Weaning Readiness Research Articles

Prognostic value of the oxygenation index measured during mechanical ventilation and weaning. A retrospective cohort study.

The aim of this study was to investigate the predictive value of the ratio of oxygen saturation (ROX) index calculated during mechanical ventilation (MV) and the weaning period in evaluating readiness to weaning and the success of the spontaneous breathing trial (SBT), extubation, and mortality. We also compared the results of the ROX index calculated with partial arterial oxygen pressure (PaO2), arterial oxygen saturation (SaO2%), and probe oxygen saturation (SpO2%). In this retrospective cohort study, the ROX index was calculated by SpO2%, PaO2, and SaO2% separately using the ROX index formula (PaO2 or SaO2 or SpO2 /FiO2)/respiratory rate. ROX was calculated during the first three days of MV treatment and the weaning period daily (SBT). Positive end-expiratory pressure and peak inspiratory pressure values were also recorded during these measurements. These ROX values were used to analyze whether they predict weaning readiness, SBT, extubation failure (EF), and mortality. The study included 107 mechanically ventilated patients. Weaning could be tried in 64 (60%) of the 107 patients; 44 (69%) of the 64 patients succeeded, and extubation was performed. 19 (43%) of 44 patients had EF. ROX values calculated with PaO2 during MV and SBT predicted readiness to wean, EF, and mortality better than ROX values calculated with SaO2 and SpO2. ROX values calculated with PaO2 during the third day of MV had the highest sensitivity and specificity for EF (sensitivity: 81%, specificity: 70% for the ROX<11 value). The results of this study suggest that the calculation of ROX index, not only with SpO2% but also with arterial blood gas PaO2 and SaO2% values, may be helpful in predicting the weaning readiness evaluation, SBT, and extubation success and mortality. Further studies with more patients are necessary to verify and standardize these results.

Predicting Successful Weaning from Mechanical Ventilation by Reduction in Positive End-expiratory Pressure Level Using Machine Learning.

Weaning patients from mechanical ventilation (MV) is a critical and resource intensive process in the Intensive Care Unit (ICU) that impacts patient outcomes and healthcare expenses. Weaning methods vary widely among providers. Prolonged MV is associated with adverse events and higher healthcare expenses. Predicting weaning readiness is a non-trivial process in which the positive end-expiratory pressure (PEEP), a crucial component of MV, has potential to be indicative but has not yet been used as the target. We aimed to predict successful weaning from mechanical ventilation by targeting changes in the PEEP-level using a supervised machine learning model. This retrospective study included 12,153 mechanically ventilated patients from Medical Information Mart for Intensive Care (MIMIC-IV) and eICU collaborative research database (eICU-CRD). Two machine learning models (Extreme Gradient Boosting and Logistic Regression) were developed using a continuous PEEP reduction as target. The data is splitted into 80% as training set and 20% as test set. The model's predictive performance was reported using 95% confidence interval (CI), based on evaluation metrics such as area under the receiver operating characteristic (AUROC), area under the precision-recall curve (AUPRC), F1-Score, Recall, positive predictive value (PPV), and negative predictive value (NPV). The model's descriptive performance was reported as the variable ranking using SHAP (SHapley Additive exPlanations) algorithm. The best model achieved an AUROC of 0.84 (95% CI 0.83-0.85) and an AUPRC of 0.69 (95% CI 0.67-0.70) in predicting successful weaning based on the PEEP reduction. The model demonstrated a Recall of 0.85 (95% CI 0.84-0.86), F1-score of 0.86 (95% CI 0.85-0.87), PPV of 0.87 (95% CI 0.86-0.88), and NPV of 0.64 (95% CI 0.63-0.66). Most of the variables that SHAP algorithm ranked to be important correspond with clinical intuition, such as duration of MV, oxygen saturation (SaO2), PEEP, and Glasgow Coma Score (GCS) components. This study demonstrates the potential application of machine learning in predicting successful weaning from MV based on continuous PEEP reduction. The model's high PPV and moderate NPV suggest that it could be a useful tool to assist clinicians in making decisions regarding ventilator management.

