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1.
Crit Care ; 24(1): 67, 2020 02 26.
Artigo em Inglês | MEDLINE | ID: mdl-32102693

RESUMO

BACKGROUND: The effect of alternative spontaneous breathing trial (SBT) techniques on extubation success and other clinically important outcomes is uncertain. A systematic review and meta-analysis was performed to clarify the preferable SBT (T-piece or pressure support ventilation [PSV]). METHODS: We searched the PubMed, Cochrane, and Embase databases for randomized controlled trials (RCTs) from inception to the 31st of July 2019. We included RCTs involving adult patients (> 18 years) who underwent at least two different SBT methods. All authors reported our primary outcome of successful extubation rate and clearly compared PS versus T-piece with clinically relevant secondary outcomes (rate of reintubation, ICU and hospital length of stay, and ICU and hospital mortality). Results were expressed as odds ratio (OR) and mean difference (MD) with accompanying 95% confidence interval (CI). RESULTS: Ten RCTs including 3165 patients were included. The results of this meta-analysis showed that there was no significant difference in the successful extubation rate between the T-piece group and PS group (odds ratio [OR] = 0.91; 95% CI, 0.78-1.07; P = 0.27; I2 = 79%). In addition, compared with the PS group, the T-piece group showed no significant difference in the rate of reintubation (odds ratio [OR] = 0.99; 95% CI, 0.78-1.26; P = 0.95; I2 = 5%), ICU mortality (odds ratio [OR] = 1.22; 95% CI, 0.83-1.80; P = 0.30; I2 = 0%), hospital mortality (odds ratio [OR] = 1.36; 95% CI, 0.99-1.87; P = 0.06; I2 = 19%), ICU length of stay (mean difference = - 0.10; 95% CI, - 0.59 to 0.39; P = 0.69; I2 = 13%), and hospital length of stay (mean difference = - 0.82;95% CI, - 2.2 to 0.55; P = 0.24; I2 = 0%). CONCLUSIONS: T-piece and PSV as SBTs are considered to have comparable predictive power of successful extubation in critically ill patients. The analysis of secondary outcomes also shows no significant difference in the rate of reintubation, ICU and hospital length of stay, and ICU and hospital mortality between the two groups. Further randomized controlled studies of SBTs are still required.


Assuntos
Extubação , Respiração Artificial , Desmame do Respirador , Extubação/métodos , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Intubação Intratraqueal , Razão de Chances , Respiração Artificial/instrumentação , Respiração Artificial/métodos , Resultado do Tratamento , Desmame do Respirador/instrumentação , Desmame do Respirador/métodos
2.
Pneumologie ; 73(12): 723-814, 2019 Dec.
Artigo em Alemão | MEDLINE | ID: mdl-31816642

RESUMO

Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by insufficiency of respiratory muscles and/or lung parenchymal disease when/after other treatments, (i. e. medication, oxygen, secretion management, continuous positive airway pressure or nasal highflow) have failed.MV is required to maintain gas exchange and to buy time for curative therapy of the underlying cause of respiratory failure. In the majority of patients weaning from MV is routine and causes no special problems. However, about 20 % of patients need ongoing MV despite resolution of the conditions which precipitated the need for MV. Approximately 40 - 50 % of time spent on MV is required to liberate the patient from the ventilator, a process called "weaning."There are numberous factors besides the acute respiratory failure that have an impact on duration and success rate of the weaning process such as age, comorbidities and conditions and complications acquired in the ICU. According to an international consensus conference "prolonged weaning" is defined as weaning process of patients who have failed at least three weaning attempts or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Prolonged weaning is a challenge, therefore, an inter- and multi-disciplinary approach is essential for a weaning success.In specialised weaning centers about 50 % of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, heterogeneity of patients with prolonged weaning precludes direct comparisons of individual centers. Patients with persistant weaning failure either die during the weaning process or are discharged home or to a long term care facility with ongoing MV.Urged by the growing importance of prolonged weaning, this Sk2-guideline was first published in 2014 on the initiative of the German Respiratory Society (DGP) together with other scientific societies involved in prolonged weaning. Current research and study results, registry data and experience in daily practice made the revision of this guideline necessary.The following topics are dealt with in the guideline: Definitions, epidemiology, weaning categories, the underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV and recommendations for end of life decisions.Special emphasis in the revision of the guideline was laid on the following topics:- A new classification of subgroups of patients in prolonged weaning- Important aspects of pneumological rehabilitation and neurorehabilitation in prolonged weaning- Infrastructure and process organization in the care of patients in prolonged weaning in the sense of a continuous treatment concept- Therapeutic goal change and communication with relativesAspects of pediatric weaning are given separately within the individual chapters.The main aim of the revised guideline is to summarize current evidence and also expert based- knowledge on the topic of "prolonged weaning" and, based on the evidence and the experience of experts, make recommendations with regard to "prolonged weaning" not only in the field of acute medicine but also for chronic critical care.Important addressees of this guideline are Intensivists, Pneumologists, Anesthesiologists, Internists, Cardiologists, Surgeons, Neurologists, Pediatricians, Geriatricians, Palliative care clinicians, Rehabilitation physicians, Nurses in intensive and chronic care, Physiotherapists, Respiratory therapists, Speech therapists, Medical service of health insurance and associated ventilator manufacturers.


Assuntos
Guias de Prática Clínica como Assunto , Pneumologia/normas , Respiração Artificial/métodos , Insuficiência Respiratória/terapia , Desmame do Respirador/métodos , Desmame do Respirador/normas , Criança , Medicina Baseada em Evidências , Alemanha , Serviços de Assistência Domiciliar , Humanos , Insuficiência Respiratória/diagnóstico , Sociedades Médicas
3.
Medicine (Baltimore) ; 98(40): e17392, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31577746

RESUMO

This study aims to construct a neural network to predict weaning difficulty among planned extubation patients in intensive care units.This observational cohort study was conducted in eight adult ICUs in a medical center about adult patients experiencing planned extubation.The data of 3602 patients with planned extubation in ICUs of Chi-Mei Medical Center (from Dec. 2009 through Dec. 2011) was used to train and test an artificial neural network (ANN) model. The input features contain 47 clinical risk factors and the outputs are classified into three categories: simple, difficult, and prolonged weaning. A deep ANN model with four hidden layers of 30 neurons each was developed. The accuracy is 0.769 and the area under receiver operating characteristic curve for simple weaning, prolonged weaning, and difficult weaning are 0.910, 0.849, and 0.942 respectively.The results revealed that the ANN model achieved a good performance in prediction the weaning difficulty in planned extubation patients. Such a model will be helpful for predicting ICU patients' successful planned extubation.


Assuntos
Extubação/métodos , Desmame do Respirador/métodos , APACHE , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Curva ROC , Estudos Retrospectivos
4.
J Card Surg ; 34(10): 1004-1011, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31374585

RESUMO

BACKGROUND: Extubation is a critical step in the intensive care unit (ICU). In this study, we aim to investigate the risk factors for both extubation failure and deterioration with further mechanical ventilation (MV). METHODS: Data were collected from a cardiothoracic ICU in a tertiary hospital. The risk factors for extubation failure and deterioration with further MV were investigated by multivariate logistic regression. RESULTS: A total of 676 patients were enrolled in the study. Patients with extubation failure had a longer ICU length of stay and a higher mortality rate than patients without extubation failure. An age greater than 65 years, abnormal heart rate, respiratory rate exceeding 20 times/min, arterial pH lower than 7.35, pressure of oxygen in arterial blood (PaO2)/fraction of inspired oxygen (FiO2) ratio lower than 300 mmHg, mean arterial pressure lower than 70 mmHg, duration of MV longer than 12 hours, and high quick Sequential Organ Failure Assessment (qSOFA) score were independent risk factors for extubation failure. Furthermore, we found that a respiratory rate greater than 20 times/min and a PaO2/fraction of Inspired Oxygen FiO2 ratio less than 300 mmHg were protective factors, while a mean arterial pressure lower than 70 mmHg, arterial pH lower than 7.35, and high qSOFA score were risk factors for deterioration on continued MV. CONCLUSIONS: Since the duration of MV increases the risk of extubation failure, physicians should consider not only the risk of extubation failure but also the risk of deterioration with further MV.


Assuntos
Extubação , Tomada de Decisões , Unidades de Terapia Intensiva , Respiração Artificial/métodos , Desmame do Respirador/métodos , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Falha de Tratamento
6.
Crit Care ; 23(1): 261, 2019 Jul 24.
Artigo em Inglês | MEDLINE | ID: mdl-31340846

RESUMO

BACKGROUND: For every day a person is dependent on mechanical ventilation, respiratory and cardiac complications increase, quality of life decreases and costs increase by > $USD 1500. Interventions that improve respiratory muscle function during mechanical ventilation can reduce ventilation duration. The aim of this pilot study was to assess the feasibility of employing an abdominal functional electrical stimulation (abdominal FES) training program with critically ill mechanically ventilated patients. We also investigated the effect of abdominal FES on respiratory muscle atrophy, mechanical ventilation duration and intensive care unit (ICU) length of stay. METHODS: Twenty critically ill mechanically ventilated participants were recruited over a 6-month period from one metropolitan teaching hospital. They were randomly assigned to receive active or sham (control) abdominal FES for 30 min, twice per day, 5 days per week, until ICU discharge. Feasibility was assessed through participant compliance to stimulation sessions. Abdominal and diaphragm muscle thickness were measured using ultrasound 3 times in the first week, and weekly thereafter by a blinded assessor. Respiratory function was recorded when the participant could first breathe independently and at ICU discharge, with ventilation duration and ICU length of stay also recorded at ICU discharge by a blinded assessor. RESULTS: Fourteen of 20 participants survived to ICU discharge (8, intervention; 6, control). One control was transferred before extubation, while one withdrew consent and one was withdrawn for staff safety after extubation. Median compliance to stimulation sessions was 92.1% (IQR 5.77%) in the intervention group, and 97.2% (IQR 7.40%) in the control group (p = 0.384). While this pilot study is not adequately powered to make an accurate statistical conclusion, there appeared to be no between-group thickness changes of the rectus abdominis (p = 0.099 at day 3), diaphragm (p = 0.652 at day 3) or combined lateral abdominal muscles (p = 0.074 at day 3). However, ICU length of stay (p = 0.011) and ventilation duration (p = 0.039) appeared to be shorter in the intervention compared to the control group. CONCLUSIONS: Our compliance rates demonstrate the feasibility of using abdominal FES with critically ill mechanically ventilated patients. While abdominal FES did not lead to differences in abdominal muscle or diaphragm thickness, it may be an effective method to reduce ventilation duration and ICU length of stay in this patient group. A fully powered study into this effect is warranted. TRIAL REGISTRATION: The Australian New Zealand Clinical Trials Registry, ACTRN12617001180303. Registered 9 August 2017.


