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Fradkin M, Elyashiv M, Camel A, Agay N, Brik M, Singer P, Dankner R. A historical cohort study on predictors for successful weaning from prolonged mechanical ventilation and up to 3-year survival follow-up in a rehabilitation center. Respir Med 2024; 227:107636. [PMID: 38642907 DOI: 10.1016/j.rmed.2024.107636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 03/04/2024] [Accepted: 04/13/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND We followed prolonged mechanically ventilated (PMV) patients for weaning attempts and explored factors associated with successful weaning and long-term survival. METHODS This historical cohort study included all adult PMV patients admitted to a single rehabilitation hospital during 2015-2018 and followed for survival according to weaning success up to 3 years or the end of 2021. RESULTS The study included 223 PMV patients. Of them, 124 (55.6 %) underwent weaning attempts, with 69 (55.6 %) successfully weaned, 55 (44.4 %) unsuccessfully weaned, and 99 patients with no weaning attempts. The mean age was 67 ± 20 years, with 39 % female patients. Age, sex distributions and albumin levels at admission were not significantly different among the groups. The successful weaning group had a 6 % higher proportion of conscious patients than the failed weaning group (55 % vs. 49 %, respectively, p = 0.45). Patients successfully weaned were less frequently treated with antibiotics for 5 days or more than those unsuccessfully weaned (74 % vs 80 %, respectively, p = 0.07). They also had a lower proportion of time from intubation to tracheostomy greater than 14 days (45 % vs 66 %, p = 0.02). The age, sex, antibiotic treatment, time to tracheostomy exceeding 14 days and time from admission to first weaning attempt adjusted one-year mortality risk of successful vs. failed weaning was somewhat lower, HR = 0.75, 95%CI: 0.33-1.60, p = 0.45, with the same trend by the end of 3 years, HR = 0.77, 95%CI: 0.42-1.39, p = 0.38. CONCLUSION Successful weaning from PMV may be associated with better survival and allows chronically ventilated patients to become independent on a ventilator. A larger study is needed to further validate our findings.
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Affiliation(s)
- Mila Fradkin
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty for Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel; Schoenbrun Academic Nursing School, Sourasky Medical Center, Tel Aviv, Israel
| | - Maya Elyashiv
- Intubation Unit, Reuth Tel-Aviv Rehabilitation Medical Center, Tel Aviv, Israel
| | - Amasha Camel
- Intubation Unit, Reuth Tel-Aviv Rehabilitation Medical Center, Tel Aviv, Israel
| | - Nirit Agay
- Center for Research of Public Health, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan, Israel
| | - Michael Brik
- Research and Development Institute, Reuth Tel-Aviv Rehabilitation Medical Center, Tel Aviv, Israel
| | - Pierre Singer
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty for Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel; General Intensive Care Department, Beilinson Hospital, Rabin Medical Center, Petah Tikva, and ICU Herzliya Medical Center, Israel
| | - Rachel Dankner
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty for Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel; Center for Research of Public Health, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan, Israel; Research and Development Institute, Reuth Tel-Aviv Rehabilitation Medical Center, Tel Aviv, Israel.
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Lin FC, Chen YH, Kuo YW, Ku SC, Jerng JS. Aerosol particle dispersion in spontaneous breathing training of oxygen delivery tracheostomized patients on prolonged mechanical ventilation. J Formos Med Assoc 2024:S0929-6646(24)00081-0. [PMID: 38336509 DOI: 10.1016/j.jfma.2024.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 12/29/2023] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Tracheostomized patients undergoing liberation from mechanical ventilation (MV) are exposed to the ambient environment through humidified air, potentially heightening aerosol particle dispersion. This study was designed to evaluate the patterns of aerosol dispersion during spontaneous breathing trials in such patients weaning from prolonged MV. METHODS Particle Number Concentrations (PNC) at varying distances from tracheostomized patients in a specialized weaning unit were quantified using low-cost particle sensors, calibrated against a Condensation Particle Counter. Different oxygen delivery methods, including T-piece and collar mask both with the humidifier or with a small volume nebulizer (SVN), and simple collar mask, were employed. The PNC at various distances and across different oxygen devices were compared using the Kruskal-Wallis test. RESULTS Of nine patients receiving prolonged MV, five underwent major surgery, and eight were successfully weaned from ventilation. PNCs at distances ranging from 30 cm to 300 cm showed no significant disparity (H(4) = 8.993, p = 0.061). However, significant differences in PNC were noted among oxygen delivery methods, with Bonferroni-adjusted pairwise comparisons highlighting differences between T-piece or collar mask with SVN and other devices. CONCLUSIONS Aerosol dispersion within 300 cm of the patient was not significantly different, while the nebulization significantly enhances ambient aerosol dispersion in tracheostomized patients on prolonged MV.
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Affiliation(s)
- Feng-Ching Lin
- Division of Respiratory Therapy, Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan; School of Respiratory Therapy, Taipei Medical University, Taipei, Taiwan
| | - Yung-Hsuan Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yao-Wen Kuo
- Division of Respiratory Therapy, Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Shih-Chi Ku
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jih-Shuin Jerng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Center for Quality Management, National Taiwan University Hospital, Taipei, Taiwan.
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Wu CH, Lin FC, Jerng JS, Shin MH, Wang YC, Lee CJ, Lin LM, Lin NH, Kuo YW, Ku SC, Wu HD. Automatic tube compensation for liberation from prolonged mechanical ventilation in tracheostomized patients: A retrospective analysis. J Formos Med Assoc 2023; 122:1132-1140. [PMID: 37169656 DOI: 10.1016/j.jfma.2023.04.020] [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: 09/16/2022] [Revised: 04/01/2023] [Accepted: 04/23/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND To analyze the predictability of an automatic tube compensation (ATC) screening test compared with the conventional direct liberation test performed before continuous oxygen support for MV liberation. METHODS This retrospective study analyzed tracheostomized patients with prolonged MV in a weaning unit of a medical center in Taiwan. In March 2020, a four-day ATC test to screen patient eligibility for ventilator liberation was implemented, intended to replace the direct liberation test. We compared the predictive accuracy of these two screening methods on the relevant outcomes in the two years before and one year after the implementation of this policy. RESULTS Of the 403 cases, 246 (61%) and 157 (39%) received direct liberation and ATC screening tests, respectively. These two groups had similar outcomes: successful weaning upon leaving the Respiratory Care Center (RCC), success on day 100 of MV, success at hospital discharge, and in-hospital survival. Receiver operating characteristic curve analysis showed that the ATC screening test had better predictive ability than the direct liberation test for RCC weaning, discharge weaning, 100-day weaning, and in-hospital survival. CONCLUSION This closed-circuit ATC screening test before ventilator liberation is a feasible and valuable method for screening PMV patients undergoing ventilator liberation in the pandemic era. Its predictability for a comparison with the open-circuit oxygen test requires further investigation.
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Affiliation(s)
- Chia-Hao Wu
- Department of Internal Medicine, National Taiwan University Hospital Hsin-chu Branch, Hsin-chu, Taiwan.
| | - Feng-Ching Lin
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan.
| | - Jih-Shuin Jerng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Ming-Hann Shin
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan.
| | - Yi-Chia Wang
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan.
| | - Cheng-Jun Lee
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan.
| | - Li-Min Lin
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan.
| | - Nai-Hua Lin
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan.
| | - Yao-Wen Kuo
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan.
| | - Shih-Chi Ku
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Huey-Dong Wu
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan.
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Lemyze M, Komorowski M, Mallat J, Arumadura C, Pauquet P, Kos A, Granier M, Grosbois JM. Early Intensive Physical Rehabilitation Combined with a Protocolized Decannulation Process in Tracheostomized Survivors from Severe COVID-19 Pneumonia with Chronic Critical Illness. J Clin Med 2022; 11:jcm11133921. [PMID: 35807206 PMCID: PMC9267397 DOI: 10.3390/jcm11133921] [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: 06/08/2022] [Revised: 06/27/2022] [Accepted: 07/03/2022] [Indexed: 01/27/2023] Open
Abstract
(1) Background: Intensive care unit (ICU) survivors from severe COVID-19 acute respiratory distress syndrome (CARDS) with chronic critical illness (CCI) may be considered vast resource consumers with a poor prognosis. We hypothesized that a holistic approach combining an early intensive rehabilitation with a protocol of difficult weaning would improve patient outcomes (2) Methods: A single-center retrospective study in a five-bed post-ICU weaning and intensive rehabilitation center with a dedicated fitness room specifically equipped to safely deliver physical activity sessions in frail patients with CCI. (3) Results: Among 502 CARDS patients admitted to the ICU from March 2020 to March 2022, 50 consecutive tracheostomized patients were included in the program. After a median of 39 ICU days, 25 days of rehabilitation were needed to restore patients’ autonomy (ADL, from 0 to 6; p < 0.001), to significantly improve their aerobic capacity (6-min walking test distance, from 0 to 253 m; p < 0.001) and to reduce patients’ vulnerability (frailty score, from 7 to 3; p < 0.001) and hospital anxiety and depression scale (HADS, from 18 to 10; p < 0.001). Forty-eight decannulated patients (96%) were discharged home. (4) Conclusions: A protocolized weaning strategy combined with early intensive rehabilitation in a dedicated specialized center boosted the physical and mental recovery.
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Affiliation(s)
- Malcolm Lemyze
- Department of Critical Care Medicine, Arras Hospital, 62000 Arras, France; (C.A.); (P.P.); (A.K.); (M.G.)
- Correspondence:
| | - Matthieu Komorowski
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Exhibition Road, London SW7 2AZ, UK;
| | - Jihad Mallat
- Department of Critical Care Medicine, Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi 112412, United Arab Emirates;
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA
- Faculty of Medicine, Normandy University, UNICAEN, ED 497, 14032 Caen, France
| | - Clotilde Arumadura
- Department of Critical Care Medicine, Arras Hospital, 62000 Arras, France; (C.A.); (P.P.); (A.K.); (M.G.)
| | - Philippe Pauquet
- Department of Critical Care Medicine, Arras Hospital, 62000 Arras, France; (C.A.); (P.P.); (A.K.); (M.G.)
| | - Adrien Kos
- Department of Critical Care Medicine, Arras Hospital, 62000 Arras, France; (C.A.); (P.P.); (A.K.); (M.G.)
| | - Maxime Granier
- Department of Critical Care Medicine, Arras Hospital, 62000 Arras, France; (C.A.); (P.P.); (A.K.); (M.G.)
| | - Jean-Marie Grosbois
- Home-Based Rehabilitation Center, FormAction Santé, 59840 Pérenchies, France;
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Chu YR, Liu CJ, Chu CC, Kung PT, Chou WY, Tsai WC. Stress on caregivers providing prolonged mechanical ventilation patient care in different facilities: A cross-sectional study. PLoS One 2022; 17:e0268884. [PMID: 35613142 PMCID: PMC9132287 DOI: 10.1371/journal.pone.0268884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 05/11/2022] [Indexed: 11/18/2022] Open
Abstract
Purpose Taiwan has implemented an integrated prospective payment program (IPP) for prolonged mechanical ventilation (PMV) patients that consists of four stages of care: intensive care unit (ICU), respiratory care center (RCC), respiratory care ward (RCW), and respiratory home care (RHC). We aimed to investigate the life impact on family caregivers of PMV patients opting for a payment program and compared different care units. Method A total of 610 questionnaires were recalled. Statistical analyses were conducted by using the chi-square test and multivariate logistic regression model. Results The results indicated no associations between caregivers’ stress levels and opting for a payment program. Participants in the non-IPP group spent less time with friends and family owing to caregiver responsibilities. The results of the family domain show that the RHC group (OR = 2.54) had worsened family relationships compared with the ICU group; however, there was less psychological stress in the RCC (OR = 0.54) and RCW (OR = 0.16) groups than in the ICU group. In the social domain, RHC interviewees experienced reduced friend and family interactivity (OR = 2.18) and community or religious activities (OR = 2.06) than the ICU group. The RCW group felt that leisure and work time had less effect (OR = 0.37 and 0.41) than the ICU group. Furthermore, RCW interviewees (OR = 0.43) were less influenced by the reduced family income than the ICU group in the economic domain. Conclusions RHC family caregivers had the highest level of stress, whereas family caregivers in the RCW group had the lowest level of stress.
