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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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Demoule A, Fossé Q, Mercat A, Bergum D, Virolle S, Bureau C, Mellemseter M, Guichou R, Similowski T, Dres M, Mortaza S. Operator independent continuous ultrasound monitoring of diaphragm excursion predicts successful weaning from mechanical ventilation: a prospective observational study. Crit Care 2024; 28:245. [PMID: 39014512 PMCID: PMC11253384 DOI: 10.1186/s13054-024-05003-0] [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: 03/27/2024] [Accepted: 06/24/2024] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND In mechanically ventilated patients, diaphragm ultrasound can identify diaphragm weakness and predict weaning failure. We evaluated whether a novel operator-independent ultrasound-based medical device allowing continuous monitoring of the diaphragm (CUSdi) could reliably (1) measure diaphragm excursion (EXdi) and peak contraction velocity (PCVdi), (2) predict weaning outcome, and (3) approximate transdiaphragmatic pressure (Pdi). METHODS In 49 mechanically ventilated patients, CUSdi was recorded during a 30-min spontaneous breathing trial (SBT), and EXdi and PCVdi were measured. In subgroups of patients, standard ultrasound measurement of EXdi and PCVdi was performed (n = 36), and Pdi derived parameters (peak and pressure time product, n = 30) were measured simultaneously. RESULTS The agreement bias between standard ultrasound and CUSdi for EXdi was 0.1 cm (95% confidence interval -0.7-0.9 cm). The regression of Passing-Bablok indicated a lack of systematic difference between EXdi measured with standard ultrasound and CUSdi, which were positively correlated (Rho = 0.84, p < 0.001). Weaning failure was observed in 54% of patients. One, two and three minutes after the onset of the SBT, EXdi was higher in the weaning success group than in the failure group. Two minutes after the onset of the SBT, an EXdi < 1.1 cm predicted weaning failure with a sensitivity of 0.83, a specificity of 0.68, a positive predictive value of 0.76, and a negative predictive value of 0.24. There was a weak correlation between EXdi and both peak Pdi (r = 0.22, 95% confidence interval 0.15 - 0.28) and pressure time product (r = 0.13, 95% confidence interval 0.06 - 0.20). Similar results were observed with PCVdi. CONCLUSIONS Operator-independent continuous diaphragm monitoring quantifies EXdi reliably and can predict weaning failure with an identified cut-off value of 1.1 cm. Trial registration clinicaltrial.gov, NCT04008875 (submitted 12 April 2019, posted 5 July 2019) and NCT03896048 (submitted 27 March 2019, posted 29 March 2019).
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Affiliation(s)
- Alexandre Demoule
- Service de Médecine Intensive - Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75651 Paris Cedex 13, 75013, Paris, France.
- UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, INSERM, 75005, Paris, France.
| | - Quentin Fossé
- Service de Médecine Intensive - Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75651 Paris Cedex 13, 75013, Paris, France
- UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, INSERM, 75005, Paris, France
| | - Alain Mercat
- Service de Réanimation Médicale et Médecine Hyperbare, Centre Hospitalier Régional Universitaire, Angers, France
| | - Daniel Bergum
- Department of Intensive Care Medicine, St. Olav University Hospital, Trondheim, Norway
| | - Sara Virolle
- Service de Médecine Intensive - Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75651 Paris Cedex 13, 75013, Paris, France
| | - Côme Bureau
- Service de Médecine Intensive - Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75651 Paris Cedex 13, 75013, Paris, France
- UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, INSERM, 75005, Paris, France
| | | | | | - Thomas Similowski
- UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, INSERM, 75005, Paris, France
- Département R3S, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
| | - Martin Dres
- Service de Médecine Intensive - Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75651 Paris Cedex 13, 75013, Paris, France
- UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, INSERM, 75005, Paris, France
| | - Satar Mortaza
- Service de Réanimation Médicale et Médecine Hyperbare, Centre Hospitalier Régional Universitaire, Angers, France
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Liu W, Chi Y, Zhao Y, He H, Long Y, Zhao Z. Occurrence of pendelluft during ventilator weaning with T piece correlated with increased mortality in difficult-to-wean patients. J Intensive Care 2024; 12:23. [PMID: 38915067 PMCID: PMC11194869 DOI: 10.1186/s40560-024-00737-z] [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: 03/07/2024] [Accepted: 06/14/2024] [Indexed: 06/26/2024] Open
Abstract
BACKGROUND Difficult-to-wean patients, typically identified as those failing the initial spontaneous breathing trial (SBT), face elevated mortality rates. Pendelluft, frequently observed in patients experiencing SBT failure, can be conveniently detected through bedside monitoring with electrical impedance tomography (EIT). This study aimed to explore the impact of pendelluft during SBT on difficult-to-wean patients. METHODS This retrospective observational study included difficult-to-wean patients undergoing spontaneous T piece breathing, during which EIT data were collected. Pendelluft occurrence was defined when its amplitude exceeded 2.5% of global tidal impedance variation. Physiological parameters during SBT were retrospectively retrieved from the EIT Examination Report Form. Other clinical data including mechanical ventilation duration, length of ICU stay, length of hospital stay, and 28-day mortality were retrieved from patient records in the hospital information system for each subject. RESULTS Pendelluft was observed in 72 (70.4%) of the 108 included patients, with 16 (14.8%) experiencing mortality by day 28. The pendelluft group exhibited significantly higher mortality (19.7% vs. 3.1%, p = 0.035), longer median mechanical ventilation duration [9 (5-15) vs. 7 (5-11) days, p = 0.041] and shorter ventilator-free days at day 28 [18 (4-22) vs. 20 (16-23) days, p = 0.043]. The presence of pendellfut was independently associated with increased mortality at day 28 (OR = 10.50, 95% confidence interval 1.21-90.99, p = 0.033). CONCLUSIONS Pendelluft occurred in 70.4% of difficult-to-wean patients undergoing T piece spontaneous breathing. Pendelluft was associated with worse clinical outcomes, including prolonged mechanical ventilation and increased mortality in this population. Our findings underscore the significance of monitoring pendelluft using EIT during SBT for difficult-to-wean patients.
