Shorter Duration Of Ventilation Research Articles

Comparing clinical and echocardiographic outcomes following valve-sparing versus transannular patch repair of tetralogy of Fallot: a systematic review and meta-analysis.

Transannular patch (TAP) repair of tetralogy of Fallot (ToF)relieves right ventricular tract obstruction but may lead to pulmonary regurgitation. Valve-sparing (VS) procedures can avoid this situation, but there is a potential for residual pulmonary stenosis. Our goal was to evaluate clinical and echocardiographic outcomes of TAP and VS repair for ToF. A systematic search of the PubMed, Embase, Scopus, Cochrane Central Register of Controlled Trials and Web of Science databases was carried out to identify articles comparing conventional TAP repair and VS repair for ToF. Random-effects models were used to perform meta-analyses of the clinical and echocardiographic outcomes. Forty studies were included in this meta-analysis with data on 11723 participants (TAP: 6171; VS: 5045). Participants who underwent a VS procedure experienced a significantly lower cardiopulmonary bypass time [mean difference (MD): -14.97; 95% confidence interval (CI): -22.54, -7.41], shorter ventilation duration (MD: -15.33; 95% CI: -30.20, -0.46) and shorter lengths of both intensive care unit (ICU) (MD: -0.67; 95% CI: -1.29, -0.06) and hospital stays (MD: -2.30; 95% CI: [-4.08, -0.52). There was also a lower risk of mortality [risk ratio: 0.40; 95% CI: (0.27, 0.60) and pulmonary regurgitation [risk ratio: 0.35; 95% CI: (0.26, 0.46)] associated with the VS group. Most other clinical and echocardiographic outcomes were comparable in the 2 groups. This meta-analysis confirms the well-established increased risk of pulmonary insufficiency following TAP repair while also demonstrating that VS repairs are associated with several improved clinical outcomes. Continued research can identify the criteria for adopting a VS approach as opposed to a traditional TAP repair.

The influence of various technologies for the use of gaseous nitric oxide on the functional and morphological state of the lungs, markers of myocardial damage and clinical outcomes in cardiosurgical interventions with cardiopulmonary bypass

The aim of the study was to evaluate the impact of various technologies for the use of gaseous nitric oxide on the state of the lungs and heart during heart valve surgery under cardiopulmonary bypass (CPB).Methods. The study included 93 patients of both sexes. All patients underwent heart valve surgery and combined surgical interventions under CPB. The patients were divided into 4 groups. Group 1 (control, n = 30) used the standard protocol for anesthetic and perfusion management. Group 2 (n = 30) received inhalation of nitric oxide (20 ppm) within 3 days before surgery, as well as before and after CPB. Group 3 (n = 30) inhaled nitric oxide (40 ppm) throughout surgery with the medication delivered through inspiratory part of the ventilator and combined with perfusion of the pulmonary artery and reduced volume ventilation during CPB. Group 4 (n = 33) received nitric oxide (40 ppm) via oxygenator of the heart-lung machine. We assessed changes in the functional parameters of the lungs at different phases of surgery, performed a morphological examination of the lungs in the initial phase (before CPB), at the peak of ischemia, and after reperfusion. The state of the myocardium after surgery was assessed by troponin I (cTnI) activity at the beginning of the operation, after transfer to the ICU, at 12, 24 and 48 hours after the surgery. Myocardial damage index (MDI) was calculated according to the following formula: MDI = TnIlate / TnIearly. The clinical outcomes of the surgeries were evaluated.Results. There were no statistically significant differences in the functional state of the lungs with various options for inhalation delivery and administration via the CPB circuit. The most intact indicators of the functional state of the lungs were seen in patients of Group 3 who received inhaled nitric oxide throughout surgery and combined mechanical ventilation with the addition of nitric oxide and perfusion of the pulmonary artery during CPB. Morphological examination of the lungs showed that inhalation of nitric oxide before CPB does not prevent the development of morphological disorders. Morphological changes found in Group 3 were the smallest. The supply of nitric oxide into the CPB circuit statistically significantly improved the restoration of pulmonary blood flow during reperfusion. The cTnI level statistically significantly increased in all groups of patients, however, it was statistically significantly lower in Groups 2, 3, and 4 compared with Group 1 at the end of surgery, in Groups 3 and 4 compared with Groups 1 and 2 after 12 and 24 hours, and in Group 3 after 48 hours. The most favorable changes in the MDI were seen in Group 3; statistically significantly lower MDI was registered 12 and 48 hours after surgery in this group compared with Groups 1, 2, and 4. A lower complication rate, a shorter duration of ventilation and stay in the ICU were observed in Groups 3 and 4.Conclusion. Nitric oxide has a protective effect on the lungs and heart when used during anesthesia and cardiopulmonary bypass in heart valve surgery. It preserves the lung function and morphology and statistically significantly reduces cTnI level and myocardial damage index in the postoperative period. The extent of the protective effect depends on the nitric oxide exposure time and is most pronounced when nitric oxide is used throughout the surgery, including during CPB.

Clinical characteristics and outcomes of COVID-19 cases admitted to adult intensive care units during the pandemic: A single center experience

BackgroundCOVID-19 is the largest recorded pandemic in history. It causes several complications such as shock, pneumonia, acute respiratory distress syndrome, and organ failure. The objective was to determine COVID-19 outcomes and risk factors in the intensive care (ICU) setting. MethodsA retrospective review of prospectively collected data was conducted. Adult patients with a positive RT-PCR test for COVID-19 admitted to ICUs of a tertiary care hospital between 2020 and 2022 were included. Patients who had severe complex trauma were excluded. The outcomes examined included ventilation use and duration, length of stay (LOS), and mortality. ResultsA total of 964 patients were included. The mean ( ± standard deviation, SD) age was 63.7 ± 16.9 years. The majority of the patients were males (59.0 %) and Saudi (75.7 %). Ventilation use was documented in 443 (57.1 %) patients, with a mean ( ± SD) ventilation duration of 9.7 ± 8.4 days. Death occurred in 361 (37.4 %) patients after a mean ( ± SD) of 33.3 ± 44.5 days from infection. The mean ( ± SD) LOS was 30.6 ± 54.1 days in hospital and 5.2 ± 5.4 days in ICU. Ventilation use was associated with older age, males, longer ICU LOS, mortality, and admission to medical-surgical ICU. Crude mortality use was associated with older age, longer ICU LOS, use of ventilator, shorter ventilation duration, and admission to medical-surgical or respiratory ICUs. ConclusionsCOVID-19 patients admitted to adult ICUs are at high risk of death and mechanical ventilation. The crude risks of both outcomes are higher in older age and longer ICU LOS and are very variable by ICU type.

Using cluster analysis to describe phenotypical heterogeneity in extremely preterm infants: a retrospective whole-population study

ObjectiveTo use cluster analysis to identify discrete phenotypic groups of extremely preterm infants.DesignSecondary analysis of a retrospective whole population study.SettingAll neonatal units in England between 2014 and 2019.ParticipantsInfants live-born at...

Practice of tracheostomy in patients with acute respiratory failure related to COVID–19 – Insights from the PRoVENT–COVID study

ObjectiveInvasively ventilated patients with acute respiratory failure related to coronavirus disease 2019 (COVID–19) potentially benefit from tracheostomy. The aim of this study was to determine the practice of tracheostomy during the first wave of the pandemic in 2020 in the Netherlands, to ascertain whether timing of tracheostomy had an association with outcome, and to identify factors that had an association with timing. MethodsSecondary analysis of the ‘PRactice of VENTilation in COVID–19’ (PRoVENT–COVID) study, a multicenter observational study, conducted from March 1, 2020 through June 1, 2020 in 22 Dutch intensive care units (ICU) in the Netherlands. The primary endpoint was the proportion of patients receiving tracheostomy; secondary endpoints were timing of tracheostomy, duration of ventilation, length of stay in ICU and hospital, mortality, and factors associated with timing. ResultsOf 1023 patients, 189 patients (18.5%) received a tracheostomy at median 21 [17 to 28] days from start of ventilation. Timing was similar before and after online publication of an amendment to the Dutch national guidelines on tracheostomy focusing on COVID–19 patients (21 [17–28] vs. 21 [17–26] days). Tracheostomy performed ≤ 21 days was independently associated with shorter duration of ventilation (median 26 [21 to 32] vs. 40 [34 to 47] days) and higher mortality in ICU (22.1% vs. 10.2%), hospital (26.1% vs. 11.9%) and at day 90 (27.6% vs. 14.6%). There were no patient demographics or ventilation characteristics that had an association with timing of tracheostomy. ConclusionsTracheostomy was performed late in COVID–19 patients during the first wave of the pandemic in the Netherlands and timing of tracheostomy possibly had an association with outcome. However, prospective studies are needed to further explore these associations. It remains unknown which factors influenced timing of tracheostomy in COVID–19 patients.

Neurally-Adjusted Ventilatory Assist (NAVA) versus Pneumatically Synchronized Ventilation Modes in Children Admitted to PICU

Traditionally, invasively ventilated children in the paediatric intensive care unit (PICU) are weaned using pneumatically-triggered ventilation modes with a fixed level of assist. The best weaning mode is currently not known. Neurally adjusted ventilatory assist (NAVA), a newer weaning mode, uses the electrical activity of the diaphragm (Edi) to synchronise ventilator support proportionally to the patient’s respiratory drive. We aimed to perform a systematic literature review to assess the effect of NAVA on clinical outcomes in invasively ventilated children with non-neonatal lung disease. Three studies (n = 285) were included for analysis. One randomised controlled trial (RCT) of all comers showed a significant reduction in PICU length of stay and sedative use. A cohort study of acute respiratory distress syndrome (ARDS) patients (n = 30) showed a significantly shorter duration of ventilation and improved sedation with the use of NAVA. A cohort study of children recovering from cardiac surgery (n = 75) showed significantly higher extubation success, shorter duration of ventilation and PICU length of stay, and a reduction in sedative use. Our systematic review presents weak evidence that NAVA may shorten the duration of ventilation and PICU length of stay, and reduce the requirement of sedatives. However, further RCTs are required to more fully assess the effect of NAVA on clinical outcomes and treatment costs in ventilated children.