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Affiliation(s)
- Yeong-Ruey Chu
- Department of Public Health, China Medical University, Taichung, Taiwan
| | - Chin-Jung Liu
- Department of Respiratory Therapy, China Medical University Hospital, Taichung, Taiwan
- School of Nursing, China Medical University, Taichung, Taiwan
| | - Chia-Chen Chu
- Department of Respiratory Therapy, China Medical University Hospital, Taichung, Taiwan
| | - Pei-Tseng Kung
- Department of Healthcare Administration, Asia University, Taichung, Taiwan
| | - Wen-Yu Chou
- Department of Health Services Administration, China Medical University, Taichung, Taiwan
| | - Wen-Chen Tsai
- Department of Health Services Administration, China Medical University, Taichung, Taiwan
- * E-mail:
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Escobar MA, Navarro E, Rositi ES, Obligado R, Morel Vulliez GG, De Vito EL. [Respiratory and physical recovery in cervical spinal cord injury. Seventeen years' experience in a weaning and rehabilitation center: An observational study]. Rehabilitacion (Madr) 2022; 56:125-132. [PMID: 33256992 DOI: 10.1016/j.rh.2020.10.009] [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: 05/23/2020] [Revised: 10/22/2020] [Accepted: 10/25/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION AND OBJECTIVES Spinal cord injury (SCI) is a devastating entity that generates substantial disability. The outcome of respiratory and motor features has an impact in human and social well-being. We analyzed demographic characteristics, motor and respiratory outcomes, and determined equipment needs at discharge in a weaning and rehabilitation center. MATERIAL AND METHOD Observational, descriptive and retrospective study of medical records between January 2002 and December 2018. Tracheostomised cervical SCI patients with invasive mechanical ventilation were included. Forced vital capacity (upright and supine), maximal inspiratory and expiratory pressures, ASIA and Spinal Cord Independence MeasureIII (SCIMIII) were obtained. RESULTS Of 1603 patients, 3.5% had SCI, and 28 met the inclusion criteria. The most frequent level of injury was C4-C5 (17/28), 21/28 had ASIAA classification, and 19 showed no change in either the ASIA or the SCIM score. In all, 22/28 patients were weaned, while 15/28 were decannulated. Twenty four patients were discharged to home. The most relevant change in SCIMIII was in the 5th component of respiration and sphincter subscale, related to weaning and tracheostomy. At discharge, 23/24 patients needed both respiratory and motor aids. CONCLUSIONS The admission rate of SCI patients was low in our weaning and rehabilitation center, with almost all being admitted for traumatic causes. Severity remained unchanged in most ASIAA patients. Respiratory recovery was more clinically significant than recovery of motor function. Upon discharge, most of our patients had to be equipped with both respiratory and motor aids.
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Affiliation(s)
- M A Escobar
- Centro del Parque, Ciudad Autónoma de Buenos Aires, Argentina; Servicio de Kinesiología y Fisiatría, Hospital Municipal de Vicente López Dr. B. Houssay, Ciudad Autónoma de Buenos Aires, Argentina
| | - E Navarro
- Centro del Parque, Ciudad Autónoma de Buenos Aires, Argentina; Unidad de Kinesiología, Hospital Carlos G. Durand, Ciudad Autónoma de Buenos Aires, Argentina.
| | - E S Rositi
- Centro del Parque, Ciudad Autónoma de Buenos Aires, Argentina; Servicio de Kinesiología, HIGA Petrona V. de Cordero, San Fernando, Buenos Aires, Argentina
| | - R Obligado
- Centro del Parque, Ciudad Autónoma de Buenos Aires, Argentina
| | - G G Morel Vulliez
- Centro del Parque, Ciudad Autónoma de Buenos Aires, Argentina; Servicio de Rehabilitación, HIGA Eva Perón, San Martín, Buenos Aires, Argentina
| | - E L De Vito
- Centro del Parque, Ciudad Autónoma de Buenos Aires, Argentina; Instituto de Investigaciones Médicas Alfredo Lanari, UBA, Argentina
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Smolin B, Raz-Pasteur A, Mashiach T, Zaidani H, Levi L, Strizevsky A, King DA, Dwolatzky T. Mechanical ventilation for older medical patients in a large tertiary medical care center. Eur Geriatr Med 2021; 13:253-265. [PMID: 34542845 PMCID: PMC8450715 DOI: 10.1007/s41999-021-00557-6] [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: 03/11/2021] [Accepted: 08/26/2021] [Indexed: 11/17/2022]
Abstract
Aim The aim of the study is to determine the factors influencing the outcomes of older ventilated medical patients in a large tertiary medical center. Findings Of 554 older patients (mean age 79 years) who underwent mechanical ventilation for the first time during the study period in-hospital mortality was 64.1% and overall 6-months survival was 26%. A combination of age 85 years and older, poor functional status prior to ventilation, and associated morbidity were the strongest negative predictors of survival after discharge from the hospital. Message The identification of factors predicting poor survival of mechanical ventilation will assist policy makers in clinical decision-making particularly at times of limited health resources. Background The development of technologies for the prolongation of life has resulted in an increase in the number of older ventilated patients in internal medicine and chronic care wards. Our study aimed to determine the factors influencing the outcomes of older ventilated medical patients in a large tertiary medical center. Methods We performed a prospective observational cohort study including all newly ventilated medical patients aged 65 years and older over a period of 18 months. Data were acquired from computerized medical records and from an interview of the medical personnel initiating mechanical ventilation. Results A total of 554 patients underwent mechanical ventilation for the first time during the study period. The average age was 79 years, and 80% resided at home. Following mechanical ventilation, 8% died in the emergency room, and the majority of patients (351; 63%) were hospitalized in internal medicine wards. In-hospital mortality was 64.1%, with 48% dying during the first week of hospitalization. Overall 6-months survival was 26%. We found that a combination of age 85 years and older, functional status prior to ventilation, and associated morbidity (diabetes with target organ injury and/or oncological solid organ disease) were the strongest negative predictors of survival after discharge from the hospital. Conclusion Mechanical ventilation at older age is associated with poor survival and it is possible to identify factors predicting survival. In the midst of the COVID-19 pandemic, the findings of this study may help in the decision-making process regarding mechanical ventilation for older people.
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Affiliation(s)
- Bella Smolin
- Internal Medicine Division, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Ayelet Raz-Pasteur
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.,Internal Medicine Ward "A", Rambam Health Care Campus, Haifa, Israel
| | - Tatiana Mashiach
- Epidemiology and Statistics Unit, Rambam Health Care Campus, Haifa, Israel
| | - Hisam Zaidani
- Internal Medicine Division, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Leon Levi
- Medical Administration, Rambam Health Care Campus, Haifa, Israel
| | | | - Daniel A King
- Pulmonary and Respiratory Intensive Care Division, Meir Medical Center, Kfar Saba, Israel
| | - Tzvi Dwolatzky
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel. .,Pulmonary and Respiratory Intensive Care Division, Meir Medical Center, Kfar Saba, Israel. .,Geriatric Unit, Rambam Health Care Campus, 8 Ha'Aliyah Street, Box 9602, 3109601, Haifa, Israel.
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Sumarsono N, Sudore RL, Smith AK, Pantilat SZ, Anderson WG, Makam AN. Availability of Palliative Care in Long-Term Acute Care Hospitals. J Am Med Dir Assoc 2021; 22:2207-2211. [PMID: 33965406 PMCID: PMC10186213 DOI: 10.1016/j.jamda.2021.04.007] [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: 11/30/2020] [Revised: 03/30/2021] [Accepted: 04/03/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the availability of palliative care programs in long-term acute care hospitals (LTACHs) DESIGN: Cross-sectional analysis using the 2016 American Hospital Association (AHA) Annual Survey. SETTING AND PARTICIPANTS LTACHs in the United States. METHOD We used descriptive analyses to compare the prevalence of palliative care programs in LTACHs across the United States in 2016. For LTACHs without a program, we also examined palliative care physician capacity in regions where those LTACHs resided to evaluate if expertise existed in those regions. RESULTS One-third (36.5%) of 405 LTACHs (50.6% response rate) self-reported having a palliative care program. Among LTACHs without palliative care, 42.4% were in regions with the highest palliative care physician capacity nationwide. CONCLUSIONS AND IMPLICATIONS LTACHs care for patients with serious and prolonged illnesses, many of whom would benefit from palliative care. Despite this, our study finds that specialty palliative care is limited in LTACHs. The limited palliative care availability in LTACHs is mismatched with the needs of this seriously ill population. Greater focus on increasing palliative care in LTACHs is essential and may be feasible as 40% of LTACHs without a palliative care program were located in regions with the highest palliative care physician capacity.
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Affiliation(s)
- Nathan Sumarsono
- University of Texas Southwestern School of Medicine, Dallas, TX, USA
| | - Rebecca L Sudore
- Division of Geriatrics, University of California, San Francisco, CA, USA; San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Alexander K Smith
- Division of Geriatrics, University of California, San Francisco, CA, USA; San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Steven Z Pantilat
- Division of Palliative Medicine, University of California, San Francisco, CA, USA
| | - Wendy G Anderson
- Division of Hospital Medicine, San Francisco General Hospital, University of California, San Francisco, CA, USA; Supportive and Palliative Care Program, San Francisco General Hospital, University of California, San Francisco, CA, USA
| | - Anil N Makam
- Division of Hospital Medicine, San Francisco General Hospital, University of California, San Francisco, CA, USA; Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, CA, USA.
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Park C, Ko RE, Jung J, Na SJ, Jeon K. Prediction of successful de-cannulation of tracheostomised patients in medical intensive care units. Respir Res 2021; 22:131. [PMID: 33910566 PMCID: PMC8080087 DOI: 10.1186/s12931-021-01732-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 04/25/2021] [Indexed: 11/28/2022] Open
Abstract
Background Limited data are available on practical predictors of successful de-cannulation among the patients who undergo tracheostomies. We evaluated factors associated with failed de-cannulations to develop a prediction model that could be easily be used at the time of weaning from MV. Methods In a retrospective cohort of 346 tracheostomised patients managed by a standardized de-cannulation program, multivariable logistic regression analysis identified variables that were independently associated with failed de-cannulation. Based on the logistic regression analysis, the new predictive scoring system for successful de-cannulation, referred to as the DECAN score, was developed and then internally validated. Results The model included age > 67 years, body mass index < 22 kg/m2, underlying malignancy, non-respiratory causes of mechanical ventilation (MV), presence of neurologic disease, vasopressor requirement, and presence of post-tracheostomy pneumonia, presence of delirium. The DECAN score was associated with good calibration (goodness-of-fit, 0.6477) and discrimination outcomes (area under the receiver operating characteristic curve 0.890, 95% CI 0.853–0.921). The optimal cut-off point for the DECAN score for the prediction of the successful de-cannulation was ≤ 5 points, and was associated with the specificities of 84.6% (95% CI 77.7–90.0) and sensitivities of 80.2% (95% CI 73.9–85.5). Conclusions The DECAN score for tracheostomised patients who are successfully weaned from prolonged MV can be computed at the time of weaning to assess the probability of de-cannulation based on readily available variables.
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Affiliation(s)
- Chul Park
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.,Department of Pulmonary Medicine, Wonkwang Medical Center, Iksan, Republic of Korea
| | - Ryoung-Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Jinhee Jung
- Intensive Care Unit Nursing Department, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea. .,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.
