Weaning Processes Research Articles

MUltiparametric Score for Ventilation Discontinuation in Intensive Care Patients: A Protocol for an Observational Study.

Mechanical ventilation significantly improves patient survival but is associated with complications, increasing healthcare costs and morbidity. Identifying optimal weaning times is paramount to minimize these risks, yet current methods rely heavily on clinical judgment, lacking specificity. This study introduces a novel multiparametric predictive score, the MUSVIP (MUltiparametric Score for Ventilation discontinuation in Intensive care Patients), aimed at accurately predicting successful extubation. Conducted at Santo Stefano Hospital's ICU, this single-center, observational, prospective cohort study will span over 12 months, enrolling adult patients undergoing invasive mechanical ventilation. The MUSVIP integrates variables measured before and during a spontaneous breathing trial (SBT) to formulate a predictive score. Preliminary analyses suggest an Area Under the Curve (AUC) of 0.815 for the MUSVIP, indicating high predictive capacity. By systematically applying this score, we anticipate identifying patients likely to succeed in weaning earlier, potentially reducing ICU length of stay and associated healthcare costs. This study's findings could significantly influence clinical practices, offering a robust, easy-to-use tool for optimizing weaning processes in ICUs.

Dam–calf contact rearing in Switzerland: Aspects of management and milking

Cow-calf contact (CCC) rearing is becoming an increasingly popular alternative to the common practice of early separation of cow and calf in dairy management. Milkability can be impaired in nursing cows, which contributes to the loss of machine milk yield caused by calf intake, especially in pure dam-calf contact (DCC) systems. The aims of this study were (1) to describe the current status quo of DCC rearing regarding management and milking and (2) to evaluate the effects of DCC (suckling and milking vs. milking alone) and the effects of different types of DCC on milkability parameters, teat condition, and behavior during milking on Swiss DCC farms. By means of 17 telephone interviews with DCC farmers, we collected data on DCC management, housing, separation and weaning processes, milking procedures and techniques, and perceived milkability problems. Subsequently, we collected data on 10 of the interviewed DCC farms (183 cows): 4 DCC farms with a whole-day contact (WDC) system, 3 farms with DCC before milking (CBM), and 3 farms with DCC after milking (CAM). Five farms on which calves had no contact with dams were chosen as reference farms (178 cows). Using a milk flow meter, the occurrence of ejection disorders, bimodality of the milk flow curve, machine milk yield, duration of the decline phase, and duration of prestimulation were measured. The average mouthpiece chamber vacuum during the main milking phase and hind leg activity during milking were measured using a pressure sensor and an accelerometer, respectively. After cluster removal, the teat condition was evaluated, and a stripping milk sample was taken for fat content analysis. The interview results revealed that 8 of the 17 farms surveyed had a WDC system, and 2 farms operated a daytime DCC system. Contact before milking was applied by 3 farms, and 3 farms allowed CAM. On one farm, calves had access to dams 3 times a day. A great diversity in cow-calf management was found. In the on-farm data collection, 20 milkings of a total of 701 milkings examined met the criteria for a clear ejection disorder, with 17 of these observations occurring on WDC farms and none on reference farms. The stripping milk fat content was lower in nursing cows, indicating a lower degree of udder emptying. Machine milk yield was higher in nursing CAM cows than in nursing WDC and CBM cows. Farm types did not differ regarding teat condition, hind leg activity, or the occurrence of bimodal milk flow curves. In conclusion, the large variation in individual management approaches to DCC rearing even within DCC types, such as calf housing or cow breeds, implies caution when interpreting results. Contact after milking may be the system most beneficial for some productivity parameters, but adequate calf supply must be ensured. Higher amounts of milk remaining in the udder after cluster removal indicate that nursing can affect milkability, but future research should consider the effects of udder filling before milking to better interpret the fat content of stripping milk.

Incidence of Weaning Failure in Obese Patients in Intensive Care Unit.

