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Affiliation(s)
- R S P Warnaar
- Cardiovascular and Respiratory Physiology, Technical Medical Centre, University of Twente, Technohal 3184, P.O. Box 217, 7500 AE, Enschede, The Netherlands.
| | - A D Cornet
- Intensive Care Centre, Medisch Spectrum Twente, Enschede, The Netherlands
| | - A Beishuizen
- Intensive Care Centre, Medisch Spectrum Twente, Enschede, The Netherlands
| | - C M Moore
- Netherlands eScience Center, Amsterdam, The Netherlands
| | - D W Donker
- Cardiovascular and Respiratory Physiology, Technical Medical Centre, University of Twente, Technohal 3184, P.O. Box 217, 7500 AE, Enschede, The Netherlands
- Intensive Care Centre, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - E Oppersma
- Cardiovascular and Respiratory Physiology, Technical Medical Centre, University of Twente, Technohal 3184, P.O. Box 217, 7500 AE, Enschede, The Netherlands
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17
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Rodriguez P, Hernández G. Weaning from mechanical ventilation: Speed it up and make it safe. Med Intensiva 2024; 48:356-359. [PMID: 38493060 DOI: 10.1016/j.medine.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 02/20/2024] [Indexed: 03/18/2024]
Affiliation(s)
| | - Gonzalo Hernández
- Complejo Hospitalario Universitario de Toledo, Toledo, Spain; Grupo de Investigación en Disfunción y Fallo Orgánico en la Agresión (IdiPAZ), Madrid, Spain; Ciber Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
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18
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Wahlster S, Sharma M, Taran S, Town JA, Stevens RD, Cinotti R, Asehnoune K, Robba C. Associations between Driving Pressure and Clinical Outcomes in Acute Brain Injury: A Subanalysis of ENIO. Am J Respir Crit Care Med 2024; 209:1400-1404. [PMID: 38502247 PMCID: PMC11146561 DOI: 10.1164/rccm.202402-0402le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 03/18/2024] [Indexed: 03/21/2024] Open
Affiliation(s)
- Sarah Wahlster
- Department of Neurology
- Department of Neurological Surgery, and
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
| | | | - Shaurya Taran
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - James A. Town
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Robert D. Stevens
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Raphaël Cinotti
- Department of Anesthesiology and Critical Care, Centre Hospitalier Universitaire Nantes, Nantes University, Nantes, France
| | - Karim Asehnoune
- Department of Anesthesiology and Critical Care, Centre Hospitalier Universitaire Nantes, Nantes University, Nantes, France
| | - Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy; and
- Anesthesia and Critical Care, San Martino Policlinico Hospital, Scientific Institute for Research, Hospitalization and Healthcare for Oncology and Neurosciences, Genoa, Italy
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19
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Coudroy R, Lejars A, Rodriguez M, Frat JP, Rault C, Arrivé F, Le Pape S, Thille AW. Physiologic Effects of Reconnection to the Ventilator for 1 Hour Following a Successful Spontaneous Breathing Trial. Chest 2024; 165:1406-1414. [PMID: 38295948 DOI: 10.1016/j.chest.2024.01.038] [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: 11/02/2023] [Revised: 01/16/2024] [Accepted: 01/20/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND Reconnection to the ventilator for 1 h following a successful spontaneous breathing trial (SBT) may reduce reintubation rates compared with direct extubation. However, the physiologic mechanisms leading to this effect are unclear. RESEARCH QUESTION Does reconnection to the ventilator for 1 h reverse alveolar derecruitment induced by SBT, and is alveolar derecruitment more pronounced with a T-piece than with pressure-support ventilation (PSV)? STUDY DESIGN AND METHODS This is an ancillary study of a randomized clinical trial comparing SBT performed with a T-piece or with PSV. Alveolar recruitment was assessed by using measurement of end-expiratory lung volume (EELV). RESULTS Of the 25 patients analyzed following successful SBT, 11 underwent SBT with a T-piece and 14 with PSV. At the end of the SBT, EELV decreased by -30% (95% CI, -37 to -23) compared with baseline prior to the SBT. This reduction was greater with a T-piece than with PSV: -43% (95% CI, -51 to -35) vs -20% (95% CI, -26 to -13); P < .001. Following reconnection to the ventilator for 1 h, EELV accounted for 96% (95% CI, 92 to 101) of baseline EELV and did not significantly differ from prior to the SBT (P = .104). Following 10 min of reconnection to the ventilator, EELV wasted at the end of the SBT was completely recovered using PSV (P = .574), whereas it remained lower than prior to the SBT using a T-piece (P = .010). INTERPRETATION Significant alveolar derecruitment was observed at the end of an SBT and was markedly more pronounced with a T-piece than with PSV. Reconnection to the ventilator for 1 h allowed complete recovery of alveolar derecruitment. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT04227639; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Rémi Coudroy
- CHU de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France; INSERM CIC 1402, IS-ALIVE Research Group, Université de Poitiers, Poitiers, France.
| | - Alice Lejars
- CHU de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Maeva Rodriguez
- CHU de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Jean-Pierre Frat
- CHU de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France; INSERM CIC 1402, IS-ALIVE Research Group, Université de Poitiers, Poitiers, France
| | - Christophe Rault
- INSERM CIC 1402, IS-ALIVE Research Group, Université de Poitiers, Poitiers, France; CHU de Poitiers, Service d'Explorations Fonctionnelles, de Physiologie Respiratoire et de l'Exercice, Poitiers, France
| | - François Arrivé
- CHU de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Sylvain Le Pape
- CHU de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Arnaud W Thille
- CHU de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France; INSERM CIC 1402, IS-ALIVE Research Group, Université de Poitiers, Poitiers, France
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20
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Groenland CNL, Blijleven MA, Ramzi I, Dubois EA, Heunks L, Endeman H, Wils EJ, Baggen VJM. The Value of Ischemic Cardiac Biomarkers to Predict Spontaneous Breathing Trial or Extubation Failure: A Systematic Review. J Clin Med 2024; 13:3242. [PMID: 38892952 PMCID: PMC11173145 DOI: 10.3390/jcm13113242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/24/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024] Open
Abstract
Background: It is unclear whether other cardiac biomarkers than NT-proBNP can be useful in the risk stratification of patients weaning from mechanical ventilation. The aim of this study is to summarize the role of ischemic cardiac biomarkers in predicting spontaneous breathing trial (SBT) or extubation failure. Methods: We systematically searched Embase, MEDLINE, Web of Science, and Cochrane Central for studies published before January 2024 that reported the association between ischemic cardiac biomarkers and SBT or extubation failure. Data were extracted using a standardized form and methodological assessment was performed using the QUIPS tool. Results: Seven observational studies investigating four ischemic cardiac biomarkers (Troponin-T, Troponin-I, CK-MB, Myoglobin) were included. One study reported a higher peak Troponin-I in patients with extubation failure compared to extubation success (50 ng/L [IQR, 20-215] versus 30 ng/L [IQR, 10-86], p = 0.01). A second study found that Troponin-I measured before the SBT was higher in patients with SBT failure in comparison to patients with SBT success (100 ± 80 ng/L versus 70 ± 130 ng/L, p = 0.03). A third study reported a higher CK-MB measured at the end of the SBT in patients with weaning failure (SBT or extubation failure) in comparison to weaning success (8.77 ± 20.5 ng/mL versus 1.52 ± 1.42 ng/mL, p = 0.047). Troponin-T and Myoglobin as well as Troponin-I and CK-MB measured at other time points were not found to be related to SBT or extubation failure. However, most studies were underpowered and with high risk of bias. Conclusions: The association with SBT or extubation failure is limited for Troponin-I and CK-MB and appears absent for Troponin-T and Myoglobin, but available studies are hampered by significant methodological drawbacks. To more definitively determine the role of ischemic cardiac biomarkers, future studies should prioritize larger sample sizes, including patients at risk of cardiac disease, using stringent SBTs and structured timing of laboratory measurements before and after SBT.
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Affiliation(s)
- Carline N. L. Groenland
- Department of Intensive Care, Erasmus MC, 3015 GD Rotterdam, The Netherlands; (M.A.B.); (I.R.); (E.A.D.); (L.H.); (H.E.); (V.J.M.B.)
| | - Maud A. Blijleven
- Department of Intensive Care, Erasmus MC, 3015 GD Rotterdam, The Netherlands; (M.A.B.); (I.R.); (E.A.D.); (L.H.); (H.E.); (V.J.M.B.)
| | - Imane Ramzi
- Department of Intensive Care, Erasmus MC, 3015 GD Rotterdam, The Netherlands; (M.A.B.); (I.R.); (E.A.D.); (L.H.); (H.E.); (V.J.M.B.)
| | - Eric A. Dubois
- Department of Intensive Care, Erasmus MC, 3015 GD Rotterdam, The Netherlands; (M.A.B.); (I.R.); (E.A.D.); (L.H.); (H.E.); (V.J.M.B.)
- Department of Cardiology, Thorax Center, Cardiovascular Institute, Erasmus MC, 3015 GD Rotterdam, The Netherlands
| | - Leo Heunks
- Department of Intensive Care, Erasmus MC, 3015 GD Rotterdam, The Netherlands; (M.A.B.); (I.R.); (E.A.D.); (L.H.); (H.E.); (V.J.M.B.)
- Department of Intensive Care, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Erasmus MC, 3015 GD Rotterdam, The Netherlands; (M.A.B.); (I.R.); (E.A.D.); (L.H.); (H.E.); (V.J.M.B.)
| | - Evert-Jan Wils
- Department of Intensive Care, Franciscus Gasthuis & Vlietland Ziekenhuis, 3045 PM Rotterdam, The Netherlands;
| | - Vivan J. M. Baggen
- Department of Intensive Care, Erasmus MC, 3015 GD Rotterdam, The Netherlands; (M.A.B.); (I.R.); (E.A.D.); (L.H.); (H.E.); (V.J.M.B.)