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SARIÇAM G. Stroke in long-term intensive care unit. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2021. [DOI: 10.32322/jhsm.823564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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11
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Prolonged Mechanical Ventilation: The Journey Toward the Goal. Crit Care Med 2020; 47:1666-1667. [PMID: 31609266 DOI: 10.1097/ccm.0000000000003987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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12
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Huang C. How prolonged mechanical ventilation is a neglected disease in chest medicine: a study of prolonged mechanical ventilation based on 6 years of experience in Taiwan. Ther Adv Respir Dis 2020; 13:1753466619878552. [PMID: 31566093 PMCID: PMC6769206 DOI: 10.1177/1753466619878552] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: An increasing number of patients require prolonged mechanical ventilation (PMV) to survive recovery from critical care. It should be emphasized that PMV is a neglected disease in chest medicine. We investigated 6 years of clinical outcomes and long-term survival rates of patients who required PMV. Methods: We analyzed retrospectively data from patients in respiratory care center (RCC) to investigate the main causes of respiratory failure leading patients to require PMV. We also studied the factors that influence the ventilator weaned rate, factors that influence the long-term ventilator dependence of patients who require PMV, as well as patients’ hospital mortality and long-term survival rates. Results: A total of 574 patients were admitted to RCC during the 6 years. Of these, 428 patients (74.6%) were older than 65 years. A total of 391 patients (68.1%) were successfully weaned from the ventilator while 83 patients (14.4%) were unsuccessfully weaned. A total of 95 patients (16.6%) died during RCC hospitalization. The most common cause of acute respiratory failure leading to patients requiring PMV was pneumonia. The factor that affected whether patients were successfully weaned from the ventilator was the cause of the respiratory failure that lead patients to require PMV. Our hospital mortality rate was 32.4%; the 1-year survival rate was 24.3%. There was a strong correlation between higher patient age and higher hospital mortality rate and poor 1-year survival rate. Patients with no comorbidity demonstrated good 1-year survival rates. Patients with four comorbidities and patients with end-stage renal disease requiring hemodialysis comorbidity showed poor 1-year survival rates. Conclusions: The factor that affected whether patients were successfully weaned from the ventilator was the cause of the respiratory failure that lead patients to require PMV. Older patients, patients with renal failure requiring hemodialysis, and those with numerous comorbidities demonstrated poor long-term survival. The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Chienhsiu Huang
- Department of Internal Medicine, Division of Chest Medicine, Dalin Tzu Chi Hospital, NO. 2, Min-Sheng Road, Dalin Town, Chiayi County, 62247, Taiwan
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13
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Lin SJ, Jerng JS, Kuo YW, Wu CL, Ku SC, Wu HD. Maximal expiratory pressure is associated with reinstitution of mechanical ventilation after successful unassisted breathing trials in tracheostomized patients with prolonged mechanical ventilation. PLoS One 2020; 15:e0229935. [PMID: 32155187 PMCID: PMC7064239 DOI: 10.1371/journal.pone.0229935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 02/17/2020] [Indexed: 01/01/2023] Open
Abstract
Objective Reinstitution of mechanical ventilation (MV) for tracheostomized patients after successful weaning may occur as the care setting changes from critical care to general care. We aimed to investigate the occurrence, consequence and associated factors of MV reinstitution. Methods We analyzed the clinical data and physiological measurements of tracheostomized patients with prolonged MV discharged from the weaning unit to general wards after successful weaning to compare between those with and without in-hospital MV reinstitution within 60 days. Results Of 454 patients successfully weaned, 116 (25.6%) reinstituted MV at general wards within 60 days; at hospital discharge, 42 (36.2%) of them were eventually liberated from MV, 51 (44.0%) remained MV dependent, and 33 (28.4%) died. Of the 338 patients without reinstitution within 60 days, only 3 (0.9%) were later reinstituted with MV before discharge (on day 67, 89 and 136 at general wards, respectively), and 322 (95.2%) were successfully weaned again at discharge, while 13 (3.8%) died. Patients with MV reinstitution had a significantly lower level of maximal expiratory pressure (PEmax) before unassisted breathing trial compared to those without reinstitution. Multivariable Cox regression analysis showed fever at RCC discharge (hazard ratio [HR] 14.00, 95% confidence interval [CI] 3.2–61.9) chronic obstructive pulmonary disease (HR 2.37, 95% CI 1.34–4.18), renal replacement therapy at the ICU (HR 2.29, 95% CI 1.50–3.49) and extubation failure before tracheostomy (HR 1.76, 95% CI 1.18–2.63) were associated with increased risks of reinstitution, while PEmax > 30 cmH2O (HR 0.51, 95% CI 0.35–0.76) was associated with a decreased risk of reinstitution. Conclusions The reinstitution of MV at the general ward is significant, with poor outcomes. The PEmax measured before unassisted breathing trial was significantly associated with the risk of reinstituting MV at the general wards.
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Affiliation(s)
- Shwu-Jen Lin
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Jih-Shuin Jerng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- * E-mail:
| | - Yao-Wen Kuo
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Chao-Ling Wu
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Shih-Chi Ku
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Huey-Dong Wu
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
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14
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Jubran A, Grant BJB, Duffner LA, Collins EG, Lanuza DM, Hoffman LA, Tobin MJ. Long-Term Outcome after Prolonged Mechanical Ventilation. A Long-Term Acute-Care Hospital Study. Am J Respir Crit Care Med 2020; 199:1508-1516. [PMID: 30624956 DOI: 10.1164/rccm.201806-1131oc] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Rationale: Patients managed at a long-term acute-care hospital (LTACH) for weaning from prolonged mechanical ventilation are at risk for profound muscle weakness and disability. Objectives: To investigate effects of prolonged ventilation on survival, muscle function, and its impact on quality of life at 6 and 12 months after LTACH discharge. Methods: This was a prospective, longitudinal study conducted in 315 patients being weaned from prolonged ventilation at an LTACH. Measurements and Main Results: At discharge, 53.7% of patients were detached from the ventilator and 1-year survival was 66.9%. On enrollment, maximum inspiratory pressure (Pimax) was 41.3 (95% confidence interval, 39.4-43.2) cm H2O (53.1% predicted), whereas handgrip strength was 16.4 (95% confidence interval, 14.4-18.7) kPa (21.5% predicted). At discharge, Pimax did not change, whereas handgrip strength increased by 34.8% (P < 0.001). Between discharge and 6 months, handgrip strength increased 6.2 times more than did Pimax. Between discharge and 6 months, Katz activities-of-daily-living summary score improved by 64.4%; improvement in Katz summary score was related to improvement in handgrip strength (r = -0.51; P < 0.001). By 12 months, physical summary score and mental summary score of 36-item Short-Form Survey returned to preillness values. When asked, 84.7% of survivors indicated willingness to undergo mechanical ventilation again. Conclusions: Among patients receiving prolonged mechanical ventilation at an LTACH, 53.7% were detached from the ventilator at discharge and 1-year survival was 66.9%. Respiratory strength was well maintained, whereas peripheral strength was severely impaired throughout hospitalization. Six months after discharge, improvement in muscle function enabled patients to perform daily activities, and 84.7% indicated willingness to undergo mechanical ventilation again.
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Affiliation(s)
- Amal Jubran
- 1 Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois.,2 Loyola University of Chicago Stritch School of Medicine, Maywood, Illinois.,3 RML Specialty Hospital, Hinsdale, Illinois
| | | | - Lisa A Duffner
- 1 Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois.,2 Loyola University of Chicago Stritch School of Medicine, Maywood, Illinois.,3 RML Specialty Hospital, Hinsdale, Illinois
| | - Eileen G Collins
- 1 Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois.,2 Loyola University of Chicago Stritch School of Medicine, Maywood, Illinois.,3 RML Specialty Hospital, Hinsdale, Illinois.,5 University of Illinois at Chicago, Chicago, Illinois
| | | | | | - Martin J Tobin
- 1 Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois.,2 Loyola University of Chicago Stritch School of Medicine, Maywood, Illinois.,3 RML Specialty Hospital, Hinsdale, Illinois
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15
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Nagata I, Takei T, Hatakeyama J, Toh M, Yamada H, Fujisawa M. Clinical features and outcomes of prolonged mechanical ventilation: a single-center retrospective observational study. JA Clin Rep 2019; 5:73. [PMID: 32026077 PMCID: PMC6966730 DOI: 10.1186/s40981-019-0284-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 09/12/2019] [Indexed: 12/05/2022] Open
Abstract
Background Information on epidemiology of prolonged mechanical ventilation (PMV) patients in the acute care setting in Japan is totally lacking. We aimed to investigate clinical features, impact, and long-term outcomes of PMV patients. Methods This was a retrospective observational study conducted in a tertiary care hospital. Adult patients who were admitted to our intensive care unit (ICU) from April 2009 to March 2014 and required mechanical ventilation (MV) for ≥ 2 days were included. PMV was defined as having MV for ≥ 21 consecutive days. Results Among 1282 MV patients, 93 (7.3%) required PMV, and median duration of MV was 37.0 days. Compared with the non-PMV patients, PMV patients had longer total ICU and high care unit (HCU) stay (34.0 vs. 7.0 days, p < 0.001), longer hospital stay (74.0 vs. 35.0 days, p < 0.001), and higher hospital mortality (54.8 vs. 21.4%, p < 0.001). In multivariable logistic regression analysis, emergency ICU admission and steroid use during MV were associated with PMV. The Kaplan–Meier curves for MV withdrawal and ICU/HCU discharge were almost identical. Among PMV patients, 52 (55.9%) died, 29 (31.2%) were successfully liberated from MV during hospitalization, and 12 (12.9%) still required MV at discharge. Conclusion In this investigation, 7.3% of the patients with MV required PMV. Most PMV patients were liberated from MV during hospitalization, while occupying critical care beds for an extended period. A nationwide survey is required to further elucidate the overall picture of PMV patients and to discuss whether specialized weaning centers to treat PMV patients are required in Japan.
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Affiliation(s)
- Isao Nagata
- Intensive Care Unit, Yokohama City Minato Red Cross Hospital, 3-12-1, Shinyamashita, Naka-ku, Yokohama, Kanagawa, 231-8682, Japan.
| | - Tetsuhiro Takei
- Intensive Care Unit, Yokohama City Minato Red Cross Hospital, 3-12-1, Shinyamashita, Naka-ku, Yokohama, Kanagawa, 231-8682, Japan
| | - Junji Hatakeyama
- Intensive Care Unit, Yokohama City Minato Red Cross Hospital, 3-12-1, Shinyamashita, Naka-ku, Yokohama, Kanagawa, 231-8682, Japan
| | - Masafumi Toh
- Intensive Care Unit, Yokohama City Minato Red Cross Hospital, 3-12-1, Shinyamashita, Naka-ku, Yokohama, Kanagawa, 231-8682, Japan
| | - Hiroyuki Yamada
- Intensive Care Unit, Yokohama City Minato Red Cross Hospital, 3-12-1, Shinyamashita, Naka-ku, Yokohama, Kanagawa, 231-8682, Japan
| | - Michiko Fujisawa
- Intensive Care Unit, Yokohama City Minato Red Cross Hospital, 3-12-1, Shinyamashita, Naka-ku, Yokohama, Kanagawa, 231-8682, Japan
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16
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Esquinas AM, Karim HMR, Mina B. In response to Na et al.'s long-term mortality of patients discharged from the hospital after successful critical care: do we need more comprehensive data? Korean J Anesthesiol 2019; 73:171-172. [PMID: 31556258 PMCID: PMC7113164 DOI: 10.4097/kja.19366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 09/04/2019] [Indexed: 11/10/2022] Open
Affiliation(s)
| | - Habib Md Reazaul Karim
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Raipur, India
| | - Bushra Mina
- Department of Pulmonary and Critical Care Medicine, Hofstra Northwell School of Medicine, Lenox Hill Hospital, New York, NY, USA
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17
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Schmidt SB, Boltzmann M, Bertram M, Bucka C, Hartwich M, Jöbges M, Ketter G, Leineweber B, Mertl-Rötzer M, Nowak DA, Platz T, Scheidtmann K, Thomas R, Rosen FV, Wallesch CW, Woldag H, Peschel P, Mehrholz J, Pohl M, Rollnik JD. Factors influencing weaning from mechanical ventilation in neurological and neurosurgical early rehabilitation patients. Eur J Phys Rehabil Med 2019. [DOI: 10.23736/s1973-9087.18.05100-6 epub 2018 jun 11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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18
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[Weaning from dialysis after acute kidney injury in chronically critically ill]. Med Klin Intensivmed Notfmed 2018; 114:459-462. [PMID: 30302526 DOI: 10.1007/s00063-018-0488-9] [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: 11/29/2017] [Revised: 07/31/2018] [Accepted: 08/30/2018] [Indexed: 10/28/2022]
Abstract
This study describes the course of renal recovery after dialysis in a specific population of chronically critically ill patients with a history of prolonged and complicated treatment in an intensive care unit. This study shows that, in a specialized center, patients can be successfully weaned from dialysis even months after acute kidney injury (AKI). Of the patients who could be recompensated (33%), approximately 20% achieved renal recovery more than 3 months after the start of dialysis. The duration of renal recovery after AKI did not differ between those patients with pre-existing chronic kidney disease (CKD) and those without. The reason for dialysis treatment such as sepsis, surgery, resuscitation, as well as the risk factors (e. g., diabetes mellitus, arterial hypertension, arteriosclerosis) did not reveal a difference in weaning in a hazard analysis. As a potential risk factor, only age significantly influenced weaning from dialysis in the multivariate hazard model.
