Mechanical ventilation in patients with idiopathic pulmonary fibrosis in Korea: a nationwide cohort study.

BACKGROUND/AIMS: The prognosis of patients with idiopathic pulmonary fibrosis (IPF) and respiratory failure requiring mechanical ventilation is poor. Therefore, mechanical ventilation is not recommended. Recently, outcomes of mechanical ventilation, including those for patients with IPF, have improved. The aim of this study was to investigate changes in the use of mechanical ventilation in patients with IPF and their outcomes over time. METHODS: This retrospective, observational cohort study used data from the National Health Insurance Service database. Patients diagnosed with IPF between January 2011 and December 2019 who were placed on mechanical ventilation were included. We analyzed changes in the use of mechanical ventilation in patients with IPF and their mortality using the Cochran- Armitage trend test. RESULTS: Between 2011 and 2019, 1,227 patients with IPF were placed on mechanical ventilation. The annual number of patients with IPF with and without mechanical ventilation increased over time. However, the ratio was relatively stable at approximately 3.5%. The overall hospital mortality rate was 69.4%. There was no improvement in annual hospital mortality rate. The overall 30-day mortality rate was 68.7%, which did not change significantly. The overall 90-day mortality rate was 85.3%. The annual 90-day mortality rate was decreased from 90.9% in 2011 to 83.1% in 2019 (p = 0.028). CONCLUSION: Despite improvements in intensive care and ventilator management, the prognosis of patients with IPF receiving mechanical ventilation has not improved significantly.

Interhospital Variation in Admissions Managed With Critical Care Therapies or Invasive Hemodynamic Monitoring in Tertiary Cardiac Intensive Care Units: An Analysis From the Critical Care Cardiology Trials Network Registry.

BACKGROUND: Wide interhospital variations exist in cardiovascular intensive care unit (CICU) admission practices and the use of critical care restricted therapies (CCRx), but little is known about the differences in patient acuity, CCRx utilization, and the associated outcomes within tertiary centers. METHODS: The Critical Care Cardiology Trials Network is a multicenter registry of tertiary and academic CICUs in the United States and Canada that captured consecutive admissions in 2-month periods between 2017 and 2022. This analysis included 17 843 admissions across 34 sites and compared interhospital tertiles of CCRx (eg, mechanical ventilation, mechanical circulatory support, continuous renal replacement therapy) utilization and its adjusted association with in-hospital survival using logistic regression. The Pratt index was used to quantify patient-related and institutional factors associated with CCRx variability. RESULTS: The median age of the study population was 66 (56-77) years and 37% were female. CCRx was provided to 62.2% (interhospital range of 21.3%-87.1%) of CICU patients. Admissions to CICUs with the highest tertile of CCRx utilization had a greater burden of comorbidities, had more diagnoses of ST-elevation myocardial infarction, cardiac arrest, or cardiogenic shock, and had higher Sequential Organ Failure Assessment scores. The unadjusted in-hospital mortality (median, 12.7%) was 9.6%, 11.1%, and 18.7% in low, intermediate, and high CCRx tertiles, respectively. No clinically meaningful differences in adjusted mortality were observed across tertiles when admissions were stratified by the provision of CCRx. Baseline patient-level variables and institutional differences accounted for 80% and 5.3% of the observed CCRx variability, respectively. CONCLUSIONS: In a large registry of tertiary and academic CICUs, there was a >4-fold interhospital variation in the provision of CCRx that was primarily driven by differences in patient acuity compared with institutional differences. No differences were observed in adjusted mortality between low, intermediate, and high CCRx utilization sites.

Adjustments of Ventilator Parameters during Operating Room-to-ICU Transition and 28-Day Mortality.

Rationale: Lung-protective mechanical ventilation strategies have been proven beneficial in the operating room (OR) and the ICU. However, differential practices in ventilator management persist, often resulting in adjustments of ventilator parameters when transitioning patients from the OR to the ICU. Objectives: To characterize patterns of ventilator adjustments during the transition of mechanically ventilated surgical patients from the OR to the ICU and assess their impact on 28-day mortality. Methods: Hospital registry study including patients undergoing general anesthesia with continued, controlled mechanical ventilation in the ICU between 2008 and 2022. Ventilator parameters were assessed 1 hour before and 6 hours after the transition. Measurements and Main Results: Of 2,103 patients, 212 (10.1%) died within 28 days. Upon OR-to-ICU transition, VT and driving pressure decreased (-1.1 ml/kg predicted body weight [IQR, -2.0 to -0.2]; P < 0.001; and -4.3 cm H2O [-8.2 to -1.2]; P < 0.001). Concomitantly, respiratory rates increased (+5.0 breaths/min [2.0 to 7.5]; P < 0.001), resulting overall in slightly higher mechanical power (MP) in the ICU (+0.7 J/min [-1.9 to 3.0]; P < 0.001). In adjusted analysis, increases in MP were associated with a higher 28-day mortality rate (adjusted odds ratio, 1.10; 95% confidence interval, 1.06-1.14; P < 0.001; adjusted risk difference, 0.7%; 95% confidence interval, 0.4-1.0, both per 1 J/min). Conclusion: During transition of mechanically ventilated patients from the OR to the ICU, ventilator adjustments resulting in higher MP were associated with a greater risk of 28-day mortality.

