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Muhle P, Claus I, Labeit B, Roderigo M, Warnecke T, Dziewas R, Suntrup-Krueger S. Pharyngeal Electrical Stimulation prior to extubation - Reduction of extubation failure rate in acute stroke patients? J Crit Care 2024; 82:154808. [PMID: 38581884 DOI: 10.1016/j.jcrc.2024.154808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 03/15/2024] [Accepted: 03/29/2024] [Indexed: 04/08/2024]
Abstract
PURPOSE The aim of our study was to assess if PES before extubation can minimize the extubation failure risk in orally intubated, mechanically ventilated stroke patients at high risk of severe dysphagia. MATERIALS AND METHODS Thirty-two ICU patients were prospectively enrolled in this study presenting with a high risk for dysphagia as defined by a DEFISS (Determine Extubation Failure In Severe Stroke) risk score and compared 1:1 to a retrospective matched patient control group. The prospective patient group received PES prior to extubation. Endpoints were need for reintubation, swallowing function as assessed with FEES, pneumonia incidence and length of stay after extubation. RESULTS Post-extubation, the Fiberoptic Endoscopic Dysphagia Severity Score (FEDSS, 4.31 ± 1.53vs.5.03 ± 1.28;p = 0.047) and reintubation rate within 72 h (9.4vs.34.4%;p = 0.032) were significantly lower in the PES group than in the historical control group. Pulmonary infections after extubation were less common in PES-treated patients although this difference was not significant (37.5vs.59.4%;p = 0.133). Time from extubation to discharge was significantly shorter after PES compared with the control group (14.09 ± 11.58vs.26.59 ± 20.49 days;p = 0.003). CONCLUSIONS In orally intubated and mechanically ventilated stroke patients at high risk of severe dysphagia, PES may improve swallowing function, reduce extubation failure risk and decrease time from extubation to discharge. Further research is required.
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Affiliation(s)
- Paul Muhle
- University Hospital Muenster, Department of Neurology with Institute for Translational Neurology, Albert-Schweitzer-Campus 1A, 48149 Muenster, Germany.
| | - Inga Claus
- University Hospital Muenster, Department of Neurology with Institute for Translational Neurology, Albert-Schweitzer-Campus 1A, 48149 Muenster, Germany
| | - Bendix Labeit
- University Hospital Muenster, Department of Neurology with Institute for Translational Neurology, Albert-Schweitzer-Campus 1A, 48149 Muenster, Germany
| | - Malte Roderigo
- University Hospital Muenster, Department of Neurology with Institute for Translational Neurology, Albert-Schweitzer-Campus 1A, 48149 Muenster, Germany
| | - Tobias Warnecke
- Klinikum Osnabrück, Department of Neurology, Am Finkenhügel 1, 49076 Osnabrück, Germany
| | - Rainer Dziewas
- Klinikum Osnabrück, Department of Neurology, Am Finkenhügel 1, 49076 Osnabrück, Germany
| | - Sonja Suntrup-Krueger
- University Hospital Muenster, Department of Neurology with Institute for Translational Neurology, Albert-Schweitzer-Campus 1A, 48149 Muenster, Germany
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Mezidi M, Yonis H, Chauvelot L, Deniel G, Dhelft F, Gaillet M, Noirot I, Folliet L, Chabert P, David G, Danjou W, Baboi L, Bettinger C, Bernon P, Girard M, Provoost J, Bazzani A, Bitker L, Richard JC. Spontaneous breathing trial with pressure support on positive end-expiratory pressure and extensive use of non-invasive ventilation versus T-piece in difficult-to-wean patients from mechanical ventilation: a randomized controlled trial. Ann Intensive Care 2024; 14:59. [PMID: 38630372 PMCID: PMC11024068 DOI: 10.1186/s13613-024-01290-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 04/04/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND The aim of this study is to assess whether a strategy combining spontaneous breathing trial (SBT) with both pressure support (PS) and positive end-expiratory pressure (PEEP) and extended use of post-extubation non-invasive ventilation (NIV) (extensively-assisted weaning) would shorten the time until successful extubation as compared with SBT with T-piece (TP) and post-extubation NIV performed in selected patients as advocated by guidelines (standard weaning), in difficult-to-wean patients from mechanical ventilation. METHODS The study is a single-center prospective open label, randomized controlled superiority trial with two parallel groups and balanced randomization with a 1:1 ratio. Eligible patients were intubated patients mechanically ventilated for more than 24 h who failed their first SBT using TP. In the extensively-assisted weaning group, SBT was performed with PS (7 cmH2O) and PEEP (5 cmH2O). In case of SBT success, an additional SBT with TP was performed. Failure of this SBT-TP was an additional criterion for post-extubation NIV in this group in addition to other recommended criteria. In the standard weaning group, SBT was performed with TP, and NIV was performed according to international guidelines. The primary outcome criterion was the time between inclusion and successful extubation evaluated with a Cox model with adjustment on randomization strata. RESULTS From May 2019 to March 2023, 98 patients were included and randomized in the study (49 in each group). Four patients were excluded from the intention-to-treat population (2 in both groups); therefore, 47 patients were analyzed in each group. The extensively-assisted weaning group had a higher median age (68 [58-73] vs. 62 [55-71] yrs.) and similar sex ratio (62% male vs. 57%). Time until successful extubation was not significantly different between extensively-assisted and standard weaning groups (median, 172 [50-436] vs. 95 [47-232] hours, Cox hazard ratio for successful extubation, 0.88 [95% confidence interval: 0.55-1.42] using the standard weaning group as a reference; p = 0.60). All secondary outcomes were not significantly different between groups. CONCLUSION An extensively-assisted weaning strategy did not lead to a shorter time to successful extubation than a standard weaning strategy. Trial registration The trial was registered on ClinicalTrials.gov (NCT03861117), on March 1, 2019, before the inclusion of the first patient. https://clinicaltrials.gov/study/NCT03861117 .
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Affiliation(s)
- Mehdi Mezidi
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France.
- Université Lyon 1, Université de Lyon, Lyon, France.
| | - Hodane Yonis
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Louis Chauvelot
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Guillaume Deniel
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
- Université Lyon 1, Université de Lyon, Lyon, France
- CREATIS INSERM, 1044 CNRS 5220, Villeurbanne, France
| | - François Dhelft
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
- Université Lyon 1, Université de Lyon, Lyon, France
| | - Maxime Gaillet
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
- Université Lyon 1, Université de Lyon, Lyon, France
| | - Ines Noirot
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Laure Folliet
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Paul Chabert
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Guillaume David
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - William Danjou
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Loredana Baboi
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Clotilde Bettinger
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Pauline Bernon
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Mehdi Girard
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Judith Provoost
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Alwin Bazzani
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
| | - Laurent Bitker
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
- Université Lyon 1, Université de Lyon, Lyon, France
- CREATIS INSERM, 1044 CNRS 5220, Villeurbanne, France
| | - Jean-Christophe Richard
- Medical Intensive Care Unit, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France
- Université Lyon 1, Université de Lyon, Lyon, France
- CREATIS INSERM, 1044 CNRS 5220, Villeurbanne, France
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Burns KEA, Rochwerg B, Seely AJE. Ventilator Weaning and Extubation. Crit Care Clin 2024; 40:391-408. [PMID: 38432702 DOI: 10.1016/j.ccc.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Increasing evidence supports specific approaches to liberate patients from invasive ventilation including the use of liberation protocols, inspiratory assistance during spontaneous breathing trials (SBTs), early extubation of patients with chronic obstructive pulmonary disease to noninvasive ventilation, and prophylactic use of noninvasive support strategies after extubation. Additional research is needed to elucidate the best criteria to identify patients who are ready to undergo an SBT and to inform optimal screening frequency, the best SBT technique and duration, extubation assessments, and extubation decision-making. Additional clarity is also needed regarding the optimal timing to measure and report extubation success.
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Affiliation(s)
- Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Medicine and Division of Critical Care, Unity Health Toronto, St. Michaels Hospital, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, Unity Health Toronto, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, Hamilton Health Sciences, Juravinski Hospital, Hamilton, Ontario, Canada; Department of Critical Care, Hamilton Health Sciences, Juravinski Hospital, Hamilton, Ontario, Canada. https://twitter.com/Bram_Rochwerg
| | - Andrew J E Seely
- Department of Critical Care, Ottawa Hospital, Ottawa, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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4
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Szafran JC, Patel BK. Invasive Mechanical Ventilation. Crit Care Clin 2024; 40:255-273. [PMID: 38432695 DOI: 10.1016/j.ccc.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Invasive mechanical ventilation allows clinicians to support gas exchange and work of breathing in patients with respiratory failure. However, there is also potential for iatrogenesis. By understanding the benefits and limitations of different modes of ventilation and goals for gas exchange, clinicians can choose a strategy that provides appropriate support while minimizing harm. The ventilator can also provide crucial diagnostic information in the form of respiratory mechanics. These, and the mechanical ventilation strategy, should be regularly reassessed.
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Affiliation(s)
- Jennifer C Szafran
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA.
| | - Bhakti K Patel
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA
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Dolinay T, Hsu L, Maller A, Walsh BC, Szűcs A, Jerng JS, Jun D. Ventilator Weaning in Prolonged Mechanical Ventilation-A Narrative Review. J Clin Med 2024; 13:1909. [PMID: 38610674 PMCID: PMC11012923 DOI: 10.3390/jcm13071909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/11/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
Patients requiring mechanical ventilation (MV) beyond 21 days, usually referred to as prolonged MV, represent a unique group with significant medical needs and a generally poor prognosis. Research suggests that approximately 10% of all MV patients will need prolonged ventilatory care, and that number will continue to rise. Although we have extensive knowledge of MV in the acute care setting, less is known about care in the post-ICU setting. More than 50% of patients who were deemed unweanable in the ICU will be liberated from MV in the post-acute setting. Prolonged MV also presents a challenge in care for medically complex, elderly, socioeconomically disadvantaged and marginalized individuals, usually at the end of their life. Patients and their families often rely on ventilator weaning facilities and skilled nursing homes for the continuation of care, but home ventilation is becoming more common. The focus of this review is to discuss recent advances in the weaning strategies in prolonged MV, present their outcomes and provide insight into the complexity of care.
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Affiliation(s)
- Tamás Dolinay
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
| | - Lillian Hsu
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
| | - Abigail Maller
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
| | - Brandon Corbett Walsh
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
- Department of Medicine, Division of Palliative Care Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Attila Szűcs
- Department of Anesthesiology, András Jósa County Hospital, 4400 Nyíregyháza, Hungary;
| | - Jih-Shuin Jerng
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, National Taiwan University Hospital, Taipei 100, Taiwan;
| | - Dale Jun
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
- Pulmonary, Critical Care and Sleep Section, West Los Angeles VA Medical Center, Los Angeles, CA 90073, USA
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6
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Lin H, Yao M, Qin Z, Fu S, Wang H. Predictive values of ultrasonic diaphragm thickening fraction combined with integrative weaning index in weaning patients with mechanical ventilation: a retrospective study. J Cardiothorac Surg 2024; 19:66. [PMID: 38321528 PMCID: PMC10845507 DOI: 10.1186/s13019-024-02544-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 01/28/2024] [Indexed: 02/08/2024] Open
Abstract
OBJECTIVE We aimed to explore the predictive values of ultrasonic diaphragm thickening fraction (DTF) combined with integrative weaning index (IWI) in weaning patients with mechanical ventilation. METHODS Patients with mechanical ventilation who received oral endotracheal intubation from September 2020 to September 2021 were included in this retrospective study. Before the start of the spontaneous breathing test (SBT), IWI was calculated according to the blood gas analysis parameters and parameters read in volume control mode. After the start of SBT, DTF was calculated according to the end-expiratory thickness and end-inspiratory thickness of the right diaphragm. The receiver operating curve (ROC) was used to evaluate the predictive value of DTF and IWI for successful weaning, and the sensitivity and specificity were calculated according to the best critical value. RESULTS The sensitivity, specificity, and best cutoff value of DTF to predict successful weaning was 0.772, 0.727, and 0.293, respectively, and the area under the curve (AUC) was 0.72 (95%CI 0.59-0.86, p = 0.003). The sensitivity, specificity, and best cutoff value of IWI to predict successful weaning was 0.614, 0.909, 53.00, respectively, and AUC was 0.82 (95%CI 0.72-0.91, p < 0.001). The sensitivity, specificity, and best cutoff value of the combination of DTF and IWI to predict successful weaning was 0.614, 0.909, 17.848, respectively, and AUC was 0.84 (95%CI 0.75-0.93, p < 0.001). CONCLUSION DTF and IWI can guide the selection of weaning, while DTF combined with IWI can improve the effect of weaning prediction and provide support for patients' weaning safety.
