Acute respiratory failure in the United States: incidence and 31-day survival

High-Flow Nasal Cannula Versus Noninvasive Ventilation as Initial Treatment in Acute Hypoxia: A Propensity Score-Matched Study

IMPORTANCE

Patients presenting to the emergency department (ED) with hypoxemia often have mixed or uncertain causes of respiratory failure. The optimal treatment for such patients is unclear. Both high-flow nasal cannula (HFNC) and noninvasive ventilation (NIV) are used.

OBJECTIVES

We sought to compare the effectiveness of initial treatment with HFNC versus NIV for acute hypoxemic respiratory failure.

DESIGN SETTING AND PARTICIPANTS

We conducted a retrospective cohort study of patients with acute hypoxemic respiratory failure treated with HFNC or NIV within 24 hours of arrival to the University of Michigan adult ED from January 2018 to December 2022. We matched patients 1:1 using a propensity score for odds of receiving NIV.

MAIN OUTCOMES AND MEASURES

The primary outcome was major adverse pulmonary events (28-d mortality, ventilator-free days, noninvasive respiratory support hours) calculated using a win ratio.

RESULTS

A total of 1154 patients were included. Seven hundred twenty-six (62.9%) received HFNC and 428 (37.1%) received NIV. We propensity score matched 668 of 1154 (57.9%) patients. Patients on NIV versus HFNC had lower 28-day mortality (16.5% vs. 23.4%, p = 0.033) and required noninvasive treatment for fewer hours (median 7.5 vs. 13.5, p < 0.001), but had no difference in ventilator-free days (median [interquartile range]: 28 [26, 28] vs. 28 [10.5, 28], p = 0.199). Win ratio for composite major adverse pulmonary events favored NIV (1.38; 95% CI, 1.15-1.65; p < 0.001).

CONCLUSIONS AND RELEVANCE

In this observational study of patients with acute hypoxemic respiratory failure, initial treatment with NIV compared with HFNC was associated with lower mortality and fewer composite major pulmonary adverse events calculated using a win ratio. These findings underscore the need for randomized controlled trials to further understand the impact of noninvasive respiratory support strategies.

Diagnosis and Epidemiology of Acute Respiratory Failure

Acute respiratory failure is a common clinical finding caused by insufficient oxygenation (hypoxemia) or ventilation (hypocapnia). Understanding the pathophysiology of acute respiratory failure can help to facilitate recognition, diagnosis, and treatment. The cause of acute respiratory failure can be identified through utilization of physical examination findings, laboratory analysis, and chest imaging.

Pediatric Ventilator-Associated Events Before and After a Multicenter Quality Improvement Initiative

Importance

Pediatric ventilator-associated events (PedVAEs, defined as a sustained worsening in oxygenation after a baseline period of stability or improvement) are useful for surveillance of complications from mechanical ventilation. It is unclear whether interventions to mitigate known risk factors can reduce PedVAE rates.

Objective

To assess whether adherence to 1 or more test factors in a quality improvement bundle was associated with a reduction in PedVAE rates.

Design, Setting, and Participants

This multicenter quality improvement study obtained data from 2017 to 2020 for patients who were mechanically ventilated and cared for in neonatal, pediatric, and cardiac intensive care units (ICUs). These ICUs were located in 95 hospitals participating in the Children's Hospitals' Solutions for Patient Safety (SPS) network in North America. Data analyses were performed between September 2021 and April 2023.

Intervention

A quality improvement bundle consisted of 3 test factors: multidisciplinary apparent cause analysis, daily discussion of extubation readiness, and daily discussion of fluid balance goals. This bundle was distributed to a subgroup of hospitals that volunteered to participate in a collaborative PedVAE prevention initiative under the SPS network guidance in July 2018.

Main Outcomes and Measures

Each SPS network hospital submitted monthly PedVAE rates from January 1, 2017, to May 31, 2020, and test factor data were submitted from July 1, 2018, to May 31, 2020. Analyses focused on hospitals that reliably submitted PedVAE rate data, defined as outcomes data submission through May 31, 2020, for at least 80% of the baseline and postbaseline periods.

Results

Of the 95 hospitals in the SPS network that reported PedVAE data, 21 were grouped in the Pioneer cohort and 74 in the non-Pioneer cohort. Only 12 hospitals (57%) from the 21 Pioneer hospitals and 33 (45%) from the 74 non-Pioneer hospitals were considered to be reliable reporters of outcome data. Among the 12 hospitals, the PedVAE rate decreased from 1.9 to 1.4 events per 1000 ventilator days (absolute rate difference, -0.6; 95% CI, -0.5 to -0.7; P < .001). No significant change in the PedVAE rate was seen among the 33 hospitals that reliably submitted PedVAE rates but did not implement the bundle. Of the 12 hospitals, 3 that reliably performed daily discussion of extubation readiness had a decrease in PedVAE rate from 2.6 to 1.2 events per 1000 ventilator days (absolute rate difference, -1.4; 95% CI, -1.0 to -1.7; P < .001), whereas the other 9 hospitals that did not implement this discussion did not have a decrease.

Conclusions and Relevance

This study found that a multicenter quality improvement intervention targeting PedVAE risk factors was associated with a substantial reduction in the rate of PedVAEs in hospital ICUs. The findings suggest that ICU teams seeking to reduce PedVAEs incorporate daily discussion of extubation readiness during morning rounds.

Prognostic value of oxygen saturation index trajectory phenotypes on ICU mortality in mechanically ventilated patients: a multi-database retrospective cohort study

BACKGROUND

Heterogeneity among critically ill patients undergoing invasive mechanical ventilation (IMV) treatment could result in high mortality rates. Currently, there are no well-established indicators to help identify patients with a poor prognosis in advance, which limits physicians' ability to provide personalized treatment. This study aimed to investigate the association of oxygen saturation index (OSI) trajectory phenotypes with intensive care unit (ICU) mortality and ventilation-free days (VFDs) from a dynamic and longitudinal perspective.

METHODS

A group-based trajectory model was used to identify the OSI-trajectory phenotypes. Associations between the OSI-trajectory phenotypes and ICU mortality were analyzed using doubly robust analyses. Then, a predictive model was constructed to distinguish patients with poor prognosis phenotypes.

RESULTS

Four OSI-trajectory phenotypes were identified in 3378 patients: low-level stable, ascending, descending, and high-level stable. Patients with the high-level stable phenotype had the highest mortality and fewest VFDs. The doubly robust estimation, after adjusting for unbalanced covariates in a model using the XGBoost method for generating propensity scores, revealed that both high-level stable and ascending phenotypes were associated with higher mortality rates (odds ratio [OR]: 1.422, 95% confidence interval [CI] 1.246-1.623; OR: 1.097, 95% CI 1.027-1.172, respectively), while the descending phenotype showed similar ICU mortality rates to the low-level stable phenotype (odds ratio [OR] 0.986, 95% confidence interval [CI] 0.940-1.035). The predictive model could help identify patients with ascending or high-level stable phenotypes at an early stage (area under the curve [AUC] in the training dataset: 0.851 [0.827-0.875]; AUC in the validation dataset: 0.743 [0.709-0.777]).

CONCLUSIONS

Dynamic OSI-trajectory phenotypes were closely related to the mortality of ICU patients requiring IMV treatment and might be a useful prognostic indicator in critically ill patients.

High-flow nasal cannula vs non-invasive ventilation in acute hypoxia: Propensity score matched study

RATIONALE

The optimal treatment for early hypoxemic respiratory failure is unclear, and both high-flow nasal cannula and non-invasive ventilation are used. Determining clinically relevant outcomes for evaluating non-invasive respiratory support modalities remains a challenge.

OBJECTIVES

To compare the effectiveness of initial treatment with high-flow nasal cannula versus non-invasive ventilation for acute hypoxemic respiratory failure.

METHODS

We conducted a retrospective cohort study of patients with acute hypoxemic respiratory failure treated with high-flow nasal cannula or non-invasive ventilation within 24 hours of Emergency Department arrival (1/2018-12/2022). We matched patients 1:1 using a propensity score for odds of receiving non-invasive ventilation. The primary outcome was major adverse pulmonary events (28-day mortality, ventilator-free days, non-invasive respiratory support hours) calculated using a Win Ratio.

MEASUREMENTS AND MAIN RESULTS

1,265 patients met inclusion criteria. 795 (62.8%) received high-flow oxygen and 470 (37.2%) received non-invasive ventilation. We propensity score matched 736/1,265 (58.2%) patients. There was no difference between non-invasive ventilation vs high-flow nasal cannula in 28-day mortality (17.7% vs 23.1%, p=0.08) or ventilator-free days (median [Interquartile Range]: 28 [25, 28] vs 28 [13, 28], p=0.50), but patients on non-invasive ventilation required treatment for fewer hours (median 7 vs 13, p< 0.001). Win Ratio for composite major adverse pulmonary events favored non-invasive ventilation (1.26, 95%CI 1.06-1.49, p< 0.001).

CONCLUSIONS

In this observational study of patients with acute hypoxemic respiratory failure, initial treatment with non-invasive ventilation was superior to high-flow nasal cannula for major pulmonary adverse events. Evaluation of composite outcomes is important in the assessment of respiratory support modalities.

Endotracheal Intubation of Difficult Airways in Emergency Settings: A Guide for Innovators

Over 400,000 Americans are intubated in emergency settings annually, with indications ranging from respiratory failure to airway obstructions to anaphylaxis. About 12.7% of emergency intubations are unsuccessful on the first attempt. Failure to intubate on the first attempt is associated with a higher likelihood of adverse events, including oxygen desaturation, aspiration, trauma to soft tissue, dysrhythmia, hypotension, and cardiac arrest. Difficult airways, as classified on an established clinical scale, are found in up to 30% of emergency department (ED) patients and are a significant contributor to failure to intubate. Difficult intubations have been associated with longer lengths of stay and significantly greater costs than standard intubations. There exists a wide range of airway management devices, both invasive and noninvasive, which are available in the emergency setting to accommodate difficult airways. Yet, first-pass success rates remain variable and leave room for improvement. In this article, we review the disease states most correlated with intubation, the current landscape of emergency airway management technologies, and the market potential for innovation. The aim of this review is to inspire new technologies to assist difficult airway management, given the substantial opportunity for translation due to two key-value signposts of medical innovation: the potential to decrease cost and the potential to improve clinical outcomes.

Association between coagulation disorder scores and in-hospital mortality in ARF patients: a retrospective analysis from the MIMIC-IV database

Introduction

Acute respiratory failure (ARF) has a high mortality rate, and currently, there is no convenient risk predictor. The coagulation disorder score was proven to be a promising metric for predicting in-hospital mortality, but its role in ARF patients remains unknown.

Methods

In this retrospective study, data were extracted from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Patients diagnosed with ARF and hospitalized for more than 2 days at their first admission were included. The coagulation disorder score was defined based on the sepsis-induced coagulopathy score and was calculated by parameters, namely, additive platelet count (PLT), international normalized ratio (INR), and activated partial thromboplastin time (APTT), based on which the participants were divided into six groups.

