Search

OBJECTIVES: Recent reviews demonstrated discordant effects of ICU-based physical rehabilitation on physical function. These inconsistencies may be related to differences in treatment fidelity—the extent to which a protocol is delivered as planned. Before evaluating the association of fidelity with outcomes, we must first understand the extent of treatment fidelity reporting in ICU-based physical rehabilitation randomized controlled trials (RCTs). DATA SOURCES: Six electronic databases from inception to December 2022. STUDY SELECTION: We included RCTs enrolling adults or children admitted to the ICU, if greater than or equal to 50% were invasively mechanically ventilated greater than 24 hours, and underwent an ICU-based physical rehabilitation intervention, with no limitation to comparators or outcomes. DATA EXTRACTION: We screened and extracted data independently and in duplicate, with a third reviewer as needed. Extracted data included study characteristics, treatment descriptions, and the presence of National Institutes of Health Behaviour Change Consortium (NIH-BCC) treatment fidelity tool components. Treatment fidelity scores were calculated as the proportion of reported (numerator) out of total NIH-BCC components (denominator). We calculated scores across studies and by treatment group (intervention vs. comparator). We used linear regression to assess for a time trend in study treatment fidelity scores. DATA SYNTHESIS: Of 20,433 citations, 94 studies met inclusion criteria. Authors reported a median (first–third quartiles) of 19% (14–26%) of treatment fidelity components across studies. Intervention group scores were higher than comparator groups (24% [19–33%] vs. 14% [5–24%], p < 0.01). We found a mean increase in study treatment fidelity scores by 0.7% (0.3 points) per year. CONCLUSIONS: Only 19% of treatment fidelity components were reported across studies, with comparator groups more poorly reported. Future research could investigate ways to optimize treatment fidelity reporting and determine characteristics associated with treatment fidelity conduct in ICU-based physical rehabilitation RCTs. [ABSTRACT FROM AUTHOR]

• Myotonic dystrophy type 1 patients often present with respiratory insufficiency. • Sleep apnea is very common in myotonic dystrophy type 1 patients. • Home mechanical ventilation is frequently needed in myotonic dystrophy patients. • Low compliance with home mechanical ventilation often occurs in myotonic dystrophy. • Respiratory features cannot predict home mechanical ventilation treatment failure. Chronic respiratory insufficiency is common in patients with myotonic dystrophy type 1 (DM1) and can be treated with noninvasive home mechanical ventilation (HMV). HMV is not always tolerated well resulting in low treatment adherence. We aimed to analyze if baseline respiratory characteristics such as pulmonary function, level of pCO 2 and presence of sleep apnea are associated with HMV treatment adherence in DM1 patients. Pulmonary function testing, polysomnography and blood gas measurement data of DM1 patients were retrospectively collected. Initiation of HMV and treatment adherence after one year was documented. Patients with low treatment adherence (average daily use of HMV <5 h) were grouped with patients that discontinued HMV and compared with patients with high treatment adherence (average daily use of HMV >5 h). HMV was initiated in 101 patients. After one year, 58 patients had low treatment adherence. There were no differences between the low and high treatment adherence group regarding the respiratory characteristics. None of the included predictors (gender, age, body mass index, cytosine-thymine-guanine repeat length, FVC, daytime pCO 2 , bicarbonate, nighttime pCO 2 , nighttime base excess, apnea-hypopnea index and mean saturation during sleep) was able to significantly predict high treatment adherence. In conclusion, the respiratory characteristics are not associated with treatment adherence with HMV in DM1 patients and cannot be used to identify patients at risk for low HMV treatment adherence. [ABSTRACT FROM AUTHOR]

This article discusses the importance of resuscitation guidelines in improving outcomes for cardiac arrest patients. It highlights the evolution of these guidelines over time, with a shift towards prioritizing circulation through prompt cardiopulmonary resuscitation (CPR) over airway management. The article also presents findings from a study that used thoracic bioimpedance technology to measure the effectiveness of bag-valve-mask ventilation during resuscitation efforts. The study found that adequate ventilation was associated with higher rates of survival and favorable neurological outcomes. While the study has some limitations, it suggests that attention to each aspect of resuscitation, including ventilation, may be crucial in saving more lives. [Extracted from the article]

Background: Viral respiratory infections are one of the main causes of hospitalization in children. Even if mortality rate is low, 2% to 3% of the hospitalized children need mechanical ventilation. Risk factors for admission to the pediatric intensive care unit (PICU) are well known, while few studies have described risk factors for invasive ventilator support and prolonged hospitalization. Methods: A retrospective study including all patients aged between 2 and 18 months with a confirmed viral respiratory infection, requiring admission to PICU from September to March between 2015 and 2019, was conducted at Bambino Gesù Children's Hospital in Rome, Italy. Results: One hundred ninety patients were enrolled, with a median age of 2.7 months; 32.1% had at least one comorbidity, mainly prematurity. The most frequent isolated viruses were RSV‐B, rhinovirus, and RSV‐A; 38.4% needed mechanical ventilation. This subgroup of patients had lower median birth weight compared with patients not requiring mechanical ventilation (2800 g vs. 3180 g, p = 0.02); moreover, comorbidities were present in 43.8% of intubated patients and in 24.8% of patients treated with non‐invasive ventilation (p = 0.006). Viral coinfection did not result to be a risk factor for mechanical support, while virus–bacteria coinfection was significantly associated with mechanical ventilation (p < 0.001). Similar risk factors were identified for prolonged hospitalization. Conclusions: Early identification of patients who could have a sudden respiratory deterioration and need of mechanical ventilation is crucial to reduce complications due to orotracheal intubation and prolonged hospitalization in PICU. Further studies are needed to define high‐risk group of patients and to design targeted interventions. [ABSTRACT FROM AUTHOR]

Objective: To describe and compare the clinical characteristics and outcomes of patients admitted to intensive care units during the first and second waves of the COVID-19 pandemic. Methods: In this retrospective single-center cohort study, data were retrieved from the Epimed Monitor System; all adult patients admitted to the intensive care unit between March 4, 2020, and October 1, 2021, were included in the study. We compared the clinical characteristics and outcomes of patients admitted to the intensive care unit of a quaternary private hospital in São Paulo, Brazil, during the first (May 1, 2020, to August 31, 2020) and second (March 1, 2021, to June 30, 2021) waves of the COVID-19 pandemic. Results: In total, 1,427 patients with COVID-19 were admitted to the intensive care unit during the first (421 patients) and second (1,006 patients) waves. Compared with the first wave group [median (IQR)], the second wave group was younger [57 (46-70) versus 67 (52-80) years; p<0.001], had a lower SAPS 3 Score [45 (42-52) versus 49 (43-57); p<0.001], lower SOFA Score on intensive care unit admission [3 (1-6) versus 4 (2-6); p=0.018], lower Charlson Comorbidity Index [0 (0-1) versus 1 (0-2); p<0.001], and were less frequently frail (10.4% versus 18.1%; p<0.001). The second wave group used more noninvasive ventilation (81.3% versus 53.4%; p<0.001) and high-flow nasal cannula (63.2% versus 23.0%; p<0.001) during their intensive care unit stay. The intensive care unit (11.3% versus 10.5%; p=0.696) and in-hospital mortality (12.3% versus 12.1%; p=0.998) rates did not differ between both waves. Conclusion: In the first and second waves, patients with severe COVID-19 exhibited similar mortality rates and need for invasive organ support, despite the second wave group being younger and less severely ill at the time of intensive care unit admission. [ABSTRACT FROM AUTHOR]

Introduction. It is common practice in on-pump cardiac surgery to stop mechanical ventilation when extracorporeal circulation is started or to continue with low tidal volumes. The aim of this study was to investigate whether patients ventilated with low tidal volumes had a lower percentage of postoperative pulmonary complications compared to patients who were not ventilated during cardiopulmonary bypass. Material and Methods. This retrospective study included patients who underwent coronary artery bypass graft surgery over a period of 14 months. Patients with lung diseases and those with an ejection fraction < 30% were excluded from the study. Results. A total of 499 patients were included in the study. Of these, 398 were ventilated with low tidal volumes, while 101 patients were not ventilated during extracorporeal circulation. The groups did not differ in baseline characteristics, comorbidities, and intraoperative data. Pulmonary complications were equally prevalent in both groups (ventilated 16%, not ventilated 17.8%). The most frequent were the need for prolonged mechanical ventilation (ventilated 5.8%, not ventilated 5.9%), and pleural effusions (ventilated 4.8%, not ventilated 5.9%). The incidence of pneumonia was identical in both groups (2%). Other complications were less frequent. Duration of mechanical ventilation after surgery, stay in the intensive care unit, and in-hospital mortality did not differ significantly between the groups. Conclusion. Pulmonary complications after cardiac surgery are still common. The experience at our clinic showed that the choice of mechanical ventilation strategy during cardiopulmonary bypass does not affect postoperative pulmonary complications. [ABSTRACT FROM AUTHOR]

