Risk factors for physical impairment after acute lung injury in a national, multicenter study

An Exploratory Analysis of Sociodemographic Factors Associated With Physical Functional Impairment in ICU Survivors

IMPORTANCE

Physical functional impairment is one of three components of postintensive care syndrome (PICS) that affects up to 60% of ICU survivors.

OBJECTIVES

To explore the prevalence of objective physical functional impairment among a diverse cohort of ICU survivors, both at discharge and longitudinally, and to highlight sociodemographic factors that might be associated with the presence of objective physical functional impairment.

DESIGN, SETTING, AND PARTICIPANTS

This was a secondary analysis of 37 patients admitted to the ICU in New Orleans, Louisiana, and Denver, Colorado between 2016 and 2019 who survived with longitudinal follow-up data.

MAIN OUTCOMES AND MEASURES

Our primary outcome of physical functional impairment was defined by handgrip strength and the short physical performance battery. We explored associations between functional impairment and sociodemographic factors that included race/ethnicity, sex, primary language, education status, and medical comorbidities.

RESULTS

More than 75% of ICU survivors were affected by physical functional impairment at discharge and longitudinally at 3- to 6-month follow-up. We did not see a significant difference in the proportion of patients with physical functional impairment by race/ethnicity, primary language, or education status. Impairment was relatively higher in the follow-up period among women, compared with men, and those with comorbidities. Among 18 patients with scores at both time points, White patients demonstrated greater change in handgrip strength than non-White patients. Four non-White patients demonstrated diminished handgrip strength between discharge and follow-up.

CONCLUSIONS AND RELEVANCE

In this exploratory analysis, we saw that the prevalence of objective physical functional impairment among ICU survivors was high and persisted after hospital discharge. Our findings suggest a possible relationship between race/ethnicity and physical functional impairment. These exploratory findings may inform future investigations to evaluate the impact of sociodemographic factors on functional recovery.

Physical and Cognitive Impairment in Acute Respiratory Failure

Recent research has brought renewed attention to the multifaceted physical and cognitive dysfunction that accompanies acute respiratory failure (ARF). This state-of-the-art review provides an overview of the evidence landscape encompassing ARF-associated neuromuscular and neurocognitive impairments. Risk factors, mechanisms, assessment tools, rehabilitation strategies, approaches to ventilator liberation, and interventions to minimize post-intensive care syndrome are emphasized. The complex interrelationship between physical disability, cognitive dysfunction, and long-term patient-centered outcomes is explored. This review highlights the need for comprehensive, multidisciplinary approaches to mitigate morbidity and accelerate recovery.

Exploring the influence of a financial incentive scheme on early mobilization and rehabilitation in ICU patients: an interrupted time-series analysis

BACKGROUND

Clinical guidelines recommend early mobilization and rehabilitation (EMR) for patients who are critically ill. However, various barriers impede its implementation in real-world clinical settings. In 2018, the Japanese universal healthcare coverage system announced a unique financial incentive scheme to facilitate EMR for patients in intensive care units (ICU). This study evaluated whether such an incentive improved patients' activities of daily living (ADL) and reduced their hospital length of stay (LOS).

METHODS

Using the national inpatient database in Japan, we identified patients admitted to the ICU, who stayed over 48 hours between April 2017 and March 2019. The financial incentive required medical institutions to form a multidisciplinary team approach for EMR, development and periodic review of the standardized rehabilitation protocol, starting rehabilitation within 2 days of ICU admission. The incentive amounted to 34.6 United States Dollars per patient per day with limit 14 days, structured as a per diem payment. Hospitals were not mandated to provide detailed information on individual rehabilitation for government, and the insurer made payments directly to the hospitals based on their claims. Exposure was the introduction of the financial incentive defined as the first day of claim by each hospital. We conducted an interrupted time-series analysis to assess the impact of the financial incentive scheme. Multivariable radon-effects regression and Tobit regression analysis were performed with random intercept for the hospital of admission.

RESULTS

A total of 33,568 patients were deemed eligible. We confirmed that the basic assumption of ITS was fulfilled. The financial incentive was associated with an improvement in the Barthel index at discharge (0.44 points change in trend per month; 95% confidence interval = 0.20-0.68) and shorter hospital LOS (- 0.66 days change in trend per month; 95% confidence interval = - 0.88 - -0.44). The sensitivity and subgroup analyses showed consistent results.

CONCLUSIONS

The study suggests a potential association between the financial incentive for EMR in ICU patients and improved outcomes. This incentive scheme may provide a unique solution to EMR barrier in practice, however, caution is warranted in interpreting these findings due to recent changes in ICU care practices.

Improving management of ARDS: uniting acute management and long-term recovery

Acute Respiratory Distress Syndrome (ARDS) is an important global health issue with high in-hospital mortality. Importantly, the impact of ARDS extends beyond the acute phase, with increased mortality and disability for months to years after hospitalization. These findings underscore the importance of extended follow-up to assess and address the Post-Intensive Care Syndrome (PICS), characterized by persistent impairments in physical, cognitive, and/or mental health status that impair quality of life over the long-term. Persistent muscle weakness is a common physical problem for ARDS survivors, affecting mobility and activities of daily living. Critical illness and related interventions, including prolonged bed rest and overuse of sedatives and neuromuscular blocking agents during mechanical ventilation, are important risk factors for ICU-acquired weakness. Deep sedation also increases the risk of delirium in the ICU, and long-term cognitive impairment. Corticosteroids also may be used during management of ARDS, particularly in the setting of COVID-19. Corticosteroids can be associated with myopathy and muscle weakness, as well as prolonged delirium that increases the risk of long-term cognitive impairment. The optimal duration and dosage of corticosteroids remain uncertain, and there's limited long-term data on their effects on muscle weakness and cognition in ARDS survivors. In addition to physical and cognitive issues, mental health challenges, such as depression, anxiety, and post-traumatic stress disorder, are common in ARDS survivors. Strategies to address these complications emphasize the need for consistent implementation of the evidence-based ABCDEF bundle, which includes daily management of analgesia in concert with early cessation of sedatives, avoidance of benzodiazepines, daily delirium monitoring and management, early mobilization, and incorporation of family at the bedside. In conclusion, ARDS is a complex global health challenge with consequences extending beyond the acute phase. Understanding the links between critical care management and long-term consequences is vital for developing effective therapeutic strategies and improving the quality of life for ARDS survivors.

Advances in post intensive care unit care: A narrative review

As the treatment options, modalities and technology have grown, mortality in intensive care unit (ICU) has been on the decline. More and more patients are being discharged to wards and in the care of their loved ones after prolonged treatment at times and sometimes in isolation. These survivors have a lower life expectancy and a poorer quality of life. They can have substantial familial financial implications and an economic impact on the healthcare system in terms of increased and continued utilisation of services, the so-called post intensive care syndrome (PICS). But it is not only the patient who is the sufferer. The mental health of the loved ones and family members may also be affected, which is termed as PICS-family. In this review, we shall be reviewing the definition, epidemiology, clinical features, diagnosis and evaluation, treatment and follow up of PICS. We shall also focus on measures to prevent, rehabilitate and understand the ICU stay from patients’ perspective on how to redesign the ICU, post ICU care needs for a better patient outcome.

A systematic review and meta-analysis of the clinimetric properties of the core outcome measurement instruments for clinical effectiveness trials of nutritional and metabolic interventions in critical illness (CONCISE)

BACKGROUND

CONCISE is an internationally agreed minimum set of outcomes for use in nutritional and metabolic clinical research in critically ill adults. Clinicians and researchers need to be aware of the clinimetric properties of these instruments and understand any limitations to ensure valid and reliable research. This systematic review and meta-analysis were undertaken to evaluate the clinimetric properties of the measurement instruments identified in CONCISE.

METHODS

Four electronic databases were searched from inception to December 2022 (MEDLINE via Ovid, EMBASE via Ovid, CINAHL via Healthcare Databases Advanced Search, CENTRAL via Cochrane). Studies were included if they examined at least one clinimetric property of a CONCISE measurement instrument or recognised variation in adults ≥ 18 years with critical illness or recovering from critical illness in any language. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist for systematic reviews of Patient-Reported Outcome Measures was used. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses were used in line with COSMIN guidance. The COSMIN checklist was used to evaluate the risk of bias and the quality of clinimetric properties. Overall certainty of the evidence was rated using a modified Grading of Recommendations, Assessment, Development and Evaluation approach. Narrative synthesis was performed and where possible, meta-analysis was conducted.

RESULTS

A total of 4316 studies were screened. Forty-seven were included in the review, reporting data for 12308 participants. The Short Form-36 Questionnaire (Physical Component Score and Physical Functioning), sit-to-stand test, 6-m walk test and Barthel Index had the strongest clinimetric properties and certainty of evidence. The Short Physical Performance Battery, Katz Index and handgrip strength had less favourable results. There was limited data for Lawson Instrumental Activities of Daily Living and the Global Leadership Initiative on Malnutrition criteria. The risk of bias ranged from inadequate to very good. The certainty of the evidence ranged from very low to high.

CONCLUSIONS

Variable evidence exists to support the clinimetric properties of the CONCISE measurement instruments. We suggest using this review alongside CONCISE to guide outcome selection for future trials of nutrition and metabolic interventions in critical illness.

TRIAL REGISTRATION

PROSPERO (CRD42023438187). Registered 21/06/2023.

