Use Of Invasive Mechanical Ventilation Research Articles

Major Symptoms and Outcome of Covid-19 Positive Patients: A Study in a Tertiary Care Hospital in Bangladesh

Background: An outbreak of Covid-19 caused by the SARS-Cov-2 initially emerged in China in December 2019 and the first Covid-19 patient was detected on 8 March 2020 in Bangladesh. The preconception about the major symptoms and outcomes of Covid-19-positive patients may be helpful for healthcare professionals in the management of Covid-19 patients. This study aimed to evaluate the major symptoms and outcomes of covid-19 positive patients.
 Methods: This prospective observational study was conducted in the Department of Medicine, Rajshahi Medical College Hospital, Rajshahi, Bangladesh from January 2021 to December 2021. In total 67 confirmed Covid-19 cases by RT-PCR tests who attended the mentioned hospital were enrolled in this study as the study population. For data collection, a pre-designed questionnaire was used. Along with demographic and clinical features data regarding in-hospital mortality, intensive care unit (ICU) admission, use of invasive mechanical ventilation, total hospital length of stay, complications, and treatment patterns were recorded. Collected data were processed, analyzed and disseminated by using the MS Excel program.
 Results: The highest number of patients were with a cough which was found among 49% of cases. Besides this, shortness of breath, hypoxemia/oxygen use, lower limb swelling and bleeding were found among 39%, 27%, 12% and the rest 7% of patients respectively. The highest number of patients were with hypertension (HTN) as comorbidity which was found in 15% of cases. Besides this, diabetes mellitus (DM), chronic kidney diseases (CKD), chronic respiratory diseases (CRD), cancer/immunodeficiency and cardiac diseases were found among 12, 10%, 7%, 4% and the rest 1% of patients, respectively. As the outcomes, the cure rate was found up to 97% and death occurred in only 3% (n=2) cases. We observed that 10% of patients did not stay at the hospital even for a single day. For only 7% of patients, ventilation facilities were in needed and the average ventilation time was 13.5 days.
 Conclusion: Cough and shortness of breath are two major symptoms for Covid-19 patients. Proper ventilation and ICU facilities can decrease the suffering, mortality as well as morbidity of Covid-19 patients.

Treatment effect modifiers in hospitalised patients with COVID-19 receiving remdesivir and dexamethasone

Background The combined effectiveness of remdesivir and dexamethasone in subgroups of hospitalised patients with COVID-19 is poorly investigated. Methods In this nationwide retrospective cohort study, we included 3826 patients with COVID-19 hospitalised between February 2020 and April 2021. The primary outcomes were use of invasive mechanical ventilation and 30-day mortality, comparing a cohort treated with remdesivir and dexamethasone with a previous cohort treated without remdesivir and dexamethasone. We used inverse probability of treatment weighting logistic regression to assess associations with progression to invasive mechanical ventilation and 30-day mortality between the two cohorts. The analyses were conducted overall and by subgroups based on patient characteristics. Results Odds ratio for progression to invasive mechanical ventilation and 30-day mortality in individuals treated with remdesivir and dexamethasone compared to treatment with standard of care alone was 0.46 (95% confidence interval, 0.37–0.57) and 0.47 (95% confidence interval, 0.39–0.56), respectively. The reduced risk of mortality was observed in elderly patients, overweight patients and in patients requiring supplemental oxygen at admission, regardless of sex, comorbidities and symptom duration. Conclusions Patients treated with remdesivir and dexamethasone had significantly improved outcomes compared to patients treated with standard of care alone. These effects were observed in most patient subgroups.

Characteristics and outcomes of an international cohort of 600 000 hospitalized patients with COVID-19.

