Ventilator Liberation Research Articles

Management of sedation during weaning from mechanical ventilation

Purposes of review Critically ill patients frequently require mechanical ventilation and often receive sedation to control pain, reduce anxiety, and facilitate patient-ventilator interactions. Weaning from mechanical ventilation is intertwined with sedation management. In this review, we analyze the current evidence for sedation management during ventilatory weaning, including level of sedation, timing of sedation weaning, analgesic and sedative choices, and sedation management in acute respiratory distress syndrome (ARDS). Recent findings Despite a large body of evidence from the past 20 years regarding the importance of light sedation and paired spontaneous awakening and spontaneous breathing trials (SATs/SBTs) to promote ventilator weaning, recent studies show that implementation of these strategies lag in practice. The recent WEAN SAFE trial highlights the delay between meeting weaning criteria and first weaning attempt, with level of sedation predicting both delays and weaning failure. Recent studies show that targeted interventions around evidence-based practices for sedation weaning improve outcomes, though long-term sustainability remains a challenge. Summary Light or no sedation strategies that prioritize analgesia prior to sedatives along with paired SATs/SBTs promote ventilator liberation. Dexmedetomidine may have a role in weaning for agitated patients. Further investigation is needed into optimal sedation management for patients with ARDS.

Monitoring and modulating respiratory drive in mechanically ventilated patients.

Respiratory drive is frequently deranged in the ICU, being associated with adverse clinical outcomes. Monitoring and modulating respiratory drive to prevent potentially injurious consequences merits attention. This review gives a general overview of the available monitoring tools and interventions to modulate drive. Airway occlusion pressure (P0.1) is an excellent measure of drive and is displayed on ventilators. Respiratory drive can also be estimated based on the electrical activity of respiratory muscles and measures of respiratory effort; however, high respiratory drive might be present in the context of low effort with neuromuscular weakness. Modulating a deranged drive requires a multifaceted intervention, prioritizing treatment of the underlying cause and adjusting ventilator settings for comfort. Additional tools include changes in PEEP, peak inspiratory flow, fraction of inspired oxygen, and sweep gas flow (in patients receiving extracorporeal life-support). Sedatives and opioids have differential effects on drive according to drug category. Monitoring response to any intervention is warranted and modulating drive should not preclude readiness to wean assessment or delay ventilation liberation. Monitoring and modulating respiratory drive are feasible based on physiological principles presented in this review. However, evidence arising from clinical trials will help determine precise thresholds and optimal interventions.

Improving Time to Goals of Care Discussions in Invasively Ventilated Preterm Infants.

The challenge of identifying preterm infants with bronchopulmonary dysplasia (BPD) that need tracheostomy placement may delay goals of care (GOC) discussions. By identifying infants with a low probability of ventilation liberation, timely GOC discussions may reduce the time to tracheostomy. Our SMART aim was to reduce the postmenstrual age (PMA) of GOC discussions by 20% in infants with BPD and prolonged invasive ventilatory requirement by October 2020. Our group conducted a quality improvement initiative at the University of Alabama at Birmingham. Infants were included if born at <32 weeks' gestation and exposed to invasive ventilation for ≥2 weeks beyond 36 weeks' PMA. Interventions included (1) consensus of BPD infants at risk for tracheostomy dependence, (2) monthly multidisciplinary tracheostomy meetings, and (3) development and utilization of tracheostomy educational content for families. Statistical process control charts were used for all analyses. A total of 79 infants were included in analyses, of which 44 infants either received a tracheostomy or died. From X-mR control chart analysis, there was special cause variation in the time to GOC discussions, which decreased from 62 to 51 weeks' PMA related to monthly multidisciplinary conferences. The average PMA at tracheostomy decreased from 80 weeks to 63 weeks with no change in the frequency of tracheostomy placement or discordant GOC discussions in which infants survived to hospital discharge without a tracheostomy. In infants with ventilator-dependent BPD, standardization of GOC discussions reduced the PMA of GOC discussions and tracheostomy.

Extended versus Standard Proning Duration for COVID-19-associated Acute Respiratory Distress Syndrome: A Target Trial Emulation Study.

