Sequential Mechanical Ventilation Research Articles

A prediction model for assessing hypoglycemia risk in critically ill patients with sepsis

BackgroundFew studies have reported the risk factors or developed a risk predictive model of hypoglycemia patients with sepsis. ObjectiveTo develop a predictive model to assess the hypoglycemia risk in critically ill patients with sepsis. MethodsFor this retrospective study, we collected the data from the Medical Information Mart for Intensive Care III and IV (MIMIC-III and MIMIC-IV). All eligible patients from the MIMIC-III were randomly divided into the training set for development of predictive model and testing set for internal validation of the predictive model at a ratio of 8:2. Patients from the MIMIC-IV database were used as the external validation set. The primary endpoint was the occurrence of hypoglycemia. Univariate and multivariate logistic model was used to screen predictors. Adopted receiver operating characteristics (ROC) and calibration curves to estimate the performance of the nomogram. ResultsThe median follow-up time was 5.13 (2.61–9.79) days. Diabetes, dyslipidemia, mean arterial pressure, anion gap, hematocrit, albumin, sequential organ failure assessment, vasopressors, mechanical ventilation and insulin were identified as the predictors for hypoglycemia risk in critically ill patients with sepsis. We constructed a nomogram for predicting hypoglycemia risk in critically ill patients with sepsis based on these predictors. An online individualized predictive tool: https://ghongyang.shinyapps.io/DynNomapp/. The established nomogram had a good predictive ability by ROC and calibration curves in the training set, testing set and external validation cohort. ConclusionA predictive model of hypoglycemia risk was constructed, with a good ability in predicting the risk of hypoglycemia in critically ill patients with sepsis.

Death-Related Factors in Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease Treated by Sequential Mechanical Ventilation

Objective To analyze the death-related factors of elderly patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) treated by sequential mechanical ventilation,so as to provide evidence for clinical practice. Methods The clinical data of 1204 elderly patients (≥60 years old) with AECOPD treated by sequential mechanical ventilation from June 2015 to June 2021 were retrospectively analyzed.The probability and influencing factors of death were analyzed. Results Among the 1204 elderly patients with AECOPD treated by sequential mechanical ventilation,167 (13.87%) died.Multivariate analysis showed that plasma procalcitonin ≥0.5 μg/L (OR=2.762, 95%CI=1.920-3.972, P<0.001),daily invasive ventilation time ≥12 h (OR=2.202, 95%CI=1.487-3.262,P<0.001),multi-drug resistant bacterial infection (OR=1.790,95%CI=1.237-2.591,P=0.002),oxygenation index<39.90 kPa (OR=2.447,95%CI=1.625-3.685,P<0.001),glycosylated hemoglobin >6% (OR=2.288,95%CI=1.509-3.470,P<0.001),and acute physiology and chronic health evaluation Ⅱ score ≥25 points (OR=2.126,95%CI=1.432-3.156,P<0.001) were independent risk factors for death in patients with AECOPD treated by sequential mechanical ventilation.Oral care>twice/d (OR=0.676,95%CI=0.457-1.000,P=0.048) and sputum excretion>twice/d (OR=0.492, 95%CI=0.311-0.776, P=0.002) were independent protective factors for death in elderly patients with AECOPD treated by sequential mechanical ventilation. Conclusions The outcomes of sequential mechanical ventilation in the treatment of elderly patients with AECOPD are affected by a variety of factors.To reduce the mortality,we put forward the following measures:attaching great importance to severe patients,restoring oxygenation function,shortening unnecessary invasive ventilation time,controlling blood glucose,preventing multidrug resistant bacterial infection,oral care twice a day,and sputum excretion twice a day.

Guidance Value of Procalcitonin Detection in Selecting Switching Points for Sequential Therapy in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease Complicated by Respiratory Failure.

ObjectiveTo analyse the guiding value of procalcitonin (PCT) for the selection of ventilation switching points in sequential mechanical ventilation for patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) and respiratory failure, and to provide a reference for the optimisation of mechanical ventilation for patients with COPD and respiratory failure.MethodsThe study included 160 patients with an acute exacerbation of COPD complicated by respiratory failure who received sequential mechanical ventilation treatment. They were divided into two groups of 80 participants. The critical point of the pulmonary infection observation window (PIC) was used as the switching point for sequential mechanical ventilation treatment in the control group, and PCT clinical node was used as the switching point for sequential mechanical ventilation treatment in the observation group. The invasive ventilation time, non-invasive mechanical ventilation time, total mechanical ventilation time, intensive care unit (ICU) treatment time, complication rate and prognosis were compared for the two groups.Results(1) There was no significant difference in the respiratory rate, heart rate, arterial systolic pressure, arterial oxygen partial pressure, arterial carbon dioxide partial pressure or pH value between the two groups after 1 day of treatment, and (2) invasive mechanical ventilation time, non-invasive mechanical ventilation time, total mechanical ventilation time, ICU treatment time and the incidence of complications were significantly different in the two groups (P = 0.0001).ConclusionDetecting PCT can guide the selection of ventilation switching points in sequential mechanical ventilation therapy for patients with COPD with respiratory failure in the acute exacerbation stage, effectively reduce the misevaluation of PIC switching points so that patients can obtain stable criteria for judgement and effectively improve the efficiency and safety of mechanical ventilation treatment for patients in the acute exacerbation stage.

Sequential treatment of severe pneumonia with respiratory failure and its influence on respiratory mechanical parameters and hemodynamics.

