Weaning Success Rate Research Articles

Weaning Failure in Elderly Patients: A Systematic Review and Meta-Analysis

Background/Objectives: Weaning failure in elderly patients undergoing mechanical ventilation presents a complex clinical challenge due to age-related physiological changes and comorbidities. Understanding the dynamics of this phenomenon through systematic analysis can provide valuable insights for clinical management. This meta-analysis aims to investigate the factors contributing to weaning failure in elderly patients and to assess the efficacy of different strategies in mitigating this challenge. Design: The design of this study is a systematic review and meta-analysis. Methods: A systematic search of electronic databases was conducted to identify relevant studies focusing on weaning failure in elderly patients. Studies reporting outcomes related to mechanical ventilation weaning failure were included. Data extraction, quality assessment, and statistical analysis were performed following established guidelines. Results: A total of 15 studies met the inclusion criteria and were included in the meta-analysis. The average age of participants throughout the studies was 66.24 ± 10.21 years. This suggests that the study population largely consisted of older adults and displayed a moderate range of ages centered around the mean. The rate of weaning failure across these studies was slightly above 31.56%, indicating a significant occurrence of this complication in the patient cohorts. The analysis revealed age-related physiological changes, such as decreased respiratory muscle strength and increased chest wall stiffness, as significant contributors to weaning failure in elderly patients. Comorbidities, including chronic pulmonary diseases and cardiovascular conditions, further exacerbated the challenge. Various interventions, including tailored weaning protocols and respiratory therapies, showed promising results in improving weaning outcomes in this population. Conclusions: Weaning failure in elderly patients undergoing mechanical ventilation is influenced by a combination of age-related physiological changes and comorbidities. Tailored interventions addressing these factors are essential for optimizing weaning success rates in this vulnerable population. Further research is warranted to refine the strategies and enhance outcomes in elderly patients requiring mechanical ventilation.

Factors Associated with Outcomes of Patients with Veno-Venous Extracorporeal Membrane Oxygenation for COVID-19.

Background: The World Health Organization recommends extracorporeal membrane oxygenation (ECMO) as a therapeutic option for the most critical cases of severe coronavirus disease 2019 (COVID-19). However, data on universally agreed-upon risk factors that contribute to ECMO weaning failure and mortality in COVID-19 patients undergoing ECMO are limited. This lack of consensus leads to significant uncertainties in developing effective management strategies for these patients. We aimed to identify the factors associated with early outcomes after ECMO support in patients with COVID-19-induced acute respiratory distress syndrome, specifically the success rate of ECMO weaning and in-hospital mortality. Methods: We reviewed 25 patients with COVID-19 who received ECMO support at a single institution between January 2020 and July 2022. This retrospective data collection and review included clinical characteristics, adjunctive treatments, complications, and early patient outcomes. Results: A total of 72% of the patients were successfully weaned off ECMO, and 68% were discharged alive. Significant associations were observed between ECMO weaning success and in-hospital survival, particularly younger age and a history of rehabilitation therapy. Furthermore, the absence of a history of immunosuppressive therapy contributed significantly to successful ECMO weaning. Conclusions: Younger age and the implementation of rehabilitation therapy are associated with improved outcomes in patients with COVID-19 receiving ECMO support.

Research progress in pulmonary rehabilitation in patients who have been weaned off mechanical ventilation: A review article.

Patients who have been treated with mechanical ventilation for more than 72 hours are susceptible to symptoms such as hypoxia and respiratory muscle fatigue after weaning, which may result in weaning difficulty and delay, as well as an increased incidence of negative emotions such as anxiety and depression. Correct pulmonary rehabilitation exercise technique and timing can improve the weaning success rate, reduce the disability rate, and reduce the incidence of pulmonary infection, as well as reduce medical expenses. This article provides a review of pulmonary rehabilitation interventions for mechanically ventilated patients, searching relevant literature through databases such as CNKI and PubMed, aiming to provide guidance for the successful weaning of mechanically ventilated patients. We selected articles related to pulmonary rehabilitation interventions for mechanically ventilated patients from CNKI (China National Knowledge Infrastructure) and PubMed over the years. This article provides a comprehensive review of the research on lung rehabilitation for patients who are mechanically ventilated during the weaning process in an effort to serve as a guide for a successful transition from mechanical ventilation. Early pulmonary rehabilitation training can effectively increase the pulmonary function level and ventilation function of patients and reduce the duration of mechanical ventilation and hospitalization, and is an effective, safe, and feasible treatment method.

