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Statlender L, Shvartser L, Teppler S, Bendavid I, Kushinir S, Azullay R, Singer P. Predicting invasive mechanical ventilation in COVID 19 patients: A validation study. PLoS One 2024; 19:e0296386. [PMID: 38166095 PMCID: PMC10760863 DOI: 10.1371/journal.pone.0296386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 12/12/2023] [Indexed: 01/04/2024] Open
Abstract
INTRODUCTION The decision to intubate and ventilate a patient is mainly clinical. Both delaying intubation (when needed) and unnecessarily invasively ventilating (when it can be avoided) are harmful. We recently developed an algorithm predicting respiratory failure and invasive mechanical ventilation in COVID-19 patients. This is an internal validation study of this model, which also suggests a categorized "time-weighted" model. METHODS We used a dataset of COVID-19 patients who were admitted to Rabin Medical Center after the algorithm was developed. We evaluated model performance in predicting ventilation, regarding the actual endpoint of each patient. We further categorized each patient into one of four categories, based on the strength of the prediction of ventilation over time. We evaluated this categorized model performance regarding the actual endpoint of each patient. RESULTS 881 patients were included in the study; 96 of them were ventilated. AUC of the original algorithm is 0.87-0.94. The AUC of the categorized model is 0.95. CONCLUSIONS A minor degradation in the algorithm accuracy was noted in the internal validation, however, its accuracy remained high. The categorized model allows accurate prediction over time, with very high negative predictive value.
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Affiliation(s)
- Liran Statlender
- Department of Gefneral Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | | | | | - Itai Bendavid
- Department of Gefneral Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Shiri Kushinir
- Rabin Medical Center Research Authority, Beilinson Hospital, Petah Tikva, Israel
| | - Roy Azullay
- TSG IT Advanced Systems Ltd., Or Yehuda, Israel
| | - Pierre Singer
- Department of Gefneral Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
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Vaidy A, O'Corragain O, Vaidya A. Diagnosis and Management of Pulmonary Hypertension and Right Ventricular Failure in the Cardiovascular Intensive Care Unit. Crit Care Clin 2024; 40:121-135. [PMID: 37973349 DOI: 10.1016/j.ccc.2023.05.003] [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: 11/19/2023]
Abstract
Pulmonary hypertension (PH) encompasses a broad range of conditions, including pulmonary artery hypertension, left-sided heart disease, and pulmonary and thromboembolic disorders. Successful diagnosis and management rely on an integrated clinical assessment of the patient's physiology and right heart function. Right ventricular (RV) heart failure is often a result of PH, but may result from varying abnormalities in preload, afterload, and intrinsic myocardial dysfunction, which require distinct management strategies. Consideration of an individual's hemodynamic phenotype and physiologic circumstances is paramount in management of PH and RV failure, particularly when there is clinical instability in the intensive care setting.
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Affiliation(s)
- Anika Vaidy
- Pulmonary Hypertension, Right Heart Failure, CTEPH Program, Division of Cardiology, Temple University Hospital, 9th floor Parkinson Pavilion, 3401 North Broad Street, Philadelphia, PA 19140, USA
| | | | - Anjali Vaidya
- Pulmonary Hypertension, Right Heart Failure, CTEPH Program, Division of Cardiology, Temple University Hospital, 9th floor Parkinson Pavilion, 3401 North Broad Street, Philadelphia, PA 19140, USA.
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Watson A, Yadollahi S, Fahmy A, Mahar S, Fritche D, Beecham R, Saeed K, Dushianthan A. Non-Invasive Ventilation for Community-Acquired Pneumonia: Outcomes and Predictors of Failure from an ICU Cohort. MEDICINA (KAUNAS, LITHUANIA) 2023; 60:81. [PMID: 38256342 PMCID: PMC10821344 DOI: 10.3390/medicina60010081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 12/27/2023] [Accepted: 12/28/2023] [Indexed: 01/24/2024]
Abstract
Background and Objectives: The use of non-invasive ventilation (NIV) for community-acquired pneumonia (CAP) remains controversial. NIV failure in the setting of acute hypoxemic respiratory failure is associated with increased mortality, highlighting the need for careful patient selection. Methods and Methods: This is a retrospective observational cohort study. We included 140 patients with severe CAP, treated with either NIV or invasive mechanical ventilation (IMV) as their primary oxygenation strategy. Results: The median PaO2/FiO2 ratio and SOFA score upon ICU admission were 151 mmHg and 6, respectively. We managed 76% of patients with NIV initially and report an NIV success rate of 59%. Overall, the 28-day mortality was 25%, whilst for patients with NIV success, the mortality was significantly lower at 13%. In the univariate analysis, NIV failure was associated with the SOFA score (OR 1.33), the HACOR score (OR 1.14) and the presence of septic shock (OR 3.99). The SOFA score has an AUC of 0.75 for NIV failure upon ICU admission, whilst HACOR has an AUC of 0.76 after 2 h of NIV. Conclusions: Our results suggest that a SOFA ≤ 4 and an HACOR ≤ 5 are reasonable thresholds to identify patients with severe CAP likely to benefit from NIV.
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Affiliation(s)
- Adam Watson
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (A.W.); (S.M.); (R.B.)
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK; (D.F.); (K.S.)
| | - Sina Yadollahi
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (A.W.); (S.M.); (R.B.)
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK; (D.F.); (K.S.)
| | - Alexander Fahmy
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (A.W.); (S.M.); (R.B.)
| | - Sania Mahar
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (A.W.); (S.M.); (R.B.)
| | - Dominic Fritche
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK; (D.F.); (K.S.)
| | - Ryan Beecham
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (A.W.); (S.M.); (R.B.)
| | - Kordo Saeed
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK; (D.F.); (K.S.)
- Department of Microbiology, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Ahilanandan Dushianthan
- General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; (A.W.); (S.M.); (R.B.)
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK; (D.F.); (K.S.)
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
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Furlong-Dillard JM, Nguyen A, Facciolo MD, Feygin YB, Napolitano N, Emeriaud G, Berkenbosch JW, Owen EB. Associations With Severe Desaturation Events Among Children Receiving Noninvasive Respiratory Support at Time of Intubation. Respir Care 2023; 68:1646-1656. [PMID: 37553217 PMCID: PMC10676262 DOI: 10.4187/respcare.10765] [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: 08/10/2023]
Abstract
BACKGROUND Endotracheal intubation is a common procedure associated with adverse events, including severe desaturation. Many patients receive noninvasive respiratory support to reduce the need for intubation. There are minimal data about the association between noninvasive respiratory support and the risk of a severe desaturation event during intubation. We aim to differentiate patients based on the level of noninvasive respiratory support, analyze the severe desaturation event by groups, and identify modifiable risk factors. METHODS Oral intubations, excluding tube exchanges or re-intubation after unplanned extubation, from October 2018 through July 2020, at the study site were reviewed. A severe desaturation event was defined as [Formula: see text] < 70% or a >15% decrease from baseline in cyanotic heart disease. We analyzed outcomes by 4 groups: room air/nasal cannula (≤0.5 L/kg/min), high-flow nasal cannula (HFNC) (0.5-2 L/kg/min), high HFNC (≥2 L/kg/min), and noninvasive ventilation (NIV). RESULTS Of 243 subjects who were intubated, 31% were receiving room air/nasal cannula, 25% were receiving HFNC, 18% were receiving high HFNC, and 26% were receiving NIV. Twelve percent of all the subjects had a severe desaturation event. In a univariate analysis, the incidence of a severe desaturation event was similar among all levels of respiratory support (P = .14). A severe desaturation event was more likely in those subjects who were receiving [Formula: see text] ≥ 0.6 at the time of the decision to intubate (19.6%) versus [Formula: see text] < 0.6 (8.1%) (P = .02). The duration of noninvasive respiratory support was longer (5 vs 1 h; P = .02) among those with a severe desaturation event. In a regression analysis, when adjusting for ≥2 intubation attempts pre-intubation, NIV use was independently associated with increased odds of severe desaturation events (odds ratio 3.14, CI 1.08-10.5). CONCLUSIONS Results of our study suggest that [Formula: see text] > 0.60, the duration of noninvasive respiratory support, and exposure to NIV before an intubation are risk factors of severe desaturation events during intubation.
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Affiliation(s)
- Jamie M Furlong-Dillard
- Division of Pediatric Critical Care, Department of Pediatrics, Norton Children's Hospital, University of Louisville School of Medicine, Louisville, Kentucky.
| | - Anh Nguyen
- Division of Pediatric Critical Care, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Michael D Facciolo
- Division of Pediatric Critical Care, Department of Pediatrics, Norton Children's Hospital, University of Louisville School of Medicine, Louisville, Kentucky
| | - Yana B Feygin
- Norton Children's Research Institute affiliated with the University of Louisville School of Medicine, Louisville, Kentucky
| | - Natalie Napolitano
- Respiratory Care Department, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Guillaume Emeriaud
- Division des Soins Intensifs Pédiatriques, Département de Pédiatrie, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - John W Berkenbosch
- Division of Pediatric Critical Care, Department of Pediatrics, Norton Children's Hospital, University of Louisville School of Medicine, Louisville, Kentucky
| | - Erin B Owen
- Division of Pediatric Critical Care, Department of Pediatrics, Norton Children's Hospital, University of Louisville School of Medicine, Louisville, Kentucky
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Feng X, Wang D, Pan Q, Yan M, Liu X, Shen Y, Fang L, Cai G, Ning G. Reinforcement Learning Model for Managing Noninvasive Ventilation Switching Policy. IEEE J Biomed Health Inform 2023; 27:4120-4130. [PMID: 37159312 DOI: 10.1109/jbhi.2023.3274568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Noninvasive ventilation (NIV) has been recognized as a first-line treatment for respiratory failure in patients with chronic obstructive pulmonary disease (COPD) and hypercapnia respiratory failure, which can reduce mortality and burden of intubation. However, during the long-term NIV process, failure to respond to NIV may cause overtreatment or delayed intubation, which is associated with increased mortality or costs. Optimal strategies for switching regime in the course of NIV treatment remain to be explored.For the goal of reducing 28-day mortality of the patients undergoing NIV, Double Dueling Deep Q Network (D3QN) of offline-reinforcement learning algorithm was adopted to develop an optimal regime model for making treatment decisions of discontinuing ventilation, continuing NIV, or intubation. The model was trained and tested using the data from Multi-Parameter Intelligent Monitoring in Intensive Care III (MIMIC-III) and evaluated by the practical strategies. Furthermore, the applicability of the model in majority disease subgroups (Catalogued by International Classification of Diseases, ICD) was investigated. Compared with physician's strategies, the proposed model achieved a higher expected return score (4.25 vs. 2.68) and its recommended treatments reduced the expected mortality from 27.82% to 25.44% in all NIV cases. In particular, for these patients finally received intubation in practice, if the model also supported the regime, it would warn of switching to intubation 13.36 hours earlier than clinicians (8.64 vs. 22 hours after the NIV treatment), granting a 21.7% reduction in estimated mortality. In addition, the model was applicable across various disease groups with distinguished achievement in dealing with respiratory disorders. The proposed model is promising to dynamically provide personalized optimal NIV switching regime for patients undergoing NIV with the potential of improving treatment outcomes.
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Downing J, Yardi I, Ren C, Cardona S, Zahid M, Tang K, Bzhilyanskaya V, Patel P, Pourmand A, Tran QK. Prevalence of peri-intubation major adverse events among critically ill patients: A systematic review and meta analysis. Am J Emerg Med 2023; 71:200-216. [PMID: 37437438 DOI: 10.1016/j.ajem.2023.06.046] [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: 01/25/2023] [Revised: 05/25/2023] [Accepted: 06/26/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Peri-intubation major adverse events (MAEs) are potentially preventable and associated with poor patient outcomes. Critically ill patients intubated in Emergency Departments, Intensive Care Units or medical wards are at particularly high risk for MAEs. Understanding the prevalence and risk factors for MAEs can help physicians anticipate and prepare for the physiologically difficult airway. METHODS We searched PubMed, Scopus, and Embase for prospective and retrospective observational studies and randomized control trials (RCTs) reporting peri-intubation MAEs in intubations occurring outside the operating room (OR) or post-anesthesia care unit (PACU). Our primary outcome was any peri-intubation MAE, defined as any hypoxia, hypotension/cardiovascular collapse, or cardiac arrest. Esophageal intubation and failure to achieve first-pass success were not considered MAEs. Secondary outcomes were prevalence of hypoxia, cardiac arrest, and cardiovascular collapse. We performed random-effects meta-analysis to identify the prevalence of each outcome and moderator analyses and meta-regressions to identify risk factors. We assessed studies' quality using the Cochrane Risk of Bias 2 tool and the Newcastle-Ottawa Scale. RESULTS We included 44 articles and 34,357 intubations. Peri-intubation MAEs were identified in 30.5% of intubations (95% CI 25-37%). MAEs were more common in the intensive care unit (ICU; 41%, 95% CI 33-49%) than the Emergency Department (ED; 17%, 95% CI 12-24%). Intubation for hemodynamic instability was associated with higher rates of MAEs, while intubation for airway protection was associated with lower rates of MAEs. Fifteen percent (15%, 95% CI 11.5-19%) of intubations were complicated by hypoxia, 2% (95% CI 1-3.5%) by cardiac arrest, and 18% (95% CI 13-23%) by cardiovascular collapse. CONCLUSIONS Almost one in three patients intubated outside the OR and PACU experience a peri-intubation MAE. Patients intubated in the ICU and those with pre-existing hemodynamic compromise are at highest risk. Resuscitation should be considered an integral part of all intubations, particularly in high-risk patients.
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Affiliation(s)
- Jessica Downing
- Program in Trauma and Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States of America.
| | - Isha Yardi
- Research Associate Program, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Christine Ren
- Program in Trauma and Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Stephanie Cardona
- Department of Critical Care Medicine, The Mount Sinai Hospital, NY, New York, United States of America
| | - Manahel Zahid
- Research Associate Program, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Kaitlyn Tang
- Research Associate Program, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Vera Bzhilyanskaya
- Research Associate Program, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Priya Patel
- University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Ali Pourmand
- Department of Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States of America
| | - Quincy K Tran
- Program in Trauma and Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States of America; Research Associate Program, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America; Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America
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Atallah FC, Caruso P, Nassar Junior AP, Torelly AP, Amendola CP, Salluh JIF, Romano TG. High-value care for critically ill oncohematological patients: what do we know thus far? CRITICAL CARE SCIENCE 2023; 35:84-96. [PMID: 37712733 PMCID: PMC10275311 DOI: 10.5935/2965-2774.20230405-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 02/26/2023] [Indexed: 09/16/2023]
Abstract
The number of patients with cancer requiring intensive care unit admission is increasing around the world. The improvement in the pathophysiological understanding of this group of patients, as well as the increasingly better and more targeted treatment options for their underlying disease, has led to a significant increase in their survival over the past three decades. Within the organizational concepts, it is necessary to know what adds value in the care of critical oncohematological patients. Practices in medicine that do not benefit patients and possibly cause harm are called low-value practices, while high-value practices are defined as high-quality care at relatively low cost. In this article, we discuss ten domains with high-value evidence in the care of cancer patients: (1) intensive care unit admission policies; (2) intensive care unit organization; (3) etiological investigation of hypoxemia; (4) management of acute respiratory failure; (5) management of febrile neutropenia; (6) urgent chemotherapy treatment in critically ill patients; (7) patient and family experience; (8) palliative care; (9) care of intensive care unit staff; and (10) long-term impact of critical disease on the cancer population. The disclosure of such policies is expected to have the potential to change health care standards. We understand that it is a lengthy process, and initiatives such as this paper are one of the first steps in raising awareness and beginning a discussion about high-value care in various health scenarios.
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Affiliation(s)
- Fernanda Chohfi Atallah
- Discipline of Anaesthesiology, Pain and Intensive Care, Escola
Paulista de Medicina, Universidade Federal de São Paulo - São Paulo
(SP), Brazil
| | - Pedro Caruso
- AC Camargo Cancer Center - São Paulo (SP), Brazil
| | | | - Andre Peretti Torelly
- Hospital Santa Rita - Santa Casa de Misericórdia de Porto
Alegre - Porto Alegre (RS), Brazil
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Maggiore SM, Jaber S, Grieco DL, Mancebo J, Zakynthinos S, Demoule A, Ricard JD, Navalesi P, Vaschetto R, Hraiech S, Klouche K, Frat JP, Lemiale V, Fanelli V, Chanques G, Natalini D, Ischaki E, Reuter D, Morán I, La Combe B, Longhini F, De Gaetano A, Ranieri VM, Brochard LJ, Antonelli M. High-Flow Versus VenturiMask Oxygen Therapy to Prevent Reintubation in Hypoxemic Patients after Extubation: A Multicenter Randomized Clinical Trial. Am J Respir Crit Care Med 2022; 206:1452-1462. [PMID: 35849787 DOI: 10.1164/rccm.202201-0065oc] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Rationale: When compared with VenturiMask after extubation, high-flow nasal oxygen provides physiological advantages. Objectives: To establish whether high-flow oxygen prevents endotracheal reintubation in hypoxemic patients after extubation, compared with VenturiMask. Methods: In this multicenter randomized trial, 494 patients exhibiting PaO2:FiO2 ratio ⩽ 300 mm Hg after extubation were randomly assigned to receive high-flow or VenturiMask oxygen, with the possibility to apply rescue noninvasive ventilation before reintubation. High-flow use in the VenturiMask group was not permitted. Measurements and Main Results: The primary outcome was the rate of reintubation within 72 hours according to predefined criteria, which were validated a posteriori by an independent adjudication committee. Main secondary outcomes included reintubation rate at 28 days and the need for rescue noninvasive ventilation according to predefined criteria. After intubation criteria validation (n = 492 patients), 32 patients (13%) in the high-flow group and 27 patients (11%) in the VenturiMask group required reintubation at 72 hours (unadjusted odds ratio, 1.26 [95% confidence interval (CI), 0.70-2.26]; P = 0.49). At 28 days, the rate of reintubation was 21% in the high-flow group and 23% in the VenturiMask group (adjusted hazard ratio, 0.89 [95% CI, 0.60-1.31]; P = 0.55). The need for rescue noninvasive ventilation was significantly lower in the high-flow group than in the VenturiMask group: at 72 hours, 8% versus 17% (adjusted hazard ratio, 0.39 [95% CI, 0.22-0.71]; P = 0.002) and at 28 days, 12% versus 21% (adjusted hazard ratio, 0.52 [95% CI, 0.32-0.83]; P = 0.007). Conclusions: Reintubation rate did not significantly differ between patients treated with VenturiMask or high-flow oxygen after extubation. High-flow oxygen yielded less frequent use of rescue noninvasive ventilation. Clinical trial registered with www.clinicaltrials.gov (NCT02107183).
