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Background: Ventilator-associated pneumonia (VAP) is a challenging nosocomial problem in low- and middle-income countries (LMICs) that face barriers to healthcare delivery and resource availability. This study aimed to examine the incidence and predictors of VAP in Egypt as an example of an LMIC while considering death as a competing event. Methods: The study included patients aged ≥ 18 years who underwent mechanical ventilation (MV) in an intensive care unit (ICU) at a tertiary care, university hospital in Egypt between May 2020 and January 2023. We excluded patients who died or were transferred from the ICU within 48 h of admission. We determined the VAP incidence based on clinical suspicion, radiological findings, and positive lower respiratory tract microbiological cultures. The multivariate Fine-Gray subdistribution hazard model was used to examine the predictors of VAP while considering death as a competing event. Results: Overall, 315 patients were included in this analysis. Sixty-two patients (19.7%) developed VAP (17.1 per 1000 ventilator days). The Fine-Gray subdistribution hazard model, after adjustment for potential confounders, revealed that emergency surgery (subdistribution hazard ratio [SHR]: 2.11, 95% confidence interval [CI]: 1.25–3.56), reintubation (SHR: 3.74, 95% CI: 2.23–6.28), blood transfusion (SHR: 2.23, 95% CI: 1.32–3.75), and increased duration of MV (SHR: 1.04, 95% CI: 1.03–1.06) were independent risk factors for VAP development. However, the new use of corticosteroids was not associated with VAP development (SHR: 0.94, 95% CI: 0.56–1.57). Klebsiella pneumoniae was the most common causative microorganism, followed by Pseudomonas aeruginosa. Conclusion: The incidence of VAP in Egypt was high, even in the ICU at a university hospital. Emergency surgery, reintubation, blood transfusion, and increased duration of MV were independently associated with VAP. Robust antimicrobial stewardship and infection control strategies are urgently needed in Egypt. [ABSTRACT FROM AUTHOR]

Background: Use of sedatives and analgesics is associated with the occurrence of delirium in critically ill patients receiving mechanical ventilation. Dexmedetomidine reduces the occurrence of delirium but may cause hypotension, bradycardia, and insufficient sedation. This substudy aims to determine whether the combination of esketamine with dexmedetomidine can reduce the side effects and risk of delirium than dexmedetomidine alone in mechanically ventilated patients. Methods: This single-center, randomized, active-controlled, superiority trial will be conducted at The First Affiliated Hospital of Nanjing Medical University. A total of 134 mechanically ventilated patients will be recruited and randomized to receive either dexmedetomidine alone or esketamine combined with dexmedetomidine, until extubation or for a maximum of 14 days. The primary outcome is the occurrence of delirium, while the second outcomes include the number of delirium-free days; subtype, severity, and duration of delirium; time to first onset of delirium; total dose of vasopressors and antipsychotics; duration of mechanical ventilation; ICU and hospital length of stay (LOS); accidental extubation, re-intubation, re-admission; and mortality in the ICU at 14 and 28 days. Discussion: There is an urgent need for a new combination regimen of dexmedetomidine due to its evident side effects. The combination of esketamine and dexmedetomidine has been applied throughout the perioperative period. However, there is still a lack of evidence on the effects of this regimen on delirium in mechanically ventilated ICU patients. This substudy will evaluate the effects of the combination of esketamine and dexmedetomidine in reducing the risk of delirium for mechanically ventilated patients in ICU, thus providing evidence of this combination to improve the short-term prognosis. The study protocol has obtained approval from the Medical Ethics Committee (ID: 2022-SR-450). Trial registration: ClinicalTrials.gov: NCT05466708, registered on 20 July 2022. [ABSTRACT FROM AUTHOR]

Background: Internal fixation for multiple rib fractures is well established. Patients with underlying chronic obstructive pulmonary disease (COPD) have a higher rate of perioperative complications. It is unclear if these patients are suitable candidates for internal fixation and if surgical interventions are harmful to these patients., Study Design and Methods: Adult patients with ≥ 3 rib fractures and underlying COPD from the Trauma Quality Improvement Program between 2017 and 2019 were eligible for inclusion. The patients were divided into two treatment groups: operative and non-operative. Furthermore, inverse probability treatment weighting was applied to analyze mortality and adverse hospital events., Results: Patients with COPD in the operative group had higher ventilator use (odds ratio [OR], 3.211; 95% confidence interval [CI], 1.993-5.175; p < 0.001). Additionally, they had a longer length of stay (coefficient β, 4.139; standard error, 0.829; p < 0.001) and longer ventilator days (coefficient β, 1.937; standard error, 0.655; p = 0.003) than in the non-operative group. Furthermore, the mortality rate was lower in the operative group than in the non-operative group (OR, 0.426; 95% CI, 0.228-0.798; p = 0.008)., Conclusion: Internal fixation of rib fractures plays a crucial role in patients with underlying COPD disease. They presented a better mortality rate without an increased perioperative complication rate., (© 2024. The Author(s).)

Background: Lower gastrointestinal perforation (LGP) is a surgical emergency disease that can result in secondary bacterial peritonitis. Microbiological studies on LGP are rare. The present study aimed to ascertain the microbiological profile of LGP in patients admitted to the intensive care unit (ICU) at our institute after surgery. In addition, we investigated whether initial empirical therapy with vancomycin was associated with in-hospital mortality, duration of ICU stay, and duration of ventilator support., Methods: This single-center, retrospective, observational study was conducted at Kobe City Medical Center General Hospital, Japan. The study population included all patients diagnosed with LGP who were admitted to the ICU after emergency surgery between 2017 and 2023. The primary outcome assessed was the microbiological profile of microorganisms isolated from ascites fluid and blood of the participants. The secondary end-points were in-hospital mortality, duration of ICU stay, and duration of ventilator support. We performed univariate and multivariate regression analyses to evaluate the end-points., Results: During the study period, 89 patients were included in the analysis. The most commonly identified pathogen from the ascites cultures was Escherichia coli (65.2%), followed by Enterococcus spp. (51.7%). E. faecium was identified in 16 (18.0%) ascites samples. The microbiological profile of critically ill patients with LGP admitted to the ICU after surgery was similar to that of previous studies on intra-abdominal infection (IAI). Therefore, the initial empirical therapy in the IAI guidelines is more appropriate for LGP. Multivariate regression analysis suggested that the combination of initial empirical therapy with vancomycin was not associated with in-hospital mortality (odds ratio [OR] = 0.96, 95% confidence interval [CI] 0.23-3.00, p = 0.955), duration of ICU stay (coefficient=-0.92, 95% CI -3.04-1.21, p = 0.393), or duration of ventilator-support (coefficient=-9.03, 95%CI -49.69-31.63, p = 0.659)., Conclusion: The microbiological profile of critically ill patients with LGP admitted to the ICU after surgery was similar to that of previous studies on IAI. However, the frequency of E. faecium in the present study was higher than that in previous studies. Initial empirical therapy with drugs such as meropenem in combination with vancomycin for E. faecium was not associated with in-hospital mortality, duration of ICU stay, and duration of ventilator support, after adjusting for confounding factors., (© 2024. The Author(s).)

Background: Bacterial pneumonia is one of the most common causes of acute respiratory distress syndrome. In fulminant cases, when mechanical ventilation fails, veno-venous extracorporeal membrane oxygenation is required. However, this method is still associated with significant mortality and a wide range of potential complications. However, there are now many case reports of good outcomes even in patients with prolonged extracorporeal oxygenation, as in our rather complicated case report., Case Presentation: Our case report describes a complicated but successful treatment of a severe, devastating bacterial pneumonia in a 39-year-old European polymorbid woman with a rare form of diabetes mellitus, which had been poorly compensated for a long time with limited compliance, in the context of a combined immunodeficiency that strongly influenced the course of the disease. The patient's hospitalization required a total of 30 days of veno-venous extracorporeal membrane oxygenation therapy and more than 50 days of mechanical ventilation. Numerous complications, particularly bleeding, required seven chest drains, two extracorporeal membrane oxygenation circuit changes, and one surgical revision. The patient's mental state required repeated psychiatric intervention., Conclusion: It is possible that even the initially severely damaged lung parenchyma can develop its regenerative potential if suitable conditions are provided for this process, including a sufficiently long period of extracorporeal membrane oxygenation. We believe that this case report may also contribute to the consideration of the indications and contraindications of extracorporeal support. The authors also discuss the limitations and risks of prolonged veno-venous extracorporeal membrane oxygenation support and periprocedural anticoagulation strategies., (© 2024. The Author(s).)

Background: Children utilizing invasive home mechanical ventilation (administered via tracheostomy tube) receive intensive care at home without the support of trained staff typically present in an intensive care unit; within the context of worsening home nursing shortages, much of the 24/7 care burden falls to families which are likely under supported. Prior reviews have explored the quality of life of children receiving various forms of mechanical ventilation, without addressing the impact on the family. Additionally, the literature inconsistently differentiates the unique experience of families with children using invasive home mechanical ventilation from non-invasive, which has lower morbidity and mortality and requires less nursing care in the home. Therefore, our study aims to explore and map the existing literature regarding the impact of invasive home mechanical ventilation on the child and family's quality of life. Identified gaps will inform future research focused on improving the family quality of life of children with invasive home mechanical ventilation., Methods: Five databases will be searched using keywords and controlled vocabulary to identify relevant studies: Ovid Medline, Embase, Scopus, and Cochrane Library. English language studies will meet inclusion criteria if they include primary research studies of children or families of children utilizing invasive home mechanical ventilation at home and assess quality of life. Children and young adults aged 0-25 years will be included. We exclude studies of hospitalized children, studies focused solely on healthcare professional experiences or clinical outcomes, and those focused on the period surrounding discharge from admission for tracheostomy placement. Two independent reviewers will screen studies at the title/abstract and full-text levels. Two independent reviewers will extract data from relevant studies. Disagreements will be resolved by an independent third reviewer. A targeted grey literature search will be performed utilizing ProQuest, clinicaltrials.gov, WHO trial registry, Google Scholar, and professional societies. Findings will be presented in tables and figures along with a narrative summary., Discussion: This scoping review seeks to map the literature and provide a descriptive report of the health-related quality of life of children using invasive home mechanical ventilation and their families., Registration: Open Science Framework https://doi.org/10.17605/OSF.IO/6GB84 Date of Registration: November 29, 2023., (© 2024. The Author(s).)

Background: To evaluate the impact of implementation of 2019 European respiratory distress syndrome (RDS) guidelines on the incidence of bronchopulmonary dysplasia (BPD)., Method: We retrospectively collected the clinical data of very preterm infants (VPIs) born before 32 gestational weeks from January 1st 2018 to December 31st 2021. VPIs were divided into group A and group B according to their birth date which was before or at/after January 1st 2020, when the 2019 European RDS guidelines were introduced. BPD is considered as primary outcome. We statistically analyzed all the data, and we compared the general characteristics, ventilation support, medication, nutrition and the outcomes between the two groups., Results: A total of 593 VPIs were enrolled, including 380 cases in group A and 213 cases in group B. There were no statistic differences regarding to gender ratio, gestational age, birth weight and delivery mode between the two groups. Compared with group A, group B showed higher rate of antenatal corticosteroid therapy (75.1% vs. 65.5%). The improvement of ventilation management in these latter patients included lower rate of invasive ventilation (40.4% vs. 50.0%), higher rate of volume guarantee (69.8% vs. 15.3%), higher positive end expiratory pressure (PEEP) [6 (5, 6) vs. 5 (5, 5) cmH 2 O] and higher rate of synchronized nasal intermittent positive pressure ventilation (sNIPPV) (36.2% vs. 5.6%). Compared with group A, group B received higher initial dose of pulmonary surfactant [200 (160, 200) vs. 170 (130, 200) mg/Kg], shorter antibiotic exposure time [13 (7, 23) vs. 17 (9, 33) days], more breast milk (86.4% vs. 70.3%) and earlier medication for hemodynamically significant patent ductus arteriosus (hsPDA) treatment [3 (3, 4) vs. 8 (4, 11) days] (p < 0.05). As the primary outcome, the incidence of BPD was significantly decreased (16.9% vs. 24.2%) (p < 0.05), along with lower extrauterine growth retardation (EUGR) rate (39.0% vs. 59.7%), while there were no statistic differences regarding to other secondary outcomes, including mortality, intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), retinopathy of preterm (ROP) and necrotizing enterocolitis (NEC). However, in the subgroups of infants less than 28 gestational weeks or infants less than 1,000 g, the incidence of BPD was not significantly decreased (p > 0.05)., Conclusions: After implementation of 2019 European RDS guidelines, the overall incidence of BPD was significantly decreased in VPIs. Continuous quality improvement is still needed in order to decrease the incidence of BPD in smaller infants who are less than 28 gestational weeks or less than 1,000 g., (© 2024. The Author(s).)

Background: At present, preterm infants with respiratory distress syndrome (RDS) in China present higher mortality and morbidity rates than those in high-income countries. The aim of this nationwide survey was to assess the clinical management of RDS in China., Methods: A nationwide cross-sectional survey to assess adherence to RDS management recommendations was performed. One neonatologist per hospital was randomly selected. The primary outcome was the key care of RDS management., Results: Among the 394 participating hospitals, 88·3% were birthing centres. The number of doctors and nurses per bed were 0·27 and 0·72, respectively. Antenatal corticosteroids (any dose) were administered to 90% of the women at risk of preterm birth at < 34 weeks of gestation (90·0% inborn vs. 50·0% outborn, p < 0·001). The median fraction of inspired oxygen (FiO 2 ) for initial resuscitation was 0·30 for babies born at ≤ 32 weeks of gestation and 0·25 for those born at > 32 weeks. T-piece resuscitators were available in 77·8% of delivery rooms (DRs) (tertiary hospitals: 82·5% vs. secondary hospitals: 63·0%, p < 0·001). Surfactant was used in 51·6% of the DRs. Less invasive surfactant administration (LISA) was used in 49·7% of the hospitals (tertiary hospitals: 55·3% vs. secondary hospitals: 31·5%, p < 0·001). Primary non-invasive ventilation was initiated in approximately 80·0% of the patients. High-frequency oscillation ventilation was primarily reserved for rescue after conventional mechanical ventilation (MV) failure. Caffeine was routinely used during MV in 59·1% of the hospitals. Bedside lung ultrasonography was performed in 54·3% of the health facilities (tertiary hospitals: 61·6% vs. secondary hospitals: 30·4%, p < 0·001). Qualified breast milk banks and Family Integrated Care (FICare) were present in 30·2% and 63·7% of the hospitals, respectively., Conclusions: Significant disparities in resource availability and guidelines adherence were evident across hospitals. Future strategies should address DR facilities and medication access, technical training, staff allocation, and ancillary facility development for a better management of RDS patients in China., (© 2024. The Author(s).)

Background: Mechanical ventilation (MV) in intensive care units (ICUs) is a stressful experience for patients. However, these experiences have not been systematically explored in low- and lower-middle-income countries (LLMICs). This systematic review (SR) aims to explore the patients' experiences of MV in ICUs in LLMICs and the factors influencing their experiences., Methods: The PICO framework will be used to operationalize the review question into key concepts: population (mechanically ventilated adult patients in ICUs), phenomenon of interest (experiences) and context (LLMICs). PubMed, Embase, PsycINFO, CINAHL, Cochrane Library, Scopus and Web of Science will be systematically searched since database inception. Citation, reference list and PubMed-related article searching of included studies will be done to ensure literature saturation. Empirical peer-reviewed literature exploring adult patients' (aged ≥ 18 years) experiences of MV in ICUs in LLMIC will be included. All study designs (quantitative, qualitative and mixed methods) will be included. Two independent reviewers will perform screening, data extraction and critical appraisal. The mixed-methods appraisal tool (MMAT) and Popay's narrative synthesis will be used for critical appraisal and data synthesis, respectively., Discussion: This SR aims to bridge a gap in knowledge as previous evidence synthesis has described this phenomenon in developed countries. The review design, with the inclusion of quantitative, qualitative and mixed-methods studies, intends to provide a rich and in-depth exploration of the issue. The findings will be presented as themes, subthemes and their explanatory narratives. The gaps in available literature will be identified, and implications of SR findings on policy, practice and future research will be presented. The strength of this SR lies in its systematic, comprehensive, transparent, robust and explicit methodology of identifying, collating, assessing and synthesizing available evidence. By prior registration and reporting of this SR protocol, we aim to ensure transparency and accountability and minimize bias., Systematic Review Registration: PROSPERO CRD42024507187., (© 2024. The Author(s).)

Background: COVID-19 infections can result in severe acute respiratory distress syndrome (ARDS) requiring admission to the intensive care unit (ICU). Cardiovascular manifestation or exacerbation of cardiovascular diseases could be another complication. Cardiac arrhythmias including New-Onset Atrial Fibrillation (NOAF), have been observed in hospitalized patients with COVID-19 infections. In this analysis, we aimed to systematically compare the complications associated with NOAF in critically ill COVID-19 patients admitted to the ICU., Methods: MEDLINE, EMBASE, Web of Science, the Cochrane database, http://www., Clinicaltrials: gov , Google Scholar and Mendeley were searched for relevant publications based on COVID-19 patients with NOAF admitted to the ICU. Complications including in-hospital mortality, ICU mortality, patients requiring mechanical ventilation, acute myocardial infarction, acute kidney injury, renal replacement therapy and pulmonary embolism were assessed. This is a meta-analysis and the analytical tool which was used was the RevMan software version 5.4. Risk ratios (RR) and 95% confidence intervals (CIs) were used to represent the data post analysis., Results: In critically ill COVID-19 patients with NOAF admitted to the ICU, the risks of ICU mortality (RR: 1.39, 95% CI: 1.07 - 1.80; P = 0.01), in-hospital mortality (RR: 1.56, 95% CI: 1.20 - 2.04; P = 0.001), patients requiring mechanical ventilation (RR: 1.32, 95% CI: 1.04 - 1.66; P = 0.02) were significantly higher when compared to the control group without AF. Acute myocardial infarction (RR: 1.54, 95% CI: 1.31 - 1.81; P = 0.00001), the risk for acute kidney injury (RR: 1.31, 95% CI: 1.11 - 1.55; P = 0.002) and patients requiring renal replacement therapy (RR: 1.83, 95% CI: 1.60 - 2.09; P = 0.00001) were also significantly higher in patients with NOAF., Conclusions: Critically ill COVID-19 patients with NOAF admitted to the ICU were at significantly higher risks of developing complications and death compared to similar patients without AF., (© 2024. The Author(s).)

Background: Severe COVID-19 carries a high morbidity and mortality. Previous studies have shown an association between COVID-19 severity and SARS-CoV-2 viral load (VL). We sought to measure VL in multiple compartments (urine, plasma, lower respiratory tract) in patients admitted to the intensive care unit (ICU) with severe COVID-19 pneumonia and correlate with clinical outcomes., Methods: Plasma, urine, and endotracheal aspirate (ETA) samples were obtained on days 1, 3, 7, 14, and 21 from subjects admitted to the ICU with severe COVID-19. VL was measured via reverse transcriptase polymerase chain reaction. Clinical data was collected from the electronic health record. Grouped comparisons were performed using Student's t-test or 1-way ANOVA. Linear regression was used to correlate VL from different compartments collected at the same time. Logistic regression was performed to model ventilator-freedom at 28 days as a function of peak plasma VL., Results: We enrolled 57 subjects with severe COVID-19 and measured VL in plasma (n = 57), urine (n = 25), and ETA (n = 34). Ventilator-associated pneumonia developed in 63% of subjects. 49% of subjects were viremic on study day 1. VL in plasma and ETA both significantly decreased by day 14 (P < 0.05), and the two were weakly correlated on study day 1 (P = 0.0037, r 2  = 0.2343) and on all study days (P < 0.001, r 2  = 0.2211). VL were not detected in urine. While no associations were observed with peak ETA VL, subjects with higher peak plasma VL experienced a greater number of respiratory complications, including ventilator-associated pneumonia and fewer ventilator-free and hospital-free days. There was no association between VL in either plasma or ETA and mortality. In viremic patients, plasma VL was significantly lower in subjects that were ICU-free and ventilator-free (P < 0.05), with trends noted for hospital-freedom, ventilator-associated pneumonia, and survival to discharge (P < 0.1). By logistic regression, plasma VL was inversely associated with ventilator-freedom at 28 days (odds ratio 0.14, 95% confidence interval 0.02-0.50)., Conclusions: Elevated SARS-CoV-2 VL in the plasma but not in the lower respiratory tract is a novel biomarker in severe COVID-19 for respiratory complications., (© 2024. The Author(s).)

Background: The diagnosis of ICU-acquired weakness (ICUAW) may be delayed due to the complexity of critically ill patients. This study aimed to investigate the value of ultrasound measurements of rectus femoris cross-sectional area (RFCSA) in predicting ICUAW in patients undergoing invasive mechanical ventilation., Methods: This was a prospective cohort study of patients undergoing mechanical ventilation for at least 48 h. RFCSA was measured using ultrasound in patients upon ICU admission and followed until discharge. Using the Medical Research Council score as the gold standard, we evaluated the diagnostic value of ultrasound measurements in predicting ICUAW. Kaplan-Meier curves were constructed to evaluate and compare the length of ICU stay and duration of invasive mechanical ventilation between patients with and without ICUAW., Results: Among the 76 patients, 34 (44.7%) were diagnosed with ICUAW using the Medical Research Council score as the gold standard. The RFCSA atrophy rate between day 1 and day 3 was significantly higher in the ICUAW group (7.9 ± 2.8% vs. 4.3 ± 2.1%, p < 0.001). By utilizing a cutoff point of 6.9%, we discovered that the RFCSA atrophy rate exhibited excellent diagnostic accuracy in predicting ICUAW, with a sensitivity of 76.5% and specificity of 92.9%. In ICUAW patients diagnosed based on an RFCSA atrophy rate, the proportion of patients with an ICU stay longer than 14 days was 42.9%, which was significantly higher compared to 22.9% in the non-ICUAW group (HR: 1.768; 95% CI 1.128-2.772; p = 0.006). Similarly, the proportion of patients continuing mechanical ventilation at 14 days was 28.6% versus 4.2% between the two groups (HR: 1.988; 95% CI 1.266-3.120; p < 0.001)., Conclusion: Ultrasound measurements of RFCSA provide a reliable method for diagnosing ICUAW and indicating prognosis in patients undergoing invasive mechanical ventilation., (© 2024. The Author(s).)

Background: Research indicates that preterm infants requiring prolonged mechanical ventilation often exhibit suboptimal neurodevelopment at follow-up, coupled with altered brain development as detected by magnetic resonance imaging (MRI) at term-equivalent age (TEA). However, specific regions of brain dysmaturation and the subsequent neurodevelopmental phenotype following early-life adverse respiratory exposures remain unclear. Additionally, it is uncertain whether brain dysmaturation mediates neurodevelopmental outcomes after respiratory adversity. This study aims to investigate the relationship between early-life adverse respiratory exposures, brain dysmaturation at TEA, and the developmental phenotype observed during follow-up in extremely preterm infants., Methods: 89 infants born < 29 weeks' gestation from 2019 to 2021 received MRI examinations at TEA for structural and lobe brain volumes, which were adjusted with sex-and-postmenstrual-age expected volumes for volume residuals. Assisted ventilation patterns in the first 8 postnatal weeks were analyzed using kmlShape analyses. Patterns for motor, cognition, and language development were evaluated from corrected age 6 to 12 months using Bayley Scales of Infant Development, third edition. Mediation effects of brain volumes between early-life respiratory exposures and neurodevelopmental phenotypes were adjusted for sex, gestational age, maternal education, and severe brain injury., Results: Two distinct respiratory trajectories with varying severity were identified: improving (n = 35, 39%) and delayed improvement (n = 54, 61%). Compared with the improving group, the delayed improvement group exhibited selectively reduced brain volume residuals in the parietal lobe (mean - 4.9 cm 3 , 95% confidence interval - 9.4 to - 0.3) at TEA and lower motor composite scores (- 8.7, - 14.2 to - 3.1) at corrected age 12 months. The association between delayed respiratory improvement and inferior motor performance (total effect - 8.7, - 14.8 to - 3.3) was partially mediated through reduced parietal lobe volume (natural indirect effect - 1.8, - 4.9 to - 0.01), suggesting a mediating effect of 20%., Conclusions: Early-life adverse respiratory exposure is specifically linked to the parietal lobe dysmaturation and neurodevelopmental phenotype of motor delay at follow-up. Dysmaturation of the parietal lobe serves as a mediator in the connection between respiratory adversity and compromised motor development. Optimizing respiratory critical care may emerge as a potential avenue to mitigate the consequences of altered brain growth and motor developmental delay in this extremely preterm population., (© 2024. The Author(s).)

Background: End-expiratory lung volume (EELV) has been observed to decrease in acute respiratory distress syndrome (ARDS). Yet, research investigating EELV in patients with COVID-19 associated ARDS (CARDS) remains limited. It is unclear whether EELV could serve as a potential metric for monitoring disease progression and identifying patients with ARDS at increased risk of adverse outcomes., Study Design and Methods: This retrospective study included mechanically ventilated patients diagnosed with CARDS during the initial phase of epidemic control in Shanghai. EELV was measured using the nitrogen washout-washin technique within 48 h post-intubation, followed by regular assessments every 3-4 days. Chest CT scans, performed within a 24-hour window around each EELV measurement, were analyzed using AI software. Differences in patient demographics, clinical data, respiratory mechanics, EELV, and chest CT findings were assessed using linear mixed models (LMM)., Results: Out of the 38 patients enrolled, 26.3% survived until discharge from the ICU. In the survivor group, EELV, EELV/predicted body weight (EELV/PBW) and EELV/predicted functional residual capacity (EELV/preFRC) were significantly higher than those in the non-survivor group (survivor group vs. non-survivor group: EELV: 1455 vs. 1162 ml, P = 0.049; EELV/PBW: 24.1 vs. 18.5 ml/kg, P = 0.011; EELV/preFRC: 0.45 vs. 0.34, P = 0.005). Follow-up assessments showed a sustained elevation of EELV/PBW and EELV/preFRC among the survivors. Additionally, EELV exhibited a positive correlation with total lung volume and residual lung volume, while demonstrating a negative correlation with lesion volume determined through chest CT scans analyzed using AI software., Conclusion: EELV is a useful indicator for assessing disease severity and monitoring the prognosis of patients with CARDS., (© 2024. The Author(s).)

Objective: This comparative analysis aimed to investigate the efficacy of Sivelestat Sodium Hydrate (SSH) combined with Ulinastatin (UTI) in the treatment of sepsis with acute respiratory distress syndrome (ARDS)., Methods: A control group and an observation group were formed with eighty-four cases of patients with sepsis with ARDS, with 42 cases in each group. The control group was intravenously injected with UTI based on conventional treatment, and the observation group was injected with SSH based on the control group. Both groups were treated continuously for 7 days, and the treatment outcomes and efficacy of both groups were observed. The Murray Lung Injury Score (MLIS), Sequential Organ Failure Assessment (SOFA), and Acute Physiology and Chronic Health Evaluation II (APACHE II) were compared. Changes in respiratory function, inflammatory factors, and oxidative stress indicators were assessed. The occurrence of adverse drug reactions was recorded., Results: The total effective rate in the observation group (95.24%) was higher than that in the control group (80.95%) (P < 0.05). The mechanical ventilation time, intensive care unit (ICU) hospitalization time, and duration of antimicrobial medication in the observation group were shorter and multiple organ dysfunction syndrome incidence was lower than those in the control group (P < 0.05). The mortality rate of patients in the observation group (35.71%) was lower than that in the control group (52.38%), but there was no statistically significant difference between the two groups (P > 0.05). MLIS, SOFA, and APACHE II scores in the observation group were lower than the control group (P < 0.05). After treatment, respiratory function, inflammation, and oxidative stress were improved in the observation group (P < 0.05). Adverse reactions were not significantly different between the two groups (P > 0.05)., Conclusion: The combination of SSH plus UTI improves lung injury and pulmonary ventilation function, and reduces inflammation and oxidative stress in patients with sepsis and ARDS., (© 2024. The Author(s).)