Utilization of spontaneous breathing trial, objective cough test, and diaphragmatic ultrasound results to predict extubation success: COBRE-US trial

BackgroundThe results of clinical and weaning readiness tests and the spontaneous breathing trial (SBT) are used to predict the success of the weaning process and extubation.MethodsWe evaluated the capacity of the cuff leak test, rate of rapid and shallow breathing, cough intensity, and diaphragmatic contraction velocity (DCV) to predict the success of the SBT and extubation in a prospective, multicenter observational study with consecutive adult patients admitted to four intensive care units. We used receiver operating characteristic (ROC) curves to assess the tests’ predictive capacity and built predictive models using logistic regression.ResultsWe recruited 367 subjects who were receiving invasive mechanical ventilation and on whom 456 SBTs were performed, with a success rate of 76.5%. To predict the success of the SBT, we derived the following equation: (0.56 × Cough) − (0.13 × DCV) + 0.25. When the cutoff point was ≥ 0.83, the sensitivity was 91.5%, the specificity was 22.1%, and the overall accuracy was 76.2%. The area under the ROC curve (AUC-ROC) was 0.63. To predict extubation success, we derived the following equation: (5.7 × SBT) + (0.75 × Cough) − (0.25 × DCV) − 4.5. When the cutoff point was ≥ 1.25, the sensitivity was 96.8%, the specificity was 78.4%, and the overall accuracy was 91.5%. The AUC-ROC of this model was 0.91.ConclusionObjective measurement of cough and diaphragmatic contraction velocity could be used to predict SBT success. The equation for predicting successful extubation, which includes SBT, cough, and diaphragmatic contraction velocity values, showed excellent discriminative capacity.

Effect of high-flow oxygen versus T-piece ventilation strategies during spontaneous breathing trials on weaning failure among patients receiving mechanical ventilation: a randomized controlled trial

BackgroundA spontaneous breathing trial (SBT) is used to determine whether patients are ready for extubation, but the best method for choosing the SBT strategy remains controversial. We investigated the effect of high-flow oxygen versus T-piece ventilation strategies during SBT on rates of weaning failure among patients receiving mechanical ventilation.MethodsThis randomized clinical trial was conducted from June 2019 through January 2022 among patients receiving mechanical ventilation for ≥ 12 h who fulfilled the weaning readiness criteria at a single-center medical intensive care unit. Patients were randomized to undergo either T-piece SBT or high-flow oxygen SBT. The primary outcome was weaning failure on day 2, and the secondary outcomes were weaning failure on day 7, ICU and hospital length of stay, and ICU and in-hospital morality.ResultsOf 108 patients (mean age, 67.0 ± 11.1 years; 64.8% men), 54 received T-piece SBT and 54 received high-flow oxygen SBT. Weaning failure on day 2 occurred in 5 patients (9.3%) in the T-piece group and 3 patients (5.6%) in the high-flow group (difference, 3.7% [95% CI, − 6.1–13.6]; p = 0.713). Weaning failure on day 7 occurred in 13 patients (24.1%) in the T-piece group and 7 patients (13.0%) in the high-flow group (difference, 11.1% [95% CI, − 3.4–25.6]; p = 0.215). A post hoc subgroup analysis showed that high-flow oxygen SBT was significantly associated with a lower rate of weaning failure on day 7 (OR, 0.17 [95% CI, 0.04–0.78]) among those patients intubated because of respiratory failure (p for interaction = 0.020). The ICU and hospital length of stay and mortality rates did not differ significantly between the two groups. During the study, no serious adverse events were recorded.ConclusionsAmong patients receiving mechanical ventilation, high-flow oxygen SBT did not significantly reduce the risk of weaning failure compared with T-piece SBT. However, the study may have been underpowered to detect a clinically important treatment effect for the comparison of high-flow oxygen SBT versus T-piece SBT, and a higher percentage of patients with simple weaning and a lower weaning failure rate than expected should be considered when interpreting the findings.Clinical trial registration This trial was registered with ClinicalTrials.gov (number NCT03929328) on April 26, 2019.

Evaluation of weaning parameters for weaning readiness from mechanical ventilation among elderly patients