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Affiliation(s)
- Salvatore Maurizio Maggiore
- University Department of Innovative Technologies in Medicine and Dentistry, Gabriele d'Annunzio University of Chieti-Pescara, Chieti, Italy
- Department of Anesthesiology, Critical Care Medicine, and Emergency, SS Annunziata Hospital, Chieti, Italy
| | - Samir Jaber
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, Montpellier; France
- PhyMedExp, INSERM U1046, CNRS UMR, 9214, University of Montpellier, Montpellier Cedex 5, France
| | - Domenico Luca Grieco
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of The Sacred Heart, Rome, Italy
| | - Jordi Mancebo
- Servei de Medicina Intensiva, Hospital Universitari de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Spyros Zakynthinos
- Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Alexandre Demoule
- Service de Pneumologie, Médecine Intensive-Réanimation (Département "R3S"), Hôpital Pitié-Salpêtrière, Sorbonne Université, AP-HP, Paris, France
- INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Paris, France
| | - Jean-Damien Ricard
- Service de Médecine Intensive-Réanimatio, DMU ESPRIT, Hôpital Louis Mourier, AP-HP, Université de Paris, Colombes, France
| | - Paolo Navalesi
- Anesthesia and Intensive Care Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Rosanna Vaschetto
- Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, Novara, Italy
- Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy
| | - Sami Hraiech
- Service de Médecine Intensive - Réanimation, AP-HM, Hôpital Nord, Aix-Marseille Université, Health Service Research and Quality of Life Center (CEReSS), Marseille, France
| | - Kada Klouche
- Intensive Care Medicine Department, Lapeyronie Hospital, Montpellier University Hospital, Montpellier, France
- PhyMedExp, INSERM, CNRS, University of Montpellier, Montpellier, France
| | - Jean-Pierre Frat
- Médecine Intensive Réanimation, CHU Poitiers, INSERM, CIC 1402, ALIVE, Université de Poitiers, Poitiers, France
- INSERM, CIC 1402, ALIVE, Université de Poitiers, Poitiers, France
| | | | - Vito Fanelli
- Department of Surgical Sciences, University of Turin, Turin, Italy
- Department of Anaesthesia, Critical Care, and Emergency, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Gerald Chanques
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, Montpellier; France
- PhyMedExp, INSERM U1046, CNRS UMR, 9214, University of Montpellier, Montpellier Cedex 5, France
| | - Daniele Natalini
- PhyMedExp, INSERM U1046, CNRS UMR, 9214, University of Montpellier, Montpellier Cedex 5, France
| | - Eleni Ischaki
- Servei de Medicina Intensiva, Hospital Universitari de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Danielle Reuter
- Service de Pneumologie, Médecine Intensive-Réanimation (Département "R3S"), Hôpital Pitié-Salpêtrière, Sorbonne Université, AP-HP, Paris, France
- INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Paris, France
| | - Indalecio Morán
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of The Sacred Heart, Rome, Italy
| | - Béatrice La Combe
- Service de Pneumologie, Médecine Intensive-Réanimation (Département "R3S"), Hôpital Pitié-Salpêtrière, Sorbonne Université, AP-HP, Paris, France
| | - Federico Longhini
- Anesthesia and Intensive Care Unit, Department of Medical and Surgical Sciences, "Mater Domini" University Hospital, "Magna Graecia" University, Catanzaro, Italy
| | | | - V Marco Ranieri
- Dipartimento di Scienze Mediche e Chirurgiche, Anestesia e Rianimazione, Policlinico di Sant'Orsola, Alma Mater Studiorum-Università di Bologna, Bologna, Italy
| | - Laurent J Brochard
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; and
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Massimo Antonelli
- PhyMedExp, INSERM U1046, CNRS UMR, 9214, University of Montpellier, Montpellier Cedex 5, France
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Muacevic A, Adler JR. Detailed Analysis of Primary Non-invasive Respiratory Support and Outcomes of Subjects With COVID-19 Acute Hypoxaemic Respiratory Failure. Cureus 2022; 14:e32362. [PMID: 36514701 PMCID: PMC9733975 DOI: 10.7759/cureus.32362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2022] [Indexed: 12/14/2022] Open
Abstract
Background The role of non-invasive (continuous positive airway pressure (CPAP) or Non-invasive ventilation (NIV)) respiratory support (NIRS) as a primary oxygenation strategy for COVID-19 patients with acute severe hypoxic respiratory failure (AHRF), as opposed to invasive mechanical ventilation (invasive-MV), is uncertain. While NIRS may prevent complications related to invasive MV, prolonged NIRS and delays in intubation may lead to adverse outcomes. This study was conducted to assess the role of NIRS in COVID-19 hypoxemic respiratory failure and to explore the variables associated with NRIS failure. Methods This is a single-center, observational study of two distinct waves of severe COVID-19 patients admitted to the ICU. Patients initially managed with non-invasive respiratory support with laboratory-confirmed SARS-CoV-2 in acute hypoxaemic respiratory failure were included. Demographics, comorbidities, admission laboratory variables, and ICU admission scores were extracted from electronic health records. Univariate and multiple logistic regression was used to identify predictive factors for invasive mechanical ventilation. Kaplan-Meier survival curves were used to summarise survival between the ventilatory and time-to-intubation groups. Results There were 291 patients, of which 232 were managed with NIRS as an initial ventilation strategy. There was a high incidence of failure (48.7%). Admission APACHE II score, SOFA score, HACOR score, ROX index, and PaO2/FiO2 were all predictive of NIRS failure. Daily (days 1-4) HACOR scores and ROX index measurements highly predicted NIRS failure. Late NIRS failure (>24 hours) was independently associated with increased mortality (44%). Conclusion NIRS is effective as first-line therapy for COVID-19 patients with AHRF. However, failure, particularly delayed failure, is associated with significant mortality. Early prediction of NIRS failure may prevent adverse outcomes.
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10
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Rolle A, De Jong A, Vidal E, Molinari N, Azoulay E, Jaber S. Cardiac arrest and complications during non-invasive ventilation: a systematic review and meta-analysis with meta-regression. Intensive Care Med 2022; 48:1513-1524. [PMID: 36112157 PMCID: PMC9483519 DOI: 10.1007/s00134-022-06821-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/06/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE The aim of this study was to perform a systematic review and meta-analysis to investigate the incidence rate of cardiac arrest and severe complications occurring under non-invasive ventilation (NIV). METHODS We performed a systematic review and meta-analysis of studies between 1981 and 2020 that enrolled adults in whom NIV was used to treat acute respiratory failure (ARF). We generated the pooled incidence and confidence interval (95% CI) of NIV-related cardiac arrest per patient (primary outcome) and performed a meta-regression to assess the association with study characteristics. We also generated the pooled incidences of NIV failure and hospital mortality. RESULTS Three hundred and eight studies included a total of 7,601,148 participants with 36,326 patients under NIV (8187 in 138 randomized controlled trials, 9783 in 99 prospective observational studies, and 18,356 in 71 retrospective studies). Only 19 (6%) of the analyzed studies reported the rate of NIV-related cardiac arrest. Forty-nine cardiac arrests were reported. The pooled incidence was 0.01% (95% CI 0.00-0.02, I2 = 0% (0-15)). NIV failure was reported in 4371 patients, with a pooled incidence of 11.1% (95% CI 9.0-13.3). After meta-regression, NIV failure and the study period (before 2010) were significantly associated with NIV-related cardiac arrest. The hospital mortality pooled incidence was 6.0% (95% CI 4.4-7.9). CONCLUSION Cardiac arrest related to NIV occurred in one per 10,000 patients under NIV for ARF treatment. NIV-related cardiac arrest was associated with NIV failure.
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Affiliation(s)
- Amélie Rolle
- Anesthesia and Critical Care Department, Saint Eloi Teaching Hospital, University of Montpellier 1, 80 Avenue Augustin Fliche, 34295, Montpellier Cedex 5, France.,Anesthesiology and Intensive Care Department, University of La Guadeloupe, 97159, Pointe A Pitre, Guadeloupe
| | - Audrey De Jong
- Anesthesia and Critical Care Department, Saint Eloi Teaching Hospital, University of Montpellier 1, 80 Avenue Augustin Fliche, 34295, Montpellier Cedex 5, France.,Phymed Exp INSERM U1046, CNRS UMR 9214, Montpellier, France
| | - Elsa Vidal
- Anesthesia and Critical Care Department, Saint Eloi Teaching Hospital, University of Montpellier 1, 80 Avenue Augustin Fliche, 34295, Montpellier Cedex 5, France.,Anesthesiology and Intensive Care Department, University of La Guadeloupe, 97159, Pointe A Pitre, Guadeloupe
| | - Nicolas Molinari
- IDESP, INSERM, Université de Montpellier, CHU Montpellier, Languedoc‑Roussillon, Montpellier, France
| | - Elie Azoulay
- Médecine Intensive et Réanimation, Groupe FAMIREA, Hôpital Saint-Louis, Université de Paris, Paris, France
| | - Samir Jaber
- Anesthesia and Critical Care Department, Saint Eloi Teaching Hospital, University of Montpellier 1, 80 Avenue Augustin Fliche, 34295, Montpellier Cedex 5, France. .,Phymed Exp INSERM U1046, CNRS UMR 9214, Montpellier, France.
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11
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Wang H, Zhao QY, Luo JC, Liu K, Yu SJ, Ma JF, Luo MH, Hao GW, Su Y, Zhang YJ, Tu GW, Luo Z. Early prediction of noninvasive ventilation failure after extubation: development and validation of a machine-learning model. BMC Pulm Med 2022; 22:304. [PMID: 35941641 PMCID: PMC9358918 DOI: 10.1186/s12890-022-02096-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 07/29/2022] [Indexed: 11/10/2022] Open
Abstract
Background Noninvasive ventilation (NIV) has been widely used in critically ill patients after extubation. However, NIV failure is associated with poor outcomes. This study aimed to determine early predictors of NIV failure and to construct an accurate machine-learning model to identify patients at risks of NIV failure after extubation in intensive care units (ICUs). Methods Patients who underwent NIV after extubation in the eICU Collaborative Research Database (eICU-CRD) were included. NIV failure was defined as need for invasive ventilatory support (reintubation or tracheotomy) or death after NIV initiation. A total of 93 clinical and laboratory variables were assessed, and the recursive feature elimination algorithm was used to select key features. Hyperparameter optimization was conducted with an automated machine-learning toolkit called Neural Network Intelligence. A machine-learning model called Categorical Boosting (CatBoost) was developed and compared with nine other models. The model was then prospectively validated among patients enrolled in the Cardiac Surgical ICU of Zhongshan Hospital, Fudan University. Results Of 929 patients included in the eICU-CRD cohort, 248 (26.7%) had NIV failure. The time from extubation to NIV, age, Glasgow Coma Scale (GCS) score, heart rate, respiratory rate, mean blood pressure (MBP), saturation of pulse oxygen (SpO2), temperature, glucose, pH, pressure of oxygen in blood (PaO2), urine output, input volume, ventilation duration, and mean airway pressure were selected. After hyperparameter optimization, our model showed the greatest accuracy in predicting NIV failure (AUROC: 0.872 [95% CI 0.82–0.92]) among all predictive methods in an internal validation. In the prospective validation cohort, our model was also superior (AUROC: 0.846 [95% CI 0.80–0.89]). The sensitivity and specificity in the prediction group is 89% and 75%, while in the validation group they are 90% and 70%. MV duration and respiratory rate were the most important features. Additionally, we developed a web-based tool to help clinicians use our model. Conclusions This study developed and prospectively validated the CatBoost model, which can be used to identify patients who are at risk of NIV failure. Thus, those patients might benefit from early triage and more intensive monitoring. Trial registration: NCT03704324. Registered 1 September 2018, https://register.clinicaltrials.gov. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-02096-7.
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Affiliation(s)
- Huan Wang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qin-Yu Zhao
- College of Engineering and Computer Science, Australian National University, Canberra, ACT, Australia
| | - Jing-Chao Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Kai Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shen-Ji Yu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jie-Fei Ma
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China.,Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China
| | - Ming-Hao Luo
- Shanghai Medical College, Fudan University, Shanghai, China
| | - Guang-Wei Hao
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ying Su
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yi-Jie Zhang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China. .,Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China. .,Shanghai Key Lab of Pulmonary Inflammation and Injury, Shanghai, China.
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12
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Kyle JM, Sturza JM, Dechert RE, Custer JR, Dahmer MK, Saba TG, Flori HR. Clinical Outcomes of Acute Respiratory Failure Associated With Noninvasive and Invasive Ventilation in a Pediatric ICU. Respir Care 2022; 67:956-966. [PMID: 35701174 PMCID: PMC9994152 DOI: 10.4187/respcare.09348] [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: 11/05/2022]
Abstract
BACKGROUND It remains unknown if pediatric patients failing initial noninvasive ventilation (NIV) experience worse clinical outcomes than those successfully treated with NIV or those primarily intubated. METHODS This was a single-center, retrospective review of patients admitted with acute respiratory failure to the University of Michigan pediatric intensive care or cardiothoracic ICUs and receiving NIV or invasive mechanical ventilation as first-line therapy. RESULTS One hundred seventy subjects met inclusion criteria and were enrolled: 65 NIV success, 55 NIV failure, and 50 invasive mechanical ventilation alone. Of those failing NIV, median time to intubation was 1.8 (interquartile range [IQR] < 1-7) h. On multivariable regression, ICU-free days were significantly different between groups (NIV success: 22.9 ± 6.9 d; NIV failure: 13.0 ± 6.6 d; invasive ventilation: 12.5 ± 6.9 d; P < .001 across all groups). Multivariable regression revealed no difference in ventilator-free days between NIV failure and invasive ventilation groups (15.4 ± 10.1 d vs 15.9 ± 9.7 d, P = .71). Of 64 subjects (37.6%) meeting Pediatric Acute Lung Injury Consensus Conference pediatric ARDS criteria, only 14% were successfully treated with NIV. Ventilator-free days were similar between the NIV failure and invasive ventilation groups (11.6 vs 13.2 d, P = .47). On multivariable analysis, ICU-free days were significantly different across pediatric ARDS groups (P < .001): NIV success: 20.8 + 31.7 d; NIV failure: 8.3 + 23.8 d; invasive alone: 8.9 + 23.9 d, yet no significant difference in ventilator-free days between those with NIV failure versus invasive alone (11.6 vs 13.2 d, P = .47). CONCLUSIONS We demonstrated that critically ill pediatric subjects unsuccessfully trialed on NIV did not experience increased ICU length of stay or fewer ventilator-free days when compared to those on invasive mechanical ventilation alone, including in the pediatric ARDS subgroup. Our findings are predicated on a median time to intubation of < 2 h in the NIV failure group and the provision of adequate monitoring while on NIV.
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Affiliation(s)
- James M Kyle
- Department of Pediatrics, Division of Pediatric Critical Care and Sedation Services, Tripler Army Medical Center, Honolulu, Hawaii
| | - Julie M Sturza
- Department of Pediatrics, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Ronald E Dechert
- Pediatric Respiratory Care, University of Michigan, Ann Arbor, Michigan
| | - Joseph R Custer
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Mary K Dahmer
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Thomas G Saba
- Division of Pediatric Pulmonology, Department of Pediatrics, University of Michigan, C.S Mott Children's Hospital, Ann Arbor, Michigan
| | - Heidi R Flori
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan.
