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Objective: to investigate the factors associated with extubation failure of patients in the intensive care unit. Method: unpaired, longitudinal, retrospective and quantitative case-control with the participation of 480 patients through clinical parameters for ventilator weaning. Data were analyzed by: Fisher’s exact test or the chi-square test; unpaired two-tailed Student’s t test; and Mann-Whitney test. Significant P values lower than or equal to 0.05 were admitted. Results: of the patients, 415 (86.5%) were successful and 65 (13.5%) failed. Success group: the most negative fluid balance, APACHE II in 20 (14-25), weak cough in 58 (13.9%). Failure group: the most positive fluid balance, APACHE II in 23 (19-29), weak cough in 31 (47.7%), abundant amount of pulmonary secretions in 47.7%. Conclusion: positive fluid balance and the presence of inefficient cough or inability to clear the airway were predictors of extubation failure. Resumo Objetivo: investigar os fatores associados à falha de extubação de pacientes na unidade de terapia intensiva. Método: caso-controle não pareado, longitudinal, retrospectivo e quantitativo com a participação de 480 pacientes por meio de parâmetros clínicos para desmame ventilatório. Dados analisados por: Teste Exato de Fisher ou o teste Qui-quadrado; teste t de Student bicaudal não pareado; e teste de Mann-Whitney. Admitiram-se significantes valores de P menores ou iguais a 0,05. Resultados: dos pacientes, 415 (86,5%) tiveram sucesso e 65 (13,5%) falharam. Grupo sucesso: balanço hídrico mais negativo, APACHE II em 20 (14-25), tosse fraca em 58 (13,9%). Grupo falha: balanço hídrico mais positivo, APACHE II em 23 (19-29), tosse fraca em 31 (47,7 %), quantidade abundante de secreção pulmonar em 47,7 %. Conclusão: o balanço hídrico positivo e a presença de tosse ineficiente ou incapacidade de higienizar a via aérea foram preditores de falhas de extubação. Resumen Objetivo: investigar los factores asociados al fracaso de la extubación de pacientes en la unidad de cuidados intensivos. Método: caso y control no apareado, longitudinal, retrospectivo y cuantitativo con la participación de 480 pacientes mediante parámetros clínicos para el destete de la ventilación. Datos analizados por: Prueba Exacta de Fisher o prueba de Chi-cuadrado; prueba t de Student de dos colas para datos no apareados; y prueba de Mann-Whitney. Se admitieron valores de P significativos menores o iguales a 0,05. Resultados: de los pacientes, 415 (86,5%) tuvieron éxito y 65 (13,5%) fracasaron. Grupo de éxito: balance hídrico más negativo, APACHE II en 20 (14-25), tos débil en 58 (13,9%). Grupo de fracaso: balance de líquidos más positivo, APACHE II en 23 (19-29), tos débil en 31 (47,7%), abundante cantidad de secreciones pulmonares en 47,7%. Conclusión: el balance hídrico positivo y la presencia de tos ineficaz o incapacidad para higienizar la vía aérea fueron predictores de fracaso de la extubación.

SUMMARY BACKGROUND: Patients with coronavirus disease 2019 on automatic mechanical ventilation have greater heart rate modulation with greater parasympathetic modulation. OBJECTIVE: To analyze the autonomic modulation of heart rate in critically ill patients with coronavirus disease 2019 on invasive mechanical ventilation. METHODS: A cross-section study was carried out with 36 individuals divided into two groups. The control group included patients of both genders, in orotracheal intubation with invasive mechanical ventilation under controlled assisted mode, hospitalized in the intensive care unit for another 24 h. In the non-COVID group, patients diagnosed with coronavirus disease 2019 in the same condition mentioned in the control group. RESULTS: There was a significant increase in heart rate variability (standard deviation of all normal RR intervals recorded at an interval of time; p=0.001; triangular interpolation histogram of RR intervals; p=0.048; and SD2; p=0.014) in the coronavirus disease group compared to the non-COVID group. Successively, the parameters that demonstrate parasympathetic modulation are shown to be higher in the group of patients with coronavirus disease 2019 (root mean square of the square of differences between adjacent normal RR intervals in an interval of time; p

Rationale: Bacterial lung microbiota are correlated with lung inflammation and acute respiratory distress syndrome (ARDS) and altered in severe coronavirus disease (COVID-19). However, the association between lung microbiota (including fungi) and resolution of ARDS in COVID-19 remains unclear. We hypothesized that increased lung bacterial and fungal burdens are related to nonresolving ARDS and mortality in COVID-19. Objectives: To determine the relation between lung microbiota and clinical outcomes of COVID-19-related ARDS. Methods: This observational cohort study enrolled mechanically ventilated patients with COVID-19. All patients had ARDS and underwent bronchoscopy with BAL. Lung microbiota were profiled using 16S rRNA gene sequencing and quantitative PCR targeting the 16S and 18S rRNA genes. Key features of lung microbiota (bacterial and fungal burden, α-diversity, and community composition) served as predictors. Our primary outcome was successful extubation adjudicated 60 days after intubation, analyzed using a competing risk regression model with mortality as competing risk. Measurements and Main Results: BAL samples of 114 unique patients with COVID-19 were analyzed. Patients with increased lung bacterial and fungal burden were less likely to be extubated (subdistribution hazard ratio, 0.64 [95% confidence interval, 0.42-0.97]; P = 0.034 and 0.59 [95% confidence interval, 0.42-0.83]; P = 0.0027 per log10 increase in bacterial and fungal burden, respectively) and had higher mortality (bacterial burden, P = 0.012; fungal burden, P = 0.0498). Lung microbiota composition was associated with successful extubation (P = 0.0045). Proinflammatory cytokines (e.g., tumor necrosis factor-α) were associated with the microbial burdens. Conclusions: Bacterial and fungal lung microbiota are related to nonresolving ARDS in COVID-19 and represent an important contributor to heterogeneity in COVID-19-related ARDS.

SUMMARY OBJECTIVE: This study aimed to assess the clonidine infusion rate in the first 6 h, as maintenance dose (first 24 h), and in the pre-extubation period (last 24 h), as well as the cumulative dose of other sedatives and the hemodynamic response. METHODS: This is a retrospective cohort study. RESULTS: Children up to the age of 2 years who were admitted to the pediatric intensive care unit of a tertiary referral hospital in the south region of Brazil, between January 2017 and December 2018, were submitted to mechanical ventilation, and received continuous clonidine infusions were included in the study. The initial, maintenance, and pre-extubation doses of clonidine; the vasoactive-inotropic score; heart rate; and systolic and diastolic blood pressure of the study participants were assessed. A total of 66 patients with a median age of 4 months who were receiving clonidine infusions were included. The main indications for mechanical ventilation were acute viral bronchiolitis (56%) and pneumonia associated with acute respiratory distress syndrome (15%). The median of clonidine infusion in the first 6 h (66 patients) was 0.53 μg/kg/h (IQR 0.49–0.88), followed by 0.85 μg/kg/h (IQR 0.53–1.03) during maintenance (57 patients) and 0.63 μg/kg/h (IQR 0.54–1.01) during extubation period (42 patients) (p=0.03). No differences were observed in the doses regarding the indication for mechanical ventilation. Clonidine infusion was not associated with hemodynamic changes and showed no differences when associated with adjuvants. CONCLUSION: Clonidine demonstrated to be a well-tolerated sedation option in pediatric patients submitted to mechanical ventilation, without relevant influence in hemodynamic variables.

