Initiation Of Mechanical Ventilation Research Articles

Incidence and Risk Factors Association for Ventilator Associated Pneumonia in Neontal Intensive Care Unit

Introduction: Ventilator Associated Pneumonia (VAP), the nosocomial pneumonia developing in mechanically ventilated patients after 48 hours of mechanical ventilation, is the second commonest nosocomial infection in the neonatal intensive care unit (NICU). VAP occurring within 96 hours of initiation of mechanical ventilation is termed as early VAP and later than that is known as late VAP. The aim of this study was to determine the incidence rate and risk factors of early and late ventilator associated pneumonia in NICU. Methods: The study was conducted from December 2015 to November 2017 in which 40 neonates were ventilated for more than 48 hours of which those who developed VAP as per CDC criteria were enrolled in the study. Birth weight, gestation age, reintubation if needed and number of days of ventilation were noted. Statistical associations were further evaluated between various parameters of VAP and time of development of VAP. Results: Incidence of Early VAP was 12.5% and that of Late VAP was 87.5%. 93.95% neonates who were reintubated developed VAP. Duration of mechanical ventilation and re-intubation were significantly associated with the time of development of VAP. Birth weight and gestation age were statistically insignificant factors in determining VAP. Conclusions: Re-intubation and duration of mechanical ventilation are a significant risk factor for development of late VAP. Gestation age and birth weight have been identified as additional risk factors. Early diagnosis is necessary for appropriate treatment and decreased hospital stay.

A CLINICAL STUDY OF VENTILATOR ASSOCIATED PNEUMONIA IN A TERTIARY CARE CENTER

Introduction: Ventilator-associated pneumonia (VAP) is a nosocomial pneumonia in mechanically ventilated patients that develops 48hours after initiation of mechanical ventilation. Despite recent advances VAP complicates 8-28% of the patients receiving mechanical ventilation.1-5 Objectives: To determine the incidence, risk factors, clinical prole and outcome of VAP in a tertiary care hospital. Methods: 100 children between 1 month to 12 years of age who received mechanical ventilation for >48hours in PICU King George Hospital were enrolled in the study. The demographic details of the patients, underlying illness, duration of ventilation, medications administered and investigations performed and outcome of these children was noted. Results: Majority of children with VAP had a Clinical Pulmonary Infection score (CPIS) of>8.Incidence of VAP was 26%. Statistically signicant difference was found with VAP in association with factors like purulent aspirate, un-cuffed ET tube, multiple intubations, and duration of mechanical ventilation>5days with gram negative bacilli(Acinetobacter and klebsiella) being the important causative agents. Conclusion: Awareness about the risk factors & their prevention will help in reducing VAP related morbidity and mortality. Early institution of empirical sensitive antibiotics improves outcomes in children with VAP and also helps to prevent the risk of multidrug resistance

Ventilatory Parameters Measured After One Week of Mechanical Ventilation and Survival in COVID-19-Related ARDS.

Ventilatory parameters measured soon after initiation of mechanical ventilation have limited ability to predict outcome of COVID-19-related ARDS. We hypothesized that ventilatory parameters measured after one week of mechanical ventilation might differ between survivors and non-survivors. One hundred twenty-seven subjects with COVID-related ARDS had gas exchange and lung mechanics assessed on the day of intubation and one week later. The main parameters of interest were PaO2 /FIO2 , ventilatory ratio (VR), respiratory system compliance (CRS), and a composite score that was calculated as (PaO2 /FIO2 /100) × CRS/VR. The primary outcome was death in the ICU. Of the 127 subjects, 42 (33%) died in the ICU and 85 (67%) were successfully extubated. On the day of intubation, PaO2 /FIO2 , CRS, and composite score of survivors and non-survivors were similar, but survivors had a lower VR. At one week, as compared to survivors, non-survivors had a significantly higher VR (2.04 ± 0.76 vs 1.60 ± 0.43, P < .001), lower CRS (27.4 ± 6.4 mL/cm H2O vs 32.4 ± 9.3 mL/cm H2O, P = .002), and lower composite score (20.6 ± 11.9 vs 34.5 ± 18.6, P < .001), with no statistically significant difference in PaO2 /FIO2 (137 ± 49 vs 155 ± 48, P = .08). In subjects with COVID ARDS, parameters that reflect dead space (VR), lung mechanics (CRS), and a combined score that included PaO2 /FIO2 , VR, and CRS differed between survivors and non-survivors after one week of mechanical ventilation but with considerable overlap of values between survivors and non-survivors.

Signatures of illness in children requiring unplanned intubation in the pediatric intensive care unit: A retrospective cohort machine-learning study.

