Initiation Of Mechanical Ventilation Research Articles

Morbidities and mortality among hospitalized patients with hypopituitarism: Prevalence, causes and management.

Hypopituitarism is a highly heterogeneous multisystem disorder that can have a major impact on long-term morbidity and mortality, but even more so during acute medical conditions requiring hospitalization. Recent studies suggest a significant in-hospital burden with prolonged length of stay, increased rate of intensive care unit (ICU) admission, and initiation of mechanical ventilation - all of which may lead to an increased risk of in-hospital mortality. On the one hand, patients with hypopituitarism are often burdened by metabolic complications, including obesity, hypertension, dyslipidemia, and hyperglycemia, which alone, or in combination, are known to significantly alter relevant physiological mechanisms, including metabolism, innate and adaptive immune responses, coagulation, and wound healing, thereby contributing to adverse in-hospital outcomes. On the other hand, depending on the extent and the number of pituitary hormone deficiencies, early recognition of hormone deficiencies and appropriate management and replacement strategy within a well-organized multidisciplinary team are even stronger determinants of short-term outcomes during acute hospitalization in this vulnerable patient population. This review aims to provide an up-to-date summary of recent advances in pathophysiologic understanding, clinical implications, and recommendations for optimized multidisciplinary management of hospitalized patients with hypopituitarism.

Effect of immediate initiation of invasive ventilation on mortality in acute hypoxemic respiratory failure: a target trial emulation

PurposeInvasive ventilation is a fundamental treatment in intensive care but its precise timing is difficult to determine. This study aims at assessing the effect of initiating invasive ventilation versus waiting, in patients with hypoxemic respiratory failure without immediate reason for intubation on one-year mortality.MethodsEmulation of a target trial to estimate the benefit of immediately initiating invasive ventilation in hypoxemic respiratory failure, versus waiting, among patients within the first 48-h of hypoxemia. The eligible population included non-intubated patients with SpO2/FiO2 ≤ 200 and SpO2 ≤ 97%. The target trial was emulated using a single-center database (MIMIC-IV) which contains granular information about clinical status. The hourly probability to receive mechanical ventilation was continuously estimated. The hazard ratios for the primary outcome, one-year mortality, and the secondary outcome, 30-day mortality, were estimated using weighted Cox models with stabilized inverse probability weights used to adjust for measured confounding.Results2996 Patients fulfilled the inclusion criteria of whom 792 were intubated within 48 h. Among the non-invasive support devices, the use of oxygen through facemask was the most common (75%). Compared to patients with the same probability of intubation but who were not intubated, intubation decreased the hazard of dying for the first year after ICU admission HR 0.81 (95% CI 0.68–0.96, p = 0.018). Intubation was associated with a 30-day mortality HR of 0.80 (95% CI 0.64–0.99, p = 0.046).ConclusionThe initiation of mechanical ventilation in patients with acute hypoxemic respiratory failure reduced the hazard of dying in this emulation of a target trial.

Rapidly improving ARDS differs clinically and biologically from persistent ARDS

BackgroundRapidly improving acute respiratory distress syndrome (RIARDS) is an increasingly appreciated subgroup of ARDS in which hypoxemia improves within 24 h after initiation of mechanical ventilation. Detailed clinical and biological features of RIARDS have not been clearly defined, and it is unknown whether RIARDS is associated with the hypoinflammatory or hyperinflammatory phenotype of ARDS. The purpose of this study was to define the clinical and biological features of RIARDS and its association with inflammatory subphenotypes.MethodsWe analyzed data from 215 patients who met Berlin criteria for ARDS (endotracheally intubated) and were enrolled in a prospective observational cohort conducted at two sites, one tertiary care center and one urban safety net hospital. RIARDS was defined according to previous studies as improvement of hypoxemia defined as (i) PaO2:FiO2 > 300 or (ii) SpO2: FiO2 > 315 on the day following diagnosis of ARDS (day 2) or (iii) unassisted breathing by day 2 and for the next 48 h (defined as absence of endotracheal intubation on day 2 through day 4). Plasma biomarkers were measured on samples collected on the day of study enrollment, and ARDS phenotypes were allocated as previously described.ResultsRIARDS accounted for 21% of all ARDS participants. Patients with RIARDS had better clinical outcomes compared to those with persistent ARDS, with lower hospital mortality (13% vs. 57%; p value < 0.001) and more ICU-free days (median 24 vs. 0; p value < 0.001). Plasma levels of interleukin-6, interleukin-8, and plasminogen activator inhibitor-1 were significantly lower among patients with RIARDS. The hypoinflammatory phenotype of ARDS was more common among patients with RIARDS (78% vs. 51% in persistent ARDS; p value = 0.001).ConclusionsThis study identifies a high prevalence of RIARDS in a multicenter observational cohort and confirms the more benign clinical course of these patients. We report the novel finding that RIARDS is characterized by lower concentrations of plasma biomarkers of inflammation compared to persistent ARDS, and that hypoinflammatory ARDS is more prevalent among patients with RIARDS. Identification and exclusion of RIARDS could potentially improve prognostic and predictive enrichment in clinical trials.