Effects of Intermittent Harem Mating on Parturition-induced Stress and Success Rate of Weaning in C57BL/6JNarl Mice.

Improving the effectiveness of mating schemes for large-scale production of mice is an ongoing challenge in animal facilities. Continuous mating, which requires fewer breeding cages than intermittent mating, has traditionally been used to take advantage of postpartum estrus for efficient production. However, the continuous mating scheme lacks flexibility because it cannot immediately accommodate the reduced needs of mice when production levels are high. In this study, we compared reproductive performance, fecal corticosterone metabolite (FCM) level as a stress indicator, and mouse mortality between the continuous trio (CT) and intermittent quad (IQ) mating schemes. The weaning rates in the IQ scheme were higher than those in the CT scheme (98.8% compared with 85.3%). The FCM levels in IQ female breeders were lower during the first 5 d after parturition than those in CT female breeders. The FCM levels in postpartum females housed with 2 adult mice were significantly higher on days 1, 3, and 5 after giving birth than those of females housed alone. This suggests that the presence of cage mates may induce stress responses in postpartum females. Increasing the individual cage area did not reduce the FCM levels of female breeders when accompanied by cage mates after parturition. In addition, the incidence of dystocia and mortality was lower in IQ breeders than in CT breeders. In summary, this breeding trial suggests that compared with the continuous mating scheme, the intermittent mating scheme improves the welfare of postpartum females with normal breeding performance in the C57BL/6JNarl production colony.

Analysis of pediatric heart transplantation supported by extracorporeal membrane oxygenation

Objective: To summarize the clinical characteristics of patients with end-stage heart failure who receive heart transplant under extracorporeal membrane oxygenation (ECMO) support. Methods: The clinical data of 12 pediatric patients who received heart transplant with ECMO support in the Seventh Medical Center of Chinese People's Liberation Army General Hospital and Guangdong Provincial People's Hospital, from January 2019 to December 2023 was collected. The data included sex, age, weight, diagnosis, pre-ECMO lactate level, left ventricular ejection fraction (LVEF), vasoactive-inotropic score (VIS), and preoperative ECMO running time. Surgical data included cold ischemia time of the donor heart, cardiopulmonary bypass time, intraoperative use of immunosuppressant, postoperative use of ECMO, duration of postoperative ECMO, rate of successful weaning from ECMO, and survival discharge rate. The paired t-test was performed to compare cardiac function indices before and after left ventricular decompression. Results: The 12 patients ranged in age from 1.1 to 15.8 years, and weighted from 8 to 63 kg. Ten children were diagnosed with dilated cardiomyopathy, one with myocardial underdensification, and one with a novel heterozygous mutation of the SCN5A gene causing overlap syndrome complicated by fatal arrhythmia. Before ECMO, the lactate ranged from 0.6 to>15.0 mmol/L, the LVEF from 6.5% to 43%, and VIS from 3 to 108. Four patients underwent left ventricular decompression supported by preoperative ECMO, and their pulse pressure was significantly increased after decompression ((17.8±2.1) vs. (9.8±1.5) mmHg, 1 mmHg=0.133 kPa, t=11.31, P=0.001), while there was no apparent change in LVEF ((26.8±4.4)% vs. (24.9±4.9)%, t=1.75, P=0.178). A total of 7 children received a second run of ECMO after surgery and 3 of them successfully weaned off ECMO and survived to discharge. In the entire cohort, 10 were successfully weaned from ECMO and 8 survived to discharge. Conclusions: For children with end-stage heart failure supported by ECMO, left ventricular decompression can significantly improve pulse pressure. These patients will eventually require heart transplantation.

Effect of Early Multiprofessional Mobilization on Quality Indicators of Intensive Care in a Less Economically Developed Country: An Action on “Rehabilitation 2030” in Brazil

