Ventilación mecánica en España, 1998-2016: cambios en la desconexión de la ventilación mecánica / Mechanical ventilation in Spain, 1998-2016: changes in the disconnection of mechanical ventilation

Objetivo Evaluar los cambios en la desconexión de la ventilación mecánica en España desde 1998 hasta 2016. Diseño Análisis post-hoc de 4 estudios de cohorte. Ámbito Un total de 138 UCI. Enfermos Un total de 2.141 enfermos extubados de forma programada. Intervenciones Ninguna. Variables de interés principales Demográficas, motivo de ventilación mecánica, complicaciones, métodos para la desconexión, fracaso del primer intento de desconexión, duración de la desconexión, reintubación, traqueotomía post-reintubación, estancia y mortalidad en la UCI. Resultados Se observa un aumento significativo (p<0,001) en la presión de soporte como técnica de desconexión. Ha aumentado, a lo largo del tiempo, la probabilidad ajustada de utilizar la presión de soporte progresivamente decreciente frente a una prueba de ventilación espontánea, tanto para el primer intento de desconexión (referencia estudio de 1998: odds ratio 0,99 en 2004, 0,57 en 2010 y 2,43 en 2016) como para la desconexión difícil/prolongada (referencia estudio de 1998: odds ratio 2,29 en 2004, 1,23 en 2010 y 2,54 en 2016). La proporción de extubación tras el primer intento de desconexión ha aumentado con el tiempo. Hay una disminución del tiempo dedicado a la desconexión (desde un 45% en 1998 hasta un 36% en 2016). Sin embargo, no ha disminuido la duración en la desconexión difícil/prolongada (mediana 3 días en todos los estudios, p=0,435). Conclusiones Ha habido cambios significativos en el modo de desconexión de la ventilación mecánica, con un aumento progresivo del uso de la presión de soporte. Se han observado mínimos cambios en los desenlaces (AU)

Purpose To evaluate changes in the disconnection of mechanical ventilation in Spain from 1998 to 2016. Design Post-hoc analysis of four cohort studies. Ambit 138 Spanish ICUs. Patients 2141 patients scheduled extubated. Interventions None. Variables of interest Demographics, reason for mechanical ventilation, complications, methods for disconnection, failure on the first attempt at disconnection, duration of weaning, reintubation, post-reintubation tracheotomy, ICU stay and mortality. Results There was a significant increase (p<0.001) in the use of gradual reduction of support pressure. The adjusted probability of using the gradual reduction in pressure support versus a spontaneous breathing trial has increased over time, both for the first attempt at disconnection (taking the 1998 study as a reference: odds ratio 0.99 in 2004, 0.57 in 2010 and 2.43 in 2016) and for difficult/prolonged disconnection (taking the 1998 study as a reference: odds ratio 2.29 in 2004, 1.23 in 2010 and 2.54 in 2016). The proportion of patients extubated after the first attempt at disconnection has increased over time. There is a decrease in the ventilation time dedicated to weaning (from 45% in 1998 to 36% in 2016). However, the duration in difficult/prolonged weaning has not decreased (median 3 days in all studies, p=0.435). Conclusions There have been significant changes in the mode of disconnection of mechanical ventilation, with a progressive increase in the use of gradual reduction of pressure support. No relevant changes in outcomes have been observed (AU)

Mechanical ventilation in Spain, 1998-2016: Changes in the disconnection of mechanical ventilation.

PURPOSE: To evaluate changes in the disconnection of mechanical ventilation in Spain from 1998 to 2016. DESIGN: Post-hoc analysis of four cohort studies. AMBIT: 138 Spanish ICUs. PATIENTS: 2141 patients scheduled extubated. INTERVENTIONS: None. VARIABLES OF INTEREST: Demographics, reason for mechanical ventilation, complications, methods for disconnection, failure on the first attempt at disconnection, duration of weaning, reintubation, post-reintubation tracheotomy, ICU stay and mortality. RESULTS: There was a significant increase (p < 0.001) in the use of gradual reduction of support pressure. The adjusted probability of using the gradual reduction in pressure support versus a spontaneous breathing trial has increased over time, both for the first attempt at disconnection (taking the 1998 study as a reference: odds ratio 0.99 in 2004, 0.57 in 2010 and 2.43 in 2016) and for difficult/prolonged disconnection (taking the 1998 study as a reference: odds ratio 2.29 in 2004, 1.23 in 2010 and 2.54 in 2016). The proportion of patients extubated after the first attempt at disconnection has increased over time. There is a decrease in the ventilation time dedicated to weaning (from 45% in 1998 to 36% in 2016). However, the duration in difficult/prolonged weaning has not decreased (median 3 days in all studies, p = 0.435). CONCLUSIONS: There have been significant changes in the mode of disconnection of mechanical ventilation, with a progressive increase in the use of gradual reduction of pressure support. No relevant changes in outcomes have been observed.

