Intensive Care Diseases Research Articles

Long-term effects on swallowing and laryngeal function after treatment for severe COVID-19 disease in intensive care

PurposeThis study aimed to assess swallowing and laryngeal function at long-term follow-up in patients treated for severe COVID-19 in the ICU.MethodsThirty-six patients with severe COVID-19 were prospectively examined with fiberendoscopic evaluation of swallowing (FEES) about 6 and 12 months after ICU discharge. Comparison with initial FEES examinations during the time in hospital was performed in 17 patients. Analysis of swallowing function and laryngeal features was performed from video recordings. Twenty-five participants responded to Eating Assessment Tool, Voice Handicap Index, and the Hospital Anxiety and Depression Scale at follow-up.ResultsPenetration to the laryngeal vestibule (PAS ≥ 3) was seen in 22% and silent aspiration (PAS = 8) in 11% of patients on at least one swallow at follow-up. Fourteen percent had obvious residue in the vallecula and/or pyriform sinuses after swallowing thick liquid or biscuits. Self-reported eating and swallowing difficulties were found in 40% of patients. Abnormal findings in the larynx were present in 53% at follow-up. Thirty-three percent had reduced or impaired vocal fold movement, of whom 22% had bilateral impaired abduction of the vocal folds. Possible anxiety and depression were found in 36% and 24% of responders, respectively.ConclusionAlthough a majority of patients appear to regain normal swallowing function by 1 year after treatment for severe COVID-19, our results indicate that dysphagia, abnormal laryngeal function, and anxiety/depression may remain in a substantial proportion of patients. This suggests that swallowing and laryngeal function, and emotional symptoms, should be followed up systematically over time in this patient group.

A Clinical Score for Quantifying Edema in Mechanically Ventilated Children With Congenital Heart Disease in Intensive Care.

To describe a 19-point clinical edema score (CES), investigate its interobserver agreement, and compare changes between such CES and body weight. Prospective observational study in a tertiary PICU of mechanically ventilated children with congenital heart disease. Differences in the median CES between observer groups. We studied 61 children, with a median age of 8.0 days (interquartile range, 1.0-14.0 d). A total of 539 CES were performed by three observer groups (medical 1 [reference], medical 2, and bedside nurse) at 0, 24, and 48 hours from enrollment. Overall, there was close agreement between observer groups in mean, median, and upper quartile of CES scores, with least agreement observed in the lower quartile of scores. Across all quartiles of CES, after adjusting for baseline weight, cardiac surgical risk, duration of cardiopulmonary bypass, or peritoneal dialysis during the study, observer groups returned similar mean scores (medical 2: 25th centile +0.1 [95% CI, -0.2 to 0.5], median +0.6 [95% CI, -0.4 to 1.5], 75th centile +0.1 [95% CI, -1.1 to 1.4] and nurse: 25th centile +0.5 [95% CI, 0.0-0.9], median +0.7 [95% CI, 0.0-1.5], 75th centile -0.2 [95% CI, -1.3 to 1.0]) Within a multivariable mixed-effects linear regression model, including adjustment for baseline CES, each 1 point increase in CES was associated with a 12.1 grams (95% CI, 3.2-21 grams) increase in body weight. In mechanically ventilated children with congenital heart disease, three groups of observers tended to agree when assessing overall edema using an ordinal clinical score assessed in six body regions, with agreement least at low edema scores. An increase in CES was associated with an increase in body weight, suggesting some validity for quantifying edema. Further exploration of the CES as a rapid clinical tool is indicated.

Decompensation of Chronic Obstructive Pulmonary Disease in Intensive Care: About 30 Cases

Summary: Chronic obstructive pulmonary disease is a slowly progressive chronic respiratory disease linked to smoking. Its evolution is marked by decompensation that can be life-threatening for the patient and thus require hospitalization in intensive care. The aim of our work is to describe the therapeutic management of patients hospitalized for decompensation of COPD and their clinical and etiological characteristics. The patients were all chronic smokers in 80% of cases with an average age of 62 years. Exacerbations were of infectious etiology in 76% with 43% bronchial superinfections and 33% pneumonia, and without identified cause in 15% of cases. Our patients were staged according to the GOLD classification. Stage 4 patients represented 63%, 56% had right heart failure and developed more exacerbations per year (4 on average) resulting in more hospitalization in intensive care (3 on average) while stage 3 patients represented 36% of all patients. Drug treatment was dominated by antibiotics, bronchodilators and corticosteroids. 80% of patients were on oxygen, 20% of whom were on long-term oxygen therapy. Ventilatory assistance was considered in 26% by means of non-invasive ventilation (NIV) and 16% required endotracheal intubation. In conclusion, decompensation of COPD alters the quality of life of patients and worsens the prognosis of COPD. According to the experience of our service, many therapeutic behaviors have been initiated by following international recommendations even if they remain controversial. However, a great effort is necessary, especially concerning the fight against tobacco.

Corticosteroids for severe acute exacerbations of chronic obstructive pulmonary disease in intensive care: From the French OUTCOMEREA cohort.

Acute exacerbation of chronic obstructive pulmonary disease (COPD) is a frequent cause of intensive care unit (ICU) admission. However, data are scarce and conflicting regarding the impact of systemic corticosteroid treatment in critically ill patients with acute exacerbation of COPD. The aim of the study was to assess the impact of systemic corticosteroids on the occurrence of death or need for continuous invasive mechanical ventilation at day 28 after ICU admission. In the OutcomeReaTM prospective French national ICU database, we assessed the impact of corticosteroids at admission (daily dose ≥ 0.5 mg/kg of prednisone or equivalent during the first 24 hours ICU stay) on a composite outcome (death or invasive mechanical ventilation) using an inverse probability treatment weighting. Between January 1, 1997 and December 31, 2018, 391 out of 1,247 patients with acute exacerbations of COPDs received corticosteroids at ICU admission. Corticosteroids improved the main composite endpoint (OR = 0.70 [0.49; 0.99], p = 0.044. However, for the subgroup of most severe COPD patients, this did not occur (OR = 1.12 [0.53; 2.36], p = 0. 770). There was no significant impact of corticosteroids on rates of non-invasive ventilation failure, length of ICU or hospital stay, mortality or on the duration of mechanical ventilation. Patients on corticosteroids had the same prevalence of nosocomial infections as those without corticosteroids, but more glycaemic disorders. Using systemic corticosteroids for acute exacerbation of COPD at ICU admission had a positive effect on a composite outcome defined by death or need for invasive mechanical ventilation at day 28.

Role of S protein in thromboembolic complications during COVID19 and activated protein C as a serious therapeutic avenue in severe forms of patients

COVID-19 (Coronavirus disease 2019) is a public health emergency of international concern. There is a pressing urgency to find treatments based upon currently available scientific knowledge and epidemiological data. In this article, we provide a novel hypothesis describing how the severity of the pathology is mainly resulting from the Antibody responses to SARS-CoV-2 (virus causing COVID-19) and not due to the direct action of the virus. SARS-CoV-2 appears to alter the endothelial cell. The pathophysiological mechanism is not yet elucidated. The damage caused resembles a systemic, multi-organ vasculitis predominantly in the lungs. An increase in thromboembolic complications has been observed in COVID-19 patients. These are manifested by pulmonary embolisms or systemic microembolism manifested by microangiopathy affecting the lungs, brain, liver, kidneys and intestines. Therefore, we hypothesize that an auto-immune acquired Protein S (PS) deficiency may be involved in the pathogenesis of thrombotic events in Covid-19. Auto-antibodies to Protein S may form immune complexes, inducing increased clearance of PS or interfering with the protein C-protein S system. COVID-19 early thromboprophylaxis in infected patients, or even effective anticoagulation, could prevent the progression to severe forms, thus reducing mortality in patients with COVID-19. Activated Protein C (APC), a physiological coagulation inhibitor with cytoprotective properties, could be an interesting avenue for the treatment of severe forms of the disease in intensive care; its administration in hypoxic patients could improve tissue oxygenation. Randomized resuscitation studies in patients with COVID19 are also needed to confirm our hypothesis.

