Days Of Invasive Mechanical Ventilation Research Articles

Prone positioning does not improve outcomes of intubated patients with pneumocystis pneumonia and moderate–severe acute respiratory distress syndrome: a single-center, retrospective, observational, cohort study

BackgroundPneumocystis pneumonia is an uncommon precipitant of acute respiratory distress syndrome and is associated with high mortality. Prone positioning ventilation has been proven to reduce mortality in patients with moderate–severe acute respiratory distress syndrome. We investigated the effect of prone positioning on oxygenation and mortality in intubated patients with pneumocystis pneumonia comorbid with moderate–severe acute respiratory distress syndrome.MethodsIn this single-center, retrospective, observational, cohort study, eligible patients were enrolled at West China Hospital of Sichuan University from January 1, 2017, to December 31, 2021. Data on demographics, clinical features, ventilation parameters, arterial blood gas, and outcomes were collected. Patients were assigned to the prone cohort or supine cohort according to whether they received prone positioning ventilation. The main outcome was 28-day mortality.FindingsA total of 79 patients were included in the study. Sixty-three patients were enrolled in the prone cohort, and 16 patients were enrolled in the supine cohort. The 28-day mortality was 61.9% in the prone cohort and 68.8% in the supine cohort (P = 0.26), and 90-day mortality was 66.7% in the prone cohort and 68.8% in the supine cohort (P = 0.55). Patients in the supine cohort had fewer invasive mechanical ventilation days and more ventilator-free days. The incidence of complications was higher in the prone cohort than in the supine cohort.ConclusionsIn patients with pneumocystis pneumonia and moderate–severe acute respiratory distress syndrome, prone positioning did not decrease 28-day or 90-day mortality.Trial registration ClinicalTrials.gov number, ChiCTR2200063889. Registered on 20 September 2022, https://www.chictr.org.cn/showproj.html?proj=174886.

ARDS Mortality Prediction Model Using Evolving Clinical Data and Chest Radiograph Analysis.

Within primary ARDS, SARS-CoV-2-associated ARDS (C-ARDS) emerged in late 2019, reaching its peak during the subsequent two years. Recent efforts in ARDS research have concentrated on phenotyping this heterogeneous syndrome to enhance comprehension of its pathophysiology. A retrospective study was conducted on C-ARDS patients from April 2020 to February 2021, encompassing 110 participants with a mean age of 63.2 ± 11.92 (26-83 years). Of these, 61.2% (68) were male, and 25% (17) experienced severe ARDS, resulting in a mortality rate of 47.3% (52). Ventilation settings, arterial blood gases, and chest X-ray (CXR) were evaluated on the first day of invasive mechanical ventilation and between days two and three. CXR images were scrutinized using a convolutional neural network (CNN). A binary logistic regression model for predicting C-ARDS mortality was developed based on the most influential variables: age, PaO2/FiO2 ratio (P/F) on days one and three, CNN-extracted CXR features, and age. Initial performance assessment on test data (23 patients out of the 110) revealed an area under the receiver operating characteristic (ROC) curve of 0.862 with a 95% confidence interval (0.654-0.969). Integrating data available in all intensive care units enables the prediction of C-ARDS mortality by utilizing evolving P/F ratios and CXR. This approach can assist in tailoring treatment plans and initiating early discussions to escalate care and extracorporeal life support. Machine learning algorithms for imaging classification can uncover otherwise inaccessible patterns, potentially evolving into another form of ARDS phenotyping. The combined features of these algorithms and clinical variables demonstrate superior performance compared to either element alone.

Establishment and efficiency test of a clinical prediction model of bronchopulmonary dysplasia associated pulmonary hypertension in very premature infants