We describe demographic features, treatments and clinical outcomes in the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) COVID-19 cohort, one of the world's largest international, standardized data sets concerning hospitalized patients. The data set analysed includes COVID-19 patients hospitalized between January 2020 and January 2022 in 52 countries. We investigated how symptoms on admission, co-morbidities, risk factors and treatments varied by age, sex and other characteristics. We used Cox regression models to investigate associations between demographics, symptoms, co-morbidities and other factors with risk of death, admission to an intensive care unit (ICU) and invasive mechanical ventilation (IMV). Data were available for 689 572 patients with laboratory-confirmed (91.1%) or clinically diagnosed (8.9%) SARS-CoV-2 infection from 52 countries. Age [adjusted hazard ratio per 10 years 1.49 (95% CI 1.48, 1.49)] and male sex [1.23 (1.21, 1.24)] were associated with a higher risk of death. Rates of admission to an ICU and use of IMV increased with age up to age 60years then dropped. Symptoms, co-morbidities and treatments varied by age and had varied associations with clinical outcomes. The case-fatality ratio varied by country partly due to differences in the clinical characteristics of recruited patients and was on average 21.5%. Age was the strongest determinant of risk of death, with a ∼30-fold difference between the oldest and youngest groups; each of the co-morbidities included was associated with up to an almost 2-fold increase in risk. Smoking and obesity were also associated with a higher risk of death.The size of our international database and the standardized data collection method make this study a comprehensive international description of COVID-19 clinical features. Our findings may inform strategies that involve prioritization of patients hospitalized with COVID-19 who have a higher risk of death.

Respiratory Support Techniques for COVID-19-Related ARDS in a Sub-Saharan African Country: A Multicenter Observational Study

Limited data from low-income countries report on respiratory support techniques in COVID-19-associated ARDS. Which respiratory support techniques are used in patients with COVID-19-associated ARDS in Uganda? A multicenter, prospective, observational study was conducted at 13 Ugandan hospitals during the pandemic and included adults with COVID-19-associated ARDS. Patient characteristics, clinical and laboratory data, initial and most advanced respiratory support techniques, and 28-day mortality were recorded. Standard tests, log-rank tests, and logistic regression analyses were used for statistical analyses. Four hundred ninety-nine patients with COVID-19-associated ARDS (mild, n= 137; moderate, n= 247; and severe, n= 115) were included (ICU admission, 38.9%). Standard oxygen therapy (SOX), high-flow nasal oxygen (HFNO), CPAP, noninvasive ventilation (NIV), and invasive mechanical ventilation (IMV) was used as the first-line (most advanced) respiratory support technique in 37.3%(35.3%), 10%(9.4%), 11.6%(4.8%), 23.4%(14.4%), and 17.6%(36.6%) of patients, respectively. The first-line respiratory support technique was escalated in 19.8%of patients. Twenty-eight-day mortality was 51.9%(mild ARDS, 13.1%; moderate ARDS, 62.3%; severe ARDS, 75.7%; P< .001) and was associated with respiratory support techniques as follows: SOX, 19.9%; HFNO, 31.9%; CPAP, 58.3%; NIV 61.1%; and IMV, 83.9%(P< .001). Proning was used in 79 patients (15.8%; 59 of 79 awake) and was associated with lower mortality (40.5%vs54%; P= .03). The oxygen saturation to Fio2 ratio (OR, 0.99; 95%CI, 0.98-0.99; P< .001) and respiratory rate (OR, 1.07; 95%CI, 1.03-1.12; P= .002) at admission and NIV (OR, 6.31; 95%CI, 2.29-17.37; P< .001) or IMV (OR, 8.08; 95%CI, 3.52-18.57; P< .001) use were independent risk factors for death. SOX, HFNO, CPAP, NIV, and IMV were used as respiratory support techniques in patients with COVID-19-associated ARDS in Uganda. Although these data are observational, they suggest that the use of SOX and HFNO therapy as well as awake proning are associated with a lower mortality resulting from COVID-19-associated ARDS in a resource-limited setting.

Predictors of invasive mechanical ventilation use in patients with acute decompensated pulmonary hypertension admitted to the intensive care unit.

In acute decompensated pulmonary hypertension, elevated nonrespiratory SOFA was associated with a higher use of invasive mechanical ventilation independently of the hypoxaemia on ICU admission and pulmonary hypertension severity https://bit.ly/3YdOHpn.

