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Sottile PD, Smith B, Stroh JN, Albers DJ, Moss M. Flow-Limited and Reverse-Triggered Ventilator Dyssynchrony Are Associated With Increased Tidal and Dynamic Transpulmonary Pressure. Crit Care Med 2024; 52:743-751. [PMID: 38214566 PMCID: PMC11018465 DOI: 10.1097/ccm.0000000000006180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
OBJECTIVES Ventilator dyssynchrony may be associated with increased delivered tidal volumes (V t s) and dynamic transpulmonary pressure (ΔP L,dyn ), surrogate markers of lung stress and strain, despite low V t ventilation. However, it is unknown which types of ventilator dyssynchrony are most likely to increase these metrics or if specific ventilation or sedation strategies can mitigate this potential. DESIGN A prospective cohort analysis to delineate the association between ten types of breaths and delivered V t , ΔP L,dyn , and transpulmonary mechanical energy. SETTING Patients admitted to the medical ICU. PATIENTS Over 580,000 breaths from 35 patients with acute respiratory distress syndrome (ARDS) or ARDS risk factors. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients received continuous esophageal manometry. Ventilator dyssynchrony was identified using a machine learning algorithm. Mixed-effect models predicted V t , ΔP L,dyn , and transpulmonary mechanical energy for each type of ventilator dyssynchrony while controlling for repeated measures. Finally, we described how V t , positive end-expiratory pressure (PEEP), and sedation (Richmond Agitation-Sedation Scale) strategies modify ventilator dyssynchrony's association with these surrogate markers of lung stress and strain. Double-triggered breaths were associated with the most significant increase in V t , ΔP L,dyn , and transpulmonary mechanical energy. However, flow-limited, early reverse-triggered, and early ventilator-terminated breaths were also associated with significant increases in V t , ΔP L,dyn , and energy. The potential of a ventilator dyssynchrony type to increase V t , ΔP L,dyn , or energy clustered similarly. Increasing set V t may be associated with a disproportionate increase in high-volume and high-energy ventilation from double-triggered breaths, but PEEP and sedation do not clinically modify the interaction between ventilator dyssynchrony and surrogate markers of lung stress and strain. CONCLUSIONS Double-triggered, flow-limited, early reverse-triggered, and early ventilator-terminated breaths are associated with increases in V t , ΔP L,dyn , and energy. As flow-limited breaths are more than twice as common as double-triggered breaths, further work is needed to determine the interaction of ventilator dyssynchrony frequency to cause clinically meaningful changes in patient outcomes.
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Affiliation(s)
- Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado | Anschutz Medical Campus, Aurora, CO, 80045
| | - Bradford Smith
- Department of Bioengineering, University of Colorado | Anschutz Medical Campus, Aurora, CO, 80045
- Division of Pediatric Pulmonary and Sleep Medicine, University of Colorado | Anschutz Medical Campus, Aurora, CO, 80045
| | - Jake N Stroh
- Department of Bioengineering, University of Colorado | Anschutz Medical Campus, Aurora, CO, 80045
| | - David J Albers
- Department of Bioengineering, University of Colorado | Anschutz Medical Campus, Aurora, CO, 80045
- Department of Biomedical Informatics, University of Colorado | Anschutz Medical Campus, Aurora, CO, 80045
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado | Anschutz Medical Campus, Aurora, CO, 80045
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Agrawal DK, Smith BJ, Sottile PD, Hripcsak G, Albers DJ. Quantifiable identification of flow-limited ventilator dyssynchrony with the deformed lung ventilator model. Comput Biol Med 2024; 173:108349. [PMID: 38547660 DOI: 10.1016/j.compbiomed.2024.108349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 03/13/2024] [Accepted: 03/17/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Ventilator dyssynchrony (VD) can worsen lung injury and is challenging to detect and quantify due to the complex variability in the dyssynchronous breaths. While machine learning (ML) approaches are useful for automating VD detection from the ventilator waveform data, scalable severity quantification and its association with pathogenesis and ventilator mechanics remain challenging. OBJECTIVE We develop a systematic framework to quantify pathophysiological features observed in ventilator waveform signals such that they can be used to create feature-based severity stratification of VD breaths. METHODS A mathematical model was developed to represent the pressure and volume waveforms of individual breaths in a feature-based parametric form. Model estimates of respiratory effort strength were used to assess the severity of flow-limited (FL)-VD breaths compared to normal breaths. A total of 93,007 breath waveforms from 13 patients were analyzed. RESULTS A novel model-defined continuous severity marker was developed and used to estimate breath phenotypes of FL-VD breaths. The phenotypes had a predictive accuracy of over 97% with respect to the previously developed ML-VD identification algorithm. To understand the incidence of FL-VD breaths and their association with the patient state, these phenotypes were further successfully correlated with ventilator-measured parameters and electronic health records. CONCLUSION This work provides a computational pipeline to identify and quantify the severity of FL-VD breaths and paves the way for a large-scale study of VD causes and effects. This approach has direct application to clinical practice and in meaningful knowledge extraction from the ventilator waveform data.
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Affiliation(s)
- Deepak K Agrawal
- Department of Biosciences and Bioengineering, Indian Institute of Technology Bombay, Mumbai, Maharashtra, 400076, India; Department of Bioengineering, University of Colorado Denver | Anschutz Medical Campus, Aurora, CO, 80045, USA.
| | - Bradford J Smith
- Department of Bioengineering, University of Colorado Denver | Anschutz Medical Campus, Aurora, CO, 80045, USA; Section of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University, New York, NY, 10027, USA
| | - David J Albers
- Department of Bioengineering, University of Colorado Denver | Anschutz Medical Campus, Aurora, CO, 80045, USA; Department of Biomedical Informatics, Columbia University, New York, NY, 10027, USA; Department of Biomedical Informatics, Univerisity of Colorado Anschutz Medical Campus, Aurora, CO 80045.
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Dunbar PJ, Peterson R, McGrath M, Pomponio R, Kiser TH, Ho PM, Vandivier RW, Burnham EL, Moss M, Sottile PD. Analgesia and Sedation Use During Noninvasive Ventilation for Acute Respiratory Failure. Crit Care Med 2024:00003246-990000000-00310. [PMID: 38506571 DOI: 10.1097/ccm.0000000000006253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
OBJECTIVES To describe U.S. practice regarding administration of sedation and analgesia to patients on noninvasive ventilation (NIV) for acute respiratory failure (ARF) and to determine the association of this practice with odds of intubation or death. DESIGN A retrospective multicenter cohort study. SETTING A total of 1017 hospitals contributed data between January 2010 and September 2020 to the Premier Healthcare Database, a nationally representative healthcare database in the United States. PATIENTS Adult (≥ 18 yr) patients admitted to U.S. hospitals requiring NIV for ARF. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified 433,357 patients on NIV of whom (26.7% [95% CI] 26.3%-27.0%) received sedation or analgesia. A total of 50,589 patients (11.7%) received opioids only, 40,646 (9.4%) received benzodiazepines only, 20,146 (4.6%) received opioids and benzodiazepines, 1.573 (0.4%) received dexmedetomidine only, and 2,639 (0.6%) received dexmedetomidine in addition to opioid and/or benzodiazepine. Of 433,357 patients receiving NIV, 50,413 (11.6%; 95% CI, 11.5-11.7%) patients underwent invasive mechanical ventilation on hospital days 2-5 or died on hospital days 2-30. Intubation was used in 32,301 patients (7.4%; 95% CI, 7.3-7.6%). Further, death occurred in 24,140 (5.6%; 95% CI, 5.5-5.7%). In multivariable analysis adjusting for relevant covariates, receipt of any medication studied was associated with increased odds of intubation or death. In inverse probability weighting, receipt of any study medication was also associated with increased odds of intubation or death (average treatment effect odds ratio 1.38; 95% CI, 1.35-1.40). CONCLUSIONS The use of sedation and analgesia during NIV is common. Medication exposure was associated with increased odds of intubation or death. Further investigation is needed to confirm this finding and determine whether any subpopulations are especially harmed by this practice.