Rationale: Prone positioning for ⩾16 hours in moderate-to-severe acute respiratory distress syndrome (ARDS) improves survival. However, the optimal duration of proning is unknown. Objectives: To estimate the effect of extended versus standard proning duration on patients with moderate-to-severe coronavirus disease (COVID-19) ARDS. Methods: Data were extracted from a five-hospital electronic medical record registry. Patients who were proned within 72 hours of mechanical ventilation were categorized as receiving extended (⩾24 h) versus standard (16-24 h) proning based on the first proning session length. We used a target trial emulation design to estimate the effect of extended versus standard proning on the primary outcome of 90-day mortality and secondary outcomes of ventilator liberation and intensive care unit (ICU) discharge. Analytically, we used inverse probability of treatment weighted (IPTW) Cox or Fine-Gray regression models. Results: A total of 314 patients were included; 234 received extended proning, and 80 received standard-duration proning. Patients who received extended proning were older, had greater comorbidity, were more often at an academic hospital, and had shorter time from admission to mechanical ventilation. After IPTW, characteristics were well balanced. Unadjusted 90-day mortality in the extended versus standard proning groups was 39% versus 58%. In doubly robust IPTW analyses, we found no significant effects of extended versus standard proning duration on mortality (hazard ratio [95% confidence interval], 0.95 [0.51-1.77]), ventilator liberation (subdistribution hazard, 1.60 [0.97-2.64], or ICU discharge (subdistribution hazard, 1.31 [0.82-2.10]). Conclusions: Using target trial emulation, we found no significant effect of extended versus standard proning duration on mortality, ventilator liberation, or ICU discharge. However, given the imprecision of estimates, further study is justified.

Outcomes of infants and children with bronchopulmonary dysplasia-associated pulmonary hypertension who required home ventilation.

To characterize a cohort of ventilator-dependent infants and children with bronchopulmonary dysplasia-associated pulmonary hypertension (BPD-PH) and to describe their cardiorespiratory outcomes. Subjects with BPD on chronic home ventilation were recruited from outpatient clinics. PH was defined by its presence on ≥1 cardiac catheterization or echocardiogram on or after 36 weeks post-menstrual age. Kaplan-Meier analysis was used to compare the timing of key events. Of the 154 subjects, 93 (60.4%) had PH and of those, 52 (55.9%) required PH-specific medications. The ages at tracheostomy, transition to home ventilator, and hospital discharge were older in those with PH. Most subjects were weaned off oxygen and liberated from the ventilator by 5 years of age, which did not occur later in subjects with PH. The mortality rate after initial discharge was 2.6%. The majority of infants with BPD-PH receiving chronic invasive ventilation at home survived after initial discharge. Subjects with BPD-PH improved over time as evidenced by weaning off oxygen and PH medications, ventilator liberation, and tracheostomy decannulation. While the presence of PH was not associated with later ventilator liberation or decannulation, the use of PH medications may be a marker of a more protracted disease trajectory. There is limited data on long-term outcomes of children with bronchopulmonary dysplasia (BPD) who receive chronic invasive ventilation at home, and no data on those with the comorbidity of pulmonary hypertension (PH). Almost all subjects with BPD-PH who were on chronic invasive ventilation at home survived after their initial hospital discharge. Subjects with BPD-PH improved over time as evidenced by weaning off oxygen, PH medications, liberation from the ventilator, and tracheostomy decannulation. The presence of PH did not result in later ventilator liberation or decannulation; however, the use of outpatient PH medications was associated with later ventilation liberation and decannulation.