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Affiliation(s)
- Wanglin Liu
- State Key Laboratory of Complex Severe and Rare Disease, Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, China
| | - Yi Chi
- State Key Laboratory of Complex Severe and Rare Disease, Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, China
| | - Yutong Zhao
- State Key Laboratory of Complex Severe and Rare Disease, Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, China
- Department of Critical Care Medicine, The First Clinical Medical College of Shanxi Medical University, Taiyuan, China
| | - Huaiwu He
- State Key Laboratory of Complex Severe and Rare Disease, Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, China.
| | - Yun Long
- State Key Laboratory of Complex Severe and Rare Disease, Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, China.
| | - Zhanqi Zhao
- State Key Laboratory of Complex Severe and Rare Disease, Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, China.
- School of Biomedical Engineering, Guangzhou Medical University, No. 1 Xinzao Rd. Panyu District, Guangzhou, China.
- Institute of Technical Medicine, Furtwangen University, VS-Schwenningen, Germany.
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Burns KEA, Sadeghirad B, Ghadimi M, Khan J, Phoophiboon V, Trivedi V, Gomez Builes C, Giammarioli B, Lewis K, Chaudhuri D, Desai K, Friedrich JO. Comparative effectiveness of alternative spontaneous breathing trial techniques: a systematic review and network meta-analysis of randomized trials. Crit Care 2024; 28:194. [PMID: 38849936 PMCID: PMC11162018 DOI: 10.1186/s13054-024-04958-4] [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: 03/31/2024] [Accepted: 05/17/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND The spontaneous breathing trial (SBT) technique that best balance successful extubation with the risk for reintubation is unknown. We sought to determine the comparative efficacy and safety of alternative SBT techniques. METHODS We searched Medline, EMBASE, and the Cochrane Central Register of Controlled Trials from inception to February 2023 for randomized or quasi-randomized trials comparing SBT techniques in critically ill adults and children and reported initial SBT success, successful extubation, reintubation (primary outcomes) and mortality (ICU, hospital, most protracted; secondary outcome) rates. Two reviewers screened, reviewed full-texts, and abstracted data. We performed frequentist random-effects network meta-analysis. RESULTS We included 40 RCTs (6716 patients). Pressure Support (PS) versus T-piece SBTs was the most common comparison. Initial successful SBT rates were increased with PS [risk ratio (RR) 1.08, 95% confidence interval (CI) (1.05-1.11)], PS/automatic tube compensation (ATC) [1.12 (1.01 -1.25), high flow nasal cannulae (HFNC) [1.07 (1.00-1.13) (all moderate certainty), and ATC [RR 1.11, (1.03-1.20); low certainty] SBTs compared to T-piece SBTs. Similarly, initial successful SBT rates were increased with PS, ATC, and PS/ATC SBTs compared to continuous positive airway pressure (CPAP) SBTs. Successful extubation rates were increased with PS [RR 1.06, (1.03-1.09); high certainty], ATC [RR 1.13, (1.05-1.21); moderate certainty], and HFNC [RR 1.06, (1.02-1.11); high certainty] SBTs, compared to T-piece SBTs. There was little to no difference in reintubation rates with PS (vs. T-piece) SBTs [RR 1.05, (0.91-1.21); low certainty], but increased reintubation rates with PS [RR 2.84, (1.61-5.03); moderate certainty] and ATC [RR 2.95 (1.57-5.56); moderate certainty] SBTs compared to HFNC SBTs. CONCLUSIONS SBTs conducted with pressure augmentation (PS, ATC, PS/ATC) versus without (T-piece, CPAP) increased initial successful SBT and successful extubation rates. Although SBTs conducted with PS or ATC versus HFNC increased reintubation rates, this was not the case for PS versus T-piece SBTs.
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Affiliation(s)
- Karen E A Burns
- Departments of Critical Care Medicine and Medicine, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, 4-045 Donnelly Wing, Toronto, ON, M5B 1W8, Canada.
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
- Li Ka Shing Knowledge Institute, Unity Health Toronto, St. Michael's Hospital, Toronto, Canada.