BACKGROUNDThe pathophysiological characteristics of severe pneumonia complicated by respiratory failure comprise pulmonary parenchymal changes leading to ventilation imbalance, alveolar capillary injury, pulmonary edema, refractory hypoxemia, and reduced lung compliance. Prolonged hypoxia can cause acid-base balance disorder, peripheral circulatory failure, blood-pressure reduction, arrhythmia, and other adverse consequences.AIMTo investigate sequential mechanical ventilation’s effect on severe pneumonia complicated by respiratory failure. METHODSWe selected 108 patients with severe pneumonia complicated by respiratory failure who underwent mechanical ventilation between January 2018 and September 2020 at the Luhe Hospital’s Intensive Care Unit and divided them into sequential and regular groups according to a randomized trial, with each group comprising 54 patients. The sequential group received invasive and non-invasive sequential mechanical ventilation, whereas the regular group received invasive mechanical ventilation. Blood-gas parameters, hemodynamic parameters, respiratory mechanical parameters, inflammatory factors, and treatment outcomes were compared between the two groups before and after mechanical-ventilation treatment. RESULTSThe arterial oxygen partial pressure and stroke volume variation values of the sequential group at 24, 48, and 72 h of treatment were higher than those of the conventional group (P < 0.05). The carbon dioxide partial pressure value of the sequential group at 72 h of treatment and the Raw value of the treatment group at 24 and 48 h were lower than those of the conventional group (P < 0.05). The pH value of the sequential group at 24 and 72 h of treatment, the central venous pressure value of the treatment at 24 h, and the Cst value of the treatment at 24 and 48 h were higher than those of the conventional group (P < 0.05). The tidal volume in the sequential group at 24 h of treatment was higher than that in the conventional group (P < 0.05), the measured values of interleukin-6 and tumor necrosis factor-α in the sequential group at 72 h of treatment were lower than those in the conventional group (P < 0.05), and the total time of mechanical ventilation in the sequential group was shorter than that in the conventional group, with a statistically significant difference (P < 0.05).CONCLUSIONTreating severe pneumonia complicated by respiratory failure with sequential mechanical ventilation is more effective in improving respiratory system compliance, reducing inflammatory response, maintaining hemodynamic stability, and improving patient blood-gas levels; however, from this study’s perspective, it cannot reduce patient mortality.

Critical coronavirus disease 2019 complicated with heparin resistance in 2 patients

To explore the diagnosis process and treatment experience of severe coronavirus disease 2019 (COVID-19) patients with heparin resistance (HR). The medical team of the First People's Hospital of Lianyungang admitted 2 severe COVID-19 patients with HR in intensive care unit (ICU) during their support to the designated hospital for the treatment of COVID-19 patients in Lianyungang City in November 2021. The clinical features, laboratory examinations, imaging features, treatment and prognosis of the two patients were analyzed. Both severe COVID-19 patients received mechanical ventilation, 1 patient was treated with extracorporeal membrane oxygenation (ECMO) support. Both patients were complicated with lower extremity deep venous thrombosis and HR phenomenon under routine dose anticoagulant therapy. The maximum daily dose of unfractionated heparin exceeded 35 000 U (up to 43 200 U), the 2 patients failed to meet the standard of anticoagulation treatment, and the course of disease was prolonged. After that, argatroban was given 0.4 μg×kg-1×min-1 combined with anticoagulant therapy, the activated partial thromboplastin time (APTT) of patients undergoing ECMO could be maintained at 55-60 seconds and the activated coagulation time (ACT) of them could be maintained at 180-200 seconds. After ECMO support or later sequential mechanical ventilation, both patients recovered and were discharged, and deep venous thrombosis was also effectively controlled. HR phenomenon often occurs during the treatment of severe COVID-19 patients, the anticoagulation regimen should be adjusted in time, and the anticoagulation effect combined with argatroban is clear.

Nomogram and Machine Learning Models Predict 1-Year Mortality Risk in Patients With Sepsis-Induced Cardiorenal Syndrome

ObjectiveEarly prediction of long-term outcomes in patients with sepsis-induced cardiorenal syndrome (CRS) remains a great challenge in clinical practice. Herein, we aimed to construct a nomogram and machine learning model for predicting the 1-year mortality risk in patients with sepsis-induced CRS.MethodsThis retrospective study enrolled 340 patients diagnosed with sepsis-induced CRS in Shanghai Tongji Hospital between January 2015 and May 2019, as a discovery cohort. Two predictive models, the nomogram and machine learning model, were used to predict 1-year mortality. The prognostic variables used to develop the nomogram were identified based on a forward stepwise binary logistic regression, and the predictive ability of the nomogram was evaluated by the areas under the receiver operating characteristic curve (AUC) and the calibration curve. Meanwhile, machine learning (ML) techniques, such as support vector machine, random forest (RF), and gradient boosted decision tree, were assessed mainly by accuracy and AUC. Feature ranking analysis was performed using the ML algorithm. Both nomogram and ML models were externally validated by an independent cohort of 103 patients diagnosed with sepsis-induced CRS between June 2019 and December 2020.ResultsAge, sequential sepsis-related organ failure score (SOFA), serum myoglobin (MYO), vasopressor use, and mechanical ventilation were identified as independent risk factors for 1-year mortality in the nomogram predictive model. In the discovery cohort, the nomogram yielded higher AUC for predicting mortality than did the SOFA score (0.855 [95% CI: 0.815–0.895] vs. 0.756 [95% CI: 0.705–0.808]). For ML, the model developed by RF showed the highest accuracy (0.765) and AUC (0.854). In feature ranking analysis, factors such as age, MYO, SOFA score, vasopressor use, and baseline serum creatinine were identified as important features affecting 1-year prognosis. Moreover, the nomogram and RF model both performed well in external validation, with an AUC of 0.877 and 0.863, respectively.ConclusionOur nomogram and ML models showed that age, SOFA score, serum MYO levels, and the use of vasopressors during hospitalization were the main factors influencing the risk of long-term mortality. Our models may serve as useful tools for assessing long-term prognosis in patients with sepsis-induced CRS.

