1
|
Poddighe D, Van Hollebeke M, Choudhary YQ, Campos DR, Schaeffer MR, Verbakel JY, Hermans G, Gosselink R, Langer D. Accuracy of respiratory muscle assessments to predict weaning outcomes: a systematic review and comparative meta-analysis. Crit Care 2024; 28:70. [PMID: 38454487 PMCID: PMC10919035 DOI: 10.1186/s13054-024-04823-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/29/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND Several bedside assessments are used to evaluate respiratory muscle function and to predict weaning from mechanical ventilation in patients on the intensive care unit. It remains unclear which assessments perform best in predicting weaning success. The primary aim of this systematic review and meta-analysis was to summarize and compare the accuracy of the following assessments to predict weaning success: maximal inspiratory (PImax) and expiratory pressures, diaphragm thickening fraction and excursion (DTF and DE), end-expiratory (Tdiee) and end-inspiratory (Tdiei) diaphragm thickness, airway occlusion pressure (P0.1), electrical activity of respiratory muscles, and volitional and non-volitional assessments of transdiaphragmatic and airway opening pressures. METHODS Medline (via Pubmed), EMBASE, Web of Science, Cochrane Library and CINAHL were comprehensively searched from inception to 04/05/2023. Studies including adult mechanically ventilated patients reporting data on predictive accuracy were included. Hierarchical summary receiver operating characteristic (HSROC) models were used to estimate the SROC curves of each assessment method. Meta-regression was used to compare SROC curves. Sensitivity analyses were conducted by excluding studies with high risk of bias, as assessed with QUADAS-2. Direct comparisons were performed using studies comparing each pair of assessments within the same sample of patients. RESULTS Ninety-four studies were identified of which 88 studies (n = 6296) reporting on either PImax, DTF, DE, Tdiee, Tdiei and P0.1 were included in the meta-analyses. The sensitivity to predict weaning success was 63% (95% CI 47-77%) for PImax, 75% (95% CI 67-82%) for DE, 77% (95% CI 61-87%) for DTF, 74% (95% CI 40-93%) for P0.1, 69% (95% CI 13-97%) for Tdiei, 37% (95% CI 13-70%) for Tdiee, at fixed 80% specificity. Accuracy of DE and DTF to predict weaning success was significantly higher when compared to PImax (p = 0.04 and p < 0.01, respectively). Sensitivity and direct comparisons analyses showed that the accuracy of DTF to predict weaning success was significantly higher when compared to DE (p < 0.01). CONCLUSIONS DTF and DE are superior to PImax and DTF seems to have the highest accuracy among all included respiratory muscle assessments for predicting weaning success. Further studies aiming at identifying the optimal threshold of DTF to predict weaning success are warranted. TRIAL REGISTRATION PROSPERO CRD42020209295, October 15, 2020.
Collapse
Affiliation(s)
- Diego Poddighe
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Marine Van Hollebeke
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Yasir Qaiser Choudhary
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
| | - Débora Ribeiro Campos
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Prêto, Brazil
| | - Michele R Schaeffer
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
| | - Jan Y Verbakel
- Department of Public Health and Primary Care, EPI-Centre, KU Leuven, Leuven, Belgium
- NIHR Community Healthcare Medtech and IVD Cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Greet Hermans
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Rik Gosselink
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Health and Rehabilitation Sciences, Faculty of Medicine, Stellenbosch University, Stellenbosch, South Africa
| | - Daniel Langer
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium.
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium.