Objective: To develop a risk prediction model for identifying bronchopulmonary dysplasia (BPD) associated pulmonary hypertension (PH) in very premature infants. Methods: This was a retrospective cohort study. The clinical data of 626 very premature infants whose gestational age <32 weeks and who suffered from BPD were collected from October 1st, 2015 to December 31st, 2021 of the Seventh Medical Center of the People's Liberation Army General Hospital as a modeling set. The clinical data of 229 very premature infants with BPD of Hunan Children's Hospital from January 1 st, 2020 to December 31st, 2021 were collected as a validation set for external verification. The very premature infants with BPD were divided into PH group and non PH group based on the echocardiogram after 36 weeks' corrected age in the modeling set and validation set, respectively. Univariate analysis was used to compare the basic clinical characteristics between groups, and collinearity exclusion was carried out between variables. The risk factors of BPD associated PH were further screened out by multivariate Logistic regression, and the risk assessment model was established based on these variables. The receiver operating characteristic (ROC) area under curve (AUC) and Hosmer-Lemeshow goodness-of-fit test were used to evaluate the model's discrimination and calibration power, respectively. And the calibration curve was used to evaluate the accuracy of the model and draw the nomogram. The bootstrap repeated sampling method was used for internal verification. Finally, decision curve analysis (DCA) to evaluate the clinical practicability of the model was used. Results: A total of 626 very premature infants with BPD were included for modeling set, including 85 very premature infants in the PH group and 541 very premature infants in the non PH group. A total of 229 very premature infants with BPD were included for validation set, including 24 very premature infants in the PH group and 205 very premature infants in the non PH group. Univariate analysis of the modeling set found that 22 variables, such as artificial conception, fetal distress, gestational age, birth weight, small for gestational age, 1 minute Apgar score ≤7, antenatal corticosteroids, placental abruption, oligohydramnios, multiple pulmonary surfactant, neonatal respiratory distress syndrome (NRDS)>stage Ⅱ, early pulmonary hypertension, moderate-severe BPD, and hemodynamically significant patent ductus arteriosus (hsPDA) all had statistically significant influence between the PH group and the non PH group (all P<0.05). Antenatal corticosteroids, fetal distress, NRDS >stage Ⅱ, hsPDA, pneumonia and days of invasive mechanical ventilation were identified as predictive variables and finally included to establish the Logistic regression model. The AUC of this model was 0.86 (95%CI 0.82-0.90), the cut-off value was 0.17, the sensitivity was 0.77, and the specificity was 0.84. Hosmer-Lemeshow goodness-of-fit test showed that P>0.05. The AUC for external validation was 0.88, and the Hosmer-Lemeshow goodness-of-fit test suggested P>0.05. Conclusions: A high sensitivity and specificity risk prediction model of PBD associated PH in very premature infants was established. This predictive model is useful for early clinical identification of infants at high risk of BPD associated PH.

Advanced Respiratory Support Days as a Novel Marker of Mortality in COVID-19 Acute Respiratory Distress Syndrome Requiring Extracorporeal Membrane Oxygenation.

Emerging evidence suggests prolonged use of noninvasive respiratory support may increase mortality of patients with coronavirus disease 2019 (COVID-19)-associated acute respiratory distress syndrome who require extracorporeal membrane oxygenation (ECMO). Using a database of adults receiving ECMO for COVID-19, we calculated survival curves and multivariable Cox regression to determine the risk of death associated with pre-ECMO use of high-flow nasal oxygen (HFNO), noninvasive ventilation (NIV), and invasive mechanical ventilation (IMV) days. We investigated the performance of a novel variable, advanced respiratory support days (composite of HFNO, NIV, and IMV days), on Respiratory ECMO Survival Prediction (RESP) score. Subjects (N = 146) with increasing advanced respiratory support days (<5, 5-9, and ≥10) had a stepwise increase in 90 day mortality (32.2%, 57.7%, and 75.4%, respectively; p = 0.002). Ninety-day mortality was significantly higher in subjects (N = 121) receiving NIV >4 days (81.8% vs. 52.4%, p < 0.001). Each additional pre-ECMO advanced respiratory support day increased the odds of right ventricular failure (odds ratio [OR]: 1.066, 95% confidence interval [CI]: 1.002-1.135) and in-hospital mortality (1.17, 95% CI: 1.08-1.27). Substituting advanced respiratory support days for IMV days improved RESP score mortality prediction (area under the curve (AUC) or: 0.64 vs. 0.71). Pre-ECMO advanced respiratory support days were associated with increased 90 day mortality compared with IMV days alone. Adjusting the RESP score for advanced respiratory support days improved mortality prediction.

Nutritional and Sarcopenia Assessment in Bilateral Lung Transplantation Recipient: Can “The Strongest One” Expect Improved Short-Term Outcomes?

Background: Scant data are available on nutritional status in bilateral lung transplant (BLT) candidates. Methods: All consecutive recipients admitted to the intensive care unit (ICU) of the University Hospital of Padua (February 2016–2020) after bilateral-lung transplant (BLT) were retrospectively screened. Data collected: (i) nutritional indices (body mass index (BMI), albumin level, prognostic nutritional index (PNI), mini nutritional assessment short-form (MNA-SF)); and (ii) muscular indices (creatinine height index (CHI)), skeletal muscle index (SMI), densitometry of paravertebral muscles on chest CT). Results: 108 BLT recipients were enrolled: 55% had a normal BMI, 83% had serum albumin levels &gt; 35 g/L; high PNI and MNA-SF scores were recorded in most of patients. A total of 74% had a “normal or slightly reduced protein state“ according to the CHI score; 17% were identified as “sarcopenic” according to muscle densitometry (Hu &lt; 30). Lower serum albumin was associated with longer invasive mechanical ventilation days (IMV) and ICU length of stay (p-value for non-linearity &lt; 0.01). PNI and BMI were also associated with an increased ICU length of stay (p-value for non-linearity &lt; 0.01). Conclusions: Most of the BLT recipients had normal nutritional and sarcopenia status. Pre-transplant albumin values correlated with the duration of IMV; serum albumin, PNI and BMI were associated with ICU stay. No nutritional or muscle parameters predicted re-intubation, 30-days rejection and overall length of hospital stay.

Mortality, incidence, and microbiological documentation of ventilated acquired pneumonia (VAP) in critically ill patients with COVID-19 or influenza

BackgroundData on ventilator associated pneumonia (VAP) in COVID-19 and influenza patients admitted to intensive care units (ICU) are scarce. This study aimed to estimate day-60 mortality related to VAP in ICU patients ventilated for at least 48 h, either for COVID-19 or for influenza, and to describe the epidemiological characteristics in each group of VAP.DesignMulticentre retrospective observational study.SettingEleven ICUs of the French OutcomeRea™ network.PatientsPatients treated with invasive mechanical ventilation (IMV) for at least 48 h for either COVID-19 or for flu.ResultsOf the 585 patients included, 503 had COVID-19 and 82 had influenza between January 2008 and June 2021. A total of 232 patients, 209 (41.6%) with COVID-19 and 23 (28%) with influenza, developed 375 VAP episodes. Among the COVID-19 and flu patients, VAP incidences for the first VAP episode were, respectively, 99.2 and 56.4 per 1000 IMV days (p < 0.01), and incidences for all VAP episodes were 32.8 and 17.8 per 1000 IMV days (p < 0.01). Microorganisms of VAP were Gram-positive cocci in 29.6% and 23.5% of episodes of VAP (p < 0.01), respectively, including Staphylococcus aureus in 19.9% and 11.8% (p = 0.25), and Gram-negative bacilli in 84.2% and 79.4% (p = 0.47). In the overall cohort, VAP was associated with an increased risk of day-60 mortality (aHR = 1.77 [1.36; 2.30], p < 0.01), and COVID-19 had a higher mortality risk than influenza (aHR = 2.22 [CI 95%, 1.34; 3.66], p < 0.01). VAP was associated with increased day-60 mortality among COVID-19 patients (aHR = 1.75 [CI 95%, 1.32; 2.33], p < 0.01), but not among influenza patients (aHR = 1.75 [CI 95%, 0.48; 6.33], p = 0.35).ConclusionThe incidence of VAP was higher in patients ventilated for at least 48 h for COVID-19 than for influenza. In both groups, Gram-negative bacilli were the most frequently detected microorganisms. In patients ventilated for either COVID-19 or influenza VAP and COVID-19 were associated with a higher risk of mortality.