Background The escalating prevalence of obesity worldwide presents unique challenges in critical care management, especially in the context of mechanical ventilation and weaning processes in intensive care units (ICUs). The present study aimed to determine the incidence of weaning failure in obese patients in an ICU. Methods A prospective observational study was carried out to gather data on patients in the ICU of Shifa International Hospital located in Islamabad, Pakistan. The target population consisted of adult patients who were both male and female, ages 18 years and above. These individuals required intubation procedures as well as mechanical ventilation during their hospitalization. The researchers followed these patients prospectively and observed their medical conditions closely to gather data about how obesity might impact critical care interventions and outcomes. Results The sample size was 288 bearing a median age of 61.0 with an interquartile range of 19 years. Older age manifested a significantly higher frequency of failed extubation (p=0.065). Higher body mass index (BMI) was significantly associated with failed extubation among the study population. It was found that a higher significant difference was associated with BMI > 30 kg/m2 (obese) in failed and successful extubation. One-half of the patients with failed extubation and only 16 (5.9%) patients with successful extubation had end-stage renal disease (p<0.001). It was found that patients who underwent failed extubation had notably increased ICU mortality (p=0.108), 28-day mortality (p=0.067), as well as mean ICU (p<0.001) and hospital stay (p=0.007). Conclusion Our study revealed some insightful correlations between obesity, age, comorbidities, length of hospitalization, ICU stay, and mortality rate in terms of weaning failure among the study population.

Physical and respiratory therapy in the critically ill patient with obesity: a narrative review.

Obesity has become increasingly prevalent in the intensive care unit, presenting a significant challenge for healthcare systems and professionals, including rehabilitation teams. Caring for critically ill patients with obesity involves addressing complex issues. Despite the well-established and safe practice of early mobilization during critical illness, in rehabilitation matters, the diverse clinical disturbances and scenarios within the obese patient population necessitate a comprehensive understanding. This includes recognizing the importance of metabolic support, both non-invasive and invasive ventilatory support, and their weaning processes as essential prerequisites. Physiotherapists, working collaboratively with a multidisciplinary team, play a crucial role in ensuring proper assessment and functional rehabilitation in the critical care setting. This review aims to provide critical insights into the key management and rehabilitation principles for obese patients in the intensive care unit.

Comprehensive, Evidence-Based, Consensus Guidelines for Prescription of Opioids for Chronic Non-Cancer Pain from the American Society of Interventional Pain Physicians (ASIPP)

BACKGROUND: Opioid prescribing in the United States is decreasing, however, the opioid epidemic is continuing at an uncontrollable rate. Available data show a significant number of opioid deaths, primarily associated with illicit fentanyl use. It is interesting to also note that the data show no clear correlation between opioid prescribing (either number of prescriptions or morphine milligram equivalent [MME] per capita), opioid hospitalizations, and deaths. Furthermore, the data suggest that the 2016 guidelines from the Centers for Disease Control and Prevention (CDC) have resulted in notable problems including increased hospitalizations and mental health disorders due to the lack of appropriate opioid prescribing as well as inaptly rapid tapering or weaning processes. Consequently, when examined in light of other policies and complications caused by COVID-19, a fourth wave of the opioid epidemic has been emerging. OBJECTIVES: In light of this, we herein seek to provide guidance for the prescription of opioids for the management of chronic non-cancer pain. These clinical practice guidelines are based upon a systematic review of both clinical and epidemiological evidence and have been developed by a panel of multidisciplinary experts assessing the quality of the evidence and the strength of recommendations and offer a clear explanation of logical relationships between various care options and health outcomes. METHODS: The methods utilized included the development of objectives and key questions for the various facets of opioid prescribing practice. Also utilized were employment of trustworthy standards, and appropriate disclosures of conflicts of interest(s). The literature pertaining to opioid use, abuse, effectiveness, and adverse consequences was reviewed. The recommendations were developed after the appropriate review of text and questions by a panel of multidisciplinary subject matter experts, who tabulated comments, incorporated changes, and developed focal responses to questions posed. The multidisciplinary panel finalized 20 guideline recommendations for prescription of opioids for chronic non-cancer pain. Summary of the results showed over 90% agreement for the final 20 recommendations with strong consensus. The consensus guidelines included 4 sections specific to opioid therapy with 1) ten recommendations particular to initial steps of opioid therapy; 2) five recommendations for assessment of effectiveness of opioid therapy; 3) three recommendations regarding monitoring adherence and side effects; and 4) two general, final phase recommendations. LIMITATIONS: There is a continued paucity of literature of long-term opioid therapy addressing chronic non-cancer pain. Further, significant biases exist in the preparation of guidelines, which has led to highly variable rules and regulations across various states. CONCLUSION: These guidelines were developed based upon a comprehensive review of the literature, consensus among expert panelists, and in alignment with patient preferences, and shared decision-making so as to improve the long-term pain relief and function in patients with chronic non-cancer pain. Consequently, it was concluded – and herein recommended – that chronic opioid therapy should be provided in low doses with appropriate adherence monitoring and understanding of adverse events only to those patients with a proven medical necessity, and who exhibit stable improvement in both pain relief and activities of daily function, either independently or in conjunction with other modalities of treatments. KEY WORDS: Chronic pain, persistent pain, non-cancer pain, controlled substances, substance abuse, prescription drug abuse, dependency, opioids, prescription monitoring, drug testing, adherence monitoring, diversion DISCLAIMER: The guidelines presented are based upon the best available evidence, and do not constitute or represent inflexible treatment recommendations. This document is not intended to be regarded and/or used as a “standard of care.”

