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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]

Abstract 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

Abstract 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.

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]

Background/Aims The prognosis of patients with idiopathic pulmonary fibrosis (IPF) and respiratory failure requiring mechanical ventilation is poor. Therefore, mechanical ventilation is not recommended. Recently, outcomes of mechanical ventilation, including those for patients with IPF, have improved. The aim of this study was to investigate changes in the use of mechanical ventilation in patients with IPF and their outcomes over time. Methods This retrospective, observational cohort study used data from the National Health Insurance Service database. Patients diagnosed with IPF between January 2011 and December 2019 who were placed on mechanical ventilation were included. We analyzed changes in the use of mechanical ventilation in patients with IPF and their mortality using the Cochran-Armitage trend test. Results Between 2011 and 2019, 1,227 patients with IPF were placed on mechanical ventilation. The annual number of patients with IPF with and without mechanical ventilation increased over time. However, the ratio was relatively stable at approximately 3.5%. The overall hospital mortality rate was 69.4%. There was no improvement in annual hospital mortality rate. The overall 30-day mortality rate was 68.7%, which did not change significantly. The overall 90-day mortality rate was 85.3%. The annual 90-day mortality rate was decreased from 90.9% in 2011 to 83.1% in 2019 (p = 0.028). Conclusions Despite improvements in intensive care and ventilator management, the prognosis of patients with IPF receiving mechanical ventilation has not improved significantly.

Rationale: Lung-protective mechanical ventilation strategies have been proven beneficial in the operating room (OR) and the ICU. However, differential practices in ventilator management persist, often resulting in adjustments of ventilator parameters when transitioning patients from the OR to the ICU. Objectives: To characterize patterns of ventilator adjustments during the transition of mechanically ventilated surgical patients from the OR to the ICU and assess their impact on 28-day mortality. Methods: Hospital registry study including patients undergoing general anesthesia with continued, controlled mechanical ventilation in the ICU between 2008 and 2022. Ventilator parameters were assessed 1 hour before and 6 hours after the transition. Measurements and Main Results: Of 2,103 patients, 212 (10.1%) died within 28 days. Upon OR-to-ICU transition, VT and driving pressure decreased (−1.1 ml/kg predicted body weight [IQR, −2.0 to −0.2]; P < 0.001; and −4.3 cm H2O [−8.2 to −1.2]; P < 0.001). Concomitantly, respiratory rates increased (+5.0 breaths/min [2.0 to 7.5]; P < 0.001), resulting overall in slightly higher mechanical power (MP) in the ICU (+0.7 J/min [−1.9 to 3.0]; P < 0.001). In adjusted analysis, increases in MP were associated with a higher 28-day mortality rate (adjusted odds ratio, 1.10; 95% confidence interval, 1.06–1.14; P < 0.001; adjusted risk difference, 0.7%; 95% confidence interval, 0.4–1.0, both per 1 J/min). Conclusion: During transition of mechanically ventilated patients from the OR to the ICU, ventilator adjustments resulting in higher MP were associated with a greater risk of 28-day mortality. [ABSTRACT FROM AUTHOR]

Purpose: Conflicting evidence exists on the choice of surgical or non-surgical treatment of flail chest injuries. We aimed to perform a meta-analysis comparing outcomes in patients presenting flail chest undergoing surgical or non-surgical treatment. Methods: Embase, PubMed, and Cochrane databases were searched for randomized controlled trials (RCTs) comparing surgery to no surgery in patients with acute unstable chest wall injuries. We computed weighted mean differences (WMDs) for continuous outcomes and risk ratios (RRs) for binary endpoints, with 95% confidence intervals (CIs). Random effects meta-analyses were performed. Heterogeneity was assessed using I2 statistics. Results: Six RCTs (544 patients) were included, and surgical treatment was used in 269 (49.4%). Compared to no surgery, surgery reduced mechanical ventilation days (WMD − 4.34, 95% CI – 6.98, − 1.69; p < 0.01; I2 = 87%; GRADE: very low; PI − 13.51, 4.84); length of intensive care unit stay (WMD − 4.62, 95% CI − 7.19, − 2.05; p < 0.01; I2 = 78%; GRADE: low; PI − 12.86, 3.61) and the incidence of pneumonia (RR 0.50, 95% CI 0.31, 0.81; p = 0.005; I2 = 54%; GRADE: moderate; PI 0.13, 1.91). No difference in mortality (RR 0.56, 95% CI 0.19, 1.65; p = 0.27; I2 = 23%; GRADE: moderate; PI 0.04, 7.25), length of hospital stay (WMD − 5.39, 95% CI − 11.38, − 0.60; p = 0.08; I2 = 89%; GRADE: very low; PI − 11.38, 0.60), or need for tracheostomy (RR 0.59, 95% CI 0.34, 1.03; p = 0.06; I2 = 54%; GRADE: moderate; PI 0.11, 3.24) was found. Conclusions: Our results suggest that surgical treatment is advantageous compared to non-surgical treatment for patients with flail chest secondary to rib fractures. [ABSTRACT FROM AUTHOR]

