1
|
Jiang Y, Yu Y, Fan J, Zhang L, Ye Y, Hu YH, Su LD. Development of Extubation Success Prediction Model for Mechanically Ventilated Patients with Spontaneous Cerebellar Hemorrhage. CEREBELLUM (LONDON, ENGLAND) 2024:10.1007/s12311-024-01737-3. [PMID: 39222195 DOI: 10.1007/s12311-024-01737-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/21/2024] [Indexed: 09/04/2024]
Abstract
Spontaneous cerebellar hemorrhage (SCH) patients have a low success rate in extubation, but there are currently no guidelines establishing specifically for SCH patients extubation. The study included 68 SCH patients who received mechanical ventilation for more than 24 h, with 39 cases (57.3%) resulting in successful extubation. The multivariate analysis identified four factors significantly associated with extubation success: patient age under 66 years, an Intracerebral Hemorrhage (ICH) score less than 4 points, the presence of tissue shift, and a Glasgow Coma Scale (GCS) score (excluding language) above 6 points at extubation. By simplifying the prediction model, we obtained the Spontaneous Cerebellar Hemorrhage Extubation Success scoring system (SCHES-SCORE). Within the scoring system, 2 points were allocated for a GCS score (excluding language) above 6 at extubation, 1 point each for age under 66 years and an ICH score below 4, while tissue shift was assigned a negative point. A score of Grade A (SCHES-SCORE = 3-4) was found to correlate with a 92.9% success rate for extubation. The area under the receiver operating characteristic curve was 0.923 (95% CI, 0.863 to 0.983). Notably, successful extubation was significantly linked to reduced durations of mechanical ventilation, intensive care unit (ICU) stay, and total hospital stay. In conclusion, the scoring system developed for assessing extubation outcomes in SCH patients has the potential to enhance the rate of successful extubation and overall patient outcomes.
Collapse
Affiliation(s)
- Yao Jiang
- Neuroscience Care Unit (Key Laboratory of Multiple Organ Failure, National Ministry of Education), The Second Affiliated Hospital of Zhejiang University School of Medicine, Jiefang Rd 88#, Hangzhou, 310009, China
- Key Laboratory of the Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, 310009, China
- Emergency Department, The First Affiliated Hospital of Ningbo University, 315010, Ningbo, China
| | - Yue Yu
- Neuroscience Care Unit (Key Laboratory of Multiple Organ Failure, National Ministry of Education), The Second Affiliated Hospital of Zhejiang University School of Medicine, Jiefang Rd 88#, Hangzhou, 310009, China
| | - Jing Fan
- Neuroscience Care Unit (Key Laboratory of Multiple Organ Failure, National Ministry of Education), The Second Affiliated Hospital of Zhejiang University School of Medicine, Jiefang Rd 88#, Hangzhou, 310009, China
| | - Lei Zhang
- Neuroscience Care Unit (Key Laboratory of Multiple Organ Failure, National Ministry of Education), The Second Affiliated Hospital of Zhejiang University School of Medicine, Jiefang Rd 88#, Hangzhou, 310009, China
| | - Yang Ye
- Neuroscience Care Unit (Key Laboratory of Multiple Organ Failure, National Ministry of Education), The Second Affiliated Hospital of Zhejiang University School of Medicine, Jiefang Rd 88#, Hangzhou, 310009, China
| | - Ying-Hong Hu
- Neuroscience Care Unit (Key Laboratory of Multiple Organ Failure, National Ministry of Education), The Second Affiliated Hospital of Zhejiang University School of Medicine, Jiefang Rd 88#, Hangzhou, 310009, China
| | - Li-da Su
- Neuroscience Care Unit (Key Laboratory of Multiple Organ Failure, National Ministry of Education), The Second Affiliated Hospital of Zhejiang University School of Medicine, Jiefang Rd 88#, Hangzhou, 310009, China.
- Key Laboratory of the Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, 310009, China.
| |
Collapse
|
2
|
Bosch-Compte R, Parrilla FJ, Muñoz-Bermúdez R, Dot I, Climent C, Masclans JR, Marin-Corral J, Pérez-Terán P. Comparing lung aeration and respiratory effort using two different spontaneous breathing trial: T-piece vs pressure support ventilation. Med Intensiva 2024; 48:501-510. [PMID: 37798153 DOI: 10.1016/j.medine.2023.07.010] [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: 05/19/2023] [Revised: 06/27/2023] [Accepted: 06/30/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVE To assess the changes in lung aeration and respiratory effort generated by two different spontaneous breathing trial (SBT): T-piece (T-T) vs pressure support ventilation (PSV). DESIGN Prospective, interventionist and randomized study. SETTING Intensive Care Unit (ICU) of Hospital del Mar. PARTICIPANTS Forty-three ventilated patients for at least 24 h and considered eligible for an SBT were included in the study between October 2017 and March 2020. INTERVENTIONS 30-min SBT with T-piece (T-T group, 20 patients) or 8-cmH2O PSV and 5-cmH2O positive end expiratory pressure (PSV group, 23 patients). MAIN VARIABLES OF INTEREST Demographics, clinical data, physiological variables, lung aeration evaluated with electrical impedance tomography (EIT) and lung ultrasound (LUS), and respiratory effort using diaphragmatic ultrasonography (DU) were collected at different timepoints: basal (BSL), end of SBT (EoSBT) and one hour after extubation (OTE). RESULTS There were a loss of aeration measured with EIT and LUS in the different study timepoints, without statistical differences from BSL to OTE, between T-T and PSV [LUS: 3 (1, 5.5) AU vs 2 (1, 3) AU; p = 0.088; EELI: -2516.41 (-5871.88, 1090.46) AU vs -1992.4 (-3458.76, -5.07) AU; p = 0.918]. Percentage of variation between BSL and OTE, was greater when LUS was used compared to EIT (68.1% vs 4.9%, p ≤ 0.001). Diaphragmatic excursion trend to decrease coinciding with a loss of aeration during extubation. CONCLUSION T-T and PSV as different SBT strategies in ventilated patients do not show differences in aeration loss, nor estimated respiratory effort or tidal volume measured by EIT, LUS and DU.
Collapse
Affiliation(s)
- Raquel Bosch-Compte
- Critical Care Department, Hospital del Mar, Critical Illness Research Group (GREPAC), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain.
| | - Francisco José Parrilla
- Critical Care Department, Hospital del Mar, Critical Illness Research Group (GREPAC), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Rosana Muñoz-Bermúdez
- Critical Care Department, Hospital del Mar, Critical Illness Research Group (GREPAC), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Irene Dot
- Critical Care Department, Hospital del Mar, Critical Illness Research Group (GREPAC), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Cristina Climent
- Critical Care Department, Hospital del Mar, Critical Illness Research Group (GREPAC), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Joan Ramon Masclans
- Critical Care Department, Hospital del Mar, Critical Illness Research Group (GREPAC), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain; Medicine and Life Sciences Department (MELIS), Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Judith Marin-Corral
- Critical Care Department, Hospital del Mar, Critical Illness Research Group (GREPAC), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain; Division of Pulmonary Diseases & Critical Care Medicine, South Texas Veterans Health Care System and University of Texas Health San Antonio, San Antonio, TX, USA
| | - Purificación Pérez-Terán
- Critical Care Department, Hospital del Mar, Critical Illness Research Group (GREPAC), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| |
Collapse
|
3
|
Eriş E, Mammadova A, Kara AT, Atasoy A, Solmaz ZS, Gürsel G. Prognostic value of the oxygenation index measured during mechanical ventilation and weaning. A retrospective cohort study. Monaldi Arch Chest Dis 2024. [PMID: 39058014 DOI: 10.4081/monaldi.2024.2840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 04/30/2024] [Indexed: 07/28/2024] Open
Abstract
The aim of this study was to investigate the predictive value of the ratio of oxygen saturation (ROX) index calculated during mechanical ventilation (MV) and the weaning period in evaluating readiness to weaning and the success of the spontaneous breathing trial (SBT), extubation, and mortality. We also compared the results of the ROX index calculated with partial arterial oxygen pressure (PaO2), arterial oxygen saturation (SaO2%), and probe oxygen saturation (SpO2%). In this retrospective cohort study, the ROX index was calculated by SpO2%, PaO2, and SaO2% separately using the ROX index formula (PaO2 or SaO2 or SpO2 /FiO2)/respiratory rate. ROX was calculated during the first three days of MV treatment and the weaning period daily (SBT). Positive end-expiratory pressure and peak inspiratory pressure values were also recorded during these measurements. These ROX values were used to analyze whether they predict weaning readiness, SBT, extubation failure (EF), and mortality. The study included 107 mechanically ventilated patients. Weaning could be tried in 64 (60%) of the 107 patients; 44 (69%) of the 64 patients succeeded, and extubation was performed. 19 (43%) of 44 patients had EF. ROX values calculated with PaO2 during MV and SBT predicted readiness to wean, EF, and mortality better than ROX values calculated with SaO2 and SpO2. ROX values calculated with PaO2 during the third day of MV had the highest sensitivity and specificity for EF (sensitivity: 81%, specificity: 70% for the ROX<11 value). The results of this study suggest that the calculation of ROX index, not only with SpO2% but also with arterial blood gas PaO2 and SaO2% values, may be helpful in predicting the weaning readiness evaluation, SBT, and extubation success and mortality. Further studies with more patients are necessary to verify and standardize these results.
Collapse
Affiliation(s)
- Esra Eriş
- Critical Care Fellowship Program, Gazi University School of Medicine, Ankara.
| | - Ayshan Mammadova
- Department of Pulmonary Critical Care Medicine, Gazi University School of Medicine, Ankara.
| | - Ayşe Taşçı Kara
- Department of Pulmonary Critical Care Medicine, Gazi University School of Medicine, Ankara.
| | - Aydın Atasoy
- Critical Care Fellowship Program, Gazi University School of Medicine, Ankara.
| | - Zeynep Sena Solmaz
- Critical Care Fellowship Program, Gazi University School of Medicine, Ankara.
| | - Gül Gürsel
- Critical Care Fellowship Program, Gazi University School of Medicine, Ankara; Department of Pulmonary Critical Care Medicine, Gazi University School of Medicine, Ankara.
| |
Collapse
|
4
|
Zhang Q, Wang L, Liu X, Liu Z, Pu Z, Fang Z, Li L, Guo D, Lu R, Jia P. Analysis of the current status of "pseudo" unplanned endotracheal extubation in ICU patients in China's tertiary hospitals. Sci Rep 2024; 14:14162. [PMID: 38898038 PMCID: PMC11187208 DOI: 10.1038/s41598-024-64996-4] [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: 03/14/2024] [Accepted: 06/14/2024] [Indexed: 06/21/2024] Open
Abstract
To analyze the current status of "pseudo" unplanned endotracheal extubation in ICU patients in China's tertiary hospitals and to provide a reference for improving the quality of medical care. Through the National Nursing Quality Data Platform, unplanned endotracheal extubation data reported by ICUs in China's tertiary hospitals from 2019 to 2022 were analyzed. The situation of reported hospitals, causes, and the current status of "pseudo" unplanned endotracheal extubation in ICU patients was analyzed. The indicator of unplanned endotracheal extubation in ICUs of China's tertiary hospitals is mainly from first-class tertiary hospitals (74.9%), most of which are self-extractions by patients (74.6%). The proportion of "pseudo" unplanned endotracheal extubation is 45.1%. "Pseudo" unplanned endotracheal extubation is common in the ICUs of China's tertiary hospitals. As such, management blind spots deserve attention from managers and clinical staff.
Collapse
Affiliation(s)
- Qin Zhang
- Department of Day Surgery, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Li Wang
- Department of NICU, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaoli Liu
- Department of Proctology, Deyang People's Hospital, Deyang, China
| | - Zhenwei Liu
- Department of NICU, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Zaichun Pu
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Ziji Fang
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Lele Li
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Danyang Guo
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Rong Lu
- Department of NICU, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China.
| | - Ping Jia
- Department of NICU, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China.
| |
Collapse
|
5
|
Murata K, Shimoyama K, Tsuruya T. Investigating the risk of reintubation by cough force assessment using cough peak expiratory flow: a single-center observational pilot study. BMC Pulm Med 2024; 24:222. [PMID: 38714988 PMCID: PMC11075268 DOI: 10.1186/s12890-024-02914-0] [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: 08/05/2023] [Accepted: 02/19/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND No objective indicator exists for evaluating cough strength during extubation of tracheally intubated patients. This study aimed to determine whether cough peak expiratory flow (CPEF) can predict the risk of reintubation due to decreased cough strength. METHODS This was a retrospective cohort study of patients who were admitted to our Emergency Intensive Care Unit between September 1, 2020 and August 31, 2021 and were under artificial ventilation management for ≥ 24 h. The patients were divided into two groups: successful extubation and reintubation groups, and the relationship between CPEF immediately before extubation and reintubation was investigated. RESULTS Seventy-six patients were analyzed. In the univariate analysis, CPEF was significantly different between the successful extubation (90.7 ± 25.9 L/min) and reintubation (57.2 ± 6.4 L/min) groups (p < 0.001). In the multivariate analysis with age and duration of artificial ventilation as covariates, CPEF was significantly lower in the reintubation group (p < 0.01). The cutoff value of CPEF for reintubation according to the receiver operating characteristic curve was 60 L/min (area under the curve, 0.897; sensitivity, 78.5%; specificity, 90.9%; p < 0.01). CONCLUSION CPEF in tracheally intubated patients may be a useful indicator for predicting the risk of reintubation associated with decreased cough strength. The cutoff CPEF value for reintubation due to decreased cough strength was 60 L/min.
