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Krupp AE, Tan A, Vasilevskis EE, Mion LC, Pun BT, Brockman A, Hetland B, Ely EW, Balas MC. Patient, Practice, and Organizational Factors Associated With Early Mobility Performance in Critically Ill Adults. Am J Crit Care 2024; 33:324-333. [PMID: 39217113 DOI: 10.4037/ajcc2024939] [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: 09/04/2024]
Abstract
BACKGROUND Adoption of early mobility interventions into intensive care unit (ICU) practice has been slow and varied. OBJECTIVES To examine factors associated with early mobility performance in critically ill adults and evaluate factors' effects on predicting next-day early mobility performance. METHODS A secondary analysis of 66 ICUs' data from patients admitted for at least 24 hours. Mixed-effects logistic regression modeling was done, with area under the receiver operating characteristic curve (AUC) calculated. RESULTS In 12 489 patients, factors independently associated with higher odds of next-day mobility included significant pain (adjusted odds ratio [AOR], 1.16; 95% CI, 1.09-1.23), documented sedation target (AOR, 1.09; 95% CI, 1.01-1.18), performance of spontaneous awakening trials (AOR, 1.77; 95% CI, 1.59-1.96), spontaneous breathing trials (AOR, 2.35; 95% CI, 2.14-2.58), mobility safety screening (AOR, 2.26; 95% CI, 2.04-2.49), and prior-day physical/occupational therapy (AOR, 1.44; 95% CI, 1.30-1.59). Factors independently associated with lower odds of next-day mobility included deep sedation (AOR, 0.44; 95% CI, 0.39-0.49), delirium (AOR, 0.63; 95% CI, 0.59-0.69), benzodiazepine administration (AOR, 0.85; 95% CI, 0.79-0.92), physical restraints (AOR, 0.74; 95% CI, 0.68-0.80), and mechanical ventilation (AOR, 0.73; 95% CI, 0.68-0.78). Black and Hispanic patients had lower odds of next-day mobility than other patients. Models incorporating patient, practice, and between-unit variations displayed high discriminant accuracy (AUC, 0.853) in predicting next-day early mobility performance. CONCLUSIONS Collectively, several modifiable and nonmodifiable factors provide excellent prediction of next-day early mobility performance.
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Affiliation(s)
- Anna E Krupp
- Anna E. Krupp is an assistant professor, College of Nursing, University of Iowa, Iowa City
| | - Alai Tan
- Alai Tan is a research professor, Center for Research and Health Analytics, The Ohio State University College of Nursing, Columbus
| | - Eduard E Vasilevskis
- Eduard E. Vasilevskis is a professor and chief of the Division of Hospital Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison
| | - Lorraine C Mion
- Lorraine C. Mion is a research professor, Center for Healthy Aging, Self-Management and Complex Care, The Ohio State University College of Nursing
| | - Brenda T Pun
- Brenda T. Pun is director of data quality, Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Audrey Brockman
- Audrey Brockman is a graduate research assistant, The Ohio State University College of Nursing
| | - Breanna Hetland
- Breanna Hetland is an assistant professor, College of Nursing, University of Nebraska Medical Center, Omaha, and a critical care nurse scientist, Nebraska Medicine, Omaha
| | - E Wesley Ely
- E. Wesley Ely is a professor, Department of Medicine and the Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, and associate director of medicine and research, Geriatric Research Education and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Michele C Balas
- Michele C. Balas is professor and associate dean of research, College of Nursing, University of Nebraska Medical Center
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Mazeraud A, Sivanandamoorthy S, Mancusi R, Clair B, Friedman D, Fadel F, Maxime V, Legouy C, Orlikowski D, Sharshar T, Heming N, Annane D. Weaning from mechanical ventilation during myasthenic crisis, a monocentric retrospective study. Sci Rep 2024; 14:19523. [PMID: 39174610 PMCID: PMC11341545 DOI: 10.1038/s41598-024-70373-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 08/16/2024] [Indexed: 08/24/2024] Open
Abstract
Mechanical ventilation in myasthenic crisis is not standardized and is at high risk of failure. We investigated liberation from mechanical ventilation during myasthenic crisis using a prolonged spontaneous breathing trials (SBT) and sequential pulmonary function tests (PFT). In this retrospective monocenter study, we included patients admitted for a first episode of myasthenic crisis between January 2001 and January 2018. The primary outcome was the incidence of weaning failure upon first extubation in our cohort of patients with MC. Secondary objectives were to determine risk factors and outcome associated with weaning failure upon first extubation in MC. We also compared the characteristics of patients with prolonged weaning. 126 episodes of MC were analyzed. Patient's age was 64 [42-76] years with 72/126 (56.5%) being women. The median delay between weaning initiation and first extubation was 6 [3-10] days and the median total length of MV was 14 [10-23] days. 118/126 (93.7%) patients underwent prolonged SBT of 8 h or more prior to first extubation. The overall weaning failure rate was 18/126 (14.3%). Extubation was more often successful when the factor precipitating the myasthenic crisis was identified (86/108 (79.6%) vs. 8/18 (44.4%); p = 0.004), whereas PFT was similar in failure or successes. Most weaning failures upon first extubation attempt (11/18; 61%) were attributed to an insufficient stabilization of myasthenia gravis. Duration of mechanical ventilation, an infectious trigger and maximal inspiratory pressure upon intubation were independent risk factors for prolonged weaning. In myasthenic crisis, a standardized protocol including prolonged SBT and respiratory function tests might improve the success of first extubation without prolonging mechanical ventilation. The results of this single center study warrant further evaluation in interventional trials.
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Affiliation(s)
- Aurélien Mazeraud
- Université Paris Cité, Paris, France.
- GHU Paris Psychiatrie et Neurosciences, Pole Neuro, Service d'anesthésie Réanimation, Paris, France.
- Memory and Perception Unit, Neurosciences Department, Institut Pasteur, Paris, France.
| | | | - Rossella Mancusi
- GHU Paris Psychiatrie et Neurosciences, Pole Neuro, Service d'anesthésie Réanimation, Paris, France
| | - Bernard Clair
- Department of Intensive Care, Raymond Poincaré Hospital, APHP University Versailles Saint Quentin-University Paris Saclay, Paris, France
| | - Diane Friedman
- Department of Intensive Care, Raymond Poincaré Hospital, APHP University Versailles Saint Quentin-University Paris Saclay, Paris, France
| | - Fouad Fadel
- Department of Intensive Care, Raymond Poincaré Hospital, APHP University Versailles Saint Quentin-University Paris Saclay, Paris, France
| | - Virginie Maxime
- Department of Intensive Care, Raymond Poincaré Hospital, APHP University Versailles Saint Quentin-University Paris Saclay, Paris, France
| | - Camille Legouy
- GHU Paris Psychiatrie et Neurosciences, Pole Neuro, Service d'anesthésie Réanimation, Paris, France
| | - David Orlikowski
- Department of Intensive Care, Raymond Poincaré Hospital, APHP University Versailles Saint Quentin-University Paris Saclay, Paris, France
- Laboratory of Infection & Inflammation-U1173, School of Medicine Simone Veil, University Versailles Saint Quentin-University Paris Saclay, INSERM, Garches, France
- Institut Hospitalo-Universitaire PROMETHEUS, Garches, France
| | - Tarek Sharshar
- Université Paris Cité, Paris, France
- GHU Paris Psychiatrie et Neurosciences, Pole Neuro, Service d'anesthésie Réanimation, Paris, France
- Unité INSERM, Institut Psychiatrie et Neurosciences, Paris, France
| | - Nicholas Heming
- Department of Intensive Care, Raymond Poincaré Hospital, APHP University Versailles Saint Quentin-University Paris Saclay, Paris, France
- Laboratory of Infection & Inflammation-U1173, School of Medicine Simone Veil, University Versailles Saint Quentin-University Paris Saclay, INSERM, Garches, France
- Institut Hospitalo-Universitaire PROMETHEUS, Garches, France
| | - Djillali Annane
- Department of Intensive Care, Raymond Poincaré Hospital, APHP University Versailles Saint Quentin-University Paris Saclay, Paris, France
- Laboratory of Infection & Inflammation-U1173, School of Medicine Simone Veil, University Versailles Saint Quentin-University Paris Saclay, INSERM, Garches, France
- Institut Hospitalo-Universitaire PROMETHEUS, Garches, France
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Clerk AM, Shah RJ, Kothari J, Sodhi K, Vadi S, Bhattacharya PK, Mishra RC. Position Statement of ISCCM Committee on Weaning from Mechanical Ventilator. Indian J Crit Care Med 2024; 28:S233-S248. [PMID: 39234223 PMCID: PMC11369923 DOI: 10.5005/jp-journals-10071-24716] [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: 08/20/2023] [Accepted: 04/15/2024] [Indexed: 09/06/2024] Open
Abstract
Background and purpose Weaning from a mechanical ventilator is a milestone in the recovery of seriously ill patients in Intensive care. Failure to wean and re-intubation adversely affects the outcome. The method of mechanical ventilation (MV) varies between different ICUs and so does the practice of weaning. Therefore, updated guidelines based on contemporary literature are designed to guide intensivists in modern ICUs. This is the first ISCCM Consensus Statement on weaning complied by a committee on weaning. The recommendations are intended to be used by all the members of the ICU (Intensivists, Registrars, Nurses, and Respiratory Therapists). Methods A Committee on weaning from MV, formed by the Indian Society of Critical Care Medicine (ISCCM) has formulated this statement on weaning from mechanical ventilators in intensive care units (ICUs) after a review of the literature. Literature was first circulated among expert committee members and allotted sections to each member. Sections of the statement written by sectional authors were peer-reviewed on multiple occasions through virtual meetings. After the final manuscript is accepted by all the committee members, it is submitted for peer review by central guideline committee of ISCCM. Once approved it has passed through review by the Editorial Board of IJCCM before it is published here as "ISCCM consensus statement on weaning from mechanical ventilator". As per the standard accepted for all its guidelines of ISCCM, we followed the modified grading of recommendations assessment, development and evaluation (GRADE) system to classify the quality of evidence and strength of recommendation. Cost-benefit, risk-benefit analysis, and feasibility of implementation in Indian ICUs are considered by the committee along with the strength of evidence. Type of ventilators and their modes, ICU staffing pattern, availability of critical care nurses, Respiratory therapists, and day vs night time staffing are aspects considered while recommending for or against any aspect of weaning. Result This document makes recommendation on various aspects of weaning, namely, definition, timing, weaning criteria, method of weaning, diagnosis of failure to wean, defining difficult to wean, Use of NIV, HFOV as adjunct to weaning, role of tracheostomy in weaning, weaning in of long term ventilated patients, role of physiotherapy, mobilization in weaning, Role of nutrition in weaning, role of diaphragmatic ultrasound in weaning prediction etc. Out of 42 questions addressed; the committee provided 39 recommendations and refrained from 3 questions. Of these 39; 32 are based on evidence and 7 are based on expert opinion of the committee members. It provides 27 strong recommendations and 12 weak recommendations (suggestions). Conclusion This guideline gives extensive review on weaning from mechanical ventilator and provides various recommendations on weaning from mechanical ventilator. Though all efforts are made to make is as updated as possible one needs to review any guideline periodically to keep it in line with upcoming concepts and standards. How to cite this article Clerk AM, Shah RJ, Kothari J, Sodhi K, Vadi S, Bhattacharya PK, et al. Position Statement of ISCCM Committee on Weaning from Mechanical Ventilator. Indian J Crit Care Med 2024;28(S2):S233-S248.
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Affiliation(s)
- Anuj M Clerk
- Department of Intensive Care, Sunshine Global Hospital, Surat, Gujarat, India
| | - Ritesh J Shah
- Department of Critical Care Medicine, Sterling Hospital, Vadodara, Gujarat, India
| | - Jay Kothari
- Department of Critical Care Medicine, Apollo International Hospital, Ahmedabad, Gujarat, India
| | | | - Sonali Vadi
- Department of Intensive Care Medicine, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, Maharashtra, India
| | - Pradip K Bhattacharya
- Department of Critical Care Medicine, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Rajesh C Mishra
- Department of MICU, Shaibya Comprehensive Care Clinic, Ahmedabad, Gujarat, India
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Subirà C, Rognoni G, Baquerizo H, García C, Cabañes S, de la Torre M, Quevedo B, Pedrós C, Tizón AI, Murillo N, Parro L, Eiras F, Rialp G, Altaba S, González-Castro A, Pacheco AF, Bayoumi P, Gómez-Medrano N, Vallverdú I, Higón Á, Navarro MD, Falcón A, Keough E, Arizo D, Martínez JF, Durán N, Rodríguez R, Popoviciu-Koborzan MR, Guerrero I, Concha P, Barral P, Batlle M, Cano S, Garcia-Castrillon S, Andorrà X, Tua Y, Arnau A, Fernández R. Effect of lung volume preservation during spontaneous breathing trial on successful extubation in patients receiving mechanical ventilation: protocol for a multicenter clinical trial. Trials 2024; 25:481. [PMID: 39014430 PMCID: PMC11251308 DOI: 10.1186/s13063-024-08297-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 06/27/2024] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND In standard weaning from mechanical ventilation, a successful spontaneous breathing test (SBT) consisting of 30 min 8 cmH2O pressure-support ventilation (PSV8) without positive end-expiratory pressure (PEEP) is followed by extubation with continuous suctioning; however, these practices might promote derecruitment. Evidence supports the feasibility and safety of extubation without suctioning. Ultrasound can assess lung aeration and respiratory muscles. We hypothesize that weaning aiming to preserve lung volume can yield higher rates of successful extubation. METHODS This multicenter superiority trial will randomly assign eligible patients to receive either standard weaning [SBT: 30-min PSV8 without PEEP followed by extubation with continuous suctioning] or lung-volume-preservation weaning [SBT: 30-min PSV8 + 5 cmH2O PEEP followed by extubation with positive pressure without suctioning]. We will compare the rates of successful extubation and reintubation, ICU and hospital stays, and ultrasound measurements of the volume of aerated lung (modified lung ultrasound score), diaphragm and intercostal muscle thickness, and thickening fraction before and after successful or failed SBT. Patients will be followed for 90 days after randomization. DISCUSSION We aim to recruit a large sample of representative patients (N = 1600). Our study cannot elucidate the specific effects of PEEP during SBT and of positive pressure during extubation; the results will show the joint effects derived from the synergy of these two factors. Although universal ultrasound monitoring of lungs, diaphragm, and intercostal muscles throughout weaning is unfeasible, if derecruitment is a major cause of weaning failure, ultrasound may help clinicians decide about extubation in high-risk and borderline patients. TRIAL REGISTRATION The Research Ethics Committee (CEIm) of the Fundació Unió Catalana d'Hospitals approved the study (CEI 22/67 and 23/26). Registered at ClinicalTrials.gov in August 2023. Identifier: NCT05526053.
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Affiliation(s)
- Carles Subirà
- Servei de Medicina Intensiva, Hospital de La Santa Creu I Sant Pau, Barcelona, Spain.
- Grup de Recerca en Malalt Crític (GMC), Institut de Recerca I Innovació en Ciències de La Vida I de La Salut a La Catalunya Central (IRIS-CC), Vic, Spain.
- CIBER Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029, Madrid, Spain.