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13
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Cosentini R, Groff P, Brambilla AM, Camajori Todeschini R, Gangitano G, Ingrassia S, Marino R, Nori F, Pagnozzi F, Panero F, Ferrari R. SIMEU position paper on non-invasive respiratory support in COVID-19 pneumonia. Intern Emerg Med 2022; 17:1175-1189. [PMID: 35103926 PMCID: PMC8803573 DOI: 10.1007/s11739-021-02906-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 12/06/2021] [Indexed: 12/19/2022]
Abstract
The rapid worldwide spread of the Coronavirus disease (COVID-19) crisis has put health systems under pressure to a level never experienced before, putting intensive care units in a position to fail to meet an exponentially growing demand. The main clinical feature of the disease is a progressive arterial hypoxemia which rapidly leads to ARDS which makes the use of intensive care and mechanical ventilation almost inevitable. The difficulty of health systems to guarantee a corresponding supply of resources in intensive care, together with the uncertain results reported in the literature with respect to patients who undergo early conventional ventilation, make the search for alternative methods of oxygenation and ventilation and potentially preventive of the need for tracheal intubation, such as non-invasive respiratory support techniques particularly valuable. In this context, the Emergency Department, located between the area outside the hospital and hospital ward and ICU, assumes the role of a crucial junction, due to the possibility of applying these techniques at a sufficiently early stage and being able to rapidly evaluate their effectiveness. This position paper describes the indications for the use of non-invasive respiratory support techniques in respiratory failure secondary to COVID-19-related pneumonia, formulated by the Non-invasive Ventilation Faculty of the Italian Society of Emergency Medicine (SIMEU) on the base of what is available in the literature and on the authors' direct experience. Rationale, literature, tips & tricks, resources, risks and expected results, and patient interaction will be discussed for each one of the escalating non-invasive respiratory techniques: standard oxygen, HFNCO, CPAP, NIPPV, and awake self-repositioning. The final chapter describes our suggested approach to the failing patient.
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Affiliation(s)
| | - Paolo Groff
- Pronto Soccorso e Osservazione Breve, Perugia, AO, Italy
| | | | | | | | - Stella Ingrassia
- Emergency Medicine Unit, Luigi Sacco Hospital, ASST FBF Sacco, Milan, Italy
| | - Roberta Marino
- Emergency Medicine, Sant'Andrea Hospital, Vercelli, Italy
| | - Francesca Nori
- Emergency Room, Emergency Care Unit, Santa Maria Della Scaletta Hospital, Imola, Italy
| | | | - Francesco Panero
- MECAU 2, Pronto Soccorso e Area Critica, ASL Città di Torino, Turin, Italy
| | - Rodolfo Ferrari
- Emergency Room, Emergency Care Unit, Santa Maria Della Scaletta Hospital, Imola, Italy
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14
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Alibrahim O, Rehder KJ, Miller AG, Rotta AT. Mechanical Ventilation and Respiratory Support in the Pediatric Intensive Care Unit. Pediatr Clin North Am 2022; 69:587-605. [PMID: 35667763 DOI: 10.1016/j.pcl.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Children admitted to the pediatric intensive care unit often require respiratory support for the treatment of respiratory distress and failure. Respiratory support comprises both noninvasive modalities (ie, heated humidified high-flow nasal cannula, continuous positive airway pressure, bilevel positive airway pressure, negative pressure ventilation) and invasive mechanical ventilation. In this article, we review the various essential elements and considerations involved in the planning and application of respiratory support in the treatment of the critically ill children.
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Affiliation(s)
- Omar Alibrahim
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA; Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Kyle J Rehder
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA; Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Andrew G Miller
- Respiratory Care Services, Duke University Medical Center, Durham, NC, USA
| | - Alexandre T Rotta
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA; Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA.
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15
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Jayasimhan D, Martynoga RA, Fairweather SM, Chang CL. Non-invasive ventilation for acute hypoxaemic respiratory failure: a propensity-matched cohort study. BMJ Open Respir Res 2022; 9:9/1/e001149. [PMID: 35580915 PMCID: PMC9114973 DOI: 10.1136/bmjresp-2021-001149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 05/05/2022] [Indexed: 11/22/2022] Open
Abstract
Background Non-invasive ventilation (NIV), although effective in treating hypercapnic respiratory failure, has not demonstrated the same efficacy in treating acute hypoxaemic respiratory failure. We aimed to examine the effect of NIV use on ventilator-free days in patients with acute hypoxaemic respiratory failure admitted to the intensive care unit (ICU). Methods We conducted a retrospective study of patients admitted to the ICU with acute hypoxaemic respiratory failure at Waikato Hospital, New Zealand, from 1 January 2009 to 31 December 2018. Patients treated with NIV as the initial oxygenation strategy were compared with controls treated with early intubation. The two groups were matched using a propensity score based on baseline characteristics. The primary outcome was the number of ventilator-free days at day 28. The secondary outcomes were ICU and hospital length of stay and in-hospital mortality. Results Out of 175 eligible patients, 79 each out of the NIV and early intubation groups were matched using a propensity score. Early NIV was associated with significantly higher median ventilator-free days than early intubation (17 days vs 23 days, p=0.013). There was no significant difference in median ICU length of stay (112.5 hours vs 117.7 hours), hospital length of stay (14 days vs 14 days) or in-hospital mortality (31.6% vs 37.9%) between the NIV and the early intubation group. Conclusion Compared with early intubation, NIV use was associated with more ventilator-free days in patients with hypoxaemic respiratory failure. However, this did not translate into a shorter length of stay or reduced mortality based on our single-centre experience.
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Affiliation(s)
- Dilip Jayasimhan
- Department of Respiratory Medicine and Respiratory Research Unit, Waikato Hospital, Hamilton, New Zealand .,Intensive Care Unit, Waikato Hospital, Hamilton, New Zealand
| | | | - Sarah M Fairweather
- Department of Respiratory Medicine and Respiratory Research Unit, Waikato Hospital, Hamilton, New Zealand
| | - Catherina L Chang
- Department of Respiratory Medicine and Respiratory Research Unit, Waikato Hospital, Hamilton, New Zealand
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16
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Sakuraya M, Douno E, Iwata W, Takaba A, Hadama K, Kawamura N, Maezawa T, Iwamoto K, Yoshino Y, Yoshida K. Accuracy evaluation of mainstream and sidestream end-tidal carbon dioxide monitoring during noninvasive ventilation: a randomized crossover trial (MASCAT-NIV trial). J Intensive Care 2022; 10:17. [PMID: 35303968 PMCID: PMC8932153 DOI: 10.1186/s40560-022-00603-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 02/24/2022] [Indexed: 12/02/2022] Open
Abstract
Background The end-tidal partial pressure of carbon dioxide (PETCO2) can be used to estimate the arterial partial pressure of carbon dioxide (PaCO2) in patients who undergo mechanical ventilation via endotracheal intubation. However, no reliable method for measuring PETCO2 during noninvasive ventilation (NIV) has been established. The purpose of this study was to evaluate the correlation and agreement between PaCO2 and PETCO2 measured by these two methods and to compare them in patients who underwent NIV after extubation. Methods This study was a randomized, open-label, crossover trial in a mixed intensive care unit. We included patients who were planned for NIV after extubation and for whom the difference between PETCO2 and PaCO2 was ≤ 5 mmHg. We compared mainstream capnography using an inner cup via face mask (the novel method) with sidestream capnography (the previous method) during NIV. The relationships between PaCO2 and PETCO2 were evaluated by computing the Pearson correlation coefficient, and the agreement between PaCO2 and PETCO2 was estimated using the Bland–Altman method. Results From April 2020 to October 2021, 60 patients were included to the study. PaCO2 and PETCO2 were well correlated in both methods (the novel methods: r = 0.92, P < 0.001; the previous method: r = 0.79, P < 0.001). Mean bias between PaCO2 and PETCO2 measured using the novel method was 2.70 (95% confidence interval [CI], 2.15–3.26) mmHg with 95% limits of agreement (LoA) ranging from − 1.61 to 7.02 mmHg, similar to the result of measurement during SBT (mean bias, 2.51; 95% CI, 2.00–3.02; 95% LoA, − 1.45 to 6.47 mmHg). In contrast, measurement using the previous method demonstrated a larger difference (mean bias, 6.22; 95% CI, 5.22–7.23; 95% LoA, − 1.54 to 13.99 mmHg). Conclusion The current study demonstrated that the novel PETCO2 measurement was superior to the previous method for PaCO2 prediction. During NIV, the novel method may collect as sufficient exhalation sample as during intubation. Continuous PETCO2 measurement combined with peripheral oxygen saturation monitoring is expected to be useful for early recognition of respiratory failure among high-risk patients after extubation. Trial registration UMIN-CTR UMIN000039459. Registered February 11, 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s40560-022-00603-w.
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Affiliation(s)
- Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Jigozen 1-3-3, Hatsukaichi, Hiroshima, 738-8503, Japan.
| | - Eri Douno
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Jigozen 1-3-3, Hatsukaichi, Hiroshima, 738-8503, Japan.,Department of Emergency and Critical Care Medicine, Urasoe General Hospital, Okinawa, Japan
| | - Wakana Iwata
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Jigozen 1-3-3, Hatsukaichi, Hiroshima, 738-8503, Japan
| | - Akihiro Takaba
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Jigozen 1-3-3, Hatsukaichi, Hiroshima, 738-8503, Japan
| | - Kosuke Hadama
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Jigozen 1-3-3, Hatsukaichi, Hiroshima, 738-8503, Japan
| | - Natsuki Kawamura
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Jigozen 1-3-3, Hatsukaichi, Hiroshima, 738-8503, Japan
| | - Toshinori Maezawa
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Jigozen 1-3-3, Hatsukaichi, Hiroshima, 738-8503, Japan
| | - Kei Iwamoto
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Jigozen 1-3-3, Hatsukaichi, Hiroshima, 738-8503, Japan.,Critical Care Medical Center, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Yuya Yoshino
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Jigozen 1-3-3, Hatsukaichi, Hiroshima, 738-8503, Japan.,Emergency and Critical Care Center, Kurashiki Central Hospital, Okayama, Japan
| | - Kenichi Yoshida
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Jigozen 1-3-3, Hatsukaichi, Hiroshima, 738-8503, Japan
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17
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Lauria MJ, Root CW, Gottula AL, Braude DA. Management of Respiratory Distress and Failure in Morbidly and Super Obese Patients During Critical Care Transport. Air Med J 2022; 41:133-140. [PMID: 35248332 DOI: 10.1016/j.amj.2021.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 08/24/2021] [Accepted: 09/21/2021] [Indexed: 06/14/2023]
Abstract
Morbidly and super obese patients are a unique patient population that presents critical care transport providers with unique clinical and logistical challenges in the setting of respiratory distress and failure. These patients are more likely to have chronic respiratory issues at baseline, unique anatomic and physiologic abnormalities, and other comorbidities that leave them poorly able to tolerate respiratory illness or injury. This requires specialized understanding of their respiratory mechanics as well as how to tailor standard treatment modalities, such as noninvasive ventilation, to meet their needs. Also, careful and deliberate planning is required to address the specific anatomic and physiologic characteristics of this population if intubation and mechanical ventilation are needed. Finally, their dimensions and weight also have distinct consequences on transport vehicle considerations. This article reviews the pathophysiology, management, and critical care transport considerations for this unique patient population in respiratory distress and failure.
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Affiliation(s)
- Michael J Lauria
- Lifeguard Air Emergency Services, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM.
| | - Christopher W Root
- Lifeguard Air Emergency Services, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM
| | - Adam L Gottula
- Department of Anesthesiology, Division of Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | - Darren A Braude
- Lifeguard Air Emergency Services, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico, Albuquerque, NM
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18
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Belenguer-Muncharaz A, Mateu-Campos ML, Vidal-Tegedor B, Ferrándiz-Sellés MD, Micó-Gómez ML, Altaba-Tena S, Arlandis-Tomás M, Álvaro-Sánchez R, Rodríguez-Martínez E, Rodríguez-Portillo J. Noninvasive ventilation versus conventional oxygen therapy after extubation failure in high-risk patients in an intensive care unit: a pragmatic clinical trial. Rev Bras Ter Intensiva 2021; 33:362-373. [PMID: 35107547 PMCID: PMC8555401 DOI: 10.5935/0103-507x.20210059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 11/22/2020] [Indexed: 11/20/2022] Open
Abstract
Objetivo Determinar la efectividad de la ventilación no invasiva frente a
oxigenoterapia convencional en pacientes con insuficiencia respiratoria
aguda tras fracaso de la extubación. Métodos Ensayo clínico pragmático realizado una unidad de cuidados
intensivos de marzo de 2009 a septiembre de 2016. Se incluyeron pacientes
sometidos a ventilación mecánica > 24 horas, y que
desarrollaron insuficiencia respiratoria aguda tras extubación
programada, siendo asignados a ventilación no invasiva u
oxigenoterapia convencional. El objetivo primario fue reducir la tasa de
reintubación. Los objetivos secundarios fueron: mejora de los
parámetros respiratorios, reducción de las complicaciones, de
la duración de la ventilación mecánica, de la estancia
en unidad de cuidados intensivos y hospitalaria, así como de la
mortalidad en unidad de cuidados intensivos, hospitalaria y a los 90
días. También se analizaron los factores relacionados con la
reintubación. Resultados De un total de 2.574 pacientes, se analizaron 77 (38 en el grupo de
ventilación no invasiva y 39 en el grupo de oxigenoterapia
convencional). La ventilación no invasiva redujo la frecuencia
respiratoria y cardíaca más rápidamente que la
oxigenoterapia convencional. La reintubación fue menor en el grupo de
ventilación no invasiva [12 (32%) versus 22(56%) en
grupo oxigenoterapia convencional, RR 0,58 (IC95% 0,34 - 0,97), p = 0,039],
el resto de los parámetros no mostró diferencias
significativas. En el análisis multivariante, la ventilación
no invasiva prevenía la reintubación [OR 0,17 (IC95% 0,05 -
0,56), p = 0,004], mientras que el fracaso hepático previo a la
extubación y la incapacidad para mantener vía aérea
permeable predisponían a la reintubación. Conclusión El empleo de la ventilación no invasiva en pacientes que fracasa la
extubación podría ser beneficiosa frente a la oxigenoterapia
convencional.
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Affiliation(s)
- Alberto Belenguer-Muncharaz
- Unidad de Cuidados Intensivos, Hospital General Universitario de Castellón - Castelló de Plana, Spain.,Unidad Predepartamental Medicina, Facultad de Ciencias de la Salud, Universitat Jaume I - Castelló de la Plana, Spain
| | - Maria-Lidón Mateu-Campos
- Unidad de Cuidados Intensivos, Hospital General Universitario de Castellón - Castelló de Plana, Spain.,Unidad Predepartamental Medicina, Facultad de Ciencias de la Salud, Universitat Jaume I - Castelló de la Plana, Spain
| | - Bárbara Vidal-Tegedor
- Unidad de Cuidados Intensivos, Hospital General Universitario de Castellón - Castelló de Plana, Spain
| | - María-Desamparados Ferrándiz-Sellés
- Unidad de Cuidados Intensivos, Hospital General Universitario de Castellón - Castelló de Plana, Spain.,Unidad Predepartamental Medicina, Facultad de Ciencias de la Salud, Universitat Jaume I - Castelló de la Plana, Spain
| | - Maria-Luisa Micó-Gómez
- Unidad de Cuidados Intensivos, Hospital General Universitario de Castellón - Castelló de Plana, Spain
| | - Susana Altaba-Tena
- Unidad de Cuidados Intensivos, Hospital General Universitario de Castellón - Castelló de Plana, Spain
| | - María Arlandis-Tomás
- Unidad de Cuidados Intensivos, Hospital General Universitario de Castellón - Castelló de Plana, Spain
| | - Rosa Álvaro-Sánchez
- Unidad de Cuidados Intensivos, Hospital General Universitario de Castellón - Castelló de Plana, Spain
| | - Enver Rodríguez-Martínez
- Unidad de Cuidados Intensivos, Hospital General Universitario de Castellón - Castelló de Plana, Spain
| | - Jairo Rodríguez-Portillo
- Unidad de Cuidados Intensivos, Hospital General Universitario de Castellón - Castelló de Plana, Spain
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19
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Loued L, Saad AB, Migaou A, Fahem N, Kaddoussi R, Joobeur S, Mhamed SC, Rouatbi N. [Factors predicting the need for invasive mechanical ventilation in patients with chronic obstructive pulmonary disease (COPD)]. Pan Afr Med J 2021; 39:119. [PMID: 34512855 PMCID: PMC8396382 DOI: 10.11604/pamj.2021.39.119.27514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 05/15/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction the use of invasive mechanical ventilation (IMV) in acute exacerbations of chronic obstructive pulmonary disease (AECOPD) constitutes a negative turning point in the progression of the disease. The purpose of this study is to determine factors predicting the need for IMV in AECOPD. Methods we conducted a retrospective study by reviewing the medical records of patients with AECOPD hospitalized in our Department over a 18-year period (2000-2017). We compared 2 groups: G1: patients with AECOPD undergoing at least one IMV and G2: patients who had never undergone IMV following AECOPD. Results the study included 1152 patients with COPD: 133 in the G1 group (11.5%), and 1019 in the G2 group (88.5%). G1 patients were more symptomatic (p < 0.001), with more severe bronchial obstruction (p < 0.001). G1 patients had more exacerbations (p < 0.001), more hospitalizations and a higher need for non-invasive ventilation (NIV) (p < 0.001). Similarly, G1 patients more often developed chronic respiratory failure (p < 0.001) and had significantly lower survival rates. Independent risk factors associated with IMV were hypercapnia and decreased pH (in patients with severe AECOPD), a history of NIV, and chronic respiratory failure (CRF). Conclusion respiratory function impairment, the severity of exacerbation and the need for NIV in a previous episode are factors predicting the need for IMV and poor outcomes.