Objectives: Evaluate the safety and efficacy of the Janus kinase (JAK)1/JAK2 inhibitor ruxolitinib in COVID-19-associated acute respiratory distress syndrome requiring mechanical ventilation.Design: Phase 3 randomized, double-blind, placebo-controlled trial Ruxolitinib in Participants With COVID-19-Associated Acute Respiratory Distress Syndrome Who Require Mechanical Ventilation (RUXCOVID-DEVENT; NCT04377620).Setting: Hospitals and community-based private or group practices in the United States (29 sites) and Russia (4 sites).Patients: Eligible patients were greater than or equal to 12 years old, hospitalized with severe acute respiratory syndrome coronavirus 2 infection, and mechanically ventilated with a Pa o2 /F io2 of less than or equal to 300 mm Hg within 6 hours of randomization.Interventions: Patients were randomized 2:2:1 to receive twice-daily ruxolitinib 15 mg, ruxolitinib 5 mg, or placebo, each plus standard therapy.Measurements and Main Results: The primary endpoint, 28-day mortality, was tested for each ruxolitinib group versus placebo using a mixed-effects logistic regression model and one-tailed significance test (significance threshold: p < 0.025); no type 1 error was allocated to secondary endpoints. Between May 24, 2020 and December 15, 2020, 211 patients (age range, 24-87 yr) were randomized (ruxolitinib 15/5 mg, n = 77/87; placebo, n = 47). Acute respiratory distress syndrome was categorized as severe in 27% of patients (58/211) at randomization; 90% (190/211) received concomitant steroids. Day-28 mortality was 51% (39/77; 95% CI, 39-62%) for ruxolitinib 15 mg, 53% (45/85; 95% CI, 42-64%) for ruxolitinib 5 mg, and 70% (33/47; 95% CI, 55-83%) for placebo. Neither ruxolitinib 15 mg (odds ratio, 0.46 [95% CI, 0.201-1.028]; one-sided p = 0.029) nor 5 mg (odds ratio, 0.42 [95% CI, 0.171-1.023]; one-sided p = 0.028) significantly reduced 28-day mortality versus placebo. Numerical improvements with ruxolitinib 15 mg versus placebo were observed in secondary outcomes including ventilator-, ICU-, and vasopressor-free days. Rates of overall and serious treatment-emergent adverse events were similar across treatments.Conclusions: The observed reduction in 28-day mortality rate between ruxolitinib and placebo in mechanically ventilated patients with COVID-19-associated acute respiratory distress syndrome was not statistically significant; however, the trial was underpowered owing to early termination. [ABSTRACT FROM AUTHOR]

Introduction: Chest compressions during CPR induce oscillations in capnography (ETCO2) waveforms. Studies suggest ETCO2 oscillation characteristics are associated with intrathoracic airflow dependent on airway patency. Oscillations can be quantified by the Airway Opening Index (AOI). We sought to evaluate multiple methods of computing AOI and their association with return of spontaneous circulation (ROSC).Methods: We conducted a retrospective study of 307 out-of-hospital cardiac arrest (OHCA) cases in Seattle, WA during 2019. ETCO2 and chest impedance waveforms were annotated for the presence of intubation and CPR. We developed four methods for computing AOI based on peak ETCO2 and the oscillations in ETCO2 during chest compressions (ΔETCO2). We examined the feasibility of automating ΔETCO2 and AOI calculation and evaluated differences in AOI across the methods using nonparametric testing (α = 0.05).Results: Median [interquartile range] AOI across all cases using Methods 1-4 was 28.0 % [17.9-45.5 %], 20.6 % [13.0-36.6 %], 18.3 % [11.4-30.4 %], and 22.4 % [12.8-38.5 %], respectively (p < 0.001). Cases with ROSC had a higher median AOI than those without ROSC across all methods, though not statistically significant. Cases with ROSC had a significantly higher median [interquartile range] ΔETCO2 of 7.3 mmHg [4.5-13.6 mmHg] compared to those without ROSC (4.8 mmHg [2.6-9.1 mmHg], p < 0.001).Conclusion: We calculated AOI using four proposed methods resulting in significantly different AOI. Additionally, AOI and ΔETCO2 were larger in cases achieving ROSC. Further investigation is required to characterize AOI's ability to predict OHCA outcomes, and whether this information can improve resuscitation care. [ABSTRACT FROM AUTHOR]