Overcoming the Challenges of Prolonged Ventilation and Critical Illness Polyneuropathy in Severe ARDS Patients Due to Extensive Viral Pneumonia: A Case Report

ARDS is a life-threatening condition requiring intensive care unit monitoring. We present a 46-year-old male patient with ARDS and its complications, ventilator-associated pneumonia (VAP) and critcal illness polyneuropathy after extensive bilateral viral pneumonia. The objective of this case report is to understand better and manage the complications of ARDS. This study addresses ARDS and its complications, providing a comprehensive clinical understanding. It details a 46-year-old male patient’s case, treatment strategies, complications, weaning processes, and rehabilitation and emphasises the importance of physical therapy. This case report discusses the successful management and weaning of a patient with extensive viral pneumonia complicated with acute respiratory distress syndrome (ARDS), impending organ dysfunction, and critical illness polyneuropathy. The patient had a medical history of diabetes, hypertension, and dyslipidemia. Initial treatment involved oxygen therapy, nebulization, and empirical antiviral for seasonal flu. However, the patient required invasive ventilation with sedation and muscle relaxants following the ARDSNET protocol due to worsening respiratory status and extensive lung infiltrates. Secondary bacterial infections were also identified and treated accordingly. The weaning process was initiated but was complicated by re-intubation and the development of critical illness polyneuropathy. After successful weaning and recovery from ARDS and associated lung infections, physical therapy was provided for polyneuropathy regularly to overcome the manifest weakness all over the body muscles, including respiratory muscle weakness. The case report highlights the successful management of a patient with viral pneumonia, ARDS, and critical illness polyneuropathy, highlighting the importance of comprehensive treatment and physical therapy.

Diagnostic value of an increase in central venous pressure during SBT for prediction of weaning failure in mechanically ventilated patients: A cross-sectional study.

Timely and successful extubation is an essential step forward in clinical practice to minimize complications of mechanical ventilation and unsuccessful weaning processes. Thus, research into predictive factors of weaning outcome to optimize spontaneous breathing trial (SBT) precision before extubation is critical in intensive care practices. In this study, we aimed to investigate the predictive factors of the weaning outcome before and during SBT in mechanically ventilated patients. In this cross-sectional study, 159 mechanically ventilated patients who were eligible for SBT were enrolled. Of these patients, 140 had successful extubation, whereas the remainder failed. Each patient's PaCO2 and PaO2 levels, respiratory rate (RR), SpO2, mean arterial pressure (MAP), heart rate (HR), and central venous pressure (CVP) values at the start of SBT, 3 min later, and at the end of SBT were measured. These values, along with the patients'clinical characteristics, were then investigated to determine if there was any correlation between these variables and the weaning outcome. Our analysis revealed that increase in CVP, independent of hemoglobin (Hb) concentration, PaO2, SpO2, duration of mechanical ventilation (MV), length of intensive care unit (ICU) stay, and SBT process, as well as underlying disease, was positively correlated with extubation/weaning failure. While age, gender, vital signs (MAP, RR, and HR), sequential organ failure assessment (SOFA), and acute physiology and chronic health evaluation (APACHE) scores had no significant correlation with patients'extubation outcomes. According to our findings, integrating CVP assessment into SBT besides routine indices measurement and monitoring can be considered for the prediction of weaning outcome in critically ill mechanically ventilated patients.