Assuntos
Estimulação Elétrica/métodos , Desmame do Respirador/instrumentação , APACHE , Adulto , Idoso , Estado Terminal/epidemiologia , Estado Terminal/terapia , Método Duplo-Cego , Estimulação Elétrica/instrumentação , Feminino , Humanos , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Reto do Abdome/irrigação sanguínea , Reto do Abdome/fisiopatologia , Desmame do Respirador/métodos , Desmame do Respirador/normas
7.
J Trauma Acute Care Surg ; 87(3): 559-565, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31205210

RESUMO

BACKGROUND: We hypothesize that if both energy expenditure and oxygenation are optimized (EEOO) toward ventilator tolerance, this would provide patients with the best condition to be liberated from the ventilator. We defined ventilator tolerance as having a respiratory quotient value between 0.7 and 1.0 while maintaining saturations above 98% with FIO2 70% or less and a normal respiratory rate without causing disturbances to the patient's pH. METHODS: This is a single-institution prospective cohort study of ventilator dependent patients within a closed trauma intensive care unit (ICU). The study period was over 52 months. A total of 1,090 patients were part of the primary analysis. The test group (EEOO) was compared to a historical cohort, comparing 26 months in each study group. The primary outcome of this study was number of ventilator days. Secondary outcomes included in-hospital mortality, ICU length of stay (LOS), overall hospital length of stay, tracheostomy rates, reintubation rates, and in-hospital complication rates, such as pneumonia and Acute Respiratory Distress Syndrome (ARDS) ARDS. Both descriptive and multivariable regression analyses were performed to compare the effects of the EEOO protocol with our standard protocols alone. RESULTS: The primary outcome of number of ventilator days was significantly shorter the EEOO cohort by nearly 3 days. This was significant even after adjustment for age, sex, race, comorbidities, nutrition type, and injury severity, (4.3 days vs. 7.2 days, p = 0.0001). The EEOO cohort also had significantly lower ICU days, hospital days, and overall complications rates. CONCLUSION: Optimizing the patient's nutritional regimen to ventilator tolerance and optimizing oxygenation by means of targeted pulmonary mechanics and inspired FIO2 may be associated with lower ventilator and ICU days, as well as overall complication rates. LEVEL OF EVIDENCE: Therapeutic, Level IV.


Assuntos
Metabolismo Energético , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Respiração Artificial/métodos , Desmame do Respirador/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Oxigênio/administração & dosagem , Estudos Prospectivos , Respiração Artificial/estatística & dados numéricos , Traqueostomia/estatística & dados numéricos , Ferimentos e Lesões/complicações , Ferimentos e Lesões/terapia , Adulto Jovem
8.
Cardiol Young ; 29(6): 787-792, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31169104

RESUMO

INTRODUCTION: Reliable predictors of extubation readiness are needed and may reduce morbidity related to extubation failure. We aimed to examine the relationship between changes in pre-extubation near-infrared spectroscopy measurements from baseline and extubation outcomes after neonatal cardiac surgery. MATERIALS AND METHODS: In this retrospective cross-sectional multi-centre study, a secondary analysis of prospectively collected data from neonates who underwent cardiac surgery at seven tertiary-care children's hospitals in 2015 was performed. Extubation failure was defined as need for re-intubation within 72 hours of the first planned extubation attempt. Near-infrared spectroscopy measurements obtained before surgery and before extubation in patients who failed extubation were compared to those of patients who extubated successfully using t-tests. RESULTS: Near-infrared spectroscopy measurements were available for 159 neonates, including 52 with single ventricle physiology. Median age at surgery was 6 days (range: 1-29 days). A total of 15 patients (9.4 %) failed extubation. Baseline cerebral and renal near-infrared spectroscopy measurements were not statistically different between those who were successfully extubated and those who failed, but pre-extubation cerebral and renal values were significantly higher in neonates who extubated successfully. An increase from baseline to time of extubation values in cerebral oximetry saturation by ≥ 5 % had a positive predictive value for extubation success of 98.6 % (95%CI: 91.1-99.8 %). CONCLUSION: Pre-extubation cerebral near-infrared spectroscopy measurements, when compared to baseline, were significantly associated with extubation outcomes. These findings demonstrate the potential of this tool as a valuable adjunct in assessing extubation readiness after paediatric cardiac surgery and warrant further evaluation in a larger prospective study.


Assuntos
Extubação , Procedimentos Cirúrgicos Cardíacos , Circulação Cerebrovascular/fisiologia , Cuidados Pós-Operatórios/métodos , Espectroscopia de Luz Próxima ao Infravermelho/métodos , Estudos Transversais , Feminino , Cardiopatias Congênitas/cirurgia , Humanos , Recém-Nascido , Masculino , Oximetria , Valor Preditivo dos Testes , Estudos Retrospectivos , Falha de Tratamento , Desmame do Respirador/métodos
9.
JAMA ; 321(22): 2175-2182, 2019 06 11.
Artigo em Inglês | MEDLINE | ID: mdl-31184740

