1
|
Freire RS, Barros CMSS, Valente J, Goulart CDL, Santos AGR, Fonseca FH, Saenz ST, Dias AS, Rodrigues MGA, Silva BM, Fernandes E, Cubas-Vega N, Sampaio V, Simão M, Baía-da-Silva D, Severin R, Arêas GPT, Gonçalves RL, Mendes RG, Martinez-Espinosa FE, Val F. Prone positioning in awake patients without ventilatory support does not alter major clinical outcomes in severe COVID-19: results from a retrospective observational cohort study, systematic review and meta-analysis. Expert Rev Respir Med 2024; 18:219-226. [PMID: 38712558 DOI: 10.1080/17476348.2024.2350587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 04/29/2024] [Indexed: 05/08/2024]
Abstract
OBJECTIVES During the Coronavirus disease (COVID-19) pandemic, clinicians recommended awake-prone positioning (APP) to avoid the worst outcomes. The objectives of this study were to investigate if APP reduces intubation, death rates, and hospital length of stay (HLOS) in acute COVID-19. METHODS We performed a retrospective cohort with non-mechanically ventilated patients hospitalized in a reference center in Manaus, Brazil, 2020. Participants were stratified into APP and awake-not-prone positioning (ANPP) groups. Also, we conducted a systematic review and performed a meta-analysis to understand if this intervention had different outcomes in resource-limited settings (PROSPERO CRD42023422452). RESULTS A total of 115 participants were allocated into the groups. There was no statistical difference between both groups regarding time to intubation (HR: 0.861; 95CI: 0.474-1.1562; p=0.622) and time to death (HR: 1.666; 95CI: 0.939-2.951; p=0.081). APP was not significantly associated with reduced HLOS. A total of 86 articles were included in the systematic review, of which 76 (88,3%) show similar findings after APP. Also, low/middle, and high-income countries were similar regarding such outcomes. CONCLUSION APP in COVID-19 does not present clinical improvement that affects mortality, intubation rate and HLOS. The lack of a prone position protocol, obtained through a controlled study, is necessary. After 3 years, APP benefits are still inconclusive.
Collapse
Affiliation(s)
- Raíssa S Freire
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Camila M S S Barros
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Jefferson Valente
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Cássia da Luz Goulart
- Research department, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil
| | - Anna G R Santos
- Programa de Pós-graduação em Ciências da Saúde, Universidade Federal do Amazonas, Manaus, Brazil
| | - Fernando H Fonseca
- Programa de Pós-graduação em Ciências da Saúde, Hospital and Pronto Socorro Delphina Rinaldi Abdel Aziz, Manaus, Brazil
| | - Sabrina T Saenz
- Clinical department, Maternidade de Referência da Zona Leste Ana Braga, Manaus, Brazil
| | - Andiana S Dias
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Maria G A Rodrigues
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Bernardo Maia Silva
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Eduardo Fernandes
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Nadia Cubas-Vega
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
- Clinical department, Postgrado Medicina de Rehabilitación, Universidad Nacional Autónoma de Honduras, Tegucigalpa, Honduras
| | - Vanderson Sampaio
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Mariana Simão
- Programa de Pós-graduação em Pesquisa Clínica em Doenças Infecciosas, Instituto Nacional de Infectologia Evandro Chagas, Rio de Janeiro, Brazil
| | - Djane Baía-da-Silva
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
- Programa de Pós-graduação em Ciências da Saúde, Universidade Federal do Amazonas, Manaus, Brazil
| | - Richard Severin
- Department of Physical Therapy, Integrative Physiologic Laboratory, College of Applied Health Sciences, University of Illinois at Chicago (UIC), Chicago, IL, USA
| | | | | | - Renata Gonçalves Mendes
- Programa de pós-graduação em Fisioterapia, Universidade Federal de São Carlos, São Carlos, Brazil
| | - Flor E Martinez-Espinosa
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
- Research department, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil
- ILMD/Fiocruz Amazônia, Instituto Leônidas & Maria Deane, Manaus, Brazil
| | - Fernando Val
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
- Research department, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil
- Programa de Pós-graduação em Ciências da Saúde, Universidade Federal do Amazonas, Manaus, Brazil
- Universidade Federal do Amazonas, Manaus, Brazil
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Pan D, Nielsen E, Chung S, Niederman MS. Management of pneumonia in the critically ill. Minerva Med 2023; 114:667-682. [PMID: 36700925 DOI: 10.23736/s0026-4806.22.08467-1] [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: 01/27/2023]
Abstract
Pneumonias continue to be major public health issues and are commonly encountered in the intensive care setting. The most common types of pneumonia leading to critical illness include severe community acquired pneumonia, hospital acquired pneumonia, and ventilator associated pneumonia. Early evaluation, diagnosis, and escalation to appropriate levels of care are imperative to improving survival. Treatment remains challenging with the need to balance antibiotic stewardship and minimizing patient harm. As evidenced in the most recent society guidelines, the identification of risk factors for severe disease and the causative pathogens are crucial in guiding the most appropriate therapy.