Results

Overall, 5,284 ARF patients were enrolled. The in-hospital mortality rate was 27.9%. High levels of additive platelet score, INR score, and APTT score were significantly associated with increased mortality in ARF patients (P < 0.001). Binary logistic regression analysis showed that a higher coagulation disorder score was significantly related to the increased risk of in-hospital mortality in ARF patients (Model 2: coagulation disorder score = 6 vs. coagulation disorder score = 0: OR, 95% CI: 7.09, 4.07-12.34, P < 0.001). The AUC of the coagulation disorder score was 0.611 (P < 0.001), which was smaller than that of sequential organ failure assessment (SOFA) (De-long test P = 0.014) and simplified acute physiology score II (SAPS II) (De-long test P < 0.001) but larger than that of additive platelet count (De-long test P < 0.001), INR (De-long test P < 0.001), and APTT (De-long test P < 0.001), respectively. In subgroup analysis, we found that in-hospital mortality was markedly elevated with an increased coagulation disorder score in ARF patients. No significant interactions were observed in most subgroups. Of note, patients who did not administrate oral anticoagulant had a higher risk of in-hospital mortality than those who administrated oral anticoagulant (P for interaction = 0.024).

Conclusion

This study found a significant positive association between coagulation disorder scores and in-hospital mortality. The coagulation disorder score was superior to the single indicators (additive platelet count, INR, or APTT) and inferior to SAPS II and SOFA for predicting in-hospital mortality in ARF patients.

Impact of age group on bloodstream infection risk evaluation in immunosuppressed patients: a retrospective, single-centre, 5-year cohort study

INTRODUCTION

Elderly patients in immunosuppressive status may have an increased occurrence of illness and risk of poor prognosis. It is a generally overlooked population that we should pay more attention to their risk factors of sickness and mortality.

METHODS

Eight hundred and nine patients who were diagnosed with bloodstream infection in immunosuppressive states during accepting treatment in our hospital were selected from 2015 to 2019.The demographic data, underlying diseases, comorbidity, inducement, complications, pathogen sources, etiologies, and the antibiotics therapy were analyzed between ages > 65 years groups and ages < 65 years groups.

RESULTS

The clinical characteristics of totally 809 immunosuppressed people diagnosed with bloodstream infection were analyzed, and among those people about 371 were ages > 65 years. By univariate logistic regression analysis and multivariate logistic regression analysis, we found that hypertension (OR: 2.864, 95% CI 2.024-4.051, P < 0.0001), cerebral Infarction (OR: 4.687, 95% CI 2.056-10.686, P < 0.0001), coronary heart disease (OR: 1.942, 95% CI 1.168-3.230, P = 0.011), acute pancreatitis (OR: 3.964, 95% CI 2.059-7.632, P < 0.0001), infective endocarditis (OR: 6.846, 95% CI 1.828-25.644, P = 0.004), aortic dissection (OR: 9.131, 95% CI 3.190-26.085, P < 0.0001), chemotherapy (OR: 3.462, 95% CI 1.815-6.603, P < 0.0001), transplant status (OR: 20.031, 95% CI 4.193-95.697, P < 0.0001), and respiratory tract infection (OR: 2.096, 95% CI 1.269-3.461, P = 0.004) were significantly different between ages > 65 years groups and ages < 65 years groups.

CONCLUSION

Hypertension, cerebral Infarction, coronary heart disease, acute pancreatitis, infective endocarditis, aortic dissection, chemotherapy, transplant status, and pathogen source of respiratory tract were the independent risk factors of ages > 65 years in immunosuppressed patients, which would have the benefit to discriminate the prognostic factors in immunosuppressive elderly people with bloodstream infection.

Elderly Patients and Management in Intensive Care Units (ICU): Clinical Challenges

There is a growing population of older adults requiring admission to the intensive care unit (ICU). This population outpaces the ability of clinicians with geriatric training to assist in their management. Specific training and education for intensivists in the care of older patients is valuable to help understand and inform clinical care, as physiologic changes of aging affect each organ system. This review highlights some of these aging processes and discusses clinical implications in the vulnerable older population. Other considerations when caring for these older patients in the ICU include functional outcomes and morbidity, as opposed to merely a focus on mortality. An overall holistic approach incorporating physiology of aging, applying current evidence, and including the patient and their family in care should be used when caring for older adults in the ICU.

Association of serum total bilirubin and potential predictors with mortality in acute respiratory failure: A retrospective cohort study

BACKGROUND

Total serum bilirubin (TBIL) levels are a risk factor in critically ill patients. However, the relationship between the dynamics of TBIL and the prognosis of acute respiratory failure (ARF) patients is unclear.

OBJECTIVES

This study aimed to investigate the impact of different levels of TBIL during hospitalization on mortality in ARF patients.

METHODS

This study used a retrospective cohort study. We extracted information on ARF patients from the Medical Information Bank for Intensive Care (MIMIC)-III (version 1.4). We used propensity score matching (PSM) to adjust for the level of potential baseline-level differences between groups. Cox regression was used to analyze mortality risk factors in patients with ARF. Subgroup analysis was used to explore special populations.

RESULTS

2673 patients were included in the study, and 19.7% developed hyperbilirubinemia (TBIL ≥ 2 mg/dL) during their hospitalization. After PSM, multivariate Cox regression showed a 50% and 135% increased risk of death for a maximum value of TBIL ≥ 5 mg/dL and minimum value of TBIL ≥ 2 mg/dL during hospitalization, respectively, compared to the control population. In addition, age ≥ 65 years, previous comorbid malignancies, respiratory rate ≥ 22 beats/min, SpO2 ≥ 95, BUN ≥ 20 mg/dL, lactate ≥ 5 mmol/L, platelet < 100 * 10 ^ 9/L were independent risk factors for 1-year mortality in ARF patients. Subgroup analysis showed that high bilirubin had a greater effect on patients aged less than 65 years (P for interaction < 0.05).

CONCLUSIONS

Hyper TBIL (TBIL max ≥ 5 mg/dL or TBIL min ≥ 2 mg/dL) was an independent risk factor for 1-year mortality in patients with ARF. This study suggests that clinicians should be aware of TBIL levels and intervene early in these patients.

Mechanical ventilation for COVID-19: Outcomes following discharge from inpatient treatment

Though mechanical ventilation (MV) is used to treat patients with severe coronavirus disease 2019 (COVID-19), little is known about the long-term health implications of this treatment. Our objective was to determine the association between MV for treatment of COVID-19 and likelihood of hospital readmission, all-cause mortality, and reason for readmission. This study was a longitudinal observational design with electronic health record (EHR) data collected between 3/1/2020 and 1/31/2021. Participants included 17,652 patients hospitalized for COVID-19 during this period who were followed through 6/30/2021. The primary outcome was readmission to inpatient care following discharge. Secondary outcomes included all-cause mortality and reason for readmission. Rates of readmission and mortality were compared between ventilated and non-ventilated patients using Cox proportional hazards regression models. Differences in reasons for readmission by MV status were compared using multinomial logistic regression. Patient characteristics and measures of illness severity were balanced between those who were mechanically ventilated and those who were not utilizing 1-to-1 propensity score matching. The sample had a median age of 63 and was 47.1% female. There were 1,131 (6.4%) patients who required MV during their initial hospitalization. Rates (32.1% versus 9.9%) and hazard of readmission were greater for patients requiring MV in the propensity score-matched samples [hazard ratio (95% confidence interval) = 3.34 (2.72-4.10)]. Rates (15.3% versus 3.4%) and hazard [hazard ratio (95% confidence interval) = 3.12 (2.32-4.20)] of all-cause mortality were also associated with MV status. Ventilated patients were more likely to be readmitted for reasons which were classified as COVID-19, infectious diseases, and respiratory diagnoses compared to non-ventilated patients. Mechanical ventilation is a necessary treatment for severely ill patients. However, it may be associated with adverse outcomes including hospital readmission and death. More intense post-discharge monitoring may be warranted to decrease this associational finding.

Effects of different types and frequencies of early rehabilitation on ventilator weaning among patients in intensive care units: A systematic review and meta-analysis

OBJECTIVE

This study aimed to investigate the effects of different types and frequencies of physiotherapy on ventilator weaning among patients in the intensive care unit (ICU) and to identify the optimal type and frequency of intervention.

DATA SOURCES

PubMed, Cochrane Library, EMBASE, and Airiti Library.

STUDY SELECTION

Randomized controlled trials that provided information on the dosage of ICU rehabilitation and the parameters related to ventilator weaning were included.

DATA EXTRACTION AND MANAGEMENT

Treatment types were classified into conventional physical therapy, exercise-based physical therapy, neuromuscular electrical stimulation (NEMS), progressive mobility, and multi-component. The frequencies were divided into high (≥ 2 sessions/day or NEMS of > 60 minutes/day), moderate (one session/day, 3-7 days/week or NEMS of 30-60 minutes/day), and low (one session/day, < 3 days/week, or NEMS of < 30 minutes/day).

DATA SYNTHESIS

Twenty-four articles were included for systematic review and 15 out of 24 articles were analyzed in the meta-analysis. Early rehabilitation, especially the progressive mobility treatment exerted an optimal effect in reducing the ventilator duration in patients in the ICU (standardized mean difference [SMD] = 0.91; 95% confidence interval [CI] = 0.23-1.58; P < 0.01). Regarding the treatment frequency, the high-frequency intervention did not result in a favorable effect on ventilator duration compared with the moderate frequency of treatment (SMD = 0.75; 95% CI = -1.13-2.64; P = 0.43).

CONCLUSION

Early rehabilitation with progressive mobility is highly recommended to decrease the ventilation duration received by patients in the ICU. Depending on clinical resources and the tolerance of patients, the frequency of interventions should reach moderate-to-high frequency, that is, at least one session per day and 3 days a week.

TRIAL REGISTRATION

Registration number: PROSPERO (CRD42021243331).

Morbimortality and Six-Month Survival Among Elderly Patients Treated With Noninvasive Mechanical Ventilation in an Intermediate Care Unit: A Retrospective Evaluation

BACKGROUND

Noninvasive mechanical ventilation (NIMV) has been established as a successful therapeutic option for patients with acute respiratory failure (ARF) with a specific etiology.

OBJECTIVES

This study evaluated the morbimortality of patients with ARF treated with NIMV in a medical intermediate care unit (UCINT) to identify factors associated with higher in-hospital mortality, six-month mortality, and three- and six-month hospital readmission rates.

METHODS

This retrospective cohort study included elderly patients admitted for ARF and treated with NIMV in the UCINT between 2015 and 2019.

RESULTS

In the sample of 102 patients, the median age was 84.2 (±5.5) years, and 57% were women. In total, 28% were on long-term oxygen therapy, and 68% had a do-not-resuscitate order. At admission, the median Charlson comorbidity index and Barthel index of activities of daily living were 7 [6; 8] and 30 [20; 57,5], respectively. The simplified acute physiology score II was 39.1±10.7, and 92% of patients had type 2 ARF. Median days on NIMV and days in UCINT were 10 [6; 16] and 6 [3; 10], respectively. The main conditions requiring UCINT admission for NIMV were heart failure, pneumonia, and exacerbation of the chronic obstructive pulmonary disease. The NIMV failure rate was 7%. At discharge, the average Barthel index was 35 [10; 55]. The in-hospital mortality rate was 23%.