- Servei de Medicina Intensiva, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain.
| | - Gina Rognoni
- Grup de Recerca en Malalt Crític (GMC), Institut de Recerca I Innovació en Ciències de La Vida I de La Salut a La Catalunya Central (IRIS-CC), Vic, Spain
- Servei de Medicina Intensiva, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain
- Programa de Doctorat en Medicina I Ciències Biomèdiques, Universitat de Vic- Universitat Central de Catalunya (UVIC-UCC), Vic, Spain
| | - Herbert Baquerizo
- Grup de Recerca en Malalt Crític (GMC), Institut de Recerca I Innovació en Ciències de La Vida I de La Salut a La Catalunya Central (IRIS-CC), Vic, Spain
- Servei de Medicina Intensiva, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain
- Programa de Doctorat en Medicina I Ciències Biomèdiques, Universitat de Vic- Universitat Central de Catalunya (UVIC-UCC), Vic, Spain
| | - Carolina García
- Servicio de Medicina Intensiva, Hospital Universitario de Canarias, San Cristóbal de La Laguna, Tenerife, Spain
| | - Sara Cabañes
- Servicio de Medicina Intensiva, Txagorritxu Hospital Universitario Araba, Gasteiz, Spain
| | | | - Beatriz Quevedo
- Servicio de Medicina Intensiva, Hospital Clínico Universitario de Valencia, València, Spain
| | - Cristina Pedrós
- Servei de Medicina Intensiva, Hospital General de Granollers, Granollers, Spain
| | - Ana I Tizón
- Servicio de Medicina Intensiva, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Natalia Murillo
- Servei de Medicina Intensiva, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
| | - Laura Parro
- Servicio de Medicina Intensiva, Hospital Universitario del Henrares, Coslada, Spain
| | - Fernando Eiras
- Servicio de Medicina Intensiva, Hospital Universitario de Pontevedra, Pontevedra, Spain
| | - Gemma Rialp
- Servei de Medicina Intensiva, Hospital Son Llàtzer, Palma de Mallorca, Spain
| | - Susana Altaba
- Servicio Medicina Intensiva, Hospital General Universitario de Castellón, Castelló de La Plana, Spain
| | | | - Andrés F Pacheco
- Servei de Medicina Intensiva, Hospital Universitari de La Vall d'Hebron, Barcelona, Spain
| | - Pablo Bayoumi
- Servicio de Medicina Intensiva, Hospital General Universitario Santa Lucía, Cartagena, Spain
| | - Norma Gómez-Medrano
- Servicio de Medicina Intensiva, Hospital General Universitario de Elche, Elx, Spain
| | - Imma Vallverdú
- Servei de Medicina Intensiva, Hospital Universitari San Joan de Reus, Reus, Spain
| | - Áurea Higón
- Servicio de Medicina Intensiva, Hospital General Universitario Morales Messeguer, Murcia, Spain
| | - María D Navarro
- Servicio de Medicina Intensiva, Hospital Arnau de Vilanova, Valencia, Spain
| | - Alirio Falcón
- Servei de Medicina Intensiva, Hospital Universitari Mútua de Terrassa, Terrassa, Spain
| | - Elena Keough
- Servicio de Medicina Intensiva, Hospital Universitario de La Princesa, Madrid, Spain
| | - David Arizo
- Servicio de Medicina Intensiva, Hospital de Sagunto, Sagunt, Spain
| | - Juan F Martínez
- Servicio de Medicina Intensiva, Hospital Regional Universitario de Málaga, Malaga, Spain
| | - Núria Durán
- Servei de Medicina Intensiva, Hospital Universitari Sagrat Cor, Barcelona, Spain
| | - Raquel Rodríguez
- CIBER Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029, Madrid, Spain
- Servicio de Medicina Intensiva, Hospital Universitario Central de Asturias, Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | | | - Isabel Guerrero
- Servicio de Medicina Intensiva, Hospital Universitario Virgen de Las Nieves, Granada, Spain
| | - Pablo Concha
- Servei de Medicina Intensiva, Hospital Verge de La Cinta, Tortosa, Spain
| | - Patricia Barral
- Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - Montserrat Batlle
- Grup de Recerca en Malalt Crític (GMC), Institut de Recerca I Innovació en Ciències de La Vida I de La Salut a La Catalunya Central (IRIS-CC), Vic, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029, Madrid, Spain
- Servei de Medicina Intensiva, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain
| | - Sílvia Cano
- Grup de Recerca en Malalt Crític (GMC), Institut de Recerca I Innovació en Ciències de La Vida I de La Salut a La Catalunya Central (IRIS-CC), Vic, Spain
- Servei de Medicina Intensiva, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain
| | - Silvia Garcia-Castrillon
- Grup de Recerca en Malalt Crític (GMC), Institut de Recerca I Innovació en Ciències de La Vida I de La Salut a La Catalunya Central (IRIS-CC), Vic, Spain
- Servei de Medicina Intensiva, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain
| | - Xavier Andorrà
- Grup de Recerca en Malalt Crític (GMC), Institut de Recerca I Innovació en Ciències de La Vida I de La Salut a La Catalunya Central (IRIS-CC), Vic, Spain
- Servei de Medicina Intensiva, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain
| | - Yenifher Tua
- Grup de Recerca en Malalt Crític (GMC), Institut de Recerca I Innovació en Ciències de La Vida I de La Salut a La Catalunya Central (IRIS-CC), Vic, Spain
- Servei de Medicina Intensiva, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain
| | - Anna Arnau
- Unitat de Recerca I Innovació, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain
- Grup de Recerca en Cronicitat de La Catalunya Central (C3RG), Institut de Recerca I Innovació en Ciències de La Vida I de La Salut a La Catalunya Central (IRIS-CC), Vic, Spain
- Facultat de Medicina, Universitat de Vic-Central de Catalunya (UVIC-UCC), Vic, Spain
| | - Rafael Fernández
- Grup de Recerca en Malalt Crític (GMC), Institut de Recerca I Innovació en Ciències de La Vida I de La Salut a La Catalunya Central (IRIS-CC), Vic, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029, Madrid, Spain
- Servei de Medicina Intensiva, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain
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Abougabal A, Hasanin A, Abdel-Fatah M, Mostafa M, Ismail AA, Habib S. Peripheral perfusion index as a predictor of reintubation in critically ill surgical patients. BMC Anesthesiol 2024; 24:227. [PMID: 38982350 PMCID: PMC11232166 DOI: 10.1186/s12871-024-02608-4] [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: 03/04/2024] [Accepted: 06/26/2024] [Indexed: 07/11/2024] Open
Abstract
PURPOSE We aimed to evaluate the ability of the peripheral perfusion index (PPI) to predict reintubation of critically ill surgical patients. METHODS This prospective observational study included mechanically ventilated adults who were extubated after a successful spontaneous breathing trial (SBT). The patients were followed up for the next 48 h for the need for reintubation. The heart rate, systolic blood pressure, respiratory rate, peripheral arterial oxygen saturation (SpO2), and PPI were measured before-, at the end of SBT, 1 and 2 h postextubation. The primary outcome was the ability of PPI 1 h postextubation to predict reintubation using area under the receiver operating characteristic curve (AUC) analysis. Univariate and multivariate analyses were performed to identify predictors for reintubation. RESULTS Data from 62 patients were analysed. Reintubation occurred in 12/62 (19%) of the patients. Reintubated patients had higher heart rate and respiratory rate; and lower SpO2 and PPI than successfully weaned patients. The AUC (95%confidence interval) for the ability of PPI at 1 h postextubation to predict reintubation was 0.82 (0.71-0.91) with a negative predictive value of 97%, at a cutoff value of ≤ 2.5. Low PPI and high respiratory rate were the independent predictors for reintubation. CONCLUSION PPI early after extubation is a useful tool for prediction of reintubation. Low PPI is an independent risk factor for reintubation. A PPI > 2.5, one hour after extubation can confirm successful extubation.
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Affiliation(s)
- Ayman Abougabal
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Hasanin
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt.
| | - Marwa Abdel-Fatah
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Maha Mostafa
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Ahmed A Ismail
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Sara Habib
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
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Ramalho F, Oliveira A, Machado A, Azevedo V, Gonçalves MR, Ntoumenopoulos G, Marques A. Physiotherapists in intensive care units: Where are we? Pulmonology 2024; 30:319-323. [PMID: 38413343 DOI: 10.1016/j.pulmoe.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/02/2024] [Accepted: 02/05/2024] [Indexed: 02/29/2024] Open
Affiliation(s)
- F Ramalho
- Lab3R - Respiratory Research and Rehabilitation Laboratory, School of Health Sciences, University of Aveiro (ESSUA), Aveiro, Portugal; Hospital Professor Doutor Fernando Fonseca, Lisbon, Portugal
| | - A Oliveira
- Lab3R - Respiratory Research and Rehabilitation Laboratory, School of Health Sciences, University of Aveiro (ESSUA), Aveiro, Portugal; iBiMED - Institute of Biomedicine, Department of Medical Sciences, University of Aveiro, Aveiro, Portugal; School of Rehabilitation Sciences, McMaster University, Canada
| | - A Machado
- Lab3R - Respiratory Research and Rehabilitation Laboratory, School of Health Sciences, University of Aveiro (ESSUA), Aveiro, Portugal; iBiMED - Institute of Biomedicine, Department of Medical Sciences, University of Aveiro, Aveiro, Portugal
| | - V Azevedo
- Centro Hospitalar Lisboa Ocidental - Egas Moniz Hospital - Polyvalent Intensive Care Unit, Alcoitão School of Health Sciences, Lisbon, Portugal
| | - M R Gonçalves
- Noninvasive Ventilatory Support Unit, Emergency and Intensive Care Medicine Department, Pulmonology Department, São João University Hospital. Faculty of Medicine, University of Porto, Portugal
| | - G Ntoumenopoulos
- Department of Physiotherapy, St Vincent's Hospital, Sydney, Australia
| | - A Marques
- Lab3R - Respiratory Research and Rehabilitation Laboratory, School of Health Sciences, University of Aveiro (ESSUA), Aveiro, Portugal; iBiMED - Institute of Biomedicine, Department of Medical Sciences, University of Aveiro, Aveiro, Portugal.
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Al-Ali AH, Alraeyes KA, Julkarnain PR, Lakshmanan AP, Alobaid A, Aljoni AY, Saleem NH, Al Odat MA, Aletreby WT. Independent Risk Factors of Failed Extubation among Adult Critically Ill Patients: A Prospective Observational Study from Saudi Arabia. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2024; 12:216-222. [PMID: 39055080 PMCID: PMC11268545 DOI: 10.4103/sjmms.sjmms_19_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 03/12/2024] [Accepted: 03/28/2024] [Indexed: 07/27/2024]
Abstract
Background Mechanical ventilation provides essential support for critically ill patients in several diagnoses; however, extubation failure can affect patient outcomes. From Saudi Arabia, no study has assessed the factors associated with extubation failure in adults. Methods This prospective observational study was conducted in the intensive care unit of a tertiary care hospital in Riyadh, Saudi Arabia. Adult patients who had been mechanically ventilated via the endotracheal tube for a minimum of 24 hours and then extubated according to the weaning protocol were included. Failed extubation was defined as reintubation within 48 hours of extubation. Results A total of 505 patients were included, of which 72 patients had failed extubation (14.3%, 95% CI: 11.4%-17.7%). Compared with the failed extubation group, the successfully extubated group had significantly shorter duration of mechanical ventilation (mean difference: -2.6 days, 95% CI: -4.3 to -1; P = 0.001), a slower respiratory rate at the time of extubation (mean difference: -2.3 breath/min, 95% CI: -3.8 to -1; P = 0.0005), higher pH (mean difference: 0.02, 95% CI: 0.001-0.04; P = 0.03), and more patients with strong cough (percent difference: 17.7%, 95% CI: 4.8%-30.5%; P = 0.02). Independent risk factors of failed extubation were age (aOR = 1.02; 95% CI: 1.002-1.03; P = 0.03), respiratory rate (aOR = 1.06, 95% CI: 1.01-1.1; P = 0.008), duration of mechanical ventilation (aOR = 1.08, 95% CI: 1.03 - 1.1; P < 0.001), and pH (aOR = 0.02, 95% CI: 0.0006-0.5; P = 0.02). Conclusion Older age, longer duration of mechanical ventilation, faster respiratory rate, and lower pH were found to be independent risk factors that significantly increased the odds of extubation failure among adults.
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Affiliation(s)
- Aqeel Hamad Al-Ali
- Respiratory Care Administration, King Saud Medical City, Riyadh, Saudi Arabia
| | | | | | | | - Alzahra Alobaid
- Respiratory Care Administration, King Saud Medical City, Riyadh, Saudi Arabia
| | - Ahmed Yahya Aljoni
- Respiratory Care Administration, King Saud Medical City, Riyadh, Saudi Arabia
| | - Nada Hadi Saleem
- Respiratory Care Administration, King Saud Medical City, Riyadh, Saudi Arabia
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Lacarra B, Hayotte A, Naudin J, Maroni A, Geslain G, Poncelet G, Levy M, Resche-Rigon M, Dauger S. Air leak test in the Paediatric Intensive Care Unit (ALTIPICU): rationale and protocol for a prospective multicentre observational study. BMJ Open 2024; 14:e081314. [PMID: 38688666 PMCID: PMC11086494 DOI: 10.1136/bmjopen-2023-081314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
INTRODUCTION In children, respiratory distress due to upper airway obstruction (UAO) is a common complication of extubation. The quantitative cuff-leak test (qtCLT) is a simple, rapid and non-invasive test that has not been extensively studied in children. The objective of the ongoing study whose protocol is reported here is to investigate how well the qtCLT predicts UAO-related postextubation respiratory distress in paediatric intensive care unit (PICU) patients. METHODS AND ANALYSIS Air Leak Test in the Paediatric Intensive Care Unit is a multicentre, prospective, observational study that will recruit 900 patients who are aged 2 days post-term to 17 years and ventilated through a cuffed endotracheal tube for at least 24 hours in any of 19 French PICUs. Within an hour of planned extubation, the qtCLT will be performed as a sequence of six measurements of the tidal volume with the cuff inflated then deflated. The primary outcome is the occurrence within 48 hours after extubation of severe UAO defined as combining a requirement for intravenous corticosteroid therapy and/or ventilator support by high-flow nasal cannula and/or by non-invasive ventilation or repeat invasive mechanical ventilation with a Westley score ≥4 with at least one point for stridor at each initiation. The results of the study are expected to identify risk factors for UAO-related postextubation respiratory distress and extubation failure, thereby identifying patient subgroups most likely to require preventive interventions. It will also determine whether qtCLT appears to be a reliable method to predict an increased risk for postextubation adverse events as severe UAO. ETHICS AND DISSEMINATION The study was approved by the Robert Debré University Hospital institutional review board (IRB) on September 2021 (approval #2021578). The report of Robert Debré University Hospital IRB is valid for all sites, given the nature of the study with respect to the French law. The results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT05328206.
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Affiliation(s)
- Boris Lacarra
- Médecine Intensive-Réanimation Pédiatrique, Robert-Debré Mother-Child University Hospital, Paris, Île-de-France, France
| | - Aurélie Hayotte
- Médecine Intensive-Réanimation Pédiatrique, Robert-Debré Mother-Child University Hospital, Paris, Île-de-France, France
- Université Paris Cité, Paris, France
| | - Jérôme Naudin
- Médecine Intensive-Réanimation Pédiatrique, Robert-Debré Mother-Child University Hospital, Paris, Île-de-France, France
| | - Arielle Maroni
- Médecine Intensive-Réanimation Pédiatrique, Robert-Debré Mother-Child University Hospital, Paris, Île-de-France, France
| | - Guillaume Geslain
- Médecine Intensive-Réanimation Pédiatrique, Robert-Debré Mother-Child University Hospital, Paris, Île-de-France, France
| | - Géraldine Poncelet
- Médecine Intensive-Réanimation Pédiatrique, Robert-Debré Mother-Child University Hospital, Paris, Île-de-France, France
| | - Michael Levy
- Médecine Intensive-Réanimation Pédiatrique, Robert-Debré Mother-Child University Hospital, Paris, Île-de-France, France
- Université Paris Cité, Paris, France
| | - Matthieu Resche-Rigon
- Université Paris Cité, Paris, France
- ECSTRRA Team-CRESS-UMR 1153, INSERM U1153, Paris, Île-de-France, France
| | - Stéphane Dauger
- Médecine Intensive-Réanimation Pédiatrique, Robert-Debré Mother-Child University Hospital, Paris, Île-de-France, France
- Université Paris Cité, Paris, France
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Al Nufaiei ZF, Al Zhranei RM. High-Flow Nasal Cannula Oxygen Therapy versus Non-Invasive Ventilation in patients at very high risk for extubating failure: A systematic review of randomized controlled trials. PLoS One 2024; 19:e0299693. [PMID: 38568930 PMCID: PMC10990192 DOI: 10.1371/journal.pone.0299693] [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: 07/05/2023] [Accepted: 02/15/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Mechanical ventilation is commonly used for managing respiratory failure in chronic obstructive pulmonary disease (COPD) patients, but weaning patients off ventilator support can be challenging and associated with complications. While many patients respond well to Non-invasive ventilation (NIV), a significant proportion may not respond as favourably. We aimed to assess whether high-flow nasal cannula (HFNC) is equally effective as NIV in reducing extubation failure among previously intubated COPD patients. METHODS This systematic review was carried out in line with PRISMA guidelines We searched PubMed, Scopus, Web of Science, and Cochrane library from inception until February 15, 2023. Randomized Clinical Trials (RCTs) of adults at high risk for extubating failure were included. We examined the use of HFNC as the intervention and NIV as the comparator. Our outcome of interest included, reintubation rate, length of hospital or intensive care unit (ICU) stay, adverse events, and time to reintubation. The Cochrane risk-of-bias tool was used for randomized trials to assess risk of bias. RESULTS We identified 348 citations, 11 of which were included, representing 2,666 patients. The trials indicate that HFNC is comparable to NIV in preventing reintubation after extubating in COPD patients. In comparison to NIV, HFNC also produced improved tolerance, comfort, and less complications such as airway care interventions. NIV with active humification may be more effective that HFNC in avoiding reintubation in patients who are at extremely high risk for extubating failure. CONCLUSION The inconclusive nature of emerging evidence highlights the need for additional studies to establish the efficacy and suitability of HFNC as an alternative to NIV for previously intubated COPD patients. Clinicians should consider the available options and individualize their approach based on patient characteristics. Future research should focus on addressing these gaps in knowledge to guide clinical decision-making and optimize outcomes for this patient population.
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Affiliation(s)
- Ziyad F. Al Nufaiei
- College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- Ministry of the National Guard—Health Affairs, Jeddah, Saudi Arabia
| | - Raid M. Al Zhranei
- College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- Ministry of the National Guard—Health Affairs, Jeddah, Saudi Arabia
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10
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Burns KEA, Rochwerg B, Seely AJE. Ventilator Weaning and Extubation. Crit Care Clin 2024; 40:391-408. [PMID: 38432702 DOI: 10.1016/j.ccc.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Increasing evidence supports specific approaches to liberate patients from invasive ventilation including the use of liberation protocols, inspiratory assistance during spontaneous breathing trials (SBTs), early extubation of patients with chronic obstructive pulmonary disease to noninvasive ventilation, and prophylactic use of noninvasive support strategies after extubation. Additional research is needed to elucidate the best criteria to identify patients who are ready to undergo an SBT and to inform optimal screening frequency, the best SBT technique and duration, extubation assessments, and extubation decision-making. Additional clarity is also needed regarding the optimal timing to measure and report extubation success.
