Aerosol particle dispersion in spontaneous breathing training of oxygen delivery tracheostomized patients on prolonged mechanical ventilation.

BACKGROUND: Tracheostomized patients undergoing liberation from mechanical ventilation (MV) are exposed to the ambient environment through humidified air, potentially heightening aerosol particle dispersion. This study was designed to evaluate the patterns of aerosol dispersion during spontaneous breathing trials in such patients weaning from prolonged MV. METHODS: Particle Number Concentrations (PNC) at varying distances from tracheostomized patients in a specialized weaning unit were quantified using low-cost particle sensors, calibrated against a Condensation Particle Counter. Different oxygen delivery methods, including T-piece and collar mask both with the humidifier or with a small volume nebulizer (SVN), and simple collar mask, were employed. The PNC at various distances and across different oxygen devices were compared using the Kruskal-Wallis test. RESULTS: Of nine patients receiving prolonged MV, five underwent major surgery, and eight were successfully weaned from ventilation. PNCs at distances ranging from 30 cm to 300 cm showed no significant disparity (H(4) = 8.993, p = 0.061). However, significant differences in PNC were noted among oxygen delivery methods, with Bonferroni-adjusted pairwise comparisons highlighting differences between T-piece or collar mask with SVN and other devices. CONCLUSIONS: Aerosol dispersion within 300 cm of the patient was not significantly different, while the nebulization significantly enhances ambient aerosol dispersion in tracheostomized patients on prolonged MV.

The impact of nontuberculous mycobacterial lung disease in critically ill patients: Significance for survival and ventilator use.

BACKGROUND: This study investigates the impact of nontuberculous mycobacterial lung disease (NTM-LD) on mortality and mechanical ventilation use in critically ill patients. METHODS: We enrolled patients with NTM-LD or tuberculosis (TB) in intensive care units (ICU) and analysed their association with 30-day mortality and with mechanical ventilator-free survival (VFS) at 30 days after ICU admission. RESULTS: A total of 5996 ICU-admitted patients were included, of which 541 (9.0 %) had TB and 173 (2.9 %) had NTM-LD. The overall 30-day mortality was 22.2 %. The patients with NTM-LD had an adjusted hazard ratio (aHR) of 1.49 (95 % CI, 1.06-2.05), and TB patients had an aHR of 2.33 (95 % CI, 1.68-3.24), compared to ICU patients with negative sputum mycobacterial culture by multivariable Cox proportional hazard (PH) regression. The aHR of age<65 years, obesity, idiopathic pulmonary fibrosis, end-stage kidney disease, active cancer and autoimmune disease and diagnosis of respiratory failure were also significantly positively associated with ICU 30-day mortality. In multivariable Cox PH regression for VFS at 30 days in patients requiring invasive mechanical ventilation, NTM-LD was negatively associated with VFS (aHR 0.71, 95 % CI: 0.56-0.92, p = 0.009), while TB showed no significant association. The diagnosis of respiratory failure itself predicted unfavourable outcome for 30-day mortality and a negative impact on VFS at 30 days. CONCLUSIONS: NTM-LD and TB were not uncommon in ICU and both were correlated with increasing 30-day mortality in ICU patients. NTM-LD was associated with a poorer outcome in terms of VFS at 30 days.

Automatic tube compensation for liberation from prolonged mechanical ventilation in tracheostomized patients: A retrospective analysis.

BACKGROUND: To analyze the predictability of an automatic tube compensation (ATC) screening test compared with the conventional direct liberation test performed before continuous oxygen support for MV liberation. METHODS: This retrospective study analyzed tracheostomized patients with prolonged MV in a weaning unit of a medical center in Taiwan. In March 2020, a four-day ATC test to screen patient eligibility for ventilator liberation was implemented, intended to replace the direct liberation test. We compared the predictive accuracy of these two screening methods on the relevant outcomes in the two years before and one year after the implementation of this policy. RESULTS: Of the 403 cases, 246 (61%) and 157 (39%) received direct liberation and ATC screening tests, respectively. These two groups had similar outcomes: successful weaning upon leaving the Respiratory Care Center (RCC), success on day 100 of MV, success at hospital discharge, and in-hospital survival. Receiver operating characteristic curve analysis showed that the ATC screening test had better predictive ability than the direct liberation test for RCC weaning, discharge weaning, 100-day weaning, and in-hospital survival. CONCLUSION: This closed-circuit ATC screening test before ventilator liberation is a feasible and valuable method for screening PMV patients undergoing ventilator liberation in the pandemic era. Its predictability for a comparison with the open-circuit oxygen test requires further investigation.

Early prediction of delirium upon intensive care unit admission: Model development, validation, and deployment.

