Receiving Ventilator Support Research Articles

The impact of home mechanical ventilation on the time and manner of death for those with Motor neurone disease (MND): A qualitative study of bereaved family members

Motor neurone disease (MND) is a progressive neurodegenerative disorder which is ultimately terminal. It causes muscle weakness which can lead to the need for assistance in breathing, for some with the disease. This paper draws on qualitative research using semi-structured interviews with 32 people bereaved by the death of a family member with MND who was dependent on home mechanical ventilation, from across the United Kingdom. Interviews explored how the end-of-life of a person who had used non-invasive ventilation to assist their breathing was experienced by participants, who had cared about, and for them. Four themes are used to examine the impact of dependent ventilation technology on the experience of dying on the part of bereaved family members. Themes are: accompanied dying, planned withdrawal of ventilation, blurred time of death, time post-death. The perception and experience of time was a key component across all four themes. Ventilator technology played a critical role in sustaining life, but it could also contribute to a complex dynamic where the realities of death were mediated or obscured. This raises ethical, emotional, and existential considerations, both for the individuals receiving ventilator support and their families, as well as for healthcare professionals involved in end-of-life care.

A Review of Chlorhexidine Oral Care in Patients Receiving Mechanical Ventilation.

Chlorhexidine gluconate has been considered the criterion standard of oral care for patients receiving mechanical ventilation because of its ability to reduce the incidence of ventilator-associated events. Optimal concentrations and frequencies remain unclear, as do adverse events related to mortality in various intensive care unit populations. To examine the current evidence for the efficacy of chlorhexidine gluconate in reducing the incidence of ventilator-associated events, mortality, intensive care unit length of stay, and duration of mechanical ventilation in patients receiving ventilator support. In this integrative review, CINAHL (Cumulative Index to Nursing and Allied Health Literature), MEDLINE, and Health Source: Nursing/Academic Edition were searched using terms related to mechanical ventilation and chlorhexidine gluconate oral care with dates ranging from 2012 to 2023. Seventeen articles were included in this review: 8 systematic reviews, 8 randomized clinical trials (3 of which were not included in any systematic review), and 1 quasi-experimental study. Chlorhexidine gluconate oral care was associated with a reduced incidence of ventilator-associated events, but efficacy depended on concentration and frequency of administration. With stratification by intensive care unit population type, a nonsignificant trend toward increased mortality was found among non-cardiac surgical patients who received this care. The evidence regarding the efficacy of chlorhexidine gluconate oral care in reducing ventilator-associated events in specific intensive care unit populations is contradictory. Recently published guidelines recommend de-implementation of chlorhexidine gluconate oral care in all patients receiving mechanical ventilation. Such care may be beneficial only in the cardiac surgical population.

Evaluation of Developmental Delay in Term Babies on Ventilator Support: A Cross-sectional Study

Introduction: Developmental limitation in two or more developmental domains that affects children under the age of five is termed as developmental delay. Due to various reasons such as drug-induced toxicity and maternal variables like a history of drinking, smoking, or infections during pregnancy (e.g., rubella), neonates may require admission to the Neonatal Intensive Care Unit (NICU). Although NICU admission improves survival rates, the extended stay and the use of different types of equipment in the NICU may lead to developmental delay. Aim: To identify the developmental delays in critically ill fullterm babies on ventilator support, using the Ages and Stages Questionnaire-3 (ASQ-3) scale. Materials and Methods: A cross-sectional study was designed to evaluate developmental delays in term babies receiving ventilator support. A total of 35 babies who met the inclusion criteria were included in the study. Once the babies reached 17 to 18 months of age, parents were given ASQ-3 to complete. The data were analysed and expressed as mean, standard deviation, frequency, and percentage. Results: Out of the 35 full-term babies on ventilator support, 22 babies (62.9%) showed lower values in gross motor function, 12 (34.3%) in fine motor function, and 12 (34.3%) in problem-solving skills compared to communication and other components, according to ASQ-3. Conclusion: The findings of this research suggest that critically ill full-term infants on ventilator support exhibit significant developmental delays, particularly in gross motor, fine motor, and problem-solving skills.