ObjectiveTo investigate the effects of implementing early multiprofessional mobilization on quality indicators of intensive care in Brazil. DesignThis is a retrospective cohort study. SettingA Brazilian educational and research-intensive care unit (ICU). ParticipantsA total of 1047 patients were hospitalized from May 2016 to April 2018. InterventionsImplementation of early multiprofessional mobilization using the MobilizAÇÃO Program (MAP). Main Outcome MeasuresClinical, ventilation and safety quality indicators, and physical function before (preprogram period) and after (postprogram period) the MAP. ResultsThere was a reduction in sedation time (4 vs 1d), hospital stay (21 vs 14d) and ICU stay (14 vs 7d), mechanical ventilation (8 vs 4d), hospital death rate (46% vs 26%) (P<.001), and ICU readmission (21% vs 16%; P=.030) from pre to post MAP. Successful weaning (42% vs 55%) and discharge rate (50% vs 71%) (P<.001) increased after MAP. No differences were found to safety quality indicators between periods. After MAP, complex physical functions assessed using the Manchester Mobility Score (MMS) were more frequent. The in-bed intervention was a predictor for readmission (P=.009; R²=0.689) and death (P=.035; R²=0.217), while walking was a predictor for successful weaning (P=.030; R²=0.907) and discharge (P=.033; R²=0.373). The postprogram period was associated with the MMS at ICU discharge (P<.001; R²=0.40). ConclusionsEarly mobilization implementation through changes in low mobility culture and multiprofessional actions improved quality indicators, including clinical, ventilation, and physical functional quality, without compromising patient safety in the ICU.

Emergent coronary revascularization with percutaneous coronary intervention and coronary artery bypass grafting in patients receiving extracorporeal cardiopulmonary resuscitation.

Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a rescue for refractory cardiac arrest, of which acute coronary syndrome is a common cause. Data on the coronary revascularization strategy in patients receiving ECPR remain limited. The ECPR databases from two referral hospitals were screened for patients who underwent emergent revascularization. The baseline characteristics were matched 1:1 using propensity score between patients who underwent coronary artery bypass grafting (CABG) and those who received percutaneous coronary intervention (PCI). Outcomes, including success rate of weaning from extracorporeal membrane oxygenation (ECMO), hospital survival, and midterm survival in hospital survivors, were compared between CABG and PCI. After matching, most of the patients (95%) had triple vessel disease. Compared with PCI (n = 40), emergent CABG (n = 40) had better early outcomes, in terms of the rates of successful ECMO weaning (71.1% vs 48.7%, P = 0.05) and hospital survival (56.4% versus 32.4%, P = 0.04). After a mean follow-up of 2 years, both revascularization strategies were associated with favourable midterm survival among hospital survivors (75.3% after CABG vs 88.9% after PCI, P = 0.49), with a trend towards fewer reinterventions in patients who underwent CABG (P = 0.07). In patients who received ECPR because of triple vessel disease, the hospital outcomes were better after emergent CABG than after PCI. More evidence is required to determine the optimal revascularization strategy for patients who receive ECPR.

Impacts of three inspiratory muscle training programs on inspiratory muscles strength and endurance among intubated and mechanically ventilated patients with difficult weaning: a multicentre randomised controlled trial

BackgroundInspiratory muscle training (IMT) is well-established as a safe option for combating inspiratory muscles weakness in the intensive care setting. It could improve inspiratory muscle strength and decrease weaning duration but a lack of knowledge on the optimal training regimen raise to inconsistent results. We made the hypothesis that an innovative mixed intensity program for both endurance and strength improvement could be more effective. We conducted a multicentre randomised controlled parallel trial comparing the impacts of three IMT protocols (low, high, and mixed intensity) on inspiratory muscle strength and endurance among difficult-to-wean patients.MethodsNinety-two patients were randomly assigned to three groups with different training programs, where each performed an IMT program twice daily, 7 days per week, from inclusion until successful extubation or 30 days. The primary outcome was maximal inspiratory pressure (MIP) increase. Secondary outcomes included peak pressure (Ppk) increase as an endurance marker, mechanical ventilation (MV) duration, ICU length of stay, weaning success defined by a 2-day ventilator-free after extubation, reintubation rate and safety.ResultsMIP increases were 10.8 ± 11.9 cmH2O, 4.5 ± 14.8 cmH2O, and 6.7 ± 14.5 cmH2O for the mixed intensity (MI), low intensity (LI), and high intensity (HI) groups, respectively. There was a non-statistically difference between the MI and LI groups (mean adjusted difference: 6.59, 97.5% CI [− 14.36; 1.18], p = 0.056); there was no difference between the MI and HI groups (mean adjusted difference: − 3.52, 97.5% CI [− 11.57; 4.53], p = 0.321). No significant differences in Ppk increase were observed among the three groups. Weaning success rate observed in MI, HI and LI group were 83.7% [95% CI 69.3; 93.2], 82.6% [95% CI 61.2; 95.0] and 73.9% [95% CI 51.6; 89.8], respectively. MV duration, ICU length of stay and reintubation rate had similar values. Over 629 IMT sessions, six adverse events including four spontaneously reversible bradycardia in LI group were possibly related to the study.ConclusionsAmong difficult-to-wean patients receiving invasive MV, no statistically difference was observed in strength and endurance progression across three different IMT programs. IMT appears to be feasible in usual cares, but some serious adverse events such as bradycardia could motivate further research on the specific impact on cardiac system.Trial registration Clinicaltrials.gov identifier: NCT02855619. Registered 28 September 2014

Treatment time limit for successful weaning from veno-arterial extracorporeal membrane oxygenation in cardiogenic shock.