Collapse
Affiliation(s)
- Kenya Murata
- Department of Nursing, Tokyo Medical University Hospital, Tokyo, Japan.
| | - Keiichiro Shimoyama
- Department of Emergency and Critical Care Medicine, Tokyo Medical University Hospital, Tokyo, Japan
| | - Takeshi Tsuruya
- Department of Nursing, Tokyo Medical University Hospital, Tokyo, Japan
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
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
|
8
|
Cheng W, Zhang N, Liang D, Zhang H, Wang L, Lin L. Derivation and validation of a quantitative risk prediction model for weaning and extubation in neurocritical patients. Front Neurol 2024; 15:1337225. [PMID: 38476193 PMCID: PMC10927993 DOI: 10.3389/fneur.2024.1337225] [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: 11/15/2023] [Accepted: 02/12/2024] [Indexed: 03/14/2024] Open
Abstract
Background Patients with severe neurological conditions are at high risk during withdrawal and extubation, so it is important to establish a model that can quantitatively predict the risk of this procedure. Methods By analyzing the data of patients with traumatic brain injury and tracheal intubation in the ICU of the affiliated hospital of Hangzhou Normal University, a total of 200 patients were included, of which 140 were in the modeling group and 60 were in the validation group. Through binary logistic regression analysis, 8 independent risk factors closely related to the success of extubation were screened out, including age ≥ 65 years old, APACHE II score ≥ 15 points, combined chronic pulmonary disease, GCS score < 8 points, oxygenation index <300, cough reflex, sputum suction frequency, and swallowing function. Results Based on these factors, a risk prediction scoring model for extubation was constructed with a critical value of 18 points. The AUC of the model was 0.832, the overall prediction accuracy was 81.5%, the specificity was 81.6%, and the sensitivity was 84.1%. The data of the validation group showed that the AUC of the model was 0.763, the overall prediction accuracy was 79.8%, the specificity was 84.8%, and the sensitivity was 64.0%. Conclusion These results suggest that the extubation risk prediction model constructed through quantitative scoring has good predictive accuracy and can provide a scientific basis for clinical practice, helping to assess and predict extubation risk, thereby improving the success rate of extubation and improving patient prognosis.
Collapse
Affiliation(s)
- Weiling Cheng
- Department of Intensive Care Medicine, Hangzhou Normal University Affiliated Hospital, Hangzhou, China
| | - Ning Zhang
- Department of Intensive Care Medicine, Hangzhou Normal University Affiliated Hospital, Hangzhou, China
| | - Dongcheng Liang
- Department of Intensive Care Medicine, Hangzhou Normal University Affiliated Hospital, Hangzhou, China
| | - Haoling Zhang
- Department of Biomedical Science, Advanced Medical and Dental Institute, Universiti Sains Malaysia, Penang, Malaysia
| | - Lei Wang
- Department of Intensive Care Medicine, Hangzhou Normal University Affiliated Hospital, Hangzhou, China
| | - Leqing Lin
- Department of Intensive Care Medicine, Hangzhou Normal University Affiliated Hospital, Hangzhou, China
| |
Collapse
|
9
|
Muttini S, Jona Falco J, Cuevas Cairo I, Umbrello M. A High Respiratory Drive Is Associated with Weaning Failure in Patients with COVID-19-Associated Acute Respiratory Distress Syndrome: The Role of the Electrical Activity of the Diaphragm. J Clin Med 2024; 13:1120. [PMID: 38398433 PMCID: PMC10889278 DOI: 10.3390/jcm13041120] [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: 12/21/2023] [Revised: 02/01/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Mechanical ventilation is the main supportive treatment of severe cases of COVID-19-associated ARDS (C-ARDS). Weaning failure is common and associated with worse outcomes. We investigated the role of respiratory drive, assessed by monitoring the electrical activity of the diaphragm (EAdi), as a predictor of weaning failure. METHODS Consecutive, mechanically ventilated patients admitted to the ICU for C-ARDS with difficult weaning were enrolled. Blood gas, ventilator, and respiratory mechanic parameters, as well as EAdi, were recorded at the time of placement of EAdi catheter, and then after 1, 2, 3, 7, and 10 days, and compared between patients with weaning success and weaning failure. RESULTS Twenty patients were enrolled: age 66 (60-69); 85% males; PaO2/FiO2 at admission 148 (126-177) mmHg. Thirteen subjects (65%) were classified as having a successful weaning. A younger age (OR(95%CI): 0.02 (0.01-0.11) per year), a higher PaO2/FiO2 ratio (OR(95%CI): 1.10 (1.01-1.21) per mmHg), and a lower EAdi (OR(95%CI): 0.16 (0.08-0.34) per μV) were associated with weaning success. CONCLUSION In critically ill patients with moderate-severe C-ARDS and difficult weaning from mechanical ventilation, a successful weaning was associated with a lower age, a higher oxygenation, and a lower respiratory drive, as assessed at the bedside via EAdi monitoring.
Collapse
Affiliation(s)
- Stefano Muttini
- Neuroscience Intensive Care Unit, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, 20151 Milano, Italy; (S.M.); (J.J.F.)
| | - Jacopo Jona Falco
- Neuroscience Intensive Care Unit, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, 20151 Milano, Italy; (S.M.); (J.J.F.)
| | - Ilmari Cuevas Cairo
- Department of Anaesthesia and Intensive Care Unit, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, 20151 Milano, Italy;
| | - Michele Umbrello
- Department of Intensive care and Anaesthesia, Ospedale Civile di Legnano, ASST Ovest Milanese, 20025 Legnano, Italy
| |
Collapse
|
10
|
Boscolo A, Sella N, Pettenuzzo T, Pistollato E, Calabrese F, Gregori D, Cammarota G, Dres M, Rea F, Navalesi P. Diaphragm Dysfunction Predicts Weaning Outcome after Bilateral Lung Transplant. Anesthesiology 2024; 140:126-136. [PMID: 37552079 DOI: 10.1097/aln.0000000000004729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
BACKGROUND Diaphragm dysfunction and its effects on outcomes of ventilator weaning have been evaluated in mixed critical care populations using diaphragm thickening fraction (the ratio of the difference between ultrasound diaphragm thickness at end-inspiration and end-expiration to diaphragm thickness at end-expiration) or neuroventilatory efficiency (the ratio of tidal volume and peak electrical activity of the diaphragm). Such data are not available in bilateral-lung transplant recipients. The authors hypothesized that (1) diaphragm dysfunction, as defined by a diaphragm thickening fraction less than 29%, is more likely to occur in difficult weaning; (2) diaphragm thickening fraction and neuroventilatory efficiency predict weaning outcome; and (3) duration of mechanical ventilation before the first spontaneous breathing trial is associated with diaphragm dysfunction. METHODS Adult bilateral-lung transplant patients admitted to the intensive care unit were screened at the time of the first spontaneous breathing trial (pressure-support of 5 cm H2O and 0 positive end-expiratory pressure). At the fifth minute, diaphragm thickening fraction and neuroventilatory efficiency were measured during three respiratory cycles. Weaning was classified as simple, difficult, or prolonged (successful extubation at the first spontaneous breathing trial, within three or after three spontaneous breathing trials, respectively). RESULTS Forty-four subjects were enrolled. Diaphragm dysfunction occurred in 14 subjects (32%), all of whom had difficult weaning (78% of the subgroup of 18 patients experiencing difficult weaning). Both diaphragm thickening fraction (24 [20 to 29] vs. 39 [35 to 45]%) and neuroventilatory efficiency (34 [26 to 45] vs. 55 [43 to 62] ml/µV) were lower in difficult weaning (both P < 0.001). The areas under the receiver operator curve predicting difficult weaning were 0.88 (95% CI, 0.73 to 0.99) for diaphragm thickening fraction and 0.85 (95% CI, 0.71 to 0.95) for neuroventilatory efficiency. The duration of ventilation demonstrated a linear inverse correlation with both diaphragm thickening fraction and neuroventilatory efficiency. CONCLUSIONS Diaphragm dysfunction is common after bilateral-lung transplantation and associated with difficult weaning. In such patients, average values for diaphragm thickening fraction and neuroventilatory efficiency were reduced compared to patients with simple weaning. Both parameters showed similar accuracy for predicting success of ventilator weaning, demonstrating an inverse relationship with duration of ventilation. EDITOR’S PERSPECTIVE
Collapse
Affiliation(s)
- Annalisa Boscolo
- Department of Medicine, and Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy; Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Nicolò Sella
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Tommaso Pettenuzzo
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | | | - Fiorella Calabrese
- Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | | | - Martin Dres
- Department of Critical Care, St. Michael's Hospital and the Critical Illness and Injury Research Center, Keenan Research Center for Biomedical Science of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Federico Rea
- Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Paolo Navalesi
- Department of Medicine, University of Padua, Padua, Italy; Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| |
Collapse
|
11
|
Zapata L, Suarez-Montero JC, López-Garzón PA. Association between diastolic dysfunction and fluid balance in critically ill patients during weaning from mechanical ventilation. Med Intensiva 2023; 47:708-716. [PMID: 37380508 DOI: 10.1016/j.medine.2023.05.012] [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: 02/22/2023] [Revised: 04/22/2023] [Accepted: 05/20/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVE To assess the role of diastolic dysfunction and fluid balance in weaning failure. DESIGN Prospective, observational, single center. SETTING Intensive care unit of a university hospital. PATIENTS Adult patients on mechanical ventilation for more than 48 h who underwent a spontaneous breathing trial (SBT). INTERVENTIONS Echocardiography was performed immediately before and at the end of SBT. Patients were classified into two groups according to weaning outcome. MAIN VARIABLE OF INTEREST Weaning failure. RESULTS Among 89 patients included, weaning failure occurred in 33 patients (37%). Isolated diastolic dysfunction at the end of the SBT was more frequent in the failure group (39.3% vs. 17.8%, p = 0.025). Average daily fluid balance from ICU admission until first SBT was less negative in patients who failed than in those who succeed in the weaning (-648 mL [-884 to -138] vs. -893 mL [-1284 to -501], p = 0.007). Average daily fluid balance from the first SBT until the ICU discharge was more negative in the weaning failure than in the success group (-973 mL [-1493 to -201] vs. -425 mL [-1065 to 12], p = 0.034). Cox regression analysis showed that diastolic dysfunction was not an independent factor related to weaning failure but needed the association of positive fluid balance and age. CONCLUSIONS Weaning failure due to diastolic dysfunction is highly related to fluid balance, and the deleterious effect of fluid balance on diastolic function is associated with age The timing of fluid removal could play a key role in this scenario.
Collapse
Affiliation(s)
- Luis Zapata
- Department of Intensive Care, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Juan Carlos Suarez-Montero
- Department of Intensive Care, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | |
Collapse
|
12
|
Menguy J, De Longeaux K, Bodenes L, Hourmant B, L'Her E. Defining predictors for successful mechanical ventilation weaning, using a data-mining process and artificial intelligence. Sci Rep 2023; 13:20483. [PMID: 37993526 PMCID: PMC10665387 DOI: 10.1038/s41598-023-47452-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/14/2023] [Indexed: 11/24/2023] Open
Abstract
Mechanical ventilation weaning within intensive care units (ICU) is a difficult process, while crucial when considering its impact on morbidity and mortality. Failed extubation and prolonged mechanical ventilation both carry a significant risk of adverse events. We aimed to determine predictive factors of extubation success using data-mining and artificial intelligence. A prospective physiological and biomedical signal data warehousing project. A 21-beds medical Intensive Care Unit of a University Hospital. Adult patients undergoing weaning from mechanical ventilation. Hemodynamic and respiratory parameters of mechanically ventilated patients were prospectively collected and combined with clinical outcome data. One hundred and eight patients were included, for 135 spontaneous breathing trials (SBT) allowing to identify physiological parameters either measured before or during the trial and considered as predictive for extubation success. The Early-Warning Score Oxygen (EWSO2) enables to discriminate patients deemed to succeed extubation, at 72-h and 7-days. Cut-off values for EWSO2 (AUC = 0.80; Se = 0.75; Sp = 0.76), mean arterial pressure and heart-rate variability parameters were determined. A predictive model for extubation success was established including body-mass index (BMI) on inclusion, occlusion pressure at 0,1 s. (P0.1) and heart-rate analysis parameters (LF/HF) both measured before SBT, and heart rate during SBT (global performance 62%; 83%). The data-mining process enabled to detect independent predictive factors for extubation success and to develop a dynamic predictive model using artificial intelligence. Such predictive tools may help clinicians to better discriminate patients deemed to succeed extubation and thus improve clinical performance.
Collapse
Affiliation(s)
- Juliette Menguy
- Medical Intensive Care Unit, CHRU de la Cavale Blanche, Bvd Tanguy-Prigent, 29609, Brest Cedex, France
| | - Kahaia De Longeaux
- Medical Intensive Care Unit, CHRU de la Cavale Blanche, Bvd Tanguy-Prigent, 29609, Brest Cedex, France
- LATIM INSERM UMR 1101, Université de Bretagne Occidentale, 29200, Brest, France
| | - Laetitia Bodenes
- Medical Intensive Care Unit, CHRU de la Cavale Blanche, Bvd Tanguy-Prigent, 29609, Brest Cedex, France
| | - Baptiste Hourmant
- Medical Intensive Care Unit, CHRU de la Cavale Blanche, Bvd Tanguy-Prigent, 29609, Brest Cedex, France
| | - Erwan L'Her
- Medical Intensive Care Unit, CHRU de la Cavale Blanche, Bvd Tanguy-Prigent, 29609, Brest Cedex, France.
- LATIM INSERM UMR 1101, Université de Bretagne Occidentale, 29200, Brest, France.
| |
Collapse
|
13
|
Jonkman AH, Telias I, Spinelli E, Akoumianaki E, Piquilloud L. The oesophageal balloon for respiratory monitoring in ventilated patients: updated clinical review and practical aspects. Eur Respir Rev 2023; 32:220186. [PMID: 37197768 PMCID: PMC10189643 DOI: 10.1183/16000617.0186-2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/22/2023] [Indexed: 05/19/2023] Open
Abstract
There is a well-recognised importance for personalising mechanical ventilation settings to protect the lungs and the diaphragm for each individual patient. Measurement of oesophageal pressure (P oes) as an estimate of pleural pressure allows assessment of partitioned respiratory mechanics and quantification of lung stress, which helps our understanding of the patient's respiratory physiology and could guide individualisation of ventilator settings. Oesophageal manometry also allows breathing effort quantification, which could contribute to improving settings during assisted ventilation and mechanical ventilation weaning. In parallel with technological improvements, P oes monitoring is now available for daily clinical practice. This review provides a fundamental understanding of the relevant physiological concepts that can be assessed using P oes measurements, both during spontaneous breathing and mechanical ventilation. We also present a practical approach for implementing oesophageal manometry at the bedside. While more clinical data are awaited to confirm the benefits of P oes-guided mechanical ventilation and to determine optimal targets under different conditions, we discuss potential practical approaches, including positive end-expiratory pressure setting in controlled ventilation and assessment of inspiratory effort during assisted modes.
