The intervention of artificial intelligence to improve the weaning outcomes of patients with mechanical ventilation: Practical applications in the medical intensive care unit and the COVID-19 intensive care unit: A retrospective study.

Patients admitted to intensive care units (ICU) and receiving mechanical ventilation (MV) may experience ventilator-associated adverse events and have prolonged ICU length of stay (LOS). We conducted a survey on adult patients in the medical ICU requiring MV. Utilizing big data and artificial intelligence (AI)/machine learning, we developed a predictive model to determine the optimal timing for weaning success, defined as no reintubation within 48 hours. An interdisciplinary team integrated AI into our MV weaning protocol. The study was divided into 2 parts. The first part compared outcomes before AI (May 1 to Nov 30, 2019) and after AI (May 1 to Nov 30, 2020) implementation in the medical ICU. The second part took place during the COVID-19 pandemic, where patients were divided into control (without AI assistance) and intervention (with AI assistance) groups from Aug 1, 2022, to Apr 30, 2023, and we compared their short-term outcomes. In the first part of the study, the intervention group (with AI, n = 1107) showed a shorter mean MV time (144.3 hours vs 158.7 hours, P = .077), ICU LOS (8.3 days vs 8.8 days, P = .194), and hospital LOS (22.2 days vs 25.7 days, P = .001) compared to the pre-intervention group (without AI, n = 1298). In the second part of the study, the intervention group (with AI, n = 88) exhibited a shorter mean MV time (244.2 hours vs 426.0 hours, P = .011), ICU LOS (11.0 days vs 18.7 days, P = .001), and hospital LOS (23.5 days vs 40.4 days, P < .001) compared to the control group (without AI, n = 43). The integration of AI into the weaning protocol led to improvements in the quality and outcomes of MV patients.

Pressure Support Ventilation Versus T-piece as Spontaneous Breathing Trials for Extubation of Patients with Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Weaning patients with COPD from mechanical ventilation (MV) presents a challenge, as literature on this topic is limited. This study compares PSV and T-piece during spontaneous breathing trials (SBT) in this specific population. METHODS: A search of PubMed, EMBASE, and Cochrane in September 2023 yielded four randomized controlled trials (RCTs) encompassing 560 patients. Among these, 287 (51%) used T-piece during SBTs. RESULTS: The PSV group demonstrated a significant improvement in the successful extubation rate compared to the T-piece (risk ratio [RR] 1.14; 95% confidence interval [CI] 1.03-1.26; p = 0.02). Otherwise, there was no statistically significant difference in the reintubation (RR 1.07; 95% CI 0.79-1.45; p = 0.67) or the ICU mortality rates (RR 0.99; 95% CI 0.63-1.55; p = 0.95). CONCLUSION: Although PSV in SBTs exhibits superior extubation success, consistent weaning protocols warrant further exploration through additional studies.

Accuracy of respiratory muscle assessments to predict weaning outcomes: a systematic review and comparative meta-analysis.

BACKGROUND: Several bedside assessments are used to evaluate respiratory muscle function and to predict weaning from mechanical ventilation in patients on the intensive care unit. It remains unclear which assessments perform best in predicting weaning success. The primary aim of this systematic review and meta-analysis was to summarize and compare the accuracy of the following assessments to predict weaning success: maximal inspiratory (PImax) and expiratory pressures, diaphragm thickening fraction and excursion (DTF and DE), end-expiratory (Tdiee) and end-inspiratory (Tdiei) diaphragm thickness, airway occlusion pressure (P0.1), electrical activity of respiratory muscles, and volitional and non-volitional assessments of transdiaphragmatic and airway opening pressures. METHODS: Medline (via Pubmed), EMBASE, Web of Science, Cochrane Library and CINAHL were comprehensively searched from inception to 04/05/2023. Studies including adult mechanically ventilated patients reporting data on predictive accuracy were included. Hierarchical summary receiver operating characteristic (HSROC) models were used to estimate the SROC curves of each assessment method. Meta-regression was used to compare SROC curves. Sensitivity analyses were conducted by excluding studies with high risk of bias, as assessed with QUADAS-2. Direct comparisons were performed using studies comparing each pair of assessments within the same sample of patients. RESULTS: Ninety-four studies were identified of which 88 studies (n = 6296) reporting on either PImax, DTF, DE, Tdiee, Tdiei and P0.1 were included in the meta-analyses. The sensitivity to predict weaning success was 63% (95% CI 47-77%) for PImax, 75% (95% CI 67-82%) for DE, 77% (95% CI 61-87%) for DTF, 74% (95% CI 40-93%) for P0.1, 69% (95% CI 13-97%) for Tdiei, 37% (95% CI 13-70%) for Tdiee, at fixed 80% specificity. Accuracy of DE and DTF to predict weaning success was significantly higher when compared to PImax (p = 0.04 and p < 0.01, respectively). Sensitivity and direct comparisons analyses showed that the accuracy of DTF to predict weaning success was significantly higher when compared to DE (p < 0.01). CONCLUSIONS: DTF and DE are superior to PImax and DTF seems to have the highest accuracy among all included respiratory muscle assessments for predicting weaning success. Further studies aiming at identifying the optimal threshold of DTF to predict weaning success are warranted. TRIAL REGISTRATION: PROSPERO CRD42020209295, October 15, 2020.

Diaphragm atrophy during invasive mechanical ventilation is related to extubation failure in preterm infants: An ultrasound study.

BACKGROUND: Diaphragm dysfunction is associated with poor outcomes in critically ill patients. Ventilator-induced diaphragmatic dysfunction (VIDD), including diaphragm atrophy (DA), is poorly studied in newborns. We aimed to assess VIDD and its associations in newborns. METHODS: Single-center prospective study. Diaphragm thickness was measured at end-inspiration (TDI) and end-expiration (TDE) on the right midaxillary line. DA was defined as decrease in TDE ≥ 10%. Daily measurements were recorded in preterm newborns on invasive mechanical ventilation (IMV) for ≥2 days. Clinical characteristics of patients and extubation failure were recorded. Univariate analysis, logistic regression, and mixed models were performed to describe VIDD and associated factors. RESULTS: We studied 17 patients (median gestational age 270/7 weeks) and 22 IMV cycles (median duration 9 days). Median TDE decreased from 0.118 cm (interquartile range [IQR] 0.094-0.165) on the first IMV day to 0.104 cm (IQR 0.083-0.120) on the last IMV day (p = .092). DA occurred in 11 IMV cycles (50%) from 10 infants early during IMV (median: second IMV day). Mean airway pressure (MAP) and lung ultrasound score (LUS) on the first IMV day were significantly higher in patients who developed DA. DA was more frequent in patients with extubation failure than in those with extubation success within 7 days (83.3 vs. 33.3%, p = .038). CONCLUSIONS: DA, significantly associated with extubation failure, occurred in 58.8% of the study infants on IMV. Higher MAP and LUS at IMV start were associated with DA. Our results suggest a potential role of diaphragm ultrasound to assess DA and predict extubation failure in clinical practice.

The Age of Older Patients Requiring Prolonged Mechanical Ventilation Is Not the Sole Determinant of Their Long-Term Survival.

Background and Objectives: There are few data on the effects of prolonged mechanical ventilation on elderly patients. Our objective is to investigate the effects of prolonged mechanical ventilation on older patients' successful weaning and long-term survival. Methods: We examined how aging affected the course and results of elderly patients on prolonged mechanical ventilation by contrasting five age groups. Age, sex, cause of acute respiratory failure, comorbidities, discharge status, weaning status, and long-term survival outcomes were among the information we gathered. Results: Patients on prolonged mechanical ventilation who had undergone tracheostomy and had been successfully weaned had a greater one-year survival rate. The 1-year survival rate was poorer for older patients with four or more comorbidities. Regarding the 5-year survival rate, the risk of death was 45% lower in the successfully weaned patients than in the unsuccessfully weaned patients. The risk of death was 46% lower in patients undergoing tracheostomy than in those not undergoing tracheostomy. Older prolonged mechanical ventilation (PMV) patients with four or more comorbidities had an increased risk of death. Conclusions: When it comes to elderly patients on prolonged mechanical ventilation, there are other factors in addition to age that influence long-term survival. Long-term survival is likewise linked to successful weaning and undergoing tracheostomy.

Spontaneous Breathing Trial Techniques for Extubating Adults and Children Who Are Critically Ill: A Systematic Review and Meta-Analysis.

Importance: Considerable controversy exists regarding the best spontaneous breathing trial (SBT) technique to use. Objective: To summarize trials comparing alternative SBTs. Data Sources: Several databases (MEDLINE [from inception to February 2023], the Cochrane Central Register of Controlled Trials [in February 2023], and Embase [from inception to February 2023] and 5 conference proceedings (from January 1990 to April 2023) were searched in this systematic review and meta-analysis. Study Selection: Randomized trials directly comparing SBT techniques in critically ill adults or children and reporting at least 1 clinical outcome were selected. Data Extraction and Synthesis: Paired reviewers independently screened citations, abstracted data, and assessed quality for the systematic review and meta-analysis using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA guidelines). Data were pooled using random-effects models. Main Outcomes and Measures: Primary outcomes included SBT success, extubation success, and reintubation. Results: The systematic review and meta-analysis identified 40 trials that included 6716 patients. Low-quality evidence (14 trials [n = 4459]) suggested that patients were not more likely to pass a pressure support (PS) compared with a T-piece SBT (risk ratio [RR], 1.04; 95% CI, 0.97-1.11; P = .31; I2 = 73%), unless 1 outlier trial accounting for all heterogeneity was excluded (RR, 1.09; 95% CI, 1.06-1.12; P < .001; I2 = 0% [13 trials; n = 3939]; moderate-quality evidence), but were significantly more likely to be successfully extubated (RR, 1.07; 95% CI, 1.04-1.10; P < .001; I2 = 0%; 16 trials [n = 4462]; moderate-quality evidence). Limited data (5 trials [n = 502]) revealed that patients who underwent automatic tube compensation/continuous positive airway pressure compared with PS SBTs had a significantly higher successful extubation rate (RR, 1.10; 95% CI, 1.00-1.21; P = .04; I2 = 0% [low-quality evidence]). Compared with T-piece SBTs, high-flow oxygen SBTs (3 trials [n = 386]) had significantly higher successful extubation (RR, 1.06; 95% CI, 1.00-1.11; P = .04; I2 = 0%) and lower reintubation (RR, 0.37; 95% CI, 0.21-0.65; P = <.001; I2 = 0% [both low-quality evidence]) rates. Credible subgroup effects were not found. Conclusions and Relevance: In this systematic review and meta-analysis, the findings suggest that patients undergoing PS compared with T-piece SBTs were more likely to be extubated successfully and more likely to pass an SBT, after exclusion of an outlier trial. Pressure support SBTs were not associated with increased risk of reintubation. Future trials should compare SBT techniques that maximize differences in inspiratory support.

Seizures in 3 juvenile dogs after intravenous anesthetic drug withdrawal during weaning from mechanical ventilation suspected to be a sign of iatrogenic withdrawal syndrome.

OBJECTIVE: To describe seizure activity in juvenile dogs successfully weaned from long-term mechanical ventilation. CASE SERIES SUMMARY: Three juvenile dogs (all approximately 3 months old) underwent long-term mechanical ventilation with IV anesthesia for suspected noncardiogenic pulmonary edema. Within 24 hours of extubation and within 10 hours of discontinuing midazolam continuous infusions, all dogs experienced seizures, which is 1 sign of iatrogenic withdrawal syndrome. Each dog was treated with an anticonvulsant protocol, and none experienced seizures after being discharged. NEW OR UNIQUE INFORMATION PROVIDED: Each dog received IV anesthesia, including fentanyl, dexmedetomidine, midazolam, and propofol, during mechanical ventilation and subsequently experienced seizures after successful weaning from mechanical ventilation. Juvenile dogs may be at risk for seizures after weaning from mechanical ventilation and IV anesthesia. Neurological monitoring and further research into an appropriate weaning protocol may prove beneficial in juvenile dogs requiring prolonged anesthesia.

Factors Associated With Successful Extubation Readiness Testing in Children With Congenital Heart Disease.

BACKGROUND: In children with congenital heart disease, extubation readiness testing (ERT) is performed to evaluate the potential for liberation from mechanical ventilation. There is a paucity of data that suggests what mechanical ventilation parameters are associated with successful ERT. We hypothesized that ERT success would be associated with certain mechanical ventilator parameters. METHODS: Data on daily ERT assessments were recorded as part of a quality improvement project. In accordance with our respiratory therapist-driven ventilator protocol, patients were assessed daily for ERT eligibility and tested daily, if eligible. Mechanical ventilation parameters were categorized a priori to evaluate the differences in levels of respiratory support. The primary outcome was ERT success. RESULTS: A total of 780 ERTs from 320 subjects (median [interquartile range] age 2.5 [0.6-6.5] months and median weight [interquartile range] 4.2 [3.3-6.9] kg) were evaluated. A total of 528 ERTs (68%) were passed, 306 successful ERTs (58%) resulted in extubation, and 30 subjects (9.4%) were re-intubated. There were statistically significant differences in the ERT pass rate for ventilator mode, peak inspiratory pressure, Δ pressure, PEEP, mean airway pressure ([Formula: see text]), and dead-space-to-tidal-volume ratio (all P < .001) but not for [Formula: see text]. ERT success decreased with increases in peak inspiratory pressure, Δ pressure, PEEP, [Formula: see text], and dead-space-to-tidal-volume ratio. Logistic regression revealed neonates, Δ pressure ≥ 11 cm H2O, and [Formula: see text] > 10 cm H2O were associated with a decreased odds of ERT success, whereas children ages 1-5 years and an [Formula: see text] of 0.31-0.40 had increased odds of ERT success. CONCLUSIONS: ERT pass rates decreased as ventilator support increased; however, some subjects were able to pass ERT despite high ventilator support. We found that [Formula: see text] was associated with ERT success and that protocols should consider using [Formula: see text] instead of PEEP thresholds for ERT eligibility. Cyanotic lesions were not associated with ERT success, which suggests that patients with cyanotic heart disease can be included in ERT protocols.

Mechanical Ventilation, Past, Present, and Future.

Mechanical ventilation (MV) has played a crucial role in the medical field, particularly in anesthesia and in critical care medicine (CCM) settings. MV has evolved significantly since its inception over 70 years ago and the future promises even more advanced technology. In the past, ventilation was provided manually, intermittently, and it was primarily used for resuscitation or as a last resort for patients with severe respiratory or cardiovascular failure. The earliest MV machines for prolonged ventilatory support and oxygenation were large and cumbersome. They required a significant amount of skills and expertise to operate. These early devices had limited capabilities, battery, power, safety features, alarms, and therefore these often caused harm to patients. Moreover, the physiology of MV was modified when mechanical ventilators moved from negative pressure to positive pressure mechanisms. Monitoring systems were also very limited and therefore the risks related to MV support were difficult to quantify, predict and timely detect for individual patients who were necessarily young with few comorbidities. Technology and devices designed to use tracheostomies versus endotracheal intubation evolved in the last century too and these are currently much more reliable. In the present, positive pressure MV is more sophisticated and widely used for extensive period of time. Modern ventilators use mostly positive pressure systems and are much smaller, more portable than their predecessors, and they are much easier to operate. They can also be programmed to provide different levels of support based on evolving physiological concepts allowing lung-protective ventilation. Monitoring systems are more sophisticated and knowledge related to the physiology of MV is improved. Patients are also more complex and elderly compared to the past. MV experts are informed about risks related to prolonged or aggressive ventilation modalities and settings. One of the most significant advances in MV has been protective lung ventilation, diaphragm protective ventilation including noninvasive ventilation (NIV). Health care professionals are familiar with the use of MV and in many countries, respiratory therapists have been trained for the exclusive purpose of providing safe and professional respiratory support to critically ill patients. Analgo-sedation drugs and techniques are improved, and more sedative drugs are available and this has an impact on recovery, weaning, and overall patients' outcome. Looking toward the future, MV is likely to continue to evolve and improve alongside monitoring techniques and sedatives. There is increasing precision in monitoring global "patient-ventilator" interactions: structure and analysis (asynchrony, desynchrony, etc). One area of development is the use of artificial intelligence (AI) in ventilator technology. AI can be used to monitor patients in real-time, and it can predict when a patient is likely to experience respiratory distress. This allows medical professionals to intervene before a crisis occurs, improving patient outcomes and reducing the need for emergency intervention. This specific area of development is intended as "personalized ventilation." It involves tailoring the ventilator settings to the individual patient, based on their physiology and the specific condition they are being treated for. This approach has the potential to improve patient outcomes by optimizing ventilation and reducing the risk of harm. In conclusion, MV has come a long way since its inception, and it continues to play a critical role in anesthesia and in CCM settings. Advances in technology have made MV safer, more effective, affordable, and more widely available. As technology continues to improve, more advanced and personalized MV will become available, leading to better patients' outcomes and quality of life for those in need.