Background: Recent meta-analyses and randomized studies have shown that among patients with acute ischemic stroke undergoing endovascular thrombectomy, general anesthesia with mechanical ventilation is associated with better functional status compared to local anesthesia and sedation, and they recommend its use. But once the procedure is completed, when is the optimal moment for extubation? Currently, there are no guidelines recommending the optimal moment for extubation. Prolonged mechanical ventilation time could potentially be linked to increased complications such as pneumonia or disturbances in cerebral blood flow due to the vasodilatation produced by most anesthetic drugs. However, premature extubation in a patient who has suffered a stroke could led to complications such as agitation, disorientation, abolished reflexes, sudden fluctuations in blood pressure, alterations in cerebral blood flow, respiratory distress, bronchial aspiration, and the need for reintubation. We therefore designed a randomized study hypothesizing that early compared with delayed extubation is associated with a better functional outcome 3 months after endovascular thrombectomy treatment under general anesthesia for acute ischemic stroke., Methods: This investigator-initiated, single-center, prospective, parallel, evaluated blinded, superiority, randomized controlled trial will include 178 patients with a proximal occlusion of the anterior circulation treated with successful endovascular thrombectomy (TICI 2b-3) under general anesthesia. Patients will be randomly allocated to receive early (< 6 h) or delayed (6-12 h) extubation after the procedure. The primary outcome measure is functional independence (mRS of 0-2) at 90 days, measured with the modified Rankin Score (mRS), ranging from 0 (no symptoms) to 6 (death)., Discussion: This will be the first trial to compare the effect of mechanical ventilation duration (early vs delayed extubation) after satisfactory endovascular thrombectomy for acute ischemic stroke under general anesthesia., Trial Registration: The study protocol was approved April 11, 2023, by the by the Santiago-Lugo Research Ethics Committee (CEI-SL), number 2023/127, and was registered into the clinicaltrials.gov clinical trials registry with No. NCT05847309. Informed consent is required. Participant recruitment begins on April 18, 2023. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences., (© 2024. The Author(s).)

Background: This review aims to study the clinical characteristics, diagnostic results, treatments, and outcomes in patients with heterotopic ossification following COVID-19 infection., Methods: A literature search for eligible articles was conducted using MEDLINE/Pubmed, Global Health, and Scopus databases (January 12th, 2023), including all case reports and case series from any country and language. The criteria for inclusion in this review were cases of COVID-19 infection subsequently developing heterotopic ossification., Results: This systematic review analysed 15 reports (n = 20 patients) documenting cases of heterotopic ossification following COVID-19 infection. 80% of the patients were male, with a median age of 59 years. All patients required intensive care unit stay with an average duration of 48.5 days. Mechanical ventilation was necessary for all patients and 30% of them underwent tracheostomy. Common symptoms included stiffness and pain, most frequently affecting multiple locations (70%), with the hips and shoulders being predominantly involved. X-rays were the most commonly used imaging modality, followed by computed tomography. Although treatment was given, some of the patients continued to experience symptoms, particularly stiffness., Conclusion: 20 patients who developed heterotopic ossification after COVID-19 have been reported, the majority of which had at least two independent risk factors for this condition. The link between those two clinical entities is therefore uncertain, requiring further investigation. It is nonetheless important to suspect heterotopic ossification in patients with severe COVID-19 infection, prolonged immobilisation, mechanical ventilation, who develop joint pain and stiffness, as this condition can significantly impact patients' quality of life., Protocol Registration: CRD42023393516., (© 2024. The Author(s).)

Background: We present the case of a woman with cancer, which weakened the immune system and increased the risk of infection. Thus, infections are a frequent complication of cancer. The development of community-acquired pneumonia, an acute respiratory infectious disease that damages the lung parenchyma, caused by the invasion of pathogenic microorganisms, can lead to respiratory failure with multiorgan failure due to respiratory sepsis., Case Presentation: Case report of a 38-year-old mixed-race woman with diabetes mellitus and irregular treatment, who was admitted with community-acquired pneumonia complicated by type I respiratory failure requiring mechanical ventilation. During her hospital stay, she developed ventilator-associated pneumonia, recurrent empyema, bronchopleural fistula, refractory septic shock and multiorgan dysfunction despite multiple interventions. The patient required prolonged mechanical ventilation, vasopressor support and antibiotic therapy. After 62 days, metastatic papillary thyroid carcinoma was diagnosed. She presented with hypoparathyroidism and permanent hypocalcemia. She died after multiple complications and a refractory critical condition., Conclusion: The case exemplifies the potential severity of community-acquired pneumonia in a patient with risk factors such as diabetes and immunosuppression. It highlights the complexity of treating multiple comorbidities and the importance of multidisciplinary management with close surveillance for timely interventions for complications., (© 2024. The Author(s).)

Introduction: Ventilator-associated pneumonia (VAP) presents a significant challenge in intensive care units (ICUs). Nebulized antibiotics, particularly colistin and tobramycin, are commonly prescribed for VAP patients. However, the appropriateness of using inhaled antibiotics for VAP remains a subject of debate among experts. This study aims to provide updated insights on the efficacy of adjunctive inhaled colistin and tobramycin through a comprehensive systematic review and meta-analysis., Methods: A thorough search was conducted in MEDLINE, EMBASE, LILACS, COCHRANE Central, and clinical trials databases ( www., Clinicaltrials: gov ) from inception to June 2023. Randomized controlled trials (RCTs) meeting specific inclusion criteria were selected for analysis. These criteria included mechanically ventilated patients diagnosed with VAP, intervention with inhaled Colistin and Tobramycin compared to intravenous antibiotics, and reported outcomes such as clinical cure, microbiological eradication, mortality, or adverse events., Results: The initial search yielded 106 records, from which only seven RCTs fulfilled the predefined inclusion criteria. The meta-analysis revealed a higher likelihood of achieving both clinical and microbiological cure in the groups receiving tobramycin or colistin compared to the control group. The relative risk (RR) for clinical cure was 1.23 (95% CI: 1.04, 1.45), and for microbiological cure, it was 1.64 (95% CI: 1.31, 2.06). However, there were no significant differences in mortality or the probability of adverse events between the groups., Conclusion: Adjunctive inhaled tobramycin or colistin may have a positive impact on the clinical and microbiological cure rates of VAP. However, the overall quality of evidence is low, indicating a high level of uncertainty. These findings underscore the need for further rigorous and well-designed studies to enhance the quality of evidence and provide more robust guidance for clinical decision-making in the management of VAP., (© 2024. The Author(s).)

Background: The optimal amount and timing of protein intake in critically ill patients are unknown. REPLENISH (Replacing Protein via Enteral Nutrition in a Stepwise Approach in Critically Ill Patients) trial evaluates whether supplemental enteral protein added to standard enteral nutrition to achieve a high amount of enteral protein given from ICU day five until ICU discharge or ICU day 90 as compared to no supplemental enteral protein to achieve a moderate amount of enteral protein would reduce all-cause 90-day mortality in adult critically ill mechanically ventilated patients., Methods: In this multicenter randomized trial, critically ill patients will be randomized to receive supplemental enteral protein (1.2 g/kg/day) added to standard enteral nutrition to achieve a high amount of enteral protein (range of 2-2.4 g/kg/day) or no supplemental enteral protein to achieve a moderate amount of enteral protein (0.8-1.2 g/kg/day). The primary outcome is 90-day all-cause mortality; other outcomes include functional and health-related quality-of-life assessments at 90 days. The study sample size of 2502 patients will have 80% power to detect a 5% absolute risk reduction in 90-day mortality from 30 to 25%. Consistent with international guidelines, this statistical analysis plan specifies the methods for evaluating primary and secondary outcomes and subgroups. Applying this statistical analysis plan to the REPLENISH trial will facilitate unbiased analyses of clinical data., Conclusion: Ethics approval was obtained from the institutional review board, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia (RC19/414/R). Approvals were also obtained from the institutional review boards of each participating institution. Our findings will be disseminated in an international peer-reviewed journal and presented at relevant conferences and meetings., Trial Registration: ClinicalTrials.gov, NCT04475666 . Registered on July 17, 2020., (© 2024. The Author(s).)

