Prognosis of patients with acute respiratory failure and prolonged intensive care unit stay

Cross-sectional pilot study of relationships between specific oral bacteria and acute respiratory failure requiring intensive care unit admission

OBJECTIVES

Acute respiratory failure (ARF) is a severe condition requiring intensive care unit (ICU) admission. Periodontal disease is a chronic inflammatory disorder caused by periodontal bacteria, though it is unknown whether specific periodontal bacteria are associated with ARF patients admitted to the ICU. The present study was conducted to compare oral environmental factors and numbers of specific oral bacteria between patients with and without ARF related to ICU admission.

METHODS

A cross-sectional investigation was performed with 64 ICU patients, divided into ARF (n = 18) and non-ARF (n = 46) groups based on the causative disease related to admission. Clinical characteristics, oral environment factors, and numbers of 12 oral bacterial species in saliva and tongue samples were examined using a DNA chip.

RESULTS

Dry mouth and coated tongue were more frequently found in the ARF than the non-ARF group. The numbers of Porphyromonas gingivalis in both saliva and tongue samples in the ARF were greater than those in the non-ARF (p = 0.013, p = 0.028, respectively). The numbers of Capnocytophaga gingivalis from the tongues in the ARF group were greater as compared with those in the non-ARF group (p = 0.032).

CONCLUSIONS

The findings obtained in this pilot study indicate the possibility that P. gingivalis and C. gingivalis are associated with ARF requiring ICU admission.

CLINICAL SIGNIFICANCE

The oral microbiota may differ between ARF patients and non-ARF patients.

Short- and long-term outcomes of pulmonary emphysema patients on mechanical ventilation admitted to the intensive care unit for acute respiratory failure: A retrospective observational study

INTRODUCTION

Acute respiratory failure is a leading cause of admission to the intensive care unit (ICU), with mortality rates remaining stagnant despite advances in resuscitation techniques. Comorbidities, notably chronic obstructive pulmonary disease, significantly impact ICU patient outcomes. Pulmonary emphysema, commonly associated with chronic obstructive pulmonary disease, poses a significant risk, yet its influence on ICU mortality remains understudied.

OBJECTIVES

The aim of this study was to assess the short- and long-term outcomes of ICU patients with pulmonary emphysema requiring mechanical ventilation for acute respiratory failure, evaluating the impact of emphysema severity.

METHODS

A single-centre retrospective cohort study was conducted from 2015 to 2021. Patients with pulmonary emphysema requiring invasive ventilation were included. Emphysema severity was assessed using chest computed tomography scans. Data on mortality, length of stay, and ventilator-free days were collected. Statistical analyses were performed to identify factors associated with outcomes.

RESULTS

Of the 89 included patients, 31.5% died during their ICU stay, with a 39.3% mortality within 12 months postdischarge. Emphysema severity did not significantly correlate with mortality or ventilator-free days. Chronic heart failure emerged as a significant predictor of ICU and in-hospital mortality.

CONCLUSIONS

Emphysema severity does not appear to independently affect mortality in intubated ICU patients with acute respiratory failure. However, mortality rates remain high, warranting further investigation into contributing factors. Our findings underline the complexity of managing critically ill patients with pulmonary emphysema and emphasise the need for comprehensive patient assessment and personalised treatment approaches.

Diaphragmatic ultrasound: approach, emerging evidence, and future perspectives in non-ICU patients

Diaphragmatic dysfunction is an important contributor to hypercapnic respiratory failure, but its presence is often challenging to determine at the bedside. Diaphragm ultrasound provides an opportunity to evaluate the function of the diaphragm noninvasively by evaluating the following parameters that can help define diaphragmatic dysfunction: diaphragm excursion, diaphragm muscle thickness, and thickening fraction. Its evaluation has the potential to assist with diagnosis of respiratory failure, provide prognosis, and assist with patient monitoring and should be considered as part of an internal medicine physician's and emergency physician's skill set. This article provides an overview on how to perform diaphragm ultrasound, review its pitfalls, and discuss the evidence of its use in patients with neuromuscular disorders and chronic obstructive pulmonary disease. Finally, its potential emerging uses in the perioperative setting and for evaluation of acute heart failure are discussed.