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Affiliation(s)
- Lobna Loued
- Service de Pneumologie et d´Allergologie, Hôpital Universitaire Fattouma Bourguiba, Monastir, Rue 1er juin, 5000 Monastir, Monastir, Tunisie
| | - Ahmed Ben Saad
- Service de Pneumologie et d´Allergologie, Hôpital Universitaire Fattouma Bourguiba, Monastir, Rue 1er juin, 5000 Monastir, Monastir, Tunisie
| | - Asma Migaou
- Service de Pneumologie et d´Allergologie, Hôpital Universitaire Fattouma Bourguiba, Monastir, Rue 1er juin, 5000 Monastir, Monastir, Tunisie
| | - Nesrine Fahem
- Service de Pneumologie et d´Allergologie, Hôpital Universitaire Fattouma Bourguiba, Monastir, Rue 1er juin, 5000 Monastir, Monastir, Tunisie
| | - Rania Kaddoussi
- Service de Pneumologie et d´Allergologie, Hôpital Universitaire Fattouma Bourguiba, Monastir, Rue 1er juin, 5000 Monastir, Monastir, Tunisie
| | - Samah Joobeur
- Service de Pneumologie et d´Allergologie, Hôpital Universitaire Fattouma Bourguiba, Monastir, Rue 1er juin, 5000 Monastir, Monastir, Tunisie
| | - Saousen Cheikh Mhamed
- Service de Pneumologie et d´Allergologie, Hôpital Universitaire Fattouma Bourguiba, Monastir, Rue 1er juin, 5000 Monastir, Monastir, Tunisie
| | - Naceur Rouatbi
- Service de Pneumologie et d´Allergologie, Hôpital Universitaire Fattouma Bourguiba, Monastir, Rue 1er juin, 5000 Monastir, Monastir, Tunisie
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20
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Feng X, Pan S, Yan M, Shen Y, Liu X, Cai G, Ning G. Dynamic prediction of late noninvasive ventilation failure in intensive care unit using a time adaptive machine model. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2021; 208:106290. [PMID: 34298473 DOI: 10.1016/j.cmpb.2021.106290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 07/09/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Noninvasive ventilation (NIV) failure is strongly associated with poor prognosis. Nowadays, plenty of mature studies have been proposed to predict early NIV failure (within 48 hours of NIV), however, the prediction for late NIV failure (after 48 hours of NIV) lacks sufficient research. Late NIV failure delays intubation resulting in the increasing mortality of the patients. Therefore, it is of great significance to expeditiously predict the late NIV failure. In order to dynamically predict late NIV failure, we proposed a Time Updated Light Gradient Boosting Machine (TULightGBM) model. MATERIAL AND METHODS In this work, 5653 patients undergoing NIV over 48 hours were extracted from the database of Medical Information Mart for Intensive Care Ⅲ (MIMIC-Ⅲ) for model construction. The TULightGBM model consists of a series of sub-models which learn clinical information from updating data within 48 hours of NIV and integrates the outputs of the sub-models by the dynamic attention mechanism to predict late NIV failure. The performance of the proposed TULightGBM model was assessed by comparison with common models of logistic regression (LR), random forest (RF), LightGBM, eXtreme gradient boosting (XGBoost), artificial neural network (ANN), and long short-term memory (LSTM). RESULTS The TULightGBM model yielded prediction results at 8, 16, 24, 36, and 48 hours after the start of the NIV with dynamic AUC values of 0.8323, 0.8435, 0.8576, 0.8886, and 0.9123, respectively. Furthermore, the sensitivity, specificity, and accuracy of the TULightGBM model were 0.8207, 0.8164, and 0.8184, respectively. The proposed model achieved superior performance over other tested models. CONCLUSIONS The TULightGBM model is able to dynamically predict the late NIV failure with high accuracy and offer potential decision support for clinical practice.
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Affiliation(s)
- Xue Feng
- Department of Biomedical Engineering, Zhejiang University, 38 Zheda Road, Hangzhou 310027, China.
| | - Su Pan
- Department of Biomedical Engineering, Zhejiang University, 38 Zheda Road, Hangzhou 310027, China
| | - Molei Yan
- Department of Intensive Care Unit, Zhejiang Hospital, 12 Lingyin Road, Hangzhou 310013, China
| | - Yanfei Shen
- Department of Intensive Care Unit, Zhejiang Hospital, 12 Lingyin Road, Hangzhou 310013, China
| | - Xiaoqing Liu
- Deepwise AI LAB, 8 Haidian Road, Beijng 100089, China
| | - Guolong Cai
- Department of Intensive Care Unit, Zhejiang Hospital, 12 Lingyin Road, Hangzhou 310013, China.
| | - Gangmin Ning
- Department of Biomedical Engineering, Zhejiang University, 38 Zheda Road, Hangzhou 310027, China.
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21
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Ghazala L, Hatipoğlu U, Devnani T, Covert E, Hanks J, Edwards K, Macmurdo M, Li M, Wang X, Duggal A. Duration of noninvasive ventilation is not a predictor of clinical outcomes in patients with acute exacerbation of COPD and respiratory failure. CANADIAN JOURNAL OF RESPIRATORY THERAPY : CJRT = REVUE CANADIENNE DE LA THERAPIE RESPIRATOIRE : RCTR 2021; 57:113-118. [PMID: 34447880 PMCID: PMC8372872 DOI: 10.29390/cjrt-2021-021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Purpose Acute exacerbation of chronic obstructive pulmonary disease (COPD) is a major cause of mortality and morbidity. Noninvasive ventilation (NIV) is proven to be effective in the majority of patients with acute exacerbation COPD (AECOPD) complicated with respiratory failure. NIV could be lifesaving but also can delay mechanical ventilation if its efficacy is not assessed in a timely manner. In this study, we analyzed potential predictors of NIV failure in AECOPD in a tertiary medical intensive care unit (MICU). In particular, we wondered whether duration of NIV among those who eventually failed was associated with poor outcomes. Methods A retrospective review of consecutive patients with a primary diagnosis of AECOPD requiring NIV admitted to the MICU was conducted for the period between 2012 and 2017. Baseline data included demographics, APACHE III score, albumin level, blood lactate, and blood gas elements. Additional chart review was performed to collect NIV setting parameters on presentation to the MICU. Clinical outcome variables collected included outcome and duration of NIV, duration of invasive mechanical ventilation, MICU length of stay, hospital length of stay, and in-hospital mortality. Multivariate regression analysis was performed to determine independent variables associated with clinical outcomes. Results There were 370 patients who met the inclusion criteria; 53.2% were male. Mean age was 64.7 ± 11.2 years old. Mean baseline FEV1 was 34 ±17% of predicted. Patients had mean pH of 7.20 ± 0.54 and PaCO2 of 70.3 ± 28.7 on presentation; 323 patients (87.3%) were successfully weaned off NIV; 47 patients (12.7%) failed NIV and required invasive mechanical ventilation. APACHE III score was higher among patients who failed NIV (68.3±18.9 versus 48.8± 15.2, P < 0.001). In the subset of 47 patients who failed NIV requiring intubation, duration of NIV was 25.0 ± 58.8 h. Multivariate regression analysis yielded a model consisting of APACHE III score and body mass index as predictive variables for NIV failure (C-statistic = 0.809). Duration of NIV was not associated with worse clinical outcomes among patients who failed NIV. Conclusions NIV is successful in preventing invasive mechanical ventilation in majority of patients with acute respiratory failure due to COPD. Patients with worse clinical status at presentation are more likely to fail NIV and require mechanical ventilation. In the subgroup of patients who failed NIV, duration of NIV prior to intubation was not associated with poor clinical outcomes.
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Affiliation(s)
- Laith Ghazala
- Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.,Trillium Health Partners, Mississauga, ON, Canada
| | - Umur Hatipoğlu
- Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tanya Devnani
- Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Erin Covert
- Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Justin Hanks
- Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | | | - Maeve Macmurdo
- Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Manshi Li
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Xiaofeng Wang
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Abhijit Duggal
- Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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22
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Sun W, Luo Z, Jin J, Cao Z, Ma Y. The Neutrophil/Lymphocyte Ratio Could Predict Noninvasive Mechanical Ventilation Failure in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Retrospective Observational Study. Int J Chron Obstruct Pulmon Dis 2021; 16:2267-2277. [PMID: 34385816 PMCID: PMC8353100 DOI: 10.2147/copd.s320529] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/19/2021] [Indexed: 12/16/2022] Open
Abstract
Purpose To determine the effectiveness of neutrophil/lymphocyte ratio (NLR), compared to traditional inflammatory markers, for predicting noninvasive mechanical ventilation (NIMV) failure in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients. Patients and Methods We conducted this retrospective observational study including 212 AECOPD patients who required NIMV during hospitalization from January 2015 to December 2020 in the department of respiratory and critical care medicine of Beijing Chao-Yang Hospital (west campus). We reviewed the medical record to determine if NIMV succeeded or failed for each patient, and compared NLR with traditional markers (leukocyte, C-reactive protein [CRP] and procalcitonin [PCT]) between NIMV failure and NIMV success group. Receiver-operating characteristic (ROC) curve and multivariate logistic regression analysis were used to assess the accuracy of these markers for predicting NIMV failure. Results A total of 38 (17.9%) patients experienced NIMV failure. NLR was a more sensitive biomarker to predict NIMV failure (AUC, 0.858; 95% CI 0.785-0.931) than leukocyte counts (AUC, 0.723; 95% CI 0.623-0.823), CRP (AUC, 0.670; 95% CI 0.567-0.773) and PCT (AUC, 0.719; 95% CI 0.615-0.823). There was statistically positive correlation between NLR and leukocytes count (r=0.35, p<0.001), between NLR and CRP (r=0.258, p<0.001), between NLR and PCT (r=0.306, p<0.001). The cutoff value of NLR to predict NIMV failure was 8.9 with sensitivity 0.688, specificity 0.886 and diagnostic accuracy 0.868. NLR>8.9 (odds ratio, 10.783; 95% CI, 2.069-56.194; P=0.05) was an independent predictor of NIMV failure in the multivariate logistic regression model. Conclusion NLR may be an effective marker for predicting NIMV failure in AECOPD patients, and the patients with NLR>8.9 should be handled with caution since they are at higher risk of NIMV failure and require intubation. Further study with a larger sample size and with more data is necessary to confirm our study.
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Affiliation(s)
- Wei Sun
- Department of Respiratory and Critical Care Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Zujin Luo
- Department of Respiratory and Critical Care Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Jiawei Jin
- Department of Respiratory and Critical Care Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Zhixin Cao
- Department of Respiratory and Critical Care Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yingmin Ma
- Department of Respiratory and Critical Care Medicine, Beijing Youan Hospital, Capital Medical University, Beijing, People’s Republic of China
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23
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Nitesh J, Kashyap R, Surani SR. What we learned in the past year in managing our COVID-19 patients in intensive care units? World J Crit Care Med 2021; 10:81-101. [PMID: 34316444 PMCID: PMC8291007 DOI: 10.5492/wjccm.v10.i4.81] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/07/2021] [Accepted: 05/17/2021] [Indexed: 02/06/2023] Open
Abstract
Coronavirus disease 2019 is a pandemic, was first recognized at Wuhan province, China in December 2019. The disease spread quickly across the globe, spreading stealthily from human to human through both symptomatic and asymptomatic individuals. A multisystem disease which appears to primarily spread via bio aerosols, it has exhibited a wide clinical spectrum involving multiple organ systems with the respiratory system pathology being the prime cause of morbidity and mortality. Initially unleashing a huge destructive trail at Wuhan China, Lombardy Italy and New York City, it has now spread to all parts of the globe and has actively thrived and mutated into new forms. Health care systems and Governments responded initially with panic, with containment measures giving way to mitigation strategies. The global medical and scientific community has come together and responded to this huge challenge. Professional medical societies quickly laid out "expert" guidelines which were conservative in their approach. Many drugs were re formulated and tested quickly with the help of national and international collaborative groups, helping carve out effective treatment strategies and help build a good scientific foundation for evidence-based medicine. Out of the darkness of chaos, we now have an orderly approach to manage this disease both from a public health preventive and therapeutic standpoint. With preventive measures such as masking and social distancing to the development of highly effective and potent vaccines, the public health success of such measures has been tempered by behavioral responses and resource mobilization. From a therapy standpoint, we now have drugs that were promising but now proven ineffective, and those that are effective when given early during viral pathogenesis or later when immune dysregulation has established, and the goal is to help reign in the destructive cascade. It has been a fascinating journey for mankind and our work here recapitulates the evolution of various aspects of critical care and other inpatient practices which continue to evolve.
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Affiliation(s)
- Jain Nitesh
- Department of Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Rahul Kashyap
- Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, United States
| | - Salim R Surani
- Department of Medicine, Texas A&M University, Corpus Christi, TX 78404, United States
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24
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Wendel Garcia PD, Aguirre-Bermeo H, Buehler PK, Alfaro-Farias M, Yuen B, David S, Tschoellitsch T, Wengenmayer T, Korsos A, Fogagnolo A, Kleger GR, Wu MA, Colombo R, Turrini F, Potalivo A, Rezoagli E, Rodríguez-García R, Castro P, Lander-Azcona A, Martín-Delgado MC, Lozano-Gómez H, Ensner R, Michot MP, Gehring N, Schott P, Siegemund M, Merki L, Wiegand J, Jeitziner MM, Laube M, Salomon P, Hillgaertner F, Dullenkopf A, Ksouri H, Cereghetti S, Grazioli S, Bürkle C, Marrel J, Fleisch I, Perez MH, Baltussen Weber A, Ceruti S, Marquardt K, Hübner T, Redecker H, Studhalter M, Stephan M, Selz D, Pietsch U, Ristic A, Heise A, Meyer Zu Bentrup F, Franchitti Laurent M, Fodor P, Gaspert T, Haberthuer C, Colak E, Heuberger DM, Fumeaux T, Montomoli J, Guerci P, Schuepbach RA, Hilty MP, Roche-Campo F. Implications of early respiratory support strategies on disease progression in critical COVID-19: a matched subanalysis of the prospective RISC-19-ICU cohort. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:175. [PMID: 34034782 PMCID: PMC8146172 DOI: 10.1186/s13054-021-03580-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 04/15/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Uncertainty about the optimal respiratory support strategies in critically ill COVID-19 patients is widespread. While the risks and benefits of noninvasive techniques versus early invasive mechanical ventilation (IMV) are intensely debated, actual evidence is lacking. We sought to assess the risks and benefits of different respiratory support strategies, employed in intensive care units during the first months of the COVID-19 pandemic on intubation and intensive care unit (ICU) mortality rates. METHODS Subanalysis of a prospective, multinational registry of critically ill COVID-19 patients. Patients were subclassified into standard oxygen therapy ≥10 L/min (SOT), high-flow oxygen therapy (HFNC), noninvasive positive-pressure ventilation (NIV), and early IMV, according to the respiratory support strategy employed at the day of admission to ICU. Propensity score matching was performed to ensure comparability between groups. RESULTS Initially, 1421 patients were assessed for possible study inclusion. Of these, 351 patients (85 SOT, 87 HFNC, 87 NIV, and 92 IMV) remained eligible for full analysis after propensity score matching. 55% of patients initially receiving noninvasive respiratory support required IMV. The intubation rate was lower in patients initially ventilated with HFNC and NIV compared to those who received SOT (SOT: 64%, HFNC: 52%, NIV: 49%, p = 0.025). Compared to the other respiratory support strategies, NIV was associated with a higher overall ICU mortality (SOT: 18%, HFNC: 20%, NIV: 37%, IMV: 25%, p = 0.016). CONCLUSION In this cohort of critically ill patients with COVID-19, a trial of HFNC appeared to be the most balanced initial respiratory support strategy, given the reduced intubation rate and comparable ICU mortality rate. Nonetheless, considering the uncertainty and stress associated with the COVID-19 pandemic, SOT and early IMV represented safe initial respiratory support strategies. The presented findings, in agreement with classic ARDS literature, suggest that NIV should be avoided whenever possible due to the elevated ICU mortality risk.