The spectrum of acute leukoencephalopathy with restricted diffusion (ALERD): A case series and review of literature.

The clinico-etiological spectrum of Acute leukoencephalopathy with restricted diffusion (ALERD) is not well known in Indian population. This is likely to vary between populations and ethnicities. We retrospectively reviewed the clinicoetiological spectrum of ALERD at a tertiary care pediatric center, and described the clinical, imaging, etiological spectrum and short-term outcomes. Eleven out of 78 children with non-traumatic encephalopathy presenting to our center had a final diagnosis of ALERD. The mean age at presentation was 34.9 months (6-80 months) and 63.6% were males. The monophasic course (72.7%) and the diffuse pattern (63.6%) on neuroimaging were predominant in these children. Dengue haemorrhagic fever was the commonest underlying/triggering infection (5 of 11 children). Ten children required mechanical ventilation in view of neurogenic respiratory failure, with mean duration of ventilation of 6.4 days (Range 2-10 days). The duration of hospital stay varied from 11 to 25 days (Mean - 15.3 days). One child (9 %) died, 6 children (54.5 %) had varying degrees of cognitive impairment and 4 (36.3 %) children had a normal outcome. Children with a shorter duration of ventilation seemed to have a better outcome. Dengue haemorrhagic fever was the commonest cause, and diffuse imaging pattern with monophasic course was the commonest presentation in Indian children with ALERD. The clinical presentation and factors influencing outcome are possibly different from previously described literature.

Effect of spontaneous breathing on ventilator-free days in critically ill patients-an analysis of patients in a large observational cohort.

BackgroundMechanical ventilation can injure lung tissue and respiratory muscles. The aim of the present study is to assess the effect of the amount of spontaneous breathing during mechanical ventilation on patient outcomes.MethodsThis is an analysis of the database of the ‘Medical Information Mart for Intensive Care (MIMIC)’-III, considering intensive care units (ICUs) of the Beth Israel Deaconess Medical Center (BIDMC), Boston, MA. Adult patients who received invasive ventilation for at least 48 hours were included. Patients were categorized according to the amount of spontaneous breathing, i.e., ≥50% (‘high spontaneous breathing’) and <50% (‘low spontaneous breathing’) of time during first 48 hours of ventilation. The primary outcome was the number of ventilator-free days.ResultsIn total, the analysis included 3,380 patients; 70.2% were classified as ‘high spontaneous breathing’, and 29.8% as ‘low spontaneous breathing’. Patients in the ‘high spontaneous breathing’ group were older, had more comorbidities, and lower severity scores. In adjusted analysis, the amount of spontaneous breathing was not associated with the number of ventilator-free days [20.0 (0.0–24.2) vs. 19.0 (0.0–23.7) in high vs. low; absolute difference, 0.54 (95% CI, –0.10 to 1.19); P=0.101]. However, ‘high spontaneous breathing' was associated with shorter duration of ventilation in survivors [6.5 (3.6 to 12.2) vs. 7.6 (4.1 to 13.9); absolute difference, –0.91 (95% CI, −1.80 to −0.02); P=0.046].ConclusionsIn patients surviving and receiving ventilation for at least 48 hours, the amount of spontaneous breathing during this period was not associated with an increased number of ventilator-free days.

Abstract 17146: Late Gestation Fetal Growth in Infants Undergoing Stage 1 Palliation for Single Ventricle Heart Disease

Introduction: Ideal timing for elective delivery of infants with single ventricle heart disease, balancing benefits of fetal growth with risk of fetal demise, remains unclear. Improved understanding of fetal growth in late gestation and postnatal outcomes related to gestational age (GA) may improve insight. Hypothesis: Patients with single ventricle heart disease and aortic hypoplasia have decreased fetal growth velocity in late gestation, but longer gestation results in improved outcomes. Methods: This was a retrospective cohort analysis of patients in phase 2 of the National Pediatric Cardiology Quality Improvement Collaborative database from 2016-2019 who were anticipated to need stage 1 palliation (S1P) and had a GA of &gt; 36 weeks. Birth weight (BW) and BW z-scores were compared across GA to normative values. Outcome measures of survival to stage 2 palliation (S2P), post-S1P length of stay, and duration of mechanical ventilation were compared by GA. Results: The cohort included 1290 infants. There was an increase in mean BW with increasing GA (2.83 kg at 36-37 weeks, 3.15 kg at 38 weeks, 3.33 kg at 39 weeks, 3.40 kg at &gt; 40 weeks; p &lt;.0001). BW z-scores were below zero at all points in late gestation (-0.29 at 36-37 weeks, -0.17 at 38 weeks, -0.20 at 39 weeks, -0.52 at &gt; 40 weeks; p &lt;.0001), with a slower rate of growth beyond 39 weeks GA. Of 1216 patients with available mechanical ventilation data, patients born at later GA had shorter durations of ventilation (11.3 days at 36-37 weeks GA, 9.2 days at 38 weeks, 7.6 days at 39 weeks, 6.6 days at &gt; 40 weeks; p=0.0001). Among 1083 survivors to discharge or S2P if not discharged, there was no difference in post S1P length of hospitalization across GA (p=0.19). Infants who reached S2P readiness milestones were more likely to undergo S2P if born after longer gestation (p=0.0001). Conclusions: Infants with single ventricle heart disease and aortic hypoplasia have decreased growth velocity in late gestation, but growth continues. Infants born after longer gestation have improved outcomes with shorter duration of ventilation and greater likelihood of undergoing S2P.