Objective: To compare the Rapid Shallow Breathing Index (RSBI) obtained by the ventilometer and from mechanical ventilation parameters. Methods: Randomized crossover trial, including 33 intubated patients, on mechanical ventilation for at least 24 hours, undergoing spontaneous breathing test. Patients were submitted to the measurement of RSBI by four methods: disconnected from the ventilator through the ventilometer; in Pressure Support Ventilation (PSV) mode at a pressure of 7.ßcm H2O; in Continuous Positive Airway Pressure (CPAP) mode at a pressure of 5.ßcmH2O with flow trigger; in CPAP mode at a pressure of 5.ßcmH2O with pressure trigger. Results: No significant difference was detected between the RSBI obtained by the ventilometer and in the CPAP mode with flow and pressure triggers, however, in the PSV mode, the values were lower than in the other measurements (p.ß

Abstract Background Ventilator-free days (VFDs) are a composite endpoint increasingly used as the primary outcome in critical care trials. However, because of the skewed distribution and competitive risk between components, sample size estimation remains challenging. This systematic review was conducted to systematically assess whether the sample size was congruent, as calculated to evaluate VFDs in trials, with VFDs’ distribution and the impact of alternative methods on sample size estimation. Methods A systematic literature search was conducted within the PubMed and Embase databases for randomized clinical trials in adults with VFDs as the primary outcome until December 2021. We focused on peer-reviewed journals with 2021 impact factors greater than five. After reviewing definitions of VFDs, we extracted the sample size and methods used for its estimation. The data were collected by two independent investigators and recorded in a standardized, pilot-tested forms tool. Sample sizes were calculated using alternative statistical approaches, and risks of bias were assessed with the Cochrane risk-of-bias tool. Results Of the 26 clinical trials included, 19 (73%) raised “some concerns” when assessing risks of bias. Twenty-four (92%) trials were two-arm superiority trials, and 23 (89%) were conducted at multiple sites. Almost all the trials (96%) were unable to consider the unique distribution of VFDs and death as a competitive risk. Moreover, significant heterogeneity was found in the definitions of VFDs, especially regarding varying start time and type of respiratory support. Methods for sample size estimation were also heterogeneous, and simple models, such as the Mann–Whitney–Wilcoxon rank-sum test, were used in 14 (54%) trials. Finally, the sample sizes calculated varied by a factor of 1.6 to 17.4. Conclusions A standardized definition and methodology for VFDs, including the use of a core outcome set, seems to be required. Indeed, this could facilitate the interpretation of findings in clinical trials, as well as their construction, especially the sample size estimation which is a trade-off between cost, ethics, and statistical power. Systematic review registration PROSPERO ID: CRD42021282304. Registered 15 December 2021 ( https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021282304 ).

• 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]

ABSTRACT Objective: To identify factors associated with prolonged weaning and mortality in critically ill COVID-19 patients admitted to ICUs and under invasive mechanical ventilation. Methods: Between March of 2020 and July of 2021, we retrospectively recorded clinical and ventilatory characteristics of critically ill COVID-19 patients from the day of intubation to the outcome. We classified the patients regarding the weaning period in accordance with established criteria. A logistic regression analysis was performed to identify variables associated with prolonged weaning and mortality. Results: The study involved 303 patients, 100 of whom (33.0%) had a prolonged weaning period. Most of the patients were male (69.6%), 136 (44.8%) had more than 50% of pulmonary involvement on chest CT, and 93 (30.6%) had severe ARDS. Within the prolonged weaning group, 62% died within 60 days. Multivariate analysis revealed that lung involvement greater than 50% on CT and delay from intubation to the first separation attempt from mechanical ventilation were significantly associated with prolonged weaning, whereas age and prolonged weaning were significantly associated with mortality. Conclusions: Prolonged weaning can be used as a milestone in predicting mortality in critically ill COVID-19 patients. Lung involvement greater than 50% on CT and delay from intubation to the first separation attempt from mechanical ventilation were identified as significant predictors of prolonged weaning. These results might provide valuable information for healthcare professionals when making clinical decisions regarding the management of critically ill COVID-19 patients who are on mechanical ventilation.

ABSTRACT 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

The objective of the study was to evaluate all available systematic reviews on the use of prone positional ventilation in adult patients with acute respiratory distress syndrome (ARDS). An umbrella review on the efficacy of prone positional ventilation in adult patients ventilation in adult patients with acute respiratory distress syndrome was conducted. We performed a systematic search in the database of Medline (Pubmed), Scopus, Cochrane Library, Web of Science, and Epistemonikos. The ROBIS tools and GRADE methodology were used to assess the risk of bias and certainty of evidence. We estimated the necessary number of patients to be treated to have benefit. For the synthesis of the result, we selected the review with the lowest risk of bias. Sixteen systematic reviews including 64 randomized clinical trials and evaluating the effect of prone positional ventilation, with or without other ventilation strategies were included. Aoyama 2019 observed prone positioning, without complementary ventilation strategies, leading to a reduction in the 28-day mortality only when compared to high-frequency oscillatory ventilation (RR 0.61; 95% CI 0.39–0.95) and lung-protective ventilation in the supine position (RR 0.69; 95% CI 0.48–0.98), with an ARR of 9.32% and 14.94%, an NNTB of 5.89 and 8.04, and a low and moderate certainty of evidence, respectively. Most reviews had severe methodological flaws that led to results with very low certainty of evidence. The review with the lowest risk of bias presented results in favor of prone positional ventilation compared with high-frequency oscillatory ventilation and lung-protective ventilation. There is a need to update the available reviews to obtain more accurate results. [ABSTRACT FROM AUTHOR]