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19
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Frengley JD, Sansone GR, Kaner RJ. Chronic Comorbid Illnesses Predict the Clinical Course of 866 Patients Requiring Prolonged Mechanical Ventilation in a Long-Term, Acute-Care Hospital. J Intensive Care Med 2018; 35:745-754. [PMID: 30270713 DOI: 10.1177/0885066618783175] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To determine whether burdens of chronic comorbid illnesses can predict the clinical course of prolonged mechanical ventilation (PMV)patients in a long-term, acute-care hospital (LTACH). METHODS Retrospective study of 866 consecutive PMV patients whose burdens of chronic comorbid illnesses were quantified using the Cumulative Illness Rating Scale (CIRS). Based on increasing CIRS scores, 6 groups were formed and compared: group A (≤25; n = 97), group B (26-28; n = 105), group C (29-31; n = 181), group D (32-34; n = 208), group E (35-37; n = 173), and group F (>37; n = 102). RESULTS As CIRS scores increased from group A to group F, rates of weaning success, home discharges, and LTACH survival declined progressively from 74% to 17%, 48% to 0%, and 79% to 21%, respectively (all P < .001). Negative correlations between the mean score of each CIRS group and correspondent outcomes also supported patients' group allocation and an accurate prediction of their clinical course (all P < .01). Long-term survival progressively declined from a median survival time of 38.9 months in group A to 3.2 months in group F (P < .001). Compared to group A, risk of death was 75% greater in group F (P = .03). Noteworthy, PMV patients with CIRS score <25 showed greater ability to recover and a low likelihood of becoming chronically critically ill. Diagnostic accuracy of CIRS to predict likelihood of weaning success, home discharges, both LTACH and long-term survival was good (area under the curves ≥0.71; all P <.001). CONCLUSIONS The burden of chronic comorbid illnesses was a strong prognostic indicator of the clinical course of PMV patients. Patients with lower CIRS values showed greater ability to recover and were less likely to become chronically critically ill. Thus, CIRS can be used to help guide clinicians caring for PMV patients in transfer decisions to and from postacute care setting.
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Affiliation(s)
- J Dermot Frengley
- Clinical Outcomes Research Group, Coler Rehabilitation and Nursing Care Center, Roosevelt Island, NY, USA.,Division of Geriatrics and Gerontology, Weill Cornell Medical College, New York city, NY, USA
| | - Giorgio R Sansone
- Clinical Outcomes Research Group, Coler Rehabilitation and Nursing Care Center, Roosevelt Island, NY, USA
| | - Robert J Kaner
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medical College, New York City, NY, USA.,Department of Genetic Medicine, Weill Cornell Medical College, NY, USA
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20
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Propensity score-matching analyses on the effectiveness of integrated prospective payment program for patients with prolonged mechanical ventilation. Health Policy 2018; 122:970-976. [PMID: 30097352 DOI: 10.1016/j.healthpol.2018.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Revised: 07/09/2018] [Accepted: 07/12/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVES An integrated delivery system with a prospective payment program (IPP) for prolonged mechanical ventilation (PMV) was launched by Taiwan's National Health Insurance (NHI) due to the costly and limited ICU resources. This study aimed to analyze the effectiveness of IPP and evaluate the factors associated with successful weaning and survival among patients with PMV. METHODS Taiwan's NHI Research Database was searched to obtain the data of patients aged ≥17 years who had PMV from 2006 to 2010 (N=50,570). A 1:1 propensity score matching approach was used to compare patients with and without IPP (N=30,576). Cox proportional hazards modeling was used to examine the factors related to successful weaning and survival. RESULTS The related factors of lower weaning rate in IPP participants (hazard ratio [HR]=0.84), were older age, higher income, catastrophic illness (HR=0.87), and higher comorbidity. The effectiveness of IPP intervention for the PMV patients showed longer days of hospitalization, longer ventilation days, higher survival rate, and higher medical costs (in respiratory care center, respiratory care ward). The 6-month mortality rate was lower (34.0% vs. 32.9%). The death risk of IPP patients compared to those non-IPP patients was lower (HR=0.91, P<0.001). CONCLUSIONS The policy of IPP for PMV patients showed higher survival rate although it was costly and related to lower weaning rate.
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21
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Schmidt SB, Boltzmann M, Bertram M, Bucka C, Hartwich M, Jöbges M, Ketter G, Leineweber B, Mertl-Rötzer M, Nowak DA, Platz T, Scheidtmann K, Thomas R, Rosen FV, Wallesch CW, Woldag H, Peschel P, Mehrholz J, Pohl M, Rollnik JD. Factors influencing weaning from mechanical ventilation in neurological and neurosurgical early rehabilitation patients. Eur J Phys Rehabil Med 2018; 54:939-946. [PMID: 29898584 DOI: 10.23736/s1973-9087.18.05100-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Studies analyzing risk factors of weaning failure in neurological and neurosurgical early rehabilitation (NNER) patients are rare. AIM The aim of this study was to identify clinical factors influencing the weaning of NNER patients. DESIGN An observational, retrospective data analysis of a German multicenter study was performed. SETTING German neurological early rehabilitation centers. POPULATION Inpatient ventilated NNER patients (N.=192) were enrolled in the study. METHODS Demographical data, main diagnosis, medical devices, special medical care and assessment instruments of functional abilities, consciousness and independence in activities of daily living were accrued and compared between patients with and without successful weaning. The prognostic power of factors associated with weaning success/failure was analyzed using binary logistic regression. RESULTS In total, 75% of the patients were successfully weaned. Colonization with multi-drug resistant bacteria and the need for dialysis were independent predictors of weaning failure. Successfully weaned patients had a shorter length of stay, better functional outcome, and lower mortality than non-successfully weaned patients. CONCLUSIONS Successfully weaned patients differ from patients with weaning failure in several clinical variables. All these variables are associated with the morbidity of the patient, indicating that the weaning process is strongly influenced by disease burden. CLINICAL REHABILITATION IMPACT Functional abilities, level of consciousness, independence in activities of daily living, colonization with multi-drug resistant bacteria, need for dialysis and disease duration might help to predict the weaning process of NNER.
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Affiliation(s)
- Simone B Schmidt
- Institute for Neurorehabilitation Research (InFo), BDH-Klinik Hessisch Oldendorf, Hannover Medical School, Hannover, Germany -
| | - Melanie Boltzmann
- Institute for Neurorehabilitation Research (InFo), BDH-Klinik Hessisch Oldendorf, Hannover Medical School, Hannover, Germany
| | | | | | | | | | - Guido Ketter
- Neurological Rehabilitation Centre "Godeshöhe", Bonn, Germany
| | | | | | | | | | | | | | | | | | - Hartwig Woldag
- Neurologisches Rehabilitationszentrum Leipzig, Leipzig, Germany
| | - Peter Peschel
- Department of Public Health, University of Dresden, Dresden, Germany
| | | | | | - Jens D Rollnik
- Institute for Neurorehabilitation Research (InFo), BDH-Klinik Hessisch Oldendorf, Hannover Medical School, Hannover, Germany
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22
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Kahn JM, Davis BS, Le TQ, Yabes JG, Chang CCH, Angus DC. Variation in mortality rates after admission to long-term acute care hospitals for ventilator weaning. J Crit Care 2018; 46:6-12. [PMID: 29627660 DOI: 10.1016/j.jcrc.2018.03.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 03/18/2018] [Accepted: 03/18/2018] [Indexed: 12/21/2022]
Abstract
PURPOSE We sought to examine variation in long-term acute care hospital (LTACH) quality based on 90-day in-hospital mortality for patients admitted for weaning from mechanical ventilation. METHODS We developed an administrative risk-adjustment model using data from Medicare claims. We validated the administrative model against a clinical model using data from LTACHs participating in a 2002 to 2003 clinical registry. We then used our validated administrative model to assess national variation in 90-day in-hospital mortality rates in LTACHs from 2013. RESULTS The administrative risk-adjustment model was derived using data from 9447 patients admitted to 221 LTACHs in 2003. The model had good discrimination (C statistic=0.72) and calibration. Compared to a clinically derived model using data from 1163 patients admitted to 14 LTACHs, the administrative model generated similar performance estimates. National variation in risk-adjusted mortality was assessed using data from 20,453 patients admitted to 380 LTACHs in 2013. LTACH-specific risk-adjusted mortality rates varied from 8.4% to 48.1% (median: 24.2%, interquartile range: 19.7%-30.7%). CONCLUSIONS LTACHs vary widely in mortality rates, underscoring the need to better understand the sources of this variation and improve the quality of care for patients requiring long-term ventilator weaning.
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Affiliation(s)
- Jeremy M Kahn
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, United States.
| | - Billie S Davis
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Tri Q Le
- Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, United States
| | - Jonathan G Yabes
- Center for Research on Health Care, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, United States
| | - Chung-Chou H Chang
- Center for Research on Health Care, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, United States
| | - Derek C Angus
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, United States
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Loss SH, Nunes DSL, Franzosi OS, Salazar GS, Teixeira C, Vieira SRR. Chronic critical illness: are we saving patients or creating victims? Rev Bras Ter Intensiva 2018; 29:87-95. [PMID: 28444077 PMCID: PMC5385990 DOI: 10.5935/0103-507x.20170013] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 09/05/2016] [Indexed: 12/15/2022] Open
Abstract
The technological advancements that allow support for organ dysfunction have led
to an increase in survival rates for the most critically ill patients. Some of
these patients survive the initial acute critical condition but continue to
suffer from organ dysfunction and remain in an inflammatory state for long
periods of time. This group of critically ill patients has been described since
the 1980s and has had different diagnostic criteria over the years. These
patients are known to have lengthy hospital stays, undergo significant
alterations in muscle and bone metabolism, show immunodeficiency, consume
substantial health resources, have reduced functional and cognitive capacity
after discharge, create a sizable workload for caregivers, and present high
long-term mortality rates. The aim of this review is to report on the most
current evidence in terms of the definition, pathophysiology, clinical
manifestations, treatment, and prognosis of persistent critical illness.
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Affiliation(s)
- Sergio Henrique Loss
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil.,Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre - Porto Alegre (RS), Brasil
| | - Diego Silva Leite Nunes
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Oellen Stuani Franzosi
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil.,Departamento de Nutrição, Hospital de Clínicas de Porto Alegre - Porto Alegre (RS), Brasil
| | | | - Cassiano Teixeira
- Faculdade de Medicina, Universidade Federal de Ciências da Saúde de Porto Alegre - Porto Alegre (RS), Brasil
| | - Silvia Regina Rios Vieira
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil.,Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre - Porto Alegre (RS), Brasil.,Departamento de Clínica Médica, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
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24
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Muzaffar SN, Gurjar M, Baronia AK, Azim A, Mishra P, Poddar B, Singh RK. Predictors and pattern of weaning and long-term outcome of patients with prolonged mechanical ventilation at an acute intensive care unit in North India. Rev Bras Ter Intensiva 2018; 29:23-33. [PMID: 28444069 PMCID: PMC5385982 DOI: 10.5935/0103-507x.20170005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 11/20/2016] [Indexed: 11/26/2022] Open
Abstract
Objective This study aimed to examine the clinical characteristics, weaning pattern,
and outcome of patients requiring prolonged mechanical ventilation in acute
intensive care unit settings in a resource-limited country. Methods This was a prospective single-center observational study in India, where all
adult patients requiring prolonged ventilation were followed for weaning
duration and pattern and for survival at both intensive care unit discharge
and at 12 months. The definition of prolonged mechanical ventilation used
was that of the National Association for Medical Direction of Respiratory
Care. Results During the one-year period, 49 patients with a mean age of 49.7 years had
prolonged ventilation; 63% were male, and 84% had a medical illness. The
median APACHE II and SOFA scores on admission were 17 and 9, respectively.
The median number of ventilation days was 37. The most common reason for
starting ventilation was respiratory failure secondary to sepsis (67%).