Acute respiratory failure requiring the initiation of invasive mechanical ventilation remains commonplace in the pediatric intensive care unit (PICU). Early recognition of patients at risk for respiratory failure may provide clinicians with the opportunity to intervene and potentially improve outcomes. Through the development of a random forest model to identify patients at risk for requiring unplanned intubation, we tested the hypothesis that subtle signatures of illness are present in physiological and biochemical time series of PICU patients in the early stages of respiratory decompensation. We included 116 unplanned intubation events as recorded in the National Emergency Airway Registry for Children in 92 PICU admissions over a 29-month period at our institution. We observed that children have a physiologic signature of illness preceding unplanned intubation in the PICU. Generally, it comprises younger age, and abnormalities in electrolyte, hematologic and vital sign parameters. Additionally, given the heterogeneity of the PICU patient population, we found differences in the presentation among the major patient groups - medical, cardiac surgical, and non-cardiac surgical. At four hours prior to the event, our random forest model demonstrated an area under the receiver operating characteristic curve of 0.766 (0.738 for medical, 0.755 for cardiac surgical, and 0.797 for non-cardiac surgical patients). The multivariable statistical models that captured the physiological and biochemical dynamics leading up to the event of urgent unplanned intubation in a PICU can be repurposed for bedside risk prediction.

Association Between Critical Events in the PICU and Outcomes in Neighboring Patients.

OBJECTIVE:PICU patients who experience critical illness events, such as intubation, are at high risk for morbidity and mortality. Little is known about the impact of these events, which require significant resources, on outcomes in other patients. Therefore, we aimed to assess the association between critical events in PICU patients and the risk of similar events in neighboring patients over the next 6 hours.DESIGN:Retrospective observational cohort study.SETTING:Quaternary care PICU at the University of Chicago.PATIENTS:All children admitted to the PICU between 2012 and 2019.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:The primary outcome was a critical event defined as the initiation of invasive ventilation, initiating vasoactive medications, cardiac arrest, or death. The exposure was the occurrence of a critical event among other patients in the PICU within the preceding 6 hours. Discrete-time survival analysis using fixed 6-hour blocks beginning at the time of PICU admission was used to model the risk of experiencing a critical event in the PICU when an event occurred in the prior 6 hours. There were 13,628 admissions, of which 1,886 (14%) had a critical event. The initiation of mechanical ventilation was the most frequent event (n = 1585; 59%). In the fully adjusted analysis, there was a decreased risk of critical events (odds ratio, 0.82; 95% CI, 0.70–0.96) in the 6 hours following exposure to a critical event. This association was not present when considering longer intervals and was more pronounced in patients younger than 6 years old when compared with patients 7 years and older.CONCLUSION:Critical events in PICU patients are associated with decreased risk of similar events in neighboring patients. Further studies targeted toward exploring the mechanism behind this effect as well as identification of other nonpatient factors that adversely affect outcomes in children are warranted.

Meta-analysis comparing the efficacy of dobutamine versus milrinone in acute decompensated heart failure and cardiogenic shock

Abstract Objective This study aims to evaluate the difference between dobutamine and milrinone in patients presenting with acute decompensated heart failure (AHF). Background Inotropes are indicated for treating AHF, especially in patients with concomitant hypoperfusion indicative of cardiogenic shock. However, previous studies have not identified the optimal inotrope. We sought to compare outcomes associated with milrinone versus dobutamine in patients with AHF. Methods A systematic literature search was performed to identify relevant trials from inception to August 2021. Our primary outcome of interest was mortality. Analysis was sub-categorized according to subpopulation, including AHF, AHF with cardiogenic shock (AHF-shock), AHF with a bridge to transplantation (AHF-BTT), and AHF with destination therapy (AHF-DT). Summary effects were calculated using a fixed-effects model as risk ratio or mean difference with 95% confidence intervals for all the clinical endpoints. Results Ten studies, including one randomized controlled trial with 21,106 patients, were included in the analysis (4918 patients were in the Milrinone group, while 15188 were in the Dobutamine group). Milrinone was associated with a lower risk of mortality in patients with AHF [relative risk (RR) 0.87; confidence interval (CI):0.79–0.97; p&amp;lt;0.05, heterogeneity I2=0%] with event rates of 9.4% vs. 9.8% [number needed to treat (NNT) of 250]. Milrinone was also associated with improved mortality with RR 0.76 (0.79–0.95; p&amp;lt;0.05) in patients with AHF-DT. There was a non-significant trend towards improved mortality in AHF-shock patients. However, AHF-BTT patients had a non-significant trend towards improved mortality with dobutamine. There was no difference between the two strategies for the outcomes of acute kidney injury, initiation of renal replacement therapy, mechanical ventilation, arrhythmias, symptomatic hypotension, and length of hospital stay (LOS) in the overall population. Intensive care unit (ICU) LOS was lower in AHF-shock patients in the milrinone group, whereas dobutamine was associated with a lower length of ICU stay in AHF patients. Conclusion The cumulative data comparing milrinone with dobutamine indicate an overall marginal benefit of milrinone compared to dobutamine in the totality of patients with AFH with or without cardiogenic shock, and whether or not they are bridged to transplantation or destination assist device. More appropriately powered prospective studies are needed to identify a conclusive benefit of one inotrope over another. Funding Acknowledgement Type of funding sources: None.

