Length Of Invasive Mechanical Ventilation Research Articles

Hypoxemia Trajectory of Non-COVID-19 Acute Respiratory Distress Syndrome Patients. An Observational Study Focusing on Hypoxemia Resolver Status.

Most studies on acute respiratory distress syndrome (ARDS) group patients by severity based on their initial degree of hypoxemia. However, this grouping has limitations, including inconsistent hypoxemia trajectories and outcomes. This study explores the benefits of grouping patients by resolver status based on their hypoxemia progression over the first 7 days. This is an observational study from a large single-center database. Medical Information Mart for Intensive Care (MIMIC)-IV and MIMIC Chest X-ray JPEG databases were used. Mechanically ventilated patients that met the Berlin ARDS criteria were included. The primary outcome was the proportion of hypoxemia resolvers vs. nonresolvers in non-COVID-19 ARDS patients. Nonresolvers were defined as those whose hypoxemia worsened or remained moderate or severe over the first 7 days. Secondary outcomes included baseline admission characteristics, initial blood gases and ventilation settings, length of invasive mechanical ventilation, length of ICU stay, and ICU survival rates across resolver groups. A total of 894 ICU admissions were included in the study. Of these, 33.9% were hypoxemia nonresolvers. The resolver groups showed no significant difference in age, body mass index, comorbidities, or Charlson score. There was no significant difference in the percentage of those with initial severe hypoxemia between the two groups (8.1% vs. 9.2%; p = 0.126). The initial Pao2/Fio2 ratio did not significantly increase the odds ratio (OR) of being a nonresolver (OR, 0.84; 95% CI, 0.65-1.10). Nonresolver mortality was 61.4%, comparable to the survival rates seen in nonresolvers in a previous large COVID-19 ARDS study. Our study shows that resolver status is a valuable grouping in ARDS. It has significant advantages over grouping by initial degree of hypoxemia, including better mapping of trajectory and comparable outcomes across other studies. While it may offer insights into disease-specific associations, future studies should include resolver status analysis for more definitive conclusions.

Role of Selective Digestive Decontamination in the Prevention of Ventilator-Associated Pneumonia in COVID-19 Patients: A Pre-Post Observational Study

The aim of our study was to evaluate whether the introduction of SDD in a structured protocol for VAP prevention was effective in reducing the occurrence of ventilator-associated pneumonia (VAP) in COVID-19 patients without changes in the microbiological pattern of antibiotic resistance. This observational pre-post study included adult patients requiring invasive mechanical ventilation (IMV) for severe respiratory failure related to SARS-CoV-2 admitted in three COVID-19 intensive care units (ICUs) in an Italian hospital from 22 February 2020 to 8 March 2022. Selective digestive decontamination (SDD) was introduced from the end of April 2021 in the structured protocol for VAP prevention. The SDD consisted of a tobramycin sulfate, colistin sulfate, and amphotericin B suspension applied in the patient's oropharynx and the stomach via a nasogastric tube. Three-hundred-and-forty-eight patients were included in the study. In the 86 patients (32.9%) who received SDD, the occurrence of VAP decreased by 7.7% (p = 0.192) compared to the patients who did not receive SDD. The onset time of VAP, the occurrence of multidrug-resistant microorganisms AP, the length of invasive mechanical ventilation, and hospital mortality were similar in the patients who received and who did not receive SDD. The multivariate analysis adjusted for confounders showed that the use of SDD reduces the occurrence of VAP (HR 0.536, CI 0.338-0.851; p = 0.017). Our pre-post observational study indicates that the use of SDD in a structured protocol for VAP prevention seems to reduce the occurrence of VAP without changes in the incidence of multidrug-resistant bacteria in COVID-19 patients.

Can the Duration of In-Hospital Ventilation in Patients with Sepsis Help Predict Long-Term Survival?

Mechanical ventilation is a cornerstone in the treatment of critical illness, especially sepsis. Prolonged mechanical ventilation, for a duration exceeding 21 days, is associated with higher rates of in-hospital and post-discharge mortality. Our aim was to assess the association between in-hospital ventilation duration and long-term life expectancy in patients ventilated in intensive care units specifically due to sepsis of any origin. We conducted a population-based retrospective cohort study of adults hospitalized in a general intensive care unit for 24 h or more during 2007–2017, who were diagnosed with sepsis or septic shock, treated with invasive mechanical ventilation for a maximum of 60 days and survived hospitalization. The primary exposure was the length of invasive mechanical ventilation. In an adjusted multivariable regression model, survival rates at 1, 2, 3 and 4 years post-hospitalization did not differ significantly between patients who were ventilated for 3–8 days (n = 169), 9–21 days (n = 160) or 22–60 days (n = 170), and those who were ventilated for 1–2 days (n = 192). We concluded that the duration of in-hospital ventilation in patients with sepsis cannot serve as a predictor for long-term survival. Thus, the duration of ventilation in itself should not guide the level of care in ventilated patients with sepsis.