In acute respiratory distress syndrome (ARDS), physiological parameters associated with outcome may help defining targets for mechanical ventilation. This study aimed to address whether transpulmonary pressures (PProspective, observational, multicentre registry of ARDS patients. Respiratory mechanics were measured early after intubation at 6 kg/ml tidal volume. We compared the predictive power of the parameters for mortality at day-60 through receiver operating characteristic (ROC) and assessed their association with 60-day mortality through unadjusted and adjusted Cox regressions. Finally, each parameter was dichotomized, and Kaplan-Meier survival curves were compared.385 patients were enrolled 2 [1-4] days from intubation (esophageal pressure and arterial blood gases in 302 and 318 patients). As continuous variables, DPDP

Artificial ventilation is widely used for various respiratory problems of human beings. The oxygen level of the corona patients has to be maintained for smooth breathing which is very difficult. For achieving this state, the air pressure should be controlled in the respiration system that has a piston mechanism driven by a motor. An Automatic respiration system model is designed and controller parameters are tuned using hybrid Optimization techniques. Hybrid Controllers like genetic algorithm based Fractional Order Proportional Integral Derivative controller (FOPID), Fmincon-Pattern search Algorithm based Proportional Integral Derivative (PID) controller, and Hybrid Model predictive control (MPC) – Proportional Integral Derivative (PID) controllers were designed and verified. Integral Square Error is considered as the objective function of the optimization technique to find the controller parameters. The output responses of all three hybrid controllers are compared based on the error indices, time domain specifications, set-point tracking and Convergence speed graph. The genetic algorithm-based FOPID controller gives better results when compared with the Fmincon-Pattern search Algorithm based Proportional Integral Derivative (PID) controller and Hybrid Model predictive control (MPC) – Proportional Integral Derivative (PID) for the proposed artificial ventilation system.

Objective: To map reported interventions addressing post-extubation dysphagia in critical care patients. Introduction: Given the associated complications, post-extubation dysphagia negatively affects patient outcomes. However, evidence for interventions to reduce or solve the problem is limited, for what it’s important to map the relevant interventions to support nursing safety care. Inclusion criteria: Studies reporting interventions addressing dysphagia in adult critical care patients, successfully extubated after artificial respiration for more than 48 hours. Patients Methods: MEDLINE, Cochrane Library, Scielo, Science Direct and CINAHL will be search in January 2023 by two reviewers and limited to papers published in Portuguese, English, Spanish and French. No time limit will be applied. Article selection and data extraction will be conducted by two reviewers. Disagreements will be resolved by a third reviewer. Data will be analysed and presented according to the type of intervention: assessment/evaluation, rehabilitation and compensatory strategies.

Risks associated with neuromuscular blocking agents (NMBAs), such as potential muscle weakness, may be minimized with appropriate monitoring and optimized administration. NMBAs are a life-saving therapy for patients with moderate to severe acute respiratory distress syndrome (ARDS)1. NMBAs reduce ventilator-induced lung injury (VILI) and ultimately improve patient outcomes2. Covid-19 has highlighted the importance of ARDS management and NMBA use. Proposed mechanisms for how NMBAs improve hypoxemia include improved ventilator synchrony, decreased work of breathing, facilitation of a lung protective strategy, better lung recruitment, and improved lung compliance2. Two large, randomized control trials have assessed the impacts of NMBA use: the ACURASYS and ROSE trials1,3. However, these trials are difficult to compare due to significant differences in the control group. Other studies have described NMBA monitoring strategies4,5; however, there are few comparisons of the effectiveness of the monitoring strategies. In 2016, the Society of Critical Care Medicine (SCCM) updated its Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient5. This update recommends monitoring the depth of neuromuscular blockade using peripheral nerve stimulation (PNS) with a train-of-four (TOF) monitor as an adjunct to clinical assessment for continuous NMBA infusions5. However, the SCCM guideline notes that this is a weak recommendation due to the very low quality of evidence. The monitoring of intermittent administration of paralytics is not addressed. Standardized care for mechanically ventilated patients with hypoxemic respiratory failure (HRF) and ARDS has improved management for these patients6. A protocol-based intervention to monitor and titrate paralytics was conducted by Hadique et al. (2021), on behalf of the SCCM, which showed a reduction in overall NMBA use and associated risks while optimizing the benefit of this therapy. Rapid practice guidelines from Alhazzani et al. (2020) describe NMBAs as a standard of care for patients with moderate to severe ARDS and suggest that a goal to reduce the overall use of NMBAs may be beneficial. The guidelines recommend starting with intermittent NMBA dosing and frequent assessments of the patient and their ventilation goals to facilitate lung protective ventilation7. Bolus dosing may be preferred to minimize overall use and the associated risks. Alhazanni et al. suggest that the optimal strategy to assess the effectiveness of paralysis is unclear, and clinicians should use the most familiar approach. Several methods to assess the effectiveness of NMBAs are described in the literature. These include PNS, End-tidal CO2 (EtCO2), esophageal balloons, and clinical targets such as ventilator dyssynchrony. Monitoring may also include trends in oxygenation with the PaO2 to FiO2 ratio and ventilator mechanics such as tidal volume, plateau pressure, positive end-expiratory pressure (PEEP) and driving pressure. Although these monitoring strategies have been described, there are few comparisons of outcomes. Current evidence does not support a superior monitoring strategy, as the effectiveness and outcomes of the current methods of monitoring NMBAs remain unclear. The aim of this scoping review is to describe the methods used to monitor the effectiveness of NMBA, the outcomes associated with these monitoring strategies, and the different study designs used to assess these strategies. This will provide clarity and guide clinical practice for NMBA monitoring for clinicians using this therapy for patients with moderate to severe ARDS.

A large number of interventions and research is subsumed under the term 'ventilator weaning'. However, there is no common definition for this term and it remains unclear which interventions are to be counted as weaning interventions. In order to sort different facets and dimensions of ventilator weaning, this scoping review will present an overview of interventions associated with the ventilator weaning process of patients undergoing an invasive mechanical ventilation. For this review, an association with ventilator weaning occurs when an intervention on ventilated patients pursues the goal of extubation or decannulation and associated spontaneous breathing in each case.

Background Ultrasound may be useful to assess the structure, activity, and function of the abdominal muscles in patients who are mechanically ventilated. Research Question Does measurement of abdominal muscle thickening on ultrasound in patients who are mechanically ventilated provide clinically relevant information about abdominal muscle function and weaning outcomes? Study Design and Methods This study consisted of two parts, a physiological study conducted in healthy subjects and a prospective observational study in patients who were mechanically ventilated. Abdominal muscle thickness and thickening fraction were measured during cough and expiratory efforts in 20 healthy subjects, and prior to and during a spontaneous breathing trial in 57 patients being ventilated. Results In healthy subjects, internal oblique and rectus abdominis thickening fraction correlated with pressure generated during expiratory efforts (P Interpretation Abdominal muscle thickening on ultrasound was correlated to the airway pressure generated by expiratory efforts. In patients who were mechanically ventilated, abdominal muscle ultrasound measurements are feasible and moderately reproducible. Among patients who passed a spontaneous breathing trial, reduced abdominal muscle thickening during cough was associated with a high risk of liberation failure. Clinical Trial Registration ClinicalTrials.gov ; No.: NCT03567564; URL: www.clinicaltrials.gov

Rationale: Although respiratory virus testing is frequently done for critically ill infants with bronchiolitis, the prognostic value of this testing is unknown for those requiring positive-pressure...

Purpose The COVID-19 pandemic threatens our current ICU capabilities nationwide. As the number of COVID-19 positive patients across the nation continues to increase, the need for options to address ventilator shortages is inevitable. Multi-patient ventilation (MPV), in which more than one patient can use a single ventilator base unit, has been proposed as a potential solution to this problem. To our knowledge, this option has been discussed but remains untested in live patients with differing severity of lung pathology. Methods The objective of this study was to address ventilator shortages and patient stacking limitations by developing and validating a modified breathing circuit for two patients with differing lung compliances using simple, off-the-shelf components. A multi-patient ventilator circuit (MPVC) was simulated with a mathematical model and validated with four animal studies. Each animal study had two human-sized pigs: one healthy and one with lipopolysaccharide (LPS) induced ARDS. LPS was chosen because it lowers lung compliance similar to COVID-19. In a previous study, a control group of four pigs was given ARDS and placed on a single patient ventilation circuit (SPVC). The oxygenation of the MPVC ARDS animals was then compared to the oxygenation of the SPVC animals. Results Based on the comparisons, similar oxygenation and morbidity rates were observed between the MPVC ARDS animals and the SPVC animals. Conclusion As healthcare systems worldwide deal with inundated ICUs and hospitals from pandemics, they could potentially benefit from this approach by providing more patients with respiratory care. Supplementary Information The online version contains supplementary material available at 10.1007/s00540-021-02948-2.

