RESUMEN

Mechanical ventilated patients are a high-risk group with impaired cough ability and require corresponding medical techniques for cough assistance to clear airway secretions. Mechanical insufflation-exsufflation (MI-E) technology is widely used in patients with cough weakness caused by neuromuscular diseases. However, there is currently a lack of standardized application procedures for mechanically ventilated patients who retain artificial airways, which can affect treatment outcomes. Chinese Society of Critical Care Medicine organized experts including critical care physicians, nurses, respiratory therapists that focused on the clinical application of mechanical insufflation-exsufflation in mechanically ventilated patients. Through systematic collection, extraction, and summary of evidence-based clinical practice evidence and clinical experience, suggestions are proposed. Expert recommendations on the clinical application of mechanical insufflation-exsufflation in mechanically ventilated patients (2024) was formed by using improved Delphi method, hoping to provide references for standardized application of this technology. At the same time, those recommendations will also provide a reference for future clinical research on the application of mechanical insufflation-exsufflation technology in mechanically ventilated patients.

Asunto(s)

Insuflación , Respiración Artificial , Humanos , Respiración Artificial/métodos , Insuflación/métodos , Tos/terapia

RESUMEN

OBJECTIVE: To evaluate the effects of different intervention measures on duration of mechanical ventilation and the length of intensive care unit (ICU) stay in critically ill patients using network Meta-analysis. METHODS: Randomized controlled trial (RCT) on the effects of different intervention measures on duration of mechanical ventilation and the length of ICU stay in critically ill patients were systematically searched in PubMed, Embase, China Biomedical Literature Database, CNKI, and other databases. The search time limit was from the establishment of the database to November 2023. Literature screening, quality assessment, and data extraction were independently conducted by two researchers. Network Meta-analysis was employed to assess the effects of each intervention on duration of mechanical ventilation and the length of ICU stay, and funnel plots were generated. RESULTS: A total of 37 RCTs were included, involving 3 977 severe patients, 2 041 in the intervention group and 1 936 in the control group. Thirteen types of interventions were analyzed, including usual care (UC), early activity (EA), early comprehensive rehabilitation (ECR), early pulmonary rehabilitation (EPR), cluster intervention strategy (CS), sedation, analgesia and cluster nursing (SACN), music therapy (MT), neuromuscular electrical stimulation (NMES), modified education and visitation (MV), virtual reality (VR), auricular point sticking (APS), acupoint acupuncture (AA), and concerted intervention (COR). Network Meta-analysis showed that MV significantly better than COR [standardized mean difference (SMD) = -2.35, 95% confidence interval (95%CI) was -4.30 to -0.39], EPR (SMD = -2.59, 95%CI was -4.81 to -0.37), and UC (SMD = -4.10, 95%CI was -5.71 to -2.49) in improving duration of mechanical ventilation in critically ill patients. COR was significantly better than UC in shortened length of ICU stay (SMD = -5.72, 95%CI was -10.07 to -1.37). The efficacy ranking results showed that for duration of mechanical ventilation, the surface under the cumulative ranking curve (SUCRA) was highest for MV (85.4%) and EA (85.4%), followed by AA (74.9%), NMES (63.1%), ECR (51.7%), CS (48.8%), SACN (34.3%), COR (29.4%), EPR (26.1%), and UC (0.7%). For the length of ICU stay, COR had the highest SUCRA (82.3%), followed by APS (79.7%), MV (77.7%), EPR (68.0%), NMES (57.6%), CS (54.4%), ECR (51.1%), SACN (41.9%), MT (39.8%), EA (39.3%), AA (33.0%), VR (15.4%), and UC (9.8%). The funnel plot results of ICU stay showed that the publication bias between studies were relatively small. CONCLUSIONS: MV and COR appear to be effective interventions for reducing mechanical ventilation time and ICU stay in critically ill patients. However, due to the number and quality of included studies, these findings require confirmation through additional high-quality research.

Asunto(s)

Enfermedad Crítica , Unidades de Cuidados Intensivos , Tiempo de Internación , Metaanálisis en Red , Ensayos Clínicos Controlados Aleatorios como Asunto , Respiración Artificial , Humanos , Respiración Artificial/métodos

RESUMEN

Respiratory failure caused by acute respiratory distress syndrome and severe pneumonia is common diseases in intensive care medicine. In recent years, with the continuous updating of treatment methods, prone position ventilation has been found to have a good therapeutic effect on such diseases, and has been widely used in clinical practice. However, prone position ventilation significantly increases the workload of medical staff and the risk of accidental extubation and pressure injuries to patients, seriously affecting the safety of diagnosis and treatment. At present, various devices such as mattresses have been used for prone position ventilation, but there are few devices specifically designed to protect and fix the head and face. Therefore, the medical staff of Affiliated Hospital of Zunyi Medical University designed and developed a head support frame for prone position ventilation, and obtained a National Utility Model Patent of China (patent number: ZL 2018 2 0056891.6). The head support frame for prone position ventilation includes a movable chassis and rollers for easy movement and fixation. The retractable column 1 is vertically fixed on the movable chassis, and its height can be freely adjusted according to the position of the patient. A transverse bridge is fixed at the top of the retractable column 1, the two ends of the bridge are designed a bulge, and the rotating ring is fixed above the transverse bridge, so that the rotating ring can rotate along the bridge at a certain angle. The rotating ring is designed with an inner ring and an inlet and outlet which can pass through the tube is designed on the rotating ring. The inflatable air bag is designed above the rotating ring to improve the comfort of patients and reduce the pressure injury of facial skin. A sliding rod is vertically designed on the upper part of the retractable column 1, and there is a retractable column 2 at the distal end of the slide rod, and the retractable column 2 is connected with the rotating ring, so that the rotating ring adjusts the angle along the cross bridge with the contraction of the collapsible column 2. A retractable column 3 is arranged in the middle of the slide rod, and a catheter clamp is arranged at its far end to facilitate the fixation of the artificial airway and the mechanical ventilation tube. The support frame is practical and convenient, which can protect the patient's head safely in the prone position, and greatly reduce the workload of medical staff.