Collapse
Affiliation(s)
- Annemijn H Jonkman
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Irene Telias
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael's Hospital-Unity Health Toronto, Toronto, ON, Canada
| | - Elena Spinelli
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Evangelia Akoumianaki
- Adult Intensive Care Unit, University Hospital of Heraklion, Heraklion, Greece
- Medical School, University of Crete, Heraklion, Greece
| | - Lise Piquilloud
- Adult Intensive Care Unit, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| |
Collapse
|
14
|
Abplanalp LA, Ionescu F, Calvo-Ayala E, Yu L, Nair GB. Static Respiratory System Compliance as a Predictor of Extubation Failure in Patients with Acute Respiratory Failure. Lung 2023:10.1007/s00408-023-00625-7. [PMID: 37300706 DOI: 10.1007/s00408-023-00625-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 05/25/2023] [Indexed: 06/12/2023]
Abstract
PURPOSE Ventilator weaning protocols rely in part on objective indices to best predict extubation failure in the critically ill. We investigated static respiratory system compliance (RC) as a predictor of extubation failure, in comparison to extubation readiness using rapid shallow breathing index (RSBI). MATERIAL AND METHODS This was a cross-sectional, multi-institutional study of mechanically ventilated patients admitted between 12/01/2017 and 12/01/2019. All patients older than 18 years with a documented spontaneous breathing trial and extubation trial were included. RC and RSBI were calculated prior to the extubation trial. The primary outcome was extubation failure-defined as need for reintubation within 72 h from time of extubation. RESULTS Of the 2263 patients, 55.8% were males with a mean age of 68 years. The population consisted mostly of Caucasians (73%) and African Americans (20.4%). 274 (12.1%) patients required reintubation within 72 h. On multivariate logistic regression after adjusting for age, sex, body mass index (BMI), admission Sequential Organ Failure Assessment (SOFA) score, number of ventilator days, and the P/F ratio on the day of extubation, RC remained the strongest predictor for extubation failure at 24 h (aOR 1.45; 95% CI 1.00-2.10) and 72 h (aOR 1.58; 95% CI 1.15-2.17). There was no significant association between RSBI and extubation failure at 24 (aOR 1.00; 95% CI 0.99-1.01) or at 72 h (aOR 1.00; 95% CI 0.99-1.01). CONCLUSION RC measured on the day of extubation is a promising physiological discriminant to potentially risk stratify patients with acute respiratory failure for extubation readiness. We recommend further validation studies in prospective cohorts.
Collapse
Affiliation(s)
- Lauren A Abplanalp
- Division of Pulmonary and Critical Care, Beaumont Health, Royal Oak, MI, USA
- OUWB School of Medicine, Rochester, MI, USA
| | - Filip Ionescu
- OUWB School of Medicine, Rochester, MI, USA
- Moffitt Cancer Center, University of South Florida Morsani Medical School, Tampa, FL, USA
| | - Enrique Calvo-Ayala
- Division of Pulmonary and Critical Care, Beaumont Health, Royal Oak, MI, USA
- OUWB School of Medicine, Rochester, MI, USA
| | - Limin Yu
- Department of Pathology, Beaumont Health, Royal Oak, MI, USA
| | - Girish B Nair
- Division of Pulmonary and Critical Care, Beaumont Health, Royal Oak, MI, USA.
- OUWB School of Medicine, Rochester, MI, USA.
| |
Collapse
|
15
|
Shin MH, Hsu HS, Chien JY, Huang CK, Kuo LC, Shun TM, Lin YT, Yeh YC. Association between microcirculation in spontaneous breathing trial and extubation success. Microvasc Res 2023; 148:104552. [PMID: 37207721 DOI: 10.1016/j.mvr.2023.104552] [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: 02/28/2023] [Revised: 05/03/2023] [Accepted: 05/16/2023] [Indexed: 05/21/2023]
Abstract
PURPOSE This study assessed the association between changes in sublingual microcirculation after a spontaneous breathing trial (SBT) and successful extubation. MATERIALS AND METHODS Sublingual microcirculation was assessed using an incident dark-field video microscope before and after each SBT and before extubation. Microcirculatory parameters before the SBT, at the end of the SBT, and before extubation were compared between the successful and failed extubation groups. RESULTS Forty-seven patients were enrolled and analysed in this study (34 patients in the successful extubation group and 13 patients in the failed extubation group). At the end of the SBT, the weaning parameters did not differ between the two groups. However, the total small vessel density (21.2 [20.4-23.7] versus 24.9 [22.6-26.5] mm/mm2), perfused small vessel density (20.6 [18.5-21.8] versus 23.1 [20.9-25] mm/mm2), proportion of perfused small vessels (91 [87-96] versus 95 [93-98] %), and microvascular flow index (2.8 [2.7-2.9] versus 2.9 [2.9-3]) were significantly lower in the failed extubation group than in the successful extubation group. The weaning and microcirculatory parameters did not differ significantly between the two groups before the SBT. CONCLUSIONS More patients are required to investigate the difference between baseline microcirculation before a successful SBT and the change in microcirculation at the end of the SBT between the successful and failed extubation groups. Better sublingual microcirculatory parameters at the end of SBT and before extubation are associated with successful extubation.
Collapse
Affiliation(s)
- Ming-Hann Shin
- Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St., Beitou Dist., Taipei 112304, Taiwan; Division of Respiratory Therapy, Department of Integrated Diagnostic and Therapeutics, National Taiwan University Hospital, No. 7, Chung Shan S. Rd., Taipei 10002, Taiwan.
| | - Han-Shui Hsu
- Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St., Beitou Dist., Taipei 112304, Taiwan; Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei 11217, Taiwan.
| | - Jung-Yien Chien
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital, No. 7, Chung Shan S. Rd., Taipei, Taiwan.
| | - Chun-Kai Huang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital, No. 7, Chung Shan S. Rd., Taipei, Taiwan
| | - Lu-Cheng Kuo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital, No. 7, Chung Shan S. Rd., Taipei, Taiwan.
| | - Tien-Mei Shun
- Division of Respiratory Therapy, Department of Integrated Diagnostic and Therapeutics, National Taiwan University Hospital, No. 7, Chung Shan S. Rd., Taipei 10002, Taiwan
| | - Yi-Tsung Lin
- Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St., Beitou Dist., Taipei 112304, Taiwan; Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei 11217, Taiwan.
| | - Yu-Chang Yeh
- Department of Anesthesiology, National Taiwan University Hospital, No. 7, Chung Shan S. Rd., Taipei 10002, Taiwan.
| |
Collapse
|
16
|
Zhang B, Zhang Z, Qin H, Jiang Z, Deng Q, Sun Q, Wang Y, Zhou J, Lin Z, He W, Hua D, Xu Y. An investigation on the respiratory mechanics of mechanically ventilated patients during spontaneous breathing trials with enhanced low-level pressure support ventilation. THE CLINICAL RESPIRATORY JOURNAL 2023. [PMID: 37158128 DOI: 10.1111/crj.13618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 02/04/2023] [Accepted: 04/04/2023] [Indexed: 05/10/2023]
Abstract
INTRODUCTION Low-level pressure support ventilation (PSV) is most commonly adopted in spontaneous breathing trials (SBTs), and some have proposed setting the positive end-expiratory pressure (PEEP) to 0 cmH2 O in order to shorten the observation time of SBTs. This study aims to investigate the effects of two PSV protocols on the patients' respiratory mechanics. MATERIAL AND METHOD A prospective randomized self-controlled crossover design was adopted in this study, which involved enrolling 30 difficult-to-wean patients who were admitted to the intensive care unit of the First Affiliated Hospital of Guangzhou Medical University between July 2019 and September 2021. Patients were subjected to the S group (pressure support: 8 cmH2 O, PEEP: 5 cmH2 O) and S1 group (PS: 8 cmH2 O, PEEP: 0 cmH2 O) for 30 min in a random order, and respiratory mechanics indices were dynamically monitored via a four-lumen multi-functional catheter with an integrated gastric tube. Among the 30 enrolled patients, 27 were successfully weaned. RESULT The S group showed higher airway pressure (Paw), intragastric pressure (Pga) and airway pressure-time product (PTP) than the S1 group. The S group also showed a shorter inspiratory trigger delay, (93.80 ± 47.85) versus (137.33 ± 85.66) ms (P = 0.004); and fewer abnormal triggers, (0.97 ± 2.65) versus (2.67 ± 4.48) (P = 0.042) compared with the S1 group. Stratification based on the causes of mechanical ventilation revealed that under the S1 protocol, patients with chronic obstructive pulmonary disease (COPD) had a longer inspiratory trigger delay compared to both post-thoracic surgery (PTS) patients and patients with acute respiratory distress syndrome. Despite providing greater respiratory support, S group led to significant reductions in inspiratory trigger delay and less abnormal triggers compared to S1 group, especially among patients with chronic obstructive pulmonary disease. CONCLUSION These findings suggest that the zero PEEP group was more likely to induce a higher number of patient-ventilator asynchronies in difficult-to-wean patients.
Collapse
Affiliation(s)
- Baozhu Zhang
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhe Zhang
- Guangzhou Respiratory Health Research Institute, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Haiping Qin
- Department of Pulmonary and Critical Care Medicine, The Second People's Hospital of Fengkai, Zhaoqing, China
| | - Zhenjie Jiang
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Qiuxue Deng
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Qingwen Sun
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yingzhi Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jing Zhou
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhimin Lin
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Weiqun He
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Dongming Hua
- Department of General Medicine, Bunbury Regional Hospital, Bunbury, Western Australia, Australia
| | - Yuanda Xu
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| |
Collapse
|
17
|
Wang Q, Peng Y, Xu S, Lin L, Chen L, Lin Y. The efficacy of high-flow nasal cannula (HFNC) versus non-invasive ventilation (NIV) in patients at high risk of extubation failure: a systematic review and meta-analysis. Eur J Med Res 2023; 28:120. [PMID: 36915204 PMCID: PMC10012596 DOI: 10.1186/s40001-023-01076-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 02/20/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Studies suggest that high-flow nasal cannula (HFNC) and non-invasive ventilation (NIV) can prevent reintubation in critically ill patients with a low risk of extubation failure. However, the safety and effectiveness in patients at high risk of extubation failure are still debated. Therefore, we conducted a systematic review and meta-analysis to compare the efficacies of HFNC and NIV in high-risk patients. METHODS We searched eight databases (MEDLINE, Cochrane Library, EMBASE, CINAHL Complete, Web of Science, China National Knowledge Infrastructure, Wan-Fang Database, and Chinese Biological Medical Database) with reintubation as a primary outcome measure. The secondary outcomes included mortality, intensive care unit (ICU) length of stay (LOS), incidence of adverse events, and respiratory function indices. Statistical data analysis was performed using RevMan software. RESULTS Thirteen randomized clinical trials (RCTs) with 1457 patients were included. The HFNC and NIV groups showed no differences in reintubation (RR 1.10, 95% CI 0.87-1.40, I2 = 0%, P = 0.42), mortality (RR 1.09, 95% CI 0.82-1.46, I2 = 0%, P = 0.54), and respiratory function indices (partial pressure of carbon dioxide [PaCO2]: MD - 1.31, 95% CI - 2.76-0.13, I2 = 81%, P = 0.07; oxygenation index [P/F]: MD - 2.18, 95% CI - 8.49-4.13, I2 = 57%, P = 0.50; respiratory rate [Rr]: MD - 0.50, 95% CI - 1.88-0.88, I2 = 80%, P = 0.47). However, HFNC reduced adverse events (abdominal distension: RR 0.09, 95% CI 0.04-0.24, I2 = 0%, P < 0.01; aspiration: RR 0.30, 95% CI 0.09-1.07, I2 = 0%, P = 0.06; facial injury: RR 0.27, 95% CI 0.09-0.88, I2 = 0%, P = 0.03; delirium: RR 0.30, 95%CI 0.07-1.39, I2 = 0%, P = 0.12; pulmonary complications: RR 0.67, 95% CI 0.46-0.99, I2 = 0%, P = 0.05; intolerance: RR 0.22, 95% CI 0.08-0.57, I2 = 0%, P < 0.01) and may have shortened LOS (MD - 1.03, 95% CI - 1.86-- 0.20, I2 = 93%, P = 0.02). Subgroup analysis by language, extubation method, NIV parameter settings, and HFNC flow rate revealed higher heterogeneity in LOS, PaCO2, and Rr. CONCLUSIONS In adult patients at a high risk of extubation failure, HFNC reduced the incidence of adverse events but did not affect reintubation and mortality. Consequently, whether or not HFNC can reduce LOS and improve respiratory function remains inconclusive.
Collapse
Affiliation(s)
- Qiaoying Wang
- School of Nursing, Fujian Medical University, No. 1, Xuefu North Road, Fuzhou, Fujian, China
| | - Yanchun Peng
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, No. 29, Xinquan Road, Fuzhou, Fujian, China
| | - Shurong Xu
- School of Nursing, Fujian Medical University, No. 1, Xuefu North Road, Fuzhou, Fujian, China
| | - Lingyu Lin
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, No. 29, Xinquan Road, Fuzhou, Fujian, China
| | - Liangwan Chen
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, No. 29, Xinquan Road, Fuzhou, Fujian, China.
| | - Yanjuan Lin
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, No. 29, Xinquan Road, Fuzhou, Fujian, China. .,Department of Nursing, Fujian Medical University Union Hospital, No. 29, Xinquan Road, Fuzhou, Fujian, China.
| |
Collapse
|
18
|
Lee HY, Lee J, Lee SM. Effect of high-flow oxygen versus T-piece ventilation strategies during spontaneous breathing trials on weaning failure among patients receiving mechanical ventilation: a randomized controlled trial. Crit Care 2022; 26:402. [PMID: 36564808 PMCID: PMC9783722 DOI: 10.1186/s13054-022-04281-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND A spontaneous breathing trial (SBT) is used to determine whether patients are ready for extubation, but the best method for choosing the SBT strategy remains controversial. We investigated the effect of high-flow oxygen versus T-piece ventilation strategies during SBT on rates of weaning failure among patients receiving mechanical ventilation. METHODS This randomized clinical trial was conducted from June 2019 through January 2022 among patients receiving mechanical ventilation for ≥ 12 h who fulfilled the weaning readiness criteria at a single-center medical intensive care unit. Patients were randomized to undergo either T-piece SBT or high-flow oxygen SBT. The primary outcome was weaning failure on day 2, and the secondary outcomes were weaning failure on day 7, ICU and hospital length of stay, and ICU and in-hospital morality. RESULTS Of 108 patients (mean age, 67.0 ± 11.1 years; 64.8% men), 54 received T-piece SBT and 54 received high-flow oxygen SBT. Weaning failure on day 2 occurred in 5 patients (9.3%) in the T-piece group and 3 patients (5.6%) in the high-flow group (difference, 3.7% [95% CI, - 6.1-13.6]; p = 0.713). Weaning failure on day 7 occurred in 13 patients (24.1%) in the T-piece group and 7 patients (13.0%) in the high-flow group (difference, 11.1% [95% CI, - 3.4-25.6]; p = 0.215). A post hoc subgroup analysis showed that high-flow oxygen SBT was significantly associated with a lower rate of weaning failure on day 7 (OR, 0.17 [95% CI, 0.04-0.78]) among those patients intubated because of respiratory failure (p for interaction = 0.020). The ICU and hospital length of stay and mortality rates did not differ significantly between the two groups. During the study, no serious adverse events were recorded. CONCLUSIONS Among patients receiving mechanical ventilation, high-flow oxygen SBT did not significantly reduce the risk of weaning failure compared with T-piece SBT. However, the study may have been underpowered to detect a clinically important treatment effect for the comparison of high-flow oxygen SBT versus T-piece SBT, and a higher percentage of patients with simple weaning and a lower weaning failure rate than expected should be considered when interpreting the findings. Clinical trial registration This trial was registered with ClinicalTrials.gov (number NCT03929328) on April 26, 2019.