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Departments of Anesthesia and Medicine, McMaster University, Hamilton, Canada
| | - Maryam Ghadimi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Jeena Khan
- Departments of Critical Care Medicine and Medicine, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, 4-045 Donnelly Wing, Toronto, ON, M5B 1W8, Canada
- Royal College of Surgeons of Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | - Vorakamol Phoophiboon
- Departments of Critical Care Medicine and Medicine, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, 4-045 Donnelly Wing, Toronto, ON, M5B 1W8, Canada
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Vatsal Trivedi
- Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Canada
| | - Carolina Gomez Builes
- Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Benedetta Giammarioli
- Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Kimberley Lewis
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Departments of Anesthesia and Medicine, McMaster University, Hamilton, Canada
- Department of Critical Care, St. Joseph's Healthcare, Hamilton, Canada
| | - Dipayan Chaudhuri
- Departments of Anesthesia and Medicine, McMaster University, Hamilton, Canada
- Department of Critical Care, St. Joseph's Healthcare, Hamilton, Canada
| | - Kairavi Desai
- Michael DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Jan O Friedrich
- Departments of Critical Care Medicine and Medicine, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, 4-045 Donnelly Wing, Toronto, ON, M5B 1W8, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto, St. Michael's Hospital, Toronto, Canada
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Jha AK. Weaning strategy in patients at low-to-medium risk of extubation failure. Intensive Care Med 2024; 50:997-998. [PMID: 38598129 DOI: 10.1007/s00134-024-07418-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 04/11/2024]
Affiliation(s)
- Ajay Kumar Jha
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India.
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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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7
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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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8
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Bruhn A, Kattan E, Cavalcanti AB. Challenges and limitations of using ventilator-free days as an outcome in critical care trials. CRITICAL CARE SCIENCE 2024; 36:e20240088en. [PMID: 38747817 PMCID: PMC11098069 DOI: 10.62675/2965-2774.20240088-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 03/14/2024] [Indexed: 05/18/2024]
Affiliation(s)
- Alejandro Bruhn
- Pontificia Universidad Católica de ChileFacultad de MedicinaDepartment of Intensive MedicineSantiagoChileDepartment of Intensive Medicine, Facultad de Medicina, Pontificia Universidad Católica de Chile - Santiago, Chile.
| | - Eduardo Kattan
- Pontificia Universidad Católica de ChileFacultad de MedicinaDepartment of Intensive MedicineSantiagoChileDepartment of Intensive Medicine, Facultad de Medicina, Pontificia Universidad Católica de Chile - Santiago, Chile.
| | - Alexandre Biasi Cavalcanti
- HCor-Hospital do CoraçãoResearch InstituteSão PauloSPBrazilResearch Institute, HCor-Hospital do Coração - São Paulo (SP), Brazil.
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Wisse JJ, Goos TG, Jonkman AH, Somhorst P, Reiss IKM, Endeman H, Gommers D. Electrical Impedance Tomography as a monitoring tool during weaning from mechanical ventilation: an observational study during the spontaneous breathing trial. Respir Res 2024; 25:179. [PMID: 38664685 PMCID: PMC11044327 DOI: 10.1186/s12931-024-02801-6] [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: 12/21/2023] [Accepted: 04/02/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Prolonged weaning from mechanical ventilation is associated with poor clinical outcome. Therefore, choosing the right moment for weaning and extubation is essential. Electrical Impedance Tomography (EIT) is a promising innovative lung monitoring technique, but its role in supporting weaning decisions is yet uncertain. We aimed to evaluate physiological trends during a T-piece spontaneous breathing trail (SBT) as measured with EIT and the relation between EIT parameters and SBT success or failure. METHODS This is an observational study in which twenty-four adult patients receiving mechanical ventilation performed an SBT. EIT monitoring was performed around the SBT. Multiple EIT parameters including the end-expiratory lung impedance (EELI), delta Tidal Impedance (ΔZ), Global Inhomogeneity index (GI), Rapid Shallow Breathing Index (RSBIEIT), Respiratory Rate (RREIT) and Minute Ventilation (MVEIT) were computed on a breath-by-breath basis from stable tidal breathing periods. RESULTS EELI values dropped after the start of the SBT (p < 0.001) and did not recover to baseline after restarting mechanical ventilation. The ΔZ dropped (p < 0.001) but restored to baseline within seconds after restarting mechanical ventilation. Five patients failed the SBT, the GI (p = 0.01) and transcutaneous CO2 (p < 0.001) values significantly increased during the SBT in patients who failed the SBT compared to patients with a successful SBT. CONCLUSION EIT has the potential to assess changes in ventilation distribution and quantify the inhomogeneity of the lungs during the SBT. High lung inhomogeneity was found during SBT failure. Insight into physiological trends for the individual patient can be obtained with EIT during weaning from mechanical ventilation, but its role in predicting weaning failure requires further study.
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Affiliation(s)
- Jantine J Wisse
- Department of Adult Intensive Care, Erasmus Medical Centre, Rotterdam, the Netherlands.