Respiratory support in patients with acute respiratory distress syndrome: an expert opinion interpretation

Acute respiratory distress syndrome (ARDS) is a common disease in intensive care unit.ARDS has attracted wide attention of clinicians for its high in-hospital mortality and high incidence of long-term mortality.This expert opinion reviews the available clinical evidence and adjuvant treatment of ventilator support.Based on clinical evidence and experience, we provide suggestions for the management of patients with ARDS.We interpret this expert opinion and some experience in children was added, hoping to provide suggestions for the treatment of children with ARDS. Key words: Ventilator support; Ventilator-induced lung injury; Tidal volume; Positive end-expiratory pressure; Esophageal pressure; Extracorporeal membrane oxygenation; Weaning

An Investigation into the Clinical Utility of Transfer Functions between the Aortic and Femoral Pressure Waveforms

Abstract Management of cardiovascular disease in intensive care would benefit from improved methods for data from clinically available, information rich arterial pressure waveforms. This paper explores the feasibility of using the transfer function between the aortic and femoral pressure waveforms as a diagnostic tool, over an experimental cohort including the progression of sepsis. Transfer functions appeared as physiologically expected, with Bode plot peaks near breathing and heartbeat frequencies. The Bode plot response to clinical interventions and disease progression also matched physiological expectations, with peaks increasing in magnitude in response to fluid infusion and attenuating in response to the progression of sepsis. While there are clear potential diagnostic benefits to the approach, further work is needed to make this information easier to rapidly interpret in a clinical environment, and to evaluate the specificity of the transfer function responses presented here to the progression of sepsis.

Can RDW be Added to Intensive Care Disease Severity Scoring Systems?

Intensive care services are high-cost services. The functioning, efficiency, and cost-effectiveness assessments of the intensive care units (ICU) should be performed according to the severity of the disease of the treated patients. For this purpose, various disease severity scores have been developed to be used in ICU. Of these severity scores, APACHE II is mostly used. The mortality prediction rates of APACHE II are high, but not 100%. Various severity scores have been developed over time, but none of them has been completely accurate in predicting mortality. Today, there are numerous studies related to the mortality by Red Cell Distribution Width (RDW). In the studies conducted on a relationship between RDW and mortality in ICU patients with different diagnosis, its relationship with mortality is clear. In this study, we have examined the publications in which laboratory parameters of APACHE II have been extensively reviewed in the literature and compared with mortality one by one and the publications in which RDW has predicted mortality. We believe that the addition of RDW as a laboratory parameter to APACHE II will have high contributions in predicting mortality.

Trends and outcomes of chronic kidney disease in intensive care: a 5-year study.

The prevalence of chronic kidney disease (CKD) is increasing in Australia and is independently associated with a higher risk of hospitalisation and death. Australian data may be useful in guiding improved hospital management of this growing cohort of patients. To assess and compare the trends and outcomes of CKD patients requiring hospital and intensive care unit (ICU) admission at a tertiary referral hospital and state public hospitals. We conducted a retrospective analysis of all acute care admissions to St Vincent's Hospital Melbourne and all Victorian public hospitals using the Victorian Admitted Episodes Data Set (VAED) for the years 2010-2014 to determine CKD prevalence, demographic and outcome associations. The Elixhauser ICD-10 comorbidity classification of renal failure was used to identify CKD (ElixRF). Chi-squared test, Kruskal-Wallis test and logistic regression were used for analysis. A total of 101 817 patients was included from our institution, with 6.4% classified as having ElixRF. ELixRF increased from 5.2% in 2010 to 8.6% in 2014 for all hospital admissions and from 8.3% to 13.3% for ICU admissions. ElixRF was associated with longer hospital and ICU length of stay, male gender, older age, higher comorbidity and independently with increased mortality. The VAED contained 2 044 507 episodes for the same period with similar trends and associations. CKD prevalence amongst patients admitted to hospital and ICU is increasing and is associated with worse outcomes. ElixRF may be a useful administrative flag for nephrologist involvement in care and for prompting consideration of advanced care planning.