IJCM_386A: Indications and Outcomes of patients under Mechanical Ventilation in a Tertiary Care hospital

Background: Mechanical ventilation is the technique through which gas is moved toward and from the lungs through an external device connected directly to the patient. Information about the mortality if patients requiring mechanical ventilation is important because it allows for better counseling of patients and their families. Objectives: To study the outcome in patients receiving mechanical ventilation for specific indications. Methodology: Patients on mechanical ventilation in Government Wenlock Hospital. It is a retrospective record-based study—a semi-structured questionnaire including all complete information from pre-recorded case sheets prepared after an extensive review of the literature. Data was analyzed using SPSS version 29. Results: The mean age was 45 years. Other details of patients suffering from Chronic kidney disease, Acute Kidney Injury, Multiple organ dysfunction syndrome, Head injuries, shock, pulmonary edema, and Pneumothorax mainly. The majority of the patients who received mechanical ventilation were below 40 years of age (37.7%). A major reason for the initiation of mechanical ventilation was pneumonia (22.3%), Sepsis (25.4%), and ARDS (16.9%). AKI (N= 12), CKD (N=9), Shock (N=7), and MODS (N=6) were the major under ‘others. The type of ventilation used in the majority of the cases was invasive (87.7%) The type of ventilation used in most cases was of invasive type (87.7%). Conclusion: Even after providing mechanical ventilation, high number of patients succumbed to the complications.

Determinants of acute kidney injury during high-power mechanical ventilation: secondary analysis from experimental data

BackgroundThe individual components of mechanical ventilation may have distinct effects on kidney perfusion and on the risk of developing acute kidney injury; we aimed to explore ventilatory predictors of acute kidney failure and the hemodynamic changes consequent to experimental high-power mechanical ventilation.MethodsSecondary analysis of two animal studies focused on the outcomes of different mechanical power settings, including 78 pigs mechanically ventilated with high mechanical power for 48 h. The animals were categorized in four groups in accordance with the RIFLE criteria for acute kidney injury (AKI), using the end-experimental creatinine: (1) NO AKI: no increase in creatinine; (2) RIFLE 1-Risk: increase of creatinine of > 50%; (3) RIFLE 2-Injury: two-fold increase of creatinine; (4) RIFLE 3-Failure: three-fold increase of creatinine;ResultsThe main ventilatory parameter associated with AKI was the positive end-expiratory pressure (PEEP) component of mechanical power. At 30 min from the initiation of high mechanical power ventilation, the heart rate and the pulmonary artery pressure progressively increased from group NO AKI to group RIFLE 3. At 48 h, the hemodynamic variables associated with AKI were the heart rate, cardiac output, mean perfusion pressure (the difference between mean arterial and central venous pressures) and central venous pressure. Linear regression and receiving operator characteristic analyses showed that PEEP-induced changes in mean perfusion pressure (mainly due to an increase in CVP) had the strongest association with AKI.ConclusionsIn an experimental setting of ventilation with high mechanical power, higher PEEP had the strongest association with AKI. The most likely physiological determinant of AKI was an increase of pleural pressure and CVP with reduced mean perfusion pressure. These changes resulted from PEEP per se and from increase in fluid administration to compensate for hemodynamic impairment consequent to high PEEP;

Associations between Present-on-Admission Do-Not-Resuscitate Orders and Short-Term Outcomes in Patients with Pneumonia.

Do-not-resuscitate (DNR) orders are used to express patient preferences for cardiopulmonary resuscitation. This study examined whether early DNR orders are associated with differences in treatments and outcomes among patients hospitalized with pneumonia. This is a retrospective cohort study of 768,015 adult patients hospitalized with pneumonia from 2010 to 2015 in 646 US hospitals. The exposure was DNR orders present on admission. Secondary analyses stratified patients by predicted in-hospital mortality. Main outcomes included in-hospital mortality, length of stay, cost, intensive care admission, invasive mechanical ventilation, noninvasive ventilation, vasopressors, and dialysis initiation. Of 768,015 patients, 94,155 (12.3%) had an early DNR order. Compared with those without, patients with DNR orders were older (mean age 80.1 ± 10.6 years vs 67.8 ± 16.4 years), with higher comorbidity burden, intensive care use (31.6% vs 30.6%), and in-hospital mortality (28.2% vs 8.5%). After adjustment via propensity score weighting, these patients had higher mortality (odds ratio [OR] 2.39, 95% confidence interval [CI] 2.33-2.45) and lower use of intensive therapies such as vasopressors (OR 0.83, 95% CI 0.81-0.85) and invasive mechanical ventilation (OR 0.68, 95% CI 0.66-0.70). Although there was little relationship between predicted mortality and DNR orders, among those with highest predicted mortality, DNR orders were associated with lower intensive care use compared with those without (66.7% vs 80.8%). Patients with early DNR orders have higher in-hospital mortality rates than those without, but often receive intensive care. These orders have the most impact on the care of patients with the highest mortality risk.