Effects of structured protocolized physical therapy on the duration of mechanical ventilation in patients with prolonged weaning.

PURPOSE: 20% of patients with mechanical ventilation (MV) have a prolonged, complex weaning process, often experiencing a condition of ICU-acquired weakness (ICUAW), with a severe decrease in muscle function and restricted long-term prognosis. We aimed to analyze a protocolized, systematic approach of physiotherapy in prolonged weaning patients and hypothesized that the duration of weaning from MV would be shortened. METHODS: ICU patients with prolonged weaning were included before (group 1) and after (group 2) introduction of a quality control measure of a structured and protocolized physiotherapy program. Primary endpoint was the tested dynamometric handgrip strength and the Surgical Intensive Care Unit Optimal Mobilization Score (SOMS). Secondary endpoints were weaning success rate, ventilator-free days, hospital mortality, the prevalence of ICUAW, infections and delirium. RESULTS: 106 patients were included. Both the SOMS and the handgrip test were significantly improved after introducing the program. Despite no differences in weaning success rates at discharge, the total length of MV was significantly shorter in group 2, which also had lower prevalence of infection and higher probability of survival. CONCLUSIONS: Protocolized, systematic physiotherapy resulted in an improvement of the clinical outcome in patients with prolonged weaning. Results were objectifiable with the SOMS and the handgrip test.

[Certification by the German Society for Neurorehabiliation, DGNR : Performance and quality of the "Centers for weaning from a ventilator in early neurological and neurosurgical rehabilitation"]. / Zertifizierung der Deutschen Gesellschaft für Neurorehabilitation e. V., DGNR : Leistung und Qualität der "Zentren für Beatmungsentwöhnung in der neurologisch-neurochirurgischen Frührehabilitation".

BACKGROUND: Certification of centers for weaning from a ventilator in neurological neurosurgical early rehabilitation (NNER) by the German Society for Neurorehabilitation (DGNR) is possible since 1 October 2021. OBJECTIVE: The results of certification of facilities in the first year after starting the procedure are presented. MATERIAL AND METHODS: As part of the certification process 28 criteria are assessed including a set of mandatory characteristics of the facility. The criteria are divided into structural criteria (i = 7), diagnostic criteria (i = 6), personnel criteria (i = 3), internal organization criteria (i = 7), and quality management criteria (i = 5). RESULTS: A total of 13 centers were certified in the first year, with a combined total of 283 beds for weaning from a ventilator in the NNER and served 2278 persons to be weaned from a ventilator in the year before certification, with a median of 134 per facility (range 44-414). Only rarely was weaning unsuccessful, requiring conversion to home mechanical ventilation before discharge (invasive home mechanical ventilation median per facility 10 persons, range 2-25; non-invasive home mechanical ventilation median 0 persons, range 0-57). A high level of process and structural quality was documented for the certified centers: across all areas of assessment, the individual certification criteria were met in the vast majority of cases (median degree of complete fulfilment 86%) or met with improvement potentials documented by the auditors (median 11%). CONCLUSION: Successful weaning in NNER and a high level of process and structural quality can be demonstrated by the certification results of centers that follow this integrative approach to weaning from a ventilator in a NNER setting.

Utilization of spontaneous breathing trial, objective cough test, and diaphragmatic ultrasound results to predict extubation success: COBRE-US trial.

BACKGROUND: The results of clinical and weaning readiness tests and the spontaneous breathing trial (SBT) are used to predict the success of the weaning process and extubation. METHODS: We evaluated the capacity of the cuff leak test, rate of rapid and shallow breathing, cough intensity, and diaphragmatic contraction velocity (DCV) to predict the success of the SBT and extubation in a prospective, multicenter observational study with consecutive adult patients admitted to four intensive care units. We used receiver operating characteristic (ROC) curves to assess the tests' predictive capacity and built predictive models using logistic regression. RESULTS: We recruited 367 subjects who were receiving invasive mechanical ventilation and on whom 456 SBTs were performed, with a success rate of 76.5%. To predict the success of the SBT, we derived the following equation: (0.56 × Cough) - (0.13 × DCV) + 0.25. When the cutoff point was ≥ 0.83, the sensitivity was 91.5%, the specificity was 22.1%, and the overall accuracy was 76.2%. The area under the ROC curve (AUC-ROC) was 0.63. To predict extubation success, we derived the following equation: (5.7 × SBT) + (0.75 × Cough) - (0.25 × DCV) - 4.5. When the cutoff point was ≥ 1.25, the sensitivity was 96.8%, the specificity was 78.4%, and the overall accuracy was 91.5%. The AUC-ROC of this model was 0.91. CONCLUSION: Objective measurement of cough and diaphragmatic contraction velocity could be used to predict SBT success. The equation for predicting successful extubation, which includes SBT, cough, and diaphragmatic contraction velocity values, showed excellent discriminative capacity.

