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Xu J, Liu Z, Wang S, Liang Z, Liu Q, Xu Z, Wu P, Liang L. Impact of pressure support ventilation duration after a spontaneous breathing trial on reintubation rates in critically ill subjects: a retrospective study. BMC Pulm Med 2025; 25:285. [PMID: 40483431 PMCID: PMC12144731 DOI: 10.1186/s12890-025-03744-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2024] [Accepted: 05/27/2025] [Indexed: 06/11/2025] Open
Abstract
BACKGROUND To investigate the effect of different durations of pressure support ventilation (PSV) after a spontaneous breathing trial (SBT) on 48-hour reintubation rates in critically ill subjects. METHODS This single-center retrospective cohort study included adult subjects who received mechanical ventilation for over 48 h, successfully completed SBT, and were scheduled for extubation in the intensive care unit of a tertiary hospital between January and December 2023. Subjects were divided into three groups based on PSV duration after SBT: direct extubation (DE, ≤ 30 min), short-term PSV (SP, 30 min-3 h), and long-term PSV (LP, 3-12 h). The primary outcome was the 48-hour reintubation rate. The secondary outcomes included intensive care unit length of stay and 28-day mortality. RESULTS A total of 982 subjects were included (638, 235, and 109 in the DE, SP, and LP groups, respectively). The 48-hour reintubation rates were 18.34%, 14.04%, and 16.51% in the DE, SP, and LP groups, respectively (P = 0.298). Multivariate logistic regression showed no significant difference in reintubation risk for SP (OR = 0.73, P = 0.141) and LP groups (OR = 0.88, P = 0.643) compared with the DE group. Age (OR = 1.18, P = 0.003) and APACHE II score (OR = 1.07, P < 0.001) were identified as independent risk factors for reintubation. The median intensive care unit length of stay was 16 days in the DE group, 18 days in the SP group, and 19 days in the LP group (P = 0.033). The 28-day mortality did not differ significantly among groups (12.85%, 11.91%, and 14.68%, respectively; P = 0.690). CONCLUSIONS PSV duration after SBT did not significantly affect reintubation rates in the overall population. While short-term PSV showed potential benefits in specific subgroups, particularly COPD patients, direct extubation after successful SBT appears safe for most patients and may reduce ICU length of stay. These findings suggest that extubation strategies should be individualized based on patient characteristics rather than applying extended PSV periods universally.
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Affiliation(s)
- Jinlong Xu
- Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Zefang Liu
- Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Simei Wang
- Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Zhenghua Liang
- Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Qiuyu Liu
- Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Zhihua Xu
- Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Pingzhen Wu
- Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Lijun Liang
- Intensive Care Unit, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China.
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Yang TM, Fang YH, Chang CH, Lin SJ, Liu CC, Tsai DMT, Lin CL, Lin CM, Hsu YC. Prolonged T-Piece Spontaneous Breathing Trial and Extubation Outcomes in Patients Received Prolonged Mechanical Ventilation. MEDICINA (KAUNAS, LITHUANIA) 2025; 61:412. [PMID: 40142223 PMCID: PMC11943584 DOI: 10.3390/medicina61030412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2024] [Revised: 01/13/2025] [Accepted: 02/25/2025] [Indexed: 03/28/2025]
Abstract
Background and Objectives: Unassisted breathing through a T-piece was the most used spontaneous breathing trial (SBT) in endotracheal intubated prolonged mechanical ventilation (PMV) patients. However, the optimal duration of an SBT in PMV patients remains uncertain. In this study, we compared the extubation outcome between a 12 h T-piece SBT and a 24 h T-piece SBT in PMV patients. Materials and Methods: We reviewed the medical records of PMV patients who were extubated after passing a 12 h or 24 h T-piece SBT. The extubation, weaning, and hospital outcomes between the 12 h T-piece SBT group and the 24 h T-piece SBT group were compared. Kaplan-Meier survival plots and Cox proportional hazard models were used to evaluate the risk of extubation failure between groups. Results: In this study, 120 patients were extubated after passing the 12 h T-piece SBT and 234 patients were extubated after passing 24 h T-piece SBT. Patients in the 24 h T-piece SBT group had higher APACHE II score and lower Glasgow coma scale upon RCC arrival than patients in the 12 h T-piece SBT group. There was no difference in gender, age, or ventilator days before extubation between these two groups of patients. After extubation, patients in the 12 h T-piece SBT group and 24 h T-piece SBT group had similar extubation failure rates within 5 days (26.7% vs. 26.1%, p = 0.904). There was no difference in the RCC weaning rate (85% vs. 85.5%, p = 0.929) and hospital mortality rate (19.8% vs. 21.8%, p = 0.821) between the 12 h T-piece SBT group and the 24 h T-piece SBT group. Subgroup analysis showed that 24 h T-piece SBT was associated with a lower extubation failure rate in PMV patients with myocardial infarction or heart failure, but not in older PMV patients or those with cerebrovascular disease. Conclusions: The extubation and weaning outcomes were similar in PMV patients extubated after passing 12 h T-piece SBT or 24 h T-piece SBT.
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Affiliation(s)
- Tsung-Ming Yang
- Division of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Chiayi 613016, Taiwan; (T.-M.Y.); (Y.-H.F.)
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan 333423, Taiwan;
| | - Yu-Hung Fang
- Division of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Chiayi 613016, Taiwan; (T.-M.Y.); (Y.-H.F.)
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi 613016, Taiwan
| | - Chia-Hao Chang
- Department of Nursing, Chang Gung University of Science and Technology, Chiayi 613016, Taiwan;
| | - Shih-Jiun Lin
- Department of Nephrology, Chang Gung Memorial Hospital, Chiayi Branch, Chiayi 613016, Taiwan; (S.-J.L.); (C.-C.L.); (D.M.T.T.)
- Kidney and Diabetic Complications Research Team (KDCRT), Chang Gung Memorial Hospital, Chiayi 613016, Taiwan
| | - Cheng-Chi Liu
- Department of Nephrology, Chang Gung Memorial Hospital, Chiayi Branch, Chiayi 613016, Taiwan; (S.-J.L.); (C.-C.L.); (D.M.T.T.)
- Kidney and Diabetic Complications Research Team (KDCRT), Chang Gung Memorial Hospital, Chiayi 613016, Taiwan
| | - David Ming Then Tsai
- Department of Nephrology, Chang Gung Memorial Hospital, Chiayi Branch, Chiayi 613016, Taiwan; (S.-J.L.); (C.-C.L.); (D.M.T.T.)
- Kidney and Diabetic Complications Research Team (KDCRT), Chang Gung Memorial Hospital, Chiayi 613016, Taiwan
| | - Chun-Liang Lin
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan 333423, Taiwan;
- Department of Nephrology, Chang Gung Memorial Hospital, Chiayi Branch, Chiayi 613016, Taiwan; (S.-J.L.); (C.-C.L.); (D.M.T.T.)
- Kidney and Diabetic Complications Research Team (KDCRT), Chang Gung Memorial Hospital, Chiayi 613016, Taiwan
- Center for Shockwave Medicine and Tissue Engineering, Chang Gung Memorial Hospital, Kaohsiung 833253, Taiwan
| | - Chieh-Mo Lin
- Division of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Chiayi 613016, Taiwan; (T.-M.Y.); (Y.-H.F.)
| | - Yung-Chien Hsu
- Department of Nephrology, Chang Gung Memorial Hospital, Chiayi Branch, Chiayi 613016, Taiwan; (S.-J.L.); (C.-C.L.); (D.M.T.T.)
- Kidney and Diabetic Complications Research Team (KDCRT), Chang Gung Memorial Hospital, Chiayi 613016, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333423, Taiwan
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Varón-Vega F, Tuta-Quintero E, Robayo-Amortegui H, Rincón A, Giraldo-Cadavid LF, Palacios J, Crevoisier S, Duarte DC, Poveda M, Cucunubo L, Monedero P. Clinical utility of rapid shallow breathing index in predicting successful weaning: secondary analysis of the COBRE-US trial. Med Intensiva 2025; 49:72-77. [PMID: 38902150 DOI: 10.1016/j.medine.2024.06.007] [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: 06/22/2024]
Abstract
OBJECTIVE To assess the predictive capacity of the Rapid Shallow Breathing Index (RSBI) for success in spontaneous breathing trials (SBT) and extubation in critically ill patients. We evaluated the association between RSBI, duration of mechanical ventilation, and ventilator-free time at 28 days. DESIGN Prospective multicenter observational study. Secondary analysis of the COBRE-US study. SETTING Intensive care unit (ICU). PATIENTS OR PARTICIPANTS 367 patients in the ICU receiving invasive mechanical ventilation. INTERVENTIONS Assessment of RSBI at the end of SBT. MAIN VARIABLES OF INTEREST RSBI, SBT, duration of mechanical ventilation, and ventilator-free time at 28 days were evaluated. RESULTS 367 patients in the ICU under invasive mechanical ventilation were evaluated, of whom 59.7% were male with a median age of 61 years (IQR: 49-72). A total of 456 SBT were conducted with a success rate of 76.5%. RSBI had a ROC-curve of 0.53 for SBT success and a ROC-curve of 0.48 for extubation. The Spearman correlation coefficient between RSBI and duration of ventilation was 0.117 (p = 0.026), while for ventilator-free time at 28 days, it was -0.116 (p = 0.028). CONCLUSIONS RSBI was not associated with success in SBT or extubation, regardless of the cutoff point used. Correlation analyses showed weak associations between RSBI and both the duration of ventilation and ventilator-free time at 28 days.
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Affiliation(s)
- Fabio Varón-Vega
- Critical Care and Lung Transplantation Service, Fundación Neumológica Colombiana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia; Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia.
| | - Eduardo Tuta-Quintero
- Critical Care and Lung Transplantation Service, Fundación Neumológica Colombiana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia; Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia; Master's Candidate in Epidemiology, Universidad de La Sabana, Chía, Colombia
| | - Henry Robayo-Amortegui
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia; Critical Care Service, Fundación Clínica Shaio, Bogotá, Colombia
| | - Adriana Rincón
- Critical Care and Lung Transplantation Service, Fundación Neumológica Colombiana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia; Master's Candidate in Epidemiology, Universidad de La Sabana, Chía, Colombia
| | - Luis F Giraldo-Cadavid
- Professor of Medicine at Facultad de Medicina, Universidad de La Sabana, Chía, Colombia; Interventional Pulmonology Service, Fundación Neumológica Colombiana, Bogotá, Colombia
| | - Jonathan Palacios
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Stephanie Crevoisier
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Diana C Duarte
- Critical Care and Lung Transplantation Service, Fundación Neumológica Colombiana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Marcela Poveda
- Critical Care Service, Fundación Clínica Shaio, Bogotá, Colombia
| | - Laura Cucunubo
- Critical Care Service, Fundación Neumológica Colombiana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Pablo Monedero
- School of Medicine. Universidad de Navarra, Pamplona, Spain
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Watson V, Ghishan S, Avalishvili T, Zeleke S, Tigabe S, White A, Zeid F, Alagha Z. Exploring Extubation Readiness in Guillain-Barré Syndrome: A Case Report and Literature Review. J Investig Med High Impact Case Rep 2025; 13:23247096251331859. [PMID: 40340471 PMCID: PMC12062643 DOI: 10.1177/23247096251331859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2025] [Revised: 03/04/2025] [Accepted: 03/15/2025] [Indexed: 05/10/2025] Open
Abstract
Guillain-Barré Syndrome (GBS) is an acute immune-mediated polyneuropathy causing rapidly progressive muscle weakness and often respiratory failure, requiring mechanical ventilation in 30% of cases. Successful weaning and extubation are crucial, focusing on readiness for spontaneous breathing trials, optimal timing, and minimizing complications such as ventilator-associated pneumonia and extubation failure. This case report describes an 83-year-old male with multiple comorbidities who was intubated after his negative inspiratory force dropped below -30 cm H₂O and treated with plasmapheresis, leading to partial improvement. Despite not meeting standard extubation criteria, he was successfully extubated, maintained stable respiratory function, and was safely discharged. This case highlights the challenges of extubation in GBS patients, where advanced age, decreased physiological reserve, and comorbidities increase the risks of prolonged intubation and complications. This case also highlights the need for individualized extubation strategies in GBS, particularly in elderly patients who may not meet standard criteria. Tailored approaches can still lead to successful outcomes. Based on our institutional experience, we propose factors that predict the success or failure of extubation in these patients. Further research is needed to refine predictive markers and improve extubation success in this population, ultimately enhancing outcomes and reducing ICU and hospital stays.
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Affiliation(s)
| | | | | | | | | | | | - Fuad Zeid
- Marshall University, Huntington, WV, USA
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Gupta A, Singh O, Juneja D. Clinical prediction scores predicting weaning failure from invasive mechanical ventilation: Role and limitations. World J Crit Care Med 2024; 13:96482. [PMID: 39655298 PMCID: PMC11577531 DOI: 10.5492/wjccm.v13.i4.96482] [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: 05/07/2024] [Revised: 08/27/2024] [Accepted: 08/30/2024] [Indexed: 10/31/2024] Open
Abstract
Invasive mechanical ventilation (IMV) has become integral to modern-day critical care. Even though critically ill patients frequently require IMV support, weaning from IMV remains an arduous task, with the reported weaning failure (WF) rates being as high as 50%. Optimizing the timing for weaning may aid in reducing time spent on the ventilator, associated adverse effects, patient discomfort, and medical care costs. Since weaning is a complex process and WF is often multi-factorial, several weaning scores have been developed to predict WF and aid decision-making. These scores are based on the patient's physiological and ventilatory parameters, but each has limitations. This review highlights the current role and limitations of the various clinical prediction scores available to predict WF.