Background: Numbers of elderly patients with acute respiratory failure continue to rise with increasing age of the general population worldwide. Ventilatory reserve decreases substantially with age as a result of multiple interrelated physiologic changes. Objective: This study aimed to evaluate the predictive value of conventional and composite weaning parameters among elderly patients. Methods: We conducted an observational prospective study among intubated patients ≥70 years old and readied for undergoing spontaneous breathing trial (SBT). Weaning parameters were recorded [heart rate, respiratory rate, tidal volume, minute ventilation (MV)] at 1 min, 30 min, and 2 hr after beginning of SBT. Cough peak expiratory flow (CPEF) and diaphragmatic thickness (DT) were also measured at 1 min after SBT. Weaning parameters were compared between the 2 patient groups (weaning success vs. weaning failure). Primary outcome was difference in weaning parameters between the 2 groups of patients. Results: All 48 subjects were enrolled. The mean (±SD) age was 80.2 (±6) years. Altogether, 38 patients (79.2%) were in the weaning success group and 10 patients (20.8%) in the weaning failure group. All baseline characteristics did not significantly differ between the 2 groups. While no difference was observed in other isolated weaning parameters between the 2 patient groups, we found that patients in the weaning success group had significantly lower MV than patients in the weaning failure group (8.3±1.8 vs. 9.9±2.5 L/min, p=0.025). Composite weaning parameters included MV/CPEF and MV/(CPEF x DT) increased predictive values for weaning failure than isolated MV with area under the receiver operating characteristics curves of 0.78, 0.80, and 0.72 respectively. The best cutoff point to predict weaning failure were MV ≥8.4 L/min, MV/CPEF ≥0.12, and MV/(CPEF x DT) ≥0.45 cm-1 Conclusion: MV was the only parameter associated with weaning failure among the elderly. Composite parameters demonstrated better predictive value for assessing weaning readiness among elderly patients.

Effect of a multicarbohydrase containing α-galactosidase in sow lactating diets with varying energy density.

Sow productivity improvements are associated with high energetic demand due to increasing prolificity. The reproductive life and longevity of sows, and the readiness for weaning of the offspring may be impaired when sows loose significant body weight (BW) during lactation. The impact of a multicarbohydrase containing α-galactosidase on a low energy dense lactation diet was evaluated in this study. Two-hundred and eight sows (208 ± 25.2 kg) were blocked by parity and BW to one of four treatments, in which a corn-soybean meal diet was formulated to have varying levels of added fat (0, 1.5%, and 3%) to titrate an energy density model. A fourth treatment replicated the 0% added fat formulation with enzyme supplementation at 250 g/tonne. Sows were weighed individually on entry, post-farrow (by calculation) and at weaning. Daily feed intakes (ADFI) and caloric intake were used for calculation of sow feed efficiency (FE) and caloric efficiency. Litter performance was characterized at birth, and size was standardized within 24h of farrow and within treatment to ensure uniform litter sizes. Average wean weight and pre-weaning mortality were determined. Piglets were weighted individually to study litter weight distribution. Data was analyzed as a randomized completely block design, using sow as the experimental unit, treatment as the main effect, and standardized average weight and litter sizes as covariates where appropriate. Although sows fed a multicarbohydrase had lower standardized litter size (P < 0.001), average wean weight was higher in this group and equivalent to the 3% added fat treatment. Enzyme supplementation tended to reduce the proportion of light weight pigs (BW < 4.1kg) within the litter, when compared with the 0% added fat diet (P < 0.1). The multicarbohydrase tended to increased sow ADFI (P < 0.10), although sows from all treatments had equivalent caloric intakes during lactation (P > 0.1). Enzyme supplementation yielded significant improvements in sow FE (P < 0.01), similar to the 3% added fat group. Thus, the carbohydrase degrading enzyme tested in this study improved the efficiency of sows, while increasing average wean weights of the offspring, suggesting an improvement in nutrient digestion and/or metabolic efficiency from typical lactation diets.

Prediction of weaning readiness off nasal CPAP in preterm infants using point-of-care lung ultrasound.

This study's primary aim was to assess whether end-expiratory lung ultrasound severity score(expLUSsc) at Day 3 of life, the second week of life, and before weaning off nasal continuous positive airway pressure (nCPAP) can predict the weaning readiness off nCPAP trial in preterm infants. The secondary aim was to evaluate the value of adding lung tidal recruitment(LTR) to expLUSsc (expLUSsc-plus-LTR) to improve predictability. We conducted a prospective study on premature infants <33 weeks of gestation. Point-of-care lung ultrasound(POC-LUS) was performed on Day 3, the second week of life, before and after the trial off nCPAP. expLUSsc, pleural thickness, and LTR were assessed. A receiver operator curve was constructed to evaluate the ability of POC-LUS to predict the weaning readiness off nCPAP. A total of 148 studies were performed on 39 infants, of them 12 weaned off nCPAP from the first trialand 27 infants failed attempts off nCPAP. An expLUSsc cut-off 8 before the first trial of weaning off nCPAP has a sensitivity and specificity of 88% and 90%, and positive and negative predictive values of 87% and 92%, respectively, with area under the curve (AUC) was 0.87 (CI: 0.8-0.93), p < .0001. If LTR is added to an expLUSsc cut-off 8 (expLUSsc-plus-LTR) before the first trial of weaning, then sensitivity and specificity of 95% and 90%, and positive and negative predictive values of 88% and 90%, respectively, with AUC was 0.95 (CI: 0.91-0.99), p < .0001. In conclusion, this study demonstrated the ability of POC-LUS to predict the weaning readiness off nCPAP in premature infants. The use of this simple bedside noninvasive test can potentially avoid the exposure of premature infants to multiple unsuccessful weaning cycles.