Association between the General Movement Optimality Score and clinical features in newborns during hospitalization: A cross-sectional study

AimsTo describe the General Movements (GMs) of hospitalized newborns to verify if their global and detailed GMA are related and if their GMs are associated with clinical features. MethodsCross-sectional study. Thirty-eight preterm and full-term newborns, who were hospitalized in the neonatal intermediate care unit of a reference hospital, were included. Prechtl's General Movement Assessment (GMA), including the General Movement Optimality Score (GMOS) list, was used as an assessment tool. Clinical variables, such as preterm birth, birthweight, length of hospitalization, Apgar scores, pregnancy problems, admission at neonatal intensive care unit, use of invasive mechanical ventilation, and brain imaging findings were also collected. Newborns were videoed at a single time for 3 min before discharge. ResultsMost newborns presented GMs with normal or poor repertoire quality. GMOS ranged from 17 to 42 points. Scores were lower in abnormal GMs. Abnormal GMs were associated with preterm birth, length of hospital stay >30 days and birthweight <2500 g. Accordingly, lower GMOSs were also associated with preterm birth, a birthweight <2500 g and a hospital stay >30 days but also with the invasive mechanical ventilation application. ConclusionPreterm and full-term newborns presented normal or abnormal GMs during hospitalization. Preterm birth, low birthweight, longer hospital stay and a time period of invasive ventilation were associated with worse GM behaviors.

Editor's Choice Articles for February.

Editor's Choice Articles for February.

Improving Outcomes for Bronchiolitis Patients After Implementing a High-Flow Nasal Cannula Holiday and Standardizing Discharge Criteria in a PICU.

To decrease length of high-flow nasal cannula (HFNC), PICU, and hospital length of stay (LOS). Quality improvement project. A quaternary academic PICU. Patients with bronchiolitis less than 24 months old. After initial implementation of a respiratory therapist (RT)-driven HFNC protocol (Plan-Do-Study-Act [PDSA] 1) in October 2017, additional interventions included adjusting HFNC wean rate (PDSA 2) in July 2020, a HFNC holiday (PDSA 3), and standardized discharge criteria (PDSA 4) in October 2021. Duration of HFNC was used as the primary outcome measure. PICU LOS and hospital LOS were used as secondary outcome measures. Noninvasive ventilation use, invasive mechanical ventilation use, and 7-day PICU and hospital readmission rates were used as balancing measures. A total of 1,310 patients were included in this study. Patients in PDSA 2, PDSA 3 and 4 groups were older compared with pre-intervention and PDSA 1 (median of 9 and 10 mo compared with 8 mo; p = 0.01). HFNC duration decreased from 2.5 to 1.8 days after PDSA 1, then to 1.3 days after PDSA 2. PICU LOS decreased from 2.6 to 2.1 days after PDSA 1, 1.8 days after PDSA 2, and 1.5 days after PDSA 3 and 4. Hospital LOS decreased from 5.7 to 4.5 days after PDSA 1, 3.1 days after PDSA 2, and 2.7 days after PDSA 3 and 4. The use of noninvasive ventilation and invasive mechanical ventilation decreased throughout the study from 23.2% in the pre-intervention group, to 6.9% at the end of the project. The 7-day PICU and hospital readmission rates did not increase after implementation. The percentage of patients discharged from the PICU increased from 6.2% to 21.5%. Modifications to an existing RT-driven HFNC protocol and standardization of discharge criteria led to an improvement in outcomes for patients admitted to the PICU with bronchiolitis without an increase in adverse events.

Clinical characteristics and determinants of invasive mechanical ventilation outcome in adult intensive care unit in Northern Ethiopia: A resource-limited setting

Objectives: Mechanical ventilation (MV) is a primary modality of supporting organ function in patients who are treated in intensive care units (ICUs). Although it is lifesaving, it is also associated with life-threatening complications. This study aims to address the existing paucity of evidence on clinical characteristics and determinants of invasive MV outcomes in adult ICU in North Ethiopia. Materials and Methods: The study was conducted in the adult ICU of Ayder Comprehensive Specialized Hospital. A hospital-based prospective study was conducted to collect data using the purposive sampling technique to include all the patients who received invasive MV from January 2017 to October 2017. Data were analyzed using SPSS version 23. Results: MV was utilized in 36.7% (n = 105) of critically ill patients admitted to the ICU. The two most common indications for invasive MV use were hypoxic respiratory failure 44.8% (n = 47) and coma 35.2% (n = 37). The mortality rate among patients who received invasive MV was 28.6%. Age above 60 years and development of septic shock after intubation were significant determinants of invasive MV-related mortality. Conclusion: A significant number of patients admitted to the ICU require respiratory support with invasive MV. Old age and the development of septic shock after intubation were significant determinants of mortality for patients under invasive MV.

Characterization of feeding skills and clinical markers of preterm newborns with gastroschisis in a neonatal therapy unit.

