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BACKGROUND: The first aim of this study was to evaluate the capacity of electrical impedance tomography (EIT) to identify the effect of PEEP on regional ventilation distribution and the regional risk of collapse, overdistention, hypoventilation, and pendelluft in mechanically ventilated patients. The second aim was to evaluate the feasibility of EIT for estimating airway opening pressure (AOP). METHODS: The EIT signal was recorded both during baseline cyclic ventilation and slow insufflation for one breath for 9 subjects with moderate-to-severe ARDS. From these data, the AOP and volumes insufflated to lung regions with or without the risk of either collapse, overdistention, hypoventilation, or pendelluft were assessed at 3 PEEP levels (5, 10, and 15 cm H2O). PEEP levels were compared by Friedman analysis of variance and the AOP measured by EIT evaluated using an F-test and the Bland and Altman method. RESULTS: The volume for which there was no specific risk significantly decreased at the highest PEEP from 55 ± 31% tidal volume (VT) at PEEP 5 or 82 ± 18% VT at PEEP 10 to 10 ± 30% VT at PEEP 15 (P = .038 between PEEP 5 vs PEEP 15; P = .01 between PEEP 10 vs PEEP 15). The volume associated with overdistention significantly increased with increasing PEEP, whereas that associated with atelectrauma significantly decreased. Pendelluft significantly decreased with increasing PEEP: VT of 8.9 ± 18.6%, 3.6 ± 7.0%, and 3.2 ± 7.1% for PEEP 5, PEEP 10, and PEEP 15, respectively. The center of ventilation tended to increase in the dependent direction with higher PEEP. The AOPs assessed by EIT and from the pressure-volume curve were in good agreement (bias 0.48 cm H2O). CONCLUSIONS: Our results suggest that EIT could aid clinicians in making personalized and reasoned choices in setting the PEEP for subjects with ARDS.
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BACKGROUND: Previous retrospective research has shown that maintaining prone positioning (PP) for an average of 40 h is associated with an increase of survival rates in intubated patients with COVID-19-related acute respiratory distress syndrome (ARDS). This study aims to determine whether a cumulative PP duration of more than 32 h during the first 2 days of intensive care unit (ICU) admission is associated with increased survival compared to a cumulative PP duration of 32 h or less. METHODS: This study is an ancillary analysis from a previous large international observational study involving intubated patients placed in PP in the first 48 h of ICU admission in 149 ICUs across France, Belgium and Switzerland. Given that PP is recommended for a 16-h daily duration, intensive PP was defined as a cumulated duration of more than 32 h during the first 48 h, whereas standard PP was defined as a duration equal to or less than 32 h. Patients were followed-up for 90 days. The primary outcome was mortality at day 60. An Inverse Probability Censoring Weighting (IPCW) Cox model including a target emulation trial method was used to analyze the data. RESULTS: Out of 2137 intubated patients, 753 were placed in PP during the first 48 h of ICU admission. The intensive PP group (n = 79) had a median PP duration of 36 h, while standard PP group (n = 674) had a median of 16 h during the first 48 h. Sixty-day mortality rate in the intensive PP group was 39.2% compared to 38.7% in the standard PP group (p = 0.93). Twenty-eight-day and 90-day mortality as well as the ventilator-free days until day 28 were similar in both groups. After IPCW, there was no significant difference in mortality at day 60 between the two-study groups (HR 0.95 [0.52-1.74], p = 0.87 and HR 1.1 [0.77-1.57], p = 0.61 in complete case analysis or in multiple imputation analysis, respectively). CONCLUSIONS: This secondary analysis of a large multicenter European cohort of intubated patients with ARDS due to COVID-19 found that intensive PP during the first 48 h did not provide a survival benefit compared to standard PP.
