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Chow JWY, Al-Bassam W, Yanase F, O'Brien Z, Bassam A, Hadzakis S, Chaba A, Maeda A, Bellomo R, Serpa Neto A. P0.1 During Pressure Support Ventilation. Am J Respir Crit Care Med 2024; 209:590-592. [PMID: 37991405 DOI: 10.1164/rccm.202307-1314le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/21/2023] [Indexed: 11/23/2023] Open
Affiliation(s)
- Joanna W Y Chow
- Alfred Hospital, Alfred Health, Melbourne, Victoria, Australia
- Box Hill Hospital, Eastern Health, Melbourne, Victoria, Australia
| | - Wisam Al-Bassam
- Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | | | - Zachary O'Brien
- Austin Health and
- Department of Critical Care, Melbourne University, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Ahmad Bassam
- Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
| | - Stefanos Hadzakis
- Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
| | | | | | - Rinaldo Bellomo
- Austin Health and
- Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Victoria, Australia
- Department of Critical Care, Melbourne University, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia; and
| | - Ary Serpa Neto
- Austin Health and
- Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Vaara ST, Serpa Neto A, Bellomo R, Adhikari NKJ, Dreyfuss D, Gallagher M, Gaudry S, Hoste E, Joannidis M, Pettilä V, Wang AY, Kashani K, Wald R, Bagshaw SM, Ostermann M. Regional Practice Variation and Outcomes in the Standard Versus Accelerated Initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) Trial: A Post Hoc Secondary Analysis. Crit Care Explor 2024; 6:e1053. [PMID: 38380940 PMCID: PMC10878545 DOI: 10.1097/cce.0000000000001053] [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] [Indexed: 02/22/2024] Open
Abstract
OBJECTIVES Among patients with severe acute kidney injury (AKI) admitted to the ICU in high-income countries, regional practice variations for fluid balance (FB) management, timing, and choice of renal replacement therapy (RRT) modality may be significant. DESIGN Secondary post hoc analysis of the STandard vs. Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial (ClinicalTrials.gov number NCT02568722). SETTING One hundred-fifty-three ICUs in 13 countries. PATIENTS Altogether 2693 critically ill patients with AKI, of whom 994 were North American, 1143 European, and 556 from Australia and New Zealand (ANZ). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Total mean FB to a maximum of 14 days was +7199 mL in North America, +5641 mL in Europe, and +2211 mL in ANZ (p < 0.001). The median time to RRT initiation among patients allocated to the standard strategy was longest in Europe compared with North America and ANZ (p < 0.001; p < 0.001). Continuous RRT was the initial RRT modality in 60.8% of patients in North America and 56.8% of patients in Europe, compared with 96.4% of patients in ANZ (p < 0.001). After adjustment for predefined baseline characteristics, compared with North American and European patients, those in ANZ were more likely to survive to ICU (p < 0.001) and hospital discharge (p < 0.001) and to 90 days (for ANZ vs. Europe: risk difference [RD], -11.3%; 95% CI, -17.7% to -4.8%; p < 0.001 and for ANZ vs. North America: RD, -10.3%; 95% CI, -17.5% to -3.1%; p = 0.007). CONCLUSIONS Among STARRT-AKI trial centers, significant regional practice variation exists regarding FB, timing of initiation of RRT, and initial use of continuous RRT. After adjustment, such practice variation was associated with lower ICU and hospital stay and 90-day mortality among ANZ patients compared with other regions.
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Affiliation(s)
- Suvi T Vaara
- Department of Perioperative and Intensive Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, VIC, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, VIC, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Data Analytics Research & Evaluation, Austin Hospital, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Neill K J Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Didier Dreyfuss
- French National Institute of Health and Medical Research (INSERM), UMR_S1155, CORAKID, Hôpital Tenon, Sorbonne Université, Paris, France
- Service de Médecine Intensive Réanimation, Hôpital Louis Mourier, Assistance Publique, Université de Paris-Cité, Paris, France
| | - Martin Gallagher
- South Western Sydney Clinical Campus, Faculty of Medicine & Health, University of New South Wales, New South Wales, NSW, Australia
- The George Institute for Global Health, University of New South Wales, New South Wales, Australia
| | - Stephane Gaudry
- French National Institute of Health and Medical Research (INSERM), UMR_S1155, CORAKID, Hôpital Tenon, Sorbonne Université, Paris, France
- AP-HP, Hôpital Avicenne, Service de Réanimation Médico-Chirurgicale, UFR SMBH, Université Sorbonne Paris Nord, Bobigny, France
| | - Eric Hoste
- Intensive Care Unit, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Ville Pettilä
- Department of Perioperative and Intensive Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Amanda Y Wang
- South Western Sydney Clinical Campus, Faculty of Medicine & Health, University of New South Wales, New South Wales, NSW, Australia
- The George Institute for Global Health, University of New South Wales, New South Wales, Australia
- The Faculty of Medicine and Medical Sciences, Macquarie University, Sydney, NSW, Australia
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Ron Wald
- Medicine Program and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Division of Nephrology, St. Michael's Hospital and the University of Toronto and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
| | - Marlies Ostermann
- Department of Critical Care Medicine, King's College London, Guy's & St Thomas' Hospital, London, United Kingdom
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McIntyre ML, Chimunda T, Murray J, Lewis TW, Doeltgen SH. The prevalence of post-extubation dysphagia in critically ill adults: an Australian data linkage study. CRIT CARE RESUSC 2022; 24:352-359. [PMID: 38047004 PMCID: PMC10692610 DOI: 10.51893/2022.4.oa5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Objective: To define the prevalence of dysphagia after endotracheal intubation in critically ill adult patients. Design: A retrospective observational data linkage cohort study using the Australian and New Zealand Intensive Care Society Adult Patient Database and a mandatory government statewide health care administration database. Setting: Private and public intensive care units (ICUs) within Victoria, Australia. Participants: Adult patients who required endotracheal intubation for the purpose of mechanical ventilation within a Victorian ICU between July 2013 and June 2018. Main outcome measures: Presence of dysphagia, aspiration pneumonia, ICU length of stay, hospital length of stay, and cost per episode of care. Results: Endotracheal intubation in the ICU was required for 71 124 patient episodes across the study period. Dysphagia was coded in 7.3% (n = 5203) of those episodes. Patients with dysphagia required longer ICU (median, 154 [interquartile range (IQR), 78-259] v 53 [IQR, 27-107] hours; P < 0.001) and hospital admissions (median, 20 [IQR, 13-30] v 8 [IQR, 5-15] days; P < 0.001), were more likely to develop aspiration pneumonia (17.2% v 5.6%; odds ratio, 3.0; 95% CI, 2.8-3.2; P < 0.001), and the median health care expenditure increased by 93% per episode of care ($73 586 v $38 108; P < 0.001) compared with patients without dysphagia. Conclusions: Post-extubation dysphagia is associated with adverse patient and health care outcomes. Consideration should be given to strategies that support early identification of patients with dysphagia in the ICU to determine if these adverse outcomes can be reduced.
