1
|
Peng L, Kang H, Chang H, Sun Y, Zhao Y, Zhao H. The ratio of parasternal intercostal muscle-thickening fraction-to-diaphragm thickening fraction for predicting weaning failure. J Crit Care 2024; 83:154847. [PMID: 38909540 DOI: 10.1016/j.jcrc.2024.154847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 05/22/2024] [Accepted: 06/14/2024] [Indexed: 06/25/2024]
Abstract
BACKGROUND Diaphragm dysfunction is associated with weaning outcomes in mechanical ventilation patients, in the case of diaphragm dysfunction, the accessory respiratory muscles would be recruited. The main purpose of this study is to explore the performance of parasternal intercostal muscle thickening fraction in relation to diaphragmatic thickening fraction ratio (TFic1/TFdi2) for predicting weaning outcomes, and compare its accuracy with D-RSBI in predicting weaning failure. MATERIALS AND METHODS We prospectively enrolled consecutive patients from 7/2022-5/2023. We measured TFic, TFdi, and diaphragmatic excursion (DE3) by ultrasound and calculated the TFic/TFdi ratio and diaphragmatic rapid shallow breathing index (D-RSBI4). Receiver-operator characteristic (ROC5) curves evaluated the accuracy of the TFic/TFdi ratio and D-RSBI in predicting weaning failure. RESULTS 161 were included in the final analysis, 114 patients (70.8%) were successfully weaned from mechanical ventilation. The TFic/TFdi ratio (AUROC = 0.887 (95% CI: 0.821-0.953)) was superior to the D-RSBI (AUROC = 0.875 (95% CI: 0.807-0.944)) for predicting weaning failure. CONCLUSIONS The TFic/TFdi ratio predicted weaning failure with high accuracy and outperformed the D-RSBI.
Collapse
Affiliation(s)
- Li Peng
- Department of Critical Care Medicine, Hebei Medical University, Shijiazhuang 050000, Hebei, China; Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang 050000, Hebei, China; Department of Intensive Care Unit, Harrison International Peace Hospital, Hengshui 053000, Hebei, China
| | - Hongshan Kang
- Department of Intensive Care Unit, Harrison International Peace Hospital, Hengshui 053000, Hebei, China
| | - Hairong Chang
- Department of Intensive Care Unit, Harrison International Peace Hospital, Hengshui 053000, Hebei, China
| | - Yue Sun
- Department of Intensive Care Unit, Harrison International Peace Hospital, Hengshui 053000, Hebei, China
| | - Yuanyuan Zhao
- Department of Intensive Care Unit, Harrison International Peace Hospital, Hengshui 053000, Hebei, China
| | - Heling Zhao
- Department of Critical Care Medicine, Hebei Medical University, Shijiazhuang 050000, Hebei, China; Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang 050000, Hebei, China.
| |
Collapse
|
2
|
Wang P, Chang MY, Hsia HY, Dai M, Liu Y, Hsu YL, Fu F, Zhao Z. The influence of different spontaneous breathing trials on regional ventilation distribution in patients with prolonged mechanical ventilation. Respir Physiol Neurobiol 2024; 327:104296. [PMID: 38879101 DOI: 10.1016/j.resp.2024.104296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/28/2024] [Accepted: 06/06/2024] [Indexed: 06/30/2024]
Abstract
OBJECTIVE This study aimed to explore the influence of different spontaneous breathing trials (SBTs) on regional ventilation distribution in patients with prolonged mechanical ventilation (PMV). METHODS A total of 24 patients with PMV were analyzed retrospectively. They received three different SBT modes which are automatic tube compensation (ATC), continuous positive airway pressure (CPAP), and T-piece (TP), over three days, and every SBT lasted two hours. Electrical impedance tomography (EIT) was used to monitor the SBT process and five-minute EIT data from five periods (pre-SBT which is t0, at the beginning and the end of the first hour SBT are t1 and t2, at the beginning and the end of the second hour SBT are t3 and t4) were analyzed. RESULTS In all PMV patients, the temporal skew of aeration (TSA) values at t3 were significantly different in three SBTs (ATC: 18.18±22.97; CPAP: 20.42±17.01; TP:11.26±11.79; p=0.05). In the weaning success group, TSA (t1) values were significantly different too (ATC: 11.11±13.88; CPAP: 19.09±15.77; TP: 9.09±12.74; p=0.04). In the weaning failure group, TSA (t4) values were significantly different in three SBTs (ATC: 36.67±18.46; CPAP: 15.38±11.69; TP: 17.65±17.93; p=0.04). The patient's inspiratory effort (Global flow index at t1) in patients with weaning failure under CPAP (3.51±4.31) was significantly higher than that in the ATC (1.15±1.47) and TP (0.89±1.28). The SBT mode with the best ventilation uniformity may be the one that activates the respiratory muscles the most which may be the optimal SBT. The SBT mode of most uniform ventilation distribution settings varies from patient to patient. CONCLUSION The regional ventilation distribution was different for each individual, making the SBT with the best ventilation distribution of patients need to be personalized. EIT is a tool that can be considered for real-time assessment.
Collapse
Affiliation(s)
- Pu Wang
- Department of Biomedical Engineering, Fourth Military Medical University, Xi'an 710032, China
| | - Mei-Yun Chang
- Department of Chest Medicine, Far Eastern Memorial Hospital, New Taipei City 220216, Chinese Taipei
| | - Hai-Yen Hsia
- Department of Chest Medicine, Far Eastern Memorial Hospital, New Taipei City 220216, Chinese Taipei
| | - Meng Dai
- Department of Biomedical Engineering, Fourth Military Medical University, Xi'an 710032, China
| | - Yifan Liu
- Department of Biomedical Engineering, Fourth Military Medical University, Xi'an 710032, China
| | - Yeong-Long Hsu
- Department of Chest Medicine, Far Eastern Memorial Hospital, New Taipei City 220216, Chinese Taipei; Department of Healthcare Management, College of Medical Technology and Nursing Yuanpei University of Medical Technology, No. 306 Yuanpei Street, Hsinchu, Chinese Taipei; Department of Electrical Engineering, Yuan Ze University, Taoyuan, Chinese Taipei.
| | - Feng Fu
- Department of Biomedical Engineering, Fourth Military Medical University, Xi'an 710032, China.
| | - Zhanqi Zhao
- School of Biomedical Engineering, Guangzhou Medical University, Guangzhou, China; Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| |
Collapse
|
3
|
Chichra A, Tickoo M, Honiden S. Managing the Chronically Ventilated Critically Ill Population. J Intensive Care Med 2024; 39:703-714. [PMID: 37787184 DOI: 10.1177/08850666231203601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
Advances in intensive care over the past few decades have significantly improved the chances of survival for patients with acute critical illness. However, this progress has also led to a growing population of patients who are dependent on intensive care therapies, including prolonged mechanical ventilation (PMV), after the initial acute period of critical illness. These patients are referred to as the "chronically critically ill" (CCI). CCI is a syndrome characterized by prolonged mechanical ventilation, myoneuropathies, neuroendocrine disorders, nutritional deficiencies, cognitive and psychiatric issues, and increased susceptibility to infections. It is associated with high morbidity and mortality as well as a significant increase in healthcare costs. In this article, we will review disease burden, outcomes, psychiatric effects, nutritional and ventilator weaning strategies as well as the role of palliative care for CCI with a specific focus on those requiring PMV.
Collapse
Affiliation(s)
- Astha Chichra
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Mayanka Tickoo
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Shyoko Honiden
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| |
Collapse
|
4
|
Blackwell T, Alvi S, Curran NR, Germanwala A. Impact of Tracheostomy Timing Within the National Veterans Affairs Population. Laryngoscope 2024; 134:3555-3561. [PMID: 38501701 DOI: 10.1002/lary.31397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 01/25/2024] [Accepted: 03/05/2024] [Indexed: 03/20/2024]
Abstract
OBJECTIVE There is a lack of a definitive study in the literature comparing early versus late tracheostomy and exploring the impact of tracheostomy timing on patient outcomes. This study may help guide treatment paradigms and contribute to a consensus for optimal tracheostomy timing. METHODS A retrospective review was performed comparing early versus late timing of tracheostomy placement and their respective outcomes. The authors used data provided by VA Informatics and Computing Infrastructure (VINCI) to find patients who received a tracheostomy at any VA Medical Center in the United States. There were a total of 25,334 tracheostomies in the database which satisfied our criteria. These occurred between the years 1999 and 2022. Propensity score matching assessed 17,074 tracheostomies, 8537 in either group. The median age of patients in the matched groups was 66 years, and approximately 97.4% of patients were male. Early tracheostomy timing was defined as the placement of the tracheostomy within 10 days of intubation. Outcomes included post-tracheostomy intensive care unit (ICU) days, post-tracheostomy hospital days, successful ventilator weaning, and all-cause mortality. RESULTS Early tracheostomy was associated with significantly fewer ICU days and hospital days, and the early group experienced higher rates of successful ventilator weaning. Survival analysis of data within 5 years of tracheostomy showed that early tracheostomy was associated with significantly lower hazard for all-cause mortality. CONCLUSION Our results add to the body of evidence that an earlier transition to mechanical ventilation by tracheostomy confers benefits in patient morbidity and mortality as well as resource utilization. LEVEL OF EVIDENCE 3 Laryngoscope, 134:3555-3561, 2024.
Collapse
Affiliation(s)
- Thomas Blackwell
- Otolaryngology Section, Department of Surgery, Jesse Brown VA Medical Center, Chicago, Illinois, USA
- Department of Otolaryngology, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
| | - Suffia Alvi
- Otolaryngology Section, Department of Surgery, Jesse Brown VA Medical Center, Chicago, Illinois, USA
- Department of Otolaryngology, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
| | | | - Arpita Germanwala
- Otolaryngology Section, Department of Surgery, Jesse Brown VA Medical Center, Chicago, Illinois, USA
- Department of Otolaryngology, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
| |
Collapse
|
5
|
Eriş E, Mammadova A, Kara AT, Atasoy A, Solmaz ZS, Gürsel G. Prognostic value of the oxygenation index measured during mechanical ventilation and weaning. A retrospective cohort study. Monaldi Arch Chest Dis 2024. [PMID: 39058014 DOI: 10.4081/monaldi.2024.2840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 04/30/2024] [Indexed: 07/28/2024] Open
Abstract
The aim of this study was to investigate the predictive value of the ratio of oxygen saturation (ROX) index calculated during mechanical ventilation (MV) and the weaning period in evaluating readiness to weaning and the success of the spontaneous breathing trial (SBT), extubation, and mortality. We also compared the results of the ROX index calculated with partial arterial oxygen pressure (PaO2), arterial oxygen saturation (SaO2%), and probe oxygen saturation (SpO2%). In this retrospective cohort study, the ROX index was calculated by SpO2%, PaO2, and SaO2% separately using the ROX index formula (PaO2 or SaO2 or SpO2 /FiO2)/respiratory rate. ROX was calculated during the first three days of MV treatment and the weaning period daily (SBT). Positive end-expiratory pressure and peak inspiratory pressure values were also recorded during these measurements. These ROX values were used to analyze whether they predict weaning readiness, SBT, extubation failure (EF), and mortality. The study included 107 mechanically ventilated patients. Weaning could be tried in 64 (60%) of the 107 patients; 44 (69%) of the 64 patients succeeded, and extubation was performed. 19 (43%) of 44 patients had EF. ROX values calculated with PaO2 during MV and SBT predicted readiness to wean, EF, and mortality better than ROX values calculated with SaO2 and SpO2. ROX values calculated with PaO2 during the third day of MV had the highest sensitivity and specificity for EF (sensitivity: 81%, specificity: 70% for the ROX<11 value). The results of this study suggest that the calculation of ROX index, not only with SpO2% but also with arterial blood gas PaO2 and SaO2% values, may be helpful in predicting the weaning readiness evaluation, SBT, and extubation success and mortality. Further studies with more patients are necessary to verify and standardize these results.
Collapse
Affiliation(s)
- Esra Eriş
- Critical Care Fellowship Program, Gazi University School of Medicine, Ankara.
| | - Ayshan Mammadova
- Department of Pulmonary Critical Care Medicine, Gazi University School of Medicine, Ankara.
| | - Ayşe Taşçı Kara
- Department of Pulmonary Critical Care Medicine, Gazi University School of Medicine, Ankara.
| | - Aydın Atasoy
- Critical Care Fellowship Program, Gazi University School of Medicine, Ankara.
| | - Zeynep Sena Solmaz
- Critical Care Fellowship Program, Gazi University School of Medicine, Ankara.
| | - Gül Gürsel
- Critical Care Fellowship Program, Gazi University School of Medicine, Ankara; Department of Pulmonary Critical Care Medicine, Gazi University School of Medicine, Ankara.
| |
Collapse
|
6
|
Chai X, Ma M, Hu W, Bai L, Duan J. Two-year survival after scheduled extubation in patients with pneumonia or ARDS: a prospective observational study. BMC Anesthesiol 2024; 24:232. [PMID: 38987670 PMCID: PMC11234770 DOI: 10.1186/s12871-024-02603-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 06/24/2024] [Indexed: 07/12/2024] Open
Abstract
PURPOSE To report two-year survival after scheduled extubation in patients with pneumonia or acute respiratory distress syndrome (ARDS). METHODS This was a prospective observational study performed in a respiratory ICU of a teaching hospital. Pneumonia or ARDS patients who successfully completed a spontaneous breathing trial were enrolled. Data were collected before extubation. Patients were followed up to two years by phone every 3 months. RESULTS A total of 230 patients were enrolled in final analysis. One-, 3-, 6-, 12-, and 24-month survival was 77.4%, 63.8%, 61.3%, 57.8%, and 47.8%, respectively. Cox regression shows that Charlson comorbidity index (hazard ratio: 1.20, 95% confidence interval: 1.10-1.32), APACHE II score before extubation (1.11, 1.05-1.17), cough peak flow before extubation (0.993, 0.986-0.999), and extubation failure (3.96, 2.51-6.24) were associated with two-year mortality. To predict death within two years, the area under the curve of receiver operating characteristic was 0.79 tested by Charlson comorbidity index, 0.75 tested by APACHE II score, and 0.75 tested by cough peak flow. Two-year survival was 31% and 77% in patients with Charlson comorbidity index ≥ 1 and < 1, 28% and 62% in patients with APACHE II score ≥ 12 and < 12, and 64% and 17% in patients with cough peak flow > 58 and ≤ 58 L/min, respectively. CONCLUSIONS Comorbidity, disease severity, weak cough and extubation failure were associated with increased two-year mortality in pneumonia or ARDS patients who experienced scheduled extubation. It provides objective information to caregivers to improve decision-making process during hospitalization and post discharge.
Collapse
Affiliation(s)
- Xuemin Chai
- Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, P. R. China
| | - Mengyi Ma
- Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, P. R. China
| | - Wenhui Hu
- Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, P. R. China
| | - Linfu Bai
- Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, P. R. China
| | - Jun Duan
- Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, P. R. China.
| |
Collapse
|
7
|
Tandon P, Nguyen KAN, Edalati M, Parchure P, Raut G, Reich DL, Freeman R, Levin MA, Timsina P, Powell CA, Fayad ZA, Kia A. Development and Validation of a Deep Learning Classifier Using Chest Radiographs to Predict Extubation Success in Patients Undergoing Invasive Mechanical Ventilation. Bioengineering (Basel) 2024; 11:626. [PMID: 38927862 PMCID: PMC11200686 DOI: 10.3390/bioengineering11060626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 05/27/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024] Open
Abstract
The decision to extubate patients on invasive mechanical ventilation is critical; however, clinician performance in identifying patients to liberate from the ventilator is poor. Machine Learning-based predictors using tabular data have been developed; however, these fail to capture the wide spectrum of data available. Here, we develop and validate a deep learning-based model using routinely collected chest X-rays to predict the outcome of attempted extubation. We included 2288 serial patients admitted to the Medical ICU at an urban academic medical center, who underwent invasive mechanical ventilation, with at least one intubated CXR, and a documented extubation attempt. The last CXR before extubation for each patient was taken and split 79/21 for training/testing sets, then transfer learning with k-fold cross-validation was used on a pre-trained ResNet50 deep learning architecture. The top three models were ensembled to form a final classifier. The Grad-CAM technique was used to visualize image regions driving predictions. The model achieved an AUC of 0.66, AUPRC of 0.94, sensitivity of 0.62, and specificity of 0.60. The model performance was improved compared to the Rapid Shallow Breathing Index (AUC 0.61) and the only identified previous study in this domain (AUC 0.55), but significant room for improvement and experimentation remains.
