Mechanical Ventilation Research Articles

Increasing heterogeneity is associated with IL-6 expression in the lung following mechanical ventilation.

This study aimed to characterize how peak inspiratory pressure (PIP) and positive end expiratory pressure (PEEP) influence regional lung volume heterogeneity as a result of mechanical ventilation, and the influence of this heterogeneity on markers of inflammation within the lungs. Four groups of BALB/C mice (n=7-8 per group) were mechanically ventilated for two hours using low or high (12 cmH2O or 20 cmH2O) peak inspiratory pressure (PIP) with or without 2 cmH2O positive end-expiratory pressure (PEEP). Four-dimensional computed tomography (4DCT) images were acquired using synchrotron-based radiation source, at baseline and after 2 hours. Regional tidal volumes were obtained by 4D cross-correlational X-ray velocimetry while end-expiratory volume was quantified by Hounsfield units. Tissue was harvested from ten lung regions, and expression of IL-6 and MCP-1 were quantified using qPCR. We found a significant reduction in specific end-expiratory volume (sEEV) in mice ventilated with low PIP and no PEEP, and a reduction in tidal volume in groups without PEEP. End-expiratory volume heterogeneity decreased in the low PIP and no PEEP group, while tidal volume heterogeneity decreased in the equivalent high PIP group, potentially due to regional redistribution of lung volumes. We found associations between IL-6 expression and tidal volume heterogeneity. In this study, we have demonstrated that changes in PIP and PEEP impact atelectasis, overdistension and heterogeneity, and that increases in tidal volume heterogeneity may be driving IL-6 mediated biotrauma. These findings highlight the importance of considering the spatial distribution of tidal volumes as a driver of lung injury during mechanical ventilation.

Investigation of the potential bronchodilatory effect of propofol constant rate infusion for suspected reflex bronchoconstriction in isoflurane-anesthetized dogs.

To evaluate the bronchodilatory effect of propofol constant rate infusion (CRI) on PaO2 and PaCO2 in dogs with suspected bronchoconstriction. In this retrospective, observational study, anesthetic records from August 2022 through July 2023 at the Seoul National University Veterinary Medical Teaching Hospital were reviewed. Dogs with PaO2 < 300 mm Hg and PaCO2 > 45 mm Hg during mechanical ventilation under inhalation anesthesia receiving a propofol CRI were included. Ventilatory parameters and arterial blood gas results were extracted, reported as median (range). Arterial partial pressure of oxygen and PaCO2 values before and after propofol CRI were compared. 7 client-owned dogs were identified. Bronchoconstriction was suspected postintubation based on ventilatory parameters (tidal volume of 8.1 [6.0 to 9.3] mL/kg; compliance respiratory system of 0.6 [0.4 to 0.8] mL/cm H2O/kg) and arterial blood gas results. Despite immediate interventions, including optimizing mechanical ventilation, deepening anesthesia, and drug therapy, PaO2 remained < 300 mm Hg. Thus, a propofol CRI (12 to 14 mg/kg/h) was initiated. Arterial partial pressure of oxygen increased following propofol CRI, rising from 153.0 (75.5 to 233.0) mm Hg to 284.0 (183.0 to 386.0) mm Hg at 30 minutes (mean difference, 130.9 mm Hg; 95% CI, 21.4 to 240.3) and to 331.5 (236.0 to 458.0) mm Hg at 60 minutes (mean difference, 168.0 mm Hg; 95% CI, 93.0 to 244.5). Arterial partial pressure of carbon dioxide levels were similar without improvement. Postoperatively, 4 dogs exhibited hypoxemia, taking 60 to 135 minutes to recover. In dogs with perioperative gas exchange problems, PaO2 increased after propofol CRI, though PaCO2 levels remained unchanged. Propofol CRI improved oxygenation in dogs with suspected bronchoconstriction and may serve as a bronchodilatory treatment option.