Abstract Background Intellectually disabled (ID) patients present unique therapeutic challenges. We aimed to describe the characteristics of ID patients admitted to a general intensive care unit (ICU). Results We conducted a retrospective cohort study comparing critically ill adult ID patients to matched patients without ID (1:2 ratio) in a single ICU (2010–2020). The main outcome measure was mortality. Secondary outcomes included complications during admission and characteristics of weaning from mechanical ventilation. The study and control groups were randomly selected based on similar age and sex. ID patients nonetheless had an average APACHE score of 18.5 ± 8.7 vs. 13.4 ± 8.5 in controls (p < 0.001). ID patients had more hematological (p = 0.04), endocrinological (p < 0.001) and neurological (p = 0.004) comorbidities and used more psychiatric medication before admission. No difference was found in mortality rates. Differences were found as there were more secondary complications, such as pulmonary and sepsis (p < 0.03), frequent requirement of vasopressors (p = 0.001), significantly higher intubation rates with more weaning attempts, tracheostomies and longer ICU and hospital admissions (p < 0.019). Conclusions Critically ill adult ID may have more comorbidities and be sicker at the time of admission compared to their age- and sex-matched counterparts. They require more supportive treatment and their weaning from mechanical ventilation may be more challenging.

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.

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]

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]

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]

Background: Intellectually disabled (ID) patients present unique therapeutic challenges. We aimed to describe the characteristics of ID patients admitted to a general intensive care unit (ICU). Results: We conducted a retrospective cohort study comparing critically ill adult ID patients to matched patients without ID (1:2 ratio) in a single ICU (2010–2020). The main outcome measure was mortality. Secondary outcomes included complications during admission and characteristics of weaning from mechanical ventilation. The study and control groups were randomly selected based on similar age and sex. ID patients nonetheless had an average APACHE score of 18.5 ± 8.7 vs. 13.4 ± 8.5 in controls (p < 0.001). ID patients had more hematological (p = 0.04), endocrinological (p < 0.001) and neurological (p = 0.004) comorbidities and used more psychiatric medication before admission. No difference was found in mortality rates. Differences were found as there were more secondary complications, such as pulmonary and sepsis (p < 0.03), frequent requirement of vasopressors (p = 0.001), significantly higher intubation rates with more weaning attempts, tracheostomies and longer ICU and hospital admissions (p < 0.019). Conclusions: Critically ill adult ID may have more comorbidities and be sicker at the time of admission compared to their age- and sex-matched counterparts. They require more supportive treatment and their weaning from mechanical ventilation may be more challenging. [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. The arm replantation is an extremely rare and challenging procedure. The recognized risk is myoglobinuria and, consenquently, ischemia reperfusion-induced renal failure. Case report. We presented two patients aged 24 and 46 years who were admitted after traumatic arm amputation. Ischemia time was six and two hours, respectively. Postoperative intensive care treatment with assisted ventilation, sedation, and obtaining sufficient urine output prevented myoglobin-induced renal injury. In the case where ischemia time was shorter, there was only one delayed reconstruction of skin defects after fasciotomy, but in the case where ischemia lasted longer, the patient had two secondary look procedures with acceptable definitive results. Conclusion. Arm replantation is a safe procedure even in cases with longer ischemia time. Postoperative control of urine output, correction of acidosis, and preventing myoglobin-induced tubular injury are crucial for stable postoperative recovery and.

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]

• Lower running costs with phrenic nerve stimulation than with mechanical ventilation. 84. • Phrenic nerve stimulation: Preferred by patients and recommendable to fund providers. 84. • Phrenic nerve stimulation: Cheaper and more reliable than mechanical ventilation. 81. • Central apnoea: Electro ventilation facilitates care and improves quality of life. 82. • Frequency of respiratory infections: A measure of quality of respiratory care. 78. Patients with central apnoea may use electro ventilation, provided their phrenic nerves and diaphragm muscles are normal. A tendency towards better survival has been found, and both an improved quality of life and facilitated nursing have been claimed with electro ventilation compared to mechanical ventilation. The high investment for the device may form a hurdle for fund providers like our hospital administration board. We, therefore, from our first patient onwards, collected clinically meaningful data in a special register of all patients using electro ventilation and their controls on mechanical ventilation. Since 1988 172 patients left our institution dependent on a respiratory device. Of these, all 48 patients with preserved phrenic nerves chose phrenic nerve stimulation. A patient on mechanical ventilation who agreed to participate was chosen as a control (n = 44). All patients were seen at least once a year. 90 patients suffered high tetraplegia, and 2 suffered central apnoea for other reasons. There is a tendency towards better survival, and there is a lower frequency of decubital ulcers (0.02) and respiratory tract infections (p0.000) with electro than with mechanical ventilation. The frequency of respiratory infections turned out to be a better measure of the quality of respiratory care than survival. The resulting decrease in the need for airway nursing, and the reduced incidence of respiratory infections repaid the high investment in electro ventilation within one year in our setting. Informed patients prefer electro to mechanical ventilation; fund providers might also agree with this preference. [ABSTRACT FROM AUTHOR]