To describe the clinical and feeding findings of premature infants with gastroschisis (GTQ) in a neonatal intensive care unit and compare them to preterm infants (NBs) without congenital anomalies. A retrospective case-control study was conducted with 50 premature NBs (25 with GTQ and 25 without comorbidities - control group). The NBs were compared regarding demographic and clinical data: risk of mortality and speech-language assessment (nonnutritive and nutritive sucking). Subsequently, a multiple logistic regression model was applied to determine the variables associated with the negative speech therapy outcome (speech therapy discharge after more than 7 days considering the first speech therapy evaluation). The results of the first analysis indicated that there was a difference between the GTQ and the CG for the following variables: total time in days of hospitalization; use of mechanical ventilation (invasive x noninvasive); days of life on the date of the first speech-language assessment; use of alternative feeding route; and the GTQ group had worse results. The results of the multiple logistic regression indicated that the diagnosis of GTQ, the use of invasive mechanical ventilation, and the absence of adequate intraoral pressure during the first speech-language evaluation were risk factors for a negative speech-language outcome. The feeding skills of preterm infants with QTG are related to the severity of the condition (gastrointestinal tract complications), requiring longer hospitalization, use of invasive mechanical ventilation, prolonged use of alternative feeding route and requiring more speech therapy to start oral feeding.

Characteristics, risk factors, and outcomes of bloodstream Candida infections in the intensive care unit: a retrospective cohort study

The main objective was to assess the clinical characteristics, associated factors, and outcomes of patients admitted to the ICU for candidemia. The secondary objective was to examine the relationship of candidemia with the length of stay and mortality. The analysis was a retrospective single-center cohort study addressing the effect of invasive candidemia on outcomes. This study was performed in a medical-surgical ICU located in a tertiary private hospital in São Paulo, Brazil. Data was collected through the review of the hospital database. In total, 18,442 patients were included in our study, including 22 patients with candidemia. The median age was similar in patients with and without candidemia [67 (56-84) vs. 67 (51-80)]. Most patients were male, and the proportion of men was higher among patients with candidemia (77% vs. 55.3%). The rates of renal replacement therapy (40.9% vs. 3.3%), mechanical ventilation (63.6% vs. 29.6%), and parenteral nutrition (40.9% vs. 4.8%) were higher in patients with candidemia than in those without candidemia. The mortality rate (77.3% vs. 11.9%) and length of hospital stay [42 days (23.0-78.8) vs. 8 days (5.0-17.0)] were significantly higher in patients with candidemia. Patients with candidemia are prone to longer hospital stay and mortality. In addition, we found associations of candidemia with the use of invasive mechanical ventilation, renal replacement therapy, and parenteral nutrition.

Consideraciones radiológicas del cáncer de pulmón y Covid-19: una mirada oncológica

Patients with SARS-Cov-2 infection and lung cancer have an unfavorable prognosis, characterized by higher rates of respiratory failure, use of invasive mechanical ventilation and higher mortality rates. Due to similarities in affected organs in Covid-19 and lung cancer, the radiological accurate diagnosis has become a challenge for physicians. Radiologic findings of lung cancer, such as parenchymal consolidation, spiculation and microlobulations are not specific. Imaging findings of Covid-19 in patients with lung cancer consist of multiple patchy multifocal bilateral ground-glass opacities and consolidations, being hardly distinguishable from an underlying lung malignancy. Differential radiological diagnosis in patients with lung cancer and Covid-19 must include pneumonitis and lung toxicity caused by chemotherapy, target therapies and radiotherapy. Follow-up and simulation tomography in radiotherapy have become an unexpected ally in the early detection of Covid-19 in asymptomatic stages in lung cancer patients. Patients with lung cancer should have particular considerations due to their high risk and the adverse effects of systemic therapies and radiotherapy.