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Affiliation(s)
- Peter J Dunbar
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, School of Medicine, Aurora, CO
| | - Ryan Peterson
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO
| | - Max McGrath
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO
| | - Raymond Pomponio
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO
| | - P Michael Ho
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - R William Vandivier
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, School of Medicine, Aurora, CO
| | - Ellen L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, School of Medicine, Aurora, CO
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, School of Medicine, Aurora, CO
| | - Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, School of Medicine, Aurora, CO
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Stroh J, Sottile PD, Wang Y, Smith BJ, Bennett TD, Moss M, Albers DJ. Identifying low-dimensional trajectories of mechanically-ventilated patient systems: Empirical phenotypes of joint patient+care processes to enhance temporal analysis in ARDS research. medRxiv 2023:2023.12.14.23299978. [PMID: 38168309 PMCID: PMC10760265 DOI: 10.1101/2023.12.14.23299978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Mechanically ventilated patients generate waveform data that corresponds to patient interaction with unnatural forcing. This breath information includes both patient and apparatus sources, imbuing data with broad heterogeneity resulting from ventilator settings, patient efforts, patient-ventilator dyssynchronies, injuries, and other clinical therapies. Lung-protective ventilator settings outlined in respiratory care protocols lack personalization, and the connections between clinical outcomes and injuries resulting from mechanical ventilation remain poorly understood. Intra- and inter-patient heterogeneity and the volume of data comprising lung-ventilator system (LVS) observations limit broader and longer-time analysis of such systems. This work presents a computational pipeline for resolving LVS systems by tracking the evolution of data-conditioned model parameters and ventilator information. For individuals, the method presents LVS trajectory in a manageable way through low-dimensional representation of phenotypic breath waveforms. More general phenotypes across patients are also developed by aggregating patient-personalized estimates with additional normalization. The effectiveness of this process is demonstrated through application to multi-day observational series of 35 patients, which reveals the complexity of changes in the LVS over time. Considerable variations in breath behavior independent of the ventilator are revealed, suggesting the need to incorporate care factors such as patient sedation and posture in future analysis. The pipeline also identifies structural similarity in pressure-volume (pV) loop characterizations at the cohort level. The design invites active learning to incorporate clinical practitioner expertise into various methodological stages and algorithm choices.
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Affiliation(s)
| | | | - Yanran Wang
- University of Colorado Denver Anschutz Medical Campus
| | | | | | - Marc Moss
- University of Colorado Anschutz Medical Campus
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Sottile PD, Smith B, Moss M, Albers DJ. The Development, Optimization, and Validation of Four Different Machine Learning Algorithms to Identify Ventilator Dyssynchrony. medRxiv 2023:2023.11.28.23299134. [PMID: 38076801 PMCID: PMC10705638 DOI: 10.1101/2023.11.28.23299134] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
UNLABELLED Invasive mechanical ventilation can worsen lung injury. Ventilator dyssynchrony (VD) may propagate ventilator-induced lung injury (VILI) and is challenging to detect and systematically monitor because each patient takes approximately 25,000 breaths a day yet some types of VD are rare, accounting for less than 1% of all breaths. Therefore, we sought to develop and validate accurate machine learning (ML) algorithms to detect multiple types of VD by leveraging esophageal pressure waveform data to quantify patient effort with airway pressure, flow, and volume data generated during mechanical ventilation, building a computational pipeline to facilitate the study of VD. MATERIALS AND METHODS We collected ventilator waveform and esophageal pressure data from 30 patients admitted to the ICU. Esophageal pressure allows the measurement of transpulmonary pressure and patient effort. Waveform data were cleaned, features considered essential to VD detection were calculated, and a set of 10,000 breaths were manually labeled. Four ML algorithms were trained to classify each type of VD: logistic regression, support vector classification, random forest, and XGBoost. RESULTS We trained ML models to detect different families and seven types of VD with high sensitivity (>90% and >80%, respectively). Three types of VD remained difficult for ML to classify because of their rarity and lack of sample size. XGBoost classified breaths with increased specificity compared to other ML algorithms. DISCUSSION We developed ML models to detect multiple types of VD accurately. The ability to accurately detect multiple VD types addresses one of the significant limitations in understanding the role of VD in affecting patient outcomes. CONCLUSION ML models identify multiple types of VD by utilizing esophageal pressure data and airway pressure, flow, and volume waveforms. The development of such computational pipelines will facilitate the identification of VD in a scalable fashion, allowing for the systematic study of VD and its impact on patient outcomes.
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Bilodeaux J, Farooqi H, Osovskaya M, Sosa A, Wallbank A, Knudsen L, Sottile PD, Albers DJ, Smith BJ. Differential effects of two-hit models of acute and ventilator-induced lung injury on lung structure, function, and inflammation. Front Physiol 2023; 14:1217183. [PMID: 37565138 PMCID: PMC10410077 DOI: 10.3389/fphys.2023.1217183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 07/13/2023] [Indexed: 08/12/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) and acute lung injury have a diverse spectrum of causative factors including sepsis, aspiration of gastric contents, and near drowning. Clinical management of severe lung injury typically includes mechanical ventilation to maintain gas exchange which can lead to ventilator-induced lung injury (VILI). The cause of respiratory failure is acknowledged to affect the degree of lung inflammation, changes in lung structure, and the mechanical function of the injured lung. However, these differential effects of injury and the role of etiology in the structure-function relationship are not fully understood. To address this knowledge gap we caused lung injury with intratracheal hydrochloric acid (HCL) or endotoxin (LPS) 2 days prior to ventilation or with an injurious lavage (LAV) immediately prior to ventilation. These injury groups were then ventilated with high inspiratory pressures and positive end expiratory pressure (PEEP) = 0 cmH2O to cause VILI and model the clinical course of ARDS followed by supportive ventilation. The effects of injury were quantified using invasive lung function measurements recorded during PEEP ladders where the end-expiratory pressure was increased from 0 to 15 cm H2O and decreased back to 0 cmH2O in steps of 3 cmH2O. Design-based stereology was used to quantify the parenchymal structure of lungs air-inflated to 2, 5, and 10 cmH2O. Pro-inflammatory gene expression was measured with real-time quantitative polymerase chain reaction and alveolocapillary leak was estimated by measuring bronchoalveolar lavage protein content. The LAV group had small, stiff lungs that were recruitable at higher pressures, but did not demonstrate substantial inflammation. The LPS group showed septal swelling and high pro-inflammatory gene expression that was exacerbated by VILI. Despite widespread alveolar collapse, elastance in LPS was only modestly elevated above healthy mice (CTL) and there was no evidence of recruitability. The HCL group showed increased elastance and some recruitability, although to a lesser degree than LAV. Pro-inflammatory gene expression was elevated, but less than LPS, and the airspace dimensions were reduced. Taken together, those data highlight how different modes of injury, in combination with a 2nd hit of VILI, yield markedly different effects.