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PURPOSE: Severe acute respiratory distress syndrome (ARDS) with PaO2/FiO2 < 80 mmHg is a life-threatening condition. The optimal management strategy is unclear. The aim of this meta-analysis was to compare the effects of low tidal volumes (Vt), moderate Vt, prone ventilation, and venovenous extracorporeal membrane oxygenation (VV-ECMO) on mortality in severe ARDS. METHODS: We performed a frequentist network meta-analysis of randomised controlled trials (RCTs) with participants who had severe ARDS and met eligibility criteria for VV-ECMO or had PaO2/FiO2 < 80 mmHg. We applied the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to discern the relative effect of interventions on mortality and the certainty of the evidence. RESULTS: Ten RCTs including 812 participants with severe ARDS were eligible. VV-ECMO reduces mortality compared to low Vt (risk ratio [RR] 0.77, 95% confidence interval [CI] 0.59-0.99, moderate certainty) and compared to moderate Vt (RR 0.75, 95% CI 0.57-0.98, low certainty). Prone ventilation reduces mortality compared to moderate Vt (RR 0.78, 95% CI 0.66-0.93, high certainty) and compared to low Vt (RR 0.81, 95% CI 0.63-1.02, moderate certainty). We found no difference in the network comparison of VV-ECMO compared to prone ventilation (RR 0.95, 95% CI 0.72-1.26), but inferences were based solely on indirect comparisons with very low certainty due to very wide confidence intervals. CONCLUSIONS: In adults with ARDS and severe hypoxia, both VV-ECMO (low to moderate certainty evidence) and prone ventilation (moderate to high certainty evidence) improve mortality relative to low and moderate Vt strategies. The impact of VV-ECMO versus prone ventilation remains uncertain.
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Oxigenación por Membrana Extracorpórea , Metaanálisis en Red , Respiración Artificial , Síndrome de Dificultad Respiratoria , Humanos , Oxigenación por Membrana Extracorpórea/métodos , Oxigenación por Membrana Extracorpórea/mortalidad , Síndrome de Dificultad Respiratoria/terapia , Síndrome de Dificultad Respiratoria/mortalidad , Síndrome de Dificultad Respiratoria/fisiopatología , Posición Prona/fisiología , Respiración Artificial/métodos , Respiración Artificial/estadística & datos numéricos , Posición Supina , Volumen de Ventilación Pulmonar/fisiología , Ensayos Clínicos Controlados Aleatorios como Asunto , Hipoxia/terapia , Hipoxia/mortalidadRESUMEN
BACKGROUND: Inhaled sedation during invasive mechanical ventilation in patients with acute respiratory distress syndrome (ARDS) has received increasing attention. However, inhaled sedation devices increase dead-space ventilation and an undesirable effect is the increase in minute ventilation needed to maintain CO2 removal. A consequence of raising minute ventilation is an increase in mechanical power (MP) that can promote lung injury. However, the effect of inhaled sedation devices on MP remains unknown. METHODS: We conducted a bench study to assess and compare the effects of three devices delivering inhaled sevoflurane currently available in ICU (AnaConDa-50 mL (ANA-50), AnaConDa-100 mL (ANA-100), and MIRUS) on MP by using a test lung model set with three compliances (20, 40, and 60 mL/cmH2O). We simulated lung-protective ventilation using a low tidal volume and two levels of positive end-expiratory pressure (5 and 15 cmH2O) under ambient temperature and dry conditions. Following the insertion of the devices, either the respiratory rate or tidal volume was increased in 15%-steps until end-tidal CO2 (EtCO2) returned to the baseline value. MP was calculated at baseline and after EtCO2 correction using a simplified equation. RESULTS: Following device insertion, the EtCO2 increase was significantly greater with MIRUS (+ 78 ± 13%) and ANA-100 (+ 100 ± 11%) than with ANA-50 (+ 49 ± 7%). After normalizing EtCO2 by adjusting minute ventilation, MP significantly increased by more than 50% with all inhaled sedation devices compared to controls. The lowest increase in MP was observed with ANA-50 (p < 0.05 versus ANA-100 and MIRUS). The Costa index, another parameter assessing the mechanical energy delivered to the lungs, calculated as driving pressure × 4 + respiratory rate, significantly increased by more than 20% in all experimental conditions. Additional experiments performed under body temperature, ambient pressure, and gas saturated with water vapor conditions, confirmed the main results with an increase in MP > 50% with all devices after normalizing EtCO2 by adjusting minute ventilation. CONCLUSION: Inhaled sedation devices substantially increased MP in this bench model of protective ventilation, which might limit their benefits in ARDS.