- Department of Cardiology, Thorax Center, Cardiovascular Institute, Erasmus MC, 3015 GD Rotterdam, The Netherlands
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21
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Bird JD, Lance ML, Banser TRW, Thrall SF, Cotton PD, Lindner JR, Eves ND, Dominelli PB, Foster GE. Quantifying Diaphragm Blood Flow With Contrast-Enhanced Ultrasound in Humans. Chest 2024:S0012-3692(24)00663-9. [PMID: 38821183 DOI: 10.1016/j.chest.2024.04.026] [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: 01/17/2024] [Revised: 04/26/2024] [Accepted: 04/29/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND Despite the known interplay between blood flow and function, to our knowledge, there is currently no minimally invasive method to monitor diaphragm hemodynamics. We used contrast-enhanced ultrasound to quantify relative diaphragm blood flow (Q˙DIA) in humans and assessed the technique's efficacy and reliability during graded inspiratory pressure threshold loading. We hypothesized that: (1) Q˙DIA would linearly increase with pressure generation, and (2) that there would be good test-retest reliability and interanalyzer reproducibility. RESEARCH QUESTION Can we validate what is, to our knowledge, the first minimally invasive method to measure relative diaphragm blood flow in humans? STUDY DESIGN AND METHODS Quantitative contrast-enhanced ultrasound of the costal diaphragm was performed in healthy participants (10 male participants, 6 female participants; mean age 28 ± 5 years; BMI 22.8 ± 2.0 kg/m) during unloaded breathing and three stages of loaded breathing on two separate days. Gastric and esophageal balloon catheters measured transdiaphragmatic pressure. Ultrasonography was performed during a constant-rate IV infusion of lipid-stabilized microbubbles following each stage. Ultrasound images were acquired after a destruction-replenishment sequence and diaphragm specific time-intensity data were used to determine Q˙DIA by two individuals. RESULTS Transdiaphragmatic pressure for unloaded and each loading stage were 15.2 ± 0.8, 26.1 ± 0.8, 34.6 ± 0.8, and 40.0 ± 0.8 percentage of the maximum, respectively. Q˙DIA increased with each stage of loading (3.1 ± 3.1, 6.9 ± 3.6, 11.0 ± 4.9, and 13.5 ± 5.4 acoustic units/s; P < .0001). The linear relationship between diaphragmatic flow and pressure was reproducible from day to day. Q˙DIA had good to excellent test-retest reliability (0.86 [0.77, 0.92]; P < .0001) and excellent interanalyzer reproducibility (0.93 [0.90, 0.95]; P < .0001) with minimal bias. INTERPRETATION Relative Q˙DIA measurements had valid physiological underpinnings, were reliable day-to-day, and were reproducible analyzer-to-analyzer. This study indicated that contrast-enhanced ultrasound is a viable, minimally invasive method for assessing costal Q˙DIA in humans and may provide a tool to monitor diaphragm hemodynamics in clinical settings.
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Affiliation(s)
- Jordan D Bird
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, BC, Canada
| | - Megan L Lance
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, BC, Canada
| | - Ty R W Banser
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, BC, Canada
| | - Scott F Thrall
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, BC, Canada
| | - Paul D Cotton
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, BC, Canada
| | - Jonathan R Lindner
- Robert M. Berne Cardiovascular Research Center, Division of Cardiovascular Medicine, University of Virginia, Charlottesville, VA
| | - Neil D Eves
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, BC, Canada
| | - Paolo B Dominelli
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Glen E Foster
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, BC, Canada.
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Song J, Luo Q, Lai X, Hu W, Yu Y, Wang M, Yang K, Chen G, Chen W, Li Q, Hu C, Gong S. Combined cardiac, lung, and diaphragm ultrasound for predicting weaning failure during spontaneous breathing trial. Ann Intensive Care 2024; 14:60. [PMID: 38641687 PMCID: PMC11031537 DOI: 10.1186/s13613-024-01294-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 04/10/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND Weaning from invasive mechanical ventilation (MV) is a complex and challenging process that involves multiple pathophysiological mechanisms. A combined ultrasound evaluation of the heart, lungs, and diaphragm during the weaning phase can help to identify risk factors and underlying mechanisms for weaning failure. This study aimed to investigate the accuracy of lung ultrasound (LUS), transthoracic echocardiography (TTE), and diaphragm ultrasound for predicting weaning failure in critically ill patients. METHODS Patients undergoing invasive MV for > 48 h and who were readied for their first spontaneous breathing trial (SBT) were studied. Patients were scheduled for a 2-h SBT using low-level pressure support ventilation. LUS and TTE were performed prospectively before and 30 min after starting the SBT, and diaphragm ultrasound was only performed 30 min after starting the SBT. Weaning failure was defined as failure of SBT, re-intubation, or non-invasive ventilation within 48 h. RESULTS Fifty-one patients were included, of whom 15 experienced weaning failure. During the SBT, the global, anterior, and antero-lateral LUS scores were higher in the failed group than in the successful group. Receiver operating characteristic curve analysis showed that the areas under the curves for diaphragm thickening fraction (DTF) and global and antero-lateral LUS scores during the SBT to predict weaning failure were 0.678, 0.719, and 0.721, respectively. There was no correlation between the LUS scores and the average E/e' ratio during the SBT. Multivariate analysis identified antero-lateral LUS score > 7 and DTF < 31% during the SBT as independent predictors of weaning failure. CONCLUSION LUS and diaphragm ultrasound can help to predict weaning failure in patients undergoing an SBT with low-level pressure support. An antero-lateral LUS score > 7 and DTF < 31% during the SBT were associated with weaning failure.
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Affiliation(s)
- Jia Song
- Department of Critical Care Medicine, Zhejiang Hospital, No. 12, Lingyin Road, Xihu District, Hangzhou, Zhejiang, 310013, China
| | - Qiancheng Luo
- Department of Critical Care Medicine, Shanghai Pudong New Area Gongli Hospital, No. 219, Miaopu Road, Pudong New Area, Shanghai, 200135, China
| | - Xinle Lai
- Department of Critical Care Medicine, Zhejiang Hospital, No. 12, Lingyin Road, Xihu District, Hangzhou, Zhejiang, 310013, China
| | - Weihang Hu
- Department of Critical Care Medicine, Zhejiang Hospital, No. 12, Lingyin Road, Xihu District, Hangzhou, Zhejiang, 310013, China
| | - Yihua Yu
- Department of Critical Care Medicine, Zhejiang Hospital, No. 12, Lingyin Road, Xihu District, Hangzhou, Zhejiang, 310013, China
| | - Minjia Wang
- Department of Critical Care Medicine, Zhejiang Hospital, No. 12, Lingyin Road, Xihu District, Hangzhou, Zhejiang, 310013, China
| | - Kai Yang
- The 2nd Clinical Medical College, Zhejiang Chinese Medical University, No. 548, Binwen Road, Binjiang District, Hangzhou, 310053, China
| | - Gongze Chen
- The 2nd Clinical Medical College, Zhejiang Chinese Medical University, No. 548, Binwen Road, Binjiang District, Hangzhou, 310053, China
| | - Wenwei Chen
- The 2nd Clinical Medical College, Zhejiang Chinese Medical University, No. 548, Binwen Road, Binjiang District, Hangzhou, 310053, China
| | - Qian Li
- The 2nd Clinical Medical College, Zhejiang Chinese Medical University, No. 548, Binwen Road, Binjiang District, Hangzhou, 310053, China
| | - Caibao Hu
- Department of Critical Care Medicine, Zhejiang Hospital, No. 12, Lingyin Road, Xihu District, Hangzhou, Zhejiang, 310013, China.
| | - Shijin Gong
- Department of Critical Care Medicine, Zhejiang Hospital, No. 12, Lingyin Road, Xihu District, Hangzhou, Zhejiang, 310013, China.
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23
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Michels-Zetsche JD, Schubert-Haack J, Tanck K, Neetz B, Iberl G, Müller M, Kempa A, Joves B, Rheinhold A, Ghiani A, Tsitouras K, Schneider A, Rauch C, Gehrig P, Biehler E, Fleischauer T, Britsch S, Frerk T, Szecsenyi J, Herth FJF, Trudzinski FC. E-learning-an interventional element of the PRiVENT project to improve weaning expertise. BMC MEDICAL EDUCATION 2024; 24:420. [PMID: 38641835 PMCID: PMC11027525 DOI: 10.1186/s12909-024-05416-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 04/11/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND PRiVENT (PRevention of invasive VENTilation) is an evaluation of a bundle of interventions aimed at the prevention of long-term invasive mechanical ventilation. One of these elements is an e-learning course for healthcare professionals to improve weaning expertise. The aim of our analysis is to examine the implementation of the course in cooperating intensive care units. METHODS The course has been developed through a peer review process by pulmonary and critical care physicians in collaboration with respiratory therapists, supported by health services researchers and a professional e-learning agency. The e-learning platform "weLearn" was made available online to participating healthcare professionals. Feedback on the e-learning programme was obtained and discussed in quality circles (QCs). We measured the acceptance and use of the programme through access statistics. RESULTS The e-learning course "Joint Prevention of Long-Term Ventilation" consists of 7 separate modules with practice-oriented training units as well as a cross-module area and corresponding interactive case studies. Users can receive 23 CME (continuing medical education) credits. The platform was released on July 1, 2021. By June 28, 2023, 214 users from 33 clinics had registered. Most users (77-98%) completed the modules, thus performing well in the test, where 90-100% passed. In the QCs, the users commended the structure and practical relevance of the programme, as well as the opportunity to earn CME credits. CONCLUSION Especially for medical staff in intensive care units, where continuous training is often a challenge during shift work, e-learning is a useful supplement to existing medical training. TRIAL REGISTRATION The PRiVENT study is registered at ClinicalTrials.gov (NCT05260853) on 02/03/2022.
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Affiliation(s)
- Julia D Michels-Zetsche
- Department of Pneumology and Critical Care, Thoraxklinik, University Hosptial Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Heidelberg, Germany.