Severe pneumonia in patients with systemic lupus erythematosus admitted to the intensive care unit.

The aim of this study was to investigate clinical characters and prognosis of patients with systemic lupus erythematosus (SLE) and severe pneumonia admitted to the intensive care unit (ICU). We conducted aretrospective study that reviewed all clinical records of patients with SLE and severe pneumonia admitted to the ICU between 2008 and 2020. Atotal of 86SLE patients with severe pneumonia during their first ICU admission were enrolled in this study. Most patients were female (n = 71, 82.5%), and the median age was 42.3 ± 14.7years. The most common organisms were gram-positive bacteria (20.9%), followed by gram-negative bacteria (18.6%) and fungi (10.4%). Atotal of 31patients died within 30days of ICU admission, and the 30-day mortality was 36%. In binary logistic regression analysis, Acute Physiologic and Chronic Health EvaluationII (APACHEII) score, Sequential Organ Failure Assessment (SOFA) score and mechanical ventilation were dependently associated with 30-day mortality (odds ratio [OR] 2.97, P = 0.016; OR = 4.02, P = 0.023; OR = 1.52, P = 0.036; respectively). Among the other 55patients, 5patients died after discharge from the ICU during the long-term follow-up. Mortality was high in SLE patients with severe pneumonia admitted to the ICU, and most of the patients died within 30days of ICU admission.

Early onset delirium incidence and risk factors in hematology oncology patients admitted to the intensive care unit: A retrospective cohort study.

Delirium occurs frequently in intensive care unit (ICU) patients; however, there are limited data evaluating its impact on critically ill hematology-oncology patients. We aimed to determine the incidence and risk factors for early-onset delirium development in hematology-oncology patients admitted to the ICU. This single-center, retrospective cohort study evaluated the primary outcome of incident delirium within 7 days of ICU admission in adults admitted to the hematology-oncology medical or surgical ICU. Patients with delirium (DEL) were compared to those without (No-DEL) for evaluation of secondary endpoints including hospital mortality, ICU, and hospital length of stay (LOS). Multivariable logistic regression modeling was performed to identify independent risk factors for delirium. Delirium occurred in 125 (51.2%) of 244 patients. Inhospital mortality was significantly higher in the DEL vs. No-DEL group (32.8% vs. 15.1%, P = 0.002). Median (1st and 3rd quartiles) ICU and hospital LOS were significantly longer in the delirium group, respectively (6 [4-10] days vs. 3 [2-5] days, P < 0.001, and 21 [14-36] days vs. 12 [8-22] days, P < 0.001). Higher Sequential Organ Failure Assessment score, high-dose corticosteroids, mechanical ventilation (MV), and brain metastases were each independently, associated with an increased delirium risk. Hematology-oncology patients admitted to the ICU frequently develop delirium. Consistent with literature in nonhematology-oncology critically ill patients, identified independent risk factors for delirium were MV and organ dysfunction. Risk factors unique to the critically ill hematology-oncology patient population include high-dose corticosteroids and brain metastases. Further research is needed to evaluate strategies to mitigate delirium development in this population based on risk assessment.

Clinical Effect of Bufei Decoction Combined with Invasive and Non-invasive Sequential Mechanical Ventilation in the Treatment of Acute Copd with Respiratory Failure

Clinical Effect of Bufei Decoction Combined with Invasive and Non-invasive Sequential Mechanical Ventilation in the Treatment of Acute Copd with Respiratory Failure

Observation of the curative effect of conservative oxygen therapy in mechanical ventilation of patients with severe pneumonia