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Affiliation(s)
- Hai Lin
- Emergency Department, Maanshan People's Hospital, No. 45 Hubei Road, Ma'anshan, Anhui, 243000, China.
| | - Mingming Yao
- Emergency Department, Maanshan People's Hospital, No. 45 Hubei Road, Ma'anshan, Anhui, 243000, China
| | - Ziwen Qin
- Emergency Department, Maanshan People's Hospital, No. 45 Hubei Road, Ma'anshan, Anhui, 243000, China
| | - Shilin Fu
- Emergency Department, Maanshan People's Hospital, No. 45 Hubei Road, Ma'anshan, Anhui, 243000, China
| | - Hongyou Wang
- Emergency Department, Maanshan People's Hospital, No. 45 Hubei Road, Ma'anshan, Anhui, 243000, China
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Burns KEA, Khan J, Phoophiboon V, Trivedi V, Gomez-Builes JC, Giammarioli B, Lewis K, Chaudhuri D, Desai K, Friedrich JO. Spontaneous Breathing Trial Techniques for Extubating Adults and Children Who Are Critically Ill: A Systematic Review and Meta-Analysis. JAMA Netw Open 2024; 7:e2356794. [PMID: 38393729 PMCID: PMC10891471 DOI: 10.1001/jamanetworkopen.2023.56794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/28/2023] [Indexed: 02/25/2024] Open
Abstract
Importance Considerable controversy exists regarding the best spontaneous breathing trial (SBT) technique to use. Objective To summarize trials comparing alternative SBTs. Data Sources Several databases (MEDLINE [from inception to February 2023], the Cochrane Central Register of Controlled Trials [in February 2023], and Embase [from inception to February 2023] and 5 conference proceedings (from January 1990 to April 2023) were searched in this systematic review and meta-analysis. Study Selection Randomized trials directly comparing SBT techniques in critically ill adults or children and reporting at least 1 clinical outcome were selected. Data Extraction and Synthesis Paired reviewers independently screened citations, abstracted data, and assessed quality for the systematic review and meta-analysis using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA guidelines). Data were pooled using random-effects models. Main Outcomes and Measures Primary outcomes included SBT success, extubation success, and reintubation. Results The systematic review and meta-analysis identified 40 trials that included 6716 patients. Low-quality evidence (14 trials [n = 4459]) suggested that patients were not more likely to pass a pressure support (PS) compared with a T-piece SBT (risk ratio [RR], 1.04; 95% CI, 0.97-1.11; P = .31; I2 = 73%), unless 1 outlier trial accounting for all heterogeneity was excluded (RR, 1.09; 95% CI, 1.06-1.12; P < .001; I2 = 0% [13 trials; n = 3939]; moderate-quality evidence), but were significantly more likely to be successfully extubated (RR, 1.07; 95% CI, 1.04-1.10; P < .001; I2 = 0%; 16 trials [n = 4462]; moderate-quality evidence). Limited data (5 trials [n = 502]) revealed that patients who underwent automatic tube compensation/continuous positive airway pressure compared with PS SBTs had a significantly higher successful extubation rate (RR, 1.10; 95% CI, 1.00-1.21; P = .04; I2 = 0% [low-quality evidence]). Compared with T-piece SBTs, high-flow oxygen SBTs (3 trials [n = 386]) had significantly higher successful extubation (RR, 1.06; 95% CI, 1.00-1.11; P = .04; I2 = 0%) and lower reintubation (RR, 0.37; 95% CI, 0.21-0.65; P = <.001; I2 = 0% [both low-quality evidence]) rates. Credible subgroup effects were not found. Conclusions and Relevance In this systematic review and meta-analysis, the findings suggest that patients undergoing PS compared with T-piece SBTs were more likely to be extubated successfully and more likely to pass an SBT, after exclusion of an outlier trial. Pressure support SBTs were not associated with increased risk of reintubation. Future trials should compare SBT techniques that maximize differences in inspiratory support.
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Affiliation(s)
- Karen E. A. Burns
- Department of Critical Care, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine, Department of Medicine, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jeena Khan
- Department of Critical Care, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | - Vorakamol Phoophiboon
- Department of Critical Care, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Vatsal Trivedi
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
| | | | - Benedetta Giammarioli
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kimberley Lewis
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Critical Care, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Dipayan Chaudhuri
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Critical Care, St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Kairavi Desai
- Michael G. DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jan O. Friedrich
- Department of Critical Care, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine, Department of Medicine, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
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Ha TS, Oh DK, Lee HJ, Chang Y, Jeong IS, Sim YS, Hong SK, Park S, Suh GY, Park SY. Liberation from mechanical ventilation in critically ill patients: Korean Society of Critical Care Medicine Clinical Practice Guidelines. Acute Crit Care 2024; 39:1-23. [PMID: 38476061 PMCID: PMC11002621 DOI: 10.4266/acc.2024.00052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 02/14/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Successful liberation from mechanical ventilation is one of the most crucial processes in critical care because it is the first step by which a respiratory failure patient begins to transition out of the intensive care unit and return to their own life. Therefore, when devising appropriate strategies for removing mechanical ventilation, it is essential to consider not only the individual experiences of healthcare professionals, but also scientific and systematic approaches. Recently, numerous studies have investigated methods and tools for identifying when mechanically ventilated patients are ready to breathe on their own. The Korean Society of Critical Care Medicine therefore provides these recommendations to clinicians about liberation from the ventilator. METHODS Meta-analyses and comprehensive syntheses were used to thoroughly review, compile, and summarize the complete body of relevant evidence. All studies were meticulously assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) method, and the outcomes were presented succinctly as evidence profiles. Those evidence syntheses were discussed by a multidisciplinary committee of experts in mechanical ventilation, who then developed and approved recommendations. RESULTS Recommendations for nine PICO (population, intervention, comparator, and outcome) questions about ventilator liberation are presented in this document. This guideline includes seven conditional recommendations, one expert consensus recommendation, and one conditional deferred recommendation. CONCLUSIONS We developed these clinical guidelines for mechanical ventilation liberation to provide meaningful recommendations. These guidelines reflect the best treatment for patients seeking liberation from mechanical ventilation.
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Affiliation(s)
- Tae Sun Ha
- Department of Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Dong Kyu Oh
- Department of Pulmonology, Dongkang Medical Center, Ulsan, Korea
| | - Hak-Jae Lee
- Division of Acute Care Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Youjin Chang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inje University Sanggye Paik Hospital, College of Medicine, Inje University, Seoul, Korea
| | - In Seok Jeong
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Gwangju, Korea
| | - Yun Su Sim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
- Lung Research Institute of Hallym University College of Medicine, Chuncheon, Korea
| | - Suk-Kyung Hong
- Division of Acute Care Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sunghoon Park
- Lung Research Institute of Hallym University College of Medicine, Chuncheon, Korea
- Department of Pulmonary, Allergy, and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - So Young Park
- Lung Research Institute of Hallym University College of Medicine, Chuncheon, Korea
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
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9
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Hernández Martínez G, Rodriguez P, Soto J, Caritg O, Castellví-Font A, Mariblanca B, García AM, Colinas L, Añon JM, Parrilla-Gomez FJ, Silva-Obregón JA, Masclans JR, Propin A, Cuadra A, Dalorzo MG, Rialp G, Suarez-Sipmann F, Roca O. Effect of aggressive vs conservative screening and confirmatory test on time to extubation among patients at low or intermediate risk: a randomized clinical trial. Intensive Care Med 2024; 50:258-267. [PMID: 38353714 DOI: 10.1007/s00134-024-07330-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/19/2024] [Indexed: 03/03/2024]
Abstract
PURPOSE This study aimed to determine the best strategy to achieve fast and safe extubation. METHODS This multicenter trial randomized patients with primary respiratory failure and low-to-intermediate risk for extubation failure with planned high-flow nasal cannula (HFNC) preventive therapy. It included four groups: (1) conservative screening with ratio of partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2) ≥ 150 and positive end-expiratory pressure (PEEP) ≤ 8 cmH2O plus conservative spontaneous breathing trial (SBT) with pressure support 5 cmH2O + PEEP 0 cmH2O); (2) screening with ratio of partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2) ≥ 150 and PEEP ≤ 8 plus aggressive SBT with pressure support 8 + PEEP 5; (3) aggressive screening with PaO2/FiO2 > 180 and PEEP 10 maintained until the SBT with pressure support 8 + PEEP 5; (4) screening with PaO2/FiO2 > 180 and PEEP 10 maintained until the SBT with pressure support 5 + PEEP 0. Primary outcomes were time-to-extubation and simple weaning rate. Secondary outcomes included reintubation within 7 days after extubation. RESULTS Randomization to the aggressive-aggressive group was discontinued at the interim analysis for safety reasons. Thus, 884 patients who underwent at least 1 SBT were analyzed (conservative-conservative group, n = 256; conservative-aggressive group, n = 267; aggressive-conservative group, n = 261; aggressive-aggressive, n = 100). Median time to extubation was lower in the groups with aggressive screening (p < 0.001). Simple weaning rates were 45.7%, 76.78% (205 patients), 71.65%, and 91% (p < 0.001), respectively. Reintubation rates did not differ significantly (p = 0.431). CONCLUSION Among patients at low or intermediate risk for extubation failure with planned HFNC, combining aggressive screening with preventive PEEP and a conservative SBT reduced the time to extubation without increasing the reintubation rate.
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Affiliation(s)
- Gonzalo Hernández Martínez
- Complejo Hospitalario Universitario de Toledo, Toledo, Spain.
- Grupo de Investigación en Disfunción y Fallo Orgánico en La Agresión (IdiPAZ), Madrid, Spain.
- Ciber Enfermedades Respiratorias (CIBERES), Health Institute Carlos III, Madrid, Spain.
| | | | - Jesus Soto
- Hospital Universitario La Paz, Madrid, Spain
| | - Oriol Caritg
- Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Vall d'Hebron Institut de Reserca (VHIR), Barcelona, Spain
| | - Andrea Castellví-Font
- Hospital del Mar, Barcelona, Spain
- Grupo de Investigación del Paciente Crítico (GREPAC), Institut Hospital del Mar d´Investigacions Mèdiques (IMIM), Barcelona, Spain
| | | | | | - Laura Colinas
- Complejo Hospitalario Universitario de Toledo, Toledo, Spain
| | - Jose Manuel Añon
- Hospital Universitario La Paz, Madrid, Spain
- Grupo de Investigación en Disfunción y Fallo Orgánico en La Agresión (IdiPAZ), Madrid, Spain
| | - Francisco Jose Parrilla-Gomez
- Hospital del Mar, Barcelona, Spain
- Grupo de Investigación del Paciente Crítico (GREPAC), Institut Hospital del Mar d´Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Jose Alberto Silva-Obregón
- Hospital Universitario de Guadalajara, Guadalajara, Spain
- Grupo de Investigación del Paciente Hematológico, Instituto de Investigación Sanitaria Hospital Universitario La Paz (IdiPAZ), Madrid, Spain
| | - Joan Ramon Masclans
- Hospital del Mar, Barcelona, Spain
- Grupo de Investigación del Paciente Crítico (GREPAC), Institut Hospital del Mar d´Investigacions Mèdiques (IMIM), Barcelona, Spain
- MELIS, Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | | | - Alicia Cuadra
- Complejo Hospitalario Universitario de Toledo, Toledo, Spain
| | | | - Gemma Rialp
- Hospital Universitario Son Llàtzer, Palma, Spain
| | | | - Oriol Roca
- Parc Taulí Hospital Universitari, Institut de Investigació i Innovació Parc Taulí (I3PT-CERCA), Sabadell, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
- Ciber Enfermedades Respiratorias (CIBERES), Health Institute Carlos III, Madrid, Spain
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10
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Klouche K, Brunot V, Larcher R, Lautrette A. Weaning from Kidney Replacement Therapy in the Critically Ill Patient with Acute Kidney Injury. J Clin Med 2024; 13:579. [PMID: 38276085 PMCID: PMC10816626 DOI: 10.3390/jcm13020579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/12/2024] [Accepted: 01/16/2024] [Indexed: 01/27/2024] Open
Abstract
Around 10% of critically ill patients suffer acute kidney injury (AKI) requiring kidney replacement therapy (KRT), with a mortality rate approaching 50%. Although most survivors achieve sufficient renal recovery to be weaned from KRT, there are no recognized guidelines on the optimal period for weaning from KRT. A systematic review was conducted using a peer-reviewed strategy, combining themes of KRT (intermittent hemodialysis, CKRT: continuous veno-venous hemo/dialysis/filtration/diafiltration, sustained low-efficiency dialysis/filtration), factors predictive of successful weaning (defined as a prolonged period without new KRT) and patient outcomes. Our research resulted in studies, all observational, describing clinical and biological parameters predictive of successful weaning from KRT. Urine output prior to KRT cessation is the most studied variable and the most widely used in practice. Other predictive factors, such as urinary urea and creatinine and new urinary and serum renal biomarkers, including cystatin C and neutrophil gelatinase-associated lipocalin (NGAL), were also analyzed in the light of recent studies. This review presents the rationale for early weaning from KRT, the parameters that can guide it, and its practical modalities. Once the patient's clinical condition has stabilized and volume status optimized, a diuresis greater than 500 mL/day should prompt the intensivist to consider weaning. Urinary parameters could be useful in predicting weaning success but have yet to be validated.