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Affiliation(s)
- Pedro D Wendel Garcia
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland.,The RISC-19-ICU Registry Board, University of Zurich, Zurich, Switzerland
| | | | - Philipp K Buehler
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Mario Alfaro-Farias
- Unidad de Cuidados Intensivos, Hospital Nostra Senyora de Meritxell, Escaldes-Engordany, Andorra
| | - Bernd Yuen
- Interdisziplinaere Intensivstation, Spital Buelach, Buelach, Switzerland
| | - Sascha David
- Department of Nephrology and Hypertension, Medical School Hannover, Hannover, Germany
| | - Thomas Tschoellitsch
- Department of Anesthesiology and Critical Care Medicine, Kepler University Hospital GmbH and Johannes Kepler University, Linz, Austria
| | - Tobias Wengenmayer
- Department of Medicine III - Interdisciplinary Medical Intensive Care, Medical Center University of Freiburg, Freiburg, Germany
| | - Anita Korsos
- Departement of Anaethesiology and Intensive Care, University of Szeged, Szeged, Hungary
| | - Alberto Fogagnolo
- Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy
| | - Gian-Reto Kleger
- Medizinische Intensivstation, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Maddalena A Wu
- Department of Internal Medicine, ASST Fatebenefratelli Sacco - "Luigi Sacco" Hospital, Milan, Italy
| | - Riccardo Colombo
- Division of Anesthesia and Intensive Care, ASST Fatebenefratelli Sacco - "Luigi Sacco" Hospital, Milan, Italy
| | - Fabrizio Turrini
- Internal Medicine, Azienda Ospedaliera Universitaria di Modena, Modena, Italy
| | | | - Emanuele Rezoagli
- Department of Anesthesia and Intensive Care Medicine, Policlinico San Marco, Gruppo Ospedaliero San Donato, Bergamo, Italy
| | - Raquel Rodríguez-García
- Servicio de Medicina intensiva, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - Pedro Castro
- Medical Intensive Care Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | | | | | - Herminia Lozano-Gómez
- Unidad de Cuidados Intensivos, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Rolf Ensner
- Klinik für Operative Intensivmedizin, Kantonsspital Aarau, Aarau, Switzerland
| | - Marc P Michot
- Medizinische Intensivstation, Kantonsspital Aarau, Aarau, Switzerland
| | - Nadine Gehring
- Intensivstation, Kantonsspital Schaffhausen, Schaffhausen, Switzerland
| | - Peter Schott
- Institut fuer Anesthaesie und Intensivmedizin, Zuger Kantonsspital AG, Baar, Switzerland
| | - Martin Siegemund
- Department Intensivmedizin, Universitaetsspital Basel, Basel, Switzerland
| | - Lukas Merki
- Intensivmedizin, St. Claraspital, Basel, Switzerland
| | - Jan Wiegand
- Interdisziplinaere Intensivmedizin, Lindenhofspital, Bern, Switzerland
| | - Marie M Jeitziner
- Department of Intensive Care Medicine, University Hospital Bern, Inselspital, Bern, Switzerland
| | - Marcus Laube
- Department Intensive Care Medicine, Spitalzentrum Biel, Biel, Switzerland
| | - Petra Salomon
- Intensivstation, Regionalspital Emmental AG, Burgdorf, Switzerland
| | | | - Alexander Dullenkopf
- Institut fuer Anaesthesie und Intensivmedizin, Spital Thurgau, Frauenfeld, Switzerland
| | - Hatem Ksouri
- Soins Intensifs, Hopital cantonal de Fribourg, Fribourg, Switzerland
| | - Sara Cereghetti
- Division of Intensive Care, University Hospitals of Geneva, Geneva, Switzerland
| | - Serge Grazioli
- Division of Neonatal and Pediatric Intensive Care, University Hospitals of Geneva, Geneva, Switzerland
| | | | - Julien Marrel
- Institut für Anaesthesiologie Intensivmedizin & Rettungsmedizin, See-Spital Horgen & Kilchberg, Horgen, Switzerland
| | - Isabelle Fleisch
- Soins Intensifs, Hirslanden Clinique Cecil, Lausanne, Switzerland
| | - Marie-Helene Perez
- Pediatric Intensive Care Unit, University Hospital Lausanne, Lausanne, Switzerland
| | | | - Samuele Ceruti
- Dipartimento Area Critica, Clinica Luganese Moncucco, Lugano, Switzerland
| | - Katharina Marquardt
- Interdisziplinaere Intensivstation, Spital Maennedorf AG, Maennedorf, Switzerland
| | - Tobias Hübner
- Institut fuer Anaesthesie und Intensivmedizin, Spital Thurgau, Muensterlingen, Switzerland
| | - Hermann Redecker
- Intensivmedizin, Schweizer Paraplegikerzentrum Nottwil, Nottwil, Switzerland
| | - Michael Studhalter
- Intensivmedizin & Intermediate Care, Kantonsspital Olten, Olten, Switzerland
| | | | - Daniela Selz
- Anaesthesie Intensivmedizin Schmerzmedizin, Spital Schwyz, Schwyz, Switzerland
| | - Urs Pietsch
- Departement of Anesthesiology and Intensive Care Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Anette Ristic
- Departement for Intensive Care Medicine, Kantonsspital Nidwalden, Stans, Switzerland
| | - Antje Heise
- Intensivstation, Spital Simmental-Thun-Saanenland AG, Thun, Switzerland
| | | | | | - Patricia Fodor
- Interdisziplinaere Intensivstation, Stadtspital Triemli, Zurich, Switzerland
| | - Tomislav Gaspert
- Abteilung für Anaesthesiologie und Intensivmedizin, Hirslanden Klinik Im Park, Zurich, Switzerland
| | - Christoph Haberthuer
- Institut für Anaesthesiologie und Intensivmedizin, Klinik Hirslanden, Zurich, Switzerland
| | - Elif Colak
- General Surgery, Samsun Training and Research Hospital, Samsun, Turkey
| | - Dorothea M Heuberger
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Thierry Fumeaux
- The RISC-19-ICU Registry Board, University of Zurich, Zurich, Switzerland.,Soins intensifs, Groupement Hospitalier de l'Ouest Lémanique, Hôpital de Nyon, Nyon, Switzerland
| | - Jonathan Montomoli
- The RISC-19-ICU Registry Board, University of Zurich, Zurich, Switzerland.,Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, Netherlands
| | - Philippe Guerci
- The RISC-19-ICU Registry Board, University of Zurich, Zurich, Switzerland.,Department of Anesthesiology and Critical Care Medicine, University Hospital of Nancy, Nancy, France
| | - Reto A Schuepbach
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland.,The RISC-19-ICU Registry Board, University of Zurich, Zurich, Switzerland
| | - Matthias P Hilty
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland.,The RISC-19-ICU Registry Board, University of Zurich, Zurich, Switzerland
| | - Ferran Roche-Campo
- Servicio de Medicina intensiva, Hospital Verge de la Cinta, Carrer de les Esplanetes 44, 43500, Tortosa, Tarragona, Spain.
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25
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Nishikimi M, Nishida K, Shindo Y, Shoaib M, Kasugai D, Yasuda Y, Higashi M, Numaguchi A, Yamamoto T, Matsui S, Matsuda N. Failure of non-invasive respiratory support after 6 hours from initiation is associated with ICU mortality. PLoS One 2021; 16:e0251030. [PMID: 33930089 PMCID: PMC8087003 DOI: 10.1371/journal.pone.0251030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/19/2021] [Indexed: 12/28/2022] Open
Abstract
A previous study has shown that late failure (> 48 hours) of high-flow nasal cannula (HFNC) was associated with intensive care unit (ICU) mortality. The aim of this study was to investigate whether failure of non-invasive respiratory support, including HFNC and non-invasive positive pressure ventilation (NPPV), was also associated with the risk of mortality even if it occurs in the earlier phase. We retrospectively analyzed 59 intubated patients for acute respiratory failure due to lung diseases between April 2014 and June 2018. We divided the patients into 2 groups according to the time from starting non-invasive ventilatory support until their intubation: ≤ 6 hours failure and > 6 hours failure group. We evaluated the differences in the ICU mortality between these two groups. The multivariate logistic regression analysis showed the highest mortality in the > 6 hours failure group as compared to the ≤ 6 hours failure group, with a statistically significant difference (p < 0.01). It was also associated with a statistically significant increased 30-day mortality and decreased ventilator weaning rate. The ICU mortality in patients with acute respiratory failure caused by lung diseases was increased if the time until failure of HFNC and NPPV was more than 6 hours.
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Affiliation(s)
- Mitsuaki Nishikimi
- Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Department of Emergency Medicine, Northwell Health, NY, NY, United States of America
- Laboratory for Critical Care Physiology at the Feinstein Institutes for Medical Research, Northwell Health, NY, NY, United States of America
- * E-mail:
| | - Kazuki Nishida
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuichiro Shindo
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Muhammad Shoaib
- Laboratory for Critical Care Physiology at the Feinstein Institutes for Medical Research, Northwell Health, NY, NY, United States of America
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States of America
| | - Daisuke Kasugai
- Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuma Yasuda
- Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Michiko Higashi
- Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Atsushi Numaguchi
- Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takanori Yamamoto
- Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shigeyuki Matsui
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naoyuki Matsuda
- Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
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26
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Karim HMR, Esquinas AM. Our insight about Mukhtar et al.'s outcome of non-invasive ventilation in COVID-19 critically ill patients. Anaesth Crit Care Pain Med 2021; 40:100781. [PMID: 33197639 PMCID: PMC7664590 DOI: 10.1016/j.accpm.2020.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 09/24/2020] [Accepted: 09/24/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Habib Md Reazaul Karim
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Raipur 492099, India,Corresponding author at: Faculty Room A001, Block A, All India Institute of Medical Sciences, Raipur 492099, India
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27
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Custodero C, Gandolfo F, Cella A, Cammalleri LA, Custureri R, Dini S, Femia R, Garaboldi S, Indiano I, Musacchio C, Podestà S, Tricerri F, Pasa A, Sabbà C, Pilotto A. Multidimensional prognostic index (MPI) predicts non-invasive ventilation failure in older adults with acute respiratory failure. Arch Gerontol Geriatr 2020; 94:104327. [PMID: 33485005 DOI: 10.1016/j.archger.2020.104327] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/15/2020] [Accepted: 12/19/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Acute respiratory failure (ARF) is a very common complication among hospitalized older adults. Non-invasive ventilation (NIV) may avoid admission to intensive care units, intubation and their related complication, but still lacks specific indications in older adults. Multidimensional Prognostic Index (MPI) based on comprehensive geriatric assessment (CGA) could have a role in defining the short-term prognosis and the best candidates for NIV among older adults with ARF. METHODS This is a retrospective observational study which enrolled patients older than 70 years, consecutively admitted to an acute geriatric unit with ARF. A standardized CGA was used to calculate the MPI at admission. Multivariate Cox regression models were used to test if MPI score could predict in-hospital mortality and NIV failure. Receiver operator curve (ROC) analysis was used to identify the discriminatory power of MPI for NIV failure. RESULTS We enrolled 231 patients (88.2 ± 5.9 years, 47% females). Mean MPI at admission was 0.76±0.16. In-hospital mortality rate was 33.8%, with similar incidence in patients treated with and without NIV. Among NIV users (26.4%), NIV failure occurred in 39.3%. Higher MPI scores at admission significantly predicted in-hospital mortality (β=4.46, p<0.0001) among patients with ARF and NIV failure (β=7.82, p = 0.001) among NIV users. MPI showed good discriminatory power for NIV failure (area under the curve: 0.72, 95% CI: 0.58-0.85, p<0.001) with optimal cut-off at MPI value of 0.84. CONCLUSIONS MPI at admission might be a useful tool to early detect patients more at risk of in-hospital death and NIV failure among older adults with ARF.
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Affiliation(s)
- Carlo Custodero
- Department of Interdisciplinary Medicine, University of Bari, Italy
| | - Federica Gandolfo
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy
| | - Alberto Cella
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy
| | - Lisa A Cammalleri
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy
| | - Romina Custureri
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy
| | - Simone Dini
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy
| | - Rosetta Femia
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy
| | - Sara Garaboldi
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy
| | - Ilaria Indiano
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy
| | - Clarissa Musacchio
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy
| | - Silvia Podestà
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy
| | - Francesca Tricerri
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy
| | - Ambra Pasa
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy
| | - Carlo Sabbà
- Department of Interdisciplinary Medicine, University of Bari, Italy
| | - Alberto Pilotto
- Department of Interdisciplinary Medicine, University of Bari, Italy; Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy.
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28
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Vahdatpour CA, Pichler A, Palevsky HI, Kallan MJ, Patel NB, Kinniry PA. Interstitial Lung Disease Associated Acute Respiratory Failure Requiring Invasive Mechanical Ventilation: A Retrospective Analysis. Open Respir Med J 2020; 14:67-77. [PMID: 33425069 PMCID: PMC7774098 DOI: 10.2174/1874306402014010067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/22/2020] [Accepted: 09/30/2020] [Indexed: 12/16/2022] Open
Abstract
Background: Interstitial Lung Disease [ILD] patients requiring Invasive Mechanical Ventilation [IMV] for Acute Respiratory Failure [ARF] are known to have a poor prognosis. Few studies have investigated determinants of outcomes and the utility of trialing Non-Invasive Positive Pressure Ventilation [NIPPV] prior to IMV to see if there are any effect[s] on mortality or morbidity. Methods: A retrospective study was designed using patients at four different intensive care units within one health care system. The primary objective was to determine if there are differences in outcomes for in-hospital and one-year mortality between patients who undergo NIPPV prior to IMV and those who receive only IMV. A secondary objective was to identify potential determinants of outcomes. Results: Out of 54 ILD patients with ARF treated with IMV, 20 (37.0%) survived until hospital discharge and 10 (18.5%) were alive at one-year. There was no significant mortality difference between patients trialed on NIPPV prior to IMV and those receiving only IMV. Several key determinants of outcomes were identified with higher mortality, including higher ventilatory support, idiopathic pulmonary fibrosis (IPF) subtype, high dose steroids, use of vasopressors, supraventricular tachycardias (SVTs), and higher body mass index. Conclusion: Considering that patients trialed on NIPPV prior to IMV were associated with no mortality disadvantage to patients treated with only IMV, trialing patients on NIPPV may identify responders and avoid complications associated with IMV. Increased ventilator support, need of vasopressors, SVTs, and high dose steroids reflect higher mortality and palliative care involvement should be considered as early as possible if a lung transplant is not an option.
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Affiliation(s)
- Cyrus A Vahdatpour
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida, Gainesville, Florida
| | - Alexander Pichler
- Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - Harold I Palevsky
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael J Kallan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Namrata B Patel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Pulmonary, Allergy, and Critical Care Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul A Kinniry
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Pulmonary, Allergy, and Critical Care Division, Department of Medicine, Pennsylvania Hospital, Philadelphia, Pennsylvania
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29
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Vashisht R, Krishnan S, Duggal A. A narrative review of non-pharmacological management of SARS-CoV-2 respiratory failure: a call for an evidence based approach. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1599. [PMID: 33437798 PMCID: PMC7791197 DOI: 10.21037/atm-20-4633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
A novel severe acute respiratory syndrome coronavirus (SARS-CoV-2) belonging to genus beta-coronavirus has been associated with an acute respiratory disease termed coronavirus disease 2019 (COVID-19). As of September 3, 2020, SARS-CoV-2 had caused 867,219 fatalities in 188 nations across the globe. Rapid progression to bronchopneumonia manifesting with severe hypoxemia and eventual evolution into acute respiratory distress syndrome (ARDS) necessitating mechanical ventilation is the hallmark of this disease. The novel nature of COVID-19 pneumonia and the high morbidity and mortality associated with the same has vexed the critical care community. A cultural shift away from evidence-based medicine, and the impetus to attempt newer unproven therapies like awake proning, interleukin receptor 6 antagonists, inhaled nitric oxide, empiric anticoagulation etc. over modalities that have been tested over the decades is slowly gaining ground. The suggestions to delay intubations and liberalize tidal volumes have polarized the medical field like never before. The lack of consistency in management practices and establishing practices based on anecdotes and experiences can lead to devastating outcomes in the patients affected by this deadly virus. In this narrative review, we attempt to re-emphasize the need for an evidence-based approach to the management of COVID-19 related ARDS and review treatment strategies that have been established after rigorous trials and have stood the test of time.
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Affiliation(s)
- Rishik Vashisht
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, USA
| | - Sudhir Krishnan
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, USA.,Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, USA
| | - Abhijit Duggal
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, USA.,Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, USA
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30
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Cabrini L, Ghislanzoni L, Severgnini P, Landoni G, Baiardo Redaelli M, Franchi F, Romagnoli S. Early versus late tracheal intubation in COVID-19 patients: a "pros/cons" debate also considering heart-lung interactions. Minerva Cardiol Angiol 2020; 69:596-605. [PMID: 33059400 DOI: 10.23736/s2724-5683.20.05356-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The best timing of orotracheal intubation and invasive ventilation in COVID-19 patients with acute respiratory distress syndrome is unknown. The use of non-invasive ventilation, a life-saving technique in many medical conditions, is debated in patients with ARDS since prolonged NIV and delayed intubation may be harmful. Shortage of intensive care beds and ventilators during a respiratory pandemic can trigger a widespread use of early non-invasive ventilation in many hospitals but which is the best way to ventilate patients with severe bilateral pneumonia and severely increased spontaneous ventilation is controversial. Moreover, viral spreading to health-care workers and other hospitalized patients is an issue for any device used to administer oxygen. Even if protective mechanical ventilation is currently the gold standard for the management of acute respiratory distress syndrome, tracheal intubation is not without risks and is associated with delirium, hemodynamic instability, immobilization and post intensive care syndrome. Both invasive and non-invasive ventilation are associated with advantages and limitations that should be carefully considered when patients with COVID-19-ARDS need our attention. In the absence of strong evidence, in this review we highlight all the pro and con of these two different approaches.