Real-Time Effort Driven Ventilator Management: A Pilot Study.

Mechanical ventilation of patients with acute respiratory distress syndrome should balance lung and diaphragm protective principles, which may be difficult to achieve in routine clinical practice. Through a Phase I clinical trial, we sought to determine whether a computerized decision support-based protocol (real-time effort-driven ventilator management) is feasible to implement, results in improved acceptance for lung and diaphragm protective ventilation, and improves clinical outcomes over historical controls. Interventional nonblinded pilot study. PICU. Mechanically ventilated children with acute respiratory distress syndrome. A computerized decision support tool was tested which prioritized lung-protective management of peak inspiratory pressure-positive end-expiratory pressure, positive end-expiratory pressure/FIO2, and ventilatory rate. Esophageal manometry was used to maintain patient effort in a physiologic range. Protocol acceptance was reported, and enrolled patients were matched 4:1 with respect to age, initial oxygenation index, and percentage of immune compromise to historical control patients for outcome analysis. Thirty-two patients were included. Acceptance of protocol recommendations was over 75%. One-hundred twenty-eight matched historical controls were used for analysis. Compared with historical controls, patients treated with real-time effort-driven ventilator management received lower peak inspiratory pressure-positive end-expiratory pressure and tidal volume, and higher positive end-expiratory pressure when FIO2 was greater than 0.60. Real-time effort-driven ventilator management was associated with 6 more ventilator-free days, shorter duration until the first spontaneous breathing trial and 3 fewer days on mechanical ventilation among survivors (all p ≤ 0.05) in comparison with historical controls, while maintaining no difference in the rate of reintubation. A computerized decision support-based protocol prioritizing lung-protective ventilation balanced with reduction of controlled ventilation to maintain physiologic levels of patient effort can be implemented and may be associated with shorter duration of ventilation.

Different hypothermic and cerebral perfusion strategies in extended arch replacement for acute type a aortic dissection: a retrospective comparative study

BackgroundThe optimal hypothermic level in total arch replacement with stented elephant trunk implantation for acute type A aortic dissection (aTAAD) has not been established, and the superiority of unilateral or bilateral cerebral perfusion remains a controversial issue. Therefore, we evaluated the application of moderate hypothermic circulatory arrest (MHCA) with a core temperature of 29 °C and bilateral selective antegrade cerebral perfusion in aTAAD treated by total arch replacement with stented elephant trunk implantation.MethodsFrom July 2019 to January 2020, 25 aTAAD patients underwent total arch replacement with stented elephant trunk implantation via MHCA (29 °C) and bilateral selective antegrade cerebral perfusion (modified group). Thirty-six patients treated by the same procedure with MHCA (25 °C) and unilateral selective antegrade cerebral perfusion during this period were selected as controls.ResultsThere were no differences between the two groups of patients in terms of age, sex, incidence of hypertension, malperfusion, and pericardial effusion, although the incidence of cardiac tamponade was higher in the modified group (control 2.8%, modified 20%; P = 0.038). The lowest mean circulatory arrest temperature was 24.6 ± 0.9 °C in the control group, and 29 ± 0.8 °C in the modified group (P < 0.001). In-hospital mortality was 4.9% (3/61) for the entire cohort (control 8.3%, modified 0; P = 0.262). The incidence of permanent neurologic deficit was 4.9% (control 8.3%, modified 0; P = 0.262). There were no significant differences in the occurrence of temporary neurological deficit, renal failure, and paraplegia between groups. The rate of major adverse events in the modified group was lower (30.6% vs. 4%, P = 0.019). A shorter duration of ventilation and ICU stay was identified in the modified group, as well as a reduced volume of drainage within the first 48 h and red blood cell transfusion.ConclusionsThe early results of MHCA (29 °C) and bilateral selective antegrade cerebral perfusion applied in total arch replacement with stented elephant trunk implantation for aTAAD were acceptable, providing similar inferior cerebral and visceral protection compared with that of the conventional strategy. A higher core temperature may account for the shorter duration of ventilation and ICU stay, as well as a reduced volume of drainage and red blood cell transfusion.

Safety and 30-day outcomes of tracheostomy for COVID-19: a prospective observational cohort study