18: EPIDEMIOLOGY OF NONINVASIVE AND INVASIVE MECHANICAL VENTILATION USE FOR CHILDREN AT THE END OF LIFE

Introduction: Invasive mechanical ventilation (IMV) is an intensive intervention commonly experienced by children at the end of life. Non-invasive mechanical ventilation (NIV) is a potential alternative to IMV, and studies have shown increasing use of NIV without decreasing IMV for adults. The objective was to describe the trends, predictors, and hospital variability in use of NIV and IMV for children at the end of life. Methods: Multi-center retrospective cohort study of children 0 to 21 years who died in 1 of 37 hospitals in Pediatrics Health Information Systems (PHIS) Database between 2010 and 2019. ICD-9, ICD-10, and CTC codes were used to identify mode of ventilation (IMV, NIV, both or none). Descriptive statistics summarized socio-demographic and clinical characteristics by mode of ventilation, and hospital NIV use quartiles were calculated. The Cochran-Armitage test assessed for trends over time and multivariable random-effect logistic regression assessed for independent predictors of ventilatory support. Results: 41,091 patients (median age 0.4, IQR [0,6.7] y, 45% female, 42% white) died in the hospital. Increasing age predicted lower odds of IMV (aOR .95 per year, 95% CI .95-.96, p<.001) or both (aOR .98 per year, 95% CI .97-.99, p=.005) compared to none. Number of complex chronic conditions (CCC) (median [IQR]) was 2 [1,3] overall and for IMV, 3 [2,3] for NIV, and 3 [2,4] for both. Self-pay patients were less likely than commercially or government insured to receive IMV (aOR .69, 95% CI .56-.84, p<.001) or both (aOR .37, 95% CI .27-.5, p<.001). From 2010 to 2019, exposure to NIV increased (771 [18.8%] vs. 1075 [25.9%], p<.001) with no change in IMV (3636 [88.6%] vs. 3669 [88.5%], p=.86); increase in NIV was more often experienced as both (688 [16.8%] vs. 944 [22.8%]) than NIV (83 [2%] vs. 131 [3.2%]). For hospitals in the highest NIV use quartile, the aOR for any NIV was 6.16 (95% CI 3.98-9.52, p<.001) and any IMV was .8 (95% CI .55-1.17, p=.249) compared to the lowest NIV use quartile. Conclusions: Use of NIV has increased over time for children nearing the end of life, without a reciprocal decrease in use of IMV. Differences exist based on age, insurance status, and chronic medical complexity. Significant interhospital variability in NIV use exists, which does not correlate with use of IMV.

711: INVASIVE VERSUS NONINVASIVE MECHANICAL VENTILATION IN PEDIATRIC ASTHMA: A SINGLE-CENTER STUDY

Introduction: Asthma is a leading cause of pediatric hospitalization. Endotracheal intubation and invasive mechanical ventilation (IMV) in status asthmaticus (SA) are associated with increased complications and mortality. Recent practice trends favor non-invasive ventilation (NIV) to support respiratory failure in SA. Comparison of patients receiving IMV or NIV for SA can help predict which patients are at risk of intubation and poor outcomes. Methods: This is a single center retrospective cohort study. The study period was from 2011-2020. Inclusion criteria were status asthmaticus and age 2-20 years. Patients who received invasive support were matched 1:2 with those receiving NIV by date of intubation. Data collected included demographics, past medical history, history of prior PICU stay, IMV or NIV use, home medications, environmental risk factors, asthma and non-asthma directed medical management, length of stay (LOS), complications, morbidity and mortality. Categorical data was compared using Chi square or Fisher’s exact test as appropriate. T-tests were used to compare means. Results: 49 patients received IMV for SA over a 10-year period and 98 patients who received NIV were identified as a control. There was no difference in gender, race, history of allergies, eczema, smoke exposure, pets, home medication or prior PICU stay. Intubated patients were 2.2 years older (p=0.02) and were more likely to have previously been intubated (18.4% vs 7.1%, p=0.04). Need for IMV was associated with a longer LOS (12.3d vs 5.4d, p< 0.01) as well as several complications, including pneumothorax, neuromyopathy, hypoxic ischemic encephalopathy, CPR and death. The groups had similar rates of pneumonia, which has previously been identified as a risk factor for intubation. Five patients (10.2%) died; all received IMV. 80% (n=4) of these patients had a pre-hospital arrest. None of the patients with mortality had previously been intubated. Conclusions: In this study, use of IMV was associated with older age and prior history of IMV. However, history of prior IMV was not associated with mortality. Pre-hospital arrest was a major driver of mortality. Efforts to reduce mortality in pediatric asthma may benefit from identifying high risk children in the community setting.

