Reintubation Rate Research Articles

Humidified Noninvasive Ventilation versus High-Flow Therapy to Prevent Reintubation in Obese Patients: A Randomized Clinical Trial.

The optimal strategy to prevent reintubation in obese patients remains uncertain. We aimed to determine whether noninvasive ventilation (NIV) with active humidification is superior to high-flow nasal cannula (HFNC) in preventing reintubation in obese patients at intermediate risk. Randomized controlled trial in two intensive care units in Spain (June 2020‒June 2021). We included patients ready for planned extubation with a body mass index (BMI) >30 and ≤3 risk factors for reintubation. Patients with hypercapnia at the end of the spontaneous breathing trial were excluded. Patients were randomized to undergo NIV with active humidification or HFNC for 48 hours after extubation. The primary outcome was reintubation rate within 7 days after extubation. As a secondary analysis, we performed a post hoc Bayesian analysis using three different priors. Of 144 patients (median age, 61 [p25-p75 61-67] years; 65 [45%] men), 72 received NIV and 72 HFNC. Reintubation was required in 17 (23.6%) patients receiving NIV and in 24 (33.3%) patients receiving HFNC (difference between groups 9.7 (95%CI: -4.9 ‒ 24.4)). All the secondary analysis showed non-significant differences. In the exploratory Bayesian analysis, the probability of a reduction in reintubation with NIV was 99% (data-driven prior), 90% (minimally informative prior), or 89% (skeptical prior). Among adult obese critically ill patients at intermediate risk for extubation failure, the rate of reintubation was not significantly lower with NIV than with HFNC. Nevertheless, there is a risk for underpowered results. Clinical trial registration available at www. gov, ID: NCT04125342.

High-flow nasal cannula oxygen therapy versus noninvasive ventilation for elderly chronic obstructive pulmonary disease patients after extubation: a noninferior randomized controlled trial protocol

IntroductionNoninvasive ventilation (NIV) is widely used for sequential extubation in patients with chronic obstructive pulmonary disease (COPD). However, NIV may cause many adverse events such as claustrophobia, facial skin compression, air leakage, bloating, and even reflux aspiration, resulting in poor patient compliance/tolerance and high failure rate, especially for older adults who are at high risk of communication difficulties and consciousness disorder. High-flow nasal cannula (HFNC) oxygen therapy is a new alternative support to NIV, but whether it can effectively reduce the rate of re-intubation after extubation in elderly patients with COPD remains controversial. The purpose of this study is to explore the safety and efficacy of HFNC versus NIV for elderly COPD patients after extubation.Methods and analysisThis study is an investigator-initiated, single-center, prospective, non-inferior, randomized controlled trial. Elderly patients (age > 65 years) who have received invasive ventilation and was diagnosed with COPD will be randomly assigned to HFNC group or NIV group immediately after extubation with a planned enrollment of 168 patients. The primary outcomes will be reintubation rates at 72 h and 7 days after extubation. Secondary outcomes will include treatment failure, post-extubation vital signs and arterial blood gases, the scores of compliance and comfort of patients, duration of respiratory support after extubation, respiratory support related adverse events, sleep quality scores, usage of sedative and analgesic drugs after extubation, and the incidence of delirium. Additionally, clinical outcomes such as ventilator-free days at 28 days post-randomization, tracheotomy rate, duration of intensive care unit (ICU) and hospital stay, ICU and hospital mortality will be evaluated.Ethics and disseminationThis study has been approved by the Ethics Committee of West China Hospital of Sichuan University (2023–2284). Informed consent is required. It is expected that a follow-up randomized controlled trial will be conducted. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences.Trial registrationThe study was retrospectively registered at ClinicalTrials.gov (ChiCTR2400087312).

Respiratory outcomes and survival after unplanned extubation in the NICU: a prospective cohort study from the SEPREVEN trial

ObjectiveTo compare reintubation rates after planned extubation and unplanned extubation (UE) in patients in neonatal intensive care units (NICUs), to analyse risk factors for reintubation after UE and to compare...