Health-related quality of life profiles, trajectories, persistent symptoms and pulmonary function one year after ICU discharge in invasively ventilated COVID-19 patients, a prospective follow-up study

BackgroundHealth-related quality of life (HRQoL) impairment is often reported among COVID-19 ICU survivors, and little is known about their long-term outcomes.We evaluated the HRQoL trajectories between 3 months and 1 year after ICU discharge, the factors influencing these trajectories and the presence of clusters of HRQoL profiles in a population of COVID-19 patients who underwent invasive mechanical ventilation (IMV). Moreover, pathophysiological correlations of residual dyspnea were tested. MethodsWe followed up 178 survivors from 16 Italian ICUs up to one year after ICU discharge. HRQoL was investigated through the 15D instrument. Available pulmonary function tests (PFTs) and chest CT scans at 1 year were also collected. A linear mixed-effects model was adopted to identify factors associated with different HRQoL trajectories and a two-step cluster analysis was performed to identify HRQoL clusters. ResultsWe found that HRQoL increased during the study period, especially for the significant increase of the physical dimensions, while the mental dimensions and dyspnea remained substantially unchanged. Four main 15D profiles were identified: full recovery (47.2%), bad recovery (5.1%) and two partial recovery clusters with mostly physical (9.6%) or mental (38.2%) dimensions affected. Gender, duration of IMV and number of comorbidities significantly influenced HRQoL trajectories. Persistent dyspnea was reported in 58.4% of patients, and weakly, but significantly, correlated with both DLCO and length of IMV. ConclusionsHRQoL impairment is frequent 1 year after ICU discharge, and the lowest recovery is found in the mental dimensions. Persistent dyspnea is often reported and weakly correlated with PFTs alterations. Trial registrationNCT04411459.

Evolution of the nutritional status of COVID-19 critically-ill patients: A prospective observational study from ICU admission to three months after ICU discharge

Background & aimsMalnutrition following intensive care unit (ICU) stay is frequent and could be especially prominent in critically ill Coronavirus Disease 2019 (COVID-19) patients as they present prolonged inflammatory state and long length stay. We aimed to determine the prevalence of malnutrition in critically ill COVID-19 patients both at the acute and recovery phases of infection.MethodsWe conducted a prospective observational study including critically ill COVID-19 patients requiring invasive mechanical ventilation discharged alive from a medical ICU of a university hospital. We collected demographic, anthropometric and ICU stay data (SAPS2, recourse to organ support and daily energy intake). Nutritional status and nutritional support were collected at one month after ICU discharge (M1) by phone interview and at 3 months after ICU discharge (M3) during a specialized and dedicated consultation conducted by a dietitian. Malnutrition diagnosis was based on weight loss and body mass index (BMI) criteria following the Global Leadership Initiative on Malnutrition. Primary outcome was the prevalence of malnutrition at M3 and secondary outcomes were the evolution of nutritional status from ICU admission to M3 and factors associated with malnutrition at M3.ResultsFrom march 13th to may 15th, 2020, 38 patients were discharged alive from the ICU, median [IQR] age 66 [59–72] years, BMI 27.8 [25.5–30.7] kg/m2 and SAPS2 47 [35–55]. Thirty-three (86%) patients were followed up to M3. Prevalence of malnutrition increased during the ICU stay, from 18% at ICU admission to 79% at ICU discharge and then decreased to 71% at M1 and 53% at M3. Severe malnutrition prevailed at ICU discharge with a prevalence of 55% decreasing 32% at M3. At M3, the only factors associated with malnutrition in univariate analysis were the length of invasive mechanical ventilation and length of ICU stay (28 [18–44] vs. 13 [11–24] days, P = 0.011 and 32 [22–48] vs. 17 [11–21] days, P = 0.006, respectively), while no ICU preadmission and admission factors, nor energy and protein intakes distinguished the two groups. Only 35% of undernourished patients at M3 had benefited from a nutritional support.ConclusionMalnutrition is frequent, protracted and probably underrecognized among critically ill Covid-19 patients requiring invasive mechanical ventilation with more than half patients still being undernourished three months after ICU discharge. A particular attention should be paid to the nutritional status of these patients not only during their ICU stay but also following ICU discharge.