Collapse
Affiliation(s)
- Pranai Tandon
- Department of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Kim-Anh-Nhi Nguyen
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (K.-A.-N.N.); (M.E.); (P.P.); (G.R.); (R.F.); (P.T.); (A.K.)
| | - Masoud Edalati
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (K.-A.-N.N.); (M.E.); (P.P.); (G.R.); (R.F.); (P.T.); (A.K.)
| | - Prathamesh Parchure
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (K.-A.-N.N.); (M.E.); (P.P.); (G.R.); (R.F.); (P.T.); (A.K.)
| | - Ganesh Raut
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (K.-A.-N.N.); (M.E.); (P.P.); (G.R.); (R.F.); (P.T.); (A.K.)
| | - David L. Reich
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA (M.A.L.)
| | - Robert Freeman
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (K.-A.-N.N.); (M.E.); (P.P.); (G.R.); (R.F.); (P.T.); (A.K.)
| | - Matthew A. Levin
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA (M.A.L.)
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Windreich Department of Artificial Intelligence and Human Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Prem Timsina
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (K.-A.-N.N.); (M.E.); (P.P.); (G.R.); (R.F.); (P.T.); (A.K.)
| | - Charles A. Powell
- Department of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Zahi A. Fayad
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Arash Kia
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (K.-A.-N.N.); (M.E.); (P.P.); (G.R.); (R.F.); (P.T.); (A.K.)
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA (M.A.L.)
| |
Collapse
|
8
|
Burns KEA, Sadeghirad B, Ghadimi M, Khan J, Phoophiboon V, Trivedi V, Gomez Builes C, Giammarioli B, Lewis K, Chaudhuri D, Desai K, Friedrich JO. Comparative effectiveness of alternative spontaneous breathing trial techniques: a systematic review and network meta-analysis of randomized trials. Crit Care 2024; 28:194. [PMID: 38849936 PMCID: PMC11162018 DOI: 10.1186/s13054-024-04958-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Accepted: 05/17/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND The spontaneous breathing trial (SBT) technique that best balance successful extubation with the risk for reintubation is unknown. We sought to determine the comparative efficacy and safety of alternative SBT techniques. METHODS We searched Medline, EMBASE, and the Cochrane Central Register of Controlled Trials from inception to February 2023 for randomized or quasi-randomized trials comparing SBT techniques in critically ill adults and children and reported initial SBT success, successful extubation, reintubation (primary outcomes) and mortality (ICU, hospital, most protracted; secondary outcome) rates. Two reviewers screened, reviewed full-texts, and abstracted data. We performed frequentist random-effects network meta-analysis. RESULTS We included 40 RCTs (6716 patients). Pressure Support (PS) versus T-piece SBTs was the most common comparison. Initial successful SBT rates were increased with PS [risk ratio (RR) 1.08, 95% confidence interval (CI) (1.05-1.11)], PS/automatic tube compensation (ATC) [1.12 (1.01 -1.25), high flow nasal cannulae (HFNC) [1.07 (1.00-1.13) (all moderate certainty), and ATC [RR 1.11, (1.03-1.20); low certainty] SBTs compared to T-piece SBTs. Similarly, initial successful SBT rates were increased with PS, ATC, and PS/ATC SBTs compared to continuous positive airway pressure (CPAP) SBTs. Successful extubation rates were increased with PS [RR 1.06, (1.03-1.09); high certainty], ATC [RR 1.13, (1.05-1.21); moderate certainty], and HFNC [RR 1.06, (1.02-1.11); high certainty] SBTs, compared to T-piece SBTs. There was little to no difference in reintubation rates with PS (vs. T-piece) SBTs [RR 1.05, (0.91-1.21); low certainty], but increased reintubation rates with PS [RR 2.84, (1.61-5.03); moderate certainty] and ATC [RR 2.95 (1.57-5.56); moderate certainty] SBTs compared to HFNC SBTs. CONCLUSIONS SBTs conducted with pressure augmentation (PS, ATC, PS/ATC) versus without (T-piece, CPAP) increased initial successful SBT and successful extubation rates. Although SBTs conducted with PS or ATC versus HFNC increased reintubation rates, this was not the case for PS versus T-piece SBTs.
Collapse
Affiliation(s)
- Karen E A Burns
- Departments of Critical Care Medicine and Medicine, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, 4-045 Donnelly Wing, Toronto, ON, M5B 1W8, Canada.
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
- Li Ka Shing Knowledge Institute, Unity Health Toronto, St. Michael's Hospital, Toronto, Canada.
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Departments of Anesthesia and Medicine, McMaster University, Hamilton, Canada
| | - Maryam Ghadimi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Jeena Khan
- Departments of Critical Care Medicine and Medicine, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, 4-045 Donnelly Wing, Toronto, ON, M5B 1W8, Canada
- Royal College of Surgeons of Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | - Vorakamol Phoophiboon
- Departments of Critical Care Medicine and Medicine, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, 4-045 Donnelly Wing, Toronto, ON, M5B 1W8, Canada
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Vatsal Trivedi
- Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Canada
| | - Carolina Gomez Builes
- Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Benedetta Giammarioli
- Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Kimberley Lewis
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Departments of Anesthesia and Medicine, McMaster University, Hamilton, Canada
- Department of Critical Care, St. Joseph's Healthcare, Hamilton, Canada
| | - Dipayan Chaudhuri
- Departments of Anesthesia and Medicine, McMaster University, Hamilton, Canada
- Department of Critical Care, St. Joseph's Healthcare, Hamilton, Canada
| | - Kairavi Desai
- Michael DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Jan O Friedrich
- Departments of Critical Care Medicine and Medicine, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, 4-045 Donnelly Wing, Toronto, ON, M5B 1W8, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto, St. Michael's Hospital, Toronto, Canada
| |
Collapse
|
9
|
Sabetian G, Mackie M, Asmarian N, Banifatemi M, Schmidt GA, Masjedi M, Paydar S, Zand F. Ultrasonographic evaluation of diaphragm thickness and excursion: correlation with weaning success in trauma patients: prospective cohort study. J Anesth 2024; 38:354-363. [PMID: 38507058 DOI: 10.1007/s00540-024-03321-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 02/04/2024] [Indexed: 03/22/2024]
Abstract
PURPOSE Prolonged mechanical ventilation (MV) subjects multiple trauma patients to ventilator-induced diaphragmatic dysfunction. There is limited evidence on the predictive role of diaphragm ultrasound (DUS) for weaning success in multiple trauma patients. Therefore, we evaluated Ultrasound of the diaphragm as a valuable indicator of weaning outcomes, in trauma patients. MATERIAL AND METHODS This prospective cohort study included 50 trauma patients from September 2018 to February 2019. DUS was performed twice: upon ICU admission and the first weaning attempt. The diagnostic accuracy of indexes was evaluated by ROC curves. RESULTS The study included patients with a mean age of 35.4 ± 17.37, and 78% being male. The median injury severity score was 75 (42-75). The failure group exhibited significantly lower right diaphragmatic excursion (DE) compared to the success group (P = 0.006). In addition, the failure group experienced a significant decrease in both right and left DE from admission to the first attempt of weaning from MV (P < 0.001). Both groups showed a significant decrease in inspiratory and expiratory thickness on both sides during weaning from MV compared to the admission time (P < 0.001). The findings from the ROC analysis indicated that the Rapid shallow breathing index (RSBI) (Sensitivity = 91.67, Specificity = 100), respiratory rate (RR)/DE (Right: Sensitivity = 87.5, Specificity = 92.31), and RR/TF (Thickening Fraction) (Right: Sensitivity = 83.33, Specificity = 80.77) demonstrated high sensitivity and specificity in predicting weaning outcome. CONCLUSION In the context of patients with multiple trauma, employing DUC and assessing diaphragmatic excursion, thickness, RR/DE index, RR/TF index, and RSBI can aid in determining successful ventilator weaning.
Collapse
Affiliation(s)
- Golnar Sabetian
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mandana Mackie
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Naeimehossadat Asmarian
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahsa Banifatemi
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Mansoor Masjedi
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shahram Paydar
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Farid Zand
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| |
Collapse
|
10
|
Zhang Z, Cai X, Ming M, Huang L, Liu C, Ren H, Qu D, Gao H, Cheng Y, Zhang F, Yang Z, Xu W, Miao H, Liu P, Liu Y, Lu G, Chen W. Incidence, outcome, and prognostic factors of prolonged mechanical ventilation among children in Chinese mainland: a multi-center survey. Front Pediatr 2024; 12:1413094. [PMID: 38873585 PMCID: PMC11171133 DOI: 10.3389/fped.2024.1413094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 05/21/2024] [Indexed: 06/15/2024] Open
Abstract
Objective To evaluate the incidence, outcome, and prognostic factors of prolonged mechanical ventilation (PMV) in children in Mainland China. Methods A prospective study was conducted in 11 pediatric intensive care units (PICUs) from May 1, 2021, to April 30, 2022. All pediatric patients on mechanical ventilation meeting the criteria for PMV were included in the study. Results Out of 5,292 patients receiving mechanical ventilation, 278 children met the criteria for PMV (5.3%). After excluding case with incomplete data or lost to follow-up, the study included 250 patients. Among them, 115 were successfully weaned from mechanical ventilation, 90 died, and 45 were still on mechanical ventilation. The 6-month survival rate was 64%. The primary associated conditions of PMV were lower airway diseases (36%), central nervous system diseases (32%), and neuromuscular diseases (14%). The stepwise multiple logistic regression analysis indicated that the utilization of vasoactive agents and an elevated pediatric logistic organ dysfunction-2 (PELOD-2) score on the day of PMV diagnosis were significantly associated with an increased of PMV death. Specifically, the odds ratio (OR) for vasoactive agent use was 2.86; (95% CI: 0.15-0.84; P = 0.018), and for the PELOD-2 score, it was 1.37; 95% CI: 1.17-1.61; P < .001). Conversely, early rehabilitation intervention was negatively associated with the risk of PMV death (OR = 0.45; 95% CI: 0.22-0.93; P = .032). Furthermore, the tracheotomy timing emerged as an independent predictor of failure to wean from PMV, with an OR of 1.08, (95% CI: 1.01-1.16; P = .030). Conclusions The study revealed a 5.3% incidence of PMV in children requiring mechanical ventilation in China. The use of vasoactive agents and a higher PELOD-2 score at PMV diagnosis were significantly associated with an increased risk of PMV death, whereas early rehabilitation intervention was identified as crucial for improving patient outcomes. The timing of tracheostomy was identified as a high-risk factor for failure to wean from mechanical ventilation.
Collapse
Affiliation(s)
- Zhengzheng Zhang
- Pediatric Intensive Care Unit, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Xiaodi Cai
- Pediatric Intensive Care Unit, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Meixiu Ming
- Pediatric Intensive Care Unit, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Li Huang
- Department of Pediatric Intensive Care Unit, National Children’s Medical Center for South Central Region, Guangzhou Women and Children’s Medical Center, Guangzhou, China
| | - Chengjun Liu
- Department of Pediatric Intensive Care Unit, Western Pediatric Development Union, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Hong Ren
- Department of Pediatric Intensive Care Unit, National Children’s Medical Center, Shanghai Children’s Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Dong Qu
- Department of Pediatric Intensive Care Unit, Children’s Hospital, Capital Institute of Pediatrics, Beijing, China
| | - Hengmiao Gao
- Department of PediatricIntensive Care Unit, National Center for Children’s Health, Beijing Children’s Hospital, Capital Medical University, Beijing, China
| | - Yibing Cheng
- Department of Pediatric Intensive Care Unit, Children’s Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Furong Zhang
- Department of Pediatric Intensive Care Unit, Wuhan Children’s Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei, China
| | - Zihao Yang
- Department of Pediatric Intensive Care Unit, National Clinical Research Center for Child Health, Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Wei Xu
- Department of Pediatric Intensive Care Unit, National Children’s (Northeast) Regional Medical Center, Shengjing Hospital of China Medical University, Shenyang, China
| | - Hongjun Miao
- Department of Emergency/Critical Medicine, Children’s Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Pan Liu
- Pediatric Intensive Care Unit, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Yuxin Liu
- Pediatric Intensive Care Unit, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Guoping Lu
- Pediatric Intensive Care Unit, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Weiming Chen
- Pediatric Intensive Care Unit, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| |
Collapse
|
11
|
Diao S, Li S, Dong R, Jiang W, Wang C, Chen Y, Wang J, He S, Wang Y, Du B, Weng L. The diaphragmatic electrical activity during spontaneous breathing trial in patients with mechanical ventilation: physiological description and potential clinical utility. BMC Pulm Med 2024; 24:263. [PMID: 38816810 PMCID: PMC11140881 DOI: 10.1186/s12890-024-03077-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 05/27/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUNDS Increased respiratory drive has been demonstrated to correlate with weaning failure, which could be quantified by electrical activity of the diaphragm (EAdi). We described the physiological process of EAdi-based parameters during the spontaneous breathing trial (SBT) and evaluated the change of EAdi-based parameters as potential predictors of weaning failure. METHODS We conducted a prospective study in 35 mechanically ventilated patients who underwent a 2-hour SBT. EAdi and ventilatory parameters were continuously measured during the SBT. Diaphragm ultrasound was performed before the SBT and at the 30 min of the SBT. Three EAdi-based parameters were calculated: neuro-ventilatory efficiency, neuro-excursion efficiency and neuro-discharge per min. RESULTS Of the thirty 35 patients studied, 25 patients were defined as SBT success, including 22 patients weaning successfully and 3 patients reintubated. Before the SBT, neuro-excursion efficiency differed significantly between two groups and had the highest predictive value for SBT failure (AUROC 0.875, p < 0.01). Early increases in EAdi were observed in SBT, which are more prominent in SBT failure group. One minute, changes in EAdi and neuro-discharge per min also predicted weaning outcome (AUROCs 0.944 and 0.918, respectively). CONCLUSIONS EAdi-based parameters, especially neuro-excursion efficiency and changes in neuro-discharge per min, may detect impending weaning failure earlier than conventional indices. EAdi monitoring provides physiological insights and a more tailored approach to facilitate successful weaning. Further research should validate these findings and explore the utility of combined EAdi and diaphragm ultrasound assessment in weaning ICU patients from mechanical ventilation. TRIAL REGISTRATION Registered at ClinicalTrials.gov on 20 September 2022 (Identifier: NCT05632822).
Collapse
Affiliation(s)
- Shitong Diao
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Shan Li
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Run Dong
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Jiang
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Chunyao Wang
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yan Chen
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jingyi Wang
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Shuhua He
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yifan Wang
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Bin Du
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Li Weng
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China.
| |
Collapse
|
12
|
Cappellini I, Cardoni A, Campagnola L, Consales G. MUltiparametric Score for Ventilation Discontinuation in Intensive Care Patients: A Protocol for an Observational Study. Methods Protoc 2024; 7:45. [PMID: 38804339 PMCID: PMC11130949 DOI: 10.3390/mps7030045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/08/2024] [Accepted: 05/17/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND Mechanical ventilation significantly improves patient survival but is associated with complications, increasing healthcare costs and morbidity. Identifying optimal weaning times is paramount to minimize these risks, yet current methods rely heavily on clinical judgment, lacking specificity. METHODS This study introduces a novel multiparametric predictive score, the MUSVIP (MUltiparametric Score for Ventilation discontinuation in Intensive care Patients), aimed at accurately predicting successful extubation. Conducted at Santo Stefano Hospital's ICU, this single-center, observational, prospective cohort study will span over 12 months, enrolling adult patients undergoing invasive mechanical ventilation. The MUSVIP integrates variables measured before and during a spontaneous breathing trial (SBT) to formulate a predictive score. RESULTS Preliminary analyses suggest an Area Under the Curve (AUC) of 0.815 for the MUSVIP, indicating high predictive capacity. By systematically applying this score, we anticipate identifying patients likely to succeed in weaning earlier, potentially reducing ICU length of stay and associated healthcare costs. CONCLUSION This study's findings could significantly influence clinical practices, offering a robust, easy-to-use tool for optimizing weaning processes in ICUs.