Abstract Background This trial aimed to evaluate the effects of a protective ventilation strategy on oxygenation/pulmonary indexes in patients undergoing robot-assisted radical prostatectomy (RARP) in the steep Trendelenburg position. Methods In phase 1, the most optimal positive end-expiratory pressure (PEEP) was determined in 25 patients at 11 cmH2O. In phase 2, 64 patients were randomized to the traditional ventilation group with tidal volume (VT) of 9 ml/kg of predicted body weight (PBW) and the protective ventilation group with VT of 7 ml/kg of PBW with optimal PEEP and recruitment maneuvers (RMs). The primary endpoint was the intraoperative and postoperative PaO2/FiO2. The secondary endpoints were the PaCO2, SpO2, modified clinical pulmonary infection score (mCPIS), and the rate of complications in the postoperative period. Results Compared with controls, PaO2/FiO2 in the protective group increased after the second RM (P=0.018), and the difference remained until postoperative day 3 (P=0.043). PaCO2 showed transient accumulation in the protective group after the first RM (T2), but this phenomenon disappeared with time. SpO2 in the protective group was significantly higher during the first three postoperative days. Lung compliance was significantly improved after the second RM in the protective group (P=0.025). The mCPIS was lower in the protective group on postoperative day 3 (0.59 (1.09) vs. 1.46 (1.27), P=0.010). Conclusion A protective ventilation strategy with lower VT combined with optimal PEEP and RMs could improve oxygenation and reduce mCPIS in patients undergoing RARP. Trial registration ChiCTR ChiCTR1800015626 . Registered on 12 April 2018.

Background Angiotensin-converting enzyme 2 facilitates the entry of severe acute respiratory syndrome coronavirus 2 into the human body. We investigated the association of renin-angiotensin-aldosterone system (RAAS) inhibitor use with severe coronavirus disease 2019 (COVID-19) outcomes in hypertensive patients. Methods We identified hypertensive patients with confirmed COVID-19 from the Korean Health Insurance Review and Assessment Service from inception to May 15, 2020. The primary outcome was the composite of intensive care unit (ICU) admission, invasive mechanical ventilation (IMV), continuous renal replacement therapy (CRRT), extracorporeal membrane oxygenation (ECMO), and death from COVID-19. The individual components were evaluated as secondary outcomes. Results Of 1,374 hypertensive patients with COVID-19, 1,076 (78.3%) and 298 (21.7%) were users and never-users of RAAS inhibitors, respectively. The RAAS inhibitor users were not associated with the risk of the primary outcome (adjusted odds ratio [aOR], 0.72; 95% confidence interval [CI], 0.46 to 1.10). The risk of ICU admission was significantly lower in the users than the never-users (aOR, 0.44; 95% CI, 0.24 to 0.84). The RAAS inhibitors were beneficial only in ICU admissions that did not require IMV (aOR, 0.28; 95% CI, 0.14 to 0.58). The risk of death from COVID-19 was comparable between the groups (aOR, 1.09; 95% CI, 0.64 to 1.85). We could not evaluate the risks of CRRT and ECMO owing to the small number of events. Conclusion RAAS inhibitor use was not associated with the composite of severe outcomes in the hypertensive patients with COVID-19 but significantly lowered the risk of ICU admission, particularly in patients who did not require IMV.

Background Evidence prior to the coronavirus disease 2019 (COVID-19) pandemic suggested that, compared with conventional ventilation strategies, airway pressure release ventilation (APRV) can improve oxygenation and reduce mortality in patients with acute respiratory distress syndrome. We aimed to assess the association between APRV use and clinical outcomes among adult patients receiving mechanical ventilation for COVID-19 and hypothesized that APRV use would be associated with improved survival compared with conventional ventilation. Methods A total of 25 patients with COVID-19 pneumonitis was admitted to intensive care units (ICUs) for invasive ventilation in Perth, Western Australia, between February and May 2020. Eleven of these patients received APRV. The primary outcome was survival to day 90. Secondary outcomes were ventilation-free survival days to day 90, mechanical complications from ventilation, and number of days ventilated. Results Patients who received APRV had a lower probability of survival than did those on other forms of ventilation (hazard ratio, 0.17; 95% confidence interval, 0.03–0.89; P=0.036). This finding was independent of indices of severity of illness to predict the use of APRV. Patients who received APRV also had fewer ventilator-free survival days up to 90 days after initiation of ventilation compared to patients who did not receive APRV, and survivors who received APRV had fewer ventilator-free days than survivors who received other forms of ventilation. There were no differences in mechanical complications according to mode of ventilation. Conclusions Based on the findings of this study, we urge caution with the use of APRV in COVID-19.

