Тривалість штучної вентиляції легень та функціонування діафрагми у дітей з гострою дихальною недостатністю

Background and purposeTracheostomy is a surgical procedure performed frequently in intensive care units (ICUs). Prolonged mechanical ventilation (MV) is the main indication for tracheostomy in ICUs. This study was conducted to investigate if early tracheostomy affects the duration of mechanical ventilation in patients with severe traumatic head injuries.Patients and MethodsIt is a prospective, randomized study in which patients with severe post-traumatic head injuries, with a Glasgow Coma Scale of less than 8, were included. Patients were randomized into two groups; group of early tracheostomy (ET) included 53 patients subjected to tracheostomy before the seventh day of intubation and group of late tracheostomy (LT) included 34 patients subjected to tracheostomy on or after the seventh day of intubation. The total duration of mechanical ventilation, the complications of tracheostomy, and mortality were recorded.ResultsThe mean duration of mechanical ventilation of ET group (ET=10.97±6.82) was statistically significantly shorter than the LT group (LT=16.28±8.65) (P=0.002). Complications were minor and not life threating. No mortalities were detected because of tracheostomy.ConclusionTracheostomy is a safe procedure with acceptable rate of minor complications. Early tracheostomy, before the seventh day of intubation, significantly shortens the duration of mechanical ventilation in patients with severe traumatic head injuries.

Background: Postoperative mechanical ventilation in liver transplant patient has an important role for reducing respiratory complications and multi-organ failure in intensive care unit (ICU). Yet there are no specific indications for predicting the duration of postoperative mechanical ventilation. Thus, we evaluated the correlation between the duration of mechanical ventilation and scoring systems such as the Acute Physiology and Chronic health Evaluