Ventilator Management Research Articles

Description of current status of implementation and management of cardiac arrest in China

Variation in the incidence, survival rate and factors associated with survival after cardiac arrest in China is reported. Some studies have tried to fill the knowledge gap regarding the epidemiology of cardiac arrest in China but were unable to identify reasons for the reported differences. Therefore, the purpose of this study was to describe Chinese management of cardiac arrest, particularly from the perspective of compression, ventilation, monitoring, treatment, and extracorporeal cardiopulmonary resuscitation. An online questionnaire with 56 questions was designed about demographic characteristics, management of cardiac arrest, compression, ventilation, treatment and medicine, as well as advanced life support and resuscitation skill training. A total of 814 copies of questionnaire were received from 23 provinces, 4 autonomous regions and 4 municipalities of China. Results were combined with official information on population density. Throughout China, hospitals resuscitate according to the guideline, however, there are still differences varies in implement with regard to chest compression, ventilation, medicine, monitoring, as well as advanced life support and resuscitation skills training because of economical and developmental level from different regions. All the startup of chest compression is manual, whereas mechanical compression instruments are increasingly involved in sequential resuscitation. Most of clinicians rotate during resuscitation every five cycles other than the guideline recommends every 2 min or when they are tired. About half of the participants don’t build the advanced airway rather than use bag valve mask to ventilate, and 75% of the rest use mechanical ventilation whether they succeed to ROSC. Most of rescuers choose endotracheal intubation which is consistent with many other clinical trials results. Various compression feedback devices play increasingly significant roles in assessment of ROSC. More and more regional hospitals have access to ECPR and implement TTM, but still lead to various divergences. Thus, more elaborate clinical trials need to be designed to verify and explore every procedure in the CPR life cycle.

Prognostic factors for successful extubation in newborns with congenital diaphragmatic hernia

IntroductionNeonates with congenital diaphragmatic hernia (CDH) have an associated high mortality and morbidity. The European CDH EURO consortium has developed guidelines for initial and perioperative ventilatory management. There are, however, no recommendations on how to wean these patients from the ventilator. Extubation failure is more frequent in this group of patients than in other neonates. The aim of this study was to describe patient characteristics and risk factors for failed extubation and to evaluate predictive factors for successful weaning.MethodsWe performed a retrospective study in a single centre tertiary pediatric intensive care unit in Stockholm, Sweden. CDH-patients (n = 38), aged 0–28 days, with extubation events were identified from 2017 to 2019. Eight patients (21.1%) needed reintubation within 24 h after the first extubation attempt. Patient demographics, surgical repair with patch, oxygenation saturation index (OSI), rapid shallow breathing index (RSBI), ventilatory settings, fluid balance and sedation on the day of extubation were recorded.ResultsPatients in the failed extubation group (FE) had lower birth weight (p < 0.05), surgical patch repair (p < 0.05), longer length of stay in intensive care (p < 0.05), longer time on the ventilator (p < 0.05) and other comorbidities (p < 0.001). Using logistic regression we identified OSI, RSBI and inspiratory pressure (Pinsp) as factors predicting a successful extubation, AUCROC 0.95 (95% CI: 0.87 to 1.00). Patients in the FE-group had significantly more often pulmonary hypertension requiring treatment (p < 0.05), a higher fraction of inspired oxygen (FiO2) (p < 0.05) and hypercapnia (p < 0.001) prior to extubation and an oxygen demand exceeding 40% two hours after extubation (p < 0.05).ConclusionUseful predictors of successful extubation in CDH patients are OSI, RSBI and Pinsp. Low birth weight, patch repair and comorbidity also appear to be important factors. Prospective studies are required to confirm findings in the present study.

Epidemiology, Ventilation Management, and Outcomes in Invasively Ventilated Coronavirus Disease 2019 Patients: An Analysis of Four Observational Studies in Four Countries on Two Continents.