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Fluctuations of consciousness and their rhythmicities have been rarely studied in patients with a disorder of consciousness after acute brain injuries. 24-h assessment of brain (EEG), behaviour (eye-opening), and circadian (clock-controlled hormones secretion from urine) functions was performed in acute brain-injured patients. The distribution, long-term predictability, and rhythmicity (circadian/ultradian) of various EEG features were compared with the initial clinical status, the functional outcome, and the circadian rhythmicities of behaviour and clock-controlled hormones. Here we show that more physiological and favourable patterns of fluctuations are associated with a higher 24 h predictability and sharp up-and-down shape of EEG switches, reminiscent of the Flip-Flop model of sleep. Multimodal rhythmic analysis shows that patients with simultaneous circadian rhythmicity for brain, behaviour, and hormones had a favourable outcome. Finally, both re-emerging EEG fluctuations and homogeneous 24-h cycles for EEG, eye-opening, and hormones appeared as surrogates for preserved functionality in brainstem and basal forebrain, which are key prognostic factors for later improvement. While the recovery of consciousness has previously been related to a high short-term complexity, we suggest in this exploratory study the importance of the high predictability of the 24 h long-term generation of brain rhythms and highlight the importance of circadian body-brain rhythms in awakening.
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Trastornos de la Conciencia , Estado de Conciencia , Humanos , Estado de Conciencia/fisiología , Ritmo Circadiano/fisiología , Sueño/fisiología , HormonasRESUMEN
Our goal was to investigate the effects of head-thorax elevation (HUP) during chest compressions (CC) on lung ventilation. A prospective study was performed on seven human cadavers. Chest was automatically compressed-decompressed in flat position and during progressive HUP from 18 to 35°. Lung ventilation was measured with electrical impedance tomography. In each cadaver, 5 sequences were randomly performed: one without CC at positive end-expiratory pressure (PEEP) 0cmH2O, 3 s with CC at PEEP0, 5 or 10cmH2O and 1 with CC and an impedance threshold device at PEEP0cmH2O. The minimal-to-maximal change in impedance (VTEIT in arbitrary unit a.u.) and the minimal impedance in every breathing cycle (EELI) the) were compared between flat, 18°, and 35° in each sequence by a mixed-effects model. Values are expressed as median (1st-3rd quartiles). With CC, between flat, 18° and 35° VTEIT decreased at each level of PEEP. It was 12416a.u. (10,689; 14,442), 11,239 (7667; 13,292), and 6457 (4631; 9516), respectively, at PEEP0. The same was true with the impedance threshold device. EELI/VTEIT significantly decreased from - 0.30 (- 0.40; - 0.15) before to - 1.13 (- 1.70; - 0.61) after the CC (P = 0.009). With HUP lung ventilation decreased with CC as compared to flat position. CC are associated with decreased in EELI.
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Respiración con Presión Positiva , Respiración Artificial , Humanos , Estudios Prospectivos , Respiración con Presión Positiva/efectos adversos , Tórax/diagnóstico por imagen , Impedancia Eléctrica , Cadáver , PulmónRESUMEN
During the COVID-19 pandemic, prone positioning (PP) emerged as a widely used supportive therapy for patients with acute hypoxemic respiratory failure caused by COVID-19 infection. In particular, awake PP (APP)-the placement of non-intubated patients in the prone position-has gained popularity and hence is detailed first herein. This review discusses recent publications on the use of PP for non-intubated and intubated subjects with COVID-19, highlighting the physiological responses, clinical outcomes, influential factors affecting treatment success, and strategies to improve adherence with APP. The use of prolonged PP and the use of PP for patients undergoing extracorporeal membrane oxygenation are also presented.