Incidence and clinical outcomes of ventilator-associated events in Russian tertiary care settings: an analysis of electronic health records

ObjectiveThis research aimed to evaluate the epidemiological and clinical characteristics of ventilator-associated events (VAE) using the CDC framework in a tertiary hospital in Moscow, Russia.ResultsIn this cohort study, we analyzed electronic health records from 407 mechanically ventilated adults who were admitted to the Kommunarka Moscow Multipurpose Clinical Center between September 2022 and December 2023. We identified a total of 35 VAE, resulting in an incidence rate of 8.39 (95% confidence interval, 5.84 to 11.67) events per 1,000 ventilator-days. The presence of VAE was associated with higher ICU mortality by day 30 from the start of mechanical ventilation (adjusted hazard ratio, 1.58; 95% confidence interval, 1.01 to 2.48), particularly in patients with infection-related ventilator-associated complications (adjusted hazard ratio, 2.09; 95% confidence interval, 1.17 to 3.74). The median durations of mechanical ventilation and ICU length of stay were comparable between patients with VAE and those without. Implementing surveillance measures and developing tailored preventive strategies for VAE may be beneficial in similar healthcare settings to improve outcomes for mechanically ventilated patients.

The relationship between admission Braden score and poor prognosis in Sepsis patients: evidence from the MIMIC-III database

BackgroundThe measurement of Braden score can be used as a useful tool for clinical care. However, the relationship between the Braden score and clinical outcomes in sepsis patients remains unclear. This study aims to investigate the association between the Braden score and clinical outcomes in sepsis patients.MethodsThe Medical Information Mart for Intensive Care III (MIMIC-III) database was searched to identify patients with sepsis who had their Braden score measured. The primary outcomes were 28-day, 60-day, and 90-day mortality. Multivariate Cox regression analysis was used to clarify the relationship between Braden score and primary outcomes, and Kaplan-Meier survival analysis and stratified analysis were used to verify our findings.ResultsA total of 8,290 patients were included in our study, during the 28-day, 60-day, and 90-day follow-up periods, mortality was recorded in 1,554, 1,938, and 2,173 patients, those with lower Braden score had a 58% increased risk of 28-day mortality (hazard ratio [HR] 1.58; 95% confidence interval [CI] 1.38, 1.81), a 50% increased risk of 60-day mortality(HR 1.50; 95% CI 1.33,1.70), and a 52% increased risk of 90-day mortality(HR 1.52; 95% CI 1.35,1.70). Patients with lower Braden score received more mechanical ventilation and vasopressors, and presented with elevated WBC counts and lactate levels. In addition, lower Braden scores were also linked to increased adjusted ICU mortality and a higher incidence of AKI within the first seven days following ICU admission.ConclusionLower Braden score is an independent risk factor for mortality in critically ill patients with sepsis. Braden score can be used as a potential indicator for assessing outcomes in such patients.

Comparative assessment of the effect of intrathecal morphine administration on the postoperative period in cardiac surgery patients

Background. The intrathecal use of morphine during cardiac surgery may improve the course of the postoperative period in patients. Earlier studies on the use of the intrathecal form of morphine to optimize postoperative anesthesia and reduce the duration of mechanical lung ventilation have shown contradictory results, and therefore this issue requires further clarification. Objective. To conduct a comparative assessment of the effect of intrathecal morphine administration at a dose of 200 mcg on the course of the postoperative period in patients who underwent elective cardiac surgery under artificial blood circulation. Material and methods. A prospective single-center study included 42 patients over 18 years old. Patients were divided into 2 groups: Group 1 - general anesthesia based on sevoflurane and fentanyl was used; Group 2 - patients who received intrathecal morphine at a dose of 200 mcg 60 minutes before the onset of general anesthesia. All patients underwent elective cardiac surgery under artificial blood circulation. In the postoperative period, the dynamics of changes in acid-base and blood gases, glucose, time to patient extubation, pain intensity, the number of complications and mortality were assessed. Results. Intrathecal morphine administration in patients results in statistically significant (p = 0.017) reduction in postoperative mechanical ventilation duration from (300 (247; 435) min) to 200 (150; 360) min. Pain intensity decreases by 2.1 points at 6 hours after surgeryand by 1.7 points at18-24 hours after surgery. Frequency of intravenous morphine administration decreases in the first postoperative day; NNT (number of patients needed to be treated) indicator was 1.67. Conclusion. Combination of general multicomponent anesthesia with intrathecal morphine administration helps to reduce ALV time, improves postoperative pain relief and reduces need for intravenous narcotic analgesics in cardiac surgery patients.

Post-Cardiopulmonary Arrest Care and Functional Outcomes in Dogs and Cats Surviving to Hospital Discharge Since Publication of the RECOVER Guidelines: 2012-2022.