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Affiliation(s)
- Melanie L. McIntyre
- Swallowing Neurorehabilitation Research Lab, Speech Pathology, Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
- Department of Speech Pathology, Bendigo Health, Bendigo, VIC, Australia
| | - Timothy Chimunda
- Department of Critical Care, Northern Health, Epping, VIC, Australia
- University of Queensland, Brisbane, QLD, Australia
- University of Melbourne, Melbourne, VIC, Australia
| | - Joanne Murray
- Swallowing Neurorehabilitation Research Lab, Speech Pathology, Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Trent W. Lewis
- Medical Devices Research Institute, Flinders University, Adelaide, SA, Australia
- College of Science Engineering, Flinders University, Adelaide, SA, Australia
| | - Sebastian H. Doeltgen
- Swallowing Neurorehabilitation Research Lab, Speech Pathology, Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
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Ni YN, Wang T, Liang BM, Liang ZA. The Effect of Conservative Oxygen Therapy in Reducing Mortality in Critical Care Patients: A Meta-Analysis and Trial Sequential Analysis. Front Med (Lausanne) 2021; 8:738418. [PMID: 34957139 PMCID: PMC8702806 DOI: 10.3389/fmed.2021.738418] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 11/09/2021] [Indexed: 02/05/2023] Open
Abstract
Background: Conservative oxygen therapy can prevent both hypoxemia and hyperoxemia, but the effect on the prognosis of patients admitted to the intensive care unit (ICU) remains controversial. Methods: All controlled studies comparing conservative oxygen therapy and conventional oxygen therapy in adult patients admitted to the ICU were searched. The primary outcome was mortality, and the secondary outcomes were length of ICU stay (ICU LOS), length of hospital stay (hospital LOS), length of mechanical ventilation (MV) hours, new organ failure during ICU stay, and new infections during ICU stay. Results: Nine trials with a total of 5,759 patients were pooled in our final studies. Compared with conventional oxygen therapy, conservative oxygen therapy did not reduce overall mortality (Z = 0.31, p = 0.75) or ICU LOS (Z = 0.17, p = 0.86), with firm evidence from trial sequential analysis, or hospital LOS (Z = 1.98, p = 0.05) or new infections during the ICU stay (Z = 1.45, p = 0.15). However, conservative oxygen therapy was associated with a shorter MV time (Z = 5.05, p < 0.00001), reduction of new organ failure during the ICU stay (Z = 2.15, p = 0.03) and lower risk of renal replacement therapy (RRT) (Z = 2.18, p = 0.03). Conclusion: Conservative oxygen therapy did not reduce mortality but did decrease MV time, new organ failure and risk of RRT in critically ill patients. Systematic Review Registration: identifier [CRD42020171055].
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Affiliation(s)
- Yue-Nan Ni
- Department of Respiratory and Critical Care, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Ting Wang
- Department of Respiratory and Critical Care, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Bin-Miao Liang
- Department of Respiratory and Critical Care, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Zong-An Liang
- Department of Respiratory and Critical Care, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
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Al-Bassam W, Parikh T, Neto AS, Idrees Y, Kubicki MA, Hodgson CL, Subramaniam A, Reddy MP, Gullapalli N, Michel C, Matthewman MC, Naughton J, Pereira J, Shehabi Y, Bellomo R. Pressure support ventilation in intensive care patients receiving prolonged invasive ventilation. CRIT CARE RESUSC 2021; 23:394-402. [PMID: 38046681 PMCID: PMC10692625 DOI: 10.51893/2021.4.oa4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: To our knowledge, the use and management of pressure support ventilation (PSV) in patients receiving prolonged (≥ 7 days) invasive mechanical ventilation has not previously been described. Objective: To collect and analyse data on the use and management of PSV in critically ill patients receiving prolonged ventilation. Design, setting and participants: We performed a multicentre retrospective observational study in Australia, with a focus on PSV in patients ventilated for ≥ 7 days. Main outcome measures: We obtained detailed data on ventilator management twice daily (8am and 8pm moments) for the first 7 days of ventilation. Results: Among 143 consecutive patients, 90/142 (63.4%) had received PSV by Day 7, and PSV accounted for 40.5% (784/1935) of ventilation moments. The most common pressure support level was 10 cmH2O (352/780) observations [45.1%]) with little variation over time, and 37 of 114 patients (32.4%) had no change in pressure support. Mean tidal volume during PSV was 8.3 (7.0-9.5) mL/kg predicted bodyweight (PBW) compared with 7.5 (7.0-8.3) mL/kg PBW during mandatory ventilation (P < 0.001). For 74.6% (247/331) of moments, despite a tidal volume of more than 8 mL/kg PBW, the pressure support level was not changed. Among 122 patients exposed to PSV, 97 (79.5%) received likely over-assistance according to rapid shallow breathing index criteria. Of 784 PSV moments, 411 (52.4%) were also likely over-assisted according to rapid shallow breathing index criteria, and 269/346 (77.7%) having no subsequent adjustment of pressure support. Conclusions: In patients receiving prolonged ventilation, almost two-thirds received PSV, which accounted for 40.5% of mechanical ventilation time. Half of the PSV-treated patients were exposed to high tidal volume and two-thirds to likely over-assistance. These observations provide evidence that can be used to inform interventional studies of PSV management.
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Affiliation(s)
- Wisam Al-Bassam
- Department of Intensive Care, Monash Medical Centre, Melbourne, VIC, Australia
| | - Tapan Parikh
- Department of Intensive Care, Monash Medical Centre, Melbourne, VIC, Australia
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Data Analytics Research and Evaluation Centre, Austin Hospital and University of Melbourne, Melbourne, VIC, Australia
| | - Yamamah Idrees
- Department of Intensive Care, Ballarat Base Hospital, Ballarat, VIC, Australia
| | - Mark A. Kubicki
- Department of Intensive Care, Ballarat Base Hospital, Ballarat, VIC, Australia
| | - Carol L. Hodgson
- Department of Intensive Care, The Alfred, Melbourne, VIC, Australia
| | - Ashwin Subramaniam
- Department of Intensive Care, Frankston Hospital, Melbourne, VIC, Australia
| | | | - Navya Gullapalli
- School of Medicine, Monash University, Melbourne, VIC, Australia
| | - Claire Michel
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | | | - Jack Naughton
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Jason Pereira
- Department of Intensive Care, The Alfred, Melbourne, VIC, Australia
| | - Yahya Shehabi
- Department of Intensive Care, Monash Medical Centre, Melbourne, VIC, Australia
- Department of Surgery, Monash University, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, Austin Hospital and University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
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6
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The incidence and clinical outcomes of postextubation dysphagia in a regional critical care setting. Aust Crit Care 2021; 35:107-112. [PMID: 34034939 DOI: 10.1016/j.aucc.2021.03.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 01/14/2021] [Accepted: 03/24/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Postextubation dysphagia (PED) has been shown to occur in 41% of critically ill patients requiring endotracheal intubation. With one-third of patients with PED experiencing silent aspiration, it is reasonable to anticipate negative health outcomes are likely, although this has not yet been systematically explored in an Australian context. OBJECTIVES The aim of the study was to determine the impact of PED, in a regional Australian intensive care unit (ICU), on rates of pneumonia, the length of stay in the ICU and hospital, and healthcare expenditure. METHODS This study was conducted as a retrospective cohort analysis, which used administrative healthcare data of patients who received endotracheal intubation for invasive mechanical ventilation. Patients with a tracheostomy or known pre-existing dysphagia were excluded. RESULTS A total of 822 patient episodes were identified, of which 7% (n = 58) presented with PED. Half of all patients within the PED cohort (53%) were intubated for fewer than 48 h. Patients with PED had a longer median length of stay in the ICU (5 days versus 3 days, p < 0.001) and were more likely to develop pneumonia (odds ratio = 2.51, 95% confidence interval = 1.28, 4.95) than extubated patients without dysphagia. Median cost per hospital admission for patients with PED was double that for extubated patients without dysphagia (AUD $42,685 versus AUD $20,840, p < 0.001). CONCLUSIONS This study highlights that even a short duration of intubation may carry a risk of PED. The presence of PED, regardless of duration of intubation, increased the rates of pneumonia, length of stay in the ICU and hospital, and healthcare expenditure.