Background: It is internationally known that our population is aging. At the same time, some patients with COVID-19, due to their symptoms, required mechanical ventilation (MV) and subsequent pulmonary rehabilitation (PR). This study aimed to compare the effects of a multimodal PR program "ADULT" versus "OLDER" people with COVID-19 who were on MV., Methods: The intervention consisted of an 8-week hybrid PR program (2x week). Forced vital capacity (FVC) was measured at the beginning and end of PR, upper and lower limb strength was obtained through hand grip strength (HGS) and the sit-to-stand test (STST), respectively, and functional exercise capacity was measured with the 6-minute walking test (6MWT)., Results: The main results were an increase in the FVC in the ADULT and OLDER groups (time effect, P = 0.000; η2 = 0.27), an increase in HGS in the ADULT and OLDER groups (time effect, P = 0.000; η2 = 0.52), in the same way, the number of repetitions on the STST increased in the ADULT and OLDER groups (time effect, P = 0.000; η2 = 0.55). Finally, the distance covered on the 6MWT increased in the ADULT and OLDER groups (time effect, P = 0.000; η2 = 0.65)., Conclusions: The PR program is an effective strategy to improve FVC, muscle strength, and functional exercise capacity similarly in adults and older people with post severe COVID-19 who required MV., (© 2024. The Author(s).)

Objective: The coronavirus disease 2019 (COVID-19) pandemic has resulted in millions of confirmed cases and deaths globally. The purpose of this study was to investigate the therapeutic effect of airway clearance technology combined with prone ventilation on patients infected with COVID-19., Methods: 38 patients with COVID-19 (severe) who were treated in the intensive rehabilitation group of Shengli Oilfield Central Hospital. They were randomly divided into a control group and an observation group. The control group received prone position ventilation intervention, and the observation group received airway clearance technology combined with prone position ventilation intervention. The changes of oxygen and index, procalcitonin (PCT), interleukin-6 (IL-6) and chest X-ray image indexes were compared between the two groups., Result: There was no significant difference in age, gender and other general data between the control group and the observation group. The results showed that oxygen index, PCT, IL-6 and chest X-ray image index in the observation group were better than that indexes in the control group., Conclusion: Airway clearance technology combined with prone ventilation intervention in patients with COVID-19 can improve the total effective rate and oxygenation index, improve the inflammatory indicators and respiratory function of patients. And it may be widely promoted and used in the treatment of patients with COVID-19 (severe)., (© 2024. The Author(s).)

Introduction: Mechanical ventilation is the most common intervention for patients with respiratory failure in the intensive care unit. There is limited data from African countries, including Ethiopia on time to death and its predictors among patients on mechanical ventilators. Therefore, this study aimed to assess time to death and its predictors among adult patients on mechanical ventilation admitted in comprehensive specialized hospitals in West Amhara, Ethiopia., Methods: An institutional-based retrospective follow-up study was conducted from January 1, 2020, to December 31, 2022. A simple random sampling was used to select a total of 391 patients' charts. Data were collected using data the extraction tool, entered into Epi-data version 4.6.0, and exported to STATA version 14 for analysis. Kaplan-Meier failure curve and the log-rank test were fitted to explore the survival difference among groups. The Cox regression model was fitted, and variables with a p-value < 0.25 in the bivariable Cox regression were candidates for the multivariable analysis. In the multivariable Cox proportional hazard regression, an adjusted hazard ratio with 95% confidence intervals were reported to declare the strength of association between mortality and predictors when a p value is < 0.05., Results: A total of 391 mechanically ventilated patients were followed for 4098 days at risk. The overall mortality of patients on mechanical ventilation admitted to the intensive care units was 62.2%, with a median time to death of 16 days (95% CI: 11, 22). Those patients who underwent tracheostomy procedure (AHR = 0.40, 95% CI: 0.20, 0.80), received cardio-pulmonary resuscitation (AHR = 8.78, 95% CI: 5.38, 14.35), being hypotensive (AHR = 2.96, 95% CI: 1.11, 7.87), and had a respiratory rate less than 12 (AHR = 2.74, 95% CI: 1.48, 5.07) were statistically significant predictors of time to death among mechanically ventilated patients., Conclusion: The mortality rate of patients on mechanical ventilation was found to be high and the time to death was short. Being cardiopulmonary resuscitated, hypotensive, and had lower respiratory rate were significant predictors of time to death, whereas patients who underwent tracheostomy was negatively associated with time to death. Tracheostomy is needed for patients who received longer mechanical ventilation, and healthcare providers should give a special attention for patients who are cardiopulmonary resuscitated, hypotensive, and have lower respiratory rate., (© 2024. The Author(s).)

Background: Most of critically ventilated patients with severe hemorrhagic shock experience metabolic acidosis, hypoalbuminemia, electrolyte imbalance, and increased production of free radical. Channa striata has a high content of albumin, an essential binding protein that contributes to homeostasis, and when combined with Moringa oleifera and Curcuma xanthorrhiza, they act as powerful antioxidants. Administration of C. striata, M. oleifera, and C. xanthorrhiza extract orally may benefit patient with hemodynamic issues, including significant blood loss., Case Report: A 40-year-old Indonesian woman came to emergency department with decreased consciousness resulting from hemorrhagic shock grade 3 due to prolonged placenta retention for 10 days after delivery of her third child. She had an emergency hysterectomy and was sent to the intensive care unit with a hemoglobin level of 4.2 gr/dL, despite already receiving two bags of packed red blood cells during operation, and she continued with four more bags within her first day in the intensive care unit. The patient was ventilated, was supported by vasopressors, and had a low albumin level of 2.1 gr/dL. Her hemodynamic profile was difficult to stabilize, with persistent gastric residue and periodic urine output less than 1 cc/kg/hour, thereby slowing the ventilator and vasopressor weaning process. Oral supplementation of C. striata, M. oleifera, and C. xanthorrhiza was given in the second day divided in three doses every 6 hours. After the second dose, gastric residue started to subside and disappeared after the third dose. The patient's condition improved in the next 24 hours; she was extubated and discharged from the hospital in the fourth day., Conclusion: This is the first case report describing the effect of C. striata, M. oleifera, and C. xanthorrhiza extract in a patient with severe hemorrhagic shock due to a prolonged placenta. Accelerated recovery showed the possibility benefit of C. striata, M. oleifera, and C. xanthorrhiza extract in stabilizing oncotic pressure, neutralizing free radicals, and preventing further damage in hypoxic cells., (© 2024. The Author(s).)

Background: Ventilator-associated pneumonia (VAP) is one of the leading causes of mortality in patients with critical care illness. Since obesity is highly prevalent, we wanted to study its impact on the outcomes of patients who develop VAP., Methods: Using the National Inpatient Sample (NIS) database from 2017 to 2020, we conducted a retrospective study of adult patients with a principal diagnosis of VAP with a secondary diagnosis with or without obesity according to 10th revision of the International Statistical Classification of Diseases (ICD-10) codes. Several demographics, including age, race, and gender, were analyzed. The primary endpoint was mortality, while the secondary endpoints included tracheostomy, length of stay in days, and patient charge in dollars. Multivariate logistic regression model analysis was used to adjust for confounders, with a p-value less than 0.05 considered statistically significant., Results: The study included 3832 patients with VAP, 395 of whom had obesity. The mean age in both groups was around 58 years, and 68% of the group with obesity were females compared to 40% in females in the group without obesity. Statistically significant comorbidities in the obesity group included a Charlson Comorbidity Index score of three and above, diabetes mellitus, hypertension, chronic kidney disease, and sleep apnea. Rates and odds of mortality were not significantly higher in the collective obesity group 39 (10%) vs. 336 (8.5%), p-value 0.62, adjusted odds ratio 1.2, p-value 0.61). The rates and odds of tracheostomy were higher in the obesity group but not statistically significant. Obese patients were also found to have a longer hospitalization. Upon subanalysis of the data, no evidence of racial disparities was found in the care of VAP for both the obese and control groups., Conclusions: Obesity was not found to be an independent risk factor for worse outcomes in patients who develop VAP in the intensive care unit., (© 2024. The Author(s).)

Background: While the prevalence of severe cases and mortality rate of coronavirus disease 2019 (COVID-19) appear to be reducing, the clinical characteristics and severity of hospitalized patients with asthma and COVID-19 remain largely unknown. This study aimed to examine the association of asthma with COVID-19 severity and mortality risk., Methods: Data from the Japanese COVID-19 Registry Database were used to investigate the association between COVID-19 and asthma. This study focused on patients hospitalized for COVID-19 in 690 facilities from January 31, 2020, to December 31, 2022. Multivariate analysis using logistic regression was conducted to assess whether asthma, compared with other conditions, represents a risk factor for mortality and invasive mechanical ventilation after COVID-19., Results: In total, 72,582 patients with COVID-19 were included in the analysis, of whom, 3731 were diagnosed with asthma. From January 2020 to June 2021, asthma showed no significant association with an increase in mortality (OR 0.837, 95% CI 0.639-1.080, p = 0.184) or invasive mechanical ventilation events (OR 1.084, 95% CI 0.878-1.326, p = 0.440). An analysis conducted after July 2021 yielded similar results. For patients with asthma, factors such as age, body-mass index, sex, and chronic kidney disease increased the risk of mechanical ventilation. However, non-vaccination status and high blood pressure increased the risk of mechanical ventilation during the second half of the study., Conclusion: Patients with asthma did not have an increased risk of mortality or mechanical ventilation due to COVID-19. However, patients with asthma had a higher risk of more severe COVID-19 due to factors such as advancing age, elevated body-mass index, chronic kidney disease, and non-vaccination., (© 2024. The Author(s).)