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Affiliation(s)
- Kada Klouche
- Intensive Care Unit Département, Lapeyronie University Hospital Montpellier, 34295 Montpellier, France; (V.B.); (R.L.)
- Phymedexp, Faculty of Medicine, Université de Montpellier, Inserm, Centre National de Recherche Scientifique (CNRS), CHRU de Montpellier, 34295 Montpellier, France
| | - Vincent Brunot
- Intensive Care Unit Département, Lapeyronie University Hospital Montpellier, 34295 Montpellier, France; (V.B.); (R.L.)
| | - Romaric Larcher
- Intensive Care Unit Département, Lapeyronie University Hospital Montpellier, 34295 Montpellier, France; (V.B.); (R.L.)
- Phymedexp, Faculty of Medicine, Université de Montpellier, Inserm, Centre National de Recherche Scientifique (CNRS), CHRU de Montpellier, 34295 Montpellier, France
| | - Alexandre Lautrette
- Centre de Lutte Contre le Cancer Jean PERRIN, Médecine Intensive Réanimation, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France;
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11
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Menguy J, De Longeaux K, Bodenes L, Hourmant B, L'Her E. Defining predictors for successful mechanical ventilation weaning, using a data-mining process and artificial intelligence. Sci Rep 2023; 13:20483. [PMID: 37993526 PMCID: PMC10665387 DOI: 10.1038/s41598-023-47452-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/14/2023] [Indexed: 11/24/2023] Open
Abstract
Mechanical ventilation weaning within intensive care units (ICU) is a difficult process, while crucial when considering its impact on morbidity and mortality. Failed extubation and prolonged mechanical ventilation both carry a significant risk of adverse events. We aimed to determine predictive factors of extubation success using data-mining and artificial intelligence. A prospective physiological and biomedical signal data warehousing project. A 21-beds medical Intensive Care Unit of a University Hospital. Adult patients undergoing weaning from mechanical ventilation. Hemodynamic and respiratory parameters of mechanically ventilated patients were prospectively collected and combined with clinical outcome data. One hundred and eight patients were included, for 135 spontaneous breathing trials (SBT) allowing to identify physiological parameters either measured before or during the trial and considered as predictive for extubation success. The Early-Warning Score Oxygen (EWSO2) enables to discriminate patients deemed to succeed extubation, at 72-h and 7-days. Cut-off values for EWSO2 (AUC = 0.80; Se = 0.75; Sp = 0.76), mean arterial pressure and heart-rate variability parameters were determined. A predictive model for extubation success was established including body-mass index (BMI) on inclusion, occlusion pressure at 0,1 s. (P0.1) and heart-rate analysis parameters (LF/HF) both measured before SBT, and heart rate during SBT (global performance 62%; 83%). The data-mining process enabled to detect independent predictive factors for extubation success and to develop a dynamic predictive model using artificial intelligence. Such predictive tools may help clinicians to better discriminate patients deemed to succeed extubation and thus improve clinical performance.
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Affiliation(s)
- Juliette Menguy
- Medical Intensive Care Unit, CHRU de la Cavale Blanche, Bvd Tanguy-Prigent, 29609, Brest Cedex, France
| | - Kahaia De Longeaux
- Medical Intensive Care Unit, CHRU de la Cavale Blanche, Bvd Tanguy-Prigent, 29609, Brest Cedex, France
- LATIM INSERM UMR 1101, Université de Bretagne Occidentale, 29200, Brest, France
| | - Laetitia Bodenes
- Medical Intensive Care Unit, CHRU de la Cavale Blanche, Bvd Tanguy-Prigent, 29609, Brest Cedex, France
| | - Baptiste Hourmant
- Medical Intensive Care Unit, CHRU de la Cavale Blanche, Bvd Tanguy-Prigent, 29609, Brest Cedex, France
| | - Erwan L'Her
- Medical Intensive Care Unit, CHRU de la Cavale Blanche, Bvd Tanguy-Prigent, 29609, Brest Cedex, France.
- LATIM INSERM UMR 1101, Université de Bretagne Occidentale, 29200, Brest, France.
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12
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Teijeiro-Paradis R, Cherkos Dawit T, Munshi L, Ferguson ND, Fan E. Liberation From Venovenous Extracorporeal Membrane Oxygenation for Respiratory Failure: A Scoping Review. Chest 2023; 164:1184-1203. [PMID: 37353070 DOI: 10.1016/j.chest.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 06/03/2023] [Accepted: 06/14/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Safe and timely liberation from venovenous extracorporeal membrane oxygenation (ECMO) would be expected to reduce the duration of ECMO, the risk of complications, and costs. However, how to liberate patients from venovenous ECMO effectively remains understudied. RESEARCH QUESTION What is the current state of the evidence on liberation from venovenous ECMO? STUDY DESIGN AND METHODS We systematically searched for relevant publications on liberation from venovenous ECMO in Medline and EMBASE. Citations were included if the manuscripts provided any of the following: criteria for readiness for liberation, a liberation protocol, or a definition of successful decannulation or decannulation failure. We included randomized trials, observational trials, narrative reviews, guidelines, editorials, and commentaries. We excluded single case reports and citations where the full text was unavailable. RESULTS We screened 1,467 citations to identify 39 key publications on liberation from venovenous ECMO. We then summarized the data into five main topics: current strategies used for liberation, criteria used to define readiness for liberation, conducting liberation trials, criteria used to proceed with decannulation, and parameters used to predict decannulation outcomes. INTERPRETATION Practices on liberation from venovenous ECMO are heterogeneous and are influenced strongly by clinician preference. Additional research on liberation thresholds is needed to define optimal liberation strategies and to close existing knowledge gaps in essential topics on liberation from venovenous ECMO.
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Affiliation(s)
- Ricardo Teijeiro-Paradis
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Tsega Cherkos Dawit
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Mekelle University College of Health Sciences, Mekelle, Ethiopia
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Respirology & Critical Care, Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Respirology & Critical Care, Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Respirology & Critical Care, Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada.
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13
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Park JE, Kim DY, Park JW, Jung YJ, Lee KS, Park JH, Sheen SS, Park KJ, Sunwoo MH, Chung WY. Development of a Machine Learning Model for Predicting Weaning Outcomes Based Solely on Continuous Ventilator Parameters during Spontaneous Breathing Trials. Bioengineering (Basel) 2023; 10:1163. [PMID: 37892893 PMCID: PMC10604888 DOI: 10.3390/bioengineering10101163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 09/30/2023] [Accepted: 10/02/2023] [Indexed: 10/29/2023] Open
Abstract
Discontinuing mechanical ventilation remains challenging. We developed a machine learning model to predict weaning outcomes using only continuous monitoring parameters obtained from ventilators during spontaneous breathing trials (SBTs). Patients who received mechanical ventilation in the medical intensive care unit at a tertiary university hospital from 2019-2021 were included in this study. During the SBTs, three waveforms and 25 numerical data were collected as input variables. The proposed convolutional neural network (CNN)-based weaning prediction model extracts features from input data with diverse lengths. Among 138 enrolled patients, 35 (25.4%) experienced weaning failure. The dataset was randomly divided into training and test sets (8:2 ratio). The area under the receiver operating characteristic curve for weaning success by the prediction model was 0.912 (95% confidence interval [CI], 0.795-1.000), with an area under the precision-recall curve of 0.767 (95% CI, 0.434-0.983). Furthermore, we used gradient-weighted class activation mapping technology to provide visual explanations of the model's prediction, highlighting influential features. This tool can assist medical staff by providing intuitive information regarding readiness for extubation without requiring any additional data collection other than SBT data. The proposed predictive model can assist clinicians in making ventilator weaning decisions in real time, thereby improving patient outcomes.
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Affiliation(s)
- Ji Eun Park
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (J.E.P.)
| | - Do Young Kim
- Land Combat System Center, Hanwha Systems, Sungnam 13524, Republic of Korea;
| | - Ji Won Park
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (J.E.P.)
| | - Yun Jung Jung
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (J.E.P.)
| | - Keu Sung Lee
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (J.E.P.)
| | - Joo Hun Park
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (J.E.P.)
| | - Seung Soo Sheen
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (J.E.P.)
| | - Kwang Joo Park
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (J.E.P.)
| | - Myung Hoon Sunwoo
- Department of Electrical and Computer Engineering, Ajou University, Suwon 16499, Republic of Korea;
| | - Wou Young Chung
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (J.E.P.)
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14
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Chichra A, Tickoo M, Honiden S. Managing the Chronically Ventilated Critically Ill Population. J Intensive Care Med 2023:8850666231203601. [PMID: 37787184 DOI: 10.1177/08850666231203601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
Advances in intensive care over the past few decades have significantly improved the chances of survival for patients with acute critical illness. However, this progress has also led to a growing population of patients who are dependent on intensive care therapies, including prolonged mechanical ventilation (PMV), after the initial acute period of critical illness. These patients are referred to as the "chronically critically ill" (CCI). CCI is a syndrome characterized by prolonged mechanical ventilation, myoneuropathies, neuroendocrine disorders, nutritional deficiencies, cognitive and psychiatric issues, and increased susceptibility to infections. It is associated with high morbidity and mortality as well as a significant increase in healthcare costs. In this article, we will review disease burden, outcomes, psychiatric effects, nutritional and ventilator weaning strategies as well as the role of palliative care for CCI with a specific focus on those requiring PMV.
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Affiliation(s)
- Astha Chichra
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Mayanka Tickoo
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Shyoko Honiden
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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15
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Grissom CK, Holubkov R, Carpenter L, Hanna B, Jacobs JR, Jones C, Knighton AJ, Leither L, Lisonbee D, Peltan ID, Winberg C, Wolfe D, Srivastava R. Implementation of coordinated spontaneous awakening and breathing trials using telehealth-enabled, real-time audit and feedback for clinician adherence (TEACH): a type II hybrid effectiveness-implementation cluster-randomized trial. Implement Sci 2023; 18:45. [PMID: 37735443 PMCID: PMC10515061 DOI: 10.1186/s13012-023-01303-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/09/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Intensive care unit (ICU) patients on mechanical ventilation often require sedation and analgesia to improve comfort and decrease pain. Prolonged sedation and analgesia, however, may increase time on mechanical ventilation, risk for ventilator associated pneumonia, and delirium. Coordinated interruptions in sedation [spontaneous awakening trials (SATs)] and spontaneous breathing trials (SBTs) increase ventilator-free days and improve mortality. Coordination of SATs and SBTs is difficult with substantial implementation barriers due to difficult-to-execute sequencing between nurses and respiratory therapists. Telehealth-enabled remote care has the potential to overcome these barriers and improve coordinated SAT and SBT adherence by enabling proactive high-risk patient monitoring, surveillance, and real-time assistance to frontline ICU teams. METHODS The telehealth-enabled, real-time audit and feedback for clinician adherence (TEACH) study will determine whether adding a telehealth augmented real-time audit and feedback to a usual supervisor-led audit and feedback intervention will yield higher coordinated SAT and SBT adherence and more ventilator-free days in mechanically ventilated patients than a usual supervisor-led audit and feedback intervention alone in a type II hybrid effectiveness-implementation cluster-randomized clinical trial in 12 Intermountain Health hospitals with 15 ICUs. In the active comparator control group (six hospitals), the only intervention is the usual supervisor-led audit and feedback implementation. The telehealth-enabled support (TEACH) intervention in six hospitals adds real-time identification of patients eligible for a coordinated SAT and SBT and consultative input from telehealth respiratory therapists, nurses, and physicians to the bedside clinicians to promote adherence including real-time assistance with execution. All intubated and mechanically ventilated patients ≥ 16 years of age are eligible for enrollment except for patients who die on the day of intubation or have preexisting brain death. Based on preliminary power analyses, we plan a 36-month intervention period that includes a 90-day run-in period. Estimated enrollment in the final analysis is up to 9900 mechanically ventilated patients over 33 months. DISCUSSION The TEACH study will enhance implementation science by providing insight into how a telehealth intervention augmenting a usual audit and feedback implementation may improve adherence to coordinated SAT and SBT and increase ventilator-free days. TRIAL REGISTRATION Clinicaltrials.gov, NCT05141396 , registered 12/02/2021.