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Affiliation(s)
- Jill Bilodeaux
- Department of Bioengineering, University of Colorado Denver | Anschutz Medical Campus, Aurora, CO, United States
- Department of Microbiology, University of Colorado Denver/Anschutz Medical Campus, Aurora, Germany
| | - Huda Farooqi
- Department of Bioengineering, University of Colorado Denver | Anschutz Medical Campus, Aurora, CO, United States
| | - Maria Osovskaya
- Department of Bioengineering, University of Colorado Denver | Anschutz Medical Campus, Aurora, CO, United States
| | - Alexander Sosa
- Department of Bioengineering, University of Colorado Denver | Anschutz Medical Campus, Aurora, CO, United States
| | - Alison Wallbank
- Department of Bioengineering, University of Colorado Denver | Anschutz Medical Campus, Aurora, CO, United States
| | - Lars Knudsen
- Institute of Functional and Applied Anatomy, Hannover Medical School, Hannover, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Centre for Lung Research (DZL), Hannover, Germany
| | - Peter D. Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - David J. Albers
- Department of Bioengineering, University of Colorado Denver | Anschutz Medical Campus, Aurora, CO, United States
- Section of Informatics and Data Science, Department of Pediatrics, School of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, United States
| | - Bradford J. Smith
- Department of Bioengineering, University of Colorado Denver | Anschutz Medical Campus, Aurora, CO, United States
- Section of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, United States
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Reynolds PM, Afshar M, Wright GC, Ho PM, Kiser TH, Sottile PD, Althoff MD, Moss M, Jolley SE, Vandivier RW, Burnham EL. Association between Substance Misuse and Outcomes in Critically III Patients with Pneumonia. Ann Am Thorac Soc 2023; 20:556-565. [PMID: 37000145 PMCID: PMC10112399 DOI: 10.1513/annalsats.202206-532oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 01/23/2023] [Indexed: 01/24/2023] Open
Abstract
Rationale: In patients with pneumonia requiring intensive care unit (ICU) admission, alcohol misuse is associated with increased mortality, but the relationship between other commonly misused substances and mortality is unknown. Objectives: We sought to establish whether alcohol misuse, cannabis misuse, opioid misuse, stimulant misuse, or misuse of more than one of these substances was associated with differences in mortality among ICU patients with pneumonia. Methods: This was a retrospective cohort study of hospitals participating in the Premier Healthcare Database between 2010 and 2017. Patients were included if they had a primary or secondary diagnosis of pneumonia and received antibiotics or antivirals within 1 day of admission. Substance misuse related to alcohol, cannabis, stimulants, and opioids, or more than one substance, were identified from the International Classification of Diseases (Ninth and Tenth Editions). The associations between substance misuse and in-hospital mortality were the primary outcomes of interest. Secondary outcomes included the measured associations between substance misuse disorders and mechanical ventilation, as well as vasopressor and continuous paralytic administration. Analyses were conducted with multivariable mixed-effects logistic regression modeling adjusting for age, comorbidities, and hospital characteristics. Results: A total of 167,095 ICU patients met inclusion criteria for pneumonia. Misuse of alcohol was present in 5.0%, cannabis misuse in 0.6%, opioid misuse in 1.5%, stimulant misuse in 0.6%, and misuse of more than one substance in 1.2%. No evidence of substance misuse was found in 91.1% of patients. In unadjusted analyses, alcohol misuse was associated with increased in-hospital mortality (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.06-1.19), whereas opioid misuse was associated with decreased in-hospital mortality (OR, 0.46; 95% CI, 0.39-0.53) compared with no substance misuse. These findings persisted in adjusted analyses. Although cannabis, stimulant, and more than one substance misuse (a majority of which were alcohol in combination with another substance) were associated with lower odds for in-hospital mortality in unadjusted analyses, these relationships were not consistently present after adjustment. Conclusions: In this study of ICU patients hospitalized with severe pneumonia, substance misuse subtypes were associated with different effects on mortality. Although administrative data can provide epidemiologic insight regarding substance misuse and pneumonia outcomes, biases inherent to these data should be considered when interpreting results.
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Affiliation(s)
- Paul M. Reynolds
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences
- Colorado Pulmonary Outcomes Research Group
- Department of Pharmacy, Rocky Mountain Regional VA Medical Center, Aurora, Colorado; and
| | - Majid Afshar
- Division of Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Garth C. Wright
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences
| | - P. Michael Ho
- Colorado Pulmonary Outcomes Research Group
- Division of Cardiology, Department of Medicine, and
| | - Tyree H. Kiser
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences
- Colorado Pulmonary Outcomes Research Group
| | - Peter D. Sottile
- Colorado Pulmonary Outcomes Research Group
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Meghan D. Althoff
- Colorado Pulmonary Outcomes Research Group
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Marc Moss
- Colorado Pulmonary Outcomes Research Group
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Sarah E. Jolley
- Colorado Pulmonary Outcomes Research Group
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - R. William Vandivier
- Colorado Pulmonary Outcomes Research Group
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ellen L. Burnham
- Colorado Pulmonary Outcomes Research Group
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Gibbs KW, Ginde AA, Prekker ME, Seitz KP, Stempek SB, Taylor C, Gandotra S, White H, Resnick-Ault D, Khan A, Mohmed A, Brainard JC, Fein DG, Aggarwal NR, Whitson MR, Halliday SJ, Gaillard JP, Blinder V, Driver BE, Palakshappa JA, Lloyd BD, Wozniak JM, Exline MC, Russell DW, Ghamande S, Withers C, Hubel KA, Moskowitz A, Bastman J, Andrea L, Sottile PD, Page DB, Long MT, Goranson JK, Malhotra R, Long BJ, Schauer SG, Connor A, Anderson E, Maestas K, Rhoads JP, Womack K, Imhoff B, Janz DR, Trent SA, Self WH, Rice TW, Semler MW, Casey JD. Protocol and statistical analysis plan for the PREOXI trial of preoxygenation with noninvasive ventilation vs oxygen mask. medRxiv 2023:2023.03.23.23287539. [PMID: 36993496 PMCID: PMC10055579 DOI: 10.1101/2023.03.23.23287539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 04/23/2023]
Abstract
Background Hypoxemia is a common and life-threatening complication during emergency tracheal intubation of critically ill adults. The administration of supplemental oxygen prior to the procedure ("preoxygenation") decreases the risk of hypoxemia during intubation. Research Question Whether preoxygenation with noninvasive ventilation prevents hypoxemia during tracheal intubation of critically ill adults, compared to preoxygenation with oxygen mask, remains uncertain. Study Design and Methods The PRagmatic trial Examining OXygenation prior to Intubation (PREOXI) is a prospective, multicenter, non-blinded randomized comparative effectiveness trial being conducted in 7 emergency departments and 17 intensive care units across the United States. The trial compares preoxygenation with noninvasive ventilation versus oxygen mask among 1300 critically ill adults undergoing emergency tracheal intubation. Eligible patients are randomized in a 1:1 ratio to receive either noninvasive ventilation or an oxygen mask prior to induction. The primary outcome is the incidence of hypoxemia, defined as a peripheral oxygen saturation <85% between induction and 2 minutes after intubation. The secondary outcome is the lowest oxygen saturation between induction and 2 minutes after intubation. Enrollment began on 10 March 2022 and is expected to conclude in 2023. Interpretation The PREOXI trial will provide important data on the effectiveness of noninvasive ventilation and oxygen mask preoxygenation for the prevention of hypoxemia during emergency tracheal intubation. Specifying the protocol and statistical analysis plan prior to the conclusion of enrollment increases the rigor, reproducibility, and interpretability of the trial. Clinical trial registration number NCT05267652.