Asunto(s)

Diseño de Equipo , Respiración Artificial , Posición Prona , Humanos , Respiración Artificial/métodos , Posicionamiento del Paciente/métodos , Cabeza

RESUMEN

BACKGROUND: Noninvasive respiratory support modalities are common alternatives to mechanical ventilation in acute hypoxemic respiratory failure. However, studies historically compare noninvasive respiratory support to conventional oxygen rather than mechanical ventilation. In this study, we compared outcomes in patients with acute hypoxemic respiratory failure treated initially with noninvasive respiratory support to patients treated initially with invasive mechanical ventilation. METHODS: This is a retrospective observational cohort study between January 1, 2018 and December 31, 2019 at a large healthcare network in the United States. We used a validated phenotyping algorithm to classify adult patients (≥18 years) with eligible International Classification of Diseases codes into two cohorts: those treated initially with noninvasive respiratory support or those treated invasive mechanical ventilation only. The primary outcome was time-to-in-hospital death analyzed using an inverse probability of treatment weighted Cox model adjusted for potential confounders. Secondary outcomes included time-to-hospital discharge alive. A secondary analysis was conducted to examine potential differences between noninvasive positive pressure ventilation and nasal high flow. RESULTS: During the study period, 3177 patients met inclusion criteria (40% invasive mechanical ventilation, 60% noninvasive respiratory support). Initial noninvasive respiratory support was not associated with a decreased hazard of in-hospital death (HR: 0.65, 95% CI: 0.35-1.2), but was associated with an increased hazard of discharge alive (HR: 2.26, 95% CI: 1.92-2.67). In-hospital death varied between the nasal high flow (HR 3.27, 95% CI: 1.43-7.45) and noninvasive positive pressure ventilation (HR 0.52, 95% CI 0.25-1.07), but both were associated with increased likelihood of discharge alive (nasal high flow HR 2.12, 95 CI: 1.25-3.57; noninvasive positive pressure ventilation HR 2.29, 95% CI: 1.92-2.74). CONCLUSIONS: These data show that noninvasive respiratory support is not associated with reduced hazards of in-hospital death but is associated with hospital discharge alive.

Asunto(s)

Mortalidad Hospitalaria , Ventilación no Invasiva , Insuficiencia Respiratoria , Humanos , Masculino , Femenino , Persona de Mediana Edad , Insuficiencia Respiratoria/terapia , Insuficiencia Respiratoria/mortalidad , Estudios Retrospectivos , Anciano , Ventilación no Invasiva/métodos , Respiración Artificial/métodos , Hipoxia/terapia , Enfermedad Aguda , Adulto

RESUMEN

In intensive care unit (ICU) patients undergoing mechanical ventilation (MV), the occurrence of difficult weaning contributes to increased ventilator-related complications, prolonged hospitalization duration, and a significant rise in healthcare costs. Therefore, early identification of influencing factors and prediction of patients at risk of difficult weaning can facilitate early intervention and preventive measures. This study aimed to strengthen airway management for ICU patients by constructing a risk prediction model with comprehensive and individualized offline programs based on machine learning techniques. This study involved the collection of data from 487 patients undergoing MV in the ICU, with a total of 36 variables recorded. The dataset was divided into a training set (70% of the data) and a test set (30% of the data). Five machine learning models, namely logistic regression, random forest, support vector machine, light gradient boosting machine, and extreme gradient boosting, were compared to predict the risk of difficult weaning in ICU patients with MV. Significant influencing factors were identified based on the results of these models, and a risk prediction model for ICU patients with MV was established. When evaluating the models using AUC (Area under the Curve of ROC) and Accuracy as performance metrics, the Random Forest algorithm exhibited the best performance among the five machine learning algorithms. The area under the operating characteristic curve for the subjects was 0.805, with an accuracy of 0.748, recall (0.888), specificity (0.767) and F1 score (0.825). This study successfully developed a risk prediction model for ICU patients with MV using a machine learning algorithm. The Random Forest algorithm demonstrated the highest prediction performance. These findings can assist clinicians in accurately assessing the risk of difficult weaning in patients and formulating effective individualized treatment plans. Ultimately, this can help reduce the risk of difficult weaning and improve the quality of life for patients.

Asunto(s)

Unidades de Cuidados Intensivos , Aprendizaje Automático , Respiración Artificial , Desconexión del Ventilador , Humanos , Desconexión del Ventilador/métodos , Masculino , Femenino , Persona de Mediana Edad , Respiración Artificial/métodos , Anciano , Medición de Riesgo/métodos , Curva ROC , Factores de Riesgo

RESUMEN

BACKGROUND: Postoperative time to extubation plays a role in prognosis after heart valve surgery; however, its exact impact has not been clarified. This study compared the postoperative outcomes of minimally invasive surgery and conventional sternotomy, focusing on early extubation and factors influencing prolonged mechanical ventilation. METHODS: Data from 744 patients who underwent heart valve surgery at the Zhejiang Provincial People's Hospital between August 2019 and June 2022 were retrospectively analyzed. The outcomes in patients who underwent conventional median sternotomy (MS) and minimally invasive (MI) video-assisted thoracoscopic surgery were compared using inverse probability of treatment weighting (IPTW) and Kaplan-Meier curves. Clinical data, including surgical data, postoperative cardiac function, postoperative complications, and intensive care monitoring data, were analyzed. RESULTS: After propensity score matching and IPTW, 196 cases of conventional MS were compared with 196 cases of MI video-assisted thoracoscopic surgery. Compared to patients in the conventional MS group, those in the MI video-assisted thoracoscopic surgery group in the matched cohort had a higher early postoperative extubation rate (P < 0.01), reduced incidence of postoperative pleural effusion (P < 0.05), significantly shorter length of stay in the intensive care unit (P < 0.01), shorter overall length of hospital stay (P < 0.01), and lower total cost of hospitalization (P < 0.01). CONCLUSIONS: Successful early tracheal extubation is important for the intensive care management of patients after heart valve surgery. The advantages of MI video-assisted thoracoscopic surgery over conventional MS include significant reductions in the duration of use of mechanical ventilation support, reduced length of intensive care unit stay, reduced total length of hospitalization, and a favorable patient recovery rate.

