Mechanical Ventilation In Patients Research Articles

Surgical fixation of the chest wall in traumatic fracture: an integrative review

This article proposes to carry out an integrative literature review on the different types of chest wall fixation after traumatic fracture and on the indications for such a procedure. There is still no clear consensus on when fixation should be performed or not, since the conservative approach is still widely used and has its advantages and disadvantages, as does the surgical procedure. This study was based on a bibliographic search on the PubMed platform from January to February 2022, using the strategy: (Rib cage) AND (Osteosynthesis) OR (Fracture Fixation, Internal) NOT (Spine) NOT (Cardiovascular Surgical Procedures), resulting in 22 articles, of which 7 were chosen. Most of the selected articles were of a retrospective nature, and also, all of them referred to an approach with early surgical intervention. Early fixation showed pain relief, shorter hospitalization and intubation time, reduced physical limitations, and better range of thoracic motion. Although no consensus was found on all indications, the literature analyzed points to the superiority of surgical fixation of the costal arches in the prevention and reduction of secondary outcomes, such as chest pain and length of hospital stay and mechanical ventilation in patients with respiratory complications is evident,corroborating the indication of this procedure for this group.

Ventilatory settings in the initial 72 h and their association with outcome in out-of-hospital cardiac arrest patients: a preplanned secondary analysis of the targeted hypothermia versus targeted normothermia after out-of-hospital cardiac arrest (TTM2) trial

PurposeThe optimal ventilatory settings in patients after cardiac arrest and their association with outcome remain unclear. The aim of this study was to describe the ventilatory settings applied in the first 72 h of mechanical ventilation in patients after out-of-hospital cardiac arrest and their association with 6-month outcomes.MethodsPreplanned sub-analysis of the Target Temperature Management-2 trial. Clinical outcomes were mortality and functional status (assessed by the Modified Rankin Scale) 6 months after randomization.ResultsA total of 1848 patients were included (mean age 64 [Standard Deviation, SD = 14] years). At 6 months, 950 (51%) patients were alive and 898 (49%) were dead. Median tidal volume (VT) was 7 (Interquartile range, IQR = 6.2–8.5) mL per Predicted Body Weight (PBW), positive end expiratory pressure (PEEP) was 7 (IQR = 5–9) cmH20, plateau pressure was 20 cmH20 (IQR = 17–23), driving pressure was 12 cmH20 (IQR = 10–15), mechanical power 16.2 J/min (IQR = 12.1–21.8), ventilatory ratio was 1.27 (IQR = 1.04–1.6), and respiratory rate was 17 breaths/minute (IQR = 14–20). Median partial pressure of oxygen was 87 mmHg (IQR = 75–105), and partial pressure of carbon dioxide was 40.5 mmHg (IQR = 36–45.7). Respiratory rate, driving pressure, and mechanical power were independently associated with 6-month mortality (omnibus p-values for their non-linear trajectories: p < 0.0001, p = 0.026, and p = 0.029, respectively). Respiratory rate and driving pressure were also independently associated with poor neurological outcome (odds ratio, OR = 1.035, 95% confidence interval, CI = 1.003–1.068, p = 0.030, and OR = 1.005, 95% CI = 1.001–1.036, p = 0.048). A composite formula calculated as [(4*driving pressure) + respiratory rate] was independently associated with mortality and poor neurological outcome.ConclusionsProtective ventilation strategies are commonly applied in patients after cardiac arrest. Ventilator settings in the first 72 h after hospital admission, in particular driving pressure and respiratory rate, may influence 6-month outcomes.

Analysis of risk factors for prolonged mechanical ventilation in patients with sepsis after abdominal surgery