| |
Collapse
|
2
|
Hong Y, Woo S, Kim Y, Lee JJ, Hong JY. Plasma concentrations of NOX4 are predictive of successful liberation from mechanical ventilation and 28-day mortality in intubated patients. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1376. [PMID: 33313121 PMCID: PMC7723573 DOI: 10.21037/atm-20-4252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Nicotinamide adenine dinucleotide phosphate (NADPH) oxidase (NOX) enzymes play important roles in generating reactive oxygen species (ROS); in particular, NOX4 plays a distinct role in regulating lung inflammation and apoptosis. Methods We determined whether plasma NOX4 level can be used as a prognostic biomarker to guide weaning from mechanical ventilation and to predict mortality in intubated patients. Plasma levels of NOX4 were measured at days 1 (NOX4 D1) and 7 (NOX4 D7) after initiation of mechanical ventilation in 184 patients. Results With increase in day 7 NOX4 quartile, the success of weaning tended to decrease and 28-day mortality tended to increase. On multivariate logistic regression, Acute Physiology, Age, Chronic Health Evaluation II (APACHE II) [odds ratio (OR): 1.10; 95% CI, 1.02–1.18], duration of mechanical ventilation (OR: 1.12; 95% CI: 1.06–1.18), and NOX4 D7 levels >18.2 ng/mL (OR: 4.40; 95% CI: 1.91–10.06) were independently associated with weaning failure. Also, Cox-hazard proportional model showed that NOX4 D7 level >18.2 ng/mL (hazard ratio [HR], 2.29; 95% CI, 1.26–4.16), APACHE II (HR: 1.07; 95% CI: 1.02–1.14), Sequential Organ Failure Assessment (SOFA) (HR: 1.10; 95% CI: 1.01–1.20) and coexisting cancer (HR: 1.99; 95% CI, 1.01–3.94), were independently associated with 28-day mortality. The longitudinal trend of NOX4 level varied according to the clinical outcomes. Conclusions An increased plasma NOX4 D7 level was associated with weaning failure and 28-day mortality in patients with mechanical ventilation. Our results suggest that NOX4-directed management may lead to improved outcomes in patients with mechanical ventilation.
Collapse
Affiliation(s)
- Yoonki Hong
- Department of Internal Medicine, Kangwon National University, Chuncheon, Republic of Korea
| | - Seongji Woo
- Institute of New frontier Research, Hallym University College of Medicine, Republic of Korea
| | - Youngmi Kim
- Institute of New frontier Research, Hallym University College of Medicine, Republic of Korea
| | - Jae Jun Lee
- Institute of New frontier Research, Hallym University College of Medicine, Republic of Korea
| | - Ji Young Hong
- Institute of New frontier Research, Hallym University College of Medicine, Republic of Korea.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Chuncheon Sacred Heart Hospital, Hallym University Medical Center, Chuncheon, Gangwon-do, Republic of Korea.,Lung Research Institute of Hallym University College of Medicine, Chuncheon, Republic of Korea
| |
Collapse
|
3
|
Sato R, Hasegawa D, Hamahata NT, Narala S, Nishida K, Takahashi K, Sempokuya T, Daoud EG. The predictive value of airway occlusion pressure at 100 msec (P0.1) on successful weaning from mechanical ventilation: A systematic review and meta-analysis. J Crit Care 2020; 63:124-132. [PMID: 33012587 DOI: 10.1016/j.jcrc.2020.09.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 09/11/2020] [Accepted: 09/22/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE The predictive value of airway occlusion pressure at 100 milliseconds (P0.1) on weaning outcome has been controversial. We performed a meta-analysis to investigate the predictive value of P0.1 on successful weaning from mechanical ventilation. MATERIALS AND METHODS We searched MEDLINE, Cochrane Central Register of Controlled Trials, and EMBASE, and two authors independently screened articles. The pooled sensitivity, specificity and the summary receiver operating characteristic (sROC) curve were estimated. Diagnostic odds ratio (DOR) was calculated using meta-regression analysis. RESULTS We included 12 prospective observational studies (n = 1089 patients). Analyses of sROC curves showed the area under the curve of 0.81 (95% confidence interval (CI): 0.77 to 0.84) for P0.1. The pooled sensitivity and specificity were 86% (95% CI, 72 to 94%) and 58% (95% CI, 37% to 76%) with substantial heterogeneity respectively. DOR was 20.09 (p = 0.019, 95%CI: 1.63-247.15). After filling the missing data using the trim-and-fill method to adjust publication bias, DOR was 36.23 (p = 0.002, 95%CI: 3.56-372.41). CONCLUSION This meta-analysis suggests that P0.1 is a useful tool to predict successful weaning. To determine clinical utility, a large prospective study investigating the sensitivity and specificity of P0.1 on weaning outcomes from mechanical ventilation is warranted.
Collapse
Affiliation(s)
- Ryota Sato
- Department of Internal Medicine, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI, USA.