Background: Measuring arterial partial pressure of carbon dioxide (PaCO 2 ) is crucial for proper mechanical ventilation, but the current sampling method is invasive. End-tidal carbon dioxide (EtCO 2 ) has been used as a surrogate, which can be measured non-invasively, but its limited accuracy is due to ventilation-perfusion mismatch. This study aimed to develop a non-invasive PaCO 2 estimation model using machine learning., Methods: This retrospective observational study included pediatric patients (< 18 years) admitted to the pediatric intensive care unit of a tertiary children's hospital and received mechanical ventilation between January 2021 and June 2022. Clinical information, including mechanical ventilation parameters and laboratory test results, was used for machine learning. Linear regression, multilayer perceptron, and extreme gradient boosting were implemented. The dataset was divided into 7:3 ratios for training and testing. Model performance was assessed using the R 2 value., Results: We analyzed total 2,427 measurements from 32 patients. The median (interquartile range) age was 16 (12-19.5) months, and 74.1% were female. The PaCO2 and EtCO2 were 63 (50-83) mmHg and 43 (35-54) mmHg, respectively. A significant discrepancy of 19 (12-31) mmHg existed between EtCO 2 and the measured PaCO 2 . The R 2 coefficient of determination for the developed models was 0.799 for the linear regression model, 0.851 for the multilayer perceptron model, and 0.877 for the extreme gradient boosting model. The correlations with PaCO 2 were higher in all three models compared to EtCO 2 ., Conclusions: We developed machine learning models to non-invasively estimate PaCO 2 in pediatric patients receiving mechanical ventilation, demonstrating acceptable performance. Further research is needed to improve reliability and external validation., (© 2024. The Author(s).)

Background: In November 2021, the B.1.1.529 (omicron) variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was detected in South Africa and subsequently rapidly spread around the world. Despite the reduced severity of the omicron variants, many patients become severely ill after infection and undergo invasive mechanical ventilation, but there are few reports on their background and prognosis throughout all variant periods. This study aimed to evaluate risk factors affecting patients requiring invasive mechanical ventilation with each variant of COVID-19 pandemic in Japan from nonvariants to omicron variants., Method: This retrospective observational study was conducted at the Department of Emergency and Critical Care Medicine, Kansai Medical University Hospital and Kansai Medical University Medical Center, Osaka, Japan, from March 2020 to March 2023. Eligible patients were those who underwent invasive ventilation for COVID-19 pneumonia. We set the primary endpoint as in-hospital mortality. Multivariable logistic regression analysis adjusted for clinically important variables was performed to evaluate the clinical outcomes., Results: We included 377 patients: 118 in the Nonvariant group, 154 in the Alpha group, 42 in the Delta group, and 63 patients in the Omicron group. Mortality rates for each group were 23.7% for the Nonvariant group, 12.3% for the Alpha group, 7.1% for the Delta group, and 30.5% for the Omicron group. Patient age was significantly associated with increased mortality (adjusted odds ratio [AOR]: 1.097; 95% confidence interval [CI]: 1.057-0.138, P < 0.001). Immunodeficiency (AOR: 3.388, 95% CI: 1.377-8.333, P = 0.008), initial SOFA score (AOR: 1.190, 95% CI: 1.056-1.341, P = 0.004), dialysis prior to COVID-19 (AOR: 3.695, 95% CI: 1.117-11.663, P = 0.026), and smoking history (AOR: 2.548, 95% CI: 1.153-5.628, P = 0.021) were significantly associated with increased mortality. Differences in variants were not significant factors associated with high mortality., Conclusion: We compared the background and prognosis of patients with COVID-19 pneumonia requiring invasive mechanical ventilation between SARS-CoV-2 variants. In these patients, differences in variants did not affect prognosis. Hospital mortality in critically ill COVID-19 patients was significantly higher in the older patients with bacterial coinfection, or patients with immunodeficiency, COPD, and chronic renal failure on dialysis., (© 2024. The Author(s).)

Background: This study assessed the impact of pressure-controlled ventilation (PCV) focusing on end-inspiratory flow rate on the incidence of postoperative pulmonary complications (PPCs) and inflammation levels in patients undergoing spinal surgery in the prone position., Methods: A total of 187 patients who underwent posterior spinal surgery were enrolled and randomly divided into 3 groups: 61 in the volume-controlled ventilation (VCV) group (group V), 62 in the PCV-volume-guaranteed (VG) group (group P 1 ), and 64 in the PCV-VG end-expiratory zero flow rate group (group P 2 ). Indicators including tidal volume (V T ), peak airway pressure (P peak ), and dynamic lung compliance (Cdyn) were recorded. The P peak , Cdyn, P ET CO2, and oxygenation index (PaO 2 /FiO 2 ) after intubation (T 0 ), after prone position (T 1 ), 60 min after prone position (T 2 ), and after supine position at the end of surgery (T 3 ) of the three groups were collected., Results: In the within-group comparison, compared with T 0 , P peak increased at T 1 - 2 in groups V and P 1 (P < 0.01), whereas it decreased at T 1 - 3 in group P 2 (P < 0.01). Cdyn decreased at T 1 - 2 and PaO2/FiO2 increased at T 1 - 3 in all three groups (P < 0.01), and PaO2/FiO2 increased at T 1 - 3 (P < 0.01). Compared with group V, P peak decreased at T 0 - 3 in group P 1 (P < 0.01) and at T 1 - 3 in group P 2 (P < 0.01), while Cdyn increased at T 0 - 3 in groups P 1 and P 2 (P < 0.01). Compared with group P 1 , P peak was elevated at T 0 (P < 0.01) and decreased at T 1 - 3 (P < 0.05), and Cdyn was elevated at T 0 - 3 in group P 2 (P < 0.01). The total incidence of PPCs in group P 2 was lower than that in group V (P < 0.01). Compared with the preoperative period, serum interleukin 6 (IL-6) and C-reactive protein (CRP) levels were increased at 24 and 72 h after surgery in group V (P < 0.01), whereas that was increased at 24 h after surgery in group P 1 and group P 2 (P < 0.01). Compared with group V, serum IL-6 and CRP levels were reduced at 24 h after surgery in groups P 1 and P 2 (P < 0.01 or < 0.05)., Conclusion: In patients undergoing spinal surgery in the prone position, PCV-VG targeting an end-inspiratory zero flow rate lowers the incidence of PPCs and inflammation levels., (© 2024. The Author(s).)

Objective: We aimed to explore the predictive values of ultrasonic diaphragm thickening fraction (DTF) combined with integrative weaning index (IWI) in weaning patients with mechanical ventilation., Methods: Patients with mechanical ventilation who received oral endotracheal intubation from September 2020 to September 2021 were included in this retrospective study. Before the start of the spontaneous breathing test (SBT), IWI was calculated according to the blood gas analysis parameters and parameters read in volume control mode. After the start of SBT, DTF was calculated according to the end-expiratory thickness and end-inspiratory thickness of the right diaphragm. The receiver operating curve (ROC) was used to evaluate the predictive value of DTF and IWI for successful weaning, and the sensitivity and specificity were calculated according to the best critical value., Results: The sensitivity, specificity, and best cutoff value of DTF to predict successful weaning was 0.772, 0.727, and 0.293, respectively, and the area under the curve (AUC) was 0.72 (95%CI 0.59-0.86, p = 0.003). The sensitivity, specificity, and best cutoff value of IWI to predict successful weaning was 0.614, 0.909, 53.00, respectively, and AUC was 0.82 (95%CI 0.72-0.91, p < 0.001). The sensitivity, specificity, and best cutoff value of the combination of DTF and IWI to predict successful weaning was 0.614, 0.909, 17.848, respectively, and AUC was 0.84 (95%CI 0.75-0.93, p < 0.001)., Conclusion: DTF and IWI can guide the selection of weaning, while DTF combined with IWI can improve the effect of weaning prediction and provide support for patients' weaning safety., (© 2024. The Author(s).)

Background: Information on the performance of oxygenation indices (OIs) and risk scores in patients requiring invasive mechanical ventilation (IMV) is limited. We determine the performance of the OIs and risk scores in hospitalized patients with COVID-19 to predict the requirement of IMV and death at 28 days after admission., Methods: A retrospective study of diagnostic tests in patients admitted to the emergency department, hospitalization, and intensive care unit diagnosed with COVID-19. The receiver operating characteristic curve (ROC-curve) were built with the OIs and risk scores to predict IMV and mortality., Results: A total of 1402 subjects entered the final analysis, of whom 19.5% (274/1402) received IMV and 23.0% (323/1402) died at 28 days. The ROC-curve of the delta PaO2/FiO2 ratio for the requirement of IMV and mortality at 28-day was 0.589 (95% CI: 0.546-0.632) and 0.567 (95% CI: 0.526-0.608), respectively. PaO2/FiO2 ≤ 300 shows a ROC curve of 0.669 (95% CI: 0.628-0.711) to predict IMV. PaO2/FiO2 ≤ 300 and 4 C mortality score in mortality at 28 days showed an ROC-curve of 0.624 (95% CI: 0.582-0.667) and 0.706 (95% CI: 0.669-0.742), respectively., Conclusion: PaO2/FiO2 ≤ 300, 4 C mortality score ≥ 8, SOFA score ≥ 4 y SaO2/FiO2 ≤ 300 were weak predictors of the IMV requirement from admission, and 4 C mortality score ≥ 8 was weak predictors of the mortality from admission in patients with pulmonary involvement by COVID-19., (© 2024. The Author(s).)