Clinical outcomes according to timing to invasive ventilation due to noninvasive ventilation failure in children

ObjectiveNoninvasive ventilation (NIV) failure it has been associated to worst clinical outcomes due to a delay in intubation and initiation of invasive mechanical ventilation (IMV). There is a lack of evidence in pediatric patients regarding this topic. The objective was to deter-mine the association between duration of IMV and length of stay, with duration of NIV prior tointubation/IMV in pediatric patients. DesignA prospective cohort study since January 2015 to October 2019. SettingA pediatric intensive care unit. PatientsChildren under 15 years with acute respiratory failure who failed to noninvasive ventilation. InterventionsNone. Main variables of interestDemographic variables, pediatric index of mortality (PIM2), pediatric acute respiratory distress syndrome (PARDS) diagnosis, IMV and NIV duration, PICU LOS were registered and intrahospital mortality. ResultsA total of 109 patients with a median (IQR) age of 7 (3–14) months were included. The main diagnosis was pneumonia (89.9%). PARDS was diagnosed in 37.6% of the sample. No association was found between NIV duration and duration of IMV after Kaplan–Meier analysis (Log rank P = .479). There was no significant difference between PICU LOS (P = .253) or hospital LOS (P = 0.669), when categorized by NIV duration before intubation. PARDS diagnosis was associated to an increased length of invasive ventilation (HR: 0.64 [95% IC: 0.42–0.99]). ConclusionsNo association was found between NIV duration prior to intubation and duration of invasive ventilation in critical pediatric patients with acute respiratory failure.

The Need for an Adult Intensive Care Unit Boot Camp for Residents and Fellows: A Cross-Sectional Survey among Intensive Care Unit Directors.

The concept of "see one, do one, teach one" raises concerns regarding patient safety in the intensive care unit (ICU) and highlights the need for prior preparation of residents/fellows for ICU rotation. This study assessed the need for an adult pre-ICU "boot camp" training course. An online questionnaire regarding the current ICU training and desirable course framework was distributed via e-mail to the ICU directors of 269 educational centers certified by the Japanese Society of Intensive Care Medicine. The response rate was 39% (106/269). The number of residents/fellows undergoing ICU rotation was 5.5 (IQR 2-12) /ICU/year, and the majority (63%) were second to fourth year post-graduate residents and fellows. ICU directors opined that of the fundamental critical care skills, residents/fellows performed well or very well in only seven out of 29 skills (24%). Only 18% of the ICU directors had an established ICU training curriculum. Overall, 72% of the directors were interested in the boot camp. The desirable course framework was 3-5 hours per day with simulations and lectures. The core skills that directors considered as important to acquire during ICU rotation were central venous catheter insertion, tracheal intubation, defibrillation, initiation of mechanical ventilation, physical examination of critically ill patients, and shock assessment. Residents/fellows began ICU rotations with suboptimal skills as reported by ICU directors. In addition, most of the ICUs had not established a training curriculum. Therefore, having an ICU boot camp is necessary to enhance critical care skills and to decrease medical errors.

Real-world effectiveness of early molnupiravir or nirmatrelvir–ritonavir in hospitalised patients with COVID-19 without supplemental oxygen requirement on admission during Hong Kong's omicron BA.2 wave: a retrospective cohort study