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Affiliation(s)
- Anish Gupta
- Institute of Critical Care Medicine, Max Hospital, Gurugram 122022, Haryana, India
| | - Omender Singh
- Institute of Critical Care Medicine, Max Super Specialty Hospital, New Delhi 110017, India
| | - Deven Juneja
- Institute of Critical Care Medicine, Max Super Specialty Hospital, New Delhi 110017, India
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Beshish AG, Fundora MP, Aronoff E, Rao N, Kelleman MS, Shaw FR, Maher KO, Wolf M. Prevalence, Risk Factors, and Etiology of Extubation Failure in Pediatric Patients After Cardiac Surgery. J Pediatr Intensive Care 2024; 13:321-329. [PMID: 39629338 PMCID: PMC11584263 DOI: 10.1055/s-0041-1742253] [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: 10/14/2021] [Accepted: 12/12/2021] [Indexed: 10/19/2022] Open
Abstract
In this article, our primary objective was to investigate the prevalence and etiology of extubation failure (EF) in patients following cardiac surgery for congenital heart disease. Secondarily, we examined the association of different risk factors with EF. This was single-center retrospective study in a 27-bed cardiac intensive care unit at a quaternary children's hospital. All patients between 0 and 18 years of age who underwent congenital cardiac surgery from January 2008 to September 2019 were included. During the study period, among 8,750 surgical encounters, 257 (2.9%) failed extubation, defined as reintubation within 48 hours from extubation. EF patients were younger, smaller, more likely to have genetic syndromes, higher Society of Thoracic Surgeons and the European Association for Cardio-Thoracic Surgery (STAT) mortality scores, single-ventricle physiology, longer cardiopulmonary bypass (CPB) and cross-clamp (XC) times, longer mechanical ventilation (MV) duration, and higher mortality ( p <0.05). In a univariate analysis, EF patients when compared to matched controls by age, gender, and STAT score, and genetic syndrome, particularly heterotaxy, were associated with increased odds of EF ( p <0.05). In a multivariable logistic regression of the entire cohort, the presence of any genetic syndrome was associated with higher odds of EF ( p <0.05). In a subgroup of neonates, a univariate analysis was performed and multivariable analysis was attempted, but both did not achieve statistical significance. In summary, EF after congenital cardiac surgery is associated with younger age, lower weight, single-ventricle physiology, longer CPB and XC times, longer duration of MV, and genetic syndromes. Patients failing extubation have increased morbidity and mortality. Recognition of these risk factors may provide clinicians the ability to identify patients at high risk allowing for timely intervention to limit adverse outcomes.
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Affiliation(s)
- Asaad G. Beshish
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Michael P. Fundora
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Elizabeth Aronoff
- Emory University School of Medicine, Atlanta, Georgia, United States
| | - Nikita Rao
- Children's Healthcare of Atlanta, Atlanta, Georgia, United States
| | - Michael S. Kelleman
- Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, United States
| | - Fawwaz R. Shaw
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Kevin O. Maher
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Michael Wolf
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, United States
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Jose AM, Prabhakaran K, Rafieezadeh A, Kirsch J, Zangbar B. Analysis of pre-admission risk factors for unplanned reintubation in geriatric trauma patients. Am J Surg 2024; 238:115882. [PMID: 39098281 DOI: 10.1016/j.amjsurg.2024.115882] [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: 03/27/2024] [Revised: 07/15/2024] [Accepted: 07/29/2024] [Indexed: 08/06/2024]
Abstract
INTRODUCTION Reintubation in unplanned scenarios, carries inherent risks and potential complications particularly in vulnerable populations such as geriatric trauma patients. We sought to identify preadmission risk factors for unplanned re-intubation (URI) in geriatric trauma patients and its effects on outcomes. METHODS Analysis of TQIP (2017-2019) of intubated geriatric trauma patients, classified into two groups, those who were successfully extubated and those who required URI. We used logistic regression to assess for preadmission risk factors of URI. RESULTS Among 23,572 patients, 20.2 % underwent URI. URI had higher mortality (13.7%vs.8.1 %, p < 0.001), in-hospital complications (p < 0.05), longer hospital and ICU LOS (p < 0.001 for both). Higher age (OR = 1.017), smoking (OR = 1.418), CRF(OR = 1.414), COPD (OR = 1.410), alcohol use (OR = 1.365), functionally dependent health status (OR = 1.339), and anticoagulant use (OR = 1.148), increased the risks of URI (p < 0.05 for all). CONCLUSION Geriatric patients with comorbidities including age, smoking, CRF, COPD, alcohol use, dependent status, and anticoagulant use are at higher risks of URI that could in turn, be associated with increased rates of mortality, complications, and longer hospital and ICU length of stay. LEVEL OF EVIDENCE Level III retrospective study.
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Affiliation(s)
- Anna Mary Jose
- Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | | | - Aryan Rafieezadeh
- Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Jordan Kirsch
- Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Bardiya Zangbar
- Westchester Medical Center, New York Medical College, Valhalla, NY, USA.
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Rouby JJ, Perbet S, Quenot JP, Zhang M, Andreu P, Assefi M, Gao Y, Deransy R, Lyu J, Arbelot C, An Y, Monsel A, Jing X, Guerci P, Qian C, Malbouisson L, Morand D, Puybasset L, Futier E, Constantin JM, Pereira B. Weaning of non COPD patients at high-risk of extubation failure assessed by lung ultrasound: the WIN IN WEAN multicentre randomised controlled trial. Crit Care 2024; 28:391. [PMID: 39593129 PMCID: PMC11590311 DOI: 10.1186/s13054-024-05166-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: 05/27/2024] [Accepted: 11/11/2024] [Indexed: 11/28/2024] Open
Abstract
BACKGROUND Postextubation respiratory failure (PRF) frequently complicates weaning from mechanical ventilation and may increase morbidity/mortality. Noninvasive ventilation (NIV) alternating with high-flow nasal oxygen (HFNO) may prevent PRF. METHODS Ventilated patients without chronic obstructive pulmonary disease (COPD) and at high-risk of PRF defined as a lung ultrasound score (LUS) ≥ 14 assessed during the spontaneous breathing trial, were included in a French-Chinese randomised controlled trial. PRF was defined by 2 among the following signs: SpO2 < 90%; Respiratory rate > 30 /min; hypercapnia; haemodynamic and/or neurological disturbances of respiratory origin. In the intervention group, prophylactic NIV alternating with HFNO was administered for 48 h following extubation. In the control group, conventional oxygen was used. Clinicians were informed on the LUS in the intervention group, those in the control group remained blind. The primary outcome was the incidence of PRF 48 h after extubation. Secondary outcomes were incidence of PRF and reintubation at day 7, number of ventilator-free days at day 28, length of ICU stay and mortality at day 28 and 90. RESULTS Two hundred and forty patients were randomised and 227 analysed (intervention group = 128 and control group = 99). PRF at H48 was reduced in the intervention group compared to the control group: relative risk 0.52 (0.31 to 0.88), p = 0.01. The benefit persisted at day 7: relative risk 0.62 (0.44 to 0.96), p = 0.02. Weaning failure imposing reconnection to mechanical ventilation was not reduced. In patients who developed PRF and were treated by rescue NIV, reintubation was avoided in 44% of control patients and in 12% of intervention patients (p = 0.008). Other secondary outcomes were not different between groups. From a resource utilisation standpoint, prophylactic NIV alternating with HFNO was more demanding and costly than conventional oxygen with rescue NIV to achieve same clinical outcome. CONCLUSIONS Compared to conventional oxygenation, prophylactic NIV alternating with HFNO significantly reduced postextubation respiratory failure but failed to reduce reintubation rate and mortality in patients without COPD at high risk of extubation failure. Prophylactic NIV alternating with HFNO was as efficient as recue NIV to treat postextubation respiratory failure.
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Affiliation(s)
- Jean-Jacques Rouby
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, La Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Sorbonne University, GRC 29, DMU DREAM, Paris, France.
| | - Sébastien Perbet
- Adult Intensive Care Unit, Department of Peri-Operative Medicine, University Hospital Estaing, University of Auvergne, Clermont-Ferrand, France
| | - Jean-Pierre Quenot
- Médecine Intensive Réanimation, University Hospital Centre Dijon, University of Bourgogne-Franche Comté, Dijon, France
| | - Mao Zhang
- Department of Emergency Medicine, 2nd Affiliated Hospital, Zhejiang University School of Medicine, Institute of Emergency Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Pascal Andreu
- Médecine Intensive Réanimation, University Hospital Centre Dijon, University of Bourgogne-Franche Comté, Dijon, France
| | - Mona Assefi
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, La Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Sorbonne University, GRC 29, DMU DREAM, Paris, France
| | - Yuzhi Gao
- Department of Emergency Medicine, 2nd Affiliated Hospital, Zhejiang University School of Medicine, Institute of Emergency Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Romain Deransy
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, La Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Sorbonne University, GRC 29, DMU DREAM, Paris, France
| | - Jie Lyu
- Critical Care Medicine Department, Peking University People's Hospital, Beijing, China
| | - Charlotte Arbelot
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, La Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Sorbonne University, GRC 29, DMU DREAM, Paris, France
| | - Youzhong An
- Critical Care Medicine Department, Peking University People's Hospital, Beijing, China
| | - Antoine Monsel
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, La Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Sorbonne University, GRC 29, DMU DREAM, Paris, France
| | - Xia Jing
- Emergency Department and Emergency/Medical Intensive Care Unit, 1st Affiliated Hospital, Kunming Medical University, Kunming, Yunnan, China
| | - Philippe Guerci
- Department of Anaesthesiology and Critical Care Medicine, Institut Lorrain du Cœur et des Vaisseaux, University Hospital of Nancy, University of Lorraine, Nancy, France
| | - Chuanyun Qian
- Emergency Department and Emergency/Medical Intensive Care Unit, 1st Affiliated Hospital, Kunming Medical University, Kunming, Yunnan, China
| | - Luiz Malbouisson
- Anesthesiology, Surgical Sciences and Perioperative Medicine, University of São Paulo Hospital das Clinicas, São Paulo, Brazil
| | - Dominique Morand
- Biostatistics Unit, Department of Clinical Research and Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Louis Puybasset
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, La Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Sorbonne University, GRC 29, DMU DREAM, Paris, France
| | - Emmanuel Futier
- Adult Intensive Care Unit, Department of Peri-Operative Medicine, University Hospital Estaing, University of Auvergne, Clermont-Ferrand, France
| | - Jean-Michel Constantin
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, La Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Sorbonne University, GRC 29, DMU DREAM, Paris, France
- Adult Intensive Care Unit, Department of Peri-Operative Medicine, University Hospital Estaing, University of Auvergne, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics Unit, Department of Clinical Research and Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
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Helmy MA, Hasanin A, Milad LM, Mostafa M, Hamimy WI, Muhareb RS, Raafat H. Ability of parasternal intercostal muscle thickening fraction to predict reintubation in surgical patients with sepsis. BMC Anesthesiol 2024; 24:294. [PMID: 39174907 PMCID: PMC11340156 DOI: 10.1186/s12871-024-02666-8] [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: 04/15/2024] [Accepted: 07/31/2024] [Indexed: 08/24/2024] Open
Abstract
OBJECTIVES We aimed to evaluate the ability of the parasternal intercostal (PIC) thickening fraction during spontaneous breathing trial (SBT) to predict the need for reintubation within 48 h after extubation in surgical patients with sepsis. METHODS This prospective observational study included adult patients with sepsis who were mechanically ventilated and indicated for SBT. Ultrasound measurements of the PIC thickening fraction and diaphragmatic excursion (DE) were recorded 15 min after the start of the SBT. After extubation, the patients were followed up for 48 h for the need for reintubation. The study outcomes were the ability of the PIC thickening fraction (primary outcome) and DE to predict reintubation within 48 h of extubation using area under receiver characteristic curve (AUC) analysis. The accuracy of the model including the findings of right PIC thickening fraction and right DE was also assessed using the current study cut-off values. Multivariate analysis was performed to identify independent risk factors for reintubation. RESULTS We analyzed data from 49 patients who underwent successful SBT, and 10/49 (20%) required reintubation. The AUCs (95% confidence interval [CI]) for the ability of right and left side PIC thickening fraction to predict reintubation were 0.97 (0.88-1.00) and 0.96 (0.86-1.00), respectively; at a cutoff value of 6.5-8.3%, the PIC thickening fraction had a negative predictive value of 100%. The AUCs for the PIC thickening fraction and DE were comparable; and both measures were independent risk factors for reintubation. The AUC (95% CI) of the model including the right PIC thickening fraction > 6.5% and right DE ≤ 18 mm to predict reintubation was 0.99 (0.92-1.00), with a positive predictive value of 100% when both sonographic findings are positive and negative predictive value of 100% when both sonographic findings are negative. CONCLUSIONS Among surgical patients with sepsis, PIC thickening fraction evaluated during the SBT is an independent risk factor for reintubation. The PIC thickening fraction has an excellent predictive value for reintubation. A PIC thickening fraction of ≤ 6.5-8.3% can exclude reintubation, with a negative predictive value of 100%. Furthermore, a combination of high PIC and low DE can also indicate a high risk of reintubation. However, larger studies that include different populations are required to replicate our findings and validate the cutoff values.
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Affiliation(s)
- Mina Adolf Helmy
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Hasanin
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt.
| | - Lydia Magdy Milad
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Maha Mostafa
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Walid I Hamimy
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Rimon S Muhareb
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Heba Raafat
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
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10
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Al-Sofyani KA. Predictors and outcomes of extubation failures in a pediatric intensive care unit: A retrospective study. J Taibah Univ Med Sci 2024; 19:516-523. [PMID: 39026556 PMCID: PMC11255959 DOI: 10.1016/j.jtumed.2024.03.005] [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: 11/05/2023] [Revised: 01/22/2024] [Accepted: 03/12/2024] [Indexed: 07/20/2024] Open
Abstract
Objectives This study was aimed at determining the extubation failure (EF) rate in a pediatric intensive care unit (PICU), and assessing the etiology, associated risk factors, and outcomes. Methods We conducted a retrospective study on 335 pediatric patients admitted to King Abdulaziz University Hospital between 2018 and 2020, ranging in age from 1 month to 14 years, who required invasive mechanical ventilation (MV) for >24 h. Extubation readiness was determined by the attending pediatric intensive care physician, according to the patients' clinical status and extubation readiness criteria. Results In the cohort of 335 patients, 42 experienced issues during extubation (failure rate, 12.5%). Cardiovascular disease (42.9%) was the main primary admission condition in patients with EF. Younger age (median, interquartile range [IQR]: 4, 1.38-36 months) was strongly associated with EF compared with successful extubation (median, IQR: 12, 2-48; p = 0.036), and with a high predicted mortality rate (10.9%; p < 0.001) and Pediatric Risk of Mortality III (PRISM) score (13; p < 0.001). Furthermore, prolonged ICU stay (25.5 days; p < 0.001) and longer MV requirements (4 days; p < 0.001) before extubation in patients with EF were associated with a high mortality rate (∼12%; p < 0.001). Interestingly, dexamethasone administration before extubation significantly alleviated EF risk (28.3%; p < 0.001). Conclusion A higher EF rate in younger patients may potentially be associated with longer ICU stays, prolonged MV requirements before extubation, and the primary diagnostic condition. Dexamethasone effectively alleviated EF incidence. Further research with a rigorous evidence-based study design is necessary to substantiate the factors identified as predictors of EF and to develop strategies to avoid EF.
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Affiliation(s)
- Khouloud A. Al-Sofyani
- Department of Pediatric, Pediatric Critical Care Unit, Faculty of Medicine, King Abdulaziz University, Jeddah, KSA
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11
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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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12
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Al-Husinat L, Jouryyeh B, Rawashdeh A, Robba C, Silva PL, Rocco PRM, Battaglini D. The Role of Ultrasonography in the Process of Weaning from Mechanical Ventilation in Critically Ill Patients. Diagnostics (Basel) 2024; 14:398. [PMID: 38396437 PMCID: PMC10888003 DOI: 10.3390/diagnostics14040398] [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: 12/31/2023] [Revised: 01/22/2024] [Accepted: 02/10/2024] [Indexed: 02/25/2024] Open
Abstract
Weaning patients from mechanical ventilation (MV) is a complex process that may result in either success or failure. The use of ultrasound at the bedside to assess organs may help to identify the underlying mechanisms that could lead to weaning failure and enable proactive measures to minimize extubation failure. Moreover, ultrasound could be used to accurately identify pulmonary diseases, which may be responsive to respiratory physiotherapy, as well as monitor the effectiveness of physiotherapists' interventions. This article provides a comprehensive review of the role of ultrasonography during the weaning process in critically ill patients.
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Affiliation(s)
- Lou’i Al-Husinat
- Department of Clinical Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan;
| | - Basil Jouryyeh
- Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan; (B.J.); (A.R.)
| | - Ahlam Rawashdeh
- Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan; (B.J.); (A.R.)
| | - Chiara Robba
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy;
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, 16132 Genova, Italy
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro 21941, Brazil; (P.L.S.); (P.R.M.R.)
| | - Patricia Rieken Macedo Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro 21941, Brazil; (P.L.S.); (P.R.M.R.)
| | - Denise Battaglini
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy;
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13
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Jia D, Wang H, Wang Q, Li W, Lan X, Zhou H, Zhang Z. Rapid shallow breathing index predicting extubation outcomes: A systematic review and meta-analysis. Intensive Crit Care Nurs 2024; 80:103551. [PMID: 37783181 DOI: 10.1016/j.iccn.2023.103551] [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] [Revised: 09/06/2023] [Accepted: 09/11/2023] [Indexed: 10/04/2023]
Abstract
OBJECTIVE This meta-analysis aimed to assess the predictive value of the rapid shallow breathing index for extubation outcomes. METHODOLOGY We conducted a systematic review of literature (inception to March 2023) and a meta-analysis. Statistical analysis was performed using Meta-Disc 1.4 software, RevMan 5.4 software and Stata 14.0 software to evaluate the predictive value of RSBI for extubation outcomes. RESULTS A total of 1,987 studies were retrieved, and after applying the inclusion criteria, 79 studies were included in the final analysis, involving 13,170 patients undergoing mechanical ventilation. The random-effects model was employed for statistical analysis. The summary receiver operating characteristic curves (SROC) area under the curve (AUC) was 0.8144. The pooled sensitivity was 0.60 (95% CI: 0.59, 0.61), the pooled specificity was 0.68 (95% CI: 0.66, 0.70). CONCLUSIONS The Rapid Shallow Breathing Index demonstrated moderate accuracy, poor pooled sensitivity and specificity in predicting successful extubation, however the study does not present adequate data to support or reject the use of this tool as a single parameter that predicts extubation outcome. Future studies should explore the combination of The Rapid Shallow Breathing Index with other indicators and clinical experience to improve the success rate of extubation and reduce the risk of extubation failure. IMPLICATIONS FOR CLINICAL PRACTICE Premature and delayed extubation in mechanically ventilated patients can have a negative impact on prognosis and prolong hospital stay. The Rapid Shallow Breathing Index is a simple, cost-effective, and easily monitored objective evaluation index, which can be used to predict the outcome of extubation, especially in primary hospitals. Our study comprehensively evaluated the value of this tool in predicting extubation outcomes, which can help clinicians combine subjective experience with objective indicators to improve the accuracy of extubation time decisions.
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Affiliation(s)
- Donghui Jia
- Department of Critical Care Medicine, the First Hospital of Lanzhou University, Lanzhou, Gansu 730000, PR China; School of Nursing, Lanzhou University, Lanzhou, Gansu 730000, PR China
| | - Hengyang Wang
- Department of Critical Care Medicine, the First Hospital of Lanzhou University, Lanzhou, Gansu 730000, PR China; School of Nursing, Lanzhou University, Lanzhou, Gansu 730000, PR China
| | - Qian Wang
- Department of Critical Care Medicine, the First Hospital of Lanzhou University, Lanzhou, Gansu 730000, PR China; School of Nursing, Lanzhou University, Lanzhou, Gansu 730000, PR China
| | - Wenrui Li
- Department of Critical Care Medicine, the First Hospital of Lanzhou University, Lanzhou, Gansu 730000, PR China; School of Nursing, Lanzhou University, Lanzhou, Gansu 730000, PR China
| | - Xuhong Lan
- Department of Critical Care Medicine, the First Hospital of Lanzhou University, Lanzhou, Gansu 730000, PR China; School of Nursing, Lanzhou University, Lanzhou, Gansu 730000, PR China
| | - Hongfang Zhou
- Department of Critical Care Medicine, the First Hospital of Lanzhou University, Lanzhou, Gansu 730000, PR China; School of Nursing, Lanzhou University, Lanzhou, Gansu 730000, PR China
| | - Zhigang Zhang
- Department of Critical Care Medicine, the First Hospital of Lanzhou University, Lanzhou, Gansu 730000, PR China; School of Nursing, Lanzhou University, Lanzhou, Gansu 730000, PR China.
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14
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Mohamed DM, SalahEldin MA, Idris AB, Idris EB, Mohamed SG, Badawi MM. Pneumonia in Sudan: Systematic and Scoping Review of the Literature and Meta-Analysis. Cureus 2023; 15:e46473. [PMID: 37927707 PMCID: PMC10623489 DOI: 10.7759/cureus.46473] [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] [Accepted: 10/03/2023] [Indexed: 11/07/2023] Open
Abstract
In addition to excessive burden of non-communicable diseases, natural and manmade disasters, and internal conflicts, Sudan is predominantly susceptible to communicable diseases, such as malaria, tuberculosis, and pneumonia, which bring about an extra burden of demand for high-quality healthcare. According to the WHO and the Sudan Health Observatory, pneumonia is one of the leading causes of death in Sudan. This study therefore aimed to illustrate pneumonia literature in Sudan, estimate infection prevalence regardless of the cause among Sudanese children and adults, and demonstrate its related risk factors. A systematic and scoping review of the literature was conducted and regulated in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). After abstract and full-text screening, only 15 articles met our inclusion criteria and passed the quality assessment procedure. Seven included studies determined prevalence of pneumonia; the overall pooled prevalence was around 30%. Furthermore, 12 research articles investigated risk factors related to pneumonia among Sudanese population. Further research with larger sample sizes targeting risk factors of pneumonia among Sudanese population is needed to be conducted.
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Affiliation(s)
- D M Mohamed
- Internal Medicine, Sultan Qaboos University Hospital, Muscat, OMN
| | - M A SalahEldin
- Medical Microbiology, University of Khartoum, Khartoum, SDN
| | - A B Idris
- General Surgery, Sudan Medical Specialization Board, Khartoum, SDN
| | - E B Idris
- Medical Microbiology, Rashid Medical Complex, Riyadh, SAU
| | - S G Mohamed
- Medical Microbiology, University of Khartoum, Khartoum, SDN
| | - Marwan M Badawi
- Medical Unit, Higher Academy for Strategic and Security Studies, Khartoum, SDN
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15
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Tanaka A, Shimomura Y, Uchiyama A, Tokuhira N, Kitamura T, Iwata H, Hashimoto H, Ishigaki S, Enokidani Y, Yamashita T, Koyama Y, Iguchi N, Yoshida T, Fujino Y. Time definition of reintubation most relevant to patient outcomes in critically ill patients: a multicenter cohort study. Crit Care 2023; 27:378. [PMID: 37777790 PMCID: PMC10544149 DOI: 10.1186/s13054-023-04668-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 09/27/2023] [Indexed: 10/02/2023] Open
Abstract
BACKGROUND Reintubation is a common complication in critically ill patients requiring mechanical ventilation. Although reintubation has been demonstrated to be associated with patient outcomes, its time definition varies widely among guidelines and in the literature. This study aimed to determine the association between reintubation and patient outcomes as well as the consequences of the time elapsed between extubation and reintubation on patient outcomes. METHODS This was a multicenter retrospective cohort study of critically ill patients conducted between April 2015 and March 2021. Adult patients who underwent mechanical ventilation and extubation in intensive care units (ICUs) were investigated utilizing the Japanese Intensive Care PAtient Database. The primary and secondary outcomes were in-hospital and ICU mortality. The association between reintubation and clinical outcomes was studied using Cox proportional hazards analysis. Among the patients who underwent reintubation, a Cox proportional hazard analysis was conducted to evaluate patient outcomes according to the number of days from extubation to reintubation. RESULTS Overall, 184,705 patients in 75 ICUs were screened, and 1849 patients underwent reintubation among 48,082 extubated patients. After adjustment for potential confounders, multivariable analysis revealed a significant association between reintubation and increased in-hospital and ICU mortality (adjusted hazard ratio [HR] 1.520, 95% confidence interval [CI] 1.359-1.700, and adjusted HR 1.325, 95% CI 1.076-1.633, respectively). Among the reintubated patients, 1037 (56.1%) were reintubated within 24 h after extubation, 418 (22.6%) at 24-48 h, 198 (10.7%) at 48-72 h, 111 (6.0%) at 72-96 h, and 85 (4.6%) at 96-120 h. Multivariable Cox proportional hazard analysis showed that in-hospital and ICU mortality was highest in patients reintubated at 72-96 h (adjusted HR 1.528, 95% CI 1.062-2.197, and adjusted HR 1.334, 95% CI 0.756-2.352, respectively; referenced to reintubation within 24 h). CONCLUSIONS Reintubation was associated with a significant increase in in-hospital and ICU mortality. The highest mortality rates were observed in patients who were reintubated between 72 and 96 h after extubation. Further studies are warranted for the optimal observation of extubated patients in clinical practice and to strengthen the evidence for mechanical ventilation.
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Affiliation(s)
- Aiko Tanaka
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan.
- Department of Intensive Care, University of Fukui Hospital, Yoshida, Fukui, Japan.
| | - Yoshimitsu Shimomura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Department of Hematology, Kobe City Hospital Organization Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Akinori Uchiyama
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Natsuko Tokuhira
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hirofumi Iwata
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Haruka Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Suguru Ishigaki
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yusuke Enokidani
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Tomonori Yamashita
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yukiko Koyama
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Naoya Iguchi
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Takeshi Yoshida
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yuji Fujino
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
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16
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Shen KH, Yu YJ, Chen SY, Chang EM, Wu HL, Lin CK, Tseng YC. Prediction of Mechanical Ventilator Weaning Outcome – A Deep Learning Approach. 2023 VTS ASIA PACIFIC WIRELESS COMMUNICATIONS SYMPOSIUM (APWCS) 2023:1-2. [DOI: 10.1109/apwcs60142.2023.10234048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
Affiliation(s)
- Kuei-Hung Shen
- National Yang Ming Chiao Tung University,Department of Computer Science,Hsinchu,Taiwan
| | - Yun-Ju Yu
- Medical Intensive Care Unit, Shin Kong Wu Ho Su Memorial Hospital,Taipei,Taiwan
| | - Szu-Yin Chen
- National Yang Ming Chiao Tung University,Department of Computer Science,Hsinchu,Taiwan
| | - En-Ming Chang
- Shin Kong Wu Ho Su Memorial Hospital,Department of Respiratory Care,Taipei,Taiwan
| | - Hsiu-Li Wu
- Respiratory Care Center, Shin Kong Wu Ho Su Memorial Hospital,Taipei,Taiwan
| | - Cheng-Kuan Lin
- National Yang Ming Chiao Tung University,Department of Computer Science,Hsinchu,Taiwan
| | - Yu-Chee Tseng
- National Yang Ming Chiao Tung University,Department of Computer Science,Hsinchu,Taiwan
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Abplanalp LA, Ionescu F, Calvo-Ayala E, Yu L, Nair GB. Static Respiratory System Compliance as a Predictor of Extubation Failure in Patients with Acute Respiratory Failure. Lung 2023:10.1007/s00408-023-00625-7. [PMID: 37300706 DOI: 10.1007/s00408-023-00625-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 05/25/2023] [Indexed: 06/12/2023]
Abstract
PURPOSE Ventilator weaning protocols rely in part on objective indices to best predict extubation failure in the critically ill. We investigated static respiratory system compliance (RC) as a predictor of extubation failure, in comparison to extubation readiness using rapid shallow breathing index (RSBI). MATERIAL AND METHODS This was a cross-sectional, multi-institutional study of mechanically ventilated patients admitted between 12/01/2017 and 12/01/2019. All patients older than 18 years with a documented spontaneous breathing trial and extubation trial were included. RC and RSBI were calculated prior to the extubation trial. The primary outcome was extubation failure-defined as need for reintubation within 72 h from time of extubation. RESULTS Of the 2263 patients, 55.8% were males with a mean age of 68 years. The population consisted mostly of Caucasians (73%) and African Americans (20.4%). 274 (12.1%) patients required reintubation within 72 h. On multivariate logistic regression after adjusting for age, sex, body mass index (BMI), admission Sequential Organ Failure Assessment (SOFA) score, number of ventilator days, and the P/F ratio on the day of extubation, RC remained the strongest predictor for extubation failure at 24 h (aOR 1.45; 95% CI 1.00-2.10) and 72 h (aOR 1.58; 95% CI 1.15-2.17). There was no significant association between RSBI and extubation failure at 24 (aOR 1.00; 95% CI 0.99-1.01) or at 72 h (aOR 1.00; 95% CI 0.99-1.01). CONCLUSION RC measured on the day of extubation is a promising physiological discriminant to potentially risk stratify patients with acute respiratory failure for extubation readiness. We recommend further validation studies in prospective cohorts.
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Affiliation(s)
- Lauren A Abplanalp
- Division of Pulmonary and Critical Care, Beaumont Health, Royal Oak, MI, USA
- OUWB School of Medicine, Rochester, MI, USA
| | - Filip Ionescu
- OUWB School of Medicine, Rochester, MI, USA
- Moffitt Cancer Center, University of South Florida Morsani Medical School, Tampa, FL, USA
| | - Enrique Calvo-Ayala
- Division of Pulmonary and Critical Care, Beaumont Health, Royal Oak, MI, USA
- OUWB School of Medicine, Rochester, MI, USA
| | - Limin Yu
- Department of Pathology, Beaumont Health, Royal Oak, MI, USA
| | - Girish B Nair
- Division of Pulmonary and Critical Care, Beaumont Health, Royal Oak, MI, USA.
- OUWB School of Medicine, Rochester, MI, USA.
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18
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Sofjan I, Vazquez S, Dominguez J, Sekhri N, Wecksell M, Samuel BM, Salik I. Risk Factors for Postoperative Unplanned Reintubation in a Cohort of Patients Undergoing General Anesthesia. Cureus 2023; 15:e38949. [PMID: 37309339 PMCID: PMC10257981 DOI: 10.7759/cureus.38949] [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] [Accepted: 05/12/2023] [Indexed: 06/14/2023] Open
Abstract
Background Unplanned post-operative reintubation (UPR) is a complication of general anesthesia (GA) that can be associated with worsened outcomes. Objective Evaluate characteristics associated with UPR in patients undergoing procedures under GA. Methods Patients over the age of 18 undergoing surgical procedures under GA were extracted from our institution's electronic medical record. Patient baseline, procedural, and anesthesia characteristics were evaluated for associations with UPR. Results In 29,284 surgical procedures undergoing GA, there were 29 (0.1%) patients that required UPR. The most common surgical service with UPR was otolaryngology; the most common surgical positioning was supine. When controlling for operative time and case complexity, UPR was predicted by high-dose opioids, defined as opioid administration greater than the 75th percentile of our institutional cohort. Prolonged operative time, estimated blood loss (EBL), body mass index (BMI), extubation time after reversal, or age were not independently associated with UPR. Conclusion Our analysis revealed that high-dose opioid administration is independently associated with intraoperative UPR. Awareness of patients at the highest risk for UPR along with provider education regarding techniques to avoid respiratory depression in this patient population is essential in reducing patient morbidity and mortality. This knowledge will help guide perioperative physicians in medical optimization, appropriate selection of intraoperative analgesics, and cautious extubation criteria to ensure patient safety.
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Affiliation(s)
- Iwan Sofjan
- Anesthesiology, Westchester Medical Center, Valhalla, USA
| | - Sima Vazquez
- Medicine, New York Medical College, Valhalla, USA
| | | | - Nitin Sekhri
- Anesthesiology, Westchester Medical Center, Valhalla, USA
| | | | - Barst M Samuel
- Anesthesiology, Westchester Medical Center, Valhalla, USA
| | - Irim Salik
- Anesthesiology, Westchester Medical Center, Valhalla, USA
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Taran S, Angeloni N, Pinto R, Lee S, McCredie VA, Schultz MJ, Robba C, Taccone FS, Adhikari NKJ. Prognostic Factors Associated With Extubation Failure in Acutely Brain-Injured Patients: A Systematic Review and Meta-Analysis. Crit Care Med 2023; 51:401-412. [PMID: 36583622 DOI: 10.1097/ccm.0000000000005769] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Extubation failure in brain-injured patients is associated with increased morbidity. Our objective was to systematically review prognostic factors associated with extubation failure in acutely brain-injured adult patients receiving invasive ventilation in an ICU. DATA SOURCES MEDLINE, Embase, and Cochrane Central were searched from inception to January 31, 2022. STUDY SELECTION Two reviewers independently screened citations and selected English-language cohort studies and randomized trials examining the association of prognostic factors with extubation failure. Studies were considered if they included greater than or equal to 80% adult patients with acute brain injury admitted to the ICU and mechanically ventilated for greater than or equal to 24 hours. DATA EXTRACTION Two reviewers extracted data on population, prognostic factors, extubation outcomes, and risk of bias (using the quality in prognostic factors tool). DATA SYNTHESIS In the primary analysis, adjusted odds ratios (aOR) for each prognostic factor were pooled using random-effects models. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation. The search identified 7,626 citations, of which 21 studies met selection criteria. Moderate-certainty evidence suggested increased risk of extubation failure with older age (aOR, 3.0 for upper vs lower tertile; 95% CI, 1.78-5.07) and longer duration of mechanical ventilation (aOR, 3.47 for upper vs lower tertile; 95% CI, 1.68-7.19). Presence of cough (aOR, 0.40; 95% CI, 0.28-0.57) and intact swallow (aOR, 0.34; 95% CI, 0.21-0.54) probably decreased risk of extubation failure (moderate certainty). Associations of other factors with extubation failure were informed by low or very low certainty evidence. CONCLUSIONS Patient age, duration of mechanical ventilation, and airway reflexes were associated with extubation failure in brain-injured patients with moderate certainty. Future studies are needed to determine the optimal application of these variables in clinical practice.
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Affiliation(s)
- Shaurya Taran
- Interdepartmental Division of Critical Care Medicine, Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Natalia Angeloni
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Shawn Lee
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care Medicine, Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Chiara Robba
- Department of Surgical Science and Diagnostics, University of Genoa, Genoa, Italy
| | - Fabio S Taccone
- Department of Intensive Care, Hôpital Erasme, Brusssels, Belgium
| | - Neill K J Adhikari
- Interdepartmental Division of Critical Care Medicine, Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Chuang CY, Hsu HS, Chen GJ, Chuang TY, Tsai MH. Underweight predicts extubation failure after planned extubation in intensive care units. PLoS One 2023; 18:e0284564. [PMID: 37053252 PMCID: PMC10101394 DOI: 10.1371/journal.pone.0284564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 04/04/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Body weight is associated with different physiological changes and the association between weight and mortality in critical care setting had been discussed before. In this study, we investigated the linkage between underweight and post-extubation failure in mechanical ventilated patients in critical setting. METHODS This is a retrospective cohort study including patients who were admitted to medical or surgical intensive care units (ICU) between June 2016 and July 2018 and had received endotracheal intubation for more than 72 hours. Those who passed spontaneous breathing trial and underwent a planned extubation were enrolled. Extubation failure was defined as those who required reintubation within the first 72 hours for any reasons. The probability of extubation failure was calculated. Demographic and clinical characteristics were recorded. Multivariate logistic regression models were then used to determine the potential risk factors associated with extubation failure. RESULTS Overall, 268 patients met the inclusion criteria and were enrolled in our study for analysis. The median age of included patients was 67 years (interquartile range, 55-80 years) with 65.3% being male; 63.1% of the patients were included from medical ICU. The proportion of extubation failure in our cohort was 7.1% (19/268; 95% confidence interval [CI], 4.3-10.9%). Overall, underweight patients had the highest risk of extubation failure (8/50), as compared with normoweight (9/135) and overweight patients (2/83). In the multivariate analysis, being underweight (adjust OR [aOR], 3.80, compared to normoweight; 95% CI, 1.23-11.7) and lower maximal inspiratory airway pressure (aOR per one cmH2O decrease, 1.05; 95% CI 1.00-1.09) remained significantly associated with extubation failure. CONCLUSION In our study, being underweight and lower maximal inspiratory airway pressure was associated with post-extubation respiratory failure after a planned extubation.
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Affiliation(s)
- Chung-Yeh Chuang
- Institute of Emergency and Critical Care Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Critical Care Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan
| | - Han-Shui Hsu
- Institute of Emergency and Critical Care Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Thoracic Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Guan-Jhou Chen
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
- Infection Control Room, Min-Sheng General Hospital, Taoyuan, Taiwan
| | - Tzu-Yi Chuang
- Department of Chest Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan
| | - Ming-Han Tsai
- Department of Critical Care Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan
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Bajaj JS, Sharma S, Mehta N, Shah A, Nimje G, Gorade M, Deshpande G. Frequency of Positive Cuff Leak Test Before Extubation in Robotic Surgeries Done in Steep Trendelenburg Position. Indian J Surg Oncol 2022; 13:896-901. [PMID: 36687248 PMCID: PMC9845466 DOI: 10.1007/s13193-022-01605-8] [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: 03/03/2022] [Accepted: 07/19/2022] [Indexed: 01/25/2023] Open
Abstract
Anaesthesia for robotic surgeries done in steep trendelenburg position are associated with risks such as facial oedema, conjunctival chemosis, raised intraocular pressure, laryngeal oedema, and delayed awakening. We proposed the use of the cuff leak test in them to record the frequency of laryngeal oedema at the end of surgery and attempted to find its correlation with probable risk factors. We conducted a prospective observational study of 100 patients aiming primarily to assess the frequency of positive cuff leak test in robotic abdominal surgeries performed in trendelenburg position. The secondary outcomes were to check its correlation with intravenous fluid administration, duration of pneumoperitoneum, and angle of trendelenburg position. We also recorded the frequency of chemosis, the frequency of post-extubation stridor in 24 h post-operatively, and the frequency of reintubation. Out of 100 participants undergoing elective abdominal robotic surgery in trendelenburg position, ninety were analysed. Total 31.6% (n = 30) participants showed positive cuff leak test. Chemosis was observed in 31 (32.6%) participants. No patient experienced post-extubation stridor or required reintubation during post-operative follow up. There was a no correlation between cuff leak test and intravenous fluid, duration of pneumo-peritoneum, or with angle of trendelenburg. The frequency of positive cuff leak test was high in patients at the end of robotic surgery but none of these patients had post-extubation stridor or required reintubations. There was no correlation with the fluid, angle, or duration of surgery. Clinical Trials Registry of India (CTRI/2017/04/008289), ctri.nic.in.
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Affiliation(s)
| | - Sudivya Sharma
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Pin 400012 India
| | | | - Akshat Shah
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Pin 400012 India
| | - Ganesh Nimje
- Mahatma Gandhi Hospital and Medical College, Jaipur, India
| | - Manoj Gorade
- Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Gargi Deshpande
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Pin 400012 India
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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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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: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Jia Y, Zhang Q. Research Progress on Diaphragm Ultrasound in Chronic Obstructive Pulmonary Disease: A Narrative Review. ULTRASOUND IN MEDICINE & BIOLOGY 2022; 48:587-597. [PMID: 35065813 DOI: 10.1016/j.ultrasmedbio.2021.10.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 09/28/2021] [Accepted: 10/28/2021] [Indexed: 06/14/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is a common disease of the respiratory system, and its prevalence and mortality remain high. COPD results in continuous impairment of lung function, which severely affects the patient's work and life. In severe cases, there will be acute respiratory failure, which endangers the lives of patients, and respiratory muscle dysfunction is one of the main reasons for this result. As the diaphragm is the most important inspiratory muscle, its dysfunction has a great impact on the deterioration of respiratory function in COPD patients. With the development of ultrasound, more and more studies have found that diaphragm ultrasound can play an important role in the diagnosis and treatment of COPD patients. The main purpose of this article is to review the research progress on diaphragm ultrasound in COPD and briefly introduce diaphragmatic ultrasound examination methods.
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Affiliation(s)
- Yuhao Jia
- Department of Ultrasound, Second Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Qunxia Zhang
- Department of Ultrasound, Second Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China.
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25
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Bansal V, Smischney NJ, Kashyap R, Li Z, Marquez A, Diedrich DA, Siegel JL, Sen A, Tomlinson AD, Venegas-Borsellino CP, Freeman WD. Reintubation Summation Calculation: A Predictive Score for Extubation Failure in Critically Ill Patients. Front Med (Lausanne) 2022; 8:789440. [PMID: 35252224 PMCID: PMC8891541 DOI: 10.3389/fmed.2021.789440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/28/2021] [Indexed: 11/13/2022] Open
Abstract
Objective To derive and validate a multivariate risk score for the prediction of respiratory failure after extubation. Patients and methods We performed a retrospective cohort study of adult patients admitted to the intensive care unit from January 1, 2006, to December 31, 2015, who received mechanical ventilation for ≥48 h. Extubation failure was defined as the need for reintubation within 72 h after extubation. Multivariate logistic regression model coefficient estimates generated the Re-Intubation Summation Calculation (RISC) score. Results The 6,161 included patients were randomly divided into 2 sets: derivation (n = 3,080) and validation (n = 3,081). Predictors of extubation failure in the derivation set included body mass index <18.5 kg/m2 [odds ratio (OR), 1.91; 95% CI, 1.12–3.26; P = 0.02], threshold of Glasgow Coma Scale of at least 10 (OR, 1.68; 95% CI, 1.31–2.16; P < 0.001), mean airway pressure at 1 min of spontaneous breathing trial <10 cmH2O (OR, 2.11; 95% CI, 1.68–2.66; P < 0.001), fluid balance ≥1,500 mL 24 h preceding extubation (OR, 2.36; 95% CI, 1.87–2.96; P < 0.001), and total mechanical ventilation days ≥5 (OR, 3.94; 95% CI 3.04–5.11; P < 0.001). The C-index for the derivation and validation sets were 0.72 (95% CI, 0.70–0.75) and 0.72 (95% CI, 0.69–0.75). Multivariate logistic regression demonstrated that an increase of 1 in RISC score increased odds of extubation failure 1.6-fold (OR, 1.58; 95% CI, 1.47–1.69; P < 0.001). Conclusion RISC predicts extubation failure in mechanically ventilated patients in the intensive care unit using several clinically relevant variables available in the electronic medical record but requires a larger validation cohort before widespread clinical implementation.
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Affiliation(s)
- Vikas Bansal
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, United States
- Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN, United States
| | - Nathan J. Smischney
- Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN, United States
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Rahul Kashyap
- Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN, United States
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Zhuo Li
- Biostatistics Unit, Mayo Clinic, Jacksonville, FL, United States
| | - Alberto Marquez
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Daniel A. Diedrich
- Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN, United States
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Jason L. Siegel
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, United States
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States
| | - Ayan Sen
- Department of Critical Care Medicine, Mayo Clinic Hospital, Phoenix, AZ, United States
- Department of Neurologic Surgery, Mayo Clinic Hospital, Phoenix, AZ, United States
| | - Amanda D. Tomlinson
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | | | - William David Freeman
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, United States
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States
- *Correspondence: William David Freeman
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Mechanical power normalized to lung-thorax compliance indicates weaning readiness in prolonged ventilated patients. Sci Rep 2022; 12:6. [PMID: 34997005 PMCID: PMC8741981 DOI: 10.1038/s41598-021-03960-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 12/13/2021] [Indexed: 11/24/2022] Open
Abstract
Since critical respiratory muscle workload is a significant determinant of weaning failure, applied mechanical power (MP) during artificial ventilation may serve for readiness testing before proceeding on a spontaneous breathing trial (SBT). Secondary analysis of a prospective, observational study in 130 prolonged ventilated, tracheotomized patients. Calculated MP’s predictive SBT outcome performance was determined using the area under receiver operating characteristic curve (AUROC), measures derived from k-fold cross-validation (likelihood ratios, Matthew's correlation coefficient [MCC]), and a multivariable binary logistic regression model. Thirty (23.1%) patients failed the SBT, with absolute MP presenting poor discriminatory ability (MCC 0.26; AUROC 0.68, 95%CI [0.59‒0.75], p = 0.002), considerably improved when normalized to lung-thorax compliance (LTCdyn-MP, MCC 0.37; AUROC 0.76, 95%CI [0.68‒0.83], p < 0.001) and mechanical ventilation PaCO2 (so-called power index of the respiratory system [PIrs]: MCC 0.42; AUROC 0.81 [0.73‒0.87], p < 0.001). In the logistic regression analysis, PIrs (OR 1.48 per 1000 cmH2O2/min, 95%CI [1.24‒1.76], p < 0.001) and its components LTCdyn-MP (1.25 per 1000 cmH2O2/min, [1.06‒1.46], p < 0.001) and mechanical ventilation PaCO2 (1.17 [1.06‒1.28], p < 0.001) were independently related to SBT failure. MP normalized to respiratory system compliance may help identify prolonged mechanically ventilated patients ready for spontaneous breathing.
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Sun J, Cui N, Han W, Li Q, Wang H, Li Z, Cheng W, Luo H, Zhao M. Implementation of Nurse-Led, Goal-Directed Lung Physiotherapy for Older Patients With Sepsis and Pneumonia in the ICU. Front Med (Lausanne) 2021; 8:753620. [PMID: 34881259 PMCID: PMC8647879 DOI: 10.3389/fmed.2021.753620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/31/2021] [Indexed: 01/26/2023] Open
Abstract
Objectives: This study aimed to investigate the effect of nurse-led, goal-directed lung physiotherapy (GDLPT) on the prognosis of older patients with sepsis caused by pneumonia in the intensive care unit. Methods: We conducted a prospective, two-phase (before-and-after) study over 3 years called the GDLPT study. All patients received standard lung therapy for sepsis caused by pneumonia and patients in phase 2 also received GDLPT. In this study, 253 older patients (age ≥ 65 years) with sepsis and pneumonia were retrospectively analyzed. The main outcome was 28 day mortality. Results: Among 742 patients with sepsis, 253 older patients with pneumonia were divided into the control group and the treatment group. Patients in the treatment group had a significantly shorter duration of mechanical ventilation [5 (4, 6) vs. 5 (4, 8) days; P = 0.045], and a lower risk of intensive care unit (ICU) mortality [14.5% (24/166) vs. 28.7% (25/87); P = 0.008] and 28 day mortality [15.1% (25/166) vs. 31% (27/87); P = 0.005] compared with those in the control group. GDLPT was an independent risk factor for 28 day mortality [odds ratio (OR), 0.379; 95% confidence interval (CI), 0.187-0.766; P = 0.007]. Conclusions: Nurse-led GDLPT shortens the duration of mechanical ventilation, decreases ICU and 28-day mortality, and improves the prognosis of older patients with sepsis and pneumonia in the ICU.
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Affiliation(s)
- Jianhua Sun
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Na Cui
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Wen Han
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Qi Li
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Hao Wang
- Department of Critical Care Medicine, Beijing Jishuitan Hospital, Beijing, China
| | - Zunzhu Li
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Wei Cheng
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Hongbo Luo
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Mingxi Zhao
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
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Wu ZH, Tang Y, Zhao M, Yu H, Li HD. Association between elevated brain natriuretic peptide levels and weaning failure: A systematic review and meta-analysis. Int J Clin Pract 2021; 75:e14850. [PMID: 34516015 DOI: 10.1111/ijcp.14850] [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: 04/30/2021] [Accepted: 09/10/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Cardiovascular dysfunction has been reported as an important mechanism of weaning failure, and recent data suggest that elevated brain natriuretic peptide (BNP) levels is associated with an increased risk of weaning failure. Therefore, we performed this meta-analysis to evaluate the correlation between elevated BNP levels and weaning failure in critically ill patients subject to mechanical ventilation. METHODS A systematic search in Cochrane Library, Embase, PubMed and Web of Science was performed up to September 25, 2019. Standard mean differences (SMD) and corresponding 95% confidence intervals (CIs) of the BNP levels were calculated for each study. RESULTS Nine studies with a total number of 589 were included in the final meta-analysis. The results showed that elevated BNP levels were significantly associated with the risk of weaning failure (SMD: 0.76, 95% CI: 0.47 to 1.05, P < .00001). The finding was consistent with the BNP measured before (SMD: 0.68, 95% CI: 0.26 to 1.11, P = .002) or at the end of spontaneous breathing trial (SBT) (SMD: 0.85, 95% CI: 0.52 to 1.18, P < .00001). CONCLUSIONS This meta-analysis showed that increased plasma BNP concentration was associated with weaning failure in ICU patients.
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Affiliation(s)
- Zeng-Hong Wu
- Department of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Infectious Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yun Tang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Meng Zhao
- School of Life Sciences, Westlake University, Hangzhou, China
- Institute of Biology, Westlake Institute for Advanced Study, Hangzhou, China
| | - Hong Yu
- Department of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hua-Dong Li
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Xu SX, Wu CS, Liu SY, Lu X. High-flow nasal cannula oxygen therapy and noninvasive ventilation for preventing extubation failure during weaning from mechanical ventilation assessed by lung ultrasound score: A single-center randomized study. World J Emerg Med 2021; 12:274-280. [PMID: 34512823 DOI: 10.5847/wjem.j.1920-8642.2021.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 06/26/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND We sought to demonstrate the superiority of a targeted therapy strategy involving high-flow nasal cannula oxygen (HFNCO2) therapy and noninvasive ventilation (NIV) using lung ultrasound score (LUS) in comparison with standard care among patients in the intensive care unit (ICU) who undergo successful weaning to decrease the incidence of extubation failure at both 48 hours and seven days. METHODS During the study period, 98 patients were enrolled in the study, including 49 in the control group and 49 in the treatment group. Patients in the control group and patients with an LUS score <14 points (at low risk of extubation failure) in the treatment group were extubated and received standard preventive care without NIV or HFNCO2. Patients with an LUS score ≥14 points (at high risk of extubation failure) in the treatment group were extubated with a second review of the therapeutic optimization to identify and address any persisting risk factors for postextubation respiratory distress; patients received HFNCO2 therapy combined with sessions of preventive NIV (4-8 hours per day for 4-8 sessions total) for the first 48 hours after extubation. RESULTS In the control group, 13 patients had the LUS scores ≥14 points, while 36 patients had scores <14 points. In the treatment group, 16 patients had the LUS scores ≥14 points, while 33 patients had scores <14 points. Among patients with the LUS score ≥14 points, the extubation failure rate within 48 hours was 30.8% in the control group and 12.5% in the treatment group, constituting a statistically significant difference (P<0.05). Conversely, among patients with an LUS score <14 points, 13.9% in the control group and 9.1% in the treatment group experienced extubation failure (P=0.61). The length of ICU stay (9.4±3.1 days vs. 7.2±2.4 days) was significantly different and the re-intubation rate (at 48 hours: 18.4% vs. 10.2%; seven days: 22.4% vs. 12.2%) significantly varied between the two groups (P<0.05). There was no significant difference in the 28-day mortality rate (6.1% vs. 8.2%) between the control and treatment groups. CONCLUSIONS Among high-risk adults being weaned from mechanical ventilation and assessed by LUS, the NIV+HFNCO2 protocol does not lessen the mortality rate but reduce the length of ICU stay, the rate of extubation failure at both 48 hours and seven days.
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Affiliation(s)
- Shan-Xiang Xu
- Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Chun-Shuang Wu
- Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Shao-Yun Liu
- Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Xiao Lu
- Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
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Tongyoo S, Tantibundit P, Daorattanachai K, Viarasilpa T, Permpikul C, Udompanturak S. High-flow nasal oxygen cannula vs. noninvasive mechanical ventilation to prevent reintubation in sepsis: a randomized controlled trial. Ann Intensive Care 2021; 11:135. [PMID: 34523035 PMCID: PMC8439370 DOI: 10.1186/s13613-021-00922-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/22/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND High-flow nasal oxygen cannula (HFNC) and noninvasive mechanical ventilation (NIV) can prevent reintubation in critically ill patients. However, their efficacy in post-extubated sepsis patients remains unclear. The objective of this study was to compare the efficacy of HFNC vs. NIV to prevent reintubation in post-extubated sepsis patients. METHODS We conducted a single-centre, prospective, open-labelled, randomised controlled trial at the medical intensive care unit of Siriraj Hospital, Mahidol University, Bangkok, Thailand. Sepsis patients who had been intubated, recovered, and passed the spontaneous breathing trial were enrolled and randomly assigned in a 1:1 ratio to receive either HFNC or NIV support immediately after extubation. The primary outcome was rate of reintubation at 72 h after extubation. RESULTS Between 1st October 2017 and 31st October 2019, 222 patients were enrolled and 112 were assigned to the HFNC group and 110 to the NIV group. Both groups were well matched in baseline characteristics. The median [IQR] age of the HFNC group was 66 [50-77] vs. 65.5 [54-77] years in the NIV group. The most common causes of intubation at admission were shock-related respiratory failure (57.1% vs. 55.5%) and acute hypoxic respiratory failure (34.8% vs. 40.9%) in the HFNC and NIV groups, respectively. The duration of mechanical ventilation before extubation was 5 [3-8] days in the HFNC group vs. 5 [3-9] days in the NIV group. There was no statistically significant difference in the primary outcome: 20/112 (17.9%) in the HFNC group required reintubation at 72 h compared to 20/110 (18.2%) in the NIV group [relative risk (RR) 0.99: 95% confidence interval (CI) (0.70-1.39); P = 0.95]. The 28-day mortality was not different: 8/112 (7.1%) with HFNC vs. 10/110 (9.1%) with NIV (RR 0.88: 95% CI (0.57-1.37); P = 0.59). CONCLUSIONS Among sepsis patients, there was no difference between HFNC and NIV in the prevention of reintubation at 72 h after extubation. Clinical Trial Registration ClinicalTrials.gov Identifier: NCT03246893; Registered 11 August 2017; https://clinicaltrials.gov/ct2/show/NCT03246893?term=surat+tongyoo&draw=2&rank=3.
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Affiliation(s)
- Surat Tongyoo
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, No. 2, Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand.
| | - Porntipa Tantibundit
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, No. 2, Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand.,Department of Emergency Medicine, Khon Kaen Hospital, Khon Kaen, Thailand
| | - Kiattichai Daorattanachai
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, No. 2, Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand.,Department of Emergency Medicine, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Tanuwong Viarasilpa
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, No. 2, Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Chairat Permpikul
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, No. 2, Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Suthipol Udompanturak
- Office of Research and Development, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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31
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Lewis K, Almubarak Y, Hylander Møller M, Jaeschke R, Perri D, Zhang Y, Du B, Nishida O, Ntoumenopoulos G, Saxena M, Truwit J, Young PJ, Alshamsi F, Arabi YM, Rochwerg B, Karachi T, Szczeklik W, Alshahrani M, Machado FR, Annane D, Antonelli M, Girard TD, Cook D, Baw B, Nanchal R, Piraino T, Guyatt G, Alhazzani W. The cuff leak test in critically ill patients: An international survey of intensivists. Acta Anaesthesiol Scand 2021; 65:1087-1094. [PMID: 36169641 DOI: 10.1111/aas.13838] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 04/17/2021] [Accepted: 04/20/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The cuff leak test (CLT) is used to assess laryngeal edema prior to extubation. There is limited evidence for its diagnostic accuracy and conflicting guidelines surrounding its use in critically ill patients who do not have risk factors for laryngeal edema. The primary study aim was to describe intensivists' beliefs, attitudes, and practice regarding the use of the CLT. METHODS A 13-item survey was developed, pilot-tested, and subjected to clinical sensibility testing. The survey was distributed electronically through MetaClinician®. Descriptive statistics and multivariable regression analysis were performed to examine associations between participant demographics and survey responses. RESULTS 1184 practicing intensivists from 17 countries in North and South America, Europe, Oceania, and Asia participated. The majority (59%) of respondents reported rarely or never perform the CLT prior to extubating patients not at high risk of laryngeal edema, which correlated with 54% of respondents reporting they believed a failed CLT did not predict reintubation. Intensivists from the Middle East were 2.4 times more likely to request a CLT compared to those from North America. Intensivists with base training in medicine or emergency medicine were more likely to request a CLT prior to extubation compared to those with base training in anesthesiology. CONCLUSION Use of the CLT prior to extubating patients not at high risk of laryngeal edema in the intensive care unit is highly variable. Practice appears to be influenced by country of practice and base specialty training.
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Affiliation(s)
- Kimberley Lewis
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Yousef Almubarak
- College of Medicine, Department of Internal Medicine and Critical Care, Imam Abdulrahman Ben Faisal University, Al Khobar, Kingdom of Saudi Arabia
| | - Morten Hylander Møller
- Department of Intensive Care Medicine, Copenhagen University Hospital, Rigshspitalet, Denmark.,Scandinavian Society of Anesthesiology and Intensive Care Medicine, Rigshspitalet, Denmark
| | - Roman Jaeschke
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Dan Perri
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Canada.,Clinical Pharmacology and Toxicology, McMaster University, Hamilton, Canada
| | - Ying Zhang
- Center for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Beijing, China
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Aichi, Japan
| | | | - Manoj Saxena
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Jonathon Truwit
- Department of Pulmonary and Critical Care Medicine, Froedtert and Medical College of Wisconsin, Milwaukee, WI, USA
| | - Paul J Young
- Intensive Care Unit, Wellington Hospital, Capital and Coast District Health Board, Wellington, New Zealand.,Intensive Care Research Programme, Medical Research Institute of New Zealand, Wellington, New Zealand.,Department of Critical Care, University of Melbourne, Melbourne, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Alain, United Arab Emirates
| | - Yaseen M Arabi
- College of Medicine, Intensive Care Department, King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Tim Karachi
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Canada
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Muhammed Alshahrani
- College of Medicine, Department of Emergency and Critical Care, Imam Abdulrahman Ben Faisal University, Al Khobar, Kingdom of Saudi Arabia
| | - Flavia R Machado
- Anesthesiology, Pain, and Intensive Care Department, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Djillali Annane
- Department of Intensive Care Medicine, University of Versailles SQY, University Paris Saclay, Raymond Poincare Hospital (AP-HP), Garches, France
| | - Massimo Antonelli
- Istituto di Anestesia e Risnimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Timothy D Girard
- Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center in the Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Deborah Cook
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Bandar Baw
- Clinical Pharmacology and Toxicology, McMaster University, Hamilton, Canada.,Division of Emergency Medicine, McMaster University, Hamilton, Canada
| | - Rahul Nanchal
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Thomas Piraino
- Division of Critical Care, St. Michael's Hospital, Toronto, Canada
| | - Gordon Guyatt
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Waleed Alhazzani
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
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Casey JD, Vaughan EM, Lloyd BD, Billas PA, Jackson KE, Hall EJ, Toporek AH, Buell KG, Brown RM, Richardson RK, Rooks JC, Buie RB, Wang L, Lindsell CJ, Ely EW, Self WH, Bernard GR, Rice TW, Semler MW. Protocolized Postextubation Respiratory Support to Prevent Reintubation: A Randomized Clinical Trial. Am J Respir Crit Care Med 2021; 204:294-302. [PMID: 33794131 DOI: 10.1164/rccm.202009-3561oc] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Respiratory support (noninvasive ventilation or high-flow nasal cannula) applied at the time of extubation has been reported to reduce reintubation rates, but concerns regarding effectiveness have limited uptake into practice.Objectives: To determine if providing postextubation respiratory support to all patients undergoing extubation in a medical ICU would decrease the incidence of reintubation.Methods: We conducted a pragmatic, two-armed, cluster-crossover trial of adults undergoing extubation from invasive mechanical ventilation between October 1, 2017, and March 31, 2019, in the medical ICU of an academic medical center. Patients were assigned to either protocolized postextubation respiratory support (a respiratory therapist-driven protocol in which patients with suspected hypercapnia received noninvasive ventilation and patients without suspected hypercapnia received high-flow nasal cannula) or usual care (postextubation management at the discretion of treating clinicians). The primary outcome was reintubation within 96 hours of extubation.Measurements and Main Results: A total of 751 patients were enrolled. Of the 359 patients assigned to protocolized support, 331 (92.2%) received postextubation respiratory support compared with 66 of 392 patients (16.8%) assigned to usual care, a difference driven by differential use of high-flow nasal cannula (74.7% vs. 2.8%). A total of 57 patients (15.9%) in the protocolized support group experienced reintubation compared with 52 patients (13.3%) in the usual care group (odds ratio, 1.23; 95% confidence interval, 0.82 to 1.84; P = 0.32).Conclusions: Among a broad population of critically ill adults undergoing extubation from invasive mechanical ventilation at an academic medical center, protocolized postextubation respiratory support, primarily characterized by an increase in the use of high-flow nasal cannula, did not prevent reintubation compared with usual care.Clinical trial registered with www.clinicaltrials.gov (NCT0328831).
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Affiliation(s)
| | - Erin M Vaughan
- Division of Allergy, Pulmonary, and Critical Care Medicine
| | | | - Peter A Billas
- Department of Anesthesiology, University of Florida, Gainesville, Florida
| | | | | | | | | | - Ryan M Brown
- Division of Allergy, Pulmonary, and Critical Care Medicine
| | | | | | - Reagan B Buie
- Vanderbilt Institute for Clinical and Translational Research
| | | | | | - E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine.,Critical Illness, Brain Dysfunction, and Survivorship Center.,Tennessee Valley Veterans Affairs Geriatric Research Education Clinical Center, and
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | | | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine
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33
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Rizzo JA, Haq M, McMahon RA, Aden JK, Brillhart DB, Cancio LC. Extubation Failure in a Burn Intensive Care Unit: Examination of Contributing Factors. J Burn Care Res 2021; 42:177-181. [PMID: 32918478 DOI: 10.1093/jbcr/iraa162] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Extubation failure is associated with negative outcomes making the identification of risk factors for failure paramount. Burn patients experience a high incidence of respiratory failure requiring mechanical ventilation. There is no consensus on the acceptable rate of extubation failure and many conventional indices do not accurately predict extubation outcomes in burn patients. The purpose of this study was to examine the rate of extubation failure in the burned population and to examine the impact of factors on extubation outcomes. Burn patients from a single center over 9 years were examined and included if they were intubated prior to arrival or within 48 hours of admission and underwent a planned extubation. From this cohort, a matched case-control analysis based on age, TBSA, and sex was performed of patients who succeeded after extubation, defined as not requiring reintubation within 72 hours, to those who failed. Characteristics and clinical parameters were compared to determine whether any factors could predict extubation failure. There was a 12.3% incidence of extubation failure. In the matched case-control analysis, the presence of inhalation injury was associated with extubation success. Higher heart rate and lower serum pH were associated with extubation failure. ANCOVA analysis demonstrated that a sodium trending higher before extubation was associated with more successes, possibly indicative of a lower volume status. Classic extubation criteria do not accurately predict extubation outcomes in burn patients; analysis of other parameters may be able to provide better predictions. A constellation of these parameters needs to be studied prospectively.
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Affiliation(s)
- Julie A Rizzo
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas.,Uniformed Services University of Health Sciences, Bethesda, Maryland
| | - Mahdi Haq
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas.,Metis Foundation, San Antonio Texas
| | - Ryan A McMahon
- Brooke Army Medical Center, Fort Sam Houston, Texas.,United States Army Medical Center of Excellence, Joint Base San Antonio, Texas
| | - James K Aden
- Brooke Army Medical Center, Fort Sam Houston, Texas
| | | | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas
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34
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Schönhofer B, Geiseler J, Dellweg D, Fuchs H, Moerer O, Weber-Carstens S, Westhoff M, Windisch W. Prolonged Weaning: S2k Guideline Published by the German Respiratory Society. Respiration 2020; 99:1-102. [PMID: 33302267 DOI: 10.1159/000510085] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/28/2023] Open
Abstract
Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.
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Affiliation(s)
- Bernd Schönhofer
- Klinikum Agnes Karll Krankenhaus, Klinikum Region Hannover, Laatzen, Germany,
| | - Jens Geiseler
- Klinikum Vest, Medizinische Klinik IV: Pneumologie, Beatmungs- und Schlafmedizin, Marl, Germany
| | - Dominic Dellweg
- Fachkrankenhaus Kloster Grafschaft GmbH, Abteilung Pneumologie II, Schmallenberg, Germany
| | - Hans Fuchs
- Universitätsklinikum Freiburg, Zentrum für Kinder- und Jugendmedizin, Neonatologie und Pädiatrische Intensivmedizin, Freiburg, Germany
| | - Onnen Moerer
- Universitätsmedizin Göttingen, Klinik für Anästhesiologie, Göttingen, Germany
| | - Steffen Weber-Carstens
- Charité, Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Virchow-Klinikum und Campus Mitte, Berlin, Germany
| | - Michael Westhoff
- Lungenklinik Hemer, Hemer, Germany
- Universität Witten/Herdecke, Herdecke, Germany
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Universität Witten/Herdecke, Herdecke, Germany
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35
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Kimura S, Ahn JB, Takahashi M, Kwon S, Papatheodorou S. Effectiveness of corticosteroids for post-extubation stridor and extubation failure in pediatric patients: a systematic review and meta-analysis. Ann Intensive Care 2020; 10:155. [PMID: 33206245 PMCID: PMC7672172 DOI: 10.1186/s13613-020-00773-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 11/07/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While the results of previous meta-analyses have shown beneficial effects of corticosteroid therapy on post-extubation stridor and extubation failure in adults, these results might not be generalizable to children because of the differences in anatomy and structure. We aimed to determine the benefits of corticosteroids on those outcomes in pediatric populations. METHODS We searched PubMed, EMBASE, and reference lists of articles from inception until February 2019. Randomized controlled trials and observational studies on the efficacy of systemic corticosteroid administration given prior to elective extubation in mechanically ventilated pediatrics were eligible. Outcomes included post-extubation stridor indicating laryngeal edema and extubation failures. RESULTS A total of ten randomized controlled trials with 591 pediatric patients were included: seven of the ten studies for post-extubation stridor/suspected upper airway obstruction and nine of the ten studies for extubation failure. The estimate of pooled odds ratios (ORs) for post-extubation stridor/suspected upper airway obstruction was 0.40 (95% CI: 0.21-0.79). When analysis was restricted to trials that had explicit data for infants and explicit data for pediatric patients under 5 years old excluding infants, the estimates of pooled ORs were 0.53 (95% CI: 0.20-1.40) and 0.68 (95% CI: 0.38-1.22), respectively. For pediatric patients who received corticosteroids, there was a 0.37-fold lower odds of extubation failure than that in pediatric patients who did not receive corticosteroids (OR, 0.37; 95% CI, 0.22-0.61). While three observational studies were included in this review, their estimates have a potential for bias and we did not perform a meta-analysis. CONCLUSIONS Despite a relatively small sample size in each randomized controlled trial and wide ranges of ages and steroid administration regimens, our results suggest that the use of corticosteroids for prevention of post-extubation stridor and extubation failure could be considered to be acceptable in pediatric patients.
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Affiliation(s)
- Satoshi Kimura
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA. .,Department of Pediatric Intensive Care Unit, The Royal Children's Hospital, 50 Flemington Rd, Parkville, VIC, 3052, Australia.
| | - JiYoon B Ahn
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA
| | - Mai Takahashi
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA.,Department of Internal Medicine, Mount Sinai Beth Israel, 317 E 17th St, New York, NY, 10003, USA
| | - Sohee Kwon
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA
| | - Stefania Papatheodorou
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA
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36
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Kuriyama A, Jackson JL, Kamei J. Performance of the cuff leak test in adults in predicting post-extubation airway complications: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:640. [PMID: 33160405 PMCID: PMC7648377 DOI: 10.1186/s13054-020-03358-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/23/2020] [Indexed: 12/17/2022]
Abstract
Background Clinical practice guidelines recommend performing a cuff leak test in mechanically ventilated adults who meet extubation criteria to screen those at high risk for post-extubation stridor. Previous systematic reviews demonstrated excellent specificity of the cuff leak test but disagreed with respect to sensitivity. We conducted a systematic review and meta-analysis to assess the diagnostic accuracy of the cuff leak test for predicting post-extubation airway complications in intubated adult patients in critical care settings. Methods We searched Medline, EMBASE, Scopus, ISI Web of Science, the Cochrane Library for eligible studies from inception to March 16, 2020, without language restrictions. We included studies that examined the diagnostic accuracy of cuff leak test if post-extubation airway obstruction after extubation or reintubation was explicitly reported as the reference standard. Two authors in duplicate and independently assessed the risk of bias using the Quality Assessment for Diagnostic Accuracy Studies-2 tool. We pooled sensitivities and specificities using generalized linear mixed model approach to bivariate random-effects meta-analysis. Our primary outcomes were post-extubation airway obstruction and reintubation. Results We included 28 studies involving 4493 extubations. Three studies were at low risk for all QUADAS-2 risk of bias domains. The pooled sensitivity and specificity of cuff leak test for post-extubation airway obstruction were 0.62 (95% CI 0.49–0.73; I2 = 81.6%) and 0.87 (95% CI 0.82–0.90; I2 = 97.8%), respectively. The pooled sensitivity and specificity of the cuff leak test for reintubation were 0.66 (95% CI 0.46–0.81; I2 = 48.9%) and 0.88 (95% CI 0.83–0.92; I2 = 87.4%), respectively. Subgroup analyses suggested that the type of cuff leak test and length of intubation might be the cause of statistical heterogeneity of sensitivity and specificity, respectively, for post-extubation airway obstruction. Conclusions The cuff leak test has excellent specificity but moderate sensitivity for post-extubation airway obstruction. The high specificity suggests that clinicians should consider intervening in patients with a positive test, but the low sensitivity suggests that patients still need to be closely monitored post-extubation.
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Affiliation(s)
- Akira Kuriyama
- Emergency and Critical Care Center, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-8602, Japan.
| | - Jeffrey L Jackson
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, USA
| | - Jun Kamei
- Emergency and Critical Care Center, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-8602, Japan
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37
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Brauer PR, Reddy CA, Burkey BB, Lamarre ED. A National Comparison of Postoperative Outcomes in Completion Thyroidectomy and Total Thyroidectomy. Otolaryngol Head Neck Surg 2020; 164:566-573. [PMID: 32838642 DOI: 10.1177/0194599820951165] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To characterize and assess the non-thyroid-specific postoperative complications of completion thyroidectomy as compared with total thyroidectomy. STUDY DESIGN Retrospective analysis: 2005 to 2017. SETTING National Surgical Quality Improvement Program database. SUBJECTS AND METHODS Patients aged >18 years receiving a completion or total thyroidectomy were eligible for inclusion. Patients not treated by otolaryngologists or general surgeons and with unknown demographic variables were excluded. RESULTS A total of 70,638 patients were analyzed, representing 64,763 total thyroidectomies and 5875 completion thyroidectomies. The 30-day mortality rate was 0.1% for both procedures (P > .05). Overall, 1.7% and 1.4% of patients undergoing total and completion thyroidectomies experienced at least 1 complication (P > .05), while 1.2% and 0.9% had a postoperative medical complication (P = .0186), respectively. On multivariable analysis, patients undergoing total thyroidectomies were significantly more likely to return to the operating room (odds ratio [OR], 1.36; 95% CI, 1.04-1.80; P = .027) and to be readmitted (OR, 1.45; 95% CI, 1.16-1.81; P = .001). Adjusted analysis also demonstrated that patients undergoing total thyroidectomies were more likely to be inpatients (OR, 1.17; 95% CI, 1.11-1.24; P < .001), be treated by nonotolaryngologists (OR, 1.36; 95% CI, 1.29-1.45; P < .001), and smoke (OR, 1.22; 95% CI, 1.13-1.33; P < .001). CONCLUSION National data suggest that total and completion thyroidectomies are relatively safe procedures but that completion thyroidectomies are associated with lower rates of postoperative complications. These findings may play a role in determining treatment plans for patients and optimizing risk reduction.
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Affiliation(s)
- Philip R Brauer
- School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA.,Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Chandana A Reddy
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brian B Burkey
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eric D Lamarre
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Rautaporras N, Furuholm J, Uittamo J, Saloniemi M, Puolakka T, Snäll J. Deep odontogenic infections-identifying risk factors for nosocomial pneumonia. Clin Oral Investig 2020; 25:1925-1932. [PMID: 32789814 PMCID: PMC7966200 DOI: 10.1007/s00784-020-03500-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/04/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To evaluate occurrence and risk factors for pneumonia in patients with deep odontogenic infection (OI). MATERIALS AND METHODS All patients treated for deep OIs and requiring intensive care and mechanical ventilation were included. The outcome variable was diagnosis of nosocomial pneumonia. Primary predictor variables were re-intubation and duration of mechanical ventilation. The secondary predictor variable was length of hospital stay (LOHS). The explanatory variables were gender, age, current smoking, current heavy alcohol and/or drug use, diabetes, and chronic pulmonary disease. RESULTS Ninety-two patients were included in the analyses. Pneumonia was detected in 14 patients (15%). It was diagnosed on postoperative day 2 to 6 (median 3 days, mean 3 days) after primary infection care. Duration of mechanical ventilation (p = 0.028) and LOHS (p = 0.002) correlated significantly with occurrence of pneumonia. In addition, re-intubation (p = 0.004) was found to be significantly associated with pneumonia; however, pneumonia was detected in 75% of these patients prior to re-intubation. Two patients (2%) died during intensive care unit stay, and both had diagnosed nosocomial pneumonia. Smoking correlated significantly with pneumonia (p = 0.011). CONCLUSION Secondary pneumonia due to deep OI is associated with prolonged hospital care and can predict the risk of death. Duration of mechanical ventilation should be reduced with prompt and adequate OI treatment, whenever possible. Smokers with deep OI have a significantly higher risk than non-smokers of developing pneumonia. CLINICAL RELEVANCE Nosocomial pneumonia is a considerable problem in OI patients with lengthy mechanical ventilation. Prompt and comprehensive OI care is required to reduce these risk factors.