Collapse
Affiliation(s)
- Iacopo Cappellini
- Department of Critical Care, Section of Anesthesiology and Critical Care, Azienda USL Toscana Centro, Ospedale Santo Stefano, 59100 Prato, Italy; (L.C.); (G.C.)
| | - Andrea Cardoni
- Department of Anesthesia and Critical Care, Azienda Ospedaliero Universitaria Careggi, 50134 Florence, Italy;
| | - Lorenzo Campagnola
- Department of Critical Care, Section of Anesthesiology and Critical Care, Azienda USL Toscana Centro, Ospedale Santo Stefano, 59100 Prato, Italy; (L.C.); (G.C.)
| | - Guglielmo Consales
- Department of Critical Care, Section of Anesthesiology and Critical Care, Azienda USL Toscana Centro, Ospedale Santo Stefano, 59100 Prato, Italy; (L.C.); (G.C.)
| |
Collapse
|
13
|
Murata K, Shimoyama K, Tsuruya T. Investigating the risk of reintubation by cough force assessment using cough peak expiratory flow: a single-center observational pilot study. BMC Pulm Med 2024; 24:222. [PMID: 38714988 PMCID: PMC11075268 DOI: 10.1186/s12890-024-02914-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 02/19/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND No objective indicator exists for evaluating cough strength during extubation of tracheally intubated patients. This study aimed to determine whether cough peak expiratory flow (CPEF) can predict the risk of reintubation due to decreased cough strength. METHODS This was a retrospective cohort study of patients who were admitted to our Emergency Intensive Care Unit between September 1, 2020 and August 31, 2021 and were under artificial ventilation management for ≥ 24 h. The patients were divided into two groups: successful extubation and reintubation groups, and the relationship between CPEF immediately before extubation and reintubation was investigated. RESULTS Seventy-six patients were analyzed. In the univariate analysis, CPEF was significantly different between the successful extubation (90.7 ± 25.9 L/min) and reintubation (57.2 ± 6.4 L/min) groups (p < 0.001). In the multivariate analysis with age and duration of artificial ventilation as covariates, CPEF was significantly lower in the reintubation group (p < 0.01). The cutoff value of CPEF for reintubation according to the receiver operating characteristic curve was 60 L/min (area under the curve, 0.897; sensitivity, 78.5%; specificity, 90.9%; p < 0.01). CONCLUSION CPEF in tracheally intubated patients may be a useful indicator for predicting the risk of reintubation associated with decreased cough strength. The cutoff CPEF value for reintubation due to decreased cough strength was 60 L/min.
Collapse
Affiliation(s)
- Kenya Murata
- Department of Nursing, Tokyo Medical University Hospital, Tokyo, Japan.
| | - Keiichiro Shimoyama
- Department of Emergency and Critical Care Medicine, Tokyo Medical University Hospital, Tokyo, Japan
| | - Takeshi Tsuruya
- Department of Nursing, Tokyo Medical University Hospital, Tokyo, Japan
| |
Collapse
|
14
|
Wang L, Pang X, Ding S, Pei K, Li Z, Wan J. Effect of postoperative oxygen therapy regimen modification on oxygenation in patients with acute type A aortic dissection. Heliyon 2024; 10:e29108. [PMID: 38638990 PMCID: PMC11024556 DOI: 10.1016/j.heliyon.2024.e29108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/31/2024] [Accepted: 04/01/2024] [Indexed: 04/20/2024] Open
Abstract
Objective In this study, we investigated the effect of various oxygen therapy regimens on oxygenation in patients with acute type A aortic dissection (AAD). Methods A quasi-randomized controlled trial was conducted, in which patients with AAD hospitalized for surgery from June to September 2021 were assigned to the control group (patients received conventional oxygen therapy after postoperative mechanical ventilation, weaning, and extubation) and those who were admitted from October to December 2021 were assigned to the observation group [patients underwent optimally adjusted therapy based on the treatment of the control group, which mainly included prioritized elevation of positive end-expiratory pressure (PEEP) and restricted use of the fraction of inspired oxygen (FiO2)].The postoperative oxygenation index, blood gas analysis, and duration of mechanical ventilation were compared between the two groups. Results There were significant differences in oxygenation observed at 2 h postoperatively between the groups. 12, 24, and 72 h postoperatively, the oxygenation index varied significantly between the two groups. There were statistically significant differences in the time effects of the oxygenation index and PaO2 between the two groups, as well as significant differences in the length of stay in the intensive care unit. Conclusion For the postoperative care of patients with AAD, it is suggested that the minimum FiO2 required for oxygenation of patients be maintained. In addition, it is possible to enhance PEEP as a priority when PaO2 is low.
Collapse
Affiliation(s)
- Li Wang
- Department of Hospital Infection Control, The Second Hospital of Shandong University, Jinan, 250033, PR China
| | - Xinyan Pang
- Department of Cardiovascular Surgery, The Second Hospital of Shandong University, Jinan, 250033, PR China
| | - Shouluan Ding
- Institute of Medicine Sciences, The Second Hospital of Shandong University, Jinan, 250033, PR China
| | - Ke Pei
- Department of Cardiovascular Surgery, The Second Hospital of Shandong University, Jinan, 250033, PR China
| | - Zijia Li
- Department of Cardiovascular Surgery, The Second Hospital of Shandong University, Jinan, 250033, PR China
| | - Jianhong Wan
- Department of Cardiovascular Surgery, The Second Hospital of Shandong University, Jinan, 250033, PR China
| |
Collapse
|
15
|
Burns KEA, Rochwerg B, Seely AJE. Ventilator Weaning and Extubation. Crit Care Clin 2024; 40:391-408. [PMID: 38432702 DOI: 10.1016/j.ccc.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Increasing evidence supports specific approaches to liberate patients from invasive ventilation including the use of liberation protocols, inspiratory assistance during spontaneous breathing trials (SBTs), early extubation of patients with chronic obstructive pulmonary disease to noninvasive ventilation, and prophylactic use of noninvasive support strategies after extubation. Additional research is needed to elucidate the best criteria to identify patients who are ready to undergo an SBT and to inform optimal screening frequency, the best SBT technique and duration, extubation assessments, and extubation decision-making. Additional clarity is also needed regarding the optimal timing to measure and report extubation success.
Collapse
Affiliation(s)
- Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Medicine and Division of Critical Care, Unity Health Toronto, St. Michaels Hospital, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, Unity Health Toronto, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, Hamilton Health Sciences, Juravinski Hospital, Hamilton, Ontario, Canada; Department of Critical Care, Hamilton Health Sciences, Juravinski Hospital, Hamilton, Ontario, Canada. https://twitter.com/Bram_Rochwerg
| | - Andrew J E Seely
- Department of Critical Care, Ottawa Hospital, Ottawa, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
16
|
Tsai CH, Liu YC, Chen PR, Loh CYY, Kao HK. Risk factors for postoperative adverse airway events in patients with primary oral cancer undergoing reconstruction without prophylactic tracheostomy. Asian J Surg 2024; 47:1763-1768. [PMID: 38212227 DOI: 10.1016/j.asjsur.2023.12.188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 12/06/2023] [Accepted: 12/29/2023] [Indexed: 01/13/2024] Open
Abstract
OBJECTIVE To identify risk factors associated with adverse airway events (AAEs) in primary oral cancer patients undergoing tumor ablation followed by free tissue transfer without prophylactic tracheostomy. METHODS We retrospectively collected primary oral cancer patients who underwent tumor ablation surgery following free-tissue transfer without prophylactic tracheostomy during February 2017 to June 2019 in Chang Gung Memorial Hospital, Linkou Medical Center, Taiwan. 379 patients were included. Data were analysed from 2020 to 2021. Demographics, comorbidities, intraoperative variables and postoperative respiration profile were obtained from the medical record. Main outcome was postoperative AAEs, including requirement of endotracheal intubation after extubation and tracheostomy after prolonged intubation. RESULTS Of the 379 patients, postoperative AAEs happened in 29 patients (7.6 %). In reintubation group, patients were older with more diabetes mellitus, hypertension and cerebrovascular disease. These patients had lower preoperative hemoglobin, creatinine, and albumin level with more intraoperative blood transfusion. In postoperative respiration profile, rapid shallow breathing index (RSBI) and PaO2/FiO2 (PF) ratio were poorer. On multivariate analysis, patient's age, tumor location, and cross-midline segmental mandibulectomy and a lower PF ratio were independent risk factors for postoperative AAEs. CONCLUSIONS In head and neck cancer patients that underwent tumor ablation followed by free tissue transfer without prophylactic tracheostomy, patient's age, tumor location, cross-midline segmental mandibulectomy and P/F ratio are associated with postoperative AAEs.
Collapse
Affiliation(s)
- Chia-Hsuan Tsai
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Keelung & Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yao-Chang Liu
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Keelung & Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Pin-Ru Chen
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital & Chang Gung University College of Medicine, Tao-Yuan, Taiwan
| | | | - Huang-Kai Kao
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital & Chang Gung University College of Medicine, Tao-Yuan, Taiwan.
| |
Collapse
|
17
|
Alvi S, Blackwell T, Curran NR, Germanwala A. Comparative impact of COVID-19 infection on tracheostomy patients. Am J Otolaryngol 2024; 45:104112. [PMID: 38039914 DOI: 10.1016/j.amjoto.2023.104112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 10/29/2023] [Indexed: 12/03/2023]
Abstract
PURPOSE We study outcomes after tracheostomy in COVID-19 positive patients versus COVID-19 negative patients who underwent tracheostomy during the same time frame in an effort to better understand the influence of COVID-19 despite variances in virus strain and treatment practices. MATERIALS AND METHODS This is a retrospective cohort study of all Veterans Affairs centers nationwide, using data provided by the Veterans Affairs Informatics and Computing Infrastructure. Our cohort consisted of veteran patients who underwent tracheostomy between March 2020 and September 2022. Patients who tested positive for COVID-19 within three months prior to tracheostomy were compared to patients who had never tested positive for COVID-19. RESULTS 956 patients were included in the analysis, and nearly 96 % of these patients were male. The COVID-19 positive group spent one more week on the ventilator and experienced lower rates of successful ventilator weaning (hazard ratio 0.74, 95 % confidence interval [0.62, 0.88], P < 0.001). Survival curves were non-proportional, and while the COVID-19 positive group had higher 30-day mortality (relative risk 1.37, 95 % confidence interval [1.09, 1.73], P = 0.007), the COVID-19 negative group had higher long-term mortality. CONCLUSIONS Our findings suggest that while infection with COVID-19 has a significant effect on short-term outcomes after tracheostomy, chronic comorbidities seem to have the more enduring impact. In spite of prolonged ventilation and higher short-term mortality, tracheostomy in COVID-19 can be a positive intervention that does not necessarily predestine patients to the same level of long-term morbidity and mortality of typical tracheostomies.
Collapse
Affiliation(s)
- Suffia Alvi
- Jesse Brown VA Medical Center, Department of Veterans Affairs, Chicago, IL, United States of America; University of Illinois at Chicago College of Medicine, Chicago, IL, United States of America
| | - Thomas Blackwell
- Jesse Brown VA Medical Center, Department of Veterans Affairs, Chicago, IL, United States of America; University of Illinois at Chicago College of Medicine, Chicago, IL, United States of America
| | - Nicholas R Curran
- University of Cincinnati Medical Center, Cincinnati, OH, United States of America
| | - Arpita Germanwala
- Jesse Brown VA Medical Center, Department of Veterans Affairs, Chicago, IL, United States of America; University of Illinois at Chicago College of Medicine, Chicago, IL, United States of America.
| |
Collapse
|
18
|
Nayak G, Chaudhuri S, Ravindranath S, Todur P. Comparison of the Recent ExPreS Score, WEANSNOW Score, and the Parsimonious HACOR Score as the Best Predictor of Weaning: An Externally Validated Prospective Observational Study. Indian J Crit Care Med 2024; 28:273-279. [PMID: 38477001 PMCID: PMC10926042 DOI: 10.5005/jp-journals-10071-24663] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 02/05/2024] [Indexed: 03/14/2024] Open
Abstract
Background Since weaning failure is multifactorial, comprehensive weaning scores encompassing not only the respiratory component but also nonrespiratory aspects are quintessential for successful weaning prediction. Materials and methods This was a single-center prospective observational study on 128 intensive care unit (ICU) patients undergoing spontaneous breathing trials (SBT). The extubation prediction score (ExPreS), heart rate, acidosis, consciousness, oxygenation, respiratory rate (HACOR), and weaning parameters, endotracheal tube size, arterial blood gas analysis, nutrition, secretions, neuromuscular affecting agents, obstructive airway problems and wakefulness (WEANSNOW) scores were compared for their diagnostic accuracy for successful weaning prediction. Results Out of 128 patients, 49 (38.3%) patients had weaning failure, and 79 (61.7%) had weaning success. The patients in the weaning failure group had significantly higher APACHE II scores, WEANSNOW scores, HACOR scores, MV days, and significantly lower ExPreS scores as compared to the successful weaning group. Multivariable regression analysis showed that ExPreS score p = 0.015, adjusted OR 0.960, 95% CI (0.929-0.992) and HACOR score p < 0.001, adjusted OR 1.357, 95% CI (1.176-1.567) were independent predictors of weaning failure. The HACOR score had an AUC of 0.830, cut-off ≥5, p < 0.001, sensitivity 76%, specificity 68%, diagnostic accuracy 70% to predict weaning failure. The ExPreS score had an AUC of 0.735, cut-off ≥69, p < 0.001, sensitivity of 70.9%, specificity of 69.4%, and diagnostic accuracy of 70.3% to predict weaning success. Both the HACOR and ExPreS scores were good models for predicting weaning outcomes (model quality 0.76 and 0.64 respectively). Conclusion The parsimonious HACOR score is comparable to the ExPreS score for the prediction of weaning outcomes in critically ill patients. How to cite this article Nayak G, Chaudhuri S, Ravindranath S, Todur P. Comparison of the Recent ExPreS Score, WEANSNOW Score, and the Parsimonious HACOR Score as the Best Predictor of Weaning: An Externally Validated Prospective Observational Study. Indian J Crit Care Med 2024;28(3):273-279.
Collapse
Affiliation(s)
- Gautham Nayak
- Department of Respiratory Therapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Souvik Chaudhuri
- Department of Critical Care Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Sunil Ravindranath
- Department of Critical Care Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Pratibha Todur
- Department of Respiratory Therapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka, India
| |
Collapse
|
19
|
Hartl WH, Kopper P, Xu L, Heller L, Mironov M, Wang R, Day AG, Elke G, Küchenhoff H, Bender A. Relevance of Protein Intake for Weaning in the Mechanically Ventilated Critically Ill: Analysis of a Large International Database. Crit Care Med 2024; 52:e121-e131. [PMID: 38156913 PMCID: PMC10876180 DOI: 10.1097/ccm.0000000000006155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
OBJECTIVES The association between protein intake and the need for mechanical ventilation (MV) is controversial. We aimed to investigate the associations between protein intake and outcomes in ventilated critically ill patients. DESIGN Analysis of a subset of a large international point prevalence survey of nutritional practice in ICUs. SETTING A total of 785 international ICUs. PATIENTS A total of 12,930 patients had been in the ICU for at least 96 hours and required MV by the fourth day after ICU admission at the latest. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We modeled associations between the adjusted hazard rate (aHR) of death in patients requiring MV and successful weaning (competing risks), and three categories of protein intake (low: < 0.8 g/kg/d, standard: 0.8-1.2 g/kg/d, high: > 1.2 g/kg/d). We compared five different hypothetical protein diets (an exclusively low protein intake, a standard protein intake given early (days 1-4) or late (days 5-11) after ICU admission, and an early or late high protein intake). There was no evidence that the level of protein intake was associated with time to weaning. However, compared with an exclusively low protein intake, a standard protein intake was associated with a lower hazard of death in MV: minimum aHR 0.60 (95% CI, 0.45-0.80). With an early high intake, there was a trend to a higher risk of death in patients requiring MV: maximum aHR 1.35 (95% CI, 0.99-1.85) compared with a standard diet. CONCLUSIONS The duration of MV does not appear to depend on protein intake, whereas mortality in patients requiring MV may be improved by a standard protein intake. Adverse effects of a high protein intake cannot be excluded.