To describe the in-hospital postcardiac arrest (PCA) care and short- and long-term functional outcomes of dogs and cats surviving to hospital discharge after naturally occurring cardiopulmonary arrest (CPA) and CPR. Multicenter retrospective observational study. Three veterinary teaching hospitals. Client-owned dogs (n=25) and cats (n=15). Medical records of animals that underwent CPR and survived to discharge were retrospectively reviewed, and information was recorded regarding CPR event, PCA hospitalization, and short- and long-term outcomes. Ninety-two percent of CPA events occurred in hospital and were witnessed, and 8% occurred out of hospital. Eighty-five percent of events occurred during general anesthesia or sedation. CPR efforts ranged from <1 to 18min, and animals remained hospitalized between 0.5 and 15.5days after return of spontaneous circulation. Seventy-three percent of animals required supplemental oxygen, 13% required mechanical ventilation, and 20% required vasopressor, positive inotropic, or glucocorticoid therapy. Hyperosmolar therapies were administered to 38% of animals, anticonvulsants were given to 18%, and 8% of animals developed new-onset PCA seizures. The median (range) modified Glasgow Coma Scale score before CPA was 18 (11-18), 12h PCA was 16 (6-18), and 72h PCA was 17.5 (14-18). Median survival time was 455days (range: 11-2650days). Twenty-five percent of owners perceived a persistent disability in their pets, from behavioral changes to required nutritional and recumbent care. Nonetheless, all owners reported their pet's PCA quality of life to be good. Good short- and long-term functional outcomes post-CPA can be achieved in dogs and cats. Functional survival remains possible in some cases of out-of-hospital CPA and after prolonged CPR, suggesting a benefit of high-quality CPR in all scenarios. Patient stabilization and neurological improvement may take 48-72h, and early discouraging findings should not prevent continuation of PCA care.

Unraveling relevant cross-waves pattern drifts in patient-hospital risk factors among hospitalized COVID-19 patients using explainable machine learning methods

BackgroundSeveral studies explored factors related to adverse clinical outcomes among COVID-19 patients but lacked analysis of the impact of the temporal data shifts on the strength of association between different predictors and adverse outcomes. This study aims to evaluate factors related to patients and hospitals in the prediction of in-hospital mortality, need for invasive mechanical ventilation (IMV), and intensive care unit (ICU) transfer throughout the pandemic waves.MethodsThis multicenter retrospective cohort included COVID-19 patients from 39 hospitals, from March/2020 to August/2022. The pandemic was divided into waves: 10/03/2020-14/11/2020 (first), 15/11/2020-25/12/2021 (second), 26/12/2021-03/08/2022 (third). Patient-related factors included clinical, demographic, and laboratory data, while hospital-related factors covered funding sources, accreditation, academic status, and socioeconomic characteristics. Shapley additive explanation (SHAP) values derived from the predictions of a light gradient-boosting machine (LightGBM) model were used to assess potential risk factors for death, IMV and ICU.ResultsOverall, 16,958 adult patients were included (median age 59 years, 54.7% men). LightGBM achieved competitive effectiveness metrics across all periods. Temporal drifts were observed due to a decrease in various metrics, such as the recall for the positive class [ICU: 0.4211 (wave 1) to 0.1951 (wave 3); IMV: 0.2089 (wave 1) to 0.0438 (wave 3); death: 0.2711 (wave 1) to 0.1175 (wave 3)]. Peripheral arterial oxygen saturation to the fraction of inspired oxygen ratio (SatO2/FiO2) at admission had great predictive capacity for all outcomes, with an optimal cut-off value for death prediction of 227.78. Lymphopenia had its association strength increased over time for all outcomes, optimal threshold for death prediction of 643 × 109/L. Thrombocytopenia was the most important feature in wave 2 (ICU); overall, values below 143,000 × 109/L were more related to death.ConclusionData drifts were observed in all scenarios, affecting potential predictive capabilities of explainable machine learning methods. Upon admission, SatO2/FiO2 values, platelet and lymphocyte count were significant predictors of adverse outcomes in COVID-19 patients. Overall, inflammatory response markers were more important than clinical characteristics. Limitations included sample representativeness and confounding factors. Integrating the drift’s knowledge into models to improve effectiveness is a challenge, requiring continuous updates and monitoring of performance in real-world applications.Clinical trial numberNot applicable.