Abstract No.: ABS1330: A prospective observational study on ultra-sound of the diaphragm in weaning mechanically ventilated patients

Background and Aims:Weaning mechanically ventilated patients is a challenging task in the intensive care unit. Rapid shallow breathing index (RSBI) is a known weaning index to guide extubation. The aim of our study was to determine the use of diaphragm ultra-sound in weaning these patients.Methods:After obtaining ethics committee approval and Clinical Trials Registry India registration, this prospective study was performed on 200 patients on mechanical ventilation for more than 24 hours. After meeting clinical weaning criteria, spontaneous breathing trial (SBT) was performed for 1 hour to assess weaning and then trachea was extubated. Independent observers recorded RSBI and performed bedside ultra-sound of the diaphragm before extubation to measure diaphragm thickening fraction (DTF) and diaphragmatic excursion (DE). We assessed the predictability of weaning success with DTF and DE. Weaning failure was defined as the requirement of non-invasive ventilation or re-intubation within 48 h.Results:One hundred and seventy one patients out of 200 were successfully weaned. The area under the receiver operating characteristic curve (AUROC) values for RSBI, DTF, and DE for successful weaning prediction were 0.422, 0.654, and 0.809, respectively. The predictability using cut-off values were RSBI <82 (sensitivity 94%, specificity 31%, Youden’s index 0.25), DTF >37% (sensitivity 80%, specificity 52%, Youden’s index 0.31), and DE >1.21 cm (sensitivity 94%, specificity 71%, Youden’s index 0.65). The AUROC values for the combination of RSBI–DTF and RSBI–DE were 0.656 and 0.807, respectively.Conclusion:Diaphragm ultra-sound helps in determining weaning readiness in mechanically ventilated patients. Both DTF and DE showed a higher specificity than RSBI, and the combination of RSBI–DE and RSBI–DTF further increased the specificity in successful weaning.ParameterCut off rangeSensitivity %Specificity %PPV %NPV %Youden’s IndexAUROCRSBI<8294.031.089.045.00.250.422DTF (%)>37%79.551.790.730.00.310.654DE (cm)>1.2193.671.495.264.50.650.809RSBI-DTF> 0.85466.769.092.726.00.360.656RSBI-DE>0.73893.071.495.262.50.640.807

Perspectives of healthcare professionals in Nigeria about physiotherapists\u2019 scope of practice and skills in ICU patients\u2019 management: a cross-sectional study

BackgroundThere is growing evidence for physiotherapy in the intensive care unit (ICU), but physiotherapy in the ICU and patients’ referral rate remains low in Nigeria. This study assessed the healthcare professionals’ perception of the physiotherapists’ scope of practice and skills in managing patients in the ICU of selected teaching hospitals in Southern Nigeria. The study was a cross-sectional survey that involved seventy healthcare professionals working in the ICU who completed an adapted and validated questionnaire. The data obtained from the cross-sectional study were presented using descriptive statistics of mean, standard deviation, frequency distribution, and percentage.ResultsThe mean age of the participants was 39.74 ± 7.08 years. The majority of the participants had a bachelor’s degree and had worked for a minimum of 5 years in the ICU, with all the participants working in a mixed ICU and 46.7% work in ICUs with four to six beds. Physiotherapists (PTs) are not posted exclusively to the ICUs, and PTs were reported to be on call in most of the ICUs during the weekdays and weekends. Patients were referred for physiotherapy by the physicians. Healthcare professionals had negative perceptions about PTs’ scope in airway suctioning, nebulization, weaning, and adjustment of mechanical ventilators, intubation, extubation, and changing tracheostomy tubes for ICU patients. Participants had a positive perception about PTs’ assessment skills in the ICU except for hypoxemia calculation, readiness for weaning, and the need for humidification.ConclusionHealthcare professionals working in the ICU in the selected hospitals had both negative and positive perceptions regarding certain areas about the scope of practice and skills of PTs in managing patients in the ICU.