| | - Daisuke Hasegawa
- Department of Anesthesiology and Critical Care medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Natsumi T Hamahata
- Department of Internal Medicine, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI, USA
| | - Swetha Narala
- Department of Internal Medicine, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI, USA
| | - Kazuki Nishida
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kunihiko Takahashi
- Department of Biostatistics, Medical and Dental Data Science Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tomoki Sempokuya
- Department of Internal Medicine, University of Nebraska Medical Center, NE, USA
| | - Ehab G Daoud
- Department of Internal Medicine, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI, USA; Department of Critical Care Medicine, Kuakini Medical Center, Honolulu, HI, USA
| |
Collapse
|
4
|
ELBatanouny M, Abdelbary AM. Use of automatic tube compensation (ATC) for weaning from mechanical ventilation in acute respiratory failure. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2017. [DOI: 10.1016/j.ejcdt.2017.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
|
5
|
Diaphragm ultrasound as a new method to predict extubation outcome in mechanically ventilated patients. Aust Crit Care 2016; 30:37-43. [PMID: 27112953 DOI: 10.1016/j.aucc.2016.03.004] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 03/15/2016] [Accepted: 03/23/2016] [Indexed: 11/23/2022] Open
Abstract
AIM To evaluate role of diaphragmatic thickening and excursion, assessed ultrasonographically, in predicting extubation outcome. METHODS Fifty-four patients who successfully passed spontaneous breathing trial (SBT) were enrolled. They were assessed by ultrasound during SBT evaluating diaphragmatic excursion, diaphragmatic thickness (Tdi) at end inspiration, at end expiration and diaphragmatic thickness fraction (DTF%). Simultaneously traditional weaning parameters were recorded. Patients were followed up for 48h after extubation. RESULTS Out of 54 included patients, 14 (25.9%) failed extubation. Diaphragmatic excursion, Tdi at end inspiration, at end expiration and DTF% were significantly higher in the successful group compared to those who failed extubation (p<0.05). Cutoff values of diaphragmatic measures associated with successful extubation were ≥10.5mm for diaphragmatic excursion, ≥21mm for Tdi at end inspiration, ≥10.5mm for Tdi at end expiration, ≥34.2% for DTF% giving 87.5%, 77.5%, 80% and 90% sensitivity respectively and 71.5%, 86.6%, 50% and 64.3% specificity respectively. Combining diaphragmatic excursion ≥10.5mm and Tdi at end inspiration ≥21mm decreased sensitivity to 64.9% but increased specificity to 100%. Rapid shallow breathing index (RSBI) <105 had 90% sensitivity but 18.7% specificity. CONCLUSION Ultrasound evaluation of diaphragmatic excursion and thickness at end inspiration could be a good predictor of extubation outcome in patients who passed SBT. It is recommended to consider the use of these parameters with RSBI consequently to improve extubation outcome.
Collapse
|
6
|
Hamzaoui O, Monnet X, Teboul JL. Sevrage difficile d’origine cardiaque. MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-011-0342-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
7
|
Liu Y, Wei LQ, Li GQ, Lv FY, Wang H, Zhang YH, Cao WL. A Decision-Tree Model for Predicting Extubation Outcome in Elderly Patients After a Successful Spontaneous Breathing Trial. Anesth Analg 2010; 111:1211-8. [DOI: 10.1213/ane.0b013e3181f4e82e] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
|
8
|
Abstract
Over the past 2 decades, the art of "weaning" from mechanical ventilation has been informed by increasing published basic science and outcomes studies. Although monitoring technologies can provide vast amounts of information before, during, and after liberation from mechanical ventilation, little data exists on how to maximally harness even routinely monitored, basic physiologic parameters. Overdependence on technology and derived variables, without data to demonstrate benefit, may even inhibit the patient's progress if it is used inappropriately. We review the scientific evidence for best using routinely available physiologic data and a few more sophisticated and invasive monitoring technologies during weaning. We also suggest future study designs that would better inform the process of liberation from the ventilator and endotracheal extubation.
Collapse
Affiliation(s)
- Jonathan M Siner
- Section of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale University School of Medicine, P.O. Box 208057, New Haven, CT 06520-8057, USA.
| | | |
Collapse
|
9
|
Abstract
Extubation failure-need for reintubation within 72 h of extubation, is common in intensive care unit (ICU). It can cause increased morbidity, higher costs, higher ICU and hospital length of stay (LOS) and mortality. Patients with advanced age, high severity of illness at ICU admission and extubation, preexisting chronic respiratory and cardiovascular disorders are at increased risk of extubation failure. Unresolved illness, development and progression of organ failure during the time from extubation to reintubation and reintubation itself have been proposed as reasons for increased morbidity and mortality. Parameters used to predict extubation failure can be categorized into parameters assessing respiratory mechanics, airway patency and protection and cardiovascular reserve. Adequate cough strength, minimal secretions and alertness are necessary for successful extubation. Evidence suggests that early institution of non-invasive ventilation and prophylactic administration of methylprednisolone may prevent reintubation in some patients. The intensivist needs to identify patients at high risk of extubation failure and be prepared to reinstitute ventilation early to prevent adverse outcomes.