Introduction: Orotracheal intubation is a procedure that implies risks such as extubation failure and laryngeal stridor, which increase the risk of morbidity. Objective: To identify factors associated with early extubation failure (≤24 hours) and the development of post-extubation laryngeal stridor in adult patients on invasive mechanical ventilation (IMV). Materials and methods: Case-control study conducted in the intensive care unit (ICU) of a quaternary care hospital in Bogotá, Colombia, between April 2019 and February 2020, in which information was collected prospectively. A total of 180 patients with IMV ≥24 hours and at least ≥1 extubation attempt were included: 30 cases defined as patients with early extubation failure (≤24 hours to extubation), and 150 controls. Differences between cases and controls regarding the variables considered were determined using the Student's t test and the Chi-squared or Fisher's exact tests. In addition, a multivariate analysis (unconditional logistic regression model) was performed to establish the factors associated with extubation failure and post-extubation laryngeal stridor, calculating the odds ratio (OR) and the respective 95% confidence intervals (95%CI). A significance level of p

ABSTRACT BACKGROUND: For critically ill patients, physicians tend to administer sufficient or even excessive oxygen to maintain oxygen saturation at a high level. However, the credibility of the evidence for this practice is unclear. OBJECTIVE: To determine the effects of different oxygen therapy strategies on the outcomes of mechanically ventilated intensive care unit (ICU) patients. DESIGN AND SETTING: Systematic review of the literature and meta-analysis conducted at Jiangxi Provincial People’s Hospital, Affiliated to Nanchang University, Nanchang, China. METHODS: We systematically searched electronic databases such as PubMed and Embase for relevant articles and performed meta-analyses on the effects of different oxygen therapy strategies on the outcomes of mechanically ventilated ICU patients. RESULTS: A total of 1802 patients from five studies were included. There were equal numbers of patients in the conservative and liberal groups (n = 910 in each group). There was no significant difference between the conservative and liberal groups with regard to 28-day mortality (risk ratio, RR = 0.88; 95% confidence interval, CI = 0.59-1.32; P = 0.55; I2 = 63%). Ninety-day mortality, infection rates, ICU length of stay, mechanical ventilation-free days up to day 28 and vasopressor-free days up to day 28 were comparable between the two strategies. CONCLUSIONS: It is not necessary to use liberal oxygen therapy strategies to pursue a higher level of peripheral oxygen saturation for mechanically ventilated ICU patients. Conservative oxygen therapy was not associated with any statistically significant reduction in mortality.

Abstract Introduction: The delayed extubation of patients undergoing mechanical ventilation (MV) in the postoperative period of cardiac surgery (CS) is associated with mortality. The adoption of spinal anesthesia (SA) combined with general anesthesia in CS influences the orotracheal intubation time (OIT). This study aims to verify if the adoption of SA reduces the time of MV after CS, compared to general anesthesia (GA) alone. Methods: Two hundred and seventeen CS patients were divided into two groups. The GA group included 108 patients (age: 56±1 years, 66 males) and the SA group included 109 patients (age: 60±13 years, 55 males). Patients were weaned from MV and, after clinical evaluation, extubated. Results: In the SA group, considering a 13-month period, 24% of the patients were extubated in the operating room (OR), compared to 10% in the GA group (P=0.00). The OIT was lower in the SA group than in the GA group (SA: 4.4±5.9 hours vs. GA: 6.0±5.6 hours, P=0.04). In July/2017, where all surgeries were performed in the GA regimen, only 7.1% of the patients were extubated in the OR. In July/2018, 94% of the surgeries were performed under SA, and 64.7% of the patients were extubated in the OR (P=0.00). The OIT on arrival at the intensive care unit to extubation, comparing July/2017 to July/2018, was 5.3±5.3 hours in the GA group vs. 1.7±3.9 hours in the SA group (P=0.04). Conclusion: The adoption of SA in CS increased the frequency of extubations in the OR and decreased OIT and MV time.

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]