Mechanical power normalized to lung-thorax compliance indicates weaning readiness in prolonged ventilated patients

Since critical respiratory muscle workload is a significant determinant of weaning failure, applied mechanical power (MP) during artificial ventilation may serve for readiness testing before proceeding on a spontaneous breathing trial (SBT). Secondary analysis of a prospective, observational study in 130 prolonged ventilated, tracheotomized patients. Calculated MP’s predictive SBT outcome performance was determined using the area under receiver operating characteristic curve (AUROC), measures derived from k-fold cross-validation (likelihood ratios, Matthew's correlation coefficient [MCC]), and a multivariable binary logistic regression model. Thirty (23.1%) patients failed the SBT, with absolute MP presenting poor discriminatory ability (MCC 0.26; AUROC 0.68, 95%CI [0.59‒0.75], p = 0.002), considerably improved when normalized to lung-thorax compliance (LTCdyn-MP, MCC 0.37; AUROC 0.76, 95%CI [0.68‒0.83], p < 0.001) and mechanical ventilation PaCO2 (so-called power index of the respiratory system [PIrs]: MCC 0.42; AUROC 0.81 [0.73‒0.87], p < 0.001). In the logistic regression analysis, PIrs (OR 1.48 per 1000 cmH2O2/min, 95%CI [1.24‒1.76], p < 0.001) and its components LTCdyn-MP (1.25 per 1000 cmH2O2/min, [1.06‒1.46], p < 0.001) and mechanical ventilation PaCO2 (1.17 [1.06‒1.28], p < 0.001) were independently related to SBT failure. MP normalized to respiratory system compliance may help identify prolonged mechanically ventilated patients ready for spontaneous breathing.

Validation of rapid shallow breathing index displayed by the ventilator compared to the standard technique in patients with readiness for weaning

BackgroundRapid shallow breathing index (RSBI) is the most commonly used parameter for predicting weaning outcome. Measurement of RSBI by Wright spirometer (RSBIstandard) is the standard method in routine clinical practice. Data specific to the accuracy and reliability of the RSBI value displayed by the ventilator (RSBIvent) are scarce. Accordingly, this study aimed to evaluate the association between the average value of RSBIvent at different time points and RSBIstandard, and to assess the accuracy and reliability of these two RSBI measurement techniques.MethodsThis prospective cohort study included mechanically ventilated patients who were ready to wean. At the beginning of spontaneous breathing trial using the flow-by method, RSBI was measured by two different techniques at the same time, including: (1) Wright spirometer (breathing frequency/average tidal volume in 1 min) (RSBIstandard), and (2) the values displayed on the ventilator at 0, 15, 30, 45, and 60 s (RSBIvent).ResultsForty-seven patients were enrolled. The RSBIvent value was significantly higher than the RSBIstandard value for every comparison. According to Spearman’s correlation coefficient (r) and intraclass correlation coefficient (ICC), the average value of RSBI from 5 time points (0, 15, 30, 45, and 60 s) showed the best correlation with the standard technique (r = 0.76 [P < 0.001], and ICC = 0.79 [95% CI 0.61–0.88], respectively). Bland–Altman plot also showed the best agreement between RSBIstandard and the RSBIvent value averaged among 5 time points (mean difference − 17.1 breaths/min/L).ConclusionsWe found that the ventilator significantly overestimates the RSBI value compared to the standard technique by Wright spirometer. The average RSBIvent value among 5 time points (0, 15, 30, 45, and 60 s) was found to best correlate with RSBIstandard.

Cardiopulmonary coupling indices to assess weaning readiness from mechanical ventilation

The ideal moment to withdraw respiratory supply of patients under Mechanical Ventilation at Intensive Care Units (ICU), is not easy to be determined for clinicians. Although the Spontaneous Breathing Trial (SBT) provides a measure of the patients’ readiness, there is still around 15–20% of predictive failure rate. This work is a proof of concept focused on adding new value to the prediction of the weaning outcome. Heart Rate Variability (HRV) and Cardiopulmonary Coupling (CPC) methods are evaluated as new complementary estimates to assess weaning readiness. The CPC is related to how the mechanisms regulating respiration and cardiac pumping are working simultaneously, and it is defined from HRV in combination with respiratory information. Three different techniques are used to estimate the CPC, including Time-Frequency Coherence, Dynamic Mutual Information and Orthogonal Subspace Projections. The cohort study includes 22 patients in pressure support ventilation, ready to undergo the SBT, analysed in the 24 h previous to the SBT. Of these, 13 had a successful weaning and 9 failed the SBT or needed reintubation –being both considered as failed weaning. Results illustrate that traditional variables such as heart rate, respiratory frequency, and the parameters derived from HRV do not differ in patients with successful or failed weaning. Results revealed that HRV parameters can vary considerably depending on the time at which they are measured. This fact could be attributed to circadian rhythms, having a strong influence on HRV values. On the contrary, significant statistical differences are found in the proposed CPC parameters when comparing the values of the two groups, and throughout the whole recordings. In addition, differences are greater at night, probably because patients with failed weaning might be experiencing more respiratory episodes, e.g. apneas during the night, which is directly related to a reduced respiratory sinus arrhythmia. Therefore, results suggest that the traditional measures could be used in combination with the proposed CPC biomarkers to improve weaning readiness.

