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Demoule A, Fossé Q, Mercat A, Bergum D, Virolle S, Bureau C, Mellemseter M, Guichou R, Similowski T, Dres M, Mortaza S. Operator independent continuous ultrasound monitoring of diaphragm excursion predicts successful weaning from mechanical ventilation: a prospective observational study. Crit Care 2024; 28:245. [PMID: 39014512 PMCID: PMC11253384 DOI: 10.1186/s13054-024-05003-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 06/24/2024] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND In mechanically ventilated patients, diaphragm ultrasound can identify diaphragm weakness and predict weaning failure. We evaluated whether a novel operator-independent ultrasound-based medical device allowing continuous monitoring of the diaphragm (CUSdi) could reliably (1) measure diaphragm excursion (EXdi) and peak contraction velocity (PCVdi), (2) predict weaning outcome, and (3) approximate transdiaphragmatic pressure (Pdi). METHODS In 49 mechanically ventilated patients, CUSdi was recorded during a 30-min spontaneous breathing trial (SBT), and EXdi and PCVdi were measured. In subgroups of patients, standard ultrasound measurement of EXdi and PCVdi was performed (n = 36), and Pdi derived parameters (peak and pressure time product, n = 30) were measured simultaneously. RESULTS The agreement bias between standard ultrasound and CUSdi for EXdi was 0.1 cm (95% confidence interval -0.7-0.9 cm). The regression of Passing-Bablok indicated a lack of systematic difference between EXdi measured with standard ultrasound and CUSdi, which were positively correlated (Rho = 0.84, p < 0.001). Weaning failure was observed in 54% of patients. One, two and three minutes after the onset of the SBT, EXdi was higher in the weaning success group than in the failure group. Two minutes after the onset of the SBT, an EXdi < 1.1 cm predicted weaning failure with a sensitivity of 0.83, a specificity of 0.68, a positive predictive value of 0.76, and a negative predictive value of 0.24. There was a weak correlation between EXdi and both peak Pdi (r = 0.22, 95% confidence interval 0.15 - 0.28) and pressure time product (r = 0.13, 95% confidence interval 0.06 - 0.20). Similar results were observed with PCVdi. CONCLUSIONS Operator-independent continuous diaphragm monitoring quantifies EXdi reliably and can predict weaning failure with an identified cut-off value of 1.1 cm. Trial registration clinicaltrial.gov, NCT04008875 (submitted 12 April 2019, posted 5 July 2019) and NCT03896048 (submitted 27 March 2019, posted 29 March 2019).
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Affiliation(s)
- Alexandre Demoule
- Service de Médecine Intensive - Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75651 Paris Cedex 13, 75013, Paris, France.
- UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, INSERM, 75005, Paris, France.
| | - Quentin Fossé
- Service de Médecine Intensive - Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75651 Paris Cedex 13, 75013, Paris, France
- UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, INSERM, 75005, Paris, France
| | - Alain Mercat
- Service de Réanimation Médicale et Médecine Hyperbare, Centre Hospitalier Régional Universitaire, Angers, France
| | - Daniel Bergum
- Department of Intensive Care Medicine, St. Olav University Hospital, Trondheim, Norway
| | - Sara Virolle
- Service de Médecine Intensive - Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75651 Paris Cedex 13, 75013, Paris, France
| | - Côme Bureau
- Service de Médecine Intensive - Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75651 Paris Cedex 13, 75013, Paris, France
- UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, INSERM, 75005, Paris, France
| | | | | | - Thomas Similowski
- UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, INSERM, 75005, Paris, France
- Département R3S, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
| | - Martin Dres
- Service de Médecine Intensive - Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75651 Paris Cedex 13, 75013, Paris, France
- UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, INSERM, 75005, Paris, France
| | - Satar Mortaza
- Service de Réanimation Médicale et Médecine Hyperbare, Centre Hospitalier Régional Universitaire, Angers, France
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Pu X, Huang H, Zhao X, Liu F, Leng Y, Deng Y, Huang L, Zhou X, Xu F, Huang Y, Guo S. Improving Lower Limb Function and Frailty in Frail Older Patients with Acute Myocardial Infarction After Percutaneous Coronary Intervention: A Randomized Controlled Study of Neuromuscular Electrical Stimulation. Clin Interv Aging 2024; 19:1163-1176. [PMID: 38974513 PMCID: PMC11225987 DOI: 10.2147/cia.s460805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 05/15/2024] [Indexed: 07/09/2024] Open
Abstract
Background A global public health problem, frailty is closely associated with poor prognosis after percutaneous coronary intervention (PCI) in older patients with acute myocardial infarction (AMI). Although exercise intervention is the most commonly used method to reverse and alleviate frailty, its application is restricted in patients with acute myocardial infarction following PCI due to cardiovascular instability and autonomic imbalance. Consequently, there is a need for a new practical intervention to address frailty syndrome in these patients. Purpose This study aimed to investigate the effect of neuromuscular electrical stimulation in frail older AMI patients post-PCI. Patients and Methods A single-blind, randomized controlled trial was carried out in the Department of Cardiovascular Medicine from March to October 2023. A total of 100 eligible participants were randomly divided into two groups: experimental (n = 50) and control (n = 50) groups, respectively. Both groups received usual care. The experimental group underwent neuromuscular electrical stimulation (NMES) on bilateral quadriceps and gastrocnemius muscles for 30 minutes daily from day 1 to day 7 after surgery. The primary outcomes measured included the frailty score, lower limb muscle strength, and lower limb muscle quality. Secondary outcomes included the activities of daily living score, inflammatory markers, and length of hospital stay. All participants were included in an intention-to-treat analysis after the study ended. Results The frailty scores of the two groups exhibited a gradual decrease over time, and the scores of the experimental group were lower than those of the control group at 4 and 7 days after surgery (P<0.001). Concurrently, the lower limb muscle strength showed an increasing trend over the time in the experimental group and a decreasing trend in the control group, and the scores of the experimental group surpassed those of the control group (p<0.001). Moreover, a statistical difference was observed in the lower limb muscle mass across the groups after 7 days postoperatively compared with baseline on both sides (p<0.05). Conclusion Neuromuscular electrical stimulation has the potential to enhance lower limb function and alleviate frailty in elderly patients with acute myocardial infarction after PCI. These findings introduce a novel intervention approach for frailty management in the elderly population.
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Affiliation(s)
- Xiamin Pu
- Department of Cardiovascular Medicine, The Affiliated Hospital, Southwest Medical University, Luzhou, 646000, People’s Republic of China
| | - Houqiang Huang
- Department of Nursing, The Affiliated Hospital, Southwest Medical University, Luzhou, 646000, People’s Republic of China
| | - Xiaolei Zhao
- Department of Hematology, The Affiliated Hospital, Southwest Medical University, Luzhou, 646000, People’s Republic of China
| | - Feng Liu
- Department of Cardiovascular Medicine, The Affiliated Hospital, Southwest Medical University, Luzhou, 646000, People’s Republic of China
| | - Yebo Leng
- Department of Orthopedics, The Affiliated Hospital, Southwest Medical University, Luzhou, 646000, People’s Republic of China
| | - Ya Deng
- School of Nursing, Southwest Medical University, Luzhou, 646000, People’s Republic of China
| | - Lingyi Huang
- School of Nursing, Southwest Medical University, Luzhou, 646000, People’s Republic of China
| | - Xingchen Zhou
- School of Nursing, Southwest Medical University, Luzhou, 646000, People’s Republic of China
| | - Fen Xu
- Department of Cardiovascular Medicine, The Affiliated Hospital, Southwest Medical University, Luzhou, 646000, People’s Republic of China
| | - Yongli Huang
- Department of Outpatient, The Affiliated Hospital, Southwest Medical University, Luzhou, People’s Republic of China
| | - Shengmin Guo
- Department of Nursing, The Affiliated Hospital, Southwest Medical University, Luzhou, 646000, People’s Republic of China
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Hassan MA, Nashwan AJ. Machine learning insights on intensive care unit-acquired weakness. World J Clin Cases 2024; 12:3285-3287. [PMID: 38983426 PMCID: PMC11229897 DOI: 10.12998/wjcc.v12.i18.3285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/14/2024] [Accepted: 04/28/2024] [Indexed: 06/13/2024] Open
Abstract
Intensive care unit-acquired weakness (ICU-AW) significantly hampers patient recovery and increases morbidity. With the absence of established preventive strategies, this study utilizes advanced machine learning methodologies to unearth key predictors of ICU-AW. Employing a sophisticated multilayer perceptron neural network, the research methodically assesses the predictive power for ICU-AW, pinpointing the length of ICU stay and duration of mechanical ventilation as pivotal risk factors. The findings advocate for minimizing these elements as a preventive approach, offering a novel perspective on combating ICU-AW. This research illuminates critical risk factors and lays the groundwork for future explorations into effective prevention and intervention strategies.
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Affiliation(s)
- Muad Abdi Hassan
- Department of Medical Education, Hamad Medical Corporation, Doha 3050, Qatar
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Le Stang V, Latronico N, Dres M, Bertoni M. Critical illness-associated limb and diaphragmatic weakness. Curr Opin Crit Care 2024; 30:121-130. [PMID: 38441088 PMCID: PMC10919276 DOI: 10.1097/mcc.0000000000001135] [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: 03/09/2024]
Abstract
PURPOSE OF REVIEW In the current review, we aim to highlight the evolving evidence on the diagnosis, prevention and treatment of critical illness weakness (CIW) and critical illness associated diaphragmatic weakness (CIDW). RECENT FINDINGS In the ICU, several risk factors can lead to CIW and CIDW. Recent evidence suggests that they have different pathophysiological mechanisms and impact on outcomes, although they share common risk factors and may overlap in several patients. Their diagnosis is challenging, because CIW diagnosis is primarily clinical and, therefore, difficult to obtain in the ICU population, and CIDW diagnosis is complex and not easily performed at the bedside. All of these issues lead to underdiagnosis of CIW and CIDW, which significantly increases the risk of complications and the impact on both short and long term outcomes. Moreover, recent studies have explored promising diagnostic techniques that are may be easily implemented in daily clinical practice. In addition, this review summarizes the latest research aimed at improving how to prevent and treat CIW and CIDW. SUMMARY This review aims to clarify some uncertain aspects and provide helpful information on developing monitoring techniques and therapeutic interventions for managing CIW and CIDW.
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Affiliation(s)
- Valentine Le Stang
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique
- AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive –Réanimation (Département ‘R3S’), Paris, France
| | - Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
- Department of Emergency, ASST Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, 25123 Brescia, Italy
- ‘Alessandra BONO’ Interdepartmental University Research Center on LOng Term Outcome (LOTO) in Critical Illness Survivors, University of Brescia, Brescia, Italy
| | - Martin Dres
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique
- AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive –Réanimation (Département ‘R3S’), Paris, France
| | - Michele Bertoni
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
- Department of Emergency, ASST Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, 25123 Brescia, Italy
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Poddighe D, Van Hollebeke M, Choudhary YQ, Campos DR, Schaeffer MR, Verbakel JY, Hermans G, Gosselink R, Langer D. Accuracy of respiratory muscle assessments to predict weaning outcomes: a systematic review and comparative meta-analysis. Crit Care 2024; 28:70. [PMID: 38454487 PMCID: PMC10919035 DOI: 10.1186/s13054-024-04823-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/29/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND Several bedside assessments are used to evaluate respiratory muscle function and to predict weaning from mechanical ventilation in patients on the intensive care unit. It remains unclear which assessments perform best in predicting weaning success. The primary aim of this systematic review and meta-analysis was to summarize and compare the accuracy of the following assessments to predict weaning success: maximal inspiratory (PImax) and expiratory pressures, diaphragm thickening fraction and excursion (DTF and DE), end-expiratory (Tdiee) and end-inspiratory (Tdiei) diaphragm thickness, airway occlusion pressure (P0.1), electrical activity of respiratory muscles, and volitional and non-volitional assessments of transdiaphragmatic and airway opening pressures. METHODS Medline (via Pubmed), EMBASE, Web of Science, Cochrane Library and CINAHL were comprehensively searched from inception to 04/05/2023. Studies including adult mechanically ventilated patients reporting data on predictive accuracy were included. Hierarchical summary receiver operating characteristic (HSROC) models were used to estimate the SROC curves of each assessment method. Meta-regression was used to compare SROC curves. Sensitivity analyses were conducted by excluding studies with high risk of bias, as assessed with QUADAS-2. Direct comparisons were performed using studies comparing each pair of assessments within the same sample of patients. RESULTS Ninety-four studies were identified of which 88 studies (n = 6296) reporting on either PImax, DTF, DE, Tdiee, Tdiei and P0.1 were included in the meta-analyses. The sensitivity to predict weaning success was 63% (95% CI 47-77%) for PImax, 75% (95% CI 67-82%) for DE, 77% (95% CI 61-87%) for DTF, 74% (95% CI 40-93%) for P0.1, 69% (95% CI 13-97%) for Tdiei, 37% (95% CI 13-70%) for Tdiee, at fixed 80% specificity. Accuracy of DE and DTF to predict weaning success was significantly higher when compared to PImax (p = 0.04 and p < 0.01, respectively). Sensitivity and direct comparisons analyses showed that the accuracy of DTF to predict weaning success was significantly higher when compared to DE (p < 0.01). CONCLUSIONS DTF and DE are superior to PImax and DTF seems to have the highest accuracy among all included respiratory muscle assessments for predicting weaning success. Further studies aiming at identifying the optimal threshold of DTF to predict weaning success are warranted. TRIAL REGISTRATION PROSPERO CRD42020209295, October 15, 2020.