Optimal timing of extubation in preterm infants.

In neonatal intensive care, endotracheal intubation is usually performed as an urgent or semi-urgent procedure in infants with critical or unstable conditions related to progressive respiratory failure. Extubation is not. Patients undergoing extubation are typically stable, with improved respiratory function. The key elements to facilitating extubation are to recognize improvement in respiratory status, promote weaning of mechanical ventilation, and accurately identify readiness for removal of the endotracheal tube. Therefore, extubation should be a planned and well-organized procedure. In this review, we will appraise the evidence for existing predictors of extubation readiness and provide patient-specific, pathophysiology-derived strategies to optimize the timing and success of extubation in neonates, with a focus on extremely preterm infants.

Delivery of a novel intervention to facilitate liberation from mechanical ventilation in paediatric intensive care: A process evaluation.

BACKGROUND: Prolonged mechanical ventilation increases the risk of mortality and morbidity. Optimising sedation and early testing for possible liberation from invasive mechanical ventilation (IMV) has been shown to reduce time on the ventilator. Alongside a multicentre trial of sedation and ventilation weaning, we conducted a mixed method process evaluation to understand how the intervention content and delivery was linked to trial outcomes. METHODS: 10,495 children admitted to 18 paediatric intensive care units (ICUs) in the United Kingdom participated in a stepped-wedge, cluster randomised controlled trial, with 1955 clinical staff trained to deliver the intervention. The intervention comprised assessment and optimisation of sedation levels, and bedside screening of respiratory parameters to indicate readiness for a spontaneous breathing trial prior to liberation from ventilation. 193 clinical staff were interviewed towards the end of the trial. Interview data were thematically analysed, and quantitative adherence data were analysed using descriptive statistics. RESULTS: The intervention led to a reduced duration of IMV (adjusted median difference- 7.1 hours, 95% CI -9.6 to -5.3, p = 0.01). Overall intervention adherence was 75% (range 59-85%). Ease and flexibility of the intervention promoted it use; designated responsibilities, explicit pathways of decision-making and a shared language for communication fostered proactivity and consistency towards extubation. Delivery of the intervention was hindered by established hospital and unit organisational and patient care routines, clinician preference and absence of clinical leadership. CONCLUSIONS: The SANDWICH trial showed a significant, although small, reduction in duration of IMV. Findings suggest that greater direction in decision-making pathways, robust embedment of new practice in unit routine, and capitalising on the skills of Advanced Nurse Practitioners and physiotherapists would have contributed to greater intervention effect. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN16998143.

A Fast-Track Respiratory Protocol for High Cervical Spine Injury: A Case Report.

BACKGROUND: Cervical spinal cord injury can greatly affect pulmonary function, resulting in complications, including respiratory failure with prolonged mechanical ventilation, ultimately leading to increased mortality and high health care costs. Weaning from mechanical ventilation is particularly challenging in patients with complete high spinal cord injury. CASE PRESENTATION: We present the case of a 42-year-old man who suffered a complete cervical 5-6 spinal cord injury following a rollover motor vehicle crash and subsequently developed postoperative pneumonia and severe hypoxemic respiratory failure. He received a novel approach to fast-track respiratory care, including early and aggressive secretion clearance management, moderate pressure level of airway pressure release ventilation, timely transition to spontaneous mode, early tracheostomy and humane care, and high-flow oxygenation via tracheotomy after weaning off the ventilator. As a result, the patient experienced significant improvement in pulmonary function and was successfully liberated from the ventilator within a 2-week period. CONCLUSION: This case highlights the potential effectiveness of fast-track respiratory care in promoting lung function restoration and expediting liberation from mechanical ventilation in patients with severe hypoxemic respiratory failure following a complete cervical spinal cord injury. However, further research is warranted to validate these findings and expand our understanding in this area.