Weaning was initiated in 39 (79.5%) patients, with success in 34 (87%). The
median weaning duration was 14 (9.5 - 19) days, and the median length of
intensive care unit stay was 39 (32 - 58.5) days. Duration of vasopressor
support and need for hemodialysis were significant independent predictors of
unsuccessful ventilator liberation. At the 12-month follow-up, 65% had
survived. Conclusion In acute intensive care units, more than one-fourth of patients with invasive
ventilation required prolonged ventilation. Successful weaning was achieved
in two-thirds of patients, and most survived at the 12-month follow-up.
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Affiliation(s)
- Syed Nabeel Muzaffar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences - Lucknow, Índia
| | - Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences - Lucknow, Índia
| | - Arvind K Baronia
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences - Lucknow, Índia
| | - Afzal Azim
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences - Lucknow, Índia
| | - Prabhakar Mishra
- Department of Biostatistics & Health Informatics, Sanjay Gandhi Postgraduate Institute of Medical Sciences - Lucknow, Índia
| | - Banani Poddar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences - Lucknow, Índia
| | - Ratender K Singh
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences - Lucknow, Índia
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Hospital Variation in Early Tracheostomy in the United States: A Population-Based Study. Crit Care Med 2017; 44:1506-14. [PMID: 27031382 DOI: 10.1097/ccm.0000000000001674] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Controversy exists regarding perceived benefits of early tracheostomy to facilitate weaning among mechanically ventilated patients, potentially leading to significant practice-pattern variation with implications for outcomes and resource utilization. We sought to determine practice-pattern variation and outcomes associated with tracheostomy timing in the United States. DESIGN In a retrospective cohort study, we identified mechanically ventilated patients with the most common causes of respiratory failure leading to tracheostomy: pneumonia/sepsis and trauma. "Early tracheostomy" was performed within the first week of mechanical ventilation. We determined between-hospital variation in early tracheostomy utilization and the association of early tracheostomy with patient outcomes using hierarchical regression. SETTING 2012 National Inpatient Sample. PATIENTS A total of 6,075 pneumonia/sepsis patients and 12,030 trauma patients with tracheostomy. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Trauma patients were twice as likely as pneumonia/sepsis patients to receive early tracheostomy (44.5% vs 21.7%; p < 0.001). Admission to hospitals with higher early tracheostomy-to-total-tracheostomy ratios was associated with increased risk for tracheostomy among mechanically ventilated trauma patients (adjusted odds ratio = 1.04; 95% CI, 1.01-1.07) but not pneumonia/sepsis (adjusted odds ratio =1.00; 95% CI, 0.98-1.02). We observed greater between-hospital variation in early tracheostomy rates among trauma patients (21.9-81.9%) compared with pneumonia/sepsis (14.9-38.3%; p < 0.0001). We found no evidence of improved hospital mortality. Pneumonia/sepsis patients with early tracheostomy had fewer feeding tube procedures and higher odds of discharge home. CONCLUSION Early tracheostomy is potentially overused among mechanically ventilated trauma patients, with nearly half of tracheostomies performed within the first week of mechanical ventilation and large unexplained hospital variation, without clear benefits. Future studies are needed to characterize potentially differential benefits for early tracheostomy between disease subgroups and to investigate factors driving hospital variation in tracheostomy timing.
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Girault C, Gacouin A. [Tracheotomy and high-flow oxygen therapy for mechanical ventilation weaning]. Rev Mal Respir 2017; 34:465-476. [PMID: 28502365 DOI: 10.1016/j.rmr.2017.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- C Girault
- Service de réanimation médicale, hôpital Charles-Nicolle, groupe de recherche sur le handicap ventilatoire (GRHV), UPRES EA 3830-institut de recherche et d'innovation biomédicale (IRIB), faculté de médecine et de pharmacie, université de Rouen, centre hospitalier universitaire-hôpitaux de Rouen, 76031 Rouen cedex, France
| | - A Gacouin
- Inserm-CIC, service des maladies infectieuses et réanimation médicale, hôpital Pontchaillou, centre hospitalier universitaire de Rennes, 35043 Rennes, France.
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Shin HJ, Chang JS, Ahn S, Kim TO, Park CK, Lim JH, Oh IJ, Kim YI, Lim SC, Kim YC, Kwon YS. Clinical factors associated with weaning failure in patients requiring prolonged mechanical ventilation. J Thorac Dis 2017; 9:143-150. [PMID: 28203417 DOI: 10.21037/jtd.2017.01.14] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND For patients requiring prolonged mechanical ventilation (PMV), weaning is difficult and mortality is very high. PMV has been defined recently, by consensus, as constituting ≥21 consecutive days of mechanical ventilation (MV) for ≥6 hours per day. This study aimed to evaluate the clinical factors predicting weaning failure in patients undergoing PMV in medical intensive care unit (ICU). METHODS We retrospectively reviewed the clinical and laboratory characteristics of 127 patients who received MV for more than 21 days in the medical ICU at Chonnam National University Hospital in South Korea between January 2005 and December 2014. Patients who underwent surgery or experienced trauma were excluded from this study. RESULTS Among the 127 patients requiring PMV, 41 (32.3%) were successfully weaned from MV. The median age of the weaning failure group was higher than that of the weaning success group (74.0 vs. 70.0 years; P=0.003). The proportion of male patients was 58.5% in the weaning success group and 72.1% in the weaning failure group, respectively. The most common reasons for ICU admission were respiratory causes (66.1%) followed by cardiovascular causes (16.5%) in both groups. ICU mortality and in-hospital mortality rates were 55.1% and 55.9%, respectively. In the multivariate analysis, respiratory causes of ICU admission [odds ratio (OR), 3.98; 95% confidence interval (CI), 1.29-12.30; P=0.016] and a high sequential organ failure assessment (SOFA) score on day 21 of MV (OR, 1.47; 95% CI, 1.17-1.85; P=0.001) were significantly associated with weaning failure in patients requiring PMV. The area under the receiver operating characteristic (ROC) curve of the SOFA score on day 21 of MV for predicting weaning failure was 0.77 (95% CI, 0.67-0.87; P=0.000). CONCLUSIONS Respiratory causes of ICU admission and a high SOFA score on day 21 of MV could be predictive of weaning failure in patients requiring PMV.
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Affiliation(s)
- Hong-Joon Shin
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Jin-Sun Chang
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Seong Ahn
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Tae-Ok Kim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Cheol-Kyu Park
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Jung-Hwan Lim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - In-Jae Oh
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Yu-Il Kim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Sung-Chul Lim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Young-Chul Kim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Yong-Soo Kwon
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
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Sansone GR, Frengley JD, Horland A, Vecchione JJ, Kaner RJ. Effects of Reinstitution of Prolonged Mechanical Ventilation on the Outcomes of 370 Patients in a Long-Term Acute Care Hospital. J Intensive Care Med 2016; 33:527-535. [PMID: 30095035 DOI: 10.1177/0885066616683669] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To investigate the effects of the reinstitution of continuous mechanical ventilator support of >21 days in 370 prolonged mechanical ventilation (PMV) patients, all free from ventilator support for ≥5 days. METHODS Four groups were formed based on the time and number of PMV reinstitutions and compared (group A: reinstitutions within 28 days, n = 51; group B: a single reinstitution after 28 days, n = 53; group C: multiple reinstitutions after 28 days, n = 52; and group D: no known reinstitutions, n = 214). RESULTS Of the 370 patients, 156 (42%) required PMV reinstitutions. Most reinstitutions occurred within 7 months: 51 (33%) of the 156 patients within 28 days and 49 (31%) within the next 6 months. Group comparisons revealed a progression of outcomes from group A, the worst, to group D, the best, with groups B and C having intermediate but significantly different values. Decannulation was associated with an 88% decreased risk of PMV reinstitution and a 43% lower risk of death (all P < .001). CONCLUSION Prolonged mechanical ventilation reinstitution rates were high, with most occurring within 7 months of freedom from MV. In general, the longer the period of ventilator freedom, the less the likelihood of a PMV reinstitution. The identification of 4 distinct PMV groups of patients by time and number of reinstitutions added useful prognostic information. Since PMV reinstitutions within 28 days lead to permanent MV support, >28 days of ventilator freedom provided an optimal cut point for assessing the likelihood of again requiring PMV.
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Affiliation(s)
- Giorgio R Sansone
- 1 Clinical Outcomes Research Group, Coler Rehabilitation and Nursing Care Center, New York, NY, USA
| | - J Dermot Frengley
- 1 Clinical Outcomes Research Group, Coler Rehabilitation and Nursing Care Center, New York, NY, USA.,2 Division of Geriatrics and Gerontology, Weill Cornell Medical College, New York, NY, USA
| | - Allan Horland
- 1 Clinical Outcomes Research Group, Coler Rehabilitation and Nursing Care Center, New York, NY, USA
| | - John J Vecchione
- 1 Clinical Outcomes Research Group, Coler Rehabilitation and Nursing Care Center, New York, NY, USA
| | - Robert J Kaner
- 3 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medical College, New York, NY, USA.,4 Department of Genetic Medicine, Weill Cornell Medical College, New York, NY, USA
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Depuydt P, Oeyen S, De Smet S, De Raedt S, Benoit D, Decruyenaere J, Derom E. Long-term outcome and health-related quality of life in difficult-to-wean patients with and without ventilator dependency at ICU discharge: a retrospective cohort study. BMC Pulm Med 2016; 16:133. [PMID: 27677445 PMCID: PMC5039890 DOI: 10.1186/s12890-016-0295-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 06/24/2016] [Indexed: 11/16/2022] Open
Abstract
Background Long-term outcome and quality of life (QOL) in patients requiring prolonged mechanical ventilation after failure to wean in the ICU is scarcely documented. We aimed to evaluate long-term survival and QOL in patients discharged from the ICU with a tracheostomy for difficult weaning, and with or without ventilator dependency at ICU discharge. Methods We retrospectively investigated post-ICU trajectories and survival in patients requiring tracheostomy for difficult weaning admitted to the medical ICU of a tertiary center between 1999 and 2013, discriminating between patients who were ventilator dependent or were weaned at ICU discharge. In 2014, a QOL assessment was done in survivors with the use of the Short Form Health Survey (SF-36) and the Severe Respiratory Insufficiency questionnaire. Results A total of 114 patients was included, of whom 59 were ventilator dependent and 55 were weaned at ICU discharge. One-year survival rates were 73 % and 69 %, respectively. Overall QOL scores for physical functioning were low, and not significantly different between patients ventilated and those weaned at ICU discharge; scores for social functioning and mental health were less below norm and similar between both groups. Conclusions Long-term survival in patients discharged from the ICU with tracheostomy and ventilator dependency after failure to wean was not significantly different from that of patients with tracheostomy and weaned at ICU discharge. Despite the physical QOL scores being low in both groups, mental QOL was acceptable. Given the intrinsic limitations of this retrospective study, prospective and preferentially multicenter studies are required to confirm these preliminary results.
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Affiliation(s)
- P Depuydt
- Intensive Care Department, Ghent University Hospital, De Pintelaan 185, Ghent, 9000, Belgium. .,Heymans Institute of Pharmacology, Ghent University Hospital, De Pintelaan 185, Ghent, 9000, Belgium.
| | - S Oeyen
- Intensive Care Department, Ghent University Hospital, De Pintelaan 185, Ghent, 9000, Belgium
| | - S De Smet
- Ghent University, Sint-Pietersnieuwstraat 10, Ghent, 9000, Belgium
| | - S De Raedt
- Ghent University, Sint-Pietersnieuwstraat 10, Ghent, 9000, Belgium
| | - D Benoit
- Intensive Care Department, Ghent University Hospital, De Pintelaan 185, Ghent, 9000, Belgium
| | - J Decruyenaere
- Intensive Care Department, Ghent University Hospital, De Pintelaan 185, Ghent, 9000, Belgium
| | - E Derom
- Department of Respiratory Diseases, Ghent University Hospital, De Pintelaan 185, Ghent, 9000, Belgium
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30
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Effects of Lung Expansion Therapy on Lung Function in Patients with Prolonged Mechanical Ventilation. Can Respir J 2016; 2016:5624315. [PMID: 27445550 PMCID: PMC4904515 DOI: 10.1155/2016/5624315] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Accepted: 09/15/2015] [Indexed: 11/18/2022] Open
Abstract
Common complications in PMV include changes in the airway clearance mechanism, pulmonary function, and respiratory muscle strength, as well as chest radiological changes such as atelectasis. Lung expansion therapy which includes IPPB and PEEP prevents and treats pulmonary atelectasis and improves lung compliance. Our study presented that patients with PMV have improvements in lung volume and oxygenation after receiving IPPB therapy. The combination of IPPB and PEEP therapy also results in increase in respiratory muscle strength. The application of IPPB facilitates the homogeneous gas distribution in the lung and results in recruitment of collapsed alveoli. PEEP therapy may reduce risk of respiratory muscle fatigue by preventing premature airway collapse during expiration. The physiologic effects of IPPB and PEEP may result in enhancement of pulmonary function and thus increase the possibility of successful weaning from mechanical ventilator during weaning process. For patients with PMV who were under the risk of atelectasis, the application of IPPB may be considered as a supplement therapy for the enhancement of weaning outcome during their stay in the hospital.