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COVID-19 , Oxigenación por Membrana Extracorpórea , Humanos , COVID-19/complicaciones , Pandemias , Posición Prona , PacientesRESUMEN
BACKGROUND: Awake prone positioning (APP) of non-intubated patients with acute hypoxaemic respiratory failure (AHRF) has been inconsistently adopted into routine care of patients with COVID-19, likely due to apparent conflicting evidence from recent trials. This short guideline aims to provide evidence-based recommendations for the use of APP in various clinical scenarios. METHODS: An international multidisciplinary panel, assembled for their expertise and representativeness, and supported by a methodologist, performed a systematic literature search, summarized the available evidence derived from randomized clinical trials, and developed recommendations using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology. RESULTS: The panel strongly recommends that APP rather than standard supine care be used in patients with COVID-19 receiving advanced respiratory support (high-flow nasal cannula, continuous positive airway pressure or non-invasive ventilation). Due to lack of evidence from randomized controlled trials, the panel provides no recommendation on the use of APP in patients with COVID-19 supported with conventional oxygen therapy, nor in patients with AHRF due to causes other than COVID-19. CONCLUSION: APP should be routinely implemented in patients with COVID-19 receiving advanced respiratory support.
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COVID-19 , Insuficiencia Respiratoria , Humanos , COVID-19/terapia , Posición Prona , Vigilia , Oxígeno , Insuficiencia Respiratoria/terapiaRESUMEN
The aim of these guidelines is to update the 2017 clinical practice guideline (CPG) of the European Society of Intensive Care Medicine (ESICM). The scope of this CPG is limited to adult patients and to non-pharmacological respiratory support strategies across different aspects of acute respiratory distress syndrome (ARDS), including ARDS due to coronavirus disease 2019 (COVID-19). These guidelines were formulated by an international panel of clinical experts, one methodologist and patients' representatives on behalf of the ESICM. The review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and grade recommendations and the quality of reporting of each study based on the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) network guidelines. The CPG addressed 21 questions and formulates 21 recommendations on the following domains: (1) definition; (2) phenotyping, and respiratory support strategies including (3) high-flow nasal cannula oxygen (HFNO); (4) non-invasive ventilation (NIV); (5) tidal volume setting; (6) positive end-expiratory pressure (PEEP) and recruitment maneuvers (RM); (7) prone positioning; (8) neuromuscular blockade, and (9) extracorporeal life support (ECLS). In addition, the CPG includes expert opinion on clinical practice and identifies the areas of future research.
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COVID-19 , Síndrome de Dificultad Respiratoria , Adulto , Humanos , COVID-19/terapia , Respiración Artificial , Respiración con Presión Positiva , Síndrome de Dificultad Respiratoria/terapia , Cuidados CríticosRESUMEN
Acute brain injury (ABI) covers various clinical entities that may require invasive mechanical ventilation (MV) in the intensive care unit (ICU). The goal of MV, which is to protect the lung and the brain from further injury, may be difficult to achieve in the most severe forms of lung or brain injury. This narrative review aims to address the respiratory issues and ventilator management, specific to ABI patients in the ICU.
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Lesiones Encefálicas , Encéfalo , Humanos , Lesiones Encefálicas/terapia , Unidades de Cuidados Intensivos , Pacientes , Respiración ArtificialRESUMEN
The health crisis has had a strong impact on intensive care units. The objective of this study was to investigate the experience of resuscitation physicians during the COVID-19 health crisis to understand the associated determinants of quality of life, burnout, and brownout. This qualitative, longitudinal study covered two periods (T1, February 2021, and T2, May 2021). The data were collected in individual semi-directed interviews with 17 intensive care physicians (ICPs) (T1). Nine of the latter also participated in a second interview (T2). The data were examined using grounded theory analysis. We identified a multiplication of burnout and brownout indicators and factors already known in intensive care. In addition, burnout and brownout indicators and factors specific to the COVID-19 crisis were added. The evolution of professional practices has disrupted the professional identity, the meaning of work, and the boundaries between private and professional life, leading to a brownout and blur-out syndrome. The added value of our study lies in identifying the positive effects of the crisis in the professional domain. Our study revealed indicators and factors of burnout and brownout associated with the crisis among ICPs. Finally, it highlights the beneficial effects of the COVID-19 crisis on work.
