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Coxwell Matthewman M, Yanase F, Costa-Pinto R, Jones D, Karalapillai D, Modra L, Radford S, Ukor IF, Warrillow S, Bellomo R. Haemodynamic changes during prone versus supine position in patients with COVID-19 acute respiratory distress syndrome. Aust Crit Care 2024; 37:391-399. [PMID: 37160405 PMCID: PMC10063572 DOI: 10.1016/j.aucc.2023.03.006] [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: 06/13/2022] [Revised: 03/10/2023] [Accepted: 03/25/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Prone positioning improves oxygenation in patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19. However, its haemodynamic effects are poorly understood. OBJECTIVES The objective of this study was to investigate the acute haemodynamic changes associated with prone position in mechanically ventilated patients with COVID-19 ARDS. The primary objective was to describe changes in cardiac index with prone position. The secondary objectives were to describe changes in mean arterial pressure, FiO2, PaO2/FiO2 ratio, and oxygen delivery (DO2) with prone position. METHODS We performed this cohort-embedded study in an Australian intensive care unit, between September and November 2021. We included adult patients with severe COVID-19 ARDS, requiring mechanical ventilation and prone positioning for respiratory failure. We placed patients in the prone position for 16 h per session. Using pulse contour technology, we collected haemodynamic data every 5 min for 2 h in the supine position and for 2 h in the prone position consecutively. RESULTS We studied 18 patients. Cardiac index, stroke volume index, and mean arterial pressure increased significantly in the prone position compared to supine position. The mean cardiac index was higher in the prone group than in the supine group by 0.44 L/min/m2 (95% confidence interval, 0.24 to 0.63) (P < 0.001). FiO2 requirement decreased significantly in the prone position (P < 0.001), with a significant increase in PaO2/FiO2 ratio (P < 0.001). DO2 also increased significantly in the prone position, from a median DO2 of 597 mls O2/min (interquartile range, 504 to 931) in the supine position to 743 mls O2/min (interquartile range, 604 to 1075) in the prone position (P < 0.001). CONCLUSION Prone position increased the cardiac index, mean arterial pressure, and DO2 in invasively ventilated patients with COVID-19 ARDS. These changes may contribute to improved tissue oxygenation and improved outcomes observed in trials of prone positioning.
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Affiliation(s)
| | - Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University School of Public Health and Preventive Medicine, Melbourne, Australia
| | | | - Daryl Jones
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | | | - Lucy Modra
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Sam Radford
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Ida-Fong Ukor
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | | | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University School of Public Health and Preventive Medicine, Melbourne, Australia; Department of Critical Care, Department of Medicine and Radiology, University of Melbourne, Melbourne, Australia; Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Australia
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Abstract
Influenza infection causes severe illness in 3 to 5 million people annually, with up to an estimated 650,000 deaths per annum. As such, it represents an ongoing burden to health care systems and human health. Severe acute respiratory infection can occur, resulting in respiratory failure requiring intensive care support. Herein we discuss diagnostic approaches, including development of CLIA-waived point of care tests that allow rapid diagnosis and treatment of influenza. Bacterial and fungal coinfections in severe influenza pneumonia are associated with worse outcomes, and we summarize the approach and treatment options for diagnosis and treatment of bacterial and Aspergillus coinfection. We discuss the available drug options for the treatment of severe influenza, and treatments which are no longer supported by the evidence base. Finally, we describe the supportive management and ventilatory approach to patients with respiratory failure as a result of severe influenza in the intensive care unit.