BackgroundData on the effectiveness of oral antivirals in patients with mild-to-moderate COVID-19 are urgently needed. This retrospective cohort study aimed to evaluate the clinical and virological outcomes associated with molnupiravir or nirmatrelvir–ritonavir use in hospitalised patients with mild-to-moderate COVID-19 during a pandemic wave dominated by the omicron BA.2 subvariant.MethodsWe analysed data from a territory-wide retrospective cohort of patients in Hong Kong who were hospitalised with a confirmed diagnosis of SARS-CoV-2 infection between Feb 26 and April 26, 2022. Data were extracted from the Hospital Authority, the Department of Health, and the Hong Kong Death Registry. Patients were eligible for inclusion if their admission date was within 3 days before or after confirmation of their COVID-19 diagnosis. Those who were admitted to hospital more than 5 days after symptom onset, were younger than 18 years, had a history of oral antiviral use before admission, required supplemental oxygen on admission, had drug-related contraindications to nirmatrelvir–ritonavir use, or had severe renal or severe liver impairment were excluded. Patients who received the oral antivirals molnupiravir or nirmatrelvir–ritonavir were matched with controls using propensity-score matching in a ratio of 1:1. The primary outcome was all-cause mortality and secondary outcomes included a composite outcome of disease progression (all-cause mortality, initiation of invasive mechanical ventilation [IMV], intensive care unit [ICU] admission, or the need for oxygen therapy) and each of these individual disease progression outcomes, and time to reaching a low viral burden (RT-PCR cycle threshold value ≥30). For each event outcome, crude incidence rates were calculated and hazard ratios (HRs) estimated using Cox regression models.FindingsWe identified 40 776 patients hospitalised with SARS-CoV-2 infection during the study period, with a mean follow-up of 41·3 days (total 925 713 person-days). After exclusions and propensity-score matching, we included 1856 molnupiravir recipients and 1856 matched controls, and 890 nirmatrelvir-ritonavir recipients and 890 matched controls. A lower risk of all-cause mortality was observed in molnupiravir recipients (crude incidence rate per 10 000 person-days 19·98 events [95% CI 16·91–23·45]) versus matched controls (38·07 events [33·85–42·67]; HR 0·48 [95% CI 0·40–0·59], p<0·0001) and in nirmatrelvir–ritonavir recipients (10·28 events [7·03–14·51]) versus matched controls (26·47 events [21·34–32·46]; HR 0·34 [0·23–0·50], p<0·0001). Oral antiviral recipients also had lower risks of the composite disease progression outcome (molnupiravir HR 0·60 [95% CI 0·52–0·69], p<0·0001; nirmatrelvir–ritonavir 0·57 [0·45–0·72], p<0·0001) and need for oxygen therapy (molnupiravir 0·69 [0·57–0·83], p=0·0001; nirmatrelvir–ritonavir 0·73 [0·54–0·97], p=0·032) compared with controls. Time to achieving a low viral burden was significantly shorter among oral antiviral recipients than matched controls (molnupiravir HR 1·38 [95% CI 1·15–1·64], p=0·0005; nirmatrelvir–ritonavir 1·38 [1·07–1·79], p=0·013). Significant differences in initiation of IMV and ICU admission were not found.InterpretationDuring a wave of SARS-CoV-2 omicron BA.2, initiation of novel oral antiviral treatments in hospitalised patients not requiring oxygen therapy on admission showed substantial clinical benefit. Our findings support the early use of oral antivirals in this population of patients.FundingHealth and Medical Research Fund (Health Bureau, Government of the Hong Kong Special Administrative Region).TranslationFor the Chinese translation of the abstract see Supplementary Materials section.

Relationships between double cycling and inspiratory effort with diaphragm thickness during the early phase of mechanical ventilation: A prospective observational study.

Increased and decreased diaphragm thickness during mechanical ventilation is associated with poor outcomes. Some types of patient-ventilator asynchrony theoretically cause myotrauma of the diaphragm. However, the effects of double cycling on structural changes in the diaphragm have not been previously evaluated. Hence, this study aimed to investigate the relationship between double cycling during the early phase of mechanical ventilation and changes in diaphragm thickness, and the involvement of inspiratory effort in the occurrence of double cycling. We evaluated adult patients receiving invasive mechanical ventilation for more than 48 h. The end-expiratory diaphragm thickness (Tdiee) was assessed via ultrasonography on days 1, 2, 3, 5 and 7 after the initiation of mechanical ventilation. Then, the maximum rate of change from day 1 (ΔTdiee%) was evaluated. Concurrently, we recorded esophageal pressure and airway pressure on days 1, 2 and 3 for 1 h during spontaneous breathing. Then, the waveforms were retrospectively analyzed to calculate the incidence of double cycling (double cycling index) and inspiratory esophageal pressure swing (ΔPes). Finally, the correlation between double cycling index as well as ΔPes and ΔTdiee% was investigated using linear regression models. In total, 19 patients with a median age of 69 (interquartile range: 65-78) years were enrolled in this study, and all received pressure assist-control ventilation. The Tdiee increased by more than 10% from baseline in nine patients, decreased by more than 10% in nine and remained unchanged in one. The double cycling indexes on days 1, 2 and 3 were 2.2%, 1.3% and 4.5%, respectively. There was a linear correlation between the double cycling index on day 3 and ΔTdiee% (R2 = 0.446, p = 0.002). The double cycling index was correlated with the ΔPes on days 2 (R2 = 0.319, p = 0.004) and 3 (R2 = 0.635, p < 0.001). Double cycling on the third day of mechanical ventilation was associated with strong inspiratory efforts and, possibly, changes in diaphragm thickness.