Collapse
|
10
|
Tobin MJ, Jubran A. Variable performance of weaning-predictor tests: role of Bayes' theorem and spectrum and test-referral bias. Intensive Care Med 2006; 32:2002-12. [PMID: 17091239 DOI: 10.1007/s00134-006-0439-4] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2006] [Accepted: 10/06/2006] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We examined whether variation in reported reliability of the frequency-to-tidal volume ratio (f/V(T)) in predicting weaning success is explained by spectrum and test-referral bias, as reflected by variation in pretest probability of success. DESIGN Two authors extracted data from all studies on reliability of f/V(T) as a weaning predictor. RESULTS Prevalence of successful weaning in studies of f/V(T) revealed significant heterogeneity; mean success rate was 0.75. The heterogeneity and high success rate reflects occurrence of spectrum bias, suggested by the lower value of f/V(T) in subsequent studies than in the original report (77.4 vs. 89.1) and test-referral bias, suggested by lower specificity of f/V(T) in subsequent studies than in the original report (0.52 vs. 0.64). When data from studies in the ACCP Task Force's meta-analysis of studies on f/V(T) were entered into a Bayesian model with pretest probability (prevalence of success) as the operating point, observed posttest probabilities were closely correlated with values predicted by the original report on f/V(T): positive-predictive value r = 0.86 and negative-predictive value r = 0.82. Average sensitivity, the most precise measure of screening-test reliability, was 0.87 +/- 0.14 and average specificity 0.52 +/- 0.26. CONCLUSIONS Much of the heterogeneity in performance of f/V(T) can be explained by variation in pretest probability of successful outcome, which may be secondary to spectrum and test-referral bias. The average sensitivity of 0.87 indicates that f/V(T) is a reliable screening test for successful weaning.
Collapse
Affiliation(s)
- Martin J Tobin
- Division of Pulmonary and Critical Care Medicine, Edward Hines Jr Veterans Affairs Hospital, and Stritch School of Medicine, Loyola University of Chicago, Hines, IL 60141, USA.
| | | |
Collapse
|
11
|
Cohen JD, Shapiro M, Grozovski E, Lev S, Fisher H, Singer P. Extubation outcome following a spontaneous breathing trial with automatic tube compensation versus continuous positive airway pressure. Crit Care Med 2006; 34:682-6. [PMID: 16505653 DOI: 10.1097/01.ccm.0000201888.32663.6a] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We hypothesized that the additional use of automatic tube compensation (ATC) during a spontaneous breathing trial with continuous positive airway pressure (CPAP), by minimizing respiratory work, would result in more patients undergoing successful extubation. DESIGN Prospective, randomized, controlled study. SETTING A ten-bed, general intensive care department at a tertiary-care hospital. PATIENTS Adult patients (n=99) who had undergone mechanical ventilation for >24 hrs and met defined criteria for a weaning trial. INTERVENTIONS Patients were randomized to undergo a 1-hr spontaneous breathing trial with either ATC with CPAP (ATC group, n=51) or CPAP alone (CPAP group, n=48). ATC was provided by commercially available mechanical ventilators. Patients tolerating the spontaneous breathing trial underwent immediate extubation. The primary outcome measure was successful extubation, defined as the ability to maintain spontaneous breathing for 48 hrs after discontinuation of mechanical ventilation and extubation. MEASUREMENTS AND MAIN RESULTS There were no significant differences in demographic, respiratory, or hemodynamic characteristics between the two groups at the start of the spontaneous breathing trial. There was a trend for more patients in the ATC group to tolerate the breathing trial and undergo extubation (96% vs. 85%; p=.08). The rate of reintubation was 14% in the ATC group and 24% in the CPAP group (p=.28). Significantly more patients in the ATC group thus met the criteria for successful extubation (82% vs. 65%; p=0.04). CONCLUSION This is the largest single-center study to date assessing the use of commercially available ATC and suggests that this might be a useful mode for performing a spontaneous breathing trial preceding extubation in a general intensive care population.