Early vvECMO implantation may be associated with lower mortality in ARDS

BackgroundVenovenous extracorporeal membrane oxygenation (vvECMO) is used to treat hypoxia in patients with severe acute respiratory distress syndrome (ARDS). Nevertheless, uncertainty exists regarding the optimal timing of initiation of vvECMO therapy. We aimed to investigate the association between number of days of invasive mechanical ventilation (IMV) prior to vvECMO implantation and mortality.MethodsIn this retrospective observational study, we included patients treated at an academic intensive care unit with vvECMO for severe ARDS. The primary outcome was all-cause 28-day mortality. We conducted a multivariate logistic regression analysis to estimate the association between number of days of IMV prior to vvECMO implantation and mortality after adjustment for confounders.ResultsOut of 274 patients who underwent ECMO for severe ARDS, 158 patients (median age: 58 years) with relevant data were included in the analysis. The mean duration of IMV prior to vvECMO was significantly shorter in survivors than in nonsurvivors [survivors median: 1; interquartile range: 1–3; non-survivors median 4; interquartile range: 1–5.75; p = 0.0001). Logistic regression showed an association between the duration of ventilation prior to vvECMO and patient mortality. The odds ratio for the all-cause 28-day mortality and in-hospital mortality was significantly reduced in patients who received vvECMO within the first 5 days of IMV.ConclusionsEarly vvECMO implantation may be associated with lower mortality in ARDS.

Outcome of glioblastoma patients after intensive care unit admission with invasive mechanical ventilation: a multicenter analysis

PurposePatients with glioblastoma are exposed to severe symptoms and organs failures (e.g., coma or acute respiratory failure), that may require intensive care unit (ICU) admission and invasive mechanical ventilation (IMV). However, only limited data are available concerning the prognosis of patients with glioblastoma receiving IMV. We sought to describe the reasons for ICU admission, and outcomes of patients with glioblastoma requiring IMV for unplanned critical complications.MethodsIn this retrospective analysis, four certified interdisciplinary brain tumor centers performed a retrospective review of their electronic data systems. All patients with glioblastoma admitted to an in-house ICU and receiving IMV between January 2015 and December 2019 were included. Clinical and prognostic factors as well as relevant outcome parameters were evaluated by group comparisons and Kaplan Meier survival curves.ResultsWe identified 33 glioblastoma patients with a duration of IMV of 9.2 ± 9.4 days. Main reasons for ICU admission were infection (n = 12; 34.3%) including 3 cases of Pneumocystis jirovecii pneumonia, status epilepticus (31.4%) and elevated intracranial pressure (22.9%). In-hospital mortality reached 60.6%. Younger age, low number of IMV days, better Karnofsky Performance Status Scale before admission and elevated intracranial pressure as cause of ICU admission were associated with positive prognostic outcome.ConclusionWe conclude that less than 50% of patients with glioblastoma have a favorable short-term outcome when unplanned ICU treatment with IMV is required. Our data mandate a careful therapy guidance and frequent reassessment of goals during ICU stay.

Critical Care Cycling to Improve Lower Extremity Strength (CYCLE): protocol for an international, multicentre randomised clinical trial of early in-bed cycling for mechanically ventilated patients

IntroductionIn-bed leg cycling with critically ill patients is a promising intervention aimed at minimising immobility, thus improving physical function following intensive care unit (ICU) discharge. We previously completed a pilot...

Association between the time-varying arterial carbon dioxide pressure and 28-day mortality in mechanically ventilated patients with acute respiratory distress syndrome

BackgroundRecent studies have shown an association between baseline arterial carbon dioxide pressure (PaCO2) and outcomes in patients with acute respiratory distress syndrome (ARDS). However, PaCO2 probably varies throughout the disease, and few studies have assessed the effect of longitudinal PaCO2 on prognosis. We thus aimed to investigate the association between time-varying PaCO2 and 28-day mortality in mechanically ventilated ARDS patients.MethodsIn this retrospective study, we included all adult (≥ 18 years) patients diagnosed with ARDS who received mechanical ventilation for at least 24 h at a tertiary teaching hospital between January 2014 and March 2021. Patients were excluded if they received extracorporeal membrane oxygenation (ECMO). Demographic data, respiratory variables, and daily PaCO2 were extracted. The primary outcome was 28-day mortality. Time-varying Cox models were used to estimate the association between longitudinal PaCO2 measurements and 28-day mortality.ResultsA total of 709 patients were eligible for inclusion in the final cohort, with an average age of 65 years, of whom 70.7% were male, and the overall 28-day mortality was 35.5%. After adjustment for baseline confounders, including age and severity of disease, a significant increase in the hazard of death was found to be associated with both time-varying PaCO2 (HR 1.07, 95% CI 1.03–1.11, p<0.001) and the time-varying coefficient of variation for PaCO2 (HR 1.24 per 10% increase, 95% CI 1.10–1.40, p<0.001) during the first five days of invasive mechanical ventilation. The cumulative proportion of exposure to normal PaCO2 (HR 0.72 per 10% increase, 95% CI 0.58–0.89, p = 0.002) was associated with 28-day mortality.ConclusionPaCO2 should be closely monitored in mechanically ventilated ARDS patients. The association between PaCO2 and 28-day mortality persisted over time. Increased cumulative exposure to normal PaCO2 was associated with a decreased risk of death.