2170. Association Between End-of-Treatment Procalcitonin Levels with Mortality &amp; Recurrent Ventilator-Associated Pneumonia

Abstract Background In the only randomized controlled trial utilizing procalcitonin in ventilator-associated pneumonia (VAP), 30% of patients failed to normalize procalcitonin levels by the end of treatment, a finding of uncertain clinical importance. The prognostic value of procalcitonin for VAP mortality has been examined only in studies with limited sample sizes and the relationship between end-of-treatment procalcitonin (EOT-P) and VAP recurrence—which affects up to 40% of patients with VAP—has never been examined. We aimed to determine the relationship between VAP EOT-P and recurrent pneumonia or mortality. Methods Retrospective single-center cohort study of hospitalized adult patients between 2013 – 2022 with VAP (defined as use of invasive mechanical ventilation for ≥ 2 days, positive respiratory culture and treatment for ≥ 5 days with pneumonia-specific antibiotics) who had serum procalcitonin levels obtained within 48 of antibiotic completion (AC). Exclusion criteria included death or discharge to hospice within 48 hours of AC. Patients with EOT-P &amp;lt; 0.5 were compared with those with EOT-P ≥ 0.5. The primary outcome was a composite endpoint of recurrent pneumonia (defined as clinical suspicion sufficient to warrant respiratory culture collection) and/or death within 30 days of AC. Results Of 140 included patients, 79 (56.4%) had EOT-P levels &amp;lt; 0.5, and 61 (43.6%) had levels ≥ 0.5. Patients with elevated EOT-P were more likely to have renal disease, longer duration of antibiotic treatment and longer antecedent hospital length of stay than those with non-elevated EOT-P. Demographic characteristics and comorbidities were otherwise similar between groups (Table 1). After multivariable adjustment, patients with elevated EOT-P were significantly more likely to have recurrent pneumonia or death within 30 days (Table 2 and Figure 1, OR 2.39 (95% 1.19-4.80 CI), adjusted OR 2.37 (95% CI 1.09-5.17)). Patient demographics of the study group. "EOT-P" = serum procalcitonin level drawn following completion of antibiotics. Patients with EOT-P &amp;lt;0.5 were compared with those with EOT-P ≥ 0.5. "Immunocompromised" = combination of HIV/AIDS positivity, actively taking immunosuppressive medications, metastatic or hematologic malignancy, history of stem cell transplant, or organ transplantation. Patient outcomes, followed for 30 days following antibiotic completion. The primary endpoint was a composite of death or recurrent pneumonia. The secondary endpoints are death or recurrent pneumonia examined separately. "EOT-P" = serum procalcitonin level drawn following completion of antibiotics. Patients with EOT-P &amp;lt;0.5 were compared with those with EOT-P ≥ 0.5. "VAP" = ventillator-assisted pneumonia. Percentage of patients who survived without recurrence of pneumonia, followed for 30 days following antibiotic completion. "EOT-P" = serum procalcitonin level drawn following completion of antibiotics. Patients with EOT-P &amp;lt;0.5 were compared with those with EOT-P ≥ 0.5. Conclusion Elevated EOT-P in VAP was independently associated with increased VAP recurrence or mortality within 30 days. To our knowledge, this is the largest study to date of the prognostic value of procalcitonin in a ventilator-associated pneumonia cohort. Use of end-of-treatment procalcitonin in VAP may serve as a candidate biomarker to predict VAP recurrence and death. Disclosures Owen Albin, MD, Charles River Laboratory: Advisor/Consultant|Cipla Pharmaceuticals: Advisor/Consultant|Shionogi Inc: Advisor/Consultant.