Antiviral effectiveness and survival correlation of azvudine and nirmatrelvir/ritonavir in elderly severe patients with COVID-19: a retrospective real-world study

Azvudine and nirmatrelvir/ritonavir are approved to treat mild-to-moderate coronavirus disease 2019 (COVID-19) in adults with a high risk for progression to severe infection. We sought to compare the antiviral effectiveness and clinical outcomes of elderly severe patients with COVID-19 receiving these two antiviral agents. In this observational study, we identified 249 elderly patients with severe COVID-19 infection who were admitted to the Second Medical Center of the People's Liberation Army General Hospital from December 2022 to January 2023, including 128 azvudine recipients, 66 nirmatrelvir/ritonavir recipients and 55 patients not received antiviral treatments. We compared the cycle threshold (Ct) value dynamic change of all three groups. The primary outcome was a composite outcome of disease progression, including all-cause death, intensive care unit admission, and initiation of invasive mechanical ventilation. The outcomes of all enrolled patients were followed up from the electronic medical record system. Kaplan-Meier and Cox risk proportional regression analyses were used to compare the clinical outcomes of all three groups. To more directly compare the effectiveness of the two antiviral drugs, we performed propensity-score matching between the two antiviral groups and compared antiviral efficacy and clinical outcomes in the matched population. Among 249 patients (mean age, 91.41 years), 77 patients died during the follow-up period. When compared to patients who did not receive any antivirals, neither nirmatrelvir/ritonavir nor azvudine demonstrated a survival benefit. The Cox analysis of the all-cause death of the three groups showed that the risk of death was 0.730 (0.423-1.262) in the azvudine group 0.802 (0.435-1.480) and in the nirmatrelvir/ritonavir group compared with the non-antiviral group. After propensity score matching, we included 58 azvudine recipients and 58 nirmatrelvir/ritonavir recipients. The fitted curve of the Ct value after matching illustrated that the rate of viral decline in the early stage of nirmatrelvir/ritonavir treatment seems to surpass that of azvudine, but there was no statistical significance. Azvudine was seemly associated with a lower risk of composite outcomes (HR:1.676, 95% CI:0.805-3.488) and short-term all-cause death (HR: 1.291, 95%CI: 0.546-3.051). Patients who received azvudine have a similar antiviral effectiveness and survival curve trend compared to nirmatrelvir/ritonavir. In this limited series, antiviral treatment was not associated with a significant clinical benefit. This lack of clinical benefit might be attributed to potential bias. This study was supported by the "National Key R&D Program of China" (Funding No. 2020YFC2008900) and the National Defense Science and Technology Innovation Special Zone Project (223-CXCY-N101-07-18-01).

The overlap of chronic obstructive pulmonary disease and obstructive sleep apnea in hospitalizations for acute exacerbation of COPD.

This study examined in-hospital outcomes for patients with both chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA), also known as COPD-OSA overlap syndrome, during hospitalizations for acute exacerbation of COPD (AECOPD). The National Inpatient Sample was used to examine in-hospital mortality, length of stay, costs, and utilization of supportive ventilation in patients with COPD-OSA overlap during AECOPD hospitalizations. A one-to-one matched case-control design was utilized to match patients with and without OSA. Multivariate logistic regression modeling was used to examine mortality and ventilatory support, while controlling for potentially confounding diagnoses. COPD-OSA overlap was associated with longer median length of stay (4 days OSA, 3 days non-OSA; P<0.001), higher mean costs ($32,197 OSA, $29,011 non-OSA; P<0.001), increased utilization of non-invasive positive pressure ventilation (NIPPV) (13.92% OSA, 6.78% non-OSA; P<0.001), and when required for greater than 96 hours, earlier initiation of mechanical ventilation (2.53 days OSA, 3.35 days non-OSA; P=0.001). However, COPD-OSA overlap was associated with reduced mortality (0.81% OSA, 1.05% non-OSA; P<0.001). These differences in mortality (adjusted OR: 0.650; 95% CI 0.624 - 0.678) and NIPPV usage (adjusted OR: 1.998; 95% CI 1.970 - 2.026) remained when adjusted for confounders. Patients with COPD-OSA overlap have higher utilization of supportive ventilation and longer length of stay during AECOPD hospitalizations, contributing to higher costs. The diagnosis of OSA is associated with reduced mortality in these hospitalizations, which may be related to greater utilization of supportive ventilation when OSA is recognized.

Lung ultrasound imaging and clinical consequences of intraoperative high inspired oxygen fraction in healthy mechanically ventilated children

Study objectiveHigh inspired oxygen concentrations (FiO2) are claimed to cause resorption atelectasis increasing the risk for perioperative hypoxemia and postoperative pulmonary complications. Pediatric physicians are still reluctant to accomplish low FiO2 strategies in children. We investigated the association between lung ultrasound score (LUS) and arterial oxygenation (PaO2/FiO2 ratio)in anesthetized mechanically ventilated children undergoing non-abdominal surgery using different FiO2 fractions. Study designObservational cohort. Study settingsOperative rooms and post-anesthesia care unit. PatientsThirty-three patients aged (3–12 years) of both sexes. InterventionPatients were anesthetized while receiving high FIO2 protocol (preoxygenation 1.0, induction and recovery 0.8, maintenance 0.6, post-extubation 1.0 and 0.21 for 2h postoperative). Measurements: LUS was performed after intubation and initiation of mechanical ventilation, after the end of surgery, and 2h postoperatively. Arterial blood gas analysis was performed at the same time points and respiratory mechanics were recorded intraoperatively. LUS scores were tested for probability of bivariate correlation with PaO2/FiO2 ratio (primary endpoint), age, weight, operation time, PaO2, and dynamic compliance. Main resultsAfter intubation, the median LUS score was 2 (Range: 0–14) which significantly decreased after surgery to 1 (0–8), (P = 0.010). At 2- hours postoperatively, it was 0 (0–6) which was significantly lower than both after intubation (P = 0.001) and after surgery (P = 0.007). No significant Correlation was found between the LUS score and any investigated parameters. ConclusionsEven though we found no significant correlation between LUS and PaO2, or PaO2/FiO2 ratio, the high values of LUS after intubation necessitate caution when administering high FiO2 levels in pediatrics. Trial registrationClinicalTrials.gov ID: NCT04581226.

A comparative analysis of mechanical power and Its components in pressure-controlled ventilation mode and AVM-2 mode

Background Mechanical ventilation is a critical therapeutic intervention in the management of patients with respiratory failure. Understanding the implications of different ventilation modes is essential in preventing ventilator-induced lung injuries (VILI). Recently, mechanical power has emerged as a critical element in the development of VILI and mortality. Previous bench work studies have suggested that new optimal (adaptive) modes, such as Adaptive Ventilation Mode 2 (AVM-2), can reduce the mechanical power in turn might reduce the rates of VILI. This study aims to compare the conventional Pressure-Controlled Ventilation (PCV) mode with an emerging design of Adaptive Ventilation Mode-2 (AVM-2), to measure the differences in mechanical power, alongside it’s components of PEEP, Tidal, Elastic, Resistive, Inspiratory, Total work, tidal volume, driving pressure and Power Compliance Index. Methods Between January 2023 and June of 2023, we conducted a prospective crossover study on twenty-two subjects admitted to our ICU within the first day after initiation of mechanical ventilation. Subjects were initially started on PCV settings chosen by the primary treatment team, then switched to AVM-2 with comparable minute ventilation. Mechanical power and its work components (tidal, resistive, PEEP, elastic, inspiratory, total), tidal volume, driving pressure, respiratory rate, and positive end-expiratory pressure, were recorded for each patient every 15 min for the duration of 2 consecutive hours on each mode. Statistical analysis, including paired t-tests were performed to assess the significance of differences between the two ventilation modes. The data is provided in means and 土 SD. Results There were significant differences between PCV and AVM-2 in mechanical power (J/min): 21.62 土 7.61 vs 14.21 土 6.41 (P &lt; 0.001), PEEP work (J): 4.83 土 2.71 vs 4.11 土 2.51 (P &lt; 0.001), Tidal work (J): 3.83 土 1.51 vs 2.21 土 0.89 (P &lt; 0.001), Elastic work (J): 8.62 土 3.13 vs 6.32 土 3.21 (P &lt; 0.001), Resistive work (J): 3.23 土 1.61 vs 1.81 土 1.31 (P 0.013), Inspiratory work (J): 6.95 土 2.58 vs 4.05 土 2.01 (P &lt; 0.001), Total work (J): 11.81 土 3.81 vs 8.11 土 4.23 (P &lt; 0.001). There were significant differences between PCV and AVM-2 in tidal volume (ml): 511 土 8.22 vs 413 土 10.21 (P &lt; 0.001), tidal volume / IBW 7.38 土 1.74 vs 6.49 土 1.72 (P 0.004), driving pressure (cmH2O): 24.45 土 6.29 vs 20.11 土 6.59 (P 0.012), minute ventilation (L/min): 8.96 土 1.34 vs 7.42 土 1.41 (P &lt; 0.001). The respiratory rate (bpm) was not significantly different between PCV and AVM-2 19.61 土 4.32 vs 18.32 土 1.43 (P 0.176). There were no significant differences between PCV and AVM-2 in static compliance (ml/cmH2O) 20.24 土 5.16 vs 22.72 土 6.79 (P 0.346), PaCO2 (mmHg) 44.94 土 9.62 vs 44.13 土 10.11 (P 0.825), and PaO2:FiO2 243.54 土 109.85 vs 274.21 土 125.13 (P 0.343), but significantly higher power compliance index in PCV vs AVM-2: 1.11 土 0.41 vs 0.71 土 0.33 (P &lt; 0.001). Conclusion This study demonstrates that the choice of mechanical ventilation mode, whether PCV or AVM-2, significantly impacts mechanical power and its constituent variables. AVM-2 mode was associated with reduced mechanical power, and its’ components alongside the driving pressure, and tidal volumes, indicating its potential superiority in terms of lung-protective ventilation strategies. Clinicians should consider these findings when selecting the most appropriate ventilation mode to minimize the risk of ventilator-associated complications and improve patient outcomes. Further research is warranted to explore the clinical implications of these findings and to refine best practices in mechanical ventilation. Key words: Mechanical power, Work, PCV, AVM-2, VILI