Systemic Immune Inflammation Index (SII) and Prognostic Nutritional Index (PNI) Associated with Prolonged Intensive Care Unit (ICU) Stay in Patients with Pneumonia Complicated with Respiratory Failure

Background

The length of intensive care unit (ICU) stay is an important index reflects the prognosis of severe pneumonia (SP) combined with respiratory failure (RF). Blood transfusion can alleviate tissue hypoxia in ICU patients, but blood transfusion can affect the prognosis of patients. The objective of this study was to evaluate the effect of immune-nutritional indices (pan-immune inflammation value (PIV), systemic immune inflammation index (SII), system inflammation response index (SIRI), neutrophil-to-albumin ratio (NAR), and prognostic nutritional index (PNI)) on length of stay in patients treated with and without transfusion.

Methods

Total of 3425 pneumonia combined with respiratory failure patients were retrospectively analyzed. Medical records (age, gender, body mass index, history of smoking, history of alcohol drinking, hypertension, diabetes mellitus, lung diseases, invasive mechanical ventilation, blood transfusion, APACHE II score, and laboratory test results) were collected, the relationship between this information and prolonged ICU stay was analyzed.

Results

The average length of ICU stay was 5.32 (2.94, 9.36) days, there were 2521 (73.6%) patients with non-prolonged ICU stay (<9 days) and 904 (26.4%) with prolonged ICU stay (≥9 days). The levels of PIV, SII, and SIRI in prolonged ICU stay patients were higher than those of non-prolonged ICU stay in patients with and without blood transfusion, respectively. Multivariate logistic regression analysis showed that high SII (odds ratio (OR): 2.115, 95% confidence interval (CI): 1.428-3.131, p<0.001), and invasive mechanical ventilation (OR: 10.205, 95% CI: 5.623-18.524, p<0.001) were associated with prolonged ICU stay in patients with blood transfusion; and low PNI (OR: 1.378, 95% CI: 1.073-1.769, p=0.012), invasive mechanical ventilation (OR: 3.566, 95% CI: 2.666-4.771, p<0.001) were associated with prolonged ICU stay in patients without blood transfusion.

Conclusion

High SII level and invasive mechanical ventilation were independently associated with prolonged ICU stay in patients treated with blood transfusion; and low PNI level and invasive mechanical ventilation were independently associated with prolonged ICU stay in patients without blood transfusion.

Long-term lung function recovery after ECMO versus non-ECMO management in acute respiratory failure: a systematic review and meta-analysis

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is increasingly employed to support lung function in patients with acute respiratory failure (ARF). However, the long-term outcomes of the approach have not been encouraging when compared to those of conventional mechanical ventilation. Further, the long-term effects of ECMO on lung function and recovery are unclear. For this review, we examined the long-term lung function outcomes of patients with ARF treated with and without ECMO.

METHODS

We searched the Embase, CENTRAL, Web of Science, and PubMed sites for studies comparing long-term (≥ 6 months) pulmonary function test results in patients with ARF treated with and without ECMO published until January 2024. We conducted a meta-analysis for percentage predicted values.

RESULTS

We included five studies. Our meta-analysis showed similar values of forced vital capacity (FVC%) (MD, 0.47; 95% CI, -3.56-4.50) and forced expiratory flow in the first second % (MD, 1.79; 95% CI, -2.17-5.75) in patients with ARF treated with or without ECMO. The FEV1/FVC % values were slightly higher in patients treated with ECMO than in those without ECMO (MD, 2.03; 95% CI, 0.01-4.04; p-value = 0.05). According to the meta-analysis, the values for total lung capacity % (MD, -3.20; 95% CI, -8.83-2.44) and carbon monoxide diffusion capacity % (MD, -0.72; 95% CI, -3.83-2.39) were also similar between patients undergoing ECMO and those without it.

