Liberation from Invasive Mechanical Ventilation with Continued Receipt of Vasopressor Infusions.

Rationale: Weaning protocols for discontinuation of invasive mechanical ventilation often mandate resolution of shock. Whether extubation while receiving vasopressors is associated with harm is uncertain. Objectives: To examine whether extubation while still receiving vasopressors is associated with worse outcomes. Methods: We performed a retrospective cohort study of adults in Calgary ICUs who received vasopressors with invasive mechanical ventilation and an extubation attempt. The primary exposure was continued vasopressor use at extubation. The primary outcome was reintubation within 96 hours. Secondary outcomes included in-hospital mortality and ICU/hospital length of stay (LOS). We assessed associations of vasopressor use at extubation with outcomes using multivariable competing-risk (reintubation/LOS) and Cox proportional-hazards (mortality) models. Measurements and Main Results: Of 6,140 patients who received invasive mechanical ventilation while on vasopressors, 721 (11.7%) were extubated while receiving vasopressors, and 5,419 (88.3%) after discontinuation. Extubation on vasopressors was not, in aggregate, significantly associated with an increased hazard of reintubation (subhazard ratio [SHR], 1.81 [95% confidence interval, 0.91-3.61]; P = 0.09). Both mortality (hazard ratio, 1.22 [1.02-1.47]; P = 0.03) and time to hospital discharge (SHR for remaining hospitalized, 0.78 [0.68-0.91]; P < 0.01) were increased. Extubation on high-dose vasopressors (>0.1 µg/kg/min) was associated with a greater hazard of reintubation (SHR, 2.25 [1.01-4.98]; P = 0.046) compared with extubation after vasopressor discontinuation. Meanwhile, extubation on low-dose vasopressors (⩽0.1 µg/kg/min) was associated with a lower mortality (hazard ratio, 0.69 [0.51-0.91]; P = 0.01) and a shorter ICU LOS (SHR, 1.34 [1.09-1.65]; P = 0.01), but no difference in reintubation or hospital LOS as compared with those weaned off vasopressors. Conclusions: Extubation while receiving high-dose but not low-dose vasopressors was associated with an increased risk of reintubation.

A Trend Analysis of Chronic Obstructive Pulmonary Disease Mortality in the United States by Race and Sex.

Rationale: Chronic respiratory diseases, among which chronic obstructive pulmonary disease (COPD) remains the largest contributor, are the fourth leading cause of death in the United States. Updated mortality trends provide insight for targeted interventions. Objectives: To provide detailed insights into COPD mortality trends. Methods: This study used death certificate data collected from the U.S. Centers for Disease Control WONDER (Wide-Ranging Online Data for Epidemiology Research) system between 2004 and 2018 among Americans 40 years of age and older. We used Joinpoint regression analysis to capture trends in annual age-adjusted COPD mortality rates and of the number of deaths caused by influenza or pneumococcal disease with COPD. To place mortality trends into perspective, we examined influenza and pneumococcal vaccination rates within the same time frame using population survey data. Results: Overall, mortality from COPD decreased, with an annual percentage change (APC) of -0.6% (95% confidence interval [CI], -0.9% to -0.3%) between 2004, at 72.9 deaths per population of 100,000, and 2018, at 67.4 deaths per population of 100,000. COPD mortality in men exceeded that in women; however, mortality in men continued to decline, with an APC of -1.2% (95% CI, -1.5% to -0.9%), unlike mortality in women, whose death rates were overall unchanged. Further stratifying sex by race, we found that African American women were the only sociodemographic group to have had an increase in COPD mortality, with an APC of 1.3% (95% CI, 0.9% to 1.6%). The number of deaths caused by influenza with COPD had increased over time, with an observed APC of 19.58% (95% CI, 6.9% to 33.8%) between 2004 and 2018. Increased influenza mortality paralleled trends of decreased influenza vaccination rates, wherein between 2011 and 2018, there was an APC of -5.1% (95% CI, -8.2% to -2.0%). This trend was also present for those with COPD; 451.4 per 1,000 respondents in 2011 were vaccinated against influenza compared with 352.1 per 1,000 respondents in 2018, resulting in an APC of -1.8% (95% CI, -3.3% to -0.2%). Pneumococcal vaccination rates between 2011 and 2018 remained unchanged; meanwhile, deaths caused by pneumococcal disease with COPD decreased, with an APC of -10.1% (95% CI, -16.6% to -3.1%). Conclusions: COPD mortality has decreased among Americans overall; however, there remain important sociodemographic groups that have not secured the same deceleration in death rates.