Illness Weakness, Polyneuropathy and Myopathy: Diagnosis, treatment, and long-term outcomes

BACKGROUND

Severe weakness associated with critical illness (CIW) is common. This narrative review summarizes the latest scientific insights and proposes a guide for clinicians to optimize the diagnosis and management of the CIW during the various stages of the disease from the ICU to the community stage.

MAIN BODY

CIW arises as diffuse, symmetrical weakness after ICU admission, which is an important differentiating factor from other diseases causing non-symmetrical muscle weakness or paralysis. In patients with adequate cognitive function, CIW can be easily diagnosed at the bedside using manual muscle testing, which should be routinely conducted until ICU discharge. In patients with delirium or coma or those with prolonged, severe weakness, specific neurophysiological investigations and, in selected cases, muscle biopsy are recommended. With these exams, CIW can be differentiated into critical illness polyneuropathy or myopathy, which often coexist. On the general ward, CIW is seen in patients with prolonged previous ICU treatment, or in those developing a new sepsis. Respiratory muscle weakness can cause neuromuscular respiratory failure, which needs prompt recognition and rapid treatment to avoid life-threatening situations. Active rehabilitation should be reassessed and tailored to the new patient's condition to reduce the risk of disease progression. CIW is associated with long-term physical, cognitive and mental impairments, which emphasizes the need for a multidisciplinary model of care. Follow-up clinics for patients surviving critical illness may serve this purpose by providing direct clinical support to patients, managing referrals to other specialists and general practitioners, and serving as a platform for research to describe the natural history of post-intensive care syndrome and to identify new therapeutic interventions. This surveillance should include an assessment of the activities of daily living, mood, and functional mobility. Finally, nutritional status should be longitudinally assessed in all ICU survivors and incorporated into a patient-centered nutritional approach guided by a dietician.

CONCLUSIONS

Early ICU mobilization combined with the best evidence-based ICU practices can effectively reduce short-term weakness. Multi-professional collaborations are needed to guarantee a multi-dimensional evaluation and unitary community care programs for survivors of critical illnesses.

Predictive factors and clinical impact of ICU-acquired weakness on functional disability in mechanically ventilated patients with COVID-19

BACKGROUND

Patients with critical COVID-19 often require invasive mechanical ventilation (IMV) and admission to the intensive care unit (ICU), resulting in a higher incidence of ICU-acquired weakness (ICU-AW) and functional decline.

OBJECTIVE

This study aimed to examine the causes of ICU-AW and functional outcomes in critically ill patients with COVID-19 who required IMV.

METHODS

This prospective, single-center, observational study included COVID-19 patients who required IMV for ≥48 h in the ICU between July 2020 and July 2021. ICU-AW was defined as a Medical Research Council sum score <48 points. The primary outcome was functional independence during hospitalization, defined as an ICU mobility score ≥9 points.

RESULTS

A total of 157 patients (age: 68 [59-73] years, men: 72.6%) were divided into two groups (ICU-AW group; n = 80 versus non-ICU-AW; n = 77). Older age (adjusted odds ratio [95% confidence interval]: 1.05 [1.01-1.11], p = 0.036), administration of neuromuscular blocking agents (7.79 [2.87-23.3], p < 0.001), pulse steroid therapy (3.78 [1.49-10.1], p = 0.006), and sepsis (7.79 [2.87-24.0], p < 0.001) were significantly associated with ICU-AW development. In addition, patients with ICU-AW had significantly longer time to functional independence than those without ICU-AW (41 [30-54] vs 19 [17-23] days, p < 0.001). The development of ICU-AW was associated with delayed time to functional independence (adjusted hazard ratio: 6.08; 95% CI: 3.05-12.1; p < 0.001).

CONCLUSIONS

Approximately half of the patients with COVID-19 requiring IMV developed ICU-AW, which was associated with delayed functional independence during hospitalization.

Mapping peripheral and abdominal sarcopenia acquired in the acute phase of COVID-19 during 7 days of mechanical ventilation

Our aim was to map acquired peripheral and abdominal sarcopenia in mechanically ventilated adults with COVID-19 through ultrasound measurements. On Days 1, 3, 5 and 7 after admission to critical care, the muscle thickness and cross-sectional area of the quadriceps, rectus femoris, vastus intermedius, tibialis anterior, medial and lateral gastrocnemius, deltoid, biceps brachii, rectus abdominis, internal and external oblique, and transversus abdominis were measured using bedside ultrasound. A total of 5460 ultrasound images were analyzed from 30 patients (age: 59.8 ± 15.6 years; 70% men). Muscle thickness loss was found in the bilateral anterior tibial and medial gastrocnemius muscles (range 11.5-14.6%) between Days 1 and 3; in the bilateral quadriceps, rectus femoris, lateral gastrocnemius, deltoid, and biceps brachii (range 16.3-39.1%) between Days 1 and 5; in the internal oblique abdominal (25.9%) between Days 1 and 5; and in the rectus and transversus abdominis (29%) between Days 1 and 7. The cross-sectional area was reduced in the bilateral tibialis anterior and left biceps brachii (range 24.6-25.6%) between Days 1 and 5 and in the bilateral rectus femoris and right biceps brachii (range 22.9-27.7%) between Days 1 and 7. These findings indicate that the peripheral and abdominal muscle loss is progressive during the first week of mechanical ventilation and is significantly higher in the lower limbs, left quadriceps and right rectus femoris muscles in critically ill patients with COVID-19.

Long-Term Evolution of Activities of Daily Life (ADLs) in Critically Ill COVID-19 Patients, a Case Series

BACKGROUND

The most common long-term symptoms of critically ill COVID-19 patients are fatigue, dyspnea and mental confusion. Adequate monitoring of long-term morbidity, mainly analyzing the activities of daily life (ADLs), allows better patient management after hospital discharge. The aim was to report long-term ADL evolution in critically ill COVID-19 patients admitted to a COVID-19 center in Lugano (Switzerland).

METHODS

A retrospective analysis on consecutive patients discharged alive from ICU with COVID-19 ARDS was performed based on a follow-up one year after hospital discharge; ADLs were assessed through the Barthel index (BI) and the Karnofsky Performance Status (KPS) scale. The primary objective was to assess differences in ADLs at hospital discharge (acute ADLs) and one-year follow-up (chronic ADLs). The secondary objective was to explore any correlations between ADLs and multiple measures at admission and during the ICU stay.

RESULTS

A total of 38 consecutive patients were admitted to the ICU; a t-test analysis between acute and chronic ADLs through BI showed a significant improvement at one year post discharge (t = -5.211, p < 0.0001); similarly, every single task of BI showed the same results (p < 0.0001 for each task of BI). The mean KPS was 86.47 (SD 20.9) at hospital discharge and 99.6 at 1 year post discharge (p = 0.02). Thirteen (34%) patients deceased during the first 28 days in the ICU; no patient died after hospital discharge.

CONCLUSIONS

Based on BI and KPS, patients reached complete functional recovery of ADLs one year after critical COVID-19.

Mitophagy-promoting miR-138-5p promoter demethylation inhibits pyroptosis in sepsis-associated acute lung injury

BACKGROUND

The present study was designed to explore the potential regulatory mechanism between mitophagy and pyroptosis during sepsis-associated acute lung injury (ALI).

METHODS

In vitro or in vivo models of sepsis-associated ALI were established by administering lipopolysaccharide (LPS) or performing caecal ligation and puncture (CLP) surgery. Pyroptosis levels were detected by electron microscopy, immunofluorescence, flow cytometry, western blotting and immunohistochemistry. Dual-luciferase reporter gene assay was applied to verify the targeting relationship between miR-138-5p and NLRP3. Methylation-specific PCR and chromatin immunoprecipitation assays were used to determine methylation of the miR-138-5p promoter. Mitophagy levels were examined by transmission electron microscopy and western blotting.

RESULTS

NLRP3 inflammasome silencing alleviated alveolar macrophage (AM) pyroptosis and septic lung injury. In addition, we confirmed the direct targeting relationship between miR-138-5p and NLRP3. Overexpressed miR-138-5p alleviated AM pyroptosis and the pulmonary inflammatory response. Moreover, the decreased expression of miR-138-5p was confirmed to depend on promoter methylation, while inhibition of miR-138-5p promoter methylation attenuated AM pyroptosis and pulmonary inflammation. Here, we discovered that an increased cytoplasmic mtDNA content in sepsis-induced ALI models induced the methylation of the miR-138-5p promoter, thereby decreasing miR-138-5p expression, which may activate the NLRP3 inflammasome and trigger AM pyroptosis. Mitophagy, a form of selective autophagy that clears damaged mitochondria, reduced cytoplasmic mtDNA levels. Furthermore, enhanced mitophagy might suppress miR-138-5p promoter methylation and relieve the pulmonary inflammatory response, changes that were reversed by treatment with isolated mtDNA.

CONCLUSIONS

In summary, our study indicated that mitophagy induced the demethylation of the miR-138-5p promoter, which may subsequently inhibit NLRP3 inflammasome, AM pyroptosis and inflammation in sepsis-induced lung injury. These findings may provide a promising therapeutic target for sepsis-associated ALI.

Respiratory recovery trajectories after severe-to-critical COVID-19: a 1-year prospective multicentre study

BACKGROUND

Survivors of severe-to-critical COVID-19 may have functional impairment, radiological sequelae and persistent symptoms requiring prolonged follow-up. This pragmatic study aimed to describe their clinical follow-up and determine their respiratory recovery trajectories, and factors that could influence them and their health-related quality of life.