Collapse
Affiliation(s)
- Hong Yeul Lee
- grid.412484.f0000 0001 0302 820XDepartment of Critical Care Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jinwoo Lee
- grid.412484.f0000 0001 0302 820XDivision of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080 Republic of Korea
| | - Sang-Min Lee
- grid.412484.f0000 0001 0302 820XDepartment of Critical Care Medicine, Seoul National University Hospital, Seoul, Republic of Korea ,grid.412484.f0000 0001 0302 820XDivision of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080 Republic of Korea
| |
Collapse
|
19
|
Hernández G, Paredes I, Moran F, Buj M, Colinas L, Rodríguez ML, Velasco A, Rodríguez P, Pérez-Pedrero MJ, Suarez-Sipmann F, Canabal A, Cuena R, Blanch L, Roca O. Effect of postextubation noninvasive ventilation with active humidification vs high-flow nasal cannula on reintubation in patients at very high risk for extubation failure: a randomized trial. Intensive Care Med 2022; 48:1751-1759. [PMID: 36400984 PMCID: PMC9676812 DOI: 10.1007/s00134-022-06919-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 10/16/2022] [Indexed: 11/19/2022]
Abstract
PURPOSE High-flow nasal cannula (HFNC) oxygen therapy was noninferior to noninvasive ventilation (NIV) for preventing reintubation in a heterogeneous population at high-risk for extubation failure. However, outcomes might differ in certain subgroups of patients. Thus, we aimed to determine whether NIV with active humidification is superior to HFNC in preventing reintubation in patients with ≥ 4 risk factors (very high risk for extubation failure). METHODS Randomized controlled trial in two intensive care units in Spain (June 2020‒June 2021). Patients ready for planned extubation with ≥ 4 of the following risk factors for reintubation were included: age > 65 years, Acute Physiology and Chronic Health Evaluation II score > 12 on extubation day, body mass index > 30, inadequate secretions management, difficult or prolonged weaning, ≥ 2 comorbidities, acute heart failure indicating mechanical ventilation, moderate-to-severe chronic obstructive pulmonary disease, airway patency problems, prolonged mechanical ventilation, or hypercapnia on finishing the spontaneous breathing trial. Patients were randomized to undergo NIV with active humidification or HFNC for 48 h after extubation. The primary outcome was reintubation rate within 7 days after extubation. Secondary outcomes included postextubation respiratory failure, respiratory infection, sepsis, multiorgan failure, length of stay, mortality, adverse events, and time to reintubation. RESULTS Of 182 patients (mean age, 60 [standard deviation (SD), 15] years; 117 [64%] men), 92 received NIV and 90 HFNC. Reintubation was required in 21 (23.3%) patients receiving NIV vs 35 (38.8%) of those receiving HFNC (difference -15.5%; 95% confidence interval (CI) -28.3 to -1%). Hospital length of stay was lower in those patients treated with NIV (20 [12‒36.7] days vs 26.5 [15‒45] days, difference 6.5 [95%CI 0.5-21.1]). No additional differences in the other secondary outcomes were observed. CONCLUSIONS Among adult critically ill patients at very high-risk for extubation failure, NIV with active humidification was superior to HFNC for preventing reintubation.
Collapse
Affiliation(s)
- Gonzalo Hernández
- Virgen de la Salud Hospital, Toledo, Spain.
- Critical Care Medicine, Hospital Virgen de la Salud, C/Tenerife 40, 2ºD, 28039, Madrid, Spain.
| | | | | | - Marcos Buj
- Virgen de la Salud Hospital, Toledo, Spain
- Vall d'Hebron University Hospital, Barcelona, Spain
| | | | | | | | | | | | | | - Alfonso Canabal
- La Princesa University Hospital, Madrid, Spain
- Francisco de Vitoria University, Madrid, Spain
| | | | - Lluis Blanch
- Parc Taulí Hospital Universitari, Institut de Investigació i Innovació Parc Taulí (I3PT), Sabadell, Spain
- Ciber Enfermedades Respiratorias (CIBERES), Health Institute Carlos III, Madrid, Spain
| | - Oriol Roca
- Parc Taulí Hospital Universitari, Institut de Investigació i Innovació Parc Taulí (I3PT), Sabadell, Spain
- Ciber Enfermedades Respiratorias (CIBERES), Health Institute Carlos III, Madrid, Spain
| |
Collapse
|
20
|
Huang C, Wu TH, Chen JC. End-of-Life Decisions of Intracranial Hemorrhage Patients Successfully Weaned From Prolonged Mechanical Ventilation. Am J Hosp Palliat Care 2022; 39:1342-1349. [PMID: 35333660 PMCID: PMC9527450 DOI: 10.1177/10499091221074636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Factors related to the end-of-life decisions of patients with intracranial hemorrhage who were successfully weaned from prolonged mechanical ventilation remain unclear. This study aimed to evaluate factors that influence the end-of-life decisions of these patients. METHODS This retrospective study examined patients with intracranial hemorrhage successfully weaned from prolonged mechanical ventilation between January 2012 and December 2017. The following data was collected and analyzed: age, gender, comorbidities, Glasgow Coma Scale scores, receipt or non-receipt of intracranial hemorrhage surgery, discharge status, and end-of-life decisions. RESULTS In total, 91 patients with intracranial hemorrhage were successfully weaned from prolonged mechanical ventilation. The families of 62 (68.1%) patients signed the do-not-resuscitate order. A Glasgow Coma Scale score of ≥10 at discharge from the respiratory care center and zero comorbidities were the influencing factors between patients whose do-not-resuscitate orders were signed and those whose orders were not signed. Patients with intracranial hemorrhage successfully weaned from prolonged mechanical ventilation had chronic kidney disease comorbidity and Glasgow Coma Scale score of <7 on admission to respiratory care center with a general ward mortality rate of 83.3%. CONCLUSIONS The families of intracranial hemorrhage patients with multiple comorbidities and higher neurologic impairment after successful weaning from the ventilator believed that palliative therapy would provide a greater benefit. Patients with intracranial hemorrhage successfully weaned from prolonged mechanical ventilation with chronic kidney disease comorbidity and Glasgow Coma Scale score of <7 on admission to respiratory care center are candidates for the consideration of hospice care with ventilator withdrawal.
Collapse
Affiliation(s)
- Chienhsiu Huang
- Department of Internal medicine, Division of Chest Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Tsung-Hsien Wu
- Department of Surgery, Division of Neurosurgery, Dalin Tzu Chi Hospital, Chia-Yi, Taiwan and school of medicine, Tzuchi University, Hualien, Taiwan
| | - Jin-Cherng Chen
- Department of Surgery, Division of Neurosurgery, Dalin Tzu Chi Hospital, Chia-Yi, Taiwan and school of medicine, Tzuchi University, Hualien, Taiwan
| |
Collapse
|
21
|
Celik NB, Tanyildiz M, Yetimakman F, Kesici S, Bayrakci B. Comparison of high flow oxygen therapy versus noninvasive mechanical ventilation for successful weaning from invasive ventilation in children: An observational study. Medicine (Baltimore) 2022; 101:e30889. [PMID: 36181066 PMCID: PMC9524993 DOI: 10.1097/md.0000000000030889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Post-extubation respiratory failure is associated with a poor prognosis due to increased ventilator-associated pneumonia, and longer length of stay in the ICU and hospital. In this study, we aimed to evaluate the efficacy of high-flow nasal cannula (HFNC) and noninvasive mechanical ventilation (NIMV) on extubation success in children. A total of 48 patients, aged between 1 month and 18 years, who were weaned to either NIMV or HFNC were included. Patients who had tracheostomy or were not weaned and underwent unplanned extubation were excluded. Age, gender, anthropometric parameters, Pediatric Risk of Mortality and Pediatric Logistic Organ Dysfunction scores, oxygenation index, mechanical ventilation length of stay (LOS), HFNC/NIMV LOS, Modified Downes-Silverman score (MDS), and venous blood gas parameters, pediatric intensive care unit (PICU) LOS were recorded. 24 patients were extubated to NIMV, and 24 patients to HFNC. HFNC LOS and NIMV LOS were similar (P = .621). The failure rates at the 48th hour of HFNC and NIMV were 33% (n = 8), and 33% respectively (n = 8) (P = 1.0). PICU LOS and mortality rate was also similar (P = .06, P = .312 respectively). MDS decreased significantly in both groups (P < .001, P = .02 respectively). Changes in blood gas parameters and MDS within the first 48-hour of device application were similar between the 2 groups. HFNC is not inferior to NIMV in patients with extubation difficulty or those expected to have such difficulty in terms of treatment success, PICU LOS, and mortality. Therefore, HFNC appears to be a weaning technique alternative to NIMV after extubation.
Collapse
Affiliation(s)
- Nur Berna Celik
- Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Murat Tanyildiz
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Filiz Yetimakman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Selman Kesici
- Department of Pediatric Critical Care Medicine, Life Support Practice and Research Center, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Benan Bayrakci
- Department of Pediatric Critical Care Medicine, Life Support Practice and Research Center, Hacettepe University Faculty of Medicine, Ankara, Turkey
| |
Collapse
|
22
|
Karic E, Mitwally H, Alansari LM, Ganaw A, Saad MO, Azhaghdani A. Impact of Early Tracheostomy on Weaning From Ventilation and Sedation in COVID-19 Pregnant and Early Postpartum Patient: Two Case Reports. Cureus 2022; 14:e29633. [PMID: 36320992 PMCID: PMC9606483 DOI: 10.7759/cureus.29633] [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] [Accepted: 09/26/2022] [Indexed: 11/20/2022] Open
Abstract
Pregnant women are at high risk of coronavirus disease 2019 (COVID-19) complications, including acute respiratory distress syndrome (ARDS) and the need for mechanical ventilation. There is no literature on the optimal strategy for the management of difficult-to-wean pregnant and early postpartum patients. We report two cases of pregnant women with COVID-19 pneumonia and ARDS, who required mechanical ventilation and high doses of analgesia, and sedation with neuromuscular blocking agents to facilitate ventilation and oxygenation. Both patients had a tracheostomy procedure to facilitate weaning from mechanical ventilation and sedation. Shortly after tracheostomy, sedation and analgesia, along with ventilatory support were weaned off. Both patients were discharged home. These cases propose early tracheostomy as a strategy to facilitate weaning from mechanical ventilation and sedation in pregnant and early postpartum patients.
Collapse
|
23
|
Shamil PK, Gupta NK, Ish P, Sen MK, Kumar R, Chakrabarti S, Gupta N. Prediction of Weaning Outcome from Mechanical Ventilation Using Diaphragmatic Rapid Shallow Breathing Index. Indian J Crit Care Med 2022; 26:1000-1005. [PMID: 36213711 PMCID: PMC9492741 DOI: 10.5005/jp-journals-10071-24316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/09/2022] [Indexed: 11/23/2022] Open
Abstract
Background Diaphragmatic dysfunction has been increasingly documented to play a critical role to determine ventilator dependency and failure of weaning. Objective The goal was to study the diagnostic accuracy of diaphragmatic rapid shallow breathing index (D-RSBI) as a predictor of weaning outcomes in comparison to RSBI. Materials and methods A prospective observational study on consecutively admitted patients who were intubated and mechanically ventilated for a duration of at least 48 hours was carried out. The right hemidiaphragm displacement [diaphragm displacement (DD)] was calculated by M-mode ultrasonography, and respiratory rate (RR) and tidal volume (TV) were documented from the ventilator readings. Rapid shallow breathing index (RSBI) was measured as RR/TV (in liters); D-RSBI was calculated as RR/DD (in millimeters) and expressed as breath/minute/millimeter. Extubation failure was defined as the reinstitution of mechanical ventilation at the end of, or during the spontaneous breathing trial (SBT), re-intubation or the need of noninvasive ventilation (NIV) for the patient within 48 hours of extubation. Results Of 101 screened patients, 50 patients met the inclusion criteria, of whom 45 patients had successful SBT, and finally, 41 patients could be successfully extubated. Hence, the overall rate of weaning failure in the study population was 18%. The areas under the receiver operator characteristic (ROC) curves for D-RSBI and RSBI were 0.97 and 0.70, respectively (p <0.0001). The Pearson's correlation among RSBI and D-RSBI was 0.81 (p-value <0.001). Conclusion Diaphragmatic rapid shallow breathing index has a positive correlation and greater diagnostic accuracy than RSBI, the conventional weaning index. How to cite this article Shamil PK, Gupta NK, Ish P, Sen MK, Kumar R, Chakrabarti S, et al. Prediction of Weaning Outcome from Mechanical Ventilation Using Diaphragmatic Rapid Shallow Breathing Index. Indian J Crit Care Med 2022;26(9):1000-1005.
