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Samanta RJ, Ercole A, Harris S, Summers C. Low Tidal Volume Ventilation Is Poorly Implemented for Patients in North American and United Kingdom ICUs Using Electronic Health Records. Chest 2024; 165:333-347. [PMID: 37775039 PMCID: PMC10851261 DOI: 10.1016/j.chest.2023.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 09/09/2023] [Accepted: 09/15/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND Low tidal volume ventilation (LTVV; < 8 mL/kg predicted body weight [PBW]) is a well-established standard of care associated with improved outcomes. This study used data collated in multicenter electronic health record ICU databases from the United Kingdom and the United States to analyze the use of LTVV in routine clinical practice. RESEARCH QUESTION What factors are associated with adherence to LTVV in the United Kingdom and North America? STUDY DESIGN This was a retrospective, multicenter study across the United Kingdom and United States of patients who were mechanically ventilated. METHODS Factors associated with adherence to LTVV were assessed in all patients in both databases who were mechanically ventilated for > 48 h. We observed trends over time and investigated whether LTVV was associated with patient outcomes (30-day mortality and duration of ventilation) and identified strategies to improve adherence to LTVV. RESULTS A total of 5,466 (Critical Care Health Informatics Collaborative [CCHIC]) and 7,384 electronic ICU collaborative research database [eICU-CRD] patients were ventilated for > 48 h and had data of suitable quality for analysis. The median tidal volume (VT) values were 7.48 mL/kg PBW (CCHIC) and 7.91 mL/kg PBW (eICU-CRD). The patients at highest risk of not receiving LTVV were shorter than 160 cm (CCHIC) and 165 cm (eICU-CRD). Those with BMI > 30 kg/m2 (CCHIC OR, 1.9 [95% CI, 1.7-2.13]; eICU-CRD OR, 1.61 [95% CI, 1.49-1.75]) and female patients (CCHIC OR, 2.39 [95% CI, 2.16-2.65]; eICU-CRD OR, 2.29 [95% CI, 2.26-2.31]) were at increased risk of having median VT > 8 mL/kg PBW. Patients with median VT < 8 mL/kg PBW had decreased 30-day mortality in the CCHIC database (CCHIC cause-specific hazard ratio, 0.86 [95% CI, 0.76-0.97]; eICU-CRD cause-specific hazard ratio, 0.9 [95% CI, 0.86-1.00]). There was a significant reduction in VT over time in the CCHIC database. INTERPRETATION There has been limited implementation of LTVV in routine clinical practice in the United Kingdom and the United States. VT > 8 mL/kg PBW was associated with worse patient outcomes.
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Affiliation(s)
- Romit J Samanta
- Victor Phillip Dahdaleh Heart & Lung Research Institute, University of Cambridge, Cambridge, England
| | - Ari Ercole
- Centre for AI in Medicine, University of Cambridge, Cambridge, England
| | - Steven Harris
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, England
| | - Charlotte Summers
- Victor Phillip Dahdaleh Heart & Lung Research Institute, University of Cambridge, Cambridge, England.
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Maddry JK, Mora AG, Perez CA, Arana AA, Medellin KL, Paciocco JA, Ng PC, Davis WT, Hunninghake JC, Bebarta VS. Improved Adherence to Best Practice Ventilation Management After Implementation of Clinical Practice Guideline (CPG) for United States Military Critical Care Air Transport Teams (CCATTs). Mil Med 2023; 188:e125-e132. [PMID: 34865107 DOI: 10.1093/milmed/usab474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 07/22/2021] [Accepted: 10/29/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Critical Care Air Transport Teams (CCATTs) play a vital role in the transport and care of critically ill and injured patients in the combat theater to include mechanically ventilated patients. Previous research has demonstrated improved morbidity and mortality when lung protective ventilation strategies are used. Our previous study of CCATT trauma patients demonstrated frequent non-adherence to the Acute Respiratory Distress Syndrome Network (ARDSNet) protocol and a corresponding association with increased mortality. The goals of our study were to examine CCATT adherence with ARDSNet guidelines in non-trauma patients, compare the findings to our previous publication of CCATT trauma patients, and evaluate adherence before and after the publication of the CCATT Ventilator Management Clinical Practice Guideline (CPG). METHODS We performed a retrospective chart review of ventilated non-trauma patients who were evacuated out of theater by Critical Care Air Transport Teams (CCATT) between January 2007 and April 2015. Data abstractors collected flight information, oxygenation status, ventilator settings, procedures, and in-flight assessments. We calculated descriptive statistics to determine the frequency of compliance with the ARDSNet protocol before and after the CCATT Ventilator CPG publication and the association between ARDSNet protocol adherence and in-flight events. RESULTS We reviewed the charts of 124 mechanically ventilated patients transported out of theater via CCATT on volume control settings. Seventy percent (n = 87/124) of records were determined to be Non-Adherent to ARDSNet recommendations predominately due to excessive tidal volume settings and/or high FiO2 settings relative to the patient's positive end-expiratory pressure setting. The Non-Adherent group had a higher proportion of in-flight respiratory events. Compared to our previous study of ventilation guideline adherence in the trauma population, the Non-Trauma population had a higher rate of non-adherence to tidal volume and ARDSNet table recommendations (75.6% vs. 61.5%). After the CPG was rolled out, adherence improved from 24% to 41% (P = 0.0496). CONCLUSIONS CCATTs had low adherence with the ARDSNet guidelines in non-trauma patients transported out of the combat theater, but implementation of a Ventilator Management CPG was associated with improved adherence.
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Affiliation(s)
- Joseph K Maddry
- Air Force 59th MDW/ST-En Route Care Research Center, JBSA Ft Sam Houston, TX 78234, USA
- Department of Emergency Medicine, Brooke Army Military Medical Center, JBSA Ft Sam Houston, TX 78234, USA
- Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, MD 20814, USA
| | - Alejandra G Mora
- Air Force 59th MDW/ST-En Route Care Research Center, JBSA Ft Sam Houston, TX 78234, USA
| | - Crystal A Perez
- Air Force 59th MDW/ST-En Route Care Research Center, JBSA Ft Sam Houston, TX 78234, USA
| | - Allyson A Arana
- Air Force 59th MDW/ST-En Route Care Research Center, JBSA Ft Sam Houston, TX 78234, USA
| | - Kimberly L Medellin
- Air Force 59th MDW/ST-En Route Care Research Center, JBSA Ft Sam Houston, TX 78234, USA
| | - Joni A Paciocco
- Air Force 59th MDW/ST-En Route Care Research Center, JBSA Ft Sam Houston, TX 78234, USA
| | - Patrick C Ng
- Air Force 59th MDW/ST-En Route Care Research Center, JBSA Ft Sam Houston, TX 78234, USA
- Department of Emergency Medicine, Brooke Army Military Medical Center, JBSA Ft Sam Houston, TX 78234, USA
- Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, MD 20814, USA
| | - William T Davis
- Air Force 59th MDW/ST-En Route Care Research Center, JBSA Ft Sam Houston, TX 78234, USA
- Department of Emergency Medicine, Brooke Army Military Medical Center, JBSA Ft Sam Houston, TX 78234, USA
- Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, MD 20814, USA
| | - John C Hunninghake
- Critical Care Medicine, Brooke Army Military Medical Center, JBSA Ft Sam Houston, TX 78234, USA
| | - Vikhyat S Bebarta
- Center for COMBAT Research, Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