Objective: Unusual clinical course Background: Multi-resistant microorganisms are a public health problem. Their incidence has risen due to COVID-19, indiscriminate antibiotics use, corticosteroid treatments, and higher admissions to intensive care units (ICUs) of patients requiring invasive mechanical ventilation. These are risk factors for bacterial over-infection. The present case study that is relevant because of the multiple isolated strains with a resistance pattern: Klebsiella pneumoniae carbapenemases (KPC), extended-spectrum beta lactamases (ESBL) and New Delhi metallo-P-lactamase (NDM) in a patient without comorbidities. Case Report: A 53-year-old Ecuadorian man with no past medical history arrived at the Emergency Department (ED) with dyspnea, nasopharyngeal swab with a positive reverse transcription polymerase chain reaction (RT-PCR) test for SARS-CoV2, and a chest computed tomography (CT) scan showing bilateral ground-glass pulmonary infiltrates with 40% involvement. On day 10 in the ICU, the presence of Klebsiella pneumoniae KPC strain was reported in an axillary swab culture. Consequently, the antibiotic was rotated to vancomycin 1 g intravenously (i.v.) every 12 h and meropenem 1 g i.v. every 8 h. On day 15 in the ICU, a tracheal secretion culture was reported with the presence of Klebsiella pneumoniae ESBL and a blood culture with Klebsiella pneumoniae NDM. Conclusions: The COVID-19 pandemic is a perfect scenario for superinfection with multi-resistant pathogens such as car-bapenem-resistant Klebsiella pneumoniae (CRKP), due to the increase in patients admitted to ICUs requiring invasive mechanical ventilation, the use of corticosteroids, and empirical broad-spectrum antibiotic management based on guidelines. The emergence of combined multidrug-resistant strains is a challenge for laboratory detection and the selection of antimicrobial treatment. [ABSTRACT FROM AUTHOR]

Transtracheal jet ventilation can be used for resuscitation of partial airway obstruction. A prerequisite for jet ventilation is that at least a minimum airway opening for gas escape must be secured. Therefore, another option should be considered in cases of complete airway obstruction. The following methods or devices has been used under cricothyrotomy using an intravenous cannula: 1) Ambu (bag valve mask) bagging, 2) Ventrain®, 3) Rapid-O2 oxygen insufflation device (Rapid-O2), and 4) jet ventilation using a dual lumen catheter. During Ambu bagging, extraordinarily high insufflation pressure is required to force oxygen through the cannula. When using a 12-G cannula, long and slow positive-pressure ventilations (10–12 breaths/min) are required, which makes it extremely difficult to compress the bag. Therefore, a 10-G or larger is recommended. Ventrain® is an expiratory assist device capable of forcibly expelling insufflated oxygen through a transtracheal cannula. It is recommended to adjust the inspiratory and expiratory times while observing the chest wall movements. Rapid-O2 is a rescue oxygenation device with adequate ventilation of less importance; therefore, the resulting hypercarbia is inevitable. A 14-G cannula is used. Lastly, jet ventilation using a dual-lumen catheter with a 16-G inflow lumen and 10-G outflow lumen was used to obtain both oxygenation and ventilation. However, the addition of the outer diameters of 16-G and 10-G results in an outer diameter of 5.1 mm, which is too large to puncture the cricothyroid membrane. In conclusion, Ventrain® is considered the most ideal device for use among the devices developed to date. [ABSTRACT FROM AUTHOR]

Objective: To describe, for the first time in the pediatric population, the use of an effective technique to mobilize secretion in a patient whose disease imposes many care limitations. Case description: 2-year-old infant with Epidermolysis Bullosa, dependent on mechanical ventilation after cardiorespiratory arrest. Infant evolved with atelectasis in the right upper lobe with restriction to all manual secretion mobilization techniques due to the risk of worsening skin lesions. We opted for tracheal aspiration in a closed system combined with expirator y pause, a technique only described in adult patients so far. Comments: This case report is the first to use this technique in a pediatric patient. The use of expiratory pause combined with tracheal aspiration not only optimized the mobilization of secretion, but it was also a safe tool for reversing atelectasis. Our case report brings an important result because it increases the possibilities of managing pediatric patients admitted to intensive care units, especially in situations of absolute contraindication for chest maneuvers. [ABSTRACT FROM AUTHOR]