Asunto(s)

Extubación Traqueal , Procedimientos Quirúrgicos Cardíacos , Tiempo de Internación , Procedimientos Quirúrgicos Mínimamente Invasivos , Cirugía Torácica Asistida por Video , Humanos , Estudios Retrospectivos , Extubación Traqueal/métodos , Masculino , Femenino , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Procedimientos Quirúrgicos Cardíacos/métodos , Cirugía Torácica Asistida por Video/métodos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Respiración Artificial/métodos , Anciano , Esternotomía/métodos , Factores de Tiempo

RESUMEN

BACKGROUND: At present, preterm infants with respiratory distress syndrome (RDS) in China present higher mortality and morbidity rates than those in high-income countries. The aim of this nationwide survey was to assess the clinical management of RDS in China. METHODS: A nationwide cross-sectional survey to assess adherence to RDS management recommendations was performed. One neonatologist per hospital was randomly selected. The primary outcome was the key care of RDS management. RESULTS: Among the 394 participating hospitals, 88·3% were birthing centres. The number of doctors and nurses per bed were 0·27 and 0·72, respectively. Antenatal corticosteroids (any dose) were administered to 90% of the women at risk of preterm birth at < 34 weeks of gestation (90·0% inborn vs. 50·0% outborn, p < 0·001). The median fraction of inspired oxygen (FiO2) for initial resuscitation was 0·30 for babies born at ≤ 32 weeks of gestation and 0·25 for those born at > 32 weeks. T-piece resuscitators were available in 77·8% of delivery rooms (DRs) (tertiary hospitals: 82·5% vs. secondary hospitals: 63·0%, p < 0·001). Surfactant was used in 51·6% of the DRs. Less invasive surfactant administration (LISA) was used in 49·7% of the hospitals (tertiary hospitals: 55·3% vs. secondary hospitals: 31·5%, p < 0·001). Primary non-invasive ventilation was initiated in approximately 80·0% of the patients. High-frequency oscillation ventilation was primarily reserved for rescue after conventional mechanical ventilation (MV) failure. Caffeine was routinely used during MV in 59·1% of the hospitals. Bedside lung ultrasonography was performed in 54·3% of the health facilities (tertiary hospitals: 61·6% vs. secondary hospitals: 30·4%, p < 0·001). Qualified breast milk banks and Family Integrated Care (FICare) were present in 30·2% and 63·7% of the hospitals, respectively. CONCLUSIONS: Significant disparities in resource availability and guidelines adherence were evident across hospitals. Future strategies should address DR facilities and medication access, technical training, staff allocation, and ancillary facility development for a better management of RDS patients in China.

Asunto(s)

Síndrome de Dificultad Respiratoria del Recién Nacido , Humanos , Síndrome de Dificultad Respiratoria del Recién Nacido/terapia , Recién Nacido , Estudios Transversales , China/epidemiología , Femenino , Masculino , Surfactantes Pulmonares/uso terapéutico , Surfactantes Pulmonares/administración & dosificación , Encuestas y Cuestionarios , Recien Nacido Prematuro , Respiración Artificial

RESUMEN

Blastomycosis can result in lung injury with high mortality rates. The literature on veno-venous extracorporeal membrane oxygenation (VV-ECMO) used as a rescue therapy is limited to case reports and small case series collected over extended time periods. This report describes the clinical course and post-hospitalization outcomes among patients with blastomycosis-induced respiratory failure requiring VV-ECMO in the most recent time frame. The data were collected retrospectively from the health records of eight patients with blastomycosis-induced respiratory failure admitted to a tertiary care center between 2019 and 2023. The mean time from the start of mechanical ventilation to ECMO initiation was 57 h. All patients survived to ECMO decannulation, and seven of them survived to hospital discharge. All six patients whose post-discharge follow-up information was available were weaned from mechanical ventilation and lived at home while two required supplemental oxygen. This includes a case where the provision of adequate ECMO support was challenging due to the patient's morbid obesity. The most common residual imaging abnormalities included pulmonary infiltrates and pneumatoceles. The study demonstrates the feasibility of VV-ECMO as a rescue therapy in patients with blastomycosis-related refractory respiratory failure. Rapid initiation of ECMO support in eligible patients may have contributed to the good outcomes.