| | - Janina Schubert-Haack
- aQua Institute for Applied Quality Improvement and Research in Health Care, Göttingen, Germany
| | - Katrin Tanck
- Common Sense eLearning & Training Consultants GmbH, Vienna, Austria
| | - Benjamin Neetz
- Department of Pneumology and Critical Care, Thoraxklinik, University Hosptial Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Gabriele Iberl
- Department of Pneumology and Critical Care, Thoraxklinik, University Hosptial Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Michael Müller
- Department of Pneumology and Critical Care, Thoraxklinik, University Hosptial Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Axel Kempa
- Department of Pneumology and Critical Care Medicine, SLK Loewenstein Lung Center, Loewenstein, Germany
| | - Biljana Joves
- Department of Pneumology and Critical Care Medicine, SLK Loewenstein Lung Center, Loewenstein, Germany
| | - Andreas Rheinhold
- Department of Pneumology and Critical Care Medicine, SLK Loewenstein Lung Center, Loewenstein, Germany
| | - Alessandro Ghiani
- Department of Pneumology and Respiratory Medicine, Robert-Bosch-Krankenhaus Klinik Schillerhöhe, Gerlingen, Germany
| | - Konstantinos Tsitouras
- Department of Pneumology and Respiratory Medicine, Robert-Bosch-Krankenhaus Klinik Schillerhöhe, Gerlingen, Germany
| | - Armin Schneider
- Department of Anaesthesia and Intensive Care Medicine Waldburg-Zeil Kliniken, Wangen im Allgäu, Germany
| | - Christoph Rauch
- Department of Pneumology, Critical Care and Allergology, Lung Centre South-West, Wangen im Allgäu, Germany
| | - Patrick Gehrig
- Department of Pneumology, Critical Care and Allergology, Lung Centre South-West, Wangen im Allgäu, Germany
| | - Elena Biehler
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Fleischauer
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Simone Britsch
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Center Mannheim, Mannheim, Germany
- European Center for Angioscience (ECAS) and German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Timm Frerk
- aQua Institute for Applied Quality Improvement and Research in Health Care, Göttingen, Germany
| | - Joachim Szecsenyi
- aQua Institute for Applied Quality Improvement and Research in Health Care, Göttingen, Germany
| | - Felix J F Herth
- Department of Pneumology and Critical Care, Thoraxklinik, University Hosptial Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Franziska C Trudzinski
- Department of Pneumology and Critical Care, Thoraxklinik, University Hosptial Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
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Mezidi M, Yonis H, Chauvelot L, Deniel G, Dhelft F, Gaillet M, Noirot I, Folliet L, Chabert P, David G, Danjou W, Baboi L, Bettinger C, Bernon P, Girard M, Provoost J, Bazzani A, Bitker L, Richard JC. Spontaneous breathing trial with pressure support on positive end-expiratory pressure and extensive use of non-invasive ventilation versus T-piece in difficult-to-wean patients from mechanical ventilation: a randomized controlled trial. Ann Intensive Care 2024; 14:59. [PMID: 38630372 PMCID: PMC11024068 DOI: 10.1186/s13613-024-01290-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 04/04/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND The aim of this study is to assess whether a strategy combining spontaneous breathing trial (SBT) with both pressure support (PS) and positive end-expiratory pressure (PEEP) and extended use of post-extubation non-invasive ventilation (NIV) (extensively-assisted weaning) would shorten the time until successful extubation as compared with SBT with T-piece (TP) and post-extubation NIV performed in selected patients as advocated by guidelines (standard weaning), in difficult-to-wean patients from mechanical ventilation. METHODS The study is a single-center prospective open label, randomized controlled superiority trial with two parallel groups and balanced randomization with a 1:1 ratio. Eligible patients were intubated patients mechanically ventilated for more than 24 h who failed their first SBT using TP. In the extensively-assisted weaning group, SBT was performed with PS (7 cmH2O) and PEEP (5 cmH2O). In case of SBT success, an additional SBT with TP was performed. Failure of this SBT-TP was an additional criterion for post-extubation NIV in this group in addition to other recommended criteria. In the standard weaning group, SBT was performed with TP, and NIV was performed according to international guidelines. The primary outcome criterion was the time between inclusion and successful extubation evaluated with a Cox model with adjustment on randomization strata. RESULTS From May 2019 to March 2023, 98 patients were included and randomized in the study (49 in each group). Four patients were excluded from the intention-to-treat population (2 in both groups); therefore, 47 patients were analyzed in each group. The extensively-assisted weaning group had a higher median age (68 [58-73] vs. 62 [55-71] yrs.) and similar sex ratio (62% male vs. 57%). Time until successful extubation was not significantly different between extensively-assisted and standard weaning groups (median, 172 [50-436] vs. 95 [47-232] hours, Cox hazard ratio for successful extubation, 0.88 [95% confidence interval: 0.55-1.42] using the standard weaning group as a reference; p = 0.60). All secondary outcomes were not significantly different between groups. CONCLUSION An extensively-assisted weaning strategy did not lead to a shorter time to successful extubation than a standard weaning strategy. Trial registration The trial was registered on ClinicalTrials.gov (NCT03861117), on March 1, 2019, before the inclusion of the first patient. https://clinicaltrials.gov/study/NCT03861117 .
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Affiliation(s)
- Mehdi Mezidi
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France.
- Université Lyon 1, Université de Lyon, Lyon, France.
| | - Hodane Yonis
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Louis Chauvelot
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Guillaume Deniel
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
- Université Lyon 1, Université de Lyon, Lyon, France
- CREATIS INSERM, 1044 CNRS 5220, Villeurbanne, France
| | - François Dhelft
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
- Université Lyon 1, Université de Lyon, Lyon, France
| | - Maxime Gaillet
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
- Université Lyon 1, Université de Lyon, Lyon, France
| | - Ines Noirot
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Laure Folliet
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Paul Chabert
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Guillaume David
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - William Danjou
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Loredana Baboi
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Clotilde Bettinger
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Pauline Bernon
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Mehdi Girard
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Judith Provoost
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Alwin Bazzani
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Laurent Bitker
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
- Université Lyon 1, Université de Lyon, Lyon, France
- CREATIS INSERM, 1044 CNRS 5220, Villeurbanne, France
| | - Jean-Christophe Richard
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
- Université Lyon 1, Université de Lyon, Lyon, France
- CREATIS INSERM, 1044 CNRS 5220, Villeurbanne, France
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Le Stang V, Latronico N, Dres M, Bertoni M. Critical illness-associated limb and diaphragmatic weakness. Curr Opin Crit Care 2024; 30:121-130. [PMID: 38441088 PMCID: PMC10919276 DOI: 10.1097/mcc.0000000000001135] [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: 03/09/2024]
Abstract
PURPOSE OF REVIEW In the current review, we aim to highlight the evolving evidence on the diagnosis, prevention and treatment of critical illness weakness (CIW) and critical illness associated diaphragmatic weakness (CIDW). RECENT FINDINGS In the ICU, several risk factors can lead to CIW and CIDW. Recent evidence suggests that they have different pathophysiological mechanisms and impact on outcomes, although they share common risk factors and may overlap in several patients. Their diagnosis is challenging, because CIW diagnosis is primarily clinical and, therefore, difficult to obtain in the ICU population, and CIDW diagnosis is complex and not easily performed at the bedside. All of these issues lead to underdiagnosis of CIW and CIDW, which significantly increases the risk of complications and the impact on both short and long term outcomes. Moreover, recent studies have explored promising diagnostic techniques that are may be easily implemented in daily clinical practice. In addition, this review summarizes the latest research aimed at improving how to prevent and treat CIW and CIDW. SUMMARY This review aims to clarify some uncertain aspects and provide helpful information on developing monitoring techniques and therapeutic interventions for managing CIW and CIDW.
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Affiliation(s)
- Valentine Le Stang
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique
- AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive –Réanimation (Département ‘R3S’), Paris, France
| | - Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
- Department of Emergency, ASST Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, 25123 Brescia, Italy
- ‘Alessandra BONO’ Interdepartmental University Research Center on LOng Term Outcome (LOTO) in Critical Illness Survivors, University of Brescia, Brescia, Italy
| | - Martin Dres
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique
- AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive –Réanimation (Département ‘R3S’), Paris, France
| | - Michele Bertoni
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
- Department of Emergency, ASST Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, 25123 Brescia, Italy
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26
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Messina A, Chew MS, Poole D, Calabrò L, De Backer D, Donadello K, Hernandez G, Hamzaoui O, Jozwiak M, Lai C, Malbrain MLNG, Mallat J, Myatra SN, Muller L, Ospina-Tascon G, Pinsky MR, Preau S, Saugel B, Teboul JL, Cecconi M, Monnet X. Consistency of data reporting in fluid responsiveness studies in the critically ill setting: the CODEFIRE consensus from the Cardiovascular Dynamic section of the European Society of Intensive Care Medicine. Intensive Care Med 2024; 50:548-560. [PMID: 38483559 DOI: 10.1007/s00134-024-07344-4] [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: 11/10/2023] [Accepted: 01/31/2024] [Indexed: 04/16/2024]
Abstract
PURPOSE To provide consensus recommendations regarding hemodynamic data reporting in studies investigating fluid responsiveness and fluid challenge (FC) use in the intensive care unit (ICU). METHODS The Executive Committee of the European Society of Intensive Care Medicine (ESICM) commissioned and supervised the project. A panel of 18 international experts and a methodologist identified main domains and items from a systematic literature, plus 2 ancillary domains. A three-step Delphi process based on an iterative approach was used to obtain the final consensus. In the Delphi 1 and 2, the items were selected with strong (≥ 80% of votes) or week agreement (70-80% of votes), while the Delphi 3 generated recommended (≥ 90% of votes) or suggested (80-90% of votes) items (RI and SI, respectively). RESULTS We identified 5 main domains initially including 117 items and the consensus finally resulted in 52 recommendations or suggestions: 18 RIs and 2 SIs statements were obtained for the domain "ICU admission", 11 RIs and 1 SI for the domain "mechanical ventilation", 5 RIs for the domain "reason for giving a FC", 8 RIs for the domain pre- and post-FC "hemodynamic data", and 7 RIs for the domain "pre-FC infused drugs". We had no consensus on the use of echocardiography, strong agreement regarding the volume (4 ml/kg) and the reference variable (cardiac output), while weak on administration rate (within 10 min) of FC in this setting. CONCLUSION This consensus found 5 main domains and provided 52 recommendations for data reporting in studies investigating fluid responsiveness in ICU patients.
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Affiliation(s)
- Antonio Messina
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano (Milan), Italy.
- Department of Biomedical Sciences, Humanitas University, via Levi Montalcin,i 4, Pieve Emanuele (Milan), Italy.
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Daniele Poole
- Anesthesia and Intensive Care Operative Unit, S. Martino Hospital, Belluno, Italy
| | - Lorenzo Calabrò
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano (Milan), Italy
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Katia Donadello
- Department of Surgery, Dentistry, Gynecology and Paediatrics, University of Verona, Via Dell'artigliere 8, 37129, Verona, Italy
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Olfa Hamzaoui
- Service de Médecine Intensive Réanimation Polyvalente, Robert Debré Hospital, University Hospitals of Reims, Unité HERVI « Hémostase et Remodelage Vasculaire Post-Ischémie » - EA 3801, University of Reims, Reims, France
| | - Mathieu Jozwiak
- Centre Hospitalier Universitaire L'Archet 1, Service de Médecine Intensive Réanimation, Nice, France
- Equipe 2 CARRES, UR2CA Unité de Recherche Clinique Université Côte d'Azur, Université Côte d'Azur, Nice, France
| | - Christopher Lai
- DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
| | - Manu L N G Malbrain
- First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Jihad Mallat
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Sheyla Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Laurent Muller
- Department of Anaesthesia, Critical Care and Emergency Medicine, Nîmes University Hospital, Place du Professeur Debré, 30029, Nîmes, France
- Hôpital universitaire Carémeau, University of Montpellier (MUSE), Nîmes, France
| | - Gustavo Ospina-Tascon
- Department of Intensive Care, Fundación Valle del Lili - Universidad ICESI, Cali, Colombia
| | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sebastian Preau
- Intensive Care Unit, Calmette Hospital, University Hospital of Lille, 59000, Lille, France
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jean-Louis Teboul
- DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
| | - Maurizio Cecconi
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano (Milan), Italy
- Department of Biomedical Sciences, Humanitas University, via Levi Montalcin,i 4, Pieve Emanuele (Milan), Italy
| | - Xavier Monnet
- DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
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27
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Robateau Z, Lin V, Wahlster S. Acute Respiratory Failure in Severe Acute Brain Injury. Crit Care Clin 2024; 40:367-390. [PMID: 38432701 DOI: 10.1016/j.ccc.2024.01.006] [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
Acute respiratory failure is commonly encountered in severe acute brain injury due to a multitude of factors related to the sequelae of the primary injury. The interaction between pulmonary and neurologic systems in this population is complex, often with competing priorities. Many treatment modalities for acute respiratory failure can result in deleterious effects on cerebral physiology, and secondary brain injury due to elevations in intracranial pressure or impaired cerebral perfusion. High-quality literature is lacking to guide clinical decision-making in this population, and deliberate considerations of individual patient factors must be considered to optimize each patient's care.