Background: The number of patients depending on home mechanical ventilation (HMV) has increased substantially in Germany in recent years. These patients receive long-term care in different nursing facilities (nursing home, shared living community, private home). However, there are limited data available on the quality of care of HMV patients. The aim of the OVER-BEAS project was to identify quality indicators (QIs) of HMV care using an evidence-based approach., Methods: A multidisciplinary board consisting of professionals and experts of HMV provision compiled a set of QIs between March and September 2019. In a structured, transparent process a set of QIs covering structures, processes and outcome of HMV patient's care were proposed and evaluated based on the best available evidence. QIs were defined as relevant, reliable and valid measurements of the quality of HMV care and furthermore to be comprehensive and applicable in practice., Results: The experts proposed 40 QIs and consented a final set of 26 QIs. Based on the final set, questionnaires to document the QIs were developed: (1) to assess the quality and describe the structure of the nursing facility; and (2) to gather information on patient-related processes and outcomes. The feasibility of the questionnaires was tested in 5 nursing facilities treating HMV patients. The remarks from the nursing specialists were categorised in three groups: (1) term missing accuracy, (2) problem of understanding, and (3) not documented or documented elsewhere. Mean documentation time by the nursing specialists for one patient was 15 min. Based on this feedback, the questionnaires were finalised., Conclusions: We proposed a set of QIs relating to long-term HMV care and developed two questionnaires to collect this information. In a pilot study, we found the set of questionnaires to be feasible in assessing the quality of HMV care according to current evidence. The development of standardised evidence-based QIs to evaluate HMV care is a step towards implementing a standardised quality assurance program to document the quality of care of HMV patients., (© 2024. The Author(s).)

Background: Patients with severe chronic obstructive pulmonary disease (COPD) could have palliative care (PC) needs because of unmet needs such as dyspnoea. This may lead to anxiety and may have an impact on patients' ability to perform daily activities of living. PC can be started when patients with COPD have unmet needs and can be provided alongside disease-modifying therapies. Non-invasive ventilation (NIV) could be an important measure to manage dyspnoea in patients with COPD in need of PC. A scoping review was conducted to gain an overview of the existing research and to identify knowledge gaps. The aim of this scoping review was to systematically map published studies on the use of NIV in patients with COPD with PC needs, including the perspectives and experiences of patients, families, and healthcare professionals (HCPs)., Methods: This review was conducted following the framework of Arksey and O'Malley. The reporting of the review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. The review protocol was published. AMED, CINAHL, Embase, MEDLINE, PEDro, and PsycInfo were searched from inception to November 14, 2022. The included studies had to report the perspectives and experiences of COPD patients, relatives, and HCPs regarding NIV in the care of patients with COPD with PC needs. In pairs, the authors independently assessed studies' eligibility and extracted data. The data were organised thematically. The results were discussed in a consultation exercise., Results: This review included 33 papers from 32 studies. Four thematic groupings were identified: preferences and attitudes towards the use of NIV; patient participation in the decision-making process of NIV treatment; conflicting results on the perceived benefits and burdens of treatment; and heterogenous clinical outcomes in experimental studies. Patients perceived NIV as a 'life buoy' to keep them alive. Many patients wanted to take part in the decision-making process regarding NIV treatment but expressed varying degrees of inclusion by HCPs in such decision-making. Conflicting findings were identified regarding the perceived benefits and burdens of NIV treatment. Diversity in heterogeneous clinical outcomes were reported in experimental studies., Conclusions: There is a need for more studies designed to investigate the effectiveness of NIV as a palliative measure for patients with COPD with PC needs using comprehensive outcomes. It is especially important to gain more knowledge on the experiences of all stakeholders in the use of home-based NIV treatment to these patients., (© 2024. The Author(s).)

Objectives: The timing of tracheostomy for critically ill patients on mechanical ventilation (MV) is a topic of controversy. Our objective was to determine the most suitable timing for tracheostomy in patients undergoing MV., Design: Retrospective cohort study., Setting and Participants: One thousand eight hundred eighty-four hospitalisations received tracheostomy from January 2011 to December 2020 in a Chinese tertiary hospital., Methods: Tracheostomy timing was divided into three groups: early tracheostomy (ET), intermediate tracheostomy (IMT), and late tracheostomy (LT), based on the duration from tracheal intubation to tracheostomy. We established two criteria to classify the timing of tracheostomy for data analysis: Criteria I (ET ≤ 5 days, 5 days < IMT ≤ 10 days, LT > 10 days) and Criteria II (ET ≤ 7 days, 7 days < IMT ≤ 14 days, LT > 14 days). Parameters such as length of ICU stay, length of hospital stay, and duration of MV were used to evaluate outcomes. Additionally, the outcomes were categorized as good prognosis, poor prognosis, and death based on the manner of hospital discharge. Student's t-test, analysis of variance (ANOVA), Mann-Whitney U test, Kruskal-Wallis test, Chi-square test, and Fisher's exact test were employed as appropriate to assess differences in demographic data and individual characteristics among the ET, IMT, and LT groups. Univariate Cox regression model and multivariable Cox proportional hazards regression model were utilized to determine whether delaying tracheostomy would increase the risk of death., Results: In both of two criterion, patients with delayed tracheostomies had longer hospital stays (p < 0.001), ICU stays (p < 0.001), total time receiving MV (p < 0.001), time receiving MV before tracheostomy (p < 0.001), time receiving MV after tracheostomy (p < 0.001), and sedation durations. Similar results were also found in sub-population diagnosed as trauma, neurogenic or digestive disorders. Multinomial Logistic regression identified LT was independently associated with poor prognosis, whereas ET conferred no clinical benefits compared with IMT., Conclusions: In a mixed ICU population, delayed tracheostomy prolonged ICU and hospital stays, sedation durations, and time receiving MV. Multinomial logistic regression analysis identified delayed tracheostomies as independently correlated with worse outcomes., Trial Registration: ChiCTR2100043905. Registered 05 March 2021. http://www.chictr.org.cn/listbycreater.aspx., (© 2024. The Author(s).)

Background: Patients with COVID-19 undergoing pressure support ventilation (PSV) with extracorporeal membrane oxygenation (ECMO) commonly had high respiratory drive, which could cause self-inflicted lung injury. The aim of this study was to evaluate the influence of different levels of partial pressure of carbon dioxide(PaCO 2 ) on respiratory effort in COVID-19 patients undergoing PSV with ECMO., Methods: ECMO gas flow was downregulated from baseline (respiratory rate < 25 bpm, peak airway pressure < 25 cm H 2 O, tidal volume < 6 mL/kg, PaCO 2  < 40 mmHg) until PaCO 2 increased by 5 - 10 mmHg. The pressure muscle index (PMI) and airway pressure swing during occlusion (ΔPOCC) were used to monitor respiratory effort, and they were measured before and after enforcement of the regulations., Results: Ten patients with COVID-19 who had undergone ECMO were enrolled in this prospective study. When the PaCO 2 increased from 36 (36 - 37) to 42 (41-43) mmHg (p = 0.0020), there was a significant increase in ΔPOCC [from 5.6 (4.7-8.0) to 11.1 (8.5-13.1) cm H 2 O, p = 0.0020] and PMI [from 3.0 ± 1.4 to 6.5 ± 2.1 cm H 2 O, p < 0.0001]. Meanwhile, increased inspiratory effort determined by elevated PaCO 2 levels led to enhancement of tidal volume from 4.1 ± 1.2 mL/kg to 5.3 ± 1.5 mL/kg (p = 0.0003) and respiratory rate from 13 ± 2 to 15 ± 2 bpm (p = 0.0266). In addition, the increase in PaCO 2 was linearly correlated with changes in ΔPOCC and PMI (R2 = 0.7293, p = 0.0003 and R2 = 0.4105, p = 0.0460, respectively)., Conclusions: In patients with COVID-19 undergoing PSV with ECMO, an increase of PaCO 2 could increase the inspiratory effort., (© 2024. The Author(s).)

Background: End-of-life (EoL) care practices (EoLCP) are procedures carried out at the EoL and bear directly on this stage in the patient's life. Public support of these practices in Israel is far from uniform. Previous studies show that while ∼30% of participants support artificial respiration or feeding of terminally ill patients, 66% support analgesic treatment, even at the risk of shortening life. This study aimed to create a typology of six end-of-life care practices in Israel and assess the association of medical, social, and normative factors with the implementation of those practices. These practices included mechanical ventilation, artificial feeding, deep sedation, providing information to the patient and family caregivers, including family caregivers in EoL decision-making, and opting for death at home., Methods: This cross-sectional study was performed as an online survey of 605 adults aged 50 or more in Israel, of which ~ 50% (n = 297) reported supporting a dying terminally ill relative in the last 3 years. Participants were requested to provide their account of the EoL process of their relative dying from a terminal illness in several aspects, as well as the EoL care practices utilized by them., Results: The accounts of the 297 interviewees who supported a dying relative reveal a varied EoL typology. The utilization of end-of-life care practices was associated with the socio-normative beliefs of family caregivers but not with their socioeconomic status. Strong correlations were found between family caregiver support for three key practices (mechanical ventilation, artificial feeding, and family involvement in EoL) and the actual utilization of these practices in the care of dying patients., Conclusions: The findings portray an important image of equity in the utilization of EoLCP in Israel, as the use of these practices was not associated with socioeconomic status. At the same time, the study found substantial diversity in family caregivers' preferences regarding EoL care practices use not related to socioeconomic status. We believe that differences in preferences that do not lead to problems with equity or other important societal values should be respected. Accordingly, policymakers and health system leaders should resist calls for legislation that would impose uniform EoL practices for all Israelis. Instead, they should take concrete steps to preserve and enhance the widespread current practice of practitioners to adapt EoL care to the varied needs and preferences of Israeli families and cultural, social, and religious subgroups. These steps should include providing frameworks and tools for family caregivers to support their loved ones close to their deaths, such as educational programs, seminars, supportive care before and during the end of life of their loved ones, etc., (© 2024. The Author(s).)