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Affiliation(s)
- Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Medicine and Division of Critical Care, Unity Health Toronto, St. Michaels Hospital, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, Unity Health Toronto, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, Hamilton Health Sciences, Juravinski Hospital, Hamilton, Ontario, Canada; Department of Critical Care, Hamilton Health Sciences, Juravinski Hospital, Hamilton, Ontario, Canada. https://twitter.com/Bram_Rochwerg
| | - Andrew J E Seely
- Department of Critical Care, Ottawa Hospital, Ottawa, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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11
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Godoy DA, Rovegno M, Jibaja M. Extubation After Acute Brain Injury: An Unsolved Dilemma!! Neurocrit Care 2024; 40:385-390. [PMID: 37667077 DOI: 10.1007/s12028-023-01828-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 07/31/2023] [Indexed: 09/06/2023]
Affiliation(s)
| | - Maximiliano Rovegno
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Manuel Jibaja
- Escuela de Medicina, Universidad San Francisco de Quito, Quito, Ecuador
- Unidad de Cuidados Intensivos, Hospital de Especialidades Eugenio Espejo, Quito, Ecuador
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12
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Rose L, Messer B. Prolonged Mechanical Ventilation, Weaning, and the Role of Tracheostomy. Crit Care Clin 2024; 40:409-427. [PMID: 38432703 DOI: 10.1016/j.ccc.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Depending on the definitional criteria used, approximately 5% to 10% of critical adults will require prolonged mechanical ventilation with longer-term outcomes that are worse than those ventilated for a shorter duration. Outcomes are affected by patient characteristics before critical illness and its severity but also by organizational characteristics and care models. Definitive trials of interventions to inform care activities, such as ventilator weaning, upper airway management, rehabilitation, and nutrition specific to the prolonged mechanical ventilation patient population, are lacking. A structured and individualized approach developed by the multiprofessional team in discussion with the patient and their family is warranted.
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Affiliation(s)
- Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, 57 Waterloo Road, London SE1 8WA, UK; Department of Critical Care and Lane Fox Unit, Guy's & St Thomas' NHS Foundation Trust, King's College London, 57 Waterloo Road, London SE1 8WA, UK.
| | - Ben Messer
- Royal Victoria Infirmary, Newcastle-Upon-Tyne NHS Hospitals NHS Foundation Trust, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK
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13
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Zhu D, Zhao Q, Guo S, Bai L, Yang S, Zhao Y, Xu Y, Zhou X. Efficacy of preventive interventions against ventilator-associated pneumonia in critically ill patients: an umbrella review of meta-analyses. J Hosp Infect 2024; 145:174-186. [PMID: 38295905 DOI: 10.1016/j.jhin.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 12/13/2023] [Accepted: 12/26/2023] [Indexed: 02/15/2024]
Abstract
Many meta-analyses have assessed the efficacy of preventive interventions against ventilator-associated pneumonia (VAP) in critically ill patients. However, there has been no comprehensive analysis of the strength and quality of evidence to date. Systematic reviews of randomized and quasi-randomized controlled trials, which evaluated the effect of preventive strategies on the incidence of VAP in critically ill patients receiving mechanical ventilation for at least 48 h, were included in this article. We identified a total of 34 interventions derived from 31 studies. Among these interventions, 19 resulted in a significantly reduced incidence of VAP. Among numerous strategies, only selective decontamination of the digestive tract (SDD) was supported by highly suggestive (Class II) evidence (risk ratio (RR)=0.439, 95% CI: 0.362-0.532). Based on data from the sensitivity analysis, the evidence for the efficacy of non-invasive ventilation in weaning from mechanical ventilation (NIV) was upgraded from weak (Class IV) to highly suggestive (Class II) (RR=0.32, 95% CI: 0.22-0.46). All preventive interventions were not supported by robust evidence for reducing mortality. Early mobilization exhibited suggestive (Class III) evidence in shortening both intensive length of stay (LOS) in the intensive care unit (ICU) (mean difference (MD)=-0.85, 95% CI: -1.21 to -0.49) and duration of mechanical ventilation (MD=-1.02, 95% CI: -1.41 to -0.63). In conclusion, SDD and NIV are supported by robust evidence for prevention against VAP, while early mobilization has been shown to significantly shorten the LOS in the ICU and the duration of mechanical ventilation. These three strategies are recommendable for inclusion in the ventilator bundle to lower the risk of VAP and improve the prognosis of critically ill patients.
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Affiliation(s)
- D Zhu
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Q Zhao
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - S Guo
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - L Bai
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - S Yang
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Y Zhao
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Y Xu
- School of Chinese Medicine, Nanjing University of Chinese Medicine, Nanjing, China.
| | - X Zhou
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China; Department of Respiratory and Critical Care Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China.
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14
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Al-Husinat L, Jouryyeh B, Rawashdeh A, Robba C, Silva PL, Rocco PRM, Battaglini D. The Role of Ultrasonography in the Process of Weaning from Mechanical Ventilation in Critically Ill Patients. Diagnostics (Basel) 2024; 14:398. [PMID: 38396437 PMCID: PMC10888003 DOI: 10.3390/diagnostics14040398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 01/22/2024] [Accepted: 02/10/2024] [Indexed: 02/25/2024] Open
Abstract
Weaning patients from mechanical ventilation (MV) is a complex process that may result in either success or failure. The use of ultrasound at the bedside to assess organs may help to identify the underlying mechanisms that could lead to weaning failure and enable proactive measures to minimize extubation failure. Moreover, ultrasound could be used to accurately identify pulmonary diseases, which may be responsive to respiratory physiotherapy, as well as monitor the effectiveness of physiotherapists' interventions. This article provides a comprehensive review of the role of ultrasonography during the weaning process in critically ill patients.
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Affiliation(s)
- Lou’i Al-Husinat
- Department of Clinical Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan;
| | - Basil Jouryyeh
- Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan; (B.J.); (A.R.)
| | - Ahlam Rawashdeh
- Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan; (B.J.); (A.R.)
| | - Chiara Robba
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy;
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, 16132 Genova, Italy
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro 21941, Brazil; (P.L.S.); (P.R.M.R.)
| | - Patricia Rieken Macedo Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro 21941, Brazil; (P.L.S.); (P.R.M.R.)
| | - Denise Battaglini
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy;
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15
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Marques MR, Pereira JM, Paiva JA, de Casasola-Sánchez GG, Tung-Chen Y. Ultrasonography to Access Diaphragm Dysfunction and Predict the Success of Mechanical Ventilation Weaning in Critical Care: A Narrative Review. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:223-236. [PMID: 37915259 DOI: 10.1002/jum.16363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/09/2023] [Indexed: 11/03/2023]
Abstract
INTRODUCTION Weaning failure is common in mechanically ventilated patients, and whether ultrasound (US) can predict weaning outcome remains controversial. This review aims to evaluate the diaphragmatic function measured by US as a predictor of weaning outcome. METHODS PubMed was searched to identify original articles about the use of diaphragmatic US in ICU patients. A total of 61 citations were retrieved initially; available data of 26 studies were included in this review. RESULTS To assess diaphragmatic dysfunction in adults, six studies evaluated excursion, five evaluated thickening fraction, and both in nine. Despite heterogeneity in the diagnostic accuracy of diaphragm US among the studies, the sonographic indices showed good diagnostic performance for predicting weaning outcome. CONCLUSIONS Diaphragmatic US can be a useful and accurate tool to detect diaphragmatic dysfunction in critically ill patients and predict weaning outcome.
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Affiliation(s)
- Marta Rafael Marques
- Department of Intensive Medicine, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - José Manuel Pereira
- Department of Intensive Medicine, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Medicine, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - José Artur Paiva
- Department of Intensive Medicine, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Medicine, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | | | - Yale Tung-Chen
- Department of Internal Medicine, Hospital Universitario La Paz, Madrid, Spain
- Department of Medicine, Universidad Alfonso X, Villanueva de la Cañada, Madrid, Spain
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Ha TS, Oh DK, Lee HJ, Chang Y, Jeong IS, Sim YS, Hong SK, Park S, Suh GY, Park SY. Liberation from mechanical ventilation in critically ill patients: Korean Society of Critical Care Medicine Clinical Practice Guidelines. Acute Crit Care 2024; 39:1-23. [PMID: 38476061 PMCID: PMC11002621 DOI: 10.4266/acc.2024.00052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 02/14/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Successful liberation from mechanical ventilation is one of the most crucial processes in critical care because it is the first step by which a respiratory failure patient begins to transition out of the intensive care unit and return to their own life. Therefore, when devising appropriate strategies for removing mechanical ventilation, it is essential to consider not only the individual experiences of healthcare professionals, but also scientific and systematic approaches. Recently, numerous studies have investigated methods and tools for identifying when mechanically ventilated patients are ready to breathe on their own. The Korean Society of Critical Care Medicine therefore provides these recommendations to clinicians about liberation from the ventilator. METHODS Meta-analyses and comprehensive syntheses were used to thoroughly review, compile, and summarize the complete body of relevant evidence. All studies were meticulously assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) method, and the outcomes were presented succinctly as evidence profiles. Those evidence syntheses were discussed by a multidisciplinary committee of experts in mechanical ventilation, who then developed and approved recommendations. RESULTS Recommendations for nine PICO (population, intervention, comparator, and outcome) questions about ventilator liberation are presented in this document. This guideline includes seven conditional recommendations, one expert consensus recommendation, and one conditional deferred recommendation. CONCLUSIONS We developed these clinical guidelines for mechanical ventilation liberation to provide meaningful recommendations. These guidelines reflect the best treatment for patients seeking liberation from mechanical ventilation.
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Affiliation(s)
- Tae Sun Ha
- Department of Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Dong Kyu Oh
- Department of Pulmonology, Dongkang Medical Center, Ulsan, Korea
| | - Hak-Jae Lee
- Division of Acute Care Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Youjin Chang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inje University Sanggye Paik Hospital, College of Medicine, Inje University, Seoul, Korea
| | - In Seok Jeong
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Gwangju, Korea
| | - Yun Su Sim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
- Lung Research Institute of Hallym University College of Medicine, Chuncheon, Korea
| | - Suk-Kyung Hong
- Division of Acute Care Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sunghoon Park
- Lung Research Institute of Hallym University College of Medicine, Chuncheon, Korea
- Department of Pulmonary, Allergy, and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - So Young Park
- Lung Research Institute of Hallym University College of Medicine, Chuncheon, Korea
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
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Arcanjo ABB, Beccaria LM. Fatores associados à falha de extubação em unidade de terapia intensiva: estudo de caso-controle. Rev Lat Am Enfermagem 2023. [DOI: 10.1590/1518-8345.6224.3865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Resumo Objetivo: investigar os fatores associados à falha de extubação de pacientes na unidade de terapia intensiva. Método: caso-controle não pareado, longitudinal, retrospectivo e quantitativo com a participação de 480 pacientes por meio de parâmetros clínicos para desmame ventilatório. Dados analisados por: Teste Exato de Fisher ou o teste Qui-quadrado; teste t de Student bicaudal não pareado; e teste de Mann-Whitney. Admitiram-se significantes valores de P menores ou iguais a 0,05. Resultados: dos pacientes, 415 (86,5%) tiveram sucesso e 65 (13,5%) falharam. Grupo sucesso: balanço hídrico mais negativo, APACHE II em 20 (14-25), tosse fraca em 58 (13,9%). Grupo falha: balanço hídrico mais positivo, APACHE II em 23 (19-29), tosse fraca em 31 (47,7 %), quantidade abundante de secreção pulmonar em 47,7 %. Conclusão: o balanço hídrico positivo e a presença de tosse ineficiente ou incapacidade de higienizar a via aérea foram preditores de falhas de extubação.
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Arcanjo ABB, Beccaria LM. Factors associated with extubation failure in an intensive care unit: a case-control study. Rev Lat Am Enfermagem 2023; 31:e3864. [PMID: 36995853 PMCID: PMC10077863 DOI: 10.1590/1518-8345.6224.3864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 10/20/2022] [Indexed: 03/29/2023] Open
Abstract
Abstract Objective: to investigate the factors associated with extubation failure of patients in the intensive care unit. Method: unpaired, longitudinal, retrospective and quantitative case-control with the participation of 480 patients through clinical parameters for ventilator weaning. Data were analyzed by: Fisher’s exact test or the chi-square test; unpaired two-tailed Student’s t test; and Mann-Whitney test. Significant P values lower than or equal to 0.05 were admitted. Results: of the patients, 415 (86.5%) were successful and 65 (13.5%) failed. Success group: the most negative fluid balance, APACHE II in 20 (14-25), weak cough in 58 (13.9%). Failure group: the most positive fluid balance, APACHE II in 23 (19-29), weak cough in 31 (47.7%), abundant amount of pulmonary secretions in 47.7%. Conclusion: positive fluid balance and the presence of inefficient cough or inability to clear the airway were predictors of extubation failure.
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Arcanjo ABB, Beccaria LM. Factores asociados al fracaso de la extubación en unidad de cuidados intensivos: estudio de caso y control. Rev Lat Am Enfermagem 2023. [DOI: 10.1590/1518-8345.6224.3863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Resumen Objetivo: investigar los factores asociados al fracaso de la extubación de pacientes en la unidad de cuidados intensivos. Método: caso y control no apareado, longitudinal, retrospectivo y cuantitativo con la participación de 480 pacientes mediante parámetros clínicos para el destete de la ventilación. Datos analizados por: Prueba Exacta de Fisher o prueba de Chi-cuadrado; prueba t de Student de dos colas para datos no apareados; y prueba de Mann-Whitney. Se admitieron valores de P significativos menores o iguales a 0,05. Resultados: de los pacientes, 415 (86,5%) tuvieron éxito y 65 (13,5%) fracasaron. Grupo de éxito: balance hídrico más negativo, APACHE II en 20 (14-25), tos débil en 58 (13,9%). Grupo de fracaso: balance de líquidos más positivo, APACHE II en 23 (19-29), tos débil en 31 (47,7%), abundante cantidad de secreciones pulmonares en 47,7%. Conclusión: el balance hídrico positivo y la presencia de tos ineficaz o incapacidad para higienizar la vía aérea fueron predictores de fracaso de la extubación.
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20
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Greenhalgh DG, Hill DM, Burmeister DM, Gus EI, Cleland H, Padiglione A, Holden D, Huss F, Chew MS, Kubasiak JC, Burrell A, Manzanares W, Gómez MC, Yoshimura Y, Sjöberg F, Xie WG, Egipto P, Lavrentieva A, Jain A, Miranda-Altamirano A, Raby E, Aramendi I, Sen S, Chung KK, Alvarez RJQ, Han C, Matsushima A, Elmasry M, Liu Y, Donoso CS, Bolgiani A, Johnson LS, Vana LPM, de Romero RVD, Allorto N, Abesamis G, Luna VN, Gragnani A, González CB, Basilico H, Wood F, Jeng J, Li A, Singer M, Luo G, Palmieri T, Kahn S, Joe V, Cartotto R. Surviving Sepsis After Burn Campaign. Burns 2023; 49:1487-1524. [PMID: 37839919 DOI: 10.1016/j.burns.2023.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/02/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION The Surviving Sepsis Campaign was developed to improve outcomes for all patients with sepsis. Despite sepsis being the primary cause of death after thermal injury, burns have always been excluded from the Surviving Sepsis efforts. To improve sepsis outcomes in burn patients, an international group of burn experts developed the Surviving Sepsis After Burn Campaign (SSABC) as a testable guideline to improve burn sepsis outcomes. METHODS The International Society for Burn Injuries (ISBI) reached out to regional or national burn organizations to recommend members to participate in the program. Two members of the ISBI developed specific "patient/population, intervention, comparison and outcome" (PICO) questions that paralleled the 2021 Surviving Sepsis Campaign [1]. SSABC participants were asked to search the current literature and rate its quality for each topic. At the Congress of the ISBI, in Guadalajara, Mexico, August 28, 2022, a majority of the participants met to create "statements" based on the literature. The "summary statements" were then sent to all members for comment with the hope of developing an 80% consensus. After four reviews, a consensus statement for each topic was created or "no consensus" was reported. RESULTS The committee developed sixty statements within fourteen topics that provide guidance for the early treatment of sepsis in burn patients. These statements should be used to improve the care of sepsis in burn patients. The statements should not be considered as "static" comments but should rather be used as guidelines for future testing of the best treatments for sepsis in burn patients. They should be updated on a regular basis. CONCLUSION Members of the burn community from the around the world have developed the Surviving Sepsis After Burn Campaign guidelines with the goal of improving the outcome of sepsis in burn patients.