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Affiliation(s)
- Colin K Grissom
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, 84107, USA.
- Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, UT, USA.
- Critical Care Operations, Intermountain Health, Canyons Region, Murray, UT, USA.
| | - Richard Holubkov
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Lori Carpenter
- Respiratory Care, Intermountain Health, Canyons Region, Salt Lake City, UT, USA
| | - Bridgett Hanna
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT, USA
| | - Jason R Jacobs
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, 84107, USA
| | - Christopher Jones
- Critical Care Operations, Intermountain Health, Canyons Region, Murray, UT, USA
| | - Andrew J Knighton
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT, USA
| | - Lindsay Leither
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, 84107, USA
| | - Dee Lisonbee
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT, USA
| | - Ithan D Peltan
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, 84107, USA
- Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Carrie Winberg
- Respiratory Care, Intermountain Health, Canyons Region, Salt Lake City, UT, USA
| | - Doug Wolfe
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT, USA
| | - Rajendu Srivastava
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT, USA
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, UT, USA
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16
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Ferrera MC, Hayes MM. How I Teach: Liberation from Mechanical Ventilation. ATS Sch 2023; 4:372-384. [PMID: 37795117 PMCID: PMC10547038 DOI: 10.34197/ats-scholar.2023-0037ht] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023] Open
Abstract
Liberation from mechanical ventilation is one of the most important decisions in the intensive care unit (ICU), as extubation failure is associated with worse outcomes. Determining readiness to extubate can be challenging in complex patients and lead to provider stress. Here, we provide our approach to teaching liberation from mechanical ventilation for learners in the ICU. We use a case-based didactic session that purposefully introduces ambiguous cases without a clear answer, utilizing aspects of both cognitive load theory and adult learning theories.
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Affiliation(s)
- Michael C Ferrera
- Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Margaret M Hayes
- Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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17
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Liu J, Shao T, Chen H, Ma C, Lu X, Yang X, Song K, Wang L, Lei S, Wang D. Serum cholinesterase as a new nutritional indicator for predicting weaning failure in patients. Front Med (Lausanne) 2023; 10:1175089. [PMID: 37502364 PMCID: PMC10368973 DOI: 10.3389/fmed.2023.1175089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/26/2023] [Indexed: 07/29/2023] Open
Abstract
Aim The objective of this study is to examine the correlation between patient serum cholinesterase (SCHE) concentration and weaning failure in the context of invasive mechanical ventilation (IMV), as well as to identify predictors of ventilator weaning failure. Additionally, this study investigates the potential relationship between SCHE and nutritional risk for developing more effective weaning strategies. Method A retrospective observational study was conducted. The sample was collected from 227 patients with IMV over 48 h who underwent SBT before weaning. Relevant experimental samples and data collection were analyzed at the time of patient admission and before the initiation of the SBT. The correlation between SCHE and weaning failure was determined by multifactorial logistic regression and propensity matching scores. Results Weaning was successful in 127 patients and failed in 100 patients. Depending on the difficulty of weaning, 55 of these patients had difficulty in weaning and 45 had long-term weaning. In the crude cohort, experimental data collected on the day of SBT showed that SCHE concentrations were higher in patients with successful weaning than in those with failed weaning (4,514 u/l vs. 3,190 u/l p < 0.01). The critical value for predicting weaning failure was SCHE 3,228 u/l (p < 0.01). Ventilator weaning failure was predicted by multifactorial logistic regression analysis of SCHE, heart rate, and PaO2 before SBT, with SCHE predicting ventilator weaning failure (AUC 0.714; 95% CI 0.647-0.782) better than heart rate (AUC 0.618; 95% CI 0.545-0.690), PaO2 (AUC 0.59; 95% CI 0.515-0.664). After propensity-matched scores, SCHE remained an independent predictor of weaning failure (p = 0.05). And the SCHE concentration was strongly correlated with the patient's weaning difficulties (p < 0.01). The Nutrition Risk in Critically Ill (NUTRIC) score was also significantly correlated with SCHE according to Spearman's correlation analysis (p < 0.01). Conclusion Our study revealed that the patients who experienced weaning failure exhibited lower SCHE values compared to those who successfully underwent weaning. Before spontaneous breathing trial (SBT), SCHE, heart rate, and PaO2 were identified as independent predictors of weaning failure. Following propensity score matching (PSM), SCHE and heart rate remained independent predictors. Patients with SCHE levels below 3,228 u/l should undergo careful evaluation before weaning. Our findings suggest that malnutrition may be a contributing factor to weaning failure in patients.
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Affiliation(s)
- Jiaping Liu
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Tianyu Shao
- Department of Oncology, Guang' Anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Hanwen Chen
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Chenyang Ma
- Department of Traditional Chinese Medicine, The Second People’s Hospital of Xiaoshan District, Hangzhou, China
| | - Xiaohui Lu
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Xiaoming Yang
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Kang Song
- The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, China
| | - Lu Wang
- The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, China
| | - Shu Lei
- The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, China
| | - Dafen Wang
- The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, China
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Ghamari AA, Amini K, Daei Sorkhabi A, Sarkesh A, Saghaleini SH, Asghari R, Rezayi M, Mahmoodpoor A. Diagnostic value of an increase in central venous pressure during SBT for prediction of weaning failure in mechanically ventilated patients: A cross-sectional study. Health Sci Rep 2023; 6:e1204. [PMID: 37064307 PMCID: PMC10102306 DOI: 10.1002/hsr2.1204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 03/12/2023] [Accepted: 03/24/2023] [Indexed: 04/18/2023] Open
Abstract
Background Timely and successful extubation is an essential step forward in clinical practice to minimize complications of mechanical ventilation and unsuccessful weaning processes. Thus, research into predictive factors of weaning outcome to optimize spontaneous breathing trial (SBT) precision before extubation is critical in intensive care practices. In this study, we aimed to investigate the predictive factors of the weaning outcome before and during SBT in mechanically ventilated patients. Methods In this cross-sectional study, 159 mechanically ventilated patients who were eligible for SBT were enrolled. Of these patients, 140 had successful extubation, whereas the remainder failed. Each patient's PaCO2 and PaO2 levels, respiratory rate (RR), SpO2, mean arterial pressure (MAP), heart rate (HR), and central venous pressure (CVP) values at the start of SBT, 3 min later, and at the end of SBT were measured. These values, along with the patients' clinical characteristics, were then investigated to determine if there was any correlation between these variables and the weaning outcome. Results Our analysis revealed that increase in CVP, independent of hemoglobin (Hb) concentration, PaO2, SpO2, duration of mechanical ventilation (MV), length of intensive care unit (ICU) stay, and SBT process, as well as underlying disease, was positively correlated with extubation/weaning failure. While age, gender, vital signs (MAP, RR, and HR), sequential organ failure assessment (SOFA), and acute physiology and chronic health evaluation (APACHE) scores had no significant correlation with patients' extubation outcomes. Conclusion According to our findings, integrating CVP assessment into SBT besides routine indices measurement and monitoring can be considered for the prediction of weaning outcome in critically ill mechanically ventilated patients.
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Affiliation(s)
- Ali Akbar Ghamari
- Intensive Care Unit, Imam Reza HospitalTabriz University of Medical SciencesTabrizIran
| | - Keivan Amini
- Student Research CommitteeTabriz University of Medical SciencesTabrizIran
| | - Amin Daei Sorkhabi
- Student Research CommitteeTabriz University of Medical SciencesTabrizIran
| | - Aila Sarkesh
- Student Research CommitteeTabriz University of Medical SciencesTabrizIran
| | - Seyed Hadi Saghaleini
- Intensive Care Unit, Imam Reza HospitalTabriz University of Medical SciencesTabrizIran
| | - Roghayeh Asghari
- Intensive Care Unit, Imam Reza HospitalTabriz University of Medical SciencesTabrizIran
| | - Mansour Rezayi
- Intensive Care Unit, Imam Reza HospitalTabriz University of Medical SciencesTabrizIran
| | - Ata Mahmoodpoor
- Intensive Care Unit, Imam Reza HospitalTabriz University of Medical SciencesTabrizIran
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19
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Girard M, Deschamps J, Razzaq S, Lavoie N, Denault A, Beaubien-Souligny W. Emerging Applications of Extracardiac Ultrasound in Critically Ill Cardiac Patients. Can J Cardiol 2023; 39:444-457. [PMID: 36509177 DOI: 10.1016/j.cjca.2022.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/21/2022] [Accepted: 11/30/2022] [Indexed: 12/13/2022] Open
Abstract
Point-of-care ultrasound has evolved as an invaluable diagnostic modality and procedural guidance tool in the care of critically ill cardiac patients. Beyond focused cardiac ultrasound, additional extracardiac ultrasound modalities may provide important information at the bedside. In addition to new uses of existing modalities, such as pulsed-wave Doppler ultrasound, the development of new applications is fostered by the implementation of additional features in mid-range ultrasound machines commonly acquired for intensive care units, such as tissue elastography, speckle tracking, and contrast-enhanced ultrasound quantification software. This review explores several areas in which ultrasound imaging technology may transform care in the future. First, we review how lung ultrasound in mechanically ventilated patients can enable the personalization of ventilator parameters and help to liberate them from mechanical ventilation. Second, we review the role of venous Doppler in the assessment of organ congestion and how tissue elastography may complement this application. Finally, we explore how contrast-enhanced ultrasound could be used to assess changes in organ perfusion.
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Affiliation(s)
- Martin Girard
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada; Department of Anaesthesiology, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Jean Deschamps
- Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | - André Denault
- Department of Anaesthesiology, Montréal Heart Institute, Montréal, Québec, Canada
| | - William Beaubien-Souligny
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada; Division of Nephrology, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada.
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20
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Morris CAD, Donaldson RE. Mechanical ventilation in snake envenomation of dogs and cats. Front Vet Sci 2023; 10:1071257. [PMID: 37065246 PMCID: PMC10090310 DOI: 10.3389/fvets.2023.1071257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 03/14/2023] [Indexed: 03/31/2023] Open
Abstract
Envenomation by snakes in Elapidae and Viperidae families have been associated with respiratory failure in dogs and cats. Mechanical ventilation may be required for hypoventilation due to neuromuscular paralysis or hypoxemia due to pulmonary hemorrhage or aspiration pneumonia. Median incidence of dogs and cats with snake envenomation that require mechanical ventilation is 13% (0.06-40%). Standard treatment of snake envenomation in dogs and cats includes prompt administration of appropriate antivenom and management of envenomation complications such as coagulopathy, rhabdomyolysis and acute kidney injury. When mechanical ventilation is required, overall prognosis is good with appropriate treatment. Standard anesthetic protocols and mechanical ventilator settings are generally appropriate, with lung protective ventilation strategies typically reserved for patients with pulmonary disease. Median survival to discharge for cats and dogs with elapid envenomation is 72% (76-84%) with 33 h (19.5-58 h) median duration of mechanical ventilation and 140 h (84-196 h) median hospitalization. This article reviews indications for mechanical ventilation in cats and dogs with snake envenomation, and discusses ventilator settings, anesthetic and nursing considerations, complications and outcomes specific to this disease.
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Affiliation(s)
- Cameron A. D. Morris
- Critical Care Department, Queensland Veterinary Specialists, Brisbane, QLD, Australia
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21
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Zheng Y, Luo Z, Cao Z. NT-proBNP change is useful for predicting weaning failure from invasive mechanical ventilation among postsurgical patients: a retrospective, observational cohort study. BMC Anesthesiol 2023; 23:84. [PMID: 36941556 PMCID: PMC10026466 DOI: 10.1186/s12871-023-02039-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 03/10/2023] [Indexed: 03/22/2023] Open
Abstract
BACKGROUND To evaluate the predictive value of N-terminal prohormone B-type natriuretic peptide (NTproBNP) for weaning failure among patients undergoing major surgeries during spontaneous breathing trial (SBT), compared to traditional weaning parameters. METHODS The observational cohort study retrospectively included postsurgical patients who received IMV and underwent a 2 h SBT. According to weaning outcome, NTproBNP level at initiation (NTproBNP1) and at end of 2 h SBT(NTproBNP2), the ΔNTproBNP%, RSBI and MV were compared between weaning failure and weaning success group. Multiple logistical regression and ROC curve were used to evaluate the capability of NTproBNP to predict weaning failure. RESULTS Out of the 323 included postsurgical patients, 45 (13.9%) patients had failed weaning. The ΔNTproBNP% was a better predictor for weaning failure (AUC 0.744;95%CI,0.693-0.791) than NTproBNP1(AUC 0.639; 95%CI,0.580-0.694)), NTproBNP2(AUC 0.742, 95%CI,0.688-0.792) and other traditional weaning index such as RSBI (AUC 0.651; 95%CI, 0.597-0.703) and MV (AUC 0.552; 95%CI,0.496-0.607). The cutoff value of ΔNTproBNP% for predicting weaning failure was 23.3% with the sensitivity75.76% and specificity73.38%. The multiple logistic regression analysis found that ΔNTproBNP%>23.3% was an independent predictor of weaning failure. CONCLUSION ΔNTproBNP% may be a useful marker for predict weaning failure for postsurgical patients, and it's better to be more careful to withdraw from invasive mechanical ventilation for those postsurgical patients with ΔNTproBNP% >23.3%. The corresponding interventions to optimize cardiac function should be actively given to these patients.