Impact of an enhanced recovery after surgery program integrating cardiopulmonary rehabilitation on post-operative prognosis of patients treated with CABG: protocol of the ERAS-CaRe randomized controlled trial

BackgroundCoronary artery bypass grafting is associated with a high occurrence of postoperative cardiopulmonary complications. Preliminary evidence suggested that enhanced recovery after surgery can effectively reduce the occurrence of postoperative cardiopulmonary complications. However, enhanced recovery after surgery with systematic integration of cardiopulmonary rehabilitation (ERAS-CaRe) into for Coronary artery bypass grafting has not been evaluated so far. We thus design the ERAS-CaRe randomized-controlled trial to evaluate possible superiority of embedding cardiopulmonary rehabilitation in ERAS over ERAS alone as well as to investigate effects of differential timing of cardiopulmonary rehabilitation within enhanced recovery after surgery (pre-, post-, perio-operative) on post-operative cardiopulmonary complications following Coronary artery bypass grafting surgery.MethodsERAS-CaRe is a pragmatic, randomized-controlled, parallel four-arm, clinical trial. Three hundred sixty patients scheduled for Coronary artery bypass grafting in two Chinese hospitals will be grouped randomly into (i) Standard enhanced recovery after surgery or (ii) pre-operative ERAS-CaRe or (iii) post-operative ERAS-CaRe or (iv) perio-operative ERAS-CaRe. Primary outcome is the occurrence of cardiopulmonary complications at 10 days after Coronary artery bypass grafting. Secondary outcomes include the occurrence of other individual complications including cardiac, pulmonary, stroke, acute kidney injury, gastrointestinal event, ICU delirium rate, reintubation rate, early drainage tube removal rate, unplanned revascularization rate, all-cause mortality, ICU readmission rate, plasma concentration of myocardial infarction-related key biomarkers etc.DiscussionThe trial is designed to evaluate the hypothesis that a cardiopulmonary rehabilitation based enhanced recovery after surgery program reduces the occurrence of cardiopulmonary complications following Coronary artery bypass grafting and to determine optimal timing of cardiopulmonary rehabilitation within enhanced recovery after surgery. The project will contribute to increasing the currently limited knowledge base in the field as well as devising clinical recommendations.Trial registrationThe trial was registered at the Chinese Clinical Trials Registry on 25 August 2023 (ChiCTR2300075125; date recorded: 25/8/2023, https://www.chictr.org.cn/).

Impact of high-flow nasal oxygen therapy on postoperative atelectasis and reintubation rate after paediatric cardiac surgery.

Airway problems emerging after congenital cardiac surgery operations may have an impact on mortality and morbidity. Recently, to improve alveolar gas exchange and reduce respiratory effort, high-flow nasal cannula (HFNC) has started to be used in paediatric cases. This study aimed to evaluate the potential effects of high-flow nasal oxygen therapy on postoperative atelectasis development and reintubation rate in paediatric cardiac surgery patients. This study was conducted retrospectively in term newborns and infants younger than six months of age who underwent congenital cardiac surgery operation from 1 November 2022 to 1 November 2023 and were followed in the paediatric cardiac ICU. Patients who were receiving mechanical ventilator support at least 12 hours postoperatively were evaluated for the development of postoperative atelectasis and reintubation in the first 3 days of extubation. The patients were grouped as HFNC and non-HFNC users. Demographic characteristics, surgery type, and ICU clinical follow-up data were obtained from medical records. The results were statistically evaluated. A total of 40 patients who did not use HFNC in the early postoperative period and 40 patients with HFNC in the late period during the study period were included in the study. The median age was 1 month (IQR 15 days-2 months) with equal gender distribution. Among patients, 70% of them were in the neonatal age group. Reintubation rates in the first 72 hours in HFNC users and non-HFNC users were 2.5% and 12.5%, respectively (p < 0.05). The median postoperative atelectasis scores at 24, 48, and 72 hours of extubation were 2 versus 2.5 (p > 0.05), 1.5 versus 3.5 (p < 0.05), and 1 versus 3 (p < 0.05) in HFNC users and non-HFNC users, respectively. HFNC therapy may have a positive effect on preventing atelectasis and reducing the reintubation rate in the early postoperative period.

Prevalence of unplanned extubation in a tertiary care neonatal intensive care unit.

Orotracheal intubation and mechanical ventilation (MV) have become routine practices in intensive care units. Unplanned extubation (UE) is one of the most important complications, particularly in premature infants and critically ill newborns. The objective of this study was to determine the prevalence of UE in a tertiary care neonatal intensive care unit (NICU). In this analytical cross-sectional retrospective study, all data, including perinatal data, indications for ventilatory support, days of MV at the time of UE, work shift, month of the event, reintubation, and postextubation complications, were obtained from the manual review of clinical charts. In total, 151 neonates, who received invasive MV, were included in this study. The prevalence of UE was 2.0/100 days of ventilation. The most affected were premature infants, with a gestational age of ≤ 32 weeks (54.7%) and a birth weight of ≤ 1500 g. The main cause for UE was deficient fixation of the endotracheal tube (ETT) (27.7%). Most UE events occurred during night shifts (48.1%). Reintubation was required in 83.3% of newborns. Immediate complications developed in 96.3% of the UE events, including desaturation (57.7%) and bradycardia (36.5%). The prevalence of UE was high, particularly in premature infants, with a high rate of reintubation and immediate complications. Standardized protocols for ETT care must be implemented to reduce these events.

Incidencia de retirada no programada de dispositivos invasivos en enfermos con COVID-19 en cuidados intensivos

IntroductionThe rate of unscheduled removal of invasive devices (ID) is an indicator of quality programmes in the critically ill. Our research group performed prevalence analyses since 2010 and another during the pandemic. The aim was to analyse the rates of use and non-planed removal of endotracheal tubes, catheters (central venous and arterial) and enteral catheters in the first wave of the COVID-19 pandemic comparing them with previous rates. MethodologyPrevalence study in a polyvalente ICU. After 4 prospective observational analyses (2010, 2011, 2018, 2019) a retrospective analysis was performed (8 March-8 May 2020). Variables: diagnosis, stay and reason for removal of ID (endotracheal tubes (ET), central venous catheters, arterial catheters and enteral catheters) and rate of reintubation after self-removal of ET. Variables analysed and described as accidental removal rates per 1000 device-days and rates of ID use. Results2026 patients were included (631 in 2010, 724 in 2011, 210 in 2018, 361 in 2019 and 100 in 2020). Significant differences, between all periods, in diagnoses (P<.001), ICU stay (P<.001) and mortality (P=.016) and, between 2020 and all other periods, in rates of use per 100 days-stay (P<.010) and per 100 admissions (P<.001) in all devices except arterial catheter. In 2020, there was an increase in ET obstruction (36.0%; rate 20.27 per 1000 intubation/days, P<.010), decrease in ET self-removals (2020 rate: 0.00 per 1000 intubation/days; P<.050) and enteral catheters (14.33 per 1000 catheter/days). Overall reintubation (all periods) after self-extubation: 12.5%. ConclusionsThe rate of devices self-removal in COVID-19 patients in the first wave of the pandemic was lower than that observed in the previous four periods. The high incidence rate of ET obstruction in these patients was significant and relevant.

A Retrospective Multicenter Study of Operating Room Extubation and Extubation Timing following Cardiac Surgery

BackgroundIn an effort to enhance recovery after cardiac surgery, intraoperative extubation has been targeted as possibly beneficial. This multi-center cohort study aimed to assess this by evaluating the outcomes of OR extubation versus extubation within six hours of intensive care unit arrival (early ICU extubation). Furthermore, we assessed time to ICU extubation and mortality and morbidity. MethodsPatients undergoing on-pump cardiac surgery across 79 hospitals between 2011-2020 were included to 1) compare outcomes among OR extubation and early ICU extubation patients, and 2) assess time to overall ICU extubation and outcomes. ResultsThe overall study cohort comprised 163,982 patients, including 95,982 patients [ [ OR extubation : n= 2,529 (2.6%)and early ICU extubation : n= 93,453 (97.4%)] who underwent comparison of OR with early ICU extubation. Following overlap weighting, OR extubation patients had longer OR times (5.6 vs. 5.1 hours, p < 0.0001), and higher rates of reintubation (5.2% vs 2.9%, p=0.003), prolonged ventilation (3% vs 2%, p = 0.021), reoperation for bleeding (1.5% vs 0.7%, p < 0,01), pneumonia (1.9% vs. 1.1% , p < 0.006), and greater in-hospital mortality on multivariable regression (OR 1.34, p < 0.001). OR extubation patients at centers with low OR extubation rates (< 10%, N=60) had higher mortality (odds ratio 1.6, p = 0.001). Beyond 22 hours of postoperative ICU ventilation, the risk of morbidity and mortality increased significantly . ConclusionsFew cardiac surgery patients are extubated in the OR, which is associated with no clinical benefit and with increased morbidity. Cardiac surgery programs should reconsider OR extubation following cardiopulmonary bypass. Additionally, increased intubation time, in particular > 22 hours, is associated with an increase in adverse outcomes.