Admission Functional Status is Associated With Intensivists Perception of Extracorporeal Membrane Oxygenation Candidacy for Pediatric Acute Respiratory Failure.

To determine the association between admission Functional Status Scale (FSS) category and perceived extracorporeal membrane oxygenation (ECMO) candidacy for pediatric acute respiratory failure. Prospective, cross-sectional study. Single-center, quaternary, and ECMO referral academic children's hospital between March 2021 and January 2022. Pediatric intensivists directly caring for patients admitted with acute respiratory failure secondary to shock or respiratory disease. None. Pediatric intensivists were surveyed about current patients within 72 hours of initiation or escalation of invasive mechanical ventilation on whether they would offer ECMO should their patient deteriorate. Baseline functional status was assessed using trichotomized admission FSS: 1) normal/mild dysfunction (6-9), 2) moderate dysfunction (10-15), and 3) severe dysfunction (> 16). Multivariable logistic regression clustered by physician was used to assess the association between admission FSS category with perceived ECMO candidacy. Thirty-seven intensivists participated with 76% (137/180) of survey responses by those with less than 10 years of experience. 81% of patients (146/180) were perceived as ECMO candidates and 19% of patients (34/180) were noncandidates. Noncandidates had worse admission FSS scores than candidates (15.5 vs. 9, p < 0.001). After adjustment for age, admission FSS category of severe dysfunction had lower odds of perceived ECMO candidacy compared with normal to mild dysfunction (odds ratio [OR] 0.18 [95% CI, 0.06-0.56], p < 0.003). Patients with an abnormal communication subscore domain had the lowest odds of being considered a candidate (unadjusted OR 0.44 [95% CI, 0.29-0.68], p < 0.0001). In this prospective, single-center, cross-sectional study, admission FSS category indicating worse baseline functional status impacted pediatric intensivists' perceptions of ECMO candidacy for patients with acute respiratory failure. Abnormal FSS subscores in the neurocognitive domains were the most important considerations. Future studies should better seek to define the decision-making priorities of both parents and medical specialists for the utilization of ECMO in children with acute respiratory failure.

Investigating the Smoker's Paradox: Acute Myocardial Infarction Outcomes in Smokers

BackgroundNon-adherence is a barrier to the control of hypertension. This study Background.Smoking is known to negatively impact cardiovascular health and reduce life expectancy. However, the smoker's paradox suggests that current smokers with acute myocardial infarction (AMI) experience lower short-term mortality rates than non-smokers. This study investigates the effect of smoking on in-hospital outcomes for AMI patients in the United States, aiming to understand the presence of this paradox within this population. MethodsIn this study, we utilized the National Inpatient Sample (NIS) for the year of 2020 to identify all patients who were admitted for a principal diagnosis of AMI. Subsequently, we isolated those patients with an ICD-10 code indicating smoking or tobacco use. To examine associations, both logistic and linear regression analyses were employed while adjusting for potential confounding factors. Our findings were considered significant if the 2-tailed p-value was 0.05 or lower. ResultsIn 2020, there were 446,834 hospitalizations for AMI. Of these cases, 230,120 (51.5%) involved patients with a secondary diagnosis of smoking history or use. After accounting for various factors such as age, race, gender, hospital bed size, location, teaching status, insurance coverage, income level, and Elixhauser comorbidities, patients admitted for AMI with a secondary diagnosis of smoking use exhibited a lower rate of in-hospital mortality (aOR 0.58, 95% CI 0.55-0.63), mechanical ventilation (aOR 0.74, 95% CI 0.66-0.74), vasopressor initiation (aOR 0.69, 95% CI 0.64-0.76), mechanical circulatory support (aOR 0.52, 95% CI 0.46-0.57), and hemodialysis initiation (aOR 0.52, 95% CI 0.48-0.56). Notably, these patients also had higher odds of receiving percutaneous coronary intervention (PCI) (aOR 1.18, 95% CI 1.37-1.98) compared to non-smoking patients with AMI (Figure 1). ConclusionOur study showed that AMI patients with a smoking history had lower odds of in-hospital mortality, mechanical ventilation, vasopressor use, circulatory support, and hemodialysis initiation, but higher odds of PCI compared to non-smokers. To fully understand the smoker's paradox, larger, robust investigations are needed to reveal underlying mechanisms, and ultimately, inform more effective patient care strategies.