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Affiliation(s)
- Liam S O'Driscoll
- Department of Intensive Care Medicine, St. James's University Hospital, Multidisciplinary Intensive Care Research Organization (MICRO), Trinity Centre for Health Sciences, Dublin, Ireland
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, St. James's University Hospital, Multidisciplinary Intensive Care Research Organization (MICRO), Trinity Centre for Health Sciences, Dublin, Ireland.,Respiratory Medicine, Hospital Clinic, IDIBAPS, Universidad de Barcelona, CIBERes, Barcelona, Spain
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3
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Falcão LF, da Silva Pontes L, Afonso da Silva BG, Vieira da Silva Franco KM, Costa LA, Barbosa Rocha RS, Simões Quaresma JA. The complexity of respiratory disease associated with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection: From immunopathogenesis to respiratory therapy. Rev Med Virol 2020. [DOI: 10.1002/rmv.2167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Luiz Fábio Falcão
- Center for Biological and Health Sciences State University of Pará Belém Pará Brazil
| | | | | | | | - Luiz Adriano Costa
- Center for Biological and Health Sciences State University of Pará Belém Pará Brazil
| | | | - Juarez Antônio Simões Quaresma
- Center for Biological and Health Sciences State University of Pará Belém Pará Brazil
- Evandro Chagas Institute Ministry of Health Ananindeua Pará Brazil
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4
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González-Castro A, Escudero-Acha P, Peñasco Y, Leizaola O, Martínez de Pinillos Sánchez V, García de Lorenzo A. [Intensive care during the 2019-coronavirus epidemic]. Med Intensiva 2020; 44:351-362. [PMID: 38620515 PMCID: PMC7271070 DOI: 10.1016/j.medin.2020.03.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 03/14/2020] [Accepted: 03/19/2020] [Indexed: 01/08/2023]
Abstract
On 31 December 2019, the Health Commission of Hubei Province of China first unveiled a group of unexplained cases of pneumonia, which WHO subsequently defined as the new coronavirus of 2019 (SARS-CoV-2). SARS-CoV-2 has presented rapid person-to-person transmission and is currently a global pandemic. In the largest number of cases described to date of hospitalized patients with SARS-CoV-2 disease (2019-nCoViD), 26% required care in an intensive care unit (ICU). This pandemic is causing an unprecedented mobilization of the scientific community, which has been associated with an exponentially growing number of publications in relation to it. This narrative literature review aims to gather the main contributions in the area of intensive care to date in relation to the epidemiology, clinic, diagnosis and management of 2019-nCoViD.
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Affiliation(s)
- A. González-Castro
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España
| | - P. Escudero-Acha
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España
| | - Y. Peñasco
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España
| | - O. Leizaola
- Servicio de Medicina Intensiva, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | | | - A. García de Lorenzo
- Servicio de Medicina Intensiva, Hospital Universitario La Paz-Carlos III, IdiPAZ, Madrid, España
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5
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Peng F, Tu L, Yang Y, Hu P, Wang R, Hu Q, Cao F, Jiang T, Sun J, Xu G, Chang C. Management and Treatment of COVID-19: The Chinese Experience. Can J Cardiol 2020; 36:915-930. [PMID: 32439306 PMCID: PMC7162773 DOI: 10.1016/j.cjca.2020.04.010] [Citation(s) in RCA: 111] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 04/13/2020] [Accepted: 04/13/2020] [Indexed: 02/08/2023] Open
Abstract
With more than 1,800,000 cases and 110,000 deaths globally, COVID-19 is one of worst infectious disease outbreaks in history. This paper provides a critical review of the available evidence regarding the lessons learned from the Chinese experience with COVID-19 prevention and management. The steps that have led to a near disappearance of new cases in China included rapid sequencing of the virus to establish testing kits, which allowed tracking of infected persons in and out of Wuhan. In addition, aggressive quarantine measures included the complete isolation of Wuhan and then later Hubei Province and the rest of the country, as well as closure of all schools and nonessential businesses. Other measures included the rapid construction of two new hospitals and the establishment of "Fangcang" shelter hospitals. In the absence of a vaccine, the management of COVID-19 included antivirals, high-flow oxygen, mechanical ventilation, corticosteroids, hydroxychloroquine, tocilizumab, interferons, intravenous immunoglobulin, and convalescent plasma infusions. These measures appeared to provide only moderate success. Although some measures have been supported by weak descriptive data, their effectiveness is still unclear pending well controlled clinical trials. In the end, it was the enforcement of drastic quarantine measures that stopped SARS-CoV-2 from spreading. The earlier the implementation, the less likely resources will be depleted. The most critical factors in stopping a pandemic are early recognition of infected individuals, carriers, and contacts and early implementation of quarantine measures with an organised, proactive, and unified strategy at a national level. Delays result in significantly higher death tolls.
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Affiliation(s)
- Fujun Peng
- Center for Systems Medicine, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Suzhou Institute of Systems Medicine, Suzhou, Jiangsu, China
| | - Lei Tu
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yongshi Yang
- Department of Allergy and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Immunologic Diseases, Beijing, China
| | - Peng Hu
- Department of Respiratory Medicine, Second Medical Center and National Clinical Research Center for Geriatric Diseases, Medical College of the People's Liberation Army, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Runsheng Wang
- Department of Respiratory Medicine, Second Medical Center and National Clinical Research Center for Geriatric Diseases, Medical College of the People's Liberation Army, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Qinyong Hu
- Renmin Hospital of Wuhan University, Wuhan, China
| | - Feng Cao
- Department of Respiratory Medicine, Second Medical Center and National Clinical Research Center for Geriatric Diseases, Medical College of the People's Liberation Army, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Taijiao Jiang
- Center for Systems Medicine, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Suzhou Institute of Systems Medicine, Suzhou, Jiangsu, China.