Collapse
Affiliation(s)
- Di Pan
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Erik Nielsen
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Samuel Chung
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Michael S Niederman
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York, NY, USA -
| |
Collapse
|
4
|
Weaver L, Saffaran S, Chikhani M, Laffey JG, Scott TE, Camporota L, Hardman JG, Bates DG. Why Reduced Inspiratory Pressure Could Determine Success of Non-Invasive Ventilation in Acute Hypoxic Respiratory Failure. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2022; 2022:3265-3268. [PMID: 36085857 DOI: 10.1109/embc48229.2022.9871901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The magnitude of inspiratory effort relief within the first 2 hours of non-invasive ventilation for hypoxic respiratory failure was shown in a recent exploratory clinical study to be an early and accurate predictor of outcome at 24 hours. We simulated the application of non-invasive ventilation to three patients whose physiological and clinical characteristics match the data in that study. Reductions in inspiratory effort corresponding to reductions of esophageal pressure swing greater than 10 cmH2O more than halved the values of total lung stress, driving pressure, power and transpulmonary pressure swing. In the absence of significant reductions in inspiratory pressure, multiple indicators of lung injury increased after application of non-invasive ventilation. Clinical Relevance- We show using computer simulation that reduced inspiratory pressure after application of noninvasive ventilation translates directly into large reductions in multiple well-established indicators of lung injury, providing a potential physiological explanation for recent clinical findings.
Collapse
|
5
|
C/MIC > 4: A Potential Instrument to Predict the Efficacy of Meropenem. Antibiotics (Basel) 2022; 11:antibiotics11050670. [PMID: 35625314 PMCID: PMC9137711 DOI: 10.3390/antibiotics11050670] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/01/2022] [Accepted: 05/14/2022] [Indexed: 02/04/2023] Open
Abstract
This prospective study aimed to explore the determinants of meropenem trough concentration (Ctrough) in patients with bacterial pneumonia and to investigate the association between its concentration and efficacy. From January 2019 to December 2019, patients with pulmonary infections were prospectively enrolled from the intensive care unit. Factors affecting the meropenem trough concentration were analyzed, and a multiple linear regression model was constructed. Logistic regression analyses were used to investigate the relationship between Ctrough and clinical efficacy. A total of 64 patients were enrolled, in whom 210 meropenem concentrations were measured. Of the total, 60.9% (39/64) were considered clinically successful after treatment. Ctrough may increase with increased blood urea nitrogen, albumin, and concomitant antifungal use. By contrast, concentration may decrease with increased endogenous creatinine clearance rate. Six variables, including Ctrough/minimum inhibitory concentration (MIC) > 4, were associated with the efficacy of meropenem. There was an independent correlation between Ctrough/MIC > 4 and efficacy after fully adjusting for confounding factors. Based upon renal function indexes, it is possible to predict changes in meropenem concentration and adjust the dosage precisely and individually. Ctrough/MIC > 4 is a potential instrument to predict successful treatment with meropenem.
