Effects of mechanical in-exsufflation in preventing postextubation acute respiratory failure in intensive care acquired weakness patients: a randomized controlled trial.

OBJECTIVE: We hypothesized that the use of mechanical insufflation-exsufflation can reduce the incidence of acute respiratory failure within the 48-hour post-extubation period in intensive care unit-acquired weakness patients. METHODS: This was a prospective randomized controlled open-label trial. Patients diagnosed with intensive care unit-acquired weakness were consecutively enrolled based on a Medical Research Council score ≤ 48/60. The patients randomly received two daily sessions; in the control group, conventional chest physiotherapy was performed, while in the intervention group, chest physiotherapy was associated with mechanical insufflation-exsufflation. The incidence of acute respiratory failure within 48 hours of extubation was evaluated. Similarly, the reintubation rate, intensive care unit length of stay, mortality at 28 days, and survival probability at 90 days were assessed. The study was stopped after futility results in the interim analysis. RESULTS: We included 122 consecutive patients (n = 61 per group). There was no significant difference in the incidence of acute respiratory failure between treatments (11.5% control group versus 16.4%, intervention group; p = 0.60), the need for reintubation (3.6% versus 10.7%; p = 0.27), mean length of stay (3 versus 4 days; p = 0.33), mortality at Day 28 (9.8% versus 15.0%; p = 0.42), or survival probability at Day 90 (21.3% versus 28.3%; p = 0.41). CONCLUSION: Mechanical insufflation-exsufflation combined with chest physiotherapy seems to have no impact in preventing postextubation acute respiratory failure in intensive care unit-acquired weakness patients. Similarly, mortality and survival probability were similar in both groups. Nevertheless, given the early termination of the trial, further clinical investigation is strongly recommended. CLINICAL TRIALS REGISTER: NCT01931228.

Effects of mechanical in-exsufflation in preventing postextubation acute respiratory failure in intensive care acquired weakness patients: a randomized controlled trial / Efeitos da insuflação-exsuflação mecânica na prevenção da insuficiência respiratória aguda pós-extubação em pacientes com fraqueza adquirida em terapia intensiva: um estudo controlado e randomizado

ABSTRACT Objective: We hypothesized that the use of mechanical insufflation-exsufflation can reduce the incidence of acute respiratory failure within the 48-hour post-extubation period in intensive care unit-acquired weakness patients. Methods: This was a prospective randomized controlled open-label trial. Patients diagnosed with intensive care unit-acquired weakness were consecutively enrolled based on a Medical Research Council score ≤ 48/60. The patients randomly received two daily sessions; in the control group, conventional chest physiotherapy was performed, while in the intervention group, chest physiotherapy was associated with mechanical insufflation-exsufflation. The incidence of acute respiratory failure within 48 hours of extubation was evaluated. Similarly, the reintubation rate, intensive care unit length of stay, mortality at 28 days, and survival probability at 90 days were assessed. The study was stopped after futility results in the interim analysis. Results: We included 122 consecutive patients (n = 61 per group). There was no significant difference in the incidence of acute respiratory failure between treatments (11.5% control group versus 16.4%, intervention group; p = 0.60), the need for reintubation (3.6% versus 10.7%; p = 0.27), mean length of stay (3 versus 4 days; p = 0.33), mortality at Day 28 (9.8% versus 15.0%; p = 0.42), or survival probability at Day 90 (21.3% versus 28.3%; p = 0.41). Conclusion: Mechanical insufflation-exsufflation combined with chest physiotherapy seems to have no impact in preventing postextubation acute respiratory failure in intensive care unit-acquired weakness patients. Similarly, mortality and survival probability were similar in both groups. Nevertheless, given the early termination of the trial, further clinical investigation is strongly recommended. Clinical Trials Register: NCT 01931228

RESUMO Objetivo: Verificar se o uso de insuflação-exsuflação mecânica pode reduzir a incidência da insuficiência respiratória aguda no período de 48 horas pós-extubação em pacientes com fraqueza adquirida em unidades de terapia intensiva. Métodos: Estudo prospectivo, randomizado, controlado e aberto. Os pacientes diagnosticados com fraqueza adquirida em unidade de terapia intensiva foram incluídos consecutivamente, com base em uma pontuação do Medical Research Council ≤ 48/60. Os pacientes receberam aleatoriamente duas sessões diárias; no grupo controle, realizou-se fisioterapia torácica convencional, enquanto no grupo intervenção, combinou-se fisioterapia torácica com insuflação-exsuflação mecânica. Avaliou-se a incidência de insuficiência respiratória aguda dentro de 48 horas após a extubação. Da mesma forma, avaliaram-se a taxa de reintubação, o tempo de permanência na unidade de terapia intensiva, a mortalidade aos 28 dias e a probabilidade de sobrevida aos 90 dias. O estudo foi interrompido após resultados de futilidade na análise intermediária. Resultados: Incluímos 122 pacientes consecutivos (n = 61 por grupo). Não houve diferença significativa na incidência de insuficiência respiratória aguda entre os tratamentos (11,5% no grupo controle versus 16,4% no grupo intervenção; p = 0,60), na necessidade de reintubação (3,6% versus 10,7%; p = 0,27), no tempo médio de internação (3 versus 4 dias; p = 0,33), na mortalidade aos 28 dias (9,8% versus 15,0%; p = 0,42) ou na probabilidade de sobrevida aos 90 dias (21,3% versus 28,3%; p = 0,41). Conclusão: A insuflação-exsuflação mecânica associada à fisioterapia torácica parece não ter impacto na prevenção da insuficiência respiratória aguda pós-extubação em pacientes com fraqueza adquirida na unidade de terapia intensiva. Da mesma forma, a mortalidade e a probabilidade de sobrevida foram semelhantes em ambos os grupos. No entanto, devido ao término precoce do estudo, recomenda-se enfaticamente uma investigação clínica mais aprofundada. Registro Clinical Trials: NCT 01931228