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Affiliation(s)
- Kevin W. Gibbs
- Section on Pulmonary, Critical Care, Allergy, and immunology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Adit A. Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine Aurora, CO, USA
| | - Matthew E. Prekker
- Division of Pulmonary and Critical Care Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Kevin P. Seitz
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Susan B. Stempek
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Caleb Taylor
- Pulmonary, Critical Care and Sleep Medicine, The Ohio State University, Columbus, OH, USA
| | - Sheetal Gandotra
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine University of Alabama at Birmingham, Birmingham, AL, USA
| | - Heath White
- Department of Medicine, Division of pulmonary & Critical Care Medicine, Baylor Scott & White Medical Center, Temple, TX, USA
| | - Daniel Resnick-Ault
- Department of Emergency Medicine, University of Colorado School of Medicine Aurora, CO, USA
| | - Akram Khan
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Amira Mohmed
- Division of Critical Care Medicine Montefiore Medical Center Bronx, NY, USA
| | - Jason C. Brainard
- Department of Anesthesiology University of Colorado School of Medicine Aurora, CO, USA
| | - Daniel G. Fein
- Division of Pulmonary Medicine Montefiore Medical Center Bronx, NY, USA
| | - Neil R. Aggarwal
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Micah R. Whitson
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Stephen J. Halliday
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wi, USA
| | - John P. Gaillard
- Department of Anesthesiology, Section on Critical Care ,Wake Forest School of Medicine, Winston-Salem, NC, USA
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Veronika Blinder
- Division of Critical Care Medicine Montefiore Medical Center Bronx, NY, USA
| | - Brian E. Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Jessica A. Palakshappa
- Section on Pulmonary, Critical Care, Allergy, and immunology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Bradley D. Lloyd
- Vanderbilt Institute for Clinical and Translational Research, and Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joanne M. Wozniak
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Matthew C. Exline
- Pulmonary, Critical Care and Sleep Medicine, The Ohio State University, Columbus, OH, USA
| | - Derek W. Russell
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine University of Alabama at Birmingham, Birmingham, AL, USA
- Pulmonary Section, Birmingham VA medical Center, Birmingham, AL, USA
| | - Shekhar Ghamande
- Department of Medicine, Division of pulmonary & Critical Care Medicine, Baylor Scott & White Medical Center, Temple, TX, USA
| | - Cori Withers
- Department of Emergency Medicine, University of Colorado School of Medicine Aurora, CO, USA
| | - Kinsley A. Hubel
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Ari Moskowitz
- Division of Critical Care Medicine Montefiore Medical Center Bronx, NY, USA
| | - Jill Bastman
- Department of Emergency Medicine, University of Colorado School of Medicine Aurora, CO, USA
| | - Luke Andrea
- Division of Critical Care Medicine Montefiore Medical Center Bronx, NY, USA
| | - Peter D. Sottile
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - David B. Page
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine University of Alabama at Birmingham, Birmingham, AL, USA
| | - Micah T. Long
- Department of Anesthesiology, University of Wisconsin School of Medicine & Public Health, Madison, WI, USA
| | - Jordan Kugler Goranson
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Rishi Malhotra
- Division of Critical Care Medicine Montefiore Medical Center Bronx, NY, USA
| | - Brit J. Long
- 59 Medical Wing, United States Air Force, Fort Sam Houston, San Antonio, TX, USA
| | - Steven G. Schauer
- United States Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston, San Antoni, TX, USA
| | - Andrew Connor
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Erin Anderson
- Department of Emergency Medicine, University of Colorado School of Medicine Aurora, CO, USA
| | - Kristin Maestas
- Department of Emergency Medicine, University of Colorado School of Medicine Aurora, CO, USA
| | - Jillian P. Rhoads
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kelsey Womack
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brant Imhoff
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David R. Janz
- University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary/Critical Care Medicine and Allergy/Immunology, Louisiana State University School of Medicine, New Orleans, LA, USA
| | - Stacy A. Trent
- Department of Emergency Medicine, University of Colorado School of Medicine Aurora, CO, USA
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, USA
| | - Wesley H. Self
- Vanderbilt Institute for Clinical and Translational Research, and Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W. Rice
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew W. Semler
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan D. Casey
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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9
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Stroh JN, Smith BJ, Sottile PD, Hripcsak G, Albers DJ. Hypothesis-driven modeling of the human lung-ventilator system: A characterization tool for Acute Respiratory Distress Syndrome research. J Biomed Inform 2023; 137:104275. [PMID: 36572279 PMCID: PMC9788853 DOI: 10.1016/j.jbi.2022.104275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 11/21/2022] [Accepted: 12/14/2022] [Indexed: 12/25/2022]
Abstract
Mechanical ventilation is an essential tool in the management of Acute Respiratory Distress Syndrome (ARDS), but it exposes patients to the risk of ventilator-induced lung injury (VILI). The human lung-ventilator system (LVS) involves the interaction of complex anatomy with a mechanical apparatus, which limits the ability of process-based models to provide individualized clinical support. This work proposes a hypothesis-driven strategy for LVS modeling in which robust personalization is achieved using a pre-defined parameter basis in a non-physiological model. Model inversion, here via windowed data assimilation, forges observed waveforms into interpretable parameter values that characterize the data rather than quantifying physiological processes. Accurate, model-based inference on human-ventilator data indicates model flexibility and utility over a variety of breath types, including those from dyssynchronous LVSs. Estimated parameters generate static characterizations of the data that are 50%-70% more accurate than breath-wise single-compartment model estimates. They also retain sufficient information to distinguish between the types of breath they represent. However, the fidelity and interpretability of model characterizations are tied to parameter definitions and model resolution. These additional factors must be considered in conjunction with the objectives of specific applications, such as identifying and tracking the development of human VILI.