RESUMO

Importance: Daily spontaneous breathing trials (SBTs) are the best approach to determine whether patients are ready for disconnection from mechanical ventilation, but mode and duration of SBT remain controversial. Objective: To evaluate the effect of an SBT consisting of 30 minutes of pressure support ventilation (an approach that is less demanding for patients) vs an SBT consisting of 2 hours of T-piece ventilation (an approach that is more demanding for patients) on rates of successful extubation. Design, Setting, and Participants: Randomized clinical trial conducted from January 2016 to April 2017 among 1153 adults deemed ready for weaning after at least 24 hours of mechanical ventilation at 18 intensive care units in Spain. Follow-up ended in July 2017. Interventions: Patients were randomized to undergo a 2-hour T-piece SBT (n = 578) or a 30-minute SBT with 8-cm H2O pressure support ventilation (n = 557). Main Outcome and Measures: The primary outcome was successful extubation (remaining free of mechanical ventilation 72 hours after first SBT). Secondary outcomes were reintubation among patients extubated after SBT; intensive care unit and hospital lengths of stay; and hospital and 90-day mortality. Results: Among 1153 patients who were randomized (mean age, 62.2 [SD, 15.7] years; 428 [37.1%] women), 1018 (88.3%) completed the trial. Successful extubation occurred in 473 patients (82.3%) in the pressure support ventilation group and 428 patients (74.0%) in the T-piece group (difference, 8.2%; 95% CI, 3.4%-13.0%; P = .001). Among secondary outcomes, for the pressure support ventilation group vs the T-piece group, respectively, reintubation was 11.1% vs 11.9% (difference, -0.8%; 95% CI, -4.8% to 3.1%; P = .63), median intensive care unit length of stay was 9 days vs 10 days (mean difference, -0.3 days; 95% CI, -1.7 to 1.1 days; P = .69), median hospital length of stay was 24 days vs 24 days (mean difference, 1.3 days; 95% CI, -2.2 to 4.9 days; P = .45), hospital mortality was 10.4% vs 14.9% (difference, -4.4%; 95% CI, -8.3% to -0.6%; P = .02), and 90-day mortality was 13.2% vs 17.3% (difference, -4.1% [95% CI, -8.2% to 0.01%; P = .04]; hazard ratio, 0.74 [95% CI, 0.55-0.99]). Conclusions and Relevance: Among patients receiving mechanical ventilation, a spontaneous breathing trial consisting of 30 minutes of pressure support ventilation, compared with 2 hours of T-piece ventilation, led to significantly higher rates of successful extubation. These findings support the use of a shorter, less demanding ventilation strategy for spontaneous breathing trials. Trial Registration: ClinicalTrials.gov Identifier: NCT02620358.


Assuntos
Intubação Intratraqueal/instrumentação , Respiração com Pressão Positiva , Desmame do Respirador/métodos , Adulto , Idoso , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Razão de Chances , Respiração Artificial , Padrão de Cuidado , Fatores de Tempo , Resultado do Tratamento
10.
Crit Care ; 23(1): 180, 2019 05 17.
Artigo em Inglês | MEDLINE | ID: mdl-31101127

RESUMO

BACKGROUND: The effect of high-flow nasal cannula (HFNC) therapy in patients after planned extubation remains inconclusive. We aimed to perform a rigorous and comprehensive systematic meta-analysis to robustly quantify the benefits of HFNC for patients after planned extubation by investigating postextubation respiratory failure and other outcomes. METHOD: We searched MEDLINE, EMBASE, Web of Science, and the Cochrane Library from inception to August 2018. Two researchers screened studies and collected the data independently. Randomized controlled trials (RCTs) and crossover studies were included. The main outcome was postextubation respiratory failure. RESULTS: Ten studies (seven RCTs and three crossover studies; HFNC group: 856 patients; Conventional oxygen therapy (COT) group: 852 patients) were included. Compared with COT, HFNC may significantly reduce postextubation respiratory failure (RR, 0.61; 95% CI, 0.41, 0.92; z = 2.38; P = 0.02) and respiratory rates (standardized mean differences (SMD), - 0.70; 95% CI, - 1.16, - 0.25; z = 3.03; P = 0.002) and increase PaO2 (SMD, 0.30; 95% CI, 0.04, 0.56; z = 2.23; P = 0.03). There were no significant differences in reintubation rate, length of ICU and hospital stay, comfort score, PaCO2, mortality in ICU and hospital, and severe adverse events between HFNC and COT group. CONCLUSIONS: Our meta-analysis demonstrated that compared with COT, HFNC may significantly reduce postextubation respiratory failure and respiratory rates, increase PaO2, and be safely administered in patients after planned extubation. Further large-scale, multicenter studies are needed to confirm our results.


Assuntos
Cânula/normas , Oxigenoterapia/instrumentação , Oxigênio/administração & dosagem , Extubação/métodos , Humanos , Ventilação não Invasiva/instrumentação , Ventilação não Invasiva/métodos , Ventilação não Invasiva/normas , Oxigênio/uso terapêutico , Oxigenoterapia/métodos , Recidiva , Desmame do Respirador/métodos
11.
Med. intensiva (Madr., Ed. impr.) ; 43(4): 197-206, mayo 2019. graf, tab
Artigo em Espanhol | IBECS | ID: ibc-183124

RESUMO

Objetivo: Analizar la relación y concordancia entre el esfuerzo respiratorio calculado con las señales del respirador (Pmus) y el medido con presión esofágica (Pes), en ventilación mecánica con diferentes niveles de asistencia respiratoria. Diseño: Estudio prospectivo de una cohorte. Ámbito: Unidad de cuidados intensivos polivalente en 2 hospitales terciarios. Pacientes: Pacientes en fase de retirada de la ventilación mecánica. Intervenciones: La presión en la vía aérea, esofágica y flujo respiratorio se registraron en CPAP, ventilación asistida controlada por volumen (ACV) y presión soporte (PS) con asistencia respiratoria completa (ACV1, PS1) y parcial (ACV5, PS5). Variables medidas en Pes y Pmus: amplitud respiratoria (Δ: cmH2O) y el producto presión tiempo por minuto (PTPm: cmH2O·s/m). Resultados: En 10 pacientes se estudiaron 41 registros. La asistencia en CPAP fue de 5cmH2O, PS1 15±5 y PS59±4cmH2O. En ACV1 el flujo inspiratorio fue 1±0,2l/s, reducido a 0,49±0,1l/s para ACV5. El esfuerzo respiratorio disminuyó con el aumento de la asistencia respiratoria: ΔPes (CPAP, ACV5, ACV1, PS5, PS1): 11±3, 6±3, 5±3, 9±6, 7±7 y en ΔPmus 16±5, 10±6, 5±3, 10±6, 5±4cmH2O (p<0,001). PTPm Pes: 213±87, 96±91, 23±24, 206±121, 108±100 (p=0,001) y en Pmus: 293±117, 156±84, 24±32, 233±121, 79±90cmH2O·s/m (p<0,001). Las medidas en Pes y Pmus mostraron una correlación Δ:0,72 y PTPm: 0,87. El análisis de Bland-Altman demostró que la diferencia ΔPes-Pmus puede ser de 16cmH2O y el PTPm de 264 y el error sistemático en Δ: −0,98±4,4 y PTPm −23,69±66,3cmH2O·s/m. Conclusiones: Los parámetros calculados de esfuerzo respiratorio y los medidos directamente presentan diferencias que no son aceptables en la práctica clínica