METHODS

Adults hospitalised for severe-to-critical COVID-19 were evaluated at 3 months and up to 12 months post-hospital discharge in this prospective, multicentre, cohort study.

RESULTS

Among 485 enrolled participants, 293 (60%) were reassessed at 6 months and 163 (35%) at 12 months; 89 (51%) and 47 (27%) of the 173 ones initially managed with standard oxygen were reassessed at 6 and 12 months, respectively. At 3 months, 34%, 70% and 56% of the participants had a restrictive lung defect, impaired DL_CO and significant radiological sequelae, respectively. During extended follow-up, DL_CO and FVC (% of predicted value) increased by means of +4 points at 6 months, and +6 points at 12 months. Sex, body mass index, chronic respiratory disease, immunosuppression, pneumonia extent or corticosteroid use during acute COVID-19 and prolonged invasive mechanical ventilation (IMV) were associated with DL_CO at month 3, but not its trajectory thereafter. Among 475 (98%) patients with at least one chest computed-tomography scan during follow-up, 196 (41%) had significant sequelae on their last images.

CONCLUSION

Although pulmonary function and radiological abnormalities improved up to 1 year post-acute-COVID-19, high percentages of severe-to-critical disease survivors, including a notable proportion of those managed with standard oxygen, had significant lung sequelae and residual symptoms justifying prolonged follow-up.

Supporting Decision-Making About Patient Mobility in the Intensive Care Unit Nurse Work Environment: Work Domain Analysis

Background

Patient mobility is an evidenced-based physical activity intervention initiated during intensive care unit (ICU) admission and continued throughout hospitalization to maintain functional status, yet mobility is a complex intervention and not consistently implemented. Cognitive work analysis (CWA) is a useful human factors framework for understanding complex systems and can inform future technology design to optimize outcomes.

Objective

The aim of this study is to understand the complexity and constraints of the ICU work environment as it relates to nurses carrying out patient mobility interventions, using CWA.

Methods

We conducted a work domain analysis and completed an abstraction hierarchy using the CWA framework. Data from documents, observation (32 hours), and interviews with nurses (N=20) from 2 hospitals were used to construct the abstraction hierarchy.

Results

Nurses seek information from a variety of sources and integrate patient and unit information to inform decision-making. The completed abstraction hierarchy depicts multiple high-level priorities that nurses balance, specifically, providing quality, safe care to patients while helping to manage unit-level throughput needs. Connections between levels on the abstraction hierarchy describe how and why nurses seek patient and hospital unit information to inform mobility decision-making. The analysis identifies several opportunities for technology design to support nurse decision-making about patient mobility.

Conclusions

Future interventions need to consider the complexity of the ICU environment and types of information nurses need to make decisions about patient mobility. Considerations for future system redesign include developing and testing clinical decision support tools that integrate critical patient and unit-level information to support nurses in making patient mobility decisions.

Survivorship After Critical Illness and Post-Intensive Care Syndrome

Improvements in critical care medicine have led to a marked increase in survivors of the intensive care unit (ICU). These survivors encounter many difficulties following ICU discharge. The term post -intensive care syndrome (PICS) provides a framework for identifying the most common symptoms which fall into three domains: cognitive, physical, and mental health. There are numerous risk factors for the development of PICS including premorbid conditions and specific elements of ICU hospitalizations. Management is complex and should take an individualized approach with interdisciplinary care. Future research should focus on prevention, identification, and treatment of this unique population.

New Insights into Clinical and Mechanistic Heterogeneity of the Acute Respiratory Distress Syndrome: Summary of the Aspen Lung Conference 2021

Clinical and molecular heterogeneity are common features of human disease. Understanding the basis for heterogeneity has led to major advances in therapy for many cancers and pulmonary diseases such as cystic fibrosis and asthma. Although heterogeneity of risk factors, disease severity, and outcomes in survivors are common features of the acute respiratory distress syndrome (ARDS), many challenges exist in understanding the clinical and molecular basis for disease heterogeneity and using heterogeneity to tailor therapy for individual patients. This report summarizes the proceedings of the 2021 Aspen Lung Conference, which was organized to review key issues related to understanding clinical and molecular heterogeneity in ARDS. The goals were to review new information about ARDS phenotypes, to explore multicellular and multisystem mechanisms responsible for heterogeneity, and to review how best to account for clinical and molecular heterogeneity in clinical trial design and assessment of outcomes. The report concludes with recommendations for future research to understand the clinical and basic mechanisms underlying heterogeneity in ARDS to advance the development of new treatments for this life-threatening critical illness.

Physiologic responses to exercise in survivors of critical illness: an exploratory pilot study

Background

ICU survivors suffer from impaired physical function and reduced exercise capacity, yet the underlying mechanisms are poorly understood. The goal of this exploratory pilot study was to investigate potential mechanisms of exercise limitation using cardiopulmonary exercise testing (CPET) and 6-min walk testing (6MWT).

Methods

We enrolled adults aged 18 years or older who were treated for respiratory failure or shock in medical, surgical, or trauma ICUs at Vanderbilt University Medical Center (Nashville, TN, United States). We excluded patients with pre-existing cardiac dysfunction, a contraindication to CPET, or the need for supplemental oxygen at rest. We performed CPET and 6MWT 6 months after ICU discharge. We measured standard CPET parameters in addition to two measures of oxygen utilization during exercise (VO₂-work rate slope and VO₂ recovery half-time).

Results

We recruited 14 participants. Low exercise capacity (i.e., VO_2Peak < 80% predicted) was present in 11 out of 14 (79%) with a median VO_2Peak of 12.6 ml/kg/min [9.6–15.1] and 6MWT distance of 294 m [240–433]. In addition to low VO_2Peak, CPET findings in survivors included low oxygen uptake efficiency slope, low oxygen pulse, elevated chronotropic index, low VO₂-work rate slope, and prolonged VO₂ recovery half-time, indicating impaired oxygen utilization with a hyperdynamic heart rate and ventilatory response, a pattern seen in non-critically ill patients with mitochondrial myopathies. Worse VO₂-work rate slope and VO₂ recovery half-time were strongly correlated with worse VO_2Peak and 6MWT distance, suggesting that exercise capacity was potentially limited by impaired muscle oxygen utilization.

Conclusions

These exploratory data suggest ICU survivors may suffer from impaired muscular oxygen metabolism due to mitochondrial dysfunction that impairs exercise capacity long-term. These findings should be further characterized in future studies that include direct assessments of muscle mitochondrial function in ICU survivors.

Neurologic Outcomes of Survivors of COVID-19-Associated Acute Respiratory Distress Syndrome Requiring Intubation

OBJECTIVES

To describe 3-6-month neurologic outcomes of survivors of COVID-19-associated acute respiratory distress syndrome, invasively ventilated in the ICU.

DESIGN

A bicentric prospective study during the two first waves of the pandemic (March to May and September to December, 2020).

SETTING

Two academic hospital ICUs, Paris, France.

PATIENTS

Adult COVID-19-associated acute respiratory distress syndrome survivors, invasively ventilated in the ICU, were eligible for a neurologic consultation between 3 and 6 months post ICU discharge.

INTERVENTIONS

Follow-up by face-to-face neurologic consultation.

MEASURES AND MAIN RESULTS

The primary endpoint was favorable functional outcome defined by a modified Rankin scale score less than 2, indicating survival with no significant disability. Secondary endpoints included mild cognitive impairment (Montreal Cognitive Assessment score < 26), ICU-acquired weakness (Medical Research Council score < 48), anxiety and depression (Hospital Anxiety and Depression score > 7), and posttraumatic stress disorder (posttraumatic stress disorder checklist for Diagnostic and Statistical Manual of Mental Disorders 5 score > 30). Of 54 eligible survivors, four non-French-speaking patients were excluded, eight patients were lost-to-follow-up, and one died during follow-up. Forty-one patients were included. Time between ICU discharge and neurologic consultation was 3.8 months (3.6-5.9 mo). A favorable functional outcome was observed in 16 patients (39%) and mild cognitive impairment in 17 of 33 patients tested (52%). ICU-acquired weakness, depression or anxiety, and posttraumatic stress disorder were reported in six of 37 cases (16%), eight of 31 cases (26%), and two of 27 cases (7%), respectively. Twenty-nine patients (74%) required rehabilitation (motor, cognitive, or psychologic). ICU and hospital lengths of stay, tracheostomy, and corticosteroids were negatively associated with favorable outcome. By contrast, use of alpha-2 agonists during ICU stay was associated with favorable outcome.

CONCLUSIONS

COVID-19-associated acute respiratory distress syndrome requiring intubation led to slight-to-severe functional disability in about 60% of survivors 4 months after ICU discharge. Cognitive impairment, muscle weakness, and psychologic symptoms were frequent. A large multicenter study is warranted to allow identification of modifiable factors for improving long-term outcome.

Post-intensive care syndrome and health-related quality of life in long-term survivors of intensive care unit

OBJECTIVE

The objective of this study was to provide preliminary data for improving the health-related quality of life of long-term intensive care unit survivors by identifying the relationship between health-related quality of life and post-intensive care syndrome.

METHODS

Using a descriptive correlation research design, data from patients who visited the outpatient department for continuous treatment after discharge from the intensive care unit were analysed. Post-intensive care syndrome was measured by physical, cognitive, and mental problems. Data were collected from 1st August to 31st December, 2019, and 121 intensive care unit survivors participated in the study.