- Department of Neonatal and Pediatric Intensive Care, Erasmus Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Tom G Goos
- Department of Neonatal and Pediatric Intensive Care, Erasmus Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Biomechanical Engineering, Faculty of Mechanical, Maritime and Materials Engineering, Delft University of Technology, Delft, The Netherlands
| | - Annemijn H Jonkman
- Department of Adult Intensive Care, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Peter Somhorst
- Department of Adult Intensive Care, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Irwin K M Reiss
- Department of Neonatal and Pediatric Intensive Care, Erasmus Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Henrik Endeman
- Department of Adult Intensive Care, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Diederik Gommers
- Department of Adult Intensive Care, Erasmus Medical Centre, Rotterdam, the Netherlands
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10
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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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11
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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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12
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Burns KEA, Rochwerg B, Seely AJE. Ventilator Weaning and Extubation. Crit Care Clin 2024; 40:391-408. [PMID: 38432702 DOI: 10.1016/j.ccc.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Increasing evidence supports specific approaches to liberate patients from invasive ventilation including the use of liberation protocols, inspiratory assistance during spontaneous breathing trials (SBTs), early extubation of patients with chronic obstructive pulmonary disease to noninvasive ventilation, and prophylactic use of noninvasive support strategies after extubation. Additional research is needed to elucidate the best criteria to identify patients who are ready to undergo an SBT and to inform optimal screening frequency, the best SBT technique and duration, extubation assessments, and extubation decision-making. Additional clarity is also needed regarding the optimal timing to measure and report extubation success.
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Affiliation(s)
- Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Medicine and Division of Critical Care, Unity Health Toronto, St. Michaels Hospital, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, Unity Health Toronto, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, Hamilton Health Sciences, Juravinski Hospital, Hamilton, Ontario, Canada; Department of Critical Care, Hamilton Health Sciences, Juravinski Hospital, Hamilton, Ontario, Canada. https://twitter.com/Bram_Rochwerg
| | - Andrew J E Seely
- Department of Critical Care, Ottawa Hospital, Ottawa, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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13
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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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14
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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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15
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Guillamet CV, Kollef MH. Is Zero Ventilator-Associated Pneumonia Achievable? Updated Practical Approaches to Ventilator-Associated Pneumonia Prevention. Infect Dis Clin North Am 2024; 38:65-86. [PMID: 38040518 DOI: 10.1016/j.idc.2023.11.001] [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: 12/03/2023]
Abstract
Ventilator-associated pneumonia (VAP) remains a significant clinical entity with reported incidence rates of 7% to 15%. Given the considerable adverse consequences associated with this infection, VAP prevention became a core measure required in most US hospitals. Many institutions took pride in implementing effective VAP prevention bundles that combined at least head of bed elevation, hand hygiene, chlorhexidine oral care, and subglottic drainage. Spontaneous breathing and awakening trials have also consistently been shown to shorten the duration of mechanical ventilation and secondarily reduce the occurrence of VAP.
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Affiliation(s)
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA.
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16
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Al-Husinat L, Jouryyeh B, Rawashdeh A, Robba C, Silva PL, Rocco PRM, Battaglini D. The Role of Ultrasonography in the Process of Weaning from Mechanical Ventilation in Critically Ill Patients. Diagnostics (Basel) 2024; 14:398. [PMID: 38396437 PMCID: PMC10888003 DOI: 10.3390/diagnostics14040398] [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: 12/31/2023] [Revised: 01/22/2024] [Accepted: 02/10/2024] [Indexed: 02/25/2024] Open
Abstract
Weaning patients from mechanical ventilation (MV) is a complex process that may result in either success or failure. The use of ultrasound at the bedside to assess organs may help to identify the underlying mechanisms that could lead to weaning failure and enable proactive measures to minimize extubation failure. Moreover, ultrasound could be used to accurately identify pulmonary diseases, which may be responsive to respiratory physiotherapy, as well as monitor the effectiveness of physiotherapists' interventions. This article provides a comprehensive review of the role of ultrasonography during the weaning process in critically ill patients.
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Affiliation(s)
- Lou’i Al-Husinat
- Department of Clinical Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan;
| | - Basil Jouryyeh
- Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan; (B.J.); (A.R.)
| | - Ahlam Rawashdeh
- Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan; (B.J.); (A.R.)
| | - Chiara Robba
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy;
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, 16132 Genova, Italy
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro 21941, Brazil; (P.L.S.); (P.R.M.R.)
| | - Patricia Rieken Macedo Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro 21941, Brazil; (P.L.S.); (P.R.M.R.)