To compare the effects of conservative oxygen therapy and conventional oxygen therapy on the efficacy and prognosis of mechanical ventilation support in patients with severe pneumonia. A prospective randomized controlled study were conducted, 110 patients with severe pneumonia requiring mechanical ventilation in intensive care unit (ICU) of Hefei First People's Hospital from May 2019 to May 2021 were selected and divided into conventional oxygen therapy group (51 cases) and conservative oxygen therapy group (55 cases) according to random number table method. Patients in both groups were treated with invasive to non-invasive sequential mechanical ventilation strategy, and the target of oxygen therapy in the conventional oxygen therapy group was set as the arterial partial pressure of oxygen (PaO2) > 150 mmHg (1 mmHg = 0.133 kPa) or pulse oxygen saturation (SpO2) > 0.96. In the conservative oxygen therapy group, PaO2 was set at 70-100 mmHg or SpO2 at 0.90-0.92. The changes of blood gas analysis, mechanical ventilation time, ICU stay time, ICU mortality, new organ dysfunction and infection more than 48 hours after admission were observed in two groups before and after treatment. Kaplan-Meier method was used to analyze the difference in cumulative survival rate between the two groups. After treatment, pH value, PaO2 and oxygenation index (PaO2/FiO2) in both groups were significantly higher than before treatment, and arterial partial pressure of carbon dioxide (PaCO2) was significantly lower than before treatment. pH value in the conservative oxygen therapy group was significantly higher than that in the conventional oxygen therapy group (7.4±0.1 vs. 7.3±0.3). PaO2, PaCO2 and PaO2/FiO2 were significantly lower than those in conventional oxygen therapy group [PaO2 (mmHg): 68.9±4.7 vs. 75.2±6.0, PaCO2 (mmHg): 42.1±5.6 vs. 50.5±7.5, PaO2/FiO2 (mmHg): 329±126 vs. 365±108, all P < 0.05]. The mechanical ventilation time in the conservative oxygen therapy group was significantly longer than that in the conventional oxygen therapy group (days: 19.7±3.5 vs. 13.9±4.5, P < 0.05), but there was no significant difference in ICU hospitalization time between the conservative oxygen therapy group and the conventional oxygen therapy group (days: 26.5±5.0 vs. 25.5±4.6, P > 0.05). Compared with the conventional oxygen therapy group, the ICU mortality, the incidence of nosocomial bloodstream infection, and the incidence of liver insufficiency, shock, and ICU acquired weakness (ICUAW) were decreased significantly in the conservative oxygen therapy group [ICU mortality: 27.3% (15/55) vs. 45.1% (23/51), liver insufficiency: 1.8% (1/55) vs. 7.8% (4/51), shock: 3.6% (2/55) vs. 9.8% (5/51), ICUAW: 5.5% (3/55) vs. 11.8% (6/51), the incidence of new bloodstream infection: 5.5% (3/55) vs. 11.8% (6/51), all P < 0.05]. Kaplan-Meier analysis showed that the cumulative survival rate of the conservative oxygen therapy group was significantly higher than that of the conventional oxygen therapy group (72.7% vs. 54.9%; Log-Rank test: χ2 = 4.244, P = 0.039). Conservative oxygen therapy can reduce ICU mortality, the incidence of shock, liver insufficiency, ICUAW, and bloodstream infection in patients with severe pneumonia, but prolong mechanical ventilation time.

Sequential non-invasive following short-term invasive mechanical ventilation in the treatment of tuberculosis with respiratory failure: a randomized controlled study

BackgroundInvasive and non-invasive mechanical ventilation (MV) have been combined as sequential MV in the treatment of respiratory failure. However, the effectiveness remains unclear. Here, we performed a randomized controlled study to assess the efficacy and safety of sequential MV in the treatment of tuberculosis with respiratory failure.MethodsForty-four tuberculosis patients diagnosed with respiratory failure were randomly divided into sequential MV group (n = 24) and conventional MV group (n = 20). Initially, the patients in both groups received invasive positive pressure ventilation. When the patients' conditions were relieved, the ventilation modality in sequential MV group was switched to oronasal face mask continuous positive airway pressure until weaning.ResultsAfter treatment, the patients in sequential MV group had similar respiratory rate, heart rate, oxygenation index, alveolo-arterial oxygen partial pressure difference (A-aDO2), blood pH, PaCO2 to those in conventional MV group (all P value > 0.05). There was no significant difference in ventilation time and ICU stay between the two groups (P > 0.05), but sequential MV group significantly reduced the time of invasive ventilation (mean difference (MD): − 36.2 h, 95% confidence interval (CI) − 53.6, − 18.8 h, P < 0.001). Sequential MV group also reduced the incidence of ventilator-associated pneumonia (VAP; relative risk (RR): 0.44, 95% CI 0.24, 0.83, P = 0.006) and atelectasis (RR:0.49, 95% CI 0.24,1.00, P = 0.040).ConclusionsSequential MV was effective in treating tuberculosis with respiratory failure. It showed advantages in reducing invasive ventilation time and ventilator-associated adverse events.Registration number for clinical trialChinese Clinical Trial Registry ChiCTR2000032311, April 21st, 2020

Tocilizumab in Coronavirus Disease 2019-Related Critical Illness: A Propensity Matched Analysis.

Retrospective, observational, multicenter, cohort study between March 15, 2020, and May 31, 2020. Using propensity score matching based on ICU admission source, C-reactive protein, Sequential Organ Failure Assessment score, vasopressor use, age, race, weight, and mechanical ventilation, patients who received tocilizumab were matched to patients who did not receive tocilizumab. Ten hospitals within the Cleveland Clinic Enterprise. Adult patients admitted to a medical, surgical, neurosciences, or mixed ICU with severe acute respiratory syndrome coronavirus 2 infection. None. Four-hundred forty-four patients were included: 342 patients (77%) did not receive tocilizumab and 102 patients (23%) received tocilizumab. Of those, 82 patients in each arm were matched. Before matching, patients who received tocilizumab had higher Sequential Organ Failure Assessment scores (6.1 ± 3.4 vs 4.7 ± 3.6), higher C-reactive protein (21.0 ± 10.2 vs 13.7 ± 9.6 mg/dL), higher frequency of intubation, vasopressor requirement, and paralytics. After matching, characteristics were more balanced and over 85% of patients required mechanical ventilation. ICU mortality was lower in tocilizumab group (23.2% vs 37.8%; risk difference, -15%; 95% CI, -29% to -1%), with more ICU-, hospital-, and vasoactive-free days at day 28 compared with those who did not receive tocilizumab. There was no difference in mechanical ventilation-free days at day 28 or development of secondary infections. Tocilizumab use was associated with a significant decrease in ICU mortality in critically ill coronavirus disease 2019 patients with severe hypoxemic respiratory failure. Future randomized controlled trials limited to tocilizumab administration in critically ill coronavirus disease 2019 patients, with severe hypoxemic respiratory failure, are needed to support these findings.