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Cardinal LA, Freeman-Sanderson A, Togher L. The speech pathology workforce in intensive care units: Results from a national survey. Aust Crit Care 2020; 33:250-258. [PMID: 32386794 DOI: 10.1016/j.aucc.2020.02.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/24/2020] [Accepted: 02/25/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Admission to the intensive care unit (ICU) with mechanical ventilation can lead to patients experiencing impaired swallowing and communication function. This can negatively affect patient experiences and outcomes. There is increasing research supporting early intervention for swallowing and communication; however, there are no published ICU workforce data to determine patient access. PURPOSE The purpose of this study was to describe national ICU access to speech pathology (SP) services and to describe the nature of this workforce. METHODS Prospective audit of Australian ICUs with a focussed workforce survey of SP service including workforce demographics, clinical practices, team environments, and training was conducted. Data are described as percentage (%, n) and as median (interquartile range). Qualitative data were analysed using thematic frameworks. RESULTS SP services were available at 99% (n = 165) of the sites; 62 sites provided workforce data (45% response rate). Seventy-one percent of respondents serviced the ICU ≤10 h per week, with 23% reporting dedicated funding. Almost a third (32%) reported not participating in ICU team activities, and more than half of the sites (56%) did not provide ICU-specific training with resulting varied clinical confidence ratings. Facilitator and barriers both highlighted team working relationships. Facilitator themes were building working relationships, understanding the SP role in the multidisciplinary team, physical presence in the unit, and access to resources. Barrier themes were the multidisciplinary team's understanding of SP roles and lack of presence of SP services in the ICU. CONCLUSIONS SP services are not standard across Australian ICUs, with variations in confidence, funding, training, and team environments. Further research into the impact of these variations on patient outcomes is needed.
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Affiliation(s)
- Lara Anne Cardinal
- The University of Sydney, 75 East Street, Lidcombe, NSW, 2141, Australia.
| | - Amy Freeman-Sanderson
- University of Technology Sydney, PO Box 123 Broadway, Ultimo, NSW, 2007, Australia; The University of Sydney, 75 East Street, Lidcombe, NSW, 2141, Australia.
| | - Leanne Togher
- The University of Sydney, 75 East Street, Lidcombe, NSW, 2141, Australia.
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Kim KT, Morton S, Howe S, Chiew YS, Knopp JL, Docherty P, Pretty C, Desaive T, Benyo B, Szlavecz A, Moeller K, Shaw GM, Chase JG. Model-based PEEP titration versus standard practice in mechanical ventilation: a randomised controlled trial. Trials 2020; 21:130. [PMID: 32007099 PMCID: PMC6995650 DOI: 10.1186/s13063-019-4035-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 12/29/2019] [Indexed: 11/12/2022] Open
Abstract
Background Positive end-expiratory pressure (PEEP) at minimum respiratory elastance during mechanical ventilation (MV) in patients with acute respiratory distress syndrome (ARDS) may improve patient care and outcome. The Clinical utilisation of respiratory elastance (CURE) trial is a two-arm, randomised controlled trial (RCT) investigating the performance of PEEP selected at an objective, model-based minimal respiratory system elastance in patients with ARDS. Methods and design The CURE RCT compares two groups of patients requiring invasive MV with a partial pressure of arterial oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio ≤ 200; one criterion of the Berlin consensus definition of moderate (≤ 200) or severe (≤ 100) ARDS. All patients are ventilated using pressure controlled (bi-level) ventilation with tidal volume = 6–8 ml/kg. Patients randomised to the control group will have PEEP selected per standard practice (SPV). Patients randomised to the intervention will have PEEP selected based on a minimal elastance using a model-based computerised method. The CURE RCT is a single-centre trial in the intensive care unit (ICU) of Christchurch hospital, New Zealand, with a target sample size of 320 patients over a maximum of 3 years. The primary outcome is the area under the curve (AUC) ratio of arterial blood oxygenation to the fraction of inspired oxygen over time. Secondary outcomes include length of time of MV, ventilator-free days (VFD) up to 28 days, ICU and hospital length of stay, AUC of oxygen saturation (SpO2)/FiO2 during MV, number of desaturation events (SpO2 < 88%), changes in respiratory mechanics and chest x-ray index scores, rescue therapies (prone positioning, nitric oxide use, extracorporeal membrane oxygenation) and hospital and 90-day mortality. Discussion The CURE RCT is the first trial comparing significant clinical outcomes in patients with ARDS in whom PEEP is selected at minimum elastance using an objective model-based method able to quantify and consider both inter-patient and intra-patient variability. CURE aims to demonstrate the hypothesized benefit of patient-specific PEEP and attest to the significance of real-time monitoring and decision-support for MV in the critical care environment. Trial registration Australian New Zealand Clinical Trial Registry, ACTRN12614001069640. Registered on 22 September 2014. (https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366838&isReview=true) The CURE RCT clinical protocol and data usage has been granted by the New Zealand South Regional Ethics Committee (Reference number: 14/STH/132).
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Affiliation(s)
- Kyeong Tae Kim
- Centre for Bioengineering, University of Canterbury, Christchurch, New Zealand.
| | - Sophie Morton
- Centre for Bioengineering, University of Canterbury, Christchurch, New Zealand
| | - Sarah Howe
- Centre for Bioengineering, University of Canterbury, Christchurch, New Zealand
| | | | - Jennifer L Knopp
- Centre for Bioengineering, University of Canterbury, Christchurch, New Zealand
| | - Paul Docherty
- Centre for Bioengineering, University of Canterbury, Christchurch, New Zealand
| | - Christopher Pretty
- Centre for Bioengineering, University of Canterbury, Christchurch, New Zealand
| | - Thomas Desaive
- GIGA Cardiovascular Science, University of Liege, Liege, Belgium
| | - Balazs Benyo
- Department of Control Engineering and Information, Budapest University of Technology and Economics, Budapest, Hungary
| | - Akos Szlavecz
- Department of Control Engineering and Information, Budapest University of Technology and Economics, Budapest, Hungary
| | - Knut Moeller
- Institute of Technical Medicine (ITeM), HFU Furtwangen University, Villingen-Schwenningen, Germany
| | - Geoffrey M Shaw
- Department of Intensive Care, Christchurch Hospital, Christchurch, New Zealand
| | - J Geoffrey Chase
- Centre for Bioengineering, University of Canterbury, Christchurch, New Zealand
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Bayram B, Şancı E. Invasive mechanical ventilation in the emergency department. Turk J Emerg Med 2019; 19:43-52. [PMID: 31065603 PMCID: PMC6495062 DOI: 10.1016/j.tjem.2019.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 03/13/2019] [Indexed: 10/29/2022] Open
Abstract
Emergency department (ED) lenght of stay of the patients requiring admission to the intensive care units has increased gradually in recent years. Mechanical ventilation is an integral part of critical care and mechanically ventilated patients have to be managed and monitored by emergency physicians for longer than expected in EDs. This early period of care has significant impact on the outcomes of these patients. Therefore, emergency physicians should have comprehensive knowledge of mechanical ventilation. This review will summarize the current literature of the basic concepts, appropriate clinical applications, monitoring parameters, components and mechanisms of mechanical ventilation in the ED.