| | - Denise Battaglini
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy;
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17
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Burns KEA, Khan J, Phoophiboon V, Trivedi V, Gomez-Builes JC, Giammarioli B, Lewis K, Chaudhuri D, Desai K, Friedrich JO. Spontaneous Breathing Trial Techniques for Extubating Adults and Children Who Are Critically Ill: A Systematic Review and Meta-Analysis. JAMA Netw Open 2024; 7:e2356794. [PMID: 38393729 PMCID: PMC10891471 DOI: 10.1001/jamanetworkopen.2023.56794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/28/2023] [Indexed: 02/25/2024] Open
Abstract
Importance Considerable controversy exists regarding the best spontaneous breathing trial (SBT) technique to use. Objective To summarize trials comparing alternative SBTs. Data Sources Several databases (MEDLINE [from inception to February 2023], the Cochrane Central Register of Controlled Trials [in February 2023], and Embase [from inception to February 2023] and 5 conference proceedings (from January 1990 to April 2023) were searched in this systematic review and meta-analysis. Study Selection Randomized trials directly comparing SBT techniques in critically ill adults or children and reporting at least 1 clinical outcome were selected. Data Extraction and Synthesis Paired reviewers independently screened citations, abstracted data, and assessed quality for the systematic review and meta-analysis using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA guidelines). Data were pooled using random-effects models. Main Outcomes and Measures Primary outcomes included SBT success, extubation success, and reintubation. Results The systematic review and meta-analysis identified 40 trials that included 6716 patients. Low-quality evidence (14 trials [n = 4459]) suggested that patients were not more likely to pass a pressure support (PS) compared with a T-piece SBT (risk ratio [RR], 1.04; 95% CI, 0.97-1.11; P = .31; I2 = 73%), unless 1 outlier trial accounting for all heterogeneity was excluded (RR, 1.09; 95% CI, 1.06-1.12; P < .001; I2 = 0% [13 trials; n = 3939]; moderate-quality evidence), but were significantly more likely to be successfully extubated (RR, 1.07; 95% CI, 1.04-1.10; P < .001; I2 = 0%; 16 trials [n = 4462]; moderate-quality evidence). Limited data (5 trials [n = 502]) revealed that patients who underwent automatic tube compensation/continuous positive airway pressure compared with PS SBTs had a significantly higher successful extubation rate (RR, 1.10; 95% CI, 1.00-1.21; P = .04; I2 = 0% [low-quality evidence]). Compared with T-piece SBTs, high-flow oxygen SBTs (3 trials [n = 386]) had significantly higher successful extubation (RR, 1.06; 95% CI, 1.00-1.11; P = .04; I2 = 0%) and lower reintubation (RR, 0.37; 95% CI, 0.21-0.65; P = <.001; I2 = 0% [both low-quality evidence]) rates. Credible subgroup effects were not found. Conclusions and Relevance In this systematic review and meta-analysis, the findings suggest that patients undergoing PS compared with T-piece SBTs were more likely to be extubated successfully and more likely to pass an SBT, after exclusion of an outlier trial. Pressure support SBTs were not associated with increased risk of reintubation. Future trials should compare SBT techniques that maximize differences in inspiratory support.
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Affiliation(s)
- Karen E. A. Burns
- Department of Critical Care, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine, Department of Medicine, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jeena Khan
- Department of Critical Care, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | - Vorakamol Phoophiboon
- Department of Critical Care, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Vatsal Trivedi
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
| | | | - Benedetta Giammarioli
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kimberley Lewis
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Critical Care, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Dipayan Chaudhuri
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Critical Care, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Kairavi Desai
- Michael G. DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jan O. Friedrich
- Department of Critical Care, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine, Department of Medicine, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
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18
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McNamara L, Baedorf Kassis E. Optimal positive-end expiratory pressure weaning in acute respiratory distress syndrome patients. Curr Opin Crit Care 2024; 30:85-88. [PMID: 38085868 DOI: 10.1097/mcc.0000000000001122] [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: 01/03/2024]
Abstract
PURPOSE OF REVIEW Positive-end expiratory pressure (PEEP) is a tool in managing acute respiratory distress syndrome (ARDS). In this review, we discuss the various approaches to weaning PEEP after the acute phase of ARDS. RECENT FINDINGS There is a paucity of research specifically looking at the differences between PEEP weaning protocols. Data in some populations though, particularly those with elevated BMI, suggest that a physiologic approach to PEEP weaning may be helpful. Use of various tools to optimize PEEP prior to and during spontaneous breathing trials (SBTs) may allow for improved alveolar recruitment and respiratory outcomes. SUMMARY Although further prospective studies are warranted, we should consider using a physiologic approach to PEEP weaning in ARDS rather than a one size fits all model, which is currently the standard used in many clinical trials and throughout many ICUs.