CONCLUSION

The meta-analysis of a small number of studies with significant selection bias indicates that patients with ARF treated with ECMO may have comparable long-term pulmonary function recovery to those treated with conventional strategies. Further investigations including a larger number of patients and focusing on the long-term impact of ECMO are needed to supplement the current evidence.

HIRA: Heart Rate Interval based Rapid Alert score to characterize autonomic dysfunction among patients with sepsis-related acute respiratory failure (ARF)

Objective. To examine whether heart rate interval based rapid alert (HIRA) score derived from a combination model of heart rate variability (HRV) and modified early warning score (MEWS) is a surrogate for the detection of acute respiratory failure (ARF) in critically ill sepsis patients.Approach. Retrospective HRV analysis of sepsis patients admitted to Emory healthcare intensive care unit (ICU) was performed between sepsis-related ARF and sepsis controls without ARF. HRV measures such as time domain, frequency domain, and nonlinear measures were analyzed up to 24 h after patient admission, 1 h before the onset of ARF, and a random event time in the sepsis controls. Statistical significance was computed by the Wilcoxon Rank Sum test. Machine learning algorithms such as eXtreme Gradient Boosting and logistic regression were developed to validate the HIRA score model. The performance of HIRA and early warning score models were evaluated using the area under the receiver operating characteristic (AUROC).Main Results. A total of 89 (ICU) patients with sepsis were included in this retrospective cohort study, of whom 31 (34%) developed sepsis-related ARF and 58 (65%) were sepsis controls without ARF. Time-domain HRV for Electrocardiogram (ECG) Beat-to-Beat RR intervals strongly distinguished ARF patients from controls. HRV measures for nonlinear and frequency domains were significantly altered (p< 0.05) among ARF compared to controls. The HIRA score AUC: 0.93; 95% confidence interval (CI): 0.88-0.98) showed a higher predictive ability to detect ARF when compared to MEWS (AUC: 0.71; 95% CI: 0.50-0.90).Significance. HRV was significantly impaired across patients who developed ARF when compared to controls. The HIRA score uses non-invasively derived HRV and may be used to inform diagnostic and therapeutic decisions regarding the severity of sepsis and earlier identification of the need for mechanical ventilation.

Elevation of serum lactate dehydrogenase during methylprednisolone pulse therapy as a predictor of high mortality in acute respiratory failure: A single-center, retrospective study

Background

Corticosteroids are common treatments in certain diseases that cause acute respiratory failure (ARF) and are sometimes administered empirically for patients with critical ARF. Associations between changes in clinical parameters following initiation of steroid pulse therapy and mortality in patients with ARF have not been previously investigated.

Methods

This was a single-center and retrospective cohort study. Parameters on the day of methylprednisolone pulse therapy initiation (day 1) and the day following the end of methylprednisolone therapy (day 4) in patients who were admitted because of ARF and underwent methylprednisolone pulse therapy between October 2008 and July 2021 were reviewed.

Results

A total of 98 patients were included in our analysis, and 45 (46%) died at our hospital. Change in lactate dehydrogenase (LDH) from day 1 to day 4 (ΔLDH) was significantly higher in the in-hospital death group than in the survival group (-68 IU/L in the survival group versus 46 IU/L in the in-hospital death group, p < 0.01). Multivariate logistic analyses showed that age >75 years old (odds ratio (OR), 3.88; 95% confidence interval (CI), 1.38-10.9; p < 0.01), previously diagnosed interstitial lung disease (OR, 3.43; 95% CI, 1.10-10.7; p = 0.03), ΔLDH > 0 (OR, 6.47; 95% CI, 2.30-18.2; p < 0.01), and ΔSequential Organ Failure Assessment score > 0 (OR, 3.06; 95% CI, 1.10-8.51; p = 0.03) were significantly associated with in-hospital mortality.

Conclusions

This study showed that elevation of serum LDH level during methylprednisolone pulse therapy was a predictive factor for high in-hospital mortality in patients with ARF.