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Affiliation(s)
- Başak Bayram
- Dokuz Eylul University, School of Medicine, Department of Emergency Medicine, Izmir, Turkey
| | - Emre Şancı
- Darıca Farabi Education and Research Hospital, Department of Emergency Medicine, Kocaeli, Turkey
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Jabaley CS, Groff RF, Sharifpour M, Raikhelkar JK, Blum JM. Modes of mechanical ventilation vary between hospitals and intensive care units within a university healthcare system: a retrospective observational study. BMC Res Notes 2018; 11:425. [PMID: 29970159 PMCID: PMC6029057 DOI: 10.1186/s13104-018-3534-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 06/26/2018] [Indexed: 01/16/2023] Open
Abstract
Objective As evidence-based guidance to aid clinicians with mechanical ventilation mode selection is scant, we sought to characterize the epidemiology thereof within a university healthcare system and hypothesized that nonconforming approaches could be readily identified. We conducted an exploratory retrospective observational database study of routinely recorded mechanical ventilation parameters between January 1, 2010 and December 31, 2016 from 12 intensive care units. Mode epoch count proportions were examined using Chi squared and Fisher exact tests as appropriate on an inter-unit basis with outlier detection for two test cases via post hoc pairwise analyses of a binomial regression model. Results Final analysis included 559,734 mode epoch values. Significant heterogeneity was demonstrated between individual units (P < 0.05 for all comparisons). One unit demonstrated heightened utilization of high-frequency oscillatory ventilation, and three units demonstrated frequent synchronized intermittent mandatory ventilation utilization. Assist control ventilation was the most commonly recorded mode (51%), followed by adaptive support ventilation (23.1%). Volume-controlled modes were about twice as common as pressure-controlled modes (64.4% versus 35.6%). Our methodology provides a means by which to characterize the epidemiology of mechanical ventilation approaches and identify nonconforming practices. The observed variability warrants further clinical study about contributors and the impact on relevant outcomes. Electronic supplementary material The online version of this article (10.1186/s13104-018-3534-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Craig S Jabaley
- Division of Critical Care Medicine, Department of Anesthesiology, Emory University, 1364 Clifton Road NE, Atlanta, GA, 30322, USA. .,Division of Critical Care Medicine, Anesthesiology Service Line, Atlanta Veterans Affairs Medical Center, Decatur, GA, USA.
| | - Robert F Groff
- Division of Critical Care Medicine, Department of Anesthesiology, Emory University, 1364 Clifton Road NE, Atlanta, GA, 30322, USA.,Division of Critical Care Medicine, Anesthesiology Service Line, Atlanta Veterans Affairs Medical Center, Decatur, GA, USA
| | - Milad Sharifpour
- Division of Critical Care Medicine, Department of Anesthesiology, Emory University, 1364 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Jayashree K Raikhelkar
- Division of Critical Care Medicine, Department of Anesthesiology, Emory University, 1364 Clifton Road NE, Atlanta, GA, 30322, USA.,Division of Critical Care Medicine, Anesthesiology Service Line, Atlanta Veterans Affairs Medical Center, Decatur, GA, USA
| | - James M Blum
- Division of Critical Care Medicine, Department of Anesthesiology, Emory University, 1364 Clifton Road NE, Atlanta, GA, 30322, USA.,Division of Critical Care Medicine, Anesthesiology Service Line, Atlanta Veterans Affairs Medical Center, Decatur, GA, USA.,Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA, USA
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Carruthers H, Astin F, Munro W. Which alternative communication methods are effective for voiceless patients in Intensive Care Units? A systematic review. Intensive Crit Care Nurs 2017; 42:88-96. [DOI: 10.1016/j.iccn.2017.03.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 03/03/2017] [Accepted: 03/04/2017] [Indexed: 01/08/2023]
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Chen YJ, Hwang SL, Li CR, Yang CC, Huang KL, Lin CY, Lee CY. Vagal withdrawal and psychological distress during ventilator weaning and the related outcomes. J Psychosom Res 2017; 101:10-16. [PMID: 28867413 DOI: 10.1016/j.jpsychores.2017.07.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 07/25/2017] [Accepted: 07/26/2017] [Indexed: 02/01/2023]
Abstract
OBJECTIVE This study investigated the associations between changes in autonomic nervous system (ANS) function, psychological status during the mechanical ventilation (MV) weaning process, and weaning outcomes. METHODS In this prospective study, we recruited 67 patients receiving MV for >24h at a medical center in northern Taiwan. Patients' ANS function, represented by heart rate variability (HRV), the rapid shallow breathing index (RSBI), anxiety, fear, and dyspnea, was repeatedly measured 10min before and 30min after undergoing a weaning trial. Forty-nine patients capable of sustaining a 2-h weaning trial were successfully weaned. RESULTS Compared with the failed group, the success group showed significantly smaller decreases in high-frequency HRV (HRV-HF) and smaller increases in RSBI (per 10 breaths/min/L), fear, dyspnea, and anxiety in response to the weaning trial (odds ratio [OR]=2.19, 0.81, 0.69, 0.66, and 0.77, respectively; p<0.05). Multivariate analyses revealed that low-frequency HRV before weaning (OR=2.32; 95% confidence interval [CI]=1.13-4.78, p=0.02), changes in HRV-HF (OR=3.33; 95% CI=1.18-9.44, p=0.02), and psychological fear during the weaning process (OR=0.50; 95% CI=0.27-0.92, p=0.03) were three independent factors associated with 2-h T-piece weaning success. CONCLUSIONS ANS responses and psychological distress during weaning were associated with T-piece weaning outcomes and may reflect the need for future studies to utilize these factors to guide weaning processes and examine their impact on outcomes.
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Affiliation(s)
- Yu-Ju Chen
- School of Nursing, National Defense Medical Center, Taipei, Taiwan.
| | - Shiow-Li Hwang
- Department of Nursing, Asia University, Taichung, Taiwan
| | - Chi-Rong Li
- Department of Teaching and Research, Taichung Hospital, Ministry of Health and Welfare, Taiwan
| | - Chia-Chen Yang
- School of Nursing, National Defense Medical Center, Taipei, Taiwan
| | - Kun-Lun Huang
- Hyperbaric Oxygen Therapy Center, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chih-Yuan Lin
- Department of Surgery, National Defense Medical Center, Division of Cardiovascular Surgery, Tri-Service General Hospital, Taipei, Taiwan
| | - Ching-Yi Lee
- Division of Pulmonary and Critical Care Medicine, Tri-Service General Hospital, Taipei, Taiwan
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Ward D, Fulbrook P. Nursing Strategies for Effective Weaning of the Critically Ill Mechanically Ventilated Patient. Crit Care Nurs Clin North Am 2016; 28:499-512. [PMID: 28236395 DOI: 10.1016/j.cnc.2016.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The risks imposed by mechanical ventilation can be mitigated by nurses' use of strategies that promote early but appropriate reduction of ventilatory support and timely extubation. Weaning from mechanical ventilation is confounded by the multiple impacts of critical illness on the body's systems. Effective weaning strategies that combine several interventions that optimize weaning readiness and assess readiness to wean, and use a weaning protocol in association with spontaneous breathing trials, are likely to reduce the requirement for mechanical ventilatory support in a timely manner. Weaning strategies should be reviewed and updated regularly to ensure congruence with the best available evidence.