Epidemiology, ventilator management, and outcomes in patients with acute respiratory distress syndrome (ARDS) because of coronavirus disease 2019 (COVID-19) have been described extensively but have never been compared between countries. We performed an individual patient data analysis of four observational studies to compare epidemiology, ventilator management, and outcomes. We used propensity score weighting to control for confounding factors. The analysis included 6,702 patients: 1,500 from Argentina, 844 from Brazil, 975 from the Netherlands, and 3,383 from Spain. There were substantial differences in baseline characteristics between countries. There were small differences in ventilation management. Intensive care unit mortality was higher in Argentina and Brazil compared with the Netherlands and Spain (59.6% and 56.6% versus 32.1% and 34.7%; P <0.001). The median number of days free from ventilation and alive at day 28 was equally low (0 [0-7], 0 [0-18], 1 [0-16], and 0 [0-16] days, respectively; P = 0.03), and the median number of days free from ventilation and alive at day 60 was higher in the Netherlands and Spain (0 [0-37], 0 [0-50], 33 [0-48], and 26 [0-48] days, respectively; P <0.001). Propensity score matching confirmed the outcome differences. Thus, the outcome of COVID-19 ARDS patients in Argentina and Brazil was substantially worse compared with that of patients in the Netherlands and Spain. It is unlikely that this results from differences in case mix or ventilation management.

Management of traumatic brain injury and acute respiratory distress syndrome-What evidence exists? A scoping review.

Up to 20% of patients with traumatic brain injury (TBI) develop acute respiratory distress syndrome (ARDS), which is associated with increased odds of mortality. Guideline-based treatment for ARDS includes "lung protective" ventilation strategies, some of which are in opposition to "brain protective" strategies used for ventilation with patients with TBI. We conducted a scoping review of ventilation management strategies with clinical outcomes among patients with TBI and ARDS. We searched three databases (MEDLINE, Embase, Web of Science) using a systematic search strategy. We included any studies of patients with TBI and ARDS with ventilation strategies including PEEP, oxygenation, prone positioning, recruitment maneuvers, pulmonary vasodilators (e.g., nitric oxide), high frequency oscillatory ventilation (HFOV), and extracorporeal membrane oxygenation (ECMO). All clinical outcomes were included. Extracted data included details about sample (age, gender), study design, inclusion/exclusion criteria, intervention details, and outcomes. The search returned 10,514 articles, 35 of which met final inclusion criteria. Interventions studied included ECMO (n = 13 articles), HFOV (n = 4), PEEP interventions (n = 3), prone positioning (n = 3), vasodilators (n = 4), and other lung recruitment maneuvers (n = 9). No randomized controlled trials were identified; studies were mostly case reports (n = 18/35, 51%) and series (n = 7/35, 20%), with some cohort studies (n = 5/35, 14%) and non-randomized experimental trials (n = 5/35, 14%), all at single institutions. Outcomes included physiologic changes (e.g., change in cerebrodynamics or hemodynamics with intervention) and clinical outcomes such as mortality, complications, or neurologic recovery. Five studies (14%) included pediatric patients. In this scoping review of ventilatory strategies for patients with concurrent TBI and ARDS, we found variation in heterogeneity of study design, interventions, and outcomes. Studies were mostly case report/series and observational studies, seriously limiting our ability to draw conclusions about effectiveness of interventions. Targeted areas of further research are discussed.

Management of mechanical ventilation and weaning in critically ill patients with neuromuscular disorders.

Myasthenia-gravis and Guillain-Barre-syndrome are two of the most common causes of acute and reversible neuromuscular-respiratory-failure(ARNRF), both may worsen respiratory-failure and need for invasive-mechanical-ventilation(IMV) for long-periods due to muscle-weakness. However, approitive IMV-mode for ARNRF patients that better gas-exchange and weaning in ARNRF remain unclear. Critically-ill-patiens with IMV due to ARNRF, who could meet the weaning-criterias (after intubation for more than 7-days; difficult-weaning), between 2013, and 2023 were included in the study. IMV-settings, simultaneous arterial-blood-gas (ABG) analyses, and prognosis were recorded for each patient on relevant days. Sixty-critically-ill-patients with ARNRF who defined as difficult-weaning were included in the study. When different IMV-modes were used in the same patient, simultaneous ABG results were compared for each ventilation-mode. It was determined that the partial-pressure-of-oxygen/fraction of inspired-oxygen-ratios were significantly higher and partial-carbon-dioxide-levels were significantly lower when critically-ill-patients were ventilated with the biphasic-positive-airway-pressure-ventilation(BIPAP) (95% CI: [0.641-1.41]; p<.001; 95% CI: [-1.05-.351]; p<.001, respectively). Length-of-time-until-weaning was significantly shorter in BIPAP-mode for each patient in the study group(95% CI: [0.717-0.188]; p<.001). Moreover, weaning-success was statistically higher in patients with ARNRF were ventilated with BIPAP one-week-before spontenous-breathing-trial (95% CI [1.026-21.65]; p=.046) than with all other IMV-modes. According to our findings, when BIPAP was selected as the IMV-settings, gas exchange was improved,and weaning-success was higher in critically-ill-patients with ARNRF.

