Discordance Between Respiratory Drive and Sedation Depth in Critically Ill Patients Receiving Mechanical Ventilation.

OBJECTIVES: In mechanically ventilated patients, deep sedation is often assumed to induce "respirolysis," that is, lyse spontaneous respiratory effort, whereas light sedation is often assumed to preserve spontaneous effort. This study was conducted to determine validity of these common assumptions, evaluating the association of respiratory drive with sedation depth and ventilator-free days in acute respiratory failure. DESIGN: Prospective cohort study. SETTING: Patients were enrolled during 2 month-long periods in 2016-2017 from five ICUs representing medical, surgical, and cardiac specialties at a U.S. academic hospital. PATIENTS: Eligible patients were critically ill adults receiving invasive ventilation initiated no more than 36 hours before enrollment. Patients with neuromuscular disease compromising respiratory function or expiratory flow limitation were excluded. INTERVENTIONS: Respiratory drive was measured via P0.1, the change in airway pressure during a 0.1-second airway occlusion at initiation of patient inspiratory effort, every 12 ± 3 hours for 3 days. Sedation depth was evaluated via the Richmond Agitation-Sedation Scale. Analyses evaluated the association of P0.1 with Richmond Agitation-Sedation Scale (primary outcome) and ventilator-free days. MEASUREMENTS AND MAIN RESULTS: Fifty-six patients undergoing 197 bedside evaluations across five ICUs were included. P0.1 ranged between 0 and 13.3 cm H2O (median [interquartile range], 0.1 cm H2O [0.0-1.3 cm H2O]). P0.1 was not significantly correlated with the Richmond Agitation-Sedation Scale (RSpearman, 0.02; 95% CI, -0.12 to 0.16; p = 0.80). Considering P0.1 terciles (range less than 0.2, 0.2-1.0, and greater than 1.0 cm H2O), patients in the middle tercile had significantly more ventilator-free days than the lowest tercile (incidence rate ratio, 0.78; 95% CI, 0.65-0.93; p < 0.01) or highest tercile (incidence rate ratio, 0.58; 95% CI, 0.48-0.70; p < 0.01). CONCLUSIONS: Sedation depth is not a reliable marker of respiratory drive during critical illness. Respiratory drive can be low, moderate, or high across the range of routinely targeted sedation depth.

Over-the-Counter Bronchodilators Use Among Asthmatic Patients in Al-Medina Al-Monawwara.

Asthma is a prevalent chronic disease that affects a significant number of individuals worldwide. Proper diagnosis and assessment of asthma patients are crucial before determining the appropriate inhaler for them. Many asthmatic patients self-medicate with over-the-counter (OTC) inhaled and orally taken bronchodilators, leading to overuse and serious adverse effects. This study aims to identify the extent of OTC bronchodilator usage in the Al-Medina Al-Monawwara region. and urge health authorities to address the issue and prevent potential side effects arising from the overuse of bronchodilators. This cross-sectional observational study was conducted among individuals with asthma residing in the Al-Medina Al-Monawwara region of Saudi Arabia. The study encompassed multiple hospitals. It was carried out between September 2021 and February 2023, utilizing a convenience sampling method. A total of 419 participants were included in the study; the majority of them, 362 (86.4%), reported being prescribed asthma inhalers at least once in their lives, while 57 (13.6%) always used asthma inhalers without a prescription. However, most of our participants reported having a prescription for their short-acting bronchodilators, with 46.3% always obtaining them with a prescription and the remaining obtaining them over the counter. The current study indicates that the use of OTC Bronchodilators increases the risk of significant ER visits; this observation is quite concerning as the increasing use of short-acting beta-agonists (SABA) might indicate less asthma control and more SABA overuse; further research is needed to address the issue of short-acting bronchodilators overuse.

A Cross-Sectional Study of the Impact of ICU-Acquired Weakness: Prevalence, Associations, and Severity.

Background and objective ICU-acquired weakness (ICU-AW) refers to a group of neuromuscular lesions that can develop in the ICU. It leads to decreased physical function, increased in-ICU and in-hospital mortality, and increased healthcare costs. Given its high prevalence and significant impact on patient outcomes, it is essential to have a deeper understanding of ICU-AW. In light of this, this study aimed to ascertain the prevalence, associations, and severity of ICU-AW at a tertiary hospital in the Kingdom of Saudi Arabia (KSA) and to evaluate physician awareness of this condition. Methods A cross-sectional study was conducted in the ICU of Al Madina General Hospital, Medina, KSA, from April 22 to August 22, 2022, involving patients who were 18 years or older and met the inclusion criteria (n=101). The overall muscle strength was assessed daily by using the Medical Research Council (MRC) scale for muscle strength. ICU-AW was identified in patients who experienced a decline in their MRC-Sum Score (MRC-SS) during their ICU stay. Results A total of 101 patients were enrolled in the study. The incidence of ICU-AW was 16.8% (n=17), with 23.5% exhibiting significant weakness and 76.5% having severe weakness. Post hoc comparisons showed that females had a higher incidence of ICU-AW. Fisher's exact test revealed a statistically significant relationship between ICU-AW and the longer duration of ICU stay (p=0.001), use of mechanical ventilation (p=0.034), and low hemoglobin levels (p=0.037). Conclusions ICU-AW was observed in 16.8% (n=17) of patients in our cohort, highlighting the significance of this condition. The study revealed a noteworthy correlation between ICU-AW and female sex, extended ICU stays, mechanical ventilation, and anemia.

Right ventricular to pulmonary artery coupling and outcome in patients with cardiac amyloidosis.