Evaluation of the delirium preventive effect of dual orexin receptor antagonist (DORA) in critically ill adult patients requiring ventilation with tracheal intubation at an advanced emergency center: A single-center, retrospective, observational study

ObjectiveICU delirium reportedly contributes to increased mortality attributed to underlying diseases, long-term cognitive decline, and increased healthcare costs. Dual orexin receptor antagonists (DORAs), suvorexant and lemborexant, have been suggested for preventing ICU delirium. Although ventilator management is a risk factor for delirium, no study has examined the efficacy of suvorexant and lemborexant in preventing delirium in critically ill patients requiring ventilation. Thus, we retrospectively evaluated the efficacy of DORA in preventing delirium in critically ill adult patients requiring ventilatory management in the emergency room. MethodThis retrospective study included patients aged ≥18 years who were admitted to the emergency room and received ventilator support between January 2015 and April 2022. The HR (95% CI) for delirium development in patients taking DORA was estimated using a Cox proportional hazards model, which was adjusted for the patient background and concomitant medications. HRs were calculated for patients taking suvorexant and those taking lemborexant using a stratified analysis. ResultsOf the 297 patients included in the study, 67 were in the DORA group; 50 were on suvorexant and 17 were on lemborexant. The DORA group had a lower incidence of delirium than the control group (p < 0.0001). The risk of delirium was lower in the DORA group compared the control group (HR, 0.22; 95% CI 0.12–0.40).The risk of developing delirium was lower with suvorexant (HR 0.22; 95% CI 0.11–0.41) and lemborexant (HR 0.25; 95% CI 0.08–0.81). ConclusionDORA is a promising drug that could have the potential to prevent delirium, and its efficacy in preventing delirium should be tested in randomized controlled trials in the future.

Early Intubation Reduces the Risk of Death Among COVID-19 Patients: An Observational Study

Background: The objective of this study was to find the association of invasive mechanical ventilation, non-invasive mechanical ventilation (N.I.V) and high flow nasal canula (HFNC) with mortality in COVID 19 pneumonia patients with ARDS. This is an observational cohort study conducted among patients those who were infected with COVID19 infection and received ventilator support. Materials and Methods: This study was a single centred, conducted among COVID19 patients, who came to a tertiary hospital in Bhubaneswar, Odisha. All patients admitted with COVID19 infection and received mechanical ventilation in between August 2020 to November 2020 was included in this study. As this is an observational cohort study, any intervention not required. Only, data collectors collected all relevant patient data using an android-based data collection platform. Result: 398 patients were found to be eligible for this study. Among them, only 24.47% patients received invasive mechanical ventilation and rest were on N.I.V (62.77%) and HFNC support (12.77%). 26 patients died among the 92 invasively ventilated patients, whereas the mortality rate among N.I.V group of patients (78.7%) was significantly higher. Increased TLC count, C-Reactive, Protein, Urea, Creatinine, Heart rate, Respiratory rate were mostly associated with increased mortality among non-invasively ventilated patients. Conclusion: Early intubation may decrease the risk of mortality in patients infected with severe COVID19 infection.

Patients with severe coronavirus disease 2019 have high frequency of factor 5 Leiden and prothrombin gene mutations.

We investigated the frequency of factor 5 Leiden (FVL) and prothrombin gene (PTG) mutations in patients with severe coronavirus disease 2019 (COVID-19). Our primary aim is to reveal whether these mutations are associated with severity of disease and mortality. A total of 249 patients were included in this cross-sectional study. Severe COVID-19 cases (with oxygen saturation of less than 90 mmHg and who received ventilation support invasively or noninvasively) were included. FVL and PTG mutations were identified by real time- PCR technique. Frequency of mutations for FVL was 11.7%, whereas for PTG was 3.5%. The frequency of FVL and PTG's mutations in our patient group was found to be significantly higher than the normal population ( P < 0.0001, 0.004, respectively). There was no difference in the frequency of mutations of FVL and PTG between the patients ventilated - invasively and noninvasively. There was also no difference in D-dimer, ferritin, fibrinogen, ex status, and entubational status between the groups of FVL and PTG mutated and wild-type. To the best of our knowledge, it is the first time that we have examined the frequencies of FVL and PGM's mutations in severe COVID-19 disease on such a large scale. The frequencies of both mutations in severe COVID-19 patients were higher than in the healthy population. We believe that studies prospectively designed, including asymptomatic and mild COVID-19 patients, will provide more comprehensive information on the subject.

Treatment of COVID-19 Patients during Second Wave in a Tertiary Care Center of Nepal

Introduction: The second wave of the COVID-19 pandemic was confirmed in Nepal in April 2021. It was caused by genetic variants of SARS-CoV2. The objective of the study was to find out severity of patients, their treatment and approximate drug cost for the treatment of COVID-19 in the second wave. Methods: In this retrospective, cross-sectional study, data of all patients who tested positive and were admitted in KIST Medical College and Teaching Hospital between April 2021 – July 2021 was collected for the study. A total of 215 patients were included. Results: Among the cases admitted, 190 (88.4%) patients were symptomatic. ICU/HDU admission was done in 113 (52.5%) cases, among which 33 (29.2%) patients received ventilator support. The patients treated in isolation unit were 102 (47.4%). Among the patients admitted, 23 (10.7%) were vaccinated. Severe cases were 80 (37%), moderate cases were 71 (33%) and mild cases were 49 (23%). Antibiotics were used in 190 (88.4%) cases. More than one antibiotics were used in 141 (65.6%) cases. Antifungals were used in 39 (18.1%) cases. Other drugs like corticosteroids were used in 185 (86%), proton- pump inhibitors in 179 (84.3%), antihistaminics in 169 (78.4%) and anticoagulants in 165 (76.7%), Vitamin C in 153 (71.2%), Vitamin D in 152 (70.7%) and zinc in 140 (65.1%) cases. The number of patients discharged after recovery was 151 (70.2%) and 41 (19.5%) patients died. The average drug cost was NPR. 3,246 in mild, 27,645 in moderate and 76,420 in severe cases. Conclusion: Majority of patients were treated in ICU/HDU. Most commonly used drugs were antibiotics, corticosteroids and anticoagulants. Mortality was high in the second wave.