Predictors of Outcome in Patients with Pulmonary Hypertension Undergoing Mitral and Tricuspid Valve Surgery

Background and Objectives: Pulmonary hypertension (PH) secondary to left-sided valvular heart disease is associated with poor cardiac surgical outcome compared with patients without PH. Our objective was to investigate the prognostic factors of surgical outcome in patients with PH undergoing mitral valve (MV) and tricuspid valve (TV) surgery, in order to risk stratify their management. Materials and Methods: This is a retrospective observational study on patients with PH who underwent MV and TV surgery from 2011 to 2019. The primary outcome was all-cause mortality. The secondary outcomes were post-op respiratory and renal complications, length of intensive care unit stay and length of hospital stay. Results: Seventy-six patients were included in this study. The all-cause mortality was 13% (n = 10), with mean survival of 92.6 months. Among the patients, 9.2% (n = 7) had post-op renal failure requiring renal replacement therapy and 6.6% (n = 5) had post-op respiratory failure requiring intubation. Univariate analysis demonstrated that pre-operative left ventricular ejection fraction (LVEF), peak systolic tissue velocity at the tricuspid annulus (S') and etiology of MV disease were associated with respiratory and renal failure. Tricuspid annular plane systolic excursion (TAPSE) was associated with respiratory failure only. S', type of operation, LVEF, urgency of surgery, and etiology of MV disease were found to be predictive of mortality. After excluding redo mitral surgery, all statistically significant findings remain unchanged, with the addition of right ventricular (RV) size being associated with respiratory failure. In the subgroup analysis of routine cases (n = 56), patients with primary mitral regurgitation who underwent mitral valve repair had better survival outcome. Conclusions: Urgency of surgery, etiology of MV disease, type of operation (replacement or repair), S' and pre-op LVEF are prognostic indicators in this small cohort of patients with PH undergoing MV and TV surgery. A larger prospective study is warranted to validate our findings.

Hemodynamic and Rhythmologic Effects of Push-Dose Landiolol in Critical Care-A Retrospective Cross-Sectional Study

BACKGROUND

The highly β1-selective beta-blocker Landiolol is known to facilitate efficient and safe rate control in non-compensatory tachycardia or dysrhythmia when administered continuously. However, efficacy and safety data of the also-available bolus formulation in critically ill patients are scarce.

METHODS

We conducted a retrospective cross-sectional study on a real-life cohort of critical care patients, who had been treated with push-dose Landiolol due to sudden-onset non-compensatory supraventricular tachycardia. Continuous hemodynamic data had been acquired via invasive blood pressure monitoring.

RESULTS

Thirty patients and 49 bolus applications were analyzed. Successful heart rate control was accomplished in 20 (41%) cases, rhythm control was achieved in 13 (27%) episodes, and 16 (33%) applications showed no effect. Overall, the heart rate was significantly lower (145 (130-150) vs. 105 (100-125) bpm, p < 0.001) in a 90 min post-application observational period in all subgroups. The median changes in blood pressure after the bolus application did not reach clinical significance. Compared with the ventilation settings before the bolus application, the respiratory settings including the required FiO2 after the bolus application did not differ significantly. No serious adverse events were seen.

CONCLUSIONS

Push-dose Landiolol was safe and effective in critically ill ICU patients. No clinically relevant impact on blood pressure was noted.

Antisynthetase syndrome sine myositis presenting as severe acute respiratory failure

A female in her late 40s presented to the emergency department during the COVID-19 pandemic with shortness of breath, fever and productive cough following a recent diagnosis of bilateral non-massive pulmonary emboli. She had elevated inflammatory markers and her chest X-ray revealed bilateral infiltrates. Her SARS-CoV-2 PCR was negative, and she was treated for community-acquired pneumonia. However, despite treatment she rapidly deteriorated and developed severe respiratory failure, requiring mechanical ventilation.On further investigation, she tested positive for anti-Jo-1 antibodies and a diagnosis of antisynthetase syndrome sine myositis was made. This led to successful treatment with high dose corticosteroids and intravenous immunoglobulin.This case highlights an uncommon presentation of a rare condition, as well as the benefits of working in a multidisciplinary team on the intensive care unit.