Three-Dimensional Electrical Impedance Imaging During Spontaneous Breathing Trials in Patients With Acute Hypoxic Respiratory Failure: A Pilot Study.

The purpose of this work is to evaluate the feasibility of lung imaging using 3D electrical impedance tomography (EIT) during spontaneous breathing trials (SBTs) in patients with acute hypoxic respiratory failure. EIT is a noninvasive, nonionizing, real-time functional imaging technique, suitable for bedside monitoring in critically ill patients. EIT data were collected in 24 mechanically ventilated patients immediately preceding and during a SBT on two rows of 16 electrodes using a simultaneous multicurrent source EIT system for 3D imaging. Dynamic 3D EIT images of conductivity were computed, as well as the EIT-derived rapid shallow breathing index, regional ventilation delay, global inhomogeneity index, and time traces of tidal volumes. 3D reconstructions and derived measures demonstrated inhomogeneity in ventilation distribution within patients. We conclude that 3D EIT images can provide information regarding ventilatory heterogeneity across the lung and may be useful in guiding ventilator management.

Prevalence, management, health-care burden, and 90-day outcomes of prolonged mechanical ventilation in the paediatric intensive care unit (LongVentKids): an international, prospective, cross-sectional cohort study.

The number of children requiring prolonged mechanical ventilation (PMV) has increased with the advancement of medical care. We aimed to estimate the prevalence of PMV worldwide, document demographic and clinical characteristics of children requiring PMV in paediatric intensive care units (PICUs), and to understand variation in clinical practice and health-care burden. This international, multicentre, cross-sectional cohort study screened participating PICUs in 28 countries for children aged >37 postgestational weeks to 17 years who had been receiving mechanical ventilation (MV; invasive or non-invasive) for at least 14 consecutive days. Screening days took place every 90 days for 3 years. Patients were eligible for inclusion in the analysis if they had been receiving MV (invasive or non-invasive) for at least 14 consecutive days by their first day of screening. Eligible patients were followed up on the subsequent screening day 90 days later or at time of hospital discharge, whichever came first. Outcome data were recorded in a validated web-based case report file. The primary outcome was the prevalence of PMV. Secondary outcomes were mortality, duration of MV, tracheostomy, and number of complications. All outcomes were assessed at 90 days post-screening. The study was registered with ClinicalTrials.gov, NCT04112459. Between Sept 4, 2019 and Dec 7, 2022, 14 595 children were screened on four separate screening days in 158 PICUs, and 2773 patients had been receiving MV for at least 14 days and were included in the analysis. The point prevalence of PMV was 25·8% (IQR 24·1-28·5). Median age was 0·4 years (IQR 0·2-5·3) and median weight was 8·1 kg (IQR 4·7-19·1). 625 (24·0%) of 2610 patients had a history of prematurity (<37 weeks gestational age at birth). 90-day outcome data were collected for 2430 patients. 441 (18·2%) of 2430 patients had died within 90 days. 649 (29·8%) of 2176 patients who initiated ventilation support upon hospital admission had a tracheostomy placed after the first 14 days of MV. The median time to tracheostomy placement after MV initiation was 26 days (IQR 18-52). 462 (21·2%) of 2176 patients had at least one failed extubation between MV initiation and their first screening date. 556 (25·6%) of 2174 patients who started MV upon hospital admission required MV for 21 days or less, whereas 1618 (74·4%) patients required MV for 22 days or more; 90-day mortality did not differ between these groups (18·2% vs 20·30%, p=0·288). Complications were recorded for 810 (38·4%) 2109 patients who initiated MV upon hospital admission; of these 539 (67%) had ventilator-associated pneumonia, and 212 (39%) of 539 patients had multiple episodes of ventilator-associated pneumonia. Timing of tracheostomy was variable, and duration of MV was longer than previously reported. The large variability in patients requiring MV and the associated health-care burden and outcomes across PICUs suggest that further investigation of the factors influencing the care of children with MV is warranted. Réseau en Santé Respiratoire du Québec (Respiratory Research Network of Quebec), Fonds de la recherche en santé du Québec, Women and Children Health Research Institute-Clinical/Community Research Integration and Support Program, Réseau mère-enfant de la francophonie. For the French and Spanish translations of the abstract see Supplementary Materials section.