Abstract Background A large proportion of patients with coronavirus disease 2019 (COVID-19) develop severe respiratory failure requiring admission to the intensive care unit (ICU) and about 80% of them need mechanical ventilation (MV). These patients show great complexity due to multiple organ involvement and a dynamic evolution over time; moreover, few information is available about the risk factors that may contribute to increase the time course of mechanical ventilation. The primary objective of this study is to investigate the risk factors associated with the inability to liberate COVID-19 patients from mechanical ventilation. Due to the complex evolution of the disease, we analyzed both pulmonary variables and occurrence of non-pulmonary complications during mechanical ventilation. The secondary objective of this study was the evaluation of risk factors for ICU mortality. Methods This multicenter prospective observational study enrolled 391 patients from fifteen COVID-19 dedicated Italian ICUs which underwent invasive mechanical ventilation for COVID-19 pneumonia. Clinical and laboratory data, ventilator parameters, occurrence of organ dysfunction, and outcome were recorded. The primary outcome measure was 28 days ventilator-free days and the liberation from MV at 28 days was studied by performing a competing risks regression model on data, according to the method of Fine and Gray; the event death was considered as a competing risk. Results Liberation from mechanical ventilation was achieved in 53.2% of the patients (208/391). Competing risks analysis, considering death as a competing event, demonstrated a decreased sub-hazard ratio for liberation from mechanical ventilation (MV) with increasing age and SOFA score at ICU admission, low values of PaO2/FiO2 ratio during the first 5 days of MV, respiratory system compliance (CRS) lower than 40 mL/cmH2O during the first 5 days of MV, need for renal replacement therapy (RRT), late-onset ventilator-associated pneumonia (VAP), and cardiovascular complications. ICU mortality during the observation period was 36.1% (141/391). Similar results were obtained by the multivariate logistic regression analysis using mortality as a dependent variable. Conclusions Age, SOFA score at ICU admission, CRS, PaO2/FiO2, renal and cardiovascular complications, and late-onset VAP were all independent risk factors for prolonged mechanical ventilation in patients with COVID-19. Trial registration NCT04411459

Objective: To explore swallowing function and risk factors associated with delayed recovery of swallowing in patients with COVID-19 post–invasive mechanical ventilation using the Functional Oral Intake Scale (FOIS). Design: Longitudinal cohort study. Setting: Three secondary-level hospitals. Participants: Invasively ventilated patients (N=28) who were hospitalized with severe COVID-19 and referred to the hospitals’ speech and language pathology (SLP) departments after mechanical ventilation between March 5 and July 5, 2020 for an evaluation of swallowing function before commencing oral diet. Interventions: SLP assessment, advice, and therapy for dysphagia. Main Outcome Measures: Oral intake levels at baseline and hospital discharge according to the FOIS. Patients were stratified according to FOIS (1-5, dysphagia; 6-7, functional oral intake). Data regarding comorbidities, frailty, intubation and tracheostomy, proning, and SLP evaluation were collected. Results: Dysphagia was found in 71% of the patients at baseline (79% men; age, 61±12y; body mass index, 30±8 kg/m2). The median FOIS score at baseline was 2 (interquartile range [IQR], 1) vs 5 (IQR, 2.5) at hospital discharge. Patients with dysphagia were older (64±8.5y vs 53±16y; P=.019), had a higher incidence of hypertension (70% vs 12%; P=.006), and were ventilated invasively longer (16±7d vs 10±2d; P=.017) or had a tracheostomy (9±9d vs 1±2d; P=.03) longer. A negative association was found between swallowing dysfunction at bedside and days hospitalized (r=–0.471, P=.01), and number of days in the intensive care unit (ICU) (r=–0.48, P=.01). Conclusion: Dysphagia is prevalent in COVID-19 patients after invasive mechanical ventilation and is associated with number of days in hospital and number of days in the ICU. Swallowing function and tolerance of oral diet improved at discharge (P

Background: Daily assessment of patient readiness for liberation from invasive mechanical ventilation can reduce the duration of ventilation. However, there is uncertainty about the effectiveness of this in a paediatric population. Objectives: To determine the effect of a ventilation liberation intervention in critically ill children who are anticipated to have a prolonged duration of mechanical ventilation (primary objective) and in all children (secondary objective). Design: A pragmatic, stepped-wedge, cluster randomised trial with economic and process evaluations. Setting: Paediatric intensive care units in the UK. Participants: Invasively mechanically ventilated children (aged

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]

DOI：10.3969/j.issn.1672⁃6731.2020.08.010

Abstract Background Protective mechanical ventilation is recommended for patients with acute respiratory distress syndrome (ARDS), but it usually requires controlled ventilation and sedation. Using neurally adjusted ventilatory assist (NAVA) or pressure support ventilation (PSV) could have additional benefits, including the use of lower sedative doses, improved patient–ventilator interaction and shortened duration of mechanical ventilation. We designed a pilot study to assess the feasibility of keeping tidal volume (V T) at protective levels with NAVA and PSV in patients with ARDS. Methods We conducted a prospective randomized crossover trial in five ICUs from a university hospital in Brazil and included patients with ARDS transitioning from controlled ventilation to partial ventilatory support. NAVA and PSV were applied in random order, for 15 min each, followed by 3 h in NAVA. Flow, peak airway pressure (Paw) and electrical activity of the diaphragm (EAdi) were captured from the ventilator, and a software (Matlab, Mathworks, USA), automatically detected inspiratory efforts and calculated respiratory rate (RR) and V T. Asynchrony events detection was based on waveform analysis. Results We randomized 20 patients, but the protocol was interrupted for five (25%) patients for whom we were unable to maintain V T below 6.5 mL/kg in PSV due to strong inspiratory efforts and for one patient for whom we could not detect EAdi signal. For the 14 patients who completed the protocol, V T was 5.8 ± 1.1 mL/kg for NAVA and 5.6 ± 1.0 mL/kg for PSV (p = 0.455) and there were no differences in RR (24 ± 7 for NAVA and 23 ± 7 for PSV, p = 0.661). Paw was greater in NAVA (21 ± 3 cmH2O) than in PSV (19 ± 3 cmH2O, p = 0.001). Most patients were under continuous sedation during the study. NAVA reduced triggering delay compared to PSV (p = 0.020) and the median asynchrony Index was 0.7% (0–2.7) in PSV and 0% (0–2.2) in NAVA (p = 0.6835). Conclusions It was feasible to keep V T in protective levels with NAVA and PSV for 75% of the patients. NAVA resulted in similar V T, RR and Paw compared to PSV. Our findings suggest that partial ventilatory assistance with NAVA and PSV is feasible as a protective ventilation strategy in selected ARDS patients under continuous sedation. Trial registration ClinicalTrials.gov (NCT01519258). Registered 26 January 2012, https://clinicaltrials.gov/ct2/show/NCT01519258