Pulmonary Function and Radiologic Features in Survivors of Critical COVID-19: A 3-Month Prospective Cohort

BackgroundMore than 20% of hospitalized patients with COVID-19 demonstrate ARDS requiring ICU admission. The long-term respiratory sequelae in such patients remain unclear.Research QuestionWhat are the major long-term pulmonary sequelae in critical patients who survive COVID-19?Study Design and MethodsConsecutive patients with COVID-19 requiring ICU admission were recruited and evaluated 3 months after hospitalization discharge. The follow-up comprised symptom and quality of life, anxiety and depression questionnaires, pulmonary function tests, exercise test (6-min walking test [6MWT]), and chest CT imaging.ResultsOne hundred twenty-five patients admitted to the ICU with ARDS secondary to COVID-19 were recruited between March and June 2020. At the 3-month follow-up, 62 patients were available for pulmonary evaluation. The most frequent symptoms were dyspnea (46.7%) and cough (34.4%). Eighty-two percent of patients showed a lung diffusing capacity of less than 80%. The median distance in the 6MWT was 400 m (interquartile range, 362-440 m). CT scans showed abnormal results in 70.2% of patients, demonstrating reticular lesions in 49.1% and fibrotic patterns in 21.1%. Patients with more severe alterations on chest CT scan showed worse pulmonary function and presented more degrees of desaturation in the 6MWT. Factors associated with the severity of lung damage on chest CT scan were age and length of invasive mechanical ventilation during the ICU stay.InterpretationThree months after hospital discharge, pulmonary structural abnormalities and functional impairment are highly prevalent in patients with ARDS secondary to COVID-19 who required an ICU stay. Pulmonary evaluation should be considered for all critical COVID-19 survivors 3 months after discharge.

439. Clinical Characteristics and Mortality of an Initial Cohort of COVID-19 Patients in México City

BackgroundAs of today, more than 8 million people have been infected and around 440,000 of them have lost their lives due to complications of SARS-CoV-2 infection.The first confirmed case of COVID-19 in Mexico was on February 28, 2020, and currently, there are more than 150,300 confirmed cases and more than 17,500 deaths have been reported, this work presents the characteristics of the first cases on a tertiary care center with special focus on common comorbidities in Mexicans.MethodsWe conducted a case series of patients with the diagnosis of pneumonia due to SARS-CoV-2 virus admitted to a tertiary care center in Mexico City, between March 14th and May 4th, 2020. Data collected included demographic information, comorbidities, clinical presentation, and outcomes. Regarding clinical outcomes, we measured the need of admission to Intensive Care Unit (ICU), mortality during hospitalization, discharge, and patients that remained hospitalized.Results85 patients were included, median age 53.5 years; 69.4% were male. Most common clinical manifestations at admission were fever (61, 71.8%), cough (29, 34.1%), headache (25, 29.4%) and dyspnea (22, 25.9%). Most common comorbidities were overweight (44/82, 53.6%), obesity (25/82, 30.5%), hypertension (18, 21.2%), and diabetes (17, 20%).31 of 85 (36.5%) patients were diagnosed with critical disease, whereas 54 of 85 (63.5%) were classified as non-critical. In the 31 critically ill patients, the length of invasive mechanical ventilation was 13 days [range {2–45}]; 5 patients (16.1%) required tracheostomy. The mean of mechanical ventilation prior to tracheostomy was 19.8 days [range {14–25}].In all patients, the total length of hospitalization was 12.1 days [range {2–52}], 14.8 days [range {3–52}] in ICU patients, and 6.7 days [range {2–30}] in floor unit patients. No readmissions were documented.Global mortality was 4.7% (9.6% in ICU, 1.8% in floor unit). Of the 4 deceased patients, 3 presented comorbidities (75%), while 1 was previously healthy, documenting massive pulmonary embolism as the cause of sudden death.ConclusionThis study shows that the clinical characteristics in this initial cohort are not different that described elsewhere. Mortality is low but it is mainly related to prevalent comorbidities in the Mexican population.Disclosures All Authors: No reported disclosures

MORTALITY IN PATIENTS WITH OR WITHOUT OSA WHO REQUIRED INVASIVE MECHANICAL VENTILATION: A PROPENSITY SCORE-MATCHED ANALYSIS