Procalcitonin kinetics to guide sequential invasive-noninvasive mechanical ventilation weaning in patients with acute exacerbation of chronic obstructive pulmonary disease and respiratory failure: procalcitonin’s adjunct role

ABSTRACT How to identify the optimum switch point of sequential invasive and noninvasive ventilation is the focus of clinical attention on the patients suffering from acute exacerbation of chronic obstructive pulmonary disease (AECOPD) complicated by acute respiratory failure (ARF). This study aims to explore the clinical significance of taking the change rate of procalcitonin (PCT) as identifying the timing of weaning on the mechanical ventilation for the patients of AECOPD followed by ARF as a complication. There were altogether 140 patients of AECOPD complicated with ARF, who were randomly selected and divided into a study group and a control group respectively. A change rate of serum PCT level exceeding 50% was taken as the switch point selection of tracheal intubation removal for the patients of the study group, while the ‘pulmonary infection control (PIC) window’ was done for those in the control group. With CRP, IL-6, TNF-a, PaCO2, PaO2, and Lac having been detected before and after treatment to them all, clinical indexes were obtained and compared between these two groups. The CRP, TNF-a, and IL-6 levels of the patients in the study group after treatment (p < 0.05) were lower than those in the control group. There was no significant difference in PaCO2, PaO2, and Lac between these two groups before and after treatment (p > 0.05). Even so, some other indexes available for the study group of patients were found to be lower than those for the control group (p < 0.05) in the following aspects: duration of invasive ventilation support, total time of mechanical ventilation support, incidence rate of ventilator-associated pneumonia, 48-hour reintubation rate, incidence rate of upper gastrointestinal bleeding, hospitalization time of critical respiratory illness, total hospitalization time, RICU treatment cost, total treatment cost, and mortality. It is preferable to take the change rate of PCT level exceeding 50% as the switch point of weaning time in sequential mechanical ventilation rather than the PIC window. Abbreviations AECOPD: acute exacerbation of chronic obstructive pulmonary disease; ARF: acute respiratory failure; PCT: procalcitonin; PaO2: the oxygen partial pressure; PaCO2: the partial pressure of carbon dioxide; TNF-a: serum tumor necrosis factor-a; IL-6: interleukin-6; CRP: serum C-reactive protein; PIC window: pulmonary infection control window; RICU: respiration and intensive care unit

Prevalence and Impact of Hyponatremia in Patients With Coronavirus Disease 2019 in New York City

Hyponatremia occurs in up to 30% of patients with pneumonia and is associated with increased morbidity and mortality. The prevalence of hyponatremia associated with coronavirus disease 2019 and the impact on outcome is unknown. We aimed to identify the prevalence, predictors, and impact on outcome of mild, moderate, and severe admission hyponatremia compared with normonatremia among coronavirus disease 2019 patients. Retrospective, multicenter, observational cohort study. Four New York City hospitals that are part of the same health network. Hospitalized, laboratory-confirmed adult coronavirus disease 2019 patients admitted between March 1, 2020, and May 13, 2020. None. Hyponatremia was categorized as mild (sodium: 130-134 mmol/L), moderate (sodium: 121-129 mmol/L), or severe (sodium: ≤ 120 mmol/L) versus normonatremia (135-145 mmol/L). The primary outcome was the association of increasing severity of hyponatremia and in-hospital mortality assessed using multivariable logistic regression analysis. Secondary outcomes included encephalopathy, acute renal failure, mechanical ventilation, and discharge home compared across sodium levels using Kruskal-Wallis and chi-square tests. In exploratory analysis, the association of sodium levels and interleukin-6 levels (which has been linked to nonosmotic release of vasopressin) was assessed. Among 4,645 patient encounters, hyponatremia (sodium < 135 mmol/L) occurred in 1,373 (30%) and 374 of 1,373 (27%) required invasive mechanical ventilation. Mild, moderate, and severe hyponatremia occurred in 1,032 (22%), 305 (7%), and 36 (1%) patients, respectively. Each level of worsening hyponatremia conferred 43% increased odds of in-hospital death after adjusting for age, gender, race, body mass index, past medical history, admission laboratory abnormalities, admission Sequential Organ Failure Assessment score, renal failure, encephalopathy, and mechanical ventilation (adjusted odds ratio, 1.43; 95% CI, 1.08-1.88; p = 0.012). Increasing severity of hyponatremia was associated with encephalopathy, mechanical ventilation, and decreased probability of discharge home (all p < 0.001). Higher interleukin-6 levels correlated with lower sodium levels (p = 0.017). Hyponatremia occurred in nearly a third of coronavirus disease 2019 patients, was an independent predictor of in-hospital mortality, and was associated with increased risk of encephalopathy and mechanical ventilation.

