Hospital cohort study on survival predictors for intubated coronavirus disease 2019 patients.

OBJECTIVE: The objective of this study was to assess the predictors of survival among patients with coronavirus disease 2019 who underwent tracheal intubation, as part of a hospital cohort study. METHODS: This retrospective cohort study in the Rio do Sul County Hospital, Santa Catarina, Brazil, from April 2020 to May 2021, focused on patients aged 18 years or older intubated for coronavirus disease 2019. We assessed the 90-day survival of intubated patients by estimating the hazard ratio using a Cox proportional hazards regression model. RESULTS: The study included 132 participants, with an average age of approximately 60 years. Tracheal intubation was successfully accomplished in 97% of cases within two attempts. The overall mortality rate was 62.9%. Notably, mortality rates were significantly higher in patients aged over 60 years (hazard ratio=2.57; 95%CI 1.54-4.29; p<0.001), those with blood oxygen saturation below 85% (hazard ratio=1.92; 95%CI 1.03-3.57; p=0.04), instances where tracheal intubation was carried out using a conventional laryngoscope (hazard ratio=2.59; 95%CI 1.22-5.48; p=0.013), and when performed by emergency physicians (hazard ratio=3.96; 95%CI 1.51-10.4; p=0.005). CONCLUSION: Our analysis unveiled that the risk of death in intubated coronavirus disease 2019 patients is four times higher when an emergency physician, as opposed to an anesthesiologist, leads the tracheal intubation team.

Atención integral por cuidados paliativos para pacientes con ventilación mecánica asistida SARS-CoV-2 severos y sus beneficios / Comprehensive care for palliative care for patients with severe SARS-CoV-2 assisted mechanical ventilation and its benefits

Resumen Objetivo. Esta investigación tiene como objetivo describir la población atendida y los beneficios del programa "Lineamiento de atención integral por Cuidados Paliativos en el Área de Salud de Palmares, para pacientes con SARS-CoV-2 severo" con ventilación mecánica asistida, hospitalizados en unidades de cuidados intensivos de la Caja Costarricense del Seguro Social durante la pandemia en Costa Rica, del 10 de junio al 31 de octubre del 2021. Métodos. Estudio descriptivo mixto de la población y los beneficios del programa por medio de indicadores cuantitativos obtenidos del informe de aplicación y cualitativos a través de la realización de una encuesta de satisfacción a usuarios en el período de estudio. Resultados. El programa atendió a 13 pacientes, brindó apoyo en manejo del duelo a los familiares de cinco pacientes que ya habían fallecido y a los cuidadores de ocho pacientes hospitalizados, también ofreció 70 consultas médicas en un período promedio de 62 días. La edad promedio de los pacientes fue de 55 años; doce pacientes presentaban algún factor de riesgo, siendo la obesidad y la falta de esquema de vacunación completo (dos dosis) los más frecuentes. Durante la implementación del programa fallecieron cinco pacientes más, obteniendo una tasa de mortalidad del 78%. A los pacientes que sobrevivieron se les atendió en promedio por 135 días. Con el apoyo del equipo, los pacientes lograron la recuperación clínica de las complicaciones respiratorias y funcionales. Lograron independencia total de actividades básicas de la vida diaria y reinserción social en menos de tres meses después del alta hospitalaria. En general, se documentó una percepción positiva del programa en el 100% de los usuarios, con cambios en el nivel de sufrimiento manifestado por las familias y el apoyo en el manejo del duelo. Conclusión. Con la optimización de uso de los recursos ya existentes en la Caja Costarricense del Seguro Social y la participación social, este programa abordó aspectos no atendidos previamente para los pacientes que sufrieron COVID 19 severo, como el manejo del sufrimiento y/o duelo durante la hospitalización y al egreso. Además, el programa colaboró en la recuperación clínica y funcional de los usuarios sobrevivientes y documentó múltiples beneficios percibidos por el paciente, sus familias, la institución y la sociedad, como el abordaje del sufrimiento, la adecuada atención al duelo, la organización de los recursos asistenciales y la pronta recuperación física, emocional y social del paciente sobreviviente.