Collapse
|
6
|
Does Prolonged Infusion Time Really Improve the Efficacy of Meropenem Therapy? A Prospective Study in Critically Ill Patients. Infect Dis Ther 2021; 11:201-216. [PMID: 34748194 PMCID: PMC8847520 DOI: 10.1007/s40121-021-00551-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 10/13/2021] [Indexed: 11/06/2022] Open
Abstract
Introduction Meropenem is a carbapenem antibiotic, which has demonstrated excellent antimicrobial activity against gram-negative clinical isolates. It is also commonly used in critically ill patients. This study aimed to determine the pharmacokinetics/pharmacodynamics of meropenem in critically ill patients and whether prolonged injection duration is really beneficial to meropenem therapy. Methods We included 209 samples in 64 patients in this prospective study. PPK analysis and Monte Carlo dosing simulations were developed using Phoenix. Results A two-compartment model described the data adequately. Clearance (CL), volume (V), clearance of peripheral compartment (CL2), and volume of peripheral compartment (V2) were 6.15 l/h, 2.83 l/h, 17.40 l, and 17.48 l, respectively. Creatinine clearance and uric acid were significant covariates. Patients with creatinine clearance ≤ 60 ml/min and uric acid > 400 μmol/l could achieve the target > 90% under the minimum inhibitory concentration (MIC) of 8 mg/l, even with the administration dose of 500 mg/8 h with a 2-h infusion. Prolonging the infusion time significantly improved the therapeutic effect when MIC < 4. However, for the pharmacodynamic (PD) effects of 100% fT > MIC and 100% fT > 4 MIC, no significant statistical difference was observed in critically ill patients. Conclusions Critically ill patients with lower creatinine clearance and higher uric acid levels tended to need a lower dosage of meropenem. Prolonged infusion time was not always beneficial for those who needed a higher therapeutic target (100% fT > MIC, 100% fT > 4 MIC) or with MIC > 4 mg/l. Increasing dose or alternative therapeutic strategies may be required for critically ill patients with drug-resistant or severe infections. The study is of great significance to guide the rational use of meropenem in critically ill patients. Trial Registration The trial was registered in the China Clinical Trial (ChiCTR1900020672). Registered on 12 January 2019. Supplementary Information The online version contains supplementary material available at 10.1007/s40121-021-00551-2. Meropenem is commonly used empirically or targeted in critically ill patients for bacterial infection. Many studies have reported that prolonged infusion time can improve the efficacy of meropenem therapy. However, we are skeptical about that. Meanwhile, prolonged injections can sometimes cause mobility problems for patients. A quantitative method is used to evaluate meropenem use. It is called the population pharmacokinetic model or pharmacodynamic study. Using this method, we found two significant influencing factors of meropenem metabolism: creatinine clearance and uric acid level. It is likely that patients with a lower level of creatinine clearance and a high uric acid level tend to require lower dosages of meropenem. As for the effect of infusion time, Monte Carlo simulation was used, which can do 3000 simulations on an individual. The result was complex. We found infusion time was beneficial only when bacteria were sensitive to meropenem. The evidence suggests that prolonged injection duration sometimes does not significantly improve the outcome of antimicrobial therapy.