Knowing the upper time limit for successful weaning from temporary mechanical circulatory support in cardiogenic shock will help with decision-making regarding advanced heart failure (HF) therapy or considering withdrawal of care. The aim of this study was to investigate the association between the support duration and successful weaning from veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in patients with cardiogenic shock. A retrospective single-centre cohort study was conducted between January 2013 and June 2023. It included 100 consecutive patients with cardiogenic shock who were treated with VA-ECMO. Patients with out-of-hospital cardiac arrest were excluded. The primary outcome was successful weaning from VA-ECMO (i.e., VA-ECMO decannulation and survival to discharge). The association between the length of support duration and the weaning success rate was analysed. Patients were divided into three groups according to ECMO support duration: Group A (≤7days), Group B (8-14days), and Group C (≥15days). Multivariable logistic regression analysis was used to evaluate the impact of the length of support duration on successful weaning of VA-ECMO. The median age was 67years, and 73% of study participants were male. The underlying aetiologies of cardiogenic shock were as follows: acute myocardial infarction, 50; fulminant myocarditis, 19; cardiomyopathy, 15; valvular heart disease, 8; and other, 8. Seventy-five patients (75%) were attempted to wean VA-ECMO, and 67 moved on to decannulation. In total, 43 (43%) patients were successfully weaned from VA-ECMO. The median length of ECMO support duration was 8 [3-15] days. Compared with those who underwent successful ECMO decannulation, those who did not had a significantly longer support duration of VA-ECMO (5 [3-9] days vs. 12 [3-22] days, P=0.004). The weaning success rate was significantly higher in patients with short support duration; 58% (29/50), 40% (10/25), 16% (4/25) in Groups A, B, and C, respectively (P=0.002). Overall, none of the patients supported for over 24days (0/11) were successfully weaned from VA-ECMO. On multivariable logistic regression analysis, the length of support duration was independently associated with successful weaning after adjusting for age, sex, underlying aetiology, and left ventricular ejection fraction (odds ratio, 0.813 [per 3days]; 95% confidence interval, 0.679-0.914; P=0.025). Long support duration of VA-ECMO was significantly associated with a low rate of successful weaning in patients with cardiogenic shock. Patients who require VA-ECMO for over 1week should start considering advanced HF therapy or withdrawal of care.

Assessing the efficacy of a graded pulmonary rehabilitation protocol in mechanically ventilated patients following brainstem hemorrhage.

The objective of this study is to assess the impact of an early-graded pulmonary rehabilitation training program on patients undergoing mechanical ventilation due to brainstem hemorrhage. Eighty patients receiving mechanical ventilation due to brainstem hemorrhage at our hospital's neurosurgery department between August 2022 and October 2023 were enrolled as participants. A sampling table was generated based on the order of admission, and 80 random sequences were generated using SPSS software. These sequences were then sorted in ascending order, with the first half designated as the control group and the second half as the intervention group, each comprising 40 cases. The control group received standard nursing care for mechanical ventilation in brainstem hemorrhage cases, while the intervention group underwent early-graded pulmonary rehabilitation training in addition to standard care. This intervention was conducted in collaboration with a multidisciplinary respiratory critical care rehabilitation team. The study compared respiratory function indices, ventilator weaning success rates, ventilator-associated pneumonia incidence, mechanical ventilation duration, and patient discharge duration between the 2 groups. The comparison between patients in the observation group and the control group regarding peak expiratory flow and maximum inspiratory pressure on days 1, 3, 5, and 7 revealed statistically significant differences (P < .05). Additionally, there was a statistically significant interaction between the main effect of intervention and the main effect of time (P < .05). The success rate of ventilator withdrawal was notably higher in the observation group (62.5%) compared to the control group (32.5%), with a statistically significant difference (P < .05). Moreover, the incidence rate of ventilator-associated pneumonia was significantly lower in the observation group (2.5%) compared to the control group (17.5%) (P < .05). Furthermore, both the duration of mechanical ventilation and hospitalization were significantly shorter in the observation group compared to the control group (P < .05). Early-graded pulmonary rehabilitation training demonstrates effectiveness in enhancing respiratory function, augmenting the ventilator withdrawal success rate, and reducing both the duration of mechanical ventilation and hospitalization in mechanically ventilated patients with brainstem hemorrhage. These findings suggest the potential value of promoting the application of this intervention in clinical practice.