ABSTRACT Objective: To describe clinical characteristics, resource use, outcomes, and to identify predictors of in-hospital mortality of patients with COVID-19 admitted to the intensive care unit. Methods: Retrospective single-center cohort study conducted at a private hospital in São Paulo (SP), Brazil. All consecutive adult (≥18 years) patients admitted to the intensive care unit, between March 4, 2020 and February 28, 2021 were included in this study. Patients were categorized between survivors and non-survivors according to hospital discharge. Results: During the study period, 1,296 patients [median (interquartile range) age: 66 (53-77) years] with COVID-19 were admitted to the intensive care unit. Out of those, 170 (13.6%) died at hospital (non-survivors) and 1,078 (86.4%) were discharged (survivors). Compared to survivors, non-survivors were older [80 (70-88) versus 63 (50-74) years; p

Introducción. En pacientes sépticos con requerimiento de ventilación mecánica invasiva pueden presentarse diferentes factores de riesgo de destete ventilatorio fallido. Objetivo. Determinar los factores de riesgo de destete ventilatorio fallido en pacientes sépticos admitidos a una unidad de cuidados intensivos (UCI) de Cali, Colombia, entre enero de 2014 y junio 2018 Materiales y métodos. Estudio de casos y controles realizado en 315 pacientes que requirieron ventilación mecánica por más de 48 horas distribuidos así: 105 casos (destete fallido) y 210 controles (destete exitoso). La información sobre variables sociodemográficas y clínicas se obtuvo a partir de la revisión de historias clínicas. Se realizó un análisis bivariado para determinar las asociaciones de cada variable independiente con el destete fallido y un análisis multivariado mediante un modelo de regresión logística en el que se ingresaron las variables que en el análisis bivariado tuvieron un valor p50%) al ingreso a UCI (OR: 3.16; 95%IC: 1.73-5.77) y tener diuresis ≤0.5 mL/kg/h (OR: 1.87; IC95% 1.0-3.50) se asociaron significativamente con el destete ventilatorio fallido. Conclusiones. En el presente estudio, el requerimiento de ventilación mecánica mayor a 7 días, la diuresis ≤0.5 mL/kg/h y un puntaje APACHE II alto al ingreso a UCI fueron factores de riesgo para destete ventilatorio fallido, pero no se observó asociación con la edad, el nitrógeno ureico en sangre, la creatinina y el balance de líquidos positivos, a pesar de que estos han sido descritos como factores de riesgo en la literatura.

ABSTRACT 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 expiratory 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 Objective: To assess the factors associated with the de-hospitalization of children and adolescents with complex chronic condition. Methods: This cross-sectional and retrospective study investigated a sample of children and adolescents admitted to the Dehospitalization Training Unit, from January 2012 to December 2017. Data were collected by consulting medical records and patient record books, from November 2018 to June 2019. The length of stay in the unit, de-hospitalization, readmissions, frequency and cause of death, age, sex, diagnosis, place of residence, number of caregivers and kinship, and use of devices were studied. The chi-square test was used to verify the association between the dependent variable (de-hospitalization) and the independent variables (age, sex, place of residence, use of devices, and clinical diagnosis). Results: A total of 93 patient records were analyzed, 37.6% aged between 7 months and 2 years old, 58.1% boys, 95.7% used tracheostomy, 92.5% gastrostomy, and 71% invasive mechanical ventilation. Hypoxic-ischemic encephalopathy was the diagnosis of 40.3% of the sample. Average hospitalization time was 288 ± 265 days; 60.2% were hospitalized between 31 days and one year, representing 50% of deaths. Of those de-hospitalized, 76.3% were discharged to the Ventilatory Assistance Homecare Program. De-hospitalization was associated with the child or adolescent's place of residence (p=0.027) and use of ventriculoperitoneal shunt (p=0.021). Conclusions: This study identified that de-hospitalization may be associated with the place of residence of the child or adolescent, with the highest number of discharges to the state capital, and non-dehospitalization when using ventricular-peritoneal shunt.