Mechanical ventilation is the most extensively employed life support intervention among patients with severe respiratory fail ure of different etiologies. In this context, consistent delivery of the most suitable tidal volume (VT) to the patientis criticalto achieving personalized mechanical ventilation. Indeed, in addition to its con tribution to minute volume for optimization of blood gas exchange,appropriate VT strategies are critical to avoid ventilator-induced lung injury in the general context of lung-protective ventilation and when specifically applying ultra-low tidal volume ventilation. Additionally, VT is required to compute respiratory system com pliance or ventilatory ratio, useful indices in the classification of patient phenotype and estimation of prognosis.

Objective: Describe the features, configurations, settings and testing procedures of rapidly manufactured ventilators (RMV) from a clinical and engineering perspective. This will help inform recommendations on effective and safety standards for use during conditions when hospital resources become or currently are limited. Introduction: RMVs are low cost machines made from readily available materials capable of performing the basic requirements of a standard hospital ventilator. They may serve as temporary mechanical ventilators during mass-casualty events (i.e., COVID-19) or supplemental resources in developing countries. However, until strict standards and criteria are established for RMV design and function, these life-support machines are unlikely to reach the clinical setting. Inclusion criteria: Papers of any design, language, and date describing RMVs designed and manufactured for treating critically ill adults and pediatric patients during limited resource conditions. Methods: An established 6-step scoping review methodology by Arksey and O’Malley, Levac et al and the Joanna Briggs Institute will be used. The search strategy developed by a health sciences librarian will be used to identify literature of all languages in numerous databases, including the grey literature. Two reviewers will independently screen relevant studies against eligibility criteria and review the full-text of the selected studies. Extracted information will include bibliographic data, study design, and various characteristics to describe RMVs. The included papers will be analyzed for commonalities across RMV designs and the results will be reported using numerical analysis and descriptive narrative summary. This will inform recommendations for effective and safe RMV design, manufacturing and clinical standards.

Purpose: To justify the use of albumin infusion in patients in post-surgery cardiac intensive care unit. Methods: All patients who were hemodynamically stable before the operation and admitted into the surgical intensive care unit following coronary artery bypass, cardiopulmonary bypass, or aortic surgery, had no excessive postoperative bleeding and not on diuretic treatment, were included in the analysis. A total of 1998 patients were divided into two cohorts, viz, the first group was placed on albumin infusion (n = 999) while the second group received normal saline infusion (n = 999). Data were obtained from DICOM files of patients and records of pharmacy. Wilcoxon test or two-tailed paired t-test followed by Tukey post-hoc tests were performed for statistical analysis at 95 % of confidence level. Results: Albumin and normal saline administration did not decrease the duration of mechanical ventilation, incidence of mechanical ventilation, need for blood transfusion, and length of hospital stay (p > 0.05). Albumin infusion decreased the need for fresh frozen plasma transfusion from 85 to 67, reduced mortality (p = 0.0005, q = 3.959), lowered serum lactate level (p < 0.0001, q = 43.853), but increased cardiac index (p < 0.0001, q = 12.192) as well as financial burden (p < 0.0001, q = 95.158) for the patients, compared to normal saline group. Conclusion: In view of the foregoing, it is recommended that the use of restriction of albumin resuscitation in surgical intensive care unit should be restricted in this subset of patients evluated in this study.

Introduction Acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19) often leads to mortality. Outcomes of patients with COVID-19-related ARDS compared to ARDS unrelated to COVID-19 is not well characterized. Areas covered We performed a systematic review of PubMed, Scopus, and MedRxiv 11/1/2019 to 3/1/2021, including studies comparing outcomes in COVID-19-related ARDS (COVID-19 group) and ARDS unrelated to COVID-19 (ARDS group). Outcomes investigated were duration of mechanical ventilation-free days, intensive care unit (ICU) length-of-stay (LOS), hospital LOS, and mortality. Random effects models were fit for each outcome measure. Effect sizes were reported as pooled median differences of medians (MDMs), mean differences (MDs), or odds ratios (ORs). Expert opinion Ten studies with 2,281 patients met inclusion criteria (COVID-19: 861 [37.7%], ARDS: 1420 [62.3%]). There were no significant differences between the COVID-19 and ARDS groups for median number of mechanical ventilator-free days (MDM: −7.0 [95% CI: −14.8; 0.7], p = 0.075), ICU LOS (MD: 3.1 [95% CI: −5.9; 12.1], p = 0.501), hospital LOS (MD: 2.5 [95% CI: −5.6; 10.7], p = 0.542), or all-cause mortality (OR: 1.25 [95% CI: 0.78; 1.99], p = 0.361). Compared to the general ARDS population, results did not suggest worse outcomes in COVID-19-related ARDS.

Many neuromuscular disease patient populations suffer from a weak, inadequate cough, which may lead to respiratory tract infections, respiratory failure, and increased mortality. Hospitalized neuro...

Objectives To measure the impact of clusters of double triggering on clinical outcomes. Design Prospective cohort study. Setting Respiratory ICU in Brazil. Patients Adult patients under recent mechanical ventilation and with expectation of mechanical ventilation for more than 24 hours after enrollment. Interventions None. Measurements and main results We used a dedicated software to analyze ventilator waveforms throughout the entire period of mechanical ventilation and detect double triggering. We defined a cluster of double triggering as a period of time containing at least six double triggering events in a 3-minute period. Patients were followed until hospital discharge. We addressed the association between the presence and the duration of clusters with clinical outcomes. A total of 103 patients were enrolled in the study and 90 (87%) had at least one cluster of double triggering. The median number of clusters per patient was 19 (interquartile range, 6-41), with a median duration of 8 minutes (6-12 min). Compared with patients who had no clusters, patients with at least one cluster had longer duration of mechanical ventilation (7 d [4-11 d] vs 2 d [2-3 d]) and ICU length of stay (9 d [7-16 d] vs 13 d [2-8 d]). Thirty-three patients had high cumulative duration of clusters of double triggering (≥ 12 hr), and it was associated with longer duration of mechanical ventilation, fewer ventilator-free days, and longer ICU length of stay. Adjusted by duration of mechanical ventilation and severity of illness, high cumulative duration of clusters was associated with shorter survival at 28 days (hazard ratio, 2.09 d; 95% CI, 1.04-4.19 d). Conclusions Clusters of double triggering are common and were associated with worse clinical outcomes. Patients who had a high cumulative duration of clusters had fewer ventilator-free days, longer duration of mechanical ventilation, longer ICU length of stay, and shorter survival than patients with low cumulative duration of cluster.