Asunto(s)

Blastomicosis , Oxigenación por Membrana Extracorpórea , Insuficiencia Respiratoria , Humanos , Masculino , Insuficiencia Respiratoria/terapia , Insuficiencia Respiratoria/etiología , Estudios Retrospectivos , Blastomicosis/terapia , Blastomicosis/complicaciones , Blastomicosis/diagnóstico , Adulto , Femenino , Persona de Mediana Edad , Resultado del Tratamiento , Respiración Artificial , Factores de Tiempo , Adulto Joven

RESUMEN

To verify if data obtained in the prehospital evaluation of patients with severe acute respiratory syndrome (SARS) during the initial response to the COVID-19 pandemic is associated with clinical outcomes: mechanical ventilation, hospital discharge, and death. This is a retrospective analysis involving secondary data from the Emergency Medical Service (EMS) records and the Health Surveillance Information System of patients assisted by the EMS in Manaus, from January to June 2020, the period of the first peak of COVID-19 cases. The combination of the two databases yielded a total of 1.190 patients, who received a first EMS response and were later admitted to hospital with SARS and had data on clinical outcomes of interest available. Patients were predominantly male (754, 63.4%), with a median age of 66 (IQR: 54.0-78.0) years. SARS illness before medical assistance was associated to need for invasive mechanical ventilation (IMV, p < 0.001). Lower pre-hospital SpO2 was associated to death (p = 0.025). Death was more common among patients with respiratory support needs, especially in the invasive ventilation group (262/287; 91.3%) (p < 0.001). In addition, IMV was more common among elderly individuals (p < 0.001). Patients admitted to ICU had a greater chance of dying when compared to non-ICU admitted patients (p < 0.001), and closely related to IMV (p < 0.001). Patients in ICU were also older (p = 0.003) and had longer hospital stay (p < 0.001). Mortality was associated with mechanical ventilation (p < 0.001), ICU admission (p < 0.001), and older age (p < 0.001). Patients who died had a shorter length of both ICU and total hospital stay (p < 0.001). Prehospital EMS may provide feasible and early recognition of critical patients with SARS in strained healthcare systems, such as in low-resource settings and pandemics.

Asunto(s)

COVID-19 , Servicios Médicos de Urgencia , Respiración Artificial , Humanos , COVID-19/mortalidad , COVID-19/terapia , COVID-19/epidemiología , Masculino , Femenino , Anciano , Persona de Mediana Edad , Estudios Retrospectivos , Saturación de Oxígeno , SARS-CoV-2/aislamiento & purificación , Hospitalización , Mortalidad Hospitalaria , Síndrome Respiratorio Agudo Grave/terapia , Síndrome Respiratorio Agudo Grave/mortalidad , Síndrome Respiratorio Agudo Grave/epidemiología

RESUMEN

Acute gastrointestinal injury (AGI) is common in mechanically ventilated (MV) patients, but the potential association between ventilatory pressure parameters and AGI grade and their impact on mortality remains unclear. This study aimed to explore the association between ventilatory pressure parameters and AGI grade, and their interaction on all-cause mortality in MV patients. This study was a secondary analysis of a multicenter, prospective, observational study that enrolled adult patients with an expected duration of mechanical ventilation ≥ 48 h from 14 general intensive care units in Zhejiang Province between March and August 2014. The AGI grade was assessed daily on the basis of gastrointestinal symptoms, intra-abdominal pressures, and feeding intolerance in the first week of admission to the ICU. This study included 331 patients (69.2% men; mean age, 64.6 ± 18.9 years). Multivariate regression analysis showed that plateau pressure (Pplat) (OR 1.044, 95% CI 1.009-1.081, P = 0.013), serum creatinine (OR 1.003, 95% CI 1.001-1.006, P = 0.042) and APACHE II score (OR 1.035, 95% CI 1.021-1.072, P = 0.045) were independently associated with global AGI grade III/IV within 7 days of ICU admission. Moreover, global AGI grade (HR 2.228, 95% CI 1.561-3.182, P < 0.001), serum creatinine (HR 1.002, 95% CI 1.001-1.003, P = 0.012) and APACHE II score (HR 1.039, 95% CI 1.015-1.063, P = 0.001) were independently associated with 60-day mortality. In addition, there were significant (Pint ≤ 0.028) interactions of Pplat and DP with AGI grade in relation to 60-days mortality, whereas no interaction (Pint = 0.061) between PEEP and AGI grade on 60-days mortality was observed. In the presence of Pplat ≥ 19 cmH2O, the patients with AGI grade III/IV had 60-day mortality rate of 72.2%, significantly higher than those with AGI grade I/II (48.7%, P = 0.018), whereas there were no significant differences (27.9% vs. 33.7%, P = 0.39) in 60-days mortality between AGI grade I/II and III/IV among the patients with Pplat < 19 cmH2O. In comparison with Pplat, DP had a similar interaction (Pint = 0.028) with AGI grade on 60-day mortality. Ventilatory pressure parameters (Pplat and DP) are independent risk factors of AGI grade III/IV. Pplat and DP interact with AGI grade on 60-days mortality, highlighting the importance of optimizing ventilatory pressure parameters to improve gastrointestinal function and survival outcomes of MV patients.Trial registration: ChiCTR-OCS-13003824.

Asunto(s)

Unidades de Cuidados Intensivos , Respiración Artificial , Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Estudios Prospectivos , APACHE , Enfermedades Gastrointestinales/mortalidad , Enfermedades Gastrointestinales/etiología , Enfermedades Gastrointestinales/fisiopatología , Anciano de 80 o más Años