Frequency of screening and SBT Technique Trial-North American Weaning Collaboration (FAST-NAWC): an update to the protocol and statistical analysis plan.

BACKGROUND: This update summarizes key changes made to the protocol for the Frequency of Screening and Spontaneous Breathing Trial (SBT) Technique Trial-North American Weaning Collaborative (FAST-NAWC) trial since the publication of the original protocol. This multicenter, factorial design randomized controlled trial with concealed allocation, will compare the effect of both screening frequency (once vs. at least twice daily) to identify candidates to undergo a SBT and SBT technique [pressure support + positive end-expiratory pressure vs. T-piece] on the time to successful extubation (primary outcome) in 760 critically ill adults who are invasively ventilated for at least 24 h in 20 North American intensive care units. METHODS/DESIGN: Protocols for the pilot, factorial design trial and the full trial were previously published in J Clin Trials ( https://doi.org/10.4172/2167-0870.1000284 ) and Trials (https://doi: 10.1186/s13063-019-3641-8). As planned, participants enrolled in the FAST pilot trial will be included in the report of the full FAST-NAWC trial. In response to the onset of the coronavirus disease of 2019 (COVID-19) pandemic when approximately two thirds of enrollment was complete, we revised the protocol and consent form to include critically ill invasively ventilated patients with COVID-19. We also refined the statistical analysis plan (SAP) to reflect inclusion and reporting of participants with and without COVID-19. This update summarizes the changes made and their rationale and provides a refined SAP for the FAST-NAWC trial. These changes have been finalized before completion of trial follow-up and the commencement of data analysis. TRIAL REGISTRATION: Clinical Trials.gov NCT02399267.

Clinical implication of thoracic skeletal muscle volume as a predictor of ventilation-weaning failure in brain-injured patients: A retrospective observational study.

Sarcopenia, a generalized loss of skeletal muscle mass that is primarily evident in the respiratory musculature, is associated with adverse outcomes in critically ill patients. However, the relationship between sarcopenia and ventilation-weaning outcomes has not yet been fully studied in patients with brain injuries. In this study, we examined the effect of reduced respiratory muscle mass on ventilation weaning in patients with brain injury. This observational study retrospectively reviewed the medical records of 73 patients with brain injury between January 2017 and December 2019. Thoracic skeletal muscle volumes were measured from thoracic CT images using the institute's three-dimensional modeling software program of our institute. The thoracic skeletal muscle volumes index (TSMVI) was normalized by dividing muscle volume by the square of patient height. Sarcopenia was defined as a TSMVI of less than the 50th sex-specific percentile. Among 73 patients with brain injury, 12 (16.5%) failed to wean from mechanical ventilation. The patients in the weaning-failure group had significantly higher sequential organ failure assessment scores [7.8 ±â€…2.7 vs 6.1 ±â€…2.2, P = .022] and lower thoracic skeletal muscle volume indexes [652.5 ±â€…252.4 vs 1000.4 ±â€…347.3, P = .002] compared with those in the weaning-success group. In multivariate analysis, sarcopenia was significantly associated with an increased risk of weaning failure (odds ratio 12.72, 95% confidence interval 2.87-70.48, P = .001). Our study showed a significant association between the TSMVI and ventilation weaning outcomes in patients with brain injury.

Effectiveness of "Physician Prompt Clinical Decision Criteria" in Weaning Outcome Prediction for Neurocritical Patients.