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Affiliation(s)
- David G Greenhalgh
- Department of Burns, Shriners Children's Northern California and Department of Surgery, University of California, Davis, Sacramento, CA, USA.
| | - David M Hill
- Department of Clinical Pharmacy & Translational Scre have been several studies that have evaluatedience, College of Pharmacy, University of Tennessee, Health Science Center; Memphis, TN, USA
| | - David M Burmeister
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Eduardo I Gus
- Division of Plastic & Reconstructive Surgery, The Hospital for Sick Children; Department of Surgery, University of Toronto, Toronto, Canada
| | - Heather Cleland
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Alex Padiglione
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Dane Holden
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Fredrik Huss
- Department of Surgical Sciences, Plastic Surgery, Uppsala University/Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - John C Kubasiak
- Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Aidan Burrell
- Department of Epidemiology and Preventative Medicine, Monash University and Alfred Hospital, Intensive Care Research Center (ANZIC-RC), Melbourne, Australia
| | - William Manzanares
- Department of Critical Care Medicine, Universidad de la República (UdelaR), Montevideo, Uruguay
| | - María Chacón Gómez
- Division of Intensive Care and Critical Medicine, Centro Nacional de Investigacion y Atencion de Quemados (CENIAQ), National Rehabilitation Institute, LGII, Mexico
| | - Yuya Yoshimura
- Department of Emergency and Critical Care Medicine, Hachinohe City Hospital, Hachinohe, Japan
| | - Folke Sjöberg
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Wei-Guo Xie
- Institute of Burns, Tongren Hospital of Wuhan University (Wuhan Third Hospital), Wuhan, China
| | - Paula Egipto
- Centro Hospitalar e Universitário São João - Burn Unit, Porto, Portugal
| | | | | | | | - Ed Raby
- Infectious Diseases Department, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | | | - Soman Sen
- Department of Burns, Shriners Children's Northern California and Department of Surgery, University of California, Davis, Sacramento, CA, USA
| | - Kevin K Chung
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | | - Chunmao Han
- Department of Burn and Wound Repair, Second Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, China
| | - Asako Matsushima
- Department of Emergency and Critical Care, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Moustafa Elmasry
- Department of Hand, Plastic Surgery and Burns, Linköping University, Linköping, Sweden
| | - Yan Liu
- Department of Burn, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Carlos Segovia Donoso
- Intensive Care Unit for Major Burns, Mutual Security Clinical Hospital, Santiago, Chile
| | - Alberto Bolgiani
- Department of Surgery, Deutsches Hospital, Buenos Aires, Argentina
| | - Laura S Johnson
- Department of Surgery, Emory University School of Medicine and Grady Health System, Georgia
| | - Luiz Philipe Molina Vana
- Disciplina de Cirurgia Plastica da Escola Paulista de Medicina da Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | | | - Nikki Allorto
- Grey's Hospital Pietermaritzburg Metropolitan Burn Service, University of KwaZulu Natal, Pietermaritzburg, South Africa
| | - Gerald Abesamis
- Alfredo T. Ramirez Burn Center, Division of Burns, Department of Surgery, University of Philippines Manila - Philippine General Hospital, Manila, Philippines
| | - Virginia Nuñez Luna
- Unidad Michou y Mau Xochimilco for Burnt Children, Secretaria Salud Ciudad de México, Mexico
| | - Alfredo Gragnani
- Disciplina de Cirurgia Plastica da Escola Paulista de Medicina da Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Carolina Bonilla González
- Department of Pediatrics and Intensive Care, Pediatric Burn Unit, Clinical Studies and Clinical Epidemiology Division, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Hugo Basilico
- Intensive Care Area - Burn Unit - Pediatric Hospital "Prof. Dr. Juan P. Garrahan", Buenos Aires, Argentina
| | - Fiona Wood
- Department of Surgery, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - James Jeng
- Department of Surgery, University of California, Irvine, CA, USA
| | - Andrew Li
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Mervyn Singer
- Department of Intensive Care Medicine, University College London, London, United Kingdom
| | - Gaoxing Luo
- Institute of Burn Research, Southwest Hospital, Army (Third Military) Medical University, Chongqing, China
| | - Tina Palmieri
- Department of Burns, Shriners Children's Northern California and Department of Surgery, University of California, Davis, Sacramento, CA, USA
| | - Steven Kahn
- The South Carolina Burn Center, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Victor Joe
- Department of Surgery, University of California, Irvine, CA, USA
| | - Robert Cartotto
- Department of Surgery, Sunnybrook Medical Center, Toronto, Ontario, Canada
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21
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Varón-Vega F, Giraldo-Cadavid LF, Uribe AM, Rincón A, Palacios J, Crevoisier S, Tuta-Quintero E, Ordoñez L, Boada N, Rincón P, Poveda M, Monedero P. Utilization of spontaneous breathing trial, objective cough test, and diaphragmatic ultrasound results to predict extubation success: COBRE-US trial. Crit Care 2023; 27:414. [PMID: 37908002 PMCID: PMC10617213 DOI: 10.1186/s13054-023-04708-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/24/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND The results of clinical and weaning readiness tests and the spontaneous breathing trial (SBT) are used to predict the success of the weaning process and extubation. METHODS We evaluated the capacity of the cuff leak test, rate of rapid and shallow breathing, cough intensity, and diaphragmatic contraction velocity (DCV) to predict the success of the SBT and extubation in a prospective, multicenter observational study with consecutive adult patients admitted to four intensive care units. We used receiver operating characteristic (ROC) curves to assess the tests' predictive capacity and built predictive models using logistic regression. RESULTS We recruited 367 subjects who were receiving invasive mechanical ventilation and on whom 456 SBTs were performed, with a success rate of 76.5%. To predict the success of the SBT, we derived the following equation: (0.56 × Cough) - (0.13 × DCV) + 0.25. When the cutoff point was ≥ 0.83, the sensitivity was 91.5%, the specificity was 22.1%, and the overall accuracy was 76.2%. The area under the ROC curve (AUC-ROC) was 0.63. To predict extubation success, we derived the following equation: (5.7 × SBT) + (0.75 × Cough) - (0.25 × DCV) - 4.5. When the cutoff point was ≥ 1.25, the sensitivity was 96.8%, the specificity was 78.4%, and the overall accuracy was 91.5%. The AUC-ROC of this model was 0.91. CONCLUSION Objective measurement of cough and diaphragmatic contraction velocity could be used to predict SBT success. The equation for predicting successful extubation, which includes SBT, cough, and diaphragmatic contraction velocity values, showed excellent discriminative capacity.
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Affiliation(s)
- Fabio Varón-Vega
- Critical Care and Lung Transplantation Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Bogotá, Colombia.
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Cra. 13B #161 - 85, 110131, Bogotá, Colombia.
| | - Luis F Giraldo-Cadavid
- Interventional Pulmonology Service, Fundación Neumológica Colombiana, Bogotá, Colombia
- School of Medicine, Universidad de La Sabana, Chía, Colombia
| | - Ana María Uribe
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Cra. 13B #161 - 85, 110131, Bogotá, Colombia
| | - Adriana Rincón
- Critical Care and Lung Transplantation Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Bogotá, Colombia
| | - Jonathan Palacios
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Cra. 13B #161 - 85, 110131, Bogotá, Colombia
| | - Stephanie Crevoisier
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Cra. 13B #161 - 85, 110131, Bogotá, Colombia
| | | | - Lina Ordoñez
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Cra. 13B #161 - 85, 110131, Bogotá, Colombia
| | - Natalia Boada
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Cra. 13B #161 - 85, 110131, Bogotá, Colombia
- Critical Care Service, Fundación Clínica Shaio, Bogotá, Colombia
| | - Paola Rincón
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardio Infantil, Cra. 13B #161 - 85, 110131, Bogotá, Colombia
- Critical Care Service, Fundación Clínica Shaio, Bogotá, Colombia
| | - Marcela Poveda
- Critical Care Service, Fundación Clínica Shaio, Bogotá, Colombia
| | - Pablo Monedero
- School of Medicine, Universidad de Navarra, Pamplona, Spain
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22
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Saunders H, Khadka S, Shrestha R, Balavenkataraman A, Hochwald A, Ball C, Helgeson SA. The Association between Non-Invasive Ventilation and the Rate of Ventilator-Associated Pneumonia. Diseases 2023; 11:151. [PMID: 37987262 PMCID: PMC10660719 DOI: 10.3390/diseases11040151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/17/2023] [Accepted: 10/25/2023] [Indexed: 11/22/2023] Open
Abstract
Ventilator-associated pneumonia (VAP) has significant effects on patient outcomes, including prolonging the duration of both mechanical ventilation and stay in the intensive care unit (ICU). The aim of this study was to assess the association between non-invasive ventilation/oxygenation (NIVO) prior to intubation and the rate of subsequent VAP. This was a multicenter retrospective cohort study of adult patients who were admitted to the medical ICU from three tertiary care academic centers in three distinct regions. NIVO was defined as continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), or high-flow nasal cannula (HFNC) for any duration during the hospitalization prior to intubation. The primary outcome variable was VAP association with NIVO. A total of 17,302 patients were included. VAP developed in 2.6% of the patients (444/17,302), 2.3% (285/12,518) of patients among those who did not have NIVO, 1.6% (30/1879) of patients who had CPAP, 2.5% (17/690) of patients who had HFNC, 8.1% (16/197) of patients who had BiPAP, and 4.8% (96/2018) of patients who had a combination of NIVO types. Compared to those who did not have NIVO, VAP was more likely to develop among those who had BiPAP (adj OR 3.11, 95% CI 1.80-5.37, p < 0.001) or a combination of NIVO types (adj OR 1.91, 95% CI 1.49-2.44, p < 0.001) after adjusting for patient demographics and comorbidities. The use of BiPAP or a combination of NIVO types significantly increases the odds of developing VAP once receiving IMV.
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Affiliation(s)
- Hollie Saunders
- Department of Pulmonary and Critical Care, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA; (S.K.); (R.S.); (A.B.)
| | - Subekshya Khadka
- Department of Pulmonary and Critical Care, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA; (S.K.); (R.S.); (A.B.)
| | - Rabi Shrestha
- Department of Pulmonary and Critical Care, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA; (S.K.); (R.S.); (A.B.)
| | - Arvind Balavenkataraman
- Department of Pulmonary and Critical Care, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA; (S.K.); (R.S.); (A.B.)
| | - Alexander Hochwald
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Colleen Ball
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Scott A. Helgeson
- Department of Pulmonary and Critical Care, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA; (S.K.); (R.S.); (A.B.)
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23
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Burns KEA, Lafrienier-Roula M, Hill NS, Cook DJ, Seely AJE, Rochwerg B, Mayette M, D'Aragon F, Devlin JW, Dodek P, Tanios M, Gouskos A, Turgeon AF, Aslanian P, Sia YT, Beitler JR, Hyzy R, Criner GJ, Kassis EB, Tsang JLY, Meade MO, Liebler JM, Wong JTY, Thorpe KE. Frequency of screening and SBT Technique Trial-North American Weaning Collaboration (FAST-NAWC): an update to the protocol and statistical analysis plan. Trials 2023; 24:626. [PMID: 37784109 PMCID: PMC10544476 DOI: 10.1186/s13063-023-07079-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 01/05/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND This update summarizes key changes made to the protocol for the Frequency of Screening and Spontaneous Breathing Trial (SBT) Technique Trial-North American Weaning Collaborative (FAST-NAWC) trial since the publication of the original protocol. This multicenter, factorial design randomized controlled trial with concealed allocation, will compare the effect of both screening frequency (once vs. at least twice daily) to identify candidates to undergo a SBT and SBT technique [pressure support + positive end-expiratory pressure vs. T-piece] on the time to successful extubation (primary outcome) in 760 critically ill adults who are invasively ventilated for at least 24 h in 20 North American intensive care units. METHODS/DESIGN Protocols for the pilot, factorial design trial and the full trial were previously published in J Clin Trials ( https://doi.org/10.4172/2167-0870.1000284 ) and Trials (https://doi: 10.1186/s13063-019-3641-8). As planned, participants enrolled in the FAST pilot trial will be included in the report of the full FAST-NAWC trial. In response to the onset of the coronavirus disease of 2019 (COVID-19) pandemic when approximately two thirds of enrollment was complete, we revised the protocol and consent form to include critically ill invasively ventilated patients with COVID-19. We also refined the statistical analysis plan (SAP) to reflect inclusion and reporting of participants with and without COVID-19. This update summarizes the changes made and their rationale and provides a refined SAP for the FAST-NAWC trial. These changes have been finalized before completion of trial follow-up and the commencement of data analysis. TRIAL REGISTRATION Clinical Trials.gov NCT02399267.
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Affiliation(s)
- Karen E A Burns
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada.
- Division of Critical Care Medicine, St Michael's Hospital, Toronto, Canada.
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Office 4-045 Donnelly Wing, Toronto, ON, M5B 1W8, Canada.
| | | | - Nicholas S Hill
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, USA
| | - Deborah J Cook
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Andrew J E Seely
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Michael Mayette
- Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada
- Centre de Recherche du Centre Hospitalier, Universitaire de Sherbrooke, Sherbrooke, Canada
| | - Frederick D'Aragon
- Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada
- Centre de Recherche du Centre Hospitalier, Universitaire de Sherbrooke, Sherbrooke, Canada
| | - John W Devlin
- Bouve College of Health Professions, Northeastern University, Boston, USA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Peter Dodek
- Centre for Health Evaluation and Outcome Sciences, Vancouver, Canada
- University of British Columbia, Vancouver, Canada
| | - Maged Tanios
- Pulmonary and Critical Care Medicine, Memorial Care, Longbeach Medical Center, Longbeach, CA, USA
| | - Audrey Gouskos
- Patient and Family Advisory Committee and Steering Committee Representative, FAST-NAWC Trial, Toronto, Canada
| | - Alexis F Turgeon
- Departments of Anesthesia and Critical Care, Hôpital Enfant-Jésus du CHU de Québec-Université Laval, Quebec City, Canada
| | - Pierre Aslanian
- Service de Soins Intensifs, Département de Médecine, Centre Hospitalier de L'Universite de Montreal, Montreal, Canada
| | - Ying Tung Sia
- Department of Critical Care Medicine, Centre Integre Universitaire de Sante et de Services Sociaux de la Mauricie-et-du-Centre-du-Quebec - Trois Rivieres, Montreal, Canada
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure and Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, NY, USA
| | - Robert Hyzy
- Division of Pulmonary and Critical Care, University of Michigan Health System, Ann Arbor, MI, USA
| | - Gerard J Criner
- Division of Pulmonary and Critical Care Medicine, Temple University, Lewis Katz School of Medicine, Philadelphia, USA
| | - Elias Baedorf Kassis
- Departments of Medicine (Division of Critical Care) and Anesthesia, Beth Israel Deaconess Medical Center, Boston, USA
| | - Jennifer L Y Tsang
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Medicine, Division of Critical Care, Niagara Health System - St. Catherines, St. Catherines, Canada
| | - Maureen O Meade
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
- Department of Medicine, McMaster University, Hamilton, Canada
- Division of Critical Care, Hamilton Health Sciences Center, Hamilton, Canada
| | - Janice M Liebler
- Divisions of Pulmonary, Critical Care, and Sleep Medicine, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Jessica T Y Wong
- Faculty of Medicine and Dentistry, University of Toronto, Toronto, Canada
| | - Kevin E Thorpe
- Applied Health Research Centre, St. Michael's Hospital, Toronto, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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24
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Lehmkuhl L, Dreyer P, Laerkner E, Tanghus Olsen H, Jespersen E, Juel Rothmann M. Getting the body back on track - Understanding the phenomenon of mobilisation when conscious and mechanically ventilated patients are mobilised in the intensive care unit. Intensive Crit Care Nurs 2023; 78:103450. [PMID: 37172466 DOI: 10.1016/j.iccn.2023.103450] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/24/2023] [Accepted: 04/29/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE To gain an in-depth understanding of the phenomenon of mobilisation when conscious and mechanically ventilated patients are mobilised in the intensive care unit. DESIGN A qualitative study with a phenomenological-hermeneutic approach. Data were generated in three intensive care units from September 2019 to March 2020. Participant observations of twelve conscious mechanically ventilated patients, thirty-five nurses and four physiotherapists were performed. Furthermore, seven semi-structured patient interviews were conducted, both on the ward and after discharge. FINDINGS Mobilisation during mechanical ventilation in the intensive care unit followed a trajectory from a failing body to a growing sense of independence in getting the body back on track. Three themes were revealed: 'Challenging to move a failing body', 'Ambiguity of both resistance and willingness in the process of strengthen the body', and 'An ongoing effort in getting the body back on track'. CONCLUSIONS Mobilisation when conscious and mechanically ventilated included support of the living body by physical prompts and ongoing bodily guidance. Resistance and willingness regarding mobilisation were found to be a way of coping with bodily reactions of comfort or discomfort, embedded in a need to feel bodily control. The trajectory of mobilisation promoted a sense of agency, as mobilisation activities at different stages during the intensive care unit stay supported the patients in becoming more active collaborators in getting the body back on track. IMPLICATIONS FOR CLINICAL PRACTICE Ongoing bodily guidance provided by healthcare professionals can promote bodily control and support conscious and mechanically ventilated patients in active participation in mobilisation. Furthermore, understanding the ambiguity of patients' reactions caused by loss of bodily control provides a potential to prepare mechanically ventilated patients for and assist them with mobilisation. In particular, the first mobilisation in the intensive care unit seems to influence the success of future mobilisation, as the body remembers negative experiences.
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Affiliation(s)
- Lene Lehmkuhl
- Department of Anaesthesiology and Intensive Care, OUH Svendborg Hospital, Baagøes Alle 15, 5700 Svendborg, Denmark; Department of Clinical Research, University of Southern Denmark, J. B. Winsløws Vej 19, 5000 Odense C, Denmark.
| | - Pia Dreyer
- Department of Public Health, Aarhus University, Bartholin's Alle 2, 8000 Aarhus C, Denmark; Department of Intensive Care, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.
| | - Eva Laerkner
- Department of Clinical Research, University of Southern Denmark, J. B. Winsløws Vej 19, 5000 Odense C, Denmark; Department of Anaesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense C, Denmark.
| | - Hanne Tanghus Olsen
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense C, Denmark.
| | - Eva Jespersen
- Department of Clinical Research, University of Southern Denmark, J. B. Winsløws Vej 19, 5000 Odense C, Denmark; Department of Oncology, Odense University Hospital, Kløvervænget 8D, 5000 Odense C, Denmark.
| | - Mette Juel Rothmann
- Department of Clinical Research, University of Southern Denmark, J. B. Winsløws Vej 19, 5000 Odense C, Denmark; Steno Diabetes Center Odense, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark; Centre for Innovative Medical Technology, Odense University Hospital, Kløvervænget 8C, 5000 Odense, Denmark; Department of Endocrinology, Odense University Hospital, J. B. Winsløws Vej 9a, 5000 Odense, Denmark.