INCEPTUS Natural History, Run-in Study for Gene Replacement Clinical Trial in X-Linked Myotubular Myopathy.

Background:X-linked myotubular myopathy (XLMTM) is a life-threatening congenital myopathy that, in most cases, is characterized by profound muscle weakness, respiratory failure, need for mechanical ventilation and gastrostomy feeding, and early death.Objective:We aimed to characterize the neuromuscular, respiratory, and extramuscular burden of XLMTM in a prospective, longitudinal study.Methods:Thirty-four participants < 4 years old with XLMTM and receiving ventilator support enrolled in INCEPTUS, a prospective, multicenter, non-interventional study. Disease-related adverse events, respiratory and motor function, feeding, secretions, and quality of life were assessed.Results:During median (range) follow-up of 13.0 (0.5, 32.9) months, there were 3 deaths (aspiration pneumonia; cardiopulmonary failure; hepatic hemorrhage with peliosis) and 61 serious disease-related events in 20 (59%) participants, mostly respiratory (52 events, 18 participants). Most participants (80%) required permanent invasive ventilation (>16 hours/day); 20% required non-invasive support (6–16 hours/day). Median age at tracheostomy was 3.5 months (95% CI: 2.5, 9.0). Thirty-three participants (97%) required gastrostomy. Thirty-one (91%) participants had histories of hepatic disease and/or prospectively experienced related adverse events or laboratory or imaging abnormalities. CHOP INTEND scores ranged from 19–52 (mean: 35.1). Seven participants (21%) could sit unsupported for≥30 seconds (one later lost this ability); none could pull to stand or walk with or without support. These parameters remained static over time across the INCEPTUS cohort.Conclusions:INCEPTUS confirmed high medical impact, static respiratory, motor and feeding difficulties, and early death in boys with XLMTM. Hepatobiliary disease was identified as an under-recognized comorbidity. There are currently no approved disease-modifying treatments.

Abstract 445: Natural history of coagulopathy in patients with cancer infected with COVID19: A real-world data (RWD) analysis