Collapse
|
7
|
Yang T, Shen Y, Park JG, Schulte PJ, Hanson AC, Herasevich V, Dong Y, Bauer PR. Outcome after intubation for septic shock with respiratory distress and hemodynamic compromise: an observational study. BMC Anesthesiol 2021; 21:253. [PMID: 34696738 PMCID: PMC8543776 DOI: 10.1186/s12871-021-01471-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 10/07/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Acute respiratory failure in septic patients contributes to higher in-hospital mortality. Intubation may improve outcome but there are no specific criteria for intubation. Intubation of septic patients with respiratory distress and hemodynamic compromise may result in clinical deterioration and precipitate cardiovascular failure. The decision to intubate is complex and multifactorial. The purpose of this study was to evaluate the impact of intubation in patients with respiratory distress and predominant hemodynamic instability within 24 h after ICU admission for septic shock. METHODS We conducted a retrospective analysis of a prospective registry of adult patients with septic shock admitted to the medical ICU at Mayo Clinic, between April 30, 2014 and December 31, 2017. Septic shock was defined by persistent lactate > 4 mmol/L, mean arterial pressure < 65 mmHg, or vasopressor use after 30 mL/kg fluid boluses and suspected or confirmed infection. Patients who remained hospitalized in the ICU at 24 h were separated into intubated while in the ICU and non-intubated groups. The primary outcome was hospital mortality. The first analysis used linear regression models and the second analysis used time-dependent propensity score matching to match intubated to non-intubated patients. RESULTS Overall, 358 (33%) ICU patients were eventually intubated after their ICU admission and 738 (67%) were not. Intubated patients were younger, transferred more often from an outside facility, more critically ill, had more lung infection, and achieved blood pressure goals more often, but lactate normalization within 6 h occurred less often. Among those who remained hospitalized in the ICU 24 h after sepsis diagnosis, the crude in-hospital mortality was higher in intubated than non-intubated patients, 89 (26%) vs. 82 (12%), p < 0.001, as was the ICU mortality and ICU and hospital length of stay. After adjustment, intubation showed no effect on hospital mortality but resulted in fewer hospital-free days through day 28. One-to-one propensity resulted in similar conclusion. CONCLUSIONS Intubation within 24 h of sepsis was not associated with hospital mortality but resulted in fewer 28-day hospital-free days. Although intubation remains a high-risk procedure, we did not identify an increased risk in mortality among septic shock patients with predominant hemodynamic compromise.
Collapse
Affiliation(s)
- Ting Yang
- Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Yongchun Shen
- Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - John G Park
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Phillip J Schulte
- Health Science Research - Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, 55905, USA
| | - Andrew C Hanson
- Health Science Research - Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, 55905, USA
| | | | - Yue Dong
- Critical Care Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Philippe R Bauer
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, 55905, USA.
| |
Collapse
|
8
|
Sklar MC, Yarnell CJ. Always Say Never: Why Studies of Timing of Invasive Ventilation Should Compare "Early versus Late/Never" as Opposed to "Early versus Late". Am J Respir Crit Care Med 2021; 204:737-738. [PMID: 34138691 PMCID: PMC8521707 DOI: 10.1164/rccm.202104-0860le] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Michael C Sklar
- St Michael's Hospital, 10071, Division of Critical Care Medicine, Toronto, Ontario, Canada
| | - Christopher J Yarnell
- Mount Sinai Hospital, Division of Critical Care Medicine, Toronto, Ontario, Canada.,University of Toronto, 7938, Institute of Health Management, Policy, and Evaluation, Toronto, Ontario, Canada;
| |
Collapse
|
9
|
