Delayed intubation associated with in-hospital mortality in patients with COVID-19 respiratory failure who fail heated and humified high flow nasal canula.

BACKGROUND: Advanced respiratory support modalities such as non-invasive positive pressure ventilation (NiPPV) and heated and humidified high flow nasal canula (HFNC) served as useful alternatives to invasive mechanical ventilatory support for acute respiratory failure (ARF) during the peak of the SARS-CoV-2/COVID-19 pandemic. Unlike NiPPV, HFNC is a newer modality and its role in the treatment of patients with severe ARF is not yet clearly defined. Furthermore, the characteristics of responders versus non-responders to HFNC have not been determined. Although recent evidence indicates that many patients with ARF treated with HFNC survive without needing intubation, those who fail and are subsequently intubated have worse outcomes. Given that prolonged use of HFNC in patients with ARF might exacerbate patient self-inflicted lung injury, we hypothesized that among those patients with ARF due to COVID-19 pneumonia, prolonged HFNC beyond 24 h before intubation would be associated with increased in-hospital mortality. METHODS: This was a retrospective, multicenter, observational cohort study of 2720 patients treated for ARF secondary to SARS-CoV-2/COVID-19 pneumonia and initially managed with HFNC within the Banner Health system during the period from March 1st, 2020, to July 31st, 2021. In the subgroup of patients for went from HFNC to IMV, we assessed the effect of the duration of HFNC prior to intubation on mortality. RESULTS: 1392 (51%) were successfully treated with HFNC alone and 1328 (49%) failed HFNC and were intubated (HFNC to IMV). When adjusted for the covariates, HFNC duration less than 24 h prior to intubation was significantly associated with reduced mortality. CONCLUSIONS: Among patients with ARF due to COVID-19 pneumonia who fail HFNC, delay of intubation beyond 24 h is associated with increased mortality.

Randomized Clinical Trial of a Combination of an Inhaled Corticosteroid and Beta Agonist in Patients at Risk of Developing the Acute Respiratory Distress Syndrome.

OBJECTIVES: Effective pharmacologic treatments directly targeting lung injury in patients with the acute respiratory distress syndrome are lacking. Early treatment with inhaled corticosteroids and beta agonists may reduce progression to acute respiratory distress syndrome by reducing lung inflammation and enhancing alveolar fluid clearance. DESIGN: Double-blind, randomized clinical trial (ClinicalTrials.gov: NCT01783821). The primary outcome was longitudinal change in oxygen saturation divided by the FIO2 (S/F) through day 5. We also analyzed categorical change in S/F by greater than 20%. Other outcomes included need for mechanical ventilation and development of acute respiratory distress syndrome. SETTING: Five academic centers in the United States. PATIENTS: Adult patients admitted through the emergency department at risk for acute respiratory distress syndrome. INTERVENTIONS: Aerosolized budesonide/formoterol versus placebo bid for up to 5 days. MEASUREMENTS AND MAIN RESULTS: Sixty-one patients were enrolled from September 3, 2013, to June 9, 2015. Median time from presentation to first study drug was less than 9 hours. More patients in the control group had shock at enrollment (14 vs 3 patients). The longitudinal increase in S/F was greater in the treatment group (p = 0.02) and independent of shock (p = 0.04). Categorical change in S/F improved (p = 0.01) but not after adjustment for shock (p = 0.15). More patients in the placebo group developed acute respiratory distress syndrome (7 vs 0) and required mechanical ventilation (53% vs 21%). CONCLUSIONS: Early treatment with inhaled budesonide/formoterol in patients at risk for acute respiratory distress syndrome is feasible and improved oxygenation as assessed by S/F. These results support further study to test the efficacy of inhaled corticosteroids and beta agonists for prevention of acute respiratory distress syndrome.

Video laryngoscopy improves intubation success and reduces esophageal intubations compared to direct laryngoscopy in the medical intensive care unit.