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Affiliation(s)
- Zachary Robateau
- Department of Neurology, University of Washington, Seattle, USA.
| | - Victor Lin
- Department of Neurology, University of Washington, Seattle, USA
| | - Sarah Wahlster
- Department of Neurology, University of Washington, Seattle, USA; Department of Neurological Surgery, University of Washington, Seattle, USA; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA
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Rose L, Messer B. Prolonged Mechanical Ventilation, Weaning, and the Role of Tracheostomy. Crit Care Clin 2024; 40:409-427. [PMID: 38432703 DOI: 10.1016/j.ccc.2024.01.008] [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
Depending on the definitional criteria used, approximately 5% to 10% of critical adults will require prolonged mechanical ventilation with longer-term outcomes that are worse than those ventilated for a shorter duration. Outcomes are affected by patient characteristics before critical illness and its severity but also by organizational characteristics and care models. Definitive trials of interventions to inform care activities, such as ventilator weaning, upper airway management, rehabilitation, and nutrition specific to the prolonged mechanical ventilation patient population, are lacking. A structured and individualized approach developed by the multiprofessional team in discussion with the patient and their family is warranted.
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Affiliation(s)
- Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, 57 Waterloo Road, London SE1 8WA, UK; Department of Critical Care and Lane Fox Unit, Guy's & St Thomas' NHS Foundation Trust, King's College London, 57 Waterloo Road, London SE1 8WA, UK.
| | - Ben Messer
- Royal Victoria Infirmary, Newcastle-Upon-Tyne NHS Hospitals NHS Foundation Trust, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK
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Dolinay T, Hsu L, Maller A, Walsh BC, Szűcs A, Jerng JS, Jun D. Ventilator Weaning in Prolonged Mechanical Ventilation-A Narrative Review. J Clin Med 2024; 13:1909. [PMID: 38610674 PMCID: PMC11012923 DOI: 10.3390/jcm13071909] [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: 02/06/2024] [Revised: 03/11/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
Patients requiring mechanical ventilation (MV) beyond 21 days, usually referred to as prolonged MV, represent a unique group with significant medical needs and a generally poor prognosis. Research suggests that approximately 10% of all MV patients will need prolonged ventilatory care, and that number will continue to rise. Although we have extensive knowledge of MV in the acute care setting, less is known about care in the post-ICU setting. More than 50% of patients who were deemed unweanable in the ICU will be liberated from MV in the post-acute setting. Prolonged MV also presents a challenge in care for medically complex, elderly, socioeconomically disadvantaged and marginalized individuals, usually at the end of their life. Patients and their families often rely on ventilator weaning facilities and skilled nursing homes for the continuation of care, but home ventilation is becoming more common. The focus of this review is to discuss recent advances in the weaning strategies in prolonged MV, present their outcomes and provide insight into the complexity of care.
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Affiliation(s)
- Tamás Dolinay
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
| | - Lillian Hsu
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
| | - Abigail Maller
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
| | - Brandon Corbett Walsh
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
- Department of Medicine, Division of Palliative Care Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Attila Szűcs
- Department of Anesthesiology, András Jósa County Hospital, 4400 Nyíregyháza, Hungary;
| | - Jih-Shuin Jerng
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, National Taiwan University Hospital, Taipei 100, Taiwan;
| | - Dale Jun
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
- Pulmonary, Critical Care and Sleep Section, West Los Angeles VA Medical Center, Los Angeles, CA 90073, USA
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30
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Bianquis C, Leiva Agüero S, Cantero C, Golfe Bonmatí A, González J, Hu X, Lacoste-Palasset T, Livesey A, Guillamat Prats R, Salai G, Sykes DL, Toland S, van Zeller C, Viegas P, Vieira AL, Zaneli S, Karagiannidis C, Fisser C. ERS International Congress 2023: highlights from the Respiratory Intensive Care Assembly. ERJ Open Res 2024; 10:00886-2023. [PMID: 38651090 PMCID: PMC11033729 DOI: 10.1183/23120541.00886-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 11/28/2023] [Indexed: 04/25/2024] Open
Abstract
Early career members of Assembly 2 (Respiratory Intensive Care) attended the 2023 European Respiratory Society International Congress in Milan, Italy. The conference covered acute and chronic respiratory failure. Sessions of interest to our assembly members and to those interested in respiratory critical care are summarised in this article and include the latest updates in respiratory intensive care, in particular acute respiratory distress syndrome and mechanical ventilation.
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Affiliation(s)
- Clara Bianquis
- Sorbonne Université, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Sebastian Leiva Agüero
- Academic unit of the University Institute of Health Science H.A. Barceló Foundation, La Rioja, Argentina
| | - Chloé Cantero
- APHP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Service de Pneumologie, Paris, France
| | | | - Jessica González
- Translational Research in Respiratory Medicine, University Hospital Arnau de Vilanova and Santa Maria, IRBLleida, Lleida, Spain
- CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, Madrid, Spain
| | - Xinxin Hu
- St Vincent's Health Network Sydney, Sydney, Australia
- University of Sydney, Sydney, Australia
| | - Thomas Lacoste-Palasset
- Assistance Publique Hôpitaux de Paris, Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin Bicêtre, France
- Université Paris–Saclay, Faculté de Médecine, Le Kremlin Bicêtre, France
| | - Alana Livesey
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Grgur Salai
- Department of Pulmonology, University Hospital Dubrava, Zagreb, Croatia
| | | | - Sile Toland
- Department of Medicine, Letterkenny University Hospital, Donegal, Ireland
| | - Cristiano van Zeller
- Department of Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Pedro Viegas
- Departamento de Pneumonologia, Centro Hospitalar de Vila Nova de Gaia/Espinho, Oporto, Portugal
| | | | - Stavroula Zaneli
- 1st Respiratory Department, Medical School, National and Kapodistrian University of Athens, “Sotiria” Chest Hospital, Athens, Greece
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, ARDS and ECMO Centre, Cologne-Merheim Hospital, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Cologne, Germany
| | - Christoph Fisser
- Department of Internal Medicine II, University Medical Centre Regensburg, Regensburg, Germany
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Michels-Zetsche JD, Gassmann V, Jasuja JK, Neetz B, Höger P, Meis J, Britsch S, Sommerwerck U, Fähndrich S, Bornitz F, Müller MM, Herth FJF, Trudzinski FC. Role of multidrug-resistant bacteria in weaning from invasive mechanical ventilation. Respir Res 2024; 25:69. [PMID: 38317197 PMCID: PMC10840161 DOI: 10.1186/s12931-024-02694-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/18/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Although multidrug-resistant bacteria (MDR) are common in patients undergoing prolonged weaning, there is little data on their impact on weaning and patient outcomes. METHODS This is a retrospective analysis of consecutive patients who underwent prolonged weaning and were at a university weaning centre from January 2018 to December 2020. The influence of MDR colonisation and infection on weaning success (category 3a and 3b), successful prolonged weaning from invasive mechanical ventilation (IMV) with or without the need for non-invasive ventilation (NIV) compared with category 3c (weaning failure 3cI or death 3cII) was investigated. The pathogen groups considered were: multidrug-resistant gram-negative bacteria (MDRGN), methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus spp. (VRE). RESULTS A total of 206 patients were studied, of whom 91 (44.2%) showed evidence of MDR bacteria (32% VRE, 1.5% MRSA and 16% MDRGN), with 25 patients also meeting the criteria for MDR infection. 70.9% of the 206 patients were successfully weaned from IMV, 8.7% died. In 72.2% of cases, nosocomial pneumonia and other infections were the main cause of death. Patients with evidence of MDR (infection and colonisation) had a higher incidence of weaning failure than those without evidence of MDR (48% vs. 34.8% vs. 21.7%). In multivariate analyses, MDR infection (OR 4.9, p = 0.004) was an independent risk factor for weaning failure, along with male sex (OR 2.3, p = 0.025), Charlson Comorbidity Index (OR 1.2, p = 0.027), pH (OR 2.7, p < 0.001) and duration of IMV before admission (OR 1.01, p < 0.001). In addition, MDR infection was the only independent risk factor for death (category 3cII), (OR 6.66, p = 0.007). CONCLUSION Patients with MDR infection are significantly more likely to die during the weaning process. There is an urgent need to develop non-antibiotic approaches for the prevention and treatment of MDR infections as well as clinical research on antibiotic stewardship in prolonged weaning as well as in ICUs.
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Affiliation(s)
- Julia D Michels-Zetsche
- Department of Pneumology and Critical Care, Thoraxklinik, University of Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Röntgenstrasse 1, D-69126, Heidelberg, Germany.