Collapse
Affiliation(s)
- Wolfgang H Hartl
- Department of General, Visceral, and Transplantation Surgery, University Medical Center, Campus Grosshadern, LMU Munich, Munich, Germany
| | - Philipp Kopper
- Statistical Consulting Unit, StaBLab, Department of Statistics, LMU Munich, Munich, Germany
- Munich Center for Machine Learning, LMU Munich, Munich, Germany
| | - Lisa Xu
- Statistical Consulting Unit, StaBLab, Department of Statistics, LMU Munich, Munich, Germany
| | - Luca Heller
- Statistical Consulting Unit, StaBLab, Department of Statistics, LMU Munich, Munich, Germany
| | - Maxim Mironov
- Statistical Consulting Unit, StaBLab, Department of Statistics, LMU Munich, Munich, Germany
| | - Ruiyi Wang
- Statistical Consulting Unit, StaBLab, Department of Statistics, LMU Munich, Munich, Germany
| | - Andrew G Day
- Clinical Evaluation Research Unit, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Gunnar Elke
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Helmut Küchenhoff
- Statistical Consulting Unit, StaBLab, Department of Statistics, LMU Munich, Munich, Germany
| | - Andreas Bender
- Statistical Consulting Unit, StaBLab, Department of Statistics, LMU Munich, Munich, Germany
- Munich Center for Machine Learning, LMU Munich, Munich, Germany
| |
Collapse
|
20
|
Choi AY, Kim MY, Song EK. [Effect of an Intervention Using Voice Recording of a Family Member on Patients Undergoing Mechanical Ventilator Weaning Process]. J Korean Acad Nurs 2024; 54:32-43. [PMID: 38480576 DOI: 10.4040/jkan.23082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 10/24/2023] [Accepted: 01/22/2024] [Indexed: 03/26/2024]
Abstract
PURPOSE This study aimed to determine the impact of an intervention using voice recording of family members on pain, anxiety, and agitation in patients undergoing weaning from mechanical ventilation. METHODS A randomized control pre-post experimental design was implemented to 53 participants, with 27 and 26 participants in the experimental and control groups, respectively. A 70-second voice recording of a family member, repeated three times at 10-minute intervals was used as an intervention for the experimental group. Meanwhile, participants in the control group used headset for 30 minutes. Structured instruments were utilized to measure pain, anxiety, agitation, and the weaning process. Wilcoxon Signed Ranks test and the Mann-Whitney U test, or χ² test, were used for data analysis. RESULTS The experimental group exhibited significant decrease in pain (Z = -3.53, p < .001), anxiety (t = 5.45, p < .001), and agitation (Z = -2.99, p = .003) scores compared with those of the control group. However, there was no significant difference between groups in the weaning process' simplification (χ² = 0.63, p = .727). CONCLUSION Intervention using family members' voice recording effectively reduces pain, anxiety, and agitation in patients undergoing weaning from mechanical ventilation. This can be actively utilized to provide a more comfortable process for patients.
Collapse
Affiliation(s)
- Ah Young Choi
- Emergency Intensive Care Unit, Ulsan University Hospital, Ulsan, Korea
| | - Min Young Kim
- Department of Nursing, Ulsan University, Ulsan, Korea.
| | | |
Collapse
|
21
|
Hernández Martínez G, Rodriguez P, Soto J, Caritg O, Castellví-Font A, Mariblanca B, García AM, Colinas L, Añon JM, Parrilla-Gomez FJ, Silva-Obregón JA, Masclans JR, Propin A, Cuadra A, Dalorzo MG, Rialp G, Suarez-Sipmann F, Roca O. Effect of aggressive vs conservative screening and confirmatory test on time to extubation among patients at low or intermediate risk: a randomized clinical trial. Intensive Care Med 2024; 50:258-267. [PMID: 38353714 DOI: 10.1007/s00134-024-07330-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/19/2024] [Indexed: 03/03/2024]
Abstract
PURPOSE This study aimed to determine the best strategy to achieve fast and safe extubation. METHODS This multicenter trial randomized patients with primary respiratory failure and low-to-intermediate risk for extubation failure with planned high-flow nasal cannula (HFNC) preventive therapy. It included four groups: (1) conservative screening with ratio of partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2) ≥ 150 and positive end-expiratory pressure (PEEP) ≤ 8 cmH2O plus conservative spontaneous breathing trial (SBT) with pressure support 5 cmH2O + PEEP 0 cmH2O); (2) screening with ratio of partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2) ≥ 150 and PEEP ≤ 8 plus aggressive SBT with pressure support 8 + PEEP 5; (3) aggressive screening with PaO2/FiO2 > 180 and PEEP 10 maintained until the SBT with pressure support 8 + PEEP 5; (4) screening with PaO2/FiO2 > 180 and PEEP 10 maintained until the SBT with pressure support 5 + PEEP 0. Primary outcomes were time-to-extubation and simple weaning rate. Secondary outcomes included reintubation within 7 days after extubation. RESULTS Randomization to the aggressive-aggressive group was discontinued at the interim analysis for safety reasons. Thus, 884 patients who underwent at least 1 SBT were analyzed (conservative-conservative group, n = 256; conservative-aggressive group, n = 267; aggressive-conservative group, n = 261; aggressive-aggressive, n = 100). Median time to extubation was lower in the groups with aggressive screening (p < 0.001). Simple weaning rates were 45.7%, 76.78% (205 patients), 71.65%, and 91% (p < 0.001), respectively. Reintubation rates did not differ significantly (p = 0.431). CONCLUSION Among patients at low or intermediate risk for extubation failure with planned HFNC, combining aggressive screening with preventive PEEP and a conservative SBT reduced the time to extubation without increasing the reintubation rate.
Collapse
Affiliation(s)
- Gonzalo Hernández Martínez
- Complejo Hospitalario Universitario de Toledo, Toledo, Spain.
- Grupo de Investigación en Disfunción y Fallo Orgánico en La Agresión (IdiPAZ), Madrid, Spain.
- Ciber Enfermedades Respiratorias (CIBERES), Health Institute Carlos III, Madrid, Spain.
| | | | - Jesus Soto
- Hospital Universitario La Paz, Madrid, Spain
| | - Oriol Caritg
- Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Vall d'Hebron Institut de Reserca (VHIR), Barcelona, Spain
| | - Andrea Castellví-Font
- Hospital del Mar, Barcelona, Spain
- Grupo de Investigación del Paciente Crítico (GREPAC), Institut Hospital del Mar d´Investigacions Mèdiques (IMIM), Barcelona, Spain
| | | | | | - Laura Colinas
- Complejo Hospitalario Universitario de Toledo, Toledo, Spain
| | - Jose Manuel Añon
- Hospital Universitario La Paz, Madrid, Spain
- Grupo de Investigación en Disfunción y Fallo Orgánico en La Agresión (IdiPAZ), Madrid, Spain
| | - Francisco Jose Parrilla-Gomez
- Hospital del Mar, Barcelona, Spain
- Grupo de Investigación del Paciente Crítico (GREPAC), Institut Hospital del Mar d´Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Jose Alberto Silva-Obregón
- Hospital Universitario de Guadalajara, Guadalajara, Spain
- Grupo de Investigación del Paciente Hematológico, Instituto de Investigación Sanitaria Hospital Universitario La Paz (IdiPAZ), Madrid, Spain
| | - Joan Ramon Masclans
- Hospital del Mar, Barcelona, Spain
- Grupo de Investigación del Paciente Crítico (GREPAC), Institut Hospital del Mar d´Investigacions Mèdiques (IMIM), Barcelona, Spain
- MELIS, Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | | | - Alicia Cuadra
- Complejo Hospitalario Universitario de Toledo, Toledo, Spain
| | | | - Gemma Rialp
- Hospital Universitario Son Llàtzer, Palma, Spain
| | | | - Oriol Roca
- Parc Taulí Hospital Universitari, Institut de Investigació i Innovació Parc Taulí (I3PT-CERCA), Sabadell, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
- Ciber Enfermedades Respiratorias (CIBERES), Health Institute Carlos III, Madrid, Spain
| |
Collapse
|
22
|
Wang W, Zhang Z, Xia F. Impact of different oxygen therapy strategies on the risk of endotracheal reintubation in mechanically ventilated patients: A systematic review and meta-analysis. Technol Health Care 2024; 32:2009-2022. [PMID: 38306070 DOI: 10.3233/thc-231024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
BACKGROUND Mechanical ventilation (MV) is a crucial intervention for the support of patients with acute and severe respiratory failure in modern intensive care medicine. However, the mechanical forces resulting from the interplay between the ventilator and the respiratory system may cause pulmonary injury. OBJECTIVE To compare the effects of high-flow nasal cannula (HFNC) therapy and other oxygen therapy modalities on the risk of endotracheal reintubation in mechanically ventilated patients after extubation in the intensive care unit (ICU). METHODS An electronic search was carried out across various databases including PubMed, Embase, Ovid, Medline, Cochrane Library, Embase, VIP, and Wanfang. The objective of this search was to locate prospective randomized controlled trials that examined the effects of multiple oxygen therapy approaches on the incidence of reintubation in patients in the ICU after undergoing mechanical ventilation. The meta package in R language was used to analyze parameters adopted by the included studies such as reintubation rate, mortality rate, and length of hospital stay. RESULTS This study enrolled 22 articles, involving 4,160 participants, with 2,061 in the study group and 2,099 in the control group. Among these, 20 articles presented data on the reintubation rate of the patients included with an odds ratio (OR) of 0.90 (95% CI: 0.74, 1.09) for HFNC and an OR of 1.77 (95% CI: 0.93, 3.38) for HFNC in the chronic obstructive pulmonary disease (COPD) subgroup. Moreover, 10 articles assessed the incidence of respiratory failure after extubation, revealing an OR for HFNC was 0.68 (95% CI: 0.55, 0.84) using a fixed-effects model. Nine articles addressed ICU mortality, while 13 pieces of literature examined hospital mortality. HFNC showed no significant impact on either ICU mortality or hospital mortality. CONCLUSION HFNC therapy markedly reduces the incidence of respiratory failure in mechanically ventilated patients following extubation in the ICU. Furthermore, it specifically reduces the risk of reintubation in patients diagnosed with COPD.
Collapse
|
23
|
Barahona J, Sahli Costabal F, Hurtado DE. Machine learning modeling of lung mechanics: Assessing the variability and propagation of uncertainty in respiratory-system compliance and airway resistance. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2024; 243:107888. [PMID: 37948910 DOI: 10.1016/j.cmpb.2023.107888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 10/12/2023] [Accepted: 10/25/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND AND OBJECTIVE Traditional assessment of patient response in mechanical ventilation relies on respiratory-system compliance and airway resistance. Clinical evidence has shown high variability in these parameters, highlighting the difficulty of predicting them before the start of ventilation therapy. This motivates the creation of computational models that can connect structural and tissue features with lung mechanics. In this work, we leverage machine learning (ML) techniques to construct predictive lung function models informed by non-linear finite element simulations, and use them to investigate the propagation of uncertainty in the lung mechanical response. METHODS We revisit a continuum poromechanical formulation of the lungs suitable for determining patient response. Based on this framework, we create high-fidelity finite element models of human lungs from medical images. We also develop a low-fidelity model based on an idealized sphere geometry. We then use these models to train and validate three ML architectures: single-fidelity and multi-fidelity Gaussian process regression, and artificial neural networks. We use the best predictive ML model to further study the sensitivity of lung response to variations in tissue structural parameters and boundary conditions via sensitivity analysis and forward uncertainty quantification. Codes are available for download at https://github.com/comp-medicine-uc/ML-lung-mechanics-UQ RESULTS: The low-fidelity model delivers a lung response very close to that predicted by high-fidelity simulations and at a fraction of the computational time. Regarding the trained ML models, the multi-fidelity GP model consistently delivers better accuracy than the single-fidelity GP and neural network models in estimating respiratory-system compliance and resistance (R2∼0.99). In terms of computational efficiency, our ML model delivers a massive speed-up of ∼970,000× with respect to high-fidelity simulations. Regarding lung function, we observed an almost matched and non-linear behavior between specific structural parameters and chest wall stiffness with compliance. Also, we observed a strong modulation of airways resistance with tissue permeability. CONCLUSIONS Our findings unveil the relevance of specific lung tissue parameters and boundary conditions in the respiratory-system response. Furthermore, we highlight the advantages of adopting a multi-fidelity ML approach that combines data from different levels to yield accurate and efficient estimates of clinical mechanical markers. We envision that the methods presented here can open the way to the development of predictive ML models of the lung response that can inform clinical decisions.
Collapse
Affiliation(s)
- José Barahona
- Department of Structural and Geotechnical Engineering, School of Engineering, Pontificia Universidad Católica de Chile, Santiago, 7820436, Chile; Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Católica de Chile, Santiago, 7820436, Chile
| | - Francisco Sahli Costabal
- Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Católica de Chile, Santiago, 7820436, Chile; Department of Mechanical and Metallurgical Engineering, School of Engineering, Pontificia Universidad Católica de Chile, Santiago, 7820436, Chile
| | - Daniel E Hurtado
- Department of Structural and Geotechnical Engineering, School of Engineering, Pontificia Universidad Católica de Chile, Santiago, 7820436, Chile; Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Católica de Chile, Santiago, 7820436, Chile; Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, 02140, USA.
| |
Collapse
|
24
|
Ma H, Fujioka H, Halpern D, Bates JHT, Gaver DP. Full-lung simulations of mechanically ventilated lungs incorporating recruitment/derecruitment dynamics. FRONTIERS IN NETWORK PHYSIOLOGY 2023; 3:1257710. [PMID: 38020240 PMCID: PMC10654632 DOI: 10.3389/fnetp.2023.1257710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023]
Abstract
This study developed and investigated a comprehensive multiscale computational model of a mechanically ventilated ARDS lung to elucidate the underlying mechanisms contributing to the development or prevention of VILI. This model is built upon a healthy lung model that incorporates realistic airway and alveolar geometry, tissue distensibility, and surfactant dynamics. Key features of the ARDS model include recruitment and derecruitment (RD) dynamics, alveolar tissue viscoelasticity, and surfactant deficiency. This model successfully reproduces realistic pressure-volume (PV) behavior, dynamic surface tension, and time-dependent descriptions of RD events as a function of the ventilation scenario. Simulations of Time-Controlled Adaptive Ventilation (TCAV) modes, with short and long durations of exhalation (T Low - and T Low +, respectively), reveal a higher incidence of RD for T Low + despite reduced surface tensions due to interfacial compression. This finding aligns with experimental evidence emphasizing the critical role of timing in protective ventilation strategies. Quantitative analysis of energy dissipation indicates that while alveolar recruitment contributes only a small fraction of total energy dissipation, its spatial concentration and brief duration may significantly contribute to VILI progression due to its focal nature and higher intensity. Leveraging the computational framework, the model may be extended to facilitate the development of personalized protective ventilation strategies to enhance patient outcomes. As such, this computational modeling approach offers valuable insights into the complex dynamics of VILI that may guide the optimization of ventilation strategies in ARDS management.