INTRODUCTION: Tracheal intubation in the Intensive Care Unit (ICU) can be challenging as patients often have anatomic and physiologic characteristics that make intubation particularly difficult. Video laryngoscopy (VL) has been shown to improve first attempt success compared to direct laryngoscopy (DL) in many clinical settings and may be an option for ICU intubations. METHODS: All intubations performed in this academic medical ICU during a 13-month period were entered into a prospectively collected quality control database. After each intubation, the operator completed a standardized form evaluating multiple aspects of the intubation including: patient demographics, difficult airway characteristics (DACs), method and device(s) used, medications used, outcomes and complications of each attempt. Primary outcome was first attempt success. Secondary outcomes were grade of laryngoscopic view, ultimate success, esophageal intubations, and desaturation. Multivariate logistic regression was performed for first attempt and ultimate success. RESULTS: Over the 13-month study period (January 2012-February 2013), a total of 234 patients were intubated using VL and 56 patients were intubated with DL. First attempt success for VL was 184/234 (78.6%; 95% CI 72.8 to 83.7) while DL was 34/56 patients (60.7%; 95% CI 46.8 to 73.5). Ultimate success for VL was 230/234 (98.3%; 95% CI 95.1 to 99.3) while DL was 52/56 patients (91.2%; 95% CI 81.3 to 97.2). In the multivariate regression model, VL was predictive of first attempt success with an odds ratio of 7.67 (95% CI 3.18 to 18.45). VL was predictive of ultimate success with an odds ratio of 15.77 (95% CI 1.92 to 129). Cormack-Lehane I or II view occurred 199/234 times (85.8%; 95% CI 79.5 to 89.1) and a median POGO (Percentage of Glottic Opening) of 82% (IQR 60 to 100) with VL, while Cormack-Lehane I or II view occurred 34/56 times (61.8%; 95% CI 45.7 to 71.9) and a median POGO of 45% (IQR 0 to 78%) with DL. VL reduced the esophageal intubation rate from 12.5% with DL to 1.3% (P = 0.001) but there was no difference in desaturation rates. CONCLUSIONS: In the medical ICU, video laryngoscopy resulted in higher first attempt and ultimate intubation success rates and improved grade of laryngoscopic view while reducing the esophageal intubation rate compared to direct laryngoscopy.

Disparities in outcomes of COVID-19 hospitalizations in native American individuals.

Objectives: This study aimed to investigate COVID-19-related disparities in clinical presentation and patient outcomes in hospitalized Native American individuals. Methods: The study was performed within 30 hospitals of the Banner Health system in the Southwest United States and included 8,083 adult patients who tested positive for SARS-CoV-2 infection and were hospitalized between 1 March 2020 and 4 September 2020. Bivariate and multivariate analyses were used to assess racial and ethnic differences in clinical presentation and patient outcomes. Results: COVID-19-related hospitalizations in Native American individuals were over-represented compared with non-Hispanic white individuals. Native American individuals had fewer symptoms at admission; greater prevalence of chronic lung disease in the older adult; two times greater risk for ICU admission despite being younger; and 20 times more rapid clinical deterioration warranting ICU admission. Compared with non-Hispanic white individuals, Native American individuals had a greater prevalence of sepsis, were more likely to require invasive mechanical ventilation, had a longer length of stay, and had higher in-hospital mortality. Conclusion: Native American individuals manifested greater case-fatality rates following hospitalization than other races/ethnicities. Atypical symptom presentation of COVID-19 included a greater prevalence of chronic lung disease and a more rapid clinical deterioration, which may be responsible for the observed higher hospital mortality, thereby underscoring the role of pulmonologists in addressing such disparities.

Adherence to a standardized infection reduction bundle decreases surgical site infections after colon surgery: a retrospective cohort study on 526 patients.

BACKGROUND: Colon surgical site infections (SSI) are detrimental to patient safety and wellbeing. To achieve clinical excellence, our hospital set to improve patient safety for those undergoing colon surgery. Our goal was to implement a perioperative SSI prevention bundle for all colon surgeries to reduce colon surgery SSI rates. METHODS: This retrospective cohort study evaluated the impact of implementing a perioperative SSI prevention bundle in patients undergoing colon surgery at Banner University Medical Center - Tucson. We compared SSI rates between the Pre- (1/1/2016 to 12/31/2016) and post-bundle (1/1/2017 to 12/31/2017) cohorts using a chi-square test. RESULTS: In total, we included 526 consecutive patients undergoing colon surgery in our study cohort; 277 pre-bundle and 249 post-bundle implementation. The unadjusted SSI rates were 8.7 % and 1.2 %, pre- and post-bundle, respectively. Our CMS reportable standard infection rate decreased by 85.4 % from 3.08 to 0.45 after implementing our SSI prevention bundle. CONCLUSIONS: Implementing a standardized colon SSI prevention bundle reduces the overall 30-day colon SSI rates and national standardized infection rates. We recommend implementing colon SSI reduction bundles to optimize patient safety and minimize colon surgical site infections.

Spectrum of critical illness in undocumented border crossers. The Arizona-Mexico border experience.