| | - Vicky Gassmann
- Department of Pneumology and Critical Care, Thoraxklinik, University of Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Röntgenstrasse 1, D-69126, Heidelberg, Germany
| | - Jasmin K Jasuja
- Department for Infectious Diseases, University Hospital Heidelberg, Heidelberg, Germany
| | - Benjamin Neetz
- Department of Pneumology and Critical Care, Thoraxklinik, University of Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Röntgenstrasse 1, D-69126, Heidelberg, Germany
| | - Philipp Höger
- Department of Pneumology and Critical Care, Thoraxklinik, University of Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Röntgenstrasse 1, D-69126, Heidelberg, Germany
| | - Jan Meis
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Simone Britsch
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, European Center for Angioscience (ECAS), University Medical Center Mannheim, German Center for Cardiovascular Research (DZHK), Partner Site, Heidelberg/Mannheim, Germany
| | - Urte Sommerwerck
- Department of Pneumology, Krankenhaus der Augustinerinnen Cologne, Cologne, Germany
| | - Sebastian Fähndrich
- Department of Pneumology, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Florian Bornitz
- Department of Pneumology and Internal Intensive Care Medicine, Asklepios Hospital Barmbek, Hamburg, Germany
| | - Michael M Müller
- Department of Pneumology and Critical Care, Thoraxklinik, University of Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Röntgenstrasse 1, D-69126, Heidelberg, Germany
| | - Felix J F Herth
- Department of Pneumology and Critical Care, Thoraxklinik, University of Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Röntgenstrasse 1, D-69126, Heidelberg, Germany
| | - Franziska C Trudzinski
- Department of Pneumology and Critical Care, Thoraxklinik, University of Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Röntgenstrasse 1, D-69126, Heidelberg, Germany
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Quickfall D, Sklar MC, Tomlinson G, Orchanian-Cheff A, Goligher EC. The influence of drugs used for sedation during mechanical ventilation on respiratory pattern during unassisted breathing and assisted mechanical ventilation: a physiological systematic review and meta-analysis. EClinicalMedicine 2024; 68:102417. [PMID: 38235422 PMCID: PMC10789641 DOI: 10.1016/j.eclinm.2023.102417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/20/2023] [Accepted: 12/20/2023] [Indexed: 01/19/2024] Open
Abstract
Background Sedation management has a major impact on outcomes in mechanically ventilated patients, but sedation strategies do not generally consider the differential effects of different sedatives on respiration and respiratory pattern. A systematic review was undertaken to quantitatively summarize the known effects of different classes of drugs used for sedation on respiratory pattern during both spontaneous breathing and assisted mechanical ventilation. Methods This was a systematic review and meta-analysis conducted using Ovid MEDLINE, Embase, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials up to June 2020 to retrieve studies that measured respiratory parameters before and after the administration of opioids, benzodiazepines, intravenous and inhaled anaesthetic agents, and other hypnotic agents (PROSPERO #CRD42020190017). A random-effects meta-analytic model was employed to estimate the mean percentage change in each of the respiratory indices according to medication exposure with and without mechanical ventilation. Risk of bias was assessed using the Cochrane risk of bias assessment tools. Findings Fifty-one studies were included in the analysis. Risk of bias was generally deemed to be low for most studies. Respiratory rate decreased with the administration of opioids in both non-ventilated patients (18% decrease, 95% CI 12-24%) and ventilated patients (26% decrease, 95% CI 15-37%) and increased with inhaled anaesthetics in non-ventilated patients (83% increase, 95% CI 49-118%) and ventilated patients (50% increase, 28-72%). In non-ventilated patients, tidal volume decreased following administration of inhaled aesthetics (55% decrease, 95% CI 25-86%), propofol (36% decrease, 95% CI 20-52%), and benzodiazepines (28% decrease, 95% CI 17-40%); in patients receiving assisted mechanical ventilation, tidal volume was not significantly affected by sedation. Administration of other hypnotic agents was not associated with changes in respiratory rate or tidal volume. Interpretation Different classes of drugs used for sedation exert differential effects on respiratory pattern, and this may influence weaning and outcomes in mechanically ventilated patients. Funding This study did not receive any funding support.
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Affiliation(s)
- Danica Quickfall
- Department of Critical Care Medicine, University of Calgary, Calgary, Canada
| | - Michael C. Sklar
- Unity Health, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - George Tomlinson
- Department of Medicine, University Health Network, Toronto, Canada
| | - Ani Orchanian-Cheff
- Library and Information Services, University Health Network, Toronto, Canada
| | - Ewan C. Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, University Health Network, Toronto, Canada
- Toronto General Hospital Research Institute, Toronto, Canada
- Department of Physiology, University of Toronto, Toronto, Canada
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Mousa A, Klompmaker P, Tuinman PR. Setting positive end-expiratory pressure: lung and diaphragm ultrasound. Curr Opin Crit Care 2024; 30:53-60. [PMID: 38085883 PMCID: PMC10962429 DOI: 10.1097/mcc.0000000000001119] [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: 01/03/2024]
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the role of lung ultrasound and diaphragm ultrasound in guiding ventilator settings with an emphasis on positive end-expiratory pressure (PEEP). Recent advances for using ultrasound to assess the effects of PEEP on the lungs and diaphragm are discussed. RECENT FINDINGS Lung ultrasound can accurately diagnose the cause of acute respiratory failure, including acute respiratory distress syndrome and can identify focal and nonfocal lung morphology in these patients. This is essential in determining optimal ventilator strategy and PEEP level. Assessment of the effect of PEEP on lung recruitment using lung ultrasound is promising, especially in the perioperative setting. Diaphragm ultrasound can monitor the effects of PEEP on the diaphragm, but this needs further validation. In patients with an acute exacerbation of chronic obstructive pulmonary disease, diaphragm ultrasound can be used to predict noninvasive ventilation failure. Lung and diaphragm ultrasound can be used to predict weaning outcome and accurately diagnose the cause of weaning failure. SUMMARY Lung and diaphragm ultrasound are useful for diagnosing the cause of respiratory failure and subsequently setting the ventilator including PEEP. Effects of PEEP on lung and diaphragm can be monitored using ultrasound.
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Affiliation(s)
- Amne Mousa
- Department of Intensive Care, Amsterdam UMC location Vrije Universiteit Amsterdam
- Amsterdam Cardiovascular Sciences research institute, Amsterdam UMC
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Peter Klompmaker
- Department of Intensive Care, Amsterdam UMC location Vrije Universiteit Amsterdam
- Amsterdam Cardiovascular Sciences research institute, Amsterdam UMC
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Pieter R. Tuinman
- Department of Intensive Care, Amsterdam UMC location Vrije Universiteit Amsterdam
- Amsterdam Cardiovascular Sciences research institute, Amsterdam UMC
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
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Hernández Martínez G, Rodriguez P, Soto J, Caritg O, Castellví-Font A, Mariblanca B, García AM, Colinas L, Añon JM, Parrilla-Gomez FJ, Silva-Obregón JA, Masclans JR, Propin A, Cuadra A, Dalorzo MG, Rialp G, Suarez-Sipmann F, Roca O. Effect of aggressive vs conservative screening and confirmatory test on time to extubation among patients at low or intermediate risk: a randomized clinical trial. Intensive Care Med 2024; 50:258-267. [PMID: 38353714 DOI: 10.1007/s00134-024-07330-w] [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: 09/15/2023] [Accepted: 01/19/2024] [Indexed: 03/03/2024]
Abstract
PURPOSE This study aimed to determine the best strategy to achieve fast and safe extubation. METHODS This multicenter trial randomized patients with primary respiratory failure and low-to-intermediate risk for extubation failure with planned high-flow nasal cannula (HFNC) preventive therapy. It included four groups: (1) conservative screening with ratio of partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2) ≥ 150 and positive end-expiratory pressure (PEEP) ≤ 8 cmH2O plus conservative spontaneous breathing trial (SBT) with pressure support 5 cmH2O + PEEP 0 cmH2O); (2) screening with ratio of partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2) ≥ 150 and PEEP ≤ 8 plus aggressive SBT with pressure support 8 + PEEP 5; (3) aggressive screening with PaO2/FiO2 > 180 and PEEP 10 maintained until the SBT with pressure support 8 + PEEP 5; (4) screening with PaO2/FiO2 > 180 and PEEP 10 maintained until the SBT with pressure support 5 + PEEP 0. Primary outcomes were time-to-extubation and simple weaning rate. Secondary outcomes included reintubation within 7 days after extubation. RESULTS Randomization to the aggressive-aggressive group was discontinued at the interim analysis for safety reasons. Thus, 884 patients who underwent at least 1 SBT were analyzed (conservative-conservative group, n = 256; conservative-aggressive group, n = 267; aggressive-conservative group, n = 261; aggressive-aggressive, n = 100). Median time to extubation was lower in the groups with aggressive screening (p < 0.001). Simple weaning rates were 45.7%, 76.78% (205 patients), 71.65%, and 91% (p < 0.001), respectively. Reintubation rates did not differ significantly (p = 0.431). CONCLUSION Among patients at low or intermediate risk for extubation failure with planned HFNC, combining aggressive screening with preventive PEEP and a conservative SBT reduced the time to extubation without increasing the reintubation rate.
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Affiliation(s)
- Gonzalo Hernández Martínez
- Complejo Hospitalario Universitario de Toledo, Toledo, Spain.
- Grupo de Investigación en Disfunción y Fallo Orgánico en La Agresión (IdiPAZ), Madrid, Spain.
- Ciber Enfermedades Respiratorias (CIBERES), Health Institute Carlos III, Madrid, Spain.
| | | | - Jesus Soto
- Hospital Universitario La Paz, Madrid, Spain
| | - Oriol Caritg
- Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Vall d'Hebron Institut de Reserca (VHIR), Barcelona, Spain
| | - Andrea Castellví-Font
- Hospital del Mar, Barcelona, Spain
- Grupo de Investigación del Paciente Crítico (GREPAC), Institut Hospital del Mar d´Investigacions Mèdiques (IMIM), Barcelona, Spain
| | | | | | - Laura Colinas
- Complejo Hospitalario Universitario de Toledo, Toledo, Spain
| | - Jose Manuel Añon
- Hospital Universitario La Paz, Madrid, Spain
- Grupo de Investigación en Disfunción y Fallo Orgánico en La Agresión (IdiPAZ), Madrid, Spain
| | - Francisco Jose Parrilla-Gomez
- Hospital del Mar, Barcelona, Spain
- Grupo de Investigación del Paciente Crítico (GREPAC), Institut Hospital del Mar d´Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Jose Alberto Silva-Obregón
- Hospital Universitario de Guadalajara, Guadalajara, Spain
- Grupo de Investigación del Paciente Hematológico, Instituto de Investigación Sanitaria Hospital Universitario La Paz (IdiPAZ), Madrid, Spain
| | - Joan Ramon Masclans
- Hospital del Mar, Barcelona, Spain
- Grupo de Investigación del Paciente Crítico (GREPAC), Institut Hospital del Mar d´Investigacions Mèdiques (IMIM), Barcelona, Spain
- MELIS, Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | | | - Alicia Cuadra
- Complejo Hospitalario Universitario de Toledo, Toledo, Spain
| | | | - Gemma Rialp
- Hospital Universitario Son Llàtzer, Palma, Spain
| | | | - Oriol Roca
- Parc Taulí Hospital Universitari, Institut de Investigació i Innovació Parc Taulí (I3PT-CERCA), Sabadell, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
- Ciber Enfermedades Respiratorias (CIBERES), Health Institute Carlos III, Madrid, Spain
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Trudzinski FC, Michels-Zetsche JD, Neetz B, Meis J, Müller M, Kempa A, Neurohr C, Schneider A, Herth FJF, Szecsenyi J, Biehler E, Fleischauer T, Wensing M, Britsch S, Schubert-Haack J, Grobe T, Frerk T. Risk factors for long-term invasive mechanical ventilation: a longitudinal study using German health claims data. Respir Res 2024; 25:60. [PMID: 38281006 PMCID: PMC10821552 DOI: 10.1186/s12931-024-02693-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 01/18/2024] [Indexed: 01/29/2024] Open
Abstract
BACKGROUND Long-term invasive mechanical ventilation (IMV) is a major burden for those affected and causes high costs for the health care system. Early risk assessment is a prerequisite for the best possible support of high-risk patients during the weaning process. We aimed to identify risk factors for long-term IMV within 96 h (h) after the onset of IMV. METHODS The analysis was based on data from one of Germany's largest statutory health insurance funds; patients who received IMV ≥ 96 h and were admitted in January 2015 at the earliest and discharged in December 2017 at the latest were analysed. OPS and ICD codes of IMV patients were considered, including the 365 days before intubation and 30 days after discharge. Long-term IMV was defined as evidence of invasive home mechanical ventilation (HMV), IMV ≥ 500 h, or readmission with (re)prolonged ventilation. RESULTS In the analysis of 7758 hospitalisations, criteria for long-term IMV were met in 38.3% of cases, of which 13.9% had evidence of HMV, 73.1% received IMV ≥ 500 h and/or 40.3% were re-hospitalised with IMV. Several independent risk factors were identified (p < 0.005 each), including pre-diagnoses such as pneumothorax (OR 2.10), acute pancreatitis (OR 2.64), eating disorders (OR 1.99) or rheumatic mitral valve disease (OR 1.89). Among ICU admissions, previous dependence on an aspirator or respirator (OR 5.13), and previous tracheostomy (OR 2.17) were particularly important, while neurosurgery (OR 2.61), early tracheostomy (OR 3.97) and treatment for severe respiratory failure such as positioning treatment (OR 2.31) and extracorporeal lung support (OR 1.80) were relevant procedures in the first 96 h after intubation. CONCLUSION This comprehensive analysis of health claims has identified several risk factors for the risk of long-term ventilation. In addition to the known clinical risks, the information obtained may help to identify patients at risk at an early stage. Trial registration The PRiVENT study was retrospectively registered at ClinicalTrials.gov (NCT05260853). Registered at March 2, 2022.