Collapse
Affiliation(s)
- Haoran Ma
- Department of Biomedical Engineering, Tulane University, New Orleans, LA, United States
| | - Hideki Fujioka
- Center for Computational Science, Tulane University, New Orleans, LA, United States
| | - David Halpern
- Department of Mathematics, University of Alabama, Tuscaloosa, AL, United States
| | - Jason H. T. Bates
- Larner College of Medicine, University of Vermont, Burlington, VT, United States
| | - Donald P. Gaver
- Department of Biomedical Engineering, Tulane University, New Orleans, LA, United States
| |
Collapse
|
25
|
Rajbanshi LK, Bajracharya A, Devkota D. Author Reply: Lung Ultrasound Score-Does It Really Predict Extubation Failure? Indian J Crit Care Med 2023; 27:857-858. [PMID: 37936801 PMCID: PMC10626228 DOI: 10.5005/jp-journals-10071-24559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
How to cite this article: Rajbanshi LK, Bajracharya A, Devkota D. Author Reply-lung Ultrasound Score-Does It Really Predict Extubation Failure? Indian J Crit Care Med 2023;27(11):857-858.
Collapse
Affiliation(s)
- Lalit Kumar Rajbanshi
- Department of Anesthesiology and Critical Care, Birat Medical College and Teaching Hospital, Morang, Nepal
| | - Akriti Bajracharya
- Department of Anesthesiology and Critical Care, Birat Medical College and Teaching Hospital, Morang, Nepal
| | - Dikshya Devkota
- Department of Anesthesiology and Critical Care, Birat Medical College and Teaching Hospital, Morang, Nepal
| |
Collapse
|
26
|
He G, Han Y, Zhan Y, Yao Y, Zhou H, Zheng X. The combined use of parasternal intercostal muscle thickening fraction and P0.1 for prediction of weaning outcomes. Heart Lung 2023; 62:122-128. [PMID: 37480723 DOI: 10.1016/j.hrtlng.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/11/2023] [Accepted: 07/12/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND A variety of parameters and diaphragmatic ultrasound in ventilator weaning has been studied extensively, and the findings yield inconsistent conclusions. The parasternal intercostal muscle holds important substantial respiratory reserve capacity when the central drive is enhanced, the predictive value of combining parasternal intercostal muscle ultrasound parameters with P0.1(airway occlusion pressure at 100 msec) in assessing ventilator weaning outcomes is still unknown. OBJECTIVES Our study aimed to evaluate the predictive efficacy of parasternal intercostal muscle ultrasound in conjunction with P0.1 in determining weaning failure. METHODS We recruited patients who had been admitted to ICU and had been receiving mechanical ventilation for over two days. All patients underwent a half-hour spontaneous breathing trial (SBT) with low-level pressure support ventilation (PSV). They were positioned semi-upright for parasternal intercostal muscle ultrasound evaluations, including parasternal intercostal muscle thickness (PIMT), and parasternal intercostal muscle thickening fraction (PIMTF); P0.1 was obtained from the ventilator. Weaning failure was defined as the need for non-invasive positive pressure ventilation or re-intubation within 48 h post-weaning. RESULTS Of the 56 enrolled patients with a mean age of 63.04 ± 15.80 years, 13 (23.2%) experienced weaning failure. There were differences in P0.1 (P = .001) and PIMTF (P = .017) between the two groups, but also in patients with a diaphragm thickness ≥ 2 mm. The predictive threshold values were PIMTF ≥ 13.15% and P0.1 ≥ 3.9 cmH2O for weaning failure. The AUROC for predicting weaning failure was 0.721 for PIMTF, 0.792 for P0.1, and 0.869 for the combination of PIMTF and P0.1. CONCLUSIONS The parasternal intercostal muscle thickening fraction and P0.1 are independently linked to weaning failure, especially in patients with normal diaphragm thickness. The combination of parasternal intercostal muscle thickening fraction and P0.1 can serve as a valuable tool for the precise clinical prediction of weaning outcomes. TRIAL REGISTRATION Chinese Clinical Trial Registry website (ChiCTR2200065422).
Collapse
Affiliation(s)
- Guojun He
- Department of Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, PR China; Key Laboratory of Clinical Evaluation Technology for Medical Device of Zhejiang Province, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, PR China
| | - Yijiao Han
- Department of Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, PR China
| | - Yasheng Zhan
- Department of Critical Care Medicine, Jinhua People's Hospital, Jinhua, Zhejiang 321000, PR China
| | - Yake Yao
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, PR China
| | - Hua Zhou
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, PR China.
| | - Xia Zheng
- Department of Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, PR China; Key Laboratory of Clinical Evaluation Technology for Medical Device of Zhejiang Province, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, PR China.
| |
Collapse
|
27
|
Xu SS, Tian Y, Ma YJ, Zhou YM, Tian Y, Gao R, Yang YL, Zhang L, Zhou JX. Development of a Prediction Score for Evaluation of Extubation Readiness in Neurosurgical Patients with Mechanical Ventilation. Anesthesiology 2023; 139:614-627. [PMID: 37535470 PMCID: PMC10566588 DOI: 10.1097/aln.0000000000004721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 07/28/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND There is no widely accepted consensus on the weaning and extubating protocols for neurosurgical patients, leading to heterogeneity in clinical practices and high rates of delayed extubation and extubation failure-related health complications. METHODS In this single-center prospective observational diagnostic study, mechanically ventilated neurosurgical patients with extubation attempts were consecutively enrolled for 1 yr. Responsive physicians were surveyed for the reasons for delayed extubation and developed the Swallowing, Tongue protrusion, Airway protection reflected by spontaneous and suctioning cough, and Glasgow Coma Scale Evaluation (STAGE) score to predict the extubation success for neurosurgical patients already meeting other general extubation criteria. RESULTS A total of 3,171 patients were screened consecutively, and 226 patients were enrolled in this study. The rates of delayed extubation and extubation failure were 25% (57 of 226) and 19% (43 of 226), respectively. The most common reasons for the extubation delay were weak airway-protecting function and poor consciousness. The area under the receiver operating characteristics curve of the total STAGE score associated with extubation success was 0.72 (95% CI, 0.64 to 0.79). Guided by the highest Youden index, the cutoff point for the STAGE score was set at 6 with 59% (95% CI, 51 to 66%) sensitivity, 74% (95% CI, 59 to 86%) specificity, 90% (95% CI, 84 to 95%) positive predictive value, and 30% (95% CI, 21 to 39%) negative predictive value. At STAGE scores of 9 or higher, the model exhibited a 100% (95% CI, 90 to 100%) specificity and 100% (95% CI, 72 to 100%) positive predictive value for predicting extubation success. CONCLUSIONS After a survey of the reasons for delayed extubation, the STAGE scoring system was developed to better predict the extubation success rate. This scoring system has promising potential in predicting extubation readiness and may help clinicians avoid delayed extubation and failed extubation-related health complications in neurosurgical patients. EDITOR’S PERSPECTIVE
Collapse
Affiliation(s)
- Shan-Shan Xu
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ye Tian
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yan-Juan Ma
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yi-Min Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ying Tian
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ran Gao
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yan-Lin Yang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Linlin Zhang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
28
|
Park JE, Kim DY, Park JW, Jung YJ, Lee KS, Park JH, Sheen SS, Park KJ, Sunwoo MH, Chung WY. Development of a Machine Learning Model for Predicting Weaning Outcomes Based Solely on Continuous Ventilator Parameters during Spontaneous Breathing Trials. Bioengineering (Basel) 2023; 10:1163. [PMID: 37892893 PMCID: PMC10604888 DOI: 10.3390/bioengineering10101163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 09/30/2023] [Accepted: 10/02/2023] [Indexed: 10/29/2023] Open
Abstract
Discontinuing mechanical ventilation remains challenging. We developed a machine learning model to predict weaning outcomes using only continuous monitoring parameters obtained from ventilators during spontaneous breathing trials (SBTs). Patients who received mechanical ventilation in the medical intensive care unit at a tertiary university hospital from 2019-2021 were included in this study. During the SBTs, three waveforms and 25 numerical data were collected as input variables. The proposed convolutional neural network (CNN)-based weaning prediction model extracts features from input data with diverse lengths. Among 138 enrolled patients, 35 (25.4%) experienced weaning failure. The dataset was randomly divided into training and test sets (8:2 ratio). The area under the receiver operating characteristic curve for weaning success by the prediction model was 0.912 (95% confidence interval [CI], 0.795-1.000), with an area under the precision-recall curve of 0.767 (95% CI, 0.434-0.983). Furthermore, we used gradient-weighted class activation mapping technology to provide visual explanations of the model's prediction, highlighting influential features. This tool can assist medical staff by providing intuitive information regarding readiness for extubation without requiring any additional data collection other than SBT data. The proposed predictive model can assist clinicians in making ventilator weaning decisions in real time, thereby improving patient outcomes.
Collapse
Affiliation(s)
- Ji Eun Park
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (J.E.P.)
| | - Do Young Kim
- Land Combat System Center, Hanwha Systems, Sungnam 13524, Republic of Korea;
| | - Ji Won Park
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (J.E.P.)
| | - Yun Jung Jung
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (J.E.P.)
| | - Keu Sung Lee
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (J.E.P.)
| | - Joo Hun Park
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (J.E.P.)
| | - Seung Soo Sheen
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (J.E.P.)
| | - Kwang Joo Park
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (J.E.P.)
| | - Myung Hoon Sunwoo
- Department of Electrical and Computer Engineering, Ajou University, Suwon 16499, Republic of Korea;
| | - Wou Young Chung
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (J.E.P.)
| |
Collapse
|
29
|
Karthika M, Al Enezi FA, Pillai LV, Arabi YM. Rate of Change of Rapid Shallow Breathing Index and Extubation Outcome in Mechanically Ventilated Patients. Crit Care Res Pract 2023; 2023:9141441. [PMID: 37795474 PMCID: PMC10547562 DOI: 10.1155/2023/9141441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 09/06/2023] [Accepted: 09/08/2023] [Indexed: 10/06/2023] Open
Abstract
Background Rapid shallow breathing index (RSBI) has been widely used as a predictor of extubation outcome in mechanically ventilated patients. We hypothesize that the rate of change of RSBI between the beginning and end of a 120-minute spontaneous breathing trial (SBT) could be a better predictor of extubation outcome than a single RSBI measured at the end of SBT in mechanically ventilated patients. Methodology. In this prospective observational study, we enrolled 193 patients who met the inclusion criteria, of whom 33 patients were unable to tolerate a 120-minute SBT and were excluded from the study. The study population consisted of 160 patients, categorized into three subgroups: patients with normal lung (no reported history of respiratory diseases), patients with airway disease, and patients with parenchymal disease who completed 120 minutes of SBT on low levels of pressure support ventilation. RSBI was obtained from the ventilator display at the 5th and the 120th minutes of SBT. The rate of change of RSBI (RSBI 5-120) was calculated as (RSBI 2-RSBI 1)/RSBI 1 × 100. Receiver-operating characteristic (ROC) curves were plotted for RSBI 5-120 and RSBI 120 in all patients and among the three subgroups (normal group, airway group, and parenchymal group) to compare the superiority of their best thresholds in predicting extubation failure. Results The RSBI 5-120 threshold for extubation failure in the entire patient group was 23% with an overall accuracy of 88% (AUC = 0.933, sensitivity = 91%, and specificity = 86%) and the threshold of RSBI 120 for extubation failure in the entire patient group was 70 breaths/min/L with an overall accuracy of 82% (AUC = 0.899, sensitivity = 85%, and specificity = 81%). In patients in the normal lung group, the threshold of RSBI 5-120 was 22%, with an overall accuracy of 89% (AUC = 0.892, sensitivity = 87.5%, and specificity = 90%), and the RSBI 120 threshold was 70 breaths/min/L, with an overall accuracy of 89% (AUC = 0.956, sensitivity = 88%, and specificity = 90%). The RSBI 5-120 threshold in patients with airway disease was 25% with an accuracy of 86% (AUC = 0.892, sensitivity = 85%, and specificity = 86%) and the threshold of RSBI 120 was 73 breaths/min/L with an accuracy of 83% (AUC = 0.874, sensitivity = 85%, and specificity = 82%). In patients in the parenchymal disease group, the threshold of RSBI 5-120 was 24%, with an accuracy of 90% (AUC = 0.966, sensitivity = 92%, and specificity = 89%) and RSBI 120 threshold was 71 breaths/min/L, which was 88% accurate (AUC = 0.893, sensitivity = 85%, and specificity = 89%). Conclusion The rate of change of RSBI between the 5th and 120th minutes was moderately more accurate than the single value of RSBI measured at the 120th minute in predicting extubation outcome.
Collapse
Affiliation(s)
- Manjush Karthika
- Faculty of Medical and Health Sciences, Liwa College, Abu Dhabi, UAE
- Faculty of Medical and Health Sciences, Symbiosis Centre for Research and Innovation, Symbiosis International University, Pune, India
| | - Farhan A. Al Enezi
- Intensive Care Department, King Abdulaziz Medical City, King Saud Bin Abdulaziz University of Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Lalitha V. Pillai
- Faculty of Medical and Health Sciences, Symbiosis Centre for Research and Innovation, Symbiosis International University, Pune, India
- Department of Critical Care Medicine, Aundh Institute of Medical Sciences, Pune, India
| | - Yaseen M. Arabi
- Intensive Care Department, King Abdulaziz Medical City, King Saud Bin Abdulaziz University of Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| |
Collapse
|
30
|
Grissom CK, Holubkov R, Carpenter L, Hanna B, Jacobs JR, Jones C, Knighton AJ, Leither L, Lisonbee D, Peltan ID, Winberg C, Wolfe D, Srivastava R. Implementation of coordinated spontaneous awakening and breathing trials using telehealth-enabled, real-time audit and feedback for clinician adherence (TEACH): a type II hybrid effectiveness-implementation cluster-randomized trial. Implement Sci 2023; 18:45. [PMID: 37735443 PMCID: PMC10515061 DOI: 10.1186/s13012-023-01303-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/09/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Intensive care unit (ICU) patients on mechanical ventilation often require sedation and analgesia to improve comfort and decrease pain. Prolonged sedation and analgesia, however, may increase time on mechanical ventilation, risk for ventilator associated pneumonia, and delirium. Coordinated interruptions in sedation [spontaneous awakening trials (SATs)] and spontaneous breathing trials (SBTs) increase ventilator-free days and improve mortality. Coordination of SATs and SBTs is difficult with substantial implementation barriers due to difficult-to-execute sequencing between nurses and respiratory therapists. Telehealth-enabled remote care has the potential to overcome these barriers and improve coordinated SAT and SBT adherence by enabling proactive high-risk patient monitoring, surveillance, and real-time assistance to frontline ICU teams. METHODS The telehealth-enabled, real-time audit and feedback for clinician adherence (TEACH) study will determine whether adding a telehealth augmented real-time audit and feedback to a usual supervisor-led audit and feedback intervention will yield higher coordinated SAT and SBT adherence and more ventilator-free days in mechanically ventilated patients than a usual supervisor-led audit and feedback intervention alone in a type II hybrid effectiveness-implementation cluster-randomized clinical trial in 12 Intermountain Health hospitals with 15 ICUs. In the active comparator control group (six hospitals), the only intervention is the usual supervisor-led audit and feedback implementation. The telehealth-enabled support (TEACH) intervention in six hospitals adds real-time identification of patients eligible for a coordinated SAT and SBT and consultative input from telehealth respiratory therapists, nurses, and physicians to the bedside clinicians to promote adherence including real-time assistance with execution. All intubated and mechanically ventilated patients ≥ 16 years of age are eligible for enrollment except for patients who die on the day of intubation or have preexisting brain death. Based on preliminary power analyses, we plan a 36-month intervention period that includes a 90-day run-in period. Estimated enrollment in the final analysis is up to 9900 mechanically ventilated patients over 33 months. DISCUSSION The TEACH study will enhance implementation science by providing insight into how a telehealth intervention augmenting a usual audit and feedback implementation may improve adherence to coordinated SAT and SBT and increase ventilator-free days. TRIAL REGISTRATION Clinicaltrials.gov, NCT05141396 , registered 12/02/2021.
Collapse
Affiliation(s)
- Colin K Grissom
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, 84107, USA.
- Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, UT, USA.