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Affiliation(s)
- Luca Cabrini
- Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy
| | - Luca Ghislanzoni
- Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy
| | - Paolo Severgnini
- Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy
| | - Giovanni Landoni
- Department of Anesthesiology and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy - .,Vita-Salute San Raffaele University, Milan, Italy
| | - Martina Baiardo Redaelli
- Department of Anesthesiology and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Federico Franchi
- Department of Medicine, Surgery and Neuroscience, Anesthesiology and Intensive Care, University Hospital of Siena, Siena, Italy
| | - Stefano Romagnoli
- Section of Anesthesiology, Intensive Care and Pain Medicine, Department of Health Sciences, University of Florence, Florence, Italy.,Department of Anesthesiology and Intensive Care, Careggi University, Florence, Italy
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31
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Smischney NJ, Khanna AK, Brauer E, Morrow LE, Ofoma UR, Kaufman DA, Sen A, Venkata C, Morris P, Bansal V. Risk Factors for and Outcomes Associated With Peri-Intubation Hypoxemia: A Multicenter Prospective Cohort Study. J Intensive Care Med 2020; 36:1466-1474. [PMID: 33000661 DOI: 10.1177/0885066620962445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Little is known about hypoxemia surrounding endotracheal intubation in the critically ill. Thus, we sought to identify risk factors associated with peri-intubation hypoxemia and its effects' on the critically ill. METHODS Data from a multicenter, prospective, cohort study enrolling 1,033 critically ill adults who underwent endotracheal intubation across 16 medical/surgical ICUs in the United States from July 2015-January 2017 were used to identify risk factors associated with peri-intubation hypoxemia and its effects on patient outcomes. We defined hypoxemia as any pulse oximetry ≤ 88% during and up to 30 minutes following endotracheal intubation. RESULTS In the full analysis (n = 1,033), 123 (11.9%) patients experienced the primary outcome. Five risk factors independently associated with our outcome were identified on multiple logistic regression: cardiac related reason for endotracheal intubation (OR 1.67, [95% CI 1.04, 2.69]); pre-intubation noninvasive ventilation (OR 1.66, [95% CI 1.09, 2.54]); emergency intubation (OR 1.65, [95% CI 1.06, 2.55]); moderate-severe difficult bag-mask ventilation (OR 2.68, [95% CI 1.72, 4.19]); and crystalloid administration within the preceding 24 hours (OR 1.24, [95% CI 1.07, 1.45]; per liter up to 4 liters). Higher baseline SpO2 was found to be protective (OR 0.93, [95% CI 0.91, 0.96]; per percent up to 97%). Consistent results were seen in a separate analysis on only stable patients (n = 921, 93 [10.1%]) (those without baseline hypoxemia ≤ 88%). Peri-intubation hypoxemia was associated with in-hospital mortality (OR 2.40, [95% CI 1.33, 4.31]; stable patients: OR 2.67, [95% CI 1.38, 5.17]) but not ICU length of stay (point estimate 0.9 days, [95% CI -1.0, 2.8 days]; stable patients: point estimate 1.5 days, [95% CI -0.4, 3.4 days]) after adjusting for age, body mass index, illness severity, airway related reason for intubation (i.e., acute respiratory failure), and baseline SPO2. CONCLUSIONS Patients with pre-existing noninvasive ventilation and volume loading who were intubated emergently in the setting of hemodynamic compromise with bag-mask ventilation described as moderate-severe were at increased risk for peri-intubation hypoxemia. Higher baseline oxygenation was found to be protective against peri-intubation hypoxemia. Peri-intubation hypoxemia was associated with in-hospital mortality but not ICU length of stay. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT02508948 and Registered Report Identifier: RR2-10.2196/11101.
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Affiliation(s)
- Nathan J Smischney
- Department of Anesthesiology and Perioperative Medicine, 4352Mayo Clinic, Rochester, MN, USA.,HEModynamic and AIRway Management (HEMAIR) Study Group Mayo Clinic, Rochester, MN, USA
| | - Ashish K Khanna
- Outcomes Research Consortium, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Anesthesia, Section on Critical Care Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Ernesto Brauer
- Department of Critical Care Medicine, Aurora Health Care, Milwaukee, WI, USA
| | - Lee E Morrow
- Department of Critical Care Medicine, Creighton University, Omaha, NE, USA
| | - Uchenna R Ofoma
- Division of Critical Care Medicine, Geisinger Health System, Danville, PA, USA
| | - David A Kaufman
- Section of Pulmonary, Critical Care, and Sleep Medicine, Bridgeport Hospital/Yale New Haven Health, Bridgeport, CT, USA
| | - Ayan Sen
- Department of Critical Care Medicine, 4352Mayo Clinic, Jacksonville, FL, USA
| | - Chakradhar Venkata
- Department of Critical Care Medicine, 7537Mercy Hospital, St. Louis, MO, USA
| | - Peter Morris
- Department of Anesthesia and Critical Care Medicine, University of Kentucky, Lexington, KY, USA
| | - Vikas Bansal
- Department of Critical Care Medicine, 4352Mayo Clinic, Scottsdale, AZ, USA. Ofoma is now with Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA; Kaufman is now with Division of Pulmonary, Critical Care, and Sleep Medicine, NYU School of Medicine, New York, NY, USA
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32
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Mortality Related to Intubation in Adult General ICUs: A Systematic Review and Meta-Analysis. ARCHIVES OF NEUROSCIENCE 2020. [DOI: 10.5812/ans.89993] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Context: Mortality related to intubation occurs as a result of multiple factors such as patient's condition, operator's skills, equipment use, intubation time, duration of laryngoscopy and intubation, and drugs and dosage used for endotracheal intubation (ETI). Objectives: This systematic review and meta-analysis aimed to determine mortality related to intubation and the overall intensive care unit (ICU) mortality rate in adult general ICUs. Methods: We performed a systematic review and meta-analysis on randomized clinical trials and cohort and cross-sectional research from three electronic databases with hand searching. The studies reported mortality related to intubation and the overall ICU mortality rate in adult general ICUs. Our search resulted in 28 published articles without any restriction on date and language. The systematic review and meta-analysis was performed to examine mortality related to intubation and the overall ICU mortality rate. Results: We found 7,866 articles in the literature review from the three databases based on our keywords, of which 28 studies were eligible to include in the study. We observed that mortality related to intubation and the overall ICU mortality rate in intubated patients were 1% and 30%, respectively. Conclusions: This was the first comprehensive systematic review on mortality related to intubation and the overall ICU mortality rate in adult general ICUs, which showed the current care of ETI. However, it was associated with increased complications, which may increase mortality.
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33
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Duan J, Chen L, Liang G, Shu W, Li L, Wang K, Wang S, Liu X, He C, He D, Chen Q, Wei B, Chen B, Shu Y, Tian Y, Fan L, Han X, Zhang R, Yang X, Peng Y, Wan D, Chen X, Ye L, Tian S, Huang Q, Jiang L, Bai L, Zhou L. Noninvasive ventilation failure in patients with hypoxemic respiratory failure: the role of sepsis and septic shock. Ther Adv Respir Dis 2020; 13:1753466619888124. [PMID: 31722614 PMCID: PMC6856973 DOI: 10.1177/1753466619888124] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Sepsis and septic shock are common in noninvasive ventilation (NIV) patients. However, studies on the association between sepsis and NIV failure are lacking. METHODS A prospective multi-center observational study was performed in 16 Chinese intensive care units (ICUs). Patients who used NIV due to hypoxemic respiratory failure were enrolled. Sepsis and septic shock were diagnosed according to the guideline of sepsis-3. RESULTS A total of 519 patients were enrolled. Sepsis developed in 365 patients (70%) and septic shock developed in 79 patients (15%). However, 75 patients (14%) had no sepsis. NIV failure was 23%, 38%, and 61% in patients, with no sepsis, sepsis, and septic shock, respectively. Multivariate analysis found that sepsis [odds ratio (OR) = 1.95, 95% confidence interval (CI): 1.06-3.61] and septic shock (OR = 2.47, 95% CI: 1.12-5.45) were independently associated with NIV failure. In sepsis and septic shock population, the NIV failure was 13%, 31%, 37%, 53%, and 67% in patients with sequential organ failure assessment (SOFA) scores of ⩽2, 3-4, 5-6, 7-8, and ⩾9, respectively. Patients with nonpulmonary induced sepsis had similar NIV failure rate compared with those with pulmonary induced sepsis, but had higher proportion of septic shock (37% versus 10%, p ⩽ 0.01) and lower ICU mortality (10% versus 22%, p ⩽ 0.01). CONCLUSIONS Sepsis was associated with NIV failure in patients with hypoxemic respiratory failure, and the association was stronger in septic shock patients. NIV failure increased with the increase of organ dysfunction caused by sepsis. The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Jun Duan
- Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing 400016, P.R. China
| | - Lijuan Chen
- Department of Respiratory and Critical Care Medicine, Sichuan Academy of Medical Science and Sichuan Provincial People's Hospital, Chengdu, Sichuan, P.R. China
| | - Guopeng Liang
- Department of Critical Care Medicine, West China hospital of Sichuan University, Chengdu, Sichuan, P.R. China
| | - Weiwei Shu
- Department of Critical Care Medicine, Yongchuan Hospital of Chongqing Medical University, Yongchuan, Chongqing, P.R. China
| | - Liucun Li
- Department of Respiratory and Critical Care Medicine, the Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Ke Wang
- Department of Respiratory and Critical Care Medicine, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Shengyu Wang
- Department of Pulmonary and Critical Care Medicine, the First Affiliated Hospital of Xi'an Medical University, Xi'an, P.R. China
| | - Xiaoyi Liu
- Department of Critical Care Medicine, the Central Hospital of Dazhou, Dazhou, Shichuan, P.R. China
| | - Chunfeng He
- Department of Respiratory and Critical Care Medicine, the Second Affiliated Hospital of Army Medical University, Chongqing, P.R. China
| | - Dehua He
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China
| | - Qimin Chen
- Department of Critical Care Medicine, the Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, P.R. China
| | - Bilin Wei
- Department of Critical Care Medicine, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, P.R. China
| | - Baixu Chen
- Department of Critical Care Medicine, West China hospital of Sichuan University, Chengdu, Sichuan, P.R. China
| | - Yuzhen Shu
- Department of Respiratory and Critical Care Medicine, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Yao Tian
- Department of Pulmonary and Critical Care Medicine, the First Affiliated Hospital of Xi'an Medical University, Xi'an, P.R. China
| | - Liping Fan
- Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Xiaoli Han
- Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Rui Zhang
- Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Xiangmei Yang
- Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Yan Peng
- Department of Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Dong Wan
- Department of Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Xiaoying Chen
- Department of Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Lin Ye
- Department of Cardiothoracic Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Shijing Tian
- Department of Surgical Intensive Care Unit, the First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Qiong Huang
- Department of Coronary Care Unit, the First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Lei Jiang
- Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Linfu Bai
- Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Lintong Zhou
- Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
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ICU Utilization for Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease Receiving Noninvasive Ventilation. Crit Care Med 2020; 47:677-684. [PMID: 30720540 DOI: 10.1097/ccm.0000000000003660] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We investigated whether patients with chronic obstructive pulmonary disease could safely receive noninvasive ventilation outside of the ICU. DESIGN Retrospective cohort study. SETTING Twelve states with ICU utilization flag from the State Inpatient Database from 2014. PATIENTS Patients greater than or equal to 18 years old with primary diagnosis of acute exacerbation of chronic obstructive pulmonary disease and secondary diagnosis of respiratory failure who received noninvasive ventilation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Multilevel logistic regression models were used to obtain hospital-level ICU utilization rates. We risk-adjusted using both patient/hospital characteristics. The primary outcome was in-hospital mortality; secondary outcomes were invasive monitoring (arterial/central catheters), hospital length of stay, and cost. We examined 5,081 hospitalizations from 424 hospitals with ICU utilization ranging from 0.05 to 0.98. The overall median in-hospital mortality was 2.62% (interquartile range, 1.72-3.88%). ICU utilization was not significantly associated with in-hospital mortality (β = 0.01; p = 0.05) or length of stay (β = 0.18; p = 0.41), which was confirmed by Spearman correlation (ρ = 0.06; p = 0.20 and ρ = 0.02; p = 0.64, respectively). However, lower ICU utilization was associated with lower rates of invasive monitor placement by linear regression (β = 0.05; p < 0.001) and Spearman correlation (ρ = 0.28; p < 0.001). Lower ICU utilization was also associated with significantly lower cost by linear regression (β = 14.91; p = 0.02) but not by Spearman correlation (ρ = 0.09; p = 0.07). CONCLUSIONS There is wide variability in the rate of ICU utilization for noninvasive ventilation across hospitals. Chronic obstructive pulmonary disease patients receiving noninvasive ventilation had similar in-hospital mortality across the ICU utilization spectrum but a lower rate of receiving invasive monitors and probably lower cost when treated in lower ICU-utilizing hospitals. Although the results suggest that noninvasive ventilation can be delivered safely outside of the ICU, we advocate for hospital-specific risk assessment if a hospital were considering changing its noninvasive ventilation delivery policy.
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Saied WI, Martin-Loeches I, Timsit JF. What is new in non-ventilated ICU-acquired pneumonia? Intensive Care Med 2020; 46:488-491. [PMID: 31938826 PMCID: PMC7223396 DOI: 10.1007/s00134-019-05859-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 11/07/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Wafa Ibn Saied
- University of Paris, IAME, INSERM, 75018, Paris, France.
| | - Ignacio Martin-Loeches
- Department of Anaesthesia and Critical Care Medicine, St. James's Hospital, Dublin, Ireland.,Multidisciplinary Intensive Care Research Organization (MICRO), St James's Hospital, Dublin, Ireland.,Pulmonary Intensive Care Unit, Respiratory Institute, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Jean-François Timsit
- University of Paris, IAME, INSERM, 75018, Paris, France.,AP-HP, Bichat Hospital, Medical and Infectious Diseases ICU (MI2), 75018, Paris, France
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Lins ARBDS, Duarte MDCMB, Andrade LBD. Noninvasive ventilation as the first choice of ventilatory support in children. Rev Bras Ter Intensiva 2019; 31:333-339. [PMID: 31618352 PMCID: PMC7005949 DOI: 10.5935/0103-507x.20190045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 04/08/2019] [Indexed: 11/20/2022] Open
Abstract
Objective To describe the use of noninvasive ventilation to prevent tracheal intubation in children in a pediatric intensive care unit and to analyze the factors related to respiratory failure. Methods A retrospective cohort study was performed from January 2016 to May 2018. The study population included children aged 1 to 14 years who were subjected to noninvasive ventilation as the first therapeutic choice for acute respiratory failure. Biological, clinical and managerial data were analyzed by applying a model with the variables that obtained significance ≤ 0.20 in a bivariate analysis. Logistic regression was performed using the ENTER method. The level of significance was set at 5%. Results The children had a mean age of 68.7 ± 42.3 months, 96.6% had respiratory disease as a primary diagnosis, and 15.8% had comorbidities. Of the 209 patients, noninvasive ventilation was the first option for ventilatory support in 86.6% of the patients, and the fraction of inspired oxygen was ≥ 0.40 in 47% of the cases. The lethality rate was 1.4%. The data for the use of noninvasive ventilation showed a high success rate of 95.3% (84.32 - 106). The Pediatric Risk of Mortality (PRISM) score and the length of stay in the intensive care unit were the significant clinical variables for the success or failure of noninvasive ventilation. Conclusion A high rate of effectiveness was found for the use of noninvasive ventilation for acute episodes of respiratory failure. A higher PRISM score on admission, comorbidities associated with respiratory symptoms and oxygen use ≥ 40% were independent factors related to noninvasive ventilation failure.
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Affiliation(s)
| | | | - Lívia Barboza de Andrade
- Unidade de Terapia Intensiva Pediátrica, Hospital Esperança Recife- Recife (PE), Brasil.,Programa de Pós-Graduação, Instituto de Medicina Integral Prof. Fernando Figueira - Recife (PE), Brasil
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Ansari SF, Memon M, Brohi N, Tahir A. Noninvasive Positive Pressure Ventilation in Patients with Acute Respiratory Failure Secondary to Acute Exacerbation of Chronic Obstructive Pulmonary Disease. Cureus 2019; 11:e5820. [PMID: 31754555 PMCID: PMC6827699 DOI: 10.7759/cureus.5820] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Introduction Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a leading cause of poor quality of life and mortality in developing countries. Noninvasive positive pressure ventilation (NIPPV) remains the first-line intervention in hospitalized patients with acute respiratory failure (ARF) due to AECOPD. However, NIPPV may fail in some patients. This study was conducted to assess the frequency of NIPPV failure and clinical parameters and outcomes in AECOPD patients with failed NIPPV and their conversion to invasive positive pressure ventilation (IPPV). Methods This prospective observational study was conducted in the pulmonology unit of a tertiary care hospital in Pakistan. AECOPD patients with ARF who were candidates of NIPPV were included after securing informed consent. Their demographic characteristics, clinical parameters, and in-hospital outcomes were recorded on a semi-structured proforma. For statistical analysis, SPSS software version 22.0 for Windows (IBM, Armonk, NY) was used. Results With 24 hours of NIPPV, 73 (70.2%) patients improved and the remaining 31 (29.8%) were shifted to IPPV. Patients in the IPPV group had higher systolic blood pressure (BP) [133.8 mmHg (±21.2) vs. 121.1 mmHg (±8.3); probability value (p): <0.000] and lower diastolic BP [68.7 mmHg (±13.4) vs. 76.2 mmHg (±10.8); p: 0.003]. Their pH was more acidic [7.20 (±0.13) vs. 7.42 (±0.01); p: <0.000], heart rates were high [131.1 (±10.5) vs. 100.2 (±7.5); p: <0.000], and the percentage of oxygen saturation was low [90.7 (±3.0) vs. 93.4 (±4.5); p: 0.004]. Patients who were managed on NIPPV throughout their hospital stay required respiratory support for fewer days [3.2 (±1.3) vs. 4.1 (±1.8); p: 0.005], and their hospital stay was shorter [3.5 (±1.2) vs. 5.3 (±2.5) days; p: <0.000]. Mortality rate in the NIPPV group was significantly lower (1.4% vs. 12.9%; p: 0.01). Conclusions Deranged blood pressure, increased heart rate, acidemia, and a low percentage of oxygen saturation are crucial clinical and biochemical parameters that can predict the success of NIPPV with 24 hours of therapy in patients with AECOPD and secondary ARF. Patients who do not improve with 24 hours of NIPPV therapy usually have poor in-hospital outcomes including mortality.