Early detection of deterioration in COVID-19 patients by continuous ward respiratory rate monitoring: a pilot prospective cohort study.

Tachypnea is among the earliest signs of pulmonary decompensation. Contactless continuous respiratory rate monitoring might be useful in isolated COVID-19 patients admitted in wards. We therefore aimed to determine whether continuous monitoring of respiratory patterns in hospitalized patients with COVID-19 predicts subsequent need for increased respiratory support. Single-center pilot prospective cohort study in COVID-19 patients who were cared for in routine wards. COVID-19 patients who had at least one escalation of pulmonary management were matched to three non-escalated patients. Contactless respiratory monitoring was instituted after patients enrolled, and continued for 15 days unless hospital discharge, initiation of invasive mechanical ventilation, or death occurred. Clinicians were blinded to respiratory rate data from the continuous monitor. The exposures were respiratory features over rolling periods of 30 min, 24 h, and 72 h before respiratory care escalation. The primary outcome was a subsequent escalation in ventilatory support beyond a Venturi mask. Among 125 included patients, 13 exhibited at least one escalation and were each matched to three non-escalated patients. A total of 28 escalation events were matched to 84 non-escalation episodes. The 30-min mean respiratory rate in escalated patients was 23 breaths per minute (bpm) ranging from 13 to 40 bpm, similar to the 22 bpm in non-escalated patients, although with less variability (range 14 to 31 bpm). However, higher respiratory rate variability, especially skewness over 1 day, was associated with higher incidence of escalation events. Our overall model, based on continuous data, had a moderate accuracy with an AUC 0.81 (95%CI: 0.73, 0.88) and a good specificity 0.93 (95%CI: 0.87, 0.99). Our pilot observational study suggests that respiratory rate variability as detected with continuous monitoring is associated with subsequent care escalation during the following 24 h. Continuous respiratory monitoring thus appears to be a valuable increment over intermittent monitoring. Our study was the initial evaluation of Circadia contactless respiratory monitoring in COVID-19 patients who are at special risk of pulmonary deterioration. The major limitation is that the analysis was largely post hoc and thus needs to be confirmed in an out-of-sample population.

Convalescent Plasma for Covid-19–Induced ARDS in Mechanically Ventilated Patients

BackgroundPassive immunization with plasma collected from convalescent patients has been regularly used to treat coronavirus disease 2019 (Covid-19). Minimal data are available regarding the use of convalescent plasma in patients with Covid-19–induced acute respiratory distress syndrome (ARDS).MethodsIn this open-label trial, we randomly assigned adult patients with Covid-19–induced ARDS who had been receiving invasive mechanical ventilation for less than 5 days in a 1:1 ratio to receive either convalescent plasma with a neutralizing antibody titer of at least 1:320 or standard care alone. Randomization was stratified according to the time from tracheal intubation to inclusion. The primary outcome was death by day 28.ResultsA total of 475 patients underwent randomization from September 2020 through March 2022. Overall, 237 patients were assigned to receive convalescent plasma and 238 to receive standard care. Owing to a shortage of convalescent plasma, a neutralizing antibody titer of 1:160 was administered to 17.7% of the patients in the convalescent-plasma group. Glucocorticoids were administered to 466 patients (98.1%). At day 28, mortality was 35.4% in the convalescent-plasma group and 45.0% in the standard-care group (P=0.03). In a prespecified analysis, this effect was observed mainly in patients who underwent randomization 48 hours or less after the initiation of invasive mechanical ventilation. Serious adverse events did not differ substantially between the two groups.ConclusionsThe administration of plasma collected from convalescent donors with a neutralizing antibody titer of at least 1:160 to patients with Covid-19–induced ARDS within 5 days after the initiation of invasive mechanical ventilation significantly reduced mortality at day 28. This effect was mainly observed in patients who underwent randomization 48 hours or less after ventilation initiation. (Funded by the Belgian Health Care Knowledge Center; ClinicalTrials.gov number, NCT04558476.)

Alveolar-Arterial Oxygen Gradient Ratio (Gaao2) As A Predictor of Early Mechanical Ventilation In A Patient with Suspected Sars Cov-2 Infection in the Adult Continuous Admission Area of The "Dr. Gaudencio González Garza” Of The La Raza National Medical Center.