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Affiliation(s)
- Darian Ward
- Education, Training and Research, Wide Bay Hospital and Health Service, 65 Main Street, Hervey Bay, Queensland 4655, Australia.
| | - Paul Fulbrook
- Nursing Research and Practice Development Centre, The Prince Charles Hospital, Brisbane 4032, Australia; School of Nursing, Midwifery and Paramedicine, Australian Catholic University, 1100 Nudgee Road, Brisbane 4014, Australia
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Frutos-Vivar F, Esteban A. Our paper 20 years later: how has withdrawal from mechanical ventilation changed? Intensive Care Med 2014; 40:1449-59. [PMID: 25053247 DOI: 10.1007/s00134-014-3362-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 06/03/2014] [Indexed: 10/25/2022]
Abstract
Withdrawal from mechanical ventilation (or weaning) is one of the most common procedures in intensive care units. Almost 20 years ago, we published one of the seminal papers on weaning in which we showed that the best method for withdrawal from mechanical ventilation in difficult-to-wean patients was a once-daily spontaneous breathing trial with a T-piece. Progress has not stood still, and in the intervening years up to the present several other studies, by our group and others, have shaped weaning into an evidence-based technique. The results of these studies have been applied progressively to routine clinical practice. Currently, withdrawal from mechanical ventilation can be summarized as the evaluation of extubation readiness based on the patient's performance during a spontaneous breathing trial. This trial can be performed with a T-piece, which is the most common approach, or with continuous positive airway pressure or low levels of pressure support. Most patients can be disconnected after passing the first spontaneous breathing trial. In patients who fail the first attempt at withdrawal, the use of a once-daily spontaneous breathing trial or a gradual reduction in pressure support are the preferred weaning methods. However, new applications of standard techniques, such as noninvasive positive pressure ventilation, or new methods of mechanical ventilation, such as automatic tube compensation, automated closed-loop systems, and automated knowledge-based weaning systems, can play a role in the management of the patients with difficult or prolonged weaning.
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Affiliation(s)
- Fernando Frutos-Vivar
- Hospital Universitario de Getafe, Carretera de Toledo Km.12,500, Getafe, Madrid, Spain
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15
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Rose L, Schultz MJ, Cardwell CR, Jouvet P, McAuley DF, Blackwood B. Automated versus non-automated weaning for reducing the duration of mechanical ventilation for critically ill adults and children. Cochrane Database Syst Rev 2014; 2014:CD009235. [PMID: 24915581 PMCID: PMC6517003 DOI: 10.1002/14651858.cd009235.pub3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Automated closed loop systems may improve adaptation of mechanical support for a patient's ventilatory needs and facilitate systematic and early recognition of their ability to breathe spontaneously and the potential for discontinuation of ventilation. This review was originally published in 2013 with an update published in 2014. OBJECTIVES The primary objective for this review was to compare the total duration of weaning from mechanical ventilation, defined as the time from study randomization to successful extubation (as defined by study authors), for critically ill ventilated patients managed with an automated weaning system versus no automated weaning system (usual care).Secondary objectives for this review were to determine differences in the duration of ventilation, intensive care unit (ICU) and hospital lengths of stay (LOS), mortality, and adverse events related to early or delayed extubation with the use of automated weaning systems compared to weaning in the absence of an automated weaning system. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 8); MEDLINE (OvidSP) (1948 to September 2013); EMBASE (OvidSP) (1980 to September 2013); CINAHL (EBSCOhost) (1982 to September 2013); and the Latin American and Caribbean Health Sciences Literature (LILACS). Relevant published reviews were sought using the Database of Abstracts of Reviews of Effects (DARE) and the Health Technology Assessment Database (HTA Database). We also searched the Web of Science Proceedings; conference proceedings; trial registration websites; and reference lists of relevant articles. The original search was run in August 2011, with database auto-alerts up to August 2012. SELECTION CRITERIA We included randomized controlled trials comparing automated closed loop ventilator applications to non-automated weaning strategies including non-protocolized usual care and protocolized weaning in patients over four weeks of age receiving invasive mechanical ventilation in an ICU. DATA COLLECTION AND ANALYSIS Two authors independently extracted study data and assessed risk of bias. We combined data in forest plots using random-effects modelling. Subgroup and sensitivity analyses were conducted according to a priori criteria. MAIN RESULTS We included 21 trials (19 adult, two paediatric) totaling 1676 participants (1628 adults, 48 children) in this updated review. Pooled data from 16 eligible trials reporting weaning duration indicated that automated closed loop systems reduced the geometric mean duration of weaning by 30% (95% confidence interval (CI) 13% to 45%), however heterogeneity was substantial (I(2) = 87%, P < 0.00001). Reduced weaning duration was found with mixed or medical ICU populations (42%, 95% CI 10% to 63%) and Smartcare/PS™ (28%, 95% CI 7% to 49%) but not in surgical populations or using other systems. Automated closed loop systems reduced the duration of ventilation (10%, 95% CI 3% to 16%) and ICU LOS (8%, 95% CI 0% to 15%). There was no strong evidence of an effect on mortality rates, hospital LOS, reintubation rates, self-extubation and use of non-invasive ventilation following extubation. Prolonged mechanical ventilation > 21 days and tracheostomy were reduced in favour of automated systems (relative risk (RR) 0.51, 95% CI 0.27 to 0.95 and RR 0.67, 95% CI 0.50 to 0.90 respectively). Overall the quality of the evidence was high with the majority of trials rated as low risk. AUTHORS' CONCLUSIONS Automated closed loop systems may result in reduced duration of weaning, ventilation and ICU stay. Reductions are more likely to occur in mixed or medical ICU populations. Due to the lack of, or limited, evidence on automated systems other than Smartcare/PS™ and Adaptive Support Ventilation no conclusions can be drawn regarding their influence on these outcomes. Due to substantial heterogeneity in trials there is a need for an adequately powered, high quality, multi-centre randomized controlled trial in adults that excludes 'simple to wean' patients. There is a pressing need for further technological development and research in the paediatric population.
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Affiliation(s)
- Louise Rose
- Sunnybrook Health Sciences Centre and Sunnybrook Research InstituteDepartment of Critical Care MedicineTorontoCanada
| | - Marcus J Schultz
- Academic Medical Center, University of AmsterdamLaboratory of Experimental Intensive Care and AnesthesiologyMeibergdreef 9AmsterdamNetherlands1105AZ
| | - Chris R Cardwell
- Queen's University BelfastCentre for Public HealthSchool of MedicineDentistry and Biomedical SciencesBelfastNorthern IrelandUKBT12 6BJ
| | - Philippe Jouvet
- Sainte‐Justine Hospital, University of MontrealDepartment of Pediatrics3175 Chemin Côte Sainte CatherineMontrealQCCanadaH3T 1C5
| | - Danny F McAuley
- Queen's University BelfastCentre for Experimental Medicine, School of Medicine, Dentistry and Biomedical SciencesWellcome‐Wolfson Building97 Lisburn RoadBelfastNorthern IrelandUKBT9 7BL
- Royal Victoria HospitalRegional Intensive Care UnitGrosvenor RoadBelfastUKBT12 6BA
| | - Bronagh Blackwood
- Queen's University BelfastCentre for Experimental Medicine, School of Medicine, Dentistry and Biomedical SciencesWellcome‐Wolfson Building97 Lisburn RoadBelfastNorthern IrelandUKBT9 7BL
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16
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Eastwood GM, Peck L, Young H, Suzuki S, Garcia M, Bellomo R. Intensive care clinicians' opinion of conservative oxygen therapy (SpO₂ 90-92%) for mechanically ventilated patients. Aust Crit Care 2013; 27:120-5. [PMID: 24369915 DOI: 10.1016/j.aucc.2013.11.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 11/20/2013] [Accepted: 11/26/2013] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND In the ICU, SpO2≥96% are regularly targeted implying that more oxygen may be given than desirable. To reduce exposure to hyperoxia a conservative oxygen therapy protocol (targeted SpO2 90-92% using lowest FiO2) for mechanically ventilated patients was introduced in a single tertiary ICU in September 2012. OBJECTIVES To describe intensive care clinicians' opinion of conservative oxygen therapy for mechanically ventilated adult patients. METHODS A structured multi-choice questionnaire of intensive care clinicians was conducted between February and March 2013. RESULTS Responses were received from 90 staff members: 81 intensive care nurses and 9 medical doctors. A majority of respondents (60.7%) considered oxygen related lung injury as 'a major concern'. Most respondents (81/89; 91.1%) felt conservative oxygen therapy was easy to perform and few respondents (6/88; 8%) considered performing conservative oxygen therapy to be stressful. Most respondents (58%) reported not performing more arterial blood gases to monitor PaO2 during conservative oxygen therapy and 90% (81/90) of respondents indicated a desire to continue conservative oxygen therapy. Free text comments indicated adoption of this protocol was a paradigm shift yet more education and research to elucidate the benefits/harm of lower oxygen saturation targeting is needed. CONCLUSIONS Intensive care clinicians readily accepted the introduction of a conservative oxygen therapy protocol into their practice. Most respondents found conservative oxygen therapy easy and not stressful to perform. Further evaluation the administration of oxygen therapy, its management by intensive care clinicians and possible impact on outcome for mechanically ventilated patients appears well accepted by clinical staff.