Optimal Postextubation Support in Critically Ill Patients: One Size Does Not Fit All.

Extubation is a crucial step in the weaning process of critically ill mechanically ventilated patients. Some patients may develop postextubation respiratory failure that may lead to the need for re-intubation, which is associated with increased morbidity and mortality. This review comprehensively explores postextubation respiratory support strategies, focusing on the efficacy of high-flow nasal cannula (HFNC) oxygen therapy and noninvasive ventilation (NIV) in reducing re-intubation rates among various patient populations. HFNC improves oxygenation and reduces the work of breathing. However, its effectiveness in preventing re-intubation varies according to the patient's characteristics and the predefined risk for re-intubation. NIV, alternatively, appears to provide substantial advantages in reducing the rates of re-intubation and respiratory failure, especially in patients with obesity and patients with hypercapnia. Therefore, the indiscriminate application of these support strategies without consideration of individual patient characteristics may not improve outcomes, highlighting the need for careful patient selection and tailored therapeutic strategies based on specific risk factors and clinical conditions. By aligning postextubation respiratory support strategies with patient-specific needs, we may improve the success rates of extubation, enhance overall recovery, and reduce the burden of reintubations in the intensive care setting.

Single vs Double Lung Transplantation in Older Adults: A Propensity-Matched Analysis

BackgroundSingle lung transplantation (SLT) is associated with worse long-term outcomes than bilateral lung transplantation (BLT) but is often performed for older adults at risk of not tolerating BLT. Research QuestionHow do the outcomes of SLT and BLT compare among older adult recipients? Study Design and MethodsThe Scientific Registry of Transplant Recipients database (2005-2022) was queried for lung transplant recipients aged ≥65 years. Patients were stratified by whether they underwent BLT or SLT, and propensity matched. Baseline characteristics and morbidity were compared with frequentist statistics. Survival was analyzed via Kaplan-Meier estimation. Risk factors for mortality were identified with Cox regression. ResultsOf 9,904 included patients, 4,829 (48.8%) underwent SLT. SLT patients had lower lung allocation scores (39.6 v. 40.6, p<0.001), more interstitial lung disease (74.4% v. 64.6%, p<0.001) and lower rates of bridging (0.7% v. 2.4%, p<0.001). Groups did not differ significantly by sex, body mass index, or donor characteristics. Propensity matching resulted in 2,539 patients in each group. On matched analysis, SLT patients had shorter lengths of stay (14 v. 18 d), lower reintubation rates (14.7% v. 19.8%), and less postoperative dialysis use (4.2% v. 6.4%) (all p<0.001). SLT patients had comparable survival at 30-days (97.6% v. 97.3%, p=0.414) and 1-year (85.5% v. 86.3%, p=0.496), but lower survival at 5-years (45.4% v. 53.4%, p<0.001) on matched analysis. SLT was a risk factor for 5-year mortality (adjusted hazard ratio: 1.19, p<0.001). InterpretationIn older adults, SLT is associated with less morbidity and comparable early survival relative to BLT, but lower five-year survival. SLT is reasonable to perform in older adults at high risk for BLT.