Background: Viruses and mainly COVID and the pneumonia it causes are among the pathologies that cause the greatest damage to the alveolus-capillary membrane of the lungs in patients with this disease. Objectives: To relate the alveolar arterial oxygen gradient (GAaO2) and the start of early mechanical ventilation in patients with SARS COV - 2 virus infection in the continuous admission area. Methodology: Descriptive, retrospective, observational, cross-sectional, with 165 clinical records of patients admitted to the emergency area in a period from April 2020 to 2021. Kolmogorov – Smirnov test, Mann-Whitney U and Pearson correlation coefficient were performed. with p&gt;0.05, ROC curve for sensitivity and specificity with Youden index and multivariable regression analysis for correlation. Results: A cut-off point of GAaO2 = 210.25 was obtained with sensitivity of 95% and specificity of 94%, with 2 times more risk of starting mechanical ventilation and correlation of 89%. Conclusion: It was observed that the cut-off point was related to greater risk and correlation of initiation of mechanical ventilation. This is a reliable value to decide the start of invasive ventilation.

Comparative Effectiveness of Dual- Versus Mono-Sedative Therapy on Opioid Administration, Sedative Administration, and Sedation Level in Mechanically Ventilated, Critically Ill Children.

We estimated the effect of early initiation of dual therapy vs monotherapy on drug administration and related outcomes in mechanically ventilated, critically ill children. We used the electronic medical record at a single tertiary medical center to conduct an active comparator, new user cohort study. We included children <18 years of age who were exposed to a sedative or analgesic within 6 hours of intubation. We used stabilized inverse probability of treatment weighting to account for confounding at baseline. We estimated the average effect of initial dual therapy vs monotherapy on outcomes including cumulative opioid, benzodiazepine, and dexmedetomidine dosing; sedation scores; time to double the opioid or benzodiazepine infusion rate; initiation of neuromuscular blockade within the first 7 days of follow-up; time to extubation; and 7-day all-cause in-hospital death. The cohort included 640 patients. Children receiving dual therapy received 0.03 mg/kg (95% CI, 0.02-0.04) more dexmedetomidine over the first 7 days after initiation of mechanical ventilation than did monotherapy patients. Dual therapy patients had similar sedation scores, time to double therapy, initiation of neuromuscular blockade, and time to extubation as monotherapy patients. Dual therapy patients had a lower incidence of death. In this study, initial dual therapy compared with monotherapy does not reduce overall drug administration during mechanical ventilation. The identified effect of dual therapy on mortality deserves further investigation.

Abstract P157: IMPACT OF CONCURRENT ATRIAL FIBRILLATION ON HYPERTENSIVE EMERGENCIES:

Introduction: In patients suffering from hypertension, the presence of concurrent atrial fibrillation tends to escalate the risk of severe conditions and worsen outcomes. This study, aimed to delve into the impact that a simultaneous diagnosis of atrial fibrillation can have on patients admitted for hypertensive emergencies during the initial year of the COVID-19 pandemic. Methods: We examined data from the 2020 National Inpatient Sample to identify patients primarily admitted due to a hypertensive emergency. We used ICD-10 codes to distinguish between those with and without concurrent atrial fibrillation. We employed logistic and linear regression analyses and accounted for potential confounders. We deemed the results as statistically significant when the 2-tailed p-value was less than 0.05. Results: During 2020, there were a total of 1,221,535 admissions for hypertensive emergencies. Notably, 470,440 (38.5%), involved patients concurrently diagnosed with atrial fibrillation. After adjusting for variables such as age, race, gender, the size and geographic location of the hospital, insurance coverage, income level, and existing comorbidities, patients hospitalized for hypertensive emergencies, who were also diagnosed with atrial fibrillation, demonstrated an elevated risk of in-hospital mortality (aOR 1.25, 95% CI 1.18-1.32). This patient group was also more likely to require the initiation of mechanical ventilation (aOR 1.06, 95% CI 1.03-1.09), vasopressor therapy (aOR 1.71, 95% CI 1.52-1.92), and mechanical circulatory support (aOR 1.71, 95% CI 1.32-2.21). Intriguingly, despite the increased risks in these areas, these patients displayed a reduced rate of hemodialysis initiation (aOR 0.82, 95% CI 0.79-0.86). Conclusion: Atrial fibrillation seemingly has a critical influence on the in-hospital outcomes of patients admitted for hypertensive emergencies, generally leading to more unfavorable results. Given the anticipated increased prevalence of atrial fibrillation in an aging population, understanding its pathophysiology and potential contribution to the complexity of diseases in patients with severe hypertension represents a crucial area for further investigation.

Macrophage-Targeted Lipid Nanoparticle Delivery of microRNA-146a to Mitigate Hemorrhagic Shock-Induced Acute Respiratory Distress Syndrome.