Factores asociados a ventilación mecánica prolongada en niños con fallo respiratorio de causa pulmonar: Estudio de cohortes del registro de LARed Network / Factors associated with prolonged mechanical ventilation in children with pulmonary failure: Cohort study from the LARed Network registry

Objetivos Identificar los factores asociados con la ventilación mecánica prolongada (pVMI) en pacientes pediátricos en la unidad de cuidados intensivos pediátricos (UCIP). Diseño Análisis secundario de una cohorte prospectiva. Ámbito UCIP en los centros que integran LARed Network entre abril del 2017 y enero del 2022. Participantes Pacientes pediátricos en ventilación mecánica (VMI) debido a causas respiratorias. Definimos pVMI como eventos con tiempo VMI mayor al percentil 75 global. Intervenciones Ninguna.Variables de interés principales Datos demográficos, diagnósticos, puntajes de gravedad, terapias, complicaciones, estancias y morbimortalidad. Resultados Se incluyó a 1.698 niños con VMI de 8 ± 7 días y se definió pVMI en 9 días. Los factores relacionados al ingreso fueron la edad menor de 6 meses (OR 1,61, IC del 95%, 1,17-2,22), la displasia broncopulmonar (OR 3,71, IC del 95%, 1,87-7,36) y las infecciones fúngicas (OR 6,66, IC del 95%, 1,87-23,74), mientras que los pacientes con asma tuvieron menor riesgo de pVMI (OR 0,30, IC del 95%, 0,12-0,78). En cuanto a la evolución y la estancia en UCIP, se relacionó a neumonía asociada a la ventilación mecánica (OR 4,27, IC del 95%, 1,79-10,20), necesidad de traqueostomía (OR 2,91, IC del 95%, 1,89-4,48), transfusiones (OR 2,94, IC del 95%, 2,18-3,96), bloqueo neuromuscular (OR 2,08, IC del 95%, 1,48-2,93) y ventilación de alta frecuencia (OR 2,91, IC del 95%, 1,89-4,48) y una mayor estadía en UCIP (OR 1,13, IC del 95%, 1,10-1,16). Además, la presión media aérea mayor a 13cmH2O se asoció a pVMI (OR 1,57, IC del 95%, 1,12-2,21). Conclusiones Se identificaron factores relacionados con VMI de duración mayor a 9 días en pacientes pediátricos en UCIP en cuanto a ingreso, evolución y estancia. (AU)

Objectives To identify factors associated with prolonged mechanical ventilation (pMV) in pediatric patients in pediatric intensive care units (PICUs). Design Secondary analysis of a prospective cohort.SettingPICUs in centers that are part of the LARed Network between April 2017 and January 2022. Participants Pediatric patients on mechanical ventilation (IMV) due to respiratory causes. We defined IMV time greater than the 75th percentile of the global cohort. Interventions None.Main variables of interestDemographic data, diagnoses, severity scores, therapies, complications, length of stay, morbidity, and mortality. Results One thousand 6hundred and ninety 8children with MV of 8±7 days were included, and pIMV was defined as 9 days. Factors related to admission were age under 6 months (OR 1.61, 95% CI 1.17–2.22), bronchopulmonary dysplasia (OR 3.71, 95% CI 1.87–7.36), and fungal infections (OR 6.66, 95% CI 1.87–23.74), while patients with asthma had a lower risk of pIMV (OR 0.30, 95% CI 0.12–0.78). Regarding evolution and length of stay in the PICU, it was related to ventilation-associated pneumonia (OR 4.27, 95% CI 1.79–10.20), need for tracheostomy (OR 2.91, 95% CI 1.89–4.48), transfusions (OR 2.94, 95% CI 2.18–3.96), neuromuscular blockade (OR 2.08, 95% CI 1.48–2.93), high-frequency ventilation (OR 2.91, 95% CI 1.89–4.48), and longer PICU stay (OR 1.13, 95% CI 1.10–1.16). In addition, mean airway pressure greater than 13cmH2O was associated with pIMV (OR 1.57, 95% CI 1.12–2.21). Conclusions Factors related to IMV duration greater than 9 days in pediatric patients in PICUs were identified in terms of admission, evolution, and length of stay. (AU)

Ultrasound assessment of diaphragm thickness, contractility, and strain in healthy pediatric patients.

BACKGROUND: Ultrasound-based diaphragmatic assessments are becoming more common in pediatric acute care, but baseline pediatric diaphragm thickness and contractility values remain unknown. METHODS: We conducted a prospective, observational study of healthy children aged <18 years undergoing elective surgery. Diaphragm thickness at end-expiration (Tdi-exp), thickening fraction (DTF) and excursion were measured by ultrasound during spontaneous breathing and during mechanical ventilation. Diaphragm strain and peak strain rate were ascertained post hoc. Measurements were compared across a priori specified age groups (<1 year, 1 to <3, 3 to <6, 6 to <12, and 12 to <18 years) and with versus without mechanical ventilation. RESULTS: Fifty subjects were evaluated (n = 10 per age group). Baseline mean Tdi-exp was 0.19 ± 0.04 cm, DTF 0.19 ± 0.09, excursion 1.69 ± 0.97 cm, strain -10.3 ± 4.9, peak strain rate -0.48 ± 0.21 s-1 . No significant difference in Tdi-exp or DTF was observed across age groups (p > .05). Diaphragm excursion increased with age (p < .0001). Diaphragm strain was significantly greater in the 12-17-year age group (-14.3 ± 6.4), p = .048, but there were no age-related differences in peak strain rate (p = .08). During mechanical ventilation, there were significant decreases in DTF 0.12 ± 0.04 (p < .0001), excursion 1.08 ± 0.31 cm (p < .0001), strain -4.60 ± 1.93 (p < .0001), and peak strain rate -0.20 ± 0.10 s-1 (p < .0001) while there was no change in Tdi-exp 0.18 ± 0.03 cm (p = .25) when compared to baseline values. CONCLUSION: Pediatric Tdi-exp, DTF, and diaphragm peak strain rate were similar across age groups. Diaphragm excursion and strain varied across age groups. All measures of diaphragm contractility were diminished during mechanical ventilation.