Abstract Background and Objective: Studies of hospitalized patients (pts) with COVID19 indicate that arterial or venous thrombotic complications occur in up to half of pts. Risk of these severe complications in pts with cancer is unknown. We estimated the incidence of arterial thrombosis (AT) and venous thromboembolism (VT) using RWD from pts with active or history of cancer with COVID19. Methods: Adult pts with cancer receiving treatment in community health systems, with COVID19 identified via ICD code or lab confirmation in 2020, were reviewed for incident AT and VT in a 90 day window following COVID19 diagnosis (index). AT was acute myocardial infarction (MI) or acute ischemic or embolic stroke (S). VT was acute deep venous thrombosis (DVT) or acute pulmonary embolism (PE). Medication use (anticoagulant, antiplatelet, statin) and comorbidities were assessed 6 months and 1 year prior to index, respectively. Results: Median age of 7,591 pts with cancer and COVID19 was 67 years and median follow up was 90 days. 32% of pts were hospitalized within 14 days, 2% received ventilator support, 6% had cardiovascular disease (CVD) and 1% had prior VT. Absolute risk of VT was significantly higher than AT (3% vs. 2%, chi square p= &amp;lt; 0.001), with 161 pts experiencing AT [81 (1%) MI; 80 (1%) S] and 240 pts experiencing VT [99 (1%) DVT; 158 (2%) PE]. This trend held across most subgroups (Table 1). The incidence rate per person-year was 0.094 for AT (0.047 MI, 0.046 S) and 0.141 for VT (0.058 DVT, 0.092 PE). CoxPH models did not show age, sex, comorbidities or medication use as significantly associated with higher probability of AT or VT. Conclusions: RWD showed pts with cancer and COVID19 were at higher risk for VT than AT. Pts who received ventilator support, or had prior VT or prior CVD had highest risk for these events. Severity of these outcomes emphasizes the need for risk reducing interventions. Acknowledgement of Reagan-Udall Foundation and Friends of Cancer Research COVID19 Evidence Accelerator. Table 1. Incidence of arterial and venous events stratified by baseline characteristics at COVID-19 diagnosis among n= 7,591 patients with cancer and infected with COVID19 Absolute Risk, N(%) Incidence Rate Total, N Arterial thrombosis Venous thromboembolism Chi square p-value Arterial thrombosis Venous thromboembolism p-value All 7,591 160 (2.1) 240 (3.2) &amp;lt;0.001 0.0935 0.1414 &amp;lt;0.001 Age 18-44 669 10 (1.5) 10 (1.5) 0.008 0.012 0.061 0.020 45-54 922 4 (0.4) 18 (2) 0.018 0.08 0.003 55-64 1751 26 (1.5) 54 (3.1) 0.062 0.129 0.001 65-74 2054 49 (2.4) 78 (3.8) 0.104 0.165 0.008 75-84 1506 55 (3.7) 60 (4) 0.169 0.184 0.557 85+ 689 24 (3.5) 20 (2.9) 0.18 0.15 0.542 Sex Female 4142 75 (1.8) 126 (3) 0.338 0.078 0.131 0.000 Male 3449 85 (2.5) 114 (3.3) 0.11 0.148 0.030 Race Black 1437 31 (2.2) 61 (4.2) 0.215 0.095 0.187 0.001 White 5054 113 (2.2) 157 (3.1) 0.098 0.137 0.003 Other/Unknown 1100 16 (1.5) 22 (2) 0.061 0.084 0.724 Severity of infection at diagnosis Not hospitalized 5815 78 (1.3) 141 (2.4) 0.0676 0.06 0.105 &amp;lt;0.001 Hospitalized, no ventilator support 1710 76 (4.4) 92 (5.4) 0.21 0.261 0.143 Hospitalized with ventilator support 106 6 (9.1) 7 (10.6) 0.326 0.326 0.965 Existing Cardiovascular disease Yes 467 94 (20.2) 23 (4.9) &amp;lt;0.001 0.105 0.06 &amp;lt;0.001 No 7124 66 (0.9) 217 (3) 0.21 0.261 &amp;lt;0.001 And baseline anticoagulant use 122 27 (22.1) 9 (7.4) &amp;lt;0.001 0.326 0.326 0.602 And no baseline anticoagulant use 7469 67 (19.5) 14 (4.1) 0.088 0.054 &amp;lt;0.001 Previous Venous thromboembolism Yes 312 12 (3.8) 64 (20.5) &amp;lt;0.001 0.184 0.981 &amp;lt;0.001 No 7279 148 (2.0) 176 (2.3) 0.089 0.105 0.542 And baseline anticoagulant use 121 9 (4.7) 22 (11.6) 0.273 0.397 0.969 &amp;lt;0.001 And no baseline anticoagulant use 7470 3 (1.6) 42 (22.1) 0.088 0.127 0.003 Existing Thrombocytosis (via ICD or platelet count &amp;gt;450 x 10^9/L) Yes 185 5 (2.7) 7 (3.8) 1 0.123 0.172 0.087 No 7406 155 (2.1) 233 (3.1) 0.091 0.137 &amp;lt;0.001 Citation Format: Jeanna Wallenta Law, Danny Idyro, Andrew Schrag, Frank Wolf, Thomas D. Brown. Natural history of coagulopathy in patients with cancer infected with COVID19: A real-world data (RWD) analysis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 445.

Clinical features and predisposing factors of delirium due to COVID-19 pneumonia in intensive care units.

Delirium is an acute disorder in which attention, perception, memory, thought, mood, psychomotor activity and sleep-wake cycles change rapidly. Delirium is also a common clinical syndrome in patients hospitalized in intensive care units due to COVID-19 pneumonia. We reviewed clinical features and predisposing factors of delirium according to psychomotor subtype in patients hospitalized in the intensive care units due to COVID-19 pneumonia. 64 patients who were hospitalized in the intensive care units due to COVID-19 pneumonia were included. Delirium status and psychomotor subtype were determined by applying the Confusion Assessment Method for the Intensive Care Unit scale to the patients daily. The gender, age, comorbidity, treatments, intubation, and mortality rates of the patients were recorded. Multivariate analyses were performed by examining predisposing factors, arterial blood gases, hemograms, biochemistry, and brain magnetic resonance imaging. There were 64 patients in delirium clinic, 65.6% (n=42) of them were male. Hypokinetic delirium was more common in 60.9% (n=39). 79.4% of the patients who received ventilator support were male (p=0.013).When mortality was analyzed in this group, hypoactive delirium was found to be significantly higher (p=0.035). In addition, leukocyte levels were higher in patients with hypokinetic delirium (p=0.029). Ferritin and fibrinogen levels were higher in patients with hyperkinetic delirium (p=0.039, p=0.008, respectively). The presence of additional diseases such as advanced age, male gender, hypertension, coronary artery disease, dementia, and hypoxia were factors that increased the frequency of delirium. In addition, the mortality rate was higher in patients with hypokinetic delirium.