SESSION TITLE: Sleep Disorders Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: The prevalence of obstructive sleep apnea (OSA) in the intensive care unit (ICU) has been reported between 6-10%. There is limited data whether there is any mortality impact of OSA in critical care setting. The purpose of this study is to compare in-hospital mortality between patients wiith versus without OSA who required invasive mechanical ventilation (IMV). METHODS: We performed a retrospective cohort study in subjects who admitted in critical care units using Medical Information Mart for Intensive Care-III (MIMIC-III) database. All patients who required IMV were included. Patients were categorized into OSA and non-OSA group. Demgraphic data, comorbidities, length of IMV, hospital length of stay (LOS), Simplified Acute Physiology Scores-II (SAPS-II), in-hospital mortality were collected. Propensity score-matched analysis for gender, ethnicity and SAPS-II was performed. RESULTS: There were 923 and 20,464 patients with OSA and without OSA, respectively. In-hospital mortality were 17.6% in total, 8.7% and 18% in OSA and non-OSA group, respectively (p<0.01). There was no significant difference of ventilator duration or hospital LOS. After propensity score matching was performed, the in-hospital mortality were 8.7% and 15.3% in OSA and non-OSA group, respectively (p<0.01). Median ventilator duration were 17.3 and 19.0 hours in OSA and non-OSA group, respectively (p=0.35). Median hospital LOS were 10.1 and 9.7 days in OSA and non-OSA group, respectively (p=0.53). CONCLUSIONS: Critically-ill patients who required IMV with OSA had lower in-hospital mortality than patients without OSA. CLINICAL IMPLICATIONS: This result might help decreasing hesitancy to place IMV in critically-ill OSA patients. DISCLOSURES: No relevant relationships by Farhan Ali, source=Web Response No relevant relationships by Nikola Djurdjevic, source=Web Response No relevant relationships by Joon Woo Kim, source=Web Response No relevant relationships by Pattharawin Pattharanitima, source=Admin input No relevant relationships by Pahnwat Taweesedt, source=Web Response

Characteristics and Outcomes of COVID-19 Patients with Respiratory Failure Admitted to a “Pandemic Ready” Intensive Care Unit – Lessons from Singapore

Singapore was one of the first countries affected by the coronavirus disease 2019 (COVID-19) pandemic but has been able to prevent its healthcare system and intensive care units (ICU) from being overwhelmed. We describe the clinical features, management and outcomes of COVID-19 patients with respiratory failure admitted to our ICU. A case series of COVID-19 patients admitted to our ICU for respiratory failure from 7 February, with data censoring at 30 June 2020, was performed from a review of medical records. Twenty-two COVID-19 patients were admitted to our ICU for respiratory failure. The median age was 54.5 years (IQR 30-45.5), 72.7% were male and had at least one comorbidity. The Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE) II scores were 2.5 (IQR 1.25-7) and 10 (8.25-12) respectively. Thirteen patients required invasive mechanical ventilation (IMV) and had a median PaO2/FiO2 ratio of 194 mmHg (IQR 173-213) after intubation. The 28-day survival was 100%, with 2 patients demising subsequently. The overall ICU mortality rate was 9.1% at the time of data censoring. In IMV survivors, length of IMV and ICU stay were 11 days (IQR 9-17.75) and 16 days (IQR 12-32) respectively. Low COVID-19 ICU mortality was observed in our "pandemic-ready" ICU. This was achieved by having adequate surge capacity to facilitate early ICU admission and IMV, lung protective ventilation, and slow weaning. Being able to maintain clinical standards and evidence-based practices without having to resort to rationing contributed to better outcomes.

Is noninvasive neurally adjusted ventilatory assistance (NIV-NAVA) an alternative to NCPAP in preventing extubation failure in preterm infants?