The therapeutic effect of levosimendan in patients with prolonged ventilator weaning and cardiac dysfunction.

To explore the therapeutic effect of levosimendan in patients with prolonged ventilator weaning and cardiac dysfunction. Patients with prolonged ventilator weaning and cardiac dysfunction were randomly allocated to receive conventional treatment (control group) or intravenous infusion of levosimendan for 24 h based on conventional treatment (levosimendan group). Weaning success rates were then compared between the two groups. The study was retrospectively registered with Research Registry (ID No. researchregistry10304). A total of 40 patients were included (20 per group). Within 3 days after initiation of treatment, significantly more cases were successfully weaned in the levosimendan group versus control group (eight versus four cases, respectively). Among the eight patients who underwent pulse indicator continuous cardiac output monitoring in the levosimendan group, the global ejection fraction increased 24 h after treatment, and the cardiac function index and cardiac index increased 72 h after treatment. For patients requiring prolonged mechanical ventilation who have concomitant cardiac dysfunction, levosimendan may be considered to increase the probability of weaning success.

Driving Pressure During Mechanical Ventilation of Acute Respiratory Distress Syndrome

Background: Driving pressure has been identified as a more accurate indicator of mortality risk than low tidal volume (VT) and pulmonary compliance (Ppl). It was also noted that when this pressure surpasses the 18 cm H2O mark, there is a significant elevation in the relative risk of death. This study aimed to evaluate the effect of driving pressure guided ventilation in acute respiratory distress syndrome (ARDS). Patients and Methods: The study included 64 subjects selected from the respiratory intensive care unit (RICU) of Al-Azhar University Hospital (Damietta). All participants received management through a protective lung strategy that was informed by driving Pressure. The study outcomes included 1). Determination of weaning categories; 2). Adverse events; 3). Length of ICU stay and duration of mechanical ventilation; 4). Mechanical Ventilation-free days, and 5). Organ/s dysfunction. Results: The commonest cause of admission was pneumonia (36%), and least percentage was septic shock (1.6%). The median ICU stay was 7 days (4 to 25 days) and weaning success rate was 76.6% with mortality rate of 23.4%. The severity was mainly severe (40.6%) and moderate (31.2%). Driving pressure at day 1 of ≤ 21 had sensitivity of 97.96%, specificity of 80.0% and area under curve (AUC) of 0.952. The driving pressure was significantly increased in cases with failure weaning than the success weaning (24.67 ± 1.05 vs 16.86 ± 1.24, respectively). In addition, it was significantly increased in died than alive patients. There was progressive significant increase of driving pressure from mild to moderate to severe cases. Pneumothorax was recorded among 9.4% and pleural effusion was recorded for 7.8% of patients. Conclusion: Use of driving pressure guided ventilation in patients with ARDS improves lung compliance, decreases the duration of mechanical ventilation and the length of ICU stay. Driving pressure &lt; 21 can predict mortality.

Diaphragm ultrasound: A predictor of extubation in head injury patients

Background: Timing is critical when determining if a patient can be successfully extubated. The criteria for obtaining the optimal time for extubation are bare minimum and subject to variability. There are not many studies that are done to use diaphragm function or diaphragm thickness (Tdi) to have any role in extubation outcome as success or failure. Aims and Objectives: The aims and objectives of the study are to apply diaphragmatic ultrasound as a predictor of extubation to reduce morbidity and mortality in these patients. Materials and Methods: This study was conducted as a prospective single-blind study among patients admitted in post-anesthesia care unit and surgical intensive care unit, Department of Anesthesiology at Trauma care Centre during the study period of June 2019–November 2021. The ultrasonographer was informed of the intensivist’s decision to start weaning. Tdi is measured at end expiration and end inspiration. The percent change in Tdi between end expiration and end inspiration (ΔTdi%) was calculated as (Tdi end inspiration–Tdi end expiration/Tdi end expiration) ×100. Results: Mean age was 46.2±15.2 years, ranging from 18 to 66 years. Tdi was above 30 in 64% cases, whereas Tdi% at end of expiration was above 0.17 cm in 62% cases. Weaning was successful in 78% cases whereas weaning failed in 22% cases. Weaning success rate was significantly associated with higher Tdi at end expiration (≥0.17 cm) (P&lt;0.05). Conclusions: Timely weaning off is very important. Delayed weaning may lead to further infection and complications. Diaphragmatic ultrasound plays a vital role in extubating the patient. Ultrasound-guided Tdi and diaphragm motion can be used as a predictor for timely extubation. Diaphragmatic thickness reflects the strength of diaphragm and hence would help us to estimate a successful extubation.