Purpose: Oral chlorhexidine is used widely for mechanically ventilated patients to prevent pneumonia, but recent studies show an association with excess mortality. We examined whether de-adoption of chlorhexidine and parallel implementation of a standardized oral care bundle reduces intensive care unit (ICU) mortality in mechanically ventilated patients. Methods: A stepped wedge cluster-randomized controlled trial with concurrent process evaluation in 6 ICUs in Toronto, Canada. Clusters were randomized to de-adopt chlorhexidine and implement a standardized oral care bundle at 2-month intervals. The primary outcome was ICU mortality. Secondary outcomes were time to infection-related ventilator-associated complications (IVACs), oral procedural pain and oral health dysfunction. An exploratory post hoc analysis examined time to extubation in survivors. Results: A total of 3260 patients were enrolled; 1560 control, 1700 intervention. ICU mortality for the intervention and control periods were 399 (23.5%) and 330 (21.2%), respectively (adjusted odds ratio [aOR], 1.13; 95% confidence interval [CI] 0.82 to 1.54; P = 0.46). Time to IVACs (adjusted hazard ratio [aHR], 1.06; 95% CI 0.44 to 2.57; P = 0.90), time to extubation (aHR 1.03; 95% CI 0.85 to 1.23; P = 0.79) (survivors) and oral procedural pain (aOR, 0.62; 95% CI 0.34 to 1.10; P = 0.10) were similar between control and intervention periods. However, oral health dysfunction scores (− 0.96; 95% CI − 1.75 to − 0.17; P = 0.02) improved in the intervention period. Conclusion: Among mechanically ventilated ICU patients, no benefit was observed for de-adoption of chlorhexidine and implementation of an oral care bundle on ICU mortality, IVACs, oral procedural pain, or time to extubation. The intervention may improve oral health. [ABSTRACT FROM AUTHOR]

The impact of chronic liver disease on outcomes in patients with COVID-19 is uncertain. Hence, we aimed to explore this association. We explored the outcomes of all adult inpatients with COVID-19 in France, in 2020. We computed adjusted odds ratios to measure the associations between chronic liver disease, alcohol use disorders, mechanical ventilation and day-30 in-hospital mortality. The sample comprised 259,110 patients (median [IQR] age 70 (54–83) years; 52% men), including 15,476 (6.0%) and 10,006 (3.9%) patients with chronic liver disease and alcohol use disorders, respectively. Death occurred in 38,203 (15%) patients, including 7,475 (28%) after mechanical ventilation, and 2,941 (19%) with chronic liver disease. The adjusted odds ratios for mechanical ventilation and day-30 mortality were 1.54 (95% CI 1.44–1.64, p < 0.001) and 1.79 (1.71–1.87, p < 0.001) for chronic liver disease; 0.55 (0.47–0.64, p < 0.001) and 0.54 (0.48–0.61, p < 0.001) for mild liver disease; 0.64 (0.53–0.76; p < 0.001) and 0.71 (0.63–0.80, p < 0.001) for compensated cirrhosis; 0.65 (0.52–0.81, p < 0.001) and 2.21 (1.94–2.51, p < 0.001) for decompensated cirrhosis; 0.34 (0.24–0.50; p < 0.001) and 1.38 (1.17–1.62, p < 0.001) for primary liver cancer; and 0.82 (0.76–0.89; p < 0.001) and 1.11 (1.05–1.17; p < 0.001) for alcohol use disorders. Chronic viral hepatitis; non-viral, non-alcoholic chronic hepatitis; organ, including liver, transplantation, and acquired immunodeficiency syndrome were not associated with COVID-19-related death. Chronic liver disease increased the risk of COVID-19-related death in France in 2020. Therapeutic effort limitation may have contributed to COVID-19-related death in French residents with a liver-related complication or an alcohol use disorder. We studied the outcomes, including mechanical ventilation and day-30 mortality, of all adults with COVID-19 who were discharged from acute and post-acute care in France in 2020 (N = 259,110). Patients with mild liver disease; compensated cirrhosis; organ, including liver, transplantation; or acquired immunodepression syndrome were not at increased risk of COVID-19-related mortality. Patients with alcohol use disorders, decompensated cirrhosis, or primary liver cancer were at increased risk of COVID-19-related mortality but were less likely to receive mechanical ventilation. Our results suggest that therapeutic effort limitation may have contributed to the excess mortality in French residents with a liver-related complication or an alcohol use disorder. [Display omitted] • We assessed the association between chronic liver disease and clinical outcomes of in-patients with COVID-19. • Chronic liver disease increased the risk of COVID-19-related death. • Therapeutic effort limitations may have contributed to death of patients with decompensated cirrhosis, primary liver cancer, or with an alcohol use disorder. [ABSTRACT FROM AUTHOR]