RESULTS

Health-related quality of life showed a negative correlation with physical, mental, and cognitive problems. The factors associated with health-related quality of life were physical and mental problems, education level, sedatives and neuromuscular relaxants, and marital status.

CONCLUSIONS

To improve the health-related quality of life of intensive care unit survivors, post-intensive care syndrome prevention is important, and a systematic strategy is required through a long-term longitudinal trace study. In addition, intensive care unit nurses and other healthcare professionals need to provide early interventions to reduce post-intensive care syndrome.

Magnesium Hydride Ameliorates Endotoxin-Induced Acute Respiratory Distress Syndrome by Inhibiting Inflammation, Oxidative Stress, and Cell Apoptosis

Acute respiratory distress syndrome (ARDS) causes uncontrolled pulmonary inflammation, resulting in high morbidity and mortality in severe cases. Given the antioxidative effect of molecular hydrogen, some recent studies suggest the potential use of molecular hydrogen as a biomedicine for the treatment of ARDS. In this study, we aimed to explore the protective effects of magnesium hydride (MgH2) on two types of ARDS models and its underlying mechanism in a lipopolysaccharide (LPS)-induced ARDS model of the A549 cell line. The results showed that LPS successfully induced oxidative stress, inflammatory reaction, apoptosis, and barrier breakdown in alveolar epithelial cells (AEC). MgH2 can exert an anti-inflammatory effect by down-regulating the expressions of inflammatory cytokines (IL-1β, IL-6, and TNF-α). In addition, MgH2 decreased oxidative stress by eliminating intracellular ROS, inhibited apoptosis by regulating the expressions of cytochrome c, Bax, and Bcl-2, and suppressed barrier breakdown by up-regulating the expression of ZO-1 and occludin. Mechanistically, the expressions of p-AKT, p-mTOR, p-P65, NLRP3, and cleaved-caspase-1 were decreased after MgH2 treatment, indicating that AKT/mTOR and NF-κB/NLRP3/IL-1β pathways participated in the protective effects of MgH2. Furthermore, the in vivo study also demonstrated that MgH2-treated mice had a better survival rate and weaker pathological damage. All these findings demonstrated that MgH2 could exert an ARDS-protective effect by regulating the AKT/mTOR and NF-κB/NLRP3/IL-1β pathways to suppress LPS-induced inflammatory reaction, oxidative stress injury, apoptosis, and barrier breakdown, which may provide a potential strategy for the prevention and treatment of ARDS.

Silence of MLK3 alleviates lipopolysaccharide-induced lung epithelial cell injury via inhibiting p53-mediated ferroptosis

Acute lung injury (ALI) is characterized with a high rate of morbidity and mortality. The injury and apoptosis of lung epithelial cells play crucial roles in the progression of ALI. Mixed lineage kinase 3 (MLK3) has been reported to be involved in the regulation of cellular biological functions, such as cell proliferation, apoptosis and ferroptosis. However, the effect of MLK3 exerted on ALI has not been reported. Here, LPS-stimulated MLE12 pulmonary epithelial cells were used as an in vitro model for ALI. In this research, LPS elevated the expression of MLK3 in MLE12 cells. The silence of MLK3 alleviated LPS-induced cell injury. Notably, LPS promoted ferroptosis through enhancing GSH depletion and the productions of MDA and iron, which was attenuated by MLK3 knockdown. Moreover, the silence of MLK3 inhibited p53 expression in LPS-induced cells along with a decrease in the expressions of p21 and Bax, while overexpressing p53 reversed these effects of MLK3 silence. Meanwhile, p53 overexpression reversed the positive effects of MLK3 knockdown on LPS-induced cell ferroptosis and injury. Together, our results confirmed that the silence of MLK3 alleviated LPS-induced lung epithelial cell injury by inhibiting p53-mediated ferroptosis.

Health-related quality of life of COVID-19 two and 12 months after intensive care unit admission

Purpose

To describe health-related quality of life (HRQoL) and dyspnea of COVID-19, 2 and 12 months after an intensive care unit (ICU) stay.

Methods

Patients discharged from the ICU between April and June 2020 and subsequently transferred to an inpatient rehabilitation facility were assessed 2 months and 12 months after ICU admission. HRQoL was assessed by the EuroQoL EQ-5D-3L (visual analog scale and time trade-off normalized to the French population algorithm) and dyspnea was assessed by the modified Medical Research Council (mMRC) dyspnea scale.

Results

We enrolled 94 patients. Median EQ-5D-3L time trade-off was 0.80 (interquartile range, 0.36–0.91) at 2 months and 0.91 (0.52–1.00) at 12 months (P = 0.12). EQ-5D-3L visual analog scale was 70 (60–85) at 2 months and 70 (60–85) at 12 months (P = 0.07). The mMRC dyspnea scale was 3 (2–4) at ICU discharge, 1 (0–2), P < 0.001 at 2 months and 1 (1–2) at 12 months. At 12 months, 68 (76%) patients reported at least one symptom that was not present prior to ICU admission and 27 (61%) of the 44 patients who were previously working had returned to work. On multiple linear regression, factors associated with EQ-5D-3L were body mass index on ICU admission, tracheostomy, male gender and active smoking.

Conclusions

Twelve months after ICU admission for COVID-19 and subsequent rehabilitation, a substantial proportion of patients reported alterations of HRQoL, dyspnea and symptoms that were not present prior to admission and a substantial proportion of these patients had not returned to work. Factors associated with a risk of poorer 12-month quality of life, may help to identify at-risk patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-00991-0.

Health-related quality of life, anxiety and depression and physical recovery after critical illness - A prospective cohort study

BACKGROUND

Critical illness is often followed by mental and physical impairments. We aimed to assess the health-related quality of life (HRQoL), symptoms of anxiety and depression, and physical function in critically ill patients after discharge from the intensive care unit.

METHODS

For this prospective cohort study we included all available adult patients admitted to the ICU for >24 h during a 12-month period. Home visits took place at 3 and 12 months after discharge from the hospital and included Short-Form Health Survey (SF-36), Hospital Anxiety and Depression Scale, and Chelsea Critical Care Assessment Too (CPAx).

RESULTS

We visited 79 patients at 3 and 53 at 12 months. In patients with data from both visits the mental components SF-36 scores (median (IQR)) were 55 (43-63) at 3, and 58.5 (49.5-64) at 12 months; physical component SF-36 scores were 35 (28-45) at 3, and 36 (28-42) at 12 months. SF-36 subdomains of mental health, social functioning, and role emotional were close to normal. Vitality, bodily pain, general health, physical functioning, and role physical were severely affected. Incidences of anxiety and depression symptoms were 16%/8% at 3 and 13%/8% at 12 months) and physical function (CPAx) was 47 at both time points).

CONCLUSION

We found no change in HRQoL, anxiety, and depression, or physical function from 3 months to 1 year. Physical health-related quality of life was impaired at both time points. Subdomain scores for physical health-related quality of life were affected more than mental domains at both time points.

Implementation of post-intensive care outpatient clinic (I-POINT) for critically ill COVID-19 survivors

Although we have enough and cumulative information about acute effects of COVID-19, our knowledge is extremely limited about long-term consequences of COVID-19, in terms of its impacts and burdens on patients, families, and the health system. Considering the underlying pathophysiological mechanisms affecting all of the organ systems in critically ill COVID-19 patients who are admitted to intensive care units, the development of post-intensive care syndrome is inevitable. This situation brings along the development of long-COVID. These patients should be followed regarding cognitive, physical, and psychiatric aspects and necessary specialist referrals should be carried out. In this article, we are presenting the experience and recommendations of our center, as a guide for the establishment process of post-intensive care outpatient clinics for the critically ill patients who required intensive care admission due to COVID-19 and could be discharged.

Aerobic exercise capacity in long-term survivors of critical illness: secondary analysis of the post-EPaNIC follow-up study

Purpose

To evaluate aerobic exercise capacity in 5-year intensive care unit (ICU) survivors and to assess the association between severity of organ failure in ICU and exercise capacity up to 5-year follow-up.

Methods

Secondary analysis of the EPaNIC follow-up cohort (NCT00512122) including 433 patients screened with cardiopulmonary exercise testing (CPET) between 1 and 5 years following ICU admission. Exercise capacity in 5-year ICU survivors (N = 361) was referenced to a historic sedentary population and further compared to demographically matched controls (N = 49). In 5-year ICU survivors performing a maximal CPET (respiratory exchange ratio > 1.05, N = 313), abnormal exercise capacity was defined as peak oxygen consumption (VO₂peak) < 85% of predicted peak oxygen consumption (%predVO₂peak), based on the historic sedentary population. Exercise liming factors were identified. To study the association between severity of organ failure, quantified as the maximal Sequential Organ Failure Assessment score during ICU-stay (SOFA-max), and exercise capacity as assessed with VO₂peak, a linear mixed model was built, adjusting for predefined confounders and including all follow-up CPET studies.

Results

Exercise capacity was abnormal in 118/313 (37.7%) 5-year survivors versus 1/48 (2.1%) controls with a maximal CPET, p < 0.001. Aerobic exercise capacity was lower in 5-year survivors than in controls (VO₂peak: 24.0 ± 9.7 ml/min/kg versus 31.7 ± 8.4 ml/min/kg, p < 0.001; %predVO₂peak: 94% ± 31% versus 123% ± 25%, p < 0.001). Muscular limitation frequently contributed to impaired exercise capacity at 5-year [71/118 (60.2%)]. SOFA-max independently associated with VO₂peak throughout follow-up.