DISCUSSION

 Older age, higher simplified acute physiology score II, higher Charlson comorbidity index, and higher number of days on NIMV were associated with higher in-hospital mortality. Long-term oxygen therapy was associated with higher three-month mortality. A higher Barthel index at the time of hospital discharge was associated with a higher six-month readmission rate.

CONCLUSION

NIMV can be used successfully in elderly patients and less studied ARF etiologies, such as pneumonia.

Mean platelet volume as a predictive biomarker for in-hospital mortality in patients receiving invasive mechanical ventilation

Background

Although mean platelet volume (MPV) has been reported to be associated with poor prognosis of various critical illness, the relationship between MPV and in-hospital mortality among patients undergoing invasive mechanical ventilation (IMV) is unclear.

Methods

A retrospective observational study including patients receiving IMV was conducted from January, 2014 to January, 2019. The patients were divided into two groups by MPV cutoff value. The receiver operating characteristics curve was used to evaluate the predictive ability of MPV for in-hospital mortality. Univariate and multivariate Cox regression analysis were conducted to analyze the value of MPV for predicting in-hospital mortality. Kaplan–Meier cumulative incidence curve was employed to observe the incidence of in-hospital mortality.

Results

A total of 274 patients were enrolled in the study, and 42 patients (15.3%) died in hospital. MPV > 11.4 fl was a valuable predictor for in-hospital mortality (AUC0.848; 95%CI, 0.800–0.889) with sensitivity 66.7%, and specificity = 86.21%. MPV > 11.4 fl was an independent risk factor for in-hospital mortality (adjusted HR 2.640, 95%CI, 1.208–5.767, P = 0.015). Compared to the group of MPV ≤ 11.4 fl, patients with MPV > 11.4 fl had increased mortality (log-rank test = 40.35, HR = 8.723, P < 0.0001). The relationship between MPV and in-hospital mortality was stronger in female patients than in male patients.

Conclusion

MPV > 11.4 fl is a more useful marker for predicting in-hospital mortality among critically ill patients receiving IMV, especially in female patients. Attention to the MPV marker is simple and profitable with immediate applicability in daily clinical practice.

Comparison of the Outcomes of Patients Starting Mechanical Ventilation in the General Ward Versus the Intensive Care Unit

OBJECTIVE

Mechanical ventilation is sometimes initiated in the general ward (GW) due to the shortage of intensive care unit (ICU) beds. We investigated whether invasive mechanical ventilation (MV) started in the GW affects the patient's prognosis compared with its initiation in the ICU.

METHODS

From January 2016 to December 2018, medical records of patients who started MV in the GW or ICU were collected. The 28-day mortality, ICU mortality, ventilator-free days, and complications related to the ventilator and the ventilator-free days were analyzed as outcomes.

RESULTS

A total of 673 patients were enrolled. Among these, 268 patients (39.8%) started MV in the GW and 405 patients (60.2%) started MV within 24 hours after admittance to the ICU. There was no difference in 28-day mortality between the 2 groups (27.2% versus 27.2%, P = 0.997). In addition, there was no difference between ventilator-related complication rates, ventilator-free days, or the length of hospital stay. A high Acute Physiology and Chronic Health Evaluation II score, the presence of solid tumor, the absence of chronic kidney diseases, and low platelet count were associated with higher 28-day mortality. However, the initiation of MV in the GW was not associated with an increase in 28-day mortality compared with the initiation in the ICU.

CONCLUSIONS

Starting MV in the GW was not a risk factor for 28-day mortality. Therefore, prompt application of a ventilator if medically indicated, regardless of the patient's location, is desirable if a skilled airway team and appropriate monitoring are available.

Mechanical Ventilation and Survival in Patients With Advanced Dementia in Medicare Advantage

CONTEXT

Medicare Advantage (MA) cares for an increasing proportion of traditional Medicare (TM) patients although, the association of MA on low-value care among hospitalized patients is uncertain.

OBJECTIVES

We sought to determine whether invasive mechanical ventilation (IMV) use or mortality differs among hospitalized patients with advanced dementia (AD) enrolled in MA vs. TM and the influence of hospital MA concentration.

METHODS

Retrospective cohort of hospitalized Medicare patients from 2016 to 2017 who were ≥66 years old with AD (n=147,153) and had a hospitalization with an assessment completed during a nursing home stay ≤120 days prior to that hospitalization indicating AD and severe cognitive/functional impairment. MA enrollment was ascertained at hospitalization; IMV use and 30- and 365-day mortality were determined via Medicare data. Multivariable logistic regression models clustered by hospital were used.

RESULTS

Among hospitalized Medicare patients with AD, 27,253 (19%) were enrolled in MA, mean age was 84 (95% CI: 83.9-84.0) and 92,736 (63%) were female. Enrollment in MA was associated with increased IMV use (Adjusted Odds Ratio(AOR)=1.11, 95% CI: 1.04-1.18), 30- (Adjusted Hazard Ratio(AHR)=1.09, 95% CI: 1.05-1.12) and 365-day mortality (AHR=1.12, 95% CI: 1.08-1.16) compared to TM. Use of IMV was not different based on concentration of MA at the hospital level.

CONCLUSION

MA may reduce hospitalizations, however, once hospitalized, patients with AD enrolled in MA experience higher rates of IMV use and worse 30- and 365-day mortality compared to TM patients. Higher hospital concentration of MA did not reduce use of IMV. MA may not offer significant benefits in reducing low-value care among patients hospitalized with serious illness, questioning the benefits of this care model.

A propensity score-matching analysis of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker exposure on in-hospital mortality in patients with acute respiratory failure

STUDY OBJECTIVE

To explore the impact of pre-hospital ACEI and ARB exposure on the prognosis of ARF patients.

DESIGN

A single-center retrospective cohort study.

SETTING

Medical Information Mart for Intensive Care-III (MIMIC-III) database.

PATIENTS

The patients meeting ICD-9 code of acute respiratory failure were enrolled.

INTERVENTION

The primary exposure was the pre-hospital exposure of ACEI and ARB.

MEASUREMENT AND MAIN RESULTS

The primary outcome was in-hospital mortality. Multiple logistic regression analysis was conducted to determine the independent effect of ACEI/ARB exposure on mortality. Propensity score matching (PSM) method was adopted to reduce bias of the confounders. Subgroup analysis and sensitivity analysis were used to test the stability of the conclusion. 5335 adult ARF patients were enrolled. Mortality was significantly decreased in patients with ACEI/ARB exposure before and after PSM, and the adjusted odds ratio (OR) of ACEI/ARB exposure was 0.56 (95% CI 0.43-0.72). In the subgroup analysis, ACEI/ARB lost its protective effect in young subgroup, but no significant interaction was found between ACEI/ARB exposure and age (p = 0.082). The point estimation and lower 95% limit of E-value was 2.97 and 2.12. In sensitivity analysis, ACEI/ARB exposure showed similar effect in ARDS cohort, but no significantly difference was found in the MIMIC-IV database, which may be explained by small sample size of the ACEI/ARB group.

CONCLUSIONS

Among patients with acute respiratory failure, pre-hospital ACEI/ARB exposure was associated with better outcomes and acted as an independent factor. The relationship between ACEI/ARB and prognosis of ARF is worth investigating further.

High flow nasal catheter therapy versus non-invasive positive pressure ventilation in acute respiratory failure (RENOVATE trial): protocol and statistical analysis plan

Background: The best way to offer non-invasive respiratory support across several aetiologies of acute respiratory failure (ARF) is presently unclear. Both high flow nasal catheter (HFNC) therapy and non-invasive positive pressure ventilation (NIPPV) may improve outcomes in critically ill patients by avoiding the need for invasive mechanical ventilation (IMV). Objective: Describe the details of the protocol and statistical analysis plan designed to test whether HFNC therapy is non-inferior or even superior to NIPPV in patients with ARF due to different aetiologies. Methods: RENOVATE is a multicentre adaptive randomised controlled trial that is recruiting patients from adult emergency departments, wards and intensive care units (ICUs). It takes advantage of an adaptive Bayesian framework to assess the effectiveness of HFNC therapy versus NIPPV in four subgroups of ARF (hypoxaemic non-immunocompromised, hypoxaemic immunocompromised, chronic obstructive pulmonary disease exacerbations, and acute cardiogenic pulmonary oedema). The study will report the posterior probabilities of non-inferiority, superiority or futility for the comparison between HFNC therapy and NIPPV. The study assumes neutral priors and the final sample size is not fixed. The final sample size will be determined by a priori determined stopping rules for non-inferiority, superiority and futility for each subgroup or by reaching the maximum of 2000 patients. Outcomes: The primary endpoint is endotracheal intubation or death within 7 days. Secondary outcomes are 28-day and 90-day mortality, and ICU-free and IMV-free days in the first 28 days. Results and conclusions: RENOVATE is designed to provide evidence on whether HFNC therapy improves, compared with NIPPV, important patient-centred outcomes in different aetiologies of ARF. Here, we describe the rationale, design and status of the trial. Trial registration:ClinicalTrials.gov NCT03643939.

Ventilator-Associated Events: Epidemiology, Risk Factors, and Prevention

The Centers for Disease Control and Prevention shifted the focus of safety surveillance in mechanically ventilated patients from ventilator-associated pneumonia to ventilator-associated events in 2013 to increase the objectivity and reproducibility of surveillance and to encourage quality improvement programs to focus on preventing a broader array of complications. Ventilator-associated events are associated with a doubling of the risk of dying. Prospective studies have found that minimizing sedation, increasing spontaneous awakening and breathing trials, and conservative fluid management can decrease event rates and the duration of ventilation. Multifaceted interventions to enhance these practices can decrease ventilator-associated event rates.

The Association Between Endotracheal Tube Size and Aspiration (During Flexible Endoscopic Evaluation of Swallowing) in Acute Respiratory Failure Survivors

OBJECTIVES

To determine whether a modifiable risk factor, endotracheal tube size, is associated with the diagnosis of postextubation aspiration in survivors of acute respiratory failure.

DESIGN

Prospective cohort study.

SETTING

ICUs at four academic tertiary care medical centers.

PATIENTS

Two hundred ten patients who were at least 18 years old, admitted to an ICU, and mechanically ventilated with an endotracheal tube for longer than 48 hours were enrolled.

INTERVENTIONS

Within 72 hours of extubation, all patients received a flexible endoscopic evaluation of swallowing examination that entailed administration of ice, thin liquid, thick liquid, puree, and cracker boluses. Patient demographics, treatment variables, and hospital outcomes were abstracted from the patient's medical records. Endotracheal tube size was independently selected by the patient's treating physicians.