Pneumomediastinum in COVID-19 critically ill patients: A case series of unusual complication from a Tunisian intensive care unit

Introduction: Coronavirus disease 2019 (COVID-19) is a new rapidly emerging and ever-evolving disease that clinicians continue to detect new manifestations and complications daily since December 2019. Pneumomediastinum, a potentially life-threatening condition, is an uncommon complication of acute respiratory distress syndrome from viral infections. By presenting this case series, we highlight that pneumomediastinum (PM) can complicate the course of a severe COVID-19 infection. Case Series: We identified four critically ill patients, two men and two women, aged between 50 and 70 years old. None of them had any underlying lung disease. On admission all cases were in acute respiratory distress syndrome. Three patients were under positive pressure ventilation both invasive (n = 2/4) and non-invasive (n = 1/4) at the time of the event; however, one patient had a spontaneous PM without any exposure to mechanical ventilation. Chest computed tomography scan (chest CT scan) was performed for all patients showing a pulmonary involvement estimated moderate (n = 3/4) to severe (n = 1/4), PM (n = 4/4) and subcutaneous emphysema (n = 2/4). For ventilated patients, PM was diagnosed 3 to 7 days after initiation of mechanical ventilation. The highest positive end-expiratory pressure was 10 cmH2O for patients receiving invasive mechanical ventilation, while 5 cmH2O for patient who had developed PM on non-invasive ventilation. The PM was managed by conservative therapy in all of the cases with reducing airway pressure. Conclusion: Our findings suggest that PM is secondary to inflammatory response due to COVID-19 and mostly triggered by the use of positive pressure ventilation and it is associated with poor outcome in critically ill COVID-19 patients.

Peripheral tissue hypoperfusion predicts post intubation hemodynamic instability

BackgroundTracheal intubation and invasive mechanical ventilation initiation is a procedure at high risk for arterial hypotension in intensive care unit. However, little is known about the relationship between pre-existing peripheral microvascular alteration and post-intubation hemodynamic instability (PIHI).MethodsProspective observational monocenter study conducted in an 18-bed medical ICU. Consecutive patients requiring tracheal intubation were eligible for the study. Global hemodynamic parameters (blood pressure, heart rate, cardiac function) and tissue perfusion parameters (arterial lactate, mottling score, capillary refill time [CRT], toe-to-room gradient temperature) were recorded before, 5 min and 2 h after tracheal intubation (TI). Post intubation hemodynamic instability (PIHI) was defined as any hemodynamic event requiring therapeutic intervention.ResultsDuring 1 year, 120 patients were included, mainly male (59%) with a median age of 68 [57–77]. The median SOFA score and SAPS II were 6 [4–9] and 47 [37–63], respectively. The main indications for tracheal intubation were hypoxemia (51%), hypercapnia (13%), and coma (29%). In addition, 48% of patients had sepsis and 16% septic shock. Fifty-one (42%) patients develop PIHI. Univariate analysis identified several baseline factors associated with PIHI, including norepinephrine prior to TI, sepsis, tachycardia, fever, higher SOFA and high SAPSII score, mottling score ≥ 3, high lactate level and prolonged knee CRT. By contrast, mean arterial pressure, baseline cardiac index, and ejection fraction were not different between PIHI and No-PIHI groups. After adjustment on potential confounders, the mottling score was associated with a higher risk for PIHI (adjusted OR: 1.84 [1.21–2.82] per 1 point increased; p = 0.005). Among both global haemodynamics and tissue perfusion parameters, baseline mottling score was the best predictor of PIHI (AUC: 0.72 (CI 95% [0.62–0.81]).ConclusionsIn non-selected critically ill patients requiring invasive mechanical ventilation, tissue hypoperfusion parameters, especially the mottling score, could be helpful to predict PIHI.

Early Titration of Oxygen During Mechanical Ventilation Reduces Hyperoxemia in a Pilot, Feasibility, Randomized Control Trial for Automated Titration of Oxygen Levels.