Compassionate Ventilator Release in Patients With Neuromuscular Disease: A Two-Case Comparison

Dyspnea, the subjective sensation of breathlessness, is a distressing and potentially traumatic symptom. Dyspnea associated with mechanical ventilation may contribute to intensive care unit (ICU) associated post-traumatic stress disorder and impaired quality of life. Dyspnea is both difficult to alleviate and a cause of significant distress to patients, their loved ones, and care providers People living with neuromuscular disease, such as amyotrophic lateral sclerosis (ALS) or myasthenia gravis (MG), often rely on a ventilator at late stages of illness due to complications of progressive respiratory muscle weakness and paralysis. When unable to wean from the ventilator, conversations turn towards goals of care and release from the ventilator for comfort and end of life (EOL). Patients with and without neuromuscular disease have high risk for dyspnea at EOL upon ventilator liberation. Although limited recommendations have been published specific to patients with ALS, no guidelines currently exist for the terminal liberation from mechanical ventilation in patients experiencing respiratory muscle insufficiency from a neuromuscular disease. Further research on this topic is needed, including creation of a protocol for ventilator release in patients with neuromuscular disease. The following case reports detail the dissimilar EOL experiences of two patients with different forms of neuromuscular disease.

Factors associated with liberation from home mechanical ventilation and tracheostomy decannulation in infants and children with severe bronchopulmonary dysplasia.

To identify factors associated with the timing of ventilator liberation and tracheostomy decannulation among infants with severe bronchopulmonary dysplasia (sBPD) who required chronic outpatient invasive ventilation. Multicenter retrospective study of 154 infants with sBPD on outpatient ventilators. Factors associated with ventilator liberation and decannulation were identified using Cox regression models and multilevel survival models. Ventilation liberation and decannulation occurred at median ages of 27 and 49 months, respectively. Older age at transition to a portable ventilator and at discharge, higher positive end expiratory pressure, and multiple respiratory readmissions were associated with delayed ventilator liberation. Surgical management of gastroesophageal reflux was associated with later decannulation. Ventilator liberation timing was impacted by longer initial admissions and higher ventilator pressure support needs, whereas decannulation timing was associated with more aggressive reflux management. Variation in the timing of events was primarily due to individual-level factors, rather than center-level factors.

Lung Protective Ventilation Adherence and Outcomes for Patients With COVID-19 Acute Respiratory Distress Syndrome Treated in an Intermediate Care Unit Repurposed to ICU Level of Care.

During the COVID-19 pandemic, some centers converted intermediate care units (IMCUs) to COVID-19 ICUs (IMCU/ICUs). In this study, we compared adherence to lung protective ventilation (LPV) and outcomes for patients with COVID-19-related acute respiratory distress syndrome (ARDS) treated in an IMCU/ICU versus preexisting medical ICUs (MICUs). Retrospective observational study using electronic medical record data. Two academic medical centers from March 2020 to September 2020 (period 1) and October 2020 to May 2021 (period 2), which capture the first two COVID-19 surges in this health system. Adults with COVID-19 receiving invasive mechanical ventilation who met ARDS oxygenation criteria (Pao2/Fio2 ≤ 300 mm Hg or Spo2/Fio2 ≤ 315). None. We defined LPV adherence as the percent of the first 48 hours of mechanical ventilation that met a restrictive definition of LPV of, tidal volume/predicted body weight (Vt/PBW) less than or equal to 6.5 mL/kg and plateau pressure (Pplat) less than or equal to 30 cm H2o. In an expanded definition, we added that if Pplat is greater than 30 cm H2o, Vt/PBW had to be less than 6.0 mL/kg. Using the restricted definition, period 1 adherence was lower among 133 IMCU/ICU versus 199 MICU patients (92% [95% CI, 50-100] vs. 100% [86-100], p = 0.05). Period 2 adherence was similar between groups (100% [75-100] vs. 95% CI [65-100], p = 0.68). A similar pattern was observed using the expanded definition. For the full study period, the adjusted hazard of death at 90 days was lower in IMCU/ICU versus MICU patients (hazard ratio [HR] 0.73 [95% CI, 0.55-0.99]), whereas ventilator liberation by day 28 was similar between groups (adjusted subdistribution HR 1.09 [95% CI, 0.85-1.39]). In patients with COVID-19 ARDS treated in an IMCU/ICU, LPV adherence was similar to, and observed survival better than those treated in preexisting MICUs. With adequate resources, protocols, and staffing, IMCUs provide an effective source of additional ICU capacity for patients with acute respiratory failure.