Comparison Between Prolonged Intubation and Reintubation Outcomes After Cardiac Surgery

Premature extubation may lead to unplanned reintubation that may affect outcomes after cardiac surgery. This study was undertaken to determine how prolonged intubation >48 hours or reintubation contributed to postoperative outcomes. Regression analyses have demonstrated that reintubation caused worse postoperative outcomes than prolonged intubation: more acute kidney injury stage 1–3, coma/encephalopathy, postoperative transfusion, increased intensive care unit length of stay, and hospital mortality beyond the contributions of other risk factors. Unplanned reintubation from untimely extubation can adversely affect outcomes after cardiac surgery. Although early extubation remains the goal, patients with marginal weaning readiness may benefit from more recovery time before extubation.

194 Efficacy of a Multicarbohydrase Containing Alpha-galactosidase in Lactating Sows: Impact on Progeny Weight and Uniformity

Abstract Modern lactating sows are under high energetic demand due to increasing prolificity. Significant body weight (BW) losses during lactation may impair sows’ reproductive life and longevity, and the readiness for weaning of the offspring. This study aimed at evaluating the impact of a multicarbohydrase containing alpha-galactosidase (CAG; AlphaGal™280P, Kerry) on a low energy dense lactation diet. Two-hundred and eight sows (218 ± 25.2kg) were blocked by parity and BW to one of 4 treatments, in which a corn-soybean meal diet was formulated to have graded levels of added fat (0, 1.5% and 3%) to titrate an energy density model (T1–T3). T4 replicated the 0% added fat formulation with CAG supplementation at 250 g/MT. Sows were weighed individually on entry, post-farrow (by calculation) and at weaning. Daily feed intakes (ADFI) were used for calculation of sow feed conversion ratio (FCR). Litter performance was characterized at birth, and size was standardized within 24h of farrow and within treatment to ensure uniform litter sizes (LS). Average wean weight (WWt) and pre-weaning mortality were determined. Litter weight distribution was also evaluated via individually weighed piglets, with consideration for pigs &amp;lt; 4.1kg BW. Data were analyzed as a RCBD, using sow as the experimental unit, treatment as the main effect, and standardized average weight and LS as covariates where appropriate. CAG tended to increase sow ADFI (P &amp;lt; 0.10) and yielded significant improvements in sow FCR (P &amp;lt; 0.01), comparable to T3. Although CAG group had lower standardized LS (P &amp;lt; 0.001), WWt was higher and equivalent to T3 upon use of standardized LS as a covariate. CAG tended to reduce the proportion of light pigs within the litter, when compared to T1. CAG improved the efficiency of sows, while increasing WWt of the offspring, suggesting an improvement in nutrient digestion and/or post absorption metabolic efficiency from typical lactation diets.

Substitution of non-forage fibre sources for cereal grains and molasses in calf starter on performance and development of ruminal function

One hundred and thirty-six, new-born female Holstein calves (body weight (BW) = 37.6±0.79 kg) were allocated to one of four starter feeds to evaluate the effects of replacing cereal grains and (or) molasses with non-forage fibre sources on intake, weight gain, and indicators of ruminal development. Diets consisted of a typical, low (16%) neutral detergent fibre (NDF) texturised calf starter, texturised calf starter with moderately higher (20%) NDF, texturised calf starter with moderately higher (21%) NDF and no molasses, and a complete pelleted high (25%) NDF calf starter. Average daily gains and starter intakes were unaffected by moderate levels of NDF. Average daily gain and feed intakes were increased in the preweaning phase but decreased in the postweaning phase by the high NDF complete pelleted diet. Total tract apparent NDF digestibility increased linearly with age but did not differ among diets. Blood concentrations of glucose and β-hydroxybutyrate (BHB) decreased and increased, respectively, with age. Further, blood BHB concentrations were largely unaffected by diet and did not change with increasing dry matter (DM) intake until a threshold was reached, and then increased linearly. Calf-side blood BHB testing resulted in an appreciable number of measurements below the limit of detection of the meter, resulting in censored data. Application of appropriate statistical methodology, required for proper parameter estimation from censored data, suggest the potential for successful field application of calf-side BHB measurements for monitoring starter intake and readiness for weaning in commercial settings. Feeding solely a complete pelleted calf starter throughout the starter phase may provide insufficient levels of effective fibre. Integration of the results of this study with previously published literature via a quantitative analysis suggests that maintaining intake may be the key to successful inclusion of non-forage fibre sources in calf starters.