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Affiliation(s)
- Diego Poddighe
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Marine Van Hollebeke
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Yasir Qaiser Choudhary
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
| | - Débora Ribeiro Campos
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Prêto, Brazil
| | - Michele R Schaeffer
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
| | - Jan Y Verbakel
- Department of Public Health and Primary Care, EPI-Centre, KU Leuven, Leuven, Belgium
- NIHR Community Healthcare Medtech and IVD Cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Greet Hermans
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Rik Gosselink
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Health and Rehabilitation Sciences, Faculty of Medicine, Stellenbosch University, Stellenbosch, South Africa
| | - Daniel Langer
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium.
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium.
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Wang L, Long DY. Significant risk factors for intensive care unit-acquired weakness: A processing strategy based on repeated machine learning. World J Clin Cases 2024; 12:1235-1242. [PMID: 38524515 PMCID: PMC10955529 DOI: 10.12998/wjcc.v12.i7.1235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/20/2024] [Accepted: 02/18/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Intensive care unit-acquired weakness (ICU-AW) is a common complication that significantly impacts the patient's recovery process, even leading to adverse outcomes. Currently, there is a lack of effective preventive measures. AIM To identify significant risk factors for ICU-AW through iterative machine learning techniques and offer recommendations for its prevention and treatment. METHODS Patients were categorized into ICU-AW and non-ICU-AW groups on the 14th day post-ICU admission. Relevant data from the initial 14 d of ICU stay, such as age, comorbidities, sedative dosage, vasopressor dosage, duration of mechanical ventilation, length of ICU stay, and rehabilitation therapy, were gathered. The relationships between these variables and ICU-AW were examined. Utilizing iterative machine learning techniques, a multilayer perceptron neural network model was developed, and its predictive performance for ICU-AW was assessed using the receiver operating characteristic curve. RESULTS Within the ICU-AW group, age, duration of mechanical ventilation, lorazepam dosage, adrenaline dosage, and length of ICU stay were significantly higher than in the non-ICU-AW group. Additionally, sepsis, multiple organ dysfunction syndrome, hypoalbuminemia, acute heart failure, respiratory failure, acute kidney injury, anemia, stress-related gastrointestinal bleeding, shock, hypertension, coronary artery disease, malignant tumors, and rehabilitation therapy ratios were significantly higher in the ICU-AW group, demonstrating statistical significance. The most influential factors contributing to ICU-AW were identified as the length of ICU stay (100.0%) and the duration of mechanical ventilation (54.9%). The neural network model predicted ICU-AW with an area under the curve of 0.941, sensitivity of 92.2%, and specificity of 82.7%. CONCLUSION The main factors influencing ICU-AW are the length of ICU stay and the duration of mechanical ventilation. A primary preventive strategy, when feasible, involves minimizing both ICU stay and mechanical ventilation duration.
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Affiliation(s)
- Ling Wang
- Intensive Care Unit, People's Hospital of Qiandongnan Miao and Dong Autonomous Prefecture, Kaili 556000, Guizhou Province, China
| | - Deng-Yan Long
- Intensive Care Unit, People's Hospital of Qiandongnan Miao and Dong Autonomous Prefecture, Kaili 556000, Guizhou Province, China
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Unoki Y, Ono S, Sasabuchi Y, Hashimoto Y, Yasunaga H, Yokota I. Exploring the influence of a financial incentive scheme on early mobilization and rehabilitation in ICU patients: an interrupted time-series analysis. BMC Health Serv Res 2024; 24:242. [PMID: 38402190 PMCID: PMC10893682 DOI: 10.1186/s12913-024-10763-0] [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: 07/18/2023] [Accepted: 02/21/2024] [Indexed: 02/26/2024] Open
Abstract
BACKGROUND Clinical guidelines recommend early mobilization and rehabilitation (EMR) for patients who are critically ill. However, various barriers impede its implementation in real-world clinical settings. In 2018, the Japanese universal healthcare coverage system announced a unique financial incentive scheme to facilitate EMR for patients in intensive care units (ICU). This study evaluated whether such an incentive improved patients' activities of daily living (ADL) and reduced their hospital length of stay (LOS). METHODS Using the national inpatient database in Japan, we identified patients admitted to the ICU, who stayed over 48 hours between April 2017 and March 2019. The financial incentive required medical institutions to form a multidisciplinary team approach for EMR, development and periodic review of the standardized rehabilitation protocol, starting rehabilitation within 2 days of ICU admission. The incentive amounted to 34.6 United States Dollars per patient per day with limit 14 days, structured as a per diem payment. Hospitals were not mandated to provide detailed information on individual rehabilitation for government, and the insurer made payments directly to the hospitals based on their claims. Exposure was the introduction of the financial incentive defined as the first day of claim by each hospital. We conducted an interrupted time-series analysis to assess the impact of the financial incentive scheme. Multivariable radon-effects regression and Tobit regression analysis were performed with random intercept for the hospital of admission. RESULTS A total of 33,568 patients were deemed eligible. We confirmed that the basic assumption of ITS was fulfilled. The financial incentive was associated with an improvement in the Barthel index at discharge (0.44 points change in trend per month; 95% confidence interval = 0.20-0.68) and shorter hospital LOS (- 0.66 days change in trend per month; 95% confidence interval = - 0.88 - -0.44). The sensitivity and subgroup analyses showed consistent results. CONCLUSIONS The study suggests a potential association between the financial incentive for EMR in ICU patients and improved outcomes. This incentive scheme may provide a unique solution to EMR barrier in practice, however, caution is warranted in interpreting these findings due to recent changes in ICU care practices.
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Affiliation(s)
- Yoko Unoki
- Department of Biostatistics, Graduate School of Medicine, Hokkaido University, N15W7, Kita-ku, Sapporo, Hokkaido, 0608638, Japan
| | - Sachiko Ono
- Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-Ku, Tokyo, 1130033, Japan
| | - Yusuke Sasabuchi
- Department of Real-world Evidence, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-Ku, Tokyo, 1130033, Japan
| | - Yohei Hashimoto
- Department of Ophthalmology, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-Ku, Tokyo, 1130033, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1, Hongo, Bunkyo-Ku, Tokyo, 1130033, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1, Hongo, Bunkyo-Ku, Tokyo, 1130033, Japan
| | - Isao Yokota
- Department of Biostatistics, Graduate School of Medicine, Hokkaido University, N15W7, Kita-ku, Sapporo, Hokkaido, 0608638, Japan.
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Major ME, Sommers J, Horrevorts E, Buist CM, Dettling-Ihnenfeldt DS, van der Schaaf M. Inspiratory muscle training for mechanically ventilated patients in the intensive care unit: Obstacles and facilitators for implementation. A mixed method quality improvement study. Aust Crit Care 2024:S1036-7314(24)00021-3. [PMID: 38320925 DOI: 10.1016/j.aucc.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/05/2023] [Accepted: 01/08/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND Mechanically ventilated patients are at risk of developing inspiratory muscle weakness (IMW), which is associated with failure to wean and poor outcomes. Inspiratory muscle training (IMT) is a recommended intervention during and after extubation but has not been widely adopted in Dutch intensive care units (ICUs). OBJECTIVES The objective of this study was to explore the potential, barriers, and facilitators for implementing IMT as treatment modality for mechanically ventilated patients. METHODS This mixed-method, proof-of-concept study was conducted in a large academic hospital in the Netherlands. An evidence-based protocol for assessing IMW and training was applied to patients ventilated for ≥24 h in the ICU during an 8-month period in 2021. Quantitative data on completed measurements and interventions during and after ICU-stay were collected retrospectively and were analysed descriptively. Qualitative data were collected through semistructured interviews with physiotherapists executing the new protocol. Interview data were transcribed and thematically analysed. FINDINGS Of the 301 screened patients, 11.6% (n = 35) met the inclusion criteria. Measurements were possible in 94.3% of the participants, and IMW was found in 78.8% of the participants. Ninety-six percent started training in the ICU, and 88.5% continued training after transfer to the ward. Follow-up measurements were achieved in 73.1% of the patients with respiratory muscle weakness. Twelve therapists were interviewed, of whom 41.7% regularly worked in the ICU. When exploring reasons for protocol deviation, three themes emerged: "professional barriers", "external factors", and "patient barriers". CONCLUSIONS Implementation of measurements of and interventions for IMW showed to be challenging in this single centre study. Clinicians' willingness to change their handling was related to beliefs regarding usefulness, effectiveness, and availability of time and material. We recommend that hospitals aiming to implement IMT during or after ventilator weaning consider these professional and organisational barriers for implementation of novel, evidence-based interventions into daily clinical practice.
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Affiliation(s)
- Mel E Major
- Department of Physical Therapy, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands; Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands; Amsterdam Movement Sciences, Ageing and Vitality, Amsterdam, the Netherlands.
| | - Juultje Sommers
- Amsterdam Movement Sciences, Ageing and Vitality, Amsterdam, the Netherlands; Amsterdam University Medical Centers, Location AMC, Department of Rehabilitation Medicine, Meibergdreef 9, Amsterdam, Netherlands
| | - Esther Horrevorts
- European School of Physiotherapy, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands
| | - Carmen M Buist
- Amsterdam University Medical Centers, Location AMC, Department of Rehabilitation Medicine, Meibergdreef 9, Amsterdam, Netherlands
| | - Daniela S Dettling-Ihnenfeldt
- Amsterdam Movement Sciences, Ageing and Vitality, Amsterdam, the Netherlands; Amsterdam University Medical Centers, Location AMC, Department of Rehabilitation Medicine, Meibergdreef 9, Amsterdam, Netherlands
| | - Marike van der Schaaf
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands; Amsterdam Movement Sciences, Ageing and Vitality, Amsterdam, the Netherlands; Amsterdam University Medical Centers, Location AMC, Department of Rehabilitation Medicine, Meibergdreef 9, Amsterdam, Netherlands
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Chen J, Huang M. Intensive care unit-acquired weakness: Recent insights. JOURNAL OF INTENSIVE MEDICINE 2024; 4:73-80. [PMID: 38263973 PMCID: PMC10800771 DOI: 10.1016/j.jointm.2023.07.002] [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: 04/12/2023] [Revised: 06/16/2023] [Accepted: 07/07/2023] [Indexed: 01/25/2024]
Abstract
Intensive care unit-acquired weakness (ICU-AW) is a common complication in critically ill patients and is associated with a variety of adverse outcomes. These include the need for prolonged mechanical ventilation and ICU stay; higher ICU, in-hospital, and 1-year mortality; and increased in-hospital costs. ICU-AW is associated with multiple risk factors including age, underlying disease, severity of illness, organ failure, sepsis, immobilization, receipt of mechanical ventilation, and other factors related to critical care. The pathological mechanism of ICU-AW remains unclear and may be considerably varied. This review aimed to evaluate recent insights into ICU-AW from several aspects including risk factors, pathophysiology, diagnosis, and treatment strategies; this provides new perspectives for future research.
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Affiliation(s)
- Juan Chen
- Department of General Intensive Care Unit, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, Zhejiang, China
| | - Man Huang
- Department of General Intensive Care Unit, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, Zhejiang, China
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Panelli A, Verfuß MA, Dres M, Brochard L, Schaller SJ. Phrenic nerve stimulation to prevent diaphragmatic dysfunction and ventilator-induced lung injury. Intensive Care Med Exp 2023; 11:94. [PMID: 38109016 PMCID: PMC10728426 DOI: 10.1186/s40635-023-00577-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 12/06/2023] [Indexed: 12/19/2023] Open
Abstract
Side effects of mechanical ventilation, such as ventilator-induced diaphragmatic dysfunction (VIDD) and ventilator-induced lung injury (VILI), occur frequently in critically ill patients. Phrenic nerve stimulation (PNS) has been a valuable tool for diagnosing VIDD by assessing respiratory muscle strength in response to magnetic PNS. The detection of pathophysiologically reduced respiratory muscle strength is correlated with weaning failure, longer mechanical ventilation time, and mortality. Non-invasive electromagnetic PNS designed for diagnostic use is a reference technique that allows clinicians to measure transdiaphragm pressure as a surrogate parameter for diaphragm strength and functionality. This helps to identify diaphragm-related issues that may impact weaning readiness and respiratory support requirements, although lack of lung volume measurement poses a challenge to interpretation. In recent years, therapeutic PNS has been demonstrated as feasible and safe in lung-healthy and critically ill patients. Effects on critically ill patients' VIDD or diaphragm atrophy outcomes are the subject of ongoing research. The currently investigated application forms are diverse and vary from invasive to non-invasive and from electrical to (electro)magnetic PNS, with most data available for electrical stimulation. Increased inspiratory muscle strength and improved diaphragm activity (e.g., excursion, thickening fraction, and thickness) indicate the potential of the technique for beneficial effects on clinical outcomes as it has been successfully used in spinal cord injured patients. Concerning the potential for electrophrenic respiration, the data obtained with non-invasive electromagnetic PNS suggest that the induced diaphragmatic contractions result in airway pressure swings and tidal volumes remaining within the thresholds of lung-protective mechanical ventilation. PNS holds significant promise as a therapeutic intervention in the critical care setting, with potential applications for ameliorating VIDD and the ability for diaphragm training in a safe lung-protective spectrum, thereby possibly reducing the risk of VILI indirectly. Outcomes of such diaphragm training have not been sufficiently explored to date but offer the perspective for enhanced patient care and reducing weaning failure. Future research might focus on using PNS in combination with invasive and non-invasive assisted ventilation with automatic synchronisation and the modulation of PNS with spontaneous breathing efforts. Explorative approaches may investigate the feasibility of long-term electrophrenic ventilation as an alternative to positive pressure-based ventilation.