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25
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Tanaka A, Shimomura Y, Uchiyama A, Tokuhira N, Kitamura T, Iwata H, Hashimoto H, Ishigaki S, Enokidani Y, Yamashita T, Koyama Y, Iguchi N, Yoshida T, Fujino Y. Time definition of reintubation most relevant to patient outcomes in critically ill patients: a multicenter cohort study. Crit Care 2023; 27:378. [PMID: 37777790 PMCID: PMC10544149 DOI: 10.1186/s13054-023-04668-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 09/27/2023] [Indexed: 10/02/2023] Open
Abstract
BACKGROUND Reintubation is a common complication in critically ill patients requiring mechanical ventilation. Although reintubation has been demonstrated to be associated with patient outcomes, its time definition varies widely among guidelines and in the literature. This study aimed to determine the association between reintubation and patient outcomes as well as the consequences of the time elapsed between extubation and reintubation on patient outcomes. METHODS This was a multicenter retrospective cohort study of critically ill patients conducted between April 2015 and March 2021. Adult patients who underwent mechanical ventilation and extubation in intensive care units (ICUs) were investigated utilizing the Japanese Intensive Care PAtient Database. The primary and secondary outcomes were in-hospital and ICU mortality. The association between reintubation and clinical outcomes was studied using Cox proportional hazards analysis. Among the patients who underwent reintubation, a Cox proportional hazard analysis was conducted to evaluate patient outcomes according to the number of days from extubation to reintubation. RESULTS Overall, 184,705 patients in 75 ICUs were screened, and 1849 patients underwent reintubation among 48,082 extubated patients. After adjustment for potential confounders, multivariable analysis revealed a significant association between reintubation and increased in-hospital and ICU mortality (adjusted hazard ratio [HR] 1.520, 95% confidence interval [CI] 1.359-1.700, and adjusted HR 1.325, 95% CI 1.076-1.633, respectively). Among the reintubated patients, 1037 (56.1%) were reintubated within 24 h after extubation, 418 (22.6%) at 24-48 h, 198 (10.7%) at 48-72 h, 111 (6.0%) at 72-96 h, and 85 (4.6%) at 96-120 h. Multivariable Cox proportional hazard analysis showed that in-hospital and ICU mortality was highest in patients reintubated at 72-96 h (adjusted HR 1.528, 95% CI 1.062-2.197, and adjusted HR 1.334, 95% CI 0.756-2.352, respectively; referenced to reintubation within 24 h). CONCLUSIONS Reintubation was associated with a significant increase in in-hospital and ICU mortality. The highest mortality rates were observed in patients who were reintubated between 72 and 96 h after extubation. Further studies are warranted for the optimal observation of extubated patients in clinical practice and to strengthen the evidence for mechanical ventilation.
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Affiliation(s)
- Aiko Tanaka
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan.
- Department of Intensive Care, University of Fukui Hospital, Yoshida, Fukui, Japan.
| | - Yoshimitsu Shimomura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Department of Hematology, Kobe City Hospital Organization Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Akinori Uchiyama
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Natsuko Tokuhira
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hirofumi Iwata
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Haruka Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Suguru Ishigaki
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yusuke Enokidani
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Tomonori Yamashita
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yukiko Koyama
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Naoya Iguchi
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Takeshi Yoshida
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yuji Fujino
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
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Toledo TG, Bacci MR. Value of Diaphragm Ultrasonography for Extubation: A Single-Blinded Randomized Clinical Trial. Crit Care Res Pract 2023; 2023:8403971. [PMID: 37766780 PMCID: PMC10522420 DOI: 10.1155/2023/8403971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 08/30/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
Introduction Daily evaluation of mechanically ventilated (MV) patients is essential for successful extubation. Proper withdrawal prevents complications and reduces the cost of hospitalization in the intensive care unit (ICU). Diaphragm ultrasonography (DUS) has emerged as a potential instrument for determining whether a patient is ready to be extubated. This study compared the efficacy rate of extubation using a standard withdrawal protocol and DUS in patients with MV. Methods A randomized, parallel, single-blind, controlled study was conducted on ICU patients undergoing MV. Patients were randomly assigned to either the control (conventional weaning protocol) group or intervention (DUS-guided weaning) group in a 1 : 1 ratio. The primary outcome measure was the rate of reintubation and hospital mortality. Results Forty patients were randomized to the trial. The mean age of the sample was 70 years, representing an older population. The extubation success rate was 90% in both groups. There was no reintubation in the first 48 hours and only two reintubations in both groups between the second and seventh days. The hospital mortality risk in patients with acute kidney injury was positively correlated with age and the need for hemodialysis. Discussion. This study demonstrates the usefulness of DUS measurement protocols for withdrawing MV. The rate of reintubation was low for both cessation methods. As a parameter, the diaphragm thickness fraction comprehensively evaluates the diaphragm function. The results demonstrate that DUS has the potential to serve as a noninvasive tool for guiding extubation decisions. In conclusion, using DUS in patients with respiratory failure revealed no difference in reintubation rates or mortality compared with the conventional method. Future research should concentrate on larger, multicentered, randomized trials employing a multimodal strategy that combines diaphragmatic parameters with traditional clinical withdrawal indices.
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Affiliation(s)
| | - M. R. Bacci
- Centro Universitario FMABC, Santo Andre, Brazil
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27
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Pérez J, Accoce M, Dorado JH, Gilgado DI, Navarro E, Cardoso GP, Telias I, Rodriguez PO, Brochard L. Failure of First Transition to Pressure Support Ventilation After Spontaneous Awakening Trials in Hypoxemic Respiratory Failure: Influence of COVID-19. Crit Care Explor 2023; 5:e0968. [PMID: 37644972 PMCID: PMC10461949 DOI: 10.1097/cce.0000000000000968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Abstract
OBJECTIVES To describe the rate of failure of the first transition to pressure support ventilation (PSV) after systematic spontaneous awakening trials (SATs) in patients with acute hypoxemic respiratory failure (AHRF) and to assess whether the failure is higher in COVID-19 compared with AHRF of other etiologies. To determine predictors and potential association of failure with outcomes. DESIGN Retrospective cohort study. SETTING Twenty-eight-bedded medical-surgical ICU in a private hospital (Argentina). PATIENTS Subjects with arterial pressure of oxygen (AHRF to Fio2 [Pao2/Fio2] < 300 mm Hg) of different etiologies under controlled mechanical ventilation (MV). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We collected data during controlled ventilation within 24 hours before SAT followed by the first PSV transition. Failure was defined as the need to return to fully controlled MV within 3 calendar days of PSV start. A total of 274 patients with AHRF (189 COVID-19 and 85 non-COVID-19) were included. The failure occurred in 120 of 274 subjects (43.7%) and was higher in COVID-19 versus non-COVID-19 (49.7% and 30.5%; p = 0.003). COVID-19 diagnosis (odds ratio [OR]: 2.22; 95% CI [1.15-4.43]; p = 0.020), previous neuromuscular blockers (OR: 2.16; 95% CI [1.15-4.11]; p = 0.017) and higher fentanyl dose (OR: 1.29; 95% CI [1.05-1.60]; p = 0.018) increased the failure chances. Higher BMI (OR: 0.95; 95% CI [0.91-0.99]; p = 0.029), Pao2/Fio2 (OR: 0.87; 95% CI [0.78-0.97]; p = 0.017), and pH (OR: 0.61; 95% CI [0.38-0.96]; p = 0.035) were protective. Failure groups had higher 60-day ventilator dependence (p < 0.001), MV duration (p < 0.0001), and ICU stay (p = 0.001). Patients who failed had higher mortality in COVID-19 group (p < 0.001) but not in the non-COVID-19 (p = 0.083). CONCLUSIONS In patients with AHRF of different etiologies, the failure of the first PSV attempt was 43.7%, and at a higher rate in COVID-19. Independent risk factors included COVID-19 diagnosis, fentanyl dose, previous neuromuscular blockers, acidosis and hypoxemia preceding SAT, whereas higher BMI was protective. Failure was associated with worse outcomes.
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Affiliation(s)
- Joaquin Pérez
- Intensive Care Unit, Sanatorio Anchorena, San Martín, Buenos Aires, Argentina
- Intensive Care Unit, Hospital Carlos G. Durand, Ciudad Autónoma de Buenos Aires, Argentina
| | - Matías Accoce
- Intensive Care Unit, Sanatorio Anchorena, San Martín, Buenos Aires, Argentina
- Intensive Care Unit, Hospital de Quemados "Dr. Arturo Humberto Illia," Ciudad Autónoma de Buenos Aires, Argentina
- Faculta de Medicina y Ciencias de la Salud, Universidad Abierta Interamericana, Ciudad Autónoma de Buenos Aires, Argentina
| | - Javier H Dorado
- Intensive Care Unit, Sanatorio Anchorena, San Martín, Buenos Aires, Argentina
| | - Daniela I Gilgado
- Intensive Care Unit, Sanatorio Anchorena, San Martín, Buenos Aires, Argentina
- Intensive Care Unit, Hospital Carlos G. Durand, Ciudad Autónoma de Buenos Aires, Argentina
| | - Emiliano Navarro
- Respiratory and physical therapy department, Centro del Parque, Ciudad Autónoma de Buenos Aires, Argentina
| | - Gimena P Cardoso
- Intensive Care Unit, Sanatorio Anchorena, San Martín, Buenos Aires, Argentina
- Intensive Care Unit, Hospital Donación Francisco Santojanni, Ciudad Autónoma de Buenos Aires, Argentina
| | - Irene Telias
- Department of Critical Care, Keenan Research Center, Li Ka Shing Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada
| | - Pablo O Rodriguez
- Intensive Care Unit, Hospital Universitario Sede Pombo (Instituto Universitario CEMIC, Centro de Educación Médica e Investigaciones Clínicas), Ciudad Autónoma de Buenos Aires, Argentina
- Pneumonology section, CEMIC, Ciudad Autónoma de Buenos Aires, Argentina
| | - Laurent Brochard
- Department of Critical Care, Keenan Research Center, Li Ka Shing Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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Ferrera MC, Hayes MM. How I Teach: Liberation from Mechanical Ventilation. ATS Sch 2023; 4:372-384. [PMID: 37795117 PMCID: PMC10547038 DOI: 10.34197/ats-scholar.2023-0037ht] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023] Open
Abstract
Liberation from mechanical ventilation is one of the most important decisions in the intensive care unit (ICU), as extubation failure is associated with worse outcomes. Determining readiness to extubate can be challenging in complex patients and lead to provider stress. Here, we provide our approach to teaching liberation from mechanical ventilation for learners in the ICU. We use a case-based didactic session that purposefully introduces ambiguous cases without a clear answer, utilizing aspects of both cognitive load theory and adult learning theories.
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Affiliation(s)
- Michael C Ferrera
- Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Margaret M Hayes
- Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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29
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Godoy M, de Souza L, da Silva A, Lugon J. Comparison of the timed inspiratory effort index with the T-piece trial as a decision-making tool for extubation: a randomized controlled non-inferiority trial. Braz J Med Biol Res 2023; 56:e12824. [PMID: 37585918 PMCID: PMC10427157 DOI: 10.1590/1414-431x2023e12824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/30/2023] [Indexed: 08/18/2023] Open
Abstract
The "timed inspiratory effort" (TIE) index, a new predictor of weaning outcome, normalizes the maximal inspiratory pressure with the time required to reach this value up to 60 s, incorporating the time domain into the assessment of inspiratory muscle function. The objective of this study was to determine whether the TIE predicts successful extubation at a similar rate as the T-piece trial with less time required. A non-inferiority randomized controlled trial was performed with ICU subjects eligible for weaning. The participants were allocated to the TIE or the T-piece groups. The primary outcome was successful weaning, and the main secondary outcome was ICU mortality. Eighty participants of each group were included in the final analysis. Time from the start of a successful test to effective extubation was significantly lower in the TIE group than in the T-piece group, 15 (10 to 24) vs 55 (40 to 75) min, P<0.001. In the Kaplan-Meier analysis, no significant differences were found in successful weaning (79.5 vs 82.5%, P=0.268) or survival rate (62.9 vs 53.8%, P=0.210) between the TIE and T-piece groups at the 30th day. In this preliminary study, the TIE index was not inferior to the T-piece trial as a decision-making tool for extubation and allowed a reduction in the decision time.
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Affiliation(s)
- M.D.P. Godoy
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina, Universidade Federal Fluminense, Niterói, RJ, Brasil
| | - L.C. de Souza
- Serviço de Fisioterapia, Hospital Icaraí, Faculdade de Fisioterapia, Universidade Estácio de Sá, Niterói, RJ, Brasil
| | | | - J.R. Lugon
- Departamento de Medicina/Nefrologia, Faculdade de Medicina, Universidade Federal Fluminense, Niterói, RJ, Brasil
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30
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Pitre T, Abdali D, Chaudhuri D, Pastores SM, Nei AM, Annane D, Rochwerg B, Zeraatkar D. Corticosteroids in Community-Acquired Bacterial Pneumonia: a Systematic Review, Pairwise and Dose-Response Meta-Analysis. J Gen Intern Med 2023; 38:2593-2606. [PMID: 37076606 PMCID: PMC10115386 DOI: 10.1007/s11606-023-08203-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 04/05/2023] [Indexed: 04/21/2023]
Abstract
INTRODUCTION International guidelines provide heterogenous guidance on use of corticosteroids for community-acquired pneumonia (CAP). METHODS We performed a systematic review of randomized controlled trials examining corticosteroids in hospitalized adult patients with suspected or probable CAP. We performed a pairwise and dose-response meta-analysis using the restricted maximum likelihood (REML) heterogeneity estimator. We assessed the certainty of the evidence using GRADE methodology and the credibility of subgroups using the ICEMAN tool. RESULTS We identified 18 eligible studies that included 4661 patients. Corticosteroids probably reduce mortality in more severe CAP (RR 0.62 [95% CI 0.45 to 0.85]; moderate certainty) with possibly no effect in less severe CAP (RR 1.08 [95% CI 0.83 to 1.42]; low certainty). We found a non-linear dose-response relationship between corticosteroids and mortality, suggesting an optimal dose of approximately 6 mg of dexamethasone (or equivalent) for a duration of therapy of 7 days (RR 0.44 [95% 0.30 to 0.66]). Corticosteroids probably reduce the risk of requiring invasive mechanical ventilation (RR 0.56 [95% CI 0.42 to 74] and probably reduce intensive care unit (ICU) admission (RR 0.65 [95% CI 0.43 to 0.97]) (both moderate certainty). Corticosteroids may reduce the duration of hospitalization and ICU stay (both low certainty). Corticosteroids may increase the risk of hyperglycemia (RR 1.76 [95% CI 1.46 to 2.14]) (low certainty). CONCLUSION Moderate certainty evidence indicates that corticosteroids reduce mortality in patients with more severe CAP, the need for invasive mechanical ventilation, and ICU admission.
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Affiliation(s)
- Tyler Pitre
- Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
| | - Daniyal Abdali
- Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
| | - Dipayan Chaudhuri
- Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
| | - Stephen M Pastores
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, USA
| | - Andrea M Nei
- Department of Pharmacy, Mayo Clinic Hospital, Rochester, Rochester, MN200 First St SW, Rochester, MN, 55905, USA
| | - Djillali Annane
- General Intensive Care Unit, Raymond Poincaré hospital (APHP); Lab infection & inflammation U1173 School of medicine Simone Veil, University Paris Saclay, Paris, France
| | - Bram Rochwerg
- Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Dena Zeraatkar
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Anesthesiology, McMaster University, Hamilton, ON, Canada
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Schweickert WD, Jablonski J, Bayes B, Chowdhury M, Whitman C, Tian J, Blette B, Tran T, Halpern SD. Structured Mobilization for Critically Ill Patients: A Pragmatic Cluster-randomized Trial. Am J Respir Crit Care Med 2023; 208:49-58. [PMID: 36996413 DOI: 10.1164/rccm.202209-1763oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 03/30/2023] [Indexed: 04/01/2023] Open
Abstract
Rationale: Small trials and professional recommendations support mobilization interventions to improve recovery among critically ill patients, but their real-world effectiveness is unknown. Objective: To evaluate a low-cost, multifaceted mobilization intervention. Methods: We conducted a stepped-wedge cluster-randomized trial across 12 ICUs with diverse case mixes. The primary and secondary samples included patients mechanically ventilated for ⩾48 hours who were ambulatory before admission, and all patients with ICU stays ⩾48 hours, respectively. The mobilization intervention included 1) designation and posting of daily mobilization goals; 2) interprofessional closed-loop communication coordinated by each ICU's facilitator; and 3) performance feedback. Measurements and Main Results: From March 4, 2019 through March 15, 2020, 848 and 1,069 patients were enrolled in the usual care and intervention phases in the primary sample, respectively. The intervention did not increase the primary outcome, patient's maximal Intensive Care Mobility Scale (range, 0-10) score within 48 hours before ICU discharge (estimated mean difference, 0.16; 95% confidence interval, -0.31 to 0.63; P = 0.51). More patients in the intervention (37.2%) than usual care (30.7%) groups achieved the prespecified secondary outcome of ability to stand before ICU discharge (odds ratio, 1.48; 95% confidence interval, 1.02 to 2.15; P = 0.04). Similar results were observed among the 7,115 patients in the secondary sample. The percentage of days on which patients received physical therapy mediated 90.1% of the intervention effect on standing. ICU mortality (31.5% vs. 29.0%), falls (0.7% vs. 0.4%), and unplanned extubations (2.0% vs. 1.8%) were similar between groups (all P > 0.3). Conclusions: A low-cost, multifaceted mobilization intervention did not improve overall mobility but improved patients' odds of standing and was safe. Clinical trial registered with www.clinicaltrials.gov (NCT03863470).