Background Prolonged use of mechanical ventilation is associated with some complications as high mortality and high morbidities as bronchopulmonary dysplasia, ventilator-associated pneumonia, and pneumothorax. However, extubation failure in preterm infants is still high (40–60%) in very low birth weight infants (VLBW). Noninvasive neurally adjusted ventilatory assistance (NIV-NAVA) is triggered by the diaphragmatic electrical activity through a nasogastric tube that synchronizes patient/ventilator respiration, cycle by cycle effectively shortening the assisted cycle trigger and the degree of ventilatory assistance, optimizing the effects of intermittent inspiratory pressure on nasal continuous positive airway pressure (NCPAP). This study aims to compare reintubation rates until 72 h after extubation in preterm infants of high risk for reintubation using NIV-NAVA or NCPAP. Methods A retrospective study of chart review data collection was performed in a private tertiary hospital. The study was approved by the local institutional Ethics Committee. We included infants considered at high risk of reintubation (BW < 1000 grams; use of invasive mechanical ventilation (IMV) for at least 7 days; or previous extubation failure episode) and compared the two groups according to the type of respiratory support after extubation: (1) NCPAP (n = 32); or (2) NIV-NAVA (n = 17). Demographics data were collected, the primary outcome was reintubation rate until 72 h after extubation. Secondary outcome was time to reintubation, BPD rate, IVH grade ≥ III, pneumothorax and death. Results There was no difference between both groups in demographic data. The reintubation rate decreased significantly in the NIV-NAVA group compared to NCPAP (50.0–11.7, p < .02) despite the significantly higher length of invasive mechanical ventilation (IMV) before extubation attempt in NIV-NAVA group (12.4 versus 5.5 days, p < .04). There was no difference between both groups in secondary outcomes. Conclusions In this small retrospective cohort study, the use of NIV-NAVA as postextubation strategy was effective in reducing extubation failure within 72 h in preterm infants when compared to traditional NCPAP.

Predictive value of dynamic serum phosphorus levels in the prognosis of patients with sepsis

To explore the predictive value of dynamic serum phosphorus levels in the evaluation of prognosis in patients with sepsis. A retrospective study was conducted. The septic patients admitted to intensive care unit (ICU) of the Second People's Hospital of Changzhou from January 2016 to June 2017 were enrolled, who were ≥18 years old and whose length of ICU stay > 72 hours. These patients were divided into survival group and death group according to 28-day outcome. The general information, the acute physiology and chronic health evaluation II (APACHE II) score within 24 hours of ICU admission, the serum phosphorus at 1, 3, 5, 7 days after admission were collected. Receiver operating characteristic curve (ROC) was plotted according to the dynamic serum phosphorus levels and APACHE II score for evaluating the predictive value of 28-day prognosis. Kaplan-Meier survival curve was used to analyze the 28-day cumulative survival rate between two groups of patients, who were divided according to the corresponding time of the serum phosphorus cut-off value. (1) Eighty-five patients with sepsis were enrolled, among whom 25 cases were in the death group and the mortality was 29.4%. APACHE II score in the death group was significantly higher than that in the survival group (22.28±3.98 vs. 16.05±5.44, P < 0.01), the rate of using vasoactive drugs was significantly higher than that in the survival group [64.0% (16/25) vs. 31.7% (19/60), P < 0.01], but there was no significant difference in the length of invasive mechanical ventilation and ICU stay between two groups. (2) The level of serum phosphorus was increased in survival group along with time of the treatment, and the death group showed a downward trend. The levels of serum phosphorus at 3, 5, 7 days after admission to ICU in death group were significantly lower than those in survival group (mmol/L: 0.90±0.24 vs. 1.05±0.19 at 3 days, 0.96±0.16 vs. 1.11±0.17 at 5 days, 0.83±0.19 vs. 1.21±0.14 at 7 days, all P < 0.01).(3) ROC curve analysis showed that APACHE II score and serum phosphorus level on the 7th day could significantly predict 28-day mortality in patients with sepsis, and the areas under ROC curve (AUC) of them were 0.813 and 0.945 respectively (both P < 0.01). The AUC of serum phosphorus level on the 3rd day and 5th day were 0.692 and 0.745 respectively (both P < 0.01). Based on serum phosphorus cut-off value 1.01 mmol/L on the 7th day to evaluate the predictive value of 28-day mortality, the sensitivity was 91.7%, the specificity was 84.0%, the positive and negative likelihood ratios were 5.73 and 0.10 respectively. (4) Kaplan-Meier survival analysis showed that the 28-day survival rate was significantly higher and the length of survival was significantly longer if the serum phosphorus were higher than the cut-off value at different time points of ICU admission. The 28-day survival rate was significantly higher and the length of survival was significantly longer in the patients with serum phosphorus > 1.01 mmol/L than those serum phosphorus ≤ 1.01 mmol/L on the 7th day [28-day survival rate: 93.2% (55/59) vs. 22.7% (5/22), χ 2 = 49.697, P = 0.000; survival period (days): 27.1±3.6 vs. 19.8±7.8, t = 4.768, P = 0.000]. The continuous decline of serum phosphorus indicates poor prognosis, and the serum phosphorus level on the 7th day is one of the most important indicator to evaluate the prognosis of patients with sepsis.