The health threat posed by the novel coronavirus that caused the COVID-19 pandemic has particular implications for people with disabilities, including vulnerability to exposure and complications, and concerns about the role of ableism in access to treatment and medical rationing decisions. Shortages of necessary medical equipment to treat COVID-19 have prompted triage guidelines outlining the ways in which lifesaving equipment, such as mechanical ventilators and intensive care unit beds, may need to be rationed among affected individuals. In this article, we explore the realities of medical rationing, and various approaches to triage and prioritization. We discuss the psychology of ableism, perceptions about quality of life, social determinants of health, and how attitudes toward disability can affect rationing decisions and access to care. In addition to the grassroots advocacy and activism undertaken by the disability community, psychology is rich in its contributions to the role of attitudes, prejudice, and discriminatory behavior on the social fabric of society. We call on psychologists to advocate for social justice in pandemic preparedness, promote disability justice in health care settings, call for transparency and accountability in rationing approaches, and support policy changes for macro- and microallocation strategies to proactively reduce the need for rationing. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

This study is intended to provide an exhaustive comparison of various non-local fractional operators when analyzing the mechanics of breathing performed by a ventilator. We present the solutions of the fractional respiratory mechanics model mainly for allowing the health care team to monitor patients' conditions in detail. The aim is to introduce the underlying model flexibly by making use of the advantages of the non-integer order operators with one, two, and three parameters. On the other hand, since we concern the usage of different types of fractional operators, most often having virtue in the application, it can be clearly observed the similarities and differences between these operators. Moreover, we observe the mobility of the solutions curves of the above-stated fractional model for different values of the parameters $\alpha$, $\rho$, and $\gamma$ with the help of many graphs.

The device UNA-1 for anesthesia with ether, cyclopropane, fluotane, nitrous oxide, trilene - in an open, half-open, half-closed and closed way, in a circulating and pendulum-like system - serves as a universal apparatus for carrying out all types of modern inhalation anesthesia.

Starting at the end of the 16th century (Volcherus Goiter - 1573) and up to our time, about sixty authors studied the accessory nerve, partly dedicating special work to it, partly giving their views on the course and ending of this nerve in the textbooks of anatomy and histology published by them. Such persistence in the study of the accessory nerve is explained by the duality of its central beginnings and endings, that is, its origin both from the oblong and from the spinal cord. Already with a rough anatomical examination, it is clear that part of the roots emerging from the lower part of the medulla oblongata, not reaching the foramen jugulare of the skull, joins the nerve trunk, which runs along the lateral surface of the spinal cord and is formed by the connection of the roots emerging from the lateral brain. This common nerve trunk, emerging from the cranial cavity through the foram. jugulare and consisting of N. accessorius vagi and N. accessorius spinalis, received the name N. accessorius Willissi, named after Thomasa Willisa (1682) who described it. After exiting the foramen jugulare, the nerve gives a thin v-point (ramus internus according to Heihendainy) to the plexus ganglioformis n. vagi, and another, thick branch, is sent to the muscles (m. sternocleido-mastoideus). Thus, without the help of a microscope, a close connection between the XI and X pairs of cranial nerves is visible. To this, it must be added that the roots of the XI nerve, emerging from the lower sections of the medulla oblongata, produce the impression of the lower roots of the X nerve, and only their entry into the common trunk of the accessory nerve forces them to be referred to it. Heidenhain, using a physiological method, proved the connection between the accessory nerve and the vagus: he pulled out the accessory nerve in rabbits on the neck and after a few days after the operation did not receive the usual slowing of heartbeats with irritation of the vagus nerve; From this, the author concludes that the retarding heartbeat fibers of the vagus nerve receive an additional one through the ramus internus. Further, the author comes to the conclusion that the fibers of the accessory nerve, which delay the heartbeat, originate from the medulla oblongata. To confirm this view, Heidenhain cites experiments in which he, during artificial respiration of an animal, provided a cut of the medulla oblongata at the apex of the pen (calamus scriptorius) and below; with a slowdown of artificial respiration in the first case, a slowdown of the heartbeat was obtained, and in the second it did not work. Finally, in rabbits, after the accessory nerve was torn out, the laryngeal paralysis was as clearly expressed as after the X nerve was cut; food got into the respiratory tract, and the animals died from pneumonia, which usually began with the upper lobes).

OBJECTIVE To provide a systematic review of liberation from positive pressure ventilation and mortality of children with chronic respiratory failure who used long-term invasive and noninvasive ventilation (LTV). METHODS Papers published from 1980 to 2018 were identified using Pubmed MEDLINE, Ovid MEDLINE, Embase, and Cochrane databases. Search results were limited to English-language papers with (a) patients less than 22 years at initiation, (b) patients who used invasive ventilation (IV) via tracheostomy or noninvasive ventilation (NIV), and (c) data on mortality or liberation from LTV. Data were presented using descriptive statistics; changes in outcomes over time were explored using linear regression. Follow-up variability, cohort heterogeneity, and insufficient data precluded combining data to estimate incidences or rates. RESULTS One hundred and thirty papers with 12 704 patients were included. The median number of patients was 37 (interquartile range [IQR] 17-74, range 6-3802). Twenty-five percent of patients were initiated on IV; 75% on NIV. The maximum follow-up ranged from 0.5 to 31.8 years (median 8.8 years). The median proportion of patients liberated in these papers was 3% (IQR 0%-21%). The median proportion of mortality was 18% (IQR 8%-27%). Proportions of liberation and mortality did not significantly change over time. Progression of underlying disease (44%), respiratory illness (19%), and LTV accident (11%) were the most common causes of death. CONCLUSIONS These papers collectively show most patients survive for many years using LTV; in many subgroups, death is a more common outcome than liberation. However, the limitations of these papers preclude robust prognostication.

The principle of human dignity is one of the universally accepted principles among nations and peoples, thus it is considered the most important human right. It is a necessary attribute for human being that cannot be separated since first breath in the womb of mother; and it continued even after the death. Hence the man deserves respect and dignity before birth in mother’s womb, in this worldly life and after death too. A person himself, as a bearer of this value of dignity, must respect the dignity of others in all his dealings. It a comparative study between the understanding of human dignity by Western philosophers and the Islamic Shrī’ah. Further there is an attempt to apply the both understandings on modern day medical cases; like abortion without any reason, cloning of human organs, blood transfusion without permission, artificial respiration after death, mercy killing by patient or medical staff, etc.

The article describes a clinical case presentation of PEEP adjustment under lung ultrasound control in a newborn with respiratory distress syndrome during artificial respiration. Diagnostic value for B-line reduction and appearance of A-lines as predictors of lung atelectasis opening is demonstrated. The practice of low-volume lung recruitment which is achieved by functional residual capacity increasing rather than raising of inspiratory peak pressure can be considered safer as to the risk of ventilator-associated lung injury and the development of severe air leakage syndrome. In addition, the absence of significant fluctuations in the partial pressure of carbon dioxide is prognostically more positive in terms of reducing cerebral perfusion. Nevertheless, additional evidence based data needs to be collected before any further conclusions can be drawn.

Purpose To investigate if respiratory mechanics and other baseline characteristics are predictors of patient-ventilator asynchrony and to evaluate the relationship between asynchrony during assisted ventilation and clinical outcomes. Methods We performed a prospective cohort study in patients under mechanical ventilation (MV). Baseline measurements included severity of illness and respiratory mechanics. The primary outcome was the Asynchrony Index (AI), defined as the number of asynchronous events divided by the number of ventilator cycles and wasted efforts. We recorded ventilator waveforms throughout the entire period of MV. Results We analyzed 11,881 h of MV from 103 subjects. Median AI during the entire period of MV was 5.1% (IQR:2.6–8.7). Intrinsic PEEP was associated with AI (OR:1.72, 95%CI:1.1–2.68), but static compliance and airway resistance were not. Simplified Acute Physiology Score 3 (OR:1.03, 95%CI:1–1.06) was also associated with AI. Median AI was higher during assisted (5.4%, IQR:2.9–9.1) than controlled (2%, IQR:0.6–4.9) ventilation, and 22% of subjects had high incidence of asynchrony (AI≥10%). Subjects with AI≥10% had more extubation failure (33%) than patients with AI Conclusions Predictors of high incidence of asynchrony were severity of illness and intrinsic PEEP. High incidence of asynchrony was associated with extubation failure, but not mortality. Trial registration: ClinicalTrials.gov , NCT02687802