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Watkin D, Welhengama C, Watmore J, Normanton R, Watson J, Wallis A, Irvine M, Main N, Crews M. Beyond audit: Embracing QI methodology to drive improvements in lung-protective ventilation. Nurs Crit Care 2023; 28:21-29. [PMID: 34766423 DOI: 10.1111/nicc.12728] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 10/16/2021] [Accepted: 10/21/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Mechanical ventilation supports patients with respiratory failure during critical illness. Evidence suggests that excessive tidal volumes (regarded as >8 mL/kg predicted body weight [PBW]) cause lung damage through increased lung stretch and alveolar inflammation. Lung-protective ventilation strategies have been shown to decrease morbidity and mortality, and that all patients should receive tidal volumes between 6 and 8 mls/kg PBW. Despite this, studies demonstrate that fewer than half of patients in critical care successfully receive lung-protective ventilation. AIM The primary aim was to reduce tidal volumes delivered to all patients receiving mandatory ventilation, with a target of >85% of tidal volumes delivered to be compliant with lung-protective ventilation strategies by the end of November 2019. METHODS A multidisciplinary team of nurses and doctors, based in a UK tertiary hospital, utilized the Institute for Healthcare Improvement's (IHI) quality improvement methodology to improve compliance with lung-protective ventilation. RESULTS Baseline data demonstrated that only 60.1% of tidal volumes recorded were compliant with lung-protective ventilation. Quality improvement (QI) methodology was utilized to systematically diagnose the aetiology of poor compliance and to produce and implement solutions. Real-time data collection and reporting were utilized to monitor and report improvement. Following 8 months of continuous data collection and repeated PDSA cycles, sustainable compliance with lung-protective ventilation for >85% of tidal volumes was achieved. CONCLUSIONS The use of QI methodology to implement low tidal volume ventilation has shown a significant improvement in the delivery of lung-protective ventilation. Using QI methodology is central to this sustained improvement and offers a useful tool to systematically approach complex clinical problems. RELEVANCE TO CLINICAL PRACTICE Lung protective ventilation is critically important in the management of ventilated patients, although compliance in intensive care is variable. Here, we describe how quality improvement methodology can lead to consistent and sustainable improvement in the delivery of lung protective ventilation.
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Affiliation(s)
- Daniel Watkin
- Critical Care Unit, Royal Liverpool Hospital, Liverpool, Merseyside, UK
| | | | - James Watmore
- Critical Care Unit, Royal Liverpool Hospital, Liverpool, Merseyside, UK
| | - Robert Normanton
- Critical Care Unit, Royal Liverpool Hospital, Liverpool, Merseyside, UK
| | | | - Alex Wallis
- Critical Care Unit, Royal Liverpool Hospital, Liverpool, Merseyside, UK
| | - Michael Irvine
- Critical Care Unit, Royal Liverpool Hospital, Liverpool, Merseyside, UK
| | - Norman Main
- Critical Care Unit, Royal Liverpool Hospital, Liverpool, Merseyside, UK
| | - Maryam Crews
- Critical Care Unit, Royal Liverpool Hospital, Liverpool, Merseyside, UK
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Villar J, Ferrando C, Tusman G, Berra L, Rodríguez-Suárez P, Suárez-Sipmann F. Unsuccessful and Successful Clinical Trials in Acute Respiratory Distress Syndrome: Addressing Physiology-Based Gaps. Front Physiol 2021; 12:774025. [PMID: 34916959 PMCID: PMC8669801 DOI: 10.3389/fphys.2021.774025] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/08/2021] [Indexed: 12/29/2022] Open
Abstract
The acute respiratory distress syndrome (ARDS) is a severe form of acute hypoxemic respiratory failure caused by an insult to the alveolar-capillary membrane, resulting in a marked reduction of aerated alveoli, increased vascular permeability and subsequent interstitial and alveolar pulmonary edema, reduced lung compliance, increase of physiological dead space, and hypoxemia. Most ARDS patients improve their systemic oxygenation, as assessed by the ratio between arterial partial pressure of oxygen and inspired oxygen fraction, with conventional intensive care and the application of moderate-to-high levels of positive end-expiratory pressure. However, in some patients hypoxemia persisted because the lungs are markedly injured, remaining unresponsive to increasing the inspiratory fraction of oxygen and positive end-expiratory pressure. For decades, mechanical ventilation was the only standard support technique to provide acceptable oxygenation and carbon dioxide removal. Mechanical ventilation provides time for the specific therapy to reverse the disease-causing lung injury and for the recovery of the respiratory function. The adverse effects of mechanical ventilation are direct consequences of the changes in pulmonary airway pressures and intrathoracic volume changes induced by the repetitive mechanical cycles in a diseased lung. In this article, we review 14 major successful and unsuccessful randomized controlled trials conducted in patients with ARDS on a series of techniques to improve oxygenation and ventilation published since 2010. Those trials tested the effects of adjunctive therapies (neuromuscular blocking agents, prone positioning), methods for selecting the optimum positive end-expiratory pressure (after recruitment maneuvers, or guided by esophageal pressure), high-frequency oscillatory ventilation, extracorporeal oxygenation, and pharmacologic immune modulators of the pulmonary and systemic inflammatory responses in patients affected by ARDS. We will briefly comment physiology-based gaps of negative trials and highlight the possible needs to address in future clinical trials in ARDS.