Conclusions

Critical illness survivors often display abnormal aerobic exercise capacity, frequently involving muscular limitation. Severity of organ failure throughout the ICU stay independently associates with these impairments.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00134-021-06541-9.

Long-term complications of COVID-19 in ICU survivors: what do we know?

Coronavirus disease 2019 (COVID-19) has caused more than 175 million persons infected and 3.8 million deaths so far and is having a devastating impact on both low and high-income countries, in particular on hospitals and intensive care units (ICU). The ICU mortality during the first pandemic wave ranged from 40% to 85% during the busiest ICU period for admissions around the peak of the surge, and those surviving are frequently faced with impairments affecting physical, cognitive, and mental health status, complicating the post-acute phase of COVID-19, which in the pre-COVID period, were defined collectively as post-intensive care syndrome (PICS). Long COVID is defined as four weeks of persisting symptoms after the acute illness, and post-COVID syndrome and chronic COVID-19 are the proposed terms to describe continued symptomatology for more than 12 weeks. Overall, 50% of ICU survivors suffer from new physical, mental, and/or cognitive problems at 1 year after ICU discharge. The prevalence, severity, and duration of the various impairments in ICU survivors are poorly defined, with substantial variations among published series, and may reflect differences in the timing of assessment, the outcome measured, the instruments utilized, and thresholds adopted to establish the diagnosis, the qualification of personnel delivering the tests, the resource availability as well diversity in patients' case-mix. Future longitudinal studies of adequate sample size with repeated assessments of validated outcomes and comparison with non-COVID-19 ICU patients are needed to fully explore the long-term outcome of ICU patients with COVID-19. In this article, we focus on chronic COVID-19 in ICU survivors and present state of the art data regarding long-term complications related to critical illness and the treatments and organ support received.

Safety, Feasibility, and Outcomes of Frequent, Long-Duration Rehabilitation in an Inpatient Rehabilitation Facility After Prolonged Hospitalization for Severe COVID-19: An Observational Study

OBJECTIVE

he objective of this study was to evaluate safety, feasibility, and outcomes of 30 patients within an inpatient rehabilitation facility following hospitalization for severe Coronavirus Disease 19 (COVID-19) infection.

METHODS

This was an observational study of 30 patients (ages 26-80 years) within a large, metropolitan, academic hospital following hospitalization for complications from severe COVID-19. Ninety percent of the participants required critical care, and 83% required mechanical ventilation during their hospitalization. Within an inpatient rehabilitation facility and model of care, frequent, long-duration rehabilitation was provided by occupational therapists, physical therapists, and speech language pathologists.

RESULTS

The average inpatient rehabilitation facility length of stay was 11 days (ranging from 4-22 days). Patients averaged 165 min/d (ranging from 140-205 minutes) total of physical therapy, occupational therapy, and speech therapy. Twenty-eight of the 30 patients (93%) were discharged to the community. One patient required readmission from an inpatient rehabilitation facility to an acute hospital. All 30 patients improved their functional status with inpatient rehabilitation.

CONCLUSION

In this cohort of 30 patients, inpatient rehabilitation after severe COVID-19 was safe and feasible. Patients were able to participate in frequent, long-duration rehabilitation with nearly all patients discharging to the community. Clinically, inpatient rehabilitation should be considered for patients with functional limitations following severe COVID-19. Given 90% of our cohort required critical care, future studies should investigate the efficacy and effectiveness of inpatient rehabilitation following hospitalization for critical illness. Frequent, long-duration rehabilitation shows promising potential to address functional impairments following hospitalization for severe COVID-19.

IMPACT

Inpatient rehabilitation facilities should be considered as a discharge location for hospitalized survivors of COVID-19, especially severe COVID-19, with functional limitations precluding community discharge. Clinicians and administrators should consider inpatient rehabilitation and inpatient rehabilitation facilities to address the rehabilitation needs of COVID-19 and critical illness survivors.

Postdischarge Outcome Domains in Pediatric Critical Care and the Instruments Used to Evaluate Them: A Scoping Review

OBJECTIVES

Assessing outcomes after pediatric critical illness is imperative to evaluate practice and improve recovery of patients and their families. We conducted a scoping review of the literature to identify domains and instruments previously used to evaluate these outcomes.

DESIGN

Scoping review.

SETTING

We queried PubMed, EMBASE, PsycINFO, Cumulative Index of Nursing and Allied Health Literature, and the Cochrane Central Register of Controlled Trials Registry for studies evaluating pediatric critical care survivors or their families published between 1970 and 2017. We identified articles using key words related to pediatric critical illness and outcome domains. We excluded articles if the majority of patients were greater than 18 years old or less than 1 month old, mortality was the sole outcome, or only instrument psychometrics or procedural outcomes were reported. We used dual review for article selection and data extraction and categorized outcomes by domain (overall health, emotional, physical, cognitive, health-related quality of life, social, family).

SUBJECTS

Manuscripts evaluating outcomes after pediatric critical illness.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 60,349 citations, 407 articles met inclusion criteria; 87% were published after 2000. Study designs included observational (85%), interventional (7%), qualitative (5%), and mixed methods (3%). Populations most frequently evaluated were traumatic brain injury (n = 96), general pediatric critical illness (n = 87), and congenital heart disease (n = 72). Family members were evaluated in 74 studies (18%). Studies used a median of 2 instruments (interquartile range 1-4 instruments) and evaluated a median of 2 domains (interquartile range 2-3 domains). Social (n = 223), cognitive (n = 183), and overall health (n = 161) domains were most frequently studied. Across studies, 366 unique instruments were used, most frequently the Wechsler and Glasgow Outcome Scales. Individual domains were evaluated using a median of 77 instruments (interquartile range 39-87 instruments).

CONCLUSIONS

A comprehensive, generalizable understanding of outcomes after pediatric critical illness is limited by heterogeneity in methodology, populations, domains, and instruments. Developing assessment standards may improve understanding of postdischarge outcomes and support development of interventions after pediatric critical illness.

Society of Critical Care Medicine's International Consensus Conference on Prediction and Identification of Long-Term Impairments After Critical Illness

BACKGROUND

After critical illness, new or worsening impairments in physical, cognitive, and/or mental health function are common among patients who have survived. Who should be screened for long-term impairments, what tools to use, and when remain unclear.

OBJECTIVES

Provide pragmatic recommendations to clinicians caring for adult survivors of critical illness related to screening for postdischarge impairments.

PARTICIPANTS

Thirty-one international experts in risk-stratification and assessment of survivors of critical illness, including practitioners involved in the Society of Critical Care Medicine's Thrive Post-ICU Collaboratives, survivors of critical illness, and clinical researchers.

DESIGN

Society of Critical Care Medicine consensus conference on post-intensive care syndrome prediction and assessment, held in Dallas, in May 2019. A systematic search of PubMed and the Cochrane Library was conducted in 2018 and updated in 2019 to complete an original systematic review and to identify pre-existing systematic reviews.

MEETING OUTCOMES

We concluded that existing tools are insufficient to reliably predict post-intensive care syndrome. We identified factors before (e.g., frailty, preexisting functional impairments), during (e.g., duration of delirium, sepsis, acute respiratory distress syndrome), and after (e.g., early symptoms of anxiety, depression, or post-traumatic stress disorder) critical illness that can be used to identify patients at high-risk for cognitive, mental health, and physical impairments after critical illness in whom screening is recommended. We recommend serial assessments, beginning within 2-4 weeks of hospital discharge, using the following screening tools: Montreal Cognitive Assessment test; Hospital Anxiety and Depression Scale; Impact of Event Scale-Revised (post-traumatic stress disorder); 6-minute walk; and/or the EuroQol-5D-5L, a health-related quality of life measure (physical function).

CONCLUSIONS

Beginning with an assessment of a patient's pre-ICU functional abilities at ICU admission, clinicians have a care coordination strategy to identify and manage impairments across the continuum. As hospital discharge approaches, clinicians should use brief, standardized assessments and compare these results to patient's pre-ICU functional abilities ("functional reconciliation"). We recommend serial assessments for post-intensive care syndrome-related problems continue within 2-4 weeks of hospital discharge, be prioritized among high-risk patients, using the identified screening tools to prompt referrals for services and/or more detailed assessments.

Cardiopulmonary Exercise Testing to Assess Persistent Symptoms at 6 Months in People With COVID-19 Who Survived Hospitalization: A Pilot Study

OBJECTIVE

The aim of this pilot study was to assess physical fitness and its relationship with functional dyspnea in survivors of COVID-19 6 months after their discharge from the hospital.

METHODS

Data collected routinely from people referred for cardiopulmonary exercise testing (CPET) following hospitalization for COVID-19 were retrospectively analyzed. Persistent dyspnea was assessed using the modified Medical Research Council dyspnea scale.

RESULTS

Twenty-three people with persistent symptoms were referred for CPET. Mean modified Medical Research Council dyspnea score was 1 (SD = 1) and was significantly associated with peak oxygen uptake (VO2peak; %) (rho = -0.49). At 6 months, those hospitalized in the general ward had a relatively preserved VO2peak (87% [SD = 20]), whereas those who had been in the intensive care unit had a moderately reduced VO2peak (77% [SD = 15]). Of note, the results of the CPET revealed that, in all individuals, respiratory equivalents were high, power-to-weight ratios were low, and those who had been in the intensive care unit had a relatively low ventilatory efficiency (mean VE/VCO2 slope = 34 [SD = 5]). Analysis of each individual showed that none had a breathing reserve <15% or 11 L/min, all had a normal exercise electrocardiogram, and 4 had a heart rate >90%.