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Affiliation(s)
- Yingying Zheng
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zujin Luo
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zhixin Cao
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.
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22
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Modrykamien AM. Enhancing the awakening to family engagement bundle with music therapy. World J Crit Care Med 2023; 12:41-52. [PMID: 37034022 PMCID: PMC10075048 DOI: 10.5492/wjccm.v12.i2.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 12/19/2022] [Accepted: 02/02/2023] [Indexed: 03/07/2023] Open
Abstract
Survivors of prolonged intensive care unit (ICU) admissions may present undesirable long-term outcomes. In particular, physical impairment and cognitive dysfunction have both been described in patients surviving episodes requiring mechanical ventilation and sedation. One of the strategies to prevent the aforementioned outcomes involves the implementation of a bundle composed by: (1) Spontaneous awakening trial; (2) Spontaneous breathing trial; (3) Choosing proper sedation strategies; (4) Delirium detection and management; (5) Early ICU mobility; and (6) Family engagement (ABCDEF bundle). The components of this bundle contribute in shortening length of stay on mechanical ventilation and reducing incidence of delirium. Since the first description of the ABCDEF bundle, other relevant therapeutic factors have been proposed, such as introducing music therapy. This mini-review describes the current evidence supporting the use of the ABCDEF bundle, as well as current knowledge on the implementation of music therapy.
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Affiliation(s)
- Ariel M Modrykamien
- Department of Pulmonary and Critical Care, Baylor University Medical Center, Dallas, TE 75246, United States
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23
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Mc Mahon A, Griffin S, Gorman E, Lennon A, Kielthy S, Flannery A, Cherian BS, Josy M, Marsh B. Patient-Centred Outcomes Following Tracheostomy in Critical Care. J Intensive Care Med 2023:8850666231160669. [PMID: 36883211 PMCID: PMC10374991 DOI: 10.1177/08850666231160669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
INTRODUCTION Around 20% of intensive care unit (ICU) patients undergo tracheostomy insertion and expect high-quality care concentrating on patient-centered outcomes including communication, oral intake, and mobilization. The majority of data has focused on timing, mortality, and resource utilization, with a paucity of information on quality of life following tracheostomy. METHODS Single center retrospective study including all patients requiring tracheostomy from 2017 to 2019. Information collected on demographics, severity of illness, ICU and hospital length of stay (LOS), ICU and hospital mortality, discharge disposition, sedation, time to vocalization, swallow and mobilization. Outcomes were compared for early versus late tracheostomy (early = <day 10) and age category (≤ 65 vs ≥ 66 years). RESULTS In total, 304 patients were included and 71% male, median age 59, APACHE II score 17. Median ICU and hospital LOS 16 and 56 days, respectively. ICU and hospital mortality 9.9% and 22.4%. Median time to tracheostomy 8 days, 8.55% open. Following tracheostomy, median days of sedation was 0, time to noninvasive ventilation (NIV) 1 day (94% of patients achieving this), ventilator-free breathing (VFB) 5 days (72%), speaking valve 7 days (60%), dynamic sitting 5 days (64%), and swallow assessment 16 days (73%). Early tracheostomy was associated with shorter ICU LOS (13 vs 26 days, P < .0001), reduced sedation (6 vs 12 days, P < .0001), faster transition to level 2 care (6 vs 10 days, P < .003), NIV (1 vs 2 days, P < .003), and VFB (4 vs 7 days, P < .005). Older patients received less sedation, had higher APACHE II scores and mortality (36.1%) and 18.5% were discharged home. Median time to VFB was 6 days (63.9%), speaking valve 7 days (64.7%), swallow assessment 20.5 days (66.7%), and dynamic sitting 5 days (62.2%). CONCLUSION Patient-centered outcomes are a worthy goal to consider when selecting patients for tracheostomy in addition to mortality or timing alone, including in older patients.
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Affiliation(s)
- A Mc Mahon
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - S Griffin
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - Emma Gorman
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - Aoife Lennon
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - Stephen Kielthy
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - Andrea Flannery
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - Bindu Sam Cherian
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - Minu Josy
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - B Marsh
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
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24
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Sepsis-Associated Muscle Wasting: A Comprehensive Review from Bench to Bedside. Int J Mol Sci 2023; 24:ijms24055040. [PMID: 36902469 PMCID: PMC10003568 DOI: 10.3390/ijms24055040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 02/21/2023] [Accepted: 03/04/2023] [Indexed: 03/08/2023] Open
Abstract
Sepsis-associated muscle wasting (SAMW) is characterized by decreased muscle mass, reduced muscle fiber size, and decreased muscle strength, resulting in persistent physical disability accompanied by sepsis. Systemic inflammatory cytokines are the main cause of SAMW, which occurs in 40-70% of patients with sepsis. The pathways associated with the ubiquitin-proteasome and autophagy systems are particularly activated in the muscle tissues during sepsis and may lead to muscle wasting. Additionally, expression of muscle atrophy-related genes Atrogin-1 and MuRF-1 are seemingly increased via the ubiquitin-proteasome pathway. In clinical settings, electrical muscular stimulation, physiotherapy, early mobilization, and nutritional support are used for patients with sepsis to prevent or treat SAMW. However, there are no pharmacological treatments for SAMW, and the underlying mechanisms are still unknown. Therefore, research is urgently required in this field.
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25
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Suleiman A, Santer P, Munoz-Acuna R, Hammer M, Schaefer MS, Wachtendorf LJ, Rumyantsev S, Berra L, Chamadia S, Johnson-Akeju O, Baedorf-Kassis EN, Eikermann M. Effects of Ketamine Infusion on Breathing and Encephalography in Spontaneously Breathing ICU Patients. J Intensive Care Med 2023; 38:299-306. [PMID: 35934953 DOI: 10.1177/08850666221119716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Preclinical studies suggest that ketamine stimulates breathing. We investigated whether adding a ketamine infusion at low and high doses to propofol sedation improves inspiratory flow and enhances sedation in spontaneously breathing critically ill patients. METHODS In this prospective interventional study, twelve intubated, spontaneously breathing patients received ketamine infusions at 5 mcg/kg/min, followed by 10 mcg/kg/min for 1 h each. Airway flow, pressure, and esophageal pressure were recorded during a spontaneous breathing trial (SBT) at baseline, and during the SBT conducted at the end of each ketamine infusion regimen. SBT consisted of one-minute breathing with zero end-expiratory pressure and no pressure support. Changes in inspiratory flow at the pre-specified time points were assessed as the primary outcome. Ketamine-induced change in beta-gamma electroencephalogram power was the key secondary endpoint. We also analyzed changes in other ventilatory parameters respiratory timing, and resistive and elastic inspiratory work of breathing. RESULTS Ketamine infusion of 5 and 10 mcg/kg/min increased inspiratory flow (median, IQR) from 0.36 (0.29-0.46) L/s at baseline to 0.47 (0.32-0.57) L/s and 0.44 (0.33-0.58) L/s, respectively (p = .013). Resistive work of breathing decreased from 0.4 (0.1-0.6) J/l at baseline to 0.2 (0.1-0.3) J/l after ketamine 10 mcg/kg/min (p = .042), while elastic work of breathing remained unchanged. Electroencephalogram beta-gamma power (19-44 Hz) increased compared to baseline (p < .01). CONCLUSIONS In intubated, spontaneously breathing patients receiving a constant rate of propofol, ketamine increased inspiratory flow, reduced inspiratory work of breathing, and was associated with an "activated" electroencephalographic pattern. These characteristics might facilitate weaning from mechanical ventilation.
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Affiliation(s)
- Aiman Suleiman
- Department of Anesthesia, Critical Care & Pain Medicine, 1859Beth Israel Deaconess Medical Center, 1811Harvard Medical School, Boston, MA, USA.,Center for Anesthesia Research Excellence (CARE), 1859Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Anesthesia and Intensive Care, Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Peter Santer
- Department of Anesthesia, Critical Care & Pain Medicine, 1859Beth Israel Deaconess Medical Center, 1811Harvard Medical School, Boston, MA, USA
| | - Ronny Munoz-Acuna
- Department of Anesthesia, Critical Care & Pain Medicine, 1859Beth Israel Deaconess Medical Center, 1811Harvard Medical School, Boston, MA, USA
| | - Maximilian Hammer
- Department of Anesthesia, Critical Care & Pain Medicine, 1859Beth Israel Deaconess Medical Center, 1811Harvard Medical School, Boston, MA, USA
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care & Pain Medicine, 1859Beth Israel Deaconess Medical Center, 1811Harvard Medical School, Boston, MA, USA.,Center for Anesthesia Research Excellence (CARE), 1859Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Anesthesiology, Duesseldorf University Hospital, Germany
| | - Luca J Wachtendorf
- Department of Anesthesia, Critical Care & Pain Medicine, 1859Beth Israel Deaconess Medical Center, 1811Harvard Medical School, Boston, MA, USA.,Center for Anesthesia Research Excellence (CARE), 1859Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Anesthesiology, 2013Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sandra Rumyantsev
- Pharmacy, 1859Beth Israel Deaconess Medical Center, 1811Harvard Medical School, Boston, MA, USA
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, 2348Massachusetts General Hospital, 1811Harvard Medical School, Boston, MA, USA
| | - Shubham Chamadia
- Department of Anesthesia, Critical Care and Pain Medicine, 2348Massachusetts General Hospital, 1811Harvard Medical School, Boston, MA, USA
| | - Oluwaseun Johnson-Akeju
- Department of Anesthesia, Critical Care and Pain Medicine, 2348Massachusetts General Hospital, 1811Harvard Medical School, Boston, MA, USA.,McCance Center for Brain Health, 2348Massachusetts General Hospital, 1811Harvard Medical School, Boston, MA, USA
| | - Elias N Baedorf-Kassis
- Department of Medicine, Division of Pulmonary and Critical Care, 1859Beth Israel Deaconess Medical Center, 1811Harvard Medical School, Boston, MA, USA
| | - Matthias Eikermann
- Department of Anesthesiology, 2013Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA.,Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany
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26
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Gosselin É, Labossière M, Lussier-Baillargeon F, Mayette M. Factors influencing the implementation of a ventilation weaning protocol in an adult intensive care unit: a qualitative multidisciplinary evaluation. Can J Anaesth 2023; 70:237-244. [PMID: 36450945 DOI: 10.1007/s12630-022-02361-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 05/18/2022] [Accepted: 07/31/2022] [Indexed: 12/03/2022] Open
Abstract
PURPOSE Development of protocolized care in the intensive care unit (ICU) improves patient outcomes, but presents multiple challenges. A mechanical ventilation weaning protocol (WP) was adopted in our institution but was underused. This study aimed to determine the factors that influenced the implementation of this protocol locally. METHODS We performed a qualitative descriptive study using semidirected interviews in small profession-specific focus groups. The interviews were based on a standardized guide covering the major domains found in the Consolidated Framework for Implementation Research. A total of 32 participants across four key professions were recruited. The interviews were transcribed and codified sequentially, followed by categorization and analysis. RESULTS Three broad factors emerged that negatively impacted the implementation of the WP. First, the goals of the WP differed between professional groups. This difference led to significant frustration and breaches in collaboration. Second, there was a lack of a continuous quality improvement process. Third, the WP was incompatible with the routine and procedures already in place at the time of implementation. Time-of-day of WP application and patient safety concerns were specifically identified issues. CONCLUSIONS Implementation of a continuous improvement process with regular and specific follow-up may help identify potential challenges and thus help ensure a more consistent use of the WP.