Collapse
Affiliation(s)
- Jonathan D Cohen
- Department of General Intensive Care, Rabin Medical Center, Campus Beilinson, Petah Tikva, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | | | | | | | | | | |
Collapse
|
12
|
Baisch SD, Wheeler WB, Kurachek SC, Cornfield DN. Extubation failure in pediatric intensive care incidence and outcomes. Pediatr Crit Care Med 2005; 6:312-8. [PMID: 15857531 DOI: 10.1097/01.pcc.0000161119.05076.91] [Citation(s) in RCA: 108] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the hypotheses that children requiring reintubation are at an increased risk of prolonged hospitalizations, congenital heart disease, and death compared with age- and disease-severity-matched control patients. DESIGN Prospective decision to evaluate all children undergoing extubation over a 5-yr time interval (1997-2001) with retrospective analysis of all failed extubation patients. SETTING A large multidisciplinary, dual-site, single-system pediatric intensive care unit caring for critically ill and injured children. PATIENTS All children intubated and ventilated during the study period (1997-2001). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Failed extubation was defined as the unanticipated requirement to replace an endotracheal tube within 48 hrs of extubation. One hundred thirty children of 3,193 pediatric intensive care unit patients failed extubation (4.1%). The median age of children who failed extubation was 6.5 months, compared with a median age of 21.3 months in the control population. The median age of failed extubation in children with cardiac disease was 9.3 months. Failed extubation patients had lengthier hospital and pediatric intensive care unit stays, longer duration of mechanical ventilation, and a higher rate of tracheostomy placement than nonfailed extubation patients (p < .001). Children with congenital heart disease who failed extubation had the longest duration of hospitalization (40.0 +/- 5.4 days). Conversely, cardiac patients who did not fail extubation had the shortest length of stay (11.2 +/- 0.4 days). CONCLUSIONS In the present trial, 4.1% of mechanically ventilated children failed extubation. Pediatric intensive care unit patients with failed extubation have longer hospital, pediatric intensive care unit, and ventilator courses but are not at increased risk of death relative to nonfailed extubation patients.
Collapse
Affiliation(s)
- Steven D Baisch
- Division of Pediatric Critical Care Medicine, Children's Hospitals and Clinics, Minneapolis and St. Paul, MN, USA
| | | | | | | |
Collapse
|
13
|
Abstract
Controversy exists as to the best means to monitor the critically ill patient and the appropriate end points of therapy. Use of global hemodynamic or metabolic parameters may be normal in the patient who has not been completely or adequately resuscitated. Decreased perfusion to the gut is not well tolerated and may contribute to the development of the multiple organ dysfunction syndrome. Gastric tonometry is a minimally invasive way to monitor splanchnic perfusion in the critically ill patient. Data suggest that tonometry is useful for outcome prognostication and for detection of early hypovolemia. In addition, use of gastric intramucosal pH or mucosal-arterial CO(2) gap as end points of resuscitation may be superior to other conventional whole-body parameters. For these reasons, gastric tonometry must be considered the hemodynamic monitor of choice.
Collapse
Affiliation(s)
- Stephen O Heard
- Department of Anesthesiology, University of Massachusetts Medical School, Worcester 01655, USA.
| |
Collapse
|
14
|
Hameed SM, Cohn SM. Gastric tonometry: the role of mucosal pH measurement in the management of trauma. Chest 2003; 123:475S-81S. [PMID: 12740232 DOI: 10.1378/chest.123.5_suppl.475s] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Effective management of hemorrhagic shock depends on titration of therapies against reliable resuscitation end points. Conventional clinical and laboratory indexes of shock are often slow to respond to progressive circulatory compromise. GI mucosal ischemia resulting from redistribution of blood flow may, however, precede uncompensated shock and may compound the initial hemorrhagic insult by touching off cascades of inflammatory responses. Trauma patients with evidence of subclinical GI ischemia have been shown to have poor outcomes. Gastric tonometry, by detecting the presence of gastric intramucosal acidosis as a proxy of splanchnic hypoperfusion, may facilitate more timely and rational shock resuscitation. This article reviews the development and validation of gastric tonometry and summarizes the clinical studies that have used this modality to guide the management of shock in trauma patients.