Objective: Study the relationship and concordance between calculated respiratory effort using the signals of the ventilator (Pmus) and that measured in esophageal pressure (Pes) on mechanical ventilation with different levels of respiratory assistance. Design: Prospective cohort study. Ambit: Intensive Care Unit of 2 universitary hospitals. Patients Patients on weaning time. Procedure: Airway, esophageal and respiratory flow were recorded on CPAP, assist volume control (ACV) and pressure support (PS), with complete (ACV1,PS1) and partial assistance (ACV5,PS5). Measurement: respiratory variations of Pes and Pmus (Δ: cmH2O) and pressure time product (PTPm: cmH2O·s/m). Results: Fourty one records were studied, the assistance was in CPAP of 5cmH2O, PS1 of 15±5 reduced to 9±4cmH2O. In ACV1 the inspiratory flow was 1±0.2l/s, reduced to 0.49±0.1l/s for ACV5. The increase in respiratory assistance decreases respiratory effort, measured in Delta Pes (CPAP, ACV5, ACV1, PS5, PS1): 11±3, 6±3, 5±3, 9±6, 7±7 and in Pmus 16±5, 10±6, 5±3, 10±6, 5±4cmH2O (P<.001). The PTP per minute measured in Pes: 213±87, 96±91, 23±24, 206±121, 108±100 (P=.001) and in Pmus: 293±117, 156±84, 24±32, 233±121, 79±90 (P<.001). The measurements in Pes and Pmus showed the following correlation, in Delta: 0.72 and PTPm, 0.87. The Bland-Altman analysis indicates that the difference between Delta Pes-Pmus can be 16 and the PTPm of 264 and the systematic error in Delta: −0.98±4.4 and PTPm −23.69±66.3cmH2O·s/m. Conclusions: Calculated and measured parameters of respiratory effort showed unacceptable differences in clinical practice


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Respiração Artificial/métodos , Estudos de Coortes , Unidades de Terapia Intensiva , Desmame do Respirador/métodos , Estudos Prospectivos , Ventilação Pulmonar , Volume de Reserva Inspiratória , Mecânica Respiratória , Eletrocardiografia , Pressão Arterial
12.
Can Respir J ; 2019: 3478968, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31019611

RESUMO

The most recent British Thoracic Society/Intensive Care Society (BTS/ICS) guidelines on the use of noninvasive ventilation (NIV) in acute hypercapnic respiratory failure (AHRF) suggest to maximize NIV use in the first 24 hours and to perform a slow tapering. However, a limited number of studies evaluated the phase of NIV weaning. The aim of this study is to describe the NIV weaning protocol used in AHRF due to acute exacerbation of chronic obstructive pulmonary disease (AE-COPD), patients' characteristics, clinical course, and outcomes in a real-life intermediate respiratory care unit (IRCU) setting. We performed a retrospective study on adult patients hospitalized at the IRCU of San Gerardo Hospital, Monza, Italy, from January 2015 to April 2017 with a diagnosis of AHRF due to COPD exacerbation. The NIV weaning protocol used in our institution consists of the interruption of one of the three daily NIV sessions at the time, starting from the morning session and finishing with the night session. The 51 patients who started weaning were divided into three groups: 20 (39%) patients (median age 80 yrs, 65% males) who completed the protocol and were discharged home without NIV (Completed Group), 20 (39%) did not complete it because they were adapted to domiciliary ventilation (Chronic NIV Group), and 11 (22%) interrupted weaning ex abrupto mainly due to NIV intolerance (Failed Group). Completed Group patients were older, had a higher burden of comorbidities, but a lower severity of COPD compared to Chronic NIV Group. Failed Group patients experienced higher frequency of delirium after NIV discontinuation. None of the patients who completed weaning had AHRF relapse during hospitalization. While other NIV weaning methods have been previously described, our study is the first to describe a protocol that implies the interruption of a ventilation session at the time. The application of a weaning protocol may prevent AHRF relapse in the early stages of NIV interruption and in elderly frail patients.