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Affiliation(s)
- Émilie Gosselin
- Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, QC, Canada.,Centre de Recherche Clinique du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Mathieu Labossière
- Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, QC, Canada. .,, 3001, 12e Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada.
| | | | - Michaël Mayette
- Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, QC, Canada.,Centre de Recherche Clinique du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
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da Silva RB, Neves VR, Montarroyos UR, Silveira MS, Sobral Filho DC. Heart rate variability as a predictor of mechanical ventilation weaning outcomes. Heart Lung 2023; 59:33-36. [PMID: 36706686 DOI: 10.1016/j.hrtlng.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 01/04/2023] [Accepted: 01/15/2023] [Indexed: 01/27/2023]
Abstract
BACKGROUND Delays in the mechanical ventilation (MV) weaning process increase mortality. The spontaneous breathing test is the gold standard to assess weaning and extubation success, although it has approximately 85% accuracy. Studies have demonstrated a correlation between decreased heart rate variability (HRV) and weaning failure. OBJECTIVES To assess the usefulness of HRV as a predictor of MV weaning outcomes. METHODS Cross-sectional analytical study in adults of both sexes on MV in intensive care unit (ICU) stay. Patients were divided into weaning success and failure groups. Clinical data were collected, and HRV records were obtained with a heart rate monitor. RESULTS The study included 68 individuals - 91.1% in the weaning success group and 8.9% in the failure group. All HRV indices analyzed in both groups were lower than the reference values. No statistical difference was found in the mean RR interval (RRi), the standard deviation of the NN interval (SDNN), and the square root of the mean squared differences of successive NN intervals (RMSSD) between the groups. The weaning failure group had a significant increase in LF (41 vs. 69.4) and LF/HF ratio (0.685 vs. 2.6) and a significant decrease in HF (58.85 vs. 30.2). CONCLUSIONS HRV measure with spectral analysis can be a good predictor of MV weaning failure. Integrating this assessment tool in ICU to predict weaning outcomes could provide more precise prognoses and more adequate assistance quality.
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Affiliation(s)
- Renata Baltar da Silva
- Postgraduation Program in Health Sciences (PPGCS), University of Pernambuco (UPE), Recife, PE, Brazil; Clinics Hospital of the Federal University of Pernambuco (HC-UFPE) - Brazilian Hospital Services Company (EBSERH), Recife, PE, Brazil; Agamenon Magalhães Hospital (HAM), UPE, Recife, PE, Brazil.
| | - Victor Ribeiro Neves
- Postgraduation Program in Functional Rehabilitation and Performance (PPGRDF), UPE, Petrolina, PE, Brazil.
| | - Ulisses Ramos Montarroyos
- Postgraduation Program in Health Sciences (PPGCS), University of Pernambuco (UPE), Recife, PE, Brazil.
| | - Matheus Sobral Silveira
- Postgraduation Program in Functional Rehabilitation and Performance (PPGRDF), UPE, Petrolina, PE, Brazil.
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O'Keeffe T, Donaldson RE. Mechanical ventilation in dogs and cats with tick paralysis. Front Vet Sci 2023; 10:1071191. [PMID: 37089405 PMCID: PMC10117792 DOI: 10.3389/fvets.2023.1071191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 03/22/2023] [Indexed: 04/25/2023] Open
Abstract
Respiratory failure from tick paralysis (TP) is an important cause of mortality in cats and dogs in Australia, occurring from a combination of respiratory muscle paralysis, upper respiratory tract obstruction and pulmonary disease. Patients may require positive-pressure ventilation in management of any combination of hypoxemia, hypoventilation or respiratory fatigue, but may also require airway management due to laryngeal paralysis. No single ventilation strategy is recommended due to the heterogenous disease presentations. Lung protective ventilation should be used in patients with pulmonary disease. Due to local and systemic effects of TP, patients are at higher risk of complications such as aspiration pneumonia and corneal ulceration and may have additional intravenous fluid and nutritional considerations. Treatment with hyperimmune serum is associated with improved outcomes. Prognosis is considered good with documented survival to discharge (STD) of 52.6-77% for animals with TP ventilated with lung disease and 90.5% for animals without lung disease. Median reported duration of ventilation for TP ranges from 23 to 48 h (range 3 h-10 days). The severity of individual neuromuscular signs and the presence of associated conditions such as aspiration pneumonia and laryngeal paralysis may necessitate longer periods of mechanical ventilation. This review aims to summarize the current recommendations regarding indications, management and prognosis of cats and dogs undergoing MV for TP and to identify areas for future research.
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29
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Misselbrook GP, Kanji H, Thiara S, Ronco JJ, Kalan S, Chen L, Sidhu A. Prediction of successful veno-venous extracorporeal life support liberation using the oxygen challenge test. Artif Organs 2023; 47:180-186. [PMID: 35957529 DOI: 10.1111/aor.14382] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 08/01/2022] [Accepted: 08/04/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND The oxygen challenge test (OCT) is an underutilized measure of lung recovery, easily performed prior to proceeding with a trial-off V-V ECLS as part of a weaning algorithm. Evidence-based thresholds for OCT results which support continuing with V-V ECLS weaning are lacking, making interpretation of these tests challenging in clinical practice. METHODS We performed a retrospective review of patients commenced on V-V ECLS as a bridge-to-recovery at Vancouver General Hospital from 2015-2019. The absolute PaO2 post-OCT and change in PaO2 proportional to incremental FiO2 change on the ventilator (∆PaO2 ) were evaluated as predictive screening metrics for identifying conditions favorable for successful trial-off of V-V ECLS. RESULTS An optimal cut-off of PaO2 ≥ 240 mm Hg post-OCT (AUC 0.77) and ∆PaO2 ≥ 250 mm Hg (AUC 0.76) was identified as a threshold for predicting successful trials-off. A total of 26 and 24 patients achieved post-OCT PaO2 and ∆PaO2 thresholds, and 100% of these patients were liberated successfully from ECLS during their admission. CONCLUSIONS The OCT can serve as an effective screen of shunt reduction and native lung recovery which can be used alongside other measures of ventilation to assess for suitability of liberation from V-V ECLS prior to a trial-off. Achieving a PaO2 ≥ 240 mm Hg post-OCT is a strong prognostic indicator for successful liberation from V-V ECLS during ICU admission.
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Affiliation(s)
- Gary P Misselbrook
- Critical Care Medicine, Vancouver General Hospital, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada.,School of Anaesthesia, Health Education England South East, Winchester, UK.,School of Medicine, Health Education England South East, Winchester, UK
| | - Hussein Kanji
- Critical Care Medicine, Vancouver General Hospital, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Sonny Thiara
- Critical Care Medicine, Vancouver General Hospital, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Juan J Ronco
- Critical Care Medicine, Vancouver General Hospital, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Simmie Kalan
- Critical Care Medicine, Vancouver General Hospital, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Leo Chen
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Amandeep Sidhu
- Critical Care Medicine, Vancouver General Hospital, University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
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Subira C, Fernández R, Batlle M, Alegre C, Cano S. A new classification to identify risk of reintubation. Med Intensiva 2022; 46:720-721. [PMID: 36442915 DOI: 10.1016/j.medine.2022.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/12/2022] [Indexed: 11/27/2022]
Affiliation(s)
- C Subira
- Critial Care Department, Althaia Xarxa Assistencial Universtaria de Manresa, Spain; CIBER, Centro de Investigación en Red de Enfermedades Respiratorias, Spain.
| | - R Fernández
- Critial Care Department, Althaia Xarxa Assistencial Universtaria de Manresa, Spain; CIBER, Centro de Investigación en Red de Enfermedades Respiratorias, Spain; Universitat Internacional de Catalunya, Spain
| | - M Batlle
- Critial Care Department, Althaia Xarxa Assistencial Universtaria de Manresa, Spain
| | - C Alegre
- Critial Care Department, Althaia Xarxa Assistencial Universtaria de Manresa, Spain
| | - S Cano
- Critial Care Department, Althaia Xarxa Assistencial Universtaria de Manresa, Spain
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Abstract
OBJECTIVES To map the evidence for ventilation liberation practices in pediatric respiratory failure using the Realist And MEta-narrative Evidence Syntheses: Evolving Standards publication standards. DATA SOURCES CINAHL, MEDLINE, COCHRANE, and EMBASE. Trial registers included the following: ClinicalTrials.gov, European Union clinical trials register, International Standardized Randomized Controlled Trial Number register. STUDY SELECTION Abstracts were screened followed by review of full text. Articles published in English language incorporating a heterogeneous population of both infants and older children were assessed. DATA EXTRACTION None. DATA SYNTHESIS Weaning can be considered as the process by which positive pressure is decreased and the patient becomes increasingly responsible for generating the energy necessary for effective gas exchange. With the growing use of noninvasive respiratory support, extubation can lie in the middle of the weaning process if some additional positive pressure is used after extubation, while for some extubation may constitute the end of weaning. Testing for extubation readiness is a key component of the weaning process as it allows the critical care practitioner to assess the capability and endurance of the patient's respiratory system to resume unassisted ventilation. Spontaneous breathing trials (SBTs) are often seen as extubation readiness testing (ERT), but the SBT is used to determine if the patient can maintain adequate spontaneous ventilation with minimal ventilatory support, whereas ERT implies the patient is ready for extubation. CONCLUSIONS Current literature suggests using a structured approach that includes a daily assessment of patient's readiness to extubate may reduce total ventilation time. Increasing evidence indicates that such daily assessments needs to include SBTs without added pressure support. Measures of elevated load as well as measures of impaired respiratory muscle capacity are independently associated with extubation failure in children, indicating that these should also be assessed as part of ERT.
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Hardin CC. Improved Protocols for Ventilator Liberation. N Engl J Med 2022; 387:1900-1901. [PMID: 36286318 DOI: 10.1056/nejme2212594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Teijeiro-Paradis R, Pesenti A, Fan E. Weaning from Veno-Venous ECMO: Lessons from 60 Years of Weaning from Mechanical Ventilation. Am J Respir Crit Care Med 2022; 206:928-930. [PMID: 35727205 PMCID: PMC9802004 DOI: 10.1164/rccm.202206-1104ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- Ricardo Teijeiro-Paradis
- Interdepartmental Division of Critical Care MedicineUniversity of TorontoToronto, Ontario, Canada
| | - Antonio Pesenti
- Dipartimento di Anestesia, Rianimazione e Emergenza-Urgenza,Fondazione IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico)Ca’ Granda Ospedale Maggiore PoliclinicoMilan, Italy,Department of Pathophysiology and TransplantationUniversity of MilanMilan, Italy
| | - Eddy Fan
- Interdepartmental Division of Critical Care MedicineUniversity of TorontoToronto, Ontario, Canada,Institute of Health Policy Management and EvaluationUniversity of TorontoToronto, Ontario, Canada
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Karic E, Mitwally H, Alansari LM, Ganaw A, Saad MO, Azhaghdani A. Impact of Early Tracheostomy on Weaning From Ventilation and Sedation in COVID-19 Pregnant and Early Postpartum Patient: Two Case Reports. Cureus 2022; 14:e29633. [PMID: 36320992 PMCID: PMC9606483 DOI: 10.7759/cureus.29633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2022] [Indexed: 11/20/2022] Open
Abstract
Pregnant women are at high risk of coronavirus disease 2019 (COVID-19) complications, including acute respiratory distress syndrome (ARDS) and the need for mechanical ventilation. There is no literature on the optimal strategy for the management of difficult-to-wean pregnant and early postpartum patients. We report two cases of pregnant women with COVID-19 pneumonia and ARDS, who required mechanical ventilation and high doses of analgesia, and sedation with neuromuscular blocking agents to facilitate ventilation and oxygenation. Both patients had a tracheostomy procedure to facilitate weaning from mechanical ventilation and sedation. Shortly after tracheostomy, sedation and analgesia, along with ventilatory support were weaned off. Both patients were discharged home. These cases propose early tracheostomy as a strategy to facilitate weaning from mechanical ventilation and sedation in pregnant and early postpartum patients.