2023 American Heart Association and American Academy of Pediatrics Focused Update on Neonatal Resuscitation: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

This 2023 focused update to the neonatal resuscitation guidelines is based on 4 systematic reviews recently completed under the direction of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Systematic reviewers and content experts from this task force performed comprehensive reviews of the scientific literature on umbilical cord management in preterm, late preterm, and term newborn infants, and the optimal devices and interfaces used for administering positive-pressure ventilation during resuscitation of newborn infants. These recommendations provide new guidance on the use of intact umbilical cord milking, device selection for administering positive-pressure ventilation, and an additional primary interface for administering positive-pressure ventilation.

Factors associated with prolonged mechanical ventilation in children with pulmonary failure: Cohort study from the LARed Network registry.

OBJECTIVES: To identify factors associated with prolonged mechanical ventilation (pMV) in pediatric patients in pediatric intensive care units (PICUs). DESIGN: Secondary analysis of a prospective cohort. SETTING: PICUs in centers that are part of the LARed Network between April 2017 and January 2022. PARTICIPANTS: Pediatric patients on mechanical ventilation (IMV) due to respiratory causes. We defined IMV time greater than the 75th percentile of the global cohort. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Demographic data, diagnoses, severity scores, therapies, complications, length of stay, morbidity, and mortality. RESULTS: 1698 children with MV of 8±7 days were included, and pIMV was defined as 9 days. Factors related to admission were age under 6 months (OR 1.61, 95% CI 1.17-2.22), bronchopulmonary dysplasia (OR 3.71, 95% CI 1.87-7.36), and fungal infections (OR 6.66, 95% CI 1.87-23.74), while patients with asthma had a lower risk of pIMV (OR 0.30, 95% CI 0.12-0.78). Regarding evolution and length of stay in the PICU, it was related to ventilation-associated pneumonia (OR 4.27, 95% CI 1.79-10.20), need for tracheostomy (OR 2.91, 95% CI 1.89-4.48), transfusions (OR 2.94, 95% CI 2.18-3.96), neuromuscular blockade (OR 2.08, 95% CI 1.48-2.93), high-frequency ventilation (OR 2.91, 95% CI 1.89-4.48), and longer PICU stay (OR 1.13, 95% CI 1.10-1.16). In addition, mean airway pressure greater than 13cmH2O was associated with pIMV (OR 1.57, 95% CI 1.12-2.21). CONCLUSIONS: Factors related to IMV duration greater than 9 days in pediatric patients in PICUs were identified in terms of admission, evolution, and length of stay.

Lesão renal aguda e COVID-19 em adultos jovens na terapia intensiva / Lesión renal aguda y COVID-19 en adultos jóvenes en cuidados intensivos / Acute kidney injury and COVID-19 in young adults in intensive care

Resumo Objetivo Descrever a prevalência de lesão renal aguda em adultos jovens com diagnóstico da COVID-19 admitidos em unidade terapia intensiva. Métodos Estudo retrospectivo, quantitativo e analítico. A amostra foi de adultos jovens (20 a 40 anos) admitidos em unidades de terapia intensiva, com diagnóstico de infecção por SARS-CoV-2 entre março e dezembro de 2020. Os dados foram obtidos por meio do prontuário eletrônico, e a lesão renal aguda foi definida pelo valor da creatinina, segundo critérios das diretrizes da Kidney Disease Improving Global Outcomes. A significância estatística foi de p≤0,05. Resultados Foram internados 58 adultos jovens, sendo 63,8% do sexo masculino. A hipertensão arterial sistêmica esteve presente em 39,6%, a obesidade em 18,9% e o diabetes mellitus em 8,6%. A lesão renal aguda foi identificada em 55,1%, sendo o estágio 3 predominante em 43,1% deles. Nesses pacientes, o uso de ventilação mecânica e de drogas vasoativas foi significativo em 92%, assim como a disfunção orgânica respiratória (80%), seguida da renal (76%). Fatores de risco, como transplante renal ou doença renal crônica e obesidade, aumentaram em 12,3 e 9,0 vezes, respectivamente, a chance de desenvolver lesão renal aguda. Conclusão Este estudo demonstrou alta prevalência de lesão renal em adultos jovens e sua associação com comorbidades prévias. Obesidade, transplante renal e doença renal crônica elevaram a chance de o adulto jovem desenvolver lesão renal aguda, resultando em desfechos a favor da morbimortalidade.