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Affiliation(s)
- Glenn M Eastwood
- Department of Intensive Care, Austin Health, Victoria, Australia.
| | - Leah Peck
- Department of Intensive Care, Austin Health, Victoria, Australia.
| | - Helen Young
- Department of Intensive Care, Austin Health, Victoria, Australia.
| | - Satoshi Suzuki
- Department of Intensive Care, Austin Health, Victoria, Australia.
| | - Mercedes Garcia
- Department of Intensive Care, Austin Health, Victoria, Australia.
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Victoria, Australia.
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17
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Rose L, Schultz MJ, Cardwell CR, Jouvet P, McAuley DF, Blackwood B. Automated versus non-automated weaning for reducing the duration of mechanical ventilation for critically ill adults and children. Cochrane Database Syst Rev 2013:CD009235. [PMID: 23740737 DOI: 10.1002/14651858.cd009235.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Automated closed loop systems may improve adaptation of the mechanical support to a patient's ventilatory needs and facilitate systematic and early recognition of their ability to breathe spontaneously and the potential for discontinuation of ventilation. OBJECTIVES To compare the duration of weaning from mechanical ventilation for critically ill ventilated adults and children when managed with automated closed loop systems versus non-automated strategies. Secondary objectives were to determine differences in duration of ventilation, intensive care unit (ICU) and hospital length of stay (LOS), mortality, and adverse events. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2); MEDLINE (OvidSP) (1948 to August 2011); EMBASE (OvidSP) (1980 to August 2011); CINAHL (EBSCOhost) (1982 to August 2011); and the Latin American and Caribbean Health Sciences Literature (LILACS). In addition we received and reviewed auto-alerts for our search strategy in MEDLINE, EMBASE, and CINAHL up to August 2012. Relevant published reviews were sought using the Database of Abstracts of Reviews of Effects (DARE) and the Health Technology Assessment Database (HTA Database). We also searched the Web of Science Proceedings; conference proceedings; trial registration websites; and reference lists of relevant articles. SELECTION CRITERIA We included randomized controlled trials comparing automated closed loop ventilator applications to non-automated weaning strategies including non-protocolized usual care and protocolized weaning in patients over four weeks of age receiving invasive mechanical ventilation in an intensive care unit (ICU). DATA COLLECTION AND ANALYSIS Two authors independently extracted study data and assessed risk of bias. We combined data into forest plots using random-effects modelling. Subgroup and sensitivity analyses were conducted according to a priori criteria. MAIN RESULTS Pooled data from 15 eligible trials (14 adult, one paediatric) totalling 1173 participants (1143 adults, 30 children) indicated that automated closed loop systems reduced the geometric mean duration of weaning by 32% (95% CI 19% to 46%, P = 0.002), however heterogeneity was substantial (I(2) = 89%, P < 0.00001). Reduced weaning duration was found with mixed or medical ICU populations (43%, 95% CI 8% to 65%, P = 0.02) and Smartcare/PS™ (31%, 95% CI 7% to 49%, P = 0.02) but not in surgical populations or using other systems. Automated closed loop systems reduced the duration of ventilation (17%, 95% CI 8% to 26%) and ICU length of stay (LOS) (11%, 95% CI 0% to 21%). There was no difference in mortality rates or hospital LOS. Overall the quality of evidence was high with the majority of trials rated as low risk. AUTHORS' CONCLUSIONS Automated closed loop systems may result in reduced duration of weaning, ventilation, and ICU stay. Reductions are more likely to occur in mixed or medical ICU populations. Due to the lack of, or limited, evidence on automated systems other than Smartcare/PS™ and Adaptive Support Ventilation no conclusions can be drawn regarding their influence on these outcomes. Due to substantial heterogeneity in trials there is a need for an adequately powered, high quality, multi-centre randomized controlled trial in adults that excludes 'simple to wean' patients. There is a pressing need for further technological development and research in the paediatric population.
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Affiliation(s)
- Louise Rose
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.
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Non invasive ventilation versus synchronized intermittent mandatory ventilation with pressure support in weaning of COPD patients: Comparative study. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2013. [DOI: 10.1016/j.ejcdt.2013.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Moorhead KT, Piquilloud L, Lambermont B, Roeseler J, Chiew YS, Chase JG, Revelly JP, Bialais E, Tassaux D, Laterre PF, Jolliet P, Sottiaux T, Desaive T. NAVA enhances tidal volume and diaphragmatic electro-myographic activity matching: a Range90 analysis of supply and demand. J Clin Monit Comput 2012; 27:61-70. [DOI: 10.1007/s10877-012-9398-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 09/15/2012] [Indexed: 10/27/2022]
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Eastwood G, Bellomo R, Bailey M, Taori G, Pilcher D, Young P, Beasley R. Arterial oxygen tension and mortality in mechanically ventilated patients. Intensive Care Med 2011; 38:91-8. [PMID: 22127482 DOI: 10.1007/s00134-011-2419-6] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Accepted: 09/25/2011] [Indexed: 12/18/2022]
Abstract
PURPOSE Early hyperoxia may be an independent risk factor for mortality in mechanically ventilated intensive care unit (ICU) patients. We examined the relationship between early arterial oxygen tension (PaO(2)) and in-hospital mortality. METHOD We retrospectively assessed arterial blood gases (ABG) with 'worst' alveolar-arterial (A-a) gradient during the first 24 h of ICU admission for all ventilated adult patients from 150 participating ICUs between 2000 and 2009. We used multivariate analysis in all patients and defined subgroups to determine the relationship between PaO(2) and mortality. We also studied the relationship between worst PaO(2), admission PaO(2) and peak PaO(2) in a random cohort of patients. RESULTS We studied 152,680 patients. Their mean PaO(2) was 20.3 kPa (SD 14.6) and mean inspired fraction of oxygen (FiO(2)) was 62% (SD 26). Worst A-a gradient ABG identified that 49.8% (76,110) had hyperoxia (PaO(2) > 16 kPa). Nineteen per cent of patients died in ICU and 26% in hospital. After adjusting for site, Simplified Acute Physiology Score II (SAPS II), age, FiO(2), surgical type, Glasgow Coma Scale (GCS) below 15 and year of ICU admission, there was an association between progressively lower PaO(2) and increasing in-hospital mortality, but not with increasing levels of hyperoxia. Similar findings were observed with a sensitivity analysis of PaO(2) derived from high FiO(2) (≥50%) versus low FiO(2) (<50%) and in defined subgroups. Worst PaO(2) showed a strong correlation with admission PaO(2) (r = 0.98) and peak PaO(2) within 24 h of admission (r = 0.86). CONCLUSION We found there was an association between hypoxia and increased in-hospital mortality, but not with hyperoxia in the first 24 h in ICU and mortality in ventilated patients. Our findings differ from previous studies and suggest that the impact of early hyperoxia on mortality remains uncertain.