Prediction models for postoperative pulmonary complications in intensive care unit patients after noncardiac thoracic surgery

BackgroundPostoperative pulmonary complication (PPC) is a leading cause of mortality and poor outcomes in postoperative patients. No studies have enrolled intensive care unit (ICU) patients after noncardiac thoracic surgery, and effective prediction models for PPC have not been developed. This study aimed to explore the incidence and risk factors and construct prediction models for PPC in these patients.MethodsThis study retrospectively recruited patients admitted to the ICU after noncardiac thoracic surgery at West China Hospital, Sichuan University, from July 2019 to December 2022. The patients were randomly divided into a development cohort and a validation cohort at a 70% versus 30% ratio. The preoperative, intraoperative and postoperative variables during the ICU stay were compared. Univariate and multivariate logistic regression analyses were applied to identify candidate predictors, establish prediction models, and compare the accuracy of the models with that of reported risk models.ResultsA total of 475 ICU patients were enrolled after noncardiac thoracic surgery (median age, 58; 72% male). At least one PPC occurred in 171 patients (36.0%), and the most common PPC was pneumonia (153/475, 32.21%). PPC significantly increased the duration of mechanical ventilation (p < 0.001), length of ICU stay (p < 0.001), length of hospital stay (LOS) (p < 0.001), and rate of reintubation (p = 0.047) in ICU patients. Seven risk factors were identified, and then the prediction nomograms for PPC were constructed. At ICU admission, the area under the curve (AUC) was 0.766, with a sensitivity of 0.71 and specificity of 0.60; after extubation, the AUC was 0.841, with a sensitivity of 0.75 and specificity of 0.83. The models showed robust discrimination in both the development cohort and the validation cohort, and they were well calibrated and more accurate than reported risk models.ConclusionsICU patients who underwent noncardiac thoracic surgery were at high risk of developing PPCs. Prediction nomograms were constructed and they were more accurate than reported risk models, with excellent sensitivity and specificity. Moreover, these findings could help assess individual PPC risk and enhance postoperative management of patients.

Thoracic sarcopenia measured by Hounsfield unit average calculation predicts morbidity and mortality in coronary artery bypass grafting.

The aim of the study was to investigate the potential prognostic role of preoperative measurement of erector spinae myosteatosis with Hounsfield unit average calculation as a marker for sarcopenia and frailty in patients undergoing coronary bypass surgery. Preoperative computer tomography-derived measurements of 479 consecutive patients undergoing coronary bypass surgery between January 2017 and December 2019 were retrospectively performed. The erector spinae muscle at the level of the 12th vertebra was manually outlined bilaterally on the axial computer tomography slices and Hounsfield unit average calculation was performed. The lower quartile of muscle density values was defined as myosteatotic and thus sarcopenic. Sarcopenic (n = 121) versus non-sarcopenic patients (n = 358) were compared regarding postoperative morbidity and short- and long-term mortality. Results were adjusted for age, body mass index, atrial fibrillation and hypertension using inverse probability weighting. Sarcopenia was associated with higher 30-day mortality (4.1% vs 0.8%; P = 0.012), mid-term mortality after 1 year (9.3% vs 3.1%; P = 0.047) and 2 years (10.8% vs 4.2%; P = 0.047). Long-term mortality (5 years) was 20.8% for sarcopenic and 13.0% for non-sarcopenic patients but was not found to be significantly different (P = 0.089). Sarcopenia was associated with higher rates of reintubation (7.5% vs 1.1%; P < 0.001), sternal wound infections (7.5% vs 2.8%; P = 0.039) and acute kidney injury requiring haemodialysis (2.5% vs 0.4%; P = 0.021). In patients undergoing coronary bypass surgery, sarcopenia was associated with increased short-term mortality, mid-term mortality and morbidity. The measurement of erector spinae myosteatosis could be an easy and useful parameter in preoperative risk assessment.

Influence of Hospital Transfer Status on Surgical Outcomes for Traumatic Thoracolumbar Spine Fractures: Insights from a Multicenter Investigation