Resumen Objetivo Describir la prevalencia de lesión renal aguda en adultos jóvenes con diagnóstico de COVID-19 admitidos en unidad de cuidados intensivos. Métodos Estudio retrospectivo, cuantitativo y analítico. La muestra fue de adultos jóvenes (20 a 40 años) admitidos en unidades de cuidados intensivos, con diagnóstico de infección por SARS-CoV-2 entre marzo y diciembre de 2020. Los datos se obtuvieron por medio de historias clínicas electrónicas, y la lesión renal aguda fue definida por el valor de la creatinina, de acuerdo con criterios de las directrices de la Kidney Disease Improving Global Outcomes. La significación estadística fue de p≤0,05. Resultados Hubo 58 adultos jóvenes internados, el 63,8 % de sexo masculino. La hipertensión arterial sistémica estuvo presente en el 39,6 %, la obesidad en el 18,9 % y la diabetes mellitus en el 8,6 %. Se identificó lesión renal aguda en el 55,1 %, de nivel 3 como predominante en el 43,1 % de los casos. En esos pacientes, el uso de ventilación mecánica y de drogas vasoactivas fue significativo en el 92 %, así como también la disfunción orgánica respiratoria (80 %), seguida de la renal (76 %). Los factores de riesgo, como trasplante renal o enfermedad renal crónica y obesidad, aumentaron 12,3 y 9,0 veces respectivamente la probabilidad de presentar lesión renal aguda. Conclusión Este estudio demostró alta prevalencia de lesión renal en adultos jóvenes y su asociación con comorbilidades previas. La obesidad, el trasplante renal y la enfermedad renal crónica aumentaron la probabilidad de que los adultos jóvenes presenten lesión renal aguda, lo que da como resultado desenlaces a favor de la morbimortalidad.

Abstract Objective To describe acute kidney injury prevalence in young adults diagnosed with COVID-19 admitted to the Intensive Care Unit. Methods This is a retrospective, quantitative and analytical study. The sample consisted of young adults (20 to 40 years old) admitted to Intensive Care Units, diagnosed with SARS-CoV-2 infection between March and December 2020. Data were obtained through electronic medical records, and kidney injury acute was defined by the creatinine value, according to the Kidney Disease Improving Global Outcomes guidelines criteria. Statistical significance was p≤0.05. Results A total of 58 young adults were hospitalized, 63.8% of whom were male. Hypertension was present in 39.6%, obesity in 18.9%, and diabetes mellitus in 8.6%. Acute kidney injury was identified in 55.1%, with stage 3 predominating in 43.1% of them. In these patients, the use of mechanical ventilation and vasoactive drugs was significant in 92% as well as respiratory organ dysfunction (80%), followed by renal organ dysfunction (76%). Risk factors such as kidney transplantation or chronic kidney disease and obesity increased by 12.3 and 9.0 times, respectively, the chances of developing acute kidney injury. Conclusion This study demonstrated a high kidney injury prevalence in young adults and its association with previous comorbidities. Obesity, kidney transplantation and chronic kidney disease increased the chance of young adults to develop acute kidney injury, resulting in outcomes in favor of morbidity and mortality.

Incidence, risk factors, progression, and involution in retinopathy of prematurity at a tertiary care center in South India.

BACKGROUND: Retinopathy of prematurity (ROP) is a vasculoproliferative disorder of immature retina, seen in preterm babies. Multiple risk factors attribute to this condition. Our aim was to correlate the role of any early neonatal surgeries with low gestational age (GA) and birth weight (BW) on preterm babies as a risk factor on the progression of ROP. METHODS: A prospective, cohort study conducted in a hospital in South India over 3 years, including 600 babies with GA <35 weeks and BW <2500 g. Babies were divided into Group A (ROP) and Group B (no ROP). Group A included A1 (severe ROP) and A2 (nonsevere ROP) based on early treatment of ROP classification. We compared various risk factors of ROP, specifically the association of any early neonatal surgery undergone by these babies, on progression of ROP. The Chi-square test, unpaired t-test, and one-way analysis of variance tests were used for the comparisons and considered statistically significant if P < 0.05. RESULTS: 28.7% babies developed ROP, with 37.6% requiring treatment (Aggressive ROP in 2.1% of babies). Low GA and BW, longer duration on ventilator, respiratory distress syndrome, apnea of prematurity, Patent Ductus Arteriosus, sepsis, anemia, thrombocytopenia, history of blood transfusion, and history of early neonatal surgery under GA were associated with babies with ROP (P < 0.005), strongly with severe ROP. The most common surgeries undergone by the babies developing ROP were inguinal herniotomy under general anesthesia. CONCLUSION: The study predicts preterm babies undergoing early surgical interventions are at risk of progressing to severe ROP, hence warranting frequent follow-ups.

Relationship between handgrip strength and inspiratory muscles with the success of the spontaneous breathing trial

Introduction: In critically ill patients on mechanical ventilation, the loss of inspiratory and peripheral muscle strength is associated with prolonged mechanical ventilation and failed weaning. Objective: To determine the relationship between handgrip strength and inspiratory muscle strength with the success of the Spontaneous Breathing Trial in adults with ventilatory support greater than 48 hours. Methodology: Prospective observational cross-sectional study performed at a tertiary hospital in Colombia. Handgrip strength and Maximal Inspiratory Pressure were measured once a day before Spontaneous Breathing Trial testing. Pearson's test and Cohen's D test were used to analyze correlations. Results: A total of 51 patients were included, 57% male, with a mean age of 51.9±20 years. A positive correlation was identified between Maximal Inspiratory Pressure and grip strength; and a negative correlation between grip strength and Maximal Inspiratory Pressure with the days of stay in the intensive care unit, (r -0.40; p<0.05) and (r -0.45; p<0.05). Conclusions: Handgrip strength and Maximal Inspiratory Pressure were positively correlated with Spontaneous Breathing Trial success. The importance of these measures to guide ventilator disconnection processes is highlighted.