RESUMEN

OBJECTIVE: To visualize the relationship between different combinations of mechanical power exposure intensity-duration and death risk in mechanical ventilation patients using a visualization method. METHODS: Critically ill patients receiving mechanical ventilation were selected from the Medical Information Mart for Intensive Care- IV v1.0 (MIMIC- IV v1.0) database. The patients were divided into four subgroups according to oxygenation index (PaO2/FiO2) including > 300 mmHg (1 mmHg ≈ 0.133 kPa) group, 201-300 mmHg group, 101-200 mmHg group and ≤100 mmHg group. The baseline characteristics, ventilator parameters, and prognostic indicators for different patient populations were collected. For each patient, the mechanical power thresholds from low to high (5-30 J/min, increasing at intervals of 1 J/min) were used to evaluate the different exposures of mechanical power (above the set threshold was recorded as one exposure), and the number of events with different exposure intensity-duration combinations was counted based on their corresponding durations. Based on the 28-day survival/non-survival status, the number of exposures for survivors and non-survivors in each exposure intensity-duration combination was calculated, and the survival odds ratio (OR) for different mechanical power exposure intensity-duration combinations was subsequently computed. Two-dimensional tables were generated with mechanical power exposure duration on the x-axis and exposure intensity on the y-axis, and the heatmap and its corresponding equipotential line view were used to visualize the OR value to assess the risk of death. RESULTS: A total of 5 378 patients receiving mechanical ventilation were enrolled in the study, of whom 2 069 patients in the PaO2/FiO2 > 300 mmHg group, 813 patients in the 201-300 mmHg group, 1 493 patients in the 101-200 mmHg group, and 1 003 patients in the ≤100 mmHg group. The severity scores of patients, including sequential organ failure assessment (SOFA) score and simplified acute physiology score II (SAPS II), gradually increased following the decrease in PaO2/FiO2, and the incidence of co-morbidities also gradually increased. In terms of ventilator parameters, mechanical power was increased gradually with decrease in PaO2/FiO2, measuring 10.4 (7.8, 13.9), 11.3 (8.5, 14.7), 13.6 (10.0, 18.2), and 16.7 (12.5, 22.0) J/min (P < 0.01). In terms of prognosis, 28-day mortality of patients was gradually increased with decrease in PaO2/FiO2 [29.1% (601/2 069), 26.9% (219/813), 28.1% (420/1 493), and 33.3% (334/1 003), respectively, P < 0.05]. In the heatmap, it could be observed that the 28-day death risk of mechanical ventilation patients was gradually increased with increase in mechanical power exposure intensity and long duration, showing two distinct areas: a region near the bottom left corner (representing low mechanical power exposure intensity and short duration) was blue, indicating a greater chance of survival. In contrast, another region near the top right corner (representing high mechanical power exposure intensity and long duration) was red, indicating a higher risk of death. According to the fitted lines of death risk, for the same risk of death, a shorter mechanical power exposure duration was required for higher exposure intensity, while lower mechanical power exposure intensity required a longer exposure duration. The above trend of change was similarly reflected in the overall population and different oxygenation populations. CONCLUSIONS: Cumulative mechanical power exposure to higher intensity and/or longer duration is associated with worse outcomes in mechanical ventilation patients. Considering both the mechanical power exposure intensity and duration may help to evaluate the effectiveness of lung protection in mechanical ventilation patients and guide adjustments in mechanical ventilation strategy to reduce the risk of ventilator-induced lung injury.

Asunto(s)

Enfermedad Crítica , Respiración Artificial , Humanos , Respiración Artificial/métodos , Respiración Artificial/efectos adversos , Masculino , Femenino , Persona de Mediana Edad , Pronóstico , Anciano , Unidades de Cuidados Intensivos

RESUMEN

OBJECTIVE: To integrate the best evidence for early rehabilitation of mechanically ventilated ICU-acquired weakness (ICU-AW) patients using evidence-based methods, providing evidence-based basis for standardized evaluation and intervention of early exercise therapy for mechanically ventilated ICU-AW patients. METHODS: A systematic search was conducted on the American Thoracic Society (ATS) Clinical Practice Guidelines, Registered Nurses' Association of Ontario (RNAO), Guidelines International Network (GIN), Canadian Medical Association Clinical Practice Guideline Library (CMACPGL), BMJ Clinical Evidence, UpToDate, Scottish Intercollegiate Guidelines Network (SIGN), PubMed, Cochrane Library, National Guideline Clearinghouse (NGC), Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), UM-library, Physiotherapy Evidence Database (PEDro), National Institute for Health and Care Excellence (NICE), New Zealand Guidelines Group (NZGG), Chinese Medical Pulse Guidelines Website, CNKI and Wanfang data and other Chinese and English databases, professional team websites, and guideline websites for expert consensus, guidelines, randomized collected trial (RCT), systematic reviews and other evidence on early exercise rehabilitation for mechanically ventilated ICU-AW patients. The search time limit was from the establishment of the database to December 31, 2023. Literature search, screening, evaluation, information extraction was independently conducted by two evaluators with cross checking, and quality evaluation of the included literature was conducted. RESULTS: A total of 21 literatures were enrolled, including 5 guidelines, 5 systematic reviews, 4 expert consensuses, and 7 RCT, all of which with high evidence level and all were enrolled. They were summarized into seven aspects with assessment screening, exercise safety standards, precautions, setting of exercise time, exercise intensity, exercise sequence, and recommended exercise content as the core, and 32 best evidences. CONCLUSIONS: The evidence summarized can provide evidence-based basis for standardized assessment and intervention of early exercise rehabilitation in mechanically ventilated ICU-AW patients. ICU medical practitioners need to combine the actual clinical environment, individual differences and rehabilitation goals of patients, to provide targeted health guidance and intervention for the prevention of ICU-AW in mechanically ventilated patients.

Asunto(s)

Terapia por Ejercicio , Unidades de Cuidados Intensivos , Debilidad Muscular , Respiración Artificial , Humanos , Terapia por Ejercicio/métodos , Debilidad Muscular/rehabilitación , Medicina Basada en la Evidencia

RESUMEN

BACKGROUND: Very low birthweight infants (VLBWIs) often undergo chest radiographic examinations without standardization or objectivity. This study aimed to assess the association of two radiographic scores, the Brixia and radiographic assessment of lung edema (RALE), with oxygenation index (OI) in ventilated VLBWIs and to determine the optimal cutoff values to predict hypoxic respiratory severity. METHODS: VLBWIs who received invasive respiratory support with arterial lines between January 2010 and October 2023 were enrolled in this study (n = 144). The correlation between the Brixia or RALE scores and OI was investigated. Receiver operating characteristic curve analysis was performed to determine the optimal cutoff points of the two radiographic scores for predicting OI values (OI ≥5, ≥10, and ≥15). RESULTS: The enrolled infants had a median gestational age of 27 weeks (interquartile range [IQR], 25-28 weeks) and a median birthweight of 855 g (IQR, 684-1003 g). Radiographic scoring methods correlated with the OI (Brixia score: r = 0.79, p < 0.001; RALE score: r = 0.72, p < 0.001). The optimal cutoff points for predicting OI values were as follows: Brixia score: OI ≥5, 10; OI ≥10, 13; OI ≥15, 15; RALE score: OI ≥5, 22; OI ≥10, 31; and OI ≥15, 40. CONCLUSIONS: Brixia and RALE scores are useful predictive markers of the oxygenation status in intubated VLBWIs with stable hemodynamics. These scores are easy to use and promising tools for clinicians to identify patients with a higher risk of hypoxic respiratory failure.