Effect of Early Vs Late Intubation on Outcomes in Critically ill Patients with COVID-19 A Protocolised Approach

Introduction: COVID-19 related ARDS (CARDS) is associated with high mortality. Optimal timing of intubation in these patients is still under research. Early intubation could avoid alternate means of oxygenation like High Frequency Nasal Canula (HFNC) or Non Invasive Ventilation(NIV), which prevents Self Inflicting Lung Injury (SILI) in patients breathing spontaneously. At the same time intubation itself may generate aerosols and delaying of intubation may mean patient could be managed with other means of oxygenation thus preventing Ventilator Induced Lung Injury (VILI). Moreover, the concept of SILI is not supported by scientific data. This study investigated the effect of timing of intubation on 28-day mortality in CARDS patients. Methodology: A retrospective observational study was performed in patients admitted in COVID ICU, between January 1st and August 31st 2021, requiring ventilation. Following data collection patients were categorised into two groups. ‘Delayed ’intubation group consisted of patients receiving Non Re-Breathing Mask (NRBM) /HFNC /NIV initially and got intubated after 24 hrs of ICU admission. The remaining patients who were intubated within 24 hrs comprised the ‘early’ intubation group. The decision for early intubation was made by following the institution protocol for ventilatory management. Results: Among 114 ventilated patients 56 were intubated within 24 hours and 58 were intubated after 24 hours. The 28-day mortality in early and delayed intubation group were 39.7% and 60.3% respectively (p = 0.01). In early intubation group duration of mechanical ventilation (5±1.4), length of ICU stay (7.3±2.1) and hospital stay (9.4±4) were significantly less compared to delayed intubation group (p value &lt;0.05). Conclusion: Decision for intubation is complex and multifactorial which is usually individualized depending on the clinical condition. Early intubation is associated with improved survival rates and reduced duration of mechanical ventilation, length of ICU stay &amp; length of hospital stay in severe CARDS patients.

Initiating Mechanical Ventilation in Critically Ill Patients: Case-based Clinical Review

Abstract Mechanical Ventilation continues to be an integral part of critical care on which patients with respiratory failure often depend on for their survival. Specific criteria that need to be met to justify initiating MV include a patient dependency assessment, a clinical indication as well as the ventilator settings that are most appropriate. Hypoxemic respiratory failure, hypercapnic respiratory failure and the need for airway protection are the common indications to initiate MV. This review uses case-based to discuss the initiation of MV. Some of the clinical use settings include Acute Respiratory Distress Syndrome (ARDS), Pneumonia, Chronic Obstructive Pulmonary Disease (COPD) exacerbations, Trauma with altered mental status. Specific scenarios of patients, clinical management and intervention measures are described for every condition to help with the best approach. The review placed special focus on assessment before intubation, the type of mechanical ventilation to choose-VCV or PCV, and the settings to be used: TVs, RR, PEEP and FiO2. Further, it highlights the topic of focussed monitoring, common ventilator problems, and the Weaning phase from MV. The review outlines certain well-documented antecedent knowledge failures of young medicos and also intensivists that need to be corrected in their curriculums for enhancing their ventilator management competencies. Knowledge of MV initiation, strict supervision, and preparation for the cessation of MV is important in order to enhance the results of the patients within the Intensive Care Unit. It is mandatory and more important to see clinical signs like bilateral symmetric chest expansion than looking at the values on the ventilator alone. The presented case-based examples provide practical translation of theoretical information into the clinical practice and enhance the development of the clinical decision-making in the framework of critical care medicine. We definitely need a curriculum integration to decrease the phobia among the new entrants to the intensive care unit whether its medical or paramedical personnel.