Introducción: En el paciente críticamente enfermo con ventilación mecánica, la pérdida de la fuerza de los músculos inspiratorios y periféricos se asocia con ventilación mecánica prolongada y destete fallido. Objetivo: Determinar la relación entre la fuerza de prensión manual y la fuerza de músculos inspiratorios con el éxito de la prueba de respiración espontánea en adultos con soporte ventilatorio mayor a 48 horas. Metodología: Estudio prospectivo observacional de corte transversal realizado en un hospital de tercer nivel en Colombia. La fuerza de prensión manual y la presión inspiratoria máxima se midieron una vez al día antes de la prueba de prueba de respiración espontánea. Se utilizaron la prueba de Pearson y la prueba D de Cohen para analizar las correlaciones. Resultados: Se incluyeron 51 pacientes, 57 % de sexo masculino, con una edad promedio de 51,9 ± 20 años. Se identificó una correlación positiva entre Presión Inspiratoria Máxima y fuerza de la mano; y una correlación negativa entre la fuerza de la mano y la Presión Inspiratoria Máxima con los días de estancia en la Unidad de Cuidados Intensivos, (r -0,40; p < 0,05) y (r -0,45;p < 0,05). Conclusiones: La fuerza de prensión manual y la Presión Inspiratoria Máxima se correlacionaron positivamente con el éxito de la Prueba de Respiración Espontánea. Se destaca la importancia de estas mediciones para guiar procesos de desconexión del ventilador.

Effects of atelectatic areas on the surrounding lung tissue during mechanical ventilation in an experimental model of acute lung injury induced by lipopolysaccharide / Efeitos das áreas atelectásicas no tecido pulmonar circundante durante a ventilação mecânica em um modelo experimental de lesão pulmonar aguda induzida por lipopolissacarídeo

ABSTRACT Objective: To assess the effect of atelectasis during mechanical ventilation on the periatelectatic and normal lung regions in a model of atelectasis in rats with acute lung injury induced by lipopolysaccharide. Methods: Twenty-four rats were randomized into the following four groups, each with 6 animals: the Saline-Control Group, Lipopolysaccharide Control Group, Saline-Atelectasis Group, and Lipopolysaccharide Atelectasis Group. Acute lung injury was induced by intraperitoneal injection of lipopolysaccharide. After 24 hours, atelectasis was induced by bronchial blocking. The animals underwent mechanical ventilation for two hours with protective parameters, and respiratory mechanics were monitored during this period. Thereafter, histologic analyses of two regions of interest, periatelectatic areas and the normally-aerated lung contralateral to the atelectatic areas, were performed. Results: The lung injury score was significantly higher in the Lipopolysaccharide Control Group (0.41 ± 0.13) than in the Saline Control Group (0.15 ± 0.51), p < 0.05. Periatelectatic regions showed higher lung injury scores than normally-aerated regions in both the Saline-Atelectasis (0.44 ± 0.06 x 0.27 ± 0.74 p < 0.05) and Lipopolysaccharide Atelectasis (0.56 ± 0.09 x 0.35 ± 0.04 p < 0.05) Groups. The lung injury score in the periatelectatic regions was higher in the Lipopolysaccharide Atelectasis Group (0.56 ± 0.09) than in the periatelectatic region of the Saline-Atelectasis Group (0.44 ± 0.06), p < 0.05. Conclusion: Atelectasis may cause injury to the surrounding tissue after a period of mechanical ventilation with protective parameters. Its effect was more significant in previously injured lungs.

RESUMO Objetivo: Avaliar o efeito da atelectasia durante a ventilação mecânica nas regiões periatelectáticas e pulmonares normais em um modelo de atelectasia em ratos com lesão pulmonar aguda induzida por lipopolissacarídeo. Métodos: Foram distribuídos aleatoriamente 24 ratos em quatro grupos, cada um com 6 animais: Grupo Salina-Controle, Grupo Lipopolissacarídeo-Controle, Grupo Salina-Atelectasia e Grupo Lipopolissacarídeo-Atelectasia. A lesão pulmonar aguda foi induzida por injeção intraperitoneal de lipopolissacarídeo. Após 24 horas, a atelectasia foi induzida por bloqueio brônquico. Os animais foram submetidos à ventilação mecânica por 2 horas com parâmetros ventilatórios protetores, e a mecânica respiratória foi monitorada durante esse período. Em seguida, foram realizadas análises histológicas de duas regiões de interesse: as áreas periatelectásicas e o pulmão normalmente aerado contralateral às áreas atelectásicas. Resultados: O escore de lesão pulmonar foi significativamente maior no Grupo Controle-Lipopolissacarídeo (0,41 ± 0,13) do que no Grupo Controle-Solução Salina (0,15 ± 0,51), com p < 0,05. As regiões periatelectásicas apresentaram escores maiores de lesão pulmonar do que as regiões normalmente aeradas nos Grupos Atelectasia-Solução Salina (0,44 ± 0,06 versus 0,27 ± 0,74, p < 0,05) e Atelectasia-Lipopolissacarídeo (0,56 ± 0,09 versus 0,35 ± 0,04, p < 0,05). O escore de lesão pulmonar nas regiões periatelectásicas foi maior no Grupo Atelectasia-Lipopolissacarídeo (0,56 ± 0,09) do que na região periatelectásica do Grupo Atelectasia-Solução Salina (0,44 ± 0,06), p < 0,05. Conclusão: A atelectasia pode causar lesão no tecido circundante após um período de ventilação mecânica com parâmetros ventilatórios protetores. Seu efeito foi mais significativo em pulmões previamente lesionados.