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Finding Your Voice to Champion Hope in the Intensive Care Unit. ATS Sch 2022; 3:343-346. [PMID: 36312798 PMCID: PMC9585700 DOI: 10.34197/ats-scholar.2022-0032vl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 07/25/2022] [Indexed: 11/26/2022] Open
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Igarashi Y, Ogawa K, Nishimura K, Osawa S, Ohwada H, Yokobori S. Machine learning for predicting successful extubation in patients receiving mechanical ventilation. Front Med (Lausanne) 2022; 9:961252. [PMID: 36035403 PMCID: PMC9403066 DOI: 10.3389/fmed.2022.961252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 07/19/2022] [Indexed: 11/13/2022] Open
Abstract
Ventilator liberation is one of the most critical decisions in the intensive care unit; however, prediction of extubation failure is difficult, and the proportion thereof remains high. Machine learning can potentially provide a breakthrough in the prediction of extubation success. A total of seven studies on the prediction of extubation success using machine learning have been published. These machine learning models were developed using data from electronic health records, 8–78 features, and algorithms such as artificial neural network, LightGBM, and XGBoost. Sensitivity ranged from 0.64 to 0.96, specificity ranged from 0.73 to 0.85, and area under the receiver operating characteristic curve ranged from 0.70 to 0.98. The features deemed most important included duration of mechanical ventilation, PaO2, blood urea nitrogen, heart rate, and Glasgow Coma Scale score. Although the studies had limitations, prediction of extubation success by machine learning has the potential to be a powerful tool. Further studies are needed to assess whether machine learning prediction reduces the incidence of extubation failure or prolongs the duration of ventilator use, thereby increasing tracheostomy and ventilator-related complications and mortality.
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Affiliation(s)
- Yutaka Igarashi
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
- *Correspondence: Yutaka Igarashi
| | - Kei Ogawa
- Department of Industrial Administration, Tokyo University of Science, Chiba, Japan
| | - Kan Nishimura
- Department of Industrial Administration, Tokyo University of Science, Chiba, Japan
| | - Shuichiro Osawa
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Hayato Ohwada
- Department of Industrial Administration, Tokyo University of Science, Chiba, Japan
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
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Nikitas GT, Kykalos S, Ntikoudi E, Vasileiadis I, Koutsoukou A, Nikiteas NI. A Novel Non-invasive Index of Cardiopulmonary Reserve for the Prediction of Failure of Weaning From Mechanical Ventilation. Cureus 2022; 14:e27150. [PMID: 36004025 PMCID: PMC9392855 DOI: 10.7759/cureus.27150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2022] [Indexed: 11/21/2022] Open
Abstract
Purpose: To develop an easy-to-implement prediction index of weaning failure for ICU patients. Materials and methods: We developed a prediction index modifying respiratory exchange ratio (RER), Mod-RER, a parameter measured during the cardiopulmonary exercise test (CPET) based on respiratory quotient. The Mod-RER index is the ratio of partial pressure of CO2 in central venous blood over the difference of partial pressure of O2 in arterial and central venous blood (Mod-RER=PcvCO2/PaO2-PcvO2, where PcvCO2 = partial pressure of CO2 in central venous blood, PaO2 = partial pressure of O2 in arterial blood, and PcvO2 = partial pressure of O2 in central venous blood). We prospectively tested its predictive value, compared to other indices of weaning outcome, in an observational study of difficult-to-wean ICU patients. Results:Mod-RER index increased significantly only in failed trials and receiver operating characteristic (ROC) analysis for prediction of outcome based on Mod-RER index change had an area under the curve (AUC) 0.80 (p<0.001). Mod-RER change exhibited the highest sensitivity (84.6%) and specificity (78.1%) among the tested indices, with the optimal cut-off of 19.3%. Comparison of AUCs did not reach statistical significance (p=0.106). Conclusions: We conclude that Mod-RER index is an accurate, easy-to-use prediction tool of weaning failure, useful in decision making of timely extubation of ICU patients, especially in the demanding era of the coronavirus disease 2019 (COVID-19) pandemic.
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ZENGİN EN. Research trends and global productivity on mechanical ventilation with the impact of COVID-19: a bibliometric analysis in the period 1980-2021. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2022. [DOI: 10.32322/jhsm.1122437] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Aim: Although the number of global studies on mechanical ventilation (MV) therapy, which plays an important role in the life process of patients in the intensive care unit, has increased, there is still no bibliometric research on this subject in the literature. This study, it was aimed to determine trend topics and global productivity by holistically analyzing scientific articles on MV published between 1980 and 2021 using various statistical methods and bibliometric approaches.
Material and Method: Articles on MV published between 1980 and 2021 were downloaded from the Web of Science (WoS) database and analyzed using various statistical methods. Spearman's correlation coefficient was used for correlation studies. Network visualization maps were used to identify the most effective studies with global collaborations, trend topics, and citation analysis.
Results: The study, which was in the category of 5323 articles out of a total of 10135 publications, was analyzed. The first 3 countries that contributed the most to the literature were the USA (n=1740), France (448), and Canada (386). The most active author was Laurent Brochard (n=50). The top 3 most active institutions were Assistance Publique Hopitaux Paris (224), University of Toronto (216), and League of European Research Universities (169). The top 3 journals that published the most articles were Critical Care Medicine (289), Chest (204), and Intensive Care Medicine (166). Gross Domestic Product (GDP) was highly effective in article productivity (r=0.719, p
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ECONOMIC FEASIBILITY OF A NOVEL TOOL TO ASSIST EXTUBATION DECISION-MAKING: AN EARLY HEALTH ECONOMIC MODELLING. Int J Technol Assess Health Care 2022; 38:e66. [PMID: 35811412 DOI: 10.1017/s0266462322000472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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40
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Akella P, Voigt LP, Chawla S. To Wean or Not to Wean: A Practical Patient Focused Guide to Ventilator Weaning. J Intensive Care Med 2022; 37:1417-1425. [PMID: 35815895 DOI: 10.1177/08850666221095436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Since the inception of critical care medicine and artificial ventilation, literature and research on weaning has transformed daily patient care in intensive care units (ICU). As our knowledge of mechanical ventilation (MV) improved, so did the need to study patient-ventilator interactions and weaning predictors. Randomized trials have evaluated the use of protocol-based weaning (vs. usual care) to study the duration of MV in ICUs, different techniques to conduct spontaneous breathing trials (SBT), and strategies to eventually extubate a patient whose initial SBT failed. Despite considerable milestones in the management of multiple diseases contributing to reversible respiratory failure, in the application of early rehabilitative interventions to preserve muscle integrity, and in ventilator technology that mitigates against ventilator injury and dyssynchrony, major barriers to successful liberation from MV persist. This review provides a broad encompassing view of weaning classification, causes of weaning failure, and evidence behind weaning predictors and weaning modes.
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Affiliation(s)
- Padmastuti Akella
- Department of Anesthesiology & Critical Care Medicine, 5803Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Louis P Voigt
- Department of Anesthesiology & Critical Care Medicine, 5803Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sanjay Chawla
- Department of Anesthesiology & Critical Care Medicine, 5803Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Tasaka S, Ohshimo S, Takeuchi M, Yasuda H, Ichikado K, Tsushima K, Egi M, Hashimoto S, Shime N, Saito O, Matsumoto S, Nango E, Okada Y, Hayashi K, Sakuraya M, Nakajima M, Okamori S, Miura S, Fukuda T, Ishihara T, Kamo T, Yatabe T, Norisue Y, Aoki Y, Iizuka Y, Kondo Y, Narita C, Kawakami D, Okano H, Takeshita J, Anan K, Okazaki SR, Taito S, Hayashi T, Mayumi T, Terayama T, Kubota Y, Abe Y, Iwasaki Y, Kishihara Y, Kataoka J, Nishimura T, Yonekura H, Ando K, Yoshida T, Masuyama T, Sanui M. ARDS Clinical Practice Guideline 2021. J Intensive Care 2022; 10:32. [PMID: 35799288 PMCID: PMC9263056 DOI: 10.1186/s40560-022-00615-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 05/10/2022] [Indexed: 12/16/2022] Open
Abstract
Background The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021. Methods The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method. Results Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4–8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO2 (PaO2) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D), we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D), we suggest against routinely implementing NO inhalation therapy (GRADE 2C), and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D). Conclusions This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jsicm.org/publication/guideline.html). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries. Supplementary Information The online version contains supplementary material available at 10.1186/s40560-022-00615-6.
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Affiliation(s)
- Sadatomo Tasaka
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, 5 Zaifucho, Hirosaki, Aomori, 036-8562, Japan.
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kazuya Ichikado
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Kenji Tsushima
- International University of Health and Welfare, Tokyo, Japan
| | - Moritoki Egi
- Department of Anesthesiology, Kobe University Hospital, Hyogo, Japan
| | - Satoru Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Osamu Saito
- Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Shotaro Matsumoto
- Division of Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Eishu Nango
- Department of Family Medicine, Seibo International Catholic Hospital, Tokyo, Japan
| | - Yohei Okada
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kenichiro Hayashi
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Mikio Nakajima
- Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Satoshi Okamori
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shinya Miura
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
| | - Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Tadashi Ishihara
- Department of Emergency and Critical Care Medicine, Urayasu Hospital, Juntendo University, Chiba, Japan
| | - Tetsuro Kamo
- Department of Critical Care Medicine, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Tomoaki Yatabe
- Department of Anesthesiology, Nishichita General Hospital, Tokai, Japan
| | | | - Yoshitaka Aoki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Yusuke Iizuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Chihiro Narita
- Department of Emergency Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Daisuke Kawakami
- Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Hiromu Okano
- Department of Critical Care and Emergency Medicine, National Hospital Organization Yokohama Medical Center, Kanagawa, Japan
| | - Jun Takeshita
- Department of Anesthesiology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Keisuke Anan
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kyoto, Japan
| | | | - Shunsuke Taito
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, Hiroshima, Japan
| | - Takuya Hayashi
- Pediatric Emergency and Critical Care Center, Saitama Children's Medical Center, Saitama, Japan
| | - Takuya Mayumi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Takero Terayama
- Department of Psychiatry, School of Medicine, National Defense Medical College, Saitama, Japan
| | - Yoshifumi Kubota
- Kameda Medical Center Department of Infectious Diseases, Chiba, Japan
| | - Yoshinobu Abe
- Division of Emergency and Disaster Medicine Tohoku Medical and Pharmaceutical University, Miyagi, Japan
| | - Yudai Iwasaki
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Yuki Kishihara
- Department of Emergency Medicine, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Jun Kataoka
- Department of Critical Care Medicine, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Tetsuro Nishimura
- Department of Traumatology and Critical Care Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroshi Yonekura
- Department of Anesthesiology and Pain Medicine, Fujita Health University Bantane Hospital, Aichi, Japan
| | - Koichi Ando
- Division of Respiratory Medicine and Allergology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Takuo Yoshida
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, Tokyo, Japan
| | - Tomoyuki Masuyama
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
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Implementing change is a science. Med Intensiva 2022. [DOI: 10.1016/j.medin.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Implementing change is a science. Med Intensiva 2022; 46:359-362. [PMID: 35753709 DOI: 10.1016/j.medine.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 05/08/2022] [Indexed: 01/05/2023]
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Plotnikow GA, Gogniat E, Accoce M, Navarro E, Dorado JH. Epidemiology of mechanical ventilation in Argentina. The EpVAr multicenter observational study. Med Intensiva 2022; 46:372-382. [PMID: 35660286 DOI: 10.1016/j.medine.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/22/2021] [Accepted: 10/04/2021] [Indexed: 06/15/2023]
Abstract
OBJETIVE To describe mechanical ventilation (MV) practices in Argentina, and to explore factors associated with ICU mortality in this population. DESIGN A prospective, multicenter, observational study was carried out. SETTING Intensive Care. PATIENTS We enrolled patients above 18 years old admitted to any of the participating ICUs requiring invasive MV for at least 12 h since the admission to the healthcare institution, including MV initiation in emergency department, operating room or other hospitals. INTERVENTIONS None. VARIABLES All variables were classified into three categories: variables related to demographic and clinical factors before the MV, factors related to the first day on MV, and factors related to events happening during the MV (complications and weaning from MV). Mechanical ventilation weaning and mortality were classified according to WIND. RESULTS The primary analysis included 950 patients. The main indication for MV was acute respiratory failure (58% of patients). Initial ventilation mode was volume control-continuous mandatory ventilation in 75% of cases. ICU and hospital mortality were 44.6% and 47.9% respectively. The variables identified as independent predictors of mortality in ICU were age (OR 3.48 IC 95% 1.22-11.66; p = 0.028), failure to implement NIV before MV (OR 2.76 IC 95% 1.02-7.10; p = 0.038), diagnosis of sepsis (OR 2.46 IC 95% 1.09-5.47; p = 0.027) and extubation failure (OR 4.50 IC 95% 2.05-9.90; p < 0.001). CONCLUSIONS The present study allowed us to describe the characteristics and clinical course of the patients who received mechanical ventilation in Argentina, finding as the main result that mortality was higher than that reported in international studies.