Endotracheal intubation and invasive mechanical ventilation are fundamental components for the resuscitation of neurocritically ill patients to achieve various goals which include ensuring the protection of the airway, participating in tissue oxygen delivery and indirectly modulating cerebral vascular reactivity. The neurocritical patients demand special attention to their systemic involvement regarding weaning. Physician prompt clinical decision criteria (PPC) can play a better role in weaning of such patients. The aim of this study was to evaluate the effectiveness of 'Physician prompt clinical decision criteria' for successful weaning in neurocritical patients. This prospective observational study was conducted in the ICU, Department of Anaesthesia, Analgesia, Palliative & Intensive Care Medicine, Dhaka Medical College Hospital (DMCH), Dhaka, Bangladesh from March 2018 to April 2020. In total 100 neurocritical patients who fulfilled the inclusion criteria were taken as samples by informed written consent. The outcome was observed as successful weaning or as failed weaning. Finally, the existence of Standard extubation criteria (SEC) was compared with Physician prompt clinical decision criteria (PPC). Weaning was succeeded in 80.0% of patients and failed in 20.0% according to the Standard extubation criteria (SEC) while weaning was succeeded in 85.7% of patients and failed in 14.28% according to the Physician prompt clinical decision criteria (PPC). There were some differences in results but no significant differences were observed statistically between the groups in predicting the weaning outcome. Physician prompt clinical decision criteria were found to be 75.0% sensitive and specificity was 50.0%. Positive predictive value for Physician prompt clinical decision criteria was 85.70% with a Positive likelihood ratio for these criteria was 1.5 times. So, according to the study findings, accuracy of Physician prompt clinical decision criteria was 70.0%. According to the findings of this current study we can conclude that Physician prompt clinical decision criteria are an effective weaning readiness predictor in neurocritical patients.

Is diaphragm ultrasound better than rapid shallow breathing index for predicting weaning in critically ill elderly patients?

Introduction: Prolonged weaning is associated with worse clinical outcomes in elderly patients. Beside traditional rapid shallow breathing index (RSBI), diaphragm ultrasound is a promising technique to evaluate the weaning process. We aimed to perform diaphragm ultrasonography for predicting the weaning process and its relation with frailty in the critically ill elderly population. Materials and Methods: We enrolled thirthy-two patients over 65 years of age who were mechanically ventilated for at least 48 hours. Thickness of diaphragm and excursion were evaluated within 48 h of intubation and during spontaneous breathing trial (SBT). Clinical parameters, frailty, diaphragm ultrasound results were compared according to the weaning status. Results: Mean age (standard deviation) was 79.3 ± 7.9 years, and 18 (56.3%) patients were classified as weaning failure. Diaphragmatic excursion during SBT was the only statistically significant parameter associated with weaning failure [2.37 cm (0.67) vs 1.43 cm (0.15), p= 0.0359]. There was no statistically significant difference regarding RSBI between the groups [70.5 (46) vs 127.5 (80), p= 0.09]. Baseline thickness of diaphragm and excursion at SBT were moderately correlated with frailty. Conclusion: Ultrasound can be used to show diaphragm dysfunction in the elderly frail population, and a multifactorial approach to the extubation process may include ultrasound instead of using traditional RSBI alone.

[Advanced monitoring during weaning of invasive mechanical ventilation in single-lung transplantation]. / Monitorización avanzada durante la desvinculación de la ventilación mecánica invasiva en el trasplante unipulmonar.

Bilateral lung transplantation is the treatment of end-stage lung diseases. However, sometimes a single lung transplant is performed. The technique is not exempt from complications such as acute hyperinflation of the native lung and changes in the diaphragm, predisposing to atelectasis and respiratory failure that can lead to negative results. Therefore, spontaneous breathing trials may fail and delay the weaning process. The combination of advanced monitoring tools, such as electrical impedance tomography and ultrasonography, to diagnose the cause of this failure, recognizing and quantifying the distribution of lung volume and its dynamic behavior could be crucial to improve outcomes. We present the case of a patient with a one-lung transplant and prolonged mechanical ventilation who, after presenting successive failures in the weaning process, underwent advanced monitoring in order to find the causes of the failure.

El trasplante de pulmón bilateral es el tratamiento de las enfermedades pulmonares en su etapa terminal. Sin embargo, a veces se realiza el trasplante de un solo pulmón. La técnica no está exenta de complicaciones como la hiperinsuflación aguda del pulmón nativo y cambios en el diafragma, predisponiendo a atelectasias e insuficiencia respiratoria que pueden derivar en resultados negativos. Por lo tanto, las pruebas de respiración espontánea pueden fallar y retrasar el proceso de desvinculación de la ventilación mecánica. La combinación de herramientas de monitorización avanzadas, como la tomografía por impedancia eléctrica y la ecografía, para diagnosticar la causa de este fallo, reconociendo y cuantificando la distribución del volumen pulmonar y su comportamiento dinámico, podría ser crucial para mejorar los resultados. Presentamos el caso de un paciente con trasplante unipulmonar y ventilación prolongada que falla en repetidas ocasiones durante la desvinculación de la ventilación mecánica, donde utilizamos herramientas de monitoreo avanzado para detectar la causa de la falla.