Timing of sequential noninvasive mechanical ventilation following early extubation in aged patients with severe community-acquired pneumonia

To explore the timing of sequential noninvasive positive pressure ventilation (NIPPV) following endotracheal intubation mechanical ventilation (ETI-MV) in aged patients with severe community-acquired pneumonia (SCAP). A prospective cohort study was conducted. The SCAP patients aged ≥ 75 years old admitted to respiratory intensive care unit (RICU) of the First Affiliated Hospital of Xinjiang Medical University from July 2017 to August 2019 were enrolled. SCAP was diagnosed according to the criteria of Guidelines for the diagnosis and treatment of community-acquired pneumonia in adults in China (2016) published by Chinese Thoracic Society. ETI-MV was initially performed as respiratory support after RICU admission. Sequential NIPPV was performed immediately following extubation when the patients exhibited pulmonary infection abated (PIA) window. The gender, age, underlying diseases, and body temperature, heart rate (HR), respiratory rate (RR), oxygenation index (PaO2/FiO2) after RICU admission, as well as acute physiology and chronic health evaluation II (APACHE II) score, improved pneumonia score of British Thoracic Society (confusion, uremia, respiratory, blood pressure, age 65 years, CURB-65), and pneumonia severity index (PSI) score within 24 hours after RICU admission were recorded. The duration and times of ETI, the incidences of ventilator associated pneumonia (VAP) and aspiration, the duration of mechanical ventilation (MV), the length of RICU and hospital stay and RICU prognosis were also recorded. The patients were divided into the ETI ≤ 7 days group and the ETI > 7 days group according to the duration of ETI, and the clinical data were compared between the two groups. Multivariate Logistic regression analysis was used to screen the risk factors of aged patients with SCAP whose ETI was more than 7 days, and receiver operator characteristic (ROC) curve was drawn to evaluate the predictive value of risk factors. Fifty aged patients with SCAP were enrolled, with 24 patients in the ETI ≤ 7 days group and 26 in the ETI > 7 days group. Univariate analysis showed that compared with the patients with ETI ≤ 7 days, the incidences of concurrent cerebrovascular diseases [46.2% (12/26) vs. 16.7% (4/24)], VAP [61.5% (16/26) vs. 16.7% (4/24)] and aspiration [69.2% (18/26) vs. 25.0% (6/24)] were significantly increased in patients with ETI > 7 days (all P < 0.05). Multivariate Logistic regression analysis indicated that VAP and aspiration were independent risk factors of ETI > 7 days in the aged SCAP patients [VAP: odds ratio (OR) = 4.852, 95% confidence interval (95%CI) was 1.076-21.877, P = 0.040; aspiration: OR = 5.903, 95%CI was 1.474-23.635, P = 0.012]. ROC curve analysis showed that the area under ROC curve (AUC) of VAP for predicting ETI > 7 days in aged patients with SCAP was 0.724, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), negative likelihood ratio (NLR) and Youden index were 61.54%, 83.33%, 80.00%, 66.67%, 3.69, 0.46 and 0.45, respectively. Similarly, the AUC of aspiration was 0.721, the sensitivity, specificity, PPV, NPV, PLR, NLR and Youden index were 69.23%, 75.00%, 75.00%, 69.23%, 2.77, 0.41 and 0.44, respectively. Analysis of prognostic indicators showed that compared with patients with ETI ≤ 7 days, the reintubation rate and RICU mortality were significantly increased in patients with ETI > 7 days [53.8% (14/26) vs. 4.2% (1/24), 38.5% (10/26) vs. 12.5% (3/24), both P < 0.05]. Moreover, the patients with ETI > 7 days had significantly prolonged total duration of MV, the length of RICU stay and total hospital stay as compared with the patients with ETI ≤ 7 days [total duration of MV (days): 23.8±11.8 vs. 11.3±3.1, length of RICU stay (days): 30.6±14.1 vs. 16.0±5.1, total length of hospital stay (days): 33.0±14.9 vs. 20.2±6.1, all P < 0.01]. Sequential NIPPV performed immediately following extubation within 7 days in the aged SCAP patients might reduce the mortality and shorten the duration of MV. The prolonged ETI duration because of the VAP or aspiration would lead to a reduced function of sequential NIPPV and an increased mortality of the aged patients with SCAP.

Clinical study on optimal switching mode in sequential noninvasive-invasive mechanical ventilation for acute exacerbation of chronic obstructive pulmonary disease

To explore the switch time of noninvasive-invasive mechanical ventilation sequential treatment for acute exacerbation of chronic obstructive pulmonary disease (AECOPD), and effectively reduce the rate of tracheal intubation. A retrospective study was performed on patients with AECOPD, who underwent mechanical ventilation in emergency resuscitation room and admitted to department of respiration of Kaifeng Central Hospital Emergency Center from July 2014 to March 2019. The patients who used noninvasive mechanical ventilation (NIV) were included in NIV group (118 cases), and those who used invasive positive pressure ventilation (IPPV) were included in IPPV group (52 cases). The usage of breathing machine time, hospital days and hospital mortality were compared between the two groups. Clinical indicators such as age, gender, body temperature, respiratory rate, body mass index (BMI), mean arterial pressure (MAP), oxygenation index (PaO2/FiO2), respiratory index (RI), pH value, D-dimer, hemoglobin (HB), albumin, blood lactate (Lac), brain natriuretic peptide (BNP), C-reactive protein (CRP), procalcitonin (PCT), serum creatinine (SCr), white blood cell count (WBC), Glasgow coma scale (GCS), sputum excretion drainage were collected. The factors influencing the failure of NIV were analyzed by Logistic stepwise regression analysis. The receiver operating characteristic (ROC) curve was used to test the value of the NIV failure risk prediction model. There was no significant difference in total mechanical ventilation time and hospital mortality between NIV group and IPPV group (hours: 65.6±11.11 vs. 66.9±12.1, 6.8% vs. 9.6%, both P > 0.05), but the hospital time in group NIV was significantly shorter than that in IPPV group (days: 12.3±2.1 vs. 14.2±2.5, P < 0.05). In NIV group, 101 cases completed NIV continuously, 17 cases of NIV failure turned to IPPV, and the failure rate of NIV was 14.4%. There were statistically significant differences in gender, PaO2/FiO2, RI, pH value, D-dimer, PCT, WBC, Lac, sputum excretion drainage and GCS score between NIV failure patients and NIV success patients. Logistic regression analysis showed that RI, pH value, WBC and sputum excretion drainage were independent risk factors for NIV failure [RI: odds ratio (OR) = 3.879, 95% confidence interval (95%CI) was 1.258-11.963, P = 0.018; pH value: OR = 3.316, 95%CI was 1.270-8.660, P = 0.014; WBC: OR = 3.684, 95%CI was 1.172-11.581, P = 0.026; sputum excretion drainage: OR = 0.125, 95%CI was 0.042-0.366, P = 0.000]. The NIV failure risk prediction model based on the above independent risk factors had a good goodness of fit (χ 2 = 9.02, P = 0.34). ROC curve analysis showed that the NIV failure risk prediction model had a high predictive value for the patients with AECOPD [the area under ROC curve (AUC) was 0.818±0.051, 95%CI was 0.718-0.918, P = 0.000]. If patients with AECOPD have relative contraindications of NIV but still insist on using NIV, further risk stratification of NIV failure is needed. For those with RI, pH value, WBC abnormalities and sputum excretion drainage, the risk of choosing NIV is significantly increased. We need to pay more attention to the change of the condition and switch to IPPV in time to avoid exacerbation of the condition.