To analyze the risk factors of prolonged mechanical ventilation (PMV) in patients with sepsis complicated by abdominal surgery, and to evaluate the predictive value of risk factors for PMV. A retrospective case-control study was conducted. The clinical data of patients with postoperative abdominal sepsis complicated with invasive mechanical ventilation who were admitted to the intensive care unit (ICU) of the Affiliated Hospital of Guizhou Medical University from January 1, 2018 to December 31, 2020 were collected. The patients were divided into PMV group (duration of mechanical ventilation longer than 48 hours) and non-PMV group (duration of mechanical ventilation shorter than 48 hours) according to the duration of mechanical ventilation in ICU. The patient's gender, age, body mass index (BMI), underlying diseases, mean arterial pressure (MAP), complete blood count, blood biochemistry, arterial blood gas, cardiac function indicators, procalcitonin (PCT) at admission to the ICU, the acute physiology and chronic health evaluation II (APACHE II) and the sequential organ failure assessment (SOFA) scores in the first 24 hours of admission to the ICU, and other clinical information were recorded. Univariate and multivariate Logistic regression models were used to analyze the risk factors for PMV. Receiver operator characteristic curve (ROC curve) was drawn to evaluate the predictive value of related indicators for PMV. A total of 195 patients with sepsis after abdominal surgery who received invasive mechanical ventilation were enrolled, including 127 males (65.1%) and 68 females (34.9%), with the median age of 65 (21, 93) years old. There were 91 patients (46.7%) in the non-PMV group and 104 patients (53.3%) in the PMV group. Univariate analysis showed that the APACHE II score, SOFA score, cardiac troponin T (cTnT), N-terminal pro-B type natriuretic peptide (NT-proBNP) in the PMV group were significantly higher than those in the non-PMV group. Oxygenation index (PaO2/FiO2), total protein (TP) and prealbumin (PA) in the PMV group were all lower than those in the non-PMV group when admitted to ICU. In the PMV group, serum creatinine (SCr), blood urea nitrogen (BUN), cystatin C (Cys C) were significantly increased, prothrombin time (PT) was significantly prolonged, the proportion of patients with septic shock and hypertension were significantly increased as compared with those in the non-PMV group. Multivariate analysis showed that low PaO2/FiO2 at ICU admission [odds ratio (OR) = 0.995, 95% confidence interval (95%CI) was 0.992-0.999, P = 0.010], high ln PCT (OR = 1.301, 95%CI was 1.088-1.555, P = 0.004), high ln cTnT (OR = 1.562, 95%CI was 1.079-2.261, P = 0.018) and septic shock (OR = 4.967, 95%CI was 2.461-10.026, P = 0.000) were the independent risk factors for PMV in patients with sepsis after abdominal surgery. ROC curve analysis showed that the PaO2/FiO2, ln cTnT, ln PCT and septic shock had certain predictive value for PMV, the area under the ROC curve (AUC) of the four variables were 0.607, 0.638, 0.690 and 0.711, the sensitivity was 50.0%, 62.5%, 86.5% and 74.0%, and the specificity was 71.4%, 62.6%, 48.3% and 68.1%, respectively. The AUC for the joint prediction of the four variables was 0.803, with a sensitivity of 76.0% and a specificity of 78.0%. It suggested that the multivariate joint prediction of PMV was more accurate. Decreased PaO2/FiO2, increased PCT, increased cTnT and the occurrence of septic shock are independent risk factors for PMV in patients with sepsis complicated by abdominal surgery. The combination of above four indices was more accurate than one single variable in predicting PMV and had higher diagnostic value.

Comparison of rapid shallow breathing index versus ultrasonographic guided diaphragmatic thickness fraction as weaning indices on mechanically ventilated patients

Background: The discontinuation or weaning from mechanical ventilation is an important clinical issue which is associated with lot of complications and patient discomfort. So we need a reliable and feasible method for early, safe and effective liberation of patients from mechanical ventilation. The objectives of our study are to determine sensitivity and specificity of rapid sequence breathing index (RSBI) and ultrasonography (USG) guided diaphragmatic thickness fraction (DFT) as weaning indices and to compare their effectiveness. Methods: The study was carried out on mechanical ventilated patients, when they were considered ready for weaning and the underlying disease is stable or resolving. The measurements of RSBI and DFT using USG were carried out. Weaning was taken as successful if the patients could maintain spontaneous breathing at least 48hrs after extubating, otherwise weaning was classified as failed. Results: RSBI and DTF group showed no statistically significant difference in extubation of mechanically ventilated patients in the intensive care unit (ICU). RSBI showed sensitivity of 96%, specificity of 74.4%, positive predictive value of 88.2%, negative predictive value of 80.5%, and accuracy of 87.2%, and DTF showed sensitivity of 96%, specificity of 69.7%, positive predictive value of 82.4%, negative predictive value of 78.9% and accuracy of 81.9%. Conclusion: In our study since there was only one reintubation in each of the groups, that is failure of weaning of one case each in RSBI and DTF groups, both RSBI and DTF has the same sensitivity of 96%, RSBI has better specificity of 74.4% than DTF of 69.7%, RSBI having a better accuracy of 87.2% than DRF which has an accuracy of 81.9%. We conclude that both the methods are equally effective when used as weaning indices for extubation of mechanically ventilated patients.

Can the Multidimensional Prognostic Index Improve the Identification of Older Hospitalized Patients with COVID-19 Likely to Benefit from Mechanical Ventilation? An Observational, Prospective, Multicenter Study.