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Affiliation(s)
- Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Multidisciplinary Organ Dysfunction Evaluation Research Network (MODERN), Research Unit, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain.,Keenan Research Center at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Carlos Ferrando
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Department of Anesthesiology and Critical Care, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clinic, Barcelona, Spain
| | - Gerardo Tusman
- Department of Anesthesiology, Hospital Privado de Comunidad, Mar del Plata, Argentina
| | - Lorenzo Berra
- Harvard Medical School, Boston, MA, United States.,Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Pedro Rodríguez-Suárez
- Department of Thoracic Surgery, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Fernando Suárez-Sipmann
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Intensive Care Unit, Hospital Universitario La Princesa, Madrid, Spain.,Hedenstierna Laboratory, Department of Surgical Sciences, Anesthesiology and Critical Care, Uppsala University Hospital, Uppsala, Sweden
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Zhou J, Wang C, Lv R, Liu N, Huang Y, Wang W, Yu L, Xie J. Protective mechanical ventilation with optimal PEEP during RARP improves oxygenation and pulmonary indexes. Trials 2021; 22:351. [PMID: 34011404 PMCID: PMC8135157 DOI: 10.1186/s13063-021-05310-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 05/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This trial aimed to evaluate the effects of a protective ventilation strategy on oxygenation/pulmonary indexes in patients undergoing robot-assisted radical prostatectomy (RARP) in the steep Trendelenburg position. METHODS In phase 1, the most optimal positive end-expiratory pressure (PEEP) was determined in 25 patients at 11 cmH2O. In phase 2, 64 patients were randomized to the traditional ventilation group with tidal volume (VT) of 9 ml/kg of predicted body weight (PBW) and the protective ventilation group with VT of 7 ml/kg of PBW with optimal PEEP and recruitment maneuvers (RMs). The primary endpoint was the intraoperative and postoperative PaO2/FiO2. The secondary endpoints were the PaCO2, SpO2, modified clinical pulmonary infection score (mCPIS), and the rate of complications in the postoperative period. RESULTS Compared with controls, PaO2/FiO2 in the protective group increased after the second RM (P=0.018), and the difference remained until postoperative day 3 (P=0.043). PaCO2 showed transient accumulation in the protective group after the first RM (T2), but this phenomenon disappeared with time. SpO2 in the protective group was significantly higher during the first three postoperative days. Lung compliance was significantly improved after the second RM in the protective group (P=0.025). The mCPIS was lower in the protective group on postoperative day 3 (0.59 (1.09) vs. 1.46 (1.27), P=0.010). CONCLUSION A protective ventilation strategy with lower VT combined with optimal PEEP and RMs could improve oxygenation and reduce mCPIS in patients undergoing RARP. TRIAL REGISTRATION ChiCTR ChiCTR1800015626 . Registered on 12 April 2018.