BackgroundThe role of tracheostomy in coronavirus disease 2019 (COVID-19) is unclear, with several consensus guidelines advising against this practice. We developed both a dedicated airway team and coordinated education programme to facilitate ward management of tracheostomised COVID-19 patients. Here, we report outcomes in the first 100 COVID-19 patients who underwent tracheostomy at our institution. MethodsThis was a prospective observational cohort study of patients confirmed to have COVID-19 who required mechanical ventilation at Queen Elizabeth Hospital, Birmingham, UK. The primary outcome measure was 30-day survival, accounting for severe organ dysfunction (Acute Physiology and Chronic Health [APACHE]-II score>17). Secondary outcomes included duration of ventilation, ICU stay, and healthcare workers directly involved in tracheostomy care acquiring COVID-19. ResultsA total of 164 patients with COVID-19 were admitted to the ICU between March 9, 2020 and April 21, 2020. A total of 100 patients (mean [standard deviation] age: 55 [12] yr; 29% female) underwent tracheostomy; 64 (age: 57 [14] yr; 25% female) did not undergo tracheostomy. Despite similar APACHE-II scores, 30-day survival was higher in 85/100 (85%) patients after tracheostomy, compared with 27/64 (42%) non-tracheostomised patients {relative risk: 3.9 (95% confidence intervals [CI]: 2.3–6.4); P<0.0001}. In patients with APACHE-II scores ≥17, 68/100 (68%) tracheotomised patients survived, compared with 12/64 (19%) non-tracheotomised patients (P<0.001). Tracheostomy within 14 days of intubation was associated with shorter duration of ventilation (mean difference: 6.0 days [95% CI: 3.1–9.0]; P<0.0001) and ICU stay (mean difference: 6.7 days [95% CI: 3.7–9.6]; P<0.0001). No healthcare workers developed COVID-19. ConclusionIndependent of the severity of critical illness from COVID-19, 30-day survival was higher and ICU stay shorter in patients receiving tracheostomy. Early tracheostomy appears to be safe in COVID-19.

P3657Annulus-sparing should be adopted in all suitable patients with Tetralogy of Fallot

Abstract Background Ongoing controversy focuses on whether relieving obstruction of dysplastic pulmonary valve annulus (PVA) requires transannular patch enlargement (TAPE) in TOF patients. Purpose Aiming to investigate clinical outcomes of annulus-sparing (AS) repair in nonselective TOF patients. Methods 87 TOF patients was included, underwent AS repair and traditional TAPE and PV-specific technical performance score (TPS) was selected to evaluate adequacy of PV. Results One patient died and one required reintervention. 100% patients achieved AS. After a mean follow-up of 24.8 months, there is no significant difference between AS groups in severe pulmonary stenosis (PS) in Class 3 (7.4% vs 3.0%, p=0.583) and a downtrend of annular peak gradient (APG) in PVA z-score &lt;−2 (-3.2±1.9) with AS repair regardless of a higher rate of PS in Class 2 (74.1% vs 42.5%, p=0.014). Compared with TAPE in PVA z-score &lt;−2 (-3.5±0.9), there is no significant difference in PS in Class 3 (7.4% vs 7.4%, p=1.000) but a lower rate in PR in Class 3 (27.3% vs 70.4%, p=0.006), shorter ventilation duration (20.0h vs 29.0h, p=0.039), quicker recovery from ICU (2.0d vs 4.0d, p=0.022) and fewer postoperative hospitalized days (8.0d vs 11.0d, p=0.008), and APG in TAPE group was demonstrated an upward trend. Table 1. Clinical outcomes Outcomes AS P value (A vs. B) TAPE P value (B vs. C) Group A Group B Group C Z-score ≥−2 (N=33) Z-score &lt;−2 (N=27) Z-score &lt;−2 (N=27) Repump 2 (6.1) 2 (7.4) 1.000 2 (7.4) 1.000 Hospital mortality 0 (0.0) 0 (0.0) 1.000 1 (3.7) 1.000 Reintervention 1 (3.0) 0 (0.0) 0.413 0 (0.0) 0.601 Adequacy of PV repair TPS for degree of PS Class 1 (APG &lt;20 mmHg) 18 (54.5) 5 (18.5) 0.004 19 (70.4) &lt;0.001 Class 2 (APG 20–40 mmHg) 14 (42.5) 20 (74.1) 0.014 6 (22.2) &lt;0.001 Class 3 (APG &gt;40 mmHg) 1 (3.0) 2 (7.4) 0.583 2 (7.4) 1.000 TPS for degree of PR Class 1 (none/trivial PR) 18 (54.5) 9 (33.3) 0.100 3 (11.1) 0.050 Class 2 (mild/mild-moderate PR) 12 (36.4) 9 (33.3) 0.807 5 (18.5) 0.214 Class 3 (moderate or greater PR) 3 (9.1) 9 (33.3) 0.020 19 (70.4) 0.006 Moderate PR 0 (0.0) 8 (29.6) 0.008 11 (40.7) 0.393 Severe PR 2 (6.1) 1 (3.7) 1.000 7 (25.9) 0.048 Figure 1. The trend of RVOT or APG. Conclusions AS remained higher APG at discharge but had a downtrend over time and long-term reintervention was rare and minimally invasive, as an alternative to TAPE in dysplastic PVA.