Outcomes of extracorporeal membrane oxygenation treatment post open congenital heart surgery

Objective: ECMO (Extra-Corporeal Membrane Oxygenation) is a technique that temporarily supports heart and lung function by a cardiopulmonary bypass system to treat patients who have failed to respond to the conventional treatments for cardiac or respiratory after congenital heart surgery. The objective of this study is to evaluate the outcomes of ECMO treatment post congenital heart surgery at the National Children's Hospital. Subjects and methods: Descriptive, cross-sectional research method on 64 ECMO patients post open heart surgery from January 1, 2017 until August 30, 2023 at the Department of Surgical Cardiovascular Intensive Care, Cardiovascular Center, National Children's Hospital. Results: Of 64 patients analyzed, the median age of the study group was 1.6 months, 89.1% of patients were children younger than 12 months old; median weight is 3.6 kg. The success rate of ECMO weaning was 56.3%. Overall survival of the cohort was 43.8%. The mean ECMO duration was 5,7 (IQR, 3,7-10,6) days, the mean hospital stay was 32 (IQR, 21,5-50) days, the mean ICU stay was 19,5 (IQR, 13,3-29) days. Mechanical complications during ECMO support include cannula bleeding and circuit thrombus. Acute kidney injury, hypertransaminase, and DIC (disseminated intravascular coagulation) are the most common patient-related complications during ECMO. Conclusion: ECMO is a viable rescue strategy for cardiac surgery patients with ECMO weaning rate and survival rate were 56.3% and 43.8%, respectively, nearly equivalent to other heart centers.

Effects of structured protocolized physical therapy on the duration of mechanical ventilation in patients with prolonged weaning

Purpose20% of patients with mechanical ventilation (MV) have a prolonged, complex weaning process, often experiencing a condition of ICU-acquired weakness (ICUAW), with a severe decrease in muscle function and restricted long-term prognosis. We aimed to analyze a protocolized, systematic approach of physiotherapy in prolonged weaning patients and hypothesized that the duration of weaning from MV would be shortened. MethodsICU patients with prolonged weaning were included before (group 1) and after (group 2) introduction of a quality control measure of a structured and protocolized physiotherapy program. Primary endpoint was the tested dynamometric handgrip strength and the Surgical Intensive Care Unit Optimal Mobilization Score (SOMS). Secondary endpoints were weaning success rate, ventilator-free days, hospital mortality, the prevalence of ICUAW, infections and delirium. Results106 patients were included. Both the SOMS and the handgrip test were significantly improved after introducing the program. Despite no differences in weaning success rates at discharge, the total length of MV was significantly shorter in group 2, which also had lower prevalence of infection and higher probability of survival. ConclusionsProtocolized, systematic physiotherapy resulted in an improvement of the clinical outcome in patients with prolonged weaning. Results were objectifiable with the SOMS and the handgrip test.

Establishment and transfer management of veno-arterial extracorporeal membrane oxygenation in patients with difficult downtime during cardiopulmonary bypass surgery