Collapse
Affiliation(s)
- S Morad Hameed
- Department of Surgery, University of Calgary, Alberta, Canada
| | | |
Collapse
|
15
|
Rothaar RC, Epstein SK. Extubation failure: magnitude of the problem, impact on outcomes, and prevention. Curr Opin Crit Care 2003; 9:59-66. [PMID: 12548031 DOI: 10.1097/00075198-200302000-00011] [Citation(s) in RCA: 121] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Extubation failure, defined as the need for reinstitution of ventilatory support within 24 to 72 hours of planned endotracheal tube removal, occurs in 2 to 25% of extubated patients. The pathophysiologic causes of extubation failure include an imbalance between respiratory muscle capacity and work of breathing, upper airway obstruction, excess respiratory secretions, inadequate cough, encephalopathy, and cardiac dysfunction. Compared with patients who tolerate extubation, those who require reintubation have a higher incidence of hospital mortality, increased length of ICU and hospital stay, prolonged duration of mechanical ventilation, higher hospital costs, and an increased need for tracheostomy. Given the lack of proven treatments for extubation failure, clinicians must be aware of the factors that predict extubation outcome to improve clinical decision making. Risk factors for extubation failure include being a medical, multidisciplinary, or pediatric patient; age greater than 70 years; a longer duration of mechanical ventilation; continuous intravenous sedation; and anemia. Tests designed to assess for upper airway obstruction, secretion volume, and the effectiveness of cough can help to improve prediction of extubation failure. Rapid reinstitution of ventilatory support in patients who fail extubation may improve outcome.
Collapse
Affiliation(s)
- Robert C Rothaar
- Pulmonary and Critical Care Division, Tufts-New England Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | | |
Collapse
|
16
|
Cohen JD, Shapiro M, Grozovski E, Singer P. Automatic tube compensation-assisted respiratory rate to tidal volume ratio improves the prediction of weaning outcome. Chest 2002; 122:980-4. [PMID: 12226043 DOI: 10.1378/chest.122.3.980] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE To assess whether the respiratory rate to tidal volume ratio (RVR) measured while receiving automatic tube compensation (ATC) [RVRATC] would have a better predictive value as a weaning measure than unassisted RVR. DESIGN Prospective cohort study. SETTING General ICU of a tertiary-care university hospital. PATIENTS Forty-three patients who received mechanical ventilation for > 24 h and were considered ready for weaning. INTERVENTIONS All patients underwent a 60-min spontaneous breathing trial (SBT) [positive end-expiratory pressure of 5 cm H(2)O; ATC, 100%]. Patients tolerating the trial (n = 35) were extubated immediately. The following parameters were measured at the onset and end of the SBT: RVR, RVRATC, peak airway pressure (Paw), airway occlusion pressure, and minute ventilation. The outcome measure was successful extubation (ability to maintain spontaneous breathing for > 48 h). MEASUREMENTS AND RESULTS Median age was 55 years (range, 25 to 88 years), median APACHE (acute physiology and chronic health evaluation) II score was 15.5 (range, 3 to 29), and median duration of mechanical ventilation prior to the SBT was 7 days (range, 1 to 40 days). Extubation was successful in 25 patients (72%). There were no significant differences in baseline characteristics between patients successfully extubated (group 1) and those requiring reintubation. On multivariate analysis, RVRATC measured at 60 min (RVR(60)ATC) was most predictive of successful extubation (p = 0.03). The area under the receiver operator characteristic curve was also highest for RVR(60)ATC (0.81 +/- 0.03) as compared to RVR (0.77 +/- 0.03), RVRATC (0.75 +/- 0.04), and RVR measured at 60 min (0.69 +/- 0.05). The ratio of RVR(60)ATC to Paw was the best predictor (0.84 +/- 0.02). CONCLUSIONS RVRATC measured at the end of the SBT was the best predictor of successful extubation. A new ratio (ratio of RVRATC to Paw) was most predictive and deserves further study.
Collapse
Affiliation(s)
- Jonathan D Cohen
- Department of General Intensive Care, Rabin Medical Center, Beilinson Campus, Petah Tiqva, and Sackler Faculty of Medicine, Tel Aviv University, Israel.
| | | | | | | |
Collapse
|
17
|
Abstract
Inadequate splanchnic perfusion is associated with increased morbidity and mortality, particularly if liver dysfunction coexists. Heart failure, increased intra-abdominal pressure, haemodialysis and the presence of obstructive sleep apnoea are among the multiple clinical conditions that are associated with impaired splanchnic perfusion in critically ill patients. Total liver blood flow is believed to be relatively protected when gut blood flow decreases, because hepatic arterial flow increases when portal venous flow decreases (the hepatic arterial buffer response [HABR]). However, there is evidence that the HABR is diminished or even abolished during endotoxaemia and when gut blood flow becomes very low. Unfortunately, no drugs are yet available that increase total hepato-splanchnic blood flow selectively and to a clinically relevant extent. The present review discusses old and new concepts of splanchnic vasoregulation from both experimental and clinical viewpoints. Recently published trials in this field are discussed.
Collapse
Affiliation(s)
- Stephan M Jakob
- Department of Intensive Care Medicine, University Hospital, Bern, Switzerland.
| |
Collapse
|