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31
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Sansone GR, Frengley JD, Vecchione JJ, Manogaram MG, Kaner RJ. Relationship of the Duration of Ventilator Support to Successful Weaning and Other Clinical Outcomes in 437 Prolonged Mechanical Ventilation Patients. J Intensive Care Med 2016; 32:283-291. [PMID: 26792815 DOI: 10.1177/0885066615626897] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To investigate the relationships between durations of ventilator support and weaning outcomes of prolonged mechanical ventilation (PMV) patients. METHODS Cohort study of 957 PMV patients sequentially admitted to a long-term acute care hospital (LTACH). The study population was 437 PMV patients who underwent weaning, having achieved ≥4 hours of sustained spontaneous breathing. They were divided into tertiles of mechanical ventilation (MV) durations and compared for differences (tertile A: 21-58 days, n = 146; tertile B: 59-103 days, n = 147; and tertile C: ≥104 days, n = 144). RESULTS Tertiles showed comparable weaning success rates and survival. As MV durations increased, LTACH postweaning days became progressively greater, whereas decannulations and discharge physical function diminished, and home discharges decreased while nursing facility discharges increased (all P < .001). Patients with lower physical function before critical illness or greater burdens of comorbidities were least likely to be weaned (all P < .001). Younger ages, lower comorbidity burdens, neurological diagnoses, higher admission prealbumin levels, and successful weaning, each independently reduced the risk of death (all P < .01). CONCLUSION Durations of MV did not affect weaning success or survival, although deleterious effects were found in discharges, decannulations, LTACH postweaning days, and discharge physical function. Durations of MV alone should not guide transfer decisions for subsequent continuing care.
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Affiliation(s)
- Giorgio R Sansone
- 1 Clinical Outcomes Research Group, Coler Rehabilitation and Nursing Care Center, New York, NY, USA
| | - J Dermot Frengley
- 1 Clinical Outcomes Research Group, Coler Rehabilitation and Nursing Care Center, New York, NY, USA.,2 Division of Geriatrics and Gerontology, Weill Cornell Medical College, New York, NY, USA
| | - John J Vecchione
- 1 Clinical Outcomes Research Group, Coler Rehabilitation and Nursing Care Center, New York, NY, USA
| | - Merlin G Manogaram
- 1 Clinical Outcomes Research Group, Coler Rehabilitation and Nursing Care Center, New York, NY, USA
| | - Robert J Kaner
- 3 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medical College, New York, NY, USA.,4 Department of Genetic Medicine, Weill Cornell Medical College, New York, NY, USA
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Marchioni A, Fantini R, Antenora F, Clini E, Fabbri L. Chronic critical illness: the price of survival. Eur J Clin Invest 2015; 45:1341-9. [PMID: 26549412 DOI: 10.1111/eci.12547] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Accepted: 10/03/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND The evolution of the techniques used in the intensive care setting over the past decades has led on one side to better survival rates in patients with acute conditions and severely impaired vital functions. On the other side, it has resulted in a growing number of patients who survive an acute event, but who then become dependent on one or more life support techniques. Such patients are called chronically critically ill patients. MATERIALS & METHODS No absolute definition of the disease is currently available, although most patients are characterized by the need for prolonged mechanical ventilation. Mortality rates are still high even after dismissal from intensive care unit (ICU) and transfer to specialized rehabilitation care settings. RESULTS In recent years, some studies have tried to clarify the pathophysiological characteristics underlying chronic critical illness (CCI), a disease that is also characterized by severe endocrine and inflammatory impairments, partly accounting for the almost constant set of symptoms. DISCUSSION Currently, no specific treatment is available. However, a strategic early therapeutic approach on ICU admission might try to prevent the progress of the acute disease towards chronic critical illness.
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Affiliation(s)
- Alessandro Marchioni
- Respiratory Disease Clinic Department of Oncology, Haematology and Respiratory Disease, University of Modena and Reggio Emilia, Modena, Italy
| | - Riccardo Fantini
- Respiratory Disease Clinic Department of Oncology, Haematology and Respiratory Disease, University of Modena and Reggio Emilia, Modena, Italy
| | - Federico Antenora
- Respiratory Disease Clinic Department of Oncology, Haematology and Respiratory Disease, University of Modena and Reggio Emilia, Modena, Italy
| | - Enrico Clini
- Respiratory Disease Clinic Department of Oncology, Haematology and Respiratory Disease, University of Modena and Reggio Emilia, Modena, Italy
| | - Leonardo Fabbri
- Respiratory Disease Clinic Department of Oncology, Haematology and Respiratory Disease, University of Modena and Reggio Emilia, Modena, Italy
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Pasqua F, Nardi I, Provenzano A, Mari A. Weaning from tracheostomy in subjects undergoing pulmonary rehabilitation. Multidiscip Respir Med 2015; 10:35. [PMID: 26629342 PMCID: PMC4666070 DOI: 10.1186/s40248-015-0032-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 10/20/2015] [Indexed: 11/17/2022] Open
Abstract
Background Weaning from tracheostomy has implications in management, quality of life, and costs of ventilated patients. Furthermore, endotracheal cannula removing needs further studies. Aim of this study was the validation of a protocol for weaning from tracheostomy and evaluation of predictor factors of decannulation. Methods Medical records of 48 patients were retrospectively evaluated. Patients were decannulated in agreement with a decannulation protocol based on the evaluation of clinical stability, expiratory muscle strength, presence of tracheal stenosis/granulomas, deglutition function, partial pressure of CO2, and PaO2/FiO2 ratio. These variables, together with underlying disease, blood gas analysis parameters, time elapsed with cannula, comordibity, Barthel index, and the condition of ventilation, were evaluated in a logistic model as predictors of decannulation. Results 63 % of patients were successfully decannulated in agreement with our protocol and no one needed to be re-cannulated. Three variables were significantly associated with the decannulation: no pulmonary underlying diseases (OR = 7.12; 95 % CI 1.2–42.2), no mechanical ventilation (OR = 9.55; 95 % CI 2.1–44.2) and period of tracheostomy ≤10 weeks (OR = 6.5; 95 % CI 1.6–27.5). Conclusions The positive course of decannulated patients supports the suitability of the weaning protocol we propose here. The strong predictive role of three clinical variables gives premise for new studies testing simpler decannulation protocols.
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Affiliation(s)
- Franco Pasqua
- Pulmonary Medicine and Rehabilitation, Villa Delle Querce Hospital, Nemi, Rome Italy ; Pulmonary Rehabilitation, San Raffaele Hospital, Montecompatri, Rome Italy
| | - Ilaria Nardi
- Pulmonary Medicine and Rehabilitation, Villa Delle Querce Hospital, Nemi, Rome Italy
| | - Alessia Provenzano
- Pulmonary Medicine and Rehabilitation, Villa Delle Querce Hospital, Nemi, Rome Italy
| | - Alessia Mari
- Pulmonary Medicine and Rehabilitation, Villa Delle Querce Hospital, Nemi, Rome Italy
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Five-Year Survival of Children With Chronic Critical Illness in Australia and New Zealand. Crit Care Med 2015; 43:1978-85. [PMID: 25962079 DOI: 10.1097/ccm.0000000000001076] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Outcomes for children with chronic critical illness are not defined. We examined the long-term survival of these children in Australia and New Zealand. DESIGN All cases of PICU chronic critical illness with length of stay more than 28 days and age 16 years old or younger in Australia and New Zealand from 2000 to 2011 were studied. Five-year survival was analyzed using Kaplan-Meir estimates, and risk factors for mortality evaluated using Cox regression. SETTING All PICUs in Australia and New Zealand. PATIENTS Nine hundred twenty-four children with chronic critical illness. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Nine hundred twenty-four children were admitted to PICU for longer than 28 days on 1,056 occasions, accounting for 1.3% of total admissions and 23.5% of bed days. Survival was known for 883 of 924 patients (95.5%), with a median follow-up of 3.4 years. The proportion with primary cardiac diagnosis increased from 27% in 2000-2001 to 41% in 2010-2011. Survival was 81.4% (95% CI, 78.6-83.9) to PICU discharge, 70% (95% CI, 66.7-72.8) at 1 year, and 65.5% (95% CI, 62.1-68.6) at 5 years. Five-year survival was 64% (95% CI, 58.7-68.6) for children admitted in 2000-2005 and 66% (95% CI, 61.7-70) if admitted in 2006-2011 (log-rank test, p = 0.37). After adjusting for admission severity of illness using the Paediatric Index of Mortality 2 score, predictors for 5-year mortality included bone marrow transplant (hazard ratio, 3.66; 95% CI, 2.26-5.92) and single-ventricle physiology (hazard ratio, 1.98; 95% CI, 1.37-2.87). Five-year survival for single-ventricle physiology was 47.2% (95% CI, 34.3-59.1) and for bone marrow transplantation 22.8% (95% CI, 8.7-40.8). CONCLUSIONS Two thirds of children with chronic critical illness survive for at-least 5 years, but there was no improvement between 2000 and 2011. Cardiac disease constitutes an increasing proportion of pediatric chronic critical illness. Bone marrow transplant recipients and single-ventricle physiology have the poorest outcomes.
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Allareddy V, Rampa S, Nalliah RP, Martinez-Schlurmann NI, Lidsky KB, Allareddy V, Rotta AT. Prevalence and Predictors of Gastrostomy Tube and Tracheostomy Placement in Anoxic/Hypoxic Ischemic Encephalopathic Survivors of In-Hospital Cardiopulmonary Resuscitation in the United States. PLoS One 2015. [PMID: 26197229 PMCID: PMC4510456 DOI: 10.1371/journal.pone.0132612] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Introduction Current prevalence estimates of gastrostomy tube (GT) /tracheostomy placement in hospitalized patients with anoxic/hypoxic ischemic encephalopathic injury (AHIE) post cardiopulmonary resuscitation (CPR) are unknown. We sought, to estimate the prevalence of AHIE in hospitalized patients who had CPR and to identify patient/hospital level factors that predict the performance of GT/tracheostomy in those with AHIE. Methods We performed a retrospective analysis of the Nationwide Inpatient Sample (years 2004–2010). All patients who developed AHIE following CPR were included. In this cohort the odds of having GT and tracheostomy was computed by multivariable logistic regression analysis. Patient and hospital level factors were the independent variables. Results During the study period, a total of 686,578 CPR events occurred in hospitalized patients. Of these, 94,336 (13.7%) patients developed AHIE. In this AHIE cohort, 6.8% received GT and 8.3% tracheostomy. When compared to the 40–49 yrs age group, those aged >70 yrs were associated with lower odds for GT (OR = 0.65, 95% CI:0.53–0.80, p<0.0001). Those aged <18 years & those >60 years were associated with lower odds for having tracheostomy when compared to the 40–49 years group (p<0.0001). Each one unit increase in co-morbid burden was associated with higher odds for having GT (OR = 1.23,p<0.0001) or tracheostomy (OR = 1.17, p<0.0001). Blacks, Hispanics, Asians/Pacific Islanders, and other races were associated with higher odds for having GT or tracheostomy when compared to whites (p<0.05). Hospitals located in northeastern regions were associated with higher odds for performing GT (OR = 1.48, p<0.0001) or tracheostomy (OR = 1.63, p<0.0001) when compared to those in Western regions. Teaching hospitals (TH) were associated with higher odds for performing tracheostomy when compared to non-TH (OR = 1.36, 1.20–1.54, p<0.0001). Conclusions AHIE injury occurs in a significant number of in-hospital arrests requiring CPR. Certain predictors of GT/ Tracheostomy placement are identified. Patients in teaching hospitals were more likely to receive tracheostomy than their counterparts.