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Affiliation(s)
- Alessandro Panelli
- Charité - Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Berlin, Germany
| | - Michael A Verfuß
- Charité - Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Berlin, Germany
| | - Martin Dres
- Sorbonne Université, INSERM UMRS 1158, Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Service de Médecine Intensive et Réanimation, Département R3S, APHP, Sorbonne Université, Hôpital Pitie Salpêtrière, Paris, France
| | - Laurent Brochard
- Unity Health Toronto, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
| | - Stefan J Schaller
- Charité - Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Berlin, Germany.
- Technical University of Munich, School of Medicine and Health, Klinikum Rechts der Isar, Department of Anesthesiology and Intensive Care Medicine, Munich, Germany.
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11
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Razi O, Teixeira AM, Tartibian B, Zamani N, Knechtle B. Respiratory issues in patients with multiple sclerosis as a risk factor during SARS-CoV-2 infection: a potential role for exercise. Mol Cell Biochem 2023; 478:1533-1559. [PMID: 36411399 PMCID: PMC9684932 DOI: 10.1007/s11010-022-04610-1] [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: 01/27/2022] [Accepted: 11/04/2022] [Indexed: 11/23/2022]
Abstract
Coronavirus disease-2019 (COVID-19) is associated with cytokine storm and is characterized by acute respiratory distress syndrome (ARDS) and pneumonia problems. The respiratory system is a place of inappropriate activation of the immune system in people with multiple sclerosis (MS), and this may cause damage to the lung and worsen both MS and infections.The concerns for patients with multiple sclerosis are because of an enhance risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The MS patients pose challenges in this pandemic situation, because of the regulatory defect of autoreactivity of the immune system and neurological and respiratory tract symptoms. In this review, we first indicate respiratory issues associated with both diseases. Then, the main mechanisms inducing lung damages and also impairing the respiratory muscles in individuals with both diseases is discussed. At the end, the leading role of physical exercise on mitigating respiratory issues inducing mechanisms is meticulously evaluated.
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Affiliation(s)
- Omid Razi
- Department of Exercise Physiology, Faculty of Physical Education and Sport Sciences, Razi University, Kermanshah, Iran
| | - Ana Maria Teixeira
- Research Center for Sport and Physical Activity, Faculty of Sport Sciences and Physical Education, University of Coimbra, Coimbra, Portugal
| | - Bakhtyar Tartibian
- Department of Exercise Physiology, Faculty of Physical Education and Sports Sciences, Allameh Tabataba’i University, Tehran, Iran
| | - Nastaran Zamani
- Department of Biology, Faculty of Science, Payame-Noor University, Tehran, Iran
| | - Beat Knechtle
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
- Medbase St. Gallen Am Vadianplatz, Vadianstrasse 26, 9001 St. Gallen, Switzerland
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Bureau C, Van Hollebeke M, Dres M. Managing respiratory muscle weakness during weaning from invasive ventilation. Eur Respir Rev 2023; 32:32/168/220205. [PMID: 37019456 PMCID: PMC10074167 DOI: 10.1183/16000617.0205-2022] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 11/08/2022] [Indexed: 04/07/2023] Open
Abstract
Weaning is a critical stage of an intensive care unit (ICU) stay, in which the respiratory muscles play a major role. Weakness of the respiratory muscles, which is associated with significant morbidity in the ICU, is not limited to atrophy and subsequent dysfunction of the diaphragm; the extradiaphragmatic inspiratory and expiratory muscles also play important parts. In addition to the well-established deleterious effect of mechanical ventilation on the respiratory muscles, other risk factors such as sepsis may be involved. Weakness of the respiratory muscles can be suspected visually in a patient with paradoxical movement of the abdominal compartment. Measurement of maximal inspiratory pressure is the simplest way to assess respiratory muscle function, but it does not specifically take the diaphragm into account. A cut-off value of -30 cmH2O could identify patients at risk for prolonged ventilatory weaning; however, ultrasound may be better for assessing respiratory muscle function in the ICU. Although diaphragm dysfunction has been associated with weaning failure, this diagnosis should not discourage clinicians from performing spontaneous breathing trials and considering extubation. Recent therapeutic developments aimed at preserving or restoring respiratory muscle function are promising.
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Affiliation(s)
- Côme Bureau
- Sorbonne Université, INSERM, UMR_S1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation, Département R3S, Paris, France
| | - Marine Van Hollebeke
- KU Leuven - University of Leuven, Department of Rehabilitation Sciences, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Martin Dres
- Sorbonne Université, INSERM, UMR_S1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation, Département R3S, Paris, France
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Klawitter F, Walter U, Axer H, Patejdl R, Ehler J. Neuromuscular Ultrasound in Intensive Care Unit-Acquired Weakness: Current State and Future Directions. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050844. [PMID: 37241077 DOI: 10.3390/medicina59050844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/15/2023] [Accepted: 04/20/2023] [Indexed: 05/28/2023]
Abstract
Intensive care unit-acquired weakness (ICUAW) is one of the most common causes of muscle atrophy and functional disability in critically ill intensive care patients. Clinical examination, manual muscle strength testing and monitoring are frequently hampered by sedation, delirium and cognitive impairment. Many different attempts have been made to evaluate alternative compliance-independent methods, such as muscle biopsies, nerve conduction studies, electromyography and serum biomarkers. However, they are invasive, time-consuming and often require special expertise to perform, making them vastly impractical for daily intensive care medicine. Ultrasound is a broadly accepted, non-invasive, bedside-accessible diagnostic tool and well established in various clinical applications. Hereby, neuromuscular ultrasound (NMUS), in particular, has been proven to be of significant diagnostic value in many different neuromuscular diseases. In ICUAW, NMUS has been shown to detect and monitor alterations of muscles and nerves, and might help to predict patient outcome. This narrative review is focused on the recent scientific literature investigating NMUS in ICUAW and highlights the current state and future opportunities of this promising diagnostic tool.
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Affiliation(s)
- Felix Klawitter
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Rostock University Medical Center, Schillingallee 35, 18057 Rostock, Germany
| | - Uwe Walter
- Department of Neurology, Rostock University Medical Center, Gehlsheimer Straße 20, 18147 Rostock, Germany
| | - Hubertus Axer
- Department of Neurology, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | - Robert Patejdl
- Department of Medicine, Health and Medical University Erfurt, 99089 Erfurt, Germany
| | - Johannes Ehler
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
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Major M, van Egmond M, Dettling-Ihnenfeldt D, Ramaekers S, Engelbert R, van der Schaaf M. Course of recovery of respiratory muscle strength and its associations with exercise capacity and handgrip strength: A prospective cohort study among survivors of critical illness. PLoS One 2023; 18:e0284097. [PMID: 37053226 PMCID: PMC10101425 DOI: 10.1371/journal.pone.0284097] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 03/23/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Mechanical ventilation affects the respiratory muscles, but little is known about long-term recovery of respiratory muscle weakness (RMW) and potential associations with physical functioning in survivors of critical illness. The aim of this study was to investigate the course of recovery of RMW and its association with functional outcomes in patients who received mechanical ventilation. METHODS We conducted a prospective cohort study with 6-month follow-up among survivors of critical illness who received ≥ 48 hours of invasive mechanical ventilation. Primary outcomes, measured at 3 timepoints, were maximal inspiratory and expiratory pressures (MIP/MEP). Secondary outcomes were functional exercise capacity (FEC) and handgrip strength (HGS). Longitudinal changes in outcomes and potential associations between MIP/MEP, predictor variables, and secondary outcomes were investigated through linear mixed model analysis. RESULTS A total of 59 participants (male: 64%, median age [IQR]: 62 [53-66]) were included in this study with a median (IQR) ICU and hospital length of stay of 11 (8-21) and 35 (21-52) days respectively. While all measures were well below predicted values at hospital discharge (MIP: 68.4%, MEP 76.0%, HGS 73.3% of predicted and FEC 54.8 steps/2m), significant 6-month recovery was seen for all outcomes. Multivariate analyses showed longitudinal associations between older age and decreased MIP and FEC, and longer hospital length of stay and decreased MIP and HGS outcomes. In crude models, significant, longitudinal associations were found between MIP/MEP and FEC and HGS outcomes. While these associations remained in most adjusted models, an interaction effect was observed for sex. CONCLUSION RMW was observed directly after hospital discharge while 6-month recovery to predicted values was noted for all outcomes. Longitudinal associations were found between MIP and MEP and more commonly used measures for physical functioning, highlighting the need for continued assessment of respiratory muscle strength in deconditioned patients who are discharged from ICU. The potential of targeted training extending beyond ICU and hospital discharge should be further explored.
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Affiliation(s)
- Mel Major
- European School of Physiotherapy, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
- Amsterdam UMC, location University of Amsterdam, Rehabilitation Medicine, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Ageing and Vitality, Amsterdam, The Netherlands
| | - Maarten van Egmond
- European School of Physiotherapy, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Ageing and Vitality, Amsterdam, The Netherlands
| | | | - Stephan Ramaekers
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
- Amsterdam UMC, location University of Amsterdam, Rehabilitation Medicine, Amsterdam, The Netherlands
| | - Raoul Engelbert
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
- Amsterdam UMC, location University of Amsterdam, Rehabilitation Medicine, Amsterdam, The Netherlands
| | - Marike van der Schaaf
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
- Amsterdam UMC, location University of Amsterdam, Rehabilitation Medicine, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Ageing and Vitality, Amsterdam, The Netherlands
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Diaphragm function in patients with sepsis and septic shock: A longitudinal ultrasound study. Aust Crit Care 2023; 36:239-246. [PMID: 35272911 DOI: 10.1016/j.aucc.2022.01.003] [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: 08/28/2021] [Revised: 12/23/2021] [Accepted: 01/13/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Previous literature on the determinants of diaphragm dysfunction in septic patients is limited. The goal of this study is to assess diaphragm dysfunction in terms of its prevalence and its potential associated factors in septic intensive care unit (ICU) patients. METHODS This prospective and observational study was conducted between June 2015 and July 2019. Ultrasound measures of diaphragm thickness were performed daily on septic patients. The primary outcome was the prevalence of diaphragm dysfunction at baseline and during the ICU stay. The secondary outcome was the diaphragm thickness. Possible associated factors were prospectively recorded. RESULTS Fifty patients were enrolled in the study. The prevalence of diaphragm dysfunction was 58%. No diaphragm atrophy was found during the ICU stay. Diaphragm dysfunction was associated with the alteration of consciousness, intra-abdominal sepsis, hypnotics and opioids, and mechanical ventilation. Administration of hypnotics, opioids, and steroids was associated with a decreased diaphragm thickening fraction. Diaphragm dysfunction had no impact on patient outcomes. CONCLUSIONS Our data reveal a high prevalence of diaphragm dysfunction in septic patients at the onset of sepsis. Administration of hypnotics, opioids, and steroids was associated with the alteration of diaphragm function as well as intra-abdominal sepsis.
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Louvaris Z, Van Hollebeke M, Poddighe D, Meersseman P, Wauters J, Wilmer A, Gosselink R, Langer D, Hermans G. Do Cerebral Cortex Perfusion, Oxygen Delivery, and Oxygen Saturation Responses Measured by Near-Infrared Spectroscopy Differ Between Patients Who Fail or Succeed in a Spontaneous Breathing Trial? A Prospective Observational Study. Neurocrit Care 2023; 38:105-117. [PMID: 36450970 PMCID: PMC9713166 DOI: 10.1007/s12028-022-01641-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 11/07/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Alterations in perfusion to the brain during the transition from mechanical ventilation (MV) to a spontaneous breathing trial (SBT) remain poorly understood. The aim of the study was to determine whether changes in cerebral cortex perfusion, oxygen delivery (DO2), and oxygen saturation (%StiO2) during the transition from MV to an SBT differ between patients who succeed or fail an SBT. METHODS This was a single-center prospective observational study conducted in a 16-bed medical intensive care unit of the University Hospital Leuven, Belgium. Measurements were performed in 24 patients receiving MV immediately before and at the end of a 30-min SBT. Blood flow index (BFI), DO2, and %StiO2 in the prefrontal cortex, scalene, rectus abdominis, and thenar muscle were simultaneously assessed by near-infrared spectroscopy using the tracer indocyanine green dye. Cardiac output, arterial blood gases, and systemic oxygenation were also recorded. RESULTS During the SBT, prefrontal cortex BFI and DO2 responses did not differ between SBT-failure and SBT-success groups (p > 0.05). However, prefrontal cortex %StiO2 decreased in six of eight patients (75%) in the SBT-failure group (median [interquartile range 25-75%]: MV = 57.2% [49.1-61.7] vs. SBT = 51.0% [41.5-62.5]) compared to 3 of 16 patients (19%) in the SBT-success group (median [interquartile range 25-75%]: MV = 65.0% [58.6-68.5] vs. SBT = 65.1% [59.5-71.1]), resulting in a significant differential %StiO2 response between groups (p = 0.031). Similarly, a significant differential response in thenar muscle %StiO2 (p = 0.018) was observed between groups. A receiver operating characteristic analysis identified a decrease in prefrontal cortex %StiO2 > 1.6% during the SBT as an optimal cutoff, with a sensitivity of 94% and a specificity of 75% to predict SBT failure and an area under the curve of 0.79 (95% CI: 0.55-1.00). Cardiac output, systemic oxygenation, scalene, and rectus abdominis BFI, DO2, and %StiO2 responses did not differ between groups (p > 0.05); however, during the SBT, a significant positive association in prefrontal cortex BFI and partial pressure of arterial carbon dioxide was observed only in the SBT-success group (SBT success: Spearman's ρ = 0.728, p = 0.002 vs. SBT failure: ρ = 0.048, p = 0.934). CONCLUSIONS This study demonstrated a reduced differential response in prefrontal cortex %StiO2 in the SBT-failure group compared with the SBT-success group possibly due to the insufficient increase in prefrontal cortex perfusion in SBT-failure patients. A > 1.6% drop in prefrontal cortex %StiO2 during SBT was sensitive in predicting SBT failure. Further research is needed to validate these findings in a larger population and to evaluate whether cerebral cortex %StiO2 measurements by near-infrared spectroscopy can assist in the decision-making process on liberation from MV.