Molecular Epidemiology, Risk Factors and Clinical Outcomes of Carbapenem-Nonsusceptible Enterobacter cloacae Complex Infections in a Taiwan University Hospital.

The genus Enterobacter is a member of the ESKAPE group, which contains the major resistant bacterial pathogens. Enterobacter cloacae complex (ECC) has emerged as a clinically significant cause of a wide variety of nosocomial infections. Carbapenem-nonsusceptible Enterobacter cloacae complex (CnsECC) has become an emerging threat to public health but there is still a lack of comprehensive molecular and clinical epidemiological analysis. A total of 157 CnsECC isolates were recovered during October 2011 to August 2017. hsp60 gene sequencing and pulsed-field gel electrophoresis (PFGE) were applied to discriminate the species, genetic clusters and clonal relatedness. All the isolates were subjected to polymerase chain reaction (PCR) analysis for carbapenemase, AmpC-type β-lactamase, and extended spectrum β-lactamase (ESBL) genes. Clinical data were collected on all patients for comparing clinical risks and outcomes between patients with carbapenemase-producing (CP)-CnsECC compared with non-CP-CnsECC infection. The most commonly identified species was E. hormaechei subsp. hoffmannii (47.1%), followed by E. hormaechei subsp. steigerwaltii (24.8%). Different species of CnsECC isolates showed heterogeneity in resistance patterns to piperacillin/tazobactam, cefepime and levofloxacin. In the present study, we observed that E. hormaechei subsp. hoffmannii was characterized with higher cefepime and levofloxacin resistance rate but lower piperacillin/tazobactam resistance rate relative to other species of CnsECC. CP-CnsECC comprised 41.1% (65 isolates) and all of these isolates carried IMP-8. In this study, 98% of patients had antimicrobial therapy prior to culture, with a total of 57/150 (38%) patients being exposed to carbapenems. Chronic pulmonary disease (OR: 2.51, 95% CI: 1.25–5.06), received ventilator support (OR: 5.54, 95% CI: 2.25–12.03), steroid exposure (OR: 3.88, 95% CI: 1.91–7.88) and carbapenems exposure (OR: 2.17, 95% CI: 1.10–4.25) were considered risk factors associated with CP-CnsECC infection. The results suggest that CP-CnsECC are associated with poorer outcomes including in-hospital mortality, 30-day mortality and 100-day mortality. Our study provides insights into the epidemic potential of IMP-8-producing E. cloacae for healthcare-associated infections and underscores the importance of understanding underlying resistance mechanisms of CnsECC to direct antibiotic treatment decisions.

Cardiac and Pulmonary Management Status of Duchenne Muscular Dystrophy in South Korea Based on Data From the National Health Insurance Database.

Background and PurposeThe purpose of this study was to determine the cardiac and pulmonary management status of patients with Duchenne muscular dystrophy (DMD) in South Korea based on the Korean National Health Insurance database.MethodsThis study used data of patients with code G71.0 in the National Health Information database, and also those with the special case of code V012. Cardiac function was assessed based on whether echocardiography and 24-h electrocardiography were performed, as well as the frequency of these investigations. Furthermore, information on the use of angiotensin-converting enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARB), and beta blockers (BB) in the drug benefit list was checked. Medical charge records were also checked regarding the prescription of respiratory functional assessments and treatments.ResultsThe diagnostic criteria were met by 479 patients, with 41% of these patients receiving a cardiac evaluation, 29.8% being prescribed ACEi at 14.4±3.7 years of age, 59.5% undergoing pulmonary function tests, and 42.1% received pulmonary rehabilitation. The age at receiving ventilator support was 19.4±2.7 years. The frequency of cardiac and respiratory function tests increased with age, but the interval between tests was longer than the recent DMD care recommendations. The trend of taking ACEi, ARB, and BB for cardiac management in South Korea did not change during the study analysis period.ConclusionsThe findings of this study will contribute to recognizing the current status and the importance of applying an anticipatory approach to cardiopulmonary function in DMD patients.

Hospital Variation in Non-Invasive Ventilation Use for Acute Respiratory Failure Due to COPD Exacerbation.