Effect of hemoglobin levels on the success of weaning and extubation processes in critical patients with mechanical ventilation: a systematic review

Effect of hemoglobin levels on the success of weaning and extubation processes in critical patients with mechanical ventilation: a systematic review

Challenges and Responsibilities of Critical Care Nurses in the Weaning Process from Mechanical Ventilation for Patients Post-Cardiothoracic Surgery: A Qualitative Study

Background: The responsibilities of critical care nurses for mechanical ventilation (MV) management may differ among countries, particularly in the weaning process. Aim: To identify nurses' perceptions, roles, and challenges regarding the weaning process for patients in intensive care units (ICUs) in Denmark, Egypt, and the Kingdom of Saudi Arabia (KSA). Methods: This study was a qualitative study using a phenomenological-hermeneutic design. Results: Nurses in Egypt and the KSA were more likely to independently adjust ventilator settings. They used body language, facial expressions, and eye contact to communicate with patients. They prepared patients for the weaning process following physicians' orders. They provided routine nursing care with no specific nursing guidelines or protocols for the weaning process. In contrast, the nurses in Denmark checked the ventilator settings frequently, assessed the consistency of secretions, and frequently performed endotracheal suctioning. They used body language, facial expressions, and eye contact, and they used low technology devices (e.g. word or picture charts, alphabet boards and rewritable magnetic boards) and advanced technological devices (e.g. electronic voice output communication aids through a computer) to communicate with their patients. Moreover, the criteria for weaning and the protocol were used to wean patients from MV. Unfortunately, no protocol was applied for patients with long-term MV. Therefore, the weaning of these patients was conducted by consultation between the nurses and physicians. Conclusion: The use of weaning protocols in Danish settings is an excellent example of collaborative teamwork to apply the best practices in MV weaning processes. It is recommended that nurses in Arab countries apply this experience.

Reconceptualizing the Curriculum for Malaysian Advanced Nursing Education: An Outlook on Mechanical Ventilation Weaning Pedagogy.

Although Advanced Nursing Education (ANE) in Malaysia is still in its early stages, the demand for skilled nurses, particularly those who can perform weaning processes from mechanical ventilation (WPMV), is increasing. These nurses, especially in the Cardiothoracic Intensive Care Unit (CICU) need to be equipped with critical thinking skills in order to make decisions on WPMV. However, the Malaysian ANE is still struggling to achieve this. Therefore, this paper is aimed at reconceptualizing the Malaysian ANE with a specific focus on the development of a Mechanical Ventilation Weaning Pedagogy framework. Building upon previous studies, relevant theories, and WPMV best practices outside Malaysia, this study proposed the development of a pedagogy based on four fundamentals: the Fundamental Pattern of Knowing, Curriculum Planning model, an ideal learning content for WPMV skills development, and local experts' opinions. The findings of this study can serve as a reference for stakeholders, nursing education providers, and relevant parties in improving the current ANE.

The use of Kumpfer\u2019s resilience framework in understanding the breastfeeding experience of employed mothers after returning to work: a qualitative study in China