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Affiliation(s)
- Niina Rautaporras
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, P.O. Box 220, (Haartmaninkatu 4E), FI-00029 HUH, Helsinki, Finland.
| | - Jussi Furuholm
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, P.O. Box 220, (Haartmaninkatu 4E), FI-00029 HUH, Helsinki, Finland
| | - Johanna Uittamo
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, P.O. Box 220, (Haartmaninkatu 4E), FI-00029 HUH, Helsinki, Finland
| | - Mikko Saloniemi
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, P.O. Box 220, (Haartmaninkatu 4E), FI-00029 HUH, Helsinki, Finland
| | - Tuukka Puolakka
- Department of Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Department of Anaesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Johanna Snäll
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, P.O. Box 220, (Haartmaninkatu 4E), FI-00029 HUH, Helsinki, Finland
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Algahtani R, Merenda A. Multimorbidity and Critical Care Neurosurgery: Minimizing Major Perioperative Cardiopulmonary Complications. Neurocrit Care 2020; 34:1047-1061. [PMID: 32794145 PMCID: PMC7426068 DOI: 10.1007/s12028-020-01072-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 07/28/2020] [Indexed: 11/19/2022]
Abstract
With increasing prevalence of chronic diseases, multimorbid patients have become commonplace in the neurosurgical intensive care unit (neuro-ICU), offering unique management challenges. By reducing physiological reserve and interacting with one another, chronic comorbidities pose a greatly enhanced risk of major postoperative medical complications, especially cardiopulmonary complications, which ultimately exert a negative impact on neurosurgical outcomes. These premises underscore the importance of perioperative optimization, in turn requiring a thorough preoperative risk stratification, a basic understanding of a multimorbid patient’s deranged physiology and a proper appreciation of the potential of surgery, anesthesia and neurocritical care interventions to exacerbate comorbid pathophysiologies. This knowledge enables neurosurgeons, neuroanesthesiologists and neurointensivists to function with a heightened level of vigilance in the care of these high-risk patients and can inform the perioperative neuro-ICU management with individualized strategies able to minimize the risk of untoward outcomes. This review highlights potential pitfalls in the intra- and postoperative neuro-ICU period, describes common preoperative risk stratification tools and discusses tailored perioperative ICU management strategies in multimorbid neurosurgical patients, with a special focus on approaches geared toward the minimization of postoperative cardiopulmonary complications and unplanned reintubation.
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Affiliation(s)
- Rami Algahtani
- Department of Neurology, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
| | - Amedeo Merenda
- Department of Neurology, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA. .,Department of Neurosurgery, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA.
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Kuriyama A, Egawa S, Kataoka J, Sakuraya M, Matsumura M. Adverse events associated with prophylactic corticosteroid use before extubation: a cohort study. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:853. [PMID: 32793697 DOI: 10.21037/atm-20-1790] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Systemic corticosteroid use is recommended before extubation in mechanically ventilated patients to prevent postextubation airway complications and reintubation. However, the adverse events associated with such use remain unclear. This study aimed to describe the incidence of adverse events associated with prophylactic corticosteroid use before extubation in mechanically ventilated adult patients. Methods This is a retrospective cohort study of 251 mechanically ventilated adults who received prophylactic corticosteroids in the intensive care units of four tertiary-care hospitals. The patients received 20 mg methylprednisolone at 12, 8, 4, and 0 hours before extubation (total dose, 80 mg) and were followed for 72 hours after extubation. The primary outcome was a clinically significant increase in blood glucose levels of ≥100 mg/dL within 24 and 72 hours after prophylactic corticosteroid administration. Results Fifty-seven (23.1%) out of 247 patients and 73 (30.3%) out of 241 patients showed a clinically significant increase in blood glucose levels within 24 and 72 hours after receiving prophylactic corticosteroids, respectively. The clinically significant increase in blood glucose levels was significantly associated with underlying diabetes mellitus and was not significantly associated with hyperglycemia within 3 days before the initiation of prophylactic corticosteroids or with patient age. New-onset infections and delirium were also common, with incidences of 7.6% and 7.7%, respectively. Conclusions Prophylactic corticosteroid use before extubation was associated with adverse events, the most common of which was increased blood glucose levels. Lower doses of prophylactic corticosteroids may need to be considered in patients with diabetes mellitus or hyperglycemia.
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Affiliation(s)
- Akira Kuriyama
- Division of General Medicine, Center for Community Medicine, Jichi Medical University School of Medicine, Tochigi, Japan.,Emergency and Critical Care Center, Kurashiki Central Hospital, Okayama, Japan
| | - Satoshi Egawa
- Neurointensive Care Unit, Department of Neurosurgery, Stroke and Epilepsy Center, TMG Asaka Medical Center, Saitama, Japan
| | - Jun Kataoka
- Department of Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital at Hatsukaichi, Hiroshima, Japan
| | - Masami Matsumura
- Division of General Medicine, Center for Community Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
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Thorarinsdottir HR, Kander T, Holmberg A, Petronis S, Klarin B. Biofilm formation on three different endotracheal tubes: a prospective clinical trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:382. [PMID: 32600373 PMCID: PMC7322705 DOI: 10.1186/s13054-020-03092-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 06/12/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Biofilm formation on endotracheal tubes (ETTs) is an early and frequent event in mechanically ventilated patients. The biofilm is believed to act as a reservoir for infecting microorganisms and thereby contribute to development and relapses of ventilator-associated pneumonia (VAP). Once a biofilm has formed on an ETT surface, it is difficult to eradicate. This clinical study aimed to compare biofilm formation on three widely used ETTs with different surface properties and to explore factors potentially predictive of biofilm formation. METHODS We compared the grade of biofilm formation on ETTs made of uncoated polyvinyl chloride (PVC), silicone-coated PVC, and PVC coated with noble metals after > 24 h of mechanical ventilation in critically ill patients. The comparison was based on scanning electron microscopy of ETT surfaces, biofilm grading, surveillance and biofilm cultures, and occurrence of VAP. RESULTS High-grade (score ≥ 7) biofilm formation on the ETTs was associated with development of VAP (OR 4.17 [95% CI 1.14-15.3], p = 0.031). Compared to uncoated PVC ETTs, the silicone-coated and noble-metal-coated PVC ETTs were independently associated with reduced high-grade biofilm formation (OR 0.18 [95% CI 0.06-0.59], p = 0.005, and OR 0.34 [95% CI 0.13-0.93], p = 0.036, respectively). No significant difference was observed between silicon-coated ETTs and noble-metal-coated ETTs (OR 0.54 [95% CI 0.17-1.65], p = 0.278). In 60% of the oropharyngeal cultures and 58% of the endotracheal cultures collected at intubation, the same microorganism was found in the ETT biofilm at extubation. In patients who developed VAP, the causative microbe remained in the biofilm in 56% of cases, despite appropriate antibiotic therapy. High-grade biofilm formation on ETTs was not predicted by either colonization with common VAP pathogens in surveillance cultures or duration of invasive ventilation. CONCLUSION High-grade biofilm formation on ETTs was associated with development of VAP. Compared to the uncoated PVC ETTs, the silicone-coated and noble-metal-coated PVC ETTs were independently associated with reduced high-grade biofilm formation. Further research on methods to prevent, monitor, and manage biofilm occurrence is needed. TRIAL REGISTRATION ClinicalTrials.gov NCT02284438 . Retrospectively registered on 21 October 2014.
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Affiliation(s)
- Hulda R Thorarinsdottir
- Department of Clinical Sciences, Lund University, Lund, Sweden. .,Division of Intensive and Perioperative Care, Skåne University Hospital, Getingevägen 4, SE-22185, Lund, Sweden.
| | - Thomas Kander
- Department of Clinical Sciences, Lund University, Lund, Sweden.,Division of Intensive and Perioperative Care, Skåne University Hospital, Getingevägen 4, SE-22185, Lund, Sweden
| | - Anna Holmberg
- Division of Infection Medicine, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Sarunas Petronis
- Chemistry, Biomaterials and Textiles, RISE Research Institutes of Sweden, Borås, Sweden
| | - Bengt Klarin
- Department of Clinical Sciences, Lund University, Lund, Sweden.,Division of Intensive and Perioperative Care, Skåne University Hospital, Getingevägen 4, SE-22185, Lund, Sweden
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Renew JR, Ratzlaff R, Hernandez-Torres V, Brull SJ, Prielipp RC. Neuromuscular blockade management in the critically Ill patient. J Intensive Care 2020; 8:37. [PMID: 32483489 PMCID: PMC7245849 DOI: 10.1186/s40560-020-00455-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 05/13/2020] [Indexed: 12/16/2022] Open
Abstract
Neuromuscular blocking agents (NMBAs) can be an effective modality to address challenges that arise daily in the intensive care unit (ICU). These medications are often used to optimize mechanical ventilation, facilitate endotracheal intubation, stop overt shivering during therapeutic hypothermia following cardiac arrest, and may have a role in the management of life-threatening conditions such as elevated intracranial pressure and status asthmaticus (when deep sedation fails or is not tolerated). However, current NMBA use has decreased during the last decade due to concerns of potential adverse effects such as venous thrombosis, patient awareness during paralysis, development of critical illness myopathy, autonomic interactions, and even residual paralysis following cessation of NMBA use. It is therefore essential for clinicians to be familiar with evidence-based practices regarding appropriate NMBA use in order to select appropriate indications for their use and avoid complications. We believe that selecting the right NMBA, administering concomitant sedation and analgesic therapy, and using appropriate monitoring techniques mitigate these risks for critically ill patients. Therefore, we review the indications of NMBA use in the critical care setting and discuss the most appropriate use of NMBAs in the intensive care setting based on their structure, mechanism of action, side effects, and recognized clinical indications. Lastly, we highlight the available pharmacologic antagonists, strategies for sedation, newer neuromuscular monitoring techniques, and potential complications related to the use of NMBAs in the ICU setting.
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Affiliation(s)
- J Ross Renew
- 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - Robert Ratzlaff
- 2Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL USA
| | - Vivian Hernandez-Torres
- 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - Sorin J Brull
- 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 USA.,3Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, MN USA
| | - Richard C Prielipp
- 3Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, MN USA
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Measuring endotracheal tube intracuff pressure: no room for complacency. J Clin Monit Comput 2020; 35:3-10. [PMID: 32198671 PMCID: PMC7223496 DOI: 10.1007/s10877-020-00501-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 03/16/2020] [Indexed: 12/19/2022]
Abstract
Tracheal intubation constitutes a routine part in the care of critically ill and anaesthetised patients. Prolonged use of endotracheal with inflated cuff is one of the major multifactorial causes of complications. Both under-inflation and over-inflation of cuff are associated with complications. Despite known problems, regular measurement of cuff pressure is not routine, and it is performed on an ad hoc basis.
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Ghiani A, Paderewska J, Sainis A, Crispin A, Walcher S, Neurohr C. Variables predicting weaning outcome in prolonged mechanically ventilated tracheotomized patients: a retrospective study. J Intensive Care 2020; 8:19. [PMID: 32123565 PMCID: PMC7035768 DOI: 10.1186/s40560-020-00437-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 02/13/2020] [Indexed: 12/02/2022] Open
Abstract
Background Several studies have assessed predictors of weaning and extubation outcome in short-term mechanically ventilated patients, but there are only few studies on predictors of weaning from prolonged mechanical ventilation. Methods Retrospective, single-center, observational study at a specialized national weaning center in Germany. Patients’ medical records were reviewed to obtain data on demographics, comorbidities, respiratory indices, and the result of a prospectively documented, standardized spontaneous breathing trial (SBT) upon admission to the weaning center. Respiratory indices assessed were the ventilatory ratio (VR) and parameters derived from calculated mechanical power (MP). Predictors associated with failure of prolonged weaning and failure of the SBT were assessed using a binary logistic regression model. Results A total of 263 prolonged mechanically ventilated, tracheotomized patients, treated over a 5-year period were analyzed. After 3 weeks of mechanical ventilation, patients with unsuccessful weaning failed a SBT more frequently and showed significantly increased values for inspiratory positive airway pressure, driving pressure, VR, absolute MP, and MP normalized to predicted body weight and dynamic lung-thorax compliance (LTC-MP). In the logistic regression analyses, variables independently correlated with weaning failure were female gender (adjusted odds ratio 0.532 [95% CI 0.291–0.973]; p = 0.040), obesity (body mass index ≥ 30 kg/m2) (2.595 [1.210–5.562]; p = 0.014), COPD (3.209 [1.563–6.589]; p = 0.002), LTC-MP (3.470 [1.067–11.284]; p = 0.039), PaCO2 on mechanical ventilation (1.101 [95% CI 1.034–1.173]; p = 0.003), and failure of the SBT (4.702 [2.250–9.825]; p < 0.001). In addition, female gender (0.401 [0.216–0.745]; p = 0.004), LTC-MP (3.017 [1.027–8.862]; p = 0.046), and PaCO2 on mechanical ventilation (1.157 [1.083–1.235]; p < 0.001) were independent risk factors for an unsuccessful SBT. Conclusions In the present study, the derived predictors of weaning point to a crucial role of the workload imposed on respiratory muscles during spontaneous breathing. Mechanical power normalized to lung-thorax compliance was independently correlated with weaning outcome and may identify patients at high risk for weaning failure.
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Affiliation(s)
- Alessandro Ghiani
- Department of Pneumology and Respiratory Medicine, Schillerhoehe Lung Clinic (Robert Bosch Hospital GmbH), Solitudestr. 18, 70839 Gerlingen, Germany
| | - Joanna Paderewska
- Department of Pneumology and Respiratory Medicine, Schillerhoehe Lung Clinic (Robert Bosch Hospital GmbH), Solitudestr. 18, 70839 Gerlingen, Germany
| | - Alexandros Sainis
- Department of Pneumology and Respiratory Medicine, Schillerhoehe Lung Clinic (Robert Bosch Hospital GmbH), Solitudestr. 18, 70839 Gerlingen, Germany.,Athens, Greece
| | - Alexander Crispin
- 3IBE - Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-University (LMU), Marchioninistr. 15, 81377 Munich, Germany
| | - Swenja Walcher
- Department of Pneumology and Respiratory Medicine, Schillerhoehe Lung Clinic (Robert Bosch Hospital GmbH), Solitudestr. 18, 70839 Gerlingen, Germany
| | - Claus Neurohr
- Department of Pneumology and Respiratory Medicine, Schillerhoehe Lung Clinic (Robert Bosch Hospital GmbH), Solitudestr. 18, 70839 Gerlingen, Germany
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Ultrasonographic evaluation of lung and heart in predicting successful weaning in mechanically ventilated neurosurgical patients. J Clin Monit Comput 2020; 35:189-197. [PMID: 31927703 PMCID: PMC7222928 DOI: 10.1007/s10877-020-00460-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 01/08/2020] [Indexed: 11/25/2022]
Abstract
In critically ill neurosurgical patients, delayed and premature extubation increases the risk of morbidity and mortality. Assessment of critically ill patients before and during spontaneous breathing trial (SBT) is crucial in predicting weaning failure. We explored the trend of changes with integrated lung and cardiac ultrasonography in predicting success of weaning in neurosurgical patients. Lung ultrasound and cardiac ultrasound was performed before and after 30 min and 120 min of SBT. Lung ultrasound score (LUS, range 0–36) was calculated using a predefined method of assessment of six chest regions on either side. The left ventricular function was evaluated by measuring fractional area change. The maximum velocities of mitral inflow E and A waves (E/A), deceleration time of E wave (DTE) and tissue doppler based E′ wave at lateral annulus to calculate E/E′, were measured to assess left ventricular filling pressure. Twenty seven patients underwent SBT, among these 22 had success and five had failure of SBT. The SBT failure group had higher baseline LUS and progressively higher LUS during SBT compared to the success group, suggesting significant lung de-recruitment. There was significant increase in the LV filling pressure (increase E/A and E/E′, decrease in DTE) after 30 and 120 min of SBT in failure group compared to the success group. Point of care lung and cardiac ultrasonography may be useful in detecting cardiopulmonary changes induced by SBT. Higher lung aeration loss and LV filling pressure were observed with SBT failure group.