Tonelli R, Fantini R, Tabbì L, Castaniere I, Pisani L, Pellegrino MR, Della Casa G, D'Amico R, Girardis M, Nava S, Clini EM, Marchioni A. Early Inspiratory Effort Assessment by Esophageal Manometry Predicts Noninvasive Ventilation Outcome in De Novo Respiratory Failure. A Pilot Study. Am J Respir Crit Care Med 2020; 202:558-567. [PMID: 32325004 PMCID: PMC7427381 DOI: 10.1164/rccm.201912-2512oc] [Citation(s) in RCA: 144] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Rationale: The role of inspiratory effort still has to be determined as a potential predictor of noninvasive mechanical ventilation (NIV) failure in acute hypoxic de novo respiratory failure.Objectives: To explore the hypothesis that inspiratory effort might be a major determinant of NIV failure in these patients.Methods: Thirty consecutive patients with acute hypoxic de novo respiratory failure admitted to a single center and candidates for a 24-hour NIV trial were enrolled. Clinical features, tidal change in esophageal pressure (ΔPes), tidal change in dynamic transpulmonary pressure (ΔPl), expiratory Vt, and respiratory rate were recorded on admission and 2-4 to 12-24 hours after NIV start and were tested for correlation with outcomes.Measurements and Main Results: ΔPes and ΔPes/ΔPl ratio were significantly lower 2 hours after NIV start in patients who successfully completed the NIV trial (n = 18) compared with those who needed endotracheal intubation (n = 12) (median [interquartile range], 11 [8-15] cm H2O vs. 31.5 [30-36] cm H2O; P < 0.0001), whereas other variables differed later. ΔPes was not related to other predictors of NIV failure at baseline. NIV-induced reduction in ΔPes of 10 cm H2O or more after 2 hours of treatment was strongly associated with avoidance of intubation and represented the most accurate predictor of treatment success (odds ratio, 15; 95% confidence interval, 2.8-110; P = 0.001 and area under the curve, 0.97; 95% confidence interval, 0.91-1; P < 0.0001).Conclusions: The magnitude of inspiratory effort relief as assessed by ΔPes variation within the first 2 hours of NIV was an early and accurate predictor of NIV outcome at 24 hours.Clinical trial registered with www.clinicaltrials.gov (NCT03826797).
Collapse
Affiliation(s)
- Roberto Tonelli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences.,Clinical and Experimental Medicine Doctoral Program
| | - Riccardo Fantini
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences
| | - Luca Tabbì
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences
| | - Ivana Castaniere
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences.,Clinical and Experimental Medicine Doctoral Program
| | - Lara Pisani
- Department of Specialistic, Diagnostic and Experimental Medicine, University of Bologna, Bologna, Italy
| | | | | | - Roberto D'Amico
- Statistics Unit, Department of Diagnostics, Clinical and Public Health Medicine, and
| | - Massimo Girardis
- Intensive Care Unit, Department of Surgical, Medical, Dental and Morphological Sciences related to Transplants Oncology and Regenerative Medicine, University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy; and
| | - Stefano Nava
- Department of Specialistic, Diagnostic and Experimental Medicine, University of Bologna, Bologna, Italy
| | - Enrico M Clini
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences
| | | |
Collapse
|
10
|
Abstract
While the world is grappling with the consequences of a global pandemic related to SARS-CoV-2 causing severe pneumonia, available evidence points to bacterial infection with Streptococcus pneumoniae as the most common cause of severe community acquired pneumonia (SCAP). Rapid diagnostics and molecular testing have improved the identification of co-existent pathogens. However, mortality in patients admitted to ICU remains staggeringly high. The American Thoracic Society and Infectious Diseases Society of America have updated CAP guidelines to help streamline disease management. The common theme is use of timely, appropriate and adequate antibiotic coverage to decrease mortality and avoid drug resistance. Novel antibiotics have been studied for CAP and extend the choice of therapy, particularly for those who are intolerant of, or not responding to standard treatment, including those who harbor drug resistant pathogens. In this review, we focus on the risk factors, microbiology, site of care decisions and treatment of patients with SCAP.
Collapse
Affiliation(s)
- Girish B Nair
- Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA.
| | - Michael S Niederman
- Weill Cornell Medical College, Pulmonary and Critical Care, New York Presbyterian/ Weill Cornell Medical Center, New York, NY, USA.