Collapse
Affiliation(s)
- PK Shamil
- Department of Pulmonary and Critical Care Medicine, VMMC and Safdarjung Hospital, New Delhi, India
| | - NK Gupta
- Department of Pulmonary and Critical Care Medicine, VMMC and Safdarjung Hospital, New Delhi, India
| | - Pranav Ish
- Department of Pulmonary and Critical Care Medicine, VMMC and Safdarjung Hospital, New Delhi, India
| | - MK Sen
- Department of Pulmonary and Critical Care Medicine, VMMC and Safdarjung Hospital, New Delhi, India
| | - Rohit Kumar
- Department of Pulmonary and Critical Care Medicine, VMMC and Safdarjung Hospital, New Delhi, India
| | - Shibdas Chakrabarti
- Department of Pulmonary and Critical Care Medicine, VMMC and Safdarjung Hospital, New Delhi, India
| | - Nitesh Gupta
- Department of Pulmonary and Critical Care Medicine, VMMC and Safdarjung Hospital, New Delhi, India
| |
Collapse
|
24
|
Analyse des Weaningprozesses bei Intensivpatienten im Hinblick auf Dokumentation und Verlegung in weiterbehandelnde Einheiten. Med Klin Intensivmed Notfmed 2022; 118:269-276. [PMID: 35816213 PMCID: PMC9272645 DOI: 10.1007/s00063-022-00941-5] [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: 11/09/2021] [Revised: 06/20/2022] [Accepted: 06/22/2022] [Indexed: 11/12/2022]
Abstract
Hintergrund und Fragestellung Die Entwöhnung von Beatmungsgeräten wird nicht immer auf der primär behandelnden Intensivstation abgeschlossen. Die Weiterverlegung in andere Behandlungseinrichtungen stellt einen sensiblen Abschnitt in der Behandlung und Rehabilitation des Weaningpatienten dar. Ziel der vorliegenden Studie war die Untersuchung des Überleitungsmanagements und des Interhospitaltransfers von Weaningpatienten unter besonderer Berücksichtigung der Dokumentationsqualität. Methodik Es erfolge eine retrospektive Datenanalyse eines Jahrs (2018) auf 2 Intensivstationen eines Universitätsklinikums. Eingeschlossen wurden alle beatmeten Patienten mit folgenden Tracerdiagnosen: COPD, Asthma, Polytrauma, Pneumonie, Sepsis, ARDS und Reanimation (Beatmung > 24 h). Ergebnisse Insgesamt konnten 750 Patienten in die Untersuchung eingeschlossen werden (Alter 64 [52, 8–76; Median, IQR]; 32 % weiblich). Davon waren 48 (6,4 %) Patienten zum Zeitpunkt der Verlegung nicht entwöhnt (v. a. Sepsis und ARDS). Die Routinedokumentation war bei den Abschnitten „Spontaneous Breathing Trial“, „Bewertung der Entwöhungsbereitschaft“ und „vermutete Entwöhnbarkeit“ ausreichend, um die Erfüllung der Parameter der S2k-Leitlinie „Prolongiertes Weaning“ adäquat zu beurteilen. Vorwiegend wurden diese Patienten mit Tracheostoma (76 %) in Rehabilitationskliniken (44 %) mittels spezialisierten Rettungsmitteln des arztbegleiteten Patiententransports verlegt (75 %). Diskussion Die Verlegung nicht entwöhnter Patienten nach initialem Intensivaufenthalt ist ein relevantes Thema für den Interhospitaltransfer. Die Routinedokumentation eines strukturierten Weaningprozesses ist in Kernelementen ausreichend, um den Weaningprozess lückenlos zu beschreiben. Dies ist für die Kontinuität in der Weiterbehandlung dieser Patienten von großer Bedeutung.
Collapse
|
25
|
Burns KEA, Agarwal A, Bosma KJ, Chaudhuri D, Girard TD. Liberation from Mechanical Ventilation: Established and New Insights. Semin Respir Crit Care Med 2022; 43:461-470. [PMID: 35760299 DOI: 10.1055/s-0042-1747929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
A substantial proportion of critically ill patients require ventilator support with the majority requiring invasive mechanical ventilation. Timely and safe liberation from invasive mechanical ventilation is a critical aspect of patient care in the intensive care unit (ICU) and is a top research priority for patients and clinicians. In this article, we discuss how to (1) identify candidates for liberation from mechanical ventilation, (2) conduct spontaneous breathing trials (SBTs), and (3) optimize patients for liberation from mechanical ventilation. We also discuss the roles for (4) extubation to noninvasive ventilation and (5) newer modes of mechanical ventilation during liberation from mechanical ventilation. We conclude that, though substantial progress has been made in identifying patients who are likely to be liberated (e.g., through the use of SBTs) and management strategies that speed liberation from the ventilator (e.g., protocolized SBTs, lighter sedation, and early mobilization), many important questions regarding liberation from mechanical ventilation in clinical practice remain unanswered.
Collapse
Affiliation(s)
- Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Departments of Critical Care and Medicine, Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Arnav Agarwal
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Division of General Internal Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Karen J Bosma
- Division of Critical Care Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, and London Health Sciences Centre, London, Ontario, Canada
| | - Dipayan Chaudhuri
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Departments of Critical Care Medicine and Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Timothy D Girard
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| |
Collapse
|
26
|
Zheng Y, Luo Z, Cao Z. Mean platelet volume is useful for predicting weaning failure: a retrospective, observational study. BMC Anesthesiol 2022; 22:160. [PMID: 35614411 PMCID: PMC9131520 DOI: 10.1186/s12871-022-01701-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/18/2022] [Indexed: 11/24/2022] Open
Abstract
Background To evaluate the usefulness of mean platelet volume (MPV), a marker of inflammation and stress, for predicting weaning failure in patients undergoing invasive mechanical ventilation (IMV) compared to traditional inflammation markers. Methods The retrospective observational study including patients who received IMV and underwent spontaneous breathing trial (SBT) was conducted in ICU at Beijing Chao-Yang hospital in China from January, 2013 to December, 2019. According to the weaning outcome, MPV, leukocyte count and C-reaction protein(CRP) were compared between weaning failure and weaning success group. Receiver-operating characteristics (ROC) curves and multivariate logistical regression analysis were constructed to analyze the value of these inflammatory markers for predicting weaning failure. Results A total of 261 patients were enrolled in the study and 54 patients (20.7%) experienced weaning failure (45 SBT failure and 9 extubation failure after successful SBT). MPV was a better predictor for weaning failure (AUC 0.777;95%CI, 0.722–0.826) than leukocyte count (AUC 0.6;95%CI,0.538–0.66) and CRP (0.627;95%CI,0.565–0.685). The cutoff value of MPV for predicting weaning failure was 11.3 fl with sensitivity 55.56%, specificity 87.92%, and diagnostic accuracy 81.22%. According to multivariate logistic regression analyses, MPV > 11.3 fl was an independent risk factor for predicting weaning failure. Conclusions MPV could be a more valuable marker for predicting weaning failure. and the patients with MPV > 11.3 fl should be attentively evaluated before weaning since they are at high risk of weaning failure, and it would be auspicable for those patients to undergo a noninvasive ventilation or high-flow nasal cannula oxygen therapy after extubation or even an early tracheostomy.
Collapse
Affiliation(s)
- Yingying Zheng
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.
| | - Zujin Luo
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zhixin Cao
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
27
|
Seo Y, Lee HJ, Ha EJ, Ha TS. 2021 KSCCM clinical practice guidelines for pain, agitation, delirium, immobility, and sleep disturbance in the intensive care unit. Acute Crit Care 2022; 37:1-25. [PMID: 35279975 PMCID: PMC8918705 DOI: 10.4266/acc.2022.00094] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 02/22/2022] [Indexed: 01/12/2023] Open
Abstract
We revised and expanded the “2010 Guideline for the Use of Sedatives and Analgesics in the Adult Intensive Care Unit (ICU).” We revised the 2010 Guideline based mainly on the 2018 “Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption (PADIS) in Adult Patients in the ICU,” which was an updated 2013 pain, agitation, and delirium guideline with the inclusion of two additional topics (rehabilitation/mobility and sleep). Since it was not possible to hold face-to-face meetings of panels due to the coronavirus disease 2019 (COVID-19) pandemic, all discussions took place via virtual conference platforms and e-mail with the participation of all panelists. All authors drafted the recommendations, and all panelists discussed and revised the recommendations several times. The quality of evidence for each recommendation was classified as high (level A), moderate (level B), or low/very low (level C), and all panelists voted on the quality level of each recommendation. The participating panelists had no conflicts of interest on related topics. The development of this guideline was independent of any industry funding. The Pain, Agitation/Sedation, Delirium, Immobility (rehabilitation/mobilization), and Sleep Disturbance panels issued 42 recommendations (level A, 6; level B, 18; and level C, 18). The 2021 clinical practice guideline provides up-to-date information on how to prevent and manage pain, agitation/sedation, delirium, immobility, and sleep disturbance in adult ICU patients. We believe that these guidelines can provide an integrated method for clinicians to manage PADIS in adult ICU patients.
Collapse
|
28
|
Bansal V, Smischney NJ, Kashyap R, Li Z, Marquez A, Diedrich DA, Siegel JL, Sen A, Tomlinson AD, Venegas-Borsellino CP, Freeman WD. Reintubation Summation Calculation: A Predictive Score for Extubation Failure in Critically Ill Patients. Front Med (Lausanne) 2022; 8:789440. [PMID: 35252224 PMCID: PMC8891541 DOI: 10.3389/fmed.2021.789440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/28/2021] [Indexed: 11/13/2022] Open
Abstract
Objective To derive and validate a multivariate risk score for the prediction of respiratory failure after extubation. Patients and methods We performed a retrospective cohort study of adult patients admitted to the intensive care unit from January 1, 2006, to December 31, 2015, who received mechanical ventilation for ≥48 h. Extubation failure was defined as the need for reintubation within 72 h after extubation. Multivariate logistic regression model coefficient estimates generated the Re-Intubation Summation Calculation (RISC) score. Results The 6,161 included patients were randomly divided into 2 sets: derivation (n = 3,080) and validation (n = 3,081). Predictors of extubation failure in the derivation set included body mass index <18.5 kg/m2 [odds ratio (OR), 1.91; 95% CI, 1.12–3.26; P = 0.02], threshold of Glasgow Coma Scale of at least 10 (OR, 1.68; 95% CI, 1.31–2.16; P < 0.001), mean airway pressure at 1 min of spontaneous breathing trial <10 cmH2O (OR, 2.11; 95% CI, 1.68–2.66; P < 0.001), fluid balance ≥1,500 mL 24 h preceding extubation (OR, 2.36; 95% CI, 1.87–2.96; P < 0.001), and total mechanical ventilation days ≥5 (OR, 3.94; 95% CI 3.04–5.11; P < 0.001). The C-index for the derivation and validation sets were 0.72 (95% CI, 0.70–0.75) and 0.72 (95% CI, 0.69–0.75). Multivariate logistic regression demonstrated that an increase of 1 in RISC score increased odds of extubation failure 1.6-fold (OR, 1.58; 95% CI, 1.47–1.69; P < 0.001). Conclusion RISC predicts extubation failure in mechanically ventilated patients in the intensive care unit using several clinically relevant variables available in the electronic medical record but requires a larger validation cohort before widespread clinical implementation.
Collapse
Affiliation(s)
- Vikas Bansal
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, United States
- Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN, United States
| | - Nathan J. Smischney
- Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN, United States
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Rahul Kashyap
- Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN, United States
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Zhuo Li
- Biostatistics Unit, Mayo Clinic, Jacksonville, FL, United States
| | - Alberto Marquez
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Daniel A. Diedrich
- Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN, United States
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Jason L. Siegel
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, United States
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States
| | - Ayan Sen
- Department of Critical Care Medicine, Mayo Clinic Hospital, Phoenix, AZ, United States
- Department of Neurologic Surgery, Mayo Clinic Hospital, Phoenix, AZ, United States
| | - Amanda D. Tomlinson
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | | | - William David Freeman
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, United States
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States
- *Correspondence: William David Freeman
| |
Collapse
|
29
|
Mechanical power normalized to lung-thorax compliance indicates weaning readiness in prolonged ventilated patients. Sci Rep 2022; 12:6. [PMID: 34997005 PMCID: PMC8741981 DOI: 10.1038/s41598-021-03960-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 12/13/2021] [Indexed: 11/24/2022] Open
Abstract
Since critical respiratory muscle workload is a significant determinant of weaning failure, applied mechanical power (MP) during artificial ventilation may serve for readiness testing before proceeding on a spontaneous breathing trial (SBT). Secondary analysis of a prospective, observational study in 130 prolonged ventilated, tracheotomized patients. Calculated MP’s predictive SBT outcome performance was determined using the area under receiver operating characteristic curve (AUROC), measures derived from k-fold cross-validation (likelihood ratios, Matthew's correlation coefficient [MCC]), and a multivariable binary logistic regression model. Thirty (23.1%) patients failed the SBT, with absolute MP presenting poor discriminatory ability (MCC 0.26; AUROC 0.68, 95%CI [0.59‒0.75], p = 0.002), considerably improved when normalized to lung-thorax compliance (LTCdyn-MP, MCC 0.37; AUROC 0.76, 95%CI [0.68‒0.83], p < 0.001) and mechanical ventilation PaCO2 (so-called power index of the respiratory system [PIrs]: MCC 0.42; AUROC 0.81 [0.73‒0.87], p < 0.001). In the logistic regression analysis, PIrs (OR 1.48 per 1000 cmH2O2/min, 95%CI [1.24‒1.76], p < 0.001) and its components LTCdyn-MP (1.25 per 1000 cmH2O2/min, [1.06‒1.46], p < 0.001) and mechanical ventilation PaCO2 (1.17 [1.06‒1.28], p < 0.001) were independently related to SBT failure. MP normalized to respiratory system compliance may help identify prolonged mechanically ventilated patients ready for spontaneous breathing.
Collapse
|
30
|
Wang Y, Lei L, Yang H, He S, Hao J, Liu T, Chen X, Huang Y, Zhou J, Lin Z, Zheng H, Lin X, Huang W, Liu X, Li Y, Huang L, Qiu W, Ru H, Wang D, Wu J, Zheng H, Zuo L, Zeng P, Zhong J, Rong Y, Fan M, Li J, Cai S, Kou Q, Liu E, Lin Z, Cai J, Yang H, Li F, Wang Y, Lin X, Chen W, Gao Y, Huang S, Sang L, Xu Y, Zhang K. Weaning critically ill patients from mechanical ventilation: a protocol from a multicenter retrospective cohort study. J Thorac Dis 2022; 14:199-206. [PMID: 35242382 PMCID: PMC8828530 DOI: 10.21037/jtd-21-1217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 12/15/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Mechanical ventilation (MV) is an important lifesaving method in intensive care unit (ICU). Prolonged MV is associated with ventilator associated pneumonia (VAP) and other complications. However, premature weaning from MV may lead to higher risk of reintubation or mortality. Therefore, timely and safe weaning from MV is important. In addition, identification of the right patient and performing a suitable weaning process is necessary. Although several guidelines about weaning have been reported, compliance with these guidelines is unknown. Therefore, the aim of this study is to explore the variation of weaning in China, associations between initial MV reason and clinical outcomes, and factors associated with weaning strategies using a multicenter cohort. METHODS This multicenter retrospective cohort study will be conducted at 17 adult ICUs in China, that included patients who were admitted in this 17 ICUs between October 2020 and February 2021. Patients under 18 years of age and patients without the possibility for weaning will be excluded. The questionnaire information will be registered by a specific clinician in each center who has been evaluated and qualified to carry out the study. DISCUSSION In a previous observational study of weaning in 17 ICUs in China, weaning practices varies nationally. Therefore, a multicenter retrospective cohort study is necessary to be conducted to explore the present weaning methods used in China. TRIAL REGISTRATION Chinese Clinical Trial Registry (ChiCTR) (No. ChiCTR2100044634).