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Affiliation(s)
- Glenn Eastwood
- Austin Health, Department of Intensive Care, Heidelberg, Victoria, Australia.
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Hewson-Conroy KM, Burrell AR, Elliott D, Webb SAR, Seppelt IM, Taylor C, Glass P. Compliance with Processes of Care in Intensive Care Units in Australia and New Zealand – A Point Prevalence Study. Anaesth Intensive Care 2011; 39:926-35. [DOI: 10.1177/0310057x1103900520] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There are indications that compliance with routine clinical practices in intensive care units (ICU) varies widely internationally, but it is currently unknown whether this is the case throughout Australia and New Zealand. A one-day point prevalence study measured the prevalence of routine care processes being delivered in Australian and New Zealand ICUs including the assessment and/or management of: nutrition, pain, sedation, weaning from mechanical ventilation, head of bed elevation, deep venous thrombosis prophylaxis, stress ulcer prophylaxis, blood glucose, pressure areas and bowel action. Using a sample of 50 adult ICUs, prevalence data were collected for 662 patients with a median age of 65 years and a median Acute Physiology and Chronic Health Evaluation II score of 18. Wide variations in compliance were evident in several care components including: assessment of nutritional goals (74%, interquartile range [IQR] 51 to 89%), pain score (35%, IQR 17 to 62%), sedation score (89%, IQR 50 to 100%); care of ventilated patients e.g. head of bed elevation >30 degrees (33%, IQR 7 to 62%) and setting weaning plans (50%, IQR 28 to 78%); pressure area risk assessment (78%, IQR 18 to 100%) and constipation management plan (43%, IQR 6 to 87%). Care components that were delivered more consistently included nutrition delivery (100%, IQR 100 to 100%), deep venous thrombosis (96%, IQR 89 to 100%) and stress ulcer (90%, IQR 78 to 100%) prophylaxis, and checking blood sugar levels (93%, IQR 88 to 100%). This point prevalence study demonstrated variability in the delivery of ‘routine’ cares in Australian and New Zealand ICUs. This may be driven in part by lack of consensus on what is best practice in intensive care units, prompting the need for further research in this area.
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Affiliation(s)
- K. M. Hewson-Conroy
- New South Wales Intensive Care Coordination and Monitoring Unit, Penrith, New South Wales, Australia
| | - A. R. Burrell
- New South Wales Intensive Care Coordination and Monitoring Unit, Penrith, New South Wales, Australia
| | - D. Elliott
- New South Wales Intensive Care Coordination and Monitoring Unit, Penrith, New South Wales, Australia
- Faculty of Nursing, Midwifery and Health, University of Technology
| | - S. A. R. Webb
- New South Wales Intensive Care Coordination and Monitoring Unit, Penrith, New South Wales, Australia
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia
| | - I. M. Seppelt
- New South Wales Intensive Care Coordination and Monitoring Unit, Penrith, New South Wales, Australia
- Department of Intensive Care Medicine, The Nepean Hospital
| | - C. Taylor
- New South Wales Intensive Care Coordination and Monitoring Unit, Penrith, New South Wales, Australia
- Critical Care and Trauma Division, The George Institute for Global Health
| | - P. Glass
- New South Wales Intensive Care Coordination and Monitoring Unit, Penrith, New South Wales, Australia
- Divisional Manager, Critical Care and Trauma Division, The George Institute for Global Health
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Rose L, Presneill JJ. Clinical Prediction of Weaning and Extubation in Australian and New Zealand Intensive Care Units. Anaesth Intensive Care 2011; 39:623-9. [DOI: 10.1177/0310057x1103900414] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Our objective was to describe, in Australian and New Zealand adult intensive care units, the relative frequency in which various clinical criteria were used to predict weaning and extubation, and the weaning methods employed. Participant intensivists at 55 intensive care units completed a self-administered questionnaire, using visual analogue scales (0=not at all predictive, 10=perfectly predictive, not used=null score) to record the perceived utility of 30 potential predictors. Survey response rate was 71% (164/230). Those variables thought most predictive of weaning readiness were respiratory rate (median score 8.0, interquartile range 7.0 to 8.6) effective cough (7.3, 5.9 to 8.2) and pressure support setting (7.2, 6.0 to 8.0). The most highly rated predictors of extubation success were effective cough (8.0, 7.0 to 9.0), respiratory rate (8.0, 7.0 to 8.5) and Glasgow Coma Score (7.9, 6.1 to 8.3). Variables perceived least predictive of weaning and extubation success were P0.1, Acute Physiological and Chronic Health Evaluation score II, mean arterial pressure, electrolytes and maximum inspiratory pressure (individual median scores <5). Most popular clinical criteria were those perceived to have high predictive accuracy, both for weaning (respiratory rate 96%, pressure support setting 94% and Glasgow coma score 91%) and extubation readiness (respiratory rate 98%, effective cough 94% and Glasgow Coma Score 92%). Weaning mostly employed pressure support ventilation (55%), with less use of synchronised intermittent mandatory ventilation (32%) and spontaneous breathing trials (13%). Classic ventilatory performance predictors including respiratory rate and effective cough were reported to be of greater clinical utility than other more recently proposed measures.
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Affiliation(s)
- L. Rose
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - J. J. Presneill
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Intensive Care Unit, Mater Hospital, Brisbane, Queensland
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Variation in duration of respiratory support among Australian and New Zealand pediatric intensive care units. Pediatr Crit Care Med 2011; 12:9-13. [PMID: 20351614 DOI: 10.1097/pcc.0b013e3181dbe90a] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To test if there was significant variation of mean adjusted duration of respiratory support (RS) at the site level among Australian and New Zealand pediatric intensive care units (PICUs) and to determine whether the pattern of variation differed from the site-level pattern of variation in length of stay (LoS). DESIGN Separate outcome prediction models for estimating PICU LoS and duration of RS were constructed, using patient data collected between 2002 and 2007. Gamma regression was used to model LoS for all admissions included in the study population, and log normal regression was used to model duration of RS for the subset of patients receiving RS. For both models, case-mix adjustment was achieved by entering patient risk factors as fixed effects, and the PICU or site of care was entered as a random effect. SETTING Data for 31,358 admissions were collected from nine specialist PICUs in Australia and New Zealand. MEASUREMENTS AND MAIN RESULTS Average risk-adjusted duration of RS and LoS for each PICU. There was significant unit-level variation in the adjusted mean LoS and duration of RS among PICUs in Australia and New Zealand. One site had a mean duration of RS that was significantly longer than expected, whereas two sites had a mean duration of RS that was significantly shorter than expected at the 95% level. Unit-level variation in duration of RS is consistent with unit-level variation in LoS for six PICUs and significantly different in two units. CONCLUSION There is unit-level variation in LoS and duration of RS, not accounted for by case-mix. Concurrent analysis of unit-level variation in LoS and duration of RS can help to identify differences in discharge practice and provide direction for improvements in clinical or administrative efficiency.