ObjectiveData on prognostic tools for indicating mechanical ventilation in older people with COVID-19 are still limited. The aim of this research was to evaluate if the Multidimensional Prognostic Index (MPI), based on the Comprehensive Geriatric Assessment (CGA), may help physicians in identifying older hospitalized patients affected by COVID-19 who might benefit from mechanical ventilation.DesignLongitudinal, multicenter study.Settings and Participants502 older people hospitalized for COVID-19 in 10 European hospitals.MethodsMPI was calculated using 8 different domains typical of the CGA. A propensity score, Cox's regression analysis was used for assessing the impact of mechanical ventilation on rehospitalization/mortality for 90 days' follow-up, stratified by MPI = 0.50. The accuracy of MPI in predicting negative outcomes (ie, rehospitalization/mortality) was assessed using the area under the curve (AUC), and the discrimination with several indexes like the Net Reclassification Improvement (NRI) and the Integrated Discrimination Improvement (IDI).ResultsAmong 502 older people hospitalized for COVID-19 (mean age: 80 years), 152 were treated with mechanical ventilation. In the propensity score analysis, during the 90-day follow-up period, there were 44 rehospitalizations and 95 deaths. Mechanical ventilation in patients with MPI values ≥ 0.50, indicating frailer participants, was associated with a higher risk of rehospitalization/mortality (hazard ratio 1.56, 95% CI 1.09-2.23), whereas in participants with MPI values < 0.50 this association was not significant. The accuracy of the model including age, sex, respiratory parameters, and MPI was good (AUC = 0.783) as confirmed by an NRI of 0.2756 (P < .001) and an IDI of 0.1858 (P < .001), suggesting a good discrimination of the model in predicting negative outcomes.Conclusions and ImplicationsMPI could be useful for better individualizing older people hospitalized by COVID-19 who could benefit from mechanical ventilation.

Effect of respiratory mechanics-guided sedation strategy on diaphragm function in mechanical ventilated patients with chronic obstructive pulmonary disease

To investigate the effects of respiratory mechanics-guided sedation strategy on diaphragm function in chronic obstructive pulmonary disease (COPD) patients treated with mechanical ventilation (MV). A prospective study was conducted. Patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) received invasive MV who were admitted to the Affiliated Huxi Hospital of Jining Medical University from May 2020 to May 2021 were enrolled. The patients were divided into observational group and control group by random number table method. All patients were intubated for MV, and received bronchodilators, glucocorticoid, anti-infectives, expectorant, nutritional support, analgesia and sedation. The sedatives were dexmedetomidine combined with propofol, and the analgesics were sufentanil in both groups. Respiratory mechanics monitoring was performed every 6 hours in the observational group, and the depth of sedation was adjusted according to the parameters of respiratory mechanics: when airway resistance (Raw) > 20 cmH2O×L-1×s-1, deep sedation was given to maintain Richmond agitation-sedation scale (RASS) ≤ -3; when the Raw was 10-20 cmH2O×L-1×s-1, the initial depth of sedation maintained to reach the RASS score of -2-0; when Raw < 10 cmH2O×L-1×s-1, withdrawn the sedation, or given light sedation, and maintained the RASS score of -2-0. While the control group received light sedation. The patients' diaphragmatic excursions (DE) was measured by bedside ultrasound, tidal volume (VT) and respiratory rate (RR) were recorded, and the diaphragmatic rapid shallow breathing index (D-RSBI, D-RSBI = RR/DE) and diaphragmatic excursion efficiency (DEE, DEE = VT/DE) were calculated. The differences in DE, D-RSBI, and DEE before and 3 days and 5 days of treatment between the two groups were compared. The difference in the RASS score within 3 days of sedation between the two groups was compared. The differences in the duration of MV and 28-day mortality between the two groups were compared. A total of 96 patients were selected. Six patients were excluded due to delirium or the duration of MV shorter than 3 days. Finally, 90 patients were enrolled, with 46 in the observational group, and 44 in the control group. There were no statistically significant differences in DE, D-RSBI or DEE before treatment between the two groups. After treatment, D-RSBI in both groups was gradually decreased, and DEE was gradually increased with time. The D-RSBI at 3 days and 5 days of treatment in the observational group were significantly lower than those in the control group (times×min-1×mm-1: 1.73±0.48 vs. 1.96±0.35 at 3 days, 1.45±0.64 vs. 1.72±0.40 at 5 days, both P < 0.05), and DEE were significantly higher than those in the control group (mL/mm: 19.7±4.3 vs. 17.1±3.9 at 3 days, 25.8±5.6 vs. 22.9±5.4 at 5 days, both P < 0.05). There was no significant difference in DE at all time points between the two groups. The RASS scores within 2 hours of sedation in the observational group were significantly lower than those in the control group (1 day: -3.78±0.92 vs. -2.34±0.68, 2 days: -2.87±1.04 vs. -2.43±0.79, both P < 0.05), while no statistical difference at 3 days was found between the two groups. The duration of MV in the observational group was significantly shorter than that in the control group (days: 5.78±2.01 vs. 6.84±2.27, P < 0.05). One patient died in each of the control group and the observational group, and there was no significant difference in the 28-day mortality between the two groups (2.3% vs. 2.2%, P > 0.05). For AECOPD patients undergoing MV, respiratory mechanics-guided sedation strategy can reduce D-RSBI, increase DEE, shorten the duration of MV, and have a certain protective effect on the diaphragm.