Collapse
Affiliation(s)
- Yingzhi Wang
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Liming Lei
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Huawei Yang
- Guangdong Hospital of Traditional Chinese Medicine, Zhuhai, China
| | | | - Junhai Hao
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Tao Liu
- Guangdong Hospital of Traditional Chinese Medicine, Zhuhai, China
| | | | - Yongbo Huang
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jing Zhou
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhimin Lin
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Haichong Zheng
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiaoling Lin
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Weixiang Huang
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiaoqing Liu
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yimin Li
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Linxi Huang
- The First Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Wenbing Qiu
- The First Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Huangyao Ru
- The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, China
| | - Danni Wang
- The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, China
| | - Jianfeng Wu
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Huifang Zheng
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Liuer Zuo
- Shunde Hospital of Southern Medical University, Foshan, China
| | - Peiling Zeng
- Shunde Hospital of Southern Medical University, Foshan, China
| | - Jian Zhong
- Shunde Hospital Guangzhou University of Chinese Medicine (Shunde District Hospital of Chinese Medicine of Foshan City), Foshan, China
| | - Yanhui Rong
- Shunde Hospital Guangzhou University of Chinese Medicine (Shunde District Hospital of Chinese Medicine of Foshan City), Foshan, China
| | - Min Fan
- The Third Affiliated Hospital of Sun Yat-sen University- Lingnan Hospital, Guangzhou, China
| | - Jianwei Li
- Zhongshan People’s Hospital, Zhongshan, China
| | | | - Qiuye Kou
- Foresea Life Insurance Guangzhou General Hospital, Guangzhou, China
| | - Enhe Liu
- Foresea Life Insurance Guangzhou General Hospital, Guangzhou, China
| | - Zhuandi Lin
- Guangzhou panyu Central Hospital, Guangzhou, China
| | - Jingjing Cai
- Guangzhou panyu Central Hospital, Guangzhou, China
| | - Hong Yang
- The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Fen Li
- The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Yanhong Wang
- The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xinfeng Lin
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Weitao Chen
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Youshan Gao
- The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Shifang Huang
- The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Ling Sang
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yuanda Xu
- Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease and National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Kouxing Zhang
- The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| |
Collapse
|
31
|
Response to the letter from Rodrigues M and Vaz IM regarding the article "Effectiveness of a preoperative breathing exercise intervention in patients undergoing cardiac surgery: a systematic review". Rev Port Cardiol 2021; 40:809-810. [PMID: 34857124 DOI: 10.1016/j.repce.2021.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|
32
|
Torrini F, Gendreau S, Morel J, Carteaux G, Thille AW, Antonelli M, Mekontso Dessap A. Prediction of extubation outcome in critically ill patients: a systematic review and meta-analysis. Crit Care 2021; 25:391. [PMID: 34782003 PMCID: PMC8591441 DOI: 10.1186/s13054-021-03802-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/24/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Extubation failure is an important issue in ventilated patients and its risk factors remain a matter of research. We conducted a systematic review and meta-analysis to explore factors associated with extubation failure in ventilated patients who passed a spontaneous breathing trial and underwent planned extubation. This systematic review was registered in PROPERO with the Registration ID CRD42019137003. METHODS We searched the PubMed, Web of Science and Cochrane Controlled Register of Trials for studies published from January 1998 to December 2018. We included observational studies involving risk factors associated with extubation failure in adult intensive care unit patients who underwent invasive mechanical ventilation. Two authors independently extracted data and assessed the validity of included studies. RESULTS Sixty-seven studies (involving 26,847 participants) met the inclusion criteria and were included in our meta-analysis. We analyzed 49 variables and, among them, we identified 26 factors significantly associated with extubation failure. Risk factors were distributed into three domains (comorbidities, acute disease severity and characteristics at time of extubation) involving mainly three functions (circulatory, respiratory and neurological). Among these, the physiological respiratory characteristics at time of extubation were the most represented. The individual topic of secretion management was the one with the largest number of variables. By Bayesian multivariable meta-analysis, twelve factors were significantly associated with extubation failure: age, history of cardiac disease, history of respiratory disease, Simplified Acute Physiologic Score II score, pneumonia, duration of mechanical ventilation, heart rate, Rapid Shallow Breathing Index, negative inspiratory force, lower PaO2/FiO2 ratio, lower hemoglobin level and lower Glasgow Coma Scale before extubation, with the latest factor having the strongest association with extubation outcome. CONCLUSIONS Numerous factors are associated with extubation failure in critically ill patients who have passed a spontaneous breathing trial. Robust multiparametric clinical scores and/or artificial intelligence algorithms should be tested based on the selected independent variables in order to improve the prediction of extubation outcome in the clinical scenario.
Collapse
Affiliation(s)
- Flavia Torrini
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, AP-HP, 1 rue Gustave Eiffel, 94010, Créteil Cedex, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
| | - Ségolène Gendreau
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, AP-HP, 1 rue Gustave Eiffel, 94010, Créteil Cedex, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
| | - Johanna Morel
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, AP-HP, 1 rue Gustave Eiffel, 94010, Créteil Cedex, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
| | - Guillaume Carteaux
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, AP-HP, 1 rue Gustave Eiffel, 94010, Créteil Cedex, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
- INSERM, IMRB, Univ Paris Est Créteil, 94010, Créteil, France
| | - Arnaud W Thille
- Centre d'Investigation Clinique 1402 ALIVE, Université de Poitiers, Poitiers, France
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | | | - Armand Mekontso Dessap
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, AP-HP, 1 rue Gustave Eiffel, 94010, Créteil Cedex, France.
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France.
- INSERM, IMRB, Univ Paris Est Créteil, 94010, Créteil, France.
| |
Collapse
|
33
|
Bureau C, Demoule A. Weaning from mechanical ventilation in neurocritical care. Rev Neurol (Paris) 2021; 178:111-120. [PMID: 34674880 DOI: 10.1016/j.neurol.2021.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 08/24/2021] [Accepted: 08/30/2021] [Indexed: 12/13/2022]
Abstract
In the intensive care unit (ICU), weaning from mechanical ventilation follows a step-by-step process that has been well established in the general ICU population. However, little data is available in brain injury patients, who are often intubated to protect airways and prevent central hypoventilation. In this narrative review, we describe the general principles of weaning and how these principles can be adapted to brain injury patients. We focus on three major issues regarding weaning from mechanic ventilation in brain injury patients: (1) sedation protocol, (2) weaning and extubation protocol and criteria, (3) criteria, timing and technique for tracheostomy.
Collapse
Affiliation(s)
- C Bureau
- Inserm, UMRS1158 neurophysiologie respiratoire expérimentale et clinique, Sorbonne université, 75005 Paris, France; Service de médecine intensive - réanimation, département R3S, site Pitié-Salpêtrière, Sorbonne université, AP-HP, Paris, France.
| | - A Demoule
- Inserm, UMRS1158 neurophysiologie respiratoire expérimentale et clinique, Sorbonne université, 75005 Paris, France; Service de médecine intensive - réanimation, département R3S, site Pitié-Salpêtrière, Sorbonne université, AP-HP, Paris, France
| |
Collapse
|
34
|
Stocker B, Byskosh A, Weiss H, Devin CL, Weingarten N, Masteller M, Johnston A, Posluszny J. A Multifaceted Extubation Protocol to Reduce Reintubation Rates in the Surgical ICU. Jt Comm J Qual Patient Saf 2021; 48:81-91. [PMID: 34756824 DOI: 10.1016/j.jcjq.2021.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 09/16/2021] [Accepted: 09/16/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Reintubation is associated with significant morbidity and mortality. The reintubation rate in surgical ICUs (SICUs) is ∼10% nationally but was 17.0% in our SICU. The objective of this study was to determine if the reintubation rate could be reduced with a protocol for extubation assessment and post-extubation care consisting of standardized extubation criteria and targeted interventions for patients at high risk for reintubation. METHODS Standardized extubation criteria for all SICU patients were identified via literature review and best-practice guidelines. High reintubation risk criteria were identified (age ≥ 65 years, chronic cardiopulmonary disease, ≥ 4 days intubated, emergency intubation, and fluid balance ≥ 5 liters) through a literature review and 13-month retrospective review of reintubations in our institution's SICU. Patients meeting at least one criterion putting them at higher risk for reintubation received interventions including post-extubation high-flow nasal cannula for 24 hours and algorithm-guided respiratory therapy. RESULTS During the 12-month period following protocol implementation, 36 of 402 extubations resulted in reintubations (9.0% vs. 17.0% preintervention, p < 0.001). Among all extubations, 305 (75.9%) were identified as high risk. Among reintubated patients, 34 (94.4%) met high-risk criteria. The mortality rate for reintubated patients was 40.0%, compared to 3.3% in those not reintubated (p < 0.001). The high-risk screening tool had a negative predictive value of 98%. CONCLUSION A multifaceted and pragmatic extubation and post-extubation care protocol significantly reduced one SICU's reintubation rate. This protocol can be easily implemented in any SICU to improve patient outcomes following extubation.
Collapse
|
35
|
Belenguer-Muncharaz A, Mateu-Campos ML, Vidal-Tegedor B, Ferrándiz-Sellés MD, Micó-Gómez ML, Altaba-Tena S, Arlandis-Tomás M, Álvaro-Sánchez R, Rodríguez-Martínez E, Rodríguez-Portillo J. Noninvasive ventilation versus conventional oxygen therapy after extubation failure in high-risk patients in an intensive care unit: a pragmatic clinical trial. Rev Bras Ter Intensiva 2021; 33:362-373. [PMID: 35107547 PMCID: PMC8555401 DOI: 10.5935/0103-507x.20210059] [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: 07/12/2020] [Accepted: 11/22/2020] [Indexed: 11/20/2022] Open
Abstract
Objetivo Determinar la efectividad de la ventilación no invasiva frente a
oxigenoterapia convencional en pacientes con insuficiencia respiratoria
aguda tras fracaso de la extubación. Métodos Ensayo clínico pragmático realizado una unidad de cuidados
intensivos de marzo de 2009 a septiembre de 2016. Se incluyeron pacientes
sometidos a ventilación mecánica > 24 horas, y que
desarrollaron insuficiencia respiratoria aguda tras extubación
programada, siendo asignados a ventilación no invasiva u
oxigenoterapia convencional. El objetivo primario fue reducir la tasa de
reintubación. Los objetivos secundarios fueron: mejora de los
parámetros respiratorios, reducción de las complicaciones, de
la duración de la ventilación mecánica, de la estancia
en unidad de cuidados intensivos y hospitalaria, así como de la
mortalidad en unidad de cuidados intensivos, hospitalaria y a los 90
días. También se analizaron los factores relacionados con la
reintubación. Resultados De un total de 2.574 pacientes, se analizaron 77 (38 en el grupo de
ventilación no invasiva y 39 en el grupo de oxigenoterapia
convencional). La ventilación no invasiva redujo la frecuencia
respiratoria y cardíaca más rápidamente que la
oxigenoterapia convencional. La reintubación fue menor en el grupo de
ventilación no invasiva [12 (32%) versus 22(56%) en
grupo oxigenoterapia convencional, RR 0,58 (IC95% 0,34 - 0,97), p = 0,039],
el resto de los parámetros no mostró diferencias
significativas. En el análisis multivariante, la ventilación
no invasiva prevenía la reintubación [OR 0,17 (IC95% 0,05 -
0,56), p = 0,004], mientras que el fracaso hepático previo a la
extubación y la incapacidad para mantener vía aérea
permeable predisponían a la reintubación. Conclusión El empleo de la ventilación no invasiva en pacientes que fracasa la
extubación podría ser beneficiosa frente a la oxigenoterapia
convencional.
Collapse
Affiliation(s)
- Alberto Belenguer-Muncharaz
- Unidad de Cuidados Intensivos, Hospital General Universitario de Castellón - Castelló de Plana, Spain.,Unidad Predepartamental Medicina, Facultad de Ciencias de la Salud, Universitat Jaume I - Castelló de la Plana, Spain
| | - Maria-Lidón Mateu-Campos
- Unidad de Cuidados Intensivos, Hospital General Universitario de Castellón - Castelló de Plana, Spain.,Unidad Predepartamental Medicina, Facultad de Ciencias de la Salud, Universitat Jaume I - Castelló de la Plana, Spain
| | - Bárbara Vidal-Tegedor
- Unidad de Cuidados Intensivos, Hospital General Universitario de Castellón - Castelló de Plana, Spain
| | - María-Desamparados Ferrándiz-Sellés
- Unidad de Cuidados Intensivos, Hospital General Universitario de Castellón - Castelló de Plana, Spain.,Unidad Predepartamental Medicina, Facultad de Ciencias de la Salud, Universitat Jaume I - Castelló de la Plana, Spain
| | - Maria-Luisa Micó-Gómez
- Unidad de Cuidados Intensivos, Hospital General Universitario de Castellón - Castelló de Plana, Spain
| | - Susana Altaba-Tena
- Unidad de Cuidados Intensivos, Hospital General Universitario de Castellón - Castelló de Plana, Spain
| | - María Arlandis-Tomás
- Unidad de Cuidados Intensivos, Hospital General Universitario de Castellón - Castelló de Plana, Spain
| | - Rosa Álvaro-Sánchez
- Unidad de Cuidados Intensivos, Hospital General Universitario de Castellón - Castelló de Plana, Spain
| | - Enver Rodríguez-Martínez
- Unidad de Cuidados Intensivos, Hospital General Universitario de Castellón - Castelló de Plana, Spain
| | - Jairo Rodríguez-Portillo
- Unidad de Cuidados Intensivos, Hospital General Universitario de Castellón - Castelló de Plana, Spain
| |
Collapse
|
36
|
Rationale and design of a mechanistic clinical trial of JAK inhibition to prevent ventilator-induced diaphragm dysfunction. Respir Med 2021; 189:106620. [PMID: 34655959 DOI: 10.1016/j.rmed.2021.106620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 08/14/2021] [Accepted: 09/18/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Ventilator-induced diaphragm dysfunction (VIDD) is an important phenomenon that has been repeatedly demonstrated in experimental and clinical models of mechanical ventilation. Even a few hours of MV initiates signaling cascades that result in, first, reduced specific force, and later, atrophy of diaphragm muscle fibers. This severe, progressive weakness of the critical ventilatory muscle results in increased duration of MV and thus increased MV-associated complications/deaths. A drug that could prevent VIDD would likely have a major positive impact on intensive care unit outcomes. We identified the JAK/STAT pathway as important in VIDD and then demonstrated that JAK inhibition prevents VIDD in rats. We subsequently developed a clinical model of VIDD demonstrating reduced contractile force of isolated diaphragm fibers harvested after ∼7 vs ∼1 h of MV during a thoracic surgical procedure. MATERIALS AND METHODS The NIH-funded clinical trial that has been initiated is a prospective, placebo controlled trial: subjects undergoing esophagectomy are randomized to receive 6 preoperative doses of the FDA-approved JAK inhibitor Tofacitinib (commonly used for rheumatoid arthritis) vs. placebo. The primary outcome variable will be the difference in the reduction that occurs in force generation of diaphragm single muscle fibers (normalized to their cross-sectional area), in the Tofacitinib vs. placebo subjects, over 6 h of MV. DISCUSSION This trial represents a first-in-human, mechanistic clinical trial of a drug to prevent VIDD. It will provide proof-of-concept in human subjects whether JAK inhibition prevents clinical VIDD, and if successful, will support an ICU-based clinical trial that would determine whether JAK inhibition impacts clinical outcome variables such as duration of MV and mortality.