Effect of the duration of prone position in ARDS patients during the SARS-CoV-2 pandemic

ObjectiveTo describe the characteristics of patients with acute respiratory distress syndrome (ARDS) due to bilateral COVID-19 pneumonia on invasive mechanical ventilation (IMV), and to analyze the effect of prone position >24 h (prolonged) (PPP) compared to prone decubitus <24 h (PP). DesignA retrospective observational descriptive study was carried out, with uni- and bivariate analyses. SettingDepartment of Intensive Care Medicine. Hospital General Universitario de Elche (Elche, Alicante, Spain). ParticipantsPatients with SARS-CoV-2 pneumonia (2020−2021) on IMV due to moderate-severe ARDS, ventilated in prone position (PP). InterventionsIMV. PP maneuvers. Main variables of interestSociodemographic characteristics, analgo-sedation, neuromuscular blockade (NMB), PD duration, ICU stay and mortality, days of IMV, non-infectious complications, healthcare associated infections. ResultsFifty-one patients required PP, and of these, 31 (69.78%) required PPP. No differences were observed in terms of patient characteristics (gender, age, comorbidities, initial severity, antiviral and antiinflammatory treatment received). Patients on PPP had poorer tolerance to supine ventilation (61.29% vs 89.47%, p = 0.031), longer hospital stay (41 vs 30 days, p = 0.023), more days of IMV (32 vs 20 days, p = 0.032), longer duration of NMB (10.5 vs 3 days, p = 0.0002), as well as a higher percentage of episodes of orotracheal tube obstruction (48.39% vs 15%, p = 0.014). ConclusionsPPP was associated with greater resource use and complications in patients with moderate-severe ARDS due to COVID-19.

Efecto de la duración del decúbito prono en pacientes con SDRA durante la pandemia por SARS-CoV-2

ObjectiveTo describe the characteristics of patients with acute respiratory distress syndrome due to bilateral COVID-19 pneumonia on invasive mechanical ventilation (IMV) and analyze the effect of prolonged prone decubitus>24h (PPD) compared to prone decubitus<24h (PD). DesignRetrospective observational descriptive study. Uni and bivariate analysis. SettingDepartment of Intensive Care Medicine. General University Hospital of Elche. ParticipantsPatients with SARS-CoV-2 pneumonia (2020–2021) in VMI for moderate-severe acute respiratory distress syndrome, ventilated in PD. InterventionsIMV. PD maneuvers. Main variables of interestSociodemographic; analgo-sedation; neuromuscular blockade; PD (duration), ICU stay and mortality, days of IMV; non-infectious complications; health care-associated infections. ResultsFifty-one patients required PD and of these 31 (69.78%) required PPD. No differences were found in patient characteristics (sex, age, comorbidities, initial severity, antiviral and anti-inflammatory treatment received). Patients on PPD had lower tolerance to supine ventilation (61.29 vs. 89.47%, p=0.031), longer hospital stay (41 vs. 30 days, p=0.023), more days of IMV (32 vs. 20 days, p=0.032), longer duration of neuromuscular blockade (10.5 vs. 3 days, p=0.0002), as well as a higher percentage of episodes of orotracheal tube obstruction (48.39 vs. 15%, p=0.014). ConclusionsPPD was associated with higher resource use and complications in patients with moderate-severe acute respiratory distress syndrome by COVID-19.

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation. WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109. Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0-4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2-6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital. In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates. European Society of Intensive Care Medicine, European Respiratory Society.

Weaning from mechanical ventilation in intensive care units: a call for new international consensus guidelines

In The Lancet Respiratory Medicine, Tài Pham and colleagues1 report the results of the WEAN SAFE study, aiming to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation. WEAN SAFE was an international, multicentre, prospective, observational study including 5869 critically ill adult patients, conducted in 481 intensive care units in 50 countries.1 The authors can be congratulated for this large convenience sample reporting novel and important findings.