Randomized Trial of 42-Day Compared with 9-Day Courses of Dexamethasone for the Treatment of Evolving Bronchopulmonary Dysplasia in Extremely Preterm Infants

To compare pulmonary and neurodevelopmental outcomes in extremely preterm infants with evolving bronchopulmonary dysplasia treated with either a 42-day course of dexamethasone or 9-day course(s) of dexamethasone. This was a prospective, randomized study in 59 infants ≤27weeks of gestation born between October 2006 and December 2010, who at day 10-21 of life had ventilatory support with mean airway pressure ≥8cmH2O and FiO2 ≥60%. Infants received dexamethasone 0.5mg/k/day×3days followed by a slow taper (42-day group, n=30) or dexamethasone 0.5mg/k/day followed by a rapid taper (9-day group, n=29). Infants in the 9-day group received additional 9-day courses if they again required entry support. The primary outcome was intact survival (normal neurologic examination, IQ >70, and functioning in school without supplemental educational support) at 7years of age. The 42-day and 9-day groups were similar for mean gestational age (25weeks) and all baseline characteristics. Nineteen of 29 infants (66%) in the 9-day group received only 1 course of dexamethasone; therefore, the total steroid dose for the 42-day group (7.56mg/kg) was significantly greater than that for the 9-day group (4.04mg/kg), P<.001. Infants in the 42-day group had shorter duration of ventilation (25 vs 37days), P<.005, received fewer transfusions (2 vs 3.5), P<.01, and reached full enteral feeds earlier (40 vs 46days), P<.05. Intact survival at school age was significantly increased in the 42-day group (75%) compared with the 9-day group (34%), P<.005. A 42-day tapering course of dexamethasone in extremely preterm infants at high risk for bronchopulmonary dysplasia decreased hospital morbidities and increased rate of survival without handicap compared with a treatment protocol that attempted to minimize steroid exposure.

The association between gestational age at delivery, closure type and perinatal outcomes in neonates with isolated gastroschisis

Objective: The objective of this study was to examine the association between gestational age at delivery and closure type for neonates with gastroschisis. In addition, we compared perinatal outcomes among the cases of gastroschisis based on the following two factors: gestational age at delivery and abdominal wall closure technique.Methods: This was a retrospective cohort study of all fetuses with isolated gastroschisis that were diagnosed prenatally and delivered between September 2000 and January 2017, in a single tertiary care center. Neonates were compared based on the gestational age at the time of delivery: early preterm (less than 350/7 weeks), late preterm (350/7 – 366/7 weeks), and early term (370/6 – 386/7 weeks), using bivariate and multivariate analyses. The primary outcome was the type of abdominal wall closure: primary surgical closure or delayed closure using spring-loaded silo. Secondary outcomes included length of ventilatory support, length of parenteral nutrition, and length of hospital stay.Results: The analysis included 206 pregnancies complicated by gastroschisis. In univariate analysis, no differences were detected in primary closure rates of gastroschisis among the gestational age at delivery groups (67.4%, at <35 weeks, 70.8% at 350/7–366/7 weeks, 73.7% at 370/6–386/7 weeks, p = .865). However, for every additional 100 grams of neonatal live birth weight there was an associated 9% increased odds of primary closure (OR 1.09, 95% CI 1.14–1.19, p = .04). Delivery in the early preterm period compared to the other two groups, was associated with longer duration of ventilation support and longer dependence on the parenteral nutrition. Neonates who underwent primary closure had shorter ventilation support, shorter time to initiation of enteral feeds and to discontinue parenteral nutrition, and shorter length of stay. In multivariate analyses, controlling for gestational age at delivery and presence of bowel atresia, primary closure continued to be associated with the shorter duration of ventilation (by 5 days), earlier initiation of enteral feeds (by 7 days), shorter hospital stay (by 17 days) and lower odds of wound infection (OR = 0.37, 95% CI 0.15–0.97).Conclusions: Our study did not find an association between gestational age at delivery and the rates of primary closure of the abdominal wall defect; however later gestational age at delivery was associated with shorter duration of ventilatory support and parenteral nutrition dependence. In addition, we found that primary closure of gastroschisis, compared with delayed closure technique, was associated with improved neonatal outcomes, including shorter time to initiate enteral feeds and discontinue parenteral nutrition, shorter hospital stay, and lower risk of surgical wound infection. Therefore, postponing delivery of fetuses with gastroschisis until 37 weeks may be considered. Other factors besides the gestational age at delivery should be explored as predictors of primary closure in neonates with gastroschisis.

Inspiratory Muscle Rehabilitation in Critically Ill Adults. A Systematic Review and Meta-Analysis.

Respiratory muscle weakness is common in critically ill patients; the role of targeted inspiratory muscle training (IMT) in intensive care unit rehabilitation strategies remains poorly defined. The primary objective of the present study was to describe the range and tolerability of published methods for IMT. The secondary objectives were to determine whether IMT improves respiratory muscle strength and clinical outcomes in critically ill patients. We conducted a systematic review to identify randomized and nonrandomized studies of physical rehabilitation interventions intended to strengthen the respiratory muscles in critically ill adults. We searched the MEDLINE, Embase, HealthSTAR, CINAHL, and CENTRAL databases (inception to September Week 3, 2017) and conference proceedings (2012 to 2017). Data were independently extracted by two authors and collected on a standardized report form. A total of 28 studies (N = 1,185 patients) were included. IMT was initiated during early mechanical ventilation (8 studies), after patients proved difficult to wean (14 studies), or after extubation (3 studies), and 3 other studies did not report exact timing. Threshold loading was the most common technique; 13 studies employed strength training regimens, 11 studies employed endurance training regimens, and 4 could not be classified. IMT was feasible, and there were few adverse events during IMT sessions (nine studies; median, 0%; interquartile range, 0-0%). In randomized trials (n = 20), IMT improved maximal inspiratory pressure compared with control (15 trials; mean increase, 6 cm H2O; 95% confidence interval [CI], 5-8 cm H2O; pooled relative ratio of means, 1.19; 95% CI, 1.14-1.25) and maximal expiratory pressure (4 trials; mean increase, 9 cm H2O; 95% CI, 5-14 cm H2O). IMT was associated with a shorter duration of ventilation (nine trials; mean difference, 4.1 d; 95% CI, 0.8-7.4 d) and a shorter duration of weaning (eight trials; mean difference, 2.3 d; 95% CI, 0.7-4.0 d), but confidence in these pooled estimates was low owing to methodological limitations, including substantial statistical and methodological heterogeneity. Most studies of IMT in critically ill patients have employed inspiratory threshold loading. IMT is feasible and well tolerated in critically ill patients and improves both inspiratory and expiratory muscle strength. The impact of IMT on clinical outcomes requires future confirmation.