Acute kidney injury in burn patients admitted to the intensive care unit: a systematic review and meta-analysis

BackgroundAcute kidney injury (AKI) is a common complication in burn patients admitted to the intensive care unit (ICU) associated with increased morbidity and mortality. Our primary aim was to review incidence, risk factors, and outcomes of AKI in burn patients admitted to the ICU. Secondary aims were to review the use of renal replacement therapy (RRT) and impact on health care costs.MethodsWe conducted a systematic search in PubMed, UpToDate, and NICE through 3 December 2018. All reviews in Cochrane Database of Systematic Reviews except protocols were added to the PubMed search. We searched for studies on AKI according to Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease (RIFLE); Acute Kidney Injury Network (AKIN); and/or Kidney Disease: Improving Global Outcomes (KDIGO) criteria in burn patients admitted to the ICU. We collected data on AKI incidence, risk factors, use of RRT, renal recovery, length of stay (LOS), mortality, and health care costs.ResultsWe included 33 observational studies comprising 8200 patients. Overall study quality, scored according to the Newcastle-Ottawa scale, was moderate. Random effect model meta-analysis revealed that the incidence of AKI among burn patients in the ICU was 38 (30–46) %. Patients with AKI were almost evenly distributed in the mild, moderate, and severe AKI subgroups. RRT was used in 12 (8–16) % of all patients. Risk factors for AKI were high age, chronic hypertension, diabetes mellitus, high Total Body Surface Area percent burnt, high Abbreviated Burn Severity Index score, inhalation injury, rhabdomyolysis, surgery, high Acute Physiology and Chronic Health Evaluation II score, high Sequential Organ Failure Assessment score, sepsis, and mechanical ventilation. AKI patients had 8.6 (4.0–13.2) days longer ICU LOS and higher mortality than non-AKI patients, OR 11.3 (7.3–17.4). Few studies reported renal recovery, and no study reported health care costs.ConclusionsAKI occurred in 38% of burn patients admitted to the ICU, and 12% of all patients received RRT. Presence of AKI was associated with increased LOS and mortality.Trial registrationPROSPERO (CRD42017060420)

Effect of invasive and noninvasive sequential mechanical ventilation on respiratory failure of critical cor pulmonale

Objective To observe and analyze the clinical effects of invasive and non-invasive sequential mechanical ventilation in the treatment of respiratory failure in patients with chronic pulmonary heart disease. Methods A total of 70 patients with chronic pulmonary ill heart disease and respiratory failure admitted to the First Hospital of Shanxi Medical University from January 2018 to March 2018 were enrolled in this study.The patients were randomly divided into control group and observation group according to the digital table, with 35 cases in each group.The control group received invasive mechanical ventilation treatment.The observation group used the pulmonary infection control window (PIC) as the switching point of invasive ventilation and non-invasive ventilation, and invasive and non-invasive sequential mechanical ventilation were given.The clinical indicators, blood gas indicators, respiratory rate and heart rate changes of the two groups were compared.The clinical efficacy of the two groups were observed to analyze. Results The invasive mechanical ventilation time, total ventilation time and hospitalization days in the observation group were (5.16±0.83)d, (7.79±0.63)d and (8.95±0.62)d, respectively, which were significantly shorter than those in the control group [(8.42±0.91)d, (11.48±0.95)d, (14.17±0.65)d], the differences were statistically significant(t=15.659, 19.151, 34.379, all P<0.05). After treatment, the PaO2 of the observation group was significantly higher than that of the control group[(85.19±5.07)mmHg vs.(79.95±4.68)mmHg], while the PaCO2[(49.85±4.17)mmHg vs.(53.36±4.82)mmHg], respiratory rate[(24.43±3.17)times/min vs.(31.19±4.08)times/min]and heart rate[(94.43±13.36)times/min vs.(113.36±17.13)times/min] in the observation group were significantly lower than those in the control group, and the total effective rate of the observation group (91.43%) was significantly higher than that of the control group(54.29%), the differences were statistically significant(t=4.493, 3.258, 7.740, 4.338, χ2=12.209, all P<0.05). Conclusion The clinical efficacy of invasive and non-invasive sequential mechanical ventilation in the treatment of patients with respiratory failure due to chronic pulmonary heart disease is significant, which can improve the clinical symptoms of patients and reduce the time of hospitalization. Key words: Pulmonary heart disease; Respiratory insufficiency; Ventilators, mechanical; Respiration, artificial; Blood gas monitoring, transcutaneous; Respiration; Heart rate; Length of stay; Controlled clinical trial