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Affiliation(s)
- Veerajalandhar Allareddy
- UH Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio, United States of America
- * E-mail:
| | - Sankeerth Rampa
- University of Nebraska, Health Services and Research department, Omaha, Nebraska, United States of America
| | - Romesh P. Nalliah
- University of Michigan, College of Dentistry, Ann Arbor, Michigan, United States of America
| | | | - Karen B. Lidsky
- UH Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Veerasathpurush Allareddy
- University of Iowa, School of Dentistry, College of Dentistry and Dental Clinics, Iowa City, Iowa, United States of America
| | - Alexandre T. Rotta
- UH Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio, United States of America
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Verceles AC, Weiler B, Koldobskiy D, Goldberg AP, Netzer G, Sorkin JD. Association Between Vitamin D Status and Weaning From Prolonged Mechanical Ventilation in Survivors of Critical Illness. Respir Care 2015; 60:1033-9. [PMID: 25715347 DOI: 10.4187/respcare.03137] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND In this study, we examined the association between 25-hydroxyvitamin D (25(OH)D) concentration and successful weaning from mechanical ventilation in a cohort of ICU survivors requiring prolonged mechanical ventilation. METHODS This was a retrospective cohort study of ICU survivors admitted to a long-term acute care hospital. Demographic data were extracted from medical records, including 25(OH)D concentrations drawn on admission. Subjects were divided into 2 groups based on their 25(OH)D concentrations (deficient, < 20 ng/mL; not deficient, ≥ 20 ng/mL), and associations between 25(OH)D concentration and successful weaning were calculated. RESULTS A total of 183 subjects were studied. A high prevalence of 25(OH)D deficiency was found (61%, 111/183). No association was found between 25(OH)D concentration and weaning from mechanical ventilation. Increased comorbidity burden (Charlson comorbidity index) was associated with decreased odds of weaning (odds ratio of 0.50, 95% CI 0.25-0.99, P = .05). CONCLUSIONS Vitamin D deficiency is common in ICU survivors requiring prolonged mechanical ventilation. Surprisingly, there was no significant relationship between 25(OH)D concentration and successful weaning. This finding may be due to the low 25(OH)D concentrations seen in our subjects. Given what is known about vitamin D and lung function and given the low vitamin D concentrations seen in patients requiring long-term ventilatory support, interventional studies assessing the effects of 25(OH)D supplementation in these patients are needed.
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Affiliation(s)
- Avelino C Verceles
- Division of Pulmonary and Critical Care Medicine University of Maryland Claude D Pepper Older Americans Independence Center
| | | | | | - Andrew P Goldberg
- University of Maryland Claude D Pepper Older Americans Independence Center Division of Geriatric Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Giora Netzer
- Division of Pulmonary and Critical Care Medicine Department of Epidemiology and Public Health
| | - John D Sorkin
- University of Maryland Claude D Pepper Older Americans Independence Center Division of Geriatric Medicine, University of Maryland School of Medicine, Baltimore, Maryland. Baltimore Veterans Affairs Geriatric Research, Education, and Clinical Center, Baltimore, Maryland
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Effects of an additional pressure support level on exercise duration in patients on prolonged mechanical ventilation. J Formos Med Assoc 2014; 114:1204-10. [PMID: 25304086 DOI: 10.1016/j.jfma.2014.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Revised: 09/01/2014] [Accepted: 09/02/2014] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND/PURPOSE Noninvasive positive pressure ventilation has been regarded as a strategy for improving exercise performance. Whether an increase in the ventilatory support level improves exercise performance in patients who have received invasive ventilation is unknown. The purpose of this study is to examine the effects of an additional level of pressure support (PS) ventilation on exercise tolerance in patients undergoing prolonged mechanical ventilation (PMV). METHODS This study examined 15 patients who were undergoing PMV. All patients performed an upper-arm exercise test at three PS levels: the baseline PS level (PS), a level 2 cmH2O higher than the baseline level (PS+2), and a level 4 cmH2O higher than the baseline level (PS+4). The physiological response, reasons for discontinuing the exercise test, and exercise duration were recorded and analyzed. RESULTS The tidal volume increased significantly from 271.7 ± 54.7 mL to 398.3 ± 88.7 mL at the PS+4 level (p = 0.01). Significant differences in exercise duration were observed at different PS levels. The exercise duration was significantly longer at the PS+4 level than at the PS and PS+2 levels (146.3 ± 139.9 seconds vs. 108.5 ± 85.9 seconds vs. 72.8 ± 43.9 seconds, p = 0.038) as their corresponding order. There were significant relationships between resting respiratory rate and exercise duration at the PS (r = -0.639, p = 0.034) and PS+2 levels (r = -0.668, p = 0.025). CONCLUSION In patients undergoing PMV, an additional PS level of up to 4 cmH2O compared with the baseline setting may help to improve exercise tolerance by prolonging exercise duration.
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Institutional care for long-term mechanical ventilation in Canada: A national survey. Can Respir J 2014; 21:357-362. [PMID: 25184510 DOI: 10.1155/2014/538687] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION No national Canadian data define resource requirements and care delivery for ventilator-assisted individuals (VAIs) requiring long-term institutional care. Such data will assist in planning health care services to this population. OBJECTIVE To describe institutional and patient characteristics, prevalence, equipment used, care elements and admission barriers for VAIs requiring long-term institutional care. METHODS Centres were identified from a national inventory and snowball referrals. The survey weblink was provided from December 2012 to April 2013. Weekly reminders were sent for six weeks. RESULTS The response rate was 84% (54 of 64), with 44 adult and 10 pediatric centres providing data for 428 VAIs (301 invasive ventilation; 127 noninvasive ventilation [NIV]), equivalent to 1.3 VAIs per 100,000 population. An additional 106 VAIs were on wait lists in 18 centres. More VAIs with progressive neuromuscular disease received invasive ventilation than NIV (P<0.001); more VAIs with chronic obstructive pulmonary disease (P<0.001), obesity hypoventilation syndrome (P<0.001) and central hypoventilation syndrome (P=0.02) required NIV. All centres used positive pressure ventilators, 21% diaphragmatic pacing, 15% negative pressure and 13% phrenic nerve stimulation. Most centres used lung volume recruitment (55%), manually (71%) and mechanically assisted cough (55%). Lack of beds and provincial funding were common admission barriers.CONCLUSIONS: Variable models and care practices exist for institutionalized care of Canadian VAIs. Patient prevalence was 1.3 per 100,000 Canadians.
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Rose L, Fowler RA, Fan E, Fraser I, Leasa D, Mawdsley C, Pedersen C, Rubenfeld G. Prolonged mechanical ventilation in Canadian intensive care units: a national survey. J Crit Care 2014; 30:25-31. [PMID: 25201807 DOI: 10.1016/j.jcrc.2014.07.023] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 07/10/2014] [Accepted: 07/23/2014] [Indexed: 12/27/2022]
Abstract
BACKGROUND We sought to describe prevalence and care practices for patients experiencing prolonged mechanical ventilation (PMV), defined as ventilation for 21 or more consecutive days and medical stability. METHODS We provided the survey to eligible units via secure Web link to a nominated unit champion from April to November 2012. Weekly telephone and e-mail reminders were sent for 6 weeks. RESULTS Response rate was 215 (90%) of 238 units identifying 308 patients requiring PMV on the survey day occupying 11% of all Canadian ventilator-capable beds. Most units (81%) used individualized plans for both weaning and mobilization. Weaning and mobilization protocols were available in 48% and 38% of units, respectively. Of those units with protocols, only 25% reported weaning guidance specific to PMV, and 11% reported mobilization content for PMV. Only 30% of units used specialized mobility equipment. Most units referred to speech language pathologists (88%); use of communication technology was infrequent (11%). Only 29% routinely referred to psychiatry/psychology, and 17% had formal discharge follow-up services. CONCLUSIONS Prolonged mechanical ventilation patients occupied 11% of Canadian acute care ventilator bed capacity. Most units preferred an individualized approach to weaning and mobilization with considerable variation in weaning methods, protocol availability, access to specialized rehabilitation equipment, communication technology, psychiatry, and discharge follow-up.
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Affiliation(s)
- Louise Rose
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada M5T 1P8; Provincial Centre of Weaning Excellence/Prolonged Ventilation Weaning Centre, Toronto East General Hospital, Toronto, Ontario, Canada M4C 3E7; Mt. Sinai Hospital, Toronto, Ontario, Canada M5G 1X5; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada M5B 1W8; Department of Critical Care, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada M4N 3M5; Sunnybrook Research Institute, Toronto, Ontario, Canada M4N 3M5.
| | - Robert A Fowler
- Department of Critical Care, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada M4N 3M5; Sunnybrook Research Institute, Toronto, Ontario, Canada M4N 3M5; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada, M5G 2C4.
| | - Eddy Fan
- Toronto General Hospital and University Health Network, Toronto, Ontario, Canada M5G 2C4; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada, M5G 2C4.
| | - Ian Fraser
- Provincial Centre of Weaning Excellence/Prolonged Ventilation Weaning Centre, Toronto East General Hospital, Toronto, Ontario, Canada M4C 3E7.
| | - David Leasa
- Department of Critical Care, London Health Sciences Centre, London, Ontario, Canada N6G 2V4; University of Western Ontario.
| | - Cathy Mawdsley
- Department of Critical Care, London Health Sciences Centre, London, Ontario, Canada N6G 2V4.
| | - Cheryl Pedersen
- Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada M5B 1W8.
| | - Gordon Rubenfeld
- Sunnybrook Research Institute, Toronto, Ontario, Canada M4N 3M5; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada, M5G 2C4; Trauma, Emergency, and Critical Care Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada M4N 3M5.
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Abstract
PURPOSE OF REVIEW The population of chronically critically ill patients is growing as advances in intensive care management improve survival from the acute phase of critical illness. These patients are characterized by complex medical needs and heavy resource utilization. This article reviews evidence supporting a comprehensive approach to the prevention and management of chronic critical illness (CCI). RECENT FINDINGS The most efficient approach to weaning patients with CCI at long-term acute care hospitals is daily unassisted breathing trials through a tracheostomy collar. However, a substantial number of patients transferred to long-term acute care hospitals pass their spontaneous weaning trials. Transfer to long-term acute care hospitals is associated with higher acute care costs and payments, but lower costs through the entire episode of illness. Universal decontamination is more effective than targeted decontamination or screening and isolation for preventing nosocomial bloodstream infections. SUMMARY Combating CCI begins with prevention in the acute phase of illness. Management strategies include a spectrum of ventilatory, nutritional, and rehabilitation support. Further patient-centered outcome-based research in this specific population is needed to continue to help guide optimal care.
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Mohamed KAE, El Maraghi SK. Role of Adaptive Support Ventilation in Weaning of COPD Patients. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2014. [DOI: 10.1016/j.ejcdt.2013.12.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Verceles AC, Lechner EJ, Halpin D, Scharf SM. The association between comorbid illness, colonization status, and acute hospitalization in patients receiving prolonged mechanical ventilation. Respir Care 2014; 58:250-6. [PMID: 22709565 DOI: 10.4187/respcare.01677] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Long-term acute care (LTAC) hospitals provide specialized care for survivors of critical illness who require prolonged mechanical ventilation. These chronically ill patients often have multiple comorbidities and are colonized with antibiotic-resistant organisms. We investigated the association of comorbidities and colonization status with outcomes in patients requiring prolonged mechanical ventilation in an LTAC facility. We hypothesized that comorbidity burden and colonization with multiple drug resistant organisms would be associated with worse clinical outcomes. METHODS We performed a retrospective, cohort study of 157 mechanically ventilated subjects in an urban LTAC facility admitted from January 2007 to September 2009. Comorbidity burden was documented from pre-admission data using the Charlson Comorbidity Index. Colonization data were obtained from surveillance cultures. Outcomes studied included transfer back to acute care facilities, stay, and ventilator weaning status. RESULTS Within 60 days, 58.6% of subjects were transferred back to an acute care facility. The most common reason for transfer was infection/sepsis (37%). The Charlson Comorbidity Index of subjects transferred to acute care, versus those who were not, was 4.9 ± 3.1 versus 3.6 ± 2.7 (P = .01), an odds ratio of 1.1 for each 1-point increase in Charlson Comorbidity Index (95% CI 1.03-1.71, P = .02). Colonization with acinetobacter was associated with higher incidence of transfer (71% vs 51%, P = .01). The odds ratio for transfer to acute care was 1.3 for each additional organism colonizing a subject (95% CI 1.11-1.53, P = .006). CONCLUSIONS Higher comorbidity burden and colonization status were associated with increased risk of transfer to acute care. Further investigation is needed to clarify this relationship between comorbidity burden and colonization with change in clinical status.