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Affiliation(s)
- Zafeiris Louvaris
- Research Group for Rehabilitation in Internal Disorders, Department of Rehabilitation Sciences, Faculty of Movement and Rehabilitation Sciences, Katholieke University Leuven, Campus Gasthuisberg O&N4, Herestraat 49, Box 1510, B-3000, Leuven, Belgium.
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium.
| | - Marine Van Hollebeke
- Research Group for Rehabilitation in Internal Disorders, Department of Rehabilitation Sciences, Faculty of Movement and Rehabilitation Sciences, Katholieke University Leuven, Campus Gasthuisberg O&N4, Herestraat 49, Box 1510, B-3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Diego Poddighe
- Research Group for Rehabilitation in Internal Disorders, Department of Rehabilitation Sciences, Faculty of Movement and Rehabilitation Sciences, Katholieke University Leuven, Campus Gasthuisberg O&N4, Herestraat 49, Box 1510, B-3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Philippe Meersseman
- Research Group for Rehabilitation in Internal Disorders, Department of Rehabilitation Sciences, Faculty of Movement and Rehabilitation Sciences, Katholieke University Leuven, Campus Gasthuisberg O&N4, Herestraat 49, Box 1510, B-3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Joost Wauters
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
- Laboratory for Clinical Infectious and Inflammatory Disorders, Department of Microbiology and Immunology, University Hospitals Leuven, Leuven, Belgium
| | - Alexander Wilmer
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
- Laboratory for Clinical Infectious and Inflammatory Disorders, Department of Microbiology and Immunology, University Hospitals Leuven, Leuven, Belgium
| | - Rik Gosselink
- Research Group for Rehabilitation in Internal Disorders, Department of Rehabilitation Sciences, Faculty of Movement and Rehabilitation Sciences, Katholieke University Leuven, Campus Gasthuisberg O&N4, Herestraat 49, Box 1510, B-3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Daniel Langer
- Research Group for Rehabilitation in Internal Disorders, Department of Rehabilitation Sciences, Faculty of Movement and Rehabilitation Sciences, Katholieke University Leuven, Campus Gasthuisberg O&N4, Herestraat 49, Box 1510, B-3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Greet Hermans
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, Katholieke University Leuven, Leuven, Belgium
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Does mechanical threshold inspiratory muscle training promote recovery and improve outcomes in patients who are ventilator-dependent in the intensive care unit? The IMPROVE randomised trial. Aust Crit Care 2022:S1036-7314(22)00092-3. [PMID: 36041982 DOI: 10.1016/j.aucc.2022.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 07/11/2022] [Accepted: 07/11/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND In patients who are ventilator-dependent in the intensive care unit, inspiratory muscle training may improve inspiratory muscle strength and accelerate liberation from the ventilator, but optimal training parameters are yet to be established, and little is known about the impact of inspiratory muscle training on quality of life or dyspnoea. Thus, we sought to ascertain whether inspiratory muscle training, commenced while ventilator-dependent, would improve outcomes for patients invasively ventilated for 7 days or longer. METHODS In this randomised trial with assessor blinding and intention-to-treat analysis, 70 participants (mechanically ventilated ≥7 days) were randomised to receive once-daily supervised high-intensity inspiratory muscle training with a mechanical threshold device in addition to usual care or to receive usual care (control). Primary outcomes were inspiratory muscle strength (maximum inspiratory pressure % predicted) and endurance (fatigue resistance index) at ventilator liberation and 1 week later. Secondary outcomes included quality of life (SF-36v2, EQ-5D), dyspnoea, physical function, duration of ventilation, and in-hospital mortality. RESULTS Thirty-three participants were randomly allocated to the training group, and 37 to the control group. There were no statistically significant differences in strength (maximum inspiratory pressure) (95% confidence interval [CI]: -7.4 to 14.0) or endurance (fatigue resistance index) (95% CI: -0.003 to 0.436). Quality of life improved significantly more in the training group than in the control group (EQ-5D: 17.2; 95% CI: 1.3-33.0) (SF-36-PCS: 6.97; 95% CI: 1.96-12.00). Only the training group demonstrated significant reductions in dyspnoea (-1.5 at rest, -1.9 during exercise). There were no between-group differences in duration of ventilation or other measures. In-hospital mortality was higher in the control group than in the training group (9 vs 4, 24% vs 12%, p = 0.23). CONCLUSIONS In patients who are ventilator-dependent, mechanical threshold loading inspiratory muscle training improves quality of life and dyspnoea, even in the absence of strength improvements or acceleration of ventilator liberation.
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Influence of Early Multidisciplinary Collaboration on Prevention of ICU-Acquired Weakness in Critically Ill Patients. DISEASE MARKERS 2022; 2022:3823368. [PMID: 35942131 PMCID: PMC9356837 DOI: 10.1155/2022/3823368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/19/2022] [Accepted: 06/27/2022] [Indexed: 11/17/2022]
Abstract
Objective. This study focused on elucidating the influence of early multidisciplinary collaboration on preventing intensive care unit- (ICU-) acquired weakness (AW) in critically ill patients (CIPs). Methods. Ninety-five CIPs admitted between December 2018 and December 2021 were selected and assigned to the following two groups according to the intervention pattern: the control group (the Con;
) treated with routine early rehabilitation intervention, and the research group (the Res;
) intervened by early multidisciplinary collaborative intervention. The incidence of complications (ICU-AW, deep vein thrombosis (DVT), and pressure ulcers (PSs)) and recovery indices (days of ventilator use, ICU treatment time, and length of hospital stay (LOS)) were recorded. Besides, patients’ activity function and quality of life (QoL) were evaluated and compared, among which the former was evaluated by the Barthel Index (BI), ICU Mobility Scale (IMS), and Medical Research Council (MRC) Scale, and the latter was assessed by the World Health Organization Quality of Life Assessment (100-item version) (WHOQOL-100). Results. The data identified statistically a lower incidence of complications (ICU-AW, DVT, and PSs) and shorter time of ventilator use, ICU residence, and LOS in the Res compared with the Con. In addition, BI, IMS, MRC, and WHOQOL-100 scores in the Res elevated statistically after treatment and were higher than those of the Con. Conclusions. Early multidisciplinary collaboration can validly prevent ICU-AW in CIPs, reduce the incidence of DVT and PSs, and promote patients’ rehabilitation, mobility, and QoL.
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Bertoni M, Piva S, Beretta A, Bongiovanni F, Contarino R, Artigas RM, Ceresoli L, Marchesi M, Falappi M, Belleri M, Goffi A, Pozzi M, Rasulo FA, Latronico N. Occurrence and Effects on Weaning From Mechanical Ventilation of Intensive Care Unit Acquired and Diaphragm Weakness: A Pilot Study. Front Med (Lausanne) 2022; 9:930262. [PMID: 35935791 PMCID: PMC9354572 DOI: 10.3389/fmed.2022.930262] [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: 04/27/2022] [Accepted: 06/21/2022] [Indexed: 11/13/2022] Open
Abstract
PurposeLimb intensive care unit (ICU)-acquired weakness (ICUAW) and ICU acquired diaphragm weakness (DW) occur frequently in mechanically ventilated (MV) patients; their coexistence in cooperative and uncooperative patients is unknown. This study was designed to (1) describe the co-occurrence of the two conditions (2) evaluate the impact of ICUAW and DW on the ventilator-free days (VFDs) at 28 days and weaning success, and (3) assess the correlation between maximal inspiratory pressure (MIP) and thickening fraction (TFdi) in patients with DW.MethodsThis prospective pilot study was conducted in a single-center on 73 critically ill MV patients. Muscle weakness was defined as a Medical Research Council score < 48 in cooperative patients or a bilateral mean simplified peroneal nerve test < 5.26 mV in uncooperative patients. Diaphragm dysfunction was defined as MIP < 30 cm H2O or as a TFdi < 29%. Weaning success was defined according to weaning according to a new definition (WIND).ResultsFifty-seven patients (78%) had ICUAW and 59 (81%) had DW. The coexistence of the two conditions occurred in 48 patients (65%), without association (χ2 = 1.06, p = 0.304). In the adjusted analysis, ICUAW was independently related to VFDs at 28-days (estimate difference 6 days, p = 0.016), and WIND (OR of 3.62 for having WIND different than short weaning), whereas DW was not. The linear mixed model showed a significant but weak correlation between MIP and TFdi (p < 0.001).ConclusionThis pilot study is the first to explore the coexistence of ICUAW and DW in both cooperative and uncooperative patients; a lack of association was found between DW and ICUAW when considering both cooperative and uncooperative patients. We found a strong correlation between ICUAW but not DW with the VFDs at 28 days and weaning success. A future larger study is warranted in order to confirm our results, and should also investigate the use of transdiaphragmatic twitch pressure measurement during bilateral anterior magnetic phrenic nerve stimulation for the diagnosis of DW.
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Affiliation(s)
- Michele Bertoni
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Simone Piva
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- *Correspondence: Simone Piva,
| | - Alessandra Beretta
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Federica Bongiovanni
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Riccardo Contarino
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Ricard Mellado Artigas
- Department of Anesthesiology, Surgical ICU, Hospital Clinic de Barcelona, Barcelona, Spain
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Lucia Ceresoli
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Mattia Marchesi
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Michele Falappi
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marta Belleri
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Alberto Goffi
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Matteo Pozzi
- Department of Emergency and Intensive Care, ASST Monza, Monza, Italy
| | - Frank Antonio Rasulo
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Nicola Latronico
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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Van Hollebeke M, Poddighe D, Clerckx B, Muller J, Hermans G, Gosselink R, Langer D, Louvaris Z. High-Intensity Inspiratory Muscle Training Improves Scalene and Sternocleidomastoid Muscle Oxygenation Parameters in Patients With Weaning Difficulties: A Randomized Controlled Trial. Front Physiol 2022; 13:786575. [PMID: 35222072 PMCID: PMC8864155 DOI: 10.3389/fphys.2022.786575] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/04/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundCritically ill patients who have difficulties weaning from the mechanical ventilator are prone to develop respiratory muscle weakness. Inspiratory muscle training (IMT) can improve respiratory muscle strength. Whether IMT can improve scalene and sternocleidomastoid muscle oxygenation parameters is unknown.AimTo compare changes in muscle oxygenation parameters of scalene and sternocleidomastoid inspiratory muscles during a standardized task between patients with weaning difficulties who received either high-intensity IMT (intervention) or sham low-intensity IMT (control).MethodForty-one patients performed daily IMT sessions (4 sets, 6–10 breaths) until weaning success or for 28 consecutive days. The training load was progressively adjusted in the intervention group (n = 22) to the highest tolerable load, whilst the control group (n = 19) kept training at 10% of their baseline maximal inspiratory pressure (PImax). Breathing characteristics (i.e., work and power of breathing, PoB), respiratory muscle function [i.e., PImax and forced vital capacity (FVC)] were measured during a standardized loaded breathing task against a load of 30% of baseline PImax before and after the IMT period. In addition, during the same loaded breathing task, absolute mean and nadir changes from baseline in local scalene and sternocleidomastoid muscle oxygen saturation index (Δ%StiO2) (an index of oxygen extraction) and nadir Δ%StiO2 normalized for the PoB were measured by near-infrared spectroscopy.ResultsAt post measures, only the intervention group improved mean PoB compared to pre measures (Pre: 0.42 ± 0.33 watts, Post: 0.63 ± 0.51watts, p-value < 0.01). At post measures, both groups significantly improved nadir scalene muscles StiO2% normalized for the mean PoB (ΔStiOnadir%/watt) compared to pre measurements and the improvement was not significant different between groups (p-value = 0.40). However, at post measures, nadir sternocleidomastoid muscle StiO2% normalized for the mean PoB (ΔStiOnadir%/watt) was significantly greater improved in the intervention group (mean difference: +18.4, 95%CI: −1.4; 38.1) compared to the control group (mean difference: +3.7, 95%CI: −18.7; 26.0, between group p-value < 0.01). Both groups significantly improved PImax (Intervention: +15 ± 13 cmH2O p-value < 0.01, Control: +13 ± 15 cmH2O p-value < 0.01). FVC only significantly improved in the intervention group (+0.33 ± 0.31 L p < 0.01) report also change in control group.ConclusionThis exploratory study suggests that high-intensity IMT induces greater improvements in scalene and sternocleidomastoid muscle oxygenation parameters attributed for oxygen delivery, utilization and oxygen saturation index compared to low-intensity IMT in patients with weaning difficulties.