Liberation from Mechanical Ventilation in Critically Ill Patients: Korean Society of Critical Care Medicine Clinical Practice Guidelines.

Successful liberation from mechanical ventilation is one of the most crucial processes in critical care, because it is the first step through which a respiratory failure patient begins to transition out of the intensive care unit, and return to normal life. Therefore, when devising appropriate strategies for removing mechanical ventilation, it is essential to consider scientific and systematic approaches, as well as the individual experiences of healthcare professionals. Recently, numerous studies have investigated methods and tools to identify when mechanically ventilated patients are ready to breathe on their own. The Korean Society of Critical Care Medicine therefore provides these recommendations to clinicians for liberation from the ventilator. Meta-analyses and comprehensive syntheses were used to thoroughly review, compile, and summarize the complete body of relevant evidence. All studies were meticulously assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) method, and the outcomes were presented succinctly as evidence profiles. These evidence syntheses were discussed by a multidisciplinary committee of experts in mechanical ventilation, who then developed and approved the recommendations. Recommendations for nine questions on ventilator liberation about Population, Intervention, Comparator, and Outcome (PICO) are presented in this document. This guideline presents seven conditional recommendations, one expert consensus recommendation, and one conditional deferred recommendation. We developed these clinical guidelines for mechanical ventilation liberation to provide meaningful recommendations. These guidelines reflect the best treatment for patients seeking liberation from mechanical ventilation.

Reducing Airway Occlusion Time Without Losing Accuracy to Predict Successful Mechanical Ventilator Liberation During the Measurement of the Timed Inspiratory Effort Index.

In 2013, a new predictor of successful mechanical ventilation liberation named timed inspiratory effort (TIE) index was devised with the normalization of the maximum inspiratory pressure (obtained within 60 s of unidirectional airway occlusion) with the time at which the value was reached. The aim of this study was to verify whether the presence of a sequence of a certain number of inspiratory effort values between 30-60 s > 1.0 cm H2O/s could predict weaning success in a performance comparable to the TIE index. This was a retrospective observational study using 4 databases of previous studies on the TIE index. All patients receiving mechanical ventilation for ≤ 24 h were eligible. Liberation from mechanical ventilation-extubation decisions was made based on performance with spontaneous breathing trials. P < .05 was considered significant. The performance of the TIE index was evaluated by calculating the area under the receiver operating characteristics (AUROC) curve. From 349 eligible patients, 165 subjects were selected for analysis. The AUROC for the TIE index in the studied sample was 0.92 (95% CI 0.87-0.97, P < .001). A sequence of ≤ 4 inspiratory efforts > 1.0 cm H2O/s was found in 51.5% of the subjects, with successful ventilatory liberation occurring in 95.3%. The highest specificity values belonged to the sequence of ≤ 4 and ≤ 5 inspiratory efforts > 1.0 cm H2O/s; the highest positive predictive value and positive likelihood ratio belonged to the sequence of ≤ 4 inspiratory efforts > 1.0 cm H2O/s. The mean time that could have been spared if the procedure were interrupted after the first sequence of 4 inspiratory efforts > 1.0 cm H2O/s was 23 ± 3 s. The presence of a sequence of ≤ 4 inspiratory efforts > 1.0 cm H2O/s during the TIE index measurement was a reliable predictor of weaning success, which could allow timely interruption of the procedure and entail a substantial reduction in airway occlusion time.

Utilizing Point of Care Ultrasound for Ventilation Liberation: A State-of-the-Art Narrative Review

Mechanical ventilation (MV) is an essential aspect of critical care for patients with acute respiratory failure, but prolonged MV can lead to various complications. Ultrasound (US) is becoming widely available and simple to use, and more people are getting trained to use it. It offers real-time radiation-free assessment of lung aeration, diaphragmatic, and cardiac function. This review explores the role of point-of-care ultrasound (POCUS) in enhancing decision-making and patient care during the weaning and liberation process from MV. Lung US aids in diagnosing lung and pleural pathologies, thereby optimizing ventilator settings and lung recruitment, while diaphragmatic ultrasound provides valuable insights into diaphragmatic atrophy and readiness for extubation. Cardiac function evaluation helps in optimizing hemodynamics that may affect weaning. Despite its advantages, it is crucial to realize that POCUS has limitations, and standardized protocols are still lacking. In conclusion, POCUS holds promise in improving the weaning process and patient care in the context of MV liberation, complementing existing weaning protocols.