BackgroundThe increasing numbers of women in the workforce is an inevitable trend in China. More and more employed women stop breastfeeding because of working stressors. Many mothers, however, overcome the challenges and insist on breastfeeding after returning to work. Their individual experience of breastfeeding may provide a new insight to promote and support breastfeeding on employed mothers. This study sought to understand mothers’ experience with insisting on breastfeeding after returning to work based on Kumpfer’s Resilience Framework in Chinese context.MethodsThis qualitative study was designed with semi-structured interviews. Purposive sampling and snowball sampling were employed to recruit 13 full-time working mothers with a stable job in the public sector who continued to breastfeed for 1 month or longer after returning to work in Haikou, Hainan Province, China. Interviews were conducted from January to March 2020 to capture participants’ experiences of breastfeed after returning to work. Grounded theory and Kumpfer’s Resilience Framework were used to analyze data via a systematic and iterative process.ResultsEmployed mothers built resilience while continuing to breastfeed after returning to work. The core concept was "dynamic interaction". Other categories were the background and explanation of this phenomenon. For working mothers who continued to breastfeed, resilience involved "dynamic interaction", which started from "experiencing stressors" and "obtaining support", two environmental factors interacted with the individual to "build resilience qualities", which interact with environment led to “behavioral resilience”. And then the ongoing dynamic interaction between behavioral resilience and environment ultimately led to three different "weaning processes", including natural weaning, active weaning, and forced weaning.ConclusionsThis study identified the framework of resilience in mothers who were in the adversity of breastfeeding after returning to work based on Kumpfer’s Resilience Framework. It provided a new insight into the resilience of employed mothers around the world to continue breastfeeding and showed the different culture of breastfeeding on employed mothers.

Extubate Before Venovenous Extracorporeal Membranous Oxygenation Decannulation or Decannulate While Remaining on the Ventilator? The EuroELSO 2019 Weaning Survey.

Extubate Before Venovenous Extracorporeal Membranous Oxygenation Decannulation or Decannulate While Remaining on the Ventilator? The EuroELSO 2019 Weaning Survey.

Reconstructing breastfeeding and weaning practices in the Bronze Age Near East using stable nitrogen isotopes.

ObjectivesBreastfeeding and childhood diet have significant impact on morbidity and mortality within a population, and in the ancient Near East, it is possible to compare bioarchaeological reconstruction of breastfeeding and weaning practices with the scant textual evidence.Materials and MethodsNitrogen stable isotopes (δ15N) are analyzed here for dietary reconstruction in skeletal collections from five Bronze Age (ca. 2,800–1,200 BCE) sites in modern Lebanon and Syria. We employed Bayesian computational modeling on cross‐sectional stable isotope data of collagen samples (n = 176) mainly from previous studies to test whether the bioarchaeological evidence aligns with the textual evidence of breastfeeding and weaning practices in the region, as well as compare the estimated weaning times to the global findings using the WARN (weaning age reconstruction with nitrogen isotope analysis) Bayesian model.ResultsThough the Near East sites in this study had different ecological settings and economic strategies, we found that weaning was introduced to the five sites at 0.5 ± 0.2 years of age and complete weaning occurred around 2.6 ± 0.3 years of age on using the WARN computational model. These weaning processes are within the time suggested by historical texts, though average estimated weaning age on the Mediterranean coast is later than inland sites.DiscussionCompared globally, these Near Eastern populations initiated the weaning process earlier but completed weaning within the global average. Early initial weaning may have created short spacing between pregnancies and a high impact on demographic growth within these agricultural populations, with some variation in subsistence practices accounting for the inland/coastal discrepancies.

Outcomes of mechanical ventilation according to WIND classification in pediatric patients

BackgroundThe outcomes of weaning processes are not well known in pediatric patients, and the International Conference Classification on weaning from mechanical ventilation showed limited application. We evaluate the relationship between the new Weaning according to a New Definition (WIND) classification and outcome in pediatric patients.MethodsWe conducted a retrospective cohort study in a tertiary pediatric intensive care unit (ICU). We included patients under 18 years of age who received invasive mechanical ventilation for more than 24 h and excluded cases with other than the first ICU admissions, tracheostomy with home ventilation before admission, intubation or weaning processes conducted in other ICU, and weaning with extracorporeal membrane oxygenation. Weaning processes were classified into four groups according to weaning duration after the first separation attempt (SA): no-SA, short weaning (< 24 h), difficult weaning (24 h–7 days), and prolonged weaning (> 7 days). Mortality rates were compared across groups using the Kruskal–Wallis test, and risk factors for the no-SA group were analyzed by multivariate logistic regression tests with age, sex, severity score at admission, admission type, and underlying disease as variables.ResultsAmong 313 patients, 224 were enrolled and had a median age of 2.1 (interquartile range 0.5–6.6) years. Spontaneous breathing tests were done in 70.1% of enrolled patients. The median duration of intubation to the first SA was 4 (range 0–36) days, and 92.8% patients underwent the first SA within 14 days. The mortality rate was 0% in the short (0/99) and difficult (0/53) weaning groups and 17.9% (5/28) in the prolonged weaning group (p < 0.001). The mortality rate of the no-SA group was 93.2% (41/44). Admission severity (hazard ratio 1.036, confidence interval 1.022–1.050) and underlying oncologic disease (hazard ratio 7.341, confidence interval 3.008–17.916) were independent risk factors for lack of SA.ConclusionsIn conclusion, WIND classification is associated with ICU mortality in pediatric patients. Further studies of this association are required to improve protocols associated with the weaning process and clinical outcomes.Trial registration Retrospectively registered.