Rate of Self-Extubation in Pediatric Intensive Care Unit Following Administration of Fentanyl, Midazolam and Midazolam-Fentanyl Combination: A Comparative Study

Background Self-extubation is a problem in pediatric intensive care unit (PICU) and can be harmful for children. Level of sedation is a determining factor for self-extubation. The aim of this study was to compare thr rate of self-extubation and duration of ventilation following different sedative modalities. Materials and Methods This prospective and randomized study was done in Mofid Children Hospital, Tehran, Iran from October 2015 to September 2016. One hundred and fifty seven children from 1 month to 15 years of age with normal consciousness level requiring mechanical ventilation were included.The rate of self-extubation, and duration of ventilation were compared among 3 groups; Midazolam group (n= 50) 0.1 mg/kg/hr, Fentanyl group (n= 50) 2 mcg/kg/hr., and Midazolam-Fentanyl group (n= 57); midazolam 0.05 mg/kg/hr and fentanyl 1 mcg/kg/hr. All administrations were IV. Optimal level of sedation was 2-3 using Ramsay score. Results: One hundred and fifty seven children were studied. The mean age of patients was 4.5 ± 1.5 years with an excess of boys (57.9% vs. 42.1%). Rate of self-extubation was lower in Midazolam-Fentanyl group; the difference was significant among 3 groups (p < 0.01). There was a significant difference in duration of ventilation in Midazolam- Fentanyl group compared the other groups (Midazolam group and Fentanyl group) (p < 0.001). Conclusion This study showed that combination therapy with Fentanyl + Midazolam was associated with lower rate of self-extubation and shorter duration of ventilation. In addition, this combination therapy seems safe.

Pulse index continuous cardiac output versus central venous pressure-based early goal-directed therapy for septic shock patients: a randomized trial

Background Central venous pressure-based early goal-directed therapy (EGDT) is considered the gold standard in the management of septic shock. We compared this approach with pulse index continuous cardiac output (PiCCO)-based EGDT in a randomized controlled study. Patients and methods Eighty septic shock patients were randomly divided into the conventional survival sepsis bundle group using central venous and arterial catheters (group C, n=40), and the modified survival sepsis bundle group using central venous and PiCCO arterial thermistor catheters (group P, n=40). Primary outcome included mortality at 28 days after diagnosis of shock. Secondary outcomes included ICU stay, days on mechanical ventilation, and renal replacement therapy (RRT). Results In comparison with group C, group P showed a lower mortality with no statistical differences at 28 days after diagnosis of shock [15 (37.5%) patients in the P group vs. 21 (52.5%) patients in the C group; P=0.11]. The population in the C group showed longer duration on ventilation, which was statistically significant [6 (5.0–7.0) in the C group vs. 3 (2.0–3.0) in the P group; P Conclusion PiCCO-based EGDT produced lower ICU stay, and shorter duration of ventilation and RRT; however, it did not reduce mortality in septic shock patients when compared with the conventional central venous pressure-based approach.

Associations between positive end-expiratory pressure and outcome of patients without ARDS at onset of ventilation: a systematic review and meta-analysis of randomized controlled trials.