255: IMPACTS OF MECHANICAL VENTILATION ON PATIENTS AND FAMILIES TWO MONTHS AFTER CRITICAL ILLNESS

Introduction: The outcomes of mechanically ventilated children surviving a critical illness remain poorly characterized, and increased knowledge may lead to strategies improving post-PICU care. We compared the outcomes of PICU survivors who received invasive mechanical ventilation (IMV) vs. non-invasive ventilation (NIV) 2 months after PICU discharge. Methods: This is a retrospective cohort study of children admitted for ≥4 days with ≥2 days of IMV or ≥4 days of NIV to the PICU of CHU Sainte-Justine. Two months after PICU discharge, patients were evaluated at the follow-up clinic, and parents were asked to fill out questionnaires (Pediatric Quality of Life Inventory, Hospital Anxiety, and Depression Scale). Continuous and dichotomous data were compared using Mann-Whitney and Fisher’s exact tests. Results: From Oct 2018 to Dec 2021, 152 patients were included. 106 patients received IMV (+/-NIV), and 46 patients exclusively received NIV. Duration of respiratory support (11.8+/-2.3 vs. 8.2 +/-3.1 days, p=0.22) was similar between groups, while duration of PICU stay was longer (34.1+/-9.2 vs 13.0+/-4.2 days, p=0.008) and worst PELOD was higher (10.4+/-0.4 vs 3.2+/-0.4, p=0.001) in IMV patients. The diagnosis was a respiratory illness in 30.2% of IMV vs. 78.3% of NIV patients (p=0.04). Quality of life scores were similar between groups (physical score 77.3+/-21.1% vs. 79.7+/-17.4%, p=0.73 and psychological score 79.7+/-16.0% vs 80.3+/-18.3% p=0.68). At follow-up, more patients in the NIV group had persistent respiratory difficulties (26.7% vs. 10.4%, p=0.01). Reported rates of fatigue (19.0% vs. 8.0%, p= 0.18), voice change (10.4% vs. 6.6%, p=0.44), and sleep disorders (17.1% vs. 8.9%, p=0.11) were similar between groups. There was no difference in parental anxiety (28.9 vs. 35.0%, p=0.83) and depression symptoms (24.7% vs. 23.5%, p=0.94) between groups. Conclusions: PICU survivors and their family experienced physical and neurobehavioral morbidities 2 months after their critical illness, whether they received IMV or NIV. Patients’ quality of life and parental symptoms of anxiety and depression did not differ according to the respiratory support. Persistent respiratory difficulties were more common in the NIV group. These findings suggest that PICU follow-up clinics should include patients receiving NIV.

The Local and Systemic Exposure to Oxygen in Children With Severe Bronchiolitis on Invasive Mechanical Ventilation: A Retrospective Cohort Study.

Oxygen supplementation is a cornerstone treatment in critically ill children with bronchiolitis in the PICU. However, potential deleterious effects of high-dose oxygen are well-known. In this study, we aim to describe the pulmonary (local) and arterial (systemic) oxygen exposure over the duration of invasive mechanical ventilation (IMV) in children with severe bronchiolitis. Our secondary aim was to estimate potentially avoidable exposure to high-dose oxygen in these patients. Retrospective cohort study. Single-center, tertiary-care PICU. Children younger than 2 years old admitted to the PICU for severe bronchiolitis receiving IMV. None. Hourly measurements of Fio2 and peripheral oxygen saturation (Spo2), and arterial blood gas data were collected up to day 10 of IMV. A total of 24,451 hours of IMV were observed in 176 patients (median age of 1.0 mo [interquartile range (IQR), 1.0-2.3 mo]). The pulmonary exposure to oxygen was highest during the first day of IMV (median time-weighted average [TWA]-Fio2 0.46 [IQR, 0.39-0.53]), which significantly decreased over subsequent days. The systemic exposure to oxygen was relatively low, as severe hyperoxemia (TWA-Pao2 > 248 Torr [> 33 kPa]) was not observed. However, overuse of oxygen was common with 52.3% of patients (n = 92) having at least 1 day of possible excessive oxygen exposure and 14.8% (n = 26) with severe exposure. Furthermore, higher oxygen dosages correlated with increasing overuse of oxygen (rrepeated measures, 0.59; 95% CI, 0.54-0.63). Additionally, caregivers were likely to keep Fio2 greater than or equal to 0.50 when Spo2 greater than or equal to 97%. Moderate to high-dose pulmonary oxygen exposure and potential overuse of oxygen were common in this cohort of severe bronchiolitis patients requiring IMV; however, this was not accompanied by a high systemic oxygen burden. Further studies are needed to determine optimal oxygenation targets to prevent overzealous use of oxygen in this vulnerable population.