BackgroundNon-invasive mechanical ventilation (NIV) use in patients admitted with acute respiratory failure due to COPD exacerbations (AECOPDs) varies significantly between hospitals. However, previous literature did not account for patients’ illness severity. Our objective was to examine the variation in risk-standardized NIV use after adjusting for illness severity.MethodsWe retrospectively analyzed AECOPD hospitalizations from 2011 to 2017 at 106 acute-care Veterans Health Administration (VA) hospitals in the USA. We stratified hospitals based on the percentage of NIV use among patients who received ventilation support within the first 24 hours of admission into quartiles, and compared patient characteristics. We calculated the risk-standardized NIV % using hierarchical models adjusting for comorbidities and severity of illness. We then stratified the hospitals by risk-standardized NIV % into quartiles and compared hospital characteristics between quartiles. We also compared the risk-standardized NIV % between rural and urban hospitals.ResultsIn 42,048 admissions for AECOPD over 6 years, the median risk-standardized initial NIV % was 57.3% (interquartile interval [IQI]=41.9–64.4%). Hospitals in the highest risk-standardized NIV % quartiles cared for more rural patients, used invasive ventilators less frequently, and had longer length of hospital stay, but had no difference in mortality relative to the hospitals in the lowest quartiles. The risk-standardized NIV % was 65.3% (IQI=34.2–84.2%) in rural and 55.1% (IQI=10.8–86.6%) in urban hospitals (p=0.047), but hospital mortality did not differ between the two groups.ConclusionNIV use varied significantly across hospitals, with rural hospitals having higher risk-standardized NIV % rates than urban hospitals. Further research should investigate the exact mechanism of variation in NIV use between rural and urban hospitals.

OUTCOMES OF PATIENTS HOSPITALIZED DUE TO ACUTE EXACERBATION OF COPD AND REQUIRING VENTILATION SUPPORT

TOPIC: Obstructive Lung Diseases TYPE: Original Investigations PURPOSE: Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD) with respiratory failure has been associated with higher mortality and morbidities. Implementation of Non-invasive ventilation (NIV) in an early stage of AECOPD with acute respiratory failure has been found to reduce the intubation rate and improve the outcomes. IMV comes in use when the patient cannot tolerate NIV or has worsening respiratory failure despite NIV or has other comorbidities. We hypothesized to see trends and temporal changes in outcomes of AECOPD hospitalizations and factors associated with poor outcomes among those who received ventilation support. METHODS: We extracted data from the Nationwide Inpatient Sample (NIS) for the years 2007-2018 for adult hospitalizations due to AECOPD by using International Classification of Diseases (9th/10th Editions) Clinical Modification diagnosis codes (ICD-9-CM/ICD-10-CM) diagnosis codes and ventilation (IMV and NIV) by procedural codes. Primary objective is to study the trends of discharge disposition (in-hospital mortality and discharge to facilities) and predictors of poor outcomes among those who required ventilation. Cochran Armitage trend test and multivariate survey logistic regression models were used to analyze the data using SAS 9.4 software. RESULTS: We extracted a total of 5,673,467 hospitalizations due to acute exacerbation of COPD from 2007-2018, out of which 455,848 (8.0%) required either IMV or NIV. During the study period, overall, in-hospital mortality has reduced (1.8% in 2007 to 0.4% in 2018; ptrend<0.001) which was largely attributed to decline in in-hospital mortality among those who received NIV (6.3% in 2007 to 2.0% in 2018; ptrend<0.001) and IMV (26.6% in 2007 to 16.7% in 2018; ptrend<0.001). We observed similar declining trends for discharge to facilities. Additionally, among those who received NIV or IMV, age above 65, females (OR 1.1; 95%CI 1.1-1.1; p 0.03), Caucasian (OR 1.5; 95%CI 1.4-1.6; p<0.01), urban-non teaching hospitals (OR 1.2; 95%CI 1.1-1.2; p<0.01), IMV (OR 5.6; 95%CI 5.2-6.0; p<0.01), sepsis (OR 3.5,95%CI 3.3-3.9; p<0.01), pneumonia, CHF, renal failure were associated with higher odds of in-hospital mortality. CONCLUSIONS: Over the years, improved outcomes among AECOPD patients were attributed to significant decline in in-hospital mortality and discharge to facilities among those who received NIV and IMV. Additionally, we also identified several demographic and hospital level characteristics associated with poor outcomes among AECOPD patients requiring ventilatory support. CLINICAL IMPLICATIONS: Our study highlights the outcomes trends of AECOPD patients who required ventilatory support in the last decade. Although outcomes have been improved, still several modifiable factors are associated with higher mortality and morbidity which our study has highlighted. Better risk stratification and strategies are required to further improve the outcomes in these complex patient population. DISCLOSURES: No relevant relationships by Faizan Malik, source=Web Response No relevant relationships by MARIO MEKHAIL, source=Web Response No relevant relationships by Achint Patel, source=Web Response No relevant relationships by Kinjalben Patel, source=Web Response No relevant relationships by Aditi Patil, source=Web Response No relevant relationships by Abdur Raheem, source=Web Response No relevant relationships by Harshil Shah, source=Web Response No relevant relationships by Shiv Shah, source=Web Response No relevant relationships by FARAZ Siddiqui, source=Web Response No relevant relationships by vimala thambi, source=Web Response