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Affiliation(s)
- J N Stroh
- Department of Biomedical Informatics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Bioengineering, University of Colorado, Denver-Anschutz Medical Campus, Aurora, CO, USA.
| | - Bradford J Smith
- Department of Bioengineering, University of Colorado, Denver-Anschutz Medical Campus, Aurora, CO, USA; Section of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University, New York, NY, USA
| | - David J Albers
- Department of Biomedical Informatics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Bioengineering, University of Colorado, Denver-Anschutz Medical Campus, Aurora, CO, USA; Department of Biomedical Informatics, Columbia University, New York, NY, USA; Section of Informatics and Data Science, Department of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
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10
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Zakrajsek JK, Min SJ, Ho PM, Kiser TH, Kannappan A, Sottile PD, Allen RR, Althoff MD, Reynolds PM, Moss M, Burnham EL, Mikkelsen ME, Vandivier RW. Extracorporeal Membrane Oxygenation for Refractory Asthma Exacerbations With Respiratory Failure. Chest 2023; 163:38-51. [PMID: 36191634 PMCID: PMC10354700 DOI: 10.1016/j.chest.2022.09.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Asthma exacerbations with respiratory failure (AERF) are associated with hospital mortality of 7% to 15%. Extracorporeal membrane oxygenation (ECMO) has been used as a salvage therapy for refractory AERF, but controlled studies showing its association with mortality have not been performed. RESEARCH QUESTION Is treatment with ECMO associated with lower mortality in refractory AERF compared with standard care? STUDY DESIGN AND METHODS This is a retrospective, epidemiologic, observational cohort study using a national, administrative data set from 2010 to 2020 that includes 25% of US hospitalizations. People were included if they were admitted to an ECMO-capable hospital with an asthma exacerbation, and were treated with short-acting bronchodilators, systemic corticosteroids, and invasive ventilation. People were excluded for age < 18 years, no ICU stay, nonasthma chronic lung disease, COVID-19, or multiple admissions. The main exposure was ECMO vs No ECMO. The primary outcome was hospital mortality. Key secondary outcomes were ICU length of stay (LOS), hospital LOS, time receiving invasive ventilation, and total hospital costs. RESULTS The study analyzed 13,714 patients with AERF, including 127 with ECMO and 13,587 with No ECMO. ECMO was associated with reduced mortality in the covariate-adjusted (OR, 0.33; 95% CI, 0.17-0.64; P = .001), propensity score-adjusted (OR, 0.36; 95% CI, 0.16-0.81; P = .01), and propensity score-matched models (OR, 0.48; 95% CI, 0.24-0.98; P = .04) vs No ECMO. Sensitivity analyses showed that mortality reduction related to ECMO ranged from OR 0.34 to 0.61. ECMO was also associated with increased hospital costs in all three models (P < .0001 for all) vs No ECMO, but not with decreased ICU LOS, hospital LOS, or time receiving invasive ventilation. INTERPRETATION ECMO was associated with lower mortality and higher hospital costs, suggesting that it may be an important salvage therapy for refractory AERF following confirmatory clinical trials.
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Affiliation(s)
- Jonathan K Zakrajsek
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Sung-Joon Min
- Division of Health Care Policy and Research, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - P Michael Ho
- Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Tyree H Kiser
- Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Arun Kannappan
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | - Meghan D Althoff
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Paul M Reynolds
- Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Ellen L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Mark E Mikkelsen
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - R William Vandivier
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO.
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11
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Sottile PD, Albert RK, Moss M. Prone Positioning for Nonintubated Patients With COVID-19-Potential Dangers of Extrapolation and Intermediate Outcome Variables. JAMA Intern Med 2022; 182:622-623. [PMID: 35435933 DOI: 10.1001/jamainternmed.2022.1086] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora
| | - Richard K Albert
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora
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12
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Agrawal DK, Smith BJ, Sottile PD, Albers DJ. A Damaged-Informed Lung Ventilator Model for Ventilator Waveforms. Front Physiol 2021; 12:724046. [PMID: 34658911 PMCID: PMC8517122 DOI: 10.3389/fphys.2021.724046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 09/01/2021] [Indexed: 12/31/2022] Open
Abstract
Motivated by a desire to understand pulmonary physiology, scientists have developed physiological lung models of varying complexity. However, pathophysiology and interactions between human lungs and ventilators, e.g., ventilator-induced lung injury (VILI), present challenges for modeling efforts. This is because the real-world pressure and volume signals may be too complex for simple models to capture, and while complex models tend not to be estimable with clinical data, limiting clinical utility. To address this gap, in this manuscript we developed a new damaged-informed lung ventilator (DILV) model. This approach relies on mathematizing ventilator pressure and volume waveforms, including lung physiology, mechanical ventilation, and their interaction. The model begins with nominal waveforms and adds limited, clinically relevant, hypothesis-driven features to the waveform corresponding to pulmonary pathophysiology, patient-ventilator interaction, and ventilator settings. The DILV model parameters uniquely and reliably recapitulate these features while having enough flexibility to reproduce commonly observed variability in clinical (human) and laboratory (mouse) waveform data. We evaluate the proof-in-principle capabilities of our modeling approach by estimating 399 breaths collected for differently damaged lungs for tightly controlled measurements in mice and uncontrolled human intensive care unit data in the absence and presence of ventilator dyssynchrony. The cumulative value of mean squares error for the DILV model is, on average, ≈12 times less than the single compartment lung model for all the waveforms considered. Moreover, changes in the estimated parameters correctly correlate with known measures of lung physiology, including lung compliance as a baseline evaluation. Our long-term goal is to use the DILV model for clinical monitoring and research studies by providing high fidelity estimates of lung state and sources of VILI with an end goal of improving management of VILI and acute respiratory distress syndrome.
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Affiliation(s)
- Deepak K. Agrawal
- Department of Bioengineering, University of Colorado Denver|Anschutz Medical Campus, Aurora, CO, United States
- Section of Informatics and Data Science, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Bradford J. Smith
- Department of Bioengineering, University of Colorado Denver|Anschutz Medical Campus, Aurora, CO, United States
- Section of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Peter D. Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - David J. Albers
- Department of Bioengineering, University of Colorado Denver|Anschutz Medical Campus, Aurora, CO, United States
- Section of Informatics and Data Science, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Department of Biomedical Informatics, Columbia University, New York, NY, United States
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13
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Lane T, Sottile PD, Peterson R, Jin Y, Moss M. Significant Variability in Surrogate Informed Consent Rates in ARDS and Prevention and Early Treatment of Acute Lung Injury Network Multicenter Trials. Chest 2021; 161:1306-1309. [PMID: 34543666 PMCID: PMC8552548 DOI: 10.1016/j.chest.2021.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 09/01/2021] [Accepted: 09/06/2021] [Indexed: 11/27/2022] Open
Affiliation(s)
- Trevor Lane
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO.
| | - Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Ryan Peterson
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Ying Jin
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO
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Sottile PD, Albers D, DeWitt PE, Russell S, Stroh JN, Kao DP, Adrian B, Levine ME, Mooney R, Larchick L, Kutner JS, Wynia MK, Glasheen JJ, Bennett TD. Real-Time Electronic Health Record Mortality Prediction During the COVID-19 Pandemic: A Prospective Cohort Study. J Am Med Inform Assoc 2021; 28:2354-2365. [PMID: 33973011 PMCID: PMC8136054 DOI: 10.1093/jamia/ocab100] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/19/2021] [Accepted: 05/06/2021] [Indexed: 11/24/2022] Open
Abstract
Objective To rapidly develop, validate, and implement a novel real-time mortality score for the COVID-19 pandemic that improves upon sequential organ failure assessment (SOFA) for decision support for a Crisis Standards of Care team. Materials and Methods We developed, verified, and deployed a stacked generalization model to predict mortality using data available in the electronic health record (EHR) by combining 5 previously validated scores and additional novel variables reported to be associated with COVID-19-specific mortality. We verified the model with prospectively collected data from 12 hospitals in Colorado between March 2020 and July 2020. We compared the area under the receiver operator curve (AUROC) for the new model to the SOFA score and the Charlson Comorbidity Index. Results The prospective cohort included 27 296 encounters, of which 1358 (5.0%) were positive for SARS-CoV-2, 4494 (16.5%) required intensive care unit care, 1480 (5.4%) required mechanical ventilation, and 717 (2.6%) ended in death. The Charlson Comorbidity Index and SOFA scores predicted mortality with an AUROC of 0.72 and 0.90, respectively. Our novel score predicted mortality with AUROC 0.94. In the subset of patients with COVID-19, the stacked model predicted mortality with AUROC 0.90, whereas SOFA had AUROC of 0.85. Discussion Stacked regression allows a flexible, updatable, live-implementable, ethically defensible predictive analytics tool for decision support that begins with validated models and includes only novel information that improves prediction. Conclusion We developed and validated an accurate in-hospital mortality prediction score in a live EHR for automatic and continuous calculation using a novel model that improved upon SOFA.