Treatment of pneumothorax and bronchopleural fistula by extracorporeal membrane oxygenation in a neonate: a case report

Intractable pneumothorax secondary to bronchopulmonary fistula is a rare complication in neonates. We present the first report of a newborn with spontaneous pneumothorax and bronchopleural fistula treated with extracorporeal membrane oxygenation (ECMO). Positive pressure mechanical ventilation resulted in persistent air leakage from the bronchopleural fistula. When ECMO was initiated, a “total lung rest” ventilation strategy was used to facilitate the healing of bronchopleural fistula and the absorption of the pneumothorax. ECMO is an effective supportive therapy for neonate pneumothorax and bronchopulmonary fistula when conventional ventilation management fails.

Associations of intraoperative end-tidal CO2 levels with postoperative outcome-secondary analysis of a worldwide observational study.

Patients receiving intraoperative ventilation during general anesthesia often have low end-tidal CO2 (etCO2). We examined the association of intraoperative etCO2 levels with the occurrence of postoperative pulmonary complications (PPCs) in a conveniently-sized international, prospective study named 'Local ASsessment of Ventilatory management during General Anesthesia for Surgery' (LAS VEGAS). Patients at high risk of PPCs were categorized as 'low etCO2' or 'normal to high etCO2' patients, using a cut-off of 35mmHg. The primary endpoint was a composite of previously defined PPCs; the individual PPCs served as secondary endpoints. The need for unplanned oxygen was defined as mild PPCs and severe PPCs included pneumonia, respiratory failure, acute respiratory distress syndrome, barotrauma, and new invasive ventilation. We performed propensity score matching and LOESS regression to evaluate the relationship between the lowest etCO2 and PPCs. The analysis included 1843 (74%) 'low etCO2' patients and 648 (26%) 'normal to high etCO2' patients. There was no difference in the occurrence of PPCs between 'low etCO2' and 'normal to high etCO2' patients (20% vs. 19%; RR 1.00 [95%-confidence interval 0.94 to 1.06]; P=0.84). The proportion of severe PPCs among total occurring PPCs, were higher in 'low etCO2' patients compared to 'normal to high etCO2' patients (35% vs. 18%; RR 1.16 [1.08 to 1.25]; P<0.001). Propensity score matching did not change these findings. LOESS plot showed an inverse relationship of intraoperative etCO2 levels with the occurrence of PPCs. In this cohort of patients at high risk of PPCs, the overall occurrence of PPCs was not different between 'low etCO2' patients and 'normal to high etCO2' patients, but severe PPCs occurred more often in 'low etCO2', with an inverse dose-dependent relationship between intraoperative etCO2 levels and PPCs. This analysis was performed without additional funding. LAS VEGAS was partially funded and endorsed by the European Society of Anesthesiology and Intensive Care (ESAIC) and the Amsterdam University Medical Centers, location 'AMC'. LAS VEGAS was registered at Clinicaltrials.gov (NCT01601223), first posted on May 17, 2012.

ECMO-weaning facilitated by neurally adjusted ventilatory assist (NAVA): a case for principal clarification.

The use of veno-venous extracorporeal membrane oxygenation (VV-ECMO) has become increasingly prevalent, particularly in respiratory disease pandemics such as H1N1-influenza and SARS-CoV-2. This surge has emphasized the importance of clear therapy recommendations, improved accessibility to ECMO technology, established ECMO teams, and structured networks to ensure access to specialized care throughout the course of the disease for patients with severe ARDS. Although the initiation criteria for VV-ECMO are well defined, treatment strategies while on ECMO regarding e.g., ventilator management or ECMO weaning strategies remain variable and with lack of consensus. NAVA (Neurally Adjusted Ventilatory Assist), as an assisted mechanical ventilation modality, offers real-time electromyographic feedback, which has been shown to enhance prolonged weaning processes from mechanical ventilation. We present a case of penetrating thoracic trauma complicated by ARDS, successfully managed with VV-ECMO. NAVA was employed to monitor and facilitate ECMO. This approach integrates ECMO weaning with ventilation settings, considering both gas exchange lung function, such as carbon dioxide removal, and respiratory mechanics in the form of neuromuscular coupling. This is a new approach to VV-ECMO weaning. More research is planned to validate the efficacy of this method in conjunction with additional parameters, such as diaphragm activity evaluated sonographically in a randomized design. This case underscores the potential of NAVA in VV-ECMO weaning, offering a promising avenue for optimizing patient care and outcomes.