Análise do tempo de ventilação mecânica e internamento em pacientes submetidos a cirurgia cardíaca

Introdução: Pacientes submetidos à cirurgia cardíaca (CC) necessitam de ventilação mecânica invasiva (VMI) após o procedimento cirúrgico, sendo que um tempo prolongado de VMI pode levar a um aumento do tempo de permanência na Unidade de Terapia Intensiva (UTI). Objetivo: Verificar se o tempo de VMI interfere no tempo de internação em UTI. Métodos: Foram analisados, prospectivamente, pacientes submetidos à CC e que permaneceram por um tempo inferior a 24 horas na VMI. Foram selecionados 69 pacientes, os quais foram admitidos na UTI e acompanhados até o momento da extubação. Com esse dado encontrou-se o tempo que permaneceram em VMI e, depois, quantos dias permaneceram internados na UTI até o momento da alta da unidade. Resultados: A maior parte dos pacientes submetidos à CC foi do sexo masculino (56,5%); a idade média foi de 55,93±14,29 anos; o tipo de cirurgia mais prevalente foi a revascularização miocárdica (71,0%); o tempo médio de circulação extracorpórea (CEC) foi de 65,05±20,06 minutos; o tempo médio de internação na UTI foi de 2,18±1,10 dias; o tempo de VMI foi de 7,32±2,66 horas. Não se verificou significância estatística entre essas duas últimas variáveis com um p=0,43. Conclusão: Pode-se concluir que não houve correlação entre o tempo de ventilação mecânica e tempo de internação em UTI em pacientes que não apresentaram complicações pós-operatórias imediatas e que permaneceram menos de 12 horas sob ventilação mecânica.

Pediatric Acute Respiratory Distress Syndrome in Pediatric Allogeneic Hematopoietic Stem Cell Transplants: A Multicenter Study.

Immunodeficiency is both a preexisting condition and a risk factor for mortality in pediatric acute respiratory distress syndrome. We describe a series of pediatric allogeneic hematopoietic stem cell transplant patients with pediatric acute respiratory distress syndrome based on the recent Pediatric Acute Lung Injury Consensus Conference guidelines with the objective to better define survival of this population. Secondary analysis of a retrospective database. Twelve U.S. pediatric centers. Pediatric allogeneic hematopoietic stem cell transplant recipients requiring mechanical ventilation. None. During the first week of mechanical ventilation, patients were categorized as: no pediatric acute respiratory distress syndrome or mild, moderate, or severe pediatric acute respiratory distress syndrome based on oxygenation index or oxygen saturation index. Univariable logistic regression evaluated the association between pediatric acute respiratory distress syndrome and PICU mortality. A total of 91.5% of the 211 patients met criteria for pediatric acute respiratory distress syndrome using the Pediatric Acute Lung Injury Consensus Conference definition: 61.1% were severe, 27.5% moderate, and 11.4% mild. Overall survival was 39.3%. Survival decreased with worsening pediatric acute respiratory distress syndrome: no pediatric acute respiratory distress syndrome 66.7%, mild 63.6%, odds ratio = 1.1 (95% CI, 0.3-4.2; p = 0.84), moderate 52.8%, odds ratio = 1.8 (95% CI, 0.6-5.5; p = 0.31), and severe 24.6%, odds ratio = 6.1 (95% CI, 2.1-17.8; p < 0.001). Nonsurvivors were more likely to have multiple consecutive days at moderate and severe pediatric acute respiratory distress syndrome (p < 0.001). Moderate and severe patients had longer PICU length of stay (p = 0.01) and longer mechanical ventilation course (p = 0.02) when compared with those with mild or no pediatric acute respiratory distress syndrome. Nonsurvivors had a higher median maximum oxygenation index than survivors at 28.6 (interquartile range, 15.5-49.9) versus 15.0 (interquartile range, 8.4-29.6) (p < 0.0001). In this multicenter cohort, the majority of pediatric allogeneic hematopoietic stem cell transplant patients with respiratory failure met oxygenation criteria for pediatric acute respiratory distress syndrome based on the Pediatric Acute Lung Injury Consensus Conference definition within the first week of invasive mechanical ventilation. Length of invasive mechanical ventilation, length of PICU stay, and mortality increased as the severity of pediatric acute respiratory distress syndrome worsened.

Tigecycline combination for ventilator-associated pneumonia caused by extensive drug-resistant Acinetobacter baumannii.