MEASUREMENTS AND MAIN RESULTS

For each flexible endoscopic evaluation of swallowing examination, laryngeal pathology was evaluated, and for each bolus, a Penetration Aspiration Scale score was assigned. Aspiration (Penetration Aspiration Scale score ≥ 6) was further categorized into nonsilent aspiration (Penetration Aspiration Scale score = 6 or 7) and silent aspiration (Penetration Aspiration Scale score = 8). One third of patients (n = 68) aspirated (Penetration Aspiration Scale score ≥ 6) on at least one bolus, 13.6% (n = 29) exhibited silent aspiration, and 23.8% (n = 50) exhibited nonsilent aspiration. In a multivariable analysis, endotracheal tube size (≤ 7.5 vs ≥ 8.0) was significantly associated with patients exhibiting any aspiration (Penetration Aspiration Scale score ≥ 6) (p = 0.016; odds ratio = 2.17; 95% CI 1.14-4.13) and with risk of developing laryngeal granulation tissue (p = 0.02).

CONCLUSIONS

Larger endotracheal tube size was associated with increased risk of aspiration and laryngeal granulation tissue. Using smaller endotracheal tubes may reduce the risk of postextubation aspiration.

Machine Learning Models to Predict 30-Day Mortality in Mechanically Ventilated Patients

Previous scoring models, such as the Acute Physiologic Assessment and Chronic Health Evaluation II (APACHE II) score, do not adequately predict the mortality of patients receiving mechanical ventilation in the intensive care unit. Therefore, this study aimed to apply machine learning algorithms to improve the prediction accuracy for 30-day mortality of mechanically ventilated patients. The data of 16,940 mechanically ventilated patients were divided into the training-validation (83%, n = 13,988) and test (17%, n = 2952) sets. Machine learning algorithms including balanced random forest, light gradient boosting machine, extreme gradient boost, multilayer perceptron, and logistic regression were used. We compared the area under the receiver operating characteristic curves (AUCs) of machine learning algorithms with those of the APACHE II and ProVent score results. The extreme gradient boost model showed the highest AUC (0.79 (0.77–0.80)) for the 30-day mortality prediction, followed by the balanced random forest model (0.78 (0.76–0.80)). The AUCs of these machine learning models as achieved by APACHE II and ProVent scores were higher than 0.67 (0.65–0.69), and 0.69 (0.67–0.71)), respectively. The most important variables in developing each machine learning model were APACHE II score, Charlson comorbidity index, and norepinephrine. The machine learning models have a higher AUC than conventional scoring systems, and can thus better predict the 30-day mortality of mechanically ventilated patients.

Development and validation of a nomogram to predict the mortality risk in elderly patients with ARF

Background

Acute respiratory failure (ARF) is a life-threatening complication in elderly patients. We developed a nomogram model to explore the risk factors of prognosis and the short-term mortality in elderly patients with ARF.

Methods

A total of 759 patients from MIMIC-III database were categorized into the training set and 673 patients from our hospital were categorized into the validation set. Demographical, laboratory variables, SOFA score and APS-III score were collected within the first 24 h after the ICU admission. A 30-day follow-up was performed for all patients.

Results

Multivariate logistic regression analysis showed that the heart rate, respiratoryrate, systolic pressure, SPO₂, albumin and 24 h urine output were independent prognostic factors for 30-day mortality in ARF patients. A nomogram was established based on above independent prognostic factors. This nomogram had a C-index of 0.741 (95% CI [0.7058-0.7766]), and the C-index was 0.687 (95% CI [0.6458-0.7272]) in the validation set. The calibration curves both in training and validation set were close to the ideal model. The SOFA had a C-index of 0.653 and the APS-III had a C-index of 0.707 in predicting 30-day mortality.

Conclusion

Our nomogram performed better than APS-III and SOFA scores and should be useful as decision support on the prediction of mortality risk in elderly patients with ARF.

High-flow nasal cannulae for respiratory support in adult intensive care patients

BACKGROUND

High-flow nasal cannulae (HFNC) deliver high flows of blended humidified air and oxygen via wide-bore nasal cannulae and may be useful in providing respiratory support for adults experiencing acute respiratory failure, or at risk of acute respiratory failure, in the intensive care unit (ICU). This is an update of an earlier version of the review.

OBJECTIVES

To assess the effectiveness of HFNC compared to standard oxygen therapy, or non-invasive ventilation (NIV) or non-invasive positive pressure ventilation (NIPPV), for respiratory support in adults in the ICU.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, Web of Science, and the Cochrane COVID-19 Register (17 April 2020), clinical trial registers (6 April 2020) and conducted forward and backward citation searches.

SELECTION CRITERIA

We included randomized controlled studies (RCTs) with a parallel-group or cross-over design comparing HFNC use versus other types of non-invasive respiratory support (standard oxygen therapy via nasal cannulae or mask; or NIV or NIPPV which included continuous positive airway pressure and bilevel positive airway pressure) in adults admitted to the ICU.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by Cochrane.

MAIN RESULTS

We included 31 studies (22 parallel-group and nine cross-over designs) with 5136 participants; this update included 20 new studies. Twenty-one studies compared HFNC with standard oxygen therapy, and 13 compared HFNC with NIV or NIPPV; three studies included both comparisons. We found 51 ongoing studies (estimated 12,807 participants), and 19 studies awaiting classification for which we could not ascertain study eligibility information. In 18 studies, treatment was initiated after extubation. In the remaining studies, participants were not previously mechanically ventilated. HFNC versus standard oxygen therapy HFNC may lead to less treatment failure as indicated by escalation to alternative types of oxygen therapy (risk ratio (RR) 0.62, 95% confidence interval (CI) 0.45 to 0.86; 15 studies, 3044 participants; low-certainty evidence). HFNC probably makes little or no difference in mortality when compared with standard oxygen therapy (RR 0.96, 95% CI 0.82 to 1.11; 11 studies, 2673 participants; moderate-certainty evidence). HFNC probably results in little or no difference to cases of pneumonia (RR 0.72, 95% CI 0.48 to 1.09; 4 studies, 1057 participants; moderate-certainty evidence), and we were uncertain of its effect on nasal mucosa or skin trauma (RR 3.66, 95% CI 0.43 to 31.48; 2 studies, 617 participants; very low-certainty evidence). We found low-certainty evidence that HFNC may make little or no difference to the length of ICU stay according to the type of respiratory support used (MD 0.12 days, 95% CI -0.03 to 0.27; 7 studies, 1014 participants). We are uncertain whether HFNC made any difference to the ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO2/FiO2) within 24 hours of treatment (MD 10.34 mmHg, 95% CI -17.31 to 38; 5 studies, 600 participants; very low-certainty evidence). We are uncertain whether HFNC made any difference to short-term comfort (MD 0.31, 95% CI -0.60 to 1.22; 4 studies, 662 participants, very low-certainty evidence), or to long-term comfort (MD 0.59, 95% CI -2.29 to 3.47; 2 studies, 445 participants, very low-certainty evidence). HFNC versus NIV or NIPPV We found no evidence of a difference between groups in treatment failure when HFNC were used post-extubation or without prior use of mechanical ventilation (RR 0.98, 95% CI 0.78 to 1.22; 5 studies, 1758 participants; low-certainty evidence), or in-hospital mortality (RR 0.92, 95% CI 0.64 to 1.31; 5 studies, 1758 participants; low-certainty evidence). We are very uncertain about the effect of using HFNC on incidence of pneumonia (RR 0.51, 95% CI 0.17 to 1.52; 3 studies, 1750 participants; very low-certainty evidence), and HFNC may result in little or no difference to barotrauma (RR 1.15, 95% CI 0.42 to 3.14; 1 study, 830 participants; low-certainty evidence). HFNC may make little or no difference to the length of ICU stay (MD -0.72 days, 95% CI -2.85 to 1.42; 2 studies, 246 participants; low-certainty evidence). The ratio of PaO2/FiO2 may be lower up to 24 hours with HFNC use (MD -58.10 mmHg, 95% CI -71.68 to -44.51; 3 studies, 1086 participants; low-certainty evidence). We are uncertain whether HFNC improved short-term comfort when measured using comfort scores (MD 1.33, 95% CI 0.74 to 1.92; 2 studies, 258 participants) and responses to questionnaires (RR 1.30, 95% CI 1.10 to 1.53; 1 study, 168 participants); evidence for short-term comfort was very low certainty. No studies reported on nasal mucosa or skin trauma.

AUTHORS' CONCLUSIONS

HFNC may lead to less treatment failure when compared to standard oxygen therapy, but probably makes little or no difference to treatment failure when compared to NIV or NIPPV. For most other review outcomes, we found no evidence of a difference in effect. However, the evidence was often of low or very low certainty. We found a large number of ongoing studies; including these in future updates could increase the certainty or may alter the direction of these effects.

Accuracy of Administrative Hospital Data to Identify Use of Life Support Modalities. A Canadian Study

Rationale: Accurately identifying use of life support in hospital administrative data enhances the data's value for quality improvement and research in critical illness.Objectives: To assess the accuracy of administrative hospital data for identifying invasive mechanical ventilation (IMV), acute renal replacement therapy (RRT), and intravenous vasoactive drugs in unselected adult intensive care unit (ICU) patients.Methods: We employed the administrative dataset of the Discharge Abstract Database from the Province of Manitoba during 2007-2012, using nationally standardized diagnosis and procedure codes to identify the three types of life support. The criterion standard was the Winnipeg ICU Database, which contains daily clinical information about all admissions to all 11 adult ICUs within the Winnipeg Regional Health Authority. For all individuals aged 40 years or older at ICU admission, we calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value of the administrative data for identifying life support. We also assessed the ability of the administrative data to identify overlapping use of the forms of life support.Results: Over the study period, there were 20,764 eligible ICU admissions; 52.6% (10,914) involved IMV, 46.8% (9,724) involved vasoactive agents, and 4.4% (907) involved acute RRT. Identification of IMV from administrative data procedure codes was good, with all four parameters exceeding 90%. The procedure code for use of selected vasoactive drugs had a sensitivity of zero; addition of diagnosis codes for shock raised the sensitivity to only 23% (95% confidence interval [CI], 22-24%). Both the sensitivity and specificity for acute RRT procedure codes exceeded 92%, but owing to low prevalence of RRT, the PPV was only 55% (95% CI, 53-58%). Addition of diagnosis codes for acute renal failure did not appreciably improve performance. Overlapping use of the three types of life support was substantial. Among those receiving any one of the types of life support, 68-76% received at least one of the two other types assessed. Considering use of any one or more of the three forms of life support, the administrative data had a PPV of 97% (95% CI, 96-97%) and a negative predictive value of 69% (95% CI, 68-70%).Conclusions: Administrative data accurately identify IMV but not use of vasoactive drugs or acute RRT.