Characteristics, therapeutic modalities and outcomes of COVID-19 ventilated patients in a tertiary care hospital in counter-insurgency zone: Our experience

BackgroundCoronavirus disease 2019 (COVID-19) can result in severe life-threatening course requiring ventilatory support. This study highlights data pertaining to ventilated patients to enhance our understanding of COVID-19 as it evolves. MethodsA descriptive, retrospective analysis was carried out on 50 COVID-19 RT-PCR positive patients who received mechanical ventilation at a tertiary care hospital in counter-insurgency (CI) zone, from June to December 2020. Data pertaining to patient characteristics, treatment, ventilator support and outcomes was analysed. ResultsOut of 50 patients, 74% were aged 50 years and above with 60% patients having comorbidities. 39 patients received non-invasive ventilation (NIV) and 04 patients received invasive mechanical ventilation (IMV) while 07 patients were converted from NIV to IMV during the hospital stay. Out of the 50 patients who received ventilator support 25 (50%) survived to discharge. The overall survival was 47.3% amongst the males while it was 58.3% for the females. The majority of survivors were in the NIV category (61.5%) while only 9.0% survived amongst those who received IMV. Average length of stay on NIV for patients was 5.3 days and for IMV was 7.5 days. All 50 patients received therapy in the form of steroids, anticoagulants, broad spectrum antibiotics and antivirals. Remdesivir was given to 40 of these patients out of which 20 survived (50%). Interleukin-6 therapy (Tocilizumab) was given to five patients of which four survived (80%). ConclusionThis study helps us to gain insights into the outcomes of COVID-19 patients managed in a tertiary care hospital in CI zone.

The Potential Risk Factors for Mortality in Patients After In-Hospital Cardiac Arrest: A Multicenter Study.

Background and Purpose: In-hospital cardiac arrest (IHCA) has high mortality rate, which needs more research. This multi-center study aims to evaluate potential risk factors for mortality in patients after IHCA.Methods: Data for this study retrospectively enrolled IHCA patients from 14 regional hospitals, two district hospitals, and five medical centers between 2013 June and 2018 December. The study enrolled 5,306 patients and there were 2,871 patients in subgroup of intensive care unit (ICU) and emergency room (ER), and 1,894 patients in subgroup of general wards.Results: As for overall IHCA patients, odds ratio (OR) for mortality was higher in older patients (OR = 1.69; 95% CI:1.33–2.14), those treated with ventilator (OR = 1.79; 95% CI:1.36–2.38) and vasoactive agents (OR = 1.88; 95% CI:1.45–2.46). Whereas, better survival was reported in IHCA patients with initial rhythm as ventricular tachycardia (OR = 0.32; 95% CI: 0.21–0.50) and ventricular fibrillation (OR = 0.26; 95% CI: 0.16–0.42). With regard to ICU and ER subgroup, there was no mortality difference among different nursing shifts, whereas for patients in general wards, overnight shift (OR = 1.83; 95% CI: 1.07–3.11) leads to poor outcome.Conclusion: For IHCA patients, old age, receiving ventilator support and vasoactive agents reported poor survival. Overnight shift had poor survival for IHCA patients in general wards, despite no significance in overall and ICU/ER subgroups.

Impact of Using a Non-Rebreathing Mask in Patients With Respiratory Failure

BackgroundLiberal oxygen therapy might increase the mortality rate of patients. Non-rebreathing masks (NRM) are a high-flow, non-invasive oxygen device that can provide oxygen concentration up to 95%. This study aimed to determine the impact of using NRM in patients with respiratory failure. MethodsThis retrospective cohort study was conducted in four medical institutions in Taiwan from January 2010 to December 2016. The association between mortality and NRM use before receiving ventilator support in patients with respiratory failure in the emergency department was analyzed. Patients were divided into the NRM treatment and no NRM treatment groups. A 1:4 propensity score matching was conducted. Regarding the duration of NRM use, treatments were grouped as 0 h, 0–1 h, 1–2 h, and >2 h. ResultsA total of 18,749 patients were included, with 1074 using NRM. After propensity score matching, 1028 patients using NRM (0–1 h: 508, 1–2 h: 193, and >2 h: 327) and 4112 patients not using NRM were analyzed. The 30-day mortality rates were 29.1%, 28.5%, 27.5%, and 35.5% in the 0 h, 0–1 h, 1–2 h, and >2 h treatment groups, respectively. Patients with respiratory failure due to pulmonary disease using NRM over 2 h had a higher mortality rate than patients not using NRM (hazard ratio: 1.3, 95% CI: 1.01–1.66). ConclusionsProlonged use of NRM in patients with respiratory failure due to pulmonary disease possibly increases mortality.

Prevalence of long-term mechanical insufflation-exsufflation in children with neurological conditions: a population-based study.