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Affiliation(s)
- Jianwei Zhou
- Department of Anesthesia, Lishui Hospital, School of Medicine, Zhejiang University, kuocang Road 289, Lishui, 323000, Zhejiang, China
| | - Chuanguang Wang
- Department of Anesthesia, Lishui Hospital, School of Medicine, Zhejiang University, kuocang Road 289, Lishui, 323000, Zhejiang, China
| | - Ran Lv
- Department of Anesthesia, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, East Qingchun Road 3, Hangzhou, 310016, Zhejiang, China
| | - Na Liu
- Department of Anesthesia, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, East Qingchun Road 3, Hangzhou, 310016, Zhejiang, China
| | - Yan Huang
- Department of Anesthesia, Lishui Hospital, School of Medicine, Zhejiang University, kuocang Road 289, Lishui, 323000, Zhejiang, China
| | - Wu Wang
- Department of Anesthesia, Lishui Hospital, School of Medicine, Zhejiang University, kuocang Road 289, Lishui, 323000, Zhejiang, China
| | - Lina Yu
- Department of Anesthesia, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, Zhejiang, China
| | - Junran Xie
- Department of Anesthesia, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, East Qingchun Road 3, Hangzhou, 310016, Zhejiang, China.
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Al-Ruweidi MKAA, Ali FH, Shurbaji S, Popelka A, Yalcin HC. Dexamethasone and transdehydroandrosterone significantly reduce pulmonary epithelial cell injuries associated with mechanical ventilation. J Appl Physiol (1985) 2021; 130:1143-1151. [PMID: 33600286 PMCID: PMC8384562 DOI: 10.1152/japplphysiol.00574.2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Many patients who suffer from pulmonary diseases cannot inflate their lungs normally, as they need mechanical ventilation (MV) to assist them. The stress associated with MV can damage the delicate epithelium in small airways and alveoli, which can cause complications resulting in ventilation-induced lung injuries (VILIs) in many cases, especially in patients with acute respiratory distress syndrome (ARDS). Therefore, efforts were directed to develop safe modes for MV. In our work, we propose a different approach to decrease injuries of epithelial cells (EpCs) upon MV. We alter EpCs’ cytoskeletal structure to increase their survival rate during airway reopening conditions associated with MV. We tested two anti-inflammatory drugs dexamethasone (DEX) and transdehydroandrosterone (DHEA) to alter the cytoskeleton. Cultured rat L2 alveolar EpCs were exposed to airway reopening conditions using a parallel-plate perfusion chamber. Cells were exposed to a single bubble propagation to simulate stresses associated with mechanical ventilation in both control and study groups. Cellular injury and cytoskeleton reorganization were assessed via fluorescence microscopy, whereas cell topography was studied via atomic force microscopy (AFM). Our results indicate that culturing cells in media, DEX solution, or DHEA solution did not lead to cell death (static cultures). Bubble flows caused significant cell injury. Preexposure to DEX or DHEA decreased cell death significantly. The AFM verified alteration of cell mechanics due to actin fiber depolymerization. These results suggest potential beneficial effects of DEX and DHEA for ARDS treatment for patients with COVID-19. They are also critical for VILIs and applicable to future clinical studies. NEW & NOTEWORTHY Preexposure of cultured cells to either dexamethasone or transdehydroandrosterone significantly decreases cellular injuries associated with mechanical ventilation due to their ability to alter the cell mechanics. This is an alternative protective method against VILIs instead of common methods that rely on modification of mechanical ventilator modes.