| |
Collapse
|
11
|
Bourke SC, Piraino T, Pisani L, Brochard L, Elliott MW. Beyond the guidelines for non-invasive ventilation in acute respiratory failure: implications for practice. THE LANCET RESPIRATORY MEDICINE 2018; 6:935-947. [DOI: 10.1016/s2213-2600(18)30388-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 09/13/2018] [Accepted: 09/13/2018] [Indexed: 12/31/2022]
|
12
|
Bauer PR, Kumbamu A, Wilson ME, Pannu JK, Egginton JS, Kashyap R, Gajic O. Timing of Intubation in Acute Respiratory Failure Associated With Sepsis: A Mixed Methods Study. Mayo Clin Proc 2017; 92:1502-1510. [PMID: 28867256 DOI: 10.1016/j.mayocp.2017.07.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 06/15/2017] [Accepted: 07/03/2017] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To analyze bedside clinicians' perspectives regarding the decision process to optimize timing of intubation in sepsis-associated acute respiratory failure. PARTICIPANTS AND METHODS This mixed methods study was conducted from March 1, 2015, through June 30, 2016. Using qualitative research methods, factors that influenced variability in the decision to intubate were organized into categories and used to build a theoretical explanatory model grounded in current practice variance. All coding schemes were independently reviewed for accuracy and consistency. Themes and findings were then refined with member checking by feedback from individuals and from an anonymous questionnaire until saturation was achieved. RESULTS The practice of intubation varied according to 3 domains: (1) patient factors included the nature of the acute illness, comorbidities, clinical presentation, severity, trajectory, and values and preferences; (2) clinician factors included background, training, experience, and practice style; and (3) system factors included workload, policies and protocols, hierarchy, communications, culture, and team dynamics. In different contexts, intubation was considered early (elective), just in time (urgent), or late (rescue). The initial assessment, initial decision, and reassessment mattered. CONCLUSION Recognizing that the variability in both the decision to intubate and its timing depends on many factors, and not on clinical criteria alone, should render the clinician more attentive to the eventual progression of the acute respiratory failure.
Collapse
Affiliation(s)
- Philippe R Bauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
| | - Ashok Kumbamu
- Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Michael E Wilson
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | - Jason S Egginton
- Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Rahul Kashyap
- Department of Anesthesia Clinical Research, Mayo Clinic, Rochester, MN
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
13
|
Cao B, Huang Y, She DY, Cheng QJ, Fan H, Tian XL, Xu JF, Zhang J, Chen Y, Shen N, Wang H, Jiang M, Zhang XY, Shi Y, He B, He LX, Liu YN, Qu JM. Diagnosis and treatment of community-acquired pneumonia in adults: 2016 clinical practice guidelines by the Chinese Thoracic Society, Chinese Medical Association. CLINICAL RESPIRATORY JOURNAL 2017; 12:1320-1360. [PMID: 28756639 PMCID: PMC7162259 DOI: 10.1111/crj.12674] [Citation(s) in RCA: 144] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 07/25/2017] [Indexed: 02/05/2023]
Abstract
Community‐acquired pneumonia (CAP) in adults is an infectious disease with high morbidity in China and the rest of the world. With the changing pattern in the etiological profile of CAP and advances in medical techniques in diagnosis and treatment over time, Chinese Thoracic Society of Chinese Medical Association updated its CAP guideline in 2016 to address the standard management of CAP in Chinese adults. Extensive and comprehensive literature search was made to collect the data and evidence for experts to review and evaluate the level of evidence. Corresponding recommendations are provided appropriately based on the level of evidence. This updated guideline covers comprehensive topics on CAP, including aetiology, antimicrobial resistance profile, diagnosis, empirical and targeted treatments, adjunctive and supportive therapies, as well as prophylaxis. The recommendations may help clinicians manage CAP patients more effectively and efficiently. CAP in pediatric patients and immunocompromised adults is beyond the scope of this guideline. This guideline is only applicable for the immunocompetent CAP patients aged 18 years and older. The recommendations on selection of antimicrobial agents and the dosing regimens are not mandatory. The clinicians are recommended to prescribe and adjust antimicrobial therapies primarily based on their local etiological profile and results of susceptibility testing, with reference to this guideline.