Laparoscopic intraperitoneal versus enhanced-view totally extraperitoneal retromuscular mesh repair for ventral hernia: a retrospective cohort study.

BACKGROUND: Laparoscopic enhanced-view totally extraperitoneal retromuscular repair (eTEP-RM) was recently introduced as a new technique for ventral hernia repair. The aim of the current study was to examine the outcomes of laparoscopic eTEP-RM compared with laparoscopic IPOM for patients with primary ventral and incisional hernia. METHODS: This was a retrospective cohort study of patients undergoing laparoscopic ventral hernia repair at a single University Hospital from June 2017 to November 2020. Medical charts of all patients subjected to IPOM and eTEP-RM were evaluated to identify patient- and procedure related variables, as well as postoperative 30-day outcomes. RESULTS: A total of 72 patients were included in the study, 43 and 29 of whom underwent IPOM and eTEP-RM repair, respectively. Patient demographics showed no differences in terms of gender, age, smoking and comorbidity. The median age was 57 years and body mass index 30.5 kg/m2. The rate of patients with incisional hernia was higher in the IPOM group (39.5% vs. 20.7%, p = 0.154). There was no difference in horizontal and vertical hernia size defect. The duration of surgery was significantly shorter for IPOM (mean 82.4 vs. 103.4 min, p = 0.010), whereas the length of stay was significantly longer after IPOM (median 1 days vs. 0 days (p < 0.001). The rate of patients requiring postoperative transversus abdominis plane (TAP) block or epidural analgesia was significantly higher after IPOM (33% vs. 0%, p = 0.002). A subgroup analysis on patients undergoing primary ventral hernia showed similar results. CONCLUSION: The study found laparoscopic eTEP-RM safe and effective compared to traditional laparoscopic IPOM. The patients undergoing eTEP-RM had significantly reduced need for additional analgesic treatment and length of stay.

Physiologic Effects of High-Flow Nasal Cannula Oxygen in Critical Care Subjects.

INTRODUCTION: High-flow nasal cannula (HFNC) can deliver heated and humidified gas (up to 100% oxygen) at a maximum flow of 60 L/min via nasal prongs or cannula. The aim of this study was to assess the short-term physiologic effects of HFNC. Inspiratory muscle effort, gas exchange, dyspnea score, and comfort were evaluated. METHODS: Twelve subjects admitted to the ICU for acute hypoxemic respiratory failure were prospectively included. Four study sessions were performed. The first session consisted of oxygen therapy given through a high-FIO2, non-rebreathing face mask. Recordings were then obtained during periods of HFNC and CPAP at 5 cm H2O in random order, and final measurements were performed during oxygen therapy delivered via a face mask. Each of these 4 periods lasted ∼20 min. RESULTS: Esophageal pressure signals, breathing pattern, gas exchange, comfort, and dyspnea were measured. Compared with the first session, HFNC reduced inspiratory effort (pressure-time product of 156.0 [119.2-194.4] cm H2O × s/min vs 204.2 [149.6-324.7] cm H2O × s/min, P < .01) and breathing frequency (P < .01). No significant differences were observed between HFNC and CPAP for inspiratory effort and breathing frequency. Compared with the first session, PaO2/FIO2 increased significantly with HFNC (167 [157-184] mm Hg vs 156 [110-171] mm Hg, P < .01). CPAP produced significantly greater PaO2/FIO2 improvement than did HFNC. Dyspnea improved with HFNC and CPAP, but this improvement was not significant. Subject comfort was not different across the 4 sessions. CONCLUSIONS: Compared with conventional oxygen therapy, HFNC improved inspiratory effort and oxygenation. In subjects with acute hypoxemic respiratory failure, HFNC is an alternative to conventional oxygen therapy. (ClinicalTrials.gov registration NCT01056952.).