Venous malformations (VMs) occurring in the tongue base or pharynx are rare, but can cause airway obstruction. Considering the potential issues or morbidity related to surgical resection in the tongue or pharynx region, sclerotherapy is often preferred. We perform sclerotherapy for such lesions without conducting tracheotomy, but keep patients intubated for a certain period. Outcomes of sclerotherapy, and benefits and cautions related with our protocol were investigated.Our subjects were 10 cases in 9 patients who underwent sclerotherapy for VMs of the tongue base (6 patients) or pharynx (3 patients) from 2008 to 2017. One patient underwent treatment sessions twice. The sclerosants used were absolute ethanol (ET) (3 cases), 5% ethanolamine oleate (EO) (4 cases), or both ET and 5%EO (3 cases).In 5 of 9 patients, postoperative MRI was performed, which revealed lesion volume reduction by 12% to 47%. The intubation period varied according to the sclerosant used: ET, 5 to 11 days; 5% EO, 2 to 12 days; and combination of ET and 5% EO, 8 days. Postoperative complications included fever of unknown (n = 2), acute psychosis (n = 3), vocal cord paralysis (n = 2), and bradycardia induced from the use of a sedative agent (n = 1). One patient complained of mild transient swallowing difficulty that lasted for a month postoperatively.Although our method mandatorily requires careful postoperative management in an ICU, including sedation with anesthetic agents and artificial respiration by intubation for a certain period of time, no serious complications or post-therapeutic morbidities occurred.

Rationale: Monitoring and controlling respiratory drive and effort may help to minimize lung and diaphragm injury. Airway occlusion pressure (P0.1) is a noninvasive measure of respiratory drive.Obj...

Percutaneous tracheostomy is an increasingly common procedure performed in the intensive care unit setting. This review discusses the evidence behind its use, provides detailed description of the techniques, and considers the principles of post-tracheostomy care based on recent national audit. It also outlines the most recent recommendations for emergency front of neck access, an essential skill for all anaesthetists and other emergency specialists.

Objective: The role of high-flow nasal cannula during and before intubation is unclear despite a number of randomized clinical trials. Our objective was to conduct a systematic review and meta-analysis examining the benefits of high-flow nasal cannula in the peri-intubation period. Data Sources: We performed a comprehensive search of relevant databases (MEDLINE, EMBASE, and Web of Science). Study Selection: We included randomized clinical trials that compared high-flow nasal cannula to other noninvasive oxygen delivery systems in the peri-intubation period. Data Extraction: Our primary outcome was severe desaturation (defined as peripheral oxygen saturation reading < 80% during intubation). Secondary outcomes included peri-intubation complications, apneic time, Pao2 before and after intubation, Paco2 after intubation, ICU length of stay, and short-term mortality. Data Synthesis: We included 10 randomized clinical trials (n = 1,017 patients). High-flow nasal cannula had no effect on the occurrence rate of peri-intubation hypoxemia (relative risk, 0.98; 95% CI, 0.68–1.42; 0.3% absolute risk reduction, moderate certainty), serious complications (relative risk, 0.87; 95% CI, 0.71–1.06), apneic time (mean difference, 10.3 s higher with high-flow nasal cannula; 95% CI, 11.0 s lower to 31.7 s higher), Pao2 measured after preoxygenation (mean difference, 3.6 mm Hg higher; 95% CI, 3.5 mm Hg lower to 10.7 mm Hg higher), or Pao2 measured after intubation (mean difference, 27.0 mm Hg higher; 95% CI, 13.2 mm Hg lower to 67.2 mm Hg higher), when compared with conventional oxygen therapy. There was also no effect on postintubation Paco2, ICU length of stay, or 28-day mortality. Conclusions: We found moderate-to-low certainty evidence that the use of high-flow nasal cannula likely has no effect on severe desaturation, serious complications, apneic time, oxygenation, ICU length of stay, or overall survival when used in the peri-intubation period when compared with conventional oxygen therapy.

Prolonged mechanical ventilation of patients in intensive care units across the United States consumes billions of health care dollars every year. Using the awakening and breathing coordination, delirium monitoring/management, and early mobility (ABCDE) bundle along with the Critical-Care Pain Observation Tool and the Richmond Agitation-Sedation Scale combines the best available evidence to optimize outcomes for critically ill patients. This study is the first to examine the effects of implementing the ABCDE bundle, the Critical-Care Pain Observation Tool, and the Richmond Agitation-Sedation Scale together in a coordinated effort across multiple disciplines. The aim of using this combination of evidence-based tools is to reduce ventilation time by reducing oversedation, decreasing the incidence of delirium, and improving pain management.

The control of complex systems is of critical importance in many branches of science, engineering, and industry, many of which are governed by nonlinear partial differential equations. Controlling an unsteady fluid flow is particularly important, as flow control is a key enabler for technologies in energy (e.g., wind, tidal, and combustion), transportation (e.g., planes, trains, and automobiles), security (e.g., tracking airborne contamination), and health (e.g., artificial hearts and artificial respiration). However, the high-dimensional, nonlinear, and multi-scale dynamics make real-time feedback control infeasible. Fortunately, these high-dimensional systems exhibit dominant, low-dimensional patterns of activity that can be exploited for effective control in the sense that knowledge of the entire state of a system is not required. Advances in machine learning have the potential to revolutionize flow control given its ability to extract principled, low-rank feature spaces characterizing such complex systems. We present a novel deep learning model predictive control framework that exploits low-rank features of the flow in order to achieve considerable improvements to control performance. Instead of predicting the entire fluid state, we use a recurrent neural network (RNN) to accurately predict the control relevant quantities of the system, which are then embedded into an MPC framework to construct a feedback loop. In order to lower the data requirements and to improve the prediction accuracy and thus the control performance, incoming sensor data are used to update the RNN online. The results are validated using varying fluid flow examples of increasing complexity.

RATIONALE: Long-term noninvasive ventilation (NIV) is a standard therapy for children with impaired sleep breathing and chronic respiratory insufficiency. Evidence of longitudinal benefits, however...

Superresolution microscopy techniques are now widely used, but their application in living animals remains a challenging task. The first superresolution imaging in a live vertebrate was demonstrated with STED microscopy in the visual cortex of an anaesthetized mouse. Here, we explain the requirements for a simple but robust in vivo STED microscope as well as the surgical preparation of the cranial window and the mounting of the mouse in detail. We have developed a mounting stage with a heating plate to keep the mouse body temperature stable and that can be adjusted to the optical axis of the microscope. We have optimised the design to avoid inducing thermal drift, which is critical for nanoscale imaging. STED microscopy with a resolution of 60 nm requires special cranial window preparation to avoid motion artefacts. We have implemented a drain tube to reduce the fluid between the glass window and the surface of the brain, which has been identified as the main cause for the motion artefacts. Together, these advances in the preparation allow the use of a simple intraperitoneal anaesthesia and make the previously used venous infusion and artificial respiration obsolete.

BACKGROUND: Venovenous extracorporeal membrane oxygenation (VV-ECMO) is used when mechanical ventilation can no longer support oxygenation or ventilation, or if the risk of ventilator-induced lung injury is considered excessive. The optimum mechanical ventilation strategy once on ECMO is unknown. We sought to describe the practice of mechanical ventilation in children on VV-ECMO and to determine whether mechanical ventilation practices are associated with clinical outcomes. METHODS: We conducted a multicenter retrospective cohort study in 10 pediatric academic centers in the United States. Children age 14 d through 18 y on VV-ECMO from 2011 to 2016 were included. Exclusion criteria were preexisting chronic respiratory failure, primary diagnosis of asthma, cyanotic heart disease, or ECMO as a bridge to lung transplant. RESULTS: Conventional mechanical ventilation was used in about 75% of children on VV-ECMO; the remaining subjects were managed with a variety of approaches. With the exception of PEEP, there was large variation in ventilator settings. Ventilator mode and pressure settings were not associated with survival. Mean ventilator FIO2 on days 1–3 was higher in nonsurvivors than in survivors (0.5 vs 0.4, P = .009). In univariate analysis, other risk factors for mortality were female gender, higher Pediatric Risk Estimate Score for Children Using Extracorporeal Respiratory Support (Ped-RESCUERS), diagnosis of cancer or stem cell transplant, and number of days intubated prior to initiation of ECMO (all P 0.5) (46% vs 22%, P = .001). CONCLUSIONS: Ventilator mode and some settings vary in practice. The only ventilator setting associated with mortality was FIO2, even after adjustment for disease severity. Ventilator FIO2 is a modifiable setting that may contribute to mortality in children on VV-ECMO.