Prediction of Fluid Responsiveness by the Effect of the Lung Recruitment Maneuver on the Perfusion Index in Mechanically Ventilated Patients During Surgery.

IntroductionExcessive or inadequate fluid administration during perioperative period affects outcomes. Adjustment of volume expansion (VE) by performing fluid responsiveness (FR) test plays an important role in optimizing fluid infusion. Since changes in stroke volume (SV) during lung recruitment maneuver (LRM) can predict FR, and peripheral perfusion index (PI) is related to SV; therefore, we hypothesized that the changes in PI during LRM (ΔPILRM) could predict FR during perioperative period.MethodsPatients who were scheduled for elective non-laparoscopic surgery under general anesthesia with a mechanical ventilator and who required VE (250 mL of crystalloid solution infusion over 10 min) were included. Before VE, LRM was performed by a continuous positive airway pressure of 30 cm H2O for 30 sec; hemodynamic variables with their changes (PI, obtained by pulse oximetry; and ΔPILRM, calculated by using [(PI before LRM—PI after LRM)/PI before LRM]*100) were obtained before and after LRM. After SV (measured by esophageal doppler) and PI had returned to the baseline values, VE was infused, and the values of these variables were recorded again, before and after VE. Fluid responders (Fluid-Res) were defined by an increase in SV ≥10% after VE. Receiver operating characteristic curves of the baseline values and ΔPILRM were constructed and reported as areas under the curve (AUC) with 95% confidence intervals, to predict FR.ResultsOf 32 mechanically ventilated adult patients included, 13 (41%) were in the Fluid-Res group. Before VE and LRM, there were no differences in the mean arterial pressure (MAP), heart rate, SV, and PI between patients in the Fluid-Res and fluid non-responders (Fluid-NonRes) groups. After LRM, SV, MAP, and, PI decreased in both groups, ΔPILRM was greater in the Fluid-Res group than in Fluid-NonRes group (55.2 ± 17.8% vs. 35.3 ± 17.3%, p < 0.001, respectively). After VE, only SV and cardiac index increased in the Fluid-Res group. ΔPILRM had the highest AUC [0.81 (0.66–0.97)] to predict FR with a cut-off value of 40% (sensitivity 92.3%, specificity 73.7%).ConclusionsΔPILRM can be applied to predict FR in mechanical ventilated patients during the perioperative period.

A Brief Analysis of a New Device to Prevent Early Intubation in Hypoxemic Patients: An Observational Study

The need for mechanical ventilation is one of the main concerns related to the care of patients with COVID-19. The aim of this study is to evaluate the efficacy of a bubble device for oxygen supplementation. This device was implemented for the selected patients hospitalized with severe COVID-19 pneumonia with persistent low oxygen saturation. Patients were selected in three major COVID-19 hospitals of Bahia state in Brazil from July to November 2020, where they remained with the device for seven days and were monitored for different factors, such as vital signs, oximetry evaluation, and arterial blood gasometry. Among the 51 patients included in the study, 68.63% successfully overcame hypoxemia without the necessity to be transferred to mechanical ventilation, whereas 31.37% required tracheal intubation (p value &lt; 0.05). There was no difference of note on the analysis of the clinical data, chemistry, and hematological evaluation, with the exception of the SpO2 on follow-up days. Multivariate analysis revealed that the independent variable, male sex, SpO2, and non-inhaled mask, was associated with the necessity of requiring early mechanical ventilation. We concluded that this bubble device should be a prior step to be utilized before indication of mechanical ventilation in patients with persistent hypoxemia of severe COVID-19 pneumonia.

Left ventricular diastolic function compared to inferior vena cava diameter variation as predictor of fluid responsiveness in mechanical ventilated patients with shock: The research protocol