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Affiliation(s)
- Franziska C Trudzinski
- Department of Pneumology and Critical Care, Thoraxklinik Heidelberg gGmbH, Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), German Center for Lung Research (DZL), Heidelberg, Germany.
| | - Julia D Michels-Zetsche
- Department of Pneumology and Critical Care, Thoraxklinik Heidelberg gGmbH, Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Benjamin Neetz
- Department of Pneumology and Critical Care, Thoraxklinik Heidelberg gGmbH, Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Jan Meis
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Michael Müller
- Department of Pneumology and Critical Care, Thoraxklinik Heidelberg gGmbH, Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Axel Kempa
- Department of Pneumology and Critical Care, SLK-Klinik Löwenstein, Löwenstein, Germany
| | - Claus Neurohr
- Department of Pneumology and Respiratory Medicine, Robert-Bosch-Krankenhaus Klinik Schillerhöhe, Gerlingen, Germany
| | - Armin Schneider
- Department of Anesthesia and Intensive Care Medicine Waldburg-Zeil Kliniken, Wangen Im Allgäu, Germany
| | - Felix J F Herth
- Department of Pneumology and Critical Care, Thoraxklinik Heidelberg gGmbH, Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
- aQua Institute for Applied Quality Improvement and Research in Health Care, Göttingen, Germany
| | - Elena Biehler
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Fleischauer
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Michel Wensing
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Simone Britsch
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Center Mannheim, Mannheim, Germany
- European Center for Angioscience (ECAS) and German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Janina Schubert-Haack
- aQua Institute for Applied Quality Improvement and Research in Health Care, Göttingen, Germany
| | - Thomas Grobe
- aQua Institute for Applied Quality Improvement and Research in Health Care, Göttingen, Germany
| | - Timm Frerk
- aQua Institute for Applied Quality Improvement and Research in Health Care, Göttingen, Germany
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Boscolo A, Sella N, Pettenuzzo T, Pistollato E, Calabrese F, Gregori D, Cammarota G, Dres M, Rea F, Navalesi P. Diaphragm Dysfunction Predicts Weaning Outcome after Bilateral Lung Transplant. Anesthesiology 2024; 140:126-136. [PMID: 37552079 DOI: 10.1097/aln.0000000000004729] [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: 08/09/2023]
Abstract
BACKGROUND Diaphragm dysfunction and its effects on outcomes of ventilator weaning have been evaluated in mixed critical care populations using diaphragm thickening fraction (the ratio of the difference between ultrasound diaphragm thickness at end-inspiration and end-expiration to diaphragm thickness at end-expiration) or neuroventilatory efficiency (the ratio of tidal volume and peak electrical activity of the diaphragm). Such data are not available in bilateral-lung transplant recipients. The authors hypothesized that (1) diaphragm dysfunction, as defined by a diaphragm thickening fraction less than 29%, is more likely to occur in difficult weaning; (2) diaphragm thickening fraction and neuroventilatory efficiency predict weaning outcome; and (3) duration of mechanical ventilation before the first spontaneous breathing trial is associated with diaphragm dysfunction. METHODS Adult bilateral-lung transplant patients admitted to the intensive care unit were screened at the time of the first spontaneous breathing trial (pressure-support of 5 cm H2O and 0 positive end-expiratory pressure). At the fifth minute, diaphragm thickening fraction and neuroventilatory efficiency were measured during three respiratory cycles. Weaning was classified as simple, difficult, or prolonged (successful extubation at the first spontaneous breathing trial, within three or after three spontaneous breathing trials, respectively). RESULTS Forty-four subjects were enrolled. Diaphragm dysfunction occurred in 14 subjects (32%), all of whom had difficult weaning (78% of the subgroup of 18 patients experiencing difficult weaning). Both diaphragm thickening fraction (24 [20 to 29] vs. 39 [35 to 45]%) and neuroventilatory efficiency (34 [26 to 45] vs. 55 [43 to 62] ml/µV) were lower in difficult weaning (both P < 0.001). The areas under the receiver operator curve predicting difficult weaning were 0.88 (95% CI, 0.73 to 0.99) for diaphragm thickening fraction and 0.85 (95% CI, 0.71 to 0.95) for neuroventilatory efficiency. The duration of ventilation demonstrated a linear inverse correlation with both diaphragm thickening fraction and neuroventilatory efficiency. CONCLUSIONS Diaphragm dysfunction is common after bilateral-lung transplantation and associated with difficult weaning. In such patients, average values for diaphragm thickening fraction and neuroventilatory efficiency were reduced compared to patients with simple weaning. Both parameters showed similar accuracy for predicting success of ventilator weaning, demonstrating an inverse relationship with duration of ventilation. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Annalisa Boscolo
- Department of Medicine, and Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy; Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Nicolò Sella
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Tommaso Pettenuzzo
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | | | - Fiorella Calabrese
- Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | | | - Martin Dres
- Department of Critical Care, St. Michael's Hospital and the Critical Illness and Injury Research Center, Keenan Research Center for Biomedical Science of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Federico Rea
- Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Paolo Navalesi
- Department of Medicine, University of Padua, Padua, Italy; Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
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Neumann B, Angstwurm K, Dohmen C, Mergenthaler P, Kohler S, Schönenberger S, Lee DH, Gerner ST, Huttner HB, Thieme A, Steinbrecher A, Dunkel J, Roth C, Schneider H, Reichmann H, Fuhrer H, Kleiter I, Schneider-Gold C, Alberty A, Zinke J, Schroeter M, Linker R, Meisel A, Bösel J, Stetefeld HR. Weaning and extubation failure in myasthenic crisis: a multicenter analysis. J Neurol 2024; 271:564-574. [PMID: 37923937 DOI: 10.1007/s00415-023-12016-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 11/06/2023]
Abstract
Myasthenic crisis (MC) requiring mechanical ventilation is a serious complication of myasthenia gravis (MG). Here we analyze the frequency and risk factors of weaning- and extubation failure as well as its impact on the clinical course in a large cohort. We performed a retrospective chart review on patients treated for MC in 12 German neurological departments between 2006 and 2015. Weaning failure (WF) was defined as negative spontaneous breathing trial, primary tracheostomy, or extubation failure (EF) (reintubation or death). WF occurred in 138 episodes (64.2%). Older Age (p = 0.039), multiple comorbidities (≥ 3) (p = 0.007, OR = 4.04), late-onset MG (p = 0.004, OR = 2.84), complications like atelectasis (p = 0.008, OR = 3.40), pneumonia (p < 0.0001, OR = 3.45), cardio-pulmonary resuscitation (p = 0.005, OR = 5.00) and sepsis (p = 0.02, OR = 2.57) were associated with WF. WF occurred often in patients treated with intravenous immungloblins (IVIG) (p = 0.002, OR = 2.53), whereas WF was less often under first-line therapy with plasma exchange or immunoadsorption (p = 0.07, OR = 0.57). EF was observed in 58 of 135 episodes (43.0%) after first extubation attempt and was related with prolonged mechanical ventilation, intensive care unit stay and hospital stay (p ≤ 0.0001 for all). Extubation success was most likely in a time window for extubation between day 7 and 12 after intubation (p = 0.06, OR = 2.12). We conclude that WF and EF occur very often in MC and are associated with poor outcome. Older age, multiple comorbidities and development of cardiac and pulmonary complications are associated with a higher risk of WF and EF. Our data suggest that WF occurs less frequently under first-line plasma exchange/immunoadsorption compared with first-line use of IVIG.
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Affiliation(s)
- Bernhard Neumann
- Department of Neurology, Donau-Isar-Klinikum Deggendorf, Deggendorf, Germany
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
| | - Klemens Angstwurm
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
| | - Christian Dohmen
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
- Department for Neurology and Neurological Intensive Care Medicine, LVR-Klinik Bonn, Bonn, Germany
| | - Philipp Mergenthaler
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
| | - Siegfried Kohler
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Department of Neurology, Sana Klinikum Landkreis Biberach, Biberach, Germany
| | | | - De-Hyung Lee
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Stefan T Gerner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
- Department of Neurology, Universitätsklinikum Gießen Und Marburg, Gießen, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
- Department of Neurology, Universitätsklinikum Gießen Und Marburg, Gießen, Germany
| | - Andrea Thieme
- Department of Neurology, HELIOS Klinikum Erfurt, Erfurt, Germany
| | | | - Juliane Dunkel
- Department of Neurology, DRK-Kliniken Nordhessen, Kassel, Germany
| | - Christian Roth
- Department of Neurology, DRK-Kliniken Nordhessen, Kassel, Germany
- Department of Neurology, Kassel General Hospital, Kassel, Germany
| | - Hauke Schneider
- Department of Neurology, University Hospital, Technische Universität Dresden, Dresden, Germany
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
| | - Heinz Reichmann
- Department of Neurology, University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Hannah Fuhrer
- Department of Neurology, Medical Center-University of Freiburg, Freiburg, Germany
- Department of Neurology, HELIOS Klinik Mühlheim, Mühlheim, Germany
| | - Ingo Kleiter
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
- Marianne-Strauß-Klinik, Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke gGmbH, Berg, Germany
| | | | - Anke Alberty
- Department of Neurology, Kliniken Maria Hilf GmbH Moenchengladbach, Moenchengladbach, Germany
| | - Jan Zinke
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Michael Schroeter
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Ralf Linker
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
| | - Andreas Meisel
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
| | - Julian Bösel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Henning R Stetefeld
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
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Thille AW, Boissier F, Coudroy R, Le Pape S, Arrivé F, Marchasson L, Frat JP, Ragot S. Sex difference in the risk of extubation failure in ICUs. Ann Intensive Care 2023; 13:130. [PMID: 38112851 PMCID: PMC10730492 DOI: 10.1186/s13613-023-01225-7] [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: 09/21/2023] [Accepted: 12/07/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Little attention has been paid to potential differences in prognosis between mechanically ventilated males and females in intensive care units (ICUs). We hypothesized that a sex gap in the risk of extubation failure in ICUs may exist. METHODS Post hoc analysis of a large-scale clinical trial including patients at high risk of extubation failure in ICUs, with the aim of assessing the risk of extubation failure according to sex. The primary outcome was reintubation within the 7 days following extubation. RESULTS Out of 641 patients, 425 (66%) were males and 216 (34%) were females. Males were more likely to be admitted for cardiac arrest and to have underlying ischemic heart disease whereas females were more likely to be admitted for coma and to have obesity. Whereas the rate of reintubation at 48 h was significantly higher in males than in females (11.0% vs. 6.0%; difference, + 5.0 [95% CI, 0.2 to 9.2]; P = 0.038), the rate of reintubation at day 7 did not significantly differ between males and females (16.7% vs. 11.1%; difference, + 5.6% [95%CI, - 0.3 to 10.8], P = 0.059). Using multivariable logistic regression analysis, male sex was independently associated with reintubation within the 7 days following extubation (adjusted OR 1.70 [95% CI, 1.01 to 2.89]; P = 0.048), even after adjustment on reason for admission, body-mass index, severity score, respiratory rate before extubation, and noninvasive ventilation after extubation. CONCLUSION In this post hoc analysis of a clinical trial including a homogeneous subset of patients at high risk of extubation failure, sex was independently associated with reintubation. The role of sex on outcomes should be systematically examined in future studies of critically ill patients.