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Affiliation(s)
- Avelino C Verceles
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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Dermot Frengley J, Sansone GR, Shakya K, Kaner RJ. Prolonged mechanical ventilation in 540 seriously ill older adults: effects of increasing age on clinical outcomes and survival. J Am Geriatr Soc 2014; 62:1-9. [PMID: 24404850 DOI: 10.1111/jgs.12597] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To investigate effects of older age, comorbidities, and physiological measures on outcomes of elderly adults requiring prolonged mechanical ventilation (PMV). DESIGN Retrospective cohort study. SETTING Public long-term acute care hospital (LTACH) with an active program for ventilator weaning from PMV. PARTICIPANTS Chronically seriously ill individuals with PMV aged 65 and older divided into six cohorts (65-69, 70-74, 75-79, 80-84, 85-89, ≥ 90) for comparative purposes (n = 540). MEASUREMENTS Main outcomes were weaning criteria met, weaning success, discharge dispositions, and long-term survival. Other outcomes included weaning duration, LTACH days, discharge physical function, tracheostomy decannulation, and relapses to ventilator support. Weaning success was defined as 4 weeks or longer entirely free from mechanical ventilator support. RESULTS The main finding from age cohort comparisons was that the likelihood of meeting weaning criteria (P = .001) and subsequent successful weaning (P = .002) decreased with age. Best predictors for weaning success in multivariable analysis were lower comorbidity burden (P < .001) and less-severe illness (P = .001). Other clinically important predictors were more-normal values in the respiratory physiology measures of rapid shallow breathing (P = .001) and static compliance (P = .003). Successful weaning was also associated with a 62% lower risk of death (P < .001). CONCLUSION Although meeting weaning criteria and being successfully weaned decreased with increasing age, age was not the dominant factor in predicting outcomes. More importantly, individuals with PMV with better respiratory physiology and lower comorbidity burdens were more likely to be weaned and have longer survival, no matter their age.
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Affiliation(s)
- J Dermot Frengley
- Division of Geriatrics and Gerontology, Weill Medical College, Cornell University, New York, New York; Outcomes Research Group, Coler-Goldwater Specialty Hospital, Roosevelt Island, New York, New York
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Clark PA, Lettieri CJ. Clinical model for predicting prolonged mechanical ventilation. J Crit Care 2013; 28:880.e1-7. [DOI: 10.1016/j.jcrc.2013.03.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 02/10/2013] [Accepted: 03/19/2013] [Indexed: 10/26/2022]
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Perren A, Brochard L. Managing the apparent and hidden difficulties of weaning from mechanical ventilation. Intensive Care Med 2013; 39:1885-95. [DOI: 10.1007/s00134-013-3014-9] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 06/27/2013] [Indexed: 01/28/2023]
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Oehmichen F, Zäumer K, Ragaller M, Mehrholz J, Pohl M. Anwendung eines standardisierten Spontanatmungsprotokolls. DER NERVENARZT 2013; 84:962-72. [DOI: 10.1007/s00115-013-3812-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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O'Connor H, Al-Qadheeb NS, White AC, Thaker V, Devlin JW. Agitation during prolonged mechanical ventilation at a long-term acute care hospital: risk factors, treatments, and outcomes. J Intensive Care Med 2013; 29:218-24. [PMID: 23753245 DOI: 10.1177/0885066613486738] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 01/08/2013] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The prevalence, risk factors, treatment practices, and outcomes of agitation in patients undergoing prolonged mechanical ventilation (PMV) in the long-term acute care hospital (LTACH) setting are not well understood. We compared agitation risk factors, management strategies, and outcomes between patients who developed agitation and those who did not, in LTACH patients undergoing PMV. METHODS Patients admitted to an LTACH for PMV over a 1-year period were categorized into agitated and nonagitated groups. The presence of agitation risk factors, management strategies, and relevant outcomes were extracted and compared between the 2 groups. RESULTS A total of 80 patients were included, 41% (33) with agitation and 59% (47) without. Compared to the nonagitated group, the agitated group had a lower Sequential Organ Failure Assessment score (P < .0006), a greater transfer rate from an academic center (P = .05), a greater delirium frequency at both baseline (P = .04) and during admission (P < .001), and a greater rate of benzodiazepine discontinuation (P = .02). Although the use of scheduled antipsychotic (P = .0005) or restraint (P = .002) therapy was more common in the agitated group, use of benzodiazepines (P = .16), opioids (P = .11), or psychiatric evaluation (P = .90) was not. Weaning success, duration of LTACH stay, and daily costs were similar. CONCLUSION Agitation among the LTACH patients undergoing PMV is associated with greater delirium and use of antipsychotics and restraints but does not influence weaning success or LTACH stay. Strategies focused on agitation prevention and treatment in this population need to be developed and formally evaluated.
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Affiliation(s)
- Heidi O'Connor
- Rose Kalman Research Center, New England Sinai Hospital, Stoughton, MA, USA Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA, USA
| | | | - Alexander C White
- Rose Kalman Research Center, New England Sinai Hospital, Stoughton, MA, USA Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA, USA
| | - Vishal Thaker
- Northeastern University School of Pharmacy, Boston, MA, USA
| | - John W Devlin
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA, USA Northeastern University School of Pharmacy, Boston, MA, USA
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Al-Qadheeb NS, O'Connor HH, White AC, Neidhardt A, Albizati M, Joseph B, Roberts RJ, Ruthazer RR, Devlin JW. Antipsychotic Prescribing Patterns, and the Factors and Outcomes Associated with Their Use, among Patients Requiring Prolonged Mechanical Ventilation in the Long-Term Acute Care Hospital Setting. Ann Pharmacother 2013; 47:181-8. [DOI: 10.1345/aph.1r521] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND: Administration of scheduled antipsychotic therapy to mechanically ventilated patients to prevent or treat delirium is common, despite the lack of evidence to support its use. Among long-term acute care hospital (LTACH) patients requiring prolonged mechanical ventilation (PMV), the frequency of scheduled antipsychotic therapy use, and the factors and outcomes associated with it, have not been described. OBJECTIVE: To identify scheduled antipsychotic therapy prescribing practices, and the factors and outcomes associated with the use of antipsychotics, among LTACH patients requiring PMV. METHODS: Consecutive patients without major psychiatric disorders or dementia who were admitted to an LTACH for PMV over 1 year were categorized as those receiving scheduled antipsychotic therapy (≥24 hours of use) and those not receiving scheduled antipsychotic therapy. Presence of delirium, use of psychiatric evaluation, nonscheduled antipsychotic therapy, and scheduled antipsychotic therapy—related adverse effects were extracted and compared between the 2 groups and when significant (p ≤ 0.05), were entered into a regression analysis using generalized estimating equation techniques. RESULTS: Among 80 patients included, 39% (31) received scheduled antipsychotic therapy and 61% (49) did not. Baseline characteristics, including age, sex, illness severity, and medical history, were similar between the 2 groups. Scheduled antipsychotic therapy was administered on 52% of LTACH days for a median (interquartile range [IQR]) of 25 (6–38) days and, in the antipsychotic group, was initiated at an outside hospital (45%) or on day 2 (1–6; median [IQR]) of the LTACH stay (55%). Quetiapine was the most frequently administered scheduled antipsychotic (77%; median dose 50 [37–72] mg/day). Use of scheduled antipsychotic therapy was associated with a greater incidence of psychiatric evaluation (OR 5.7; p = 0.01), delirium (OR 2.4; p = 0.05), as-needed antipsychotic use (OR 4.1; p = 0.005) and 1:1 sitter use (OR 7.3; p = 0.001), but not benzodiazepine use (p = 0.19). CONCLUSIONS: Among LTACH patients requiring PMV, scheduled antipsychotic therapy is used frequently and is associated with a greater incidence of psychiatric evaluation, delirium, as-needed psychotic use, and sitter use. Although scheduled antipsychotic therapy—related adverse effects are uncommon, these effects are infrequently monitored.
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Affiliation(s)
- Nada S Al-Qadheeb
- Nada S Al-Qadheeb PharmD BCPS FCCP, Critical Care Pharmacy Fellow, School of Pharmacy, Northeastern University, Boston, MA
| | - Heidi H O'Connor
- Heidi H O'Connor MD, Staff Physician, Rose Kalman Research Center, New England Sinai Hospital, Stoughton, MA
| | - Alexander C White
- Alexander C White MD, Staff Physician, Rose Kalman Research Center, New England Sinai Hospital
| | - Aura Neidhardt
- Aura Neidhardt, PharmD Student, School of Pharmacy, Northeastern University
| | - Mark Albizati
- Mark Albizati, PharmD Student, School of Pharmacy, Northeastern University
| | - Bernard Joseph
- Bernard Joseph MD, Research Physician, Rose Kalman Research Center, New England Sinai Hospital
| | - Russel J Roberts
- Russel J Roberts PharmD, Senior Clinical Specialist, Critical Care, Department of Pharmacy, Tufts Medical Center, Boston
| | - Robin R Ruthazer
- Robin R Ruthazer MPH, Associate Director, Biostatistics Research Center, Tufts Medical Center
| | - John W Devlin
- John W Devlin PharmD FCCM FCCP, Associate Professor, School of Pharmacy, Northeastern University; Special and Scientific Staff, Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center
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Characteristics and Outcome for Very Elderly Patients (≥ 80 years) Admitted to a Respiratory Care Center in Taiwan. INT J GERONTOL 2012. [DOI: 10.1016/j.ijge.2012.01.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Patient characteristics and outcomes of a provincial prolonged-ventilation weaning centre: a retrospective cohort study. Can Respir J 2012; 19:216-20. [PMID: 22679615 DOI: 10.1155/2012/358265] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Growing numbers of critically ill patients require prolonged mechanical ventilation and experience difficulty with weaning. Specialized centres may facilitate weaning through focused interprofessional expertise with an emphasis on rehabilitation. OBJECTIVE To characterize the population of a specialized prolonged-ventilation weaning centre (PWC) in Ontario, and to report weaning, mobility, discharge and survival outcomes. METHODS Data from consecutively admitted patients were retrospectively extracted from electronic and paper medical records by research staff and verified by the primary investigator. RESULTS From January 2004 to March 2011, 144 patients were admitted: 115 (80%) required ventilator weaning, and 29 (20%) required tracheostomy weaning or noninvasive ventilation. Intensive care unit length of stay before admission was a median 51 days (interquartile range [IQR] 35 to 86 days). Of the patients admitted for ventilator weaning, 76 of 115 (66% [95% CI 55% to 75%]) achieved a 24 h tracheostomy mask trial in a median of 15 days (IQR eight to 25 days). Weaning success, defined as no further ventilation for seven consecutive days, was achieved by 61 patients (53% [95% CI 44% to 62%]) in a median duration of 62 days (IQR 46 to 95 days) of ventilation, and 14 days (IQR nine to 29 days) after PWC admission. Seventeen patients died during admission. Of the 91 patients discharged from the PWC for one year, 43 (47.3% [95% CI 37.3% to 57.4%]) survived; of the 78 discharged for two years, 27 (34.6% [95% CI 25.0% to 45.7%]) were alive; of the 53 discharged for three years, 19 (35.9% [95% CI 24.3% to 49.3%]) were alive; and seven of 22 (31.8% [95% CI 16.4% to 52.7%]) survived to five years. CONCLUSIONS Weaning success was moderate despite a prolonged intensive care unit stay before admission, but was comparable with studies reporting weaning outcomes from centres in other countries. Few patients survived to five years.
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