Background: Fluid responsiveness, defined as an increase in cardiac output by 15% after a fluid challenge, is recommended to be evaluated in-patients with shock. Left ventricular (LV) diastolic dysfunction is associated with a lower increment of cardiac output after fluid challenge. Despite being a non-invasive test, the echocardiographic evaluation of the left ventricular diastolic function was rarely studied for the prediction of fluid responsiveness. The objective of this study is to evaluate the efficacy of LV diastolic function in predicting fluid responsiveness, comparing with inferior vena cava (IVC) diameter variation method, among shock patients who required mechanical ventilation. Methods: We plan to enroll adult patients with shock admitted to the intensive care unit (ICU). The echocardiographic hemodynamic parameters include IVC diameter variation, peak velocity of early diastolic filling of mitral valve inflow (E wave), peak early diastolic velocity of the mitral valve annulus (Ea), mitral E/Ea ratio, left ventricular ejection fraction (LVEF) and transaortic cardiac output (CO), all at baseline and after fluid therapy are measured. A fluid challenge with an infusion of 300 ml of acetate Ringer’s solution within 15 minutes will be given. Patients who have an increase in systolic blood pressure of at least 10 mmHg, mean arterial pressure of at least 5 mmHg or cardiac output of at least 15% are defined as fluid responders. The primary outcome of this study is the efficacy of the mitral E/Ea ratio comparing with IVC diameter variation in predicting fluid responsiveness. The secondary outcomes include the rate of fluid responsiveness in mechanically ventilated patients and LVEF and CO in patients with shock in the intensive care units. Conclusion: This study will evaluate the efficacy of left ventricular diastolic function measured by the echocardiography (Mitral E/Ea ratio) in predicting fluid responsiveness among mechanical ventilated patients with shock. Trial registrations: Clinicaltrials.gov NCT05066256, registered on January 10th, 2021

Factors Associated With Deep Sedation Practice in Mechanically Ventilated Patients: A Post hoc Analysis of a Cross-Sectional Survey Combined With a Questionnaire for Physicians on Sedation Practices.

PurposeThe study aimed to explore factors associated with deep sedation practice in intensive care units (ICUs).Materials and MethodsA post hoc analysis was conducted for a cross–sectional survey on sedation practices in mechanically ventilated (MV) patients, combined with a questionnaire for physicians regarding their preferences for light sedation (P–pls Score) in 92 Chinese ICUs.ResultsThere were 457 and 127 eligible MV patients in the light and deep sedation groups respectively. A multivariable logistic regression analysis demonstrated that the control mode of mechanical ventilation, plasma lactate level, and the Sequential Organ Failure Assessment (SOFA) score were independent risk factors for deep sedation practice (p <0.01). Notably, the adjusted odds ratio (95% CI) of the average P–pls score in the ICU ≤ 2 for deep sedation practice was 1.861 (1.163, 2.978, p = 0.01). In addition, the areas under curves of receiver operating characteristics (AUC–ROC) of the model to predict the probability of deep sedation practice were 0.753 (0.699, 0.806) and 0.772 (0.64, 0.905) in the training set and the validation set, respectively. The 28–day mortality was increased in patients with exposure to deep sedation practice but not significantly.ConclusionBoth factors related to stressful stimuli and the ICU physicians' perception of patient tolerability in mechanical ventilation were likely associated with deep sedation practice in MV patients.

Early versus delayed enteral nutrition in mechanically ventilated patients with circulatory shock: a nested cohort analysis of an international multicenter, pragmatic clinical trial

IntroductionReal-world evidence on the timing and efficacy of enteral nutrition (EN) practices in intensive care unit (ICU) patients with circulatory shock is limited. We hypothesized early EN (EEN), as compared to delayed EN (DEN), is associated with improved clinical outcomes in mechanically ventilated (MV) patients with circulatory shock.MethodsWe analyzed a dataset from an international, multicenter, pragmatic randomized clinical trial (RCT) evaluating protein dose in ICU patients. Data were collected from ICU admission, and EEN was defined as initiating < 48 h from ICU admission and DEN > 48 h. We identified MV patients in circulatory shock to evaluate the association between the timing of EN initiation and clinical outcomes. The regression analysis model controlled for age, mNUTRIC score, APACHE II score, sepsis, and Site.ResultsWe included 626 patients, from 52 ICUs in 14 countries. Median age was 60 years [18–93], 55% had septic shock, 99% received norepinephrine alone, 91% received EN alone, and 50.3% were randomized to a usual protein dose. Forty-two percent of EEN patients had persistent organ dysfunction syndrome plus death at day 28, compared to 53% in the DEN group (p = 0.04). EEN was associated with more ICU-free days (9.3 ± 9.2 vs. 5.7 ± 7.9, p = 0.0002), more days alive and free of vasopressors (7.1 ± 3.1 vs. 6.3 ± 3.2, p = 0.007), and shorter duration of MV among survivors (9.8 ± 10.9 vs. 13.8 ± 14.5, p = 0.0002). This trend was no longer observed in the adjusted analysis. There were no differences in ICU/60-day mortality or feeding intolerance rates between groups.ConclusionIn MV patients with circulatory shock, EEN, as compared to DEN, was associated with improved clinical outcomes, but no longer when adjusting for illness severity. RCTs comparing the efficacy of EEN to DEN in MV patients with circulatory shock are warranted.

Front-Loaded Versus Low-Intermittent Phenobarbital Dosing for Benzodiazepine-Resistant Severe Alcohol Withdrawal Syndrome.