Asunto(s)

Recién Nacido de muy Bajo Peso , Humanos , Recién Nacido , Femenino , Masculino , Respiración Artificial , Oxígeno/sangre , Estudios Retrospectivos , Curva ROC , Índice de Severidad de la Enfermedad , Hipoxia , Pulmón/diagnóstico por imagen , Radiografía Torácica/métodos , Edad Gestacional

RESUMEN

IMPORTANCE: A time-limited trial (TLT) is a collaborative plan among clinicians, patients, and families to use life-sustaining therapy for a defined duration, after which the patient's response informs whether to continue care directed toward recovery or shift the focus toward comfort. TLTs are a promising approach to help navigate uncertainty in critical illness, yet little is known about their current use. OBJECTIVES: To characterize TLT use in patients with acute respiratory failure (ARF). DESIGN, SETTING, AND PARTICIPANTS: Prospective 12-month observational cohort study at an U.S. academic medical center of adult ICU patients with ARF receiving invasive mechanical ventilation for greater than or equal to 48 hours. MAIN OUTCOMES AND MEASURES: Primary exposure was TLT participation, identified by patients' ICU physician. Patient characteristics, care delivery elements, and hospital outcomes were extracted from the electronic medical record. RESULTS: Among 176 eligible patients, 36 (20.5%) participated in a TLT. Among 18 ICU attending physicians, nine (50%) participated in greater than or equal to 1 TLT (frequency 0-39% of patients cared for). Median TLT duration was 3.0 days (interquartile range [IQR], 3.0-4.5 d). TLT patients had a higher mean age (67.4 yr [sd, 12.0 yr] vs. 60.0 yr [sd, 16.0 yr]; p < 0.01), higher Charlson Comorbidity Index (5.1 [sd, 2.2] vs. 3.8 [sd, 2.6]; p < 0.01), and similar Sequential Organ Failure Assessment score (9.6 [sd, 3.3] vs. 9.5 [sd, 3.7]; p = 0.93), compared with non-TLT patients. TLT patients were more likely to die or be discharged to hospice (80.6% vs. 42.1%; p < 0.05) and had shorter ICU length of stay (median, 5.7 d [IQR, 4.0-9.0 d] vs. 10.3 d [IQR, 5.5-14.5 d]; p < 0.01). CONCLUSIONS AND RELEVANCE: In this study, approximately one in five patients with ARF participated in a TLT. Our findings suggest TLTs are used primarily in patients near end of life but with substantial physician variation, highlighting a need for evidence to guide optimal use.

Asunto(s)

Unidades de Cuidados Intensivos , Insuficiencia Respiratoria , Humanos , Estudios Prospectivos , Femenino , Masculino , Persona de Mediana Edad , Anciano , Insuficiencia Respiratoria/terapia , Respiración Artificial , Estudios de Cohortes , Factores de Tiempo , Síndrome de Dificultad Respiratoria/terapia , Enfermedad Crítica

RESUMEN

The COVID-19 pandemic has undeniably changed the way intensivists manage acute hypoxaemic respiratory failure. Paradigms had evolved particularly in the way we support patients with respiratory failure, and the adjunctive therapies which can be used. Many questions have been answered, and many more generated, from the last few years. For example, is COVID-19 acute respiratory failure and acute respiratory distress syndrome similar to non-COVID-19? How can we personalize therapy in patients with COVID-19, and what are some new statistical tools that we can use to aid in this approach? Is intubation and invasive mechanical ventilation the only way to support patients with acute respiratory failure, or can we turn to other modalities of respiratory support? And what about patients with the most severe form of respiratory failure, how can we support them? In this chapter, we explore the lessons learnt, identifying gaps and advances in knowledge in terms of the pathophysiology of acute respiratory failure, its prognostic factors, oxygen supports, and other therapies. We also touch on how physicians treating patients can tap on international networks to create a "whole that is more than the sum of its parts", and impart clinical insights on the management of acute respiratory failure. Finally, we highlight the importance of a cautious skepticism in our approach to both clinical medicine and evidence-based medicine, highlighting how evidence in a pandemic can rapidly evolve both within an ICU, and longitudinally around the world.

Asunto(s)

COVID-19 , Respiración Artificial , Insuficiencia Respiratoria , SARS-CoV-2 , Humanos , COVID-19/complicaciones , COVID-19/terapia , Insuficiencia Respiratoria/terapia , Insuficiencia Respiratoria/virología , Respiración Artificial/métodos , Síndrome de Dificultad Respiratoria/terapia , Síndrome de Dificultad Respiratoria/virología