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Casey JD, Vaughan ER, Lloyd BD, Bilas PA, Hall EJ, Toporek AH, Buell KG, Brown RM, Richardson RK, Rooks JC, Wang L, Lindsell CJ, Ely EW, Self WH, Bernard GR, Rice TW, Semler MW. Protocolized Post-Extubation Respiratory Support to prevent reintubation: protocol and statistical analysis plan for a clinical trial. BMJ Open 2019; 9:e030476. [PMID: 31377713 PMCID: PMC6687016 DOI: 10.1136/bmjopen-2019-030476] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/06/2019] [Accepted: 06/21/2019] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Following extubation from invasive mechanical ventilation, nearly one in seven critically ill adults requires reintubation. Reintubation is independently associated with increased mortality. Postextubation respiratory support (non-invasive ventilation or high-flow nasal cannula applied at the time of extubation) has been reported in small-to-moderate-sized trials to reduce reintubation rates among hypercapnic patients, high-risk patients without hypercapnia and low-risk patients without hypercapnia. It is unknown whether protocolised provision of postextubation respiratory support to every patient undergoing extubation would reduce the overall reintubation rate, compared with usual care. METHODS AND ANALYSIS The Protocolized Post-Extubation Respiratory Support (PROPER) trial is a pragmatic, cluster cross-over trial being conducted between 1 October 2017 and 31 March 2019 in the medical intensive care unit of Vanderbilt University Medical Center. PROPER compares usual care versus protocolized post-extubation respiratory support (a respiratory therapist-driven protocol that advises the provision of non-invasive ventilation or high-flow nasal cannula based on patient characteristics). For the duration of the trial, the unit is divided into two clusters. One cluster receives protocolised support and the other receives usual care. Each cluster crosses over between treatment group assignments every 3 months. All adults undergoing extubation from invasive mechanical ventilation are enrolled except those who received less than 12 hours of mechanical ventilation, have 'Do Not Intubate' orders, or have been previously reintubated during the hospitalisation. The anticipated enrolment is approximately 630 patients. The primary outcome is reintubation within 96 hours of extubation. ETHICS AND DISSEMINATION The trial was approved by the Vanderbilt Institutional Review Board. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences. TRIAL REGISTRATION NUMBER NCT03288311.
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Affiliation(s)
- Jonathan Dale Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Erin R Vaughan
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bradley D Lloyd
- Division of Respiratory Care, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Peter A Bilas
- Department of Anesthesiology, University of Florida, Gainesville, Florida, USA
| | - Eric J Hall
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alexandra H Toporek
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kevin G Buell
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ryan M Brown
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Roger K Richardson
- Division of Respiratory Care, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - J Craig Rooks
- Division of Respiratory Care, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christopher J Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Gordon R Bernard
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Lewis K, Culgin S, Jaeschke R, Perri D, Marchildon C, Hassall K, Piraino T, Thabane L, Almubarak Y, Alshahrani MS, Rochwerg B, Baw B, Szczeklik W, Karachi T, Alhazzani W. Cuff Leak Test and Airway Obstruction in Mechanically Ventilated ICU Patients (COMIC): a pilot randomised controlled trial protocol. BMJ Open 2019; 9:e029394. [PMID: 31326936 PMCID: PMC6661599 DOI: 10.1136/bmjopen-2019-029394] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Endotracheal intubation and invasive mechanical ventilation are lifesaving interventions that are commonly performed in the intensive care unit (ICU). Laryngeal oedema is a known complication of intubation that may cause airway obstruction in a patient on extubation. To date, the only test available to predict this complication is the cuff leak test (CLT); however, its diagnostic accuracy and utility remains uncertain. Herein, we report the protocol for the CuffLeak and AirwayObstruction in MechanicallyVentilated ICU Patients (COMIC) pilottrial. METHODS AND ANALYSIS This will be a multicentred, pragmatic, pilot randomised controlled trial (RCT). We will enrol 100 mechanically ventilated patients in the ICU who are deemed ready for extubation. We will exclude patients at a high risk of laryngeal oedema. All enrolled patients will have a CLT done before extubation. In the intervention arm, the results of the CLT will be communicated to the bedside physician, and decision to extubate will be left to the treating team. In the control arm, respiratory therapist will not communicate the results of the CLT to the treating physician, and the patient will be extubated regardless of the CLT result. Randomisation will be done in a 1:1 allocation ratio, stratified by size of the endotracheal tube and duration of invasive mechanical ventilation.Although we will examine all clinical outcomes relevant for the future COMIC RCT, the primary outcomes of the COMIC pilottrial will be feasibility outcomes including: consent rate, recruitment rate and protocol adherence. Clinical outcomes include postextubation stridor, reintubation, emergency surgical airway, ICU mortality, in hospital mortality, duration of mechanical ventilation and ICU length of stay in days. ETHICS AND DISSEMINATION The Hamilton Integrated Research Ethics Board, Imam Abdulrahman Bin Faisal University Institutional Review Board and Bioethical Commission of the Jagiellonian University approved this study. The trial results will be disseminated via publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03372707.
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Affiliation(s)
- Kimberley Lewis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sarah Culgin
- The Research Institute of St. Joseph’s Healthcare Hamilton, St Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Roman Jaeschke
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Dan Perri
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | | | | | - Thomas Piraino
- Department of Critical Care, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Lehana Thabane
- The Research Institute of St. Joseph’s Healthcare Hamilton, St Joseph’s Healthcare, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Yousef Almubarak
- Department of Critical Care, Imam Abdulrahman Ben Faisal University, Dammam, Saudi Arabia
| | - Mohammed S Alshahrani
- Department of Emergency and Critical Care, Imam Abdulrahman Ben Faisal University, Dammam, Saudi Arabia
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Bandar Baw
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Wojciech Szczeklik
- Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Tim Karachi
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- St. Joseph’s Healthcare, Hamilton, Ontario, Canada
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Cork G, Camporota L, Osman L, Shannon H. Physiotherapist prediction of extubation outcome in the adult intensive care unit. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2019; 24:e1793. [PMID: 31237395 PMCID: PMC6852206 DOI: 10.1002/pri.1793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 05/02/2019] [Accepted: 05/17/2019] [Indexed: 11/08/2022]
Abstract
Objective Most patients requiring intubation and mechanical ventilation are extubated successfully at the first attempt; however, a minority experience extubation failure, which is associated with increased risk of ventilator‐associated pneumonia, prolonged intensive care unit (ICU) length of stay and mortality. Physiotherapists have expertise to assess cough strength, work of breathing, respiratory muscle strength, and respiratory secretion load, which are important factors in the outcome of extubation. Accurate prediction of extubation outcome could help to inform management plans pre‐extubation and postextubation. The primary objective of this service evaluation was to report the accuracy of physiotherapists' prediction of extubation outcome in the adult ICU. Methods A single‐centre case note review was undertaken. All subjects who received a physiotherapy assessment of extubation suitability prior to extubation between January and March 2016 in the adult ICU of a large teaching hospital in the United Kingdom were included. Assessment, by both specialist and nonspecialist physiotherapists—which included risk stratification of extubation failure as “high,” “moderate,” or “low”—was undertaken prior to extubation. Logistic regression analysis was performed to determine which pre‐extubation factors were predictive of extubation outcome. Results During the evaluation period, 68 subjects were extubated following a physiotherapy assessment. Physiotherapy risk stratification as “high risk” (OR 4; 95% confidence interval, CI, [1.312]; p=0.009) and “inappropriate” neurological status (OR 3.3; 95% CI [1.0410]; p=0.037) were the only pre‐extubation factors significantly associated with extubation failure. Assessment by specialist physiotherapists demonstrated greater sensitivity (100% vs. 22%) but lower specificity (68% vs. 95%) to detect extubation failure compared with the assessment performed by nonspecialist physiotherapists. Conclusion Patients classified as “high risk” of extubation failure by a physiotherapist are significantly more likely to fail extubation. Specialist physiotherapists should be involved in the decision to extubate patients in the adult ICU.
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Affiliation(s)
- Gabriella Cork
- Department of Physiotherapy, Guy's and St Thomas' NHS Foundation Trust, London, UK.,University College London Institute of Child Health, UCL Great Ormond Street Institute of Child Health, London, UK.,School of Health Sciences, University of Liverpool, Liverpool, UK
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's Health Partners, Division of Asthma, Allergy and Lung Biology, King's College London, London, UK
| | - Leyla Osman
- Department of Physiotherapy, Guy's and St Thomas' NHS Foundation Trust, London, UK.,University College London Institute of Child Health, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Harriet Shannon
- University College London Institute of Child Health, UCL Great Ormond Street Institute of Child Health, London, UK
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Xu Y, Lai C, Xu G, Meng W, Zhang J, Hou H, Pi H. Risk factors of ventilator-associated pneumonia in elderly patients receiving mechanical ventilation. Clin Interv Aging 2019; 14:1027-1038. [PMID: 31289438 PMCID: PMC6566835 DOI: 10.2147/cia.s197146] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 04/26/2019] [Indexed: 01/07/2023] Open
Abstract
Purpose: The aim of this study was to verify the potential risk factors of ventilator-associated pneumonia (VAP) in elderly Chinese patients receiving mechanical ventilation (MV). The secondary aim of this study was to present logistical regression prediction models of VAP occurrence in elderly Chinese patients receiving MV. Methods: Patients (aged 80 years or above) receiving MV for ≥48 h were enrolled from the Chinese People's Liberation Army (PLA) General Hospital from January 2011 to December 2015. A chi-squared test and Mann-Whitney U-test were used to compare the data between participants with VAP and without VAP. Univariate logistic regression models were performed to explore the relationship between risk factors and VAP. Results: A total of 901 patients were included in the study, of which 156 were diagnosed as VAP (17.3%). The incidence density of VAP was 4.25/1,000 ventilator days. Logistic regression analysis showed that the independent risk factors for elderly patients with VAP were COPD (OR =1.526, P < 0.05), intensive care unit (ICU) admission (OR=1.947, P < 0.01), the MV methods (P < 0.023), the number of antibiotics administered (OR=4.947, P < 0.01), the number of central venous catheters (OR=1.809, P < 0.05), the duration of indwelling urinary catheter (OR=1.805, P < 0.01) and the use of corticosteroids prior to MV (OR=1.618, P < 0.05). Logistic regression prediction model of VAP occurrence in the Chinese elderly patients with mechanical ventilation:L o g i t P = - 6 . 468 + 0 . 423 X 1 + 0 . 666 X 2 + 0 . 871 X 3 + - 0 . 501 X 5 + 0 . 122 X 6 + 0 . 593 X 7 + 0 . 590 X 8 + 1 . 599 X 9 . Conclusion: VAP occurrence is associated with a variety of controllable factors including the MV methods and the number of antibiotics administered. A model was established to predict VAP occurrence so that high-risk patients could be identified as early as possible.
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Affiliation(s)
- Yue Xu
- Department of Nursing, Chinese People’s Liberation Army (PLA) General Hospital, Chinese PLA Medical Academy, Beijing, People’s Republic of China
| | - Chunyun Lai
- Department of Respiratory, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Guogang Xu
- The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Wenwen Meng
- The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Jie Zhang
- Department of Nursing, Chinese People’s Liberation Army (PLA) General Hospital, Chinese PLA Medical Academy, Beijing, People’s Republic of China
| | - Huiru Hou
- Department of Nursing, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Hongying Pi
- Department of Nursing, Chinese People’s Liberation Army (PLA) General Hospital, Chinese PLA Medical Academy, Beijing, People’s Republic of China
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Compare the effect of noninvasive ventilation and tracheotomy in critically ill mechanically ventilated neurosurgical patients: a retrospective observe cohort study. BMC Neurol 2019; 19:79. [PMID: 31043155 PMCID: PMC6495499 DOI: 10.1186/s12883-019-1297-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 04/11/2019] [Indexed: 02/05/2023] Open
Abstract
Objective Patients with severe brain injury is usual at high risk of extubation failure, despite of those with no/minor primary respiratory problem, majority of them still needs long term respiratory support and has severe pulmonary complications. This retrospective study aimed to compare the effect of noninvasive ventilation (NIV) and tracheotomy on the prognosis in critically ill mechanically ventilated neurosurgical patients. Methods This is a single center, retrospective observe cohort study. Postoperative patients with brain injury consecutively admitted to ICU from November 1st, 2015 through February 28th, 2017, who had received invasive mechanical ventilation more than 48 h were screened, those who received NIV or tracheotomy procedure, meanwhile with Glasgow Coma Scale (GCS) score between 8 and 13 points before using NIV or undergoing tracheotomy, were retrospectively included in this study. The demographic data and clinical main outcomes such as ICU and hospital mortality, time of mechanical ventilation, length of ICU and hospital were collected. The primary outcome was the incidence of postoperative pulmonary infection between two groups. Results 77 patients were included in this study. 33 patients received NIV, and 44 patients received tracheotomy through the ICU duration. The incidence of postoperative pulmonary infection in NIV group was significantly lower than that in tracheotomy group (54.5% VS 84.1%, P < 0.05), Application of NIV was associated with shorter duration of invasive mechanical ventilation ([median 123.0 h VS 195.0 h, P < 0.05). Moreover, GCS score at ICU discharge, as well as the difference of GCS score between at admission to ICU and ICU discharge were also better than the tracheotomy group (P < 0.001). Conclusion Compared with tracheotomy, use of NIV after extubation in critically ill mechanically ventilated neurosurgical patients may be associated with lower incidence of postoperative pulmonary infection, shorter duration of invasive mechanical ventilation and better improvement in brain function. Further studies need to verify the effect of NIV in this kind of patients.
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