Terapia de electroestimulación diafragmática transcutánea temprana en pacientes críticos con ventilación mecánica invasiva: su repercusión en el destete

IntroductionThere is a rapid diaphragmatic atrophy in the first 6h of invasive mechanical ventilation (IMV). Ultrasound is useful in the assessment of diaphragmatic function. Rehabilitation is a fundamental part in the recovery of the critically ill patient. ObjectiveTo determine the usefulness of early transcutaneous diaphragmatic electrostimulation therapy in critically ill patients with IMV for successful weaning from IMV. Material and methodProspective, analytical case-control study in 46 patients with IMV: 23 cases (group A, intervention group, with application of transcutaneous diaphragmatic electrostimulation therapy at 6h from admission to ICU) and 23 controls (group B); from August 1, 2021 to December 30, 2021, in the IMSS ICU, UMAE HE No. 1, CMN del Bajío, León Guanajuato. Ultrasound measurement of diaphragmatic thickness, shortening fraction, and diaphragmatic excursion of all patients were taken into consideration. From the statistical analysis, χ2 test, Spearman correlation and analysis of variance were performed. ResultsGroup A presented 16.66% extubation failure, group B had 66% failure (P=.051). A moderate correlation was obtained (r=0.419; P=.047) with total days of IMV and diaphragmatic thickness assessed at extubation. ConclusionsInitiation of early transcutaneous diaphragmatic electrostimulation therapy rehabilitation at 6h from ICU admission results in better outcomes after extubation with a lower failure rate and fewer days of IMV.

Duration of Noninvasive Respiratory Support and Extracorporeal Membrane Oxygenation Outcomes: Connecting the Dots.

To the Editor: We thank Lo Presti et al.1 for their letter related to our examination of the impact of duration of noninvasive respiratory support (RS) in patients with COVID-19 supported with extracorporeal membrane oxygenation (ECMO). The points raised highlight the challenges faced in the retrospective analysis of a complex disease process. The inability to account for baseline triage characteristics, lung compliance, or reason for RS failure are valid critiques of our analysis. Without reservation, our study should be viewed in the context of rapidly emerging evidence related to the support of patients with COVID-19. Given the absence of prospective trials, clinicians are left to weigh available indirect evidence that the duration of RS may be associated with worse outcomes in this context. Since authoring our manuscript, several additional studies have further corroborated our group’s findings. We wish to draw attention to these works, discuss the relevance to our findings, and emphasize the need for further investigation in this domain. First, Barbaro et al.2 presented registry data of patients with COVID-19 supported with ECMO. These investigators identified an increase in mortality over the course of the pandemic. What changed during this period to account for this observation? The authors postulated several reasons, of which, changes in pre-ECMO treatment and more frequent employment of noninvasive ventilation relate specifically to our findings. Similarly, Braaten et al.3 analyzed temporal trends in ECMO outcomes and found worse mortality in patients supported with ECMO later in the pandemic, and further, that longer time from admission to ECMO cannulation was associated with worse ECMO outcomes. In our cohort, a longer duration of RS (days) was significantly associated with a diminished rate of ECMO decannulation (sHR: 0.93; 95% CI, 0.87–0.98), whereas the duration of invasive mechanical ventilation (IMV) (sHR: 0.98; 95% CI, 0.88–1.09) was not. Moreover, the duration of RS remained significantly associated with worse ECMO outcomes even when adjusted for the duration of IMV.4 Though we dichotomize the duration of RS by median duration in our article, the precise threshold duration of RS associated with the poorest outcomes remains to be elucidated. The finding that duration of IMV is not related to ECMO outcomes in COVID-19 has been replicated by other investigators.5,6 Notably, Riera et al.6 reported days from symptoms to cannulation (possibly reflective of prolonged RS), but not IMV days, were independently associated with mortality. ECMO is a tool to decrease the physiologic insult of IMV by facilitating less damaging native lung ventilation strategies. It reasons that violation of lung-protective goals either during IMV or before tracheal intubation would similarly result in lung damage and worse overall outcomes. Clinician awareness and implementation of lung-protective ventilation in patients receiving IMV have likely improved over time and may explain the absence of impact of IMV duration on ECMO outcomes seen in patients with COVID-19. Paradoxically, crisis care during the current pandemic may have resulted in more frequent violation of lung-protective metrics via deleterious RS settings as a strategy to avoid IMV. Direct evidence implicating the duration of RS to worse ECMO outcomes in patients with COVID-19 is limited but growing. Connecting the dots of available evidence supports our preliminary findings, and we, like Lo Presti et al.5, support a prospective study of this hypothesis.