AIMS: To investigate the prognostic value of the right ventricle-to-pulmonary artery (RV-PA) coupling in patients with either transthyretin (ATTR) or immunoglobulin light-chain (AL) cardiac amyloidosis (CA). METHODS AND RESULTS: Overall, 283 patients with CA from 3 Italian high-volume centres were included (median age 76 years; 63% males; 53% with ATTR-CA, 47% with AL-CA). The RV-PA coupling was evaluated by using the tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) ratio. The median value of TAPSE/PASP was 0.45 (0.33-0.63) mm/mmHg. Patients with a TAPSE/PASP ratio <0.45 were older, had lower systolic blood pressure, more severe symptoms, higher cardiac troponin and N-terminal pro-B-type natriuretic peptide levels, greater left ventricular (LV) thickness, and worse LV systolic and diastolic function. A TAPSE/PASP ratio <0.45 was independently associated with a higher risk of all-cause death or heart failure (HF) hospitalization [hazard ratio (HR) 1.98, 95% confidence interval (CI) 1.32-2.96; P = 0.001] and all-cause death (HR 2.18, 95% CI 1.31-3.62; P = 0.003). The TAPSE/PASP ratio reclassified the risk of both endpoints [net reclassification index 0.46 (95% CI 0.18-0.74) P = 0.001 and 0.49 (0.22-0.77) P < 0.001, respectively], while TAPSE or PASP alone did not (all P > 0.05). The prognostic impact of the TAPSE/PASP ratio was significant both in AL-CA patients (HR for the composite endpoint 2.47, 95% CI 1.58-3.85; P < 0.001) and in ATTR-CA (HR 1.81, 95% CI 1.11-2.95; P = 0.017). The receiver operating characteristic curve showed that the optimal cut-off for predicting prognosis was 0.47 mm/mmHg. CONCLUSION: In patients with CA, RV-PA coupling predicted the risk of mortality or HF hospitalization. The TAPSE/PASP ratio was more effective than TAPSE or PASP in predicting prognosis.

Value of the HFA-PEFF and H2 FPEF scores in patients with heart failure and preserved ejection fraction caused by cardiac amyloidosis.

AIMS: The HFA-PEFF and H2 FPEF scores have been developed to diagnose heart failure with preserved ejection fraction (HFpEF), and hold prognostic value. Their value in patients with HFpEF caused by cardiac amyloidosis (CA) has never been investigated. METHODS AND RESULTS: We evaluated the diagnostic and prognostic value of the HFA-PEFF and H2 FPEF scores in 304 patients from three cohorts with HFpEF caused by transthyretin CA (n = 160, 53%) or immunoglobulin light-chain CA (n = 144, 47%). A diagnosis of HFpEF was more likely using the HFA-PEFF score with 2 (1%), 71 (23%), and 231 (76%) patients ranked as having a low (0-1), intermediate (2-4), or high (5, 6) probability of HFpEF, respectively. Conversely, 36 (12%), 179 (59%) and 89 (29%) of patients ranked as having a low (0-1), intermediate (2-5), or high (6-9) probability of HFpEF using the H2 FPEF score. During a median follow-up of 19 months (interquartile range 8-40), 132 (43%) patients died. The HFA-PEFF score, but not the H2 FPEF score, predicted a high risk of all-cause death which remained significant after adjustment for age, AL-CA diagnosis, high-sensitivity troponin T, N-terminal pro-B-type natriuretic peptide, and echocardiographic parameters, including left ventricular global longitudinal strain, left ventricular diastolic function and right ventricular function (hazard ratio 1.51, 95% confidence interval 1.16-1.95, p = 0.002 for every 1-point increase in HFA-PEFF). CONCLUSIONS: The HFA-PEFF score has a higher diagnostic utility in HFpEF caused by CA and holds independent prognostic value for all-cause mortality, while the H2 FPEF score does not.

Respiratory Pathophysiology of Mechanically Ventilated COVID-19 Patients.

Background and objectives Coronavirus disease 2019 (COVID-19) is mainly a disease of the respiratory system that can lead to acute respiratory distress syndrome (ARDS). The pathophysiology of COVID-19 ARDS and consequently its management is a disputable subject. Early COVID-19 investigators hypothesized that the pathogenesis of COVID-19 ARDS is different from the usual ARDS. The aim of this study was to describe the lung mechanics in mechanically ventilated COVID-19 patients with ARDS. Methodology An observational retrospective cohort study was conducted on adult COVID-19 patients with ARDS who needed mechanical ventilation in the ICU of Ohoud Hospital, Madinah, KSA, from June to September 2020. Data were collected from the patients' medical charts and electronic medical records and analyzed using Statistical Package for the Social Sciences (SPSS) software package version 22 (IBM Corp., Armonk, NY) for descriptive statistical analysis. Measurements and main results A total of 52 patients were analyzed: on intubation, the median positive end-expiratory pressure (PEEP) was 10 cm H2O (IQR, 2.3-16), the median plateau pressure was 27 cm H2O (IQR, 12-40), and the median driving pressure was 17 cm H2O (IQR, 3-30). The median static compliance of the respiratory system was 24.7 mL/cm H2O (IQR, 12.8-153.3). 59.5% had severe ARDS (the PaO2/FiO2 ratio was less than 100 mmHg), and 33% had moderate ARDS (the PaO2/FiO2 ratio ranged from 100 to 200 mmHg). Conclusion Our results suggest that the lung mechanics in COVID-19 ARDS patients who need mechanical ventilation do not differ from non-COVID-19 patients.