Background: Whether early dietary fiber intake in septic patients is associated with a better clinical prognosis remains unclear, especially the time and the amount. Therefore, we assessed the association between early dietary fiber intake and clinical outcomes in septic patients by examining an extensive database., Methods: We conducted a retrospective cohort study using data from the MIMIC IV 2.1 database, focusing on consecutive septic patients requiring mechanical ventilation in medical or mixed medical-surgical ICUs. We collected patient demographics and nutritional data. Dietary fiber amounts were calculated according to enteral nutrition instructions from manufacturers within the first 72 h after admission. After adjusting for covariates, we employed restricted cubic spline (RCS) regression to investigate the relationship between fiber intake (FI) and 28-day mortality. Patients were categorized into three groups based on their fiber index (FI) within 72 h of admission: low fiber index (LFI) group when FI was < 3 g/(%), medium fiber index (MFI) group when FI ranged from 3 to 35 g(%), and high fiber index (HFI) group when FI ≥ 35 g(%). Univariate and multivariate Cox proportional hazards regression models were utilized to assess the association between early FI and 28-day mortality. We ultimately employed Kaplan-Meier (KM) curves and log-rank test visually represent the association between FI and 90-day mortality. The second outcomes include ICU-acquired infections and the hospital and ICU death, length of hospital and ICU stay, and length of mechanical ventilation., Results: Among 1057 subjects, 562 (53.2%) were male, with a median age of 64.8 years (IQR 53.4-75.2). We observed a J-shaped relationship between FI and 28-day mortality. The MFI group exhibited the lowest 28-day mortality [adjusted HR 0.64 (0.45-0.91), p = 0.013] and the lowest rate of hospital mortality [adjusted OR 0.60 (0.39-0.93), p = 0.022], with no statistically significant differences noted in the HFI group when compared to the LFI group. Similar patterns were observed for 60-day and 90-day mortality. However, no statistically significant differences were observed in other secondary outcomes after adjusting for covariates., Conclusion: Early medium fiber index intake improved 28-day mortality and lower hospital mortality in septic M/SICU patients on mechanical ventilation., (© 2023. The Author(s).)

Background: Mechanical power (MP) is the total energy released into the entire respiratory system per minute which mainly comprises three components: elastic static power, Elastic dynamic power and resistive power. However, the energy to overcome resistance to the gas flow is not the key factor in causing lung injury, but the elastic power (EP) which generates the baseline stretch of the lung fibers and overcomes respiratory system elastance may be closely related to the ARDS severity. Thus, this study aimed to investigate whether EP is superior to other ventilator variables for predicting the severity of lung injury in ARDS patients., Methods: We retrieved patient data from the Medical Information Mart for Intensive Care III (MIMIC-III) database. The retrieved data involved adults (≥ 18 years) diagnosed with ARDS and subjected to invasive mechanical ventilation for ≥ 48 h. We employed univariate and multivariate logistic regression analyses to investigate the correlation between EP and development of moderate-severe ARDS. Furthermore, we utilized restricted cubic spline models to assess whether there is a linear association between EP and incidence of moderate-severe ARDS. In addition, we employed a stratified linear regression model and likelihood ratio test in subgroups to identify potential modifications and interactions., Results: Moderate-severe ARDS occurred in 73.4% (296/403) of the patients analyzed. EP and MP were significantly associated with moderate-severe ARDS (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.15-1.28, p < 0.001; and OR 1.15, 95%CI 1.11-1.20, p < 0.001; respectively), but EP showed a higher area-under-curve (95%CI 0.72-0.82, p < 0.001) than plateau pressure, driving pressure, and static lung compliance in predicting ARDS severity. The optimal cutoff value for EP was 14.6 J/min with a sensitivity of 75% and specificity of 66%. Quartile analysis revealed that the relationship between EP and ARDS severity remained robust and reliable in subgroup analysis., Conclusion: EP is a good ventilator variable associated with ARDS severity and can be used for grading ARDS severity. Close monitoring of EP is advised in patients undergoing mechanical ventilation. Additional experimental trials are needed to investigate whether adjusting ventilator variables according to EP can yield significant improvements in clinical outcomes., (© 2023. The Author(s).)

Background: Pneumothorax (PTX) and pneumomediastinum (PM) have been reported as potential complications in patients with coronavirus disease 2019 (COVID-19); however, their risk factors and etiology remain unknown. Herein, we investigated the clinical characteristics of mechanically ventilated patients with COVID-19 with PTX or PM., Methods: We examined patients with severe COVID-19 requiring mechanical ventilation who were admitted to the intensive care unit of a tertiary-level emergency medical center in Tokyo, Japan between April 1, 2020. and October 31, 2021. We collected and analyzed the clinical characteristics of the patients who presented with either PTX or PM during mechanical ventilation., Results: During the study period, a total of 165 patients required mechanical ventilation, and 15 patients with PTX/PM during mechanical ventilation were selected. Three patients with obvious causes were excluded, and the remaining 12 patients were analyzed (7.3%). The mortality rate in these patients was as high as 50%, demonstrating the difficulty of treatment in the presence of PTX/PM. PTX/PM occurred 14.5 days after intubation. A peak pressure of > 30 cmH 2 O was only apparent in one patient, suggesting that high positive pressure ventilation may be less involved than mentioned in the literature. In addition, the inspiratory effort was not strong in our group of patients. (P0.1 was 2.1 cm H2O [1.0-3.8])., Conclusion: Various factors are associated with the development of PTX/PM in patients on mechanical ventilation for COVID-19. We did not find a strong correlation between PTM/PM and barotrauma or strong inspiratory efforts, which have been identified as potential causes in previous studies., (© 2023. The Author(s).)

Background: Therapeutic drug monitoring (TDM) of vancomycin is widely recommended for clinical treatment. Due to the complexity of 24-h area under the curve (AUC) guided vancomycin monitoring in clinical practice, the vancomycin trough level remains the most common and practical method. The purpose of this study was designed to investigate the differences in the safety and efficacies of vancomycin TDM based on the two different monitoring methods, and further explore the clinical application of trough-guided vancomycin monitoring in patients with gastrointestinal cancer requiring mechanical ventilation., Methods: We included a total of 78 gastrointestinal cancer patients who required mechanical ventilation due to various diseases. All patients included in this study were aged 18 years or older and were treated with intravenous vancomycin therapy for more than 2 days due to documented or suspected Gram-positive bacterial infections, and have at least one available vancomycin plasma concentration. First, we compared the safety and efficacies of vancomycin TDM based on different monitoring methods as trough-guided monitoring or AUC-guided monitoring. Then, based on whether the initial vancomycin concentration achieving the target trough concentration (less than 48 h), patients were divided into early and delayed groups, and the clinical factors were compared between them. The primary endpoints include the incidence of new-onset acute kidney injury (AKI) or renal replacement therapy (RRT), clinical success rate and 28-day all-cause mortality. Finally, the overall relationship between trough concentration and potential covariates is screened by univariate and multivariate analysis to explore potential information covariates., Results: The research revealed that patients with gastrointestinal cancer exhibited significantly lower initial vancomycin trough concentrations (median [interquartile range (IQR)]: 6.90[5.28-11.20] mg/L). And there were no statistically significant differences in the safety and efficacies of vancomycin TDM based on the two different monitoring methods for the primary endpoint. Moreover, base on trough-guided vancomycin monitoring, the early group demonstrated a notably shorter duration of mechanical ventilation compared with the delayed group (χ 2  = 4.532; p < 0.05; Fig. 2E). Propensity score weighting further confirmed that the duration of mechanical ventilation (χ 2  = 6.607; p < 0.05; Fig. 2F) and duration of vasoactive agent (χ 2  = 6.106; p < 0.05; Fig. 2D) were significantly shorter in the early group compared with delayed group. Multivariate regression analysis revealed that Cystatin C (Cys-C) was the most important variable for vancomycin target trough achievement (odds ratio, 5.274; 95% CI, 1.780 to 15.627; p = 0.003)., Conclusions: Trough-guided vancomycin monitoring is a simple and effective marker of TDM for ventilated patients with gastrointestinal cancer. Timely achievement of target trough concentrations for vancomycin can improve partial clinical outcomes in Gram-positive bacterial infections. Cys-C level is a potentially valuable parameter for predicting the vancomycin concentration., (© 2023. The Author(s).)