Impact of vertical positioning on lung aeration among mechanically ventilated intensive care unit patients: a randomized crossover clinical trial / Impacto do posicionamento vertical na aeração pulmonar em pacientes de unidades de terapia intensiva ventilados mecanicamente: um estudo clínico transversal randomizado

ABSTRACT Objective: To assess the impact of different vertical positions on lung aeration in patients receiving invasive mechanical ventilation. Methods: An open-label randomized crossover clinical trial was conducted between January and July 2020. Adults receiving invasive mechanical ventilation for > 24 hours and < 7 days with hemodynamic, respiratory and neurological stability were randomly assigned at a 1:1 ratio to the sitting position followed by passive orthostasis condition or the passive orthostasis followed by the sitting position condition. The primary outcome was lung aeration assessed using the lung ultrasound score (score ranges from 0 [better] to 36 [worse]). Results: A total of 186 subjects were screened; of these subjects, 19 were enrolled (57.8% male; mean age, 73.2 years). All participants were assigned to receive at least one verticalization protocol. Passive orthostasis resulted in mean lung ultrasound scores that did not differ significantly from the sitting position (11.0 versus 13.7; mean difference, -2.7; [95%CI -6.1 to 0.71; p = 0.11). Adverse events occurred in three subjects in the passive orthostasis group and in one in the sitting position group (p = 0.99). Conclusion: This analysis did not find significant differences in lung aeration between the sitting and passive orthostasis groups. A randomized crossover clinical trial assessing the impact of vertical positioning on lung aeration in patients receiving invasive mechanical ventilation is feasible. Unfortunately, the study was interrupted due to the need to treat COVID-19 patients. ClinicalTrials.gov registry: NCT04176445

RESUMO Objetivo: Avaliar o impacto de diferentes posicionamentos verticais na aeração pulmonar em pacientes em ventilação mecânica invasiva. Métodos: Trata-se de ensaio clínico aberto, randomizado e transversal, realizado entre janeiro e julho de 2020. Adultos em ventilação mecânica invasiva por mais de 24 horas e menos de 7 dias com estabilidade hemodinâmica, respiratória e neurológica foram distribuídos aleatoriamente em uma proporção de 1:1 à postura sentada seguida da condição de ortostatismo passivo ou o ortostatismo passivo seguido de postura sentada. O desfecho primário foi a aeração pulmonar avaliada pelo lung ultrasound score. O escore varia de zero (melhor) a 36 (pior). Resultados: Foram selecionados 186 indivíduos; destes, 19 foram incluídos (57,8% do sexo masculino; média idade de 73,2 anos). Todos os participantes foram selecionados para receber pelo menos um protocolo de verticalização. O ortostatismo passivo resultou em escores médios de aeração pulmonar por ultrassonografia que não diferiram significativamente da postura sentada (11,0 versus 13,7; diferença média, -2,7; IC95% -6,1 a 0,71; p = 0,11). Ocorreram eventos adversos em três indivíduos no grupo ortostatismo passivo e em um no grupo postura sentada (p = 0,99). Conclusão: Esta análise não encontrou diferenças significativas na aeração pulmonar entre os grupos ortostatismo passivo e postura sentada. É factível conduzir um estudo clínico transversal randomizado para avaliar o impacto do posicionamento vertical na aeração pulmonar em pacientes em ventilação mecânica invasiva. Infelizmente, o estudo foi interrompido devido à necessidade de tratar pacientes com COVID-19. Registro ClinicalTrials.gov: NCT04176445

[Comment on article "Risk factors at admission associated with intubation in patients with COVID-19"]. / Comentario al artículo "Factores de riesgo al ingreso asociados a intubación en pacientes con COVID-19".

Risk factors associated with intubation in patients with COVID-19, should not be confused with criteria for intubation in patients with respiratory problems. In the treatment of patients with COVID-19, it is important to consider the time from the onset of symptoms and the delay of patients to seek hospital care. This could be another factor influencing patient's evolution. Taking account steroids as a predictor of intubation requires a more in-depth analysis of the steroid used, its dose and the timing in which they are used. There are many factors that can explain the uncertain evolution of patients with COVID-19. Identifying them can help to develop strategies to reduce the delay in mechanical ventilation, and therefore improve the prognosis.

Los factores de riesgo asociados a intubación en pacientes con COVID-19, no se debe confundir con los criterios para intubación en pacientes con problemas respiratorios. En el tratamiento de pacientes con COVID -19 es importante considerar el tiempo desde el inicio de los síntomas y el retraso en la atención hospitalaria. Esto puede ser otro factor que influya en la evolución de los pacientes. Considerar a los esteroides como un factor predictor de intubación, requiere un análisis más profundo sobre el tipo, la dosis y el momento en el que se utilizan. Hay muchos factores que pueden explicar la mala evolución de los pacientes con COVID-19. Identificarlos puede ayudar a que surjan estrategias para disminuir el retraso en la ventilación mecánica, y por lo tanto mejorar el pronóstico.

Protocol-directed weaning versus conventional weaning from mechanical ventilation for neurocritical patients in an intensive care unit: a nonrandomized quasi-experimental study.