STUDY OBJECTIVE: To develop, validate, and deploy models for predicting delirium in critically ill adult patients as early as upon intensive care unit (ICU) admission. DESIGN: Retrospective cohort study. SETTING: Single university teaching hospital in Taipei, Taiwan. PATIENTS: 6238 critically ill patients from August 2020 to August 2021. MEASUREMENTS: Data were extracted, pre-processed, and split into training and testing datasets based on the time period. Eligible variables included demographic characteristics, Glasgow Coma Scale, vital signs parameters, treatments, and laboratory data. The predicted outcome was delirium, defined as any positive result (a score ≥ 4) of the Intensive Care Delirium Screening Checklist that was assessed by primary care nurses in each 8-h shift within 48 h after ICU admission. We trained models to predict delirium upon ICU admission (ADM) and at 24 h (24H) after ICU admission by using logistic regression (LR), gradient boosted trees (GBT), and deep learning (DL) algorithms and compared the models' performance. MAIN RESULTS: Eight features were extracted from the eligible features to train the ADM models, including age, body mass index, medical history of dementia, postoperative intensive monitoring, elective surgery, pre-ICU hospital stays, and GCS score and initial respiratory rate upon ICU admission. In the ADM testing dataset, the incidence of ICU delirium occurred within 24 h and 48 h was 32.9% and 36.2%, respectively. The area under the receiver operating characteristic curve (AUROC) (0.858, 95% CI 0.835-0.879) and area under the precision-recall curve (AUPRC) (0.814, 95% CI 0.780-0.844) for the ADM GBT model were the highest. The Brier scores of the ADM LR, GBT, and DL models were 0.149, 0.140, and 0.145, respectively. The AUROC (0.931, 95% CI 0.911-0.949) was the highest for the 24H DL model and the AUPRC (0.842, 95% CI 0.792-0.886) was the highest for the 24H LR model. CONCLUSION: Our early prediction models based on data obtained upon ICU admission could achieve good performance in predicting delirium occurred within 48 h after ICU admission. Our 24-h models can improve delirium prediction for patients discharged >1 day after ICU admission.

Clinical Trajectories and Causes of Death in Septic Patients with a Low APACHE II Score.

Clinical course and mortality in septic patients with low disease severity remain poorly understood and is worth further investigation. We enrolled septic patients admitted to intensive care units (ICUs) between 2010 and 2014 with Acute Physiology and Chronic Health Evaluation II (APACHE II) scores of ≤15. We sought to determine their clinical trajectories and causes of death, and to analyze risk factors associated with in-hospital mortality. A total of 352 patients were included, of whom 89 (25%) did not survive to hospital discharge, at a rate higher than predicted (<21%) by the APACHE II score. Approximately one third (31/89) of non-survivors succumbed to index sepsis; however, more patients (34/89) died of subsequent sepsis. New-onset ICU sepsis developed in 99 (28%) patients and was an independent risk factor for mortality. In addition, septic patients with comorbid malignancy or index infection acquired in the hospital settings were more likely to have in-hospital mortality than those without. In conclusion, septic patients with low APACHE II scores were at a higher mortality risk than expected, and subsequent sepsis rather than index sepsis was the primary cause of death. This study provides insight into unexpected clinical trajectories and outcomes of septic patients with low disease severity at ICU admission and highlights the need for more research and clinical attention in this patient population.

Tongue weakness and somatosensory disturbance following oral endotracheal extubation.

The tongue plays important roles in mastication, swallowing, and speech, but its sensorimotor function might be affected by endotracheal intubation. The objective of this pilot study was to describe disturbances in the sensorimotor functions of the tongue over 14 days following oral endotracheal extubation. We examined 30 post-extubated patients who had prolonged (≥48 h) oral endotracheal intubation from six medical intensive care units. Another 36 patients were recruited and examined from dental and geriatric outpatient clinics served as a comparison group. Tongue strength was measured by the Iowa Oral Performance Instrument. Sensory disturbance of the tongue was measured by evaluating light touch sensation, oral stereognosis, and two-point discrimination with standardized protocols. Measurements were taken at three time points (within 48 h, and 7 and 14 days post-extubation) for patients with oral intubation but only once for the comparison group. The results show that independent of age, gender, tobacco used, and comorbidities, tongue strength was lower and its sensory functions were more impaired in patients who had oral intubation than in the comparison group. Sensory disturbances of the tongue gradually recovered, taking 14 days to be comparable with the comparison group, while weakness of the tongue persisted. In conclusion, patients with oral endotracheal intubation had weakness and somatosensory disturbances of the tongue lasting at least 14 days from extubation but whether is caused by intubation and whether is contributed to postextubation dysphagia should be further investigated.

Antimicrobial drug-resistant microbes associated with hospitalized community-acquired and healthcare-associated pneumonia: a multi-center study in Taiwan.