Background: Recruitment maneuvers are a dynamic process of transient increases in transpulmonary pressure intended to open unstable airless alveoli. Due to concerns regarding the hemodynamic consequences of recruitment maneuvers in children with heart disease, these maneuvers have not been widely utilized in this population. The objective of this study was to demonstrate the safety and efficacy of lung recruitment maneuvers in post-operative pediatric cardiac patients. We hypothesized that multiple recruitment maneuvers are physiologically beneficial and hemodynamically tolerated in children with congenital cardiac disease. Methods: Retrospective chart review was conducted of post-operative cardiac surgical subjects who received recruitment maneuvers, as well as a matched control group who did not, at a Cardiac ICU in a quaternary care free-standing children’s hospital. Repetitive lung recruitment maneuvers using incremental positive end-expiratory pressure were performed. Hemodynamic and respiratory physiologic variables were recorded. Results: Sixty-one post-operative cardiac subjects had a total of 435 lung recruitment maneuvers. Assessment of hemodynamic tolerability demonstrated no change in MAP, HR, or CVP during or after the maneuvers. There was a 28% increase in dynamic compliance following recruitment maneuvers (p

Background: The ABCDE bundle is a set of evidence-based practices to systematically reduce the risks of sedation, delirium, and immobility in intensive care patients. Implementing the bundle improves clinical outcome. Aims and Objectives: To investigate the association between patient outcomes and compliance with bundle components ABC (analgosedation algorithms), D (delirium protocol), and E (early mobilization protocol). Design: A Spanish multicentre cohort study of adult patients receiving invasive mechanical ventilation (IMV) for ≥48 h until extubation. Methods: The primary outcome was pain level, cooperation to permit Medical Research Council Scale administration, patient days of delirium, and mobility. The secondary outcome was cumulative drug dosing by IMV days. Tertiary outcomes (ICU days, IMV days, bed rest days, ICU mortality, ICUAW) and independent variables (analgosedation, delirium, early mobilization protocols) were also studied. Results: Data were collected from 605 patients in 80 ICUs and 5214 patient days with IMV. Two-thirds of the ICUs studied applied no protocols. Pain was not assessed on 83.6% of patient days. Patient cooperation made scale administration feasible on 20.7% of days. Delirium and immobility were found on 4.2% and 69.9% of days, respectively. Patients had shorter stays in ICUs with bundle protocols and fewer days of IMV in ICUs with delirium and mobilization bundle components (P = 0.006 and P = 0.03, respectively). Analgosedation protocols were associated with more opioid dosing (P = 0.02), and delirium and early mobilization protocols with more propofol (P = 0.001), dexmedetomidine (P = 0.001), and lower benzodiazepine dosing (P = 0.008). Conclusions: The implementation rate of ABCDE bundle components was very low in our Spanish setting, but when implemented, patients had a shorter ICU stay, more analgesia dosing, and lighter sedation. Relevance to clinical practice: Applying some but not all the bundle components, there is increased analgesia and light sedation drug use, decreased benzodiazepines, and increased patient cooperation and mobility, resulting in a shorter ICU stay and fewer days of IMV.

Background. Streptococcal toxic shock-like syndrome (TSLS) is a severe infection caused by group A hemolytic streptococcus. It is clinically characterized by rapidly progressive septic shock and multiple organ failure within just a few hours. TSLS presenting as primary peritonitis is rare, especially in a male. Herein, we report a case of TSLS in a male presenting with primary peritonitis, with a review of 25 cases in Japan. Case Presentation. A 51-year-old male was referred to our hospital with abdominal pain and hypotension. We made a preoperative diagnosis of peritonitis with septic shock and performed an emergency operation. Intraoperative findings indicated no marked origin of the peritonitis. Preoperative blood culture showed the presence of group A hemolytic streptococcus. The patient required intensive care involving artificial respiration, abdominal drainage and cytokine absorption therapy, and was discharged on postoperative day 25. Conclusion. TSLS in a male presenting as primary peritonitis is rare. Although this condition is a severe infection, it can be treated by multimodal therapy.

Rationale Deciding about pediatric home ventilation is exceptionally challenging for parents. Understanding the decision-making needs of parents who made different choices for their children could inform clinician counseling that better supports parents' diverse values and goals. Objectives To determine how clinicians can meet the decisional needs of parents considering home ventilation using a balanced sample of families who chose for or against intervention. Methods We conducted semi-structured interviews of parents who chose for or against home ventilation for their child within the previous five years. Parents were recruited from three academic centers across the United States. Interviews focused on parent-clinician communication during decision-making and how clinicians made the process easier or more difficult. Qualitative analysis was used to generate themes and identify key results. Results Thirty-eight parents were interviewed; 20 chose for and 18 chose against home ventilation. Five themes described their perspectives on how clinicians can facilitate high-quality decision-making: demonstrating dedication to families, effectively managing the medical team, introducing the concept of home ventilation with intention, facilitating meaningful conversation about the treatment options, and supporting and respecting the family's decision. Conclusions High quality decision-making around home ventilation depends on individual clinician actions and the complex operations of large academic settings. Strong working relationships with parents, collaborative alliances with colleagues, and appropriate delivery of key content can help meet the needs of parents considering invasive breathing supports for their children. This article is protected by copyright. All rights reserved.

Early delivery occurs increasingly often and involves underdeveloped lungs. Normally, lungs mature in the womb, but in the case of early delivery the maturing process takes place outside this protective environment. The most vulnerable infants receive at this stage so-called “surfactant therapy”, which facilitates the breathing, as well as mechanical respiration. However, applying therapies to these delicate lungs can unintentionally cause damage. This dissertation describes studies into the functions of the surfactant and shows that this therapy can keep inflammatory reactions within bounds. By means of a cell cultivation model that imitates the pulmonary alveoli, this dissertation shows also for the first time that surfactant has a positive influence on the wound recovery.