Collapse
|
37
|
Rodrigues SN, Henriques HR, Henriques MA. Response to the letter from Rodrigues M and Vaz IM regarding the article "Effectiveness of a preoperative breathing exercise intervention in patients undergoing cardiac surgery: a systematic review". Rev Port Cardiol 2021; 40:S0870-2551(21)00351-6. [PMID: 34465491 DOI: 10.1016/j.repc.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Soraia Nicola Rodrigues
- Lisbon University, Lisbon, Portugal; Lisbon Nursing School, Lisbon, Portugal; Centro Hospitalar de Vila Nova de Gaia/Espinho, Oporto, Portugal.
| | | | | |
Collapse
|
38
|
Discordances Between Factors Associated With Withholding Extubation and Extubation Failure After a Successful Spontaneous Breathing Trial. Crit Care Med 2021; 49:2080-2089. [PMID: 34259451 DOI: 10.1097/ccm.0000000000005107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To identify whether factors associated with withholding extubation in the ICU also predict the risk of extubation failure. DESIGN Retrospective cohort study. SETTING Eight medical-surgical ICUs in Toronto. PATIENTS Adult patients receiving invasive mechanical ventilation, with a first successful spontaneous breathing trial within 28 days of initial ICU admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary end point had three mutually exclusive levels, including: 1) withholding extubation after a successful spontaneous breathing trial, 2) extubation failure within 48 hours, and 3) successful extubation. Among 9,910 patients, 38% of patients were not extubated within 24 hours of their first successful spontaneous breathing trial. A total of 12.9% of patients who were promptly extubated failed within the next 48 hours. Several discrepancies were evident in the association of factors with risk of withholding extubation and extubation failure. Specifically, both age and female sex were associated with withholding extubation (odds ratio, 1.07; 95% CI, 1.03-1.11; and odds ratio, 1.13; 95% CI, 1.02-1.26, respectively) but not a higher risk of failed extubation (odds ratio, 0.99; 95% CI, 0.93-1.05; and odds ratio, 0.93; 95% CI, 0.77-1.11, respectively). Conversely, both acute cardiovascular conditions and intubation for hypoxemic respiratory failure were associated with a higher risk of failed extubation (odds ratio, 1.32; 95% CI, 1.06-1.66; and odds ratio, 1.46; 95% CI, 1.16-1.82, respectively) but not a higher odds of a withheld extubation attempt (odds ratio, 0.79; 95% CI, 0.68-0.91; and odds ratio, 1.07; 95% CI, 0.93-1.23, respectively). CONCLUSIONS Several factors showed discordance between the decision to withhold extubation and the risk of extubation failure. This discordance may lead to longer duration of mechanical ventilation or higher reintubation rates. Improving the decision-making behind extubation may help to reduce both exposure to invasive mechanical ventilation and extubation failure.
Collapse
|
39
|
Abstract
PURPOSE OF REVIEW Obesity prevalence is increasing in most countries in the world. In the United States, 42% of the population is obese (body mass index (BMI) > 30) and 9.2% is obese class III (BMI > 40). One of the greatest challenges in critically ill patients with obesity is the optimization of mechanical ventilation. The goal of this review is to describe respiratory physiologic changes in patients with obesity and discuss possible mechanical ventilation strategies to improve respiratory function. RECENT FINDINGS Individualized mechanical ventilation based on respiratory physiology after a decremental positive end-expiratory pressure (PEEP) trial improves oxygenation and respiratory mechanics. In a recent study, mortality of patients with respiratory failure and obesity was reduced by about 50% when mechanical ventilation was associated with the use of esophageal manometry and electrical impedance tomography (EIT). SUMMARY Obesity greatly alters the respiratory system mechanics causing atelectasis and prolonged duration of mechanical ventilation. At present, novel strategies to ventilate patients with obesity based on individual respiratory physiology showed to be superior to those based on standard universal tables of mechanical ventilation. Esophageal manometry and EIT are essential tools to systematically assess respiratory system mechanics, safely adjust relatively high levels of PEEP, and improve chances for successful weaning.
Collapse
|
40
|
Gok F, Mercan A, Kilicaslan A, Sarkilar G, Yosunkaya A. Diaphragm and Lung Ultrasonography During Weaning From Mechanical Ventilation in Critically Ill Patients. Cureus 2021; 13:e15057. [PMID: 34007779 PMCID: PMC8126179 DOI: 10.7759/cureus.15057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aim: Optimum timing is crucial to avoid negative outcomes of weaning. We aimed to investigate predictive values of diaphragmatic thickening fraction (DTF), diaphragmatic excursion (DE), and anterolateral lung ultrasound (LUS) scores in extubation success and compare with rapid shallow breathing index (RSBI) in patients extubated under traditional parameters. Methods: Patients undergoing mechanical ventilation for >48 hours were included in the study. In patients planned for extubation, sonographic evaluations of the diaphragm and lung were performed at the T-tube stage. RSBI was achieved in the pressure support (PS) ventilation stage. Predictive values of DTF, DE, and anterolateral LUS scores were compared with RSBI in extubation success. Results: Sixty-two patients were enrolled in the study. The study population consisted mostly of trauma patients (77%). A cut-off value of 64 was obtained for RSBI. The positive predictive value (PPV) was found at 97% in extubation success. Cut-off values of 27.5 for DTF, 1.3 cm for the DE, and 6.5 for LUS scores were obtained at the T-tube stage, respectively. PPVs of all sonographic parameters were found over 90%. At the first stage, weaning and extubation failures were determined as 35 and 9.6%, respectively. RSBI was found as a powerful parameter in determining extubation success (r=0.774, p≤0.001) and moderately correlated with sonographic parameters. Conclusion: Investigating the lung and diaphragm via ultrasound provides real-time information to increase extubation success. Cut-off values of 64 for RSBI, 27.5 for DTF, 1.3 cm for the DE, and 6.5 for LUS scores were obtained, respectively, and PPVs of all sonographic parameters were found over 90%. We consider that sonographic evaluations accompanied by an RSBI will increase extubation success in the weaning process.
Collapse
Affiliation(s)
- Funda Gok
- Department of Critical Care Medicine, Necmettin Erbakan University, Meram School of Medicine, Konya, TUR
| | - Aysel Mercan
- Department of Anesthesiology and Reanimation, Necmettin Erbakan University, Meram School of Medicine, Konya, TUR
| | - Alper Kilicaslan
- Department of Anesthesiology and Reanimation, Necmettin Erbakan University, Meram School of Medicine, Konya, TUR
| | - Gamze Sarkilar
- Department of Anesthesiology and Reanimation, Necmettin Erbakan University, Meram School of Medicine, Konya, TUR
| | - Alper Yosunkaya
- Department of Critical Care Medicine, Necmettin Erbakan University, Meram School of Medicine, Konya, TUR
| |
Collapse
|
41
|
Bagate F, Bedet A, Tomberli F, Boissier F, Razazi K, de Prost N, Carteaux G, Mekontso Dessap A. Critical illness-related corticosteroid insufficiency during difficult weaning from mechanical ventilation. Ann Intensive Care 2021; 11:65. [PMID: 33900478 PMCID: PMC8072727 DOI: 10.1186/s13613-021-00852-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 04/10/2021] [Indexed: 12/19/2022] Open
Abstract
Background Critical illness-related corticosteroid insufficiency (CIRCI) is common during critical illness and is usually associated with poor outcomes, as prolonged duration of mechanical ventilation (MV) and higher mortality. CIRCI may alter cardiac and vascular functions. Weaning-induced pulmonary oedema (WiPO) is a major mechanism of weaning failure. The aim of this study was to evaluate the role of CIRCI in patients with difficult ventilator weaning and its possible relation with WiPO. Methods This is a prospective study conducted in the intensive care of a university hospital in France. Patients under MV for more than 24 h, meeting weaning criteria and having failed the first spontaneous breathing trial (SBT) underwent a corticotropin stimulation test, with assessment of total blood cortisol levels immediately before (T0) 0.25 mg iv of tetracosactrin and 30 and 60 min afterward. Δmax was defined as the difference between the maximal value after the test and T0. CIRCI was defined as T0 < 10 μg/dL (276 nmol/L) and/or Δmax < 9 μg/dL (248 nmol/L) and inadequate adrenal reserve as Δmax < 9 μg/dL. Biomarkers (natriuretic peptide and protidemia) sampling and echocardiograms were performed during the second SBT and were used to diagnose WiPO, which was defined according to two definitions (one liberal and one conservative) derived from recent publications on the topic. Successful extubation was defined as patient alive without reintubation 7 days after extubation. A competing risk analysis was used to assess extubation failure and mortality. Results Seventy-six consecutive patients (63 ± 14 years; 49 men) with difficult weaning were enrolled. CIRCI and inadequate adrenal reserve occurred in 25 (33%) and 17 (22%) patients, respectively. The probability of successful extubation was significantly decreased in patients with CIRCI or inadequate adrenal reserve, as compared to their counterparts, and this association persisted after adjustment on severity (SOFA score at first SBT). WiPO occurred in 44 (58%) and 8 (11%) patients, according to the liberal and conservative definition, respectively. WiPO was not associated with CIRCI nor with inadequate adrenal reserve. Conclusion CIRCI was common during difficult weaning and was associated with its prolongation. We did not find a significant association between CIRCI and WiPO. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00852-2.
Collapse
Affiliation(s)
- François Bagate
- AP-HP, DHU A-TVB, Service de Médecine Intensive Réanimation, Centre Hospitalo-Universitaire Henri Mondor, 51, avenue du Mal de Lattre de Tassigny, 94010, Créteil Cedex, France. .,Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010, Créteil, France.
| | - Alexandre Bedet
- AP-HP, DHU A-TVB, Service de Médecine Intensive Réanimation, Centre Hospitalo-Universitaire Henri Mondor, 51, avenue du Mal de Lattre de Tassigny, 94010, Créteil Cedex, France.,Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010, Créteil, France
| | - Françoise Tomberli
- AP-HP, DHU A-TVB, Service de Médecine Intensive Réanimation, Centre Hospitalo-Universitaire Henri Mondor, 51, avenue du Mal de Lattre de Tassigny, 94010, Créteil Cedex, France.,Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010, Créteil, France
| | - Florence Boissier
- AP-HP, DHU A-TVB, Service de Médecine Intensive Réanimation, Centre Hospitalo-Universitaire Henri Mondor, 51, avenue du Mal de Lattre de Tassigny, 94010, Créteil Cedex, France.,Service de Réanimation Médicale, CHU de Poitiers, Poitiers, France.,INSERM CIC 1402 (ALIVE Group), Université de Poitiers, Poitiers, France
| | - Keyvan Razazi
- AP-HP, DHU A-TVB, Service de Médecine Intensive Réanimation, Centre Hospitalo-Universitaire Henri Mondor, 51, avenue du Mal de Lattre de Tassigny, 94010, Créteil Cedex, France.,Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010, Créteil, France
| | - Nicolas de Prost
- AP-HP, DHU A-TVB, Service de Médecine Intensive Réanimation, Centre Hospitalo-Universitaire Henri Mondor, 51, avenue du Mal de Lattre de Tassigny, 94010, Créteil Cedex, France.,Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010, Créteil, France.,INSERM U955, Institut Mondor de Recherche Biomédicale, 94010, Créteil, France
| | - Guillaume Carteaux
- AP-HP, DHU A-TVB, Service de Médecine Intensive Réanimation, Centre Hospitalo-Universitaire Henri Mondor, 51, avenue du Mal de Lattre de Tassigny, 94010, Créteil Cedex, France.,Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010, Créteil, France.,INSERM U955, Institut Mondor de Recherche Biomédicale, 94010, Créteil, France
| | - Armand Mekontso Dessap
- AP-HP, DHU A-TVB, Service de Médecine Intensive Réanimation, Centre Hospitalo-Universitaire Henri Mondor, 51, avenue du Mal de Lattre de Tassigny, 94010, Créteil Cedex, France.,Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010, Créteil, France.,INSERM U955, Institut Mondor de Recherche Biomédicale, 94010, Créteil, France
| |
Collapse
|
42
|
Shi ZH, Jonkman AH, Tuinman PR, Chen GQ, Xu M, Yang YL, Heunks LMA, Zhou JX. Role of a successful spontaneous breathing trial in ventilator liberation in brain-injured patients. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:548. [PMID: 33987246 PMCID: PMC8105847 DOI: 10.21037/atm-20-6407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 12/18/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Spontaneous breathing trials (SBTs) have been shown to improve outcomes in critically ill patients. However, in patients with brain injury, indications for intubation and mechanical ventilation are different from those of non-neurological patients, and the role of an SBT in patients with brain injury is less established. The aim of the present study was to compare key respiratory variables acquired during a successful SBT between patients with successful ventilator liberation versus failed ventilator liberation. METHODS In this prospective study, patients with brain injury (≥18 years of age), who completed a 30-min SBT, were enrolled. Airway pressure, flow, esophageal pressure, and diaphragm electrical activity (ΔEAdi) were recorded before (baseline) and during the SBT. Respiratory rate (RR), tidal volume, inspiratory muscle pressure (ΔPmus), ΔEAdi, and neuromechanical efficiency (ΔPmus/ΔEAdi) of the diaphragm were calculated breath by breath and compared between the liberation success and failure groups. Failed liberation was defined as the need for invasive ventilator assistance within 48 h after the SBT. RESULTS In total, 46 patients (51.9±13.2 years, 67.4% male) completed the SBT. Seventeen (37%) patients failed ventilator liberation within 48 h. Another 11 patients required invasive ventilation within 7 days after completing the SBT. There were no differences in baseline characteristics between the success and failed groups. In-depth analysis showed similar changes in patterns and values of respiratory physiological parameters between the groups. CONCLUSIONS In patients with brain injury, ventilator liberation failure was common after successful SBT. In-depth physiological analysis during the SBT did not provide data to predict successful liberation in these patients. TRIAL REGISTRATION The trial was registered at ClinicalTrials.gov (No. NCT02863237).