Épuration extracorporelle du CO2 pour suppléance d’une pneumonie organisée sévère

Acute lung injuries are usually found in intensive care unit. The diffuse alveolar damage (DAD) is the associated histological pattern and the most severe end-stage of the disease. Organizing pneumonia (OP), for which corticosteroids are the reference therapy, can mimic DAD. While postponing the response to treatment, to limit mechanical ventilation side effects, extracorporeal membrane oxygene can be proposed. We present a case of a severe OP for which extracorporeal CO2 removal (ECCO2R) is used as a bridge to recovery under corticosteroid therapy. In the context of a flu-like syndrome, the non-recovery of a lung impairment is reported to a severe OP. ECCO2R is applied when using an ultraprotective ventilation and while waiting for lung healing under corticosteroid. This strategy allowed successful recovery, early physical therapy and active mobilization. This observation presents the diagnostic and therapeutic difficulties of the lung parenchymental disease in intensive care. OP must be recognized. ECCO2R can be used in severe OP as a bridge to recovery while waiting for the corticosteroid efficacy.

The chronic critical illness: a new disease in intensive care.

Advances in intensive care medicine have created a new disease called the chronic critical illness. While a significant proportion of severely ill patients who twenty years ago would have died survive the acute phase, they remain heavily dependent on intensive care for a prolonged period of time. These patients, who can be called "Patient Long Séjour" in French (PLS) or Prolonged Length of Stay patients in English, develop specific health issues that are still poorly recognised. They require special care, which differs from treatments that are given during the acute phase of their illness. A multidisciplinary team dedicated to ensuring their management and follow-up acquired a wide range of knowledge and expertise about these PLSs. Many new monitoring tools and diverse human approaches were implemented to ensure that care was targeted to these patients' needs. This multimodal care management aims to optimise the patients' and their families' quality of life during and following intensive care, whilst maintaining the motivation of the healthcare team of the unit. The purpose of this article is to present new management techniques to hospital and ambulatory caregivers, physicians and nurses, who may be taking care of such patients.

A new method of securing the airway for differential lung ventilation in intensive care

Differential lung ventilation to achieve optimised ventilation for each lung is a procedure rarely used in the intensive care unit, to treat select cases of severe unilateral lung disease in intensive care. However, existing techniques both for securing the airway and ventilating the lungs are challenging and have complications. We present the use of differential lung ventilation in the intensive care setting, securing the airway with a technique not previously described, using endotracheal tubes inserted through a tracheotomy and orally. In the course of 1 month, we treated three patients with unilateral atelectatic and consolidated lungs by differential lung ventilation. The left lung was ventilated through an endotracheal tube inserted into the left main stem bronchus through a tracheotomy. The right lung was ventilated through an endotracheal tube with the cuff positioned immediately under the vocal cord. In patient 1, the diseased lung remained consolidated after 24 h of differential lung ventilation. In the two other patients, the diseased lungs responded to differential lung ventilation by increased compliance and radiographic increased aeration. Differential ventilation of the lungs with this novel technique is feasible and may increase the likelihood of successful treatment of atelectatic lungs refractory to conventional ventilator strategies.

Chronic Obstructive Pulmonary Disease in Intensive Care: A Retrospective Analysis of 19 Years

Chronic Obstructive Pulmonary Disease in Intensive Care: A Retrospective Analysis of 19 Years

Applicability of theoretical model to families of children with chronic disease in intensive care

This study examines the applicability of the theoretical model "Looking to maintain the balance to meet the demands and take care of the hospitalized child" to families of children with chronic diseases in intensive care. This is a qualitative study that complied with Resolution 466/2012, and was approved by the Ethics Committee through the Resolution 0111.0.441.099-11. The Grounded Theory was adopted as methodological framework. The data were collected through semi-structured interviews with seven families of children hospitalized for chronic diseases. The research identified three phenomena, which were analyzed according to the theoretical model cited above: Difficult experience for the family; Modifying the functioning and family routine; and Receiving support in coping with chronic illness. The study showed that the theoretical model used can be applied to families of children with chronic illnesses because they experience an unexpected event that disrupts their daily life and demand the search for new strategies for coping.

Changing outcomes in patients with chronic liver disease in intensive care: a decade of experience

Patients with chronic liver disease requiring intensive care are thought to carry a poor prognosis in comparison with noncirrhotic patients with similar severity of illness. During the last decade improvements in multiple areas of management in patients in the ICU have occurred but improvement in outcomes in patients with cirrhosis has not been shown.