Abstract Aim. This research aims to describe the population served and the benefits of the program "Guidelines for integral care for patients with severe SARS-CoV-2 by Palliative Care at the Area de Salud de Palmares " to patients with assisted mechanical ventilation, hospitalized in intensive care units of the Caja Costarricense del Seguro Social during the pandemic in Costa Rica, from June 10 to October 31, 2021. Methods. This study is a mixed descriptive investigation that analyzes quantitative indicators from the report on the program's application and qualitative indicators from a satisfaction survey for the users in the study period. Results. The program treated 13 patients, provided grief management support to the relatives of five patients who had already died and to the caregivers of eight hospitalized patients, and offered 70 medical consultations in an average period of 62 days. The average age of the patients was 55 years; twelve patients had some risk factors, and obesity and lack of a complete vaccination schedule (two doses) were the most frequent. During the program implementation, five more patients died, obtaining a mortality rate of 78%. The average treatment day for surviving patients was 135 days. Through the team's support, patients accomplished clinical recovery from respiratory and functional complications. They got independent basics activities of daily living and social reintegration in less tan three months after discharge. A positive perception of the program was documented in 100% of the program's users, with changes in the level of suffering manifested by the families and the support in grief management. Conclusion. With the optimization of the use of existing resources in the the Caja Costarricense del Seguro Social and the social participation, this program addressed aspects not previously attended to patients who suffered severe COVID 19, such as the management of suffering and/or grief during hospitalization and upon discharge. In addition, the program helped in the clinical and functional recovery of the surviving users, and documented multiple benefits perceived by the patient, their families, the institution, and society, such as the approach to suffering, adequate bereavement care, organization of care resources, and early physical, emotional and social recovery of the survivor patient.

Association Between FIASMAs and Reduced Risk of Intubation or Death in Individuals Hospitalized for Severe COVID-19: An Observational Multicenter Study.

Several medications commonly used for a number of medical conditions share a property of functional inhibition of acid sphingomyelinase (ASM), or FIASMA. Preclinical and clinical evidence suggest that the ASM/ceramide system may be central to severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) infection. We examined the potential usefulness of FIASMA use among patients hospitalized for severe coronavirus disease 2019 (COVID-19) in an observational multicenter study conducted at Greater Paris University hospitals. Of 2,846 adult patients hospitalized for severe COVID-19, 277 (9.7%) were taking an FIASMA medication at the time of their hospital admission. The primary end point was a composite of intubation and/or death. We compared this end point between patients taking vs. not taking an FIASMA medication in time-to-event analyses adjusted for sociodemographic characteristics and medical comorbidities. The primary analysis was a Cox regression model with inverse probability weighting (IPW). Over a mean follow-up of 9.2 days (SD = 12.5), the primary end point occurred in 104 patients (37.5%) receiving an FIASMA medication, and 1,060 patients (41.4%) who did not. Despite being significantly and substantially associated with older age and greater medical severity, FIASMA medication use was significantly associated with reduced likelihood of intubation or death in both crude (hazard ratio (HR) = 0.71, 95% confidence interval (CI) = 0.58-0.87, P < 0.001) and primary IPW (HR = 0.58, 95%CI = 0.46-0.72, P < 0.001) analyses. This association remained significant in multiple sensitivity analyses and was not specific to one particular FIASMA class or medication. These results show the potential importance of the ASM/ceramide system in COVID-19 and support the continuation of FIASMA medications in these patients. Double-blind controlled randomized clinical trials of these medications for COVID-19 are needed.

Impact of chronic respiratory diseases on re-intubation rate in critically ill patients: a cohort study.

Chronic respiratory diseases' (CRDs) impact on re-intubation rate remains unclear. We investigated the association between these factors in mechanically ventilated patients. Data were extracted from the freely available online Medical Information Mart for Intensive Care III database. CRDs were defined according to ICD-9 codes. Generalised linear regression and propensity score matching were performed. Of 13,132 patients, 7.9% required re-intubation. Patients with chronic obstructive pulmonary disease (COPD) had higher re-intubation (OR 2.48, 95% CI 1.83-3.33) and mortality rates (OR 1.64, 95% CI 1.15-2.34) than those without. Patients with asthma had a lower mortality rate (OR 0.63, 95% CI 0.43-0.92) but a similar re-intubation rate to those of patients without. These findings remained stable after propensity score matching and bootstrapping analysis. The association of COPD with re-intubation was significantly stronger in patients with high oxygen-partial pressure (PaO2) or mild disease severity but was independent of carbon dioxide partial pressure. Corticosteroid use was associated with increased re-intubation rates in subgroups without CRDs (OR 1.77-1.99, p < 0.001) but not in subgroups with CRDs. COPD patients with high post-extubation PaO2 or mild disease severity should be carefully monitored as they have higher re-intubation and mortality rates.

Difficult tracheal intubation in neonates and infants. NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE): a prospective European multicentre observational study.

BACKGROUND: Neonates and infants are susceptible to hypoxaemia in the perioperative period. The aim of this study was to analyse interventions related to anaesthesia tracheal intubations in this European cohort and identify their clinical consequences. METHODS: We performed a secondary analysis of tracheal intubations of the European multicentre observational trial (NEonate and Children audiT of Anaesthesia pRactice IN Europe [NECTARINE]) in neonates and small infants with difficult tracheal intubation. The primary endpoint was the incidence of difficult intubation and the related complications. The secondary endpoints were the risk factors for severe hypoxaemia attributed to difficult airway management, and 30 and 90 day outcomes. RESULTS: Tracheal intubation was planned in 4683 procedures. Difficult tracheal intubation, defined as two failed attempts of direct laryngoscopy, occurred in 266 children (271 procedures) with an incidence (95% confidence interval [CI]) of 5.8% (95% CI, 5.1-6.5). Bradycardia occurred in 8% of the cases with difficult intubation, whereas a significant decrease in oxygen saturation (SpO2<90% for 60 s) was reported in 40%. No associated risk factors could be identified among co-morbidities, surgical, or anaesthesia management. Using propensity scoring to adjust for confounders, difficult anaesthesia tracheal intubation did not lead to an increase in 30 and 90 day morbidity or mortality. CONCLUSIONS: The results of the present study demonstrate a high incidence of difficult tracheal intubation in children less than 60 weeks post-conceptual age commonly resulting in severe hypoxaemia. Reassuringly, the morbidity and mortality at 30 and 90 days was not increased by the occurrence of a difficult intubation event. CLINICAL TRIAL REGISTRATION: NCT02350348.