Phenobarbital is frequently used to manage severe alcohol withdrawal. The purpose of this study was to compare the incidence of mechanical ventilation in patients with benzodiazepine-resistant alcohol withdrawal between front-loaded and low-intermittent phenobarbital dosing strategies. In this retrospective before-after study, we analyzed patients that received phenobarbital for severe alcohol withdrawal syndrome in a tertiary medical ICU. Patients received low-intermittent phenobarbital doses (260mg intravenous push × 1 followed by 130mg intravenous push every 15min as needed) from January2013 to July 2015, and front-loaded phenobarbital doses (10mg/kg intravenous infusion over 30min) from July 2015 to January 2017. In total, 87 patients met inclusion criteria for this study:41received low-intermittentphenobarbital and 46 receivedfront-loadedphenobarbital). The incidence of mechanical ventilation was 13 (28%) in the front-loaded dosing group vs. 26 (63%) in the low-intermittent dosing group (odds ratio 4.4 [95% CI 1.8-10.9]). The cumulative dose of phenobarbital administered and serum phenobarbital levels were similar between both groups, although the front-loaded group had significantly lower benzodiazepine requirements than the low-intermittent group (median 86mg [IQR 24-197] vs. 228mg [115-298], P < 0.01) and reduced need for any continuous sedative infusion (OR 7.7 [95% CI 1.6-27], P < 0.01). There was no difference in respiratory failure or hypotension. Front-loaded phenobarbital dosing, when compared to low-intermittent phenobarbital dosing, for benzodiazepine-resistant alcohol withdrawal was associated with significantly lower mechanical ventilation incidence and continuous sedative use.

Study on the Effect of the Airway Management Team Intervention on the Incidence of Complications in Mechanical Ventilation in Patients with COPD with Respiratory Failure

Study on the Effect of the Airway Management Team Intervention on the Incidence of Complications in Mechanical Ventilation in Patients with COPD with Respiratory Failure

Nasogastric tube in mechanical ventilated patients: ETCO2 and pH measuring to confirm correct placement. A pilot study.

Nasogastric tube (NGT) placement is a procedure commonly performed in mechanically ventilated (MV) patients. Chest X-Ray is the diagnostic gold-standard to confirm its correct placement, with the downsides of requiring MV patients' mobilization and of intrinsic actinic risk. Other potential methods to confirm NGT placement have shown lower accuracy compared to chest X-ray; end-tidal CO2 (ETCO2) and pH analysis have already been singularly investigated as an alternative to the gold standard. Aim of this study was to determine threshold values in ETCO2 and pH measurement at which correct NGT positioning can be confirmed with the highest accuracy. This was a prospective, multicenter, observational trial; a continuous cohort of eligible patients was allocated with site into two arms. Patients underwent general anesthesia, orotracheal intubation and MV; in the first and second group we respectively assessed the difference between tracheal and esophageal ETCO2 and between esophageal and gastric pH values. From November 2020 to March 2021, 85 consecutive patients were enrolled: 40 in the ETCO2 group and 45 in the pH group. The ETCO2 ROC analysis for predicting NGT tracheal misplacement demonstrated an optimal ETCO2 cutoff value of 25.5 mmHg, with both sensitivity and specificity reaching 1.0 (AUC 1.0, p < 0.001). The pH ROC analysis for predicting NGT correct gastric placement resulted in an optimal pH cutoff value of 4.25, with mild diagnostic accuracy (AUC 0.79, p < 0.001). In patients receiving MV, ETCO2 and pH measurements respectively identified incorrect and correct NGT placement, allowing the identification of threshold values potentially able to improve correct NGT positioning. NCT03934515 (www.clinicaltrials.gov).

Factors influencing the choice of endotracheal intubation and mechanical ventilation in patients with acute respiratory distress syndrome caused by viral pneumonia