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Affiliation(s)
- Marine Van Hollebeke
- Faculty of Movement and Rehabilitation Sciences, Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
- *Correspondence: Marine Van Hollebeke,
| | - Diego Poddighe
- Faculty of Movement and Rehabilitation Sciences, Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Beatrix Clerckx
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Jan Muller
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Greet Hermans
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Rik Gosselink
- Faculty of Movement and Rehabilitation Sciences, Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Daniel Langer
- Faculty of Movement and Rehabilitation Sciences, Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Zafeiris Louvaris
- Faculty of Movement and Rehabilitation Sciences, Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
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21
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Yuan G, Zhang J, Mou Z, Luo J, Xie Y. Acute reduction of erector spinae muscle cross-sectional area is associated with ICU-AW and worse prognosis in patients with mechanical ventilation in the ICU: A prospective observational study. Medicine (Baltimore) 2021; 100:e27806. [PMID: 34964749 PMCID: PMC8615325 DOI: 10.1097/md.0000000000027806] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/27/2021] [Accepted: 10/27/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND To investigate the values of erector spinae muscle cross-sectional area (ESMcsa) loss for diagnosing intensive care unit-acquired weakness (ICU-AW) and predicting the 60-day survival status in patients with mechanical ventilation. METHODS Patients who were admitted into the intensive care unit (ICU) and received invasive mechanical ventilation therapy from June 2018 to June 2020 were selected. And they were divided into an ICU-AW group and a non-ICU-AW group, which were compared based on the ESMcsa and The British Medical Research Council muscle strength score (MRC-score) on the 1st and 7th day of ICU admission. The receiver operating characteristic curve was employed to measure the values of the ESMcsa Loss and ESMcsa Loss Ratio on the 7th day in order to diagnose ICU-AW in patients with mechanical ventilation. The survival curves of the patients were plotted to analyze the ESMcsa Loss Ratio values for predicting the 60-day survival status. RESULTS A total of 104 patients were enrolled, they were divided into the ICU-AW group (n = 56) and the non-ICU-AW group (n = 48). The mechanical ventilation time, ICU stay time, and hospital stay time of the ICU-AW group were all significantly higher than those of the non-ICU-AW group. On the 1st day, no significant difference in the ESMcsa or MRC-score between the 2 groups of patients was observed. On the 7th day, the ESMcsa and MRC-score of the ICU-AW group were significantly lower than those of the non-ICU-AW group. The ESMcsa Loss and ESMcsa Loss Ratio were both significantly negatively correlated with the MRC-score. The ESMcsa Loss and ESMcsa Loss Ratio on the 7th day were both valuable for the prediction of ICU-AW in patients with mechanical ventilation (areas under the receiver operating characteristic curve = 0.904, 0.835, and 0.889, P < .001). The survival rate of the patients in the high- and low-ESMcsa Loss Ratio groups were 60.0% and 80.0% (P < .05). CONCLUSIONS As suggested by the ESMcsa Loss Ratios of the patients with mechanical ventilation on the 7th day of ICU admission, it offers a desirable objective indicator for the diagnosis of ICU-AW, and provides certain values for predicting the 60-day survival status of patients with mechanical ventilation in the ICU.
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Affiliation(s)
- Gang Yuan
- Department of Radiology, Lianyungang Clinical College of Nanjing Medical University, The First People's Hospital of Lianyungang, Lianyungang, China
| | - Jie Zhang
- Department of Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, The First People's Hospital of Lianyungang, Lianyungang, China
| | - Zhifang Mou
- Department of Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, The First People's Hospital of Lianyungang, Lianyungang, China
| | - Jiye Luo
- Department of Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, The First People's Hospital of Lianyungang, Lianyungang, China
| | - Yongpeng Xie
- Department of Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, The First People's Hospital of Lianyungang, Lianyungang, China
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Cottereau G, Messika J, Megarbane B, Guérin L, da Silva D, Bornstain C, Santos M, Ricard JD, Sztrymf B. Handgrip strength to predict extubation outcome: a prospective multicenter trial. Ann Intensive Care 2021; 11:144. [PMID: 34601639 PMCID: PMC8487340 DOI: 10.1186/s13613-021-00932-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 09/23/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND ICU-acquired weakness (ICUAW) has been shown to be associated with prolonged duration of mechanical ventilation and extubation failure. It is usually assessed through Medical Research Council (MRC) score, a time-consuming score performed by physiotherapists. Handgrip strength (HG) can be monitored very easily at the bedside. It has been shown to be a reproducible and reliable marker of global muscular strength in critical care patients. We sought to test if muscular weakness, as assessed by handgrip strength, was associated with extubation outcome. METHODS Prospective multicenter trial over an 18 months period in six mixed ICUs. Adults receiving mechanical ventilation for at least 48 h were eligible. Just before weaning trial, HG, Maximal Inspiratory Pressure (MIP), Peak Cough Expiratory Flow (PCEF) and Medical Research Council (MRC) score were registered. The attending physicians were unaware of the tests results and weaning procedures were conducted according to guidelines. Occurrence of unscheduled reintubation, non-invasive ventilation (NIV) or high-flow nasal continuous oxygen (HFNC) because of respiratory failure within 7 days after extubation defined extubation failure. The main outcome was the link between HG and extubation outcome. RESULTS 233 patients were included. Extubation failure occurred in 51 (22.5%) patients, 39 (17.2%) required reintubation. Handgrip strength was 12 [6-20] kg and 12 [8-20] kg, respectively, in extubation success and failure (p = 0.85). There was no association between extubation outcome and MRC score, MIP or PCEF. Handgrip strength was well correlated with MRC score (r = 0.718, p < 0.0001). ICU and hospital length of stay were significantly higher in the subset of patients harboring muscular weakness as defined by handgrip performed at the first weaning trial (respectively, 15 [10-25] days vs. 11 [7-17] days, p = 0.001 and 34 [19-66] days vs. 22 [15-43] days, p = 0.002). CONCLUSION No association was found between handgrip strength and extubation outcome. Whether this was explained by the appropriateness of the tool in this specific setting, or by the precise impact of ICUAW on extubation outcome deserves to be further evaluated. Trial registration Clinical Trials; NCT02946502, 10/27/2016, URL: https://clinicaltrials.gov/ct2/results?cond=&term=gripwean&cntry=&state=&city=&dist=.
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Affiliation(s)
- Guillaume Cottereau
- AP-HP, Service de Rééducation Fonctionnelle et Kinésithérapie, Hôpital Antoine Béclère, 92140, Clamart, France
| | - Jonathan Messika
- AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Service de Médecine Intensive Réanimation, Université de Paris, 92700, Colombes, France
- PHERE UMRS 1152, Université de Paris, 75018, Paris, France
| | - Bruno Megarbane
- Réanimation Médicale et Toxicologique, Fédération de toxicologie, Hôpital Lariboisière, Université Paris-Diderot, Inserm UMRS 1144, 2, rue Ambroise-Paré, 75010, Paris, France
| | - Laurent Guérin
- AP-HP, Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service de Réanimation Médicale, 78, Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
- Faculté de Médecine Paris-Sud, Univ Paris-Sud, Inserm UMR_S 999, 94270, Le Kremlin-Bicêtre, France
| | - Daniel da Silva
- Réanimation Polyvalente, Hôpital Delafontaine, 93200, Saint-Denis, France
| | - Caroline Bornstain
- Réanimation Polyvalente, Hôpital Intercommunal de Montfermeil, 93370, Montfermeil, France
| | - Matilde Santos
- AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Service de Médecine Intensive Réanimation, Université de Paris, 92700, Colombes, France
| | - Jean-Damien Ricard
- AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Service de Médecine Intensive Réanimation, Université de Paris, 92700, Colombes, France
- PHERE UMRS 1152, Université de Paris, 75018, Paris, France
| | - Benjamin Sztrymf
- AP-HP, Service de réanimation polyvalente et surveillance continue, Hôpital Antoine Béclère, 157 rue de la porte de Triveaux, 92140, Clamart, France.
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Hearn E, Gosselink R, Freene N, Boden I, Green M, Bissett B. Inspiratory muscle training in intensive care unit patients: An international cross-sectional survey of physiotherapist practice. Aust Crit Care 2021; 35:527-534. [PMID: 34507849 DOI: 10.1016/j.aucc.2021.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/03/2021] [Accepted: 08/07/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Inspiratory muscle training is safe and effective in reversing inspiratory muscle weakness and improving outcomes in patients who have experienced prolonged mechanical ventilation in the intensive care unit (ICU). The degree of worldwide implementation of inspiratory muscle training in such patients has not been investigated. OBJECTIVES The objectives of this study were to describe the current practice of inspiratory muscle training by intensive care physiotherapists and investigate barriers to implementation in the intensive care context and additionally to determine if any factors are associated with the use of inspiratory muscle training in patients in the ICU and identify preferred methods of future education. METHOD Online cross-sectional surveys of intensive care physiotherapists were conducted using voluntary sampling. Multivariate logistic regression analysis was used to identify factors associated with inspiratory muscle training use in patients in the ICU. RESULTS Of 360 participants, 63% (95% confidence interval [CI] = 58 to 68) reported using inspiratory muscle training in patients in the ICU, with 69% (95% CI = 63 to 75) using a threshold device. Only 64% (95% CI = 58 to 70) of participants who used inspiratory muscle training routinely assessed inspiratory muscle strength. The most common barriers to implementing inspiratory muscle training sessions in eligible patients were sedation and delirium. Participants were 4.8 times more likely to use inspiratory muscle training in patients if they did not consider equipment a barrier and were 4.1 times more likely to use inspiratory muscle training if they aware of the evidence for this training in these patients. For education about inspiratory muscle training, 41% of participants preferred online training modules. CONCLUSION In this first study to describe international practice by intensive care therapists, 63% reported using inspiratory muscle training. Improving access to equipment and enhancing knowledge of inspiratory muscle training techniques could improve the translation of evidence into practice.
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Affiliation(s)
- Ellie Hearn
- Discipline of Physiotherapy, University of Canberra, Australia; Physiotherapy Department, John Hunter Hospital, Newcastle, Australia
| | - Rik Gosselink
- Department of Rehabilitation Sciences, KU Leuven, Belgium
| | - Nicole Freene
- Discipline of Physiotherapy, University of Canberra, Australia
| | - Ianthe Boden
- Physiotherapy Department, Launceston General Hospital, Launceston, Australia; School of Medicine, University of Tasmania, Australia
| | - Margot Green
- Canberra Hospital and Health Services, Canberra, Australia
| | - Bernie Bissett
- Discipline of Physiotherapy, University of Canberra, Australia; Physiotherapy Department, Canberra Hospital, Australia.
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De Marchi T, Frâncio F, Ferlito JV, Weigert R, de Oliveira C, Merlo AP, Pandini DL, Pasqual-Júnior BA, Giovanella D, Tomazoni SS, Leal-Junior EC. Effects of Photobiomodulation Therapy Combined with Static Magnetic Field in Severe COVID-19 Patients Requiring Intubation: A Pragmatic Randomized Placebo-Controlled Trial. J Inflamm Res 2021; 14:3569-3585. [PMID: 34335043 PMCID: PMC8318710 DOI: 10.2147/jir.s318758] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 07/10/2021] [Indexed: 12/15/2022] Open
Abstract
Purpose We aimed to investigate the effects of photobiomodulation therapy combined with static magnetic field (PBMT-sMF) on the length of intensive care unit (ICU) stay and mortality rate of severe COVID-19 patients requiring invasive mechanical ventilation and assess its role in preserving respiratory muscles and modulating inflammatory processes. Patients and Methods We conducted a prospectively registered, triple-blinded, randomized, placebo-controlled trial of PBMT-sMF in severe COVID-19 ICU patients requiring invasive mechanical ventilation. Patients were randomly assigned to receive either PBMT-sMF or a placebo daily throughout their ICU stay. The primary outcome was length of ICU stay, defined by either discharge or death. The secondary outcomes were survival rate, diaphragm muscle function, and the changes in blood parameters, ventilatory parameters, and arterial blood gases. Results Thirty patients were included and equally randomized into the two groups. There were no significant differences in the length of ICU stay (mean difference, MD = −6.80; 95% CI = −18.71 to 5.11) between the groups. Among the secondary outcomes, significant differences were observed in diaphragm thickness, fraction of inspired oxygen, partial pressure of oxygen/fraction of inspired oxygen ratio, C-reactive protein levels, lymphocyte count, and hemoglobin (p < 0.05). Conclusion Among severe COVID-19 patients requiring invasive mechanical ventilation, the length of ICU stay was not significantly different between the PBMT-sMF and placebo groups. In contrast, PBMT-sMF was significantly associated with reduced diaphragm atrophy, improved ventilatory parameters and lymphocyte count, and decreased C-reactive protein levels and hemoglobin count. Trial Registration Number (Clinical Trials.gov) NCT04386694.