Collapse
Affiliation(s)
- Bin Cao
- National Clinical Research Center of Respiratory Diseases, Center for Respiratory Diseases, China-Japan Friendship Hospital, Capital Medical University, Beijing 100029, China
| | - Yi Huang
- Department of Respiratory and Critical Care Medicine, Changhai Hospital, the Second Military Medical University, Shanghai 200433, China
| | - Dan-Yang She
- Department of Respiratory and Critical Care Medicine, Chinese PLA General Hospital, Beijing 100853, China
| | - Qi-Jian Cheng
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200025, China
| | - Hong Fan
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Sichuan 610041, China
| | - Xin-Lun Tian
- Department of Pulmonary Medicine, Peking Union Medical College Hospital, Beijing 100730, China
| | - Jin-Fu Xu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Jing Zhang
- Department of Respiratory and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yu Chen
- Department of Respiratory and Critical Care Medicine, Shengjing Hospital, China Medical University, Shenyang 110004, China
| | - Ning Shen
- Department of Respiratory Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Hui Wang
- Department of Laboratory Medicine, Peking University People's Hospital, Beijing 100044, China
| | - Mei Jiang
- State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Diseases, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Xiang-Yan Zhang
- Department of Respiratory and Critical Care Medicine, Guizhou Provincial People's Hospital, Guizhou 550002, China
| | - Yi Shi
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Nanjing 210002, China
| | - Bei He
- Department of Respiratory Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Li-Xian He
- Department of Respiratory and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - You-Ning Liu
- Department of Respiratory and Critical Care Medicine, Chinese PLA General Hospital, Beijing 100853, China
| | - Jie-Ming Qu
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200025, China
| |
Collapse
|
14
|
Ouchi K, Hohmann S, Goto T, Ueda P, Aaronson EL, Pallin DJ, Testa MA, Tulsky JA, Schuur JD, Schonberg MA. Index to Predict In-hospital Mortality in Older Adults after Non-traumatic Emergency Department Intubations. West J Emerg Med 2017; 18:690-697. [PMID: 28611890 PMCID: PMC5468075 DOI: 10.5811/westjem.2017.2.33325] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 02/10/2017] [Accepted: 02/15/2017] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Our goal was to develop and validate an index to predict in-hospital mortality in older adults after non-traumatic emergency department (ED) intubations. METHODS We used Vizient administrative data from hospitalizations of 22,374 adults ≥75 years who underwent non-traumatic ED intubation from 2008-2015 at nearly 300 U.S. hospitals to develop and validate an index to predict in-hospital mortality. We randomly selected one half of participants for the development cohort and one half for the validation cohort. Considering 25 potential predictors, we developed a multivariable logistic regression model using least absolute shrinkage and selection operator method to determine factors associated with in-hospital mortality. We calculated risk scores using points derived from the final model's beta coefficients. To evaluate calibration and discrimination of the final model, we used Hosmer-Lemeshow chi-square test and receiver-operating characteristic analysis and compared mortality by risk groups in the development and validation cohorts. RESULTS Death during the index hospitalization occurred in 40% of cases. The final model included six variables: history of myocardial infarction, history of cerebrovascular disease, history of metastatic cancer, age, admission diagnosis of sepsis, and admission diagnosis of stroke/ intracranial hemorrhage. Those with low-risk scores (<6) had 31% risk of in-hospital mortality while those with high-risk scores (>10) had 58% risk of in-hospital mortality. The Hosmer-Lemeshow chi-square of the model was 6.47 (p=0.09), and the c-statistic was 0.62 in the validation cohort. CONCLUSION The model may be useful in identifying older adults at high risk of death after ED intubation.