686: THERAPEUTIC THRESHOLDS OF DEXMEDETOMIDINE IN THE DEVELOPMENT OF ICU DELIRIUM

Introduction: The use of dexmedetomidine is increasing as a sedation agent in the pediatric population. The aim of this study is to determine if there is a dose-dependent relationship between dexmedetomidine and the development of ICU delirium in the pediatric cardiac intensive care unit (PCICU). We sought to describe a relationship between both the cumulative dose and the average continuous dose of dexmedetomidine with ICU delirium in patients admitted to a PCICU. Methods: This is a single-center, retrospective chart review of patients age 0-21 years admitted to the PCICU for more than 24 hours, who had delirium assessments performed using the Cornell Assessment of Pediatric Delirium (CAPD). CAPD scores were collected. Exposures prior to each CAPD score were collected in 12-hour time intervals. The primary outcome was cumulative dose exposure of dexmedetomidine in micrograms per kilogram over the course of each admission. Cumulative dosing was obtained by accounting for the amount of both the continuous infusions and intermittent bolus received over the entire admission. Average dose exposure in micrograms/kilogram/hour was also obtained over each twelve-hour time period before the next CAPD score was recorded. Descriptive statistics was used to characterize the cohort and report dosing outcomes. Results: Two-hundred and seventy-seven patients were included in the analysis, which accounted for a total of 5,031 CAPD assessments. Increased length of stay, use of invasive mechanical ventilation, and exposure to dexmedetomidine, benzodiazepines, or opiates, were independently associated with delirium. Patients with delirium received a higher cumulative dose of dexmedetomidine (0.81 microgram/kilogram vs 15.01 micrograms/kilogram, p = 0.003). Additionally, patients with delirium, on average, received a higher continuous infusion dose of dexmedetomidine (0.23 micrograms/kilogram/hour vs 0.54 micrograms/kilogram/hour, p < 0.001). Conclusions: Patients with delirium in the PCICU had a higher cumulative dose of dexmedetomidine and higher average dose of a continuous infusion of dexmedetomidine. Future initiatives and studies examining institutional protocols for sedation in this population should incorporate considerations for their impact on the development of ICU delirium.

607: IMPLEMENTING A HIGH-FLOW NASAL CANNULA HOLIDAY AND DISCHARGE CRITERIA FOR BRONCHIOLITIS PATIENTS

Introduction: Costs for bronchiolitis have risen over the years. Previous studies have shown that respiratory therapist (RT) driven high flow nasal cannula (HFNC) management protocols can decrease length of HFNC as well as pediatric intensive care unit (PICU) and hospital length of stay (LOS). The aim of this study was to determine if modifications to an existing RT-driven HFNC management protocol could further safely decrease length of HFNC and PICU and hospital LOS. Methods: This is a quality improvement project performed at a quaternary academic PICU. This study included patients less than 24 months of age admitted to the PICU with an admission diagnosis of bronchiolitis requiring HFNC. After initial implementation of a (RT)-driven HFNC protocol [Plan-Do-Study-Act (PDSA) 1] in October 2017, additional interventions included adjusting HFNC wean rate (PDSA 2) in July 2020, a HFNC holiday (PDSA 3), and standardized discharge criteria (PDSA 4) in October 2021. Duration of HFNC was used as the primary outcome measure and PICU LOS and hospital LOS were used as secondary outcome measures. Noninvasive ventilation use, invasive mechanical ventilation use and 7-day PICU and hospital readmission rates were used as balancing measures. Results: A total of 1,310 patients were included. Patients in PDSA 2, PDSA 3&4 groups were older compared to pre-intervention and PDSA 1 (median of 9 and 10 months compared to 8 months, p=0.01). HFNC duration decreased from 2.5 to 1.8 days after PDSA 1, then to 1.3 days after PDSA 2. PICU LOS decreased from 2.6 to 2.1 days after PDSA 1, 1.8 days after PDSA 2 and 1.5 days after PDSA 3&4. Hospital LOS decreased from 5.7 days to 4.5 days after PDSA 1, 3.1 days after PDSA 2 and 2.7 days after PDSA 3&4. The use of non-invasive ventilation and invasive mechanical ventilation decreased throughout the study from 23.2% in the pre-intervention group, to 6.9% at end of the project. The 7-day PICU and hospital readmission rates did not increase. The percentage of patients discharged from the PICU increased from 6.2% to 21.5%. Conclusions: Modifications to an existing RT-driven HFNC protocol and standardized discharge criteria led to an improvement in bronchiolitis patients’ outcomes without an increase in adverse events.

Does High Flow Nasal Cannula avoid intubation and improve the mortality of adult patients in acute respiratory failure in the intensive care setting, when compared to others methods as Conventional Oxygen Therapy or Non-Invasive Ventilation? A narrative review

High-flow oxygen therapy via nasal cannula (HFNC) has been used for many years to oxygenate patients in respiratory failure. However, scientific data in literature are divergent about its value to prevent invasive mechanical ventilation and mortality. The use of HFNC has increased following the COVID-19 pandemic. Our review considers the impact of HFNC on intubation rates and mortality compared with conventional oxygen therapy (COT) and noninvasive ventilation (NIV). HFNC would decrease the use of invasive mechanical ventilation compared to COT and would be equivalent to NIV. Combination of NIV and HFNC would have a benefit compared to NIV alone. Some etiologies of respiratory failure would benefit more from this technique as post-extubation critical ill patient or COVID-19 pneumonia. HFNC seems to reduce mortality in COVID-19 patients compared to NIV.