RATIONALE: Approximately 150-250 migrants die each year while attempting to cross the border from Mexico to the Southwest United States. Many border crossers survive the journey, but some develop life-threatening medical complications. Such complications have been subject to little formal analysis. OBJECTIVES: We sought to determine the causes of critical illness in this population and to analyze the hospital course and outcomes of these patients. METHODS: We retrospectively identified border crossers admitted to the intensive care units (ICUs) of two major teaching hospitals in southern Arizona. We recorded admitting diagnoses, severity of illness, length of stay, resource use, discharge diagnoses, and mortality. RESULTS: Our investigation identified 55 admissions to adult ICUs between January 1, 2010 and December 31, 2012. The median age of patients was 27 years. The median hospital length of stay was 7 days, with a median ICU length of stay of 3 days. The median temperature on arrival to the emergency department was 36.8°C. The most common admission diagnoses included trauma (40), rhabdomyolysis (27), acute liver injury (25), dehydration (24), acute kidney injury (19), and encephalopathy (17). Thirteen patients presented with respiratory failure, six patients with severe sepsis, and two with septic shock. A total of 19 patients required ventilator support during their hospital stay, and 30 required at least one surgical intervention. One patient required renal replacement therapy. The median Acute Physiology and Chronic Health Evaluation II score was 6. All but one patient survived to discharge from the hospital. CONCLUSIONS: Border crossers are a unique population of young individuals exposed to high temperatures and extreme conditions. Our review of border crosser admissions showed that most patients demonstrated signs of dehydration and leukocytosis, despite a normal median temperature. The median ICU stay was short, despite a high number of patients requiring ventilator support and surgical intervention. Only one death occurred in this cohort.

Acute cardiopulmonary failure from sleep-disordered breathing.

Sleep-disordered breathing (SDB) comprises a diverse set of disorders marked by abnormal respiration during sleep. Clinicians should realize that SDB may present as acute cardiopulmonary failure in susceptible patients. In this review, we discuss three clinical phenotypes of acute cardiopulmonary failure from SDB: acute ventilatory failure, acute congestive heart failure, and sudden death. We review the pathophysiologic mechanisms and recommend general principles for management. Timely recognition of, and therapy for, SDB in the setting of acute cardiopulmonary failure may improve short- and long-term outcomes.

Intrabronchial valves: a case series describing a minimally invasive approach to bronchopleural fistulas in medical intensive care unit patients.

BACKGROUND: Bronchopleural fistulas (BPF) are conditions associated with prolonged hospital course, high morbidity, and possibly increased mortality. The presence of BPFs in critically ill patients may cause difficulty in ventilation and increased oxygen requirements. Intrabronchial valves (Spiration IBV) serve as a noninvasive therapeutic option for the closure of BPFs. METHODS: This report is a retrospective description of 3 patients transferred to our medical intensive care unit (ICU) with BPFs and persistent air leaks (PAL). One patient required high levels of oxygen supplementation through a nonrebreather face mask, whereas 2 required mechanical ventilation because of respiratory failure. IBVs were placed in each patient with the intention of closing their BPF and weaning them from respiratory support. RESULTS: The use of IBVs in ICU patients with BPFs and PALs resulted in 1 patient being weaned from the persistent need for a nonrebreather face mask to room air and also aided in the liberation from mechanical ventilation of 2 patients who had been failing spontaneous breathing trials. CONCLUSIONS: The use of IBVs is safe and well tolerated in ICU patients with BPFs and PALs. The placement of IBVs results in significant clinical improvement, allowing for either weaning from high levels of oxygen support or liberation from mechanical ventilation.

Early cardiac arrest in patients hospitalized with pneumonia: a report from the American Heart Association's Get With The Guidelines-Resuscitation Program.