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Affiliation(s)
- G A Plotnikow
- Capítulo de Kinesiología Intensivista, Sociedad Argentina de Terapia Intensiva, CABA, Argentina; Hospital Británico de Buenos Aires, CABA, Argentina; Docente Adjunto de Cátedra de Kinesfisiatría Cardiorrespiratoria de la Carrera de Kinesiología y Fisiatría, Universidad Abierta Interamericana, CABA, Argentina; Director del Grupo de Estudios Especializados en VM, Universidad Abierta Interamericana, CABA, Argentina.
| | - E Gogniat
- Capítulo de Kinesiología Intensivista, Sociedad Argentina de Terapia Intensiva, CABA, Argentina
| | - M Accoce
- Capítulo de Kinesiología Intensivista, Sociedad Argentina de Terapia Intensiva, CABA, Argentina; Docente Adjunto de Cátedra de Kinesfisiatría Cardiorrespiratoria de la Carrera de Kinesiología y Fisiatría, Universidad Abierta Interamericana, CABA, Argentina; Sanatorio Anchorena San Martín, Buenos Aires, Argentina
| | - E Navarro
- Capítulo de Kinesiología Intensivista, Sociedad Argentina de Terapia Intensiva, CABA, Argentina; Sanatorio Anchorena San Martín, Buenos Aires, Argentina; Centro del Parque, CABA, Argentina
| | - J H Dorado
- Capítulo de Kinesiología Intensivista, Sociedad Argentina de Terapia Intensiva, CABA, Argentina; Sanatorio Anchorena San Martín, Buenos Aires, Argentina
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Mechanical ventilation in Spain, 1998-2016: Changes in the disconnection of mechanical ventilation. Med Intensiva 2022; 46:363-371. [PMID: 35570188 DOI: 10.1016/j.medine.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/02/2021] [Accepted: 04/15/2021] [Indexed: 01/05/2023]
Abstract
PURPOSE To evaluate changes in the disconnection of mechanical ventilation in Spain from 1998 to 2016. DESIGN Post-hoc analysis of four cohort studies. AMBIT 138 Spanish ICUs. PATIENTS 2141 patients scheduled extubated. INTERVENTIONS None. VARIABLES OF INTEREST Demographics, reason for mechanical ventilation, complications, methods for disconnection, failure on the first attempt at disconnection, duration of weaning, reintubation, post-reintubation tracheotomy, ICU stay and mortality. RESULTS There was a significant increase (p < 0.001) in the use of gradual reduction of support pressure. The adjusted probability of using the gradual reduction in pressure support versus a spontaneous breathing trial has increased over time, both for the first attempt at disconnection (taking the 1998 study as a reference: odds ratio 0.99 in 2004, 0.57 in 2010 and 2.43 in 2016) and for difficult/prolonged disconnection (taking the 1998 study as a reference: odds ratio 2.29 in 2004, 1.23 in 2010 and 2.54 in 2016). The proportion of patients extubated after the first attempt at disconnection has increased over time. There is a decrease in the ventilation time dedicated to weaning (from 45% in 1998 to 36% in 2016). However, the duration in difficult/prolonged weaning has not decreased (median 3 days in all studies, p = 0.435). CONCLUSIONS There have been significant changes in the mode of disconnection of mechanical ventilation, with a progressive increase in the use of gradual reduction of pressure support. No relevant changes in outcomes have been observed.
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Tasaka S, Ohshimo S, Takeuchi M, Yasuda H, Ichikado K, Tsushima K, Egi M, Hashimoto S, Shime N, Saito O, Matsumoto S, Nango E, Okada Y, Hayashi K, Sakuraya M, Nakajima M, Okamori S, Miura S, Fukuda T, Ishihara T, Kamo T, Yatabe T, Norisue Y, Aoki Y, Iizuka Y, Kondo Y, Narita C, Kawakami D, Okano H, Takeshita J, Anan K, Okazaki SR, Taito S, Hayashi T, Mayumi T, Terayama T, Kubota Y, Abe Y, Iwasaki Y, Kishihara Y, Kataoka J, Nishimura T, Yonekura H, Ando K, Yoshida T, Masuyama T, Sanui M. ARDS clinical practice guideline 2021. Respir Investig 2022; 60:446-495. [PMID: 35753956 DOI: 10.1016/j.resinv.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/07/2022] [Accepted: 05/13/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021. METHODS The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method. RESULTS Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4-8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO2 (PaO2) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D); we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D); we suggest against routinely implementing NO inhalation therapy (GRADE 2C); and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D). CONCLUSIONS This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jrs.or.jp/publication/jrs_guidelines/). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries.
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Affiliation(s)
- Sadatomo Tasaka
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, Aomori, Japan.
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Saitama, Japan
| | - Kazuya Ichikado
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Kenji Tsushima
- International University of Health and Welfare, Tokyo, Japan
| | - Moritoki Egi
- Department of Anesthesiology, Kobe University Hospital, Hyogo, Japan
| | - Satoru Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Osamu Saito
- Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Shotaro Matsumoto
- Division of Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Eishu Nango
- Department of Family Medicine, Seibo International Catholic Hospital, Tokyo, Japan
| | - Yohei Okada
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kenichiro Hayashi
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Mikio Nakajima
- Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Satoshi Okamori
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shinya Miura
- Paediatric Intensive Care Unit, The Royal Children's Hospital Melbourne, Melbourne, Australia
| | - Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Tadashi Ishihara
- Department of Emergency and Critical Care Medicine, Juntendo University, Urayasu Hospital, Chiba, Japan
| | - Tetsuro Kamo
- Department of Critical Care Medicine, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Tomoaki Yatabe
- Department of Anesthesiology, Nishichita General Hospital, Aichi, Japan
| | | | - Yoshitaka Aoki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Yusuke Iizuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University, Urayasu Hospital, Chiba, Japan
| | - Chihiro Narita
- Department of Emergency Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Daisuke Kawakami
- Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Hiromu Okano
- Department of Critical Care and Emergency Medicine, National Hospital Organization Yokohama Medical Center, Kanagawa, Japan
| | - Jun Takeshita
- Department of Anesthesiology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Keisuke Anan
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Shunsuke Taito
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, Hiroshima, Japan
| | - Takuya Hayashi
- Pediatric Emergency and Critical Care Center, Saitama Children's Medical Center, Saitama, Japan
| | - Takuya Mayumi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Takero Terayama
- Department of Psychiatry, School of Medicine, National Defense Medical College, Saitama, Japan
| | - Yoshifumi Kubota
- Department of Infectious Diseases, Kameda Medical Center, Chiba, Japan
| | - Yoshinobu Abe
- Division of Emergency and Disaster Medicine, Tohoku Medical and Pharmaceutical University, Miyagi, Japan
| | - Yudai Iwasaki
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Yuki Kishihara
- Department of Emergency Medicine, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Jun Kataoka
- Department of Critical Care Medicine, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Tetsuro Nishimura
- Department of Traumatology and Critical Care Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroshi Yonekura
- Department of Anesthesiology and Pain Medicine, Fujita Health University Bantane Hospital, Aichi, Japan
| | - Koichi Ando
- Division of Respiratory Medicine and Allergology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Takuo Yoshida
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, Tokyo, Japan
| | - Tomoyuki Masuyama
- Department of Emergency and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Saitama, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
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Liu W, Guo H, Wang J, Ding F. Effect of spontaneous breathing trial on extubation in patients with acute exacerbation of chronic obstructive pulmonary disease under mechanical ventilation. BMC Emerg Med 2022; 22:112. [PMID: 35729524 PMCID: PMC9210748 DOI: 10.1186/s12873-022-00672-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 06/09/2022] [Indexed: 11/18/2022] Open
Abstract
Objective To evaluate how spontaneous breathing trial (SBT) affects successful extubation and prognosis in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients under mechanical ventilation. Methods AECOPD patients under invasive mechanical ventilation were recruited into the study and divided into the SBT and non-SBT groups. SBT patients received SBT for 60 min before extubation, while non-SBT patients that met weaning criteria were immediately extubated without SBT. Results A total of 64 patients were enrolled in analysis, including 32 in SBT group and 32 in non-SBT group. Patients in the two groups had similar baseline demographics and clinical characteristics (all parameters: p = > 0.05). Four (12.5%) patients in the SBT group and 5 (15.6%) in the non-SBT group were reintubated in 48 h of extubation (p = 0.821). During the 28-day follow-up after extubation, 3 patients died, 1 (3.1%) in the SBT group and 2 (6.3%) in the non-SBT group (p = 0.554). Conclusion Our findings indicate that SBT did not affect extubation success, in-hospital mortality, and 28-day survival in AECOPD patients under mechanical ventilation.
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Affiliation(s)
- Wenjing Liu
- Department of Respiratory and Critical Care Medicine, Harrison International Peace Hospital Affiliated to Hebei Medical University, Hengshui, 053000, China.
| | - Hong Guo
- Department of Neurosurgery, Harrison International Peace Hospital Affiliated to Hebei Medical University, 180 Middle Renmin Road, Hengshui, 053000, China
| | - Jing Wang
- Department of Respiratory and Critical Care Medicine, Harrison International Peace Hospital Affiliated to Hebei Medical University, Hengshui, 053000, China
| | - Fang Ding
- Department of Gerontology, Harrison International Peace Hospital Affiliated to Hebei Medical University, Hengshui, 053000, China
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Burns KEA, Agarwal A, Bosma KJ, Chaudhuri D, Girard TD. Liberation from Mechanical Ventilation: Established and New Insights. Semin Respir Crit Care Med 2022; 43:461-470. [PMID: 35760299 DOI: 10.1055/s-0042-1747929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
A substantial proportion of critically ill patients require ventilator support with the majority requiring invasive mechanical ventilation. Timely and safe liberation from invasive mechanical ventilation is a critical aspect of patient care in the intensive care unit (ICU) and is a top research priority for patients and clinicians. In this article, we discuss how to (1) identify candidates for liberation from mechanical ventilation, (2) conduct spontaneous breathing trials (SBTs), and (3) optimize patients for liberation from mechanical ventilation. We also discuss the roles for (4) extubation to noninvasive ventilation and (5) newer modes of mechanical ventilation during liberation from mechanical ventilation. We conclude that, though substantial progress has been made in identifying patients who are likely to be liberated (e.g., through the use of SBTs) and management strategies that speed liberation from the ventilator (e.g., protocolized SBTs, lighter sedation, and early mobilization), many important questions regarding liberation from mechanical ventilation in clinical practice remain unanswered.
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Affiliation(s)
- Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Departments of Critical Care and Medicine, Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Arnav Agarwal
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Division of General Internal Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Karen J Bosma
- Division of Critical Care Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, and London Health Sciences Centre, London, Ontario, Canada
| | - Dipayan Chaudhuri
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Departments of Critical Care Medicine and Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Timothy D Girard
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Zheng Y, Luo Z, Cao Z. Mean platelet volume is useful for predicting weaning failure: a retrospective, observational study. BMC Anesthesiol 2022; 22:160. [PMID: 35614411 PMCID: PMC9131520 DOI: 10.1186/s12871-022-01701-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/18/2022] [Indexed: 11/24/2022] Open
Abstract
Background To evaluate the usefulness of mean platelet volume (MPV), a marker of inflammation and stress, for predicting weaning failure in patients undergoing invasive mechanical ventilation (IMV) compared to traditional inflammation markers. Methods The retrospective observational study including patients who received IMV and underwent spontaneous breathing trial (SBT) was conducted in ICU at Beijing Chao-Yang hospital in China from January, 2013 to December, 2019. According to the weaning outcome, MPV, leukocyte count and C-reaction protein(CRP) were compared between weaning failure and weaning success group. Receiver-operating characteristics (ROC) curves and multivariate logistical regression analysis were constructed to analyze the value of these inflammatory markers for predicting weaning failure. Results A total of 261 patients were enrolled in the study and 54 patients (20.7%) experienced weaning failure (45 SBT failure and 9 extubation failure after successful SBT). MPV was a better predictor for weaning failure (AUC 0.777;95%CI, 0.722–0.826) than leukocyte count (AUC 0.6;95%CI,0.538–0.66) and CRP (0.627;95%CI,0.565–0.685). The cutoff value of MPV for predicting weaning failure was 11.3 fl with sensitivity 55.56%, specificity 87.92%, and diagnostic accuracy 81.22%. According to multivariate logistic regression analyses, MPV > 11.3 fl was an independent risk factor for predicting weaning failure. Conclusions MPV could be a more valuable marker for predicting weaning failure. and the patients with MPV > 11.3 fl should be attentively evaluated before weaning since they are at high risk of weaning failure, and it would be auspicable for those patients to undergo a noninvasive ventilation or high-flow nasal cannula oxygen therapy after extubation or even an early tracheostomy.
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Affiliation(s)
- Yingying Zheng
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.
| | - Zujin Luo
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zhixin Cao
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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50
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Subira C, Fernández R, Batlle M, Alegre C, Cano S. A new classification to identify risk of reintubation. Med Intensiva 2022. [DOI: 10.1016/j.medin.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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