Alcohol related hepatitis in intensive care units: clinical and biological spectrum and mortality risk factors: a multicenter retrospective study

BackgroundAlcohol related hepatitis is responsible for high morbidity and mortality, but little is known about the management of patients with hepatitis specifically in intensive care units (ICU).MethodsRetrospective study including patients with alcohol related hepatitis hospitalized in 9 French ICUs (2006–2017). Alcohol related hepatitis was defined histologically or by an association of clinical and biological criteria according to current guidelines.Results187 patients (median age: 53 [43–60]; male: 69%) were included. A liver biopsy was performed in 51% of cases. Patients were admitted for impaired consciousness (71%), sepsis (64%), shock (44%), respiratory failure (37%). At admission, median SOFA and MELD scores were 10 [7–13] and 31 [26–40] respectively. 63% of patients received invasive mechanical ventilation, 62% vasopressors, and 36% renal replacement therapy. 66% of patients received corticosteroids, and liver transplantation was performed in 16 patients (8.5%). ICU and in-hospital mortality were 37% and 53% respectively. By multivariate analysis, ICU mortality was associated with SOFA score (without total bilirubin) (SHR 1.08 [1.02–1.14] per one-point increase), arterial lactate (SHR 1.08 [1.03–1.13] per 1 mmol/L) and MELD score (SHR 1.09 [1.04–1.14] per 1 point), while employment was associated with increased survival (HR 0.49 [0.28–0.86]). After propensity score weighting, the use of corticosteroids did not affect ICU mortality in the overall population but had a beneficial effect in the subgroup of patients with histological proof. Patient prognosis was also better in responders assessed by Lille score at day 7 (OR 6.67 [2.44–20.15], p < 0.001).ConclusionAlcohol related hepatitis is a severe condition leading to high mortality in ICU patients. Severity of organ failure at admission are mortality risk factors. Outcome was significantly better in responders to corticosteroids therapy according to Lille score. Early referral to tertiary centers to discuss liver transplantation should more widely be considered.

Efficacy of tocilizumab for hospitalized patients with COVID-19 pneumonia and high IL-6 levels: A randomized controlled trial.

The objective of this clinical trial is to evaluate the efficacy and safety of IL-6 driven personalized treatment strategy with tocilizumab in patients with severe COVID-19 pneumonia. Randomized, controlled, open-label, single-center trial of a tocilizumab treatment strategy in adult patients hospitalized with severe COVID-19 pneumonia and IL-6 serum levels > 40pg/mL. Patients were randomized 1:1 to receive standard of care (SOC) or SOC plus one dose of tocilizumab. The primary outcome was death or need for invasive mechanical ventilation (IMV) within 28days after randomization. Secondary outcomes included ICU admission, days on IMV and hospital stay. A meta-analysis of clinical trials to evaluate the effect of tocilizumab on mortality and need of IMV in patients with COVID-19 pneumonia was performed. Sixty-two patients were included: 30 in the SOC arm and 32 in the standard-treatment plus tocilizumab arm. The primary outcome occurred in 12.9% in the tocilizumab arm and 32.3% in the SOC arm(p = 0.068). There was a trend towards fewer days on IMV (7.5 vs 19.5days, p = 0.073) and a shorter hospital stay (4 vs 8days, p = 0.134) in the tocilizumab group. No serious adverse events were reported. The meta-analysis revealed a RR for death or IMV of 0.83 (95% CI: 0.77-0.89) in patients receiving tocilizumab, compared to patients receiving SOC. Tocilizumab could be effective to prevent death or IMV in patients with severe COVID-19 pneumonia and high IL-6 serum levels. Safety profile of tocilizumab does not arise major concern in patients with severe COVID19.

Dural arteriovenous fistula in a neonate presenting with respiratory distress

The patient, a 20-day-old male, was admitted due to respiratory distress that had persisted for 20 days after birth. The main clinical manifestations included gradually worsening respiratory distress and edema. The patient received treatment including mechanical ventilation and diuretics. Echocardiography indicated cardiomegaly, pulmonary hypertension, and heart failure. A comprehensive systemic examination revealed a significant blowing vascular murmur upon auscultation over the anterior fontanelle and bilateral temporal regions. Further imaging studies including cranial magnetic resonance imaging, magnetic resonance angiography, and magnetic resonance venography showed marked dilation of the superior sagittal sinus, transverse sinus, and sigmoid sinus, leading to a definitive diagnosis of dural arteriovenous fistula. After a multidisciplinary consultation, the patient underwent cerebral angiography and partial embolization of the left parietal arteriovenous fistula. Postoperatively, the patient was treated with positive inotropes, diuretics, and fluid restriction. Ultimately, the patient was weaned off the ventilator and discharged in improved condition. This article reports a case of neonatal dural arteriovenous fistula presenting with respiratory distress and discusses the multidisciplinary approach to managing this condition, which aids in early disease recognition and guides clinical decision-making.