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Affiliation(s)
- Arnaud W Thille
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, 2 Rue La Milétrie, 86021, Poitiers Cedex, France.
- INSERM, CIC 1402 IS-ALIVE, University of Poitiers, Poitiers, France.
| | - Florence Boissier
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, 2 Rue La Milétrie, 86021, Poitiers Cedex, France
- INSERM, CIC 1402 IS-ALIVE, University of Poitiers, Poitiers, France
| | - Rémi Coudroy
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, 2 Rue La Milétrie, 86021, Poitiers Cedex, France
- INSERM, CIC 1402 IS-ALIVE, University of Poitiers, Poitiers, France
| | - Sylvain Le Pape
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, 2 Rue La Milétrie, 86021, Poitiers Cedex, France
| | - François Arrivé
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, 2 Rue La Milétrie, 86021, Poitiers Cedex, France
| | - Laura Marchasson
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, 2 Rue La Milétrie, 86021, Poitiers Cedex, France
| | - Jean-Pierre Frat
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, 2 Rue La Milétrie, 86021, Poitiers Cedex, France
- INSERM, CIC 1402 IS-ALIVE, University of Poitiers, Poitiers, France
| | - Stéphanie Ragot
- INSERM, CIC 1402 IS-ALIVE, University of Poitiers, Poitiers, France
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Teijeiro-Paradis R, Cherkos Dawit T, Munshi L, Ferguson ND, Fan E. Liberation From Venovenous Extracorporeal Membrane Oxygenation for Respiratory Failure: A Scoping Review. Chest 2023; 164:1184-1203. [PMID: 37353070 DOI: 10.1016/j.chest.2023.06.018] [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: 03/04/2023] [Revised: 06/03/2023] [Accepted: 06/14/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Safe and timely liberation from venovenous extracorporeal membrane oxygenation (ECMO) would be expected to reduce the duration of ECMO, the risk of complications, and costs. However, how to liberate patients from venovenous ECMO effectively remains understudied. RESEARCH QUESTION What is the current state of the evidence on liberation from venovenous ECMO? STUDY DESIGN AND METHODS We systematically searched for relevant publications on liberation from venovenous ECMO in Medline and EMBASE. Citations were included if the manuscripts provided any of the following: criteria for readiness for liberation, a liberation protocol, or a definition of successful decannulation or decannulation failure. We included randomized trials, observational trials, narrative reviews, guidelines, editorials, and commentaries. We excluded single case reports and citations where the full text was unavailable. RESULTS We screened 1,467 citations to identify 39 key publications on liberation from venovenous ECMO. We then summarized the data into five main topics: current strategies used for liberation, criteria used to define readiness for liberation, conducting liberation trials, criteria used to proceed with decannulation, and parameters used to predict decannulation outcomes. INTERPRETATION Practices on liberation from venovenous ECMO are heterogeneous and are influenced strongly by clinician preference. Additional research on liberation thresholds is needed to define optimal liberation strategies and to close existing knowledge gaps in essential topics on liberation from venovenous ECMO.
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Affiliation(s)
- Ricardo Teijeiro-Paradis
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Tsega Cherkos Dawit
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Mekelle University College of Health Sciences, Mekelle, Ethiopia
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Respirology & Critical Care, Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Respirology & Critical Care, Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Respirology & Critical Care, Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada.
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Varón-Vega F, Giraldo-Cadavid LF, Uribe AM, Rincón A, Palacios J, Crevoisier S, Tuta-Quintero E, Ordoñez L, Boada N, Rincón P, Poveda M, Monedero P. Utilization of spontaneous breathing trial, objective cough test, and diaphragmatic ultrasound results to predict extubation success: COBRE-US trial. Crit Care 2023; 27:414. [PMID: 37908002 PMCID: PMC10617213 DOI: 10.1186/s13054-023-04708-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/24/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND The results of clinical and weaning readiness tests and the spontaneous breathing trial (SBT) are used to predict the success of the weaning process and extubation. METHODS We evaluated the capacity of the cuff leak test, rate of rapid and shallow breathing, cough intensity, and diaphragmatic contraction velocity (DCV) to predict the success of the SBT and extubation in a prospective, multicenter observational study with consecutive adult patients admitted to four intensive care units. We used receiver operating characteristic (ROC) curves to assess the tests' predictive capacity and built predictive models using logistic regression. RESULTS We recruited 367 subjects who were receiving invasive mechanical ventilation and on whom 456 SBTs were performed, with a success rate of 76.5%. To predict the success of the SBT, we derived the following equation: (0.56 × Cough) - (0.13 × DCV) + 0.25. When the cutoff point was ≥ 0.83, the sensitivity was 91.5%, the specificity was 22.1%, and the overall accuracy was 76.2%. The area under the ROC curve (AUC-ROC) was 0.63. To predict extubation success, we derived the following equation: (5.7 × SBT) + (0.75 × Cough) - (0.25 × DCV) - 4.5. When the cutoff point was ≥ 1.25, the sensitivity was 96.8%, the specificity was 78.4%, and the overall accuracy was 91.5%. The AUC-ROC of this model was 0.91. CONCLUSION Objective measurement of cough and diaphragmatic contraction velocity could be used to predict SBT success. The equation for predicting successful extubation, which includes SBT, cough, and diaphragmatic contraction velocity values, showed excellent discriminative capacity.
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Affiliation(s)
- Fabio Varón-Vega
- Critical Care and Lung Transplantation Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Bogotá, Colombia.
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Cra. 13B #161 - 85, 110131, Bogotá, Colombia.
| | - Luis F Giraldo-Cadavid
- Interventional Pulmonology Service, Fundación Neumológica Colombiana, Bogotá, Colombia
- School of Medicine, Universidad de La Sabana, Chía, Colombia
| | - Ana María Uribe
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Cra. 13B #161 - 85, 110131, Bogotá, Colombia
| | - Adriana Rincón
- Critical Care and Lung Transplantation Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Bogotá, Colombia
| | - Jonathan Palacios
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Cra. 13B #161 - 85, 110131, Bogotá, Colombia
| | - Stephanie Crevoisier
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Cra. 13B #161 - 85, 110131, Bogotá, Colombia
| | | | - Lina Ordoñez
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Cra. 13B #161 - 85, 110131, Bogotá, Colombia
| | - Natalia Boada
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Cra. 13B #161 - 85, 110131, Bogotá, Colombia
- Critical Care Service, Fundación Clínica Shaio, Bogotá, Colombia
| | - Paola Rincón
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Cra. 13B #161 - 85, 110131, Bogotá, Colombia
- Critical Care Service, Fundación Clínica Shaio, Bogotá, Colombia
| | - Marcela Poveda
- Critical Care Service, Fundación Clínica Shaio, Bogotá, Colombia
| | - Pablo Monedero
- School of Medicine, Universidad de Navarra, Pamplona, Spain
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Havaldar AA, Krishna B. Wean to Win. Indian J Crit Care Med 2023; 27:695-696. [PMID: 37908418 PMCID: PMC10613874 DOI: 10.5005/jp-journals-10071-24556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023] Open
Abstract
How to cite this article: Havaldar AA, Krishna B. Wean to Win. Indian J Crit Care Med 2023;27(10):695-696.
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Affiliation(s)
- Amarja Ashok Havaldar
- Department of Critical Care, St. John's Medical College Hospital, Bengaluru, Karnataka, India
| | - Bhuvana Krishna
- Department of Critical Care, St. John's Medical College Hospital, Bengaluru, Karnataka, India
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Ghiani A, Kneidinger N, Neurohr C, Frank S, Hinske LC, Schneider C, Michel S, Irlbeck M. Mechanical Power Density Predicts Prolonged Ventilation Following Double Lung Transplantation. Transpl Int 2023; 36:11506. [PMID: 37799668 PMCID: PMC10548550 DOI: 10.3389/ti.2023.11506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 09/11/2023] [Indexed: 10/07/2023]
Abstract
Prolonged mechanical ventilation (PMV) after lung transplantation poses several risks, including higher tracheostomy rates and increased in-hospital mortality. Mechanical power (MP) of artificial ventilation unifies the ventilatory variables that determine gas exchange and may be related to allograft function following transplant, affecting ventilator weaning. We retrospectively analyzed consecutive double lung transplant recipients at a national transplant center, ventilated through endotracheal tubes upon ICU admission, excluding those receiving extracorporeal support. MP and derived indexes assessed up to 36 h after transplant were correlated with invasive ventilation duration using Spearman's coefficient, and we conducted receiver operating characteristic (ROC) curve analysis to evaluate the accuracy in predicting PMV (>72 h), expressed as area under the ROC curve (AUROC). PMV occurred in 82 (35%) out of 237 cases. MP was significantly correlated with invasive ventilation duration (Spearman's ρ = 0.252 [95% CI 0.129-0.369], p < 0.01), with power density (MP normalized to lung-thorax compliance) demonstrating the strongest correlation (ρ = 0.452 [0.345-0.548], p < 0.01) and enhancing PMV prediction (AUROC 0.78 [95% CI 0.72-0.83], p < 0.01) compared to MP (AUROC 0.66 [0.60-0.72], p < 0.01). Mechanical power density may help identify patients at risk for PMV after double lung transplantation.