Veno-Venous Extracorporeal Lung Support as a Bridge to or Through Lung Volume Reduction Surgery in Patients with Severe Hypercapnia

Extracorporeal lung support (ECLS) represents an essential support tool especially for critically ill patients undergoing thoracic surgical procedures. Lung volume reduction surgery (LVRS) is an important treatment option for end-stage lung emphysema in carefully selected patients. Here, we report the efficacy of veno-venous ECLS (VV ECLS) as a bridge to or through LVRS in patients with end-stage lung emphysema and severe hypercapnia. Between January 2016 and May 2017, 125 patients with end-stage lung emphysema undergoing LVRS were prospectively enrolled into this study. Patients with severe hypercapnia caused by chronic respiratory failure were bridged to or through LVRS with low-flow VV ECLS (65 patients, group 1). Patients with preoperative normocapnia served as a control group (60 patients, group 2). In group 1, VV ECLS was implemented preoperatively in five patients and in 60 patients intraoperatively. Extracorporeal lung support was continued postoperatively in all 65 patients. Mean length of postoperative VV ECLS support was 3 ± 1 day. The 90 day mortality rate was 7.8% in group 1 compared with 5% in group 2 (p = 0.5). Postoperatively, a significant improvement was observed in quality of life, exercise capacity, and dyspnea symptoms in both groups. VV ECLS in patients with severe hypercapnia undergoing LVRS is an effective and well-tolerated treatment option. In particular, it increases the intraoperative safety, supports de-escalation of ventilatory strategies, and reduces the rate of postoperative complications in a cohort of patients considered "high risk" for LVRS in the current literature.

Multidimensional prognostic index (MPI) predicts non-invasive ventilation failure in older adults with acute respiratory failure

BACKGROUND

Acute respiratory failure (ARF) is a very common complication among hospitalized older adults. Non-invasive ventilation (NIV) may avoid admission to intensive care units, intubation and their related complication, but still lacks specific indications in older adults. Multidimensional Prognostic Index (MPI) based on comprehensive geriatric assessment (CGA) could have a role in defining the short-term prognosis and the best candidates for NIV among older adults with ARF.

METHODS

This is a retrospective observational study which enrolled patients older than 70 years, consecutively admitted to an acute geriatric unit with ARF. A standardized CGA was used to calculate the MPI at admission. Multivariate Cox regression models were used to test if MPI score could predict in-hospital mortality and NIV failure. Receiver operator curve (ROC) analysis was used to identify the discriminatory power of MPI for NIV failure.

RESULTS

We enrolled 231 patients (88.2 ± 5.9 years, 47% females). Mean MPI at admission was 0.76±0.16. In-hospital mortality rate was 33.8%, with similar incidence in patients treated with and without NIV. Among NIV users (26.4%), NIV failure occurred in 39.3%. Higher MPI scores at admission significantly predicted in-hospital mortality (β=4.46, p<0.0001) among patients with ARF and NIV failure (β=7.82, p = 0.001) among NIV users. MPI showed good discriminatory power for NIV failure (area under the curve: 0.72, 95% CI: 0.58-0.85, p<0.001) with optimal cut-off at MPI value of 0.84.

CONCLUSIONS

MPI at admission might be a useful tool to early detect patients more at risk of in-hospital death and NIV failure among older adults with ARF.

What are the prognostic factors affecting 30-day mortality in geriatric patients with respiratory failure in the Intensive Care Unit?

Objective:

We aimed to investigate the prognostic factors related to 30 day mortality of elderly patients with respiratory failure in the intensive care unit (ICU).

Methods:

We performed a single centre, retrospective study and analyzed the main variables and outcomes of 238 geriatric patients admitted to an ICU with ARF between December 2017- January 2019 in Chest Disease Hospital, were included and classified as survivors and nonsurvivors. Main characteristics, laboratory datas, severity and nutrition scores were evaluated and logistic regression analysis were used.

Results:

The nonsurvivor group included 110 cases (40% female,) with a median age of 79, had higher scores in the followings; Acute Physiology Chronic Health Evaluation II score (APACHE-II) (p < 0.001), Charlson Comorbidity Index (CCI) (p < 0.001), Sequential Organ Failure Assessment score (p < 0.001). The inotropic support requirement was also higher in the nonsurvivor group (48,2%). As a comorbidity, malignancy and Type-I respiratory failure were higher in the nonsurvivor group (p=0.03, p < 0.001). The overall 30-day mortality was 46%. Blood urea nitrogen, procalsitonin, C-reactive protein and creatinine levels were higher in the nonsurvivor group (p < 0.001). However, albumin (p < 0.001), BMI (p=0.03) and longer hospital stay (p < 0.001) were higher in the survivor group. Inotropic support, APACHE-II score and CCI were independently related to increased mortality risk, whereas albumin was associated with decreased mortality risk.

Conclusion:

High APACHE II score, low CCI, low albumin levels and the requirement for inotropic support were found to be independently risk factors of 30-day mortality in the geriatric patients with respiratory failure in ICU.

Predictors and outcomes of acute respiratory failure in hospitalised patients with acute pancreatitis

BACKGROUND AND AIM

Acute pancreatitis (AP) is associated with organ failures and systemic complications, most commonly acute respiratory failure (ARF) and acute kidney injury. So far, no studies have analysed the predictors and hospitalisation outcomes, of patients with AP who developed ARF. The aim of this study was to measure the prevalence of ARF in AP and to determine the clinical predictors for ARF and mortality in AP.

METHODS

This is a retrospective cohort study using the Nationwide Inpatient Sample database from the year 2005-2014. The study population consisted of all hospitalisations with a primary or secondary discharge diagnosis of AP, which is further stratified based on the presence of ARF. The outcome measures include in-hospital mortality, hospital length of stay and hospitalisation cost.

RESULTS

In our study, about 5.4% of patients with AP had a codiagnosis of ARF, with a mortality rate of 26.5%. The significant predictors for ARF include sepsis, pleural effusion, pneumonia and cardiogenic shock. Key variables that were associated with a higher risk of mortality include mechanical ventilation, age more than 65 years, sepsis and cancer (excluding pancreatic cancer). The presence of ARF increased hospital stay by 8.3 days and hospitalisation charges by US$103 460.

CONCLUSION

In this study, we demonstrate that ARF is a significant risk factor for increased hospital mortality, greater length of stay and higher hospitalisation charges in patients with AP. This underlines significantly higher resource utilisation in patients with a dual diagnosis of AP-ARF.

Serum ionised calcium and the risk of acute respiratory failure in hospitalised patients: a single-centre cohort study in the USA

OBJECTIVES

The objective of this study was to evaluate the risk of acute respiratory failure in all hospitalised patients based on admission serum ionised calcium.

DESIGN

A retrospective cohort study.

SETTING

A tertiary referral hospital in Rochester, Minnesota, USA.

PARTICIPANTS

All hospitalised patients who had serum ionised calcium measurement within 24 hours of hospital admission from January 2009 to December 2013. Patients who were mechanically ventilated at admission were excluded.

PREDICTORS

Admission serum ionised calcium levels was stratified into six groups: ≤4.39, 4.40-4.59, 4.60-4.79, 4.80-4.99, 5.00-5.19 and ≥5.20 mg/dL.

PRIMARY OUTCOME MEASURE

The primary outcome was the development of acute respiratory failure requiring mechanical ventilation during hospitalisation. Logistic regression analysis was fit to assess the independent risk of acute respiratory failure based on various admission serum ionised calcium, using serum ionised calcium of 5.00-5.19 mg/dL as the reference group.

RESULTS

Of 25 709 eligible patients, with the mean serum ionised calcium of 4.8±0.4 mg/dL, acute respiratory failure requiring mechanical ventilation occurred in 2563 patients (10%). The incidence of acute respiratory failure was lowest when admission serum ionised calcium was 5.00-5.19 mg/dL, with the progressively increased risk of acute respiratory failure with decreased serum ionised calcium. In multivariate analysis with adjustment for potential confounders, the increased risk of acute respiratory failure requiring mechanical ventilation was significantly associated with admission serum ionised calcium of ≤4.39 (OR 2.52; 95% CI 2.12 to 3.00), 4.40-4.59 (OR 1.76; 95% CI 1.49 to 2.07) and 4.60-4.79 mg/dL (OR 1.48; 95% CI 1.27 to 1.72), compared with serum ionised calcium of 5.00-5.19 mg/dL. The risk of acute respiratory failure was not significantly increased when serum ionised calcium was at least 4.80 mg/dL.

CONCLUSION

The increased risk of acute respiratory failure requiring mechanical ventilation was observed when admission serum ionised calcium was lower than 4.80 mg/dL in hospitalised patients.

Risk of respiratory failure among hospitalized patients with various admission serum potassium levels

BACKGROUND

The objective of this study was to assess the relationship between admission serum potassium and the risk of respiratory failure requiring mechanical ventilation in all hospitalized patients.

METHODS

All non-dialysis and non-mechanically ventilated patients who had serum potassium measurement at admission from 2011 to 2013 were studied. Serum potassium levels were stratified into five groups; ≤3.4, 3.5 to 3.9, 4.0 to 4.4, 4.5 to 4.9, 5.0 to 5.4, and ≥5.5 mEq/L. The outcome of interest was the respiratory failure requiring mechanical ventilation during hospitalization. Logistic regression analysis was performed to assess the independent risk of in-hospital respiratory failure requiring mechanical ventilation based on various admission serum potassium, using serum potassium of 4.0 to 4.4 mEq/L as the reference group.

RESULTS

Of 67,034 eligible patients, with the mean admission serum potassium of 4.2 ± 0.5 mEq/L, 2,886 (4.3%) patients developed respiratory failure requiring mechanical ventilation during hospitalization. As demonstrated by U-shaped association, increased risk of in-hospital respiratory failure was significantly associated with low admission serum potassium ≤ 3.4 mEq/L (odds ratio 1.36, p-value <0.001) and high admission serum potassium ≥5.5 mEq/L (odds ratio 1.37, p-value = 0.01).

CONCLUSION

Increased risk of in-hospital respiratory failure requiring mechanical ventilation was noted when serum potassium was below 3.5 mEq/L or above 5.4 mEq/L at the time of hospital admission. Patients with either hypokalemia or hyperkalemia are at risk of respiratory failure requiring mechanical ventilation.

Can we predict patients that will not benefit from invasive mechanical ventilation? A novel scoring system in intensive care: the IMV Mortality Prediction Score (IMPRES)

Background/aim

The present study aimed to define the clinical and laboratory criteria for predicting patients that will not benefit from invasive mechanical ventilation (IMV) treatment and determine the prediction of mortality and prognosis of these critical ill patients.

Materials and methods

The study was designed as an observational, multicenter, prospective, and cross-sectional clinical study. It was conducted by 75 researchers at 41 centers in intensive care units (ICUs) located in various geographical areas of Turkey. It included a total of 1463 ICU patients who were receiving invasive mechanical ventilation (IMV) treatment. A total of 158 parameters were examined via logistic regression analysis to identify independent risk factors for mortality; using these data, the IMV Mortality Prediction Score (IMPRES) scoring system was developed.

Results

The following cut-off scores were used to indicate mortality risk: <2, low risk; 2–5, moderate risk; 5.1–8, high risk; >8, very high risk. There was a 26.8% mortality rate among the 254 patients who had a total IMPRES score of lower than 2. The mortality rate was 93.3% for patients with total IMPRES scores of greater than 8 (P < 0.001).