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Affiliation(s)
| | - Elias Baedorf Kassis
- Division of Pulmonary and Critical Care
- Department of Anesthesia, Pain and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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19
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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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20
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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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21
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Tanaka A, Shimomura Y, Uchiyama A, Tokuhira N, Kitamura T, Iwata H, Hashimoto H, Ishigaki S, Enokidani Y, Yamashita T, Koyama Y, Iguchi N, Yoshida T, Fujino Y. Time definition of reintubation most relevant to patient outcomes in critically ill patients: a multicenter cohort study. Crit Care 2023; 27:378. [PMID: 37777790 PMCID: PMC10544149 DOI: 10.1186/s13054-023-04668-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 09/27/2023] [Indexed: 10/02/2023] Open
Abstract
BACKGROUND Reintubation is a common complication in critically ill patients requiring mechanical ventilation. Although reintubation has been demonstrated to be associated with patient outcomes, its time definition varies widely among guidelines and in the literature. This study aimed to determine the association between reintubation and patient outcomes as well as the consequences of the time elapsed between extubation and reintubation on patient outcomes. METHODS This was a multicenter retrospective cohort study of critically ill patients conducted between April 2015 and March 2021. Adult patients who underwent mechanical ventilation and extubation in intensive care units (ICUs) were investigated utilizing the Japanese Intensive Care PAtient Database. The primary and secondary outcomes were in-hospital and ICU mortality. The association between reintubation and clinical outcomes was studied using Cox proportional hazards analysis. Among the patients who underwent reintubation, a Cox proportional hazard analysis was conducted to evaluate patient outcomes according to the number of days from extubation to reintubation. RESULTS Overall, 184,705 patients in 75 ICUs were screened, and 1849 patients underwent reintubation among 48,082 extubated patients. After adjustment for potential confounders, multivariable analysis revealed a significant association between reintubation and increased in-hospital and ICU mortality (adjusted hazard ratio [HR] 1.520, 95% confidence interval [CI] 1.359-1.700, and adjusted HR 1.325, 95% CI 1.076-1.633, respectively). Among the reintubated patients, 1037 (56.1%) were reintubated within 24 h after extubation, 418 (22.6%) at 24-48 h, 198 (10.7%) at 48-72 h, 111 (6.0%) at 72-96 h, and 85 (4.6%) at 96-120 h. Multivariable Cox proportional hazard analysis showed that in-hospital and ICU mortality was highest in patients reintubated at 72-96 h (adjusted HR 1.528, 95% CI 1.062-2.197, and adjusted HR 1.334, 95% CI 0.756-2.352, respectively; referenced to reintubation within 24 h). CONCLUSIONS Reintubation was associated with a significant increase in in-hospital and ICU mortality. The highest mortality rates were observed in patients who were reintubated between 72 and 96 h after extubation. Further studies are warranted for the optimal observation of extubated patients in clinical practice and to strengthen the evidence for mechanical ventilation.
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Affiliation(s)
- Aiko Tanaka
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan.
- Department of Intensive Care, University of Fukui Hospital, Yoshida, Fukui, Japan.
| | - Yoshimitsu Shimomura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Department of Hematology, Kobe City Hospital Organization Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Akinori Uchiyama
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Natsuko Tokuhira
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hirofumi Iwata
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Haruka Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Suguru Ishigaki
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yusuke Enokidani
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Tomonori Yamashita
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yukiko Koyama
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Naoya Iguchi
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Takeshi Yoshida
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yuji Fujino
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
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22
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Bonny V, Joffre J, Gabarre P, Urbina T, Missri L, Ladoire M, Gasperment M, Baudel JL, Guidet B, Dumas G, Maury E, Brochard L, Ait-Oufella H. Sonometric assessment of cough predicts extubation failure: SonoWean-a proof-of-concept study. Crit Care 2023; 27:368. [PMID: 37749612 PMCID: PMC10521471 DOI: 10.1186/s13054-023-04653-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: 08/10/2023] [Accepted: 09/19/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Extubation failure is associated with increased mortality. Cough ineffectiveness may be associated with extubation failure, but its quantification for patients undergoing weaning from invasive mechanical ventilation (IMV) remains challenging. METHODS Patients under IMV for more than 24 h completing a successful spontaneous T-tube breathing trial (SBT) were included. At the end of the SBT, we performed quantitative sonometric assessment of three successive coughing efforts using a sonometer. The mean of the 3-cough volume in decibels was named Sonoscore. RESULTS During a 1-year period, 106 patients were included. Median age was 65 [51-75] years, mainly men (60%). Main reasons for IMV were acute respiratory failure (43%), coma (25%) and shock (17%). Median duration of IMV at enrollment was 4 [3-7] days. Extubation failure occurred in 15 (14%) patients. Baseline characteristics were similar between success and failure extubation groups, except percentage of simple weaning which was lower and MV duration which was longer in extubation failure patients. Sonoscore was significantly lower in patients who failed extubation (58 [52-64] vs. 75 [70-78] dB, P < 0.001). After adjustment on MV duration and comorbidities, Sonoscore remained associated with extubation failure. Sonoscore was predictive of extubation failure with an area under the ROC curve of 0.91 (IC95% [0.83-0.99], P < 0.001). A threshold of Sonoscore < 67.1 dB predicted extubation failure with a sensitivity of 0.93 IC95% [0.70-0.99] and a specificity of 0.82 IC95% [0.73-0.90]. CONCLUSION Sonometric assessment of cough strength might be helpful to identify patients at risk of extubation failure in patients undergoing IMV.
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Affiliation(s)
- Vincent Bonny
- Service de Médecine Intensive Réanimation, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, 184 Rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
- Sorbonne Université, Paris, France
| | - Jeremie Joffre
- Service de Médecine Intensive Réanimation, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, 184 Rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
- Sorbonne Université, Paris, France
| | - Paul Gabarre
- Service de Médecine Intensive Réanimation, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, 184 Rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Tomas Urbina
- Service de Médecine Intensive Réanimation, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, 184 Rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Louai Missri
- Service de Médecine Intensive Réanimation, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, 184 Rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
- Sorbonne Université, Paris, France
| | - Mathilde Ladoire
- Service de Médecine Intensive Réanimation, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, 184 Rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Maxime Gasperment
- Service de Médecine Intensive Réanimation, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, 184 Rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Jean-Luc Baudel
- Service de Médecine Intensive Réanimation, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, 184 Rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Bertrand Guidet
- Service de Médecine Intensive Réanimation, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, 184 Rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
- Sorbonne Université, Paris, France
| | - Guillaume Dumas
- Service de Médecine Intensive-Réanimation, CHU Grenoble-Alpes, INSERM U1042-HP2, Université Grenoble-Alpes, Grenoble, France
| | - Eric Maury
- Service de Médecine Intensive Réanimation, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, 184 Rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
- Sorbonne Université, Paris, France
| | - Laurent Brochard
- Unity Health Toronto, Keenan Research Centre, Interdepartmental Division of Critical Care Medicine, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, 508783, Canada
| | - Hafid Ait-Oufella
- Service de Médecine Intensive Réanimation, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, 184 Rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.