Surgical intervention for unstable thoracolumbar spine fractures is common, but delayed management and complications can impact outcomes. This study compares perioperative outcomes between patients directly admitted and those transferred from another facility for thoracolumbar spine surgery, aiming to identify predictors of complications and mortality. A multicenter retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2021 identified 61,626 patients undergoing fusion surgeries for thoracolumbar spine fractures, excluding spinal cord injury or pathological fractures. Patients were categorized as Direct (admitted from the emergency department) and Transfer (transferred from another facility). Perioperative outcomes, including operative time, length of stay (LOS), 30-day mortality, and complications, were compared. Our patient population (54.3% female, mean age 62.4±12.9years) comprised 12.2% Transfer and 87.8% Direct patients. Following propensity score matching, Transfer patients had a longer hospital LOS (5.1 ± 5.7days vs. 4.5 ± 4.6days, P < 0.001). Transfer exhibited higher rates of superficial incisional surgical site infection (1.7% vs. 1.1%, P= 0.003), sepsis (1.7% vs. 1.3%, P= 0.038), pneumonia (1.7% vs. 1.2%, P= 0.019), postoperative reintubation (0.9% vs. 0.6%, P= 0.036), and failure to wean off ventilator >48hours postsurgery (0.7% vs. 0.3%, P= 0.005) compared to Direct admissions. Direct group had a higher rate of perioperative transfusion (16.5% vs. 13.4%, P < 0.001). Transfer patients also had a higher 30-day mortality rate compared to Direct admissions (1.1% vs. 0.6%, P= 0.002). Interhospital transfers significantly affect hospital LOS, postoperative morbidity, and mortality in thoracolumbar spine surgery. Enhancing postoperative monitoring for transfer patients is crucial.

Risks for prolonged mechanical ventilation and reintubation after cervical malignant tumor surgery: a nested case-control study.

Prolonged mechanical ventilation (PMV) and reintubation are among the most serious postoperative adverse events associated with malignant cervical tumors. In this study, we aimed to clarify the incidence, characteristics, and risk factors for PMV and reintubation in target patients. This retrospective nested case-control study was performed between January 2014 and January 2020 at a large spinal tumor center in China. Univariate analysis was used to identify the possible risk factors associated with PMV and reintubation. Logistic regression analysis was performed to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) with covariates of a probability < 0.05 in univariate analysis. From a cohort of 560 patients with primary malignant (n = 352) and metastatic (n = 208) cervical tumors, 27 patients required PMV and 20 patients underwent reintubation. The incidence rates of PMV and reintubation were 4.82% and 3.57%, respectively. Three variables (all p < 0.05) were independently associated with an increased risk of PMV: Karnofsky Performance Status < 50 compared to ≥ 80, operation duration ≥ 8h compared to < 6h, and C4 nerve root encased by the tumor. Longer operative duration and preoperative hypercapnia (all p < 0.05) were independent risk factors for postoperative reintubation, both of which led to longer length of stay (32.6 ± 30.8 vs. 10.7 ± 5.95days, p < 0.001), with an in-hospital mortality of 17.0%. Our results demonstrate the risk factors for PMV or reintubation after surgery for malignant cervical tumors. Adequate assessment, early detection, and prevention are necessary for this high-risk population.

Noninvasive high-frequency oscillation ventilation as post- extubation respiratory support in neonates: Systematic review and meta-analysis.

Noninvasive High-Frequency Oscillatory Ventilation (NHFOV) is increasingly being adopted to reduce the need for invasive ventilation after extubation. To evaluate the benefits and harms of NHFOV as post-extubation respiratory support in newborns compared to other non-invasive respiratory support modes. We included randomized controlled trials comparing NHFOV with other non-invasive modes post-extubation in newborns. Data sources were MEDLINE (via Pubmed), Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, WHO international clinical trials registry platform and Clinical Trial Registry, forward and backward citation search. Methodological quality of studies was assessed by Cochrane's Risk of Bias tool 1.0. This systematic review included 21 studies and 3294 participants, the majority of whom were preterm. NHFOV compared to nasal continuous positive airway pressure (NCPAP) reduced reintubation within seven days (RR 0.34, 95% CI 0.22 to 0.53) after extubation. It also reduced extubation failure (RR 0.39, 95% CI 0.30 to 0.51) and reintubation within 72 hrs (RR 0.40, 95% CI 0.31 to 0.53), bronchopulmonary dysplasia (RR 0.59, 95% CI 0.37 to 0.94) and pulmonary air leak (RR 0.46, 95% CI 0.27 to 0.79) compared to NCPAP. The rate of reintubation within seven days (RR 0.62, 95% CI 0.18 to 2.14) was similar whereas extubation failure (RR 0.65, 95% CI 0.50 to 0.83) and reintubation (RR 0.68, 95% CI 0.52 to 0.89) within 72 hrs were lower in NHFOV group compared to nasal intermittent positive pressure ventilation. There was no effect on other outcomes. Overall quality of the evidence was low to very low in both comparisons. NHFOV may reduce the rate of reintubation and extubation failure post-extubation without increasing complications. Majority of the trials were exclusively done in preterm neonates. Further research with high methodological quality is warranted.