Role of neutrophil-to-lymphocyte, lymphocyte-to-monocyte and platelet-to-lymphocyte ratios as predictors of disease severity in COVID-19 patients.

Direct viral damage and uncontrolled inflammation contribute to disease severity in SARS-CoV-2 infection. The aim of this study was to investigate the prognostic significance of neutrophil-to-lymphocyte [NLR], lymphocyte-to-monocyte [LMR] and platelet-to-lymphocyte [PLR] ratios in COVID-19 patients. All 184 COVID-19 patients hospitalized in our institution between March - April 2020 were retrospectively analyzed. The patients were grouped into intubated and non-intubated, and subgrouped into survived and deceased. An unpaired Student's t-test was used for continuous variables, and the Pearson Chi-square (χ2) test for categorical. Univariate and multivariate logistic regression models were developed to assess the independent relationship between NLR, LMR and PLR and unfavorable outcomes. Non-parametric correlations were calculated using Spearman's Rho correlation coefficient. The mean age of the patients was 64.7; mean BMI was 29.10; 73 (39.67%) were female and 111 male (60.33%). No statistical difference between groups was identified with regard to NLR (mean 8.29, standard deviation [SD] 7.86). On multivariate regression analysis, only PLR and LMR were shown to influence the ratio and it was positively correlated with PLR, lactate and C-reactive protein [CRP]. LMR for non-intubated survived [NI-S] (mean 2.29, SD 1.31) and non-intubated deceased [NI-D] (mean 1.79, SD 0.81) groups were statistically significant (p=0.03). LMR was influenced only by NLR on regression analysis. A positive correlation of LMR with body mass index [BMI] was ascertained. No statistical significance was found between groups for PLR (mean 269.85, SD 207.98) and the ratio was influenced by age and NLR on regression analysis, and positively correlated with NLR. To conclude, previously reported findings of a prognostic role of NLR, LMR and PLR in COVID-19 were not validated in our cohort and we would caution against using the ratios in question as independent markers for disease severity.

Evaluación de la relajación neuromuscular y predictores de vía aérea difícil en pacientes programados para cirugía general Hospital Central Universitario Dr. Antonio María Pineda / Evaluation of muscle relaxation and predictors of difficult airway in patients programmed for general surgery Hospital Central Universitario Dr. Antonio María Pineda

Se realizó una investigación experimental tipo ensayo clínico controlado simple ciego con el fin de evaluar la relajación muscular y los predictores de vía aérea difícil en pacientes programados para cirugía general en el Hospital Central Universitario Dr. Antonio María Pineda. La muestra estuvo conformada por 100 pacientes distribuidos aleatoriamente en cuatro grupos de 25 pacientes cada uno. En los grupos Experimental-1 (E-1) y Control-1 (C-1) se utilizó una dosis del bloqueante neuromuscular Bromuro de Rocuronio de 0,6 mg/kg y en los grupos Experimental-2 (E-2) y Control-2 (C-2) de 1 mg/kg. La edad promedio de los pacientes fue de 34,8 ± 9,8 años; en los grupos E-1 y E-2, los predictores de vía aérea difícil predominantes fueron distancia esternomentoniana (32% y 42%), distancia tiromentoniana (24% y 40%), distancia interincisivos clase I (88% y 92 %), circunferencia de cuello  40 cm (16% y 8 %), Mallampati (88% y 40%), extensión atlanto-occipital (28% y 20%) y protrusión mandibular (28% y 20%). En el 72% y 80% de los pacientes de los grupos experimentales y control no hubo intento adicional de intubación orotraqueal (IOT); el tiempo invertido para alcanzar la IOT fue < 1 minuto en el grupo C-2 (64%) y E-2 (72%). Existen diferencias estadísticamente significativas entre el número de intentos para alcanzar la IOT, la presencia de predictores de vía aérea difícil y la dosis de bloqueante neuromuscular utilizada lo que evidencia de que a medida que se aumenta la dosis del medicamento hay mayor posibilidad de éxitos en la IOT, aun cuando estén presentes predictores de vía aérea difícil(AU)