- Sorbonne Université, Paris, France.
- Inserm U970, Centre de Recherche Cardiovasculaire de Paris (PARCC), Paris, France.
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Ferrera MC, Hayes MM. How I Teach: Liberation from Mechanical Ventilation. ATS Sch 2023; 4:372-384. [PMID: 37795117 PMCID: PMC10547038 DOI: 10.34197/ats-scholar.2023-0037ht] [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] [Indexed: 10/06/2023] Open
Abstract
Liberation from mechanical ventilation is one of the most important decisions in the intensive care unit (ICU), as extubation failure is associated with worse outcomes. Determining readiness to extubate can be challenging in complex patients and lead to provider stress. Here, we provide our approach to teaching liberation from mechanical ventilation for learners in the ICU. We use a case-based didactic session that purposefully introduces ambiguous cases without a clear answer, utilizing aspects of both cognitive load theory and adult learning theories.
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Affiliation(s)
- Michael C Ferrera
- Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Margaret M Hayes
- Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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24
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Godoy M, de Souza L, da Silva A, Lugon J. Comparison of the timed inspiratory effort index with the T-piece trial as a decision-making tool for extubation: a randomized controlled non-inferiority trial. Braz J Med Biol Res 2023; 56:e12824. [PMID: 37585918 PMCID: PMC10427157 DOI: 10.1590/1414-431x2023e12824] [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: 04/21/2023] [Accepted: 06/30/2023] [Indexed: 08/18/2023] Open
Abstract
The "timed inspiratory effort" (TIE) index, a new predictor of weaning outcome, normalizes the maximal inspiratory pressure with the time required to reach this value up to 60 s, incorporating the time domain into the assessment of inspiratory muscle function. The objective of this study was to determine whether the TIE predicts successful extubation at a similar rate as the T-piece trial with less time required. A non-inferiority randomized controlled trial was performed with ICU subjects eligible for weaning. The participants were allocated to the TIE or the T-piece groups. The primary outcome was successful weaning, and the main secondary outcome was ICU mortality. Eighty participants of each group were included in the final analysis. Time from the start of a successful test to effective extubation was significantly lower in the TIE group than in the T-piece group, 15 (10 to 24) vs 55 (40 to 75) min, P<0.001. In the Kaplan-Meier analysis, no significant differences were found in successful weaning (79.5 vs 82.5%, P=0.268) or survival rate (62.9 vs 53.8%, P=0.210) between the TIE and T-piece groups at the 30th day. In this preliminary study, the TIE index was not inferior to the T-piece trial as a decision-making tool for extubation and allowed a reduction in the decision time.
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Affiliation(s)
- M.D.P. Godoy
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina, Universidade Federal Fluminense, Niterói, RJ, Brasil
| | - L.C. de Souza
- Serviço de Fisioterapia, Hospital Icaraí, Faculdade de Fisioterapia, Universidade Estácio de Sá, Niterói, RJ, Brasil
| | | | - J.R. Lugon
- Departamento de Medicina/Nefrologia, Faculdade de Medicina, Universidade Federal Fluminense, Niterói, RJ, Brasil
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25
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Wu C, Hu L, Shen Q, Xu H, Huang H. Predictive value of extubation failure by decrease in central venous oxygen saturation: A systematic review and meta-analysis. Heliyon 2023; 9:e18227. [PMID: 37519770 PMCID: PMC10375794 DOI: 10.1016/j.heliyon.2023.e18227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 06/16/2023] [Accepted: 07/12/2023] [Indexed: 08/01/2023] Open
Abstract
Background The predictive power of extubation failure diagnosed by decrease in central venous oxygen saturation (ΔScvO2) varies by studies. Here we summarized the diagnostic value of extubation failure tested by ΔScvO2. Methods A comprehensive online search was performed to select potentially eligible studies that evaluated the predictive power of extubation failure tested by ΔScvO2. A manual search was also performed to identify additional studies. Data were extracted to calculate the pooled sensitivity, specificity, positive likelihood ratio (LR), negative LR, diagnostic odds ratio (DOR), and area under the receiver operating characteristic curve (AUC) to evaluate the predictive power of extubation failure. Results Overall, five studies including 353 patients were included in this review, of whom 105 (30%) were extubation failure. The cutoff values of ΔScvO2 varied across studies, ranging from 3.8% to 5.4%. Heterogeneity between studies was assessed with an overall Q = 0.007, I2 = 0%, and P = 0.498. The pooled sensitivity and specificity for the overall population were 0.83 (95% CI: 0.74-0.90) and 0.88 (95% CI: 0.83-0.92), respectively. The pooled positive LR and negative LR were 7.2 (95%CI: 4.6-11.2) and 0.19 (95%CI: 0.12-0.31), respectively. The DOR was 38 (95% CI: 17-86). Overall, the pooled AUROC was 0.92 (95% CI: 0.90-0.94). Conclusions The ΔScvO2 performed well in predicting extubation failure in adult mechanical ventilation patients. Further studies with a larger data set and well-designed models are required to confirm the diagnostic accuracy and utility of ScvO2 in predicting extubation outcomes in mechanical ventilation patients.