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Affiliation(s)
- Thiago De Marchi
- University Center of Bento Gonçalves (UNICNEC), Bento Gonçalves, Rio Grande do Sul, Brazil.,Laboratory of Phototherapy and Innovative Technologies in Health (LaPIT), Post-graduate Program in Rehabilitation Sciences, Nove de Julho University, São Paulo, Brazil
| | - Fabiano Frâncio
- University Center of Bento Gonçalves (UNICNEC), Bento Gonçalves, Rio Grande do Sul, Brazil.,Hospital Tacchini, Bento Gonçalves, Rio Grande do Sul, Brazil
| | | | - Renata Weigert
- Hospital Tacchini, Bento Gonçalves, Rio Grande do Sul, Brazil
| | | | - Ana Paula Merlo
- Hospital Tacchini, Bento Gonçalves, Rio Grande do Sul, Brazil
| | | | | | | | - Shaiane Silva Tomazoni
- Physiotherapy Research Group, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,ELJ Consultancy, Scientific Consultants, São Paulo, Brazil
| | - Ernesto Cesar Leal-Junior
- Laboratory of Phototherapy and Innovative Technologies in Health (LaPIT), Post-graduate Program in Rehabilitation Sciences, Nove de Julho University, São Paulo, Brazil.,Physiotherapy Research Group, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,ELJ Consultancy, Scientific Consultants, São Paulo, Brazil
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25
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De Marchi T, Frâncio F, Ferlito JV, Weigert R, de Oliveira C, Merlo AP, Pandini DL, Pasqual-Júnior BA, Giovanella D, Tomazoni SS, Leal-Junior EC. Effects of Photobiomodulation Therapy Combined with Static Magnetic Field in Severe COVID-19 Patients Requiring Intubation: A Pragmatic Randomized Placebo-Controlled Trial. J Inflamm Res 2021; 14:3569-3585. [PMID: 34335043 DOI: 10.1101/2020.12.02.20237974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 07/10/2021] [Indexed: 05/28/2023] Open
Abstract
PURPOSE We aimed to investigate the effects of photobiomodulation therapy combined with static magnetic field (PBMT-sMF) on the length of intensive care unit (ICU) stay and mortality rate of severe COVID-19 patients requiring invasive mechanical ventilation and assess its role in preserving respiratory muscles and modulating inflammatory processes. PATIENTS AND METHODS We conducted a prospectively registered, triple-blinded, randomized, placebo-controlled trial of PBMT-sMF in severe COVID-19 ICU patients requiring invasive mechanical ventilation. Patients were randomly assigned to receive either PBMT-sMF or a placebo daily throughout their ICU stay. The primary outcome was length of ICU stay, defined by either discharge or death. The secondary outcomes were survival rate, diaphragm muscle function, and the changes in blood parameters, ventilatory parameters, and arterial blood gases. RESULTS Thirty patients were included and equally randomized into the two groups. There were no significant differences in the length of ICU stay (mean difference, MD = -6.80; 95% CI = -18.71 to 5.11) between the groups. Among the secondary outcomes, significant differences were observed in diaphragm thickness, fraction of inspired oxygen, partial pressure of oxygen/fraction of inspired oxygen ratio, C-reactive protein levels, lymphocyte count, and hemoglobin (p < 0.05). CONCLUSION Among severe COVID-19 patients requiring invasive mechanical ventilation, the length of ICU stay was not significantly different between the PBMT-sMF and placebo groups. In contrast, PBMT-sMF was significantly associated with reduced diaphragm atrophy, improved ventilatory parameters and lymphocyte count, and decreased C-reactive protein levels and hemoglobin count. TRIAL REGISTRATION NUMBER CLINICAL TRIALSGOV NCT04386694.
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Affiliation(s)
- Thiago De Marchi
- University Center of Bento Gonçalves (UNICNEC), Bento Gonçalves, Rio Grande do Sul, Brazil
- Laboratory of Phototherapy and Innovative Technologies in Health (LaPIT), Post-graduate Program in Rehabilitation Sciences, Nove de Julho University, São Paulo, Brazil
| | - Fabiano Frâncio
- University Center of Bento Gonçalves (UNICNEC), Bento Gonçalves, Rio Grande do Sul, Brazil
- Hospital Tacchini, Bento Gonçalves, Rio Grande do Sul, Brazil
| | | | - Renata Weigert
- Hospital Tacchini, Bento Gonçalves, Rio Grande do Sul, Brazil
| | | | - Ana Paula Merlo
- Hospital Tacchini, Bento Gonçalves, Rio Grande do Sul, Brazil
| | | | | | | | - Shaiane Silva Tomazoni
- Physiotherapy Research Group, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- ELJ Consultancy, Scientific Consultants, São Paulo, Brazil
| | - Ernesto Cesar Leal-Junior
- Laboratory of Phototherapy and Innovative Technologies in Health (LaPIT), Post-graduate Program in Rehabilitation Sciences, Nove de Julho University, São Paulo, Brazil
- Physiotherapy Research Group, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- ELJ Consultancy, Scientific Consultants, São Paulo, Brazil
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Dres M, Rozenberg E, Morawiec E, Mayaux J, Delemazure J, Similowski T, Demoule A. Diaphragm dysfunction, lung aeration loss and weaning-induced pulmonary oedema in difficult-to-wean patients. Ann Intensive Care 2021; 11:99. [PMID: 34181105 PMCID: PMC8237539 DOI: 10.1186/s13613-021-00886-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 06/09/2021] [Indexed: 11/16/2022] Open
Abstract
Background Diaphragm dysfunction and weaning-induced pulmonary oedema are commonly involved during weaning failure, but their physiological interactions have been poorly reported. Our hypothesis was that diaphragm dysfunction is not particularly associated with weaning-induced pulmonary oedema. Methods It was a single-centre and physiological study conducted in patients who had failed a first spontaneous breathing trial and who underwent a second trial. The diaphragm function was evaluated by measuring the tracheal pressure generated in response to a bilateral magnetic phrenic nerves stimulations. Weaning-induced pulmonary oedema was diagnosed in case of failure of the spontaneous breathing trial if patients exhibited signs of plasma concentration or echocardiographic diagnosis of pulmonary artery occlusion pressure elevation. Results Fifty-three patients were included and 31/53 (58%) failed the spontaneous breathing trial, including 24/31 (77%) patients with weaning-induced pulmonary oedema. Diaphragm dysfunction was present in 33/53 (62%) patients. Diaphragm dysfunction or weaning-induced pulmonary oedema were present in 26/31 (84%) of the patients who failed the spontaneous breathing trial. Weaning-induced pulmonary oedema occurred in 20/33 (61%) patients with a diaphragm dysfunction and in 4/20 (20%) patients without (p = 0.005). Conclusion Weaning-induced pulmonary oedema was three times more frequent in case of diaphragm dysfunction. Even in case of diaphragm dysfunction, physicians might be encouraged to investigate the presence of weaning-induced pulmonary oedema during weaning failure.
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Affiliation(s)
- Martin Dres
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, 75013, Paris, France. .,Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.
| | - Emmanuel Rozenberg
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Elise Morawiec
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Julien Mayaux
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Julie Delemazure
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Thomas Similowski
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, 75013, Paris, France.,Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Alexandre Demoule
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, 75013, Paris, France.,Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
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Fontela PC, Glaeser SS, Martins LF, Condessa RL, Prediger DT, Forgiarini SG, Forgiarini LA, Lisboa TC, Friedman G. Medical Research Council Scale Predicts Spontaneous Breathing Trial Failure and Difficult or Prolonged Weaning of Critically Ill Individuals. Respir Care 2021; 66:733-741. [PMID: 33653914 PMCID: PMC9994125 DOI: 10.4187/respcare.07739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Handgrip strength is an alternative measure to assess peripheral muscle strength and is correlated with the Medical Research Council (MRC) scale, with promising values for diagnosing ICU-acquired weakness (ICUAW). Because ICUAW has been associated with delayed weaning from mechanical ventilation, we hypothesized that ICUAW evaluated with both the MRC scale score and handgrip strength are associated with failure of a spontaneous breathing trial (SBT) and duration of mechanical ventilation weaning. METHODS We conducted a prospective observational study in 3 general ICUs with a total of 54 beds at 2 academic hospitals. Adult subjects with > 48 h of mechanical ventilation who were eligible for weaning were included in the study. RESULTS In the evaluation before the first SBT, the MRC score (P < .001) and handgrip strength (P < .001) were significantly different between subjects extubated after a successful first SBT (simple weaning) and those extubated any time after a failed first SBT (difficult weaning). Only the MRC score discriminated between first SBT success or failure (P < .001); in multivariate analysis, the MRC score was significantly associated with first SBT failure (odds ratio 0.91, 95% CI 0.88-0.97, P < .001) and difficult weaning (odds ratio 0.91, 95% CI 0.87-0.96, P < .001). Handgrip strength exhibited good accuracy in identifying ICUAW. CONCLUSIONS MRC score was independently associated with SBT failure and difficult or prolonged weaning.
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Affiliation(s)
- Paula C Fontela
- Pneumological Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Sheila S Glaeser
- Physiotherapy Service, Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Luciane Fg Martins
- Physiotherapy Service, Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Robledo L Condessa
- Physiotherapy Service, Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Douglas T Prediger
- Physiotherapy Service, Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Soraia Gi Forgiarini
- Physiotherapy, Centro Universitário Metodista, Porto Alegre, Rio Grande do Sul, Brazil
| | - Luiz A Forgiarini
- Health and Human Development and Physiotherapy, Universidade LaSalle, Canoas, Rio Grande do Sul, Brazil
| | - Thiago C Lisboa
- Pneumological Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
- Intensive Care Medicine Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Gilberto Friedman
- Pneumological Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil.
- Intensive Care Medicine Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
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Abstract
PURPOSE OF REVIEW Ventilator weaning forms an integral part in critical care medicine and strategies to shorten duration are rapidly evolving alongside our knowledge of the relevant physiological processes. The purpose of the current review is to discuss new physiological and clinical insights in ventilator weaning that help us to fasten liberation from mechanical ventilation. RECENT FINDINGS Several new concepts have been introduced in the field of ventilator weaning in the past 2 years. Approaches to shorten the time until ventilator liberation include frequent spontaneous breathing trials, early noninvasive mechanical ventilation to shorten invasive ventilation time, novel ventilatory modes, such as neurally adjusted ventilatory assist and drugs to enhance the contractile efficiency of respiratory muscles. Equally important, ultrasound has been shown to be a versatile tool to monitor physiological changes of the cardiorespiratory system during weaning and steer targeted interventions to improve extubation outcome. SUMMARY A thorough understanding of the physiological adaptations during withdrawal of positive pressure ventilation is extremely important for clinicians in the ICU. We summarize and discuss novel insights in this field.
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29
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Van Aerde N, Meersseman P, Debaveye Y, Wilmer A, Gunst J, Casaer MP, Wauters J, Wouters PJ, Gosselink R, Van den Berghe G, Hermans G. Five-year outcome of respiratory muscle weakness at intensive care unit discharge: secondary analysis of a prospective cohort study. Thorax 2021; 76:561-567. [PMID: 33712505 DOI: 10.1136/thoraxjnl-2020-216720] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/02/2021] [Accepted: 02/18/2021] [Indexed: 12/31/2022]
Abstract
PURPOSE To assess the association between respiratory muscle weakness (RMW) at intensive care unit (ICU) discharge and 5-year mortality and morbidity, independent from confounders including peripheral muscle strength. METHODS Secondary analysis of the prospective 5-year follow-up of the EPaNIC cohort (ClinicalTrials.gov: NCT00512122), limited to 366 patients screened for respiratory and peripheral muscle strength in the ICU with maximal inspiratory pressure (MIP) after removal of the artificial airway, and the Medical Research Council sum score. RMW was defined as an absolute value of MIP <30 cmH2O. Associations between RMW at (or closest to) ICU discharge and all-cause 5-year mortality, and key measures of 5-year physical function, comprising respiratory muscle strength (MIP), hand-grip strength (HGF), 6 min walk distance (6MWD) and physical function of the SF-36 quality-of-life questionnaire (PF-SF-36), were assessed with Cox proportional hazards and linear regression models, adjusted for confounders including peripheral muscle strength. RESULTS RMW was present in 136/366 (37.2%) patients at ICU discharge. RMW was not independently associated with 5-year mortality (HR with 95% CI 1.273 (0.751 to 1.943), p=0.352). Among 156five-year survivors, those with, as compared with those without RMW demonstrated worse physical function (MIP (absolute value, cmH2O): 62(42-77) vs 94(78-109), p<0.001; HGF (%pred): 67(44-87) vs 96(68-110), p<0.001; 6MWD (%pred): 87(74-102) vs 99 (80-111), p=0.009; PF-SF-36 (score): 55 (30-80) vs 80 (55-95), p<0.001). Associations between RMW and morbidity endpoints remained significant after adjustment for confounders (effect size with 95% CI: MIP: -23.858 (-32.097 to -15.027), p=0.001; HGF: -18.591 (-30.941 to -5.744), p=0.001; 6MWD (transformed): -1587.007 (-3073.763 to -179.253), p=0.034; PF-SF-36 (transformed): 1.176 (0.144-2.270), p=0.036). CONCLUSIONS RMW at ICU discharge is independently associated with 5-year morbidity but not 5-year mortality.
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Affiliation(s)
| | - Philippe Meersseman
- Medical Intensive Care Unit, Department of General Internal Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Yves Debaveye
- Cellular and Molecular Medicine, KU Leuven, Leuven, Flanders, Belgium.,Intensive Care Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Alexander Wilmer
- Cellular and Molecular Medicine, KU Leuven, Leuven, Flanders, Belgium.,Medical Intensive Care Unit, Department of General Internal Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Jan Gunst
- Cellular and Molecular Medicine, KU Leuven, Leuven, Flanders, Belgium.,Intensive Care Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Michael P Casaer
- Cellular and Molecular Medicine, KU Leuven, Leuven, Flanders, Belgium.,Intensive Care Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Joost Wauters
- Medical Intensive Care Unit, Department of General Internal Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium.,Laboratory for Clinical Infectious and Inflammatory Disorders, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Flanders, Belgium
| | - Pieter J Wouters
- Cellular and Molecular Medicine, KU Leuven, Leuven, Flanders, Belgium.,Intensive Care Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Rik Gosselink
- Rehabilitation Sciences, KU Leuven, Leuven, Flanders, Belgium
| | - Greet Van den Berghe
- Cellular and Molecular Medicine, KU Leuven, Leuven, Flanders, Belgium.,Intensive Care Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Greet Hermans
- Cellular and Molecular Medicine, KU Leuven, Leuven, Flanders, Belgium .,Medical Intensive Care Unit, Department of General Internal Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
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30
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Tan BH, Liu JM, Gui Y, Wu S, Suo JL, Li YC. Neurological involvement in the respiratory manifestations of COVID-19 patients. Aging (Albany NY) 2021; 13:4713-4730. [PMID: 33582654 PMCID: PMC7906194 DOI: 10.18632/aging.202665] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 02/03/2021] [Indexed: 02/06/2023]
Abstract
The peculiar features of coronavirus disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), are challenging the current biological knowledge. Early in Feb, 2020, we suggested that SARS-CoV-2 may possess neuroinvasive potential similar to that of many other coronaviruses. Since then, a variety of neurological manifestations have been associated with SARS-CoV-2 infection, which was supported in some patients with neuroimaging and/or cerebrospinal fluid tests. To date, at least 27 autopsy studies on the brains of COVID-19 patients can be retrieved through PubMed/MEDLINE, among which neuropathological alterations were observed in the brainstem in 78 of 134 examined patients, and SARS-CoV-2 nucleic acid and viral proteins were detected in the brainstem in 16/49 (32.7%) and 18/71 (25.3%) cases, respectively. To shed some light on the peculiar respiratory manifestations of COVID-19 patients, this review assessed the existing evidence about the neurogenic mechanism underlying the respiratory failure induced by SARS-CoV-2 infection. Acknowledging the neurological involvement has important guiding significance for the prevention, treatment, and prognosis of SARS-CoV-2 infection.