Conclusion

The present study included a large number of patients from various geographical areas of the country who were admitted to various types of ICUs, had diverse diagnoses and comorbidities, were intubated with various indications in either urgent or elective settings, and were followed by physicians from various specialties. Therefore, our data are more general and can be applied to a broader population. This study devised a new scoring system for decision-making for critically ill patients as to whether they need to be intubated or not and presents a rapid and accurate prediction of mortality and prognosis prior to ICU admission using simple clinical data.

Evaluation of the association between decreased skeletal muscle mass and extubation failure after long-term mechanical ventilation

BACKGROUND & AIMS

Elderly patients are being increasingly admitted to the intensive care unit (ICU) for mechanical ventilation (MV) and prevalence of decreased skeletal muscle mass which develop with aging is subsequently increasing. The objective of this study was to identify the association between decreased skeletal muscle mass and extubation failure in patients undergoing long-term MV.

METHODS

Adults (≥18 years of age) with long-term MV for > 7 days between January 2014 and February 2019 were included retrospectively. Patients who died or were transferred with MV, underwent tracheostomy with failure of weaning from MV, and had not undergone abdominal computed tomography within 3 days before or after intubation were excluded. Failed extubation was defined as reintubation within 48 h after extubation following long-term MV for >7 days. We divided the patients into extubation success and failure groups.

RESULTS

Parameters including patients' demographics, cause of intubation, initial setting of MV, maximum inspiratory pressure (MIP) and rapid shallow breath index (RSBI) at extubation, and skeletal muscle mass were compared between the two groups. Decreased skeletal muscle mass was set a standard as a L3 muscle index of less than 49 cm²/m² for men and of less than 31 cm²/m² for women using Korean-specific cut-offs for sarcopenia as evaluated on previous epidemiologic study. Among 104 patients who were screened, 45 were included, and 11 (24.4%) failed to be extubated. Mean MIP (23.5 ± 11.8 vs. 32.4 ± 9.3, p = 0.134) and RSBI (57.2 ± 26.5 vs. 55.3 ± 20.4, p = 0.803) were not different between the two groups. The proportions of patients whose MIP or RSBI satisfied the cutoff for extubation were not different between the groups. There were no significant differences in age, sex, body mass index, comorbidities, nutritional status, and cause of intubation between the two groups. The extubation failure group showed a higher proportion of decreased skeletal muscle mass (90.9% vs. 58.8%, p = 0.05) and longer duration of MV (10.7 ± 4.1 vs. 9.6 ± 3.4, p < 0.001) than the extubation success group. Multivariate analysis showed that the duration of intubation (OR = 1.439, 95% CI = 1.12-1.85), and decreased skeletal muscle mass (OR = 24.382, 95% CI = 1.00-594.86) were associated with extubation failure.

CONCLUSIONS

Decreased skeletal muscle mass was associated with extubation failure after long-term MV for > 7 days. It is important to diagnose decreased skeletal muscle mass in critically ill patients to reduce extubation failure rates.

Thirty-Day Spending and Outcomes for an Episode of Pneumonia Care Among Medicare Beneficiaries

BACKGROUND

Recent policy initiatives aim to improve the value of care for patients hospitalized with pneumonia. It is unclear whether higher 30-day episode spending at the hospital level is associated with any difference in patient mortality among fee-for-service Medicare beneficiaries.

METHODS

This retrospective cohort study assessed the association between hospital-level spending and patient-level mortality for a 30-day episode of care. The study used data for Medicare fee-for-service beneficiaries hospitalized at an acute care hospital with a principal diagnosis of pneumonia from July 2011 to June 2014. Analysis was conducted by using Medicare payment data made publicly available by the Centers for Medicare & Medicaid Services on the Hospital Compare website combined with Medicare Part A claims data to identify patient outcomes.

RESULTS

A total of 1,017,353 Medicare fee-for-service beneficiaries were hospitalized for pneumonia across 3,021 US hospitals during the study period. Mean ± SD 30-day spending for an episode of pneumonia care was $14,324 ± $1,305. The observed 30-day all-cause mortality rate was 11.9%. After adjusting for patient and hospital characteristics, no association was found between higher 30-day episode spending at the hospital level and 30-day patient mortality (adjusted OR, 1.00 for every $1,000 increase in spending; 95% CI, 0.99-1.01).

CONCLUSIONS

Higher hospital-level spending for a 30-day episode of care for pneumonia was not associated with any difference in patient mortality.

Prognostic factors associated with mortality in mechanically ventilated patients in the intensive care unit: A single-center, retrospective cohort study of 905 patients

Data on outcomes of patients receiving mechanical ventilation (MV) in China are scarce.To investigate factors associated with the prognosis of patients given MV in the intensive care unit (ICU).A 12-year (January 1, 2006-December 31, 2017) retrospective cohort study.ICU of Beijing Geriatric Hospital, China.A total of 905 patients aged ≥16 years given MV during the study period.None.Among 905 patients included (610 men; median age, 78 years; Acute Physiology and Chronic Health Evaluation [APACHE]-II score, 27.3 ± 8.9), 585 survived (388 men; median age, 77 years; average APACHE-II score, 25.6 ± 8.4), and 320 died in the ICU (222 men; median age, 78 years; APACHE-II score, 30.6 ± 8.9). All-cause ICU mortality was 35.4%. In patients aged <65 years, factors associated with ICU mortality were APACHE-II score (odds ratio [OR], 1.108; 95% confidence interval [95% CI], 1.021-1.202; P = .014), nosocomial infection (OR, 6.618; 95% CI, 1.065-41.113; P = .043), acute kidney injury (OR, 17.302; 95% CI, 2.728-109.735; P = .002), invasive hemodynamic monitoring (OR, 10.051; 95% CI, 1.362-74.191; P = .024), MV for cardiopulmonary resuscitation (OR, 0.122; 95% CI, 0.016-0.924; P = .042), duration of MV (OR, 0.993; 95% CI, 0.988-0.998; P = .008), successful weaning from MV (OR, 0.012; 95% CI, 0.002-0.066; P < .001), and renal replacement therapy (OR, 0.039; 95% CI, 0.005-0.324; P = .003). In patients aged ≥65 years, factors associated with mortality were APACHE-II score (OR, 1.062; 95% CI, 1.030-1.096; P < .001), nosocomial infection (OR, 2.427; 95% CI, 1.359-4.334; P = .003), septic shock (OR, 2.017; 95% CI, 1.153-3.529; P = .014), blood transfusion (OR, 1.939; 95% CI, 1.174-3.202; P = .010), duration of MV (OR, 0.999; 95% CI, 0.999-1.000; P = .043), and successful weaning from MV (OR, 0.027; 95% CI, 0.015-0.047; P < .001).APACHE-II score, successful weaning, and nosocomial infection in the ICU are independently associated with the prognosis of patients given MV in the ICU.

Cardiovascular Risks Associated with Gender and Aging

The aging and elderly population are particularly susceptible to cardiovascular disease. Age is an independent risk factor for cardiovascular disease (CVD) in adults, but these risks are compounded by additional factors, including frailty, obesity, and diabetes. These factors are known to complicate and enhance cardiac risk factors that are associated with the onset of advanced age. Sex is another potential risk factor in aging adults, given that older females are reported to be at a greater risk for CVD than age-matched men. However, in both men and women, the risks associated with CVD increase with age, and these correspond to an overall decline in sex hormones, primarily of estrogen and testosterone. Despite this, hormone replacement therapies are largely shown to not improve outcomes in older patients and may also increase the risks of cardiac events in older adults. This review discusses current findings regarding the impacts of age and gender on heart disease.

Early high-flow nasal cannula oxygen therapy in adults with acute hypoxemic respiratory failure in the ED: A before-after study

OBJECTIVES

To compare clinical impact after early initiation of high-flow nasal cannula oxygen therapy (HFNC) versus standard oxygen in patients admitted to an emergency department (ED) for acute hypoxemic respiratory failure.

METHODS

We performed a prospective before-after study at EDs in two centers including patients with acute hypoxemic respiratory failure defined by a respiratory rate above 25 breaths/min or signs of increased breathing effort under additional oxygen for a pulse oximetry above 92%. Patients with cardiogenic pulmonary edema or exacerbation of chronic lung disease were excluded. All patients were treated with standard oxygen during the first period and with HFNC during the second. The primary outcome was the proportion of patients with improved respiratory failure 1 h after treatment initiation (respiratory rate ≤ 25 breaths/min without signs of increased breathing effort). Dyspnea and blood gases were also assessed.

RESULTS

Among the 102 patients included, 48 were treated with standard oxygen and 54 with HFNC. One hour after treatment initiation, patients with HFNC were much more likely to recover from respiratory failure than those treated with standard oxygen: 61% (33 of 54 patients) versus 15% (7 of 48 patients), P < 0.001. They also showed greater improvement in oxygenation (increase in PaO₂ was 31 mm Hg [0-67] vs. 9 [-9-36], P = 0.02), and in feeling of breathlessness.

CONCLUSIONS

As compared to standard oxygen, patients with acute hypoxemic respiratory failure treated with HFNC at the ED had better oxygenation, less breathlessness and were more likely to show improved respiratory failure 1 h after initiation.

Epidemiology of mechanically ventilated patients treated in ICU and non-ICU settings in Japan: a retrospective database study

BACKGROUND

In most countries, patients receiving mechanical ventilation (MV) are treated in intensive care units (ICUs). However, in some countries, including Japan, many patients on MV are not treated in ICUs. There are insufficient epidemiological data on these patients. Here, we sought to describe the epidemiology of patients on MV in Japan by comparing and contrasting patients on MV treated in ICUs and in non-ICU settings. A preliminary comparison of patient outcomes between ICU and non-ICU patients was a secondary objective.

METHODS

Data on adult patients receiving MV for at least 3 days in ICUs or non-ICU settings from April 2010 through March 2012 were obtained from the Quality Indicator/Improvement Project, a voluntary data-administration project covering more than 400 acute-care hospitals in Japan. We excluded patients with cancer-related diagnoses. Patient demographic data and the critical care provided were compared between groups.

RESULTS

Over the study period, 17,775 patients on MV were treated only in non-ICU settings, whereas 20,516 patients were treated at least once in ICUs (46.4% vs. 53.6%). Average age was higher in non-ICU patients than in ICU patients (72.8 vs. 70.2, P < 0.001). Mean number of ventilation days was greater in non-ICU patients (11.7 vs. 9.5, P < 0.001). Hospital mortality was higher in non-ICU patients (41.4% vs. 38.8%, P < 0.001). Standard critical care (e.g., arterial line placement, enteral nutrition, and stress-ulcer prevention) was provided significantly less often in non-ICU patients. Multivariate analysis showed that ICU admission significantly decreased hospital mortality (adjusted odds ratio 0.713, 95% CI 0.676 to 0.753).

CONCLUSIONS

A large proportion of Japanese patients on MV were treated in non-ICU settings. Analysis of administrative data indicated preliminarily that hospital mortality rates in these patients were higher in non-ICU settings than in ICUs. Prospective analyses comparing non-ICU and ICU patients on MV by severity scoring are needed.