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Conci D, Fortis S, Ramos F, Ong P, Balasingham S, Manthous CA. Factitious Respiratory Failure: Bound to the Ventilator by Pressure Support. Am J Respir Crit Care Med 2010; 182:1208-9. [DOI: 10.1164/ajrccm.182.9.1208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Diego Conci
- Bridgeport Hospital and Yale University School of Medicine
Bridgeport, Connecticut
| | - Spiros Fortis
- Bridgeport Hospital and Yale University School of Medicine
Bridgeport, Connecticut
| | - Frederick Ramos
- Bridgeport Hospital and Yale University School of Medicine
Bridgeport, Connecticut
| | - Philip Ong
- Bridgeport Hospital and Yale University School of Medicine
Bridgeport, Connecticut
| | - Shiva Balasingham
- Bridgeport Hospital and Yale University School of Medicine
Bridgeport, Connecticut
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Rose L, Gerdtz MF. Use of invasive mechanical ventilation in Australian emergency departments. Emerg Med Australas 2010; 21:108-16. [PMID: 19422407 DOI: 10.1111/j.1742-6723.2009.01167.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE There are few published reports describing the use of invasive mechanical ventilation in EDs. We explored the characteristics of patients receiving mechanical ventilation, the ventilator modes and parameters used as well as the duration of ventilation and the nature of ventilator decision-making in Australian ED. METHODS We conducted a 2 month prospective survey of adult patients who received invasive mechanical ventilation in 24 Australian ED. Data forms were completed by ED staff during the patient's ED presentation. We documented ventilator settings post intubation, after a 1 h stabilization period, and immediately before ED discharge or extubation. The person responsible for selection of ventilator settings was noted at each time point. RESULTS Data were recorded on 307 patients. Altered mental status (179/307 [58%, 95% CI 53-64]) was the most common indication for mechanical ventilation. Volume-controlled modes were most frequently used at all measured time points; with a median tidal volume of 8 mL/kg. Responsibility for initial selection of ventilator settings was shared between ED physicians (157/307 [51%, 95% CI 46-57]), ED nurses (111/307 [36%, 95% CI 31-42]) and ICU or paramedic staff (9/307 [3%, 95% CI 1-5]) (not recorded 30/307 [10%, 95% CI 6-13]). Ongoing responsibility for titration of ventilation was more commonly that of the ED nurse. CONCLUSION The application of mechanical ventilation was similar to descriptions reported in the critical care literature both in Australia and internationally. Decision-making responsibilities were shared by ED medical and nursing staff.
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Affiliation(s)
- Louise Rose
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.
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Neurally adjusted ventilatory assist improves patient–ventilator interaction. Intensive Care Med 2010; 37:263-71. [DOI: 10.1007/s00134-010-2052-9] [Citation(s) in RCA: 163] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2010] [Accepted: 07/25/2010] [Indexed: 12/25/2022]
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Rose L. Clinical application of ventilator modes: Ventilatory strategies for lung protection. Aust Crit Care 2010; 23:71-80. [PMID: 20378369 DOI: 10.1016/j.aucc.2010.03.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Revised: 03/09/2010] [Accepted: 03/12/2010] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION Identification of the mortality reducing effect of lung protective ventilation using low tidal volumes and pressure limitation is one of the biggest advances in the application of mechanical ventilation. Yet studies continue to demonstrate low adoption of this style of ventilation. Critical care nurses in Australia and New Zealand have a high level of responsibility and autonomy for mechanical ventilation and weaning practices and therefore require in-depth knowledge of ventilator technology, its clinical application and the current evidence for effective ventilation strategies. AIM To present an overview of current knowledge and research relating to lung protective ventilation. METHOD A multidatabase literature search using the terms protective ventilation, open lung, high frequency oscillatory ventilation, airway pressure release ventilation, and weaning. RESULTS Based on clinical trials and physiological evidence lung protective strategies using low tidal volumes and moderate levels of PEEP have been recommended as strategies to prevent tidal alveolar collapse and overdistension in patients with ALI/ARDS. Evidence now suggests these strategies may also be beneficial in patients with normal lungs. Lung protective ventilation may be applied with either volume or pressure-controlled ventilation. Pressure-controlled ventilation allows regulation over injurious peak inspiratory pressures; however no study has identified the superiority of pressure-controlled ventilation over low tidal volume strategies using volume-control. Other lung protective ventilation strategies include moderate to high positive-end expiratory pressure, recruitment manoeuvres, high frequency oscillatory ventilation, and airway pressure release ventilation though definitive trials identifying consistently improved patient outcomes are still needed. No ventilation strategy can be more lung protective than the timely discontinuation of mechanical ventilation. Despite the above recommendations, evidence suggests the decision to commence weaning and attempt extubation continue to be delayed. Critical care nurses play a vital role in the recognition of patients capable of spontaneous breathing and ready for extubation. Organisational interventions such as weaning protocols as well as computerised weaning systems may have less effect when nurses are able to manage weaning processes effectively. CONCLUSIONS Lung protective ventilatory strategies are not consistently applied and weaning and extubation continue to be delayed. Critical care nurses need to establish a strong knowledge base to promote effective and appropriate management of patients requiring mechanical ventilation.
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Affiliation(s)
- Louise Rose
- Lawrence S. Bloomberg Limited Term Professor in Critical Care Nursing, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.
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Ortiz G, Frutos-Vivar F, Ferguson ND, Esteban A, Raymondos K, Apezteguía C, Hurtado J, González M, Tomicic V, Elizalde J, Abroug F, Arabi Y, Pelosi P, Anzueto A. Outcomes of patients ventilated with synchronized intermittent mandatory ventilation with pressure support: a comparative propensity score study. Chest 2009; 137:1265-77. [PMID: 20022967 DOI: 10.1378/chest.09-2131] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Few data are available regarding the benefits of one mode over another for ventilatory support. We set out to compare clinical outcomes of patients receiving synchronized intermittent mandatory ventilation with pressure support (SIMV-PS) compared with assist-control (A/C) ventilation as their primary mode of ventilatory support. METHODS This was a secondary analysis of an observational study conducted in 349 ICUs from 23 countries. A propensity score stratified analysis was used to compare 350 patients ventilated with SIMV-PS with 1,228 patients ventilated with A/C ventilation. The primary outcome was in-hospital mortality. RESULTS In a logistic regression model, patients were more likely to receive SIMV-PS if they were from North America, had lower severity of illness, or were ventilated postoperatively or for trauma. SIMV-PS was less likely to be selected if patients were ventilated because of asthma or coma, or if they developed complications such as sepsis or cardiovascular failure during mechanical ventilation. In the stratified analysis according to propensity score, we did not find significant differences in the in-hospital mortality. After adjustment for propensity score, overall effect of SIMV-PS on in-hospital mortality was not significant (odds ratio, 1.04; 95% CI, 0.77-1.42; P = .78). CONCLUSIONS In our cohort of ventilated patients, ventilation with SIMV-PS compared with A/C did not offer any advantage in terms of clinical outcomes, despite treatment-allocation bias that would have favored SIMV-PS.
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