Evaluation of Neighborhood Resources and Pediatric Status Epilepticus Outcomes in the Intensive Care Unit Across the United States.

This study aimed to investigate outcomes for children with underlying epilepsy admitted to an intensive care unit for status epilepticus in relation to Child Opportunity Index. Data were obtained from the Pediatric Health Information System for patients aged 1 month to 21 years admitted to the intensive care unit for a primary diagnosis of epilepsy with status epilepticus. Mixed effects regression models were used to estimate the association between Child Opportunity Index and our outcomes: invasive mechanical ventilation, vasoactive medication administration, and in-hospital mortality. Encounters with very low, low, and moderate Child Opportunity Index levels were more likely to receive invasive mechanical ventilation compared to very high Child Opportunity Index level, though there were no differences for vasoactive medication administration or in-hospital mortality. This demonstration of neighborhood disparities specifically for children with epilepsy presenting in status epilepticus to an intensive care unit should inform future interventions aimed at improving neighborhood resources.

In-hospital outcomes of rhinovirus and respiratory syncytial virus infections: a retrospective cohort study

BackgroundAcute respiratory viral infections (ARVI) contribute to hospitalizations, morbidity, and mortality. While rhinoviruses are considered less virulent, respiratory syncytial virus (RSV) shows higher virulence. Limited studies compare in-hospital outcomes of rhinovirus and RSV infections in adults, especially during the COVID-19 Omicron era. Our aim is to compare these outcomes among hospitalized adults.MethodsThis retrospective cohort study evaluated ARVI severity caused by RSV and rhinovirus in adult inpatients at Moinhos de Vento Hospital, Brazil, from April 2022 to July 2023, during the SARS-CoV-2 Omicron period. The primary outcome was a composite of in-hospital death, mechanical ventilation, and ICU admission, with secondary outcomes including individual components, hospital length of stay (LOS), and days alive and out of the hospital (DAOH) over 30 days.Results3,329 tests were conducted, yielding 329 positive results for either rhinovirus (n = 216) or RSV (n = 113). RSV cohort was older than the rhinovirus cohort (69.72 vs. 64.10 years, p = 0.03). No significant differences were found between the groups in gender or comorbidity burden. In the rhinovirus cohort, 33.80% experienced the primary composite outcome, similar to the RSV cohort (37.17%, p = 0.94). Secondary outcomes were also similar, with mean DAOH at 20.20 days for rhinovirus and 20.10 days for RSV (p = 0.12).ConclusionOur study revealed high rates of adverse in-hospital outcomes among adults with rhinovirus and RSV, with over a quarter experiencing death, mechanical ventilation, or ICU admission. Notably, rhinovirus outcomes were similar to those of RSV, challenging the view of rhinovirus as a milder pathogen.

Dyspnea Among Mechanically Ventilated Patients: A Systematic Review.

Dyspnea is a common and distressing symptom; yet, how frequently and intensely mechanically ventilated patients experience dyspnea remains unclear. We performed a systematic review to identify the prevalence and severity of dyspnea in communicative, mechanically ventilated critically ill adults. We also identified factors associated with dyspnea in the short-term and long-term and potential management strategies. We performed a systematic search of the following databases: MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science Core Collection, PsycInfo, and CINAHL. Our search strategy used variations of these terms: dyspnea, mechanical ventilation, and critical care. We included prospective observational studies and randomized controlled trials. Two independent reviewers screened citations and extracted data using a predrafted report form to examine dyspnea prevalence and severity, association with short-term and long-term outcomes, and interventions to mitigate dyspnea. Of 6290 records screened, we included 21 observational studies and 3 randomized controlled trials. We calculated percentages and 95% CIs for prevalence using Stata 17 se. Dyspnea was present in 475 of 1169 communicative, mechanically ventilated patients (40.6%, 95% CI, 37.8-43.5) and was found to be moderate to severe. In the lone study to examine long-term outcomes, dyspnea was associated with posttraumatic stress disorder (PTSD) at 90 days. Interventions to reduce dyspnea included: mechanical threshold inspiratory muscle training, ventilation adjustments, supplemental high-flow nasal cannula, opioids, hyperoxemia, and nonpharmacologic interventions, including music and fan therapy. In this systematic review, we found that dyspnea among mechanically ventilated patients is common and moderate to severe in its intensity. Dyspnea is associated with adverse long-term outcomes, including probable PTSD. Strategies to manage, or palliate, dyspnea were identified. Future study is warranted to examine how this information can be incorporated into clinical practice to improve short-term and long-term outcomes.