CONCLUSION

At 6 months, persistent dyspnea was associated with reduced physical fitness. This study offers initial insights into the mid-term physical fitness of people who required hospitalization for COVID-19. It also provides novel pathophysiological clues about the underlaying mechanism of the physical limitations associated with persistent dyspnea. Those with persistent dyspnea should be offered a tailored rehabilitation intervention, which should probably include muscle reconditioning, breathing retraining, and perhaps respiratory muscle training.

IMPACT

This study is the first, to our knowledge, to show that a persistent breathing disorder (in addition to muscle deconditioning) can explain persistent symptoms 6 months after hospitalization for COVID-19 infection and suggests that a specific rehabilitation intervention is warranted.

Five-year outcome of respiratory muscle weakness at intensive care unit discharge: secondary analysis of a prospective cohort study

PURPOSE

To assess the association between respiratory muscle weakness (RMW) at intensive care unit (ICU) discharge and 5-year mortality and morbidity, independent from confounders including peripheral muscle strength.

METHODS

Secondary analysis of the prospective 5-year follow-up of the EPaNIC cohort (ClinicalTrials.gov: NCT00512122), limited to 366 patients screened for respiratory and peripheral muscle strength in the ICU with maximal inspiratory pressure (MIP) after removal of the artificial airway, and the Medical Research Council sum score. RMW was defined as an absolute value of MIP <30 cmH₂O. Associations between RMW at (or closest to) ICU discharge and all-cause 5-year mortality, and key measures of 5-year physical function, comprising respiratory muscle strength (MIP), hand-grip strength (HGF), 6 min walk distance (6MWD) and physical function of the SF-36 quality-of-life questionnaire (PF-SF-36), were assessed with Cox proportional hazards and linear regression models, adjusted for confounders including peripheral muscle strength.

RESULTS

RMW was present in 136/366 (37.2%) patients at ICU discharge. RMW was not independently associated with 5-year mortality (HR with 95% CI 1.273 (0.751 to 1.943), p=0.352). Among 156five-year survivors, those with, as compared with those without RMW demonstrated worse physical function (MIP (absolute value, cmH₂O): 62(42-77) vs 94(78-109), p<0.001; HGF (%pred): 67(44-87) vs 96(68-110), p<0.001; 6MWD (%pred): 87(74-102) vs 99 (80-111), p=0.009; PF-SF-36 (score): 55 (30-80) vs 80 (55-95), p<0.001). Associations between RMW and morbidity endpoints remained significant after adjustment for confounders (effect size with 95% CI: MIP: -23.858 (-32.097 to -15.027), p=0.001; HGF: -18.591 (-30.941 to -5.744), p=0.001; 6MWD (transformed): -1587.007 (-3073.763 to -179.253), p=0.034; PF-SF-36 (transformed): 1.176 (0.144-2.270), p=0.036).

CONCLUSIONS

RMW at ICU discharge is independently associated with 5-year morbidity but not 5-year mortality.

Severe covid-19 pneumonia: pathogenesis and clinical management

Severe covid-19 pneumonia has posed critical challenges for the research and medical communities. Older age, male sex, and comorbidities increase the risk for severe disease. For people hospitalized with covid-19, 15-30% will go on to develop covid-19 associated acute respiratory distress syndrome (CARDS). Autopsy studies of patients who died of severe SARS CoV-2 infection reveal presence of diffuse alveolar damage consistent with ARDS but with a higher thrombus burden in pulmonary capillaries. When used appropriately, high flow nasal cannula (HFNC) may allow CARDS patients to avoid intubation, and does not increase risk for disease transmission. During invasive mechanical ventilation, low tidal volume ventilation and positive end expiratory pressure (PEEP) titration to optimize oxygenation are recommended. Dexamethasone treatment improves mortality for the treatment of severe and critical covid-19, while remdesivir may have modest benefit in time to recovery in patients with severe disease but shows no statistically significant benefit in mortality or other clinical outcomes. Covid-19 survivors, especially patients with ARDS, are at high risk for long term physical and mental impairments, and an interdisciplinary approach is essential for critical illness recovery.

Primary graft dysfunction attenuates improvements in health-related quality of life after lung transplantation, but not disability or depression

Disability, depressive symptoms, and impaired health-related quality of life (HRQL) are common among patients with life-threatening respiratory compromise. We sought to determine if primary graft dysfunction (PGD), a syndrome of acute lung injury, attenuates improvements in patient-reported outcomes after transplantation. In a single-center prospective cohort, we assessed disability, depressive symptoms, and HRQL before and at 3- to 6-month intervals after lung transplantation. We estimated the magnitude of change in disability, depressive symptoms, and HRQL with hierarchical segmented linear mixed-effects models. Among 251 lung transplant recipients, 50 developed PGD Grade 3. Regardless of PGD severity, participants had improvements in disability and depressive symptoms, as well as generic-physical, generic-mental, respiratory-specific, and health-utility HRQL, exceeding 1- to 4-fold the minimally clinically important difference across all instruments. Participants with PGD Grade 3 had a lower magnitude of improvement in generic-physical HRQL and health-utility than in all other participants. Among participants with PGD Grade 3, prolonged mechanical ventilation was associated with greater attenuation of improvements. PGD remains a threat to the 2 primary aims of lung transplantation, extending survival and improving HRQL. Attenuation of improvement persists long after hospital discharge. Future studies should assess if interventions can mitigate the impact of PGD on patient-reported outcomes.

Nebulised heparin for patients with or at risk of acute respiratory distress syndrome: a multicentre, randomised, double-blind, placebo-controlled phase 3 trial

Background

Mechanical ventilation in intensive care for 48 h or longer is associated with the acute respiratory distress syndrome (ARDS), which might be present at the time ventilatory support is instituted or develop afterwards, predominantly during the first 5 days. Survivors of prolonged mechanical ventilation and ARDS are at risk of considerably impaired physical function that can persist for years. An early pathogenic mechanism of lung injury in mechanically ventilated, critically ill patients is inflammation-induced pulmonary fibrin deposition, leading to thrombosis of the microvasculature and hyaline membrane formation in the air sacs. The main aim of this study was to determine if nebulised heparin, which targets fibrin deposition, would limit lung injury and thereby accelerate recovery of physical function in patients with or at risk of ARDS.

Methods

The Can Heparin Administration Reduce Lung Injury (CHARLI) study was an investigator-initiated, multicentre, double-blind, randomised phase 3 trial across nine hospitals in Australia. Adult intensive care patients on invasive ventilation, with impaired oxygenation defined by a PaO₂/FiO₂ ratio of less than 300, and with the expectation of invasive ventilation beyond the next calendar day were recruited. Key exclusion criteria were heparin allergy, pulmonary bleeding, and platelet count less than 50 X 10⁹/L. Patients were randomly assigned 1:1, with stratification by site and using blocks of variable size and random seed, via a web-based system, to either unfractionated heparin sodium 25 000 IU in 5 mL or identical placebo (sodium chloride 0·9% 5 mL), administered using a vibrating mesh membrane nebuliser every 6 h to day 10 while invasively ventilated. Patients, clinicians, and investigators were masked to treatment allocation. The primary outcome was the Short Form 36 Health Survey Physical Function Score (out of 100) of survivors at day 60. Prespecified secondary outcomes, which are exploratory, included development of ARDS to day 5 among at-risk patients, deterioration of the Murray Lung Injury Score (MLIS) to day 5, mortality at day 60, residence of survivors at day 60, and serious adverse events. Analyses followed the intention-to-treat principle. There was no imputation of missing data. The trial is registered with the Australian and New Zealand Clinical Trials Register, number ACTRN12612000418875 .

Findings

Between Sept 4, 2012, and Aug 23, 2018, 256 patients were randomised. Final follow-up was on Feb 25, 2019. We excluded three patients who revoked consent and one ineligible participant who received no intervention. Of 252 patients included in data analysis, the mean age was 58 years (SD 15), 157 (62%) were men, and 118 (47%) had ARDS. 128 (51%) patients were assigned to the heparin group and 124 (49%) to the placebo group, all of whom received their assigned intervention. Survivors in the heparin group (n=97) had similar SF-36 Physical Function Scores at day 60 compared to the placebo group (n=94; mean 53·6 [SD 31·6] vs 48·7 [35·7]; difference 4·9 [95% CI −4·8 to 14·5]; p=0·32). Compared with the placebo group, the heparin group had fewer cases of ARDS develop to day 5 among the at-risk patients (nine [15%] of 62 patients vs 21 [30%] of 71 patients; hazard ratio 0·46 [95% CI 0·22 to 0·98]; p=0·0431), less deterioration of the MLIS to day 5 (difference −0·14 [–0·26 to −0·02]; p=0·0215), similar day 60 mortality (23 [18%] of 127 patients vs 18 [15%] of 123 patients; odds ratio [OR] 1·29 [95% CI 0·66 to 2·53]; p=0·46), and more day 60 survivors at home (86 [87%] of 99 patients vs 73 [73%] of 100 patients; OR 2·45 [1·18 to 5·08]; p=0·0165). A similar number of serious adverse events occurred in each group (seven [5%] of 128 patients in the heparin group vs three [2%] of 124 patients in the placebo group; OR 2·33 [0·59 to 9·24]; p=0·23), which were a transient increase in airway pressure during nebulisation (n=3 in the heparin group), major non-pulmonary bleeding (n=2 in each group), haemoptysis (n=1 in the heparin group), tracheotomy site bleeding (n=1 in the heparin group), and hypoxaemia during nebulisation (n=1 in the placebo group).