BACKGROUND/PURPOSE: Community-acquired pneumonia (CAP) and healthcare-associated pneumonia (HCAP) may be caused by potential antimicrobial drug-resistant (PADR) microbes. The aims of this study were to evaluate the incidences and risk factors associated with PADR microbes observed in patients with pneumonia occurring outside the hospital setting in Taiwan. METHODS: We conducted a retrospective study of patients with CAP or HCAP admitted to six medical centers in the northern, central, and southern regions of Taiwan in 2007. The pathogens were evaluated by microbiological specimens within 72 hours after admission. The patients' comorbidities, pathogens, and outcomes were evaluated. The risk factors of PADR microbes were identified by logistic regression analysis. RESULTS: The enrolled patients exhibited HCAP (n=713) and CAP (n=933). The pathogens associated with HCAP (n=383) and CAP (n=441) included Pseudomonas spp. (29%vs. 10%, p<0.001), Klebsiella spp. (24% vs. 25%, p=0.250), Escherichia coli (6% vs. 8%, p=0.369), Haemophilus influnezae (3% vs. 7%, p=0.041), Streptococcus pneumoniae (2% vs. 6%, p=0.003) and methicillin-resistant Staphylococcus aureus (MRSA) (8% vs. 4%, p=0.008). The core pathogens of CAP and HCAP differed among the three regions of Taiwan. PADR microbes, including Pseudomonas spp. (n=191), Acinetobacter spp. (n=41), MRSA (n=49) and cefotaxime- or ceftazidime-resistant Enterbacteriaceae (n=25), were isolated from 13% of patients with CAP and 23% of patients with HCAP. Previous hospitalization, and neoplastic and neurological diseases were significant risk factors for acquiring PADR microbes. CONCLUSION: PADR microbes were common in patients with HCAP and CAP in Taiwan. Broad-spectrum antibiotics targeting PADR microbes should be administered to patients who have undergone previous hospitalization and who exhibit neurological disorders and/or malignancies.

Serum soluble triggering receptor expressed on myeloid cells-1 in acute respiratory distress syndrome: a prospective observational cohort study.

BACKGROUND/PURPOSE: Serum soluble triggering receptor expressed on myeloid cells-1 (sTREM-1), a detector of acute inflammatory response to microbial products and a good marker for diagnosing sepsis and pneumonia, has not yet been described as a predictor for infection or a prognostic factor in patients with acute respiratory distress syndrome (ARDS). METHODS: This prospective observational cohort study enrolled 63 ventilated adult patients with ARDS; 50 as septic and 13 as non-septic, and followed them for 28 days in intensive care units at a university hospital in Taiwan. Serial serum sTREM-1 levels and cytokines, such as interleukin (IL)-1, IL-8, and tumor necrosis factor-α, on days 1, 3, 5, 7 and 14 were measured by an enzyme-linked immunosorbent assay. The association between biomarkers and clinical infectious diagnosis/outcome in ARDS was explored. RESULTS: Serum sTREM-1 and cytokine levels could not differentiate septic from non-septic ARDS. Serum log sTREM-1 and inflammatory cytokine levels were correlated positively (r = 0.325 for IL-1ß; r = 0.247 for IL-8; r = 0.480 for tumor necrosis factor-α). As prognostic factors, higher serum sTREM-1 level on day 1 and increasing levels over time, especially in the first 5 days, were independent predictors of mortality on day 28, using a multivariate Cox regression model. Serum sTREM-1 levels remained stable or even increased in the non-surviving patients, but decreased in the survivors. CONCLUSION: Serum sTREM-1 level might not be a reliable marker for infection in ARDS patients. However, as an inflammatory marker, initial serum sTREM-1 level and its trend over time, especially in the first 5 days, could be predictive of short-term mortality. A progressive decline in serum sTREM-1 levels during follow-up indicates a favorable outcome, whereas persistently elevated sTREM-1 indicates a poor prognosis and should lead to a re-evaluation of therapy.

Impact of therapeutic interventions on survival of patients with hepatic hydrothorax.

BACKGROUND/PURPOSE: Hepatic hydrothorax is an uncommon but important complication of liver cirrhosis. The optimal management of this condition remains unclear. This retrospective study evaluated the impact of therapeutic interventions on the outcome of patients with hepatic hydrothorax. METHODS: From August 1996 to March 2004, the medical charts of 52 patients with hepatic hydrothorax in the National Taiwan University Hospital were reviewed. Treatment methods, outcome of interventions, and survival time were described and analyzed. RESULTS: At the time of diagnosis, four patients were Child-Pugh class A, 20 were class B, and 28 were class C. Twenty-eight (53.8%) patients received supportive care with thoracentesis for symptom relief. Among the other 24 patients, 16 (30.8%) were treated by chemical pleurodesis, 14 (26.9%) underwent surgical interventions, and six (11.5%) received both interventions. Intervention success, defined as resolution of hydrothorax for at least 3 months after the procedure, was achieved in 37.5% and 42.9% of patients who underwent chemical pleurodesis and surgery, respectively, with an overall success rate of 50%. The median survival of all patients was 8.6 months (range, 0.2-77.6 months). The median survival of patients with intervention success (22.5 months) was significantly longer than those with intervention failure (5.4 months) and supportive care (6.3 months). Multivariate analysis showed that only intervention success (p = 0.010, hazard ratio = 0.25) was an independent predictor of survival. CONCLUSION: For patients with hepatic hydrothorax, aggressive medical or surgical intervention might improve survival over supportive management, especially when resolution of hydrothorax can be maintained for at least 3 months.