RESUMEN

INTRODUCTION: Arguments over the appropriate Crisis Standards of Care (CSC) for public health emergencies often assume that there is a tradeoff between saving the most lives, saving the most life-years, and preventing racial disparities. However, these assumptions have rarely been explored empirically. To quantitatively characterize possible ethical tradeoffs, we aimed to simulate the implementation of five proposed CSC protocols for rationing ventilators in the context of the COVID-19 pandemic. METHODS: A Monte Carlo simulation was used to estimate the number of lives saved and life-years saved by implementing clinical acuity-, comorbidity- and age-based CSC protocols under different shortage conditions. This model was populated with patient data from 3707 adult admissions requiring ventilator support in a New York hospital system between April 2020 and May 2021. To estimate lives and life-years saved by each protocol, we determined survival to discharge and estimated remaining life expectancy for each admission. RESULTS: The simulation demonstrated stronger performance for age-sensitive protocols. For a capacity of 1 bed per 2 patients, ranking by age bands saves approximately 29 lives and 3400 life-years per thousand patients. Proposed protocols from New York and Maryland which allocated without considering age saved the fewest lives (~13.2 and 8.5 lives) and life-years (~416 and 420 years). Unlike other protocols, the New York and Maryland algorithms did not generate significant disparities in lives saved and life-years saved between White non-Hispanic, Black non-Hispanic, and Hispanic sub-populations. For all protocols, we observed a positive correlation between lives saved and life-years saved, but also between lives saved overall and inequality in the number of lives saved in different race and ethnicity sub-populations. CONCLUSION: While there is significant variance in the number of lives saved and life-years saved, we did not find a tradeoff between saving the most lives and saving the most life-years. Moreover, concerns about racial discrimination in triage protocols require thinking carefully about the tradeoff between enforcing equality of survival rates and maximizing the lives saved in each sub-population.

Asunto(s)

COVID-19 , Nivel de Atención , Humanos , COVID-19/terapia , COVID-19/epidemiología , Anciano , Persona de Mediana Edad , Adulto , Ventiladores Mecánicos/provisión & distribución , Masculino , Femenino , Método de Montecarlo , SARS-CoV-2 , Asignación de Recursos para la Atención de Salud/ética , New York , Pandemias , Anciano de 80 o más Años , Simulación por Computador , Respiración Artificial

RESUMEN

X-linked myotubular myopathy (XLMTM) is a rare, life-threatening congenital myopathy. Most (80%) children with XLMTM have profound muscle weakness and hypotonia at birth resulting in severe respiratory insufficiency, the inability to sit up, stand or walk, and early mortality. At birth, 85-90% of children with XLMTM require mechanical ventilation, with more than half requiring invasive ventilator support. Historically, ventilator-dependent children with neuromuscular-derived respiratory failure of this degree and nature, static or progressive, are not expected to achieve complete independence from mechanical ventilator support. In the ASPIRO clinical trial (NCT03199469), participants receiving a single intravenous dose of an investigational gene therapy (resamirigene bilparvovec) started showing significant improvements in daily hours of ventilation support compared with controls by 24 weeks post-dosing, and 16 of 24 dosed participants achieved ventilator independence between 14 and 97 weeks after dosing. At the time, there was no precedent or published guidance for weaning chronically ventilated children with congenital neuromuscular diseases off mechanical ventilation. When the first ASPIRO participants started showing dramatically improved respiratory function, the investigators initiated efforts to safely wean them off ventilator support, in parallel with primary protocol respiratory outcome measures. A group of experts in respiratory care and physiology and management of children with XLMTM developed an algorithm to safely wean children in the ASPIRO trial off mechanical ventilation as their respiratory muscle strength increased. The algorithm developed for this trial provides recommendations for assessing weaning readiness, a stepwise approach to weaning, and monitoring of children during and after the weaning process.

Asunto(s)

Algoritmos , Terapia Genética , Miopatías Estructurales Congénitas , Respiración Artificial , Humanos , Miopatías Estructurales Congénitas/terapia , Miopatías Estructurales Congénitas/genética , Miopatías Estructurales Congénitas/diagnóstico , Masculino , Respiración Artificial/métodos , Terapia Genética/métodos , Terapia Genética/tendencias , Preescolar , Niño , Lactante , Desconexión del Ventilador/métodos , Resultado del Tratamiento , Insuficiencia Respiratoria/terapia , Insuficiencia Respiratoria/diagnóstico , Adolescente , Privación de Tratamiento/tendencias

RESUMEN

BACKGROUND: To detect preload responsiveness in patients ventilated with a tidal volume (Vt) at 6 mL/kg of predicted body weight (PBW), the Vt-challenge consists in increasing Vt from 6 to 8 mL/kg PBW and measuring the increase in pulse pressure variation (PPV). However, this requires an arterial catheter. The perfusion index (PI), which reflects the amplitude of the photoplethysmographic signal, may reflect stroke volume and its respiratory variation (pleth variability index, PVI) may estimate PPV. We assessed whether Vt-challenge-induced changes in PI or PVI could be as reliable as changes in PPV for detecting preload responsiveness defined by a PLR-induced increase in cardiac index (CI) ≥ 10%. METHODS: In critically ill patients ventilated with Vt = 6 mL/kg PBW and no spontaneous breathing, haemodynamic (PICCO2 system) and photoplethysmographic (Masimo-SET technique, sensor placed on the finger or the forehead) data were recorded during a Vt-challenge and a PLR test. RESULTS: Among 63 screened patients, 21 (33%) were excluded because of an unstable PI signal and/or atrial fibrillation and 42 were included. During the Vt-challenge in the 16 preload responders, CI decreased by 4.8 ± 2.8% (percent change), PPV increased by 4.4 ± 1.9% (absolute change), PIfinger decreased by 14.5 ± 10.7% (percent change), PVIfinger increased by 1.9 ± 2.6% (absolute change), PIforehead decreased by 18.7 ± 10.9 (percent change) and PVIforehead increased by 1.0 ± 2.5 (absolute change). All these changes were larger than in preload non-responders. The area under the ROC curve (AUROC) for detecting preload responsiveness was 0.97 ± 0.02 for the Vt-challenge-induced changes in CI (percent change), 0.95 ± 0.04 for the Vt-challenge-induced changes in PPV (absolute change), 0.98 ± 0.02 for Vt-challenge-induced changes in PIforehead (percent change) and 0.85 ± 0.05 for Vt-challenge-induced changes in PIfinger (percent change) (p = 0.04 vs. PIforehead). The AUROC for the Vt-challenge-induced changes in PVIforehead and PVIfinger was significantly larger than 0.50, but smaller than the AUROC for the Vt-challenge-induced changes in PPV. CONCLUSIONS: In patients under mechanical ventilation with no spontaneous breathing and/or atrial fibrillation, changes in PI detected during Vt-challenge reliably detected preload responsiveness. The reliability was better when PI was measured on the forehead than on the fingertip. Changes in PVI during the Vt-challenge also detected preload responsiveness, but with lower accuracy.