Clinical Characteristics, Achievement of Secondary Prevention Goals, and Outcomes of Patients with Recurrent Acute Coronary Syndrome

BACKGROUND

Because development of acute coronary syndrome (ACS) worsens the prognosis of patients with coronary artery disease, preventing recurrent ACS is crucial. However, the degree to which secondary prevention treatment goals are achieved in patients with recurrent ACS is unknown.

METHODS

214 consecutive ACS patients were classified as having First ACS (n=182) or Recurrent ACS (n=32), and the clinical characteristics of these groups were compared. Fifteen patients died or developed cardiovascular (CV) events during hospitalization, and the remaining 199 patients were followed from the date of hospital discharge to evaluate subsequent CV events.

RESULTS

Patients in the Recurrent ACS group were older than those in the First ACS group (76.8±10.8 years vs 68.8±13.4 years, p=0.002) and had a higher rate of diabetes mellitus (DM) (65.6% vs 36.8%, p=0.003). The rate of achieving a low-density lipoprotein cholesterol (LDL-C) level of <70 mg/dL in the Recurrent ACS group was only 28.1%, even though 68.8% of these patients were taking statins. An HbA1c level of <7.0% was achieved in 66.7% of patients with recurrent ACS who had been diagnosed with DM. Overall, 12.5% of patients with recurrent ACS had received optimal treatment for secondary prevention. CV events after hospital discharge were noted in 37.9% of the Recurrent ACS group and 21.2% of the First ACS group (log-rank test: p=0.004). However, recurrent ACS was not an independent risk factor for CV events (adjusted hazard ratio: 2.09, 95% confidence interval: 0.95 to 4.63, p=0.068).

CONCLUSION

Optimal treatment for secondary prevention was not achieved in some patients with recurrent ACS, and achievement of the guideline-recommended LDL-C goal for secondary prevention was especially low in this population.

Association of Low Alanine Aminotransferase Values with Extubation Failure in Adult Critically Ill Patients: A Retrospective Cohort Study

Background: Liberation from mechanical ventilation is a cardinal landmark during hospitalization of ventilated patients. Decreased muscle mass and sarcopenia are associated with a high risk of extubation failure. A low level of alanine aminotransferase (ALT) is a known biomarker of sarcopenia. This study aimed to determine whether low levels of ALT are associated with increased risk of extubation failure among critically ill patients. Methods: This was a retrospective single-center cohort study of mechanically ventilated patients undergoing their first extubation. The study’s outcome was extubation failure within 48 h and 7 days. Multivariable logistic and Cox regression were performed to determine whether ALT was an independent predictor of these outcomes. Results: The study included 329 patients with a median age of 62.4 years (IQR 48.1–71.2); 210 (63.8%) patients were at high risk for extubation failure. 66 (20.1%) and 83 (25.2%) failed the extubation attempt after 48 h and 7 days, respectively. Low ALT values were more common among patients requiring reintubation (80.3–61.5% vs. 58.6–58.9%, p < 0.002). Multivariable logistic regression analysis identified ALT as an independent predictor of extubation failure at 48 h and 7 days. ALT ≤ 21 IU/L had an adjusted hazard ratio (HR) of 2.41 (95% CI 1.31–4.42, p < 0.001) for extubation failure at 48 h and ALT ≤ 16 IU/L had adjusted HR of 1.94 (95% CI 1.25–3.02, p < 0.001) for failure after 7 days. Conclusions: Low ALT, an established biomarker of sarcopenia and frailty, is an independent risk factor for extubation failure among hospitalized patients. This simple laboratory parameter can be used as an effective adjunct predictor, along with other weaning parameters, and thereby facilitate the identification of high-risk patients.