Assuntos
Ventilação não Invasiva , Doença Pulmonar Obstrutiva Crônica/complicações , Insuficiência Respiratória/terapia , Desmame do Respirador/métodos , Idoso , Idoso de 80 Anos ou mais , Progressão da Doença , Estudos de Viabilidade , Feminino , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/mortalidade , Estudos Retrospectivos , Desmame do Respirador/mortalidade
13.
Medicine (Baltimore) ; 98(11): e14841, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30882675

RESUMO

Unplanned extubation (UE) may cause considerable adverse effects in patients receiving mechanical ventilation (MV). Previous literature showed inconsistent prognosis in patients with UE. This study aimed to evaluate the clinical implications and outcomes of UE.The intubated adult patients with MV support in our hospital were enrolled, and they were divided into the UE and non-UE groups. Demographic data, admission unit, MV duration, overall weaning rate, and mortality rates were compared. The outcomes of UE in ordinary ward and intensive care unit (ICU) were also assessed.Totally 9245 intubated adult patients were included. UE occurred in 303 (3.5%) patients, and the UE events were 0.27 times/100 MV days. Old age, nonoperation related MV cause, and admission out of the ICU were significant factors associated with UE events. UE patients showed a trend of better overall weaning rate (71.9% vs 66.7%, P = .054) than non-UE. However, the in-hospital mortality rate (25.7% vs 24.8%, P = .713) were similar between the UE and non-UE patients. The reintubation rate of UE patients was 44.1% (142/322). Successful UEs were associated with patients in weaning process (52.8% vs 38.7%, P = .012), and patients received non-invasive positive pressure ventilation (NIPPV) support after UE (19.4% vs 3.5%, P < .001). Patients with successful UE had significantly shorter MV days, higher overall weaning rate, and lower mortality than those with unsuccessful UE. Outcomes of UE in ordinary ward and in ICU had similar MV duration, reintubation rate, overall weaning rate, and in-hospital mortality rate.The overall weaning rate and in-hospital mortality rates of the UE and non-UE patients were similar. UE occurred in ordinary ward had similar outcomes to those in ICU. Patients receiving MV should be assessed daily for weaning indications to reduce delayed extubation, and therefore, may decrease UE occurrence. Once the UE happened, NIPPV support may reduce the reintubation rate.


Assuntos
Extubação , Unidades de Terapia Intensiva/estatística & dados numéricos , Quartos de Pacientes/estatística & dados numéricos , Respiração Artificial , Retratamento/estatística & dados numéricos , Desmame do Respirador , Idoso , Extubação/efeitos adversos , Extubação/estatística & dados numéricos , Estudos de Casos e Controles , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Cooperação do Paciente , Prognóstico , Respiração Artificial/efeitos adversos , Respiração Artificial/métodos , Respiração Artificial/estatística & dados numéricos , Retratamento/efeitos adversos , Taiwan/epidemiologia , Desmame do Respirador/efeitos adversos , Desmame do Respirador/métodos , Desmame do Respirador/estatística & dados numéricos
14.
Crit Care Resusc ; 21(1): 18-24, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30857508

RESUMO

OBJECTIVE: To evaluate the prevalence of "likely overassistance" (categorised by respiratory rate [RR] ≤ 17 breaths/min or rapid shallow breathing index [RSBI] ≤ 37 breaths/min/L) during invasive pressure support ventilation (PSV), and the additional prevalence of fixed ventilator settings. DESIGN: Multicentre prospective observational study of invasive PSV practice in six general Victorian intensive care units with blinding of staff members to data collection. PATIENTS: At each hospital, investigators collected data between 11 am and 2 pm on all invasive PSV-treated patients on 60 sequential days, excluding weekends and public holidays, between 22 February and 30 August 2017. Each patient was included for maximum of 3 days. MAIN RESULTS: We studied 231 patients, with a total of 379 observations episodes over the study period. There were 131 patients (56.7%) with at least one episode of RR ≤ 17 breaths/min; 146 patients (63.2%) with at least one episode of RSBI ≤ 37 breaths/min/L, and 85 patients (36.8%) with at least one episode of combined RR ≤ 17 breaths/min and RSBI ≤ 37 breaths/min/L. Moreover, the total number of observations with "likely overassistance" (RR ≤ 17 or RSBI ≤ 37 breaths/min/L) was 178 (47%) and 204 (53.8%), respectively; while for both combined criteria, it was 154 (40.6%). We also found that 10 cmH2O pressure support was delivered on 210 of the observations (55.4%) and adjusted in less than 25% of observations. Finally, less than half (179 observations) of all PSV-delivered tidal volumes (VT) were at the recommended value of 6-8 mL/kg predicted body weight (PBW) and more than 20% (79 observations) were at ≥ 10 mL/kg PBW. CONCLUSION: In a cohort of Victorian hospitals in Australia, during invasive PSV, "likely overassistance" was common, and the pressure support level was delivered in a standardised and unadjusted manner at 10 cmH2O, resulting in the frequent delivery of potentially injurious VT.


Assuntos
Unidades de Terapia Intensiva , Respiração com Pressão Positiva/métodos , Insuficiência Respiratória/terapia , Desmame do Respirador/métodos , Austrália , Humanos , Estudos Prospectivos
15.
Am J Surg ; 217(6): 1072-1075, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30890263

RESUMO

BACKGROUND: Failed extubation has been shown to increase ICU stay, transfers to rehabilitation facilities, and mortality. The purpose of this study was to assess the differences in rates of failed extubation before and after implementation of an extubation checklist. METHODS: We performed a retrospective study from January 2013-April 2017 on adult trauma patients (age 18-89) who were admitted to the ICU and required mechanical ventilation. Patients were grouped before and after implementation of an extubation checklist and compared. RESULTS: A total of 993 patients were included in this study. After checklist implementation, significantly fewer patients required reintubation compared to those prior to checklist (7% vs 3%, p = 0.005). There was no difference in mortality (20% vs 21%, p = 0.54) or hospital length of stay between the two groups (16 days vs 15 days, p = 0.16). CONCLUSION: Our study reveals that implementing an extubation checklist is associated with fewer failed extubations.