OBJECTIVES:Timely regulation of oxygen (Fio2) is essential to prevent hyperoxemia or episodic hypoxemia. Exposure to excessive Fio2 is often noted early after onset of mechanical ventilation. In this pilot study, we examined the feasibility, safety, and efficacy of a clinical trial to prioritize Fio2 titration with electronic alerts to respiratory therapists.STUDY DESIGN:Open-labeled, randomized control pilot trial.SETTING:Medical ICU.SUBJECTS:Adults requiring mechanical ventilation.INTERVENTIONS:Protocolized oxygen titration was initiated one hour after initiation of mechanical ventilation. When Spo2 exceeded 92% while on Fio2 ≥ 0.5, an electronic alert to respiratory therapists was triggered at 30-minute intervals. In the control arm, respiratory therapists titrated Fio2 by standard physician’s orders.MEASUREMENTS AND MAIN RESULTS:The primary end point was to determine if early Fio2 titration based on automated alerts was feasible in terms of reducing hyperoxemia. Secondary analyses included the number and frequency of alerts, mechanical ventilation duration, and ICU length of stay. Among 135 randomized patients, 72 were assigned to the intervention arm and 63 to the control arm. A total 877 alerts were sent. Exposure to hyperoxemia was significantly reduced in the intervention group by a median of 7.5 hours (13.7 [interquartile range (IQR), 2.9–31.1] vs 21.2 [IQR, 10.9–64.4]; p < 0.0004). Maximal Fio2 titration during the first quartile resulted in significant reduction in mechanical ventilation duration and ICU stay. Minor hypoxemic events (Spo2 < 88%) represented 12% of alerts, 9% were transient and responded to a single Fio2 increase, whereas 3% of alerts were associated with recurrent transient hypoxemia.CONCLUSIONS:Our pilot study indicates that early Fio2 titration driven by automated alerts is feasible in the ICU, as reflected by a statistically significant reduction of hyperoxemia exposure, limited consequential hypoxemia, and reduced ICU resource utilization. The encouraging results of this pilot study need to be validated in a larger ICU cohort.

ACUTE TRACHEAL TEAR: A POTENTIAL CAUSE OF SPONTANEOUS PNEUMOMEDIASTINUM IN PATIENTS WITH COVID-19

TYPE: Abstract TOPIC: Critical Care PURPOSE: Spontaneous pneumomediastinum (SP) is defined as free air in the mediastinum without a precipitating cause and has recently been described as an additional potential complication of coronavirus disease 2019 (COVID-19). It may carry a poor prognosis. We aim to identify a potential cause for patients with COVID-19 who present with spontaneous pneumomediastinum prior to initiation of mechanical ventilation. METHODS: Three male patients, age 66, 61, and 70, average body mass index 28kg/m2, with severe COVID-19 pneumonia were admitted to intensive care with SP prior to initiation of mechanical ventilation had bronchoscopic and radiological evidence of acute tracheal tear. None developed associated pneumothoraces. Upon further deterioration each patient was commenced on mechanical ventilatory support. RESULTS: Acute tracheal tear was confirmed in all patients in the lower membranous trachea, with one patient having two diametrically opposite tracheal tears. Following multidisciplinary team discussions, all were managed conservatively. Unfortunately, each patient died of multi-organ failure. CONCLUSIONS: Our findings suggest that the development of pneumomediastinum and subcutaneous emphysema, following prolonged periods of severe coughing, should raise the suspicion of tracheal rupture in COVID-19 patients. CLINICAL IMPLICATIONS: We recommend that all COVID-19 positive patients, who show signs of SP, should undergo urgent bronchoscopy to exclude a tracheal tear. Early diagnosis is essential to permit multidisciplinary team discussions to define therapeutic strategies. DISCLOSURE: Nothing to declare. KEYWORD: COVID-19

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.