Mechanical ventilation in Spain, 1998-2016: changes in the disconnection of mechanical ventilation. / Ventilación mecánica en España, 1998-2016: cambios en la desconexión de la ventilación mecánica.

PURPOSE: To evaluate changes in the disconnection of mechanical ventilation in Spain from 1998 to 2016. DESIGN: Post-hoc analysis of four cohort studies. AMBIT: 138 Spanish ICUs. PATIENTS: 2141 patients scheduled extubated. INTERVENTIONS: None. VARIABLES OF INTEREST: Demographics, reason for mechanical ventilation, complications, methods for disconnection, failure on the first attempt at disconnection, duration of weaning, reintubation, post-reintubation tracheotomy, ICU stay and mortality. RESULTS: There was a significant increase (p<0.001) in the use of gradual reduction of support pressure. The adjusted probability of using the gradual reduction in pressure support versus a spontaneous breathing trial has increased over time, both for the first attempt at disconnection (taking the 1998 study as a reference: odds ratio 0.99 in 2004, 0.57 in 2010 and 2.43 in 2016) and for difficult/prolonged disconnection (taking the 1998 study as a reference: odds ratio 2.29 in 2004, 1.23 in 2010 and 2.54 in 2016). The proportion of patients extubated after the first attempt at disconnection has increased over time. There is a decrease in the ventilation time dedicated to weaning (from 45% in 1998 to 36% in 2016). However, the duration in difficult/prolonged weaning has not decreased (median 3 days in all studies, p=0.435). CONCLUSIONS: There have been significant changes in the mode of disconnection of mechanical ventilation, with a progressive increase in the use of gradual reduction of pressure support. No relevant changes in outcomes have been observed.

Mechanical ventilation in Spain, 1998-2016: Epidemiology and outcomes. / Ventilación mecánica en España, 1998-2016: epidemiología y desenlaces.

PURPOSE: To evaluate changes in the epidemiology of mechanical ventilation in Spain from 1998 to 2016. DESIGN: A post hoc analysis of four cohort studies was carried out. SETTING: A total of 138 Spanish ICUs. PATIENTS: A sample of 4293 patients requiring invasive mechanical ventilation for more than 12h or noninvasive ventilation for more than 1h. INTERVENTIONS: None. VARIABLES OF INTEREST: Demographic variables, reason for mechanical ventilation, variables related to ventilatory support (ventilation mode, tidal volume, PEEP, airway pressures), complications during mechanical ventilation, duration of mechanical ventilation, ICU stay and ICU mortality. RESULTS: There was an increase in severity (SAPSII: 43 points in 1998 vs. 47 points in 2016), changes in the reason for mechanical ventilation (decrease in chronic obstructive pulmonary disease and acute respiratory failure secondary to trauma, and increase in neurological disease and post-cardiac arrest). There was an increase in noninvasive mechanical ventilation as the first mode of ventilatory support (p<0.001). Volume control ventilation was the most commonly used mode, with increased support pressure and pressure-regulated volume-controlled ventilation. A decrease in tidal volume was observed (9ml/kg actual b.w. in 1998 and 6.6ml/kg in 2016; p<0.001) as well as an increase in PEEP (3cmH2O in 1998 and 6cmH2O in 2016; p<0.001). In-ICU mortality decreased (34% in 1998 and 27% in 2016; p<0.001), without geographical variability (median OR 1.43; p=0.258). CONCLUSIONS: A significant decrease in mortality was observed in patients ventilated in Spanish ICUs. These changes in mortality could be related to modifications in ventilation strategy to minimize ventilator-induced lung injury.