Extensive drug-resistant Acinetobacter baumannii (XDR A. baumannii) has emerged as an important pathogen in patients with ventilator-associated pneumonia (VAP) worldwide. This study determined whether or not combination tigecycline (TGC) treatment improved the short-term outcome of patients with XDR A. baumannii-induced VAP. Methods: Fifty-eight patients admitted to our intensive care unit (ICU) with confirmed XDR A. baumannii VAP between January 2011 and June 2013 were retrospectively studied. Fourteen patients were excluded. The included subjects were classified into two groups depending on treatment regimens with or without TGC (TGC group, n=20; non-TGC group, n=24). Thirty-day mortality rates, and clinical and microbiologic responses were reviewed and compared in detail. Microbiological eradication was observed in 3 patients (15.0%) in the TGC group and 7 patients (29.2%) in the non-TGC group (P=0.264). The mean time-to-eradication of XDR A. baumannii was 5.3±2.1 versus 7.6±4.0 days (P=0.395). Ten of 20 (50%) patients developed resistance to TGC after initiation of TGC therapy in the TGC group. Clinical cure were achieved in 50.0% of the patients (10/20) in the TGC group and 45.8% of the patients (7/24) in the non-TGC group (P=1.000). No differences existed in the 30-day mortality, length of ICU stay, length of hospital stay (LOS), and length of invasive mechanical ventilation (MV) between the two groups. The occurrence of septic shock was significantly lower in the TGC group (20.0% vs. 54.2%; P=0.030). TGC combination therapy did not improve the clinical cure and microbiologic eradication in patients with XDR A. baumannii VAP. TGC combination therapy did not decrease all-cause mortality in patients with XDR A. baumannii VAP. TGC combination therapy reduced the incidence of septic shock in patients with XDR A. baumannii VAP, and might decrease the incidence of poly-microbial VAP. TGC combination therapy can only be recommended as an option when other optimized therapeutics, such as colistin, are unavailable.

Quality of life of critically ill patients in a developing country: a prospective longitudinal study.

[Purpose] To evaluate the quality of life of critical illness survivors in a developing country over the time after hospital discharge and to assess the influence of clinical variables on quality of life. [Subjects and Methods] A prospective longitudinal study was conducted in a large, tertiary, public hospital in Sao Paulo, Brazil. We included patients ≥18 years old, hospitalized in the intensive care unit with ≥24 hours of invasive mechanical ventilation. Quality of life was assessed using the Medical Outcomes Study 36-Item Short Form Health Survey, which was applied by telephone interview at the first, third and sixth months after hospital discharge. [Results] 75 patients were included in the study. Quality of life improved progressively after hospital discharge; role-physical was the most compromised domain. The physical component was influenced by the age. Quality of life was not influenced by Apache II categorization, length of invasive mechanical ventilation, intensive care unit stay or hospital stay. [Conclusion] Survivors of critical illness in a developing country present poor quality of life, which improves over time. Age influenced the physical component of quality of life.

An analysis of prognostic factors in patients suffering from acute lung injury/acute respiratory distress syndrome complicated with Yangming Fushi syndrome: a report of 206 cases from multiple centers