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Affiliation(s)
- Alessandro Ghiani
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart–Schillerhoehe Lung Clinic GmbH, Robert-Bosch-Hospital GmbH, Stuttgart, Germany
| | - Nikolaus Kneidinger
- Department of Medicine V, LMU University Hospital, LMU Munich, Munich, Germany
- Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), Munich, Germany
| | - Claus Neurohr
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart–Schillerhoehe Lung Clinic GmbH, Robert-Bosch-Hospital GmbH, Stuttgart, Germany
- Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), Munich, Germany
| | - Sandra Frank
- Department of Anesthesiology, Ludwig-Maximilians-University (LMU) of Munich, Munich, Germany
| | - Ludwig Christian Hinske
- Department of Anesthesiology, Ludwig-Maximilians-University (LMU) of Munich, Munich, Germany
- Institute for Digital Medicine, University Hospital Augsburg, Augsburg, Germany
| | - Christian Schneider
- Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), Munich, Germany
- Department of Thoracic Surgery, Ludwig-Maximilians-University (LMU) of Munich, Munich, Germany
| | - Sebastian Michel
- Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), Munich, Germany
- Clinic of Cardiac Surgery, Ludwig-Maximilians-University (LMU) of Munich, Munich, Germany
| | - Michael Irlbeck
- Department of Anesthesiology, Ludwig-Maximilians-University (LMU) of Munich, Munich, Germany
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Michels JD, Trudzinski FC, Bornitz F, Ewert R, Müller M, Trinkmann F, Schellenberg M, Windisch W, Herth FJF. Costs of Weaning Failure: A Prospective, Multicentre, Controlled, Non-Randomised, Interventional Study on Economic Implications for the German Health Care System. Respiration 2023; 102:813-820. [PMID: 37619539 DOI: 10.1159/000533333] [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: 03/15/2023] [Accepted: 07/28/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Intensive care patients with respiratory failure often need invasive mechanical ventilation (IMV). With increasing population age and multimorbidity, the number of patients who cannot be weaned from IMV rises as well. Up to 85% of these patients have no access to a certified weaning centre. Their medical care is associated with impaired quality of life and high costs for the German health care system. OBJECTIVES This study examined the weaning outcome of patients in certified weaning centres after a primarily unsuccessful weaning attempt in order to calculate saving expenses compared to patients on long-term IMV in an outpatient setting. METHODS In this multicentre, controlled, non-randomised, interventional, prospective study, 61 patients (16 from out-of-hospital long-term IMV, 49 from other hospitals) were referred to a certified weaning centre for a second weaning phase. The incurred costs after 1 year of the latter were compared to insurance claim data of patients who were discharged from an acute hospital stay to receive IMV in an outpatient setting. RESULTS In the intervention group, 50 patients (82%) could be completely weaned or partially weaned using non-invasive ventilation, thus not needing IMV any longer. The costs per patient for weaning and out-of-hospital care in the intervention group were EUR 114,877.08, and the costs in the comparison cohort were EUR 234,442.62. CONCLUSIONS Early transfer to a certified weaning centre can increase weaning success and reduce total costs by approximately EUR 120,000 per patient in the first year. Given the existing structural prerequisites in Germany, every patient should have access to a weaning centre before being transferred to long-term IMV, from a medical and health economical point of view.
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Affiliation(s)
- Julia D Michels
- Thoraxklinik Heidelberg, Department of Pneumology and Critical Care, Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Franziska C Trudzinski
- Thoraxklinik Heidelberg, Department of Pneumology and Critical Care, Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Florian Bornitz
- Asklepios Hospital Barmbek, Pneumology and Internal Intensive Care Medicine, Hamburg, Germany
| | - Ralf Ewert
- Department of Internal Medicine B, Cardiology, Pneumology, Weaning, Infectious Diseases, Intensive Care Medicine, University Hospital Greifswald, Greifswald, Germany
| | - Michael Müller
- Thoraxklinik Heidelberg, Department of Pneumology and Critical Care, Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Frederik Trinkmann
- Thoraxklinik Heidelberg, Department of Pneumology and Critical Care, Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Mavi Schellenberg
- Thoraxklinik Heidelberg, Department of Pneumology and Critical Care, Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Wolfram Windisch
- Department of Pneumology, Cologne Merheim Hospital, Witten/Herdecke University, Cologne, Germany
| | - Felix J F Herth
- Thoraxklinik Heidelberg, Department of Pneumology and Critical Care, Heidelberg, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
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Heunks L, Duiverman ML. New insights into acute and chronic respiratory failure: highlights from the Respiratory Failure and Mechanical Ventilation Conference 2022. Eur Respir Rev 2023; 32:230027. [PMID: 37019460 PMCID: PMC10074168 DOI: 10.1183/16000617.0027-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 02/07/2023] [Indexed: 04/07/2023] Open
Abstract
The European Respiratory Society (ERS) is home to clinicians, scientists and students interested in respiratory medicine. In June 2022, the Society organised the second edition of the “Respiratory Failure and Mechanical Ventilation Conference”. This event focuses on clinical and scientific aspects of acute and chronic respiratory failure. Faculty and participants from 50 countries around the globe met in Berlin, although this time most of the sessions could also be accessed online. Participants with very diverse backgrounds, including medicine, nursing, physiotherapy and industry, discussed all aspects of respiratory failure including physiology, interventions for respiratory support, advanced diagnostic techniques, quality of life, and end of life care. Our common ground was passion for respiratory failure. The quality of the sessions during this 3-day conference was outstanding, and many of the presentations are still available for conference participants through the ERS website. However, the conference organisers felt that many of the topics discussed deserved an even broader audience. Highlights from the Respiratory Failure and Mechanical Ventilation Conference 2022 https://bit.ly/3HMWKTp
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Affiliation(s)
- Leo Heunks
- Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marieke L Duiverman
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Wahlster S, Town JA, Battaglini D, Robba C. Brain-lung crosstalk: how should we manage the breathing brain? BMC Pulm Med 2023; 23:180. [PMID: 37221544 DOI: 10.1186/s12890-023-02484-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 05/16/2023] [Indexed: 05/25/2023] Open
Abstract
Recent studies have drawn increasing attention to brain-lung crosstalk in critically ill patients. However, further research is needed to investigate the pathophysiological interactions between the brain and lungs, establish neuroprotective ventilatory strategies for brain-injured patients, provide guidance on potentially conflicting treatment priorities in patients with concomitant brain and lung injury, and enhance prognostic models to inform extubation and tracheostomy decisions. To bring together such research, BMC Pulmonary Medicine welcomes submissions to its new Collection on 'Brain-lung crosstalk'.
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Affiliation(s)
- Sarah Wahlster
- Department of Neurology, University of Washington, Seattle, WA, USA.
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA.
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.
| | - James A Town
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, USA
| | | | - Chiara Robba
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genova, Italy
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Pham T, Heunks L, Bellani G, Brochard L, Laffey J. WEAN SAFE and the definition of the first separation attempt - Authors' reply. THE LANCET. RESPIRATORY MEDICINE 2023; 11:e44. [PMID: 36934737 DOI: 10.1016/s2213-2600(23)00089-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 02/21/2023] [Indexed: 03/18/2023]
Affiliation(s)
- Tài Pham
- Service de Médecine Intensive-Réanimation, AP-HP, Hôpital de Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de recherche CARMAS, Hôpitaux Universitaires Paris-Saclay, Le Kremlin-Bicêtre, France; Université Paris-Saclay, UVSQ, Université Paris-Sud, INSERM U1018, Equipe d'Epidémiologie Respiratoire Intégrative, CESP, Villejuif, France
| | - Leo Heunks
- Department of Intensive Care Medicine, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Canada
| | - John Laffey
- Anaesthesia and Intensive Care Medicine, Galway University Hospitals, Galway, Ireland; School of Medicine, Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, University of Galway, Galway H91 TK33, Ireland.
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Cuyas CS, Fernández RF. WEAN SAFE and the definition of the first separation attempt. THE LANCET. RESPIRATORY MEDICINE 2023; 11:e43. [PMID: 36934738 DOI: 10.1016/s2213-2600(23)00051-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 03/18/2023]
Affiliation(s)
- Carles Subira Cuyas
- Critical Care Department, Althaia Xarxa Assistencial Manresa, Barcelona 08243, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Keenan Research Center, Toronto, ON, Canada.
| | - Rafael Fernández Fernández
- Critical Care Department, Althaia Xarxa Assistencial Manresa, Barcelona 08243, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
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Weaning from mechanical ventilation in intensive care units: a call for new international consensus guidelines. THE LANCET. RESPIRATORY MEDICINE 2023; 11:398-400. [PMID: 36693399 DOI: 10.1016/s2213-2600(22)00502-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 12/05/2022] [Indexed: 01/23/2023]
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Zambelli V, Murphy EJ, Delvecchio P, Rizzi L, Fumagalli R, Rezoagli E, Bellani G. Treatment with levosimendan in an experimental model of early ventilator-induced diaphragmatic dysfunction. Drug Target Insights 2023; 17:39-44. [PMID: 37070031 PMCID: PMC10105369 DOI: 10.33393/dti.2023.2574] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 03/29/2023] [Indexed: 04/19/2023] Open
Abstract
Introduction Mechanical ventilation (MV) is a life-saving approach in critically ill patients. However, it may affect the diaphragmatic structure and function, beyond the lungs. Levosimendan is a calcium sensitizer widely used in clinics to improve cardiac contractility in acute heart failure patients. In vitro studies have demonstrated that levosimendan increased force-generating capacity of the diaphragm in chronic obstructive pulmonary disease patients. Thus the aim of this study was to evaluate the effects of levosimendan administration in an animal model of ventilator-induced diaphragmatic dysfunction (VIDD) on muscle contraction and diaphragm muscle cell viability. Methods Sprague-Dawley rats underwent prolonged MV (5 hours). VIDD+Levo group received a starting bolus of levosimendan immediately after intratracheal intubation and then an intravenous infusion of levosimendan throughout the study. Diaphragms were collected for ex vivo contractility measurement (with electric stimulation), histological analysis and Western blot analysis. Healthy rats were used as the control. Results Levosimendan treatment maintained an adequate mean arterial pressure during the entire experimental protocol, preserved levels of autophagy-related proteins (LC3BI and LC3BII) and the muscular cell diameter demonstrated by histological analysis. Levosimendan did not affect the diaphragmatic contraction or the levels of proteins involved in the protein degradation (atrogin). Conclusions Our data suggest that levosimendan preserves muscular cell structure (cross-sectional area) and muscle autophagy after 5 hours of MV in a rat model of VIDD. However, levosimendan did not improve diaphragm contractile efficiency.
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Affiliation(s)
- Vanessa Zambelli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza - Italy
| | - Emma J Murphy
- LIFE - Health and Bioscience Research Institute, Midwest Campus, Technological University of the Shannon, Limerick - Ireland
| | - Paolo Delvecchio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza - Italy
| | - Laura Rizzi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza - Italy
| | - Roberto Fumagalli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza - Italy
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan - Italy
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza - Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza - Italy
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza - Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza - Italy
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