P92 ADVANCED CIRCULATORY SUPPORT IN A PATIENT WITH ISCHEMIC HEART DISEASE, SEVERE AORTIC STENOSIS AND CARDIAC TAMPONADE

Abstract The use of mechanical left ventricle assistance device in the context of severe aortic stenosis is far from routine. The clinical case we’re presenting highlights the possibility of achieving therapeutic success through appropriate patient selection and choice of the most useful strategy based on the clinical scenario. Our patient is a 70 years old man with several cardiovascular risk factors (DM2, hypertension, active smoker, overweight), CKD IV; his clinical history is characterized by NSTEMI in 2010, treated with PCI and subsequent implantation of 2 DES (on LAD and RM), and by an hospital admission in 2019 for AHF with diagnosis of severe AS. He refused any invasive treatment for underlying valvopathy. In January 2021, a dual–chamber pacemaker implant was required due to the finding of 3rd degree AV block: again, TAVI was refused. A few days after the last discharge, a new ER admission was necessary: the patients had dyspnea (NYHA III–IV) with severe EF depression (50–&amp;gt;25%) and slight troponin elevation: no significant lesions were discovered by coronarography exam. The patient finally agreed to start examinations preparatory to TAVI. After resolution of AHF and approximately 14 days after coronarography, the patient developed pericardial effusion to tamponade, of possible uremic etiology: in addition to compression on the right chambers, echocardiography showed a further dramatic decline in EF (10–15%); despite placement of pericardial drainage and IABP, the initiation of advanced amine support and mechanical ventilation, the patient was classified Intermacs 2. Following a collegial discussion (interventional cardiologist, cardiac surgeon and anesthesiologist), it was decided to perform procedure in the cath–lab in order to undertake an advanced support strategy as birdge–to–therapy: – Valver valvuloplasty with increasing balloon size (18 mm – 20 mm – 23 mm – 25 mm). Rapid pacing was performed through previously implanted PMK, resulting in subsequent hemodynamic benefit (mean gradient 45–&amp;gt;25 mmHg); – Placement of Impella CP (P8, output 3–3.2 L/min). The following post–procedural hospitalization, despite the need for antibiotic therapy and multiple transfusions, was characterized by a progressive hemodynamics improvement until feasibility of weaning from both mechanical and amine therapy and discharge to the rehabilitation center in anticipation of TAVR procedure, which will then be successfully performed in October 2021.

Characteristics and Factors Associated With Mortality in Patients With Coronavirus Disease 2019 and Pneumothorax.

ObjectiveTo describe the incidence, clinical characteristics, and factors associated with mortality in patients hospitalized for coronavirus disease 2019 (COVID-19) in whom pneumothorax developed.Patients and MethodsThis study was a retrospective analysis conducted using a large administrative database of adult patients hospitalized for COVID-19 in the United States from February 1, 2020, to June 10, 2021. We characterized the clinical features of patients in whom pneumothorax developed and the factors associated with mortality and stratified pneumothorax by the timing of the initiation of invasive mechanical ventilation (IMV) and by the time of hospital admission (early versus late).ResultsA total of 811,065 adult patients had a positive test result for severe acute respiratory syndrome coronavirus 2, of whom 103,858 (12.8%) were hospitalized. Pneumothorax occurred in 1915 patients (0.24% overall and 1.84% among hospitalized patients). Over time, the use of steroids and remdesivir increased, whereas the use of IMV, pneumothorax rates, and mortality decreased. The clinical characteristics associated with pneumothorax were male sex; the receipt of IMV; and treatment with steroids, remdesivir, or convalescent plasma. Most patients with pneumothorax received IMV, but pneumothorax developed before the initiation of IMV and/or early during hospitalization in majority. Multivariable analysis revealed that pneumothorax increased the risk of death (adjusted hazard ratio [aHR], 1.15; 95% CI, 1.06-1.24). In patients who did not receive IMV, pneumothorax led to nearly twice the mortality (aHR, 1.99; 95% CI, 1.56-2.54). Increased mortality was also noted when pneumothorax occurred before IMV (aHR, 1.37; 95% CI, 1.11-1.69) and within 7 days of hospital admission (aHR, 1.60; 95% CI, 1.29-1.98).ConclusionThe overall incidence of pneumothorax in patients hospitalized for COVID-19 was low. Pneumothorax is an independent risk factor for death.

Role of Early Enteral Nutrition in Mechanically Ventilated COVID-19 Patients.