AARC Clinical Practice Guideline: Spontaneous Breathing Trials for Liberation From Adult Mechanical Ventilation.

Despite prior publications of clinical practice guidelines related to ventilator liberation, some questions remain unanswered. Many of these questions relate to the details of bedside implementation. We, therefore, formed a guidelines committee of individuals with experience and knowledge of ventilator liberation as well as a medical librarian. Using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, we make the following recommendations: (1) We suggest that calculation of a rapid shallow breathing index is not needed to determine readiness for a spontaneous breathing trial (SBT) (conditional recommendation; moderate certainty); (2) We suggest that SBTs can be conducted with or without pressure support ventilation (conditional recommendation, moderate certainty); (3) We suggest a standardized approach to assessment and, if appropriate, completion of an SBT before noon each day (conditional recommendation, very low certainty); and (4) We suggest that FIO2 should not be increased during an SBT (conditional recommendation, very low certainty). These recommendations are intended to assist bedside clinicians to liberate adult critically ill patients more rapidly from mechanical ventilation.

Implementing the Pediatric Ventilator Liberation Guidelines Using the Most Current Evidence.

Invasive mechanical ventilation is prevalent and associated with considerable morbidity. Pediatric critical care teams must identify the best timing and approach to liberating (extubating) children from this supportive care modality. Unsurprisingly, practice variation varies widely. As a first step to minimizing that variation, the first evidence-based pediatric ventilator liberation guidelines were published in 2023 and included 15 recommendations. Unfortunately, there is often a substantial delay before clinical guidelines reach widespread clinical practice. As such, it is important to consider barriers and facilitators using a systematic approach during implementation planning and design. In this narrative review, we will (1) summarize guideline recommendations, (2) discuss recent evidence and identify practice gaps relating to those recommendations, and (3) hypothesize about potential barriers and facilitators to their implementation in clinical practice.

The Neuromechanics of Inspiratory Muscles in Mechanical Ventilation Liberation Success and Failure.

Assessing the neuromechanical coupling of inspiratory muscles during mechanical ventilation (MV) could reveal the physiological mechanism of MV failure. This study examined the respiratory neuromechanical characteristics between MV liberation success and failure. This is an observational prospective study that included patients during their ventilator liberation process. Assessment of surface electromyography (sEMG) of inspiratory muscles, including the diaphragm and extra-diaphragmatic (scalene, sternocleidomastoid, and parasternal) muscles, was performed 15 minutes after the initiation of spontaneous breathing trials. Neuromechanical efficiency of the diaphragm (NMEDia) and extra-diaphragmatic muscles (NMEExtra) were comparedin patients who were successfully liberated from MV with those who failed MV liberation within 72 hours after extubation. A total of 45 patients were enrolled and 28 were female (67%). The sample median age was 63 (IQR 47, 69) years old. One-third of patients failed MV liberation within 72 hours of their spontaneous breathing trials (SBTs). NMEDia was significantly lower in patients who failed MV liberation with a root mean square of (M 0.27), (IQR 0.21, 0.37) compared with (M 0.371), (IQR 0.3, 0.631) for the success group (p=0.0222). The area under the curve for NMEDia was lower in the failure group (M 0.270), (IQR 0.160, 0.370) and (M 0.485), (IQR 0.280, 0.683) for the success group (p=0.024). However, NMEExtra was not statistically different between the two groups. Reduced NMEDia is a predictor of MV liberation failure. NMEExtra was not a major contributor to MV liberation outcomes. Further studies should assess the performance of inspiratory muscles NME indices to predict MV liberation outcomes.

A New Metric to the Efficiency of the Ventilator Liberation Process.

A New Metric to the Efficiency of the Ventilator Liberation Process.