Critical patients COVID-19 has changed the management and outcomes in the ICU after 1 year of the pandemic? A multicenter, prospective, observational study

ObjectiveTo compare the clinical characteristics, treatments, and evolution of critical patients with COVID-19 pneumonia treated in Intensive Care Units (ICU) after one year of pandemic. MethodologyMulticenter, prospective study, which included critical COVID-19 patients in 9 ICUs in northwestern Spain. The clinical characteristics, treatments, and evolution of patients admitted to the ICU during the months of March-April 2020 (period 1) were compared with patients admitted in January-February 2021 (period 2). Results337 patients were included (98 in period 1 and 239 in period 2). In period 2, fewer patients required invasive mechanical ventilation (IMV) (65% vs 84%, p < 0.001), using high-flow nasal cannulas (CNAF) more frequently (70% vs 7%, p < 0.001), ventilation non-invasive mechanical (NIMV) (40% vs 14%, p < 0.001), corticosteroids (100% vs 96%, p = 0.007) and prone position in both awake (42% vs 28%, p = 0.012), and intubated patients (67% vs 54%, p = 0.034). The days of IMV, ICU stay and hospital stay were lower in period 2. Mortality was similar in the two periods studied (16% vs 17%). ConclusionsAfter 1 year of pandemic, we observed that in patients admitted to the ICU, CNAF, NIMV, use of the prone position, and corticosteroids have been used more frequently, reducing the number of patients in IMV, and the length of stay in the ICU and hospital stay. Mortality was similar in the two study periods.

Hourly Analysis of Mechanical Ventilation Parameters in Critically Ill Adult Covid-19 Patients: Association with Mortality

Objective: There exists controversy about the pathophysiology and lung mechanics of COVID-19 associated acute respiratory distress syndrome (ARDS), because some report severe hypoxemia with preserved respiratory system mechanics, contrasting with “classic” ARDS. We performed a detailed hourly analysis of the characteristics and time course of lung mechanics and biochemical analysis of patients requiring invasive mechanical ventilation (IMV) for COVID-19-associated ARDS, comparing survivors and non-survivors. Methods: Retrospective analysis of the data stored in the ICU information system of patients admitted in our hospital ICU that required IMV due to confirmed SARS-CoV-2 pneumonia between March 5th and April 30th, 2020. We compare respiratory system mechanics and gas exchange during the first ten days of IMV, discriminating volume and pressure controlled modes, between ICU survivors and non-survivors. Results: 140 patients were included, analyzing 11 138 respiratory mechanics recordings. Global mortality was 38.6%. Multivariate analysis showed that age (OR 1.092, 95% (CI 1.014-1.176)) and need of renal replacement therapies (OR 10.15, (95% CI 1.58-65.11)) were associated with higher mortality. Previous use of Angiotensin Converting Enzyme inhibitor (ACEI)/angiotensin-receptor blockers (ARBs) also seemed to show an increased mortality (OR 4.612, (95% CI 1.19-17.84)) although this significance was lost when stratifying by age. Respiratory variables start to diverge significantly between survivors and non-survivors after the 96 to 120 hours (hs) from mechanical ventilation initiation, particularly respiratory system compliance. In non survivors, mechanical power at 24 and 96 hs was higher regardless ventilatory mode. Conclusions: In patients admitted for SARS-CoV-2 pneumonia and requiring mechanical ventilation, non survivors have different respiratory system mechanics than survivors in the first 10 days of ICU admission. We propose a checkpoint at 96–120 hs to assess patients improvement or worsening in order to consider escalating to extracorporeal therapies.