Interpretation

In patients with or at risk of ARDS, nebulised heparin did not improve self-reported performance of daily physical activities, but was well tolerated and exploratory outcomes suggest less progression of lung injury and earlier return home. Further research is justified to establish if nebulised heparin accelerates recovery in those who have or are at risk of ARDS.

Funding

Rowe Family Foundation, TR and RB Ditchfield Medical Research Endowment Fund, Patricia Madigan Charitable Trust, and The J and R McGauran Trust Fund.

Beneficial effects of multi-disciplinary rehabilitation in postacute COVID-19: an observational cohort study

BACKGROUND

The Coronavirus Disease 2019 (COVID-19) pandemic increases the demand for postacute care in patients after a severe disease course. Various long-term sequelae are expected and rehabilitation medicine is challenged to support physical and cognitive recovery.

AIM

We aimed to explore the dysfunctions and outcome of COVID-19 survivors after early postacute rehabilitation.

DESIGN

Observational cohort study.

METHODS

This study evaluated the postacute sequelae of patients hospitalized for SARS-CoV-2 infection and analyzed rehabilitative outcomes of a subgroup of patients included in the prospective observational multicenter CovILD study.

RESULTS

A total of 23 subjects discharged after severe to critical COVID-19 infection underwent an individualized, multiprofessional rehabilitation. At the start of postacute rehabilitation, impairment of pulmonary function (87%), symptoms related to postintensive care syndrome, and neuropsychological dysfunction (85%) were frequently found, whereas cardiac function appeared to be largely unaffected. Of interest, multi-disciplinary rehabilitation resulted in a significant improvement in lung function, as reflected by an increase of forced vital capacity (P=0.007) and forced expiratory volume in one second (P=0.014), total lung capacity (P=0.003), and diffusion capacity for carbon monoxide (P=0.002). Accordingly, physical performance status significantly improved as reflected by a mean increase of six-minute walking distance by 176 (SD±137) meters. Contrarily, a considerable proportion of patients still had limited diffusion capacity (83%) or neurological symptoms including peripheral neuropathy at the end of rehabilitation.

CONCLUSIONS

Individuals discharged after a severe course of COVID-19 frequently present with persisting physical and cognitive dysfunctions after hospital discharge. Those patients significantly benefit from multi-disciplinary inpatient rehabilitation.

CLINICAL REHABILITATION IMPACT

Our data demonstrated the highly promising effects of early postacute rehabilitation in survivors of severe or critical COVID-19. This findings urge further prospective evaluations and may impact future treatment and rehabilitation strategies.

Survivors of Acute Lung Injury Have Greater Impairments in Strength and Exercise Capacity Than Survivors of Other Critical Illnesses as Measured Shortly After ICU Discharge

PURPOSE

To compare the physical function on ICU discharge in adults who survived an ICU admission for acute lung injury (ALI) with those admitted for a critical illness other than ALI.

MATERIALS AND METHODS

Two groups were recruited, (i) those who survived an ICU admission for ALI and, (ii) those who survived an ICU admission for a critical illness other than ALI. Within 7 days of discharge from ICU, in all participants, measures were collected of peripheral muscle strength, balance, walking speed and functional exercise capacity.

RESULTS

Recruitment was challenging and ceased prior to achieving the desired sample size. Participants with ALI (n = 22) and critical illness (n = 33) were of similar median age (50 vs. 57 yr, p = 0.09), sex proportion (males %, 45 vs. 58, p = 0.59) and median APACHE II score (21.5 vs. 23.0, p = 0.74). Compared with the participants with critical illness, those with ALI had lower hand grip (mean ± SD, 18 ± 9 vs. 13 ± 8 kg, p = 0.018) and shoulder flexion strength (10 ± 4 vs. 7 ± 3 kg, p = 0.047), slower 10-meter walk speed (median [IQR], 1.03 [0.78 to 1.14] vs. 0.78 [0.67 to 0.94] m/s, p = 0.039) and shorter 6-minute walk distance (265 [71 to 328] vs. 165 [53 to 220] m, p = 0.037). The Berg balance scores were similar in both groups.

CONCLUSIONS

Compared with survivors of a critical illness that is not ALI, those with ALI are likely to have greater physical impairment when measured shortly after discharge to the ward.

Frailty subtypes and recovery in older survivors of acute respiratory failure: a pilot study

BACKGROUND

Identifying subtypes of acute respiratory failure survivors may facilitate patient selection for post-intensive care unit (ICU) follow-up clinics and trials.

METHODS

We conducted a single-centre prospective cohort study of 185 acute respiratory failure survivors, aged ≥ 65 years. We applied latent class modelling to identify frailty subtypes using frailty phenotype and cognitive impairment measurements made during the week before hospital discharge. We used Fine-Gray competing risks survival regression to test associations between frailty subtypes and recovery, defined as returning to a basic Activities of Daily Living disability count less than or equal to the pre-hospitalisation count within 6 months. We characterised subtypes by pre-ICU frailty (Clinical Frailty Scale score ≥ 5), the post-ICU frailty phenotype, and serum inflammatory cytokines, hormones and exosome proteomics during the week before hospital discharge.

RESULTS

We identified five frailty subtypes. The recovery rate decreased 49% across each subtype independent of age, sex, pre-existing disability, comorbidity and Acute Physiology and Chronic Health Evaluation II score (recovery rate ratio: 0.51, 95% CI 0.41 to 0.63). Post-ICU frailty phenotype prevalence increased across subtypes, but pre-ICU frailty prevalence did not. In the subtype with the slowest recovery, all had cognitive impairment. The three subtypes with the slowest recovery had higher interleukin-6 levels (p=0.03) and a higher prevalence of ≥ 2 deficiencies in insulin growth factor-1, dehydroepiandrostersone-sulfate, or free-testosterone (p=0.02). Exosome proteomics revealed impaired innate immunity in subtypes with slower recovery.

CONCLUSIONS

Frailty subtypes varied by prehospitalisation frailty and cognitive impairment at hospital discharge. Subtypes with the slowest recovery were similarly characterised by greater systemic inflammation and more anabolic hormone deficiencies at hospital discharge.

miR‑26a‑5p alleviates lipopolysaccharide‑induced acute lung injury by targeting the connective tissue growth factor

The aim of the present study was to investigate the regulatory functions of microRNA (miR)‑26a‑5p on lipopolysaccharide (LPS)‑induced acute lung injury (ALI) and its molecular mechanisms. The role of miR‑26a‑5p on an ALI mouse model was evaluated by examining the histological changes, wet/dry (W/D) ratio, myeloperoxidase (MPO) activity, malondialdehyde (MDA) expression levels in lung tissues and the survival of ALI mice. Moreover, the protein concentration and the number of neutrophils and lymphocytes in bronchoalveolar lavage fluid (BALF) was analyzed. To explore the effect of miR‑26a‑5p on inflammatory responses and apoptosis, the expression levels of tumour necrosis factor‑α (TNF‑α), interleukin (IL)‑1β and IL‑6 and apoptosis were measured by ELISA, terminal deoxynucleotidyl transferase‑mediated dUTP nick end labelling staining and flow cytometry in BALF, A549 cells and lung tissues. B‑cell lymphoma‑2 (Bcl‑2), Bax and cleaved caspase‑3 in lung tissues were measured by western blotting and reverse transcription‑quantitative PCR. Connective tissue growth factor (CTGF) was predicted as a direct target of miR‑26a‑5p using dual luciferase reporter assay. The present study sought to determine whether CTGF overexpression reversed the effect of miR‑26a‑5p on apoptosis and inflammatory responses in LPS‑induced A549 cells. The data revealed that miR‑26a‑5p overexpression ameliorated LPS‑induced ALI, which was implicated by fewer histopathological changes, W/D ratio, apoptosis in lung tissues and the survival of ALI mice. Moreover, miR‑26a‑5p overexpression alleviated LPS‑induced inflammatory responses in ALI mice via the reduction of total protein, neutrophil and lymphocyte counts and the expression levels of TNF‑α, IL‑1β, IL‑6, MDA and MPO activity in BALF. Similarly, miR‑26a‑5p overexpression decreased apoptosis and the expression of TNF‑α, IL‑1β and IL‑6 in LPS‑induced A549 cells. CTGF was a direct target of miR‑26a‑5p. CTGF overexpression reversed the effect of miR‑26a‑5p on cell apoptosis and inflammatory responses in LPS‑induced A549 cells. The present study demonstrated that miR‑26a‑5p could attenuate lung inflammation and apoptosis in LPS‑induced ALI by targeting CTGF.

Predictive variables for poor long-term physical recovery after intensive care unit stay: An exploratory study

BACKGROUND

Elucidating factors that influence physical recovery of survivors after an intensive care unit (ICU) stay is paramount in maximizing long-term functional outcomes. We examined potential predictors for poor long-term physical recovery in ICU survivors.