Weaning process and subadult diets in a monumental Brazilian shellmound

Studies on settlement patterns suggested that the fisher-hunter-gatherers who constructed the shellmounds (or sambaquis) scattered along the Brazilian Southeastern coast must have experienced considerable population growth by living in rich coastal settings. In this paper we assess, using stable isotopes, the weaning patterns and subadult diets of the sambaqui Jabuticabeira II (1214–830 cal BC to 118–413 cal AD) to test: 1) if weaning strategies are compatible with scenarios of high population density and 2) if there are evidences of dietary sex differences and sex-biased parental investment. Stable isotope data (δ15N, δ13Ccol, and δ13Cap) of 106 samples from 60 individuals (adults and subadults) were analyzed by combining bone cross-sectional and tooth serial-sectioning approaches to simulate a longitudinal study. Various analytical methods were used to describe weaning processes by identifying age-related changes in the diet of juveniles compared to those of adults. The isotopic results show that although exclusive breastfeeding length is variable, the introduction of a supplementary diet occurs around 6 months of age, whereas complete weaning was achieved for most children at approximately 2–3 years of age (more probably ~2.3 years of age). Little variability was observed in weaning and post-weaning diets. Differences between adult males and females suggest sex-biased dietary peculiarities. However, no clear cut difference in parental investment strategies favoring boys could be found. Because a weaning completion age of 2.3 years (and the presumed inter-birth interval that corresponds to) can be associated with slow to moderate growth, our reconstruction of weaning patterns and subadult diets of this sambaqui group partially supports a scenario compatible with high population growth.

Vagal withdrawal and psychological distress during ventilator weaning and the related outcomes

ObjectiveThis study investigated the associations between changes in autonomic nervous system (ANS) function, psychological status during the mechanical ventilation (MV) weaning process, and weaning outcomes. MethodsIn this prospective study, we recruited 67 patients receiving MV for >24h at a medical center in northern Taiwan. Patients' ANS function, represented by heart rate variability (HRV), the rapid shallow breathing index (RSBI), anxiety, fear, and dyspnea, was repeatedly measured 10min before and 30min after undergoing a weaning trial. Forty-nine patients capable of sustaining a 2-h weaning trial were successfully weaned. ResultsCompared with the failed group, the success group showed significantly smaller decreases in high-frequency HRV (HRV-HF) and smaller increases in RSBI (per 10 breaths/min/L), fear, dyspnea, and anxiety in response to the weaning trial (odds ratio [OR]=2.19, 0.81, 0.69, 0.66, and 0.77, respectively; p<0.05). Multivariate analyses revealed that low-frequency HRV before weaning (OR=2.32; 95% confidence interval [CI]=1.13–4.78, p=0.02), changes in HRV-HF (OR=3.33; 95% CI=1.18–9.44, p=0.02), and psychological fear during the weaning process (OR=0.50; 95% CI=0.27–0.92, p=0.03) were three independent factors associated with 2-h T-piece weaning success. ConclusionsANS responses and psychological distress during weaning were associated with T-piece weaning outcomes and may reflect the need for future studies to utilize these factors to guide weaning processes and examine their impact on outcomes.

Factors that impact on the use of mechanical ventilation weaning protocols in critically ill adults and children: a qualitative evidence-synthesis.

Factors that impact on the use of mechanical ventilation weaning protocols in critically ill adults and children: a qualitative evidence-synthesis.

Efficacy of neuromuscular electrical stimulation in patients with COPD followed in intensive care unit.