Collapse
Affiliation(s)
- Zhong-Hua Shi
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Intensive Care, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
| | - Annemijn H. Jonkman
- Department of Intensive Care, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
| | - Pieter Roel Tuinman
- Department of Intensive Care, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
| | - Guang-Qiang Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming Xu
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yan-Lin Yang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Leo M. A. Heunks
- Department of Intensive Care, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
43
|
Rizzo JA, Haq M, McMahon RA, Aden JK, Brillhart DB, Cancio LC. Extubation Failure in a Burn Intensive Care Unit: Examination of Contributing Factors. J Burn Care Res 2021; 42:177-181. [PMID: 32918478 DOI: 10.1093/jbcr/iraa162] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Extubation failure is associated with negative outcomes making the identification of risk factors for failure paramount. Burn patients experience a high incidence of respiratory failure requiring mechanical ventilation. There is no consensus on the acceptable rate of extubation failure and many conventional indices do not accurately predict extubation outcomes in burn patients. The purpose of this study was to examine the rate of extubation failure in the burned population and to examine the impact of factors on extubation outcomes. Burn patients from a single center over 9 years were examined and included if they were intubated prior to arrival or within 48 hours of admission and underwent a planned extubation. From this cohort, a matched case-control analysis based on age, TBSA, and sex was performed of patients who succeeded after extubation, defined as not requiring reintubation within 72 hours, to those who failed. Characteristics and clinical parameters were compared to determine whether any factors could predict extubation failure. There was a 12.3% incidence of extubation failure. In the matched case-control analysis, the presence of inhalation injury was associated with extubation success. Higher heart rate and lower serum pH were associated with extubation failure. ANCOVA analysis demonstrated that a sodium trending higher before extubation was associated with more successes, possibly indicative of a lower volume status. Classic extubation criteria do not accurately predict extubation outcomes in burn patients; analysis of other parameters may be able to provide better predictions. A constellation of these parameters needs to be studied prospectively.
Collapse
Affiliation(s)
- Julie A Rizzo
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas.,Uniformed Services University of Health Sciences, Bethesda, Maryland
| | - Mahdi Haq
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas.,Metis Foundation, San Antonio Texas
| | - Ryan A McMahon
- Brooke Army Medical Center, Fort Sam Houston, Texas.,United States Army Medical Center of Excellence, Joint Base San Antonio, Texas
| | - James K Aden
- Brooke Army Medical Center, Fort Sam Houston, Texas
| | | | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas
| |
Collapse
|
44
|
Schönhofer B, Geiseler J, Dellweg D, Fuchs H, Moerer O, Weber-Carstens S, Westhoff M, Windisch W. Prolonged Weaning: S2k Guideline Published by the German Respiratory Society. Respiration 2020; 99:1-102. [PMID: 33302267 DOI: 10.1159/000510085] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/28/2023] Open
Abstract
Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.
Collapse
Affiliation(s)
- Bernd Schönhofer
- Klinikum Agnes Karll Krankenhaus, Klinikum Region Hannover, Laatzen, Germany,
| | - Jens Geiseler
- Klinikum Vest, Medizinische Klinik IV: Pneumologie, Beatmungs- und Schlafmedizin, Marl, Germany
| | - Dominic Dellweg
- Fachkrankenhaus Kloster Grafschaft GmbH, Abteilung Pneumologie II, Schmallenberg, Germany
| | - Hans Fuchs
- Universitätsklinikum Freiburg, Zentrum für Kinder- und Jugendmedizin, Neonatologie und Pädiatrische Intensivmedizin, Freiburg, Germany
| | - Onnen Moerer
- Universitätsmedizin Göttingen, Klinik für Anästhesiologie, Göttingen, Germany
| | - Steffen Weber-Carstens
- Charité, Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Virchow-Klinikum und Campus Mitte, Berlin, Germany
| | - Michael Westhoff
- Lungenklinik Hemer, Hemer, Germany
- Universität Witten/Herdecke, Herdecke, Germany
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Universität Witten/Herdecke, Herdecke, Germany
| |
Collapse
|
45
|
Roy A, Singh P, Saha S, Sen A, Ray M, Deb Majumder S, Dutta S, Chowdhuri S, Mundhra R. Design of a Multi-Control Objective Rescue Mechanical Ventilation System (Linshomator). FRONTIERS IN MEDICAL TECHNOLOGY 2020; 2:575964. [PMID: 35047880 PMCID: PMC8757753 DOI: 10.3389/fmedt.2020.575964] [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: 06/24/2020] [Accepted: 10/21/2020] [Indexed: 11/17/2022] Open
Abstract
In recent years, the need for a low-cost emergency ventilation system has increased unprecedentedly. Mechanical ventilation systems are widely used to cater to sudden oxygen demands, low breathing rates, and critical conditions during bradycardia and tachycardia. In this research, a new design of mechanical ventilation system synced with the tidal volume requirements of the patient using a piezoelectric belt has been proposed. The device proposed has various modes of ventilation—ACV (assisted controlled ventilation), SIMV (synchronized intermittent mandatory ventilation), and NIV (non-invasive ventilation), depending on the patient's requirements. A digital interface or user-friendly software has also been developed to help medical professionals easily monitor a patient's medical conditions. Finally, the automation that controls the ventilation mechanism of the device has been tested and validated with a conventional ventilator, and it has been found that the accuracy of the device in terms of delivering the exact quantity of air into the patient according to his requirements has been improved significantly. Further, the comparative study of the experimental data indicated that 5–10% error in detecting inhale and exhale attempt of a patient was detected with the conventional ventilator.
Collapse
Affiliation(s)
- Aritra Roy
- Department of Electronics and Communication Engineering, Institute of Engineering & Management, Kolkata, India
| | - Pushpak Singh
- Department of Mechanical Engineering, Institute of Engineering & Management, Kolkata, India
| | - Simran Saha
- Department of Information Technology, Institute of Engineering & Management, Kolkata, India
| | - Arvil Sen
- Department of Electrical Engineering, Institute of Engineering & Management, Kolkata, India
| | - Mayukh Ray
- Department of Information Technology, Institute of Engineering & Management, Kolkata, India
| | - Samarpan Deb Majumder
- Department of Mechanical Engineering, Institute of Engineering & Management, Kolkata, India
- *Correspondence: Samarpan Deb Majumder
| | - Sagnik Dutta
- Department of Mechanical Engineering, Institute of Engineering & Management, Kolkata, India
| | | | - Raghav Mundhra
- Department of Mechanical Engineering, Indian Institute of Technology, Kharagpur, India
| |
Collapse
|
46
|
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
|
47
|
IJland MM, Lemson J, van der Hoeven JG, Heunks LMA. The impact of critical illness on the expiratory muscles and the diaphragm assessed by ultrasound in mechanical ventilated children. Ann Intensive Care 2020; 10:115. [PMID: 32852710 PMCID: PMC7450159 DOI: 10.1186/s13613-020-00731-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 08/17/2020] [Indexed: 12/26/2022] Open
Abstract
Background Critical illness has detrimental effects on the diaphragm, but the impact of critical illness on other major muscles of the respiratory pump has been largely neglected. This study aimed to determine the impact of critical illness on the most important muscles of the respiratory muscle pump, especially on the expiratory muscles in children during mechanical ventilation. In addition, the correlation between changes in thickness of the expiratory muscles and the diaphragm was assessed. Methods This longitudinal observational cohort study performed at a tertiary pediatric intensive care unit included 34 mechanical ventilated children (> 1 month– < 18 years). Thickness of the diaphragm and expiratory muscles (obliquus interna, obliquus externa, transversus abdominis and rectus abdominis) was assessed daily using ultrasound. Contractile activity was estimated from muscle thickening fraction during the respiratory cycle. Results Over the first 4 days, both diaphragm and expiratory muscles thickness decreased (> 10%) in 44% of the children. Diaphragm and expiratory muscle thickness increased (> 10%) in 26% and 20% of the children, respectively. No correlation was found between contractile activity of the muscles and the development of atrophy. Furthermore, no correlation was found between changes in thickness of the diaphragm and the expiratory muscles (P = 0.537). Decrease in expiratory muscle thickness was significantly higher in patients failing extubation compared to successful extubation (− 34% vs − 4%, P = 0.014). Conclusions Changes in diaphragm and expiratory muscles thickness develop rapidly after the initiation of mechanical ventilation. Changes in thickness of the diaphragm and expiratory muscles were not significantly correlated. These data provide a unique insight in the effects of critical illness on the respiratory muscle pump in children.
Collapse
Affiliation(s)
- Marloes M IJland
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Joris Lemson
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Johannes G van der Hoeven
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Leo M A Heunks
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Postbox 7057, 1007MB, Amsterdam, The Netherlands.
| |
Collapse
|
48
|
Peñuelas Ó, Frutos-Vivar F, Mancebo J. Invasive Mechanical Ventilation in Chronic Obstructive Pulmonary Disease Exacerbations. Semin Respir Crit Care Med 2020; 41:798-805. [PMID: 32746470 DOI: 10.1055/s-0040-1714396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) continues to be an important cause of morbidity, mortality, and health care costs worldwide. Although there exist some heterogeneity between patients, the course of COPD is characterized by recurrent acute exacerbations, which are among the most common causes of medical admission to hospital. Patients with frequent exacerbations have accelerated lung function decline, worse quality of life, and greater mortality. Therefore, interest is growing in assessing the effectiveness of interventions used to treat exacerbations. The present review summarizes the current evidence regarding the use of ventilatory management to treat COPD and the implementation of novel cost-effective strategies, such as high-flow oxygenation or extracorporeal carbon dioxide removal to improve clinical outcomes and functional recovery in this disease and to reduce the associated costs.
Collapse
Affiliation(s)
- Óscar Peñuelas
- Intensive Care Unit, Hospital Universitario de Getafe, CIBER de Enfermedades Respiratorias, CIBERES, Madrid, Spain
| | - Fernando Frutos-Vivar
- Intensive Care Unit, Hospital Universitario de Getafe, CIBER de Enfermedades Respiratorias, CIBERES, Madrid, Spain
| | - Jordi Mancebo
- Intensive Care Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| |
Collapse
|
49
|
Worraphan S, Thammata A, Chittawatanarat K, Saokaew S, Kengkla K, Prasannarong M. Effects of Inspiratory Muscle Training and Early Mobilization on Weaning of Mechanical Ventilation: A Systematic Review and Network Meta-analysis. Arch Phys Med Rehabil 2020; 101:2002-2014. [PMID: 32750371 DOI: 10.1016/j.apmr.2020.07.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 06/26/2020] [Accepted: 07/02/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To compare the effectiveness and rank order of physical therapy interventions, including conventional physical therapy (CPT), inspiratory muscle training (IMT), and early mobilization (EM) on mechanical ventilation (MV) duration and weaning duration. DATA SOURCES PubMed, The Cochrane Library, Scopus, and CINAHL complete electronic databases were searched through August 2019. STUDY SELECTION Randomized controlled trials (RCTs) investigating the effect of IMT, EM, or CPT on MV duration and the weaning duration in patients with MV were included. Studies that were determined to meet the eligibility criteria by 2 independent authors were included. A total of 6498 relevant studies were identified in the search, and 18 RCTs (934 participants) were included in the final analysis. DATA EXTRACTION Data were extracted independently by 2 authors and assessed the study quality by the Cochrane risk-of-bias tool. The primary outcomes were MV duration and weaning duration. DATA SYNTHESIS Various interventions of physical therapy were identified in the eligible studies, including IMT, IMT+CPT, EM, EM+CPT, and CPT. The data analysis demonstrated that compared with CPT, IMT+CPT significantly reduced the weaning duration (mean difference; 95% confidence interval) (-2.60; -4.76 to -0.45) and EM significantly reduced the MV duration (-2.01; -3.81 to -0.22). IMT+CPT and EM had the highest effectiveness in reducing the weaning duration and MV duration, respectively. CONCLUSION IMT or EM should be recommended for improving the weaning outcomes in mechanically ventilated patients. However, an interpretation with caution is required due to the heterogeneity.
Collapse
Affiliation(s)
- Salinee Worraphan
- Department of Physical Therapy, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai
| | - Attalekha Thammata
- Department of Physical Therapy, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai
| | | | - Surasak Saokaew
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao; Unit of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao; Unit of Excellence on Herbal Medicine, School of Pharmaceutical Sciences, University of Phayao, Phayao; Division of Pharmacy Practice, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | - Kirati Kengkla
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao; Unit of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao
| | - Mujalin Prasannarong
- Department of Physical Therapy, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai.
| |
Collapse
|
50
|
The impact of tracheostomy timing on clinical outcomes and adverse events in intubated patients with infratentorial lesions: early versus late tracheostomy. Neurosurg Rev 2020; 44:1513-1522. [PMID: 32583308 PMCID: PMC7314615 DOI: 10.1007/s10143-020-01339-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/18/2020] [Accepted: 06/17/2020] [Indexed: 12/19/2022]
Abstract
We evaluated the association between the timing of tracheostomy and clinical outcomes in patients with infratentorial lesions. We performed a retrospective observational cohort study in a neurosurgical intensive care unit (ICU) at a tertiary academic medical center from January 2014 to December 2018. Consecutive adult patients admitted to the ICU who underwent resection of infratentorial lesions as well as tracheostomy were included for analysis. Early tracheostomy was defined as performed on postoperative days 1-10 and late tracheostomy on days 10-20 after operation. Univariate and multivariate analyses were used to compare the characteristics and outcomes between both cohorts. A total of 143 patients were identified, and 96 patients received early tracheostomy. Multivariable analysis identified early tracheostomy as an independent variable associated with lower occurrence of pneumonia (odds ratio, 0.25; 95% CI, 0.09-0.73; p = 0.011), shorter stays in ICUs (hazard ratio, 0.4; 95% CI, 0.3-0.6; p = 0.03), and earlier decannulation (hazard ratio, 0.5; 95% CI, 0.4-0.8; p = 0.003). However, no significant differences were observed between the early and late tracheostomy groups regarding hospital mortality (p > 0.999) and the modified Rankin scale after 6 months (p = 0.543). We also identified postoperative brainstem deficits, including cough, swallowing attempts, and extended tongue as well as GCS < 8 at ICU admission as the risk factors independently associated with patients underwent tracheostomy. There is a significant association between early tracheostomy and beneficial clinical outcomes or reduced adverse event occurrence in patients with infratentorial lesions.
Collapse
|