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Affiliation(s)
- Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - David Albers
- Section of Informatics and Data Science, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Peter E DeWitt
- Section of Informatics and Data Science, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Seth Russell
- Data Science to Patient Value Initiative, University of Colorado School of Medicine, Aurora, CO, USA
| | - J N Stroh
- Department of Bioengineering, University of Colorado-Denver College of Engineering, Design, and Computing, Denver, CO, USA
| | - David P Kao
- Divisions of Cardiology and Bioinformatics/Personalized Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Bonnie Adrian
- UCHealth Clinical Informatics and University of Colorado College of Nursing, Aurora, CO, USA
| | - Matthew E Levine
- Department of Computational and Mathematical Sciences, California Institute of Technology, Pasadena, CA, USA
| | | | | | - Jean S Kutner
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Chief Medical Officer, University of Colorado Hospital/UCHealth, Aurora, CO, USA
| | - Matthew K Wynia
- Center for Bioethics and Humanities, University of Colorado and Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jeffrey J Glasheen
- Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine and Chief Quality Officer, UCHealth, Aurora, CO, USA
| | - Tellen D Bennett
- Section of Informatics and Data Science, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.,Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
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15
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Sottile PD, Albers D, DeWitt PE, Russell S, Stroh JN, Kao DP, Adrian B, Levine ME, Mooney R, Larchick L, Kutner JS, Wynia MK, Glasheen JJ, Bennett TD. Real-Time Electronic Health Record Mortality Prediction During the COVID-19 Pandemic: A Prospective Cohort Study. medRxiv 2021. [PMID: 33469601 DOI: 10.1101/2021.01.14.21249793] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Background The SARS-CoV-2 virus has infected millions of people, overwhelming critical care resources in some regions. Many plans for rationing critical care resources during crises are based on the Sequential Organ Failure Assessment (SOFA) score. The COVID-19 pandemic created an emergent need to develop and validate a novel electronic health record (EHR)-computable tool to predict mortality. Research Questions To rapidly develop, validate, and implement a novel real-time mortality score for the COVID-19 pandemic that improves upon SOFA. Study Design and Methods We conducted a prospective cohort study of a regional health system with 12 hospitals in Colorado between March 2020 and July 2020. All patients >14 years old hospitalized during the study period without a do not resuscitate order were included. Patients were stratified by the diagnosis of COVID-19. From this cohort, we developed and validated a model using stacked generalization to predict mortality using data widely available in the EHR by combining five previously validated scores and additional novel variables reported to be associated with COVID-19-specific mortality. We compared the area under the receiver operator curve (AUROC) for the new model to the SOFA score and the Charlson Comorbidity Index. Results We prospectively analyzed 27,296 encounters, of which 1,358 (5.0%) were positive for SARS-CoV-2, 4,494 (16.5%) included intensive care unit (ICU)-level care, 1,480 (5.4%) included invasive mechanical ventilation, and 717 (2.6%) ended in death. The Charlson Comorbidity Index and SOFA scores predicted overall mortality with an AUROC of 0.72 and 0.90, respectively. Our novel score predicted overall mortality with AUROC 0.94. In the subset of patients with COVID-19, we predicted mortality with AUROC 0.90, whereas SOFA had AUROC of 0.85. Interpretation We developed and validated an accurate, in-hospital mortality prediction score in a live EHR for automatic and continuous calculation using a novel model, that improved upon SOFA. Take Home Points Study Question: Can we improve upon the SOFA score for real-time mortality prediction during the COVID-19 pandemic by leveraging electronic health record (EHR) data?Results: We rapidly developed and implemented a novel yet SOFA-anchored mortality model across 12 hospitals and conducted a prospective cohort study of 27,296 adult hospitalizations, 1,358 (5.0%) of which were positive for SARS-CoV-2. The Charlson Comorbidity Index and SOFA scores predicted all-cause mortality with AUROCs of 0.72 and 0.90, respectively. Our novel score predicted mortality with AUROC 0.94.Interpretation: A novel EHR-based mortality score can be rapidly implemented to better predict patient outcomes during an evolving pandemic.
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16
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Lin CT, Bookman K, Sieja A, Markley K, Altman RL, Sippel J, Perica K, Reece L, Davis C, Horowitz E, Pisney L, Sottile PD, Kao D, Adrian B, Szkil M, Griffin J, Youngwerth J, Drew B, Pell J. Clinical informatics accelerates health system adaptation to the COVID-19 pandemic: examples from Colorado. J Am Med Inform Assoc 2020; 27:1955-1963. [PMID: 32687152 PMCID: PMC7454679 DOI: 10.1093/jamia/ocaa171] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/07/2020] [Accepted: 07/17/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Large health systems responding to the coronavirus disease 2019 (COVID-19) pandemic face a broad range of challenges; we describe 14 examples of innovative and effective informatics interventions. MATERIALS AND METHODS A team of 30 physician and 17 nurse informaticists with an electronic health record (EHR) and associated informatics tools. RESULTS To meet the demands posed by the influx of patients with COVID-19 into the health system, the team built solutions to accomplish the following goals: 1) train physicians and nurses quickly to manage a potential surge of hospital patients; 2) build and adjust interactive visual pathways to guide decisions; 3) scale up video visits and teach best-practice communication; 4) use tablets and remote monitors to improve in-hospital and posthospital patient connections; 5) allow hundreds of physicians to build rapid consensus; 6) improve the use of advance care planning; 7) keep clinicians aware of patients' changing COVID-19 status; 8) connect nurses and families in new ways; 9) semi-automate Crisis Standards of Care; and 10) predict future hospitalizations. DISCUSSION During the onset of the COVID-19 pandemic, the UCHealth Joint Informatics Group applied a strategy of "practical informatics" to rapidly translate critical leadership decisions into understandable guidance and effective tools for patient care. CONCLUSION Informatics-trained physicians and nurses drew upon their trusted relationships with multiple teams within the organization to create practical solutions for onboarding, clinical decision-making, telehealth, and predictive analytics.