Pragmatic Recommendations for the Management of Acute Respiratory Failure and Mechanical Ventilation in Patients with COVID-19 in Low- and Middle-Income Countries.

ABSTRACTManagement of patients with severe or critical COVID-19 is mainly modeled after care for patients with severe pneumonia or acute respiratory distress syndrome (ARDS) from other causes, and these recommendations are based on evidence that often originates from investigations in resource-rich intensive care units located in high-income countries. Often, it is impractical to apply these recommendations to resource-restricted settings, particularly in low- and middle-income countries (LMICs). We report on a set of pragmatic recommendations for acute respiratory failure and mechanical ventilation management in patients with severe/critical COVID-19 in LMICs. We suggest starting supplementary oxygen when SpO2 is persistently lower than 94%. We recommend supplemental oxygen to keep SpO2 at 88–95% and suggest higher targets in settings where continuous pulse oximetry is not available but intermittent pulse oximetry is. We suggest a trial of awake prone positioning in patients who remain hypoxemic; however, this requires close monitoring, and clear failure and escalation criteria. In places with an adequate number and trained staff, the strategy seems safe. We recommend to intubate based on signs of respiratory distress more than on refractory hypoxemia alone, and we recommend close monitoring for respiratory worsening and early intubation if worsening occurs. We recommend low–tidal volume ventilation combined with FiO2 and positive end-expiratory pressure (PEEP) management based on a high FiO2/low PEEP table. We recommend against using routine recruitment maneuvers, unless as a rescue therapy in refractory hypoxemia, and we recommend using prone positioning for 12–16 hours in case of refractory hypoxemia (PaO2/FiO2 < 150 mmHg, FiO2 ≥ 0.6 and PEEP ≥ 10 cmH2O) in intubated patients as standard in ARDS patients. We also recommend against sharing one ventilator for multiple patients. We recommend daily assessments for readiness for weaning by a low-level pressure support and recommend against using a T-piece trial because of aerosolization risk.

The Effect of Nursing Interventions Based on Burns Wean Assessment Program on Successful Weaning from Mechanical Ventilation: A Randomized Controlled Clinical Trial.

Background:The effective design and implementation of the nursing interventions to evaluate the patients' readiness for ventilator weaning will reduce their connection time to the ventilator and the complications of their connection to it. This study was conducted to examine the effect of nursing interventions based on the Burns Wean Assessment Program (BWAP) on successful weaning from Mechanical Ventilation (MV).Materials and Methods:In this clinical trial, 70 patients undergoing MV in the Intensive Care Units (ICUs) of Golestan Hospital (Ahvaz, Iran) in 2018 were randomly assigned to intervention and control groups. The nursing interventions designed based on BWAP were implemented on the patients in the intervention group, who were later weaned from the device according to this program. The recorded data included demographic information, BWAP score, vital signs, and laboratory values, which were analyzed using the Pearson correlation coefficient, Chi-Square, Fisher, and Mann-Whitney U tests.Results:There was a statistically significant and inverse correlation between the BWAP score and the MV duration such that a high BWAP score was associated with a shorter MV time (p = 0.041). Also, the mean number of re-intubation (p = 0.001) and the number of re-connection to the ventilator in the intervention group were significantly lower (p = 0.005).Conclusions:The results showed that nurses' assessment of patient's readiness for weaning from MV based on this tool and designed nursing care reduced the duration of MV, re-intubation, and re-connection.