AimTo determine the prevalence of long‐term mechanical insufflation‐exsufflation (MI‐E) and concomitant mechanical ventilation in children with neurological conditions, with reported reasons behind the initiation of treatment.MethodThis was a population‐based, cross‐sectional study using Norwegian national registries and a questionnaire.ResultsIn total, 114 of 19 264 children with a neurological condition had an MI‐E device. Seventy‐three of 103 eligible children (31 females, 42 males), median (min–max) age of 10 years 1 month (1y 5mo–17y 10mo), reported their MI‐E treatment initiation. Overall, 76% reported airway clearance as the main reason to start long‐term MI‐E. A prophylactic use was mainly reported by children with neuromuscular disorders (NMDs). Prevalence and age at initiation differed by diagnosis. In spinal muscular atrophy and muscular dystrophies, MI‐E use was reported in 34% and 7% of children, of whom 83% and 57% respectively received ventilator support. One‐third of the MI‐E users were children with central nervous system (CNS) conditions, such as cerebral palsy and degenerative disorders, and ventilator support was provided in 31%. The overall use of concomitant ventilatory support among the long‐term MI‐E users was 56%.InterpretationThe prevalence of MI‐E in a neuropaediatric population was 6 per 1000, with two‐thirds having NMDs and one‐third having conditions of the CNS. The decision to initiate MI‐E in children with neurological conditions relies on clinical judgment.What this paper adds The prevalence and age at initiation of mechanical insufflation/exsufflation (MI‐E) differed between diagnoses.MI‐E was most commonly used in spinal muscular atrophy, where it generally coincided with ventilatory support.One‐third of MI‐E devices were given to children with central nervous system conditions, and one‐third also received ventilatory support.

Effect of corticosteroid therapy in patients with an acute exacerbation of chronic obstructive pulmonary disease receiving ventilatory support

Background Chronic obstructive pulmonary disease (COPD) is a common, preventable, and treatable disease characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities, usually caused by significant exposure to noxious particles or gases. The chronic airflow limitation that characterizes COPD is caused by a mixture of small airway disease (e.g. obstructive bronchiolitis) and parenchymal destruction (emphysema), the relative contributions of which vary from person to person. Aim The aim of the study was to determine the effect of systemic corticosteroids in patients with severe acute exacerbations of COPD admitted to the ICU receiving ventilatory support. Patients and methods A total of 100 patients with acute exacerbations of COPD leading to hypoxemia and respiratory acidosis with pH less than 7.35 and PaCO2 more than 45 mmHg admitted to the ICU who were receiving ventilator support (invasive or noninvasive mechanical ventilation) were included. Results It was noticed that steroid group had significantly lower duration of mechanical ventilation (4.67±2.76 vs. 2.76±1.11 days; P=0.01), ICU stay (5.33±2.87 vs. 7.89±3.36 days; P=0.04), and hospital stay (11.65±3.89 vs. 16.67±4.44 days; P=0.03). Conclusion Corticosteroid therapy was associated with significantly lower duration of mechanical ventilation, ICU stay, and hospital stay.

Ventilatory Support Use in Hospitalized Patients With Community-Acquired Pneumonia. Fifteen-year Trends in Spain (2001–2015)

AimWe examined fifteen years trends (2001–2015) in the use of non-invasive ventilation (NIV), invasive mechanical ventilation (IMV) or both (NIV+IMV) among patients hospitalized for community acquired pneumonia (CAP). We also analyzed trends overtime and the influence of patient factors in the in-hospital mortality (IHM) after receiving NIV, IMV or NIV+IMV. MethodsObservational retrospective epidemiological study. Our data source was the Spanish National Hospital Discharge Database. ResultsOver a total of 1,486,240 hospitalized patients with CAP, we identified 56,158 who had received ventilator support in Spain over the study period. Of them, 54.82% received NIV, 37.04% IMV and 8.14% both procedures. The use of NIV and NIV+IMV increased significantly (p<0.001) over time (from 0.91 to 12.84 per 100.000 inhabitant and from 0.23 to 1.19 per 100.000 inhabitants, respectively), while the IMV utilization decreased (from 3.55 to 2.79 per 100,000 inhabitants; p<0.001). Patients receiving NIV were the oldest and had the highest mean value in the Charlson comorbidity index (CCI) score and readmission rate. Patients who received only IMV had the highest IHM. Factors associated with IHM for all groups analyzed included age, comorbidities and readmission. IHM decreased significantly over time in patients with CAP who received NIV, IMV and NIV+IMV. ConclusionsWe found an increase in NIV use and a decline in IMV utilization in patients hospitalized for CAP over the study period. Patients receiving NIV were the oldest and had the highest CCI score and readmission rate. IHM decreased significantly over time in patients with CAP who received NIV, IMV and NIV+IMV.