Asunto(s)

Índice de Perfusión , Fotopletismografía , Volumen de Ventilación Pulmonar , Humanos , Fotopletismografía/métodos , Volumen de Ventilación Pulmonar/fisiología , Masculino , Femenino , Persona de Mediana Edad , Anciano , Índice de Perfusión/métodos , Presión Sanguínea/fisiología , Volumen Sistólico/fisiología , Hemodinámica/fisiología , Respiración Artificial/métodos

RESUMEN

BACKGROUND: Postoperative hypoxemia and pulmonary complications remain a frequent event after on-pump cardiac surgery and mostly characterized by pulmonary atelectasis. Surfactant dysfunction or hyposecretion happens prior to atelectasis formation, and sigh represents the strongest stimulus for surfactant secretion. The role of sigh breaths added to conventional lung protective ventilation in reducing postoperative hypoxemia and pulmonary complications among cardiac surgery is unknown. METHODS: The perioperative sigh ventilation in cardiac surgery (E-SIGHT) trial is a single-center, two-arm, randomized controlled trial. In total, 192 patients scheduled for elective cardiac surgery with cardiopulmonary bypass (CPB) and aortic cross-clamp will be randomized into one of the two treatment arms. In the experimental group, besides conventional lung protective ventilation, sigh volumes producing plateau pressures of 35 cmH2O (or 40 cmH2O for patients with body mass index > 35 kg/m2) delivered once every 6 min from intubation to extubation. In the control group, conventional lung protective ventilation without preplanned recruitment maneuvers is used. Lung protective ventilation (LPV) consists of low tidal volumes (6-8 mL/kg of predicted body weight) and positive end-expiratory pressure (PEEP) setting according to low PEEP/FiO2 table for acute respiratory distress syndrome (ARDS). The primary endpoint is time-weighted average SpO2/FiO2 ratio during the initial post-extubation hour. Main secondary endpoint is the severity of postoperative pulmonary complications (PPCs) computed by postoperative day 7. DISCUSSION: The E-SIGHT trial will be the first randomized controlled trial to evaluate the impact of perioperative sigh ventilation on the postoperative outcomes after on-pump cardiac surgery. The trial will introduce and assess a novel perioperative ventilation approach to mitigate the risk of postoperative hypoxemia and PPCs in patients undergoing cardiac surgery. Also provide the basis for a future larger trial aiming at verifying the impact of sigh ventilation on postoperative pulmonary complications. TRIAL REGISTRATION: ClinicalTrials.gov NCT06248320. Registered on January 30, 2024. Last updated February 26, 2024.

Asunto(s)

Procedimientos Quirúrgicos Cardíacos , Puente Cardiopulmonar , Hipoxia , Respiración con Presión Positiva , Complicaciones Posoperatorias , Ensayos Clínicos Controlados Aleatorios como Asunto , Humanos , Hipoxia/etiología , Hipoxia/prevención & control , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Respiración con Presión Positiva/métodos , Puente Cardiopulmonar/efectos adversos , Resultado del Tratamiento , Atelectasia Pulmonar/etiología , Atelectasia Pulmonar/prevención & control , Factores de Tiempo , Atención Perioperativa/métodos , Persona de Mediana Edad , Femenino , Masculino , Adulto , Pulmón/fisiopatología , Pulmón/cirugía , Anciano , Respiración Artificial/efectos adversos , Enfermedades Pulmonares/etiología , Enfermedades Pulmonares/prevención & control , Enfermedades Pulmonares/diagnóstico

RESUMEN

COVID-19 associated pulmonary aspergillosis (CAPA) had been reported, and raised concern about this secondary infection due to the high mortality. This study aimed to investigate the risk factors for CAPA. The enrolled 114 COVID-19 patients were further divided into CAPA group and non-CAPA group. Demographic characteristics, underlying diseases, laboratory parameters and therapeutic schedule between the two groups were compared to identify the independent risk factors for CAPA by univariate analysis and multivariable logistic regression analysis. Sensitivity and specificity of independent risk factors were confirmed by receiver operating characteristic (ROC) curve analysis. Univariate analysis showed that renal transplant, IL-6 and CRP levels, decreased CD4 + T cell and CD8 + T cell, duration of antibiotics therapy, and prolonged mechanical ventilation were risk factors for development of CAPA. These factors were further analyzed by multivariable logistic regression analysis and the results indicated that elevated IL-6 level, decreased CD4 + T cell and prolonged mechanical ventilation could be recognized as independent risk factors for CAPA in COVID-19 patients. Identification of these risk factors is essential to initiate antifungal therapy as soon as possible to improve outcome of patients with CAPA.

Asunto(s)

COVID-19 , Aspergilosis Pulmonar Invasiva , Humanos , Masculino , COVID-19/complicaciones , Femenino , Aspergilosis Pulmonar Invasiva/complicaciones , Factores de Riesgo , Persona de Mediana Edad , Anciano , Interleucina-6/sangre , Adulto , Respiración Artificial , SARS-CoV-2/aislamiento & purificación , Curva ROC , Linfocitos T CD4-Positivos/inmunología