THE EFFECT OF ELECTRONIC ICU IMPLEMENTATION ON WEEKEND EXTUBATION RATES

SESSION TITLE: Critical Care Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: The electronic intensive care unit (eICU) is a form of telemedicine that allows remotely located intensivists and critical care nurses to partner with bedside teams to manage patients in an intensive care unit (ICU). Its goal is to improve the quality and safety of patient through an additional layer of monitoring and support. Timely liberation from mechanical ventilation (MV) is one of the main goals of any medical ICU (MICU). One of the tasks of an eICU can be to facilitate and support timely extubations. Whether the bedside intensivist has taken care of the ICU during the preceding workweek (continuous coverage) or is picking up the service that weekend (discontinuous coverage) may influence the weekend extubation rates. METHODS: eICU support was implemented in January 2016. We performed a retrospective observational analysis of all WE extubations between March 2016 and December 2019 in our quaternary care hospital MICU. Each WE during this period was defined as bedside intensivist “continuity” or “non-continuity”. RESULTS: 190 weekends were analyzed of which 53 (28%) were continuity WEs while 137 (72%) were non-continuity WEs. Over the course of the 4 years, there was no significant impact on the overall number of extubations per WE in our MICU with averages of 1.7 in 2016, 1.7 in 2017, 1.5 in 2018 and 1.9 in 2019. However, there was a noticeable impact of eICU implementation on the non-continuity WEs with the number of extubations increasing from averages of 1.5 in 2016 to 1.7 in 2017 to 1.7 in 2018 to 2.3 in 2019. CONCLUSIONS: As the consequences of prolonged MV include delirium, pneumonia and myopathy among others, efforts are being made to install protocols for more efficient liberation. This can translate into lower length of stay and possibly mortality and morbidity. One such intervention has been the involvement of the eICU in tracking ventilator days, helping in the assessment of readiness for weaning and ultimately facilitating and supporting extubations. This task may become particularly useful during weekends when other factors may be at play such as changes in coverage. CLINICAL IMPLICATIONS: Our study demonstrated a greater impact of the eICU on weekends where the bedside attending was less familiar with the patients in the ICU. DISCLOSURES: No relevant relationships by Christian Becker, source=Web Response No relevant relationships by Dipak Chandy, source=Web Response No relevant relationships by Zeeshan Hafeez, source=Web Response No relevant relationships by Precious Macauley, source=Web Response No relevant relationships by Hamid Yaqoob, source=Web Response

Ventilator Liberation in the Pediatric ICU.

Despite the accepted importance of minimizing time on mechanical ventilation, only limited guidance on weaning and extubation is available from the pediatric literature. A significant proportion of patients being evaluated for weaning are actually ready for extubation, suggesting that weaning is often not considered early enough in the course of ventilation. Indications for extubation are often not clear, although a trial of spontaneous breathing on CPAP without pressure support seems an appropriate prerequisite in many cases. Several indexes have been developed to predict weaning and extubation success, but the available literature suggests they offer little or no improvement over clinical judgment. New techniques for assessing readiness for weaning and predicting extubation success are being developed but are far from general acceptance in pediatric practice. While there have been some excellent physiologic, observational, and even randomized controlled trials on aspects of pediatric ventilator liberation, robust research data are lacking. Given the lack of data in many areas, a determined approach that combines systematic review with consensus opinion of international experts could generate high-quality recommendations and terminology definitions to guide clinical practice and highlight important areas for future research in weaning, extubation readiness, and liberation from mechanical ventilation following pediatric respiratory failure.

Diaphragm and Lung Ultrasound Indices in Prediction of Outcome of Weaning from Mechanical Ventilation in Pediatric Intensive Care Unit.

ObjectiveTo predict the added value of diaphragmatic and lung ultrasound indices (US) in anticipation of the outcome of mechanical ventilation of pediatric patients in the intensive care unit.MethodsThis prospective study was conducted in Zagazig University, Pediatric Hospitals, PICU; Egypt. One hundred six mechanically ventilated children aged between 1 mo to 170 mo were included in the study. All patients were candidates for weaning and have been given a chance for spontaneous breathing trial (SBT), during which diaphragmatic and lung US was performed for them. The diaphragm thickening fraction (DTF), the diaphragmatic excursion and the lung US score (LUS), that included 4 US aeration forms, were assessed.ResultsThere were statistically significant differences between patients with failed weaning and those with successful weaning regarding DTF, diaphragmatic excursion and LUS (p < 0.001). The best cut-off value of DTF, diaphragmatic excursion, and LUS for predicting weaning failure was ≥23.175%, ≥ 6.2 mm, and ≥ 12 with an AUC (area under curve) of 0.932, 0.876, and 0.934, respectively.ConclusionsDiaphragmatic and lung US add a quick, accurate and non-invasive indices to the weaning readiness parameters compared to the other standard parameters alone. So, it is recommended to be added to the predictive parameters of weaning outcome.