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Agotamiento Profesional , COVID-19 , Médicos , Humanos , Calidad de Vida , Estudios Longitudinales , COVID-19/epidemiología , Agotamiento Psicológico , Agotamiento Profesional/epidemiología , Cuidados Críticos , Encuestas y CuestionariosRESUMEN
BACKGROUND: The spontaneous breathing trial (SBT) is the final step of weaning from invasive mechanical ventilation. An SBT is aimed at predicting work of breathing (WOB) after extubation and, most importantly, a patient's eligibility for extubation. The optimal SBT modality remains debated. A high-flow oxygen (HFO) has been tested during SBT in clinical study only, which is why no definite conclusion can be drawn on its physiologic effects on the endotracheal tube. Our objective was to assess, on a bench, inspiratory tidal volume (VT), total PEEP, and WOB across 3 different SBT modalities: T-piece, 40 L/min HFO, and 60 L/min HFO. METHODS: A test lung model was set with 3 conditions of resistance and linear compliance, 3 inspiratory efforts (low, normal, and high), each at 2 breathing frequencies (low and high for 20 and 30 breaths/min, respectively). Pairwise comparisons and a quasi-Poisson generalized linear model that compared SBT modalities were performed. RESULTS: Inspiratory VT, total PEEP, and WOB differed from one SBT modality to another. Inspiratory VT remained higher with the T-piece than in the HFO independent of the mechanical condition, effort intensity, and breathing frequency (P < .001 in each comparison). WOB adjusted by the inspiratory VT was significantly lower during SBT performed with an HFO than when performed with the T-piece (P < .001 in each comparison). The total PEEP was significantly higher in the HFO at 60 L/min than in the other modalities (P < .001). The end points were significantly influenced by breathing frequency, effort intensity, and mechanical condition. CONCLUSIONS: With the same effort intensity and breathing frequency, inspiratory VT was higher in the T-piece than in the other modalities. Compared with the T-piece, WOB was significantly lower in the HFO condition and higher flow was a benefit. Based on the results of the present study, the HFO as an SBT modality would seem to require clinical testing.
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Extubación Traqueal , Respiración Artificial , Humanos , Modelos Lineales , Oxígeno , Cooperación del PacienteRESUMEN
Awake prone positioning (APP) of patients with acute hypoxaemic respiratory failure gained considerable attention during the early phases of the coronavirus disease 2019 (COVID-19) pandemic. Prior to the pandemic, reports of APP were limited to case series in patients with influenza and in immunocompromised patients, with encouraging results in terms of tolerance and oxygenation improvement. Prone positioning of awake patients with acute hypoxaemic respiratory failure appears to result in many of the same physiological changes improving oxygenation seen in invasively ventilated patients with moderate-severe acute respiratory distress syndrome. A number of randomised controlled studies published on patients with varying severity of COVID-19 have reported apparently contrasting outcomes. However, there is consistent evidence that more hypoxaemic patients requiring advanced respiratory support, who are managed in higher care environments and who can be prone for several hours, benefit most from APP use. We review the physiological basis by which prone positioning results in changes in lung mechanics and gas exchange and summarise the latest evidence base for APP primarily in COVID-19. We examine the key factors that influence the success of APP, the optimal target populations for APP and the key unknowns that will shape future research.