Early Prediction of High-Flow Oxygen Therapy Failure in COVID-19 Acute Hypoxemic Respiratory Failure: A Retrospective Study of Scores and Thresholds.

Background High-flow oxygen therapy (HFOT) has been widely used as an effective alternative to invasive mechanical ventilation (IMV) in some critically ill patients with COVID-19pneumonia. This study aimed to compare different tools, including the respiratory rate and oxygenation (ROX) index, to predict HFOT failure in this setting. Methodology This single-center retrospective observational study was conducted from September to December 2020 and assessed COVID-19 patients who required HFOT as the first treatment at admission; HFOT failure was defined as IMV use. Prognostic scoring tools were as follows: the Sequential Organ Failure Assessment (SOFA), Acute Physiology And Chronic Health Evaluation (APACHE) II, and Simplified Acute Physiology Score (SAPS) III scores; C-reactive protein; lung consolidation percentage on chest CT; mean partial pressure of oxygen in arterial blood (PaO2)/fraction of inspired oxygen (FiO2) ratio; and ROX index and modified ROX index, calculated using PaO2 instead of blood oxygen saturation, within the first 24 hours after admission to theintensive care unit (ICU). These scores were analyzed using a multivariate Cox proportional hazard model; optimal cutoffs were computed using the R system for statistical computing. Results The study enrolled 52 patients, 31 (60%) of whom experienced HFOT failure. The best predictors of HFOT failure measured 24 hours after HFOT initiation were as follows: PaO2/FiO2 (threshold 123.6, sensitivity 87%, specificity 81%, hazard ratio [HR] 7.76, and 95% confidence interval [CI] 2.39-17.1); ROX index (threshold 5.63, sensitivity 68%, specificity 95%, HR 6.18, and 95% CI2.54-13.4); and modified ROX index (threshold 4.94, sensitivity 81%, specificity 90%, HR 8.16, and 95% CI3.16-21.5) (P < 0.001 for all). Conclusions Early assessment of the ROX index, modified ROX index, and PaO2/FiO2ratio can adequately predict, with high accuracy, HFOT failure in COVID-19 patients. Because thresholds remain debated and are still not sufficiently validated, we advocate using them with caution for clinical decision-making in this context.

Spontaneous pneumomediastinum: a surrogate of P-SILI in critically ill COVID-19 patients

Spontaneous pneumomediastinum (SP) has been described early during the COVID-19 pandemic in large series of patients with severe pneumonia, but most patients were receiving invasive mechanical ventilation (IMV) at the time of SP diagnosis. In this retrospective multicenter observational study, we aimed at describing the prevalence and outcomes of SP during severe COVID-19 with pneumonia before any IMV, to rule out mechanisms induced by IMV in the development of pneumomediastinum.Among 549 patients, 21 patients (4%) developed a SP while receiving non-invasive respiratory support, after a median of 6 days [4–12] from ICU admission. The proportion of patients requiring IMV was similar. However, the time to tracheal intubation was longer in patients with SP (6 days [5–13] vs. 2 days [1–4]; P = 0.00002), with a higher first-line use of non-invasive ventilation (n = 11; 52% vs. n = 150; 28%; P = 0.02). The 21 patients who developed a SP had persisting signs of severe lung disease and respiratory failure with lower ROX index between ICU admission and occurrence of SP (3.94 [3.15–5.55] at admission vs. 3.25 [2.73–4.02] the day preceding SP; P = 0.1), which may underline potential indirect signals of Patient-self inflicted lung injury (P-SILI).In this series of critically ill COVID-19 patients, the prevalence of SP without IMV was not uncommon, affecting 4% of patients. They received more often vasopressors and had a longer ICU length of stay, as compared with their counterparts. One pathophysiological mechanism may potentially be carried out by P-SILI related to a prolonged respiratory failure, as underlined by a delayed use of IMV and the evolution of the ROX index between ICU admission and the day preceding SP.