Adult Pulmonary Intensive and Intermediate Care Units: The Italian Thoracic Society (ITS-AIPO) Position Paper

The imbalance between the prevalence of patients with acute respiratory failure (ARF) and acute-on-chronic respiratory failure and the number of intensive care unit (ICU) beds requires new solutions. The increasing use of non-invasive respiratory tools to support patients at earlier stages of ARF and the increased expertise of non-ICU clinicians in other types of supportive care have led to the development of adult pulmonary intensive care units (PICUs) and pulmonary intermediate care units (PIMCUs). As in other European countries, Italian PICUs and PIMCUs provide an intermediate level of care as the setting designed for managing ARF patients without severe non-pulmonary dysfunction. The PICUs and PIMCUs may also act as step-down units for weaning patients from prolonged mechanical ventilation and for discharging patients still requiring ventilatory support at home. These units may play an important role in the on-going coronavirus disease 2019 pandemic. This position paper promoted by the Italian Thoracic Society (ITS-AIPO) describes the models, facilities, staff, equipment, and operating methods of PICUs and PIMCUs.

Long-stay patients in pediatric intensive care units. Five-years, 2-points, cross-sectional study

Objectives:

To explore the changing patterns of long-stay patients (LSP) to improve the utilization of pediatric intensive care units (PICUs) resources.

Methods:

This is a 2-points cross-sectional study (5 years apart; 2014-2019) conducted among PICUs and SCICUs in Riyadh, Saudi Arabia. Children who have stayed in PICU for more than 21 days were included.

Results:

Out of the 11 units approached, 10 (90%) agreed to participate. The prevalence of LSP in all these hospitals decreased from 32% (48/150) in 2014 to 23.4% (35/149) in 2019. The length of stay ranged from 22 days to 13.5 years. The majority of LSP had a neuromuscular or cardiac disease and were admitted with respiratory compromise. Ventilator-associated pneumonia was the most prevalent complication (37.5%). The most commonly used resources were mechanical ventilation (93.8%), antibiotics (60.4%), and blood-products transfusions (35.4%). The most common reason for the extended stay was medical reasons (51.1%), followed by a lack of family resources (26.5%) or lack of referral to long-term care facilities (22.4%).

Conclusion:

A long-stay is associated with significant critical care bed occupancy, complications, and utilization of resources that could be otherwise utilized as surge capacity for critical care services. Decreasing occupancy in this multicenter study deserves further engagement of the healthcare leaders and families to maximize the utilization of resources.

The comparison of GNRI and other nutritional indexes on short-term survival in geriatric patients treated for respiratory failure

BACKGROUND

There are several screening tools used in the detection of malnutrition to facilitate nutritional support and predict prognosis in the elderly.

AIMS

We aimed to compare the prognostic predictive value of geriatric nutritional risk index (GNRI) with other nutritional indices on 1 month survival in geriatric patients hospitalized for respiratory failure in intensive care unit (ICU).

METHODS

A total of 191 geriatric patients (> 65 years) admitted to a specialized chest hospital with respiratory failure between January 2018 and January 2019 were analyzed. Patients were classified into two category according to 30-day survival: Survivors and Non-survivors. Nutritional assesment was done via GNRI, OPNI, NRS 2002, Nutric Scores in ICU.

RESULTS

Using GNRI, 146 (76.3%) geriatric patients found to be at risk of malnutrition (GNRI score: ≤ 92). GNRI < 86.9 showed significantly higher 30-day mortality rate and patients with malnutrition risk were older, had significantly lower BMI, OPNI, and higher SOFA score. The Age, NRS 2002, Nutric and SOFA score had negative correlation with GNRI. Nutric score, prealbumin and GNRI were detected as significant independent risk factors of 30-day mortality. GNRI had higher sensitivity (76.7%) but lower specificity (57.1%) compared to Nutric score and OPNI for the prediction of 30-day hospital mortality.

CONCLUSIONS

Compared to others, Geriatric Nutritional Risk Index (GNRI) seems to be a good predictor of 30-day mortality and having a score of less than 86.9 increase the malnutrition risk in geriatric patients hospitalized for respiratory failure in ICU.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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