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Affiliation(s)
- Chen-Tan Lin
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kelly Bookman
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Amber Sieja
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | - Richard L Altman
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jeffrey Sippel
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | | | - Christopher Davis
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | - Larissa Pisney
- Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - David Kao
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | | | | | - Jeanie Youngwerth
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | - Jonathan Pell
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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17
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Sottile PD, Albers D, Smith BJ, Moss MM. Ventilator dyssynchrony - Detection, pathophysiology, and clinical relevance: A Narrative review. Ann Thorac Med 2020; 15:190-198. [PMID: 33381233 PMCID: PMC7720746 DOI: 10.4103/atm.atm_63_20] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 07/05/2020] [Indexed: 01/21/2023] Open
Abstract
Mortality associated with the acute respiratory distress syndrome remains unacceptably high due in part to ventilator-induced lung injury (VILI). Ventilator dyssynchrony is defined as the inappropriate timing and delivery of a mechanical breath in response to patient effort and may cause VILI. Such deleterious patient–ventilator interactions have recently been termed patient self-inflicted lung injury. This narrative review outlines the detection and frequency of several different types of ventilator dyssynchrony, delineates the different mechanisms by which ventilator dyssynchrony may propagate VILI, and reviews the potential clinical impact of ventilator dyssynchrony. Until recently, identifying ventilator dyssynchrony required the manual interpretation of ventilator pressure and flow waveforms. However, computerized interpretation of ventilator waive forms can detect ventilator dyssynchrony with an area under the receiver operating curve of >0.80. Using such algorithms, ventilator dyssynchrony occurs in 3%–34% of all breaths, depending on the patient population. Moreover, two types of ventilator dyssynchrony, double-triggered and flow-limited breaths, are associated with the more frequent delivery of large tidal volumes >10 mL/kg when compared with synchronous breaths (54% [95% confidence interval (CI), 47%–61%] and 11% [95% CI, 7%–15%]) compared with 0.9% (95% CI, 0.0%–1.9%), suggesting a role in propagating VILI. Finally, a recent study associated frequent dyssynchrony-defined as >10% of all breaths-with an increase in hospital mortality (67 vs. 23%, P = 0.04). However, the clinical significance of ventilator dyssynchrony remains an area of active investigation and more research is needed to guide optimal ventilator dyssynchrony management.
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Affiliation(s)
- Peter D Sottile
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - David Albers
- Department of Pediatrics, Division of Clinical Informatics, University of Colorado, Aurora, Colorado, USA
| | - Bradford J Smith
- Department of Bioengineering, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Marc M Moss
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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Affiliation(s)
- Matthew K Wynia
- University of Colorado School of Medicine
- University of Colorado Center for Bioethics and Humanities
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Sottile PD, Kiser TH, Burnham EL, Ho PM, Allen RR, Vandivier RW, Moss M. An Observational Study of the Efficacy of Cisatracurium Compared with Vecuronium in Patients with or at Risk for Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2019; 197:897-904. [PMID: 29241014 DOI: 10.1164/rccm.201706-1132oc] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
RATIONALE The neuromuscular blocking agent cisatracurium may improve mortality for patients with moderate-to-severe acute respiratory distress syndrome (ARDS). Other neuromuscular blocking agents, such as vecuronium, are commonly used and have different mechanisms of action, side effects, cost, and availability in the setting of drug shortages. OBJECTIVES To determine whether cisatracurium is associated with improved outcomes when compared with vecuronium in patients at risk for and with ARDS. METHODS Using a nationally representative database, patients who were admitted to the ICU with a diagnosis of ARDS or an ARDS risk factor, received mechanical ventilation, and were treated with a continuous infusion of neuromuscular blocking agent for at least 2 days within 2 days of hospital admission were included. Patients were stratified into two groups: those who received cisatracurium or vecuronium. Propensity matching was used to balance both patient- and hospital-specific factors. Outcomes included hospital mortality, duration of mechanical ventilation, ICU and hospital duration, and discharge location. MEASUREMENTS AND MAIN RESULTS Propensity matching successfully balanced all covariates for 3,802 patients (1,901 per group). There was no significant difference in mortality (odds ratio, 0.932; P = 0.40) or hospital days (-0.66 d; P = 0.411) between groups. However, patients treated with cisatracurium had fewer ventilator days (-1.01 d; P = 0.005) and ICU days (-0.98 d; P = 0.028) but were equally likely to be discharged home (odds ratio, 1.19; P = 0.056). CONCLUSIONS When compared with vecuronium, cisatracurium was not associated with a difference in mortality but was associated with improvements in other clinically important outcomes. These data suggest that cisatracurium may be the preferred neuromuscular blocking agent for patients at risk for and with ARDS.
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Affiliation(s)
- Peter D Sottile
- 1 Division of Pulmonary Sciences and Critical Care Medicine and
| | - Tyree H Kiser
- 2 Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy, Aurora, Colorado; and
| | - Ellen L Burnham
- 1 Division of Pulmonary Sciences and Critical Care Medicine and
| | - P Michael Ho
- 3 Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | | | | | - Marc Moss
- 1 Division of Pulmonary Sciences and Critical Care Medicine and
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Prohaska CC, Sottile PD, Nordon-Craft A, Gallagher MD, Burnham EL, Clark BJ, Ho M, Kiser TH, Vandivier RW, Liu W, Schenkman M, Moss M. Patterns of utilization and effects of hospital-specific factors on physical, occupational, and speech therapy for critically ill patients with acute respiratory failure in the USA: results of a 5-year sample. Crit Care 2019; 23:175. [PMID: 31097017 PMCID: PMC6524324 DOI: 10.1186/s13054-019-2467-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 05/05/2019] [Indexed: 05/30/2023]
Abstract
Background Timely initiation of physical, occupational, and speech therapy in critically ill patients is crucial to reduce morbidity and improve outcomes. Over a 5-year time interval, we sought to determine the utilization of these rehabilitation therapies in the USA. Methods We performed a retrospective cohort study utilizing a large, national administrative database including ICU patients from 591 hospitals. Patients over 18 years of age with acute respiratory failure requiring invasive mechanical ventilation within the first 2 days of hospitalization and for a duration of at least 48 h were included. Results A total of 264,137 patients received invasive mechanical ventilation for a median of 4.0 [2.0–8.0] days. Overall, patients spent a median of 5.0 [3.0–10.0] days in the ICU and 10.0 [7.0–16.0] days in the hospital. During their hospitalization, 66.5%, 41.0%, and 33.2% (95% CI = 66.3–66.7%, 40.8–41.2%, 33.0–33.4%, respectively) received physical, occupational, and speech therapy. While on mechanical ventilation, 36.2%, 29.7%, and 29.9% (95% CI = 36.0–36.4%, 29.5–29.9%, 29.7–30.1%) received physical, occupational, and speech therapy. In patients receiving therapy, their first physical therapy session occurred on hospital day 5 [3.0–8.0] and hospital day 6 [4.0–10.0] for occupational and speech therapy. Of all patients, 28.6% (95% CI = 28.4–28.8%) did not receive physical, occupational, or speech therapy during their hospitalization. In a multivariate analysis, patients cared for in the Midwest and at teaching hospitals were more likely to receive physical, occupational, and speech therapy (all P < 0.05). Of patients with identical covariates receiving therapy, there was a median of 61%, 187%, and 70% greater odds of receiving physical, occupational, and speech therapy, respectively, at one randomly selected hospital compared with another (median odds ratio 1.61, 2.87, 1.70, respectively). Conclusions Physical, occupational, and speech therapy are not routinely delivered to critically ill patients, particularly while on mechanical ventilation in the USA. The utilization of these therapies varies according to insurance coverage, geography, and hospital teaching status, and at a hospital level. Electronic supplementary material The online version of this article (10.1186/s13054-019-2467-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Clare C Prohaska
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, 80045, USA. .,Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Box C272, 12700 E 19th Ave, Aurora, CO, 80045, USA.
| | - Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Box C272, 12700 E 19th Ave, Aurora, CO, 80045, USA
| | - Amy Nordon-Craft
- Department of Physical Therapy, University of Colorado Hospital, Aurora, CO, 80045, USA
| | | | - Ellen L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Box C272, 12700 E 19th Ave, Aurora, CO, 80045, USA
| | - Brendan J Clark
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Box C272, 12700 E 19th Ave, Aurora, CO, 80045, USA
| | - Michael Ho
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, 80045, USA
| | - R William Vandivier
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Box C272, 12700 E 19th Ave, Aurora, CO, 80045, USA
| | - Wenhui Liu
- VA Eastern Colorado Health Care System, Aurora, CO, 80045, USA
| | - Margaret Schenkman
- Department of Physical Therapy, University of Colorado Hospital, Aurora, CO, 80045, USA
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Box C272, 12700 E 19th Ave, Aurora, CO, 80045, USA
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Sottile PD, Albers D, Moss MM. Neuromuscular blockade is associated with the attenuation of biomarkers of epithelial and endothelial injury in patients with moderate-to-severe acute respiratory distress syndrome. Crit Care 2018. [PMID: 29523157 PMCID: PMC5845220 DOI: 10.1186/s13054-018-1974-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Background Neuromuscular blockade (NMB) is a therapy for acute respiratory distress syndrome (ARDS). However, the mechanism by which NMB may improve outcome for ARDS patients remains unclear. We sought to determine whether NMB attenuates biomarkers of epithelial and endothelial lung injury and systemic inflammation in ARDS patients, and whether the association is dependent on tidal volume size and the initial degree of hypoxemia. Methods We performed a secondary analysis of patients enrolled in the ARDS network low tidal volume ventilation (ARMA) study. Our primary predictor variable was the number of days receiving NMB between study enrollment and day 3. Our primary outcome variables were the change in concentration of biomarkers of epithelial injury (serum surfactant protein-D (SP-D)), endothelial injury (von Willebrand factor (VWF)), and systemic inflammation (interleukin (IL)-8). Multivariable regression analysis was used to compare the change in biomarker concentration controlling for multiple covariates. Patients were stratified by treatment arm (12 versus 6 cm3/kg) and by an initial arterial oxygen tension (PaO2) to fractional inspired oxygen (FiO2) (P/F) ratio of 120. Results A total of 446 (49%) patients had complete SP-D, VWF, and IL-8 measurements on study enrollment and day 3. After adjusting for baseline differences, each day of NMB was associated with a decrease in SP-D (−23.7 ng/ml/day, p = 0.029), VWF (−33.5% of control/day, p = 0.015), and IL-8 (−362.6 pg/ml/day, p = 0.030) in patients with an initial P/F less than or equal to 120 and receiving low tidal volume ventilation. However, patients with a P/F ratio of greater than 120 or receiving high tidal volume ventilation had either no change or an increase in SP-D, WVF, or IL-8 concentrations. Conclusion NBM is associated with decreased biomarkers of epithelial and endothelial lung injury and systemic inflammation in ARDS patients receiving low tidal volume ventilation and those with a P/F ratio less than or equal to 120. Electronic supplementary material The online version of this article (10.1186/s13054-018-1974-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, 12700 E. 19th Ave., RC2 9th Floor, C272, Aurora, CO, 80045, USA.
| | - David Albers
- Department of Biomedical Informatics, Columbia University Medical Center, 622 W. 168th Street, Presbyterian Building 20th Floor, New York, NY, 10032, USA
| | - Marc M Moss
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, 12700 E. 19th Ave., RC2 9th Floor, C272, Aurora, CO, 80045, USA
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Sottile PD, Nordon-Craft A, Malone D, Schenkman M, Moss M. Patient and family perceptions of physical therapy in the medical intensive care unit. J Crit Care 2015; 30:891-5. [PMID: 26038155 DOI: 10.1016/j.jcrc.2015.04.119] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Revised: 04/20/2015] [Accepted: 04/24/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE Patient and family member perceptions of physical therapy (PT) in the intensive care unit and the factors that influence their degree of satisfaction have not been described. METHODS A panel of experts developed a questionnaire that assessed patient and family perceptions of PT. Critically ill patients and their family members were asked to complete the survey. Patient and family member scores were compared and stratified by age, sex, and mechanical ventilation for greater than 14 days compared to 14 days or less. RESULTS A total of 55 patients and 49 family members completed the survey. Patients and family members reported that PT was necessary and beneficial to recovery, despite associating PT with difficulty, exertion, and discomfort. Patient perceptions were similar regardless of age or sex. Family members underestimated a patient's enjoyment of PT (P = .03). For individuals who required prolonged mechanical ventilation (>14 days), patients reported that PT was more difficult (P = .03) and less enjoyable (P = .049), and family members reported PT as causing greater discomfort (P = .005). In addition, family members of patients who required prolonged mechanical ventilation felt that PT was less beneficial (P = .01). CONCLUSIONS Physical therapy is perceived as necessary and beneficial to recovery by critically ill patients and family members.
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Affiliation(s)
- Peter D Sottile
- University Colorado Anschutz Medical Campus, Aurora, CO 80045.
| | | | - Daniel Malone
- University Colorado Anschutz Medical Campus, Aurora, CO 80045.
| | | | - Marc Moss
- University Colorado Anschutz Medical Campus, Aurora, CO 80045.
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Abstract
BACKGROUND Little is known about why surrogate decision makers for patients with advanced illness often have overly optimistic expectations about prognosis. OBJECTIVE To determine how surrogates interpret prognostic statements and to explore factors influencing surrogates' interpretations of grim prognostic information. DESIGN Multicenter, mixed-methods study. SETTING Intensive care units of 3 hospitals in San Francisco, California. PARTICIPANTS 80 surrogates of critically ill patients. MEASUREMENTS Participants recorded their interpretation of 16 prognostic statements using a standard probability scale. Generalized estimating equations were used to determine whether participants interpreted statements more optimistically as the expressed probability of survival decreased. Fifteen surrogates whose responses exhibited this trend participated in a semistructured interview. RESULTS Participants' interpretations of prognostic statements expressing a low risk for death were relatively accurate, but interpretations of statements conveying a high risk for death were more optimistic than the actual meaning (P < 0.001; generalized estimating equation model). Interpretations of the statement "90% chance of surviving" did not differ from the actual meaning, but interpretations of "5% chance of surviving" were more optimistic and showed substantial variability (median, 90% [interquartile range, 90% to 95%; P = 0.11] vs. 15% [interquartile range, 5% to 40%; P < 0.001], respectively). Two main themes from the interviews explained this trend: surrogates' need to register optimism in the face of a poor prognosis and surrogates' belief that patient attributes unknown to the physician would lead to better-than-predicted outcomes. LIMITATION Surrogates' interpretations were elicited in an experimental setting rather than during actual clinician-surrogate conversations. CONCLUSION Inaccurate interpretations of physicians' prognostications by surrogates arise partly from optimistic biases rather than simply from misunderstandings. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute.
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Affiliation(s)
- Lucas S Zier
- University of California, San Francisco, San Francisco, California 94143-0119, USA
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