Candida Bloodstream Infections and Associated Risk Factors in Pediatric Cardiac Intensive Care

Background: Candida infections have become a significant cause of morbidity and mortality in pediatric cardiac intensive care units following congenital heart surgery, ranking among the most common causes of complications in this patient population. There is a paucity of information available regarding the epidemiology, clinical features, and risk factors associated with candidemia in this patient population. The present study evaluates the incidence of Candida bloodstream infections in pediatric cardiac intensive care units. Methods: The study was conducted retrospectively on cases of patients under the age of 18 who were admitted to the pediatric cardiac intensive care unit between 1 January 2021 and 1 January 2024. The isolated pathogens were recorded. A reanalysis was conducted on 36 patients with Candida bloodstream infections, with data pertaining to age, weight, cardiac pathologies, duration of mechanical ventilation, length of hospital stay, and antibiotic use being subjected to further examination. Each case was matched with two control patients based on age and date of surgery. The results were analyzed statistically. Results: A total of 36 cases of candidemia were identified and matched with 72 control cases. The incidence of candidemia was found to be 21.8 episodes per 1000 hospital admissions. The median age of patients with candidemia was four months. Candida species were identified in the blood cultures of 36 out of 1650 patients (0.21%). Candida albicans (n = 12, 33.3%), Candida parapsilosis (n = 16, 44.4%), Candida glabrata (n = 2, 5.5%), and other non-albicans Candida species (n = 6, 16.6%) were isolated. The mortality rate associated with Candida bloodstream infections was 61.1% (22/36). The following independent risk factors were identified as being associated with candidemia: a birth weight of less than 2500 g (OR: 3.2; 95% confidence interval (CI): 2.5–5; p = 0.009), a RACHS-1 score of 4 or above (OR: 2.1; 95% CI: 1.3–6; p = 0.01), cumulative antibiotic exposure of seven days or more (OR: 2.5; 95% CI: 2–10; p &lt; 0.001), duration of central venous catheterization (CVC) of ≥14 days (OR: 6.1; 95% CI: 4–18; p &lt; 0.001), mechanical ventilation dependency of ≥10 days (OR: 4.2; 95% CI: 3–11; p = 0.01), a requirement for total parenteral nutrition (OR: 9; 95% CI: 6–24; p &lt; 0.001), and delayed sternal closure of ≥2 days (OR: 1.8; 95% CI: 1–4; p = 0.04). Conclusions: Postoperative candidemia represents a significant complication in pediatric patients with congenital heart disease (CHD), with different Candida species identified as a potential cause. The primary risk factors that contribute to the likelihood of a Candida bloodstream infection in these cases are a low birth weight, a high RACHS-1 score, dependence on mechanical ventilation, prolonged exposure to antibiotics, prolonged central venous catheter duration, delayed sternal closure, and total parenteral nutrition.

Echocardiography-Based Pulmonary Artery Pulsatility Index Correlates with Outcomes in Patients with Acute Pulmonary Embolism

Objectives: The pulmonary artery pulsatility index (PAPI) is a novel hemodynamic parameter that reflects right ventricular (RV) function. PAPI was shown to be useful in predicting outcomes following left ventricular assist device (LVAD) implantation, acute RV infarction, and in patients with chronic RV failure. The standard method to estimate PAPI is during right heart catheterization (RHC); however, echocardiography-based PAPI was also shown to be accurate. In the current study, we evaluated the ability of echocardiography-based PAPI to predict outcomes of patients with acute pulmonary embolism (PE). Methods: A total of 177 patients (mean age 67 ± 15, 54.1% male) with acute PE were included in the study. PAPI was calculated based on measurements from standard transthoracic echocardiography. Results: 27% of patients needed oxygen support, 5.6% were on mechanical ventilation, and 7.3% were on inotropic support. The 30-day mortality rate in the whole cohort was 8.3%. Lower PAPI measurements were associated with increased 30-day mortality (p &lt; 0.05), a higher rate of RV failure (p &lt; 0.001), and the need for inotropic support (p &lt; 0.05). There was no association between PAPI and the need for oxygen support (p = 0.59), mechanical ventilation (0.06), or length of stay (LOS) (p = 0.414). PAPI was superior to tricuspid annular plane systolic excursion (TAPSE) in predicting mortality and RV failure. Conclusions: Echocardiography-derived PAPI is feasible and superior over TAPSE in predicting RV failure and mortality among patients with acute PE.