Serious problems on muscle strength and functional status can be seen in bedridden-patients with chronic obstructive pulmonary diseases (COPD) receiving mechanical ventilation. We aimed to investigate the impact of active extremity mobilization and neuromuscular electrical stimulation (NMES) on weaning processes, discharge from hospital and inflammatory mediators in COPD patients receiving mechanical ventilation. Thirty conscious COPD patients (F/M:15/15) hospitalized in the intensive care unit (ICU) with diagnosis of respiratory failure were enrolled to this study. Patients were randomized into three groups, including 10 patients for each. Active extremity-exercise training and NMES were applied to Group-1, only NMES was applied to Group-2 and active extremity exercise training was applied to Group-3. Muscle strengths, mobilization duration and weaning situation were evaluated. Serum cytokine levels were evaluated. Lower extremity muscle-strength was significantly improved in Group-1 (from 3.00 to 5.00, P = 0.014) and 2 (from 4.00 to 5.00, P = 0.046). Upper extremity muscle strength was also significantly improved in all three groups (from 4.00 to 5.00 for all groups, P = 0.038, P = 0.046 and P = 0.034, respectively). Duration of mobilization and discharge from the ICU were similar among groups. There was a significant decrease in serum interleukin (IL)-6 level in Group-1 and in serum IL-8 level in Group-1 and Group-2 after rehabilitation. This study indicates that pulmonary rehabilitation can prevent loss of muscle strength in ICU. Nevertheless, we consider that further studies with larger populations are needed to examine the impact of NMES and/or active and passive muscle training in bedridden ICU patients who are mechanically ventilated.

Protocolized weaning from mechanical strategy in chronic obstructive pulmonary disease: respiratory therapists versus physician directed-who guides best?

Weaning from mechanical ventilation is a complex process that is essential to start as soon as possible in chronic obstructive pulmonary disease (COPD) to avoid infectious and non-infectious complications during endotracheal intubation (1). Currently, 25% of the weaning processes are named as difficult weaning (1). In this complex scenario, evaluation and impact of non-protocolized versus protocolized weaning methods on the duration of mechanical ventilation and weaning, intensive care unit (ICU) stay, successful weaning and mortality are still unresolved questions.

Nutritional Status Compared with Nutritional History of Preschool Aged Children in Gaza Strip: Cross Sectional Study

Breast Feeding (BF) is critical for sustaining new born and infant health. Complementary Feeding (CF) is the introduction of foods other than breast milk or infant formula into the infants diets where their primary role is to increase dietary diversity, not to reduce breast milk intake. Weaning is the term used to describe the process of cessation of BF after a time period of its successful feeding. The study aims to compare anthropometric nutritional indicators of Preschool Children (PSC) aged 5-6 years in Gaza Strip (GS) with their nutritional history during in fanthood that included: Exclusive Breast feeding (EBF), CF and Weaning Practices (WP). The study design was a cross sectional. The study sample consisted of 571 cases aged 5-6 years old. Data were collected through face to face interviews with the children's mothers. The questionnaire contained issues about anthropometric measures, history of feeding and weaning processes of PSC during early childhood. Anthropometric measures were carried out in order to measure Body Mass Index (BMI) and categorize nutritional indicators of PSC. Descriptive statistics and Chi-square test were used to analyze obtained data. According to the BMI categorization, the prevalence of thinness, stunting and overweight among PSC were 4.2%, 11.9% and 10.3%, respectively. There were no statistical significant relationships between weaning periods and any of these nutritional indicators among PSC. It was also observed that the prevalence of stunting was 39.7% among children that received EBF for six months and more. About sixty percent (58.3%) of thinned children received EBF for less than six months. Moreover, it was recorded that 44.1% of the overweight children received EBF for six months and more. The prevalence of thinness was generally lower among children who received CF after six months. With the exception of milled rice or family food, no statistical significant relations were observed between other types of CF and thinness among PSC. In addition, it was also found that higher percentage of overweight children usually receive CF after four months of age. None of different types of CF were associated with stunting and overweight. The study emphasized that some foods that introduced early to the child had a risk of thinness where most of thin children received CF before six months. Moreover, after six months of child age, CF also was found strongly correlated with EBF.