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Affiliation(s)
- Sheeba F Ansari
- Internal Medicine, Liaquat University of Medical and Health Sciences, Jamshoro, PAK
| | | | - Naveed Brohi
- Pulmonology, Jinnah Postgraduate Medical Centre Hospital, Karachi, PAK
| | - Amber Tahir
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
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Duan J, Wang S, Liu P, Han X, Tian Y, Gao F, Zhou J, Mou J, Qin Q, Yu J, Bai L, Zhou L, Zhang R. Early prediction of noninvasive ventilation failure in COPD patients: derivation, internal validation, and external validation of a simple risk score. Ann Intensive Care 2019; 9:108. [PMID: 31565779 PMCID: PMC6766459 DOI: 10.1186/s13613-019-0585-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 09/21/2019] [Indexed: 01/04/2023] Open
Abstract
Background Early identification of noninvasive ventilation (NIV) failure is a promising strategy for reducing mortality in chronic obstructive pulmonary disease (COPD) patients. However, a risk-scoring system is lacking. Methods To develop a scale to predict NIV failure, 500 COPD patients were enrolled in a derivation cohort. Heart rate, acidosis (assessed by pH), consciousness (assessed by Glasgow coma score), oxygenation, and respiratory rate (HACOR) were entered into the scoring system. Another two groups of 323 and 395 patients were enrolled to internally and externally validate the scale, respectively. NIV failure was defined as intubation or death during NIV. Results Using HACOR score collected at 1–2 h of NIV to predict NIV failure, the area under the receiver operating characteristic curves (AUC) was 0.90, 0.89, and 0.71 for the derivation, internal-validation, and external-validation cohorts, respectively. For the prediction of early NIV failure in these three cohorts, the AUC was 0.91, 0.96, and 0.83, respectively. In all patients with HACOR score > 5, the NIV failure rate was 50.2%. In these patients, early intubation (< 48 h) was associated with decreased hospital mortality (unadjusted odds ratio = 0.15, 95% confidence interval 0.05–0.39, p < 0.01). Conclusions HACOR scores exhibited good predictive power for NIV failure in COPD patients, particularly for the prediction of early NIV failure (< 48 h). In high-risk patients, early intubation was associated with decreased hospital mortality.
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Affiliation(s)
- Jun Duan
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, People's Republic of China.
| | - Shengyu Wang
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Xi'an Medical University, Xi'an, 710077, People's Republic of China
| | - Ping Liu
- Department of Respiratory and Critical Care Medicine, The People's Hospital of Changshou, Chongqing, 401220, People's Republic of China
| | - Xiaoli Han
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, People's Republic of China
| | - Yao Tian
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Xi'an Medical University, Xi'an, 710077, People's Republic of China
| | - Fan Gao
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Xi'an Medical University, Xi'an, 710077, People's Republic of China
| | - Jing Zhou
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Xi'an Medical University, Xi'an, 710077, People's Republic of China
| | - Junhuan Mou
- Department of Respiratory and Critical Care Medicine, The People's Hospital of Changshou, Chongqing, 401220, People's Republic of China
| | - Qian Qin
- Department of Respiratory and Critical Care Medicine, The People's Hospital of Changshou, Chongqing, 401220, People's Republic of China
| | - Jingrong Yu
- Department of Respiratory and Critical Care Medicine, The People's Hospital of Changshou, Chongqing, 401220, People's Republic of China
| | - Linfu Bai
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, People's Republic of China
| | - Lintong Zhou
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, People's Republic of China
| | - Rui Zhang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, People's Republic of China
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Outcomes of Noninvasive Positive Pressure Ventilation in Acute Respiratory Distress Syndrome and Their Predictors: A National Cohort. Crit Care Res Pract 2019; 2019:8106145. [PMID: 31641538 PMCID: PMC6766679 DOI: 10.1155/2019/8106145] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 08/24/2019] [Indexed: 02/07/2023] Open
Abstract
Rationale Although noninvasive positive pressure ventilation (NIPPV) is increasingly used in acute respiratory distress syndrome (ARDS) to avoid invasive mechanical ventilation (IMV), the data supporting its benefit for this indication are lacking. Objectives To analyze the all-cause in-hospital mortality rate and length of stay (LOS) for ARDS patients who received NIPPV in the United States (US) compared to those who were initially intubated. Our secondary outcome of interest was to determine the predicting factors for NIPPV failure. Methods We used the 2016 National Inpatient Sample database to identify 4,277 adult records with ARDS who required positive pressure ventilation. We divided the cohort into initial treatment with IMV or NIPPV. Then, the NIPPV group was further subdivided into NIPPV failure or success. We defined NIPPV failure as same-patient use of NIPPV and IMV either on the same day or using IMV at a later date. We analyzed the in-hospital mortality, LOS, and NIPPV failure rate. Linear regression of log-transformed LOS and logistic regression of binary outcomes were used to test for associations. Results The NIPPV success group had the lowest mortality rate (4.9% [3.8, 6.4]) and the shortest LOS (7 days [6.6, 7.5]). The NIPPV failure rate was 21%. Sepsis, pneumonia, and chronic liver disease were associated with higher odds of NIPPV failure (adjusted OR: 4.47, 2.65, and 2.23, respectively). There was no significant difference between NIPPV failure and IMV groups in-hospital mortality (26.9% [21.8, 32.8] vs. 25.1% [23.5, 26.9], p=0.885) or LOS (16 [14, 18] vs. 15.6 [15, 16.3], p=0.926). Conclusions NIPPV success in ARDS exhibits significantly lower hospital mortality rates and shorter LOS compared with IMV, and NIPPV failure exhibits no significant difference in hospital mortality or LOS compared with patients who were initially intubated. Therefore, an initial trial of NIPPV may be considered in ARDS. Sepsis, pneumonia, and chronic liver disease were associated with higher odds of NIPPV failure; these factors should be used to stratify patients to the most suitable ventilation modality.
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Liu J, Li DY, Liu ZQ, Lu GY, Li XQ, Qiao LN. [High-risk factors for early failure of high-flow nasal cannula oxygen therapy in children]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2019; 21:650-655. [PMID: 31315763 PMCID: PMC7389095 DOI: 10.7499/j.issn.1008-8830.2019.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 04/28/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To determine the high-risk factors for early failure of high-flow nasal cannula (HFNC) oxygen therapy in children with acute respiratory insufficiency (ARI). METHODS The clinical data of 123 children with ARI were reviewed who received HFNC oxygen therapy in the pediatric intensive care unit from January to June, 2018. The children who did not require an upgrade of respiratory support during hospitalization and were successfully weaned from HFNC were classified as HFNC success group (69 cases). Of the remaining children (54 cases) who required an upgrade of their respiratory support during hospitalization, those that needed to upgrade their respiratory support within 48 hours of receiving HFNC were classified as early HFNC failure group (46 cases). Risk factors for early failure of HFNC were determined using multivariate logistic regression analysis. RESULTS The incidence rates of shock, sepsis, intracranial hypertension syndrome, and multiple organ dysfunction syndrome were significantly higher in the early HFNC failure group than in the HFNC success group (P<0.05). Before implementation of respiratory support, the early HFNC failure group had significantly lower Glasgow coma score, pH value, and oxygenation index and significantly higher Pediatric Risk of Mortality (PRISM) score and PaCO2/PaO2 ratio than the HFNC success group (P<0.05). Multivariate logistic regression analysis showed that PRISM score >4.5 and PaCO2/PaO2 ratio >0.64 were independent risk factors for early HFNC failure (OR=5.535 and 9.089 respectively; P<0.05). CONCLUSIONS Pediatric ARI patients with PRISM score >4.5 or PaCO2/PaO2 ratio >0.64 have relatively high risk of early HFNC failure.
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Affiliation(s)
- Jie Liu
- Pediatric Intensive Care Unit, West China Second Hospital of Sichuan University, Chengdu 610041, China.
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Reply: Carbon Dioxide Narcosis or Sleep Deprivation? Ann Am Thorac Soc 2019; 16:778. [PMID: 30916987 PMCID: PMC6543469 DOI: 10.1513/annalsats.201903-204le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Iranpour R, Armanian AM, Abedi AR, Farajzadegan Z. Nasal high-frequency oscillatory ventilation (nHFOV) versus nasal continuous positive airway pressure (NCPAP) as an initial therapy for respiratory distress syndrome (RDS) in preterm and near-term infants. BMJ Paediatr Open 2019; 3:e000443. [PMID: 31414062 PMCID: PMC6668751 DOI: 10.1136/bmjpo-2019-000443] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 06/18/2019] [Accepted: 06/27/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Currently, various forms of non-invasive respiratory support have been used in the management of respiratory distress syndrome (RDS) in preterm neonates. However, nasal high-frequency oscillatory ventilation (nHFOV) has not yet been applied commonly as an initial treatment. OBJECTIVES This study was designed to investigate the efficacy and safety of nHFOV compared with nasal continuous positive airway pressure (NCPAP) in preterm and near-term infants with RDS. METHODS In a randomised clinical trial, a total of 68 neonates (gestational age (GA) between 30 and 36 weeks and 6 days) with a clinical diagnosis of RDS were randomly assigned to either the NCPAP (n=34) or the nHFOV (n=34) group. The primary outcome was the duration of non-invasive respiratory support (duration of using NCPAP or nHFOV). RESULT The median (IQR) duration of non-invasive respiratory support, was significantly shorter in the nHFOV group than that in the NCPAP group (20 (15-25.3) versus 26.5 (15-37.4) hours, respectively; p=0.02). The need for a ventilator occurred in 4 out of 34 (11.8%) neonates in the NCPAP group and in none of the neonates in the nHFOV group (p=0.03). In addition, intraventricular haemorrhage (IVH) occurred in nine cases (6.9%) in the NCPAP group and two cases (3.3%) in the nHFOV group, which showed a significant difference (p=0.04). The incidence of pneumothorax, chronic lung disease, pulmonary haemorrhage and necrotising enterocolitis was similar between the two groups. CONCLUSION This study showed that nHFOV significantly reduced the duration of non-invasive respiratory support and decreased the need for intubation compared with NCPAP in infants with RDS. Furthermore, nHFOV seems to reduce the incidence of IVH without increasing other complications. TRIAL REGISTRATION NUMBER IRCT2017062734782N1.
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Affiliation(s)
- Ramin Iranpour
- Division of Neonatology, Department of Pediatrics, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amir-Mohammad Armanian
- Division of Neonatology, Department of Pediatrics, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ahmad-Reza Abedi
- Division of Neonatology, Department of Pediatrics, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ziba Farajzadegan
- Community and preventive Medicine Department, Isfahan University of Medical Sciences, Isfahan, Iran
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Non-invasive positive pressure ventilation in lung transplant recipients with acute respiratory failure: Beyond the perioperative period. J Crit Care 2018; 47:287-294. [PMID: 30098575 DOI: 10.1016/j.jcrc.2018.07.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 07/30/2018] [Accepted: 07/31/2018] [Indexed: 11/20/2022]
Abstract
PURPOSE The purpose of this study is to evaluate outcomes in MICU lung transplant recipients with acute respiratory failure treated with non-invasive positive pressure ventilation (NPPV) and identify factors associated with NPPV failure (need for intubation). METHODS Retrospective chart review of all lung transplant recipients who were admitted with acute respiratory failure to the MICU from January 2009-August 2016 was completed. Logistic regression analysis was performed to determine which factors were independently associated with NPPV failure. RESULTS Of 156 patients included in the study, 125 (80.1%) were tried on NPPV. Sixty-eight (54.4%) were managed successfully with NPPV with a hospital survival rate of 94.1%. Subjects who failed NPPV had higher hospital mortality, similar to those intubated from the outset (15 [48.3%]; 22 [38.6%], p = .37). In multivariate analyses, APACHE III scores >78 (9.717 [3.346, 28.22]) and PaO2/FiO2 ≤ 151 (4.54 [1.72, 11.99]) were associated with greater likelihood of NPPV failure. There was no difference in NPPV failure based on the presence of BOS. In patients with high severity of illness, there was no difference in mortality between initial IMV and NPPV failure when stratified on the basis of hypoxemia (PaO2/FiO2 > 151, p-value 0.34; PaO2/FiO2 ≤ 151, p-value 0.99). CONCLUSIONS NPPV is a viable option for lung transplant recipients with acute respiratory failure. Extreme caution should be exercised when used in patients with high severity of illness (APACHE III >78) and/or severe hypoxemia (PaO2/FiO2 ≤ 151).
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Leoni D, Encina B, Rello J. Managing the oncologic patient with suspected pneumonia in the intensive care unit. Expert Rev Anti Infect Ther 2017; 14:943-60. [PMID: 27573637 DOI: 10.1080/14787210.2016.1228453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Solid cancer patients are frequently admitted in intensive care units for critical events. Improving survival rates in this setting is considered an achievable goal today. Respiratory failure is the main reason for admission, representing a primary target for research. AREAS COVERED This review presents a diagnostic and therapeutic algorithm for pneumonia and other severe respiratory events in the solid cancer population. It aims to increase awareness of the risk factors and the different etiologies in this changing scenario in which neutropenia no longer seems to be a decisive factor in poor outcome. Bacterial pneumonia is the leading cause, but opportunistic diseases and non-infectious etiologies, especially unexpected adverse effects of radiation, biological drugs and monoclonal antibodies, are becoming increasingly frequent. Options for respiratory support and diagnostics are discussed and indications for antibiotics in the management of pneumonia are detailed. Expert commentary: Prompt initiation of critical care to facilitate optimal decision-making in the management of respiratory failure, early etiological assessment and appropriate antibiotic therapy are cornerstones in management of severe pneumonia in oncologic patients.
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Affiliation(s)
- D Leoni
- a Infectious Disease Department , Tor Vergata University Hospital, University of 'La Sapienza' , Rome , Italy.,b Clinical Research & Innovation in Pneumonia & Sepsis (CRIPS) , Vall d'Hebron Institute of Research , Barcelona , Spain
| | - B Encina
- b Clinical Research & Innovation in Pneumonia & Sepsis (CRIPS) , Vall d'Hebron Institute of Research , Barcelona , Spain
| | - J Rello
- b Clinical Research & Innovation in Pneumonia & Sepsis (CRIPS) , Vall d'Hebron Institute of Research , Barcelona , Spain.,c Centro de Investigación Biomédica En Red - Enfermedades Respiratorias (CIBERES) , Vall d'Hebron Institute of Research , Barcelona , Spain.,d Department of Medicine , Universitat Autònoma de Barcelona , Barcelona , Spain
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Rochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, Nava S, Navalesi P, Antonelli M, Brozek J, Conti G, Ferrer M, Guntupalli K, Jaber S, Keenan S, Mancebo J, Mehta S, Raoof S. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J 2017. [PMID: 28860265 DOI: 10.1183/13993003.02426–2016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Noninvasive mechanical ventilation (NIV) is widely used in the acute care setting for acute respiratory failure (ARF) across a variety of aetiologies. This document provides European Respiratory Society/American Thoracic Society recommendations for the clinical application of NIV based on the most current literature.The guideline committee was composed of clinicians, methodologists and experts in the field of NIV. The committee developed recommendations based on the GRADE (Grading, Recommendation, Assessment, Development and Evaluation) methodology for each actionable question. The GRADE Evidence to Decision framework in the guideline development tool was used to generate recommendations. A number of topics were addressed using technical summaries without recommendations and these are discussed in the supplementary material.This guideline committee developed recommendations for 11 actionable questions in a PICO (population-intervention-comparison-outcome) format, all addressing the use of NIV for various aetiologies of ARF. The specific conditions where recommendations were made include exacerbation of chronic obstructive pulmonary disease, cardiogenic pulmonary oedema, de novo hypoxaemic respiratory failure, immunocompromised patients, chest trauma, palliation, post-operative care, weaning and post-extubation.This document summarises the current state of knowledge regarding the role of NIV in ARF. Evidence-based recommendations provide guidance to relevant stakeholders.
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Affiliation(s)
- Bram Rochwerg
- Dept of Medicine, Dept of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Research Centre and Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Mark W Elliott
- Dept of Respiratory Medicine, St James's University Hospital, Leeds, UK
| | - Dean Hess
- Respiratory Care Dept, Massachusetts General Hospital and Dept of Anesthesia, Harvard Medical School, Boston, MA, USA
| | - Nicholas S Hill
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA, USA
| | - Stefano Nava
- Dept of Specialistic, Diagnostic and Experimental Medicine, Respiratory and Critical Care, Sant'Orsola Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Paolo Navalesi
- Anesthesia and Intensive Care, Dept of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Massimo Antonelli
- Dept of Anesthesiology and Intensive Care Medicine, Catholic University of Rome, A. Gemelli University Hospital, Rome, Italy
| | - Jan Brozek
- Dept of Medicine, Dept of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Giorgio Conti
- Dept of Anesthesiology and Intensive Care Medicine, Catholic University of Rome, A. Gemelli University Hospital, Rome, Italy
| | - Miquel Ferrer
- Dept of Pneumology, Respiratory Institute, Hospital Clinic, IDIBAPS, University of Barcelona and CIBERES, Barcelona, Spain
| | - Kalpalatha Guntupalli
- Depts of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Samir Jaber
- Dept of Critical Care Medicine and Anesthesiology (DAR B), Research Unit INSERM U1046, Saint Eloi University Hospital and Montpellier School of Medicine, Montpellier, France
| | - Sean Keenan
- Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada.,Dept of Critical Care Medicine, Royal Columbian Hospital, New Westminster, BC, Canada
| | - Jordi Mancebo
- Servei de Medicina Intensiva, Hospital de Sant Pau, Barcelona, Spain
| | - Sangeeta Mehta
- Mount Sinai Hospital and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Suhail Raoof
- Pulmonary and Critical Care Medicine, Lenox Hill Hospital, New York, NY, USA.,Hofstra Northwell School of Medicine, Hempstead, NY, USA
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Rochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, Nava S, Navalesi P, Antonelli M, Brozek J, Conti G, Ferrer M, Guntupalli K, Jaber S, Keenan S, Mancebo J, Mehta S, Raoof S. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J 2017; 50:50/2/1602426. [PMID: 28860265 DOI: 10.1183/13993003.02426-2016] [Citation(s) in RCA: 716] [Impact Index Per Article: 102.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 06/15/2017] [Indexed: 12/13/2022]
Abstract
Noninvasive mechanical ventilation (NIV) is widely used in the acute care setting for acute respiratory failure (ARF) across a variety of aetiologies. This document provides European Respiratory Society/American Thoracic Society recommendations for the clinical application of NIV based on the most current literature.The guideline committee was composed of clinicians, methodologists and experts in the field of NIV. The committee developed recommendations based on the GRADE (Grading, Recommendation, Assessment, Development and Evaluation) methodology for each actionable question. The GRADE Evidence to Decision framework in the guideline development tool was used to generate recommendations. A number of topics were addressed using technical summaries without recommendations and these are discussed in the supplementary material.This guideline committee developed recommendations for 11 actionable questions in a PICO (population-intervention-comparison-outcome) format, all addressing the use of NIV for various aetiologies of ARF. The specific conditions where recommendations were made include exacerbation of chronic obstructive pulmonary disease, cardiogenic pulmonary oedema, de novo hypoxaemic respiratory failure, immunocompromised patients, chest trauma, palliation, post-operative care, weaning and post-extubation.This document summarises the current state of knowledge regarding the role of NIV in ARF. Evidence-based recommendations provide guidance to relevant stakeholders.