Use of Life Support and Outcomes Among Patients Admitted to Intensive Care Units.

Nationwide data are unavailable regarding changes in intensive care unit (ICU) outcomes and use of life support over the past 10 years, limiting understanding of practice changes. To portray the epidemiology of US critical care before, during, and after the COVID-19 pandemic. Retrospective cohort study of adult patients admitted to an ICU for any reason, using data from the 54 US health systems continuously contributing to the Epic Cosmos database from 2014-2023. Patient demographics, COVID-19 status, and pandemic era. In-hospital mortality unadjusted and adjusted for patient demographics, comorbidities, and illness severity; ICU length of stay; and receipt of life-support interventions, including mechanical ventilation and vasopressor medications. Of 3 453 687 admissions including ICU care, median age was 65 (IQR, 53-75) years. Patients were 55.3% male; 17.3% Black and 6.1% Hispanic or Latino; and overall in-hospital mortality was 10.9%. The adjusted in-hospital mortality was elevated during the pandemic in COVID-negative (adjusted odds ratio [aOR], 1.3 [95% CI, 1.2-1.3]) and COVID-positive (aOR, 4.3 [95% CI, 3.8-4.8]) patients and returned to baseline by mid-2022. The median ICU length of stay was 2.1 (IQR, 1.1-4.2) days, with increases during the pandemic among COVID-positive patients (difference for COVID-positive vs COVID-negative patients, 2.0 days [95% CI, 2.0-2.1]). Rates of invasive mechanical ventilation were 23.2% (95% CI, 23.1%-23.2%) before the pandemic, increased to 25.8% (95% CI, 25.8%-25.9%) during the pandemic, and declined below prepandemic baseline thereafter (22.0% [95% CI, 21.9%-22.2%]). The use of vasopressors increased from 7.2% to 21.6% of ICU stays. Pandemic-era increases in length of stay and adjusted in-hospital mortality among US ICU patients returned to recent historical baselines. Fewer patients are now receiving mechanical ventilation than prior to the pandemic, while more patients are administered vasopressor medications.

Racial Disparities in Septic Shock Outcomes: A Nationwide Analysis (2016-2020).

The mortality rate and outcomes of septic shock can vary, depending on the patient's race. The most comprehensive national study on these racial disparities is dated, and recent studies have reported mixed findings. To gain insight into racial variation in outcomes of septic shock and understand underlying factors. A retrospective analysis using National Inpatient Sample data (2016-2020). Patients were grouped by race, and patient and hospital characteristics, outcomes, and complications were compared. Multivariable logistic regression analyses were conducted. Hospitalized patients aged ≥ 18 years with septic shock. In-hospital mortality, mechanical ventilation, vasopressor use, acute kidney injury, need for hemodialysis, acute myocardial infarction, requirement for blood transfusion, length of stay, the financial burden on healthcare, and resource utilization. Among 2,789,890 patients, 67.5% were White, 14.4% Black, 10.9% Hispanic, 3.3% Asian or Pacific Islander, and 0.8% Native American; 46.2% were aged > 70 years. Compared to White patients, Black patients had 23% higher odds of mortality (adjusted odds ratio [aOR] 1.23, 95% CI 1.21-1.25) and the highest odds of invasive mechanical ventilation (aOR 1.42) and hemodialysis (aOR 1.96). Native American patients had the highest odds of acute respiratory distress syndrome (aOR 2.03), while Asian or Pacific Islander patients had increased odds of blood transfusions (aOR 1.52). Palliative care consultations were less common among Asian, Black, and Hispanic patients compared to White patients. Racial disparities persist in septic shock outcomes, with higher mortality and complications among Black, Hispanic, Asian, and Native American patients, along with less utilization of palliative care services compared to White patients.