To investigate the influencing factors of endotracheal intubation and mechanical ventilation (ETI-MV) in patients with acute respiratory distress syndrome (ARDS) caused by viral pneumonia, and to provide evidence for individualized use of ETI-MV. Patients with ARDS due to viral pneumonia admitted to the respiratory intensive care unit (RICU) of the First Affiliated Hospital of Xinjiang Medical University were retrospectively analyzed from November 2017 to March 2022. The gender, age, concomitant diseases, clinical symptoms and signs, complications, lab results, ARDS severity, infectious virus type, acute physiology and chronic health evaluation II (APACHE II), respiratory support methods and prognosis-related variables were collected. Univariate analysis was performed on each factor, and the variables with statistical significance in the univariate analysis were subjected multivariate logistic regression analysis. The receiver operating characteristic curve (ROC curve) was drawn to evaluate the predictive value of each index for the implementation of ETI-MV. A total of 117 patients were enrolled in the study, including 61 patients in the ETI-MV group, and 3 patients (4.9%), 39 patients (63.9%) and 19 patients (31.1%) with mild, moderate and severe ARDS, respectively. There were 56 patients in non-ETI-MV group, and the mild, moderate and severe ARDS cases were 16 cases (28.6%), 38 cases (67.8%) and 2 cases (3.6%), respectively. There was significant difference between the two groups (P < 0.05). Univariate analysis showed that during 24 hours admitted to RICU, the levels of interleukin-6 [IL-6 (ng/L): 104.0±90.0 vs. 62.4±76.0], oxygenation index [PaO2/FiO2 (mmHg, 1 mmHg ≈ 0.133 kPa): 123.9±30.9 vs. 173.6±28.5], the proportion of cases with pulmonary infiltrating opacity distribution range ≥ 3/4 lung fields [85.3% (52/61) vs. 21.5% (12/56)], APACHE II score ≥ 16.5 [67.2% (41/61) vs. 42.9% (24/56)], the rate of nosocomial invasive aspergillus infection [14.8% (9/61) vs. 3.6% (2/56)], the percentage of nosocomial bacterial infection [16.4% (10/61) vs. 3.6% (2/56)], and the lowest CD4+ T lymphocyte count in the course of the disease [cells/mm3: 192.2±35.8 vs. 215.0±58.3] had significant differences between ETI-MV and non-ETI-MV group (all P < 0.05). Multivariate Logistic regression analysis showed that during 24 hours admitted to RICU the distribution range of pulmonary infiltrating opacity ≥ 3/4 the lung fields [odds ratio (OR) = 12.527, 95% confidence interval (95%CI) = 3.279-47.859, P < 0.001], APACHE II score ≥ 16.5 (OR = 30.604, 95%CI = 4.318-216.932, P = 0.001), PaO2/FiO2 (OR = 0.948, 95%CI = 0.925-0.972, P < 0.001), CD4+ T lymphocytes cell count (OR = 0.975, 95%CI = 0.955-0.995, P = 0.015), and nosocomial bacterial infection (OR = 38.338, 95%CI = 1.638-897.158, P = 0.023) were independent risk factors for ETI-MV. The area under the ROC curve (AUC) of ROC showed that PaO2/FiO2 had the greatest predictive value for ETI-MV, with AUC of 0.903, sensitivity of 91.1% and specificity of 95.1% in case of cutoff value of 151 mmHg. The AUC of pulmonary infiltrating opacity distribution range was 0.809, the sensitivity of 85.2%, specificity of 78.6% when the cutoff value was ≥ 3/4 lung field. APACHE II scores had the lowest predictive value for selecting ETI-MV, with AUC of 0.704, sensitivity of 83.6% and specificity of 57.1% under the cutoff value was 16.5. For patients with ARDS caused by viral pneumonia, PaO2/FiO2 is still the classic reference for selecting ETI-MV, however, the distribution range of pulmonary infiltrating opacity and the systemic severity of the disease during 24 hours admitted to the RICU may provide supplemental helpful information to determine whether the patients choose ETI-MV, especially for moderate ARDS.

Positive end-expiratory pressure and risk of postoperative pulmonary complications in patients living at high altitudes and undergoing surgery at low altitudes: a single-centre, retrospective observational study in China

ObjectivesTo examine whether a high positive end-expiratory pressure (PEEP ≥5 cmH2O) has a protective effect on the risk of postoperative pulmonary complications (PPCs) in a cohort of patients living at...

Mechanical Ventilation during ECMO: Lessons from Clinical Trials and Future Prospects.

Acute Respiratory Distress Syndrome (ARDS) accounts for 10% of ICU admissions and affects 3 million patients each year. Despite decades of research, it is still associated with one of the highest mortality rates in the critically ill. Advances in supportive care, innovations in technologies and insights from recent clinical trials have contributed to improved outcomes and a renewed interest in the scope and use of Extracorporeal life support (ECLS) as a treatment for severe ARDS, including high flow veno-venous Extracorporeal Membrane Oxygenation (VV-ECMO) and low flow Extracorporeal Carbon Dioxide Removal (ECCO2R). The rationale being that extracorporeal gas exchange allows the use of lung protective ventilator settings, thereby minimizing ventilator-induced lung injury (VILI). Ventilation strategies are adapted to the patient's condition during the different stages of ECMO support. Several areas in the management of mechanical ventilation in patients on ECMO, such as the best ventilator mode, extubation-decannulation sequence and tracheostomy timing, are tailored to the patients' recovery. Reduction in sedation allowing mobilization, nutrition and early rehabilitation are subsequent therapeutic goals after lung rest has been achieved.