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Affiliation(s)
- William D Schweickert
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Brian Bayes
- Palliative and Advanced Illness Research Center
| | | | | | - Jenny Tian
- Palliative and Advanced Illness Research Center
| | - Bryan Blette
- Palliative and Advanced Illness Research Center
- Department of Biostatistics, Epidemiology, and Informatics, and
| | - Teresa Tran
- Palliative and Advanced Illness Research Center
| | - Scott D Halpern
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
- Palliative and Advanced Illness Research Center
- Department of Biostatistics, Epidemiology, and Informatics, and
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
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Liu J, Li F, Qi X, Zhuang X, Cui Z. Positive- vs. negative-pressure extubation technique: a scoping review. Front Med (Lausanne) 2023; 10:1169879. [PMID: 37250624 PMCID: PMC10213366 DOI: 10.3389/fmed.2023.1169879] [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: 02/20/2023] [Accepted: 04/19/2023] [Indexed: 05/31/2023] Open
Abstract
Objectives This review aimed to summarize the recent literature on positive-pressure extubation. Design A scoping review was conducted under the framework of the Joanna Briggs Institute. Data sources Web of Science, PubMed, Ovid, Cumulative Index to Nursing & Allied Health, EBSCO, Cochrane Library, Wan Fang Data, China National Knowledge Infrastructure, and China Biology Medicine databases were searched for studies on adults and children. Study selection All articles describing the use of positive-pressure extubation were considered eligible for inclusion. The exclusion criteria were articles not available in English or Chinese, and those without full text available. Data extraction and synthesis The database searches identified 8,381 articles, 15 of which could be included in this review, with an aggregated patient number of 1,544. Vital signs, including mean arterial pressure, heart rate, R-R interval, and SpO2 before and after extubation; blood gas analysis indexes, including pH, oxygen saturation, PaO2, and PaCO2 before and after extubation; and incidence of respiratory complications, including bronchospasm, laryngeal edema, aspiration atelectasis, hypoxemia, and hypercapnia, were reported in the included studies. Results The majority of these studies reported that the positive-pressure extubation technique can maintain stable vital signs and blood gas analysis indices as well as prevent complications during the peri-extubation period. Conclusions The positive-pressure extubation technique has a safety performance similar to that of the traditional negative-pressure extubation technique and may lead to better clinical outcomes, including stable vital signs, arterial blood gas analysis, and a lower incidence of respiratory complications.
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Parada-Gereda HM, Tibaduiza AL, Rico-Mendoza A, Molano-Franco D, Nieto VH, Arias-Ortiz WA, Perez-Terán P, Masclans JR. Effectiveness of diaphragmatic ultrasound as a predictor of successful weaning from mechanical ventilation: a systematic review and meta-analysis. Crit Care 2023; 27:174. [PMID: 37147688 PMCID: PMC10161591 DOI: 10.1186/s13054-023-04430-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 04/04/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND Several measurements have been used to predict the success of weaning from mechanical ventilation; however, their efficacy varies in different studies. In recent years, diaphragmatic ultrasound has been used for this purpose. We conducted a systematic review and meta-analysis to evaluate the effectiveness of diaphragmatic ultrasound in predicting the success of weaning from mechanical ventilation. METHODS Two investigators independently searched PUBMED, TRIP, EMBASE, COCHRANE, SCIENCE DIRECT, and LILACS for articles published between January 2016 and July 2022. The methodological quality of the studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool; additionally, the certainty of the evidence is evaluated using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology. Sensitivity and specificity analysis was performed for diaphragmatic excursion and diaphragmatic thickening fraction; positive and negative likelihood ratios and diagnostic odds ratios (DOR) with their confidence intervals (95% CI) were calculated by random effects analysis, summary receiver operating characteristic curve was estimated. Sources of heterogeneity were explored by subgroup analysis and bivariate meta-regression. RESULTS Twenty-six studies were included, of which 19 were included in the meta-analysis (1204 patients). For diaphragmatic excursion, sensitivity was 0.80 (95% CI 0.77-0.83), specificity 0.80 (95% CI 0.75-0.84), area under the summary receiver operating characteristic curve 0.87 and DOR 17.1 (95% CI 10.2-28.6). For the thickening fraction, sensitivity was 0.85 (95% CI 0.82-0.87), specificity 0.75 (95% CI 0.69-0.80), area under the summary receiver operating characteristic curve 0.87 and DOR 17.2 (95% CI 9.16-32.3). There was heterogeneity among the included studies. When performing a subgroup analysis and excluding studies with atypical cutoff values, sensitivity and specificity increased for diaphragmatic thickening fraction; sensitivity increased and specificity decreased for diaphragmatic excursion; when comparing studies using pressure support (PS) versus T-tube, there was no significant difference in sensitivity and specificity; bivariate meta-regression analysis shows that patient position at the time of testing was a factor of heterogeneity in the included studies. CONCLUSIONS Measurement of diaphragmatic excursion and diaphragmatic thickening fraction predict the probability of successful weaning from mechanical ventilation with satisfactory diagnostic accuracy; however, significant heterogeneity was evident in the different included studies. Studies of high methodological quality in specific subgroups of patients in intensive care units are needed to evaluate the role of diaphragmatic ultrasound as a predictor of weaning from mechanical ventilation.
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Affiliation(s)
- Henry M Parada-Gereda
- Intensive Care Unit Clínica Reina Sofia, Clínica Colsanitas, Grupo de Investigación en Nutrición Clínica y Rehabilitación, Fundación Universitaria Sanitas, Keralty Bogotá- Colombia, Universidad del Rosario Bogotá- Colombia, Faculty of Medicine. Research group Medicina Comunitaria y Salud Colectiva Universidad El Bosque, Bogotá, Colombia.
| | - Adriana L Tibaduiza
- Physician Subinvestigator Oficina de Investigaciones Hospital San Ignacio, Bogotá, Colombia
| | - Alejandro Rico-Mendoza
- Epidemiology Master's Degree Coordinator. Universidad El Bosque. Faculty of Medicine. Research group Medicina Comunitaria y Salud Colectiva. Bogotá Colombia, Universidad El Bosque, Bogotá, Colombia
| | - Daniel Molano-Franco
- Intensive Care Cobos Medical Center - Universidad El Bosque, group Recerca-GRIBOS, Bogota, Colombia
| | - Victor H Nieto
- Intensive Care Cobos Medical Center - Universidad El Bosque, group Recerca-GRIBOS, Bogota, Colombia
- Head of Intensive Care Unit Centro de Tratamento e Investigación sobre Cáncer CTIC, group Recerca- GRIBOS, Bogotá, Colombia
| | - Wanderley A Arias-Ortiz
- Master in Epidemiology, Specialist in Applied Statistics, Universidad El Bosque. Faculty of Medicine. Research group Medicina Comunitaria y Salud Colectiva, Bogotá, Colombia
| | - Purificación Perez-Terán
- Critical Care Department Hospital del Mar-Parc de Salut MAR. GREPAC-Group Recerca Departamento de Medicina y Ciencias de la Vida Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Joan R Masclans
- Critical Care Department Hospital del Mar-Parc de Salut MAR. GREPAC-Group Recerca Departamento de Medicina y Ciencias de la Vida Universitat Pompeu Fabra (UPF), Barcelona, Spain
- Director de Docencia PSMAR, Intensive Care Unit Hospital del Mar. Professor of Medicine Universitat Pompeu Fabra (UPF) IMIM (GREPAC - Group Recerca Patologia Critica) Departamento de Medicina Y Ciencias de la Vida (MELIS), Universidad Pompeu Fabra (UPF), Barcelona, Spain
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Panuganti BA, Pang J, Francis DO, Klebaner D, Asturias A, Alattar A, Wood S, Terry M, Bryson PC, Tipton CB, Zhao EE, O'Rourke A, Maria CS, Grimm DR, Sung CK, Lao WP, Thompson JM, Crawley BK, Rosen S, Berezovsky A, Kupfer R, Hennesy TB, Clary M, Joseph IT, Sarhadi K, Kuhn M, Abdel-Aty Y, Kennedy MM, Lott DG, Weissbrod PA. Clinicodemographic Predictors of Tracheotomy Tube Size and Decannulation: A Multiinstitutional Retrospective Cohort Study on Tracheotomy. Ann Surg 2023; 277:e1138-e1142. [PMID: 35001037 DOI: 10.1097/sla.0000000000005356] [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: 11/26/2022]
Abstract
OBJECTIVE We aimed to discern clinico-demographic predictors of large (≥8) tracheostomy tube size placement, and, secondarily, to assess the effect of large tracheostomy tube size and other parameters on odds of decannulation before hospital discharge. SUMMARY OF BACKGROUND DATA Factors determining choice of tracheostomy tube size are not well-characterized in the current literature, despite evidence linking large tracheostomy tube size with posttracheotomy tracheal stenosis. The effect of tracheostomy tube size on timing of decannulation is also unknown, an important consideration given reported associations between endotracheal tube size and probability of failed extubation. METHODS We collected information pertaining to patients who underwent tracheotomy at 1 of 10 U.S. health care institutions between 2010 and 2019. Tracheostomy tube size was dichotomized (≥8 and <8). Multivariable logistic regression models were fit to identify predictors of (1) large tracheostomy tube size, and (2) decannulation before hospital discharge. RESULTS The study included 5307 patients, including 2797 (52.7%) in the large tracheostomy cohort. Patient height (odds ratio [OR] = 1.060 per inch; 95% confidence interval [CI] 1.041-1.070) and obesity (1.37; 95% CI 1.1891.579) were associated with greater odds of large tracheostomy tube; otolaryngology performing the tracheotomy was associated with significantly lower odds of large tracheostomy tube (OR = 0.155; 95% CI 0.131-0.184). Large tracheostomy tube size (OR = 1.036; 95% CI 0.885-1.213) did not affect odds of decannulation. CONCLUSIONS Obesity was linked with increased likelihood of large tracheostomy tube size, independent of patient height. Probability of decannulation before hospital discharge is influenced by multiple patient-centric factors, but not by size of tracheostomy tube.
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Affiliation(s)
| | - John Pang
- University of Washington, Department of Otolaryngology, Seattle, WA
| | - David O Francis
- University of Wisconsin, Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Madison, WI
| | - Dasha Klebaner
- University of California, School of Medicine, La Jolla, CA
| | | | - Ali Alattar
- University of California, School of Medicine, La Jolla, CA
| | - Samuel Wood
- University of California, School of Medicine, La Jolla, CA
| | - Morgan Terry
- Cleveland Clinic, Department of Otolaryngology, Cleveland, OH
| | - Paul C Bryson
- Cleveland Clinic, Department of Otolaryngology, Cleveland, OH
| | - Courtney B Tipton
- Medical University of South Carolina, Department of Otolaryngology, Charleston, SC
| | - Elise E Zhao
- Medical University of South Carolina, Department of Otolaryngology, Charleston, SC
| | - Ashli O'Rourke
- Medical University of South Carolina, Department of Otolaryngology, Charleston, SC
| | | | - David R Grimm
- Stanford University, Department of Otolaryngology, Palo Alto, CA
| | - C Kwang Sung
- Stanford University, Department of Otolaryngology, Palo Alto, CA
| | - Wilson P Lao
- Loma Linda University, Department of Otolaryngology, Loma Linda, CA
| | | | | | - Sarah Rosen
- University of Wisconsin, Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Madison, WI
| | - Anna Berezovsky
- University of Michigan, Department of Otolaryngology, Ann Arbor, MI
| | - Robbi Kupfer
- University of Michigan, Department of Otolaryngology, Ann Arbor, MI
| | | | - Matthew Clary
- University of Colorado, Department of Otolaryngology, Aurora, CA
| | - Ian T Joseph
- University of California Davis, Department of Otolaryngology, Sacramento, CA; and
| | - Kamron Sarhadi
- University of California Davis, Department of Otolaryngology, Sacramento, CA; and
| | - Maggie Kuhn
- University of California Davis, Department of Otolaryngology, Sacramento, CA; and
| | - Yassmeen Abdel-Aty
- Medical University of South Carolina, Department of Otolaryngology, Charleston, SC
| | - Maeve M Kennedy
- Mayo Clinic Arizona, Department of Otolaryngology, Phoenix, AZ
| | - David G Lott
- Mayo Clinic Arizona, Department of Otolaryngology, Phoenix, AZ
| | - Philip A Weissbrod
- University of California San Diego, Department of Otolaryngology, La Jolla, CA
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Lehmkuhl L, Olsen HT, Brønd JC, Rothmann MJ, Dreyer P, Jespersen E. Daily variation in physical activity during mechanical ventilation and stay in the intensive care unit. Acta Anaesthesiol Scand 2023; 67:462-469. [PMID: 36636823 DOI: 10.1111/aas.14195] [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: 08/26/2022] [Revised: 12/21/2022] [Accepted: 01/03/2023] [Indexed: 01/14/2023]
Abstract
BACKGROUND Early mobilisation of mechanically ventilated patients during their stay at an intensive care unit (ICU) can improve physical recovery. Yet, an objective and specified description of physical activities while in the ICU is lacking. Therefore, our aim was to describe the objectively assessed type, quantity, and daily variation of physical activity among mechanically ventilated patients while in the ICU. METHOD In an observational study in two mixed medical/surgical ICUs, we measured body posture in 39 patients on mechanical ventilation using a thigh- and chest-worn accelerometer while in the ICU. The accelerometer describes time spent lying, sitting, moving, in-bed cycling, standing and walking. Descriptive analysis of physical activity and daily variation was done using STATA. RESULTS We found that mechanically ventilated patients spend 20/24 h lying in bed, 3 h sitting and only 1 h standing, moving, walking or bicycling while in the ICU. Intervals of non-lying time appeared from 9.00 to 12.00 and again from 18.00 to 21.30, with peaks at the hours of 9.00 and 18.00. CONCLUSION ICU patients on mechanical ventilation were primarily sedentary. Physical activity of mechanically ventilated patients seems to be related to nurse- and/or physiotherapy-initiated activities. There is a need to create an awareness of improving clinical routines, towards active mobilisation throughout the day, for this vulnerable patient population during their stay in the ICU.
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Affiliation(s)
- Lene Lehmkuhl
- Department of Anaesthesiology and Intensive Care, Odense University Hospital Svendborg Hospital, Svendborg, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Hanne Tanghus Olsen
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Jan Christian Brønd
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Research Unit for Exercise Epidemiology, University of Southern Denmark, Odense, Denmark
- Centre of Research in Childhood Health, University of Southern Denmark, Odense, Denmark
| | - Mette Juel Rothmann
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
- Centre for Innovative Medical Technology, Odense University Hospital, Odense, Denmark
| | - Pia Dreyer
- Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
- Section of Nursing, Institute of Public Health, Aarhus University, Aarhus, Denmark
- Bergen University, Bergen, Norway
| | - Eva Jespersen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Oncology, Odense University Hospital, Odense, Denmark
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Cuyas CS, Fernández RF. WEAN SAFE and the definition of the first separation attempt. THE LANCET. RESPIRATORY MEDICINE 2023; 11:e43. [PMID: 36934738 DOI: 10.1016/s2213-2600(23)00051-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 03/18/2023]
Affiliation(s)
- Carles Subira Cuyas
- Critical Care Department, Althaia Xarxa Assistencial Manresa, Barcelona 08243, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Keenan Research Center, Toronto, ON, Canada.
| | - Rafael Fernández Fernández
- Critical Care Department, Althaia Xarxa Assistencial Manresa, Barcelona 08243, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
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Rabinstein AA, Cinotti R, Bösel J. Liberation from Mechanical Ventilation and Tracheostomy Practice in Traumatic Brain Injury. Neurocrit Care 2023; 38:439-446. [PMID: 36859490 DOI: 10.1007/s12028-023-01693-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 02/06/2023] [Indexed: 03/03/2023]
Abstract
Liberating patients with severe traumatic brain injury (TBI) from mechanical ventilation is often a challenging task. These patients frequently require prolonged ventilation and have persistent alterations in the level and content of consciousness. Questions about their ability to protect their airway are common. Pulmonary complications and copious respiratory secretions are also very prevalent. Thus, it is hardly surprising that rates of extubation failure are high. This is a major problem because extubation failure is associated with a host of poor outcome measures. When the safety of an extubation attempt is uncertain, direct tracheostomy is favored by some, but there is no evidence that this practice leads to better outcomes. Current knowledge is insufficient to reliably predict extubation outcomes in TBI, and practices vary substantially across trauma centers. Yet observational studies provide relevant information that must be weighted when considering the decision to attempt extubation in patients with head injury. This review discusses available evidence on liberation from mechanical ventilation in TBI, proposes priorities for future research, and offers practical advice to guide decisions at the bedside.