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Affiliation(s)
- Mahmoud Khatib A A Al-Ruweidi
- Biomedical Research Centre, Qatar University, Doha, Qatar.,Department of Chemistry and Earth Sciences, Qatar University, Doha, Qatar
| | | | - Samar Shurbaji
- Biomedical Research Centre, Qatar University, Doha, Qatar
| | - Anton Popelka
- Center of Advanced Materials, Qatar University, Doha, Qatar
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Tallo FS, Vendrame LS, Baitello AL. Comparison of three methods for teaching mechanical ventilation in an emergency setting to sixth-year medical students: a randomized trial. Rev Assoc Med Bras (1992) 2020; 66:1409-1413. [DOI: 10.1590/1806-9282.66.10.1409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/23/2020] [Indexed: 11/22/2022] Open
Abstract
SUMMARY OBJECTIVE: To determine if there are significant differences between the tutorial, simulation, or clinical-case-based discussion teaching methods regarding the transmission of medical knowledge on mechanical ventilation. METHODS: A randomized, multicenter, open-label controlled trial was carried out using 3 teaching methods on mechanical ventilation: clinical-case-based discussion, simulation, and online tutorial. Voluntary students of the sixth year of medical school from 11 medical colleges answered a validated questionnaire on knowledge about mechanical ventilation for medical students before, immediately after, and 6 months after in-person training consisting of 20 multiple-choice questions, and 5 questions about the participants' demographic profile. RESULTS: Immediately after the test there was no difference between the scores in the simulation and clinical case groups,[15,06 vs 14,63] whereas, after some time, there was a significant difference in retention between the case-based and simulation groups, with the score in the simulation group 1.46 [1.31; 1.64] times higher than the score of the case group (p-value < 0.001). In the multivariate analysis, an individual who had received more than 4 hours of information showed an increase of 20.0% [09.0%; 33.0%] in the score (p-value = 0.001). CONCLUSIONS: Our results indicate that, in comparison with other forms of training, simulation in mechanical ventilation provides long-lasting knowledge in the medium term. Further studies are needed to improve the designing and evaluation of training that provides minimal mechanical ventilation skills.
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Shen Y, Cai G, Chen S, Hu C, Yan J. Fluid intake-related association between urine output and mortality in acute respiratory distress syndrome. Respir Res 2020; 21:24. [PMID: 31937303 PMCID: PMC6961352 DOI: 10.1186/s12931-020-1286-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 01/08/2020] [Indexed: 01/15/2023] Open
Abstract
Background Acute respiratory distress syndrome (ARDS), a complex response to various insults, has a high mortality rate. As pulmonary edema resulting from increased vascular permeability is a hallmark of ARDS, management of the fluid status, including the urine output (UO) and fluid intake (FI), is essential. However, the relationships between UO, FI, and mortality in ARDS remain unclear. This retrospective study aimed to investigate the interactive associations among UO, FI, and mortality in ARDS. Methods This was a secondary analysis of a prospective randomized controlled trial performed at 10 centers within the ARDS Network of the National Heart, Lung, and Blood Institute research network. The total UO and FI volumes within the 24-h period preceding the trial, the UO to FI ratio (UO/FI), demographic data, biochemical measurements, and other variables from 835 patients with ARDS, 539 survivors, and 296 non-survivors, were analyzed. The associations among UO, FI, the UO/FI, and mortality were assessed using a multivariable logistic regression. Results In all 835 patients, an increased UO was significantly associated with decreased mortality when used as a continuous variable (odds ratio [OR]: 0.98, 95% confidence interval [CI]: 0.98–0.99, P = 0.002) and as a quartile variable (OR of Q2 to Q4: 0.69–0.46, with Q1 as reference). To explore the interaction between UO and FI, the UO/FI was calculated, and a cut-off value of 0.5 was detected for the association with mortality. For patients with a UO/FI ≤0.5, an increased UO/FI was significantly associated with decreased mortality (OR: 0.09, 95% CI: 0.03–0.253, P < 0.001); this association was not significant for patients with UO/FI ratios > 0.5 (OR: 1.04, 95% CI: 0.96–1.14, P = 0.281). A significant interaction was observed between UO and the UO/FI. The association between UO and mortality was significant in the subgroup with a UO/FI ≤0.5 (OR: 0.97, 95% CI: 0.96–0.99, P = 0.006), but not in the subgroup with a UO/FI > 0.5. Conclusions The association between UO and mortality was mediated by the UO/FI status, as only patients with low UO/FI ratios benefitted from a higher UO.