OBJECTIVES:Current guidance recommends initiation of early enteral nutrition (early EN) within 24–36 hours of ICU admission in critically ill COVID-19 patients. Despite this recommendation, there is quite limited evidence describing the effect of early EN on outcomes in COVID-19 patients. The association between early EN (within 3 d post intubation) and clinical outcomes in adult COVID-19 patients requiring mechanical ventilation (within 2 d post ICU admission) was evaluated.DESIGN:We performed a nationwide observational cohort study using a nationwide administrative-financial database (Premier) in United States.SETTING:Information pertaining to all COVID-19 patients admitted to ICU from 75 hospitals between April and December 2020 was analyzed.PATIENTS:A total of 861 COVID-19 patients were included.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:Clinical outcomes were assessed via regression models to control for patient and hospital characteristics. We identified 513 COVID-19 ICU patients (59.2%) requiring mechanical ventilation who received early EN and had similar baseline characteristics to late EN group. Compared with late EN group, the early EN group had shorter ICU (hazard ratio [HR], 1.39; 95% CI, 1.15–1.68) and hospital length of stays (LOS) (HR, 1.53; 95% CI, 1.23–1.91), fewer mechanical ventilation days (HR, 1.25; 95% CI, 1.01–1.54), and lower cost (–$22,443; 95% CI, –$32,342 to –$12,534). All comparisons were statistically significant (p < 0.05).CONCLUSIONS:In patients with COVID-19 requiring mechanical ventilation, early EN is associated with earlier liberation from mechanical ventilation, shorter ICU and hospital LOS, and decreased cost. Our results are among the first to support guideline recommendations for initiation of early EN in COVID-19 ICU patients. Further, our data show nearly 40% of critically ill COVID-19 patients fail to have early EN initiated, even at 3 d post initiation of mechanical ventilation. These results emphasize the need for targeted strategies promoting initiation of early EN, as this may lead to improved clinical and economic outcomes in severe COVID-19 patients.

To study the ventilator associated pneumonia in the ICU patients in a tertiary care hospital: Incidence, risk factors and etiological agents

Ventilator Associated Pneumonia (VAP) is the second most common nosocomial infection in the United States, with high mortality and morbidity. Duration of hospital stay increased in average of 7 to 9 days with increase in treatment cost of $40,000 per patient. However, clinical evidence on the incidence of this infection is poor, especially from ICUs in India. : To study the incidence, risk factors and etiological agents in ICU patients developing VAP in a tertiary care hospital in India.In this study, patients who were kept on ventilator for more than 48 hours in ICU were enrolled. To clinically diagnose VAP, the modified clinical pulmonary infection score (CPIS) and clinical criteria were used as a screening tool. A full clinical history of the patients was documented, as well as the date of admission to the ICU, the date of initiation of mechanical ventilation, and the method of access to the patients' airway. A standard PROFORMA was used and the collected data was observed and analysed further. : In the present study out of 45 patients enrolled for the study, only 6 patients (13.3%) showed VAP. The presence of early VAP was observed in 3 patients whereas late VAP was also observed in 3 patients. The male and female patients exhibited similar incidences of VAP. The patients with an age group more than 70 years showed a maximum (37.5%) prevalence of VAP. Clinical features like fever and increased amount of secretions were found to be associated with the occurrence of VAP. Smoking and diseases like hypertension, kidney disease, malignancy and chronic lung disease were non-significantly associated with VAP. Whereas disease states like coma and enteral nutrition were found to be significantly associated with VAP. Acinetobacter and Klebsiella were the most common organisms isolated in our institution.: VAP remains a significant concern to patients admitted to an ICU for mechanical ventilation, highlighting the critical need for preventive measures.

Does closed-loop automated oxygen control reduce the duration of mechanical ventilation? A randomised controlled trial in ventilated preterm infants

BackgroundMany preterm infants require supplemental oxygen in the newborn period but experience frequent fluctuations of their oxygen saturation levels. Intermittent episodes of hypoxia or hyperoxia increase the risk of complications. Compliance with achievement of oxygen saturation targets is variable, and the need for frequent adjustments of the inspired oxygen concentration increases workload.Closed-loop automated oxygen control systems (CLAC) improve achievement of oxygen saturation targets and reduce both episodes of hypoxia and hyperoxia and the number of manual adjustments. This study investigates whether CLAC compared with manual oxygen control reduces the duration of mechanical ventilation in preterm infants born at less than 31 weeks of gestation.MethodsThis randomised controlled trial performed at a single tertiary neonatal unit is recruiting 70 infants born at less than 31 weeks of gestational age and within 48 h of initiation of mechanical ventilation. Infants are randomised to CLAC or manual oxygen control from recruitment until successful extubation. The primary outcome is the duration of mechanical ventilation, and secondary outcomes are the percentage of time spent within target oxygen saturation ranges, the time spent in hypoxia or hyperoxia, the number of manual adjustments required, the number of days on oxygen, the incidence of bronchopulmonary dysplasia and the length and cost of neonatal unit stay. The study is performed following informed parental consent and was approved by the Yorkshire and the Humber-Sheffield Research Ethics Committee (protocol version 1.1, 13 July 2021).DiscussionThis trial will investigate the effect of CLAC on the duration of mechanical ventilation, which is an important clinical outcome as prolonged mechanical ventilation is associated with important adverse outcomes, such as bronchopulmonary dysplasia.Trial registrationClinicalTrials.Gov NCT05030337. Registered on 17 August 2021