An experimental simple blind controlled clinical trial was carried out to evaluate muscle relaxation and predictors of difficult airway in patients scheduled for general surgery at the Hospital Central Universitario Dr. Antonio María Pineda. The sample consisted of 100 patients randomly distributed into four groups of 25 patients each. Patients from the Experimental-1 (E-1) and Control-1 (C-1) groups received 0.6 mg/kg of the neuromuscular blocking agent Rocuronium Bromide while Experimetal-2 (E-2) and Control-2 (C-2) patients received a dosage of 1 mg/kg. Average age of participants was 34.8 ± 9.8 years. Predictors of difficult airway in E-1 and E-2 were sternomental distance (32% and 42%, thyromental distance (24% and 40%), interincisive distance class 1 (88% and 92%), neck circumference  40 cm (16% and 8%), Mallampati (88% and 40%), atlanto-occipital extension (28% and 20%) and mandibular protrusion (28% and 20%). In 72% and 80% of patients from the E and C groups there was not an additional attempt of orotracheal intubation (OTI); the time invested to reach the OTI was less than one minute in 64% of patients from the C-2 and 72% of the E-2. There are statistically significant differences between the number of attempts to reach the OTI, presence of predictors of difficult airway and the dose of Rocuronium Bromide which means that as the drug dosage increases, there is a greater possibility of success in the OTI, even when predictors of difficult airway are present(AU)

The impact of tracheostomy timing on clinical outcomes and adverse events in intubated patients with infratentorial lesions: early versus late tracheostomy.

We evaluated the association between the timing of tracheostomy and clinical outcomes in patients with infratentorial lesions. We performed a retrospective observational cohort study in a neurosurgical intensive care unit (ICU) at a tertiary academic medical center from January 2014 to December 2018. Consecutive adult patients admitted to the ICU who underwent resection of infratentorial lesions as well as tracheostomy were included for analysis. Early tracheostomy was defined as performed on postoperative days 1-10 and late tracheostomy on days 10-20 after operation. Univariate and multivariate analyses were used to compare the characteristics and outcomes between both cohorts. A total of 143 patients were identified, and 96 patients received early tracheostomy. Multivariable analysis identified early tracheostomy as an independent variable associated with lower occurrence of pneumonia (odds ratio, 0.25; 95% CI, 0.09-0.73; p = 0.011), shorter stays in ICUs (hazard ratio, 0.4; 95% CI, 0.3-0.6; p = 0.03), and earlier decannulation (hazard ratio, 0.5; 95% CI, 0.4-0.8; p = 0.003). However, no significant differences were observed between the early and late tracheostomy groups regarding hospital mortality (p > 0.999) and the modified Rankin scale after 6 months (p = 0.543). We also identified postoperative brainstem deficits, including cough, swallowing attempts, and extended tongue as well as GCS < 8 at ICU admission as the risk factors independently associated with patients underwent tracheostomy. There is a significant association between early tracheostomy and beneficial clinical outcomes or reduced adverse event occurrence in patients with infratentorial lesions.

Impact of a Critical Care Specialist Intervention on First Pass Success for Emergency Airway Management Outside the ICU.

BACKGROUND: There has been limited investigation into the procedural outcomes of patients undergoing emergent endotracheal intubation (EEI) by a critical care medicine (CCM) specialist outside the intensive care unit (ICU). We hypothesized that EEI outside an ICU would be associated with lower rates of first pass success (FPS) as compared to inside an ICU. METHODS: We performed a retrospective cohort study of all adult patients admitted to our academic medical center between January 1, 2016, and July 31, 2018, who underwent EEI by a CCM practitioner. The primary outcome of FPS was identified in the EEI procedure note. Secondary outcomes included difficult intubation (> 2 attempts at laryngoscopy) and mortality following EEI. RESULTS: In total, 1958 patients (1035 [52.9%] inside ICU and 923 [47.1%]) outside an ICU) were included in the final cohort. Unadjusted rate of FPS was not different between patients intubated out of the ICU and patients intubated inside of the ICU (689 [74.7%] vs 775 [74.9%]; P = .91). There was also no difference in FPS between groups after adjusting for predictors of difficult intubation and baseline covariates (odds ratio: 0.95; 95% confidence interval, 0.75-1.2, P = .65). Mortality of patients undergoing EEI out of the ICU was higher at each examined time interval following EEI. DISCUSSION: For EEI done by CCM practitioners, rate of FPS is not different between patients undergoing EEI outside an ICU as compared to inside an ICU. Despite the lack of difference between rates of procedural success, patient mortality following EEI outside an ICU is higher than EEI inside an ICU at all examined time points during hospitalization.

Tracheotomy Timing and Outcomes in the Critically Ill: Complexity and Opportunities for Progress.