OBJECTIVE: To investigate whether protocol-directed weaning in neurocritical patients would reduce the rate of extubation failure (as a primary outcome) and the associated complications (as a secondary outcome) compared with conventional weaning. METHODS: A quasi-experimental study was conducted in a medical-surgical intensive care unit from January 2016 to December 2018. Patients aged 18 years or older with an acute neurological disease who were on mechanical ventilation > 24 hours were included. All patients included in the study were ready to wean, with no or minimal sedation, Glasgow coma score ≥ 9, spontaneous ventilatory stimulus, noradrenaline ≤ 0.2µgr/kg/ minute, fraction of inspired oxygen ≤ 0.5, positive end-expiratory pressure ≤ 5cmH2O, maximal inspiratory pressure < -20cmH2O, and occlusion pressure < 6cmH2O. RESULTS: Ninety-four of 314 patients admitted to the intensive care unit were included (50 in the Intervention Group and 44 in the Control Group). There was no significant difference in spontaneous breathing trial failure (18% in the Intervention Group versus 34% in the Control Group, p = 0.12). More patients in the Intervention Group were extubated than in the Control Group (100% versus 79%, p = 0.01). The rate of extubation failure was not signifiantly diffrent between the groups (18% in the Intervention Group versus 17% in the Control Group; relative risk 1.02; 95%CI 0.64 - 1.61; p = 1.00). The reintubation rate was lower in the Control Group (16% in the Intervention Group versus 11% in the Control Group; relative risk 1.15; 95%CI 0.74 - 1.82; p = 0.75). The need for tracheotomy was lower in the Intervention Group [4 (8%) versus 11 (25%) in the Control Group; relative risk 0.32; 95%CI 0.11 - 0.93; p = 0.04]. At Day 28, the patients in the Intervention Group had more ventilator-free days than those in the Control Group [28 (26 - 28) days versus 26 (19 - 28) days; p = 0.01]. The total duration of mechanical ventilation was shorter in the Intervention Group than in the Control Group [5 (2 - 13) days versus 9 (3 - 22) days; p = 0.01]. There were no diffrences in the length of intensive care unit stay, 28-day free from mechanical ventilation, hospital stay or 90-day mortality. CONCLUSION: Considering the limitations of our study, the application of a weaning protocol for neurocritical patients led to a high percentage of extubation, a reduced need for tracheotomy and a shortened duration of mechanical ventilation. However, there was no reduction in extubation failure or the 28-day free of from mechanical ventilation compared with the Control Group.ClinicalTrials.gov Registry: NCT03128086.

Fitness checklist model for spontaneous breathing tests in pediatrics.

OBJECTIVE: To evaluate whether a model of a daily fitness checklist for spontaneous breathing tests is able to identify predictive variables of extubation failure in pediatric patients admitted to a Brazilian intensive care unit. METHODS: This was a single-center, cross-sectional study with prospective data collection. The checklist model comprised 20 items and was applied to assess the ability to perform spontaneous breathing tests. RESULTS: The sample consisted of 126 pediatric patients (85 males (67.5%)) on invasive mechanical ventilation, for whom 1,217 daily assessments were applied at the bedside. The weighted total score of the prediction model showed the highest discriminatory power for the spontaneous breathing test, with sensitivity and specificity indices for fitness failure of 89.7% or success of 84.6%. The cutoff point suggested by the checklist was 8, with a probability of extubation failure less than 5%. Failure increased progressively with increasing score, with a maximum probability of predicting extubation failure of 85%. CONCLUSION: The extubation failure rate with the use of this model was within what is acceptable in the literature. The daily checklist model for the spontaneous breathing test was able to identify predictive variables of failure in the extubation process in pediatric patients.

National Cost Estimates of Invasive Mechanical Ventilation and Tracheostomy in Acute Stroke, 2008-2017.

BACKGROUND: Patients with stroke receiving invasive mechanical ventilation (IMV) and tracheostomy incur intense treatment and long hospitalizations. We aimed to evaluate US hospitalization costs for patients with stroke requiring IMV, tracheostomy, or no ventilation. METHODS: We performed a retrospective observational study of US hospitalizations for acute ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage receiving IMV, tracheostomy, or none using the National Inpatient Sample, 2008 to 2017. We calculated hospitalization costs using cost-to-charge ratios adjusted to 2017 US dollars for inpatients with stroke by ventilation status (no IMV, IMV alone, tracheostomy). RESULTS: Of an estimated 5.2 million (95% CI, 5.1-5.3) acute stroke hospitalizations, 2008 to 2017; 9.4% received IMV alone and 1.4% received tracheostomy. Length of stay for patients without IMV was shorter (median, 4 days; interquartile range [IQR], 2-6) compared with IMV alone (median, 6 days; [IQR, 2-13]), and tracheostomy (median, 25 days; [IQR, 18-36]; P<0.001). Mortality for patients without IMV was 3.2% compared with 51.2% for IMV alone and 9.8% for tracheostomy (P<0.001). Median hospitalization costs for patients without IMV was $9503 (IQR, $6544-$14 963), compared with $23 774 (IQR, $10 900-$47 735) for IMV alone and $95 380 (IQR, $63 921-$144 019) for tracheostomy. Tracheostomy placement in ≤7 days had lower costs compared with placement in >7 days (median, $71 470 [IQR, $47 863-$108 250] versus $102 979 [IQR, $69 563-$152 543]; P<0.001). Each day awaiting tracheostomy was associated with a 2.9% cost increase (95% CI, 2.6%-3.1%). US hospitalization costs for patients with acute stroke were $8.7 billion/y (95% CI, $8.5-$8.9 billion). For IMV alone, costs were $1.8 billion/y (95% CI, $1.7-$1.9 billion) and for tracheostomy $824 million/y (95% CI, $789.7-$858.3 million). CONCLUSIONS: Patients with acute stroke who undergo tracheostomy account for 1.4% of stroke admissions and 9.5% of US stroke hospitalization costs. Future research should focus on the added value to society and patients of IMV and tracheostomy, in particular after 7 days for the latter procedure given the increased costs incurred and poor outcomes in stroke.