Artificial Intelligence in the Management of Patients with Respiratory Failure Requiring Mechanical Ventilation: A Scoping Review

Background: Mechanical ventilation (MV) is one of the most frequently used organ replacement modalities in the intensive care unit (ICU). Artificial intelligence (AI) presents substantial potential in optimizing mechanical ventilation management. The utility of AI in MV lies in its ability to harness extensive data from electronic monitoring systems, facilitating personalized care tailored to individual patient needs. This scoping review aimed to consolidate and evaluate the existing evidence for the application of AI in managing respiratory failure among patients necessitating MV. Methods: The literature search was conducted in PubMed, Scopus, and the Cochrane Library. Studies investigating the utilization of AI in patients undergoing MV, including observational and randomized controlled trials, were selected. Results: Overall, 152 articles were screened, and 37 were included in the analysis. We categorized the goals of AI in the included studies into the following groups: (1) prediction of requirement in MV; (2) prediction of outcomes in MV; (3) prediction of weaning from MV; (4) prediction of hypoxemia after extubation; (5) prediction models for MV–associated severe acute kidney injury; (6) identification of long-term outcomes after prolonged MV; (7) prediction of survival. Conclusions: AI has been studied in a wide variety of patients with respiratory failure requiring MV. Common applications of AI in MV included the assessment of the performance of ML for mortality prediction in patients with respiratory failure, prediction and identification of the most appropriate time for extubation, detection of patient-ventilator asynchrony, ineffective expiration, and the prediction of the severity of the respiratory failure.

Maximum insulin dose in patients admitted to the intensive care units with severe COVID-19 in the "Cross ICU Searchable Information System" study: A multicenter retrospective cohort study.

This study aimed to determine the maximum daily insulin dose (MDI) and associated factors in critically ill patients with coronavirus disease 2019 (COVID-19) receiving insulin therapy, under ventilator and/or extracorporeal membrane oxygenation (ECMO) management. This cross-sectional analysis used the Cross ICU Searchable Information System data from a Japanese multicenter retrospective observational cohort study of critically ill patients with COVID-19 receiving ventilation and/or ECMO, from February 2020 to March 2022. Maximum daily insulin dose was determined, and factors associated with it and maximum daily insulin dose per body weight were assessed using linear regression analysis. The analysis included 788 patients. Their mean age, glycated hemoglobin level, maximum daily insulin dose, and time from admission to the maximum daily insulin dose were 65.2 ± 13.0 years, 7.0 ± 1.5% (53.0 ± 7.1 mmol/mol), 46.0 ± 43.6 U/day, and 7.3 ± 7.0 days, respectively. Male sex (β = 6.902, P = 0.034), body mass index (β = 1.020, P = 0.001), glycated hemoglobin (β = 12.272, P < 0.001), and having renal failure (β = 20.637, P = 0.003) were independent determinants of maximum daily insulin dose. Age (β = 0.004, P = 0.035), glycated hemoglobin (β = 0.154, P < 0.001), and having renal failure (β = 0.282, P = 0.004) were independent determinants of maximum daily insulin dose per body weight. In patients with COVID-19 on ventilator and/or ECMO management, the maximum daily insulin dose reached after about 1 week of hospitalization was approximately 46.0 U/day. Glycated hemoglobin and renal failure were both associated with the maximum daily insulin dose and maximum daily insulin dose per body weight.

Acute Lung Injury.

Acute lung injury (ALI) is acute pulmonary inflammation with underlying pathology of disruption of the pulmonary vasculature endothelial and alveolar epithelial barriers. ALI is not an uncommon diagnosis and has a myriad of causes including pulmonary infection, (including sepsis), drugs, connective tissue disease, and polytrauma. Patients present clinically with hypoxemia with imaging supportive of bilateral pulmonary findings without pulmonary edema. The imaging findings in ALI mirror pathologic changes, with a transition from an early ("exudative") phase to a later fibroblast-rich ("organizing" or "proliferative") phase to, in some cases, a fibrotic phase. The diagnosis of ALI is separate from, but can clinically overlap in presentation with, acute respiratory distress syndrome and is characterized by diffuse alveolar damage and organizing pneumonia patterns on pathology. Clinical management is most often supportive and can include corticosteroids, mechanical ventilation, and careful fluid management, with the goal of preserving and recovering lung function.