Assuntos
Extubação/normas , Lista de Checagem , Desmame do Respirador/normas , Ferimentos e Lesões/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Extubação/métodos , Extubação/mortalidade , Extubação/estatística & dados numéricos , Feminino , Humanos , Unidades de Terapia Intensiva , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Desmame do Respirador/métodos , Desmame do Respirador/mortalidade , Desmame do Respirador/estatística & dados numéricos , Ferimentos e Lesões/mortalidade , Adulto Jovem
16.
BMJ Open ; 9(2): e022600, 2019 02 12.
Artigo em Inglês | MEDLINE | ID: mdl-30760513

RESUMO

INTRODUCTION: Predicting successful liberation from mechanical ventilation (MV) among critically ill patients receiving MV can be challenging. The current parameters used to predict successful extubation have shown variable predictive value. Brain natriuretic peptide (BNP) has been proposed as a novel biomarker to help guide decision-making in readiness for liberation of MV following a spontaneous breathing trial (SBT). Current evidence on the predictive ability of BNP has been uncertain, and BNP has not been integrated into clinical practice guidelines. METHODS AND ANALYSIS: We will perform a systematic review and meta-analysis to evaluate the value of BNP during SBT to predict success of liberation from MV. A search strategy will be developed in collaboration with a research librarian, and electronic databases (MEDLINE, EMBASE, Cochrane Library, Web of Science) and additional sources will be searched. Search themes will include: (1) BNP and (2) weaning, extubation and/or liberation from MV. Citation screening, selection, quality assessment and data abstraction will be performed in duplicate. The primary outcome will be liberation from MV; secondary outcomes will include time to reintubation, mortality, MV duration, total and postextubation intensive care unit (ICU) stay, hospitalisation duration, tracheostomy rate, ICU-acquired weakness rate and ventilator-free days. Primary statistical analysis will include predictive value of BNP by receiver operating characteristic curve, sensitivity/specificity and likelihood ratios for combination of BNP and SBT parameters for failure of liberation from MV. Secondary statistical analysis will be performed on individual and combinations of extracted metrics. ETHICS AND DISSEMINATION: Our review will add knowledge by mapping the current body of evidence on the value of BNP testing for prediction of successful liberation from MV, and describe knowledge gaps and research priorities. Our findings will be disseminated through peer-reviewed publication, presentation at a scientific congress, through regional/national organisations and social media. Research ethics approval is not required. PROSPERO REGISTRATION NUMBER: CRD42018087474.


Assuntos
Estado Terminal/terapia , Peptídeo Natriurético Encefálico/sangue , Desmame do Respirador/métodos , Biomarcadores/sangue , Humanos , Valor Preditivo dos Testes
17.
BMJ Case Rep ; 12(2)2019 Feb 21.
Artigo em Inglês | MEDLINE | ID: mdl-30796070

RESUMO

One-fifth of healthcare beneficiaries in developed nations get discharged from hospitals to physician supervised skilled nursing care facilities. In low-income and middle-income countries like India, postdischarge skilled nursing facilities are at a very nascent stage and largely underequipped in terms of infrastructure, skilled nursing and physician staff to manage complicated patients. Hence the responsibility of management of such patients lies largely with their families. We present a case where a 26-year-old man with Duchenne Muscular Dystrophy who became ventilator dependent following major surgeries was weaned off his ventilator and rehabilitated back to his prehospital state. This was done at his home with visiting nurses and rehabilitation services under telemedicine supervision by a critical care specialist. Use of telemedicine services could be a viable and cost-effective option to ensure adherence to evidence-based medicine and standardisation of care in resource limited countries such as India.


Assuntos
Estado Terminal/reabilitação , Serviços de Assistência Domiciliar , Distrofia Muscular de Duchenne/reabilitação , Telemedicina , Desmame do Respirador/métodos , Adulto , Análise Custo-Benefício , Medicina Baseada em Evidências , Pesquisa sobre Serviços de Saúde , Humanos , Índia , Masculino , Resultado do Tratamento
18.
Trials ; 20(1): 60, 2019 Jan 17.
Artigo em Inglês | MEDLINE | ID: mdl-30654837

RESUMO

BACKGROUND: Mechanical ventilation (MV) is a life-saving technology that restores or assists breathing. Like any treatment, MV has side effects. In some patients it can cause diaphragmatic atrophy, injury, and dysfunction (ventilator-induced diaphragmatic dysfunction, VIDD). Accumulating evidence suggests that VIDD makes weaning from MV difficult, which involves increased morbidity and mortality. METHODS AND ANALYSIS: This paper describes the protocol of a randomized, controlled, open-label, multicenter trial that is designed to investigate the safety and effectiveness of a novel therapy, temporary transvenous diaphragm pacing (TTVDP), to improve weaning from MV in up to 88 mechanically ventilated adult patients who have failed at least two spontaneous breathing trials over at least 7 days. Patients will be randomized (1:1) to TTVDP (treatment) or standard of care (control) groups. The primary efficacy endpoint is time to successful extubation with no reintubation within 48 h. Secondary endpoints include maximal inspiratory pressure and ultrasound-measured changes in diaphragm thickness and diaphragm thickening fraction over time. In addition, observational data will be collected and analyzed, including 30-day mortality and time to discharge from the intensive care unit and from the hospital. The hypothesis to be tested postulates that more TTVDP patients than control patients will be successfully weaned from MV within the 30 days following randomization. DISCUSSION: This study is the first large-scale clinical trial of a novel technology (TTVDP) aimed at accelerating difficult weaning from MV. The technology tested provides the first therapy directed specifically at VIDD, an important cause of delayed weaning from MV. Its results will help delineate the place of this therapeutic approach in clinical practice and help design future studies aimed at defining the indications and benefits of TTVDP. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03096639 . Registered on 30 March 2017.