To investigate the establishment method, coordination points and safe transport management strategy of vena-arterial extracorporeal membrane oxygenation (VA-ECMO) in patients with downtime difficulties during cardiopulmonary bypass (CPB). A observation study was conducted. The patients admitted to the department of critical care medicine of the First Affiliated Hospital of Wannan Medical College (Yijishan Hospital) from January 2020 to October 2022 were enrolled. These patients could not be separated from CPB and received VA-ECMO-assisted CPB surgery. The clinical data of the patients were recorded, including the basic information of the patients, the data of VA-ECMO establishment and transport process, the clinical indicators before and after VA-ECMO installation, the operation data of VA-ECMO and clinical outcomes. The experience was summarized from the aspects of extracorporeal membrane oxygenation (ECMO) establishment, transport process, team cooperation, and adverse events during transport. The clinical indicators before and after ECMO operation were compared. According to whether ECMO was successfully weaned, the patients were divided into a successful weaning group and a failure weaning group, and the clinical data between the two groups were compared. Eighteen patients who underwent VA-ECMO-assisted CPB were enrolled, including 10 males and 8 females. The average age was (56.7±12.3) years old. Preoperative left ventricular ejection fraction (LVEF) was 0.46±0.10, and the main reasons for switching to VA-ECMO assistance included right ventricular systolic weakness in 6 cases, total cardiac systolic weakness in 5 cases, left ventricular systolic weakness in 4 cases, high pulmonary arterial pressure in 2 cases, and intractable ventricular fibrillation in 1 case. Among the 18 patients transferred from CPB to VA-ECMO, 10 cases were successfully weaned and 8 cases failed. In ICU, 8 cases survived, 5 cases died, and 5 cases gave up treatment and discharged. The average time for successful CPB to VA-ECMO establishment was (24.6±7.4) minutes, initial blood flow was (3.3±0.4) L/min, and transit time was (8.4±1.5) minutes. ECMO-assisted duration averaged (82.0±69.3) hours. Adverse events occurred in 9 patients during ECMO establishment and transfer. Post-ECMO onboarding for 4 hours, significant improvements were noted in blood lactic acid (Lac), pH value, mean arterial pressure (MAP), central venous oxygen saturation (ScvO2) as compared with pre-ECMO onboarding [Lac (mmol/L): 10.5±7.0 vs. 15.2±6.8, pH value: 7.38±0.92 vs. 7.26±0.87, MAP (mmHg, 1 mmHg ≈ 0.133 kPa): 74.9±13.7 vs. 58.4±17.0, ScvO2: 0.678±0.065 vs. 0.611±0.061, all P < 0.01], and vasoactive-inotropic score (VIS) was also decreased (39.8±29.8 vs. 68.9±64.4, P < 0.01). Compared with successful weaning group, the patients in the failed weaning group exhibited higher pre-machine Lac (mmol/L: 18.8±7.8 vs. 12.3±4.3, P < 0.05), longer CPB time [minutes: 238.0 (208.8, 351.2) vs. 200.0 (185.8, 217.0), P < 0.05], and shorter ECMO-assisted time [hours: 19.5 (11.0, 58.8) vs. 94.5 (65.8, 179.8), P < 0.01]. However, there was no statistically significant difference in pre-machine pH value, ScvO2, MAP, VIS score, and initial blood flow and establishment time of ECMO between the two groups. VA-ECMO is an effective circulatory aid for CPB surgery that cannot be weaned after CPB. The establishment and transfer of CPB "bridge" to ECMO aid depends on multi-disciplinary treatment (MDT) cooperation. The success rate of ECMO weaning is related to the Lac and CPB duration. If it is not possible to detach from the CPB successfully, VA-ECMO should be initiated as early as possible.

Important step of weaning from mechanical ventilation: accurate assessment of respiratory muscle strength

Mechanical ventilation (MV) is a powerful mean to rescue patients with respiratory failure. In view of the different etiology and basic respiratory function of patients with respiratory failure, weaning failure often occurs. Prolonged MV time is often accompanied by many complications. Thus, deeply understanding the pathophysiological changes of respiratory failure and strengthen monitoring of respiratory mechanics are helpful to optimize MV parameter settings, reduce ventilator-induced lung injury and wean from MV as early as possible. A successful weaning from MV depends on many factors, the most important factors are respiratory muscle strength, respiratory load and respiratory drive. Spontaneous breathing trial (SBT) is an important part of weaning process. The main purpose of implementing SBT is to screen patients and opportunities to weaning from MV, and find reversible reasons for not passing SBT. Because the accuracy of SBT in assessing weaning prognosis is about 85%, it is not adequate for difficult weaning patients. Standardized measurement of weaning indicators for patients with difficulty weaning is conducive to accurate assessment of respiratory muscle strength and improve the success rate of weaning from MV.

Impact of Tracheostomy Timing Within the National Veterans Affairs Population.