OBJECTIVES/HYPOTHESIS: To characterize the effects of tracheotomy timing at our institution on intensive care unit (ICU) length of stay (LOS) and overall hospital LOS. STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective study was performed at a tertiary care medical center for patients undergoing tracheotomy over 2.5 years from January 1, 2016 through June 30, 2018. Demographics, survival, duration of endotracheal intubation, timing of tracheotomy, and ICU and overall hospital LOS were assessed. Tracheotomy was considered early (ET) if it was performed by day 7 of mechanical ventilation and late (LT) thereafter. Readmission, mortality, and costs were also tabulated for each aggregate group. Nonparametric statistics were used to compare results. RESULTS: Of the 536 patients included in the analysis, 160 received tracheotomy early and 376 late. Differences between age and sex were not statistically significant. Duration of total ICU stay was shortened by 65% (12.84 ± 17.69 days vs. 38.49 ± 26.61 days; P < .0001), and length of overall hospital course was reduced by 54% (22.71 ± 26.65 days vs. 50.37 ± 34.20 days; P < .0001) in the early tracheotomy group. Observed/expected (O/E) values standardized results to case mix index and revealed LOS of 1.5 for ET and 2.5 for LT, and mortality of 0.76 for ET and 1.25 for LT, and comparable readmissions of both groups. CONCLUSIONS: Early tracheotomy in ICU patients is associated with earlier ICU discharge, decreased length of overall hospital stay, and lower mortality when controlling for case mix index. Opportunities exist to optimize patient outcomes and O/E performance. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:282-287, 2021.

Emergency tracheal intubation during off-hours is not associated with increased mortality in hospitalized patients: a retrospective cohort study.

BACKGROUND: The prognosis of hospitalized patients after emergent endotracheal intubation (ETI) remains poor. Our aim was to evaluate the 30-d hospitalization mortality of subjects undergoing ETI during daytime or off-hours and to analyze the possible risk factors affecting mortality. METHODS: A single-center retrospective study was performed at a university teaching facility from January 2015 to December 2018. All adult inpatients who received ETI in the general ward were included. Information on patient demographics, vital signs, ICU (Intensive care unit) admission, intubation time (daytime or off-hours), the department in which ETI was performed (surgical ward or medical ward), intubation reasons, and 30-d hospitalization mortality after ETI were obtained from a database. RESULTS: Over a four-year period, 558 subjects were analyzed. There were more male than female in both groups (115 [70.1%] vs 275 [69.8%]; P = 0.939). A total of 394 (70.6%) patients received ETI during off-hours. The patients who received ETI during the daytime were older than those who received ETI during off-hours (64.95 ± 17.54 vs 61.55 ± 17.49; P = 0.037). The BMI of patients who received ETI during the daytime was also higher than that of patients who received ETI during off-hours (23.08 ± 3.38 vs 21.97 ± 3.25; P < 0.001). The 30-d mortality after ETI was 66.8% (373), which included 68.0% (268) during off-hours and 64.0% (105) during the daytime (P = 0.361). Multivariate Cox regression analysis found that the significant factors for the risk of death within 30 days included ICU admission (HR 0.312, 0.176-0.554) and the department in which ETI was performed (HR 0.401, 0.247-0.653). CONCLUSIONS: The 30-d hospitalization mortality after ETI was 66.8%, and off-hours presentation was not significantly associated with mortality. ICU admission and ETI performed in the surgical ward were significant factors for decreasing the risk of death within 30 days. TRIAL REGISTRATION: This trial was retrospectively registered with the registration number of ChiCTR2000038549 .

Obesity and the Risk of Intubation or Death in Patients With Coronavirus Disease 2019.

OBJECTIVES: To characterize the impact of obesity on disease severity in patients with coronavirus disease 2019. DESIGN: This was a retrospective cohort study designed to evaluate the association between body mass index and risk of severe disease in patients with coronavirus disease 2019. Data were abstracted from the electronic health record. The primary endpoint was a composite of intubation or death. SETTING: Two hospitals in Massachusetts (one quaternary referral center and one affiliated community hospital). PATIENTS: Consecutive patients hospitalized with confirmed coronavirus disease 2019 admitted between March 13, 2020, and April 3, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 305 patients were included in this study. We stratified patients by body mass index category: < 25 kg/m (54 patients, 18%), ≥ 25 kg/m to < 30 kg/m (124 patients, 41%), ≥ 30 kg/m to < 35 kg/m (58 patients, 19%), and ≥ 35 kg/m (69 patients, 23%). In total, 128 patients (42%) had a primary endpoint (119 patients [39%] were intubated and nine died [3%] without intubation). Sixty-five patients (51%) with body mass index greater than or equal to 30 kg/m were intubated or died. Adjusted Cox models demonstrated that body mass index greater than or equal to 30 kg/m was associated with a 2.3-fold increased risk of intubation or death (95% CI, 1.2-4.3) compared with individuals with body mass index less than 25 kg/m. Diabetes was also independently associated with risk of intubation or death (hazard ratio, 1.8; 95% CI, 1.2-2.7). Fifty-six out of 127 patients (44%) with body mass index greater than or equal to 30 kg/m had diabetes, and the combination of both diabetes and body mass index greater than or equal to 30 kg/m was associated with a 4.5-fold increased risk of intubation or death (95% CI, 2.0-10.2) compared with patients without diabetes and body mass index less than 25 kg/m. CONCLUSIONS: Among consecutive patients hospitalized with coronavirus disease 2019, obesity was an independent risk factor for intubation or death.