Spinal cord perfusion pressure correlates with breathing function in patients with acute, cervical traumatic spinal cord injuries: an observational study

ObjectiveThis study aims to determine the relationship between spinal cord perfusion pressure (SCPP) and breathing function in patients with acute cervical traumatic spinal cord injuries.MethodsWe included 8 participants without cervical TSCI plus 13 patients with cervical traumatic spinal cord injuries, American Spinal Injury Association Impairment Scale grades A–C. In the TSCI patients, we monitored intraspinal pressure from the injury site for up to a week and computed the SCPP as mean arterial pressure minus intraspinal pressure. Breathing function was quantified by diaphragmatic electromyography using an EDI (electrical activity of the diaphragm) nasogastric tube as well as by ultrasound of the diaphragm and the intercostal muscles performed when sitting at 20°–30°.ResultsWe analysed 106 ultrasound examinations (total 1370 images/videos) and 198 EDI recordings in the patients with cervical traumatic spinal cord injuries. During quiet breathing, low SCPP (< 60 mmHg) was associated with reduced EDI-peak (measure of inspiratory effort) and EDI-min (measure of the tonic activity of the diaphragm), which increased and then plateaued at SCPP 60–100 mmHg. During quiet and deep breathing, the diaphragmatic thickening fraction (force of diaphragmatic contraction) plotted versus SCPP had an inverted-U relationship, with a peak at SCPP 80–90 mmHg. Diaphragmatic excursion (up and down movement of the diaphragm) during quiet breathing did not correlate with SCPP, but diaphragmatic excursion during deep breathing plotted versus SCPP had an inverse-U relationship with a peak at SCPP 80–90 mmHg. The thickening fraction of the intercostal muscles plotted versus SCPP also had inverted-U relationship, with normal intercostal function at SCPP 80–100 mmHg, but failure of the upper and middle intercostals to contract during inspiration (i.e. abdominal breathing) at SCPP < 80 or > 100 mmHg.ConclusionsAfter acute, cervical traumatic spinal cord injuries, breathing function depends on the SCPP. SCPP 80–90 mmHg correlates with optimum diaphragmatic and intercostal muscle function. Our findings raise the possibility that intervention to maintain SCPP in this range may accelerate ventilator liberation which may reduce stay in the neuro-intensive care unit.

Effect of Target-Driven Sedation Protocol to Ventilator Liberation in Pediatric Intensive Care Unit: Pre- and Postimplementation Single-Center Study

AbstractOversedation of mechanically ventilated children is common in many pediatric intensive care units (PICUs). This practice is driven by the challenges of dealing with children of different ages as they have different behavioral, mental, and emotional statuses. We aimed to evaluate the effect of implementing a target-driven sedation protocol in the PICU on ventilator-free days (VFDs), PICU stays, and hospitalization. A 2-year retrospective cohort study was performed in our PICU between October 1, 2018, and October 1, 2020. All intubated children up to 12 years of age were included. Descriptive analyses and a pre- and postintervention comparison of VFDs and length of stay were used to assess the protocol's effectiveness. A total of 134 patients were studied. There was a significant increase in VFDs in cases with respiratory illness requiring mechanical ventilation after implementing this protocol (19.9 vs. 22.3, respectively, with a p-value of 0.031). Also, there was a trend of reduction in the length of PICU stay (median of 9 vs. 8 days, p = 0.816), post-PICU length of stay (median of 4 vs. 3 days, p = 0.055), and hospitalization duration (median of 16 vs. 13 days, p = 0.062) though not statistically significant. Implementing a target-driven sedation protocol in the PICU significantly affects VFDs in mechanically ventilated respiratory cases. Though inconclusive in our study, implementing such a protocol will influence patients' care and reduce unnecessary sedation uses that will reduce sedation hazards.