| | - Jinlyu Sun
- Department of Allergy and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Immunologic Diseases, Beijing, China.
| | - Guogang Xu
- Department of Respiratory Medicine, Second Medical Center and National Clinical Research Center for Geriatric Diseases, Medical College of the People's Liberation Army, Chinese People's Liberation Army General Hospital, Beijing, China.
| | - Christopher Chang
- Division of Pediatric Immunology and Allergy, Joe DiMaggio Children's Hospital, Hollywood, Florida, USA; Division of Rheumatology, Allergy, and Clinical Immunology, University of California, Davis, California, USA.
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Li L, Li R, Wu Z, Yang X, Zhao M, Liu J, Chen D. Therapeutic strategies for critically ill patients with COVID-19. Ann Intensive Care 2020; 10:45. [PMID: 32307593 PMCID: PMC7167303 DOI: 10.1186/s13613-020-00661-z] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 04/06/2020] [Indexed: 02/07/2023] Open
Abstract
Since the 2019 novel coronavirus disease (COVID-19) outbreak originated from Wuhan, Hubei Province, China, at the end of 2019, it has become a clinical threat to the general population worldwide. Among people infected with the novel coronavirus (2019-nCoV), the intensive management of the critically ill patients in intensive care unit (ICU) needs substantial medical resource. In the present article, we have summarized the promising drugs, adjunctive agents, respiratory supportive strategies, as well as circulation management, multiple organ function monitoring and appropriate nutritional strategies for the treatment of COVID-19 in the ICU based on the previous experience of treating other viral infections and influenza. These treatments are referable before the vaccine and specific drugs are available for COVID-19.
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Affiliation(s)
- Lei Li
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China
| | - Ranran Li
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China
| | - Zhixiong Wu
- Department of Surgical Intensive Care Unit, Huadong Hospital Affiliated to Fudan University, Shanghai, 200040, People's Republic of China
| | - Xianghong Yang
- Department of Critical Care Medicine, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, 310014, People's Republic of China
| | - Mingyan Zhao
- Department of Critical Care Medicine, The First Hospital Affiliated to Harbin Medical University, Harbin, 150001, People's Republic of China
| | - Jiao Liu
- Department of Critical Care Medicine, Ruijin North Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 201800, People's Republic of China.
| | - Dechang Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China.
- Department of Critical Care Medicine, Ruijin North Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 201800, People's Republic of China.
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7
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Arabi YM, Fowler R, Hayden FG. Critical care management of adults with community-acquired severe respiratory viral infection. Intensive Care Med 2020; 46:315-328. [PMID: 32040667 PMCID: PMC7079862 DOI: 10.1007/s00134-020-05943-5] [Citation(s) in RCA: 112] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 01/16/2020] [Indexed: 02/06/2023]
Abstract
With the expanding use of molecular assays, viral pathogens are increasingly recognized among critically ill adult patients with community-acquired severe respiratory illness; studies have detected respiratory viral infections (RVIs) in 17-53% of such patients. In addition, novel pathogens including zoonotic coronaviruses like the agents causing Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome (MERS) and the 2019 novel coronavirus (2019 nCoV) are still being identified. Patients with severe RVIs requiring ICU care present typically with hypoxemic respiratory failure. Oseltamivir is the most widely used neuraminidase inhibitor for treatment of influenza; data suggest that early use is associated with reduced mortality in critically ill patients with influenza. At present, there are no antiviral therapies of proven efficacy for other severe RVIs. Several adjunctive pharmacologic interventions have been studied for their immunomodulatory effects, including macrolides, corticosteroids, cyclooxygenase-2 inhibitors, sirolimus, statins, anti-influenza immune plasma, and vitamin C, but none is recommended at present in severe RVIs. Evidence-based supportive care is the mainstay for management of severe respiratory viral infection. Non-invasive ventilation in patients with severe RVI causing acute hypoxemic respiratory failure and pneumonia is associated with a high likelihood of transition to invasive ventilation. Limited existing knowledge highlights the need for data regarding supportive care and adjunctive pharmacologic therapy that is specific for critically ill patients with severe RVI. There is a need for more pragmatic and efficient designs to test different therapeutics both individually and in combination.