Noninvasive ventilation on reintubation in patients with obesity and hypoxemic respiratory failure following abdominal surgery: a post hoc analysis of a randomized clinical trial.

Although noninvasive ventilation (NIV) may reduce reintubation in patients with acute hypoxemic respiratory failure following abdominal surgery, this strategy has not been specifically assessed in patients with obesity. We conducted a post hoc analysis of a multicenter randomized controlled trial comparing NIV delivered via facial mask to standard oxygen therapy among patients with obesity and acute hypoxemic respiratory failure within 7 days after abdominal surgery. The primary outcome was reintubation within 7 days. Secondary outcomes were invasive ventilation-free days at day 30, intensive care unit (ICU)-acquired pneumonia and 30-day survival. Among 293 patients with hypoxemic respiratory failure following abdominal surgery, 76 (26%) patients had obesity and were included in the intention-to-treat analysis. Reintubation rate was significantly lower with NIV (13/42, 31%) than with standard oxygen therapy (19/34, 56%) within 7 days (absolute difference: - 25%, 95% confidence interval (CI) - 49 to - 1%, p = 0.03). NIV was associated with significantly more invasive ventilation-free days compared with standard oxygen therapy (27.1 ± 8.6 vs 22.7 ± 11.1days; p = 0.02), while fewer patients developed ICU-acquired pneumonia (1/42, 2% vs 6/34, 18%; p = 0.04). The 30-day survival was 98% in the NIV group (41/42) versus 85% in the standard oxygen therapy (p = 0.08). In patients with body mass index (BMI) < 30kg/m2, no significant difference was observed between NIV (36/105, 34%) and standard oxygen therapy (47/109, 43%, p = 0.03). An interaction test showed no statistically significant difference between the two subsets (BMI ≥ 30kg/m2 and BMI < 30kg/m2). Among patients with obesity and hypoxemic respiratory failure following abdominal surgery, use of NIV compared with standard oxygen therapy reduced the risk of reintubation within 7 days, contrary to patients without obesity. However, no interaction was found according to the presence of obesity or not, suggesting either a lack of power to conclude in the non-obese subgroup despite existing differences, or that the statistical difference found in the overall sample was driven by a large effect in the obese subsets.

Impacts of three inspiratory muscle training programs on inspiratory muscles strength and endurance among intubated and mechanically ventilated patients with difficult weaning: a multicentre randomised controlled trial

BackgroundInspiratory muscle training (IMT) is well-established as a safe option for combating inspiratory muscles weakness in the intensive care setting. It could improve inspiratory muscle strength and decrease weaning duration but a lack of knowledge on the optimal training regimen raise to inconsistent results. We made the hypothesis that an innovative mixed intensity program for both endurance and strength improvement could be more effective. We conducted a multicentre randomised controlled parallel trial comparing the impacts of three IMT protocols (low, high, and mixed intensity) on inspiratory muscle strength and endurance among difficult-to-wean patients.MethodsNinety-two patients were randomly assigned to three groups with different training programs, where each performed an IMT program twice daily, 7 days per week, from inclusion until successful extubation or 30 days. The primary outcome was maximal inspiratory pressure (MIP) increase. Secondary outcomes included peak pressure (Ppk) increase as an endurance marker, mechanical ventilation (MV) duration, ICU length of stay, weaning success defined by a 2-day ventilator-free after extubation, reintubation rate and safety.ResultsMIP increases were 10.8 ± 11.9 cmH2O, 4.5 ± 14.8 cmH2O, and 6.7 ± 14.5 cmH2O for the mixed intensity (MI), low intensity (LI), and high intensity (HI) groups, respectively. There was a non-statistically difference between the MI and LI groups (mean adjusted difference: 6.59, 97.5% CI [− 14.36; 1.18], p = 0.056); there was no difference between the MI and HI groups (mean adjusted difference: − 3.52, 97.5% CI [− 11.57; 4.53], p = 0.321). No significant differences in Ppk increase were observed among the three groups. Weaning success rate observed in MI, HI and LI group were 83.7% [95% CI 69.3; 93.2], 82.6% [95% CI 61.2; 95.0] and 73.9% [95% CI 51.6; 89.8], respectively. MV duration, ICU length of stay and reintubation rate had similar values. Over 629 IMT sessions, six adverse events including four spontaneously reversible bradycardia in LI group were possibly related to the study.ConclusionsAmong difficult-to-wean patients receiving invasive MV, no statistically difference was observed in strength and endurance progression across three different IMT programs. IMT appears to be feasible in usual cares, but some serious adverse events such as bradycardia could motivate further research on the specific impact on cardiac system.Trial registration Clinicaltrials.gov identifier: NCT02855619. Registered 28 September 2014