Potential Predictors of Poor Prognosis among Critical COVID-19 Pneumonia Patients Requiring Tracheal Intubation.

Coronavirus disease 2019 (COVID-19) is a global public health concern that can be classified as mild, moderate, severe, or critical, based on disease severity. Since the identification of critical patients is crucial for developing effective management strategies, we evaluated clinical characteristics, laboratory data, treatment provided, and oxygenation to identify potential predictors of mortality among critical COVID-19 pneumonia patients. We retrospectively utilized data from seven critical patients who were admitted to our hospital during April 2020 and required mechanical ventilation. The primary endpoint was to clarify potential predictor of mortality. All patients were older than 70 years, five were men, six had hypertension, and three ultimately died. Compared with survivors, non-survivors tended to be never smokers (0 pack-years vs. 30 pack-years, p = 0.08), to have higher body mass index (31.3 kg/m2 vs. 25.3 kg/m2, p = 0.06), to require earlier tracheal intubation after symptom onset (2.7 days vs. 5.5 days, p = 0.07), and had fewer lymphocytes on admission (339 /µL vs. 518 /µL, p = 0.05). During the first week after tracheal intubation, non-survivors displayed lower values for minimum ratio of the partial pressure of oxygen to fractional inspiratory oxygen concentration (P/F ratio) (44 mmHg vs. 122 mmHg, p < 0.01) and poor response to intensive therapy compared with survivors. In summary, we show that obesity and lymphopenia could predict the severity of COVID-19 pneumonia and that the trend of lower P/F ratio during the first week of mechanical ventilation could provide useful prognostic information.

High-flow nasal oxygen reduces endotracheal intubation: a randomized clinical trial.

BACKGROUND: The benefits of high-flow nasal cannula (HFNC) as primary intervention in patients with acute hypoxemic respiratory failure (AHRF) are still a matter in debate. Our objective was to compare HFNC therapy versus conventional oxygen therapy (COT) in the prevention of endotracheal intubation in this group of patients. METHODS: An open-label, controlled and single-centre clinical trial was conducted in patients with severe AHRF, defined by a PaO2/FIO2 ratio ⩽200, to compare HFNC with a control group (CG) treated by COT delivered through a face mask, with the need to perform intubation as the primary outcome. The secondary outcomes included tolerance of the HFNC device and to look for the predictive factors for intubation in these patients. RESULTS: A total of 46 patients were included (22 in the COT group and 24 in the HFNC group) 48% of whom needed intubation: 63% in the COT group and 33% in the HFNC group, with significant differences both in intention to treat [χ2 = 4.2; p = 0.04, relative risk (RR) = 0.5; confidence interval (CI) 95%: 0.3-1.0] and also in treatment analysis (χ2 = 4.7; p = 0.03; RR = 0.5; IC 95%: 0.3-0.9) We obtained a number needed to treat (NNT) = 3 patients treated to avoid an intubation. Intubation occurred significantly later in the HFNC group. Estimated PaO2/FIO2, respiratory rate and dyspnea were significantly better in the HFNC group. Patients treated with HFNC who required intubation presented significant worsening after the first 8 h, as compared with non-intubated HFNC group patients. Mortality was 22% with no differences. The HFNC group patients were hospitalized for almost half of the time in the intensive care unit (ICU) and in the ward, with significantly less hospital length of stay. A total of 14 patients in the HFNC group (58%) complained of excessive heat and 17% of noise; 3 patients did not tolerate HFNC. CONCLUSION: Patients with severe acute hypoxemic respiratory failure who tolerate HFNC present a significantly lower need for endotracheal intubation compared with conventional oxygen therapy. CLINICAL TRIAL REGISTER: EUDRA CT number: 2012-001671-36The reviews of this paper are available via the supplemental material section.

Survival predictors after intubation in medical wards: A prospective study in 151 patients.