Rapid response to COVID-19, escalation and de-escalation strategies to match surge capacity of Intensive Care beds to a large scale epidemic. / Respuesta rápida a COVID-19, estrategias de escalada y desescalada para ajustar la capacidad suplementaria de camas de UVI a una epidemia de gran magnitud.

BACKGROUND: A major challenge during the COVID-19 outbreak is the sudden increase in ICU bed occupancy rate. In this article we reviewed the strategies of escalation and de-escalation put in place at a large university hospital in Madrid during the COVID-19 outbreak, in order to meet the growing demand of ICU beds. MATERIALS AND METHODS: The data displayed originated from the hospital information system and the hospital contingency plan. RESULTS: The COVID-19 outbreak produced a surge of ICU patients which saturated the available ICU capacity within a few days. A total of four new ICUs had to be opened in order to accommodate all necessary new ICU admissions. Management challenges included infrastructure, material allocation and ICU staffing. Through the strategies put in place the hospital was able to generate a surge capacity of ICU beds of 340%, meet all requirements and also maintain minimal surgical activity. CONCLUSIONS: Hospital surge capacity is to date hardly quantifiable and often has to face physical limitations (material, personnel, spaces). However an extremely flexible and adaptable management strategy can help to overcome some of these limitations and stretch the system capacities during times of extreme need.

Compliance-guided versus FiO2-driven positive-end expiratory pressure in patients with moderate or severe acute respiratory distress syndrome according to the Berlin definition.

OBJECTIVE: To study the effect of setting positive end-expiratory pressure (PEEP) in an individualized manner (based on highest static compliance) compared to setting PEEP according to FiO2 upon mortality at 28 and 90 days, in patients with different severity acute respiratory distress syndrome (ARDS). SETTING: A Spanish medical-surgical ICU. DESIGN: A post hoc analysis of a randomized controlled pilot study. PATIENTS: Patients with ARDS. INTERVENTIONS: Ventilation with low tidal volumes and pressure limitation at 30cmH2O, randomized in two groups according to the method used to set PEEP: FiO2-guided PEEP group according to FiO2 applied and compliance-guided group according to the highest compliance. PRIMARY VARIABLES OF INTEREST: Demographic data, risk factors and severity of ARDS, APACHE II and SOFA scores, daily Lung Injury Score, ventilatory measurements, ICU and hospital stay, organ failure and mortality at day 28 and 90 after inclusion. RESULTS: A total of 159 patients with ARDS were evaluated, but just 70 patients were included. Severe ARDS patients showed more organ dysfunction-free days at 28 days (12.83±10.70 versus 3.09±7.23; p=0.04) and at 90 days (6.73±22.31 vs. 54.17±42.14, p=0.03), and a trend toward lower 90-days mortality (33.3% vs. 90.9%, p=0.02), when PEEP was applied according to the best static compliance. Patients with moderate ARDS did not show these effects. CONCLUSIONS: In patients with severe ARDS, individualized PEEP selection based on the best static compliance was associated to lower mortality at 90 days, with an increase in organ dysfunction-free days at 28 and 90 days.

Alteraciones tiroideas: ¿Predictores de mortalidad en Cuidados Intensivos? / Thyroid disorders: Predictors of mortality in Intensive Care?

Introducción: El objetivo del estudio es describir y analizar la función tiroidea en el paciente crítico. Describir si algún patrón se asocia a una mayor tasa de mortalidad. Métodos: Se analizó a todos los pacientes ingresados en nuestra Unidad de Cuidados Intensivos, entre enero de 2015 y agosto de 2016, y que permanecieron allí, al menos, siete días. Resultados: Se incluyeron 242 pacientes. Se hallaron diferencias significativas en los valores medios de los índices de gravedad entre los no supervivientes y los supervivientes: SOFA (10,45 vs. 7,9); APACHE II (24,42 vs. 20,71); SAPS II (63,14 vs. 50,69). Se encontraron diferencias estadísticamente significativas en los valores medios de T3 en el grupo de supervivientes y no supervivientes: 1,5 pg/ml vs. 1,15 pg/ml (p <0,001; IC95% 0,224 ± 0,487). No hubo diferencias estadísticamente significativas en los valores medios de T4 y TSH. Al realizar el subanálisis según grupo de ingreso, no se hallaron diferencias estadísticamente significativas entre las cifras de TSH, T3 o T4. Sí hubo diferencias significativas en los valores medios de T3 en la mayor parte de los subgrupos. Conclusiones: Se hallaron diferencias estadísticamente significativas entre los valores medios de T3 en el grupo de supervivientes y no supervivientes. Los valores de T3 parecen asociarse a la mortalidad. Su descenso no parece asociarse a la enfermedad subyacente, sino a su gravedad.(AU)