Association between age-related factors and extubation failure in elderly patients

BACKGROUND

Elderly patients are being increasingly admitted to the intensive care unit (ICU) for mechanical ventilation. Previous studies demonstrated that 20% to 35% of elderly patients were reintubated within 48 to 72 hours after extubation. Given the age-related physiologic changes and multiple comorbidities in elderly patients, the current conventional parameters for predicting extubation outcomes may not be applicable to this population. This study was performed to identify the association between age-related parameters and extubation failure in elderly patients.

METHODS

Intubated elderly patients (age of ≥60 years) admitted to the medical ICU of a university-based hospital from October 2014 to July 2015 were included. Failed extubation was defined as reintubation within 48 hours after the first extubation. The associations of extubation failure with demographic data, vital signs, cognition and anxiety, and ventilator parameters at the time of intubation and extubation were analyzed.

RESULTS

In total, 127 intubated elderly patients were recruited. Extubation failure occurred in 15 patients (11.8%). Patients with failed extubation had a lower body temperature (37.0°C vs. 37.3°C, P < 0.05) but a higher Facial Anxiety Scale (FAS) score than those with successful extubation (3 vs. 2, P < 0.05). Patients with extubation failure had significantly higher levels of blood urea nitrogen (BUN) (39.88 vs. 58.47 g/dL), serum sodium (137.66 vs. 141.47 mmol/L), and serum calcium (9.52 vs. 10.0 g/dL) but a wider anion gap (12.23 vs. 9.97), but no significant differences in respiratory parameters were found between the two groups. Multiple logistic regression revealed no independent factors associated with successful extubation.

CONCLUSION

This study revealed no strong predictive factors. However, several physiological parameters (lower body temperature and higher FAS scores) and metabolic parameters (BUN, sodium, calcium, and anion gap) were significantly associated with the rate of extubation failure.

Reassessing access to intensive care using an estimate of the population incidence of critical illness

Background

The consistently observed male predominance of patients in intensive care units (ICUs) has raised concerns about gender-based disparities in ICU access. Comparing rates of ICU admission requires choosing a normalizing factor (denominator), and the denominator usually used to compare such rates between subpopulations is the size of those subpopulations. However, the appropriate denominator is the number of people whose medical condition warranted ICU care. We devised an estimate of the number of critically ill people in the general population, and used it to compare rates of ICU admission by gender and income.

Methods

This population-based, retrospective analysis included all adults in the Canadian province of Manitoba, 2004–2015. We created an estimate for the number of critically ill people who warrant ICU care, and used it as the denominator to generate critical illness-normalized rates of ICU admission. These were compared to the usual population-normalized rates of ICU care.

Results

Men outnumbered women in ICUs for all age groups; population-normalized male:female rate ratios significantly exceed 0 for every age group, ranging from 1.15 to 2.10. Using critical-illness normalized rates, this male predominance largely disappeared; critically ill men and women aged 45–74 years were admitted in equivalent proportions (critical-illness normalized rate ratios 0.96–1.01). While population-normalized rates of ICU care were higher in lower income strata (p < 0.001), the gradient for critical illness-based rates was reversed (p < 0.001).

Conclusions

Across a 30-year adult age span, the male predominance of ICU patients was accounted for by higher estimated rates of critical illness among men. People in lower income strata had lower critical-illness normalized rates of ICU admission. Our methods highlight that correct inferences about access to healthcare require calculating rates using denominators appropriate for this purpose.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2132-8) contains supplementary material, which is available to authorized users.

Factors determining outcomes in adult patient undergoing mechanical ventilation: A "real-world" retrospective study in an Indian Intensive Care Unit

Background:

Characteristics of patients admitted to intensive care units with respiratory failure (RF) and undergoing mechanical ventilation (MV) have been described for particular indications and diseases, but there are few studies in the general Intensive Care Unit (ICU) population and even lesser from developing countries.

Objective:

This study aims to study clinical characteristics, outcomes, and factors affecting outcomes in adult patients with RF on MV admitted to ICU.

Methods:

A retrospective study of medical records of all patients admitted to ICU between January 1, 2015, and March 31, 2016. Patients receiving MV for more than 6 h were included in the study. Patients younger than 12 years were excluded. Data were recorded of all patients receiving MV during this period regarding demographics, indications for MV, type and characteristics of ventilation, concomitant complications and treatment, and outcomes. Data were recorded at the initiation of MV and daily all throughout the course of MV. The main outcome measure was all-cause mortality at the end of ICU stay.

Results:

Of the 500 patients admitted to the ICU during the period of the study, a total of 122 patients received MV (and were included in study) for mean (standard deviation [SD]) duration of 4 (3.4) days. The mean (SD) stay in ICU and hospital was 4.49 (3.52) and 6.4 (3.6), respectively. Overall mortality for the unselected general ICU patients on MV was 67.21% while that for ARDS patients was 76.1%. The main factors independently associated with increased mortality were (i) pre-MV factors: age, Apache II scores, heart failure (odds ratio [OR], 1.42; 95% confidence interval [CI], 0.54–3.73; P < 0.001); (ii) patient management factors: positive end-expiratory pressure (OR, 2.69; 95% CI, 0.84–8.61; P < 0.001); (iii) Factors occurring over the course of MV: PaO₂/FiO₂ ratio < 100 (OR, 1.66; 95% CI, 0.67–4.11; P < 0.001) and development of renal failure (OR, 2.33; 95% CI, 2.05–2.42; P < 0.001) and hepatic failure (OR, 2.07; 95% CI, 1.91–2.24; P < 0.001) after initiation of MV.

Conclusions:

Outcomes of patients undergoing MV are dependent on various factors (including patient demographics, nature of associated morbidity, characteristics of the MV received, and conditions developing over course of MV) and these factors may be present before or develop after initiation of MV.

Predictive factors of in-hospital mortality in ventilated intensive care unit: A prospective cohort study

Although it is clear that ventilated intensive care unit (ICU) patients have worse outcomes than those who are not, information about the risk factors of in-hospital mortality remains important for medical groups to target interventions for these patients.The purpose of this study was to identify predictive factors of in-hospital mortality in ventilated ICU patients with an admission diagnosis of acute respiratory failure.We conducted a prospective cohort study in 3 medical ICUs in a 3600-bed university hospital. Consecutive patients with acute respiratory failure who received mechanical ventilation (MV) for at least 96 hours without evidence of pre-existing neuromuscular diseases were followed until discharge. Upon inclusion, the following parameters were collected or evaluated: demographics, clinical history (admission body mass index [BMI], etiology of acute respiratory failure, comorbidity, Charlson comorbidity index, laboratory data), Acute Physiology and Chronic Health Evaluation (APACHE) II, and right and left quadriceps femoris muscle force. The days of MV before extubation, ICU length of stay, survival status at discharge, and hospital length of stay were recorded from the hospital discharge summary. The primary endpoint was in-hospital mortality.In all, 113 patients (65.49% males) were recruited with a mean age of 69.78 years and mean APACHE II score of 22.63. The mean ICU length of stay was 14.88 ± 9.79 days. Overall in-hospital mortality was 25.66% (29 out of 113 patients). Multivariate analysis showed that the essential factors associated with increased in-hospital mortality were lower BMI (P = .013), and lower scores on the right or left quadriceps femoris muscle force (P = .002 and .010, respectively).Our study suggests that lower BMI and lower scores on lower limb muscle force may be associated with increased in-hospital mortality in ventilated ICU patients.

Pediatric In-Hospital Acute Respiratory Compromise: A Report From the American Heart Association's Get With the Guidelines-Resuscitation Registry

OBJECTIVES

The main objectives of this study were to describe in-hospital acute respiratory compromise among children (< 18 yr old), and its association with cardiac arrest and in-hospital mortality.

DESIGN

Observational study using prospectively collected data.

SETTING

U.S. hospitals reporting data to the "Get With The Guidelines-Resuscitation" registry.

PATIENTS

Pediatric patients (< 18 yr old) with acute respiratory compromise. Acute respiratory compromise was defined as absent, agonal, or inadequate respiration that required emergency assisted ventilation and elicited a hospital-wide or unit-based emergency response.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was in-hospital mortality. Cardiac arrest during the event was a secondary outcome. To assess the association between patient, event, and hospital characteristics and the outcomes, we created multivariable logistic regressions models accounting for within-hospital clustering. One thousand nine hundred fifty-two patients from 151 hospitals were included. Forty percent of the events occurred on the wards, 19% in the emergency department, 25% in the ICU, and 16% in other locations. Two hundred eighty patients (14.6%) died before hospital discharge. Preexisting hypotension (odds ratio, 3.26 [95% CI, 1.89-5.62]; p < 0.001) and septicemia (odds ratio, 2.46 [95% CI, 1.52-3.97]; p < 0.001) were associated with increased mortality. The acute respiratory compromise event was temporally associated with a cardiac arrest in 182 patients (9.3%), among whom 46.2% died. One thousand two hundred eight patients (62%) required tracheal intubation during the event. In-hospital mortality among patients requiring tracheal intubation during the event was 18.6%.

CONCLUSIONS

In this large, multicenter study of acute respiratory compromise, 40% occurred in ward settings, 9.3% had an associated cardiac arrest, and overall in-hospital mortality was 14.6%. Preevent hypotension and septicemia were associated with increased mortality rate.

Ventilator-Associated Events and Their Prevention

The Centers for Disease Control and Prevention shifted the focus of safety surveillance in mechanically ventilated patients from ventilator-associated pneumonia to ventilator-associated events (VAEs) in 2013. The shift was designed to increase the objectivity and reproducibility of surveillance and to encourage quality-improvement programs to tackle a broader array of complications in mechanically ventilated patients. Prospective intervention studies have found that minimizing sedation, increasing the use of spontaneous awakening and breathing trials, and conservative fluid management can lower VAE rates and decrease duration of mechanical ventilation. Additional strategies to prevent VAEs include early mobility programs, low tidal volume ventilation, and restrictive transfusion thresholds.

Adherence to Evidence-Base Endotracheal Intubation Practice Patterns by Intensivists and Emergency Department Physicians

BACKGROUND

Endotracheal intubation outside the operating room (OR) is mainly performed by intensive care (IC) physicians and emergency department (ED) physicians. We hypothesized that difference in practice patterns exists between these two groups of physicians.

METHODS

A retrospective chart review was performed on all endotracheal intubations that were performed out of OR over a fi ve year period at our health care facility. Practice patterns of IC and ED physicians were compared regarding use of (a) video laryngoscopy, (b) paralytic agents, (c) waveform capnography, and (d) use of larger size of endotracheal tube (internal diameter ≥ 8 mm).

RESULTS

A total of 201 patients underwent out of OR intubations over a 5 year period. IC physicians used more often than ED physicians video laryngoscopy (67% vs. 49%; p = 0.008), waveform capnography (99% vs. 86%; p = 0.001) and larger size endotracheal tubes (95% vs. 60%; p < 0.001). Conversely, paralytic agents were used less frequently by IC than ED physicians (12% vs. 51%; p < 0.001). The success of fi rst intubation attempt was higher by IC than ED physicians (82% vs. 67%; p = 0.018).