INTRODUCTION: In health care systems in need of additional intensive care unit (ICU) beds, the decision to mechanically ventilate critically ill patients in Internal Medicine (IM) Department wards needs to balance patients' health outcomes, possible futility, and logistics. We aimed to examine the survival rates and predictors in these patients. METHODS: We prospectively enrolled consecutive patients receiving mechanical ventilation during their care in the IM wards of a tertiary University hospital between April 2016 and December 2018. Primary outcome was 90-day mortality and secondary outcomes were in-hospital mortality and ICU transfer. RESULTS: Our cohort consisted of 151 unique patient intubations, of whom 74 (49%) patients were transferred to ICU within a median of 0 days (range 0-7). Compared to patients who remained in the wards, patients transferred to ICU had lower in-hospital and 90-day mortality (65% vs. 97%, and 70% vs. 99%, respectively, p<0.001 for both). Amongst several possible predictors of survival in the ICU, sequential organ failure assessment (SOFA) score at the time of intubation had the best prognostic accuracy with an AUROC of 0.818 and 0.855 for in-hospital and 90-day mortality, respectively. A baseline SOFA score ≤8 had a 100% sensitivity for survival prediction in ICU. However, out of 26 patients with SOFA score ≤8 who remained in the wards, only one survived, whereas 19 patients with SOFA score >8 who were transferred to ICUs received futile care. CONCLUSION: Mortality for patients receiving mechanical ventilation in IM wards is almost inevitable when ICU availability is lacking. Therefore, applying additional transfer criteria beyond the SOFA score is imperative.

Sustained versus standard inflations during neonatal resuscitation to prevent mortality and improve respiratory outcomes.

BACKGROUND: At birth, infants' lungs are fluid-filled. For newborns to have a successful transition, this fluid must be replaced by air to enable gas exchange. Some infants are judged to have inadequate breathing at birth and are resuscitated with positive pressure ventilation (PPV). Giving prolonged (sustained) inflations at the start of PPV may help clear lung fluid and establish gas volume within the lungs. OBJECTIVES: To assess the benefits and harms of an initial sustained lung inflation (SLI) (> 1 second duration) versus standard inflations (≤ 1 second) in newborn infants receiving resuscitation with intermittent PPV. SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 3), MEDLINE via PubMed (1966 to 1 April 2019), Embase (1980 to 1 April 2019), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 1 April 2019). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles to identify randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-RCTs comparing initial sustained lung inflation (SLI) versus standard inflations given to infants receiving resuscitation with PPV at birth. DATA COLLECTION AND ANALYSIS: We assessed the methodological quality of included trials using Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria (assessing randomisation, blinding, loss to follow-up, and handling of outcome data). We evaluated treatment effects using a fixed-effect model with risk ratio (RR) for categorical data; and mean standard deviation (SD), and weighted mean difference (WMD) for continuous data. We used the GRADE approach to assess the quality of evidence. MAIN RESULTS: Ten trials enrolling 1467 infants met our inclusion criteria. Investigators in nine trials (1458 infants) administered sustained inflation with no chest compressions. Use of sustained inflation had no impact on the primary outcomes of this review: mortality in the delivery room (typical RR 2.66, 95% confidence interval (CI) 0.11 to 63.40 (I² not applicable); typical RD 0.00, 95% CI -0.02 to 0.02; I² = 0%; 5 studies, 479 participants); and mortality during hospitalisation (typical RR 1.09, 95% CI 0.83 to 1.43; I² = 42%; typical RD 0.01, 95% CI -0.02 to 0.04; I² = 24%; 9 studies, 1458 participants). The quality of the evidence was low for death in the delivery room because of limitations in study design and imprecision of estimates (only one death was recorded across studies). For death before discharge the quality was moderate: with longer follow-up there were more deaths (n = 143) but limitations in study design remained. Among secondary outcomes, duration of mechanical ventilation was shorter in the SLI group (mean difference (MD) -5.37 days, 95% CI -6.31 to -4.43; I² = 95%; 5 studies, 524 participants; low-quality evidence). Heterogeneity, statistical significance, and magnitude of effects of this outcome are largely influenced by a single study at high risk of bias: when this study was removed from the analysis, the size of the effect was reduced (MD -1.71 days, 95% CI -3.04 to -0.39; I² = 0%). Results revealed no differences in any of the other secondary outcomes (e.g. risk of endotracheal intubation outside the delivery room by 72 hours of age (typical RR 0.91, 95% CI 0.79 to 1.04; I² = 65%; 5 studies, 811 participants); risk of surfactant administration during hospital admission (typical RR 0.99, 95% CI 0.91 to 1.08; I² = 0%; 9 studies, 1458 participants); risk of chronic lung disease (typical RR 0.99, 95% CI 0.83 to 1.18; I² = 0%; 4 studies, 735 participants); pneumothorax (typical RR 0.89, 95% CI 0.57 to 1.40; I² = 34%; 8 studies, 1377 infants); or risk of patent ductus arteriosus requiring pharmacological treatment (typical RR 0.99, 95% CI 0.87 to 1.12; I² = 48%; 7 studies, 1127 infants). The quality of evidence for these secondary outcomes was moderate (limitations in study design ‒ GRADE) except for pneumothorax (low quality: limitations in study design and imprecision of estimates ‒ GRADE). We could not perform any meta-analysis in the comparison of the use of initial sustained inflation versus standard inflations in newborns receiving resuscitation with chest compressions because we identified only one trial for inclusion (a pilot study of nine preterm infants). AUTHORS' CONCLUSIONS: Our meta-analysis of nine studies shows that sustained lung inflation without chest compression was not better than intermittent ventilation for reducing mortality in the delivery room (low-quality evidence ‒ GRADE) or during hospitalisation (moderate-quality evidence ‒ GRADE), which were the primary outcomes of this review. However, the single largest study, which was well conducted and had the greatest number of enrolled infants, was stopped early for higher mortality rate in the sustained inflation group. When considering secondary outcomes, such as rate of intubation, rate or duration of respiratory support, or bronchopulmonary dysplasia, we found no benefit of sustained inflation over intermittent ventilation (moderate-quality evidence ‒ GRADE). Duration of mechanical ventilation was shortened in the SLI group (low-quality evidence ‒ GRADE); this result should be interpreted cautiously, however, as it might have been influenced by study characteristics other than the intervention. There is no evidence to support the use of sustained inflation based on evidence from our review.