Effect of lung volume preservation during spontaneous breathing trial on successful extubation in patients receiving mechanical ventilation: protocol for a multicenter clinical trial

BackgroundIn standard weaning from mechanical ventilation, a successful spontaneous breathing test (SBT) consisting of 30 min 8 cmH2O pressure-support ventilation (PSV8) without positive end-expiratory pressure (PEEP) is followed by extubation with continuous suctioning; however, these practices might promote derecruitment. Evidence supports the feasibility and safety of extubation without suctioning. Ultrasound can assess lung aeration and respiratory muscles. We hypothesize that weaning aiming to preserve lung volume can yield higher rates of successful extubation.MethodsThis multicenter superiority trial will randomly assign eligible patients to receive either standard weaning [SBT: 30-min PSV8 without PEEP followed by extubation with continuous suctioning] or lung-volume-preservation weaning [SBT: 30-min PSV8 + 5 cmH2O PEEP followed by extubation with positive pressure without suctioning]. We will compare the rates of successful extubation and reintubation, ICU and hospital stays, and ultrasound measurements of the volume of aerated lung (modified lung ultrasound score), diaphragm and intercostal muscle thickness, and thickening fraction before and after successful or failed SBT. Patients will be followed for 90 days after randomization.DiscussionWe aim to recruit a large sample of representative patients (N = 1600). Our study cannot elucidate the specific effects of PEEP during SBT and of positive pressure during extubation; the results will show the joint effects derived from the synergy of these two factors. Although universal ultrasound monitoring of lungs, diaphragm, and intercostal muscles throughout weaning is unfeasible, if derecruitment is a major cause of weaning failure, ultrasound may help clinicians decide about extubation in high-risk and borderline patients.Trial registrationThe Research Ethics Committee (CEIm) of the Fundació Unió Catalana d’Hospitals approved the study (CEI 22/67 and 23/26). Registered at ClinicalTrials.gov in August 2023. Identifier: NCT05526053.

Efficacy of respiratory physiotherapy preceding to heart surgery with extracorporeal circulation

Introduction and objectivesHeart surgery is one of the most important tools for the treatment of cardiovascular diseases. Postoperative pulmonary complications in patients undergoing heart surgery represent a meaningful clinical problem.Respiratory physiotherapy is essential in the management of patients during postoperative period, contributing to a better prognosis.Our objective is to evaluate the efficacy of respiratory physiotherapy prior to cardiac surgery in reducing postoperative complications and hospital stay. MethodsRandomized, controlled and observational study. A group of 92 patients who underwent heart surgery with extracorporeal circulation were analyzed in the Hospital Puerta del Mar (Spain), divided into 2 groups (control group and experimental group with previous respiratory physiotherapy). We study different postoperative complications and hospital stay. ResultsAtelectasis, pleural effusion, and sternal dehiscence were altered between both groups. An improvement in the intubation time and the reintubation rate was reported in the experimental group, in addition, lower oxygen consumption, an improvement in the fulfillment of respiratory physiotherapy following surgery and a shorter overall hospital stay and in the post-operative care unit was also observed. ConclusionFulfillment of respiratory physiotherapy preceding to heart surgery decreases pulmonary complications and hospital stay, as well as accelerates the recovery of the breathing capacity.

Non-invasive high-frequency oscillatory ventilation (NHFOV) versus nasal continuous positive airway pressure (NCPAP) for preterm infants: a systematic review and meta-analysis

ObjectiveTo compare the efficacy and safety of non-invasive high-frequency oscillatory ventilation (NHFOV) and nasal continuous positive airway pressure (NCPAP) in preterm infants.DesignThe study conducted a comprehensive analysis across three databases,...