Regional anesthesia in the obese patient

Regional anesthesia in obese patients presents significant challenges due to the high prevalence of comorbidities such as hypertension, diabetes, and obstructive sleep apnea (OSA), which increase the risk of perioperative complications. Additionally, the excess adipose tissue complicates the administration of anesthesia, making it necessary to adjust the technique and dosage of anesthetics to improve safety and surgical outcomes. Obesity, considered a multisystem disease, imposes additional requirements in the management of ventilation, venous access, and effective analgesia.

Effect of Infectious Disease Risk Management on Indoor Environmental Quality in Lecture Rooms: Current Performance and Future Considerations

The global COVID-19 pandemic has resulted in significant and accelerated developments in ventilation practises, where the need to ventilate buildings has been put centre stage. Longer-term ventilation approaches are now more likely to utilise hybrid ventilation strategies to address the challenge of ensuring resilient indoor thermal environments that are carbon neutral while also minimising the risk of long-range airborne infectious spread of viral pathogens. In the short term, there are many existing buildings which may not undergo retrofit for some time, and consequently, risk mitigation strategies have been implemented in these buildings by utilising existing systems. This paper will present an indoor environmental quality evaluation of ten university lecture rooms both before, during and after changes in ventilation management behaviour and systems that were accelerated due to the COVID-19 pandemic. The results indicate a mean reduction in internal carbon dioxide levels of between 46% and 67% when pre-COVID-19 and COVID-19 datasets are compared and between 11% and 62% when pre-COVID-19 and post-COVID-19 datasets are compared. Changes in behaviour and systems have reduced the time spent above thresholds conducive to virus growth by between 8% and 54%, depending on the lecture room. Despite this, a “rebound” can be observed in many rooms, with CO2 levels appearing to be trending toward pre-pandemic levels. This work indicates the effect of behavioural and system changes on ventilation and the potential risk for virus spread. The results indicate a need to retrofit existing lecture rooms with more advanced natural or mechanical systems to ensure consistent indoor environmental quality.

Respiratory muscle strength, pain and pulmonary complications in adult patients following median sternotomy during hospital stay: a longitudinal observational study

BackgroundPulmonary complications influence morbidity, mortality and hospital stay in patients following cardiac surgery. Acute post-operative pain and less than optimal respiratory muscle strength may affect a patient’s ability to take deep breaths, cough and clear secretions, thereby influencing recovery after surgery. To date, few studies described patients’ pain levels, respiratory muscle strength and the presence of pulmonary dysfunction preoperatively and evaluated the effect of a median sternotomy on parameters at hospital discharge. This study investigates this in patients at a private urban hospital in South Africa.MethodsParticipants were consecutively sampled for this longitudinal observational study and assessed at hospital admission and discharge. The visual analogue scale provides information on participants’ pain levels. Respiratory muscle strength (maximal inspiratory pressure and peak inspiratory flow) was assessed with a POWERbreathe KHI device. The presence of pulmonary complications was determined with a chest X-ray radiographic scoring tool. Descriptive and inferential analyses with significance set at p ≤ 0.05 were performed.ResultsThe population consisted of 61 participants [males: n = 47 (77%)], and the majority underwent coronary artery bypass graft surgery (n = 35, 57%) and had a theatre time of 5.84 (± 1.30) h and time on cardiopulmonary bypass 2.01 (IQR1.14) h. Intensive care stay was 5 (IQR 2.75) days with mechanical ventilation time 17.33 (IQR 11.21) h and hospital stay 9 (IQR 7) days. Forty-one (67.2%) participants had weak respiratory muscles at hospital admission. Respiratory muscle strength reduced significantly between hospital admission and discharge: maximal inspiratory pressure: 55 cmH20 vs 30.66 cmH20, p < 0.001, and peak inspiratory flow: 2.70 l/s vs. 1.66 l/s, p < 0.001. Atelectasis (n = 28, 46, 6%) and pleural fluid (n = 26, 43, 3%) were chest X-ray abnormalities at hospital discharge. Chest X-ray scores (Z = − 5.825, p < 0.001) and pain levels (Z = − 5.867, p < 0.001) increased significantly over time. There was a fair, negative correlation between admission maximal inspiratory pressure and chest X-ray scores, which was statistically significant (r = − 0.356, p = 0.004).ConclusionsRespiratory muscle weakness, abnormal chest X-ray findings and persistent pain were noted in study participants. This study highlights the need for continued rehabilitation services to optimise patient outcomes as it relates to ventilation and pain management.