Risk factors and associated complications with unplanned intubation in patients with craniotomy for brain tumor.

Patients undergoing surgical resection of a brain tumor have the potential risk for beingintubated post-operatively, which may be associated with significant morbidity and/or mortality after surgery. This study was analyzed various preoperative patient characteristics, postoperative outcomes, and complications to identify risk factors for unplanned intubation (UI) in adult patients undergoing craniotomy for a brain tumor and created a risk score framework for that cohort. Patients undergoing surgery for a brain tumor were identified according to primary Current Procedural Terminology codes, and information found in The American College of Surgeons (ACS) National Surgical Quality Improvement Project (NSQIP) database from 2012 to 2015 was reviewed. A total of 18,642 adult brain tumor patients were included in the ACS-NSQIP. The rate of unplanned intubation in this cohort was 2.30% (4 2 8). The mortality rate of patients who underwent UI after surgical resection of brain tumor was 24.78% compared to an overall mortality of 2.46%. During the first 30 days after surgery, 33% of patients who underwent UI had an unplanned reoperation, compared to 4.76% of patients who did not undergo unplanned intubation. Bivariate and multivariate analyses identified several predictors and computed a risk score for UI. A risk score based on patient factors for those undergoing a craniotomy for a brain tumor predicts the postoperative UI rate. This could aid in surgical decision-making by identify patients at a higher risk of UI, while modifying perioperative management may help prevent UI.

Association of Intraoperative Ventilator Management With Postoperative Oxygenation, Pulmonary Complications, and Mortality.

BACKGROUND: "Lung-protective ventilation" describes a ventilation strategy involving low tidal volumes (VTs) and/or low driving pressure/plateau pressure and has been associated with improved outcomes after mechanical ventilation. We evaluated the association between intraoperative ventilation parameters (including positive end-expiratory pressure [PEEP], driving pressure, and VT) and 3 postoperative outcomes: (1) PaO2/fractional inspired oxygen tension (FIO2), (2) postoperative pulmonary complications, and (3) 30-day mortality. METHODS: We retrospectively analyzed adult patients who underwent major noncardiac surgery and remained intubated postoperatively from 2006 to 2015 at a single US center. Using multivariable regressions, we studied associations between intraoperative ventilator settings and lowest postoperative PaO2/FIO2 while intubated, pulmonary complications identified from discharge diagnoses, and in-hospital 30-day mortality. RESULTS: Among a cohort of 2096 cases, the median PEEP was 5 cm H2O (interquartile range = 4-6), median delivered VT was 520 mL (interquartile range = 460-580), and median driving pressure was 15 cm H2O (13-19). After multivariable adjustment, intraoperative median PEEP (linear regression estimate [B] = -6.04; 95% CI, -8.22 to -3.87; P < .001), median FIO2 (B = -0.30; 95% CI, -0.50 to -0.10; P = .003), and hours with driving pressure >16 cm H2O (B = -5.40; 95% CI, -7.2 to -4.2; P < .001) were associated with decreased postoperative PaO2/FIO2. Higher postoperative PaO2/FIO2 ratios were associated with a decreased risk of pulmonary complications (adjusted odds ratio for each 100 mm Hg = 0.495; 95% CI, 0.331-0.740; P = .001, model C-statistic of 0.852) and mortality (adjusted odds ratio = 0.495; 95% CI, 0.366-0.606; P < .001, model C-statistic of 0.820). Intraoperative time with VT >500 mL was also associated with an increased likelihood of developing a postoperative pulmonary complication (adjusted odds ratio = 1.06/hour; 95% CI, 1.00-1.20; P = .042). CONCLUSIONS: In patients requiring postoperative intubation after noncardiac surgery, increased median FIO2, increased median PEEP, and increased time duration with elevated driving pressure predict lower postoperative PaO2/FIO2. Intraoperative duration of VT >500 mL was independently associated with increased postoperative pulmonary complications. Lower postoperative PaO2/FIO2 ratios were independently associated with pulmonary complications and mortality. Our findings suggest that postoperative PaO2/FIO2 may be a potential target for future prospective trials investigating the impact of specific ventilation strategies for reducing ventilator-induced pulmonary injury.