- Critical Care Operations, Intermountain Health, Canyons Region, Murray, UT, USA.
| | - Richard Holubkov
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Lori Carpenter
- Respiratory Care, Intermountain Health, Canyons Region, Salt Lake City, UT, USA
| | - Bridgett Hanna
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT, USA
| | - Jason R Jacobs
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, 84107, USA
| | - Christopher Jones
- Critical Care Operations, Intermountain Health, Canyons Region, Murray, UT, USA
| | - Andrew J Knighton
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT, USA
| | - Lindsay Leither
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, 84107, USA
| | - Dee Lisonbee
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT, USA
| | - Ithan D Peltan
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, 84107, USA
- Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Carrie Winberg
- Respiratory Care, Intermountain Health, Canyons Region, Salt Lake City, UT, USA
| | - Doug Wolfe
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT, USA
| | - Rajendu Srivastava
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT, USA
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, UT, USA
| |
Collapse
|
31
|
Imaizumi M, Suyama K, Goto A, Hosoya M, Murono S. Flowchart for selecting an appropriate surgical airway in neurologically impaired pediatric intubated patients: a case series. Braz J Otorhinolaryngol 2023; 89:101290. [PMID: 37467656 PMCID: PMC10372357 DOI: 10.1016/j.bjorl.2023.101290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 06/29/2023] [Indexed: 07/21/2023] Open
Abstract
OBJECTIVE Medical advances have resulted in increased survival rates of neurologically impaired children who may require mechanical ventilation and subsequent tracheostomy as a surgical airway. However, at present, there is no definite consensus regarding the timing and methods for placement of a surgical airway in a neurologically impaired intubated child who needs to be cared for over a long-term period. We therefore created a flowchart for the selection of a surgical airway for Neurologically Impaired Pediatric Patients (NIPPs). METHODS The flowchart includes information on the patients' backgrounds, such as intubation period, prognosis related to reversibility, and history of aspiration pneumonia. To evaluate the importance of the flowchart, first we conducted a survey of pediatricians regarding selection of a surgical airway, and we also evaluated the appropriateness of the flowchart among pediatricians and caregivers through questionnaire surveys which include satisfaction with the decision-making process, and postoperative course after discharge. RESULTS A total of 21 NIPPs with intubation underwent surgery and a total of 24 participants (14 pediatricians and 10 caregivers) completed the survey. The answers regarding the importance of the flowchart showed that eleven pediatricians had experience selecting of surgical airways, nine of whom had had experiences in which they had to make a difficult decision. The answers regarding the appropriateness of the flowchart revealed that all pediatricians and caregivers were satisfied with the decision-making process and postoperative course after discharge using the flowchart. CONCLUSIONS The present study demonstrated the effectiveness of our flowchart for selecting an appropriate surgical airway in NIPP. By referring to our flowchart, pediatricians and caregivers are likely to be able to select an appropriate surgical airway, leading to increased satisfaction with the decision-making process and postoperative course. LEVEL OF EVIDENCE: 4
Collapse
Affiliation(s)
- Mitsuyoshi Imaizumi
- Fukushima Medical University, School of Medicine, Department of Otolaryngology, Fukushima, Japan.
| | - Kazuhide Suyama
- Fukushima Medical University, School of Medicine, Department of Pediatrics, Fukushima, Japan
| | - Aya Goto
- Fukushima Medical University, Health Information and Epidemiology Center for Integrated Science and Humanities, Fukushima, Japan
| | - Mitsuaki Hosoya
- Fukushima Medical University, School of Medicine, Department of Pediatrics, Fukushima, Japan
| | - Shigeyuki Murono
- Fukushima Medical University, School of Medicine, Department of Otolaryngology, Fukushima, Japan
| |
Collapse
|
32
|
Ferrera MC, Hayes MM. How I Teach: Liberation from Mechanical Ventilation. ATS Sch 2023; 4:372-384. [PMID: 37795117 PMCID: PMC10547038 DOI: 10.34197/ats-scholar.2023-0037ht] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023] Open
Abstract
Liberation from mechanical ventilation is one of the most important decisions in the intensive care unit (ICU), as extubation failure is associated with worse outcomes. Determining readiness to extubate can be challenging in complex patients and lead to provider stress. Here, we provide our approach to teaching liberation from mechanical ventilation for learners in the ICU. We use a case-based didactic session that purposefully introduces ambiguous cases without a clear answer, utilizing aspects of both cognitive load theory and adult learning theories.
Collapse
Affiliation(s)
- Michael C Ferrera
- Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Margaret M Hayes
- Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
33
|
Bahk J, Dolan B, Sharma V, Sehmbhi M, Fung JY, Lee YI. Characteristics and Outcomes of Tracheostomized Patients With and Without COVID-19. Crit Care Explor 2023; 5:e0950. [PMID: 37546230 PMCID: PMC10403025 DOI: 10.1097/cce.0000000000000950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Abstract
Outcomes of tracheostomized patients with COVID-19 are seldomly investigated with conflicting evidence from the existing literature. OBJECTIVES To create a study evaluating the impact of COVID-19 on tracheostomized patients by comparing clinical outcomes and weaning parameters in COVID-19 positive and negative cohorts. DESIGN SETTING AND PARTICIPANTS A retrospective observational cohort study of 604 tracheostomized patients hospitalized in 16 ICUs in New York City between March 9, 2020, and September 8, 2021. MAIN OUTCOMES AND MEASURES Patients were stratified into two cohorts: 398 COVID-19 negative (COVID-ve) and 206 COVID-19 positive (COVID+ve) patients. Clinical characteristics, outcomes, and weaning parameters (first pressure support [PS], tracheostomy collar [TC], speech valve placement, and decannulation) were analyzed. RESULTS COVID+ve had fewer comorbidities including coronary artery disease, congestive heart failure, malignancy, chronic kidney disease, liver disease, and HIV (p < 0.05). Higher Fio2 (53% vs 44%), positive end-expiratory pressure (PEEP) (7.15 vs 5.69), Pco2 (45.8 vs 38.2), and lower pH (7.41 vs 7.43) were observed at the time of tracheostomy in COVID+ve (p < 0.005). There was no statistical difference in post-tracheostomy complication rates. Longer time from intubation to tracheostomy (15.90 vs 13.60 d; p = 0.002), tracheostomy to first PS (2.87 vs 1.80 d; p = 0.005), and TC placement (11.07 vs 4.46 d; p < 0.001) were seen in COVID+ve. However, similar time to speech valve placement, decannulation, and significantly lower 1-year mortality (23.3% vs 36.7%; p = 0.001) with higher number of discharges to long-term acute care hospital (LTACH) (23.8% vs 13.6%; p = 0.015) were seen in COVID+ve. CONCLUSIONS AND RELEVANCE Patients with COVID-19 required higher Fio2 and PEEP ventilatory support at the time of tracheostomy, with no observed change in complication rates. Despite longer initial weaning period with PS or TC, similar time to speech valve placement or decannulation with significantly lower mortality and higher LTACH discharges suggest favorable outcome in COVID-19 positive patients. Higher ventilatory support requirements and prolonged weaning should not be a deterrent to pursuing a tracheostomy.
Collapse
Affiliation(s)
- Jeeyune Bahk
- Department of Medicine, Mount Sinai Morningside and Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Bridget Dolan
- Department of Medicine, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Venus Sharma
- Department of Medicine, Mount Sinai Morningside and Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Mantej Sehmbhi
- Department of Medicine, Mount Sinai Morningside and Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jennifer Y Fung
- Division of Pulmonary and Critical Care, Department of Medicine, Mount Sinai Morningside, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Young Im Lee
- Division of Pulmonary and Critical Care, Department of Medicine, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, NY
| |
Collapse
|
34
|
Barbas CSV, Taniguchi C, de Oliveira EP. Predictors of Noninvasive Ventilation Failure in the Postextubation Period: What Else? Crit Care Med 2023; 51:970-972. [PMID: 37318292 DOI: 10.1097/ccm.0000000000005897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Carmen Silvia Valente Barbas
- Respiratory ICU, Pulmonary Division, INCOR, HC-FMUSP, University of São Paulo Medical School, Sao Paulo, Brazil
- Adult-ICU Albert Einstein Hospital, São Paulo, Brazil
| | | | | |
Collapse
|
35
|
Rajbanshi LK, Bajracharya A, Devkota D. Prediction of Successful Spontaneous Breathing Trial and Extubation of Trachea by Lung Ultrasound in Mechanically Ventilated Patients in Intensive Care Unit. Indian J Crit Care Med 2023; 27:482-487. [PMID: 37502293 PMCID: PMC10369321 DOI: 10.5005/jp-journals-10071-24487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 06/14/2023] [Indexed: 07/29/2023] Open
Abstract
Introduction Spontaneous breathing trial (SBT) is always successful in mechanically ventilated patients. This study was conducted to assess the prediction of successful SBT and extubation of trachea by bedside lung ultrasound in mechanically ventilated patients. Methodology This was a prospective observational study for 1 year conducted at a tertiary teaching hospital ICU on 102 patients with age more than 18 years and who were mechanically ventilated for more than 24 hours. Bedside lung ultrasound was used to assess the lung ultrasound score (LUS) and lung profiles in patients who clinically met the criteria for SBT. The LUS at the beginning of SBT and 30 minutes after SBT were used to predict the successful SBT and tracheal extubation. Result Spontaneous breathing trial and tracheal extubation were successful in 73 (71.6%) and 57 (55.8%) of the patients. The AUC for lung ultrasound in predicting successful SBT at the beginning and 30 minutes of SBT were 0.781 (CI 95% 0.674-0.888, p < 0.001) and 0.841 (CI 95% 0.742-0.941, p < 0.001) with a cut-off value of 17.5 and 19.5, respectively. Similarly, AUC for LUS in relation to tracheal extubation was 0.786 (CI 95% 0.694-0.879, p < 0.001) and 0.841(CI 95% 0.756-0.925, p < 0.001) at 0 and 30 minutes. About 57.5% of the patients with A profiles tolerated successful SBT while 48.3% of the patients having C profile had failed SBT (p < 0.001). COPD, lung ultrasound, higher SOFA score, and longer duration of mechanical ventilation had a statistically significant negative correlation with successful SBT. Conclusion Lower LUS and A profiles lung ultrasound are associated with more successful weaning and tracheal extubation in mechanically ventilated patients. How to cite this article Rajbanshi LK, Bajracharya A, Devkota D. Prediction of Successful Spontaneous Breathing Trial and Extubation of Trachea by Lung Ultrasound in Mechanically Ventilated Patients in Intensive Care Unit. Indian J Crit Care Med 2023;27(7):482-487.
Collapse
Affiliation(s)
- Lalit Kumar Rajbanshi
- Department of Anesthesiology and Critical Care, Birat Medical College and Teaching Hospital, Biratnagar, Koshi, Nepal
| | - Akriti Bajracharya
- Department of Anesthesiology and Critical Care, Birat Medical College and Teaching Hospital, Biratnagar, Koshi, Nepal
| | - Dikshya Devkota
- Department of Anesthesiology and Critical Care, Birat Medical College and Teaching Hospital, Biratnagar, Koshi, Nepal
| |
Collapse
|
36
|
Abplanalp LA, Ionescu F, Calvo-Ayala E, Yu L, Nair GB. Static Respiratory System Compliance as a Predictor of Extubation Failure in Patients with Acute Respiratory Failure. Lung 2023:10.1007/s00408-023-00625-7. [PMID: 37300706 DOI: 10.1007/s00408-023-00625-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 05/25/2023] [Indexed: 06/12/2023]
Abstract
PURPOSE Ventilator weaning protocols rely in part on objective indices to best predict extubation failure in the critically ill. We investigated static respiratory system compliance (RC) as a predictor of extubation failure, in comparison to extubation readiness using rapid shallow breathing index (RSBI). MATERIAL AND METHODS This was a cross-sectional, multi-institutional study of mechanically ventilated patients admitted between 12/01/2017 and 12/01/2019. All patients older than 18 years with a documented spontaneous breathing trial and extubation trial were included. RC and RSBI were calculated prior to the extubation trial. The primary outcome was extubation failure-defined as need for reintubation within 72 h from time of extubation. RESULTS Of the 2263 patients, 55.8% were males with a mean age of 68 years. The population consisted mostly of Caucasians (73%) and African Americans (20.4%). 274 (12.1%) patients required reintubation within 72 h. On multivariate logistic regression after adjusting for age, sex, body mass index (BMI), admission Sequential Organ Failure Assessment (SOFA) score, number of ventilator days, and the P/F ratio on the day of extubation, RC remained the strongest predictor for extubation failure at 24 h (aOR 1.45; 95% CI 1.00-2.10) and 72 h (aOR 1.58; 95% CI 1.15-2.17). There was no significant association between RSBI and extubation failure at 24 (aOR 1.00; 95% CI 0.99-1.01) or at 72 h (aOR 1.00; 95% CI 0.99-1.01). CONCLUSION RC measured on the day of extubation is a promising physiological discriminant to potentially risk stratify patients with acute respiratory failure for extubation readiness. We recommend further validation studies in prospective cohorts.
Collapse
Affiliation(s)
- Lauren A Abplanalp
- Division of Pulmonary and Critical Care, Beaumont Health, Royal Oak, MI, USA
- OUWB School of Medicine, Rochester, MI, USA
| | - Filip Ionescu
- OUWB School of Medicine, Rochester, MI, USA
- Moffitt Cancer Center, University of South Florida Morsani Medical School, Tampa, FL, USA
| | - Enrique Calvo-Ayala
- Division of Pulmonary and Critical Care, Beaumont Health, Royal Oak, MI, USA
- OUWB School of Medicine, Rochester, MI, USA
| | - Limin Yu
- Department of Pathology, Beaumont Health, Royal Oak, MI, USA
| | - Girish B Nair
- Division of Pulmonary and Critical Care, Beaumont Health, Royal Oak, MI, USA.
- OUWB School of Medicine, Rochester, MI, USA.
| |
Collapse
|
37
|
Ghamari AA, Amini K, Daei Sorkhabi A, Sarkesh A, Saghaleini SH, Asghari R, Rezayi M, Mahmoodpoor A. Diagnostic value of an increase in central venous pressure during SBT for prediction of weaning failure in mechanically ventilated patients: A cross-sectional study. Health Sci Rep 2023; 6:e1204. [PMID: 37064307 PMCID: PMC10102306 DOI: 10.1002/hsr2.1204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 03/12/2023] [Accepted: 03/24/2023] [Indexed: 04/18/2023] Open
Abstract
Background Timely and successful extubation is an essential step forward in clinical practice to minimize complications of mechanical ventilation and unsuccessful weaning processes. Thus, research into predictive factors of weaning outcome to optimize spontaneous breathing trial (SBT) precision before extubation is critical in intensive care practices. In this study, we aimed to investigate the predictive factors of the weaning outcome before and during SBT in mechanically ventilated patients. Methods In this cross-sectional study, 159 mechanically ventilated patients who were eligible for SBT were enrolled. Of these patients, 140 had successful extubation, whereas the remainder failed. Each patient's PaCO2 and PaO2 levels, respiratory rate (RR), SpO2, mean arterial pressure (MAP), heart rate (HR), and central venous pressure (CVP) values at the start of SBT, 3 min later, and at the end of SBT were measured. These values, along with the patients' clinical characteristics, were then investigated to determine if there was any correlation between these variables and the weaning outcome. Results Our analysis revealed that increase in CVP, independent of hemoglobin (Hb) concentration, PaO2, SpO2, duration of mechanical ventilation (MV), length of intensive care unit (ICU) stay, and SBT process, as well as underlying disease, was positively correlated with extubation/weaning failure. While age, gender, vital signs (MAP, RR, and HR), sequential organ failure assessment (SOFA), and acute physiology and chronic health evaluation (APACHE) scores had no significant correlation with patients' extubation outcomes. Conclusion According to our findings, integrating CVP assessment into SBT besides routine indices measurement and monitoring can be considered for the prediction of weaning outcome in critically ill mechanically ventilated patients.