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Affiliation(s)
| | - Raphael Cinotti
- Department of Anesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel Dieu, 44000, Nantes, France.,Methods in Patient-Centered Outcomes and Health Research, University of Nantes, University of Tours, INSERM, 22 Boulevard Benoni Goulin, 44200, Nantes, France
| | - Julian Bösel
- Department of Neurology, Kassel General Hospital, Kassel, Germany.,Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
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Nyquist P. Extubation Anxiety, It Is All in the Brain. Crit Care Med 2023; 51:424-427. [PMID: 36809266 DOI: 10.1097/ccm.0000000000005784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- Paul Nyquist
- Anesthesia and Critical Care Medicine, Neurosurgery, General Integral Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Sekihara K, Okamoto T, Shibasaki T, Matsuda W, Funai K, Yonehiro Y, Matsubara C, Kimura A. Evaluation of a bundle approach for the prophylaxis of ventilator-associated pneumonia: A retrospective single-center Study. Glob Health Med 2023; 5:33-39. [PMID: 36865901 PMCID: PMC9974225 DOI: 10.35772/ghm.2022.01038] [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: 04/25/2022] [Revised: 08/17/2022] [Accepted: 09/12/2022] [Indexed: 11/08/2022]
Abstract
Ventilator-associated pneumonia (VAP) is defined as pneumonia occurring after the first 48 hours of intubation and mechanical ventilation and is the most frequent hospital-acquired infection associated with intensive care unit (ICU) admissions. Herein, we defined a novel VAP bundle including 10 preventive items. We analyzed compliance rates and clinical effectiveness associated with this bundle in patients undergoing intubation at our medical center. A total of 684 consecutive patients who underwent mechanical ventilation were admitted to the ICU between June 2018 and December 2020. VAP was diagnosed by at least two physicians based on the relevant United States Centers for Disease Control and Prevention criteria. We retrospectively evaluated associations between compliance and VAP incidence. The overall compliance rate was 77%, and compliance generally remained steady during the observation period. Moreover, although the number of ventilatory days remained unchanged, the incidence of VAP improved statistically significantly over time. Low compliance was identified in four categories: head-of-bed elevation of 30- 45º, avoidance of oversedation, daily assessment for extubation, and early ambulation and rehabilitation. The incidence of VAP was lower in those with an overall compliance rate of ≥ 75% than its incidence in the lower compliance group (15.8 vs. 24.1%, p = 0.018). When comparing low-compliance items between these groups, we found a statistically significant difference only for daily assessment for extubation (8.3 vs. 25.9%, p = 0.011). In conclusion, the evaluated bundle approach is effective for the prophylaxis of VAP and is thus eligible for inclusion in the Sustainable Development Goals.
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Affiliation(s)
- Keigo Sekihara
- Department of Intensive Care Medicine, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan;,Department of First Surgery, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Tatsuya Okamoto
- Department of Intensive Care Medicine, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan;,Address correspondence to:Tatsuya Okamoto, Department of Intensive Care Medicine, National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjuku, Tokyo 162-8655, Japan. E-mail:
| | - Takatoshi Shibasaki
- Department of Intensive Care Medicine, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan;,Department of Emergency Medicine and Critical Care, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan
| | - Wataru Matsuda
- Department of Intensive Care Medicine, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan;,Department of Emergency Medicine and Critical Care, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan
| | - Kazuhito Funai
- Department of First Surgery, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Yuki Yonehiro
- Department of Intensive Care Medicine, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan
| | - Chieko Matsubara
- Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
| | - Akio Kimura
- Department of Intensive Care Medicine, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan;,Department of Emergency Medicine and Critical Care, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan
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Chen X, Li J, Liu G, Chen X, Huang S, Li H, Liu S, Li D, Yang H, Zheng H, Hu L, Kong L, Liu H, Bellou A, Lei L, Liang H. Identification of Distinct Clinical Phenotypes of Heterogeneous Mechanically Ventilated ICU Patients Using Cluster Analysis. J Clin Med 2023; 12:jcm12041499. [PMID: 36836034 PMCID: PMC9962046 DOI: 10.3390/jcm12041499] [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: 12/23/2022] [Revised: 02/01/2023] [Accepted: 02/09/2023] [Indexed: 02/16/2023] Open
Abstract
This retrospective study aimed to derive the clinical phenotypes of ventilated ICU patients to predict the outcomes on the first day of ventilation. Clinical phenotypes were derived from the eICU Collaborative Research Database (eICU) cohort via cluster analysis and were validated in the Medical Information Mart for Intensive Care (MIMIC-IV) cohort. Four clinical phenotypes were identified and compared in the eICU cohort (n = 15,256). Phenotype A (n = 3112) was associated with respiratory disease, had the lowest 28-day mortality (16%), and had a high extubation success rate (~80%). Phenotype B (n = 3335) was correlated with cardiovascular disease, had the second-highest 28-day mortality (28%), and had the lowest extubation success rate (69%). Phenotype C (n = 3868) was correlated with renal dysfunction, had the highest 28-day mortality (28%), and had the second-lowest extubation success rate (74%). Phenotype D (n = 4941) was associated with neurological and traumatic diseases, had the second-lowest 28-day mortality (22%), and had the highest extubation success rate (>80%). These findings were validated in the validation cohort (n = 10,813). Additionally, these phenotypes responded differently to ventilation strategies in terms of duration of treatment, but had no difference in mortality. The four clinical phenotypes unveiled the heterogeneity of ICU patients and helped to predict the 28-day mortality and the extubation success rate.
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Affiliation(s)
- Xuanhui Chen
- Medical Big Data Center, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Jiaxin Li
- Department of Intensive Care Unit of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Guangzhou 510080, China
| | - Guangjian Liu
- Shenzhen Dymind Biotechnology Co., Ltd., Shenzhen 518000, China
| | - Xiujuan Chen
- Medical Big Data Center, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Shuai Huang
- Medical Big Data Center, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Huixian Li
- Medical Big Data Center, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Siyi Liu
- Department of Intensive Care Unit of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Guangzhou 510080, China
| | - Dantong Li
- Medical Big Data Center, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Huan Yang
- Medical Big Data Center, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Haiqing Zheng
- Medical Big Data Center, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Lianting Hu
- Medical Big Data Center, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Lingcong Kong
- Medical Big Data Center, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Huazhang Liu
- Medical Big Data Center, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Abdelouahab Bellou
- Institute of Sciences in Emergency Medicine, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI 48201, USA
- Correspondence: (A.B.); (L.L.); (H.L.)
| | - Liming Lei
- Department of Intensive Care Unit of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Guangzhou 510080, China
- Correspondence: (A.B.); (L.L.); (H.L.)
| | - Huiying Liang
- Medical Big Data Center, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
- Correspondence: (A.B.); (L.L.); (H.L.)
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Li W, Zhang Y, Wang Z, Jia D, Zhang C, Ma X, Han X, Zhao T, Zhang Z. The risk factors of reintubation in intensive care unit patients on mechanical ventilation: A systematic review and meta-analysis. Intensive Crit Care Nurs 2023; 74:103340. [PMID: 36369190 DOI: 10.1016/j.iccn.2022.103340] [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: 07/29/2022] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To assess risk factors of reintubation in intensive care unit patients on mechanical ventilation. METHODOLOGY We conducted a systematic review of literature (inception to May 2022) and a meta-analysis. Data are reported as pooled odds ratios for categorical variables and mean differences for continuous variables. RESULTS A total of 2459 studies were retrieved of which 38 studies were included in a meta-analysis involving 22,304 patients. Risk factors identified were: older age, higher APACHE II scores, COPD, pneumonia, shock, low SaO2, low PaO2, low PaO2/FiO2, low hemoglobin, low albumin, high brain natriuretic peptide, low pH, high respiratory rate, low tidal volume, a higher rapid shallow breathing index, a lower vital capacity, a higher number of spontaneous breathing trials, prolonged length of mechanical ventilation, weak cough, a reduced patient's cough peak flow and positive cuff leak test. Subgroup analysis showed that risk factors substantially overlap when reintubation was considered within 48 hours or within 72 hours after extubation. CONCLUSIONS We identified 21 factors associated with increased risk for reintubation. These allow to recognize the patient at high risk for reintubation at an early stage. Future studies may combine these factors to develop comprehensive predictive algorithms allowing appropriate vigilance.
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Affiliation(s)
- Wenrui Li
- Department of Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, Gansu 730000, PR China; School of Nursing, Lanzhou University, Lanzhou, Gansu 730000, PR China
| | - Ying Zhang
- Department of Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, Gansu 730000, PR China
| | - Zhenzhen Wang
- Department of Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, Gansu 730000, PR China; School of Nursing, Lanzhou University, Lanzhou, Gansu 730000, PR China
| | - Donghui Jia
- Department of Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, Gansu 730000, PR China; School of Nursing, Lanzhou University, Lanzhou, Gansu 730000, PR China
| | - Caiyun Zhang
- School of Nursing, Lanzhou University, Lanzhou, Gansu 730000, PR China; Outpatient Department, The First Hospital of Lanzhou University, Lanzhou, Gansu 730000, PR China
| | - Xiujuan Ma
- Department of Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, Gansu 730000, PR China; School of Nursing, Lanzhou University, Lanzhou, Gansu 730000, PR China
| | - Xinyi Han
- Department of Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, Gansu 730000, PR China; School of Nursing, Lanzhou University, Lanzhou, Gansu 730000, PR China
| | - Tana Zhao
- Department of Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, Gansu 730000, PR China; School of Nursing, Lanzhou University, Lanzhou, Gansu 730000, PR China
| | - Zhigang Zhang
- Department of Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, Gansu 730000, PR China; School of Nursing, Lanzhou University, Lanzhou, Gansu 730000, PR China.
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Black K, Doucet J. Reducing Systemic Risks in a Traumatic Panfacial Injury Patient. Facial Plast Surg Clin North Am 2023; 31:315-324. [PMID: 37001934 DOI: 10.1016/j.fsc.2023.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
Panfacial trauma refers to injuries caused by high-energy mechanisms to two or more regions of the craniofacial skeleton, including the frontal bone, the midface, and the occlusal unit. As with any trauma, Advanced Trauma Life Support protocols should be followed in unstable patients. For the patient with panfacial traumatic injury, advanced perioperative care or critical care is frequently required. This article describes surgical critical care for panfacial injuries, a component of the acute-care surgery model, to reduce systemic risks, improve the patient's condition, and enable a successful surgical outcome.
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Tsai WW, Hung KC, Huang YT, Yu CH, Lin CH, Chen IW, Sun CK. Diagnostic efficacy of sonographic measurement of laryngeal air column width difference for predicting the risk of post-extubation stridor: A meta-analysis of observational studies. Front Med (Lausanne) 2023; 10:1109681. [PMID: 36744149 PMCID: PMC9893004 DOI: 10.3389/fmed.2023.1109681] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/05/2023] [Indexed: 01/20/2023] Open
Abstract
Background This meta-analysis aimed at assessing the diagnostic accuracy of ultrasound-measured laryngeal air column width difference (ACWD) in predicting post-extubation stridor (PES) in intubated adult patients. Methods We searched the Medline, Cochrane Library, EMBASE, and Google scholar databases from inception to October, 2022 to identify studies that examined the diagnostic accuracy of ACWD for PES. The primary outcome was the diagnostic performance by calculating the pooled sensitivity, specificity, and area under the curve (AUC). The secondary outcomes were the differences in ACWD and duration of intubation between patients with and without PES. Results Following literature search, 11 prospective studies (intensive care setting, n = 10; operating room setting, n = 1) involving 1,322 extubations were included. The incidence of PES among the studies was 4-25%. All studies were mixed-gender (females: 24.1-68.5%) with sample sizes ranging between 41 and 432. The cut-off values of ACWD for prediction of PES varied from 0.45 to 1.6 mm. The pooled sensitivity and specificity of ACWD for PES were 0.8 (95% CI = 0.69-0.88, I 2: 37.26%, eight studies) and 0.81 (95% CI = 0.72-0.88, I 2: 89.51%, eight studies), respectively. The pooled AUC was 0.87 (95% CI = 0.84-0.90). Patients with PES had a smaller ACWD compared to those without PES (mean difference = -0.54, 95% CI = -0.79 to -0.28, I 2: 97%, eight studies). Moreover, patients with PES had a longer duration of tracheal intubation than that in those without (mean difference = 2.75 days, 95% CI = 0.92, 4.57, I 2: 90%, seven studies). Conclusion Ultrasound-measured laryngeal ACWD showed satisfactory sensitivity and specificity for predicting PES. Because of the limited number of studies available, further investigations are needed to support our findings. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42022375772.
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Affiliation(s)
- Wen-Wen Tsai
- Department of Education, Chi Mei Medical Center, Tainan City, Taiwan
| | - Kuo-Chuan Hung
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung City, Taiwan,Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Yen-Ta Huang
- Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan City, Taiwan
| | - Chia-Hung Yu
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Chien-Hung Lin
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan City, Taiwan,I-Wen Chen,
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan,School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung City, Taiwan,*Correspondence: Cheuk-Kwan Sun,
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Cui N, Yang R, Zhang H, Chen D, Wu J, Zhang Y, Ma Y, Jin J. Using the evidence to decision frameworks to formulate the direction and strength of recommendations for adapted guidelines of physical restraints in critical care: A Delphi study. Intensive Crit Care Nurs 2023; 76:103382. [PMID: 36638685 DOI: 10.1016/j.iccn.2022.103382] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 12/20/2022] [Accepted: 12/22/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND It has been shown that the use of physical restraints has negative physiological and psychological impacts on critically ill patients. The development of clinical practice guidelines is necessary for minimizing the use of physical restraints. OBJECTIVE As part of a guideline adaptation project, this study aimed to formulate the direction and strength of recommendations for adapted guidelines of physical restraints in critical care. METHODS Literature retrieval of guidelines and systematic reviews was performed and guideline steering committee discussions were conducted to develop an inquiry questionnaire. From February to April 2022, a two-round study, including 27 multidisciplinary experts, was conducted using the evidence to decision frameworks and Delphi methods. RESULTS The 27 experts were from 22 of the 33 provinces/municipalities/autonomous regions of mainland China. For the first and second questionnaires, the recovery rates were 85.7% and 100%, respectively. In the first and second rounds, the average authoritative coefficients were 0.93 and 0.94, respectively. Regarding Kendall W values, the values were 0.555 and 0.120, respectively. A consensus was reached on 15 recommendations, including one strong recommendation, seven conditional recommendations and seven good practice statements. CONCLUSION In the two rounds of consultations, a consensus was reached on 15 recommendations for the adapted physical restraint guidelines in critical care through the evidence to decision frameworks and Delphi methods. Recommendations in the adapted physical restraint guidelines are related to institutional and educational interventions, risk assessment, the management of patients' unsafe behaviours, pain, mechanical ventilation, sleep, family engagement, mobility, sedation, and delirium. IMPLICATIONS FOR CLINICAL PRACTICE Based on our recommendations, we uggest nurses develop a physical restraint education bundle.
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Affiliation(s)
- Nianqi Cui
- Nursing Department, The Second Affiliated Hospital Zhejiang University School of Medicine (SAHZU), Hangzhou, Zhejiang, China
| | - Ruiqi Yang
- Department of Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hui Zhang
- Department of Cardiology, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
| | - Dandan Chen
- Faculty of Nursing, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jingjie Wu
- Faculty of Nursing, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yuping Zhang
- Nursing Department, The Second Affiliated Hospital Zhejiang University School of Medicine (SAHZU), Hangzhou, Zhejiang, China
| | - Yajun Ma
- Nursing Department, The Second Affiliated Hospital Zhejiang University School of Medicine (SAHZU), Hangzhou, Zhejiang, China
| | - Jingfen Jin
- Nursing Department, The Second Affiliated Hospital Zhejiang University School of Medicine (SAHZU), Hangzhou, Zhejiang, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, Zhejiang, China; Changxing Branch Hospital of SAHZU, Huzhou, Zhejiang, China.
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Nicolotti D, Grossi S, Nicolini F, Gallingani A, Rossi S. Difficult Respiratory Weaning after Cardiac Surgery: A Narrative Review. J Clin Med 2023; 12:jcm12020497. [PMID: 36675426 PMCID: PMC9867514 DOI: 10.3390/jcm12020497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/28/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023] Open
Abstract
Respiratory weaning after cardiac surgery can be difficult or prolonged in up to 22.7% of patients. The inability to wean from a ventilator within the first 48 h after surgery is related to increased short- and long-term morbidity and mortality. Risk factors are mainly non-modifiable and include preoperative renal failure, New York Heart Association, and Canadian Cardiac Society classes as well as surgery and cardio-pulmonary bypass time. The positive effects of pressure ventilation on the cardiovascular system progressively fade during the progression of weaning, possibly leading to pulmonary oedema and failure of spontaneous breathing trials. To prevent this scenario, some parameters such as pulmonary artery occlusion pressure, echography-assessed diastolic function, brain-derived natriuretic peptide, and extravascular lung water can be monitored during weaning to early detect hemodynamic decompensation. Tracheostomy is considered for patients with difficult and prolonged weaning. In such cases, optimal patient selection, timing, and technique may be important to try to reduce morbidity and mortality in this high-risk population.