ELEVATIONS OF PROCALCITONIN AND D-DIMER IN PATIENTS WITH COVID-19 CORRELATE WITH VENTILATOR-ASSOCIATED PNEUMONIA IN THE SETTING OF VENTILATOR-ASSOCIATED EVENTS AND SPUTUM PRODUCTION

TYPE: Abstract TOPIC: Critical Care PURPOSE: It is undetermined whether trending of inflammatory markers in mechanically-ventilated COVID-19 patients is useful in identifying ventilator-associated pneumonia (VAP). The goal of this study is to determine if initial intubation, ventilator-associated events (VAE), or sputum collection was associated with elevations in inflammatory markers, procalcitonin, or positive cultures. METHODS: 287 patients were enrolled in this retrospective study. Data was analyzed into three cohorts: initial intubation, VAE, and sputum collection. Within each group, markers associated with each inciting event were compared to admission values RESULTS: The VAE cohort exhibited differences in WBC (14.1 vs 7.2, p=0.006), d-dimer (4144 vs 881, p<0.001), and CRP (10.4 vs 16, p=0.049). There were no significant differences in procalcitonin and ferritin. The sputum collection cohort revealed differences in WBC (16.8 vs 7.7, p<0.001), procalcitonin (2.95 vs 0.65, p=0.01), and CRP (10.2 vs 15.8, p=0.047). There were no significant differences in FiO2, PEEP, d-dimer, or ferritin. The VAE cohort identified a cultured organism 83% of the time, the initial intubation cohort 35%, and sputum collection cohort 38%. CONCLUSIONS: VAE was associated with a rise in d-dimer, while sputum culture collection was associated with elevated procalcitonin. Interestingly, VAE is suggestive of VAP with an identified organism 83% of the time. Furthermore, d-dimer was associated with VAE and positive organism identification. CLINICAL IMPLICATIONS: This data suggests a role for trending d-dimer and procalcitonin for identification of VAP in setting of a VAE or sputum collection. DISCLOSURE: Nothing to declare. KEYWORD: procalcitonin

Gender Differences in Prolonged Mechanical Ventilation Patients - A Retrospective Observational Study.

BackgroundThe gender differences in patients requiring prolonged mechanical ventilation are not understood. We investigated the effects of gender differences in terms of age, causes of respiratory failure, discharge status, successful weaning, mortality rate and long-term survival outcomes in patients receiving prolonged mechanical ventilation.MethodsWe conducted a six-year retrospective study of patients requiring prolonged mechanical ventilation. Survival curves for all patients requiring prolonged mechanical ventilation and those who were very old (aged ≥ 80 years) were compared based on gender.ResultsAmong the 574 patients enrolled. There was no statistically significant difference between male and female patients regarding successful weaning, ventilator dependence, or in-hospital mortality. We gathered long-term follow-up data on 296 patients, including 70 very old male patients and 41 very old female patients. The 6-month, 3-year, and 5-year mortality rates for the 189 male patients were 75.1%, 85.2%, and 89.9%, respectively; the corresponding rates for the 107 female patients were 66.4%, 86.0%, and 88.8%, respectively. There was no statistically significant difference between two groups regarding mortality rates. The five-year survival curve of male patients was similar to that of female patients. The 6-month, 1-year, and 5-year mortality rates for the 70 very old male patients were 90.0%, 95.7%, and 97.1%, respectively; the corresponding rates for the 41 very old female patients were 63.4%, 90.2%, and 95.1%, respectively. There was a statistically significant difference between very old male and very old female patients in the 6-month mortality rate and the five-year survival curve.ConclusionThere were no gender differences in weaning status, ventilator dependence, in-hospital mortality, or survival outcomes among patients requiring prolonged mechanical ventilation. Among very old patients requiring prolonged mechanical ventilation, the risk of death was 34% lower in very old female patients than in very old male patients for a period of five years.

Effectiveness of augmented alternative communication method on physiological parameters among conscious mechanical ventilation patients

Background: Conscious mechanical ventilation patients in intensive care unit experience intense anxiety due to inability to communicate which might also affect their physiological parameters. Aim: to evaluate the effectiveness of augmented alternative communication method on physiological parameters (heart rate, systolic blood pressure, diastolic blood pressure, respiratory rate and SpO2-oxygen saturation) among conscious MV patients in the ICU. Methodology/Design: Quantitative evaluative approach with quasi experimental (pretest, posttest with control group) research design was adopted in the present study.120 conscious mechanical ventilated patients were randomized into two groups, experimental and conventional care group (60 in each group).The experimental group, mechanical ventilation patients who were awake, aware and responsive to verbal communication was served by a simple assistive communication tool ( augmented alternative communication) for continuous three days. In contrast, only routine or usual nursing communication practice or standard care was provided to the control group. The socio-demographic data, clinical profile, communication difficulties self-evaluation questionnaire, patient satisfaction self-evaluation questionnaire, self-rating Face anxiety scale and Physiological parameters was used to measure study parameters.