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26
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Rabinstein AA, Cinotti R, Bösel J. Liberation from Mechanical Ventilation and Tracheostomy Practice in Traumatic Brain Injury. Neurocrit Care 2023; 38:439-446. [PMID: 36859490 DOI: 10.1007/s12028-023-01693-6] [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: 08/11/2022] [Accepted: 02/06/2023] [Indexed: 03/03/2023]
Abstract
Liberating patients with severe traumatic brain injury (TBI) from mechanical ventilation is often a challenging task. These patients frequently require prolonged ventilation and have persistent alterations in the level and content of consciousness. Questions about their ability to protect their airway are common. Pulmonary complications and copious respiratory secretions are also very prevalent. Thus, it is hardly surprising that rates of extubation failure are high. This is a major problem because extubation failure is associated with a host of poor outcome measures. When the safety of an extubation attempt is uncertain, direct tracheostomy is favored by some, but there is no evidence that this practice leads to better outcomes. Current knowledge is insufficient to reliably predict extubation outcomes in TBI, and practices vary substantially across trauma centers. Yet observational studies provide relevant information that must be weighted when considering the decision to attempt extubation in patients with head injury. This review discusses available evidence on liberation from mechanical ventilation in TBI, proposes priorities for future research, and offers practical advice to guide decisions at the bedside.
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Affiliation(s)
| | - Raphael Cinotti
- Department of Anesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel Dieu, 44000, Nantes, France.,Methods in Patient-Centered Outcomes and Health Research, University of Nantes, University of Tours, INSERM, 22 Boulevard Benoni Goulin, 44200, Nantes, France
| | - Julian Bösel
- Department of Neurology, Kassel General Hospital, Kassel, Germany.,Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
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27
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Zijlstra GJ, de Grooth HJS. Spontaneous-Breathing Trials with Mechanical Ventilation. N Engl J Med 2023; 388:670. [PMID: 36791177 DOI: 10.1056/nejmc2216379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Affiliation(s)
- G Jan Zijlstra
- Amsterdam University Medical Centers, location VUMC, Amsterdam, the Netherlands
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28
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Extubation von Risikopatienten: Druckunterstütze Beatmung oder T-Stück? Pneumologie 2023. [DOI: 10.1055/a-1988-3553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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29
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Nicolotti D, Grossi S, Nicolini F, Gallingani A, Rossi S. Difficult Respiratory Weaning after Cardiac Surgery: A Narrative Review. J Clin Med 2023; 12:jcm12020497. [PMID: 36675426 PMCID: PMC9867514 DOI: 10.3390/jcm12020497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/28/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023] Open
Abstract
Respiratory weaning after cardiac surgery can be difficult or prolonged in up to 22.7% of patients. The inability to wean from a ventilator within the first 48 h after surgery is related to increased short- and long-term morbidity and mortality. Risk factors are mainly non-modifiable and include preoperative renal failure, New York Heart Association, and Canadian Cardiac Society classes as well as surgery and cardio-pulmonary bypass time. The positive effects of pressure ventilation on the cardiovascular system progressively fade during the progression of weaning, possibly leading to pulmonary oedema and failure of spontaneous breathing trials. To prevent this scenario, some parameters such as pulmonary artery occlusion pressure, echography-assessed diastolic function, brain-derived natriuretic peptide, and extravascular lung water can be monitored during weaning to early detect hemodynamic decompensation. Tracheostomy is considered for patients with difficult and prolonged weaning. In such cases, optimal patient selection, timing, and technique may be important to try to reduce morbidity and mortality in this high-risk population.
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Affiliation(s)
- Davide Nicolotti
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
- Correspondence: ; Tel.: +39-0521-703286
| | - Silvia Grossi
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Francesco Nicolini
- Department of Cardiac Surgery, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Alan Gallingani
- Department of Cardiac Surgery, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Sandra Rossi
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
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30
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[Focus ventilation, oxygen therapy and weaning 2021/2022 : Summary of selected intensive medical care studies]. DIE ANAESTHESIOLOGIE 2023; 72:199-208. [PMID: 36695839 PMCID: PMC9876412 DOI: 10.1007/s00101-023-01250-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/02/2023] [Indexed: 01/26/2023]
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31
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Hardin CC. Improved Protocols for Ventilator Liberation. N Engl J Med 2022; 387:1900-1901. [PMID: 36286318 DOI: 10.1056/nejme2212594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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