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Affiliation(s)
- Bram Rochwerg
- Dept of Medicine, Dept of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Research Centre and Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Mark W Elliott
- Dept of Respiratory Medicine, St James's University Hospital, Leeds, UK
| | - Dean Hess
- Respiratory Care Dept, Massachusetts General Hospital and Dept of Anesthesia, Harvard Medical School, Boston, MA, USA
| | - Nicholas S Hill
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA, USA
| | - Stefano Nava
- Dept of Specialistic, Diagnostic and Experimental Medicine, Respiratory and Critical Care, Sant'Orsola Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Paolo Navalesi
- Anesthesia and Intensive Care, Dept of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Massimo Antonelli
- Dept of Anesthesiology and Intensive Care Medicine, Catholic University of Rome, A. Gemelli University Hospital, Rome, Italy
| | - Jan Brozek
- Dept of Medicine, Dept of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Giorgio Conti
- Dept of Anesthesiology and Intensive Care Medicine, Catholic University of Rome, A. Gemelli University Hospital, Rome, Italy
| | - Miquel Ferrer
- Dept of Pneumology, Respiratory Institute, Hospital Clinic, IDIBAPS, University of Barcelona and CIBERES, Barcelona, Spain
| | - Kalpalatha Guntupalli
- Depts of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Samir Jaber
- Dept of Critical Care Medicine and Anesthesiology (DAR B), Research Unit INSERM U1046, Saint Eloi University Hospital and Montpellier School of Medicine, Montpellier, France
| | - Sean Keenan
- Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada.,Dept of Critical Care Medicine, Royal Columbian Hospital, New Westminster, BC, Canada
| | - Jordi Mancebo
- Servei de Medicina Intensiva, Hospital de Sant Pau, Barcelona, Spain
| | - Sangeeta Mehta
- Mount Sinai Hospital and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Suhail Raoof
- Pulmonary and Critical Care Medicine, Lenox Hill Hospital, New York, NY, USA.,Hofstra Northwell School of Medicine, Hempstead, NY, USA
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47
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Bellani G, Laffey JG, Pham T, Madotto F, Fan E, Brochard L, Esteban A, Gattinoni L, Bumbasirevic V, Piquilloud L, van Haren F, Larsson A, McAuley DF, Bauer PR, Arabi YM, Ranieri M, Antonelli M, Rubenfeld GD, Thompson BT, Wrigge H, Slutsky AS, Pesenti A. Noninvasive Ventilation of Patients with Acute Respiratory Distress Syndrome. Insights from the LUNG SAFE Study. Am J Respir Crit Care Med 2017; 195:67-77. [PMID: 27753501 DOI: 10.1164/rccm.201606-1306oc] [Citation(s) in RCA: 358] [Impact Index Per Article: 51.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
RATIONALE Noninvasive ventilation (NIV) is increasingly used in patients with acute respiratory distress syndrome (ARDS). The evidence supporting NIV use in patients with ARDS remains relatively sparse. OBJECTIVES To determine whether, during NIV, the categorization of ARDS severity based on the PaO2/FiO2 Berlin criteria is useful. METHODS The LUNG SAFE (Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure) study described the management of patients with ARDS. This substudy examines the current practice of NIV use in ARDS, the utility of the PaO2/FiO2 ratio in classifying patients receiving NIV, and the impact of NIV on outcome. MEASUREMENTS AND MAIN RESULTS Of 2,813 patients with ARDS, 436 (15.5%) were managed with NIV on Days 1 and 2 following fulfillment of diagnostic criteria. Classification of ARDS severity based on PaO2/FiO2 ratio was associated with an increase in intensity of ventilatory support, NIV failure, and intensive care unit (ICU) mortality. NIV failure occurred in 22.2% of mild, 42.3% of moderate, and 47.1% of patients with severe ARDS. Hospital mortality in patients with NIV success and failure was 16.1% and 45.4%, respectively. NIV use was independently associated with increased ICU (hazard ratio, 1.446 [95% confidence interval, 1.159-1.805]), but not hospital, mortality. In a propensity matched analysis, ICU mortality was higher in NIV than invasively ventilated patients with a PaO2/FiO2 lower than 150 mm Hg. CONCLUSIONS NIV was used in 15% of patients with ARDS, irrespective of severity category. NIV seems to be associated with higher ICU mortality in patients with a PaO2/FiO2 lower than 150 mm Hg. Clinical trial registered with www.clinicaltrials.gov (NCT 02010073).
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Affiliation(s)
- Giacomo Bellani
- 1 Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,2 Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - John G Laffey
- 3 Department of Anesthesia.,4 Department of Critical Care Medicine, and.,5 Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.,6 Department of Anesthesia.,7 Department of Physiology.,8 Interdepartmental Division of Critical Care Medicine
| | - Tài Pham
- 9 Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Unité de Réanimation Médico-Chirurgicale, Pôle Thorax Voies Aériennes, Groupe Hospitalier des Hôpitaux Universitaires de l'Est Parisien, Paris, France.,10 Unité Mixte de Recherche 1153, Inserm, Sorbonne Paris Cité, Epidémiologie Clinique et Statistiques, pour la Recherche en Santé Team, Université Paris Diderot, Paris, France.,11 Sorbonne Universités, Université Pierre et Marie Curie, Paris 06, France
| | - Fabiana Madotto
- 12 Research Centre on Public Health, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Eddy Fan
- 8 Interdepartmental Division of Critical Care Medicine.,13 Institute of Health Policy, Management and Evaluation, and.,14 Department of Medicine, University of Toronto, Toronto, Canada.,15 Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada
| | - Laurent Brochard
- 4 Department of Critical Care Medicine, and.,8 Interdepartmental Division of Critical Care Medicine.,14 Department of Medicine, University of Toronto, Toronto, Canada.,15 Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada
| | - Andres Esteban
- 16 Hospital Universitario de Getafe, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
| | - Luciano Gattinoni
- 17 Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Vesna Bumbasirevic
- 18 School of Medicine, University of Belgrade, Belgrade, Serbia.,19 Department of Anesthesia and Intensive Care, Emergency Center, Clinical Center of Serbia, Belgrade, Serbia
| | - Lise Piquilloud
- 20 Adult Intensive Care and Burn Unit, University Hospital of Lausanne, Lausanne, Switzerland.,21 Department of Medical Intensive Care, University Hospital of Angers, Angers, France
| | - Frank van Haren
- 22 Intensive Care Unit, The Canberra Hospital, Canberra, Australia.,23 Australian National University, Canberra, Australia
| | - Anders Larsson
- 24 Section of Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Daniel F McAuley
- 25 Centre for Experimental Medicine, Queen's University of Belfast, Wellcome-Wolfson Institute for Experimental Medicine, Belfast, United Kingdom.,26 Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, United Kingdom
| | - Philippe R Bauer
- 27 Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Yaseen M Arabi
- 28 King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,29 King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Marco Ranieri
- 30 Dipartimento di Anestesia e Rianimazione, Policlinico Umberto I, Sapienza Università di Roma, Roma, Italy
| | - Massimo Antonelli
- 31 Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore-Fondazione Policlinico Universitario A. Gemelli, Roma, Italy
| | - Gordon D Rubenfeld
- 8 Interdepartmental Division of Critical Care Medicine.,14 Department of Medicine, University of Toronto, Toronto, Canada.,32 Sunnybrook Health Sciences Center, Toronto, Canada
| | - B Taylor Thompson
- 33 Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hermann Wrigge
- 34 Department of Anesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
| | - Arthur S Slutsky
- 5 Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.,8 Interdepartmental Division of Critical Care Medicine.,14 Department of Medicine, University of Toronto, Toronto, Canada
| | - Antonio Pesenti
- 35 Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione Istituto di ricovero e Cura a Carattere Scientifico Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy; and.,36 Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
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Rialp G, Forteza C, Muñiz D, Romero M. Role of First-Line Noninvasive Ventilation in Non-COPD Subjects With Pneumonia. Arch Bronconeumol 2016; 53:480-488. [PMID: 27988055 DOI: 10.1016/j.arbres.2016.08.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 07/28/2016] [Accepted: 08/18/2016] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The use of noninvasive ventilation (NIV) in non-COPD patients with pneumonia is controversial due to its high rate of failure and the potentially harmful effects when NIV fails. The purpose of the study was to evaluate outcomes of the first ventilatory treatment applied, NIV or invasive mechanical ventilation (MV), and to identify predictors of NIV failure. METHODS Historical cohort study of 159 non-COPD patients with pneumonia admitted to the ICU with ventilatory support. Subjects were divided into 2 groups: invasive MV or NIV. Univariate and multivariate analyses with demographic and clinical data were performed. Analysis of mortality was adjusted for the propensity of receiving first-line invasive MV. RESULTS One hundred and thirteen subjects received first-line invasive MV and 46 received first-line NIV, of which 27 needed intubation. Hospital mortality was 35, 37 and 56%, respectively, with no significant differences among groups. In the propensity-adjusted analysis (expressed as OR [95% CI]), hospital mortality was associated with age (1.05 [1.02-1.08]), SAPS3 (1.03 [1.00-1.07]), immunosuppression (2.52 [1.02-6.27]) and NIV failure compared to first-line invasive MV (4.3 [1.33-13.94]). Compared with invasive MV, NIV failure delayed intubation (p=.004), and prolonged the length of invasive MV (p=.007) and ICU stay (p=.001). NIV failure was associated with need for vasoactive drugs (OR 7.8 [95% CI, 1.8-33.2], p=.006). CONCLUSIONS In non-COPD subjects with pneumonia, first-line NIV was not associated with better outcome compared with first-line invasive MV. NIV failure was associated with longer duration of MV and hospital stay, and with increased hospital mortality. The use of vasoactive drugs predicted NIV failure.
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Affiliation(s)
- Gemma Rialp
- Servicio de Cuidados Intensivos, Hospital Son Llàtzer, Palma de Mallorca, Islas Baleares, España; Instituto de Investigación Sanitaria de Palma (IDISPA), Fundación de Investigación Sanitaria Illes Balears, Hospital Universitario Son Espases, Palma de Mallorca, Islas Baleares, España.
| | - Catalina Forteza
- Servicio de Cuidados Intensivos, Hospital Son Llàtzer, Palma de Mallorca, Islas Baleares, España; Instituto de Investigación Sanitaria de Palma (IDISPA), Fundación de Investigación Sanitaria Illes Balears, Hospital Universitario Son Espases, Palma de Mallorca, Islas Baleares, España
| | - Daniel Muñiz
- Servicio de Cuidados Intensivos, Hospital Comarcal d'Inca, Inca, Islas Baleares, España; Instituto de Investigación Sanitaria de Palma (IDISPA), Fundación de Investigación Sanitaria Illes Balears, Hospital Universitario Son Espases, Palma de Mallorca, Islas Baleares, España
| | - Maria Romero
- Servicio de Cuidados Intensivos, Hospital Son Llàtzer, Palma de Mallorca, Islas Baleares, España; Instituto de Investigación Sanitaria de Palma (IDISPA), Fundación de Investigación Sanitaria Illes Balears, Hospital Universitario Son Espases, Palma de Mallorca, Islas Baleares, España
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Shimabukuro-Vornhagen A, Böll B, Kochanek M, Azoulay É, von Bergwelt-Baildon MS. Critical care of patients with cancer. CA Cancer J Clin 2016; 66:496-517. [PMID: 27348695 DOI: 10.3322/caac.21351] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Answer questions and earn CME/CNE The increasing prevalence of patients living with cancer in conjunction with the rapid progress in cancer therapy will lead to a growing number of patients with cancer who will require intensive care treatment. Fortunately, the development of more effective oncologic therapies, advances in critical care, and improvements in patient selection have led to an increased survival of critically ill patients with cancer. As a consequence, critical care has become an important cornerstone in the continuum of modern cancer care. Although, in many aspects, critical care for patients with cancer does not differ from intensive care for other seriously ill patients, there are several challenging issues that are unique to this patient population and require special knowledge and skills. The optimal management of critically ill patients with cancer necessitates expertise in oncology, critical care, and palliative medicine. Cancer specialists therefore have to be familiar with key principles of intensive care for critically ill patients with cancer. This review provides an overview of the state-of-the-art in the individualized management of critically ill patients with cancer. CA Cancer J Clin 2016;66:496-517. © 2016 American Cancer Society.
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Affiliation(s)
- Alexander Shimabukuro-Vornhagen
- Consultant, Medical Intensive Care Program, Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Member, Cologne-Bonn Center for Integrated Oncology, University Hospital of Cologne, Cologne, Germany
- Founding Member, Intensive Care in Hemato-Oncologic Patients (iCHOP), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Boris Böll
- Member, Cologne-Bonn Center for Integrated Oncology, University Hospital of Cologne, Cologne, Germany
- Founding Member, Intensive Care in Hemato-Oncologic Patients (iCHOP), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Head of Medical Intensive Care Program, Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Matthias Kochanek
- Member, Cologne-Bonn Center for Integrated Oncology, University Hospital of Cologne, Cologne, Germany
- Founding Member, Intensive Care in Hemato-Oncologic Patients (iCHOP), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Program Director, Medical Intensive Care Program, Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Éli Azoulay
- Director, Medical Intensive Care Unit, St. Louis Hospital, Paris, France
- Professor of Medicine, Teaching and Research Unit, Department of Medicine, Paris Diderot University, Paris, France
- Chair, Study Group for Respiratory Intensive Care in Malignancies, St. Louis Hospital, Paris, France
| | - Michael S von Bergwelt-Baildon
- Founding Member, Intensive Care in Hemato-Oncologic Patients (iCHOP), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Program Director, Medical Intensive Care Program, Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Professor, Cologne-Bonn Center for Integrated Oncology, University Hospital of Cologne, Cologne, Germany
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50
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Ma KC, Chung A, Aronson KI, Krishnan JK, Barjaktarevic IZ, Berlin DA, Schenck EJ. Bronchoscopic intubation is an effective airway strategy in critically ill patients. J Crit Care 2016; 38:92-96. [PMID: 27875775 DOI: 10.1016/j.jcrc.2016.10.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 09/21/2016] [Accepted: 10/31/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE American Society of Anesthesiologists guidelines recommend the use of bronchoscopic intubation as a rescue technique in critically ill patients. We sought to assess the safety and efficacy of bronchoscopic intubation as an initial approach in critically ill patients. METHODS We performed a retrospective cohort study of patients who underwent endotracheal intubation in the medical intensive care unit of a tertiary urban referral center over 1 academic year. The primary outcome was first-pass success rate. MEASUREMENTS AND MAIN RESULTS We identified 219 patients who underwent either bronchoscopic (n=52) or laryngoscopic guided (n=167) intubation as the initial attempt. There was a higher first-pass success rate in the bronchoscopic intubation group than in the laryngoscopic group (96% vs 78%; P=.003). The bronchoscopic intubation group had a higher body mass index (28.4 vs 25.9; P=.027) and higher preintubation fraction of inspired oxygen requirement (0.73±0.27 vs 0.63±0.30; P=.044) than the laryngoscopic group. There were no cases of right mainstem intubation, esophageal intubation, or pneumothorax with bronchoscopic intubation. Rates of postintubation hypotension and hypoxemia were similar in both groups. The association with first-pass success remained with multivariate and propensity matched analysis. CONCLUSIONS Bronchoscopic intubation as an initial strategy in critically ill patients is associated with a higher first-pass success rate than laryngoscopic intubation, and is not associated with an increase in complications.
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Affiliation(s)
- Kevin C Ma
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York
| | - Augustine Chung
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine UCLA, Los Angeles
| | - Kerri I Aronson
- Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, New York
| | - Jamuna K Krishnan
- Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, New York
| | - Igor Z Barjaktarevic
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine UCLA, Los Angeles
| | - David A Berlin
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York
| | - Edward J Schenck
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York.
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