Orientadores: Sebastião Araujo Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas Resumo: Antecedentes. A aferição da pressão inspiratória máxima (PImax) é um método efetivo para avaliação da força muscular inspiratória, usada também como método diagnóstico e como índice preditivo de desmame da ventilação mecânica. Porém, não existe consenso na literatura sobre o tempo de oclusão de vias aéreas necessário para se obter uma PImax verdadeira durante o desmame da ventilação mecânica. Objetivos. Comparar dois métodos de mensuração da PImax e avaliar se o nível de consciência interfere nos valores obtidos. Métodos. Vinte e oito pacientes de ambos os sexos, hemodinamicamente estáveis, sem sedação, com suporte ventilatório mecânico por tempo = 48 horas, com parâmetros mínimos de desmame da ventilação, foram divididos em dois grupos: pacientes com pontuação na escala de coma de Glasgow (ECGL) = 15 e ECGL < 15. A aferição foi dividida em duas fases e, em cada fase, foram realizadas três mensurações com um intervalo de um minuto entre elas, obtendo-se assim a média entre as três: a via aérea foi ocluída com uma válvula unidirecional por 20 segundos (PImaxT20), ou, por um tempo máximo de um minuto, se um platô de pressão inspiratória não fosse observado durante três inspirações consecutivas (PImaxTid). Após um descanso de 15 minutos, foram realizadas novamente as mensurações na ordem previamente estabelecida (aleatória). Resultados. A média das medidas da PImaxTid (55,8 ± 25,0 cmH2O), no grupo total (n = 28), foi maior que a média das medidas da PImaxT20 (43,1 ± 15,5 cmH2O), com p = 0,002, e o tempo médio para a obtenção da PImaxTid foi de 30,2 ± 11 segundos. Quando divididos em dois grupos, ECGL = 15 (n = 14) e ECGL < 15 (n = 14), esse tempo médio foi de 23,8 ± 7,7 e 36,7 ± 10,0 segundos, respectivamente (p = 0,0019). Conclusões. A PImaxTid, neste grupo heterogêneo de pacientes em desmame da ventilação mecânica, mostrou valores superiores àqueles da PImaxT20, especialmente naqueles com algum grau de comprometimento do estado de consciência (ECGL < 15), sugerindo que necessitem de um tempo maior de oclusão da válvula unidirecional para se atingir a PImax real. Assim, o método comumente utilizado de 20s parece ser insuficiente para se mensurar a verdadeira PImax em pacientes com ECGL < 15. Novos estudos são necessários, agora num grupo mais homogêneo de pacientes (exemplo: com comprometimento neurológico estrutural), para determinar se realmente há necessidade de um tempo de oclusão maior que 20 segundos, ou se os valores obtidos no presente estudo simplesmente representam uma supervalorização desta PImax Abstract: Background. Maximum inspiratory pressure (PImax) is an effective parameter for the evaluation of inspiratory muscular force and an useful predictive index during weaning from mechanical ventilation (MV). However, there is no consensus in the literature concerning the time of airway occlusion necessary to get a true PImax during weaning from MV. Objectives. To compare two methods of PImax measurement and to evaluate the influence of patients¿ level of conscience (LOC) on their values. Methods. Twenty eight patients of both sexes, hemodynamically stable, without sedation, with MV support for a time = 48 hours and in a weaning process, were divided into two groups: patients with Glasgow coma scale score (GCS) = 15 and GCS < 15. PImax measurement was done in two phases and, in each phase, three measures, with an interval of one minute between them, had been carried through, getting thus the average between the three ones: the airway was occluded with an unidirectional valve for 20 seconds (PImaxT20), or, for a maximum time of one minute, if a plateau of inspiratory pressure was not observed during three consecutive inspirations (PImaxTid). After a rest of 15 minutes, PImax measurement had been carried through again in an order previously randomized. Results. The average of measures of the PImaxTid (55.8 ± 25.0 cmH2O), in the total group (n = 28), was greater that the average of the measures of the PImaxT20 (43.1 ± 15.5 cmH2O), with p = 0.002, and the average time for the attainment of the PImaxTid was of 30.2 ± 11 seconds. When divided in two groups, GCS = 15 (n = 14) and GCS < 15 (n = 14), the average times were of 23.8 ± 7.7 and 36.7 ± 10.0 seconds, respectively (p = 0.0019). Conclusions. PImaxTid, in this heterogeneous group of patients in MV weaning, has shown greater values than those of PImaxT20 especially in those with some degree of the state of LOC alteration (GCS < 15), suggesting that the formers need a longer time of airway occlusion with the unidirectional valve to reach the real PImax. Thus, the method commonly used of 20 seconds seems to be insufficient to measure the true PImax in patients with GCS

Funder: Humboldt-Universität zu Berlin (1034), PURPOSE: Adequate patient allocation is pivotal for optimal resource management in strained healthcare systems, and requires detailed knowledge of clinical and virological disease trajectories. The purpose of this work was to identify risk factors associated with need for invasive mechanical ventilation (IMV), to analyse viral kinetics in patients with and without IMV and to provide a comprehensive description of clinical course. METHODS: A cohort of 168 hospitalised adult COVID-19 patients enrolled in a prospective observational study at a large European tertiary care centre was analysed. RESULTS: Forty-four per cent (71/161) of patients required invasive mechanical ventilation (IMV). Shorter duration of symptoms before admission (aOR 1.22 per day less, 95% CI 1.10-1.37, p < 0.01) and history of hypertension (aOR 5.55, 95% CI 2.00-16.82, p < 0.01) were associated with need for IMV. Patients on IMV had higher maximal concentrations, slower decline rates, and longer shedding of SARS-CoV-2 than non-IMV patients (33 days, IQR 26-46.75, vs 18 days, IQR 16-46.75, respectively, p < 0.01). Median duration of hospitalisation was 9 days (IQR 6-15.5) for non-IMV and 49.5 days (IQR 36.8-82.5) for IMV patients. CONCLUSIONS: Our results indicate a short duration of symptoms before admission as a risk factor for severe disease that merits further investigation and different viral load kinetics in severely affected patients. Median duration of hospitalisation of IMV patients was longer than described for acute respiratory distress syndrome unrelated to COVID-19.

Background Previous studies have stated that hyperventilation often occurs in cardiopulmonary resuscitation (CPR) mainly due to excessive ventilation frequencies, especially when a manual valve bag is used. Transport ventilators may provide mandatory ventilation with predetermined tidal volumes and without the risk of hyperventilation. Nonetheless, interactions between chest compressions and ventilations are likely to occur. We investigated whether transport ventilators can provide adequate alveolar ventilation during continuous chest compression in adult CPR. Methods A three-period crossover study with three common transport ventilators in a cadaver model of CPR was carried out. The three ventilators ‘MEDUMAT Standard²’, ‘Oxylog 3000 plus’, and ‘Monnal T60’ represent three different interventions, providing volume-controlled continuous mandatory ventilation (VC-CMV) via an endotracheal tube with a tidal volume of 6 mL/kg predicted body weight. Proximal airflow was measured, and the net tidal volume was derived for each respiratory cycle. The deviation from the predetermined tidal volume was calculated and analysed. Several mixed linear models were calculated with the cadaver as a random factor and ventilator, height, sex, crossover period and incremental number of each ventilation within the period as covariates to evaluate differences between ventilators. Results Overall median deviation of net tidal volume from predetermined tidal volume was − 21.2 % (IQR: 19.6, range: [− 87.9 %; 25.8 %]) corresponding to a tidal volume of 4.75 mL/kg predicted body weight (IQR: 1.2, range: [0.7; 7.6]). In a mixed linear model, the ventilator model, the crossover period, and the cadaver’s height were significant factors for decreased tidal volume. The estimated effects of tidal volume deviation for each ventilator were − 14.5 % [95 %-CI: −22.5; −6.5] (p = 0.0004) for ‘Monnal T60’, − 30.6 % [95 %-CI: −38.6; −22.6] (p p Conclusions All investigated transport ventilators were able to provide alveolar ventilation even though chest compressions considerably decreased tidal volumes. Our results support the concept of using ventilators to avoid excessive ventilatory rates in CPR. This experimental study suggests that healthcare professionals should carefully monitor actual tidal volumes to recognise the occurrence of hypoventilation during continuous chest compressions.

Background Each July, teaching hospitals in the United States experience an influx of new resident and fellow physicians. It has been theorized that this occurrence may be associated with increased patient mortality, complication rates, and health care resource use, a phenomenon known as the “July effect.” Objective To assess the existence of a July effect in clinical outcomes of patients with acute respiratory distress syndrome (ARDS) receiving mechanical ventilation in the intensive care unit in US teaching hospitals. Methods The National Inpatient Sample database was queried for all adult patients with ARDS who received mechanical ventilation from 2012 to 2014. Using a multivariate difference-in-differences (DID) model, differences in mortality, ventilator-associated pneumonia, iatrogenic pneumothorax, central catheter–associated bloodstream infection, and Clostridium difficile infection were compared between teaching and nonteaching hospitals during April-May and July-August. Results There were 70 535 and 43 175 hospitalizations meeting study criteria in teaching and nonteaching hospitals, respectively. Multivariate analyses revealed no differential effect on the rates of all-cause inpatient mortality (DID, 0.66; 95% CI, −0.42 to 1.75), C difficile infection (DID, 0.29; 95% CI, −0.19 to 0.78), central catheter–associated bloodstream infection (DID, 0.14; 95% CI, −0.04 to 0.33), iatrogenic pneumothorax (DID, 0.00; 95% CI, −0.25 to 0.24), ventilator-associated pneumonia (DID, 0.22; 95% CI, −0.05 to 0.49), and any complication (DID, 0.60; 95% CI, −0.01 to 1.20) for July-August versus April-May in teaching hospitals compared with nonteaching hospitals. Conclusion This study did not show a differential July effect on mortality outcomes and complication rates in ARDS patients receiving mechanical ventilation in teaching hospitals compared with nonteaching hospitals.