Introduction: The aim of this study is to describe and analyse the thyroid function in the critically ill patient, and to describe if any pattern is associated with a higher mortality rate. Methods: Patients admitted to the Intensive Care Unit, between January 2015 and August 2016, with a stay of seven days or more, were enrolled. Results: Two hundred and forty-two patients were included. Significant differences were observed in the severity scores related to mortality during their stay in the Intensive Care Unit (no survivors vs. survivors): SOFA (10.45 vs. 7.9); APACHE II (24.42 vs. 20.71); SAPS II (63.14 vs. 50.69). Statistically significant differences were observed in the mean values of T3 between survivors and non-survivors: 1.5 pg/ml vs. 1.15 pg/ml (p <0.001; CI95% 0.224 ± 0.487). There were no statistically significant differences in the mean values of T4 and TSH. After subgroup analysis according to the admission group, no significant differences among the TSH, T3 and T4 values were detected. However a statistically difference in T3 average value was found in most subgroups. Conclusions: A statistically significant difference was found in mean T3 values in survivors and non-survivors. T3 concentration appears to be associated with mortality. Decrease of this thyroid hormone does not seem to associate with the underlying disease, but with its severity.(AU)

Mortality and functional status at one-year of follow-up in elderly patients with prolonged ICU stay. / Mortalidad y estado funcional al año de pacientes ancianos con ingreso prolongado en una unidad de cuidados intensivos.

OBJECTIVE: To evaluate mortality and functional status at one year of follow-up in patients>75 years of age who survive Intensive Care Unit (ICU) admission of over 14 days. DESIGN: A prospective observational study was carried out. SETTING: A Spanish medical-surgical ICU. PATIENTS: Patients over 75 years of age admitted to the ICU. PRIMARY VARIABLES OF INTEREST: ICU admission: demographic data, baseline functional status (Barthel index), baseline mental status (Red Cross scale of mental incapacity), severity of illness (APACHE II and SOFA), stay and mortality. One-year follow-up: hospital stay and mortality, functional and mental status, and one-year follow-up mortality. RESULTS: A total of 176 patients were included, of which 22 had a stay of over 14 days. Patients with prolonged stay did not show more ICU mortality than those with a shorter stay in the ICU (40.9% vs 25.3% respectively, P=.12), although their hospital (63.6% vs 33.8%, P<.01) and one-year follow-up mortality were higher (68.2% vs 41.2%, P=.02). Among the survivors, one-year mortality proved similar (87.5% vs 90.6%, P=.57). These patients presented significantly greater impairment of functional status at hospital discharge than the patients with a shorter ICU stay, and this difference persisted after three months. The levels of independence at one-year follow-up were never similar to baseline. No such findings were observed in relation to mental status. CONCLUSIONS: Patients over 75 years of age with a ICU stay of more than 14 days have high hospital and one-year follow-up mortality. Patients who survive to hospital admission did not show greater mortality, though their functional dependency was greater.

Individualized positive end-expiratory pressure application in patients with acute respiratory distress syndrome.

Current treatment of acute respiratory distress syndrome is based on ventilatory support with a lung protective strategy, avoiding the development of iatrogenic injury, including ventilator-induced lung injury. One of the mechanisms underlying such injury is atelectrauma, and positive end-expiratory pressure (PEEP) is advocated in order to avoid it. The indicated PEEP level has not been defined, and in many cases is based on the patient oxygen requirements for maintaining adequate oxygenation. However, this strategy does not consider the mechanics of the respiratory system, which varies in each patient and depends on many factors-including particularly the duration of acute respiratory distress syndrome. A review is therefore made of the different methods for adjusting PEEP, focusing on the benefits of individualized application.