Intracranial response to positive end-expiratory pressure is influenced by lung recruitability and gas distribution during mechanical ventilation in acute brain injury patients: a proof-of-concept physiological study

BackgroundThe effect of positive end-expiratory pressure (PEEP) on intracranial pressure (ICP) dynamics in patients with acute brain injury (ABI) remains controversial. PEEP can benefit oxygenation by promoting alveolar recruitment, but its influence on ICP is complex. The primary aims of this study were to investigate 1) how lung recruitability influences oxygenation and 2) how lung recruitability and regional gas distribution, measured via recruitment-to-inflation (RI) ratio and electrical impedance tomography (EIT), affect ICP in response to PEEP changes in critically ill patients in their early phase of ABI.MethodsTen mechanically ventilated ABI patients were included. Pressure reactivity index (PRx) was estimated. Using RI manoeuvre and EIT, lung recruitability and gas distribution were assessed in response to a standardised PEEP change (from high to low levels, with a delta of 10 cmH2O). Changes in ICP (ΔICP) were calculated between high and low PEEP. Lung inhomogeneity indices (global inhomogeneity index [GI] and local inhomogeneity index [LI]) were derived from EIT. Correlations between ventilatory variables and ICP were analysed.ResultsBlood oxygenation significantly decreased, going from high (14 [IQR: 12–15] cmH₂O) to low (4 [IQR: 2–5] cmH₂O) PEEP. Reducing PEEP significantly increased ICP (from 9 [IQR: 5–13] to 12 [IQR: 8–16] mmHg, p < 0.01), while cerebral perfusion pressure (CPP) improved (from 71 [IQR:67–83] to 75 [IQR: 70–84] mmHg, p = 0.03) and mean arterial pressure (MAP) increased (from 79 [IQR: 69–95] to 84 [IQR: 76–99] mmHg, p < 0.01). The RI ratio correlated significantly with ΔICP (rho = 0.87, p < 0.01), as did Vrec% (proportion of recruited volume, rho = 0.65) and GI (rho = 0.5). LI did not correlate with ΔICP. PRx was 0.30 [IQR: 0.12–0.42], indicating a deranged cerebral autoregulation.ConclusionsPatients with a higher potential for lung recruitability had a more beneficial effect of PEEP on oxygenation. These effects should be interpreted cautiously, given that lung recruitability and global inhomogeneity of gas distribution significantly influenced the intracranial response to PEEP in ABI patients. As indicated by MAP and CPP, PEEP may impact systemic haemodynamics and cerebral perfusion when cerebral autoregulation is deranged. These findings underscore the importance of multimodal (i.e. respiratory, cerebral and haemodynamics) monitoring for optimising ventilation strategies in ABI patients and provide a framework for future research. Trial registration Registration number: NCT05363085, Date of registration: May 2022

Swedish national cohort of children living with long-term respiratory support (DISCOVERY-P): cohort profile

PurposeChildren living with respiratory support rely on medical technology, either fully or partially, throughout the day to meet their breathing requirements. Although children and young people living with respiratory support...

Chiari malformation type I with an associated syrinx presenting as acute central cord syndrome in a child: illustrative case.

Chiari malformation type I (CM-I) usually manifests with chronic symptoms. The most common symptoms observed in the pediatric population include headache, neck pain, vertigo, and ataxia. Some unusual presentations have been reported in children, including a diversity of acute neurological deficits in previously asymptomatic patients. The authors report the case of a 4-year-old previously healthy boy who presented to the emergency department with clinical findings of incomplete cervical spinal cord injury and respiratory function decline after a minor fall. The cervical spine CT scan did not show evidence of fracture. MRI revealed findings of CM-I, a complex cervicothoracic cyst syrinx, and spinal cord signal hyperintensity. The patient required urgent intubation and mechanical ventilation for airway protection and was thought to have an ascending cervical cord injury. He underwent suboccipital craniectomy, C1 and C2 partial laminectomies, and patch duraplasty. After surgery, he showed progressive improvement and was discharged to acute inpatient rehabilitation. Postoperative MRI showed near-complete resolution of the cord edema and the syrinx. The authors describe the case of a previously healthy child presenting with acute central cord syndrome and a decline in respiratory effort as the initial presentation of CM-I with a syrinx. Although rare, clinicians should consider CM-I in the differential diagnosis of pediatric patients presenting with acute cervical spinal cord injury, especially if imaging does not show spinal fractures. https://thejns.org/doi/10.3171/CASE24829.