The pro-inflammatory response of alveolar macrophages to injurious physical forces during mechanical ventilation is regulated by the anti-inflammatory microRNA, miR-146a. Increasing miR-146a expression to supraphysiologic levels using untargeted lipid nanoparticles reduces ventilator-induced lung injury but requires a high initial dose of miR-146a making it less clinically applicable. In this study, we developed mannosylated lipid nanoparticles that can effectively mitigate lung injury at the initiation of mechanical ventilation with lower doses of miR-146a. We used a physiologically relevant humanized in vitro coculture system to evaluate the cell-specific targeting efficiency of the mannosylated lipid nanoparticle. We discovered that mannosylated lipid nanoparticles preferentially deliver miR-146a to alveolar macrophages and reduce force-induced inflammation in vitro. Our in vivo study using a clinically relevant mouse model of hemorrhagic shock-induced acute respiratory distress syndrome demonstrated that delivery of a low dose of miR-146a (0.1 nmol) using mannosylated lipid nanoparticles dramatically increases miR-146a levels in mouse alveolar macrophages and decreases lung inflammation. These data suggest that mannosylated lipid nanoparticles may have the therapeutic potential to mitigate lung injury during mechanical ventilation.

Experience of nurses in the prevention of Ventilator-Associated Pneumonia among critically ill patients at Muhimbili National Hospital in Dar Es Salaam

Background: Ventilator-associated pneumonia (VAP) is one of the most common nosocomial infections that occur more than 48 hours after intubation and initiation of mechanical ventilation. It is associated with morbidity and mortality, increased health costs, and prolonged hospital stays. The estimated incidence of VAP globally is about 5-40% whereby in low and middle-income countries is about 47.9 per 1000 ventilator days. However, there is limited literature about VAP prevention in hospitals in Tanzania. Therefore this study aimed to explore nurses’ experience in the prevention of VAP. Methods: An exploratory descriptive study design was conducted with 15 nurses who were purposefully recruited from medical and surgical ICUs. A semi-structured interview guide consisting of main questions and probes was used to collect data. All interviews were audio-recorded and transcribed verbatim. Data were analyzed using an inductive thematic analytical approach. Results: Four main themes emerged; nurses’ roles in the prevention of VAP, nurses’ challenges toward care provision, nurses’ competency in implementing VAP prevention strategies, and enablers toward the implementation of VAP. The revealed prevention strategies were suctioning, early weaning, head of bed elevation of 30-45°, oral care, administration of medication, and implementation of IPC measures. The study has also revealed important barriers such are inadequate equipment, lack of VAP prevention protocols, shortage of staff, and inadequate knowledge. However, the major facilitators were responsible leadership, a quality control team, the availability of IPC guidelines, and individual motivation. Conclusion: This study provides insights into the experience of nurses in the prevention of VAP. Nurses face several challenges including a shortage of staff, shortage of equipment and supplies, lack of training, lack of VAP prevention protocols, and inadequate knowledge of VAP prevention. Despite these challenges nurses in their capacity are involved in VAP preventive measures. Keywords: Ventilator-associated pneumonia, strategies, experience, nurses, critically ill patients.

Pheochromocytoma crisis with refractory Acute Respiratory Distress Syndrome (ARDS), Takotsubo syndrome, emergency adrenalectomy, and need for Extracorporeal Membrane Oxygenation (ECMO) in a previously undiagnosed and asymptomatic patient, due to the use of metoclopramide

BackgroundPheochromocytoma (PCC) crisis is a rare life-threatening endocrine emergency. The diagnosis and treatment of PCC crisis, with acute respiratory distress syndrome (ARDS) as the first manifestation, is highly challenging, and traditional PCC management strategies are no longer suitable for these patients.Case presentationA 46-year-old female patient was admitted to the Intensive Care Unit (ICU) following sudden-onset acute respiratory distress and subsequent initiation of mechanical ventilation via endotracheal intubation. She was initially suspected of having a PCC crisis through the bedside critical care ultrasonic examination protocol. The computed tomography examination revealed a left adrenal neoplasm of 6.5cm × 5.9cm. The plasma-free metanephrine level was 100 times higher than the reference value. These findings were compatible with her PCC diagnosis. Alpha-blockers and fluid intake were started immediately. The endotracheal intubation was removed on the 11th day after admission to the ICU. The patient progressed to severe ARDS again, and invasive ventilation and continuous renal replacement therapy were needed. Despite aggressive therapy, her condition deteriorated. Therefore, she underwent veno-arterial extracorporeal membrane oxygenation (VA-ECMO)-assisted emergency adrenalectomy after multidisciplinary discussion. Postoperatively, the patient was supported by VA-ECMO for 7days. She was discharged from the hospital on day 30 after tumor resection.ConclusionsThis case highlighted the challenges in diagnosing and managing ARDS associated with PCC crisis. The traditional preoperative preparation protocol and optimal operation timing for patients with PCC are not suitable for patients with PCC crisis. Patients with life-threatening PCC crisis may benefit from early tumor removal, and VA-ECMO could maintain hemodynamic stability during and after surgery.