Correlation Between EtCO2 and PCO2 in Patients Undergoing Critical Care Transport

Objectives End-tidal carbon dioxide (EtCO2) monitoring is widely used as a surrogate for the partial pressure of carbon dioxide (PCO2) in critically ill patients receiving manual or mechanical ventilation in prehospital, emergency, and critical care settings. Specific targets for ETCO2 are a key component of Emergency Medical Services (EMS) protocols, especially for specific patient groups such as those with traumatic brain injury. However, the correlation between EtCO2 and venous or arterial PCO2 is uncertain. We aimed to assess the correlation between EtCO2 and PCO2 in intubated patients undergoing critical care transport (CCT), and in specific subgroups of patients. Methods We performed a retrospective review of patients undergoing emergency transport by a multi-state CCT agency. Patients were included if they had an advanced airway and both an EtCO2 and PCO2 reading within 5 min of each other. We obtained data on patient demographics, transport characteristics, medical categories, vital signs, lab values, and specific interventions. We performed univariable and multivariable binary logistic regression to assess the association between delta PCO2 and these characteristics. Results We included 6,459 patients (mean age 58.4 years [SD 18.5], 57.1% male), of which a subset of 551 patients had multiple EtCO2-PCO2 measurements within 5 min. The median (IQR) initial delta PCO2 was 12.9 mmHg (7.1, 21.9). 3,967 (61.4%) patients had a delta PCO2 >10 mmHg and 1,843 (28.5%) had a delta PCO2 >20 mmHg. We identified an independent association between delta PCO2 >10 mmHg and age, male sex, interfacility transport, venous sampling site, respiratory rate, hypotension, hypoxia, and thoracostomy. In patients with multiple blood gas measurements, 76% had delta PCO2 >10 mmHg over the duration of the transport. Conclusions We identified substantial differences between EtCO2 and PCO2 across patients with medical and traumatic conditions undergoing critical care transport. The PCO2 assessment should be strongly considered as part of ventilatory management in patients encountered in emergency and critical care settings.

The characteristics of occult foreign body aspiration and predicting factors in children

ObjectiveTo summarize the clinical characteristics and risk factors of occult foreign body aspiration (FBA) in children, which can help with early diagnosis and timely intervention, potentially preventing further exacerbations. MethodsWe retrospectively analyzed the clinical data of the children with a final diagnosis of FBA by flexible bronchoscopy in our hospital from 2017 to 2023. The patients were divided into occult and typical groups, and two groups were compared. Multivariate binary logistic regression analysis was employed to identify risk factors associated with the occurrence of occult FBA. ResultsAmong 1031 patients, the incidence of occult FBA was 4.3 % (44 cases). Compared to the typical group, children in the occult group had higher odds of ventilator management (P = .006) and longer postoperative hospitalization time (P < .001). Risk factors for predicting occult FBA were identified as age greater than 3 years old [OR: 6. 918; 95%CI (3.150–15.191)], fever [OR: 2.323; 95%CI (1.092–4.939)], inspiratory laryngeal stridor [OR: 6.514; 95%CI (1.863–22.781)], atelectasis [OR: 3.372; 95%CI (1.418–8.020)], and infiltration [OR: 2.749; 95%CI (1.195–6.323)]. ConclusionsUnlike typical FBA, the diagnosis of occult FBA is far more challenging, and occult foreign bodies are linked to a further exacerbation. This study identifies a few risk factors that have the potential to facilitate an early diagnosis of occult FBA in children. Further multicenter studies should be conducted to validate the findings.