BACKGROUND: Pneumonia is the leading infectious cause of death. Early deterioration and death commonly result from progressive sepsis, shock, respiratory failure, and cardiac complications. Recent data suggest that cardiac arrest may also be common, yet few previous studies have addressed this. Accordingly, we sought to characterize early cardiac arrest in patients who are hospitalized with coexisting pneumonia. METHODS: We performed a retrospective analysis of a multicenter cardiac arrest database, with data from > 500 North American hospitals. We included in-hospital cardiac arrest events that occurred in community-dwelling adults with pneumonia within the first 72 h after hospital admission. We compared patient and event characteristics for patients with and without pneumonia. For patients with pneumonia, we also compared events according to event location. RESULTS: We identified 4,453 episodes of early cardiac arrest in patients who were hospitalized with pneumonia. Among patients with preexisting pneumonia, only 36.5% were receiving mechanical ventilation and only 33.3% were receiving infusions of vasoactive drugs prior to cardiac arrest. Only 52.3% of patients on the ward were receiving ECG monitoring prior to cardiac arrest. Shockable rhythms were uncommon in all patients with pneumonia (ventricular tachycardia or fibrillation, 14.8%). Patients on the ward were significantly older than patients in the ICU. CONCLUSIONS: In patients with preexisting pneumonia, cardiac arrest may occur in the absence of preceding shock or respiratory failure. Physicians should be alert to the possibility of abrupt cardiopulmonary collapse, and future studies should address this possibility. The mechanism may involve myocardial ischemia, a maladaptive response to hypoxia, sepsis-related cardiomyopathy, or other phenomena.

Derangements in blood glucose following initial resuscitation from in-hospital cardiac arrest: a report from the national registry of cardiopulmonary resuscitation.

STUDY AIMS: Hyperglycemia is associated with poor outcomes in critically ill patients. We examined blood glucose values following in-hospital cardiac arrest (IHCA) to (1) characterize post-arrest glucose ranges, (2) develop outcomes-based thresholds of hyperglycemia and hypoglycemia, and (3) identify risk factors associated with post-arrest glucose derangements. METHODS: We retrospectively studied 17,800 adult IHCA events reported to the National Registry of Cardiopulmonary Resuscitation (NRCPR) from January 1, 2005 through February 1, 2007. RESULTS: Data were available from 3218 index events. Maximum blood glucose values were elevated in diabetics (median 226 mg/dL [IQR, 165-307 mg/dL], 12.5 mmol/L [IQR 9.2-17.0 mmol/L]) and non-diabetics (median 176 mg/dL [IQR, 135-239 mg/dL], 9.78 mmol/L [IQR 7.5-13.3 mmol/L]). Unadjusted survival to hospital discharge was higher in non-diabetics than diabetics (45.5% [95% CI, 43.3-47.6%] vs. 41.7% [95% CI, 38.9-44.5%], p=0.037). Non-diabetics displayed decreased adjusted survival odds for minimum glucose values outside the range of 71-170 mg/dL (3.9-9.4 mmol/L) and maximum values outside the range of 111-240 mg/dL (6.2-13.3 mmol/L). Diabetic survival odds decreased for minimum glucose greater than 240 mg/dL (13.3 mmol/L). In non-diabetics, arrest duration was identified as a significant factor associated with the development of hypo- and hyperglycemia. CONCLUSIONS: Hyperglycemia is common in diabetics and non-diabetics following IHCA. Survival odds in diabetics are relatively insensitive to blood glucose with decreased survival only associated with severe (>240 mg/dL, >13.3 mmol/dL) hyperglycemia. In non-diabetics, survival odds were sensitive to hypoglycemia (<70 mg/dL, <3.9 mmol/L).

Predictors of patients who will develop prolonged occult hypoperfusion following blunt trauma.

BACKGROUND: Prolonged occult hypoperfusion or POH (serum lactate >2.4 mmol/L persisting >12 hours from admission) represents a reversible risk factor for adverse outcomes following traumatic injury. We hypothesized that patients at increased risk for POH could be identified at the time of admission. METHODS: Prospective data from adult trauma admissions between January 1, 1998 and December 31, 2000 were analyzed. Potential risk factors for POH were determined by univariate analysis (p < or =0.10= significant). Significant factors were tested in a logistic regression model (LR) (p < or =0.05= significant). The predictive ability of the LR was tested by receiver operating curve (ROC) analysis (p < or =0.05= significant). RESULTS: Three hundred seventy-eight patients were analyzed, 129 with POH. Injury Severity Score (ISS), emergency department Glasgow Coma Scale score, hypotension, and the individual Abbreviated Injury Scale score (AIS) for Head (H), Abdominal/Pelvic Viscera (A) and Pelvis/Bony Extremity (P) were significantly associated with POH. LR demonstrated that ISS, A-AIS > or =3 and P-AIS > or =3 were independent predictors of POH (p <0.05). ROC analysis of the LR equation was statistically significant (Area=0.69, p <0.001). CONCLUSIONS: We identified factors at admission that placed patients at higher risk for developing POH. Select patients may benefit from rapid, aggressive monitoring and resuscitation, possibly preventing POH and its associated morbidity and mortality.