BackgroundThe aim of this investigation was to compare ventilation at different levels of positive end-expiratory pressure (PEEP) with regard to clinical important outcomes of intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) at onset of ventilation.MethodsMeta-analysis of randomized controlled trials (RCTs) comparing a lower level of PEEP with a higher level of PEEP was performed. The primary outcome was in-hospital mortality.ResultsTwenty-one RCTs (1393 patients) were eligible. PEEP ranged from 0 to 10 cmH2O and from 5 to 30 cmH2O in the lower PEEP and the higher PEEP arms of included RCTs, respectively. In-hospital mortality was not different between the two PEEP arms in seven RCTs (risk ratio [RR] 0.87; 95% confidence interval [CI] 0.62–1.21; I 2 = 26%, low quality of evidence [QoE]), as was duration of mechanical ventilation in three RCTs (standardized mean difference [SMD] 0.68; 95% CI −0.24 to 1.61; I 2 = 82%, very low QoE). PaO2/FiO2 was higher in the higher PEEP arms in five RCTs (SMD 0.72; 95% CI 0.10–1.35; I 2 = 86%, very low QoE). Development of ARDS and the occurrence of hypoxemia (2 RCTs) were lower in the higher PEEP arms in four RCTs and two RCTs, respectively (RR 0.43; 95% CI 0.21–0.91; I 2 = 56%, low QoE; RR 0.42; 95%–CI 0.19–0.92; I 2 = 19%, low QoE). There was no association between the level of PEEP and any hemodynamic parameter (four RCTs).ConclusionVentilation with higher levels of PEEP in ICU patients without ARDS at onset of ventilation was not associated with lower in-hospital mortality or shorter duration of ventilation, but with a lower incidence of ARDS and hypoxemia, as well as higher PaO2/FiO2. These findings should be interpreted with caution, as heterogeneity was moderate to high, the QoE was low to very low, and the available studies prevented us from addressing the effects of moderate levels of PEEP.Electronic supplementary materialThe online version of this article (doi:10.1186/s13613-016-0208-7) contains supplementary material, which is available to authorized users.

Synchronized mechanical ventilation for respiratory support in newborn infants.

During synchronised mechanical ventilation, positive airway pressure and spontaneous inspiration coincide. If synchronous ventilation is provoked, adequate gas exchange should be achieved at lower peak airway pressures, potentially reducing baro/volutrauma, air leak and bronchopulmonary dysplasia. Synchronous ventilation can potentially be achieved by manipulation of rate and inspiratory time during conventional ventilation and employment of patient-triggered ventilation. To compare the efficacy of:(i) synchronised mechanical ventilation, delivered as high-frequency positive pressure ventilation (HFPPV) or patient-triggered ventilation (assist control ventilation (ACV) and synchronous intermittent mandatory ventilation (SIMV)), with conventional ventilation or high-frequency oscillation (HFO);(ii) different types of triggered ventilation (ACV, SIMV, pressure-regulated volume control ventilation (PRVCV), SIMV with pressure support (PS) and pressure support ventilation (PSV)). We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 5), MEDLINE via PubMed (1966 to June 5 2016), EMBASE (1980 to June 5 2016), and CINAHL (1982 to June 5 2016). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. Randomised or quasi-randomised clinical trials comparing synchronised ventilation delivered as HFPPV to CMV, or ACV/SIMV to CMV or HFO in neonates. Randomised trials comparing different triggered ventilation modes (ACV, SIMV, SIMV plus PS, PRVCV and PSV) in neonates. Data were collected regarding clinical outcomes including mortality, air leaks (pneumothorax or pulmonary interstitial emphysema (PIE)), severe intraventricular haemorrhage (grades 3 and 4), bronchopulmonary dysplasia (BPD) (oxygen dependency beyond 28 days), moderate/severe BPD (oxygen/respiratory support dependency beyond 36 weeks' postmenstrual age (PMA) and duration of weaning/ventilation.Eight comparisons were made: (i) HFPPV versus CMV; (ii) ACV/SIMV versus CMV; (iii) SIMV or SIMV + PS versus HFO; iv) ACV versus SIMV; (v) SIMV plus PS versus SIMV; vi) SIMV versus PRVCV; vii) SIMV vs PSV; viii) ACV versus PSV. Data analysis was conducted using relative risk for categorical outcomes, mean difference for outcomes measured on a continuous scale. Twenty-two studies are included in this review. The meta-analysis demonstrates that HFPPV compared to CMV was associated with a reduction in the risk of air leak (typical relative risk (RR) for pneumothorax was 0.69, 95% confidence interval (CI) 0.51 to 0.93). ACV/SIMV compared to CMV was associated with a shorter duration of ventilation (mean difference (MD) -38.3 hours, 95% CI -53.90 to -22.69). SIMV or SIMV + PS was associated with a greater risk of moderate/severe BPD compared to HFO (RR 1.33, 95% CI 1.07 to 1.65) and a longer duration of mechanical ventilation compared to HFO (MD 1.89 days, 95% CI 1.04 to 2.74).ACV compared to SIMV was associated with a trend to a shorter duration of weaning (MD -42.38 hours, 95% CI -94.35 to 9.60). Neither HFPPV nor triggered ventilation was associated with a significant reduction in the incidence of BPD. There was a non-significant trend towards a lower mortality rate using HFPPV versus CMV and a non-significant trend towards a higher mortality rate using triggered ventilation versus CMV. No disadvantage of HFPPV or triggered ventilation was noted regarding other outcomes. Compared to conventional ventilation, benefit is demonstrated for both HFPPV and triggered ventilation with regard to a reduction in air leak and a shorter duration of ventilation, respectively. In none of the trials was complex respiratory monitoring undertaken and thus it is not possible to conclude that the mechanism of producing those benefits is by provocation of synchronised ventilation. Triggered ventilation in the form of SIMV ± PS resulted in a greater risk of BPD and duration of ventilation compared to HFO. Optimisation of trigger and ventilator design with respect to respiratory diagnosis is encouraged before embarking on further trials. It is essential that newer forms of triggered ventilation are tested in randomised trials that are adequately powered to assess long-term outcomes before they are incorporated into routine clinical practice.