Background: This trial aimed to evaluate the effects of a protective ventilation strategy on oxygenation/pulmonary indexes in patients undergoing robot-assisted radical prostatectomy (RARP) in the steep Trendelenburg position.Methods: In phase 1, the most optimal positive end-expiratory pressure (PEEP) was determined in 25 patients at 11 cmH2O. In phase 2, 64 patients were randomized to the traditional ventilation group with tidal volume (VT) of 9 ml/kg of predicted body weight (PBW) and the protective ventilation group with VT of 7 ml/kg of PBW with optimal PEEP and recruitment maneuvers (RMs). The primary endpoint was the intraoperative and postoperative PaO2/FiO2. The secondary endpoints were the PaCO2, SpO2, modified clinical pulmonary infection score (mCPIS), and the rate of complications in the postoperative period.Results: Compared with controls, PaO2/FiO2 in the protective group increased after the second RM (P=0.018), and the difference remained until postoperative day 3 (P=0.043). PaCO2 showed transient accumulation in the protective group after the first RM (T2), but this phenomenon disappeared with time. SpO2 in the protective group was significantly higher during the first three postoperative days. Lung compliance was significantly improved after the second RM in the protective group (P=0.025). The mCPIS was lower in the protective group on postoperative day 3 (0.59 (1.09) vs. 1.46 (1.27), P=0.010).Conclusion: A protective ventilation strategy with lower VT combined with optimal PEEP and RMs could improve oxygenation and reduce mCPIS in patients undergoing RARP.Trial Registration: ChiCTR ChiCTR1800015626 . Registered on 12 April 2018. [ABSTRACT FROM AUTHOR]

For extubation in pediatric patients, the evaluation of readiness is strongly recommended. However, a device or practice that is superior to clinical judgment has not yet been accurately determined. Thus, it is important to conduct a review on the techniques of choice in clinical practice to predict extubation failure in pediatric patients. Based on a search in the PubMed®, Biblioteca Virtual em Saúde, Cochrane Library and Scopus databases, we conducted a survey of the predictive variables of extubation failure most commonly used in clinical practice in pediatric patients. Of the eight predictors described, the three most commonly used were the spontaneous breathing test, the rapid shallow breathing index and maximum inspiratory pressure. Although the disparity of the data presented in the studies prevented statistical treatment, it was still possible to describe and analyze the performance of these tests. [ABSTRACT FROM AUTHOR]

Objective: To describe the usual practice of mobility therapy in the adult intensive care unit for patients with and without COVID-19. Methods: Online survey in which physical therapists working in an adult intensive care unit in Argentina participated. Sixteen multiple-choice or single-response questions grouped into three sections were asked. The first section addressed personal, professional and work environment data. The second section presented questions regarding usual care, and the third focused on practices under COVID-19 pandemic conditions. Results: Of 351 physical therapists, 76.1% answer that they were exclusively responsible for patient mobility. The highest motor-based goal varied according to four patient scenarios: Mechanically ventilated patients, patients weaned from mechanical ventilation, patients who had never ABSTRACT required mechanical ventilation, and patients with COVID-19 under mechanical ventilation. In the first and last scenarios, the highest goal was to optimize muscle strength, while for the other two, it was to perform activities of daily living. Finally, the greatest limitation in working with patients with COVID-19 was respiratory and/ or contact isolation. Conclusion: Physical therapists in Argentina reported being responsible for the mobility of patients in the intensive care unit. The highest motor-based therapeutic goals for four classic scenarios in the closed area were limited by the need for mechanical ventilation. The greatest limitation when mobilizing patients with COVID-19 was respiratory and contact isolation. [ABSTRACT FROM AUTHOR]

Objective: To relate functional independence to the degree of pulmonary impairment in adult patients 3 months after discharge from the intensive care unit. Methods: This was a retrospective cohort study conducted in one adult intensive care unit and a multi- professional post-intensive care unit outpatient clinic of a single center. Patients admitted to the intensive care unit from January 2012 to December 2013 who underwent (3 months later) spirometry and answered the Functional Independence Measure Questionnaire were included. Results: Patients were divided into groups according to the classification of functional independence and spirometry. The study included 197 patients who were divided into greater dependence (n = 4), lower dependence (n = 12) and independent (n = 181) groups. Comparing the three groups, regarding the classification of the Functional Independence Measure, patients with greater dependence had higher Acute Physiology and Chronic ABSTRACT Health Evaluation II and Sequential Organ Failure Assessment values at intensive care unit admission with more advanced age, more days on mechanical ventilation, and longer stay in the intensive care unit and hospital. The majority of patients presented with pulmonary impairment, which was the obstructive pattern observed most frequently. When comparing functional independence with pulmonary function, it was observed that the lower the functional status, the worse the pulmonary function, with a significant difference being observed in peak expiratory flow (p = 0.030). Conclusion: The majority of patients who returned to the outpatient clinic 3 months after discharge had good functional status but did present with pulmonary impairment, which is related to the degree of functional dependence. [ABSTRACT FROM AUTHOR]