BackgroundObjective and early identification of hospitalized patients, and particularly those with novel coronavirus disease 2019 (COVID-19), who may require mechanical ventilation (MV) may aid in delivering timely treatment.Research questionCan a transparent deep learning (DL) model predict the need for MV in hospitalized patients and those with COVID-19 up to 24h in advance?Study design and methodsWe trained and externally validated a transparent DL algorithm to predict the future need for MV in hospitalized patients, including those with COVID-19, using commonly available data in electronic health records. Additionally, commonly used clinical criteria (heart rate, oxygen saturation, respiratory rate, Fio2, and pH) were used to assess future need for MV. Performance of the algorithm was evaluated using the area under receiver operating characteristic curve (AUC), sensitivity, specificity, and positive predictive value.ResultsWe obtained data from more than 30,000 ICU patients (including more than 700 patients with COVID-19) from two academic medical centers. The performance of the model with a 24-h prediction horizon at the development and validation sites was comparable (AUC, 0.895 vs0.882, respectively), providing significant improvement over traditional clinical criteria (P< .001). Prospective validation of the algorithm among patients with COVID-19 yielded AUCs in the range of 0.918 to 0.943.InterpretationA transparent deep learning algorithm improves on traditional clinical criteria to predict the need for MV in hospitalized patients, including in those with COVID-19. Such an algorithm may help clinicians to optimize timing of tracheal intubation, to allocate resources and staff better, and to improve patient care.

BACKGROUND: Use of negative-pressure ventilation is neither well described nor widespread in pediatric critical care; existing data are from small, specialized populations. We sought to describe a general population of critically ill subjects with acute respiratory failure supported with negative-pressure ventilation to find predictors of response or failure. METHODS: We conducted a retrospective cohort study of subjects 0–18 y old admitted to a single (non-cardiac) pediatric ICU who received acute respiratory failure support via negative-pressure ventilation from May 2015 through May 2016. RESULTS: In 118 subjects, the most common causes of acute respiratory failure were viral bronchiolitis (86.4%) and pneumonia (15.3%). A majority of subjects (68.6%) stabilized with negative-pressure ventilation and did not need a change of respiratory support; in those who failed with negative-pressure ventilation, median time to respiratory support change was 5.1 h (interquartile range 1.9–11.0). Subjects stabilized with negative-pressure ventilation did not differ from those needing a change of respiratory support in terms of age, comorbidities, or FIO2 at initiation of ventilation. Compared to those who did not respond to negative-pressure ventilation, mean SpO2/FIO2 was higher at 1 h after start of negative-pressure ventilation (218.8 vs 131.7) in those who did respond. Subjects with SpO2/FIO2 97% at 1 h after the start of negative-pressure ventilation. CONCLUSIONS: Negative-pressure ventilation successfully supported 69% of pediatric subjects with all-cause acute respiratory failure. Oxygen requirement was lower in subjects who were responsive to negative-pressure ventilation within 1 h of initiation. Standardized negative-pressure ventilation protocols should include weaning of supplemental oxygen to determine responsiveness.

Introduction: Staphylococcal colonization is a risk factor for healthcare-associated infections, which are frequent in Neonatal Intensive Care Units (NICU). This study analyzed microbiology, epidemiology and clinical aspects of Staphylococcus spp. colonizing neonates. Methodology: Nasal or periumbilical swabs were evaluated from 175 newborns admitted to a NICU of a Rio de Janeiro hospital from March to September 2009. Clinical data were obtained from the medical records. SCCmec typing and the mecA and Panton-Valentine Leukocidin (PVL) genes were detected by PCR. Clonal diversity was evaluated by pulsed-field gel electrophoresis. Results: Staphylococcus spp. isolates were detected in 98 (56%) neonates, 66.3% of them had birth weight ≤ 2500 g, 62.2% were preterm (˂ 37 weeks) and the mean length of hospitalization was 14.9 days. Among the 133 isolates identified, 48.1% were S. epidermidis, 23.3% S. haemolyticus and 13.5% S. aureus. Methicillin-resistant Staphylococcus isolate was detected in 77.6% of neonates. The methicillin-resistant S. aureus isolates carried the SCCmec type IV, while 94.6% of S. epidermidis and 85.7% of S. haemolyticus presented non-typeable cassettes. Among the S. aureus, 55.6% had PVL genes and the USA800 genotype was prevalent. Two genotypes of S. epidermidis and one of S. haemolyticus clustered 42.2% and 25.8% of the isolates, respectively. S haemolyticus colonization was associated with the use of parenteral nutrition and mechanical ventilation. Conclusion: High rate of neonates colonized by methicillin-resistant Staphylococcus species and the permanence of clones circulating in the NICU highlight the importance for continuous and preventive surveillance in this high-risk population.

Mechanical ventilation is a well-established and commonly employed modality of treatment for critically ill patients in the ICU. Pneumonia is a frequent complication in mechanically ventilated patients. Patients who develop ventilator-associated pneumonia (VAP) incur higher medical costs, have prolonged ICU and hospital stays, and have increased mortality risk. There is growing interest in finding new treatment modalities for this condition because the success rate for treating VAP with systemic antibiotics continues to be < 70%. Accordingly, clinicians are reevaluating the role of aerosolized antibiotics, either as a sole therapy or as adjuncts to systemic antibiotics, in an attempt to improve clinical outcomes in patients with VAP. There are several clinical settings in which aerosolized antibiotics could be used for treating pneumonia, including their use for prevention, as monotherapy, as adjunctive therapy with systemic antibiotics, and for treatment of extensively drug-resistant or pan drug-resistant pathogens. However, aerosolized antibiotics have not been uniformly effective for improving clinical outcomes of patients with VAP, and local and systemic side effects could complicate their use. Moreover, many questions about aerosolized antibiotics, such as optimal formulations and dosage and treatment regimens, remain unanswered and warrant future investigations.

The effects of the route of nutrition on the gut mucosa of patients with shock are unclear. Plasma citrulline concentration is a marker of enterocyte mass, and plasma intestinal fatty acid binding protein (I-FABP) concentration is a marker of enterocyte damage. We aimed to study the effect of the route of nutrition on plasma citrulline concentration measured at day 3 of nutrition. Ancillary study of the NUTRIREA-2 trial. Ventilated adults with shock were randomly assigned to receive enteral or parenteral nutrition. Enterocyte biomarkers were measured at baseline, day 3, and day 8 of nutrition. A total of 165 patients from 13 French ICUs were included in the study: 85 patients in the enteral group and 80 patients in the parenteral group. At baseline, plasma citrulline was low without difference between groups (12.2 µmol L−1 vs 13.3 µmol L−1). At day 3, plasma citrulline concentration was higher in the enteral group than in the parenteral group (18.7 µmol L−1 vs 15.3 µmol L−1, p = 0.01). Plasma I-FABP concentration was increased at baseline, without difference between groups (245 pg mL−1 vs 244 pg mL−1). Plasma I-FABP concentration was higher in the enteral group than in the parenteral group at day 3 and day 8 (158 pg mL−1 vs 50 pg mL−1, p = 0.005 and 225 pg mL−1 vs 50 pg mL−1, p = 0.03). Plasma citrulline concentration was higher after 3 days of enteral nutrition than after 3 days of parenteral nutrition. This result raises the question of the possibility that enteral nutrition is associated with a more rapid restoration of enterocyte mass than parenteral nutrition.