Collapse
Affiliation(s)
- Kei Ouchi
- Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts.,Ariadne Labs, Serious Illness Care Program, Boston, Massachusetts
| | - Samuel Hohmann
- Vizient, Center for Advanced Analytics, Irving, Texas.,Rush University, Department of Health Systems Management, Chicago, Illinois
| | - Tadahiro Goto
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Peter Ueda
- Harvard T.H. Chan School of Public Health, Department of Global Health and Population, Boston, Massachusetts
| | - Emily L Aaronson
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Daniel J Pallin
- Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Marcia A Testa
- Harvard T.H. Chan School of Public Health, Department of Global Health and Population, Boston, Massachusetts.,Harvard T.H. Chan School of Public Health, Department of Biostatistics, Boston, Massachusetts
| | - James A Tulsky
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology and Palliative Care, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Medicine, Division of Palliative Medicine, Boston, Massachusetts
| | - Jeremiah D Schuur
- Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Mara A Schonberg
- Beth Israel Deaconess Medical Center, Department of Medicine, Boston, Massachusetts
| |
Collapse
|
15
|
Abstract
PURPOSE OF REVIEW Community-acquired pneumonia (CAP) is a pervasive disease that is encountered in outpatient and inpatient settings. CAP is the leading cause of death from an infectious disease and accounts for significant worldwide morbidity and mortality. This update reviews current advances that can be used to promote improved outcomes in CAP. RECENT FINDINGS Early recognition of CAP and its severe presentations, with appropriate site of care decisions, leads to reduced patient mortality. In addition to traditional prognostic tools, certain serum biomarkers can assist in defining disease severity and guide treatment and management strategies. The use of macrolides as part of combination antibiotic therapy has shown beneficial mortality effects across the CAP disease spectrum, especially for those with severe illness. When treating community-associated, methicillin-resistant Staphylococcus aureus pneumonia, use of an antitoxin antibiotic is likely to be valuable. Adjunctive therapy with corticosteroids may prevent delayed clinical resolution in selected patients with severe CAP. Recent data expand on the interaction of CAP with comorbid disease, particularly cardiovascular disease, and its impact on mortality in CAP patients. SUMMARY Improved diagnostic tools, optimized treatment regimens, and enhanced understanding of CAP-induced perturbations in comorbid disease states hold promise to improve patient outcomes.
Collapse
|
16
|
Phua J, Dean NC, Guo Q, Kuan WS, Lim HF, Lim TK. Severe community-acquired pneumonia: timely management measures in the first 24 hours. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:237. [PMID: 27567896 PMCID: PMC5002335 DOI: 10.1186/s13054-016-1414-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Mortality rates for severe community-acquired pneumonia (CAP) range from 17 to 48 % in published studies.In this review, we searched PubMed for relevant papers published between 1981 and June 2016 and relevant files. We explored how early and aggressive management measures, implemented within 24 hours of recognition of severe CAP and carried out both in the emergency department and in the ICU, decrease mortality in severe CAP.These measures begin with the use of severity assessment tools and the application of care bundles via clinical decision support tools. The bundles include early guideline-concordant antibiotics including macrolides, early haemodynamic support (lactate measurement, intravenous fluids, and vasopressors), and early respiratory support (high-flow nasal cannulae, lung-protective ventilation, prone positioning, and neuromuscular blockade for acute respiratory distress syndrome).While the proposed interventions appear straightforward, multiple barriers to their implementation exist. To successfully decrease mortality for severe CAP, early and close collaboration between emergency medicine and respiratory and critical care medicine teams is required. We propose a workflow incorporating these interventions.
Collapse
Affiliation(s)
- Jason Phua
- Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Hospital, National University Health System, Tower Block, Level 10, 1E Kent Ridge Road, Singapore, 119228, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Nathan C Dean
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Qi Guo
- Department of Respiratory Medicine, Affiliated Futian Hospital, Guangdong Medical College, Shenzhen, Guangdong, China.,Guangzhou Institute of Respiratory Diseases (State Key Laboratory of Respiratory Diseases), First Affiliated Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Win Sen Kuan
- Department of Emergency Medicine, National University Hospital, National University Health System, Singapore, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Hui Fang Lim
- Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Hospital, National University Health System, Tower Block, Level 10, 1E Kent Ridge Road, Singapore, 119228, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Tow Keang Lim
- Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Hospital, National University Health System, Tower Block, Level 10, 1E Kent Ridge Road, Singapore, 119228, Singapore. .,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
| |
Collapse
|