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Affiliation(s)
- Yanfei Shen
- Department of Intensive Care, Zhejiang Hospital, No. 12, Linyin Road, Hangzhou, Zhejiang, 310000, People's Republic of China
| | - Guolong Cai
- Department of Intensive Care, Zhejiang Hospital, No. 12, Linyin Road, Hangzhou, Zhejiang, 310000, People's Republic of China
| | - Shangzhong Chen
- Department of Intensive Care, Zhejiang Hospital, No. 12, Linyin Road, Hangzhou, Zhejiang, 310000, People's Republic of China
| | - Caibao Hu
- Department of Intensive Care, Zhejiang Hospital, No. 12, Linyin Road, Hangzhou, Zhejiang, 310000, People's Republic of China
| | - Jing Yan
- Department of Intensive Care, Zhejiang Hospital, No. 12, Linyin Road, Hangzhou, Zhejiang, 310000, People's Republic of China.
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Affiliation(s)
- Mark Griffiths
- Barts Heart Centre, St Bartholomews Hospital, London, UK .,NHLI, Imperial College London, London, UK
| | - Eddy Fan
- Toronto General Hospital, Toronto, Ontario, Canada
| | - Simon V Baudouin
- Department of Medicine, Newcastle University, Newcastle upon Tyne, UK
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10
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Grune J, Tabuchi A, Kuebler WM. Alveolar dynamics during mechanical ventilation in the healthy and injured lung. Intensive Care Med Exp 2019; 7:34. [PMID: 31346797 PMCID: PMC6658629 DOI: 10.1186/s40635-019-0226-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 02/13/2019] [Indexed: 02/12/2023] Open
Abstract
Mechanical ventilation is a life-saving therapy in patients with acute respiratory distress syndrome (ARDS). However, mechanical ventilation itself causes severe co-morbidities in that it can trigger ventilator-associated lung injury (VALI) in humans or ventilator-induced lung injury (VILI) in experimental animal models. Therefore, optimization of ventilation strategies is paramount for the effective therapy of critical care patients. A major problem in the stratification of critical care patients for personalized ventilation settings, but even more so for our overall understanding of VILI, lies in our limited insight into the effects of mechanical ventilation at the actual site of injury, i.e., the alveolar unit. Unfortunately, global lung mechanics provide for a poor surrogate of alveolar dynamics and methods for the in-depth analysis of alveolar dynamics on the level of individual alveoli are sparse and afflicted by important limitations. With alveolar dynamics in the intact lung remaining largely a "black box," our insight into the mechanisms of VALI and VILI and the effectiveness of optimized ventilation strategies is confined to indirect parameters and endpoints of lung injury and mortality.In the present review, we discuss emerging concepts of alveolar dynamics including alveolar expansion/contraction, stability/instability, and opening/collapse. Many of these concepts remain still controversial, in part due to limitations of the different methodologies applied. We therefore preface our review with an overview of existing technologies and approaches for the analysis of alveolar dynamics, highlighting their individual strengths and limitations which may provide for a better appreciation of the sometimes diverging findings and interpretations. Joint efforts combining key technologies in identical models to overcome the limitations inherent to individual methodologies are needed not only to provide conclusive insights into lung physiology and alveolar dynamics, but ultimately to guide critical care patient therapy.
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Affiliation(s)
- Jana Grune
- Institute of Physiology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, 10117 Berlin, Germany
| | - Arata Tabuchi
- Institute of Physiology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Wolfgang M. Kuebler
- Institute of Physiology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, 10117 Berlin, Germany
- The Keenan Research Centre for Biomedical Science at St. Michael’s, Toronto, Canada
- Departments of Surgery and Physiology, University of Toronto, Toronto, Canada
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Yüksek A, Bakı ED, Sarıtaş TB, Sıvacı R. A Comparison of the Effects of Lung Protective Ventilation and Conventional Ventilation on Thermoregulation During Anaesthesia. Turk J Anaesthesiol Reanim 2018; 47:173-178. [PMID: 31183462 DOI: 10.5152/tjar.2018.73659] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 07/12/2018] [Indexed: 02/06/2023] Open
Abstract
Objective During prolonged surgery, hypothermia is an unwanted condition that frequently develops and increases complication rates. It has been shown that positive end-expiratory pressure (PEEP) during mechanical ventilation reduces hypothermia development by providing earlier peripheral vasoconstriction. In the present study, an investigation was made of the effect of two different ventilation models on perioperative hypothermia development. Methods A total of 40 patients undergoing elective lumbar disc surgery were randomised to either the conventional group (Group C, n=20, tidal volume=10 mL kg-1, PEEP=0 cm H2O) or the lung protective ventilation group (Group P, n=20, tidal volume=6 mL kg-1, PEEP=5 cm H2O). Demographic data on gender, age, weight, height, preoperative-postoperative temperatures and haemodynamic values were recorded. The point where the forearm to fingertip skin temperature difference reached 0°C was determined as the peripheral vasoconstriction development. At this point, the core temperature was recorded as the thermoregulatory vasoconstriction threshold. Results Demographic characteristics of the patients and haemodynamic variables were similar between the groups. Preoperative and postoperative temperature gradients were not significantly different between the two groups (p=0.827). There was also no significant difference between the two groups in respect of the vasoconstriction threshold of the patients (p=0.432). Conclusion The study results showed that lung protective ventilation has no advantage in preserving the perioperative core temperature compared to conventional ventilation.