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Affiliation(s)
- Bai-Hong Tan
- Laboratory Teaching Center of Basic Medicine, Norman Bethune Health Science Center of Jilin University, Jilin, China
| | - Jia-Mei Liu
- Department of Histology and Embryology, College of Basic Medical Sciences, Norman Bethune College of Medicine, Jilin University, Changchun, Jilin, China
| | - Yue Gui
- Department of Histology and Embryology, College of Basic Medical Sciences, Norman Bethune College of Medicine, Jilin University, Changchun, Jilin, China
| | - Shuang Wu
- Department of Histology and Embryology, College of Basic Medical Sciences, Norman Bethune College of Medicine, Jilin University, Changchun, Jilin, China
| | - Jia-Le Suo
- Department of Histology and Embryology, College of Basic Medical Sciences, Norman Bethune College of Medicine, Jilin University, Changchun, Jilin, China
| | - Yan-Chao Li
- Department of Histology and Embryology, College of Basic Medical Sciences, Norman Bethune College of Medicine, Jilin University, Changchun, Jilin, China
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31
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Carámbula A, Pereyra S, Barbato M, Angulo M. Combined Diaphragm and Limb Muscle Atrophy Is Associated With Increased Mortality in Mechanically Ventilated Patients: A Pilot Study. Arch Bronconeumol 2021; 57:377-379. [PMID: 33637339 DOI: 10.1016/j.arbres.2020.12.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/07/2020] [Accepted: 12/20/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Agustín Carámbula
- Intensive Care Unit, Hospital Maciel, Montevideo, Uruguay; National Institute of Cell, Tissue, and Organ Donation and Transplantation, Montevideo, Uruguay
| | - Sebastián Pereyra
- Department of Diagnostic Ultrasound, Hospital Maciel, Montevideo, Uruguay
| | | | - Martín Angulo
- Intensive Care Unit, Hospital Maciel, Montevideo, Uruguay; Respiratory Function Laboratory and Critical Care Department, School of Medicine, Universidad de la República, Montevideo, Uruguay; Pathophysiology Department, School of Medicine, Universidad de la República, Montevideo, Uruguay.
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32
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Sklar MC, Madotto F, Jonkman A, Rauseo M, Soliman I, Damiani LF, Telias I, Dubo S, Chen L, Rittayamai N, Chen GQ, Goligher EC, Dres M, Coudroy R, Pham T, Artigas RM, Friedrich JO, Sinderby C, Heunks L, Brochard L. Duration of diaphragmatic inactivity after endotracheal intubation of critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:26. [PMID: 33430930 PMCID: PMC7798017 DOI: 10.1186/s13054-020-03435-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/11/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND In patients intubated for mechanical ventilation, prolonged diaphragm inactivity could lead to weakness and poor outcome. Time to resume a minimal diaphragm activity may be related to sedation practice and patient severity. METHODS Prospective observational study in critically ill patients. Diaphragm electrical activity (EAdi) was continuously recorded after intubation looking for resumption of a minimal level of diaphragm activity (beginning of the first 24 h period with median EAdi > 7 µV, a threshold based on literature and correlations with diaphragm thickening fraction). Recordings were collected until full spontaneous breathing, extubation, death or 120 h. A 1 h waveform recording was collected daily to identify reverse triggering. RESULTS Seventy-five patients were enrolled and 69 analyzed (mean age ± standard deviation 63 ± 16 years). Reasons for ventilation were respiratory (55%), hemodynamic (19%) and neurologic (20%). Eight catheter disconnections occurred. The median time for resumption of EAdi was 22 h (interquartile range 0-50 h); 35/69 (51%) of patients resumed activity within 24 h while 4 had no recovery after 5 days. Late recovery was associated with use of sedative agents, cumulative doses of propofol and fentanyl, controlled ventilation and age (older patients receiving less sedation). Severity of illness, oxygenation, renal and hepatic function, reason for intubation were not associated with EAdi resumption. At least 20% of patients initiated EAdi with reverse triggering. CONCLUSION Low levels of diaphragm electrical activity are common in the early course of mechanical ventilation: 50% of patients do not recover diaphragmatic activity within one day. Sedatives are the main factors accounting for this delay independently from lung or general severity. Trial Registration ClinicalTrials.gov (NCT02434016). Registered on April 27, 2015. First patients enrolled June 2015.
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Affiliation(s)
- Michael Chaim Sklar
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 4th Floor, Room 411, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Fabiana Madotto
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 4th Floor, Room 411, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada.,Value Based Health-Care Unit, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy
| | - Annemijn Jonkman
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 4th Floor, Room 411, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada.,Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - Michela Rauseo
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 4th Floor, Room 411, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada
| | - Ibrahim Soliman
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 4th Floor, Room 411, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada
| | - L Felipe Damiani
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 4th Floor, Room 411, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada.,Departamento de Ciencias de La Salud, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Irene Telias
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 4th Floor, Room 411, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada
| | - Sebastian Dubo
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 4th Floor, Room 411, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada.,Departamento de Kinesiologiá, Facultad de Medicina, Universidad de Concepción, Concepción, Chile.,Programa de Doctorado en Ciencias Médicas, Universidad de La Frontera, Temuco, Chile
| | - Lu Chen
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 4th Floor, Room 411, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada
| | - Nuttapol Rittayamai
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 4th Floor, Room 411, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada.,Division of Respiratory Diseases and Tuberculosis, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 65106, Thailand
| | - Guang-Qiang Chen
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 4th Floor, Room 411, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada
| | - Ewan C Goligher
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 4th Floor, Room 411, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Toronto General Hospital Research Institute, Toronto, ON, Canada.,Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, ON, Canada
| | - Martin Dres
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 4th Floor, Room 411, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada.,Pneumology and Critical Care Department, Public Assistance - Paris Hospital, Pitie-Salpetriere Hospital, Paris, France
| | - Remi Coudroy
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 4th Floor, Room 411, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada.,Médecine Intensive Réanimation, CHU de Poitiers, INSERM CIC1402 Alive Group, Université de Poitiers, Poitiers, France
| | - Tai Pham
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 4th Floor, Room 411, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada.,Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Le Kremlin-Bicêtre, Paris, France
| | - Ricard M Artigas
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 4th Floor, Room 411, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada
| | - Jan O Friedrich
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 4th Floor, Room 411, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Christer Sinderby
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 4th Floor, Room 411, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Institute for Biomedical Engineering and Science Technology (iBEST), Ryerson University and St-Michael's Hospital, Toronto, Canada
| | - Leo Heunks
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 4th Floor, Room 411, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada.,Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - Laurent Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 4th Floor, Room 411, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
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Krishnakumar M, Muthuchellappan R, Chakrabarti D. Diaphragm Function Assessment During Spontaneous Breathing Trial in Patients with Neuromuscular Diseases. Neurocrit Care 2020; 34:382-389. [PMID: 33210265 PMCID: PMC7673684 DOI: 10.1007/s12028-020-01141-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 10/27/2020] [Indexed: 12/02/2022]
Abstract
Introduction The optimal time to discontinue patients from mechanical ventilation is critical as premature discontinuation as well as delayed weaning can result in complications. The literature on diaphragm function assessment during the weaning process in the intriguing subpopulation of critically ill neuromuscular disease patients is lacking. Methods Patients with neuromuscular diseases, on mechanical ventilation for more than 7 days, and who were ready for weaning were studied. During multiple T-piece trials over days, diaphragm function using ultrasound and diaphragm electrical activity (Edi peaks using NAVA catheter) was measured every 30 min till a successful 2 h weaning. Results A total of 18 patients were screened for eligibility over 5-month period and eight patients fulfilled the inclusion criteria. Sixty-three data points in these 8 subjects were available for analysis. A successful breathing trial was predicted by Edi reduction (1.22 μV for every 30 min increase in weaning duration; 0.69 μV for every day of weaning) and increase in diaphragm excursion (2.81 mm for every 30 min increase in weaning duration; 2.18 mm for every day of weaning). Conclusion The Edi and diaphragm excursion changes can be used as additional objective tools in the decision-making of the weaning trials in neuromuscular disease. Electronic supplementary material The online version of this article (10.1007/s12028-020-01141-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mathangi Krishnakumar
- Department of Neuroanaesthesia and Neurocritical Care, III Floor, Neurosciences Faculty Centre, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru, Karnataka, 560029, India.
| | - Radhakrishnan Muthuchellappan
- Department of Neuroanaesthesia and Neurocritical Care, III Floor, Neurosciences Faculty Centre, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru, Karnataka, 560029, India
| | - Dhritiman Chakrabarti
- Department of Neuroanaesthesia and Neurocritical Care, III Floor, Neurosciences Faculty Centre, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru, Karnataka, 560029, India
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34
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Jonkman AH, Frenzel T, McCaughey EJ, McLachlan AJ, Boswell-Ruys CL, Collins DW, Gandevia SC, Girbes ARJ, Hoiting O, Kox M, Oppersma E, Peters M, Pickkers P, Roesthuis LH, Schouten J, Shi ZH, Veltink PH, de Vries HJ, Shannon Weickert C, Wiedenbach C, Zhang Y, Tuinman PR, de Man AME, Butler JE, Heunks LMA. Breath-synchronized electrical stimulation of the expiratory muscles in mechanically ventilated patients: a randomized controlled feasibility study and pooled analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:628. [PMID: 33126902 PMCID: PMC7596623 DOI: 10.1186/s13054-020-03352-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/16/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Expiratory muscle weakness leads to difficult ventilator weaning. Maintaining their activity with functional electrical stimulation (FES) may improve outcome. We studied feasibility of breath-synchronized expiratory population muscle FES in a mixed ICU population ("Holland study") and pooled data with our previous work ("Australian study") to estimate potential clinical effects in a larger group. METHODS Holland: Patients with a contractile response to FES received active or sham expiratory muscle FES (30 min, twice daily, 5 days/week until weaned). Main endpoints were feasibility (e.g., patient recruitment, treatment compliance, stimulation intensity) and safety. Pooled: Data on respiratory muscle thickness and ventilation duration from the Holland and Australian studies were combined (N = 40) in order to estimate potential effect size. Plasma cytokines (day 0, 3) were analyzed to study the effects of FES on systemic inflammation. RESULTS Holland: A total of 272 sessions were performed (active/sham: 169/103) in 20 patients (N = active/sham: 10/10) with a total treatment compliance rate of 91.1%. No FES-related serious adverse events were reported. Pooled: On day 3, there was a between-group difference (N = active/sham: 7/12) in total abdominal expiratory muscle thickness favoring the active group [treatment difference (95% confidence interval); 2.25 (0.34, 4.16) mm, P = 0.02] but not on day 5. Plasma cytokine levels indicated that early FES did not induce systemic inflammation. Using a survival analysis approach for the total study population, median ventilation duration and ICU length of stay were 10 versus 52 (P = 0.07), and 12 versus 54 (P = 0.03) days for the active versus sham group. Median ventilation duration of patients that were successfully extubated was 8.5 [5.6-12.2] versus 10.5 [5.3-25.6] days (P = 0.60) for the active (N = 16) versus sham (N = 10) group, and median ICU length of stay was 10.5 [8.0-14.5] versus 14.0 [9.0-19.5] days (P = 0.36) for those active (N = 16) versus sham (N = 8) patients that were extubated and discharged alive from the ICU. During ICU stay, 3/20 patients died in the active group versus 8/20 in the sham group (P = 0.16). CONCLUSION Expiratory muscle FES is feasible in selected ICU patients and might be a promising technique within a respiratory muscle-protective ventilation strategy. The next step is to study the effects on weaning and ventilator liberation outcome. TRIAL REGISTRATION ClinicalTrials.gov, ID NCT03453944. Registered 05 March 2018-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03453944 .