METHODS

Based on secondary analysis of a trial of 50 ICU patients who underwent mobilization in the ICU and were followed for one year, linear regression analysis examined the associations of exposure variables (baseline characteristics, severity of illness variables, ICU-related variables, and lengths of ICU and hospital stay), with physical recovery variables (muscle strength, exercise capacity, and self-reported physical function), measured one year after ICU discharge.

RESULTS

When the data were adjusted for age, female gender was associated with reduced muscle strength (P = .003), exercise capacity (P < .0001), and self-reported physical function (P = .01). Older age, when adjusted for gender, was associated with reduced exercise capacity (P < .001). After adjusting for gender and age, an association was observed between a lower score on one or two physical recovery variables and exposure variables, specifically, high body mass index, low functional independence, comorbidity and low self-reported physical function at baseline, muscle weakness at ICU discharge, and longer hospital stay. No adjustment was made for cumulative type I error rate due to small number of participants.

CONCLUSION

Elucidating risk factors for poor long-term physical recovery after ICU stay, including gender, may be critical if mobilization and exercise are to be prescribed expediently during and after ICU stay, to ensure maximal long-term recovery.

Cytosolic DNA-STING-NLRP3 axis is involved in murine acute lung injury induced by lipopolysaccharide

The role of NOD-like receptor protein 3 (NLRP3)-mediated pyroptosis in acute lung injury (ALI) has been well identified previously. Stimulator of interferon genes (STING) is an indispensable adaptor protein, which could regulate inflammation and pyroptosis during infection; however, its role in lipopolysaccharide (LPS)-induced ALI remains obscure. This study aimed to explore whether STING participated in the development of LPS-induced ALI as well as the underlying mechanism. We confirmed that LPS significantly enhanced the expression and phosphorylation of STING in lung tissue and primary macrophages from mice. STING deficiency relieved inflammation and oxidative stress in LPS-treated murine lungs and macrophages. Meanwhile, STING deficiency also abolished the activation of NLRP3 inflammasome and pyroptosis; however, NLRP3 overexpression by adenovirus offset the beneficial effects of STING deficiency in macrophages treated with LPS. Additionally, the level of mitochondrial DNA (mt-DNA) significantly increased in macrophages after LPS treatment. Intriguingly, although exogenous mt-DNA stimulation did not influence the level of STING, it could still trigger the phosphorylation of STING as well as pyroptosis, inflammation, and oxidative stress of macrophages. And the adverse effects induced by mt-DNA could be offset after STING was knocked out. Furthermore, the inhibition of the sensory receptor of cytosolic DNA (cyclic GMP-AMP synthase, cGAS) also blocked the activation of STING and NLRP3 inflammasome, meanwhile, it alleviated ALI without affecting the expression of STING after LPS challenge. Furthermore, cGAS inhibition also blocked the production of cGAMP induced by LPS, indicating that mt-DNA and cGAS could activate STING-NLRP3-mediated pyroptosis independent of the expression of STING. Finally, we found that LPS upregulated the expression of transcription factor c-Myc, which subsequently enhanced the activity of STING promoter and promoted its expression without affecting its phosphorylation. Collectively, our study disclosed that LPS could activate STING in a cytosolic DNA-dependent manner and upregulate the expression of STING in a c-Myc-dependent manner, which cooperatively contribute to ALI.

Physical Therapy and Rehabilitation in Chronic Obstructive Pulmonary Disease Patients Admitted to the Intensive Care Unit

Chronic obstructive pulmonary disease (COPD) is a progressive lung condition that affects a person's ability to exercise and undertake normal physical function due to breathlessness, poor physical fitness, and muscle fatigue. Patients with COPD often experience exacerbations due to pulmonary infections, which result in worsening of their symptoms, more loss of function, and often require hospital treatment or in severe cases admission to intensive care units. Recovery from such exacerbations is often slow, and some patients never fully return to their previous level of activity. This can lead to permanent disability and premature death.Physical therapists play a key role in the respiratory management and rehabilitation of patients admitted to intensive care following acute exacerbation of COPD. This article discusses the key considerations for respiratory management of patients requiring invasive mechanical ventilation, providing an evidence-based summary of commonly used interventions. It will also explore the evidence to support the introduction of early and structured programs of rehabilitation to support recovery in both the short and the long term, as well as active mobilization, which includes strategies to minimize or prevent physical loss through early retraining of both peripheral and respiratory muscles.

Impact of Polytrauma and Acute Respiratory Distress Syndrome on Markers of Fibrinolysis: A Prospective Pilot Study

Acute respiratory distress syndrome (ARDS), which is associated with major morbidity and high mortality, is commonly developed by polytraumatized patients. Its pathogenesis is complex, and its development is difficult to anticipate, as candidate biomarkers for the prediction of ARDS were found not to be reliable for clinical use. In this prospective study, we assessed the serum antigen levels of tissue plasminogen activator (tPA) and plasminogen activator inhibitor type-1 (PAI-1) of 28 survivors of blunt polytrauma (age ≥18 years; injury severity score ≥16) at admission and on days 1, 3, 5, 7, 10, 14, and 21 of hospitalization. Our results show that these patients presented high mean tPA and PAI-1 antigen levels at admission; despite their decline, these parameters remained elevated for 3 weeks. Over this period, the mean tPA antigen level was higher in polytrauma victims suffering from ARDS than in those without ARDS, whereas the mean PAI-1 level was higher in polytrauma victims sustaining pneumonia than in those without pneumonia. Moreover, in each individual developing ARDS, the polytrauma-related elevated tPA antigen level either continued to rise after admission or suffered a second increase up to the onset of ARDS, declining immediately thereafter. Therefore, our findings support the assessment of serum tPA antigen levels after the initial treatment of polytraumatized patients, as this parameter shows potential as a biomarker for the development of ARDS and for the consequent identification of high-risk individuals.

Occupational Therapy in the ICU: A Scoping Review of 221 Documents

OBJECTIVES

Occupational therapists have specialized expertise to enable people to perform meaningful "occupations" that support health, well-being, and participation in life roles. Given the physical, cognitive, and psychologic disability experienced by ICU survivors, occupational therapists could play an important role in their recovery. We conducted a scoping review to determine the state of knowledge of interventions delivered by occupational therapists in adult ICU patients.

DATA SOURCES

Eight electronic databases from inception to 05/2018.

STUDY SELECTION

We included reports of adult patients receiving direct patient care from an occupational therapist in the ICU, all study designs, and quantitative and qualitative traditions.

DATA EXTRACTION

Independently in duplicate, interprofessional team members screened titles, abstracts, and full texts and extracted report and intervention characteristics. From original research articles, we also extracted study design, number of patients, and primary outcomes. We resolved disagreements by consensus.

DATA SYNTHESIS

Of 50,700 citations, 221 reports met inclusion criteria, 74 (79%) published after 2010, and 125 (56%) appeared in critical care journals. The three most commonly reported types of interventions were mobility (81%), physical rehabilitation (61%), and activities of daily living (31%). We identified 46 unique original research studies of occupational therapy interventions; the most common study research design was before-after studies (33%).

CONCLUSIONS

The role of occupational therapists in ICU rehabilitation is not currently well established. Current interventions in the ICU are dominated by physical rehabilitation with a growing role in communication and delirium prevention and care. Given the diverse needs of ICU patients and the scope of occupational therapy, there could be an opportunities for occupational therapists to expand their role and spearhead original research investigating an enriched breadth of ICU interventions.

Anemia in Critically Ill Patients With Acute Respiratory Distress Syndrome and Posthospitalization Physical Outcomes

Objective:

Anemia is common during critical illness and often persists after hospital discharge; however, its potential association with physical outcomes after critical illness is unclear. Our objective was to assess the associations between hemoglobin at intensive care unit (ICU) and hospital discharge with physical status at 3-month follow-up in acute respiratory distress syndrome (ARDS) survivors.

Methods:

This is a secondary analysis of a multisite prospective cohort study of 195 mechanically ventilated ARDS survivors from 13 ICUs at 4 teaching hospitals in Baltimore, Maryland. Multivariable regression was utilized to assess the relationships between ICU and hospital discharge hemoglobin concentrations with measures of physical status at 3 months, including muscle strength (Medical Research Council sumscore), exercise capacity (6-minute walk distance [6MWD]), and self-reported physical functioning (36-Item Short-Form Health Survey [SF-36v2] Physical Function score and Activities of Daily Living [ADL] dependencies).

Results:

Median (interquartile range) hemoglobin concentrations at ICU and hospital discharge were 9.5 (8.5-10.7) and 10.0 (9.0-11.2) g/dL, respectively. In multivariable regression analyses, higher ICU discharge hemoglobin concentrations (per 1 g/dL) were associated with greater 3-month 6MWD mean percent of predicted (3.7% [95% confidence interval 0.8%-6.5%]; P = .01) and fewer ADL dependencies (−0.2 [−0.4 to −0.1]; P = .02), but not with percentage of maximal muscle strength (0.7% [−0.9 to 2.3]; P = .37) or SF-36v2 normalized Physical Function scores (0.8 [−0.3 to 1.9]; P = .15). The associations of physical outcomes and hospital discharge hemoglobin concentrations were qualitatively similar, but none were statistically significant.

Conclusions:

In ARDS survivors, higher hemoglobin concentrations at ICU discharge, but not hospital discharge, were significantly associated with improved exercise capacity and fewer ADL dependencies. Future studies are warranted to further assess these relationships.