Assuntos
Diafragma/inervação , Terapia por Estimulação Elétrica/métodos , Pulmão/fisiopatologia , Respiração Artificial , Respiração , Insuficiência Respiratória/terapia , Desmame do Respirador/métodos , Extubação , Diafragma/diagnóstico por imagem , Terapia por Estimulação Elétrica/efeitos adversos , Terapia por Estimulação Elétrica/mortalidade , França , Alemanha , Humanos , Tempo de Internação , Estudos Multicêntricos como Assunto , Alta do Paciente , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Recuperação de Função Fisiológica , Testes de Função Respiratória , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/mortalidade , Insuficiência Respiratória/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia , Desmame do Respirador/efeitos adversos , Desmame do Respirador/mortalidade
19.
Pediatr Cardiol ; 40(3): 602-609, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30600369

RESUMO

The objective of this study is to establish reliable markers for mortality in children with refractory cardiogenic shock who underwent extracorporeal membrane oxygenation. A retrospective observational cohort study was performed at academic children's hospital for forty-three consecutive pediatric patients who required veno-arterial extracorporeal membrane oxygenation (ECMO) support with refractory cardiogenic shock from January 2011 to October 2017. 30-day mortality in this cohort was 39.5% (17/43), and successful ECMO weaning rate was 69.8%. Blood lactate was elevated before ECMO implantation and the lactate peak concentration had significant differences between survivors and non-survivors, 8.4 ± 4.3 vs 13.9 ± 6.6 mmol/L. AUC to ROC curve analysis of lactate peak was 0.745 (p < 0.05), and the best cut-off value was 14.2 mmmol/L (sensitivity: 53%, specificity: 92%). The length of lactate level > 5 mmol/L was the most significant connection to 30-day mortality. Its AUC was 0.722 (p < 0.05), and the best cut-off value was 3.3 h (sensitivity: 67%, specificity: 80%). Non-survivors had significantly higher lactate levels during 0-6 h of ECMO support, compared to survivors, which also persisted at 7-12-h, 13-24-h, and 25-48-h ECMO. However, lactate clearance at 12 h, 24 h, 48 h revealed no significant differences between survivors and non-survivors based on 30-day mortality. Lactate peak and the duration of high lactate concentration before ECMO were reliable markers for 30-day mortality of pediatric patients with refractory cardiogenic shock. Static lactate values after ECMO implantation were associated with mortality while dynamic lactate value was not. Ensuring adequate ECMO support after cannulation and early diagnostic and intervention should be implemented to normalize the lactate level.


Assuntos
Biomarcadores/sangue , Oxigenação por Membrana Extracorpórea/métodos , Ácido Láctico/sangue , Choque Cardiogênico/sangue , Área Sob a Curva , Criança , Pré-Escolar , Estudos de Coortes , Oxigenação por Membrana Extracorpórea/efeitos adversos , Feminino , Mortalidade Hospitalar , Hospitais Pediátricos , Humanos , Lactente , Masculino , Curva ROC , Estudos Retrospectivos , Choque Cardiogênico/mortalidade , Choque Cardiogênico/terapia , Sobreviventes , Resultado do Tratamento , Desmame do Respirador/efeitos adversos , Desmame do Respirador/métodos
20.
Crit Care ; 23(1): 2, 2019 01 07.
Artigo em Inglês | MEDLINE | ID: mdl-30616669

RESUMO

BACKGROUND: Prolonged weaning is a major issue in intensive care patients and tracheostomy is one of the last resort options. Optimized patient-ventilator interaction is essential to weaning. The purpose of this study was to compare patient-ventilator synchrony between pressure support ventilation (PSV) and neurally adjusted ventilatory assist (NAVA) in a selected population of tracheostomised patients. METHODS: We performed a prospective, sequential, non-randomized and single-centre study. Two recording periods of 60 min of airway pressure, flow, and electrical activity of the diaphragm during PSV and NAVA were recorded in a random assignment and eight periods of 1 min were analysed for each mode. We searched for macro-asynchronies (ineffective, double, and auto-triggering) and micro-asynchronies (inspiratory trigger delay, premature, and late cycling). The number and type of asynchrony events per minute and asynchrony index (AI) were determined. The two respiratory phases were compared using the non-parametric Wilcoxon test after testing the equality of the two variances (F-Test). RESULTS: Among the 61 patients analysed, the total AI was lower in NAVA than in PSV mode: 2.1% vs 14% (p < 0.0001). This was mainly due to a decrease in the micro-asynchronies index: 0.35% vs 9.8% (p < 0.0001). The occurrence of macro-asynchronies was similar in both ventilator modes except for double triggering, which increased in NAVA. The tidal volume (ml/kg) was lower in NAVA than in PSV (5.8 vs 6.2, p < 0.001), and the respiratory rate was higher in NAVA than in PSV (28 vs 26, p < 0.05). CONCLUSION: NAVA appears to be a promising ventilator mode in tracheotomised patients, especially for those requiring prolonged weaning due to the decrease in asynchronies.


Assuntos
Suporte Ventilatório Interativo/métodos , Vias Neurais/fisiologia , Respiração Artificial/normas , Traqueostomia/métodos , Idoso , Feminino , França , Humanos , Suporte Ventilatório Interativo/instrumentação , Suporte Ventilatório Interativo/normas , Masculino , Pessoa de Meia-Idade , Ventilação não Invasiva/instrumentação , Ventilação não Invasiva/métodos , Respiração com Pressão Positiva/métodos , Estudos Prospectivos , Respiração Artificial/instrumentação , Respiração Artificial/métodos , Índice de Gravidade de Doença , Escala Psicológica Aguda Simplificada , Traqueostomia/normas , Desmame do Respirador/instrumentação , Desmame do Respirador/métodos
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