There is a lack of a definitive study in the literature comparing early versus late tracheostomy and exploring the impact of tracheostomy timing on patient outcomes. This study may help guide treatment paradigms and contribute to a consensus for optimal tracheostomy timing. A retrospective review was performed comparing early versus late timing of tracheostomy placement and their respective outcomes. The authors used data provided by VA Informatics and Computing Infrastructure (VINCI) to find patients who received a tracheostomy at any VA Medical Center in the United States. There were a total of 25,334 tracheostomies in the database which satisfied our criteria. These occurred between the years 1999 and 2022. Propensity score matching assessed 17,074 tracheostomies, 8537 in either group. The median age of patients in the matched groups was 66 years, and approximately 97.4% of patients were male. Early tracheostomy timing was defined as the placement of the tracheostomy within 10 days of intubation. Outcomes included post-tracheostomy intensive care unit (ICU) days, post-tracheostomy hospital days, successful ventilator weaning, and all-cause mortality. Early tracheostomy was associated with significantly fewer ICU days and hospital days, and the early group experienced higher rates of successful ventilator weaning. Survival analysis of data within 5 years of tracheostomy showed that early tracheostomy was associated with significantly lower hazard for all-cause mortality. Our results add to the body of evidence that an earlier transition to mechanical ventilation by tracheostomy confers benefits in patient morbidity and mortality as well as resource utilization. 3 Laryngoscope, 134:3555-3561, 2024.

Prediction of ventilator weaning failure in postoperative cardiac surgery patients using vasoactive-ventilation-renal score and nomogram analysis.

This study evaluated the predictive value of the vasoactive-ventilation-renal (VVR) score in identifying the risk of weaning failure after cardiac surgery and developing a nomogram model to help physicians improve the success rate of weaning from mechanical ventilation in adult patients undergoing postoperative cardiac surgery. Clinical data were retrospectively collected from adult patients who underwent extracorporeal circulation cardiac surgery at the First Affiliated Hospital of Nanjing Medical University between August 2022 and April 2023 and who were subsequently transferred to the Intensive Care Unit (ICU) and treated with vasoactive drugs. Patients were divided into successful and unsuccessful weaning groups based on first-attempt weaning success. Variable selection was regularized using univariate logistic regression and Least absolute shrinkage and selection operator (LASSO) regularization. Multivariate logistic regression was performed to identify predictors and a nomogram was created to predict the risk of weaning failure. A total of 519 patients were included in the study. After selecting multiple stepwise variables, the VVR score before weaning, the modified Sequential Organ Failure Assessment (mSOFA) score on weaning day, and mechanical ventilation duration before weaning were determined as predictive indicators of weaning failure in adult patients after cardiac surgery. The optimal cut-off values for these indicators were 18.46 points, 4.33 points, and 20.50 h, respectively. The predictive model constructed using these three factors demonstrated good predictive performance. The VVR score before weaning accurately predicts the probability of weaning failure in adult patients after cardiac surgery. The weaning risk-predictive nomogram model, established based on the VVR score, mSOFA score, and mechanical ventilation duration before weaning, demonstrated robust predictive ability.

DCROX and ROX Indices Predict Clinical Outcomes in Patients with COVID-19 Pneumonia Treated with High-Flow Nasal Cannula Oxygen Therapy.

High-flow nasal cannula (HFNC) therapy is a common respiratory support in patients with COVID-19 pneumonia. Predictive tools for the evaluation of successful weaning from HFNC therapy for COVID-19 pneumonia have been limited. This study aimed to develop a new predictor for weaning success from HFNC treatment in patients with COVID-19 pneumonia. We conducted a retrospective cohort study at Thammasat University Hospital, Thailand. Patients with COVID-19 pneumonia requiring HFNC therapy from April 2020 to September 2021 were included. The ROX index was defined as the ratio of oxygen saturation (SpO2)/fraction of inspired oxygen (FiO2) to respiratory rate. The CROX index was defined as the ratio of C-reactive protein (CRP) to the ROX index. dCROX was defined as the difference in CROX index between 24 hours and 72 hours. Weaning success was defined as the ability to sustain spontaneous breathing after separation from HFNC without any invasive or noninvasive ventilatory support for ≥48 hours or death. A total of 106 patients (49.1% male) were included. The mean age was 62.1 ± 16.2 years. Baseline SpO2/FiO2 was 276.1 ± 124.8. The rate of HFNC weaning success within 14 days was 61.3%. The best cutoff value of the dCROX index to predict HFNC weaning success was 3.15 with 66.2% sensitivity, 70.7% specificity, and an area under the ROC curve (AUC) of 0.71 (95% CI: 0.59-0.81, p < 0.001). The best cutoff value of the ROX index was 9.13, with 75.4% sensitivity, 78.0% specificity, and an AUC of 0.79 (95% CI: 0.69-0.88, p < 0.001). ROX index has the highest accuracy for predicting successful weaning from HFNC in patients with COVID-19 pneumonia. dCROX index is the alternative tool for this setting. However, a larger prospective cohort study is needed to verify these indices for determining separation from HFNC therapy. This trial is registered with TCTR20221107004.