Comprehensive approach to weaning in difficult-to-wean infantile and juvenile-onset glycogen-storage disease type II patients: a case series

BackgroundGlycogen storage disease type II (GSD II) is caused by acid alpha-glucosidase (GAA) deficiency. Both infantile-onset and juvenile-onset GSD II lead to proximal muscle weakness and respiratory insufficiency and require mechanical ventilation. However, GSD II is also independently associated with delayed weaning from mechanical ventilation. This study aimed to describe a comprehensive approach including sequential invasive-noninvasive mechanical ventilation weaning and enzyme replacement therapy (ERT) in patients with weaning difficulties.Case presentationWe studied six difficult-to-wean GSD II (three juvenile-onset, three infantile-onset) patients at the First Affiliated Hospital, Sun Yat-sen University from October 2015 to December 2017. Difficulty in weaning was defined as follows: the need for more than three spontaneous breathing trials or more than 1 week to achieve successful weaning. All patients received comprehensive treatment including sequential invasive-noninvasive mechanical ventilation weaning, ERT and general treatment. Recombinant human acid alpha-glucosidase enzyme therapy (20 mg/kg every 14 days) was used after diagnosis, and Patients 1–6 received ERT for 15.5, 4.5, 2, 2.5, 17, and 2 months, respectively. The therapeutic effect of the comprehensive treatment was observed.The patients’ respiratory function and limb muscle strength improved after each ERT session. Patients who successfully completed a spontaneous breathing trial could proceed to extubation, and then start non-invasive ventilation. The patients’ age range at initial mechanical ventilation was 3–47 (median 26.5) months, duration of invasive ventilation was 1–36 (median 2.75) months, and duration of noninvasive ventilation was 0–0.6 (median 0.05) month. The patients’ nutritional status improved after enhanced nutritional support. Patients 2, 3, and 5 were successfully weaned off the ventilator. Patient 1 underwent tracheal intubation after six weaning failures, and Patients 4 and 6 died after therapy was abandoned by their parents.Discussion and conclusionsMale sex, GSD II type, and the presence of malnutrition and neurological impairment may predict poor respiratory outcomes. The above-described comprehensive sequential invasive-noninvasive mechanical ventilation weaning strategy may increase the success rate of weaning from mechanical ventilation.

Evaluation of the effect of intensive care mode in patients with COPD complicated with respiratory failure

Objective To explore the effects of sequential mechanical ventilation on pulmonary function, blood gas analysis, quality of life and patientsundefined satisfaction with nursing care in patients with chronic obstructive pulmonary disease (COPD) and respiratory failure (COPD) treated by sequential mechanical ventilation. Methods From March 2016 to March 2017, 90 COPD patients with respiratory failure treated by sequential mechanical ventilation were selected and divided into two groups according to the digital random method. 45 patients in the control group were treated with routine nursing. 45 patients in the observation group were treated with intensive care mode. The forced vital capacity (forced vital capacity, FVC), 1s forced expiratory volume (forced expiratory volume in one second, FEV1) was compared between the two groups before intervention (on admission) and after intervention (1 day before discharge). Arterial partial pressure of carbon dioxide (PaCO2) and partial pressure of blood oxygen (PaO2) were different. The quality of life (QOL) was evaluated by using QOL-74 (Generic Quality of Life Inventory-74, GQOL-74 before and after intervention. Results There was no significant difference in FVC, FEV1, FEV1/FVC, PaCO2, PaO2 between the two groups (P > 0.05). After nursing intervention, the FVC of the patients in the observation group was (2.75±0.62) L and FEV1 was (2.05±0.51) L, respectively. FEV1/FVC was (49.1±5.3)%, PaCO2 was (36.62±2.73) mmHg, PaO2 (94.72±4.57) mmHg, and control group was (2.38±0.74) L, (1.69±0.45) L, (62.6±4.4)%. (48.45±5.36) mmHg, (88.25±4.02) mmHg, t=2.571, t=3.551, t=13.147, t=13.193, t=7.130,group was superior to the control group (P 0.05), but the scores of four dimensions in the control group were (66. 4 ±10.5) after nursing. (70.3±12.8), (72.2±13.6), (70.7±11.8), (72.8±9.7), (81.5±15.2), (78.4±12.9), (79.6 ±15.5), t=3.003)、t=3.780、t= 2.219、t= 3.065, P < 0.05. The success rate of rescue was 86.67%in the observation group, the mortality was 6.67%, the average hospitalization time was (12.8±4.2) days, the satisfaction degree for nursing was 94.87%, and the four items in the control group were 68.89% and 26.67%, respectively. (17.1±3.3) d, the satisfaction degree for nursing was 77.42%, P < 0.05. The difference between the two groups was statistically significant (P < 0.05), and there was a significant difference between the two groups (P < 0.05), and the difference between the two groups was statistically significant (P < 0.05), and the difference between the two groups was statistically significant (P < 0.05). Conclusion COPD patients with respiratory failure can significantly improve the success rate of rescue, promote the recovery of pulmonary function, improve the quality of life, and enhance the recognition of medical services. Key words: Pulmonary disease, chronic obstructive; Critical care full-time nursing model; Respiratory failure; Blood gas analysis