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Affiliation(s)
- Annemijn H Jonkman
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7505, 1007 MB, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Tim Frenzel
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Euan J McCaughey
- Neuroscience Research Australia, 139 Barker Street, Randwick, NSW, 2031, Australia.,School of Medical Sciences, University of New South Wales, Kensington, NSW, 2052, Australia
| | | | - Claire L Boswell-Ruys
- Neuroscience Research Australia, 139 Barker Street, Randwick, NSW, 2031, Australia.,School of Medical Sciences, University of New South Wales, Kensington, NSW, 2052, Australia
| | | | - Simon C Gandevia
- Neuroscience Research Australia, 139 Barker Street, Randwick, NSW, 2031, Australia.,School of Medical Sciences, University of New South Wales, Kensington, NSW, 2052, Australia
| | - Armand R J Girbes
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7505, 1007 MB, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Oscar Hoiting
- Department of Intensive Care Medicine, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Matthijs Kox
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eline Oppersma
- Cardiovascular and Respiratory Physiology Group, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Marco Peters
- Department of Intensive Care Medicine, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lisanne H Roesthuis
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jeroen Schouten
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Zhong-Hua Shi
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7505, 1007 MB, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Peter H Veltink
- Department of Biomedical Signals and Systems, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Heder J de Vries
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7505, 1007 MB, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Cyndi Shannon Weickert
- Neuroscience Research Australia, 139 Barker Street, Randwick, NSW, 2031, Australia.,School of Psychiatry, University of New South Wales, Kensington, NSW, 2052, Australia.,Department of Neuroscience and Physiology, Upstate Medical University, New York, 13210, USA
| | - Carsten Wiedenbach
- Department of Intensive Care Medicine, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Yingrui Zhang
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7505, 1007 MB, Amsterdam, The Netherlands
| | - Pieter R Tuinman
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7505, 1007 MB, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Angélique M E de Man
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7505, 1007 MB, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Jane E Butler
- Neuroscience Research Australia, 139 Barker Street, Randwick, NSW, 2031, Australia.,School of Medical Sciences, University of New South Wales, Kensington, NSW, 2052, Australia
| | - Leo M A Heunks
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7505, 1007 MB, Amsterdam, The Netherlands. .,Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands.
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Abstract
The aim of the study was to establish the prevalence of diaphragmatic dysfunction (DD), depending on the strategy of mechanical ventilation (MV).
Materials and methods. We completed the prospective single-center cohort study. Data analysis included 82 patients (1 month – 18 years old), divided into I group (lung-protective MV) and II group (diaphragm-protective in addition to lung-protective MV).
Patients were divided into age subgroups. Stages of the study: 1st day (d1), 3rd (d3), 5th (d5), 7th (d7), 9th (d9), 14th (d14), 28th (d28). We studied amplitude of diaphragm movement; thickening fraction, parameters of acid-base balance and MV. Results are described as median [IQR - interquartile range] with level of significance p.
Results. In patients of the 1st age subgroup in I group there were episodes with under-assist during MV, while in II group diaphragm overload was registered only on d5.
In patients of 2nd subgroup in I group we found over-assist of MV with excessive work of the right hemidiaphragm and low contractions of left dome at all stages of study, while in II group – the only episode of diaphragmatic weakness on d3 due to under-assist of MV. In the 3rd subgroup the proper diaphragmatic activity in I group was restored significantly later than in II group. In 4th subgroup of I group there was episode of high work of diaphragm on d5, whereas in II group – all data were within the recommended parameters for diaphragm-protective strategy of MV. In 5th subgroup of I group excessive work of both right and left domes of diaphragm was significantly more often registered than in II group, however, in II group there were found episodes of both type changes – diaphragmatic weakness and excessive work.
Conclusion: The prevalence and variety of manifestations of DD depend on the strategy of MV. Low incidence of DD was associated with lower duration of MV: in 1st age subgroup in 1.5 times; in 2nd age subgroup – in 2.4 times; in 4th age subgroup – in 1.75 times; in 5th age subgroup – in 4.25 times.
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Brosnahan SB, Jonkman AH, Kugler MC, Munger JS, Kaufman DA. COVID-19 and Respiratory System Disorders: Current Knowledge, Future Clinical and Translational Research Questions. Arterioscler Thromb Vasc Biol 2020; 40:2586-2597. [PMID: 32960072 PMCID: PMC7571846 DOI: 10.1161/atvbaha.120.314515] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The severe acute respiratory syndrome coronavirus-2 emerged as a serious human pathogen in late 2019, causing the disease coronavirus disease 2019 (COVID-19). The most common clinical presentation of severe COVID-19 is acute respiratory failure consistent with the acute respiratory distress syndrome. Airway, lung parenchymal, pulmonary vascular, and respiratory neuromuscular disorders all feature in COVID-19. This article reviews what is known about the effects of severe acute respiratory syndrome coronavirus-2 infection on different parts of the respiratory system, clues to understanding the underlying biology of respiratory disease, and highlights current and future translation and clinical research questions.
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Affiliation(s)
- Shari B Brosnahan
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, NYU School of Medicine (S.B.B., M.C.K., J.S.M., D.A.K.)
| | - Annemijn H Jonkman
- Keenan Centre for Biomedical Research, Critical Care Department, St. Michael's Hospital, Toronto, Canada (A.H.J.).,Department of Intensive Care Medicine, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands (A.H.J.)
| | - Matthias C Kugler
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, NYU School of Medicine (S.B.B., M.C.K., J.S.M., D.A.K.)
| | - John S Munger
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, NYU School of Medicine (S.B.B., M.C.K., J.S.M., D.A.K.)
| | - David A Kaufman
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, NYU School of Medicine (S.B.B., M.C.K., J.S.M., D.A.K.)
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38
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Thille AW, Boissier F, Muller M, Levrat A, Bourdin G, Rosselli S, Frat JP, Coudroy R, Vivier E. Role of ICU-acquired weakness on extubation outcome among patients at high risk of reintubation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:86. [PMID: 32164739 PMCID: PMC7069045 DOI: 10.1186/s13054-020-2807-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 02/25/2020] [Indexed: 12/21/2022]
Abstract
Background Whereas ICU-acquired weakness may delay extubation in mechanically ventilated patients, its influence on extubation failure is poorly known. This study aimed at assessing the role of ICU-acquired weakness on extubation failure and the relation between limb weakness and cough strength. Methods A secondary analysis of two previous prospective studies including patients at high risk of reintubation after a planned extubation, i.e., age greater than 65 years, with underlying cardiac or respiratory disease, or intubated for more than 7 days prior to extubation. Patients intubated less than 24 h and those with a do-not-reintubate order were not included. Limb and cough strength were assessed by a physiotherapist just before extubation. ICU-acquired weakness was clinically diagnosed as limb weakness defined as Medical Research Council (MRC) score < 48 points and severe weakness as MRC sum-score < 36. Cough strength was assessed using a semi-quantitative 5-Likert scale. Extubation failure was defined as reintubation or death within the first 7 days following extubation. Results Among 344 patients at high risk of reintubation, 16% experienced extubation failure (56/344). They had greater severity and lower MRC sum-score (41 ± 16 vs. 49 ± 13, p < 0.001) and were more likely to have ineffective cough than the others. The prevalence of ICU-acquired weakness at the time of extubation was 38% (130/244). The extubation failure rate was 12% (25/214) in patients with no limb weakness vs. 18% (12/65) and 29% (19/65) in those with moderate and severe limb weakness, respectively (p < 0.01). MRC sum-score and cough strength were weakly but significantly correlated (rho = 0.28, p < .001). After multivariate logistic regression analyses, the lower the MRC sum-score the greater the risk of reintubation; severe limb weakness was independently associated with extubation failure, even after adjustment on cough strength and severity at admission. Conclusion ICU-acquired weakness was diagnosed in 38% in this population of patients at high risk at the time of extubation and was independently associated with extubation failure in the ICU.
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Affiliation(s)
- Arnaud W Thille
- ALIVE Research group INSERM CIC 1402, University of Poitiers, Poitiers, France. .,Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers, France. .,Réanimation Médicale, CHU de Poitiers, 2 rue la Milétrie, 86021, Poitiers Cedex, France.
| | - Florence Boissier
- ALIVE Research group INSERM CIC 1402, University of Poitiers, Poitiers, France.,Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Michel Muller
- Centre Hospitalier Annecy Genevoix, Réanimation Polyvalente, Metz-Tessy, France
| | - Albrice Levrat
- Centre Hospitalier Annecy Genevoix, Réanimation Polyvalente, Metz-Tessy, France
| | - Gaël Bourdin
- Centre Hospitalier Saint Joseph Saint Luc, Réanimation Polyvalente, Lyon, France
| | - Sylvène Rosselli
- Centre Hospitalier Saint Joseph Saint Luc, Réanimation Polyvalente, Lyon, France
| | - Jean-Pierre Frat
- ALIVE Research group INSERM CIC 1402, University of Poitiers, Poitiers, France.,Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Rémi Coudroy
- ALIVE Research group INSERM CIC 1402, University of Poitiers, Poitiers, France.,Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Emmanuel Vivier
- Centre Hospitalier Saint Joseph Saint Luc, Réanimation Polyvalente, Lyon, France
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39
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Flatres A, Aarab Y, Nougaret S, Garnier F, Larcher R, Amalric M, Klouche K, Etienne P, Subra G, Jaber S, Molinari N, Matecki S, Jung B. Real-time shear wave ultrasound elastography: a new tool for the evaluation of diaphragm and limb muscle stiffness in critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:34. [PMID: 32014005 PMCID: PMC6998330 DOI: 10.1186/s13054-020-2745-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 01/16/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Muscle weakness following critical illness is the consequence of loss of muscle mass and alteration of muscle quality. It is associated with long-term disability. Ultrasonography is a reliable tool to quantify muscle mass, but studies that evaluate muscle quality at the critically ill bedside are lacking. Shear wave ultrasound elastography (SWE) provides spatial representation of soft tissue stiffness and measures of muscle quality. The reliability and reproducibility of SWE in critically ill patients has never been evaluated. METHODS Two operators tested in healthy controls and in critically ill patients the intra- and inter-operator reliability of the SWE using transversal and longitudinal views of the diaphragm and limb muscles. Reliability was calculated using the intra-class correlation coefficient and a bootstrap sampling method assessed their consistency. RESULTS We collected 560 images. Longitudinal views of the diaphragm (ICC 0.83 [0.50-0.94]), the biceps brachii (ICC 0.88 [0.67-0.96]) and the rectus femoris (ICC 0.76 [0.34-0.91]) were the most reliable views in a training set of healthy controls. Intra-class correlation coefficient for inter-operator reproducibility and intra-operator reliability was above 0.9 for all muscles in a validation set of healthy controls. In critically ill patients, inter-operator reproducibility and intra-operator 1 and 2 reliability ICCs were respectively 0.92 [0.71-0.98], 0.93 [0.82-0.98] and 0.92 [0.81-0.98] for the diaphragm; 0.96 [0.86-0.99], 0.98 [0.94-0.99] and 0.99 [0.96-1] for the biceps brachii and 0.91 [0.51-0.98], 0.97 [0.93-0.99] and 0.99 [0.97-1] for the rectus femoris. The probability to reach intra-class correlation coefficient greater than 0.8 in a 10,000 bootstrap sampling for inter-operator reproducibility was respectively 81%, 84% and 78% for the diaphragm, the biceps brachii and the rectus femoris respectively. CONCLUSIONS SWE is a reliable technique to evaluate limb muscles and the diaphragm in both healthy controls and in critically ill patients. TRIAL REGISTRATION The study was registered (ClinicalTrial NCT03550222).
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Affiliation(s)
- Aurelien Flatres
- Medical Intensive Care Unit, Montpellier University and Montpellier Lapeyronie Teaching Hospital, Avenue du Doyen Gaston Giraud, 34000, Montpellier, France.,INSERM U1046, CNRS UMR9214, Université de Montpellier, Montpellier, France
| | - Yassir Aarab
- Medical Intensive Care Unit, Montpellier University and Montpellier Lapeyronie Teaching Hospital, Avenue du Doyen Gaston Giraud, 34000, Montpellier, France.,INSERM U1046, CNRS UMR9214, Université de Montpellier, Montpellier, France
| | - Stephanie Nougaret
- IRCM, INSERM U1194, and Department of Radiology, Montpellier Cancer Research Institute, 208 Ave des Apothicaires, 34295, Montpellier, France
| | - Fanny Garnier
- Medical Intensive Care Unit, Montpellier University and Montpellier Lapeyronie Teaching Hospital, Avenue du Doyen Gaston Giraud, 34000, Montpellier, France.,INSERM U1046, CNRS UMR9214, Université de Montpellier, Montpellier, France
| | - Romaric Larcher
- Medical Intensive Care Unit, Montpellier University and Montpellier Lapeyronie Teaching Hospital, Avenue du Doyen Gaston Giraud, 34000, Montpellier, France.,INSERM U1046, CNRS UMR9214, Université de Montpellier, Montpellier, France
| | - Mathieu Amalric
- Medical Intensive Care Unit, Montpellier University and Montpellier Lapeyronie Teaching Hospital, Avenue du Doyen Gaston Giraud, 34000, Montpellier, France
| | - Kada Klouche
- Medical Intensive Care Unit, Montpellier University and Montpellier Lapeyronie Teaching Hospital, Avenue du Doyen Gaston Giraud, 34000, Montpellier, France.,INSERM U1046, CNRS UMR9214, Université de Montpellier, Montpellier, France
| | - Pascal Etienne
- Laboratoire Charles Coulomb (L2C), University of Montpellier, CNRS, Montpellier, France
| | - Gilles Subra
- Institut des Biomolécules Max Mousseron (IBMM), UMR5247 CNRS, ENSCM, Université de Montpellier, 34000, Montpellier, France
| | - Samir Jaber
- INSERM U1046, CNRS UMR9214, Université de Montpellier, Montpellier, France.,Saint Eloi Anesthesiology and Critical Care Medicine, Montpellier University and Montpellier Teaching Hospital, Montpellier, France
| | - Nicolas Molinari
- Biostatistics Department, Montpellier University and Montpellier Teaching Hospital, Montpellier, France
| | - Stefan Matecki
- INSERM U1046, CNRS UMR9214, Université de Montpellier, Montpellier, France
| | - Boris Jung
- Medical Intensive Care Unit, Montpellier University and Montpellier Lapeyronie Teaching Hospital, Avenue du Doyen Gaston Giraud, 34000, Montpellier, France. .,INSERM U1046, CNRS UMR9214, Université de Montpellier, Montpellier, France.
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