Collapse
Affiliation(s)
- Ali Akbar Ghamari
- Intensive Care Unit, Imam Reza HospitalTabriz University of Medical SciencesTabrizIran
| | - Keivan Amini
- Student Research CommitteeTabriz University of Medical SciencesTabrizIran
| | - Amin Daei Sorkhabi
- Student Research CommitteeTabriz University of Medical SciencesTabrizIran
| | - Aila Sarkesh
- Student Research CommitteeTabriz University of Medical SciencesTabrizIran
| | - Seyed Hadi Saghaleini
- Intensive Care Unit, Imam Reza HospitalTabriz University of Medical SciencesTabrizIran
| | - Roghayeh Asghari
- Intensive Care Unit, Imam Reza HospitalTabriz University of Medical SciencesTabrizIran
| | - Mansour Rezayi
- Intensive Care Unit, Imam Reza HospitalTabriz University of Medical SciencesTabrizIran
| | - Ata Mahmoodpoor
- Intensive Care Unit, Imam Reza HospitalTabriz University of Medical SciencesTabrizIran
| |
Collapse
|
38
|
Kimura R, Barroga E, Hayashi N. Effects of Mechanical Ventilator Weaning Education on ICU Nurses and Patient Outcomes: A Scoping Review. J Contin Educ Nurs 2023; 54:185-192. [PMID: 37001122 DOI: 10.3928/00220124-20230310-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Abstract
BACKGROUND Assessment of mechanical ventilator (MV) weaning is a complex process that requires education for nurses. This scoping review aimed to clarify the effects of MV weaning education on intensive care unit nurses and patient outcomes. METHOD Four databases were searched. The inclusion criteria were studies on MV weaning education for nurses, outcome measures for patients or nurses, and quantitative research. RESULTS In total, 663 studies were identified. The criteria for a full review (n = 15) were educational protocols (n = 13) and the Burns Wean Assessment Program (n = 2). Patient outcomes determined the MV duration. The weaning protocol was convenient for nurses. Nevertheless, their clinical judgment skills must be improved, regardless of the availability of a protocol. Education is crucial for producing positive outcomes. CONCLUSION Education for nurses on MV weaning showed shortened MV duration. No significant effects were found for other outcomes. [J Contin Educ Nurs. 2023;54(4):185-192.].
Collapse
|
39
|
Zheng Y, Luo Z, Cao Z. NT-proBNP change is useful for predicting weaning failure from invasive mechanical ventilation among postsurgical patients: a retrospective, observational cohort study. BMC Anesthesiol 2023; 23:84. [PMID: 36941556 PMCID: PMC10026466 DOI: 10.1186/s12871-023-02039-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 03/10/2023] [Indexed: 03/22/2023] Open
Abstract
BACKGROUND To evaluate the predictive value of N-terminal prohormone B-type natriuretic peptide (NTproBNP) for weaning failure among patients undergoing major surgeries during spontaneous breathing trial (SBT), compared to traditional weaning parameters. METHODS The observational cohort study retrospectively included postsurgical patients who received IMV and underwent a 2 h SBT. According to weaning outcome, NTproBNP level at initiation (NTproBNP1) and at end of 2 h SBT(NTproBNP2), the ΔNTproBNP%, RSBI and MV were compared between weaning failure and weaning success group. Multiple logistical regression and ROC curve were used to evaluate the capability of NTproBNP to predict weaning failure. RESULTS Out of the 323 included postsurgical patients, 45 (13.9%) patients had failed weaning. The ΔNTproBNP% was a better predictor for weaning failure (AUC 0.744;95%CI,0.693-0.791) than NTproBNP1(AUC 0.639; 95%CI,0.580-0.694)), NTproBNP2(AUC 0.742, 95%CI,0.688-0.792) and other traditional weaning index such as RSBI (AUC 0.651; 95%CI, 0.597-0.703) and MV (AUC 0.552; 95%CI,0.496-0.607). The cutoff value of ΔNTproBNP% for predicting weaning failure was 23.3% with the sensitivity75.76% and specificity73.38%. The multiple logistic regression analysis found that ΔNTproBNP%>23.3% was an independent predictor of weaning failure. CONCLUSION ΔNTproBNP% may be a useful marker for predict weaning failure for postsurgical patients, and it's better to be more careful to withdraw from invasive mechanical ventilation for those postsurgical patients with ΔNTproBNP% >23.3%. The corresponding interventions to optimize cardiac function should be actively given to these patients.
Collapse
Affiliation(s)
- Yingying Zheng
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zujin Luo
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zhixin Cao
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.
| |
Collapse
|
40
|
Raj I, Kumar Nagaiah S. Ultrasonography of Diaphragm to Predict Extubation Outcome. Cureus 2023; 15:e36514. [PMID: 37090312 PMCID: PMC10120388 DOI: 10.7759/cureus.36514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2023] [Indexed: 04/25/2023] Open
Abstract
Background and objectives An intensivist's decision, when it comes to weaning off a patient from mechanical ventilation and extubation, is based on many criteria. Problems can be associated with both prolonged ventilation and early extubation. Therefore, for optimal functioning of the diaphragm, the primary inspiratory muscle, it is important to resume spontaneous ventilation after extubation irrespective of the cause of respiratory failure. Thus, diaphragmatic parameters can prove useful in predicting the rate of success of extubation. However, till date in our institute, extubation has been done using only the standard parameters; hence, in this study, diaphragmatic parameters obtained by ultrasonography-diaphragmatic thickening fraction (dTF) and diaphragmatic excursion (DE) have been studied to predict extubation outcome. The objectives of this study are to (1) measure the diaphragmatic thickening fraction (dTF) in % and diaphragmatic excursion (DE) in cm before and after the spontaneous breathing trial (SBT) and (2) compare dTF and DE with standard extubation parameters in order to predict extubation outcome. Materials and methods This is a prospective, double-blind, observational study. The number of patients involved was 41. After obtaining ethical committee clearance, informed consent was taken from the patients' attendants. In this study, we divided doctors into the treating team and the research team. The treating team comprised the primary doctors working in the intensive care unit (ICU), and they evaluated the patients' readiness for pressure support ventilation. The research team performed diaphragmatic ultrasonography on those patients who met the inclusion criteria. The treating team was blinded to the dTF and DE results obtained by the research team. Prior to extubation, all the patients had to satisfy the standard extubation criteria followed at R. L. Jalappa Hospital and Research Centre (RLJH), Kolar Results We observed that 68.29 (%) of the patients with normal dTF and DE values and 21.95(%) with slightly lower dTF and DE values were extubated successfully, and 7.31 (%) with normal dTF and DE values were reintubated; 2.43 (%) were extubated onto non-invasive ventilation (NIV). Conclusion From our study, we have concluded that bedside ultrasonography of the diaphragm, that is the measurement of diaphragm for dTF and DE always compliments the standard criteria for extubation and can be used for weaning the patients from mechanical ventilation, as bedside ultrasonography is not only easy and convenient but also a reliable parameter in predicting the outcome of weaning, however, it cannot be used as a sole criteria.
Collapse
Affiliation(s)
- Ishita Raj
- Anaesthesiology, Sri Devaraj Urs Medical College, Kolar, IND
| | | |
Collapse
|
41
|
Slow and Steady: Optimizing Intensive Care Unit Treatment Weans for Children with Chronic Critical Illness. J Pediatr Intensive Care 2023. [DOI: 10.1055/s-0043-1763256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
AbstractPediatric chronic critical illness (PCCI) is characterized by prolonged and recurrent hospitalizations, multiorgan conditions, and use of medical technology. Our prior work explored the mismatch between intensive care unit (ICU) acute care models and the chronic needs of patients with PCCI. The objective of this study was to examine whether the number and frequency of treatment weans in ICU care were associated with clinical setbacks and/or length of stay for patients with PCCI. A retrospective chart review of the electronic medical record for 300 pediatric patients with PCCI was performed at the neonatal intensive care unit, pediatric intensive care unit, and cardiac intensive care unit of two urban children's hospitals. Daily patient care data related to weans and setbacks were collected for each ICU day. Data were analyzed using multilevel mixed multiple logistic regression analysis and a multilevel mixed Poisson regression. The patient-week level adjusted regression analysis revealed a strong correlation between weans and setbacks: three or more weekly weans yielded an odds ratio of 3.35 (95% confidence interval [CI] = 2.06–5.44) of having one or more weekly setback. There was also a correlation between weans and length of stay, three or more weekly weans were associated with an incidence rate ratio of 1.09 (95% CI = 1.06–1.12). Long-stay pediatric ICU patients had more clinical setbacks and longer hospitalizations if they had more than two treatment weans per week. This suggests that patients with PCCI may benefit from a slower pace of care than is traditionally used in the ICU. Future research to explore the causative nature of the correlation is needed to improve the care of such challenging patients.
Collapse
|
42
|
Friedrich S, Teja B, Latronico N, Berger J, Muse S, Waak K, Fassbender P, Azimaraghi O, Eikermann M, Wongtangman K. Subjective Assessment of Motor Function by the Bedside Nurses in Mechanically Ventilated Surgical Intensive Care Unit Patients Predicts Tracheostomy. J Intensive Care Med 2023; 38:151-159. [PMID: 35695208 DOI: 10.1177/08850666221107839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE In many institutions, intensive care unit (ICU) nurses assess their patients' muscle function as part of their routine bedside examination. We tested the research hypothesis that this subjective examination of muscle function prior to extubation predicts tracheostomy requirement. METHODS Adult, mechanically ventilated patients admitted to 7 ICUs at Beth Israel Deaconess Medical Center (BIDMC) between 2008 and 2019 were included in this observational study. Assessment of motor function was performed every four hours by ICU nurses. Multivariable logistic regression analysis controlled for acute disease severity, delirium risk assessment through the confusion assessment method for the ICU (CAM-ICU), and pre-defined predictors of extubation failure was applied to examine the association of motor function and tracheostomy within 30 days after extubation. RESULTS Within 30 days after extubation, 891 of 9609 (9.3%) included patients required a tracheostomy. The inability to spontaneously move and hold extremities against gravity within 24 h prior to extubation was associated with significantly higher odds of 30-day tracheostomy (adjusted OR 1.56, 95% CI 1.27-1.91, p < 0.001, adjusted absolute risk difference (aARD) 2.8% (p < 0.001)). The effect was magnified among patients who were mechanically ventilated for >7 days (aARD 21.8%, 95% CI 12.4-31.2%, p-for-interaction = 0.015). CONCLUSIONS ICU nurses' subjective assessment of motor function is associated with 30-day tracheostomy risk, independent of known risk factors. Muscle function measurements by nursing staff in the ICU should be discussed during interprofessional rounds.
Collapse
Affiliation(s)
- Sabine Friedrich
- Department of Anesthesiology, 2013Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Anesthesia, Critical Care and Pain Medicine, 1859Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.,Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Germany
| | - Bijan Teja
- Department of Anesthesia, Critical Care and Pain Medicine, 1859Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Nicola Latronico
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, University of Brescia, Brescia, Italy
| | - Jay Berger
- Department of Anesthesiology, 2013Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sandra Muse
- Department of Nursing & Patient Care, 1811Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Karen Waak
- Department of Physical Therapy, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Philipp Fassbender
- Department of Anesthesia, Critical Care and Pain Medicine, 1859Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.,Klinik für Anästhesiologie, operative Intensivmedizin, Schmerz- und Palliativmedizin, Marien Hospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Herne, Germany
| | - Omid Azimaraghi
- Department of Anesthesiology, 2013Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Matthias Eikermann
- Department of Anesthesiology, 2013Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA.,Klinik für Anästhesiologie und Intensivmedizin, 39081Universität Duisburg-Essen, Essen, Germany
| | - Karuna Wongtangman
- Department of Anesthesiology, 2013Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, 65106Mahidol University, Bangkok, Thailand
| | | |
Collapse
|
43
|
da Silva RB, Neves VR, Montarroyos UR, Silveira MS, Sobral Filho DC. Heart rate variability as a predictor of mechanical ventilation weaning outcomes. Heart Lung 2023; 59:33-36. [PMID: 36706686 DOI: 10.1016/j.hrtlng.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 01/04/2023] [Accepted: 01/15/2023] [Indexed: 01/27/2023]
Abstract
BACKGROUND Delays in the mechanical ventilation (MV) weaning process increase mortality. The spontaneous breathing test is the gold standard to assess weaning and extubation success, although it has approximately 85% accuracy. Studies have demonstrated a correlation between decreased heart rate variability (HRV) and weaning failure. OBJECTIVES To assess the usefulness of HRV as a predictor of MV weaning outcomes. METHODS Cross-sectional analytical study in adults of both sexes on MV in intensive care unit (ICU) stay. Patients were divided into weaning success and failure groups. Clinical data were collected, and HRV records were obtained with a heart rate monitor. RESULTS The study included 68 individuals - 91.1% in the weaning success group and 8.9% in the failure group. All HRV indices analyzed in both groups were lower than the reference values. No statistical difference was found in the mean RR interval (RRi), the standard deviation of the NN interval (SDNN), and the square root of the mean squared differences of successive NN intervals (RMSSD) between the groups. The weaning failure group had a significant increase in LF (41 vs. 69.4) and LF/HF ratio (0.685 vs. 2.6) and a significant decrease in HF (58.85 vs. 30.2). CONCLUSIONS HRV measure with spectral analysis can be a good predictor of MV weaning failure. Integrating this assessment tool in ICU to predict weaning outcomes could provide more precise prognoses and more adequate assistance quality.
Collapse
Affiliation(s)
- Renata Baltar da Silva
- Postgraduation Program in Health Sciences (PPGCS), University of Pernambuco (UPE), Recife, PE, Brazil; Clinics Hospital of the Federal University of Pernambuco (HC-UFPE) - Brazilian Hospital Services Company (EBSERH), Recife, PE, Brazil; Agamenon Magalhães Hospital (HAM), UPE, Recife, PE, Brazil.
| | - Victor Ribeiro Neves
- Postgraduation Program in Functional Rehabilitation and Performance (PPGRDF), UPE, Petrolina, PE, Brazil.
| | - Ulisses Ramos Montarroyos
- Postgraduation Program in Health Sciences (PPGCS), University of Pernambuco (UPE), Recife, PE, Brazil.
| | - Matheus Sobral Silveira
- Postgraduation Program in Functional Rehabilitation and Performance (PPGRDF), UPE, Petrolina, PE, Brazil.
| | | |
Collapse
|
44
|
Ye X, Waters D, Yu HJ. The effectiveness of pressure support ventilation and T-piece in differing duration among weaning patients: A systematic review and network meta-analysis. Nurs Crit Care 2023; 28:120-132. [PMID: 35647738 DOI: 10.1111/nicc.12781] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 04/22/2022] [Accepted: 05/06/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND A spontaneous breathing trial (SBT) is recommended to help patients to liberate themselves from mechanical ventilation as soon as possible in the ICU. The respiratory workload in SBT, which depends on being with or without respiratory support and a specific time, is more accurate to reflect how much support the weaning patients need compared with only considering SBT technologies. AIM To compare and rank the effectiveness of different respiratory workloads during SBT via differing technologies (Pressure Support Ventilation and T-piece) and differing duration (30 and 120 min) in SBTs. STUDY DESIGN A comprehensive literature search was performed in six English electronic databases to identify eligible randomized controlled trials (RCTs) published before September 2020. The pooled risk ratio (RR) with 95% confidence interval (CI) was calculated by Markov chain Monte Carlo methods. A Bayesian network meta-analysis was conducted using "gemtc" version 0.8.2 of R software. Each intervention's ranking possibilities were calculated using the surface under the cumulative ranking analysis (SUCRA). RESULTS A total of nine RCTs including 3115 participants were eligible for this network meta-analysis involving four different commonly used SBT strategies and four outcomes. The only statistically significant difference was between Pressure Support Ventilation (PSV) 30 min and T-piece 120 min in the outcome of the rate of success in SBTs (RR = 0.91; 95% CI, 0.84-0.98). The cumulative rank probability showed that the rate of success in SBT from best to worst was PSV 30 min, PSV 120 min, T-piece 30 min and T-piece 120 min. PSV 30 min and PSV 120 min are more likely to have a higher rate of extubation (SUCRA values of 82.5% for 30 min PSV, 70.7% for 120 min PSV, 36.4% for T-piece 30 min, 10.4% for T-piece 120). Meanwhile, T-piece 120 min (SUCRA, 62.9%) and PSV 120 min (SUCRA, 60.9%) may result in lower reintubation rates, followed by T-piece 30 min (SUCRA, 41.8%) and PSV 30 min (SUCRA, 34.4%). CONCLUSIONS AND RELEVANCE TO CLINICAL PRACTICE In comprehensive consideration of four outcomes, regarding SBT strategies, 30-min PSV was superior in simple-to-wean patients. Besides, 120-min T-piece and 120-min PSV are more likely to achieve a lower reintubation rate. Thus, the impact of duration is more significant among patients who have a high risk of reintubation. It is still unclear whether the SBTs affect the outcome of mortality; further studies may need to explore the underlying mechanism.