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Affiliation(s)
- Yaseen M. Arabi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Intensive Care Department, King Abdulaziz Medical City, P.O. Box 22490, Riyadh, 11426 Saudi Arabia
| | - Robert Fowler
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Canada
- Department of Critical Care Medicine, Sunnybrook Hospital, Toronto, Canada
- Department of Medicine, Sunnybrook Hospital, Toronto, Canada
| | - Frederick G. Hayden
- Department of Medicine, Division of Infectious Diseases and International Health, University of Virginia School of Medicine, Charlottesville, VA USA
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Kao KC, Chang KW, Chan MC, Liang SJ, Chien YC, Hu HC, Chiu LC, Chen WC, Fang WF, Chen YM, Sheu CC, Tsai MJ, Perng WC, Peng CK, Wu CL, Wang HC, Yang KY. Predictors of survival in patients with influenza pneumonia-related severe acute respiratory distress syndrome treated with prone positioning. Ann Intensive Care 2018; 8:94. [PMID: 30251181 PMCID: PMC6153196 DOI: 10.1186/s13613-018-0440-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 09/15/2018] [Indexed: 02/03/2023] Open
Abstract
Background Patients with influenza complicated with pneumonia are at high risk of rapid progression to acute respiratory distress syndrome (ARDS). Prone positioning with longer duration and lung-protective strategies might reduce the mortality level in ARDS. The aim of this study is to investigate the survival predictors of prone positioning in patients with ARDS caused by influenza pneumonia. Methods This retrospective study was conducted by eight tertiary referral centers in Taiwan. From January 1 to March 31 in 2016, all of the patients in intensive care units with virology-proven influenza pneumonia were collected, while all of those patients with ARDS and receiving prone positioning were enrolled. Demographic data, laboratory examinations, management records, ventilator settings and clinical outcomes were collected for analysis. Results During the study period, 336 patients with severe influenza pneumonia were screened and 263 patients met the diagnosis of ARDS. Totally, 65 patients receiving prone positioning were included for analysis. The 60-day survivors had lower Acute Physiology and Chronic Health Evaluation (APACHE) II score, pneumonia severity index (PSI), creatinine level and lower rate of receiving renal replacement therapy than non-survivors (22.4 ± 8.5 vs. 29.2 ± 7.4, p = 0.003; 106.6 ± 40.9 vs. 135.3 ± 48.6, p = 0.019; 1.2 ± 0.9 mg/dL vs. 3.1 ± 3.6 mg/dL, p = 0.040; and 4% vs. 42%, p < 0.005). Multivariate Cox regression analysis identified PSI (hazard ratio 1.020, 95% confidence interval 1.009–1.032; p < 0.001), renal replacement therapy (hazard ratio 6.248, 95% confidence interval 2.245–17.389; p < 0.001), and increase in dynamic driving pressure (hazard ratio 1.372, 95% confidence interval 1.095–1.718; p = 0.006) which were independent predictors associated with 60-day mortality. Conclusions In the present study, in evaluating the effect of prone positioning in patients with influenza pneumonia-related ARDS, pneumonia severity index, renal replacement therapy and increase in dynamic driving pressure were associated with 60-day mortality in patients with influenza pneumonia-related ARDS receiving prone positioning. Electronic supplementary material The online version of this article (10.1186/s13613-018-0440-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kuo-Chin Kao
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ko-Wei Chang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ming-Cheng Chan
- Division of Chest Medicine, Department of Internal Medicine, and Section of Critical Care and Respiratory Therapy, Taichung Veterans General Hospital, Taichung, Taiwan.,Central Taiwan University of Science and Technology, Taichung, Taiwan
| | - Shinn-Jye Liang
- Division of Pulmonary and Critical Care, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Ying-Chun Chien
- Division of Chest Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Han-Chung Hu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Li-Chung Chiu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wei-Chih Chen
- Department of Chest Medicine, Taipei Veterans General Hospital, No. 201, Section 2 Shi-Pai Road, Taipei, 11217, Taiwan.,Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wen-Feng Fang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi, Taiwan
| | - Yu-Mu Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chau-Chyun Sheu
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Ju Tsai
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wann-Cherng Perng
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chung-Kan Peng
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chieh-Liang Wu
- Center for Quality Management, Taichung Veterans General Hospital, Taichung, Taiwan.,Office of Medical Administration, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hao-Chien Wang
- Division of Chest Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Kuang-Yao Yang
- Department of Chest Medicine, Taipei Veterans General Hospital, No. 201, Section 2 Shi-Pai Road, Taipei, 11217, Taiwan. .,Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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