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COVID-19 , Síndrome de Dificultad Respiratoria , Insuficiencia Respiratoria , Humanos , Vigilia , Posición Prona/fisiología , Insuficiencia Respiratoria/diagnóstico , Insuficiencia Respiratoria/terapia , Pulmón , Posicionamiento del Paciente/métodosRESUMEN
INTRODUCTION: Lung protective ventilation (LPV) comprising low tidal volume (VT) and high positive end-expiratory pressure (PEEP) may compromise cerebral perfusion in acute brain injury (ABI). In patients with ABI, we investigated whether LPV is associated with increased intracranial pressure (ICP) and/or deranged cerebral autoregulation (CA), brain compensatory reserve and oxygenation. METHODS: In a prospective, crossover study, 30 intubated ABI patients with normal ICP and no lung injury were randomly assigned to receive low VT [6 ml/kg/predicted (pbw)]/at either low (5 cmH2O) or high PEEP (12 cmH2O). Between each intervention, baseline ventilation (VT 9 ml/kg/pbw and PEEP 5 cmH2O) were resumed. The safety limit for interruption of the intervention was ICP above 22 mmHg for more than 5 min. Airway and transpulmonary pressures were continuously monitored to assess respiratory mechanics. We recorded ICP by using external ventricular drainage or a parenchymal probe. CA and brain compensatory reserve were derived from ICP waveform analysis. RESULTS: We included 27 patients (intracerebral haemorrhage, traumatic brain injury, subarachnoid haemorrhage), of whom 6 reached the safety limit, which required interruption of at least one intervention. For those without intervention interruption, the ICP change from baseline to "low VT/low PEEP" and "low VT/high PEEP" were 2.2 mmHg and 2.3 mmHg, respectively, and considered clinically non-relevant. None of the interventions affected CA or oxygenation significantly. Interrupted events were associated with high baseline ICP (p < 0.001), low brain compensatory reserve (p < 0.01) and mechanical power (p < 0.05). The transpulmonary driving pressure was 5 ± 2 cmH2O in both interventions. Partial arterial pressure of carbon dioxide was kept in the range 34-36 mmHg by adjusting the respiratory rate, hence, changes in carbon dioxide were not associated with the increase in ICP. CONCLUSIONS: The present study found that most patients did not experience any adverse effects of LPV, neither on ICP nor CA. However, in almost a quarter of patients, the ICP rose above the safety limit for interrupting the interventions. Baseline ICP, brain compensatory reserve, and mechanical power can predict a potentially deleterious effect of LPV and can be used to personalize ventilator settings. Trial registration NCT03278769 . Registered September 12, 2017.
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Lesiones Encefálicas , Lesión Pulmonar , Humanos , Frecuencia Respiratoria , Dióxido de Carbono , Estudios Prospectivos , Estudios Cruzados , Volumen de Ventilación Pulmonar/fisiología , Lesiones Encefálicas/complicaciones , Lesiones Encefálicas/terapia , EncéfaloRESUMEN
BACKGROUND: Mechanical insufflation-exsufflation (MI-E) devices are used to improve airway clearance in individuals with acute respiratory failure. Some MI-E devices measure cough peak flow (CPF) during MI-E to optimize pressure adjustments. The aim was to compare CPF and effective cough volume (ECV: volume expired/coughed > 3 L/s) measurements between 4 MI-E devices under simulated conditions of stable versus collapsed airway. METHODS: Four MI-E devices were tested on the bench. Each device was connected via a standard circuit to a collapsible tube placed in an airtight chamber that was attached to a lung model with adjustable compliance and resistance. Pressure was measured upstream and downstream the collapsing tube; air flow was measured between the chamber and the lung model. Each device was tested in 2 conditions: collapse condition (0 cm H2O) and no-collapse condition (-70 cm H2O). For each condition, 6 combinations of inspiratory/expiratory pressures were applied. CPF was measured at the "mouth level" by the device built-in flow meter and at the "tracheal level" by a dedicated pneumotachograph. Comparisons were performed with non-parametric tests. RESULTS: CPF values measured at the tracheal level and ECV values differed between devices for each inspiratory/expiratory pressure in the collapse and no-collapse conditions (P < .001). CPF values were significantly lower at the tracheal level in the collapse as compared with the no-collapse condition (P < .001 for each device), whereas they were higher at the mouth level (P < .05) for 3 of the 4 devices. CONCLUSIONS: CPF values differed significantly across MI-E devices, highlighting limitation(s) of using only CPF values to determine cough effectiveness. In simulated of airway collapse, CPF increased at the mouth, whereas it decreased at the tracheal level.