Collapse
Affiliation(s)
- Xiaomei Ye
- Intensive Care Unit, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - David Waters
- School of Nursing and Midwifery, Birmingham City University, Birmingham, UK
| | - Hong-Jing Yu
- Nursing Administration Department, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| |
Collapse
|
45
|
Chuang CY, Hsu HS, Chen GJ, Chuang TY, Tsai MH. Underweight predicts extubation failure after planned extubation in intensive care units. PLoS One 2023; 18:e0284564. [PMID: 37053252 PMCID: PMC10101394 DOI: 10.1371/journal.pone.0284564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 04/04/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Body weight is associated with different physiological changes and the association between weight and mortality in critical care setting had been discussed before. In this study, we investigated the linkage between underweight and post-extubation failure in mechanical ventilated patients in critical setting. METHODS This is a retrospective cohort study including patients who were admitted to medical or surgical intensive care units (ICU) between June 2016 and July 2018 and had received endotracheal intubation for more than 72 hours. Those who passed spontaneous breathing trial and underwent a planned extubation were enrolled. Extubation failure was defined as those who required reintubation within the first 72 hours for any reasons. The probability of extubation failure was calculated. Demographic and clinical characteristics were recorded. Multivariate logistic regression models were then used to determine the potential risk factors associated with extubation failure. RESULTS Overall, 268 patients met the inclusion criteria and were enrolled in our study for analysis. The median age of included patients was 67 years (interquartile range, 55-80 years) with 65.3% being male; 63.1% of the patients were included from medical ICU. The proportion of extubation failure in our cohort was 7.1% (19/268; 95% confidence interval [CI], 4.3-10.9%). Overall, underweight patients had the highest risk of extubation failure (8/50), as compared with normoweight (9/135) and overweight patients (2/83). In the multivariate analysis, being underweight (adjust OR [aOR], 3.80, compared to normoweight; 95% CI, 1.23-11.7) and lower maximal inspiratory airway pressure (aOR per one cmH2O decrease, 1.05; 95% CI 1.00-1.09) remained significantly associated with extubation failure. CONCLUSION In our study, being underweight and lower maximal inspiratory airway pressure was associated with post-extubation respiratory failure after a planned extubation.
Collapse
Affiliation(s)
- Chung-Yeh Chuang
- Institute of Emergency and Critical Care Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Critical Care Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan
| | - Han-Shui Hsu
- Institute of Emergency and Critical Care Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Thoracic Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Guan-Jhou Chen
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
- Infection Control Room, Min-Sheng General Hospital, Taoyuan, Taiwan
| | - Tzu-Yi Chuang
- Department of Chest Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan
| | - Ming-Han Tsai
- Department of Critical Care Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan
| |
Collapse
|
46
|
Shahu A, Banna S, Applefeld W, Rampersad P, Alviar CL, Ali T, Luk A, Fajardo E, van Diepen S, Miller PE. Liberation From Mechanical Ventilation in the Cardiac Intensive Care Unit. JACC. ADVANCES 2023; 2:100173. [PMID: 38939038 PMCID: PMC11198553 DOI: 10.1016/j.jacadv.2022.100173] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 10/18/2022] [Accepted: 11/16/2022] [Indexed: 06/29/2024]
Abstract
The prevalence of respiratory failure is increasing in the contemporary cardiac intensive care unit (CICU) and is associated with a significant increase in morbidity and mortality. For patients that survive their initial respiratory decompensation, liberation from invasive mechanical ventilation (IMV) and the decision to extubate requires careful clinical assessment and planning. Therefore, it is essential for the CICU clinician to know how to assess and manage the various stages of IMV liberation, including ventilator weaning, evaluation of extubation readiness, and provide post-extubation care. In this review, we provide a comprehensive approach to liberation from IMV in the CICU, including cardiopulmonary interactions relative to withdrawal from positive pressure ventilation, evaluation of readiness for and assessment of spontaneous breathing trials, sedation management to optimize extubation, strategies for patients at a high risk for extubation failure, and tracheostomy in the cardiovascular patient.
Collapse
Affiliation(s)
- Andi Shahu
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Soumya Banna
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Willard Applefeld
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Penelope Rampersad
- The Tomsich Family Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Connecticut, USA
| | - Carlos L. Alviar
- The Leon H. Charney Division of Cardiovascular Medicine, New York University Langone Medicine Center, New York, New York, USA
| | - Tariq Ali
- Division of Pulmonary and Critical Care, Mayo, Rochester, Minnesota, USA
| | - Adriana Luk
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Elaine Fajardo
- Division of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sean van Diepen
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - P. Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
47
|
Lee HY, Lee J, Lee SM. Effect of high-flow oxygen versus T-piece ventilation strategies during spontaneous breathing trials on weaning failure among patients receiving mechanical ventilation: a randomized controlled trial. Crit Care 2022; 26:402. [PMID: 36564808 PMCID: PMC9783722 DOI: 10.1186/s13054-022-04281-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND A spontaneous breathing trial (SBT) is used to determine whether patients are ready for extubation, but the best method for choosing the SBT strategy remains controversial. We investigated the effect of high-flow oxygen versus T-piece ventilation strategies during SBT on rates of weaning failure among patients receiving mechanical ventilation. METHODS This randomized clinical trial was conducted from June 2019 through January 2022 among patients receiving mechanical ventilation for ≥ 12 h who fulfilled the weaning readiness criteria at a single-center medical intensive care unit. Patients were randomized to undergo either T-piece SBT or high-flow oxygen SBT. The primary outcome was weaning failure on day 2, and the secondary outcomes were weaning failure on day 7, ICU and hospital length of stay, and ICU and in-hospital morality. RESULTS Of 108 patients (mean age, 67.0 ± 11.1 years; 64.8% men), 54 received T-piece SBT and 54 received high-flow oxygen SBT. Weaning failure on day 2 occurred in 5 patients (9.3%) in the T-piece group and 3 patients (5.6%) in the high-flow group (difference, 3.7% [95% CI, - 6.1-13.6]; p = 0.713). Weaning failure on day 7 occurred in 13 patients (24.1%) in the T-piece group and 7 patients (13.0%) in the high-flow group (difference, 11.1% [95% CI, - 3.4-25.6]; p = 0.215). A post hoc subgroup analysis showed that high-flow oxygen SBT was significantly associated with a lower rate of weaning failure on day 7 (OR, 0.17 [95% CI, 0.04-0.78]) among those patients intubated because of respiratory failure (p for interaction = 0.020). The ICU and hospital length of stay and mortality rates did not differ significantly between the two groups. During the study, no serious adverse events were recorded. CONCLUSIONS Among patients receiving mechanical ventilation, high-flow oxygen SBT did not significantly reduce the risk of weaning failure compared with T-piece SBT. However, the study may have been underpowered to detect a clinically important treatment effect for the comparison of high-flow oxygen SBT versus T-piece SBT, and a higher percentage of patients with simple weaning and a lower weaning failure rate than expected should be considered when interpreting the findings. Clinical trial registration This trial was registered with ClinicalTrials.gov (number NCT03929328) on April 26, 2019.
Collapse
Affiliation(s)
- Hong Yeul Lee
- grid.412484.f0000 0001 0302 820XDepartment of Critical Care Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jinwoo Lee
- grid.412484.f0000 0001 0302 820XDivision of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080 Republic of Korea
| | - Sang-Min Lee
- grid.412484.f0000 0001 0302 820XDepartment of Critical Care Medicine, Seoul National University Hospital, Seoul, Republic of Korea ,grid.412484.f0000 0001 0302 820XDivision of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080 Republic of Korea
| |
Collapse
|
48
|
Arora H, Encarnacion JA, Li Q, Liu Y, Kumar PA, Smeltz AM. Hypothermia and Prolonged Time From Procedure End to Extubation After Endovascular Thoracic Aortic Surgery. J Cardiothorac Vasc Anesth 2022; 36:4320-4326. [PMID: 36216686 DOI: 10.1053/j.jvca.2022.09.077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/23/2022] [Accepted: 09/06/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Perioperative hypothermia (core temperature <36°C) occurs in 50%-to-80% of patients recovering from thoracic aortic surgery, though its effects have not been described fully in this context. The authors, therefore, sought to characterize the incidence of perioperative hypothermia and its association with time from procedure end to extubation in endovascular aortic surgical patients. DESIGN A retrospective cohort study. SETTING At a single academic tertiary center. PARTICIPANTS Patients recovering from thoracic aortic surgery with lumbar drains. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS A total of 196 patients were included in this study, 55 of whom were hypothermic with temperatures <35.0°C at the end of surgery. Though the unadjusted time to extubation was not statistically different in the hypothermic group (median 8 minutes, IQR 5-13.5 minutes) compared to the normothermic group (median 7 minutes, IQR 4-12 minutes; p = 0.062), multivariate predictors of increased time from procedure end to extubation included hypothermia (p = 0.011), age (p = 0.009), diabetes (p = 0.015), history of carotid disease (p = 0.040), and crystalloid volume (p = 0.019). CONCLUSIONS Hypothermia in patients recovering from endovascular aortic surgery was associated with prolonged time from procedure end to extubation. Because of the retrospective observational nature of the authors' analysis, it was not possible to determine the extent to which prolonged mechanical ventilation was influenced by low temperature.
Collapse
Affiliation(s)
- Harendra Arora
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Outcomes Research Consortium, Cleveland, OH
| | - John A Encarnacion
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Quefeng Li
- Department of Biostatistics, Gillings School of Public Health, University of North Carolina, Chapel Hill, NC
| | - Yutong Liu
- Department of Biostatistics, Gillings School of Public Health, University of North Carolina, Chapel Hill, NC
| | - Priya A Kumar
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Outcomes Research Consortium, Cleveland, OH
| | - Alan M Smeltz
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| |
Collapse
|
49
|
Papi D, Montigiani G, Bucciardini L. How the work of respiratory physiotherapists changes the tracheostomy management and decannulation in a NICU department: an Italian experience. Monaldi Arch Chest Dis 2022; 93. [PMID: 36426898 DOI: 10.4081/monaldi.2022.2451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 10/06/2022] [Indexed: 11/25/2022] Open
Abstract
Tracheotomy is a clinical procedure that is often necessary though not without complications, hence the need for appropriate and timely decannulation. The inclusion of trained respiratory physiotherapists (RPT) in the staff and the use of shared protocols could help the team to manage the patient with tracheotomy cannula. The objective of this study was to describe the difference in the rate of decannulation and clinical outcomes of tracheostomized patients admitted to a NeuroIntensive Care Unit (NICU) team after the inclusion of a group of physiotherapists specialized in respiratory physiotherapy and a new phoniatric protocol. It is a 6-year retrospective study, in which two periods of 3 years each were compared: in the first period (P1: September 2013-August 2016) physiotherapists were called to treat NICU patients on a consultative basis (2 hours/day for 5 days a week); in the second period (P2: September 2016-August 2019) two full-time respiratory physiotherapists were present on the ward (7 hours/day, 6/7 days/week). In P2 period, a decannulation protocol was used. Patients who had undergone a tracheotomy procedure and who were alive at the time of discharge were retrospectively evaluated. We described the number of decannulations, the length of stay in NICU and decannulation time; the diagnosis of decannulated patients and the number of deaths. 928 total patients were analysed: 468 in P1, 460 in P2. Total length of stay or number of deaths did not change significantly between the two periods, while the number of decannulated patients before the discharge was higher in P2 143 (64%), compared with P1 79 (36%) p<0.001. More patients with neurological pathologies involving possible swallowing disorders, such as cerebral haemorrhage, head trauma and stroke, have been successfully decannulated in P2 than in P1 (120 patients in P2 vs 54 in P1). A multidisciplinary approach, including respiratory physiotherapist, dedicated to tracheostomy management, decannulation and early mobilization in NICU is safe, feasible and seems to improve the number of severe patients decannulated, even if no change was observed in NICU length of stay or deaths. Further studies must confirm our results in other ICU settings.
Collapse
Affiliation(s)
- Davide Papi
- NeuroIntensive Care Unit, Careggi University Hospital, Florence.
| | | | - Luca Bucciardini
- NeuroIntensive Care Unit, Careggi University Hospital, Florence.
| |
Collapse
|
50
|
Kifle N, Zewdu D, Abebe B, Tantu T, Wondwosen M, Hailu Y, Bekele G, Woldetensay M. Incidence of extubation failure and its predictors among adult patients in intensive care unit of low-resource setting: A prospective observational study. PLoS One 2022; 17:e0277915. [PMID: 36395287 PMCID: PMC9671430 DOI: 10.1371/journal.pone.0277915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 11/05/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Previous studies have found an association between various predictors and extubation failure (EF) in intensive care units (ICUs). However, this problem remains unexplored in low-resource settings, where predicting the extubation outcomes are more challenging. This study investigates the incidence of EF and its predictors among patients who received mechanical ventilation (MV). METHODS This is a prospective observational study of 123 patients' ≥ 18 years of age receiving MV for ≥ 48 hours and tolerated spontaneous breathing trials (SBTs) in the ICU of a low-resource setting. We collected data on the baseline characteristics and clinical profiles before and after SBTs. Patients were categorized into extubation failure (EF) and extubation success (ES) groups. Multivariate logistic regression analyses were performed to identify independent predictors for EF. A p-value < 0.05 is considered statistically significant. RESULTS We included 123 patients, and 42 (34.15%) had developed EF. The identified predictors for EF: Moderate to copious secretions (adjusted odds ratio [AOR]: 3.483 [95% confidence interval [CI] 1.10-11.4]), age > 60 years of age ([AOR]: 4.157 [95% CI 1.38-12.48]), and prolonged duration of MV ≥ 10 days ([AOR]: 4.77 [95% CI 1.55-14.66]). CONCLUSION Moderate to copious secretions, patients > 60 years of age, and prolonged duration of MV ≥ 10 days were the best predictors of EF. Based on our findings, we recommend that the identified predictors could help in the decision-making process of extubation from MV.
Collapse
Affiliation(s)
- Natnael Kifle
- Department of Anesthesiology and Critical Care, Addis Ababa University, Addis Ababa, Ethiopia
| | - Dereje Zewdu
- Department of Anesthesia, College of Medicine and Health Science, Wolkite University, Wolkite, Ethiopia
- * E-mail:
| | - Bisrat Abebe
- Department of Anesthesiology and Critical Care, College of Medicine and Health Science, Wolaita Sodo University, Wolaita Sodo, Ethiopia
| | - Temesgen Tantu
- Department of Obstetrics and Gynecology, College of Medicine and Health Science, Wolkite University, Wolkite, Ethiopia
| | - Mekete Wondwosen
- Department of Surgery, College of Medicine and Health Science, Wolkite University, Wolkite, Ethiopia
| | - Yirgalem Hailu
- Department of Internal Medicine, College of Medicine and Health Science, Wolkite University, Wolkite, Ethiopia
| | - Girma Bekele
- Department of Internal Medicine, College of Medicine and Health Science, Wolkite University, Wolkite, Ethiopia
| | - Meron Woldetensay
- Department of Internal Medicine, College of Medicine and Health Science, Wolkite University, Wolkite, Ethiopia
| |
Collapse
|