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Affiliation(s)
- Ahmet Yüksek
- Department of Anaesthesiology and Reanimation, Afyon Kocatepe University School of Medicine, Afyonkarahisar, Turkey
| | - Elif Doğan Bakı
- Department of Anaesthesiology and Reanimation, Afyon Kocatepe University School of Medicine, Afyonkarahisar, Turkey
| | - Tuba Berrak Sarıtaş
- Department of Anaesthesiology and Reanimation, Afyon Kocatepe University School of Medicine, Afyonkarahisar, Turkey
| | - Remziye Sıvacı
- Department of Anaesthesiology and Reanimation, Afyon Kocatepe University School of Medicine, Afyonkarahisar, Turkey
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Maddry JK, Mora AG, Savell SC, Perez CA, Mason PE, Aden JK, Bebarta VS. Impact of Critical Care Air Transport Team (CCATT) ventilator management on combat mortality. J Trauma Acute Care Surg 2018; 84:157-64. [PMID: 28570350 DOI: 10.1097/TA.0000000000001607] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Aeromedical evacuation platforms such as Critical Care Air Transport Teams (CCATTs) play a vital role in the transport and care of critically injured and ill patients in the combat theater. Mechanical ventilation is used to support patients with failing respiratory function and patients requiring high levels of sedation. Mechanical ventilation, if not managed appropriately, can worsen or cause lung injury and contribute to increased morbidity. The purpose of this study was to evaluate the impact of ARDSNet protocol compliance during aeromedical evacuation of ventilated combat injured patients. METHODS We performed a retrospective chart review of combat injured patients transported by CCATTs from Afghanistan to Landstuhl Regional Medical Center (LRMC) in Germany between January 2007 and January 2012. After univariate analyses, we performed regression analyses to assess compliance and post-flight outcomes. Cox proportional hazard models were used to evaluate associations between the risk factor of non-compliance with increased number of ventilator, ICU, or hospital days. Nominal logistic regression models were performed to evaluate the association between non-compliance and mortality. RESULTS Sixty-two percent (n = 669) of 1,086 patients required mechanical ventilation during transport. A total of 650 patients required volume-controlled mechanical ventilation and were included in the analysis. Of the 650 subjects, 62% (n = 400) were non-compliant per tidal volume and ARDSNet table recommendations. The groups were similar in all demographic variables, except the Non-compliant group had a higher Injury Severity Score compared to the Compliant group. Subjects in the Compliant group were less likely to have an incidence of acute respiratory distress, acute respiratory failure, and ventilator-associated pneumonia when combing the variables (2% vs. 7%, p < 0.0069). The Non-compliant group had an increased incidence of in-flight respiratory events, required more days on the ventilator and in the ICU, and had a higher mortality rate. CONCLUSIONS Compliance with the ARDSNet guidelines was associated with a decrease in ventilator days, ICU days, and 30-day mortality. LEVEL OF EVIDENCE Therapeutic/care management, level IV.
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