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Tos , Insuflación , Humanos , Respiración Artificial , Pulmón , Ápice del Flujo EspiratorioRESUMEN
Rationale: Nurse-to-nurse familiarity at work should strengthen the components of teamwork and enhance its efficiency. However, its impact on patient outcomes in critical care remains poorly investigated. Objectives: To explore the role of nurse-to-nurse familiarity on inpatient deaths during ICU stay. Methods: This was a retrospective observational study in eight adult academic ICUs between January 1, 2011 and December 31, 2016. Measurements and Main Results: Nurse-to-nurse familiarity was measured across day and night 12-hour daily shifts as the mean number of previous collaborations between each nursing team member during previous shifts within the given ICU (suboptimal if <50). Primary outcome was a shift with at least one inpatient death, excluding death of patients with a decision to forego life-sustaining therapy. A multiple modified Poisson regression was computed to identify the determinants of mortality per shift, taking into account ICU, patient characteristics, patient-to-nurse and patient-to-assistant nurse ratios, nurse experience length, and workload. A total of 43,479 patients were admitted, of whom 3,311 (8%) died. The adjusted model showed a lower risk of a shift with mortality when nurse-to-nurse familiarity increased in the shift (relative risk, 0.90; 95% confidence interval per 10 shifts, 0.82-0.98; P = 0.012). Low nurse-to-nurse familiarity during the shift combined with suboptimal patient-to-nurse and patient-to-assistant nurse ratios (suboptimal if >2.5 and >4, respectively) were associated with increased risk of shift with mortality (relative risk, 1.84; 95% confidence interval, 1.15-2.96; P < 0.001). Conclusions: Shifts with low nurse-to-nurse familiarity were associated with an increased risk of patient deaths.
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Enfermedad Crítica , Admisión y Programación de Personal , Adulto , Humanos , Mortalidad Hospitalaria , Carga de Trabajo , Unidades de Cuidados IntensivosRESUMEN
BACKGROUND: Automatic tube compensation (ATC) is an option available in any ICU ventilator that compensates for the resistive pressure drop due to the endotracheal tube. The goal of the present study was to compare ATC to other patient triggered modes of support in terms of spontaneous breathing trial (SBT) and extubation success. METHODS: Two authors (JB and PCF), independently and blinded to each other, searched through PubMed, Web of Science, and Cochrane from inception-May 26, 2021, with the following search terms entered as MeSH terms in all fields: "Automatic Tube Compensation." INCLUSION CRITERIA: randomized studies that included subjects > 16 y old undergoing an SBT. EXCLUSION CRITERIA: crossover studies, pediatric studies, animal studies, or experimental studies on test lungs or on computer simulation; other languages than French, Spanish, or English; studies not published in a full-text format (eg, abstract or letter); and reviews. A frequentist network meta-analysis was conducted with the aim to investigate the effectiveness of ATC on SBT and extubation outcomes. SBT was defined as successful if patients could tolerate the SBT based on predetermined criteria, whether it was followed by extubation. Successful extubation was defined as the absence of re-intubation, noninvasive ventilation, or signs of respiratory distress within the 48 h after extubation. The pooled analyses used random-effect models, and the effect size was expressed as relative risk or mean difference for categorical and continuous variables, respectively. P-scores were used to rank all treatments and to identify the intervention with the highest probability of being the best. RESULTS: Of the 234 retrieved papers, 7 met the inclusion criteria. In terms of SBT success, ATC100+PEEP < 7.5 and PS10+PEEP < 7.5 were superior to T-piece. Likewise, PS10+PEEP < 7.5 was the intervention with the highest probability of being the best (P-score: 0.90). In terms of extubation success, ATC100+PEEP < 7.5 cm H2O was significantly better than PEEP < 7.5 and T-piece. Likewise, it had the highest probability of being the best (P-score= 0.90). CONCLUSIONS: ATC is the modality with the highest probability of extubation success but not in terms of SBT success.