2022 Year in Review: Ventilator Liberation.

Mechanical ventilation is ubiquitous in critical care, and duration of ventilator liberation is variable and multifactorial. While ICU survival has increased over the last two decades, positive-pressure ventilation can cause harm to patients. Weaning and discontinuation of ventilatory support is the first step in ventilator liberation. Clinicians have a wealth of evidence-based literature at their disposal; however, more high-quality research is needed to describe outcomes. Additionally, this knowledge must be distilled into evidence-based practice and applied at the bedside. A proliferation of research on the subject of ventilator liberation has been published in the last 12 months. Whereas some authors have reconsidered the value of applying the rapid shallow breathing index in weaning protocols, others have begun to investigate new indices to predict liberation outcomes. New tools such as diaphragmatic ultrasonography have begun to appear in the literature as a tool for outcome prediction. A number of systematic reviews with both meta-analysis and network meta-analysis that synthesize the literature on ventilator liberation have also been published in the last year. This review describes changes in performance, monitoring of spontaneous breathing trials, and evaluations of successful ventilator liberation.

Predictors and Impact of Pneumonia on Adverse Outcomes in Inhalation Injury Patients.

Inhalation injury (II) is the third mortality prognostic factor for burn injury following age and burn size. II can lead to pulmonary complications such as pneumonia and acute respiratory distress syndrome (ARDS); all of which have been hypothesized to increase morbidity and mortality in II. Herein, we aimed to identify variables associated with the risk of developing pneumonia and to determine the impact of pneumonia on selected II outcomes. De-identified data from the Prospective Inhalation Study (ISIS) were used. II was confirmed by fiberoptic bronchoscopy. Demographics, injury, and hospital course information were recorded. P <0.05 was considered significant. One hundred subjects were included. On univariate analysis, pneumonia was associated with burn severity, race, and receipt of colloid during the first 24h. Patients who developed pneumonia spent more time on a ventilator, had longer hospitalizations (LOS) and were more likely to need a tracheostomy. On multivariate analysis, total number of ventilator days was associated with pneumonia (OR = 1.122 [1.048-1.200], p = 0.001). Both pneumonia and receipt of colloid were predictive of increased ventilator days (OR = 2.545 [1.363-4.753], p < 0.001 and OR = 2.809 [1.548-5.098], p < 0.001, respectively). Pneumonia was not an independent predictor of LOS, ARDS, or mortality. Pneumonia remains a high-risk complication associated with two times more ventilator days in II. Future research should focus on prevention of pneumonia and the relationship between colloid fluids and pneumonia and early ventilator liberation in II patients.

Fibrotic-Like Pulmonary Radiographic Patterns Are Not Associated With Adverse Outcomes in COVID-19 Chronic Critical Illness.

Pulmonary fibrosis is a feared complication of COVID-19. To characterize the risks and outcomes associated with fibrotic-like radiographic abnormalities in patients with COVID-19-related acute respiratory distress syndrome (ARDS) and chronic critical illness. Single-center prospective cohort study. We examined chest CT scans performed between ICU discharge and 30 days after hospital discharge using established methods to quantify nonfibrotic and fibrotic-like patterns. Adults hospitalized with COVID-19-related ARDS and chronic critical illness (> 21 d of mechanical ventilation, tracheostomy, and survival to ICU discharge) between March 2020 and May 2020. None. We tested associations of fibrotic-like patterns with clinical characteristics and biomarkers, and with time to mechanical ventilator liberation and 6-month survival, controlling for demographics, comorbidities, and COVID-19 therapies. A total of 141 of 616 adults (23%) with COVID-19-related ARDS developed chronic critical illness, and 64 of 141 (46%) had a chest CT a median (interquartile range) 66 days (42-82 d) after intubation. Fifty-five percent had fibrotic-like patterns characterized by reticulations and/or traction bronchiectasis. In adjusted analyses, interleukin-6 level on the day of intubation was associated with fibrotic-like patterns (odds ratio, 4.40 per quartile change; 95% CI, 1.90-10.1 per quartile change). Other inflammatory biomarkers, Sequential Organ Failure Assessment score, age, tidal volume, driving pressure, and ventilator days were not. Fibrotic-like patterns were not associated with longer time to mechanical ventilator liberation or worse 6-month survival. Approximately half of adults with COVID-19-associated chronic critical illness have fibrotic-like patterns that are associated with higher interleukin-6 levels at intubation. Fibrotic-like patterns are not associated with longer time to liberation from mechanical ventilation or worse 6-month survival.