To investigate the risk factors of patients with acute lung injury/acute respiratory distress syndrome (ALI/ARDS) complicated with Yangming Fushi syndrome. A prospective study was conducted. From August 2009 to July 2013, 206 patients with Yangming Fushi syndrome combined with ALI/ARDS were enrolled in the intensive care units (ICUs) of the following five hospitals: Tianjin Nankai Hospital, Dongzhimen Hospital Affiliated to Beijing Traditional Chinese Medicine University, General Hospital of Tianjin Medical University, the First Affiliated Hospital of Dalian Medical University, and Wuxi Third People's Hospital in Jiangsu Province. According to the mortality occurring in ICU, the patients were divided into death group and survival group. The gender, age, acute physiology and chronic health evaluation II (APACHEII) score within the first 24 hours after admission, the length of invasive mechanical ventilation, usage of vasoactive agents, ratio of operative intervention, the length of stay in ICU, application of continuous renal replacement therapy (CRRT), amount of blood transfusion, the level of C-reactive protein (CRP), lactulose/mannitol (L/M) ratio, the number of organs with dysfunction, oxygenation index (PaO2/FiO2), levels of lactate and serum creatinine (SCr) of both groups were recorded. Logistic regression analysis was used to look for the independent risk factors of death of patients. There were 124 cases with severe acute pancreatitis (SAP), which was the most common disease with manifestation of Yangming Fushi syndrome combined with ALI/ARDS, accounting for 60.19% of all the patients. During the period of hospitalization in ICU, 171 patients survived and 35 died, and the mortality rate was 16.99%. The risk factors of the two groups were analyzed by variable analysis, and it was shown that compared with those in survival group, the age (years: 57.26±16.23 vs. 48.07±13.48, t=3.544, P=0.000), APACHEII score (20.83±9.73 vs. 12.61±6.63, t=4.777, P=0.000), the length of invasive mechanical ventilation (days: 10.97±7.71 vs. 6.91±2.48, t=2.555, P=0.015) and the number of dysfunction organs (3.11±1.21 vs. 1.60±1.34, t=6.222, P=0.000) in death group were significantly higher. The level of PaO2/FiO2 [mmHg (1 mmHg=0.133 kPa): 218.56±64.90 vs. 244.58±85.10, t=-2.024, P=0.044] in the death group was significantly lower than that of the survival group, while the length of ICU stay (days: 14.33±10.81 vs. 9.11±7.37, t=2.600, P=0.010), the usage rates of CRRT [28.57% (10/35) vs. 15.20% (26/171), χ2=3.968, P=0.046], vasoactive agents [28.57% (10/35) vs. 12.28% (21/171), χ2=6.511, P=0.011], and blood transfusion ratio [42.86% (15/35) vs. 23.39% (40/171), χ2=7.042, P=0.008] were all obviously higher in the death group than those in the survival group. There were no statistically significant differences in gender, number of operation, the levels of CRP, L/M ratio, lactate and SCr between the two groups (all P>0.05). Multivariate logistic regression analysis showed that age [ odds ratio (OR)=0.938, 95% confidence interval (95%CI)=0.898-0.980, P=0.004], APACHE II score (OR=0.914, 95%CI=0.839-0.996, P=0.041), the number of dysfunction organs≥3 (OR=0.223, 95%CI=0.066-0.754, P=0.016), and the level of PaO2/FiO2 (OR=0.990, 95%CI=0.982-0.998, P=0.015) were independent risk factors for mortality. The age, APACHE II score, number of dysfunction organs≥3 and the level of PaO2/FiO2 are of significance in predicting the prognosis of patients with Yangming Fushi syndrome combined with ALI/ARDS. Patients with risk factors of high mortality should be more carefully monitored and treated aggressively.

Noninvasive mechanical ventilation in chronic obstructive pulmonary disease and in acute cardiogenic pulmonary edema

Noninvasive ventilation (NIV) with conventional therapy improves the outcome of patients with acute respiratory failure due to hypercapnic decompensation of chronic obstructive pulmonary disease (COPD) or acute cardiogenic pulmonary edema (ACPE). This review summarizes the main effects of NIV in these pathologies. In COPD, NIV improves gas exchange and symptoms, reducing the need for endotracheal intubation, hospital mortality and hospital stay compared with conventional oxygen therapy. NIV may also avoid reintubation and may decrease the length of invasive mechanical ventilation. In ACPE, NIV accelerates the remission of symptoms and the normalization of blood gas parameters, reduces the need for endotracheal intubation, and is associated with a trend towards lesser mortality, without increasing the incidence of myocardial infarction. The ventilation modality used in ACPE does not affect the patient prognosis.

Invasive Mechanical Ventilation in Premature Infants: Where do we Stand Today?

Invasive Mechanical Ventilation in Premature Infants: Where do we Stand Today?

Ventilación mecánica no invasiva en la enfermedad pulmonar obstructiva crónica y en el edema agudo de pulmón cardiogénico

Noninvasive ventilation (NIV) with conventional therapy improves the outcome of patients with acute respiratory failure due to hypercapnic decompensation of chronic obstructive pulmonary disease (COPD) or acute cardiogenic pulmonary edema (ACPE). This review summarizes the main effects of NIV in these pathologies. In COPD, NIV improves gas exchange and symptoms, reducing the need for endotracheal intubation, hospital mortality and hospital stay compared with conventional oxygen therapy. NIV may also avoid reintubation and may decrease the length of invasive mechanical ventilation. In ACPE, NIV accelerates the remission of symptoms and the normalization of blood gas parameters, reduces the need for endotracheal intubation, and is associated with a trend towards lesser mortality, without increasing the incidence of myocardial infarction. The ventilation modality used in ACPE does not affect the patient prognosis.