CONCLUSIONS

IC physicians more often adhered to currently considered preferable practices for endotracheal intubation than ED physicians in this single center retrospective study. Although larger scale studies are needed to unveil the effects of different practice patterns on short and long term outcomes, the present study identifi es opportunity to bridge practice gaps that could lead to improved outcomes.

High-flow nasal cannulae for respiratory support in adult intensive care patients

BACKGROUND

High-flow nasal cannulae (HFNC) deliver high flows of blended humidified air and oxygen via wide-bore nasal cannulae and may be useful in providing respiratory support for adult patients experiencing acute respiratory failure in the intensive care unit (ICU).

OBJECTIVES

We evaluated studies that included participants 16 years of age and older who were admitted to the ICU and required treatment with HFNC. We assessed the safety and efficacy of HFNC compared with comparator interventions in terms of treatment failure, mortality, adverse events, duration of respiratory support, hospital and ICU length of stay, respiratory effects, patient-reported outcomes, and costs of treatment.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 3), MEDLINE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Web of Science, proceedings from four conferences, and clinical trials registries; and we handsearched reference lists of relevant studies. We conducted searches from January 2000 to March 2016 and reran the searches in December 2016. We added four new studies of potential interest to a list of 'Studies awaiting classification' and will incorporate them into formal review findings during the review update.

SELECTION CRITERIA

We included randomized controlled studies with a parallel or cross-over design comparing HFNC use in adult ICU patients versus other forms of non-invasive respiratory support (low-flow oxygen via nasal cannulae or mask, continuous positive airway pressure (CPAP), and bilevel positive airway pressure (BiPAP)).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, extracted data, and assessed risk of bias.

MAIN RESULTS

We included 11 studies with 1972 participants. Participants in six studies had respiratory failure, and in five studies required oxygen therapy after extubation. Ten studies compared HFNC versus low-flow oxygen devices; one of these also compared HFNC versus CPAP, and another compared HFNC versus BiPAP alone. Most studies reported randomization and allocation concealment inadequately and provided inconsistent details of outcome assessor blinding. We did not combine data for CPAP and BiPAP comparisons with data for low-flow oxygen devices; study data were insufficient for separate analysis of CPAP and BiPAP for most outcomes. For the primary outcomes of treatment failure (1066 participants; six studies) and mortality (755 participants; three studies), investigators found no differences between HFNC and low-flow oxygen therapies (risk ratio (RR), Mantel-Haenszel (MH), random-effects 0.79, 95% confidence interval (CI) 0.49 to 1.27; and RR, MH, random-effects 0.63, 95% CI 0.38 to 1.06, respectively). We used the GRADE approach to downgrade the certainty of this evidence to low because of study risks of bias and different participant indications. Reported adverse events included nosocomial pneumonia, oxygen desaturation, visits to general practitioner for respiratory complications, pneumothorax, acute pseudo-obstruction, cardiac dysrhythmia, septic shock, and cardiorespiratory arrest. However, single studies reported adverse events, and we could not combine these findings; one study reported fewer episodes of oxygen desaturation with HFNC but no differences in all other reported adverse events. We downgraded the certainty of evidence for adverse events to low because of limited data. Researchers noted no differences in ICU length of stay (mean difference (MD), inverse variance (IV), random-effects 0.15, 95% CI -0.03 to 0.34; four studies; 770 participants), and we downgraded quality to low because of study risks of bias and different participant indications. We found no differences in oxygenation variables: partial pressure of arterial oxygen (PaO₂)/fraction of inspired oxygen (FiO₂) (MD, IV, random-effects 7.31, 95% CI -23.69 to 41.31; four studies; 510 participants); PaO₂ (MD, IV, random-effects 2.79, 95% CI -5.47 to 11.05; three studies; 355 participants); and oxygen saturation (SpO₂) up to 24 hours (MD, IV, random-effects 0.72, 95% CI -0.73 to 2.17; four studies; 512 participants). Data from two studies showed that oxygen saturation measured after 24 hours was improved among those treated with HFNC (MD, IV, random-effects 1.28, 95% CI 0.02 to 2.55; 445 participants), but this difference was small and was not clinically significant. Along with concern about risks of bias and differences in participant indications, review authors noted a high level of unexplained statistical heterogeneity in oxygenation effect estimates, and we downgraded the quality of evidence to very low. Meta-analysis of three comparable studies showed no differences in carbon dioxide clearance among those treated with HFNC (MD, IV, random-effects -0.75, 95% CI -2.04 to 0.55; three studies; 590 participants). Two studies reported no differences in atelectasis; we did not combine these findings. Data from six studies (867 participants) comparing HFNC versus low-flow oxygen showed no differences in respiratory rates up to 24 hours according to type of oxygen delivery device (MD, IV, random-effects -1.51, 95% CI -3.36 to 0.35), and no difference after 24 hours (MD, IV, random-effects -2.71, 95% CI -7.12 to 1.70; two studies; 445 participants). Improvement in respiratory rates when HFNC was compared with CPAP or BiPAP was not clinically important (MD, IV, random-effects -0.89, 95% CI -1.74 to -0.05; two studies; 834 participants). Results showed no differences in patient-reported measures of comfort according to oxygen delivery devices in the short term (MD, IV, random-effects 0.14, 95% CI -0.65 to 0.93; three studies; 462 participants) and in the long term (MD, IV, random-effects -0.36, 95% CI -3.70 to 2.98; two studies; 445 participants); we downgraded the certainty of this evidence to low. Six studies measured dyspnoea on incomparable scales, yielding inconsistent study data. No study in this review provided data on positive end-expiratory pressure measured at the pharyngeal level, work of breathing, or cost comparisons of treatment.

AUTHORS' CONCLUSIONS

We were unable to demonstrate whether HFNC was a more effective or safe oxygen delivery device compared with other oxygenation devices in adult ICU patients. Meta-analysis could be performed for few studies for each outcome, and data for comparisons with CPAP or BiPAP were very limited. In addition, we identified some risks of bias among included studies, differences in patient groups, and high levels of statistical heterogeneity for some outcomes, leading to uncertainty regarding the results of our analysis. Consequently, evidence is insufficient to show whether HFNC provides safe and efficacious respiratory support for adult ICU patients.

A Randomized Trial of an Intensive Physical Therapy Program for Patients with Acute Respiratory Failure

RATIONALE

Early physical therapy (PT) interventions may benefit patients with acute respiratory failure by preventing or attenuating neuromuscular weakness. However, the optimal dosage of these interventions is currently unknown.

OBJECTIVES

To determine whether an intensive PT program significantly improves long-term physical functional performance compared with a standard-of-care PT program.

METHODS

Patients who required mechanical ventilation for at least 4 days were eligible. Enrolled patients were randomized to receive PT for up to 4 weeks delivered in an intensive or standard-of-care manner. Physical functional performance was assessed at 1, 3, and 6 months in survivors who were not currently in an acute or long-term care facility. The primary outcome was the Continuous Scale Physical Functional Performance Test short form (CS-PFP-10) score at 1 month.

MEASUREMENTS AND MAIN RESULTS

A total of 120 patients were enrolled from five hospitals. Patients in the intensive PT group received 12.4 ± 6.5 sessions for a total of 408 ± 261 minutes compared with only 6.1 ± 3.8 sessions for 86 ± 63 minutes in the standard-of-care group (P < 0.001 for both analyses). Physical function assessments were available for 86% of patients at 1 month, for 76% at 3 months, and for 60% at 6 months. In both groups, physical function was reduced yet significantly improved over time between 1, 3, and 6 months. When we compared the two interventions, we found no differences in the total CS-PFP-10 scores at all three time points (P = 0.73, 0.29, and 0.43, respectively) or in the total CS-PFP-10 score trajectory (P = 0.71).

CONCLUSIONS

An intensive PT program did not improve long-term physical functional performance compared with a standard-of-care program. Clinical trial registered with www.clinicaltrials.gov (NCT01058421).

A prospective cohort study of thoracic ultrasound in acute respiratory failure: the C3PO protocol

OBJECTIVES

This study was performed to assess the clinical utility of a standardised thoracic ultrasound examination when added to standard care in patients with acute respiratory failure admitted to an intermediate care unit. This study aimed to assess the impact on clinical diagnosis, clinician confidence and management. Ultrasound has been shown to have utility in patients admitted to intensive care and emergency; however, utility in a ward setting is unknown.

DESIGN

Prospective cohort study.

SETTING

Tertiary hospital in Melbourne, Australia.

PARTICIPANTS

50 patients with acute respiratory failure requiring admission to an intermediate care unit.

MAIN OUTCOME MEASURES

(1) Change in clinical diagnosis or additional clinical diagnosis following thoracic ultrasound. (2) Change in diagnostic confidence following thoracic ultrasound. (3) Change to management following thoracic ultrasound.

RESULTS

In 34% of patients, ultrasound detected unexpected findings that changed or added to the clinical diagnosis. Diagnostic confidence was increased in 44%, and the treating clinician altered the management plan in 30% as a result of the ultrasound. Ultrasound was particularly useful in clarifying the diagnosis in patients with multiple initial diagnoses, reducing to a single diagnosis in 69%.

CONCLUSIONS

Thoracic ultrasound has clinical utility in non-intubated adults with acute respiratory failure managed outside intensive care settings. It changed aetiological diagnosis, increases diagnostic confidence and altered clinical management in one out of three patients scanned. Our results suggest extended utility of thoracic ultrasound in acute respiratory failure to a broader context outside the intensive care unit population.

Predicting in-hospital mortality for initial survivors of acute respiratory compromise (ARC) events: Development and validation of the ARC Score

AIM

Acute respiratory compromise (ARC) is a common and highly morbid event in hospitalized patients. To date, however, few investigators have explored predictors of outcome in initial survivors of ARC events. In the present study, we leveraged the American Heart Association's Get With The Guidelines^®-Resuscitation (GWTG-R) ARC data registry to develop a prognostic score for initial survivors of ARC events.

METHODS

Using GWTG-R ARC data, we identified 13,193 index ARC events. These events were divided into a derivation cohort (9807 patients) and a validation cohort (3386 patients). A score for predicting in-hospital mortality was developed using multivariable modeling with generalized estimating equations.

RESULTS

The two cohorts were well balanced in terms of baseline demographics, illness-types, pre-event conditions, event characteristics, and overall mortality. After model optimization, nine variables associated with the outcome of interest were included. Age, hypotension preceding the event, and intubation during the event were the greatest predictors of in-hospital mortality. The final score demonstrated good discrimination in both the derivation and validation cohorts. The score was also very well calibrated in both cohorts. Observed average mortality was <10% in the lowest score category of both cohorts and >70% in the highest category, illustrating a wide range of mortality separated effectively by the scoring system.

CONCLUSIONS

In the present study, we developed and internally validated a prognostic score for initial survivors of in-hospital ARC events. This tool will be useful for clinical prognostication, selecting cohorts for interventional studies, and for quality improvement initiatives seeking to risk-adjust for hospital-to-hospital comparisons.