High-Dose Inhaled Nitric Oxide in Acute Hypoxemic Respiratory Failure Due to COVID-19: A Multicenter Phase II Trial.

Rationale: The effects of high-dose inhaled nitric oxide on hypoxemia in coronavirus disease (COVID-19) acute respiratory failure are unknown. Objectives: The primary outcome was the change in arterial oxygenation (PaO2/FiO2) at 48 hours. The secondary outcomes included: time to reach a PaO2/FiO2.300mmHg for at least 24 hours, the proportion of participants with a PaO2/FiO2.300mmHg at 28 days, and survival at 28 and at 90 days. Methods: Mechanically ventilated adults with COVID-19 pneumonia were enrolled in a phase II, multicenter, single-blind, randomized controlled parallel-arm trial. Participants in the intervention arm received inhaled nitric oxide at 80 ppm for 48 hours, compared with the control group receiving usual care (without placebo). Measurements and Main Results: A total of 193 participants were included in the modified intention-to-treat analysis. The mean change in PaO2/FiO2 ratio at 48 hours was 28.3mmHg in the intervention group and 21.4mmHg in the control group (mean difference, 39.1mmHg; 95% credible interval [CrI], 18.1 to 60.3). The mean time to reach a PaO2/FiO2.300mmHg in the interventional group was 8.7 days, compared with 8.4 days for the control group (mean difference, 0.44; 95% CrI, 23.63 to 4.53). At 28 days, the proportion of participants attaining a PaO2/FiO2.300mmHg was 27.7% in the inhaled nitric oxide group and 17.2% in the control subjects (risk ratio, 2.03; 95% CrI, 1.11 to 3.86). Duration of ventilation and mortality at 28 and 90 days did not differ. No serious adverse events were reported. Conclusions: The use of high-dose inhaled nitric oxide resulted in an improvement of PaO2/FiO2 at 48 hours compared with usual care in adults with acute hypoxemic respiratory failure due to COVID-19.

Role of respiratory characteristics in treatment adherence with noninvasive home mechanical ventilation in myotonic dystrophy type 1, a retrospective study.

Chronic respiratory insufficiency is common in patients with myotonic dystrophy type 1 (DM1) and can be treated with noninvasive home mechanical ventilation (HMV). HMV is not always tolerated well resulting in low treatment adherence. We aimed to analyze if baseline respiratory characteristics such as pulmonary function, level of pCO2 and presence of sleep apnea are associated with HMV treatment adherence in DM1 patients. Pulmonary function testing, polysomnography and blood gas measurement data of DM1 patients were retrospectively collected. Initiation of HMV and treatment adherence after one year was documented. Patients with low treatment adherence (average daily use of HMV <5 h) were grouped with patients that discontinued HMV and compared with patients with high treatment adherence (average daily use of HMV >5 h). HMV was initiated in 101 patients. After one year, 58 patients had low treatment adherence. There were no differences between the low and high treatment adherence group regarding the respiratory characteristics. None of the included predictors (gender, age, body mass index, cytosine-thymine-guanine repeat length, FVC, daytime pCO2, bicarbonate, nighttime pCO2, nighttime base excess, apnea-hypopnea index and mean saturation during sleep) was able to significantly predict high treatment adherence. In conclusion, the respiratory characteristics are not associated with treatment adherence with HMV in DM1 patients and cannot be used to identify patients at risk for low HMV treatment adherence.

Sample size estimation in clinical trials using ventilator-free days as the primary outcome: a systematic review.

BACKGROUND: Ventilator-free days (VFDs) are a composite endpoint increasingly used as the primary outcome in critical care trials. However, because of the skewed distribution and competitive risk between components, sample size estimation remains challenging. This systematic review was conducted to systematically assess whether the sample size was congruent, as calculated to evaluate VFDs in trials, with VFDs' distribution and the impact of alternative methods on sample size estimation. METHODS: A systematic literature search was conducted within the PubMed and Embase databases for randomized clinical trials in adults with VFDs as the primary outcome until December 2021. We focused on peer-reviewed journals with 2021 impact factors greater than five. After reviewing definitions of VFDs, we extracted the sample size and methods used for its estimation. The data were collected by two independent investigators and recorded in a standardized, pilot-tested forms tool. Sample sizes were calculated using alternative statistical approaches, and risks of bias were assessed with the Cochrane risk-of-bias tool. RESULTS: Of the 26 clinical trials included, 19 (73%) raised "some concerns" when assessing risks of bias. Twenty-four (92%) trials were two-arm superiority trials, and 23 (89%) were conducted at multiple sites. Almost all the trials (96%) were unable to consider the unique distribution of VFDs and death as a competitive risk. Moreover, significant heterogeneity was found in the definitions of VFDs, especially regarding varying start time and type of respiratory support. Methods for sample size estimation were also heterogeneous, and simple models, such as the Mann-Whitney-Wilcoxon rank-sum test, were used in 14 (54%) trials. Finally, the sample sizes calculated varied by a factor of 1.6 to 17.4. CONCLUSIONS: A standardized definition and methodology for VFDs, including the use of a core outcome set, seems to be required. Indeed, this could facilitate the interpretation of findings in clinical trials, as well as their construction, especially the sample size estimation which is a trade-off between cost, ethics, and statistical power. Systematic review registration PROSPERO ID: CRD42021282304. Registered 15 December 2021 ( https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021282304 ).