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Affiliation(s)
- Davide Nicolotti
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
- Correspondence: ; Tel.: +39-0521-703286
| | - Silvia Grossi
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Francesco Nicolini
- Department of Cardiac Surgery, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Alan Gallingani
- Department of Cardiac Surgery, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Sandra Rossi
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
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Laguado-Nieto MA, Roberto-Avilán SL, Naranjo-Junoy F, Meléndez-Flórez HJ, Lozada-Martinez ID, Domínguez-Alvarado GA, Campos-Castillo VA, Ríos-Orozco SU, Narváez-Rojas AR. Diaphragmatic Dynamics and Thickness Parameters Assessed by Ultrasonography Predict Extubation Success in Critically Ill Patients. CLINICAL MEDICINE INSIGHTS: CIRCULATORY, RESPIRATORY AND PULMONARY MEDICINE 2023; 17:11795484231165940. [PMID: 37008792 PMCID: PMC10052899 DOI: 10.1177/11795484231165940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 03/08/2023] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION A frequent cause of weaning and extubation failure in critically ill mechanically ventilated patients is diaphragm muscle dysfunction. Ultrasound (US) evaluation of the diaphragm yields important data regarding its thickness (diaphragm thickening fraction [TFdi]) and its movement or excursion (diaphragmatic dynamics) that reveal the presence of diaphragmatic dysfunction. METHODS Cross-sectional study, which included patients older than 18 years with invasive mechanical ventilation with an expected duration of more than 48 h, in a tertiary referral center in Colombia. The excursion of the diaphragm, inspiratory and expiratory thickness, and TFdi were evaluated by US. Prevalence and use of medications were evaluated, and the association with failure in ventilatory weaning and extubation was analyzed. RESULTS Sixty-one patients were included. The median age and APACHE IV score were 62.42 years and 78.23, respectively. The prevalence of diaphragmatic dysfunction (assessed by excursion and TFdi) was 40.98%. The sensibility, specificity, positive predictive value, and negative predictive value for TFdi < 20% was 86%, 24%, 75%, and 40%, respectively, with an area under the receiver operating characteristic (ROC) curve of 0.6. The ultrasonographic analysis of excursion of the diaphragm, inspiratory and expiratory thickness, and TFdi (>20%) allow in its set and with normal values, predict success or failure for the extubation with an area under the ROC curve of 0.87. CONCLUSION Diaphragmatic dynamics and thickness parameters together assessed by ultrasonography could predict the success of extubation in critically ill patients in Colombia, based on the finding of diaphragmatic dysfunction.
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Affiliation(s)
| | | | - Francisco Naranjo-Junoy
- Department of Critical Medicine and Intensive Care, FOSCAL International Clinic, Bucaramanga, Colombia
| | | | - Ivan David Lozada-Martinez
- Medical and Surgical Research Center, Future Surgeons Chapter, Colombian Surgery Association, Bogotá, Colombia
- Grupo Prometheus y Biomedicina Aplicada a las Ciencias Clínicas, School of Medicine, Universidad de Cartagena, Cartagena, Colombia
- International Coalition on Surgical Research, Universidad Nacional Autónoma de Nicaragua, Managua, Nicaragua
| | | | | | | | - Alexis Rafael Narváez-Rojas
- International Coalition on Surgical Research, Universidad Nacional Autónoma de Nicaragua, Managua, Nicaragua
- Division of Breast Surgical Oncology, DeWitt Daughtry Family Department of Surgery, Jackson Health System / University of Miami Miller School of Medicine, Miami, FL, USA
- Alexis Rafael Narvaez-Rojas, International Coalition on Surgical Research, Universidad Nacional Autónoma de Nicaragua, Managua, Nicaragua; Breast Surgical Oncology Division, DeWitt Daughtry Family Department of Surgery, Jackson Health System / University of Miami Miller School of Medicine, FL, USA.
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Shahu A, Banna S, Applefeld W, Rampersad P, Alviar CL, Ali T, Luk A, Fajardo E, van Diepen S, Miller PE. Liberation From Mechanical Ventilation in the Cardiac Intensive Care Unit. JACC. ADVANCES 2023; 2:100173. [PMID: 38939038 PMCID: PMC11198553 DOI: 10.1016/j.jacadv.2022.100173] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 10/18/2022] [Accepted: 11/16/2022] [Indexed: 06/29/2024]
Abstract
The prevalence of respiratory failure is increasing in the contemporary cardiac intensive care unit (CICU) and is associated with a significant increase in morbidity and mortality. For patients that survive their initial respiratory decompensation, liberation from invasive mechanical ventilation (IMV) and the decision to extubate requires careful clinical assessment and planning. Therefore, it is essential for the CICU clinician to know how to assess and manage the various stages of IMV liberation, including ventilator weaning, evaluation of extubation readiness, and provide post-extubation care. In this review, we provide a comprehensive approach to liberation from IMV in the CICU, including cardiopulmonary interactions relative to withdrawal from positive pressure ventilation, evaluation of readiness for and assessment of spontaneous breathing trials, sedation management to optimize extubation, strategies for patients at a high risk for extubation failure, and tracheostomy in the cardiovascular patient.
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Affiliation(s)
- Andi Shahu
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Soumya Banna
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Willard Applefeld
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Penelope Rampersad
- The Tomsich Family Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Connecticut, USA
| | - Carlos L. Alviar
- The Leon H. Charney Division of Cardiovascular Medicine, New York University Langone Medicine Center, New York, New York, USA
| | - Tariq Ali
- Division of Pulmonary and Critical Care, Mayo, Rochester, Minnesota, USA
| | - Adriana Luk
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Elaine Fajardo
- Division of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sean van Diepen
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - P. Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Morris AH, Horvat C, Stagg B, Grainger DW, Lanspa M, Orme J, Clemmer TP, Weaver LK, Thomas FO, Grissom CK, Hirshberg E, East TD, Wallace CJ, Young MP, Sittig DF, Suchyta M, Pearl JE, Pesenti A, Bombino M, Beck E, Sward KA, Weir C, Phansalkar S, Bernard GR, Thompson BT, Brower R, Truwit J, Steingrub J, Hiten RD, Willson DF, Zimmerman JJ, Nadkarni V, Randolph AG, Curley MAQ, Newth CJL, Lacroix J, Agus MSD, Lee KH, deBoisblanc BP, Moore FA, Evans RS, Sorenson DK, Wong A, Boland MV, Dere WH, Crandall A, Facelli J, Huff SM, Haug PJ, Pielmeier U, Rees SE, Karbing DS, Andreassen S, Fan E, Goldring RM, Berger KI, Oppenheimer BW, Ely EW, Pickering BW, Schoenfeld DA, Tocino I, Gonnering RS, Pronovost PJ, Savitz LA, Dreyfuss D, Slutsky AS, Crapo JD, Pinsky MR, James B, Berwick DM. Computer clinical decision support that automates personalized clinical care: a challenging but needed healthcare delivery strategy. J Am Med Inform Assoc 2022; 30:178-194. [PMID: 36125018 PMCID: PMC9748596 DOI: 10.1093/jamia/ocac143] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/27/2022] [Accepted: 08/22/2022] [Indexed: 12/15/2022] Open
Abstract
How to deliver best care in various clinical settings remains a vexing problem. All pertinent healthcare-related questions have not, cannot, and will not be addressable with costly time- and resource-consuming controlled clinical trials. At present, evidence-based guidelines can address only a small fraction of the types of care that clinicians deliver. Furthermore, underserved areas rarely can access state-of-the-art evidence-based guidelines in real-time, and often lack the wherewithal to implement advanced guidelines. Care providers in such settings frequently do not have sufficient training to undertake advanced guideline implementation. Nevertheless, in advanced modern healthcare delivery environments, use of eActions (validated clinical decision support systems) could help overcome the cognitive limitations of overburdened clinicians. Widespread use of eActions will require surmounting current healthcare technical and cultural barriers and installing clinical evidence/data curation systems. The authors expect that increased numbers of evidence-based guidelines will result from future comparative effectiveness clinical research carried out during routine healthcare delivery within learning healthcare systems.
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Affiliation(s)
- Alan H Morris
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
- Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Christopher Horvat
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Brian Stagg
- Department of Ophthalmology and Visual Sciences, Moran Eye Center, University of Utah, Salt Lake City, Utah, USA
| | - David W Grainger
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah, USA
| | - Michael Lanspa
- Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - James Orme
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
- Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Terry P Clemmer
- Department of Internal Medicine (Critical Care), Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Lindell K Weaver
- Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Frank O Thomas
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Colin K Grissom
- Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Ellie Hirshberg
- Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Thomas D East
- SYNCRONYS - Chief Executive Officer, Albuquerque, New Mexico, USA
| | - Carrie Jane Wallace
- Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Michael P Young
- Department of Critical Care, Renown Regional Medical Center, Reno, Nevada, USA
| | - Dean F Sittig
- School of Biomedical Informatics, University of Texas Health Science Center, Houston, Texas, USA
| | - Mary Suchyta
- Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - James E Pearl
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
- Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Antinio Pesenti
- Faculty of Medicine and Surgery—Anesthesiology, University of Milan, Milano, Lombardia, Italy
| | - Michela Bombino
- Department of Emergency and Intensive Care, San Gerardo Hospital, Monza (MB), Italy
| | - Eduardo Beck
- Faculty of Medicine and Surgery - Anesthesiology, University of Milan, Ospedale di Desio, Desio, Lombardia, Italy
| | - Katherine A Sward
- Department of Biomedical Informatics, College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | - Charlene Weir
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Shobha Phansalkar
- Wolters Kluwer Health—Clinical Solutions—Medical Informatics, Wolters Kluwer Health, Newton, Massachusetts, USA
| | - Gordon R Bernard
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - B Taylor Thompson
- Pulmonary and Critical Care Division, Department of Internal Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Roy Brower
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jonathon Truwit
- Department of Internal Medicine, Pulmonary and Critical Care, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jay Steingrub
- Department of Internal Medicine, Pulmonary and Critical Care, University of Massachusetts Medical School, Baystate Campus, Springfield, Massachusetts, USA
| | - R Duncan Hiten
- Department of Internal Medicine, Pulmonary and Critical Care, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Douglas F Willson
- Pediatric Critical Care, Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jerry J Zimmerman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Martha A Q Curley
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Christopher J L Newth
- Childrens Hospital Los Angeles, Department of Anesthesiology and Critical Care, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Université de Montréal Faculté de Médecine, Montreal, Quebec, Canada
| | - Michael S D Agus
- Division of Medical Pediatric Critical Care, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kang Hoe Lee
- Department of Intensive Care Medicine, Ng Teng Fong Hospital and National University Centre of Transplantation, National University Singapore Yong Loo Lin School of Medicine, Singapore
| | - Bennett P deBoisblanc
- Department of Internal Medicine, Pulmonary and Critical Care, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
| | - Frederick Alan Moore
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - R Scott Evans
- Department of Medical Informatics, Intermountain Healthcare, and Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Dean K Sorenson
- Department of Medical Informatics, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Anthony Wong
- Department of Data Science Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Michael V Boland
- Department of Ophthalmology, Massachusetts Ear and Eye Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Willard H Dere
- Endocrinology and Metabolism Division, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Alan Crandall
- Department of Ophthalmology and Visual Sciences, Moran Eye Center, University of Utah, Salt Lake City, Utah, USA
- Posthumous
| | - Julio Facelli
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Stanley M Huff
- Department of Medical Informatics, Intermountain Healthcare, Department of Biomedical Informatics, University of Utah, and Graphite Health, Salt Lake City, Utah, USA
| | - Peter J Haug
- Department of Medical Informatics, Intermountain Healthcare, and Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Ulrike Pielmeier
- Aalborg University Faculty of Engineering and Science - Department of Health Science and Technology, Respiratory and Critical Care Group, Aalborg, Nordjylland, Denmark
| | - Stephen E Rees
- Aalborg University Faculty of Engineering and Science - Department of Health Science and Technology, Respiratory and Critical Care Group, Aalborg, Nordjylland, Denmark
| | - Dan S Karbing
- Aalborg University Faculty of Engineering and Science - Department of Health Science and Technology, Respiratory and Critical Care Group, Aalborg, Nordjylland, Denmark
| | - Steen Andreassen
- Aalborg University Faculty of Engineering and Science - Department of Health Science and Technology, Respiratory and Critical Care Group, Aalborg, Nordjylland, Denmark
| | - Eddy Fan
- Internal Medicine, Pulmonary and Critical Care Division, Institute of Health Policy, Management and Evaluation, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Roberta M Goldring
- Department of Internal Medicine, Pulmonary and Critical Care, New York University School of Medicine, New York, New York, USA
| | - Kenneth I Berger
- Department of Internal Medicine, Pulmonary and Critical Care, New York University School of Medicine, New York, New York, USA
| | - Beno W Oppenheimer
- Department of Internal Medicine, Pulmonary and Critical Care, New York University School of Medicine, New York, New York, USA
| | - E Wesley Ely
- Internal Medicine, Pulmonary and Critical Care, Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Tennessee Valley Veteran’s Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, Tennessee, USA
| | - Brian W Pickering
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA
| | - David A Schoenfeld
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Irena Tocino
- Department of Radiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Russell S Gonnering
- Department of Ophthalmology and Visual Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Peter J Pronovost
- Department of Anesthesiology and Critical Care Medicine, University Hospitals, Highland Hills, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Lucy A Savitz
- Northwest Center for Health Research, Kaiser Permanente, Oakland, California, USA
| | - Didier Dreyfuss
- Assistance Publique—Hôpitaux de Paris, Université de Paris, Sorbonne Université - INSERM unit UMR S_1155 (Common and Rare Kidney Diseases), Paris, France
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - James D Crapo
- Department of Internal Medicine, National Jewish Health, Denver, Colorado, USA
| | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Brent James
- Department of Internal Medicine, Clinical Excellence Research Center (CERC), Stanford University School of Medicine, Stanford, California, USA
| | - Donald M Berwick
- Institute for Healthcare Improvement, Cambridge, Massachusetts, USA
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Rose L, Istanboulian L, Amaral ACKB, Burry L, Cox CE, Cuthbertson BH, Iwashyna TJ, Dale CM, Fraser I. Co-designed and consensus based development of a quality improvement checklist of patient and family-centered actionable processes of care for adults with persistent critical illness. J Crit Care 2022; 72:154153. [PMID: 36174432 DOI: 10.1016/j.jcrc.2022.154153] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/15/2022] [Accepted: 09/06/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Few quality improvement tools specific to patients with persistent or chronic critical illness exist to aid delivery of high-quality care. Using experience-based co-design methods, we sought consensus from key stakeholders on the most important actionable processes of care for inclusion in a quality improvement checklist. METHODS Item generation methods: systematic review, semi-structured interviews (ICU survivors and family) members, touchpoint video creation, and semi-structured interviews (ICU clinicians). Consensus methods: modified online Delphi and a virtual meeting using nominal group technique methods. RESULTS We enrolled 138 ICU interprofessional team, patients, and family members. We obtained consensus on a quality improvement checklist comprising 11 core domains: patient and family involvement in decision-making; patient communication; physical comfort and complication prevention; promoting self-care and normalcy; ventilator weaning; physical therapy; swallowing; pharmacotherapy; psychological issues; delirium; and appropriate referrals. An additional 27 actionable processes are contained within 6 core domains that provide more specific direction on the actionable process to be targeted. CONCLUSIONS Using a highly collaborative and methodologically rigorous process, we generated a quality improvement checklist of actionable processes to improve patient and family-centred care considered important by key stakeholders. Future research is needed to understand optimal implementation strategies and impact on outcomes and experience.
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Affiliation(s)
- Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK.
| | - Laura Istanboulian
- Provincial Centre of Weaning Excellence, Michael Garron Hospital, Toronto, Toronto East Health Network, Canada
| | - Andre Carlos Kajdacsy-Balla Amaral
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada; Sunnybrook Research Institute, Toronto, Canada
| | - Lisa Burry
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada; Mount Sinai Hospital, Sinai Health System, Toronto, ON, Canada
| | | | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada; Sunnybrook Research Institute, Toronto, Canada; University Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Theodore J Iwashyna
- University of Michigan, Ann Arbor, VA Health System, United States of America
| | - Craig M Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Ian Fraser
- Provincial Centre of Weaning Excellence, Michael Garron Hospital, Toronto East Health Network, Toronto, Canada
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50
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Brault C, Mancebo J, Suarez Montero JC, Bentall T, Burns KEA, Piraino T, Lellouche F, Bouchard PA, Charbonney E, Carteaux G, Maraffi T, Beduneau G, Mercat A, Skrobik Y, Zuo F, Lafreniere-Roula M, Thorpe K, Brochard L, Bosma KJ. The PROMIZING trial enrollment algorithm for early identification of patients ready for unassisted breathing. Crit Care 2022; 26:188. [PMID: 35739553 PMCID: PMC9219177 DOI: 10.1186/s13054-022-04063-4] [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: 03/24/2022] [Accepted: 05/09/2022] [Indexed: 12/04/2022] Open
Abstract
Background Liberating patients from mechanical ventilation (MV) requires a systematic approach. In the context of a clinical trial, we developed a simple algorithm to identify patients who tolerate assisted ventilation but still require ongoing MV to be randomized. We report on the use of this algorithm to screen potential trial participants for enrollment and subsequent randomization in the Proportional Assist Ventilation for Minimizing the Duration of MV (PROMIZING) study. Methods The algorithm included five steps: enrollment criteria, pressure support ventilation (PSV) tolerance trial, weaning criteria, continuous positive airway pressure (CPAP) tolerance trial (0 cmH2O during 2 min) and spontaneous breathing trial (SBT): on fraction of inspired oxygen (FiO2) 40% for 30–120 min. Patients who failed the weaning criteria, CPAP Zero trial, or SBT were randomized. We describe the characteristics of patients who were initially enrolled, but passed all steps in the algorithm and consequently were not randomized. Results Among the 374 enrolled patients, 93 (25%) patients passed all five steps. At time of enrollment, most patients were on PSV (87%) with a mean (± standard deviation) FiO2 of 34 (± 6) %, PSV of 8.7 (± 2.9) cmH2O, and positive end-expiratory pressure of 6.1 (± 1.6) cmH2O. Minute ventilation was 9.0 (± 3.1) L/min with a respiratory rate of 17.4 (± 4.4) breaths/min. Patients were liberated from MV with a median [interquartile range] delay between initial screening and extubation of 5 [1–49] hours. Only 7 (8%) patients required reintubation. Conclusion The trial algorithm permitted identification of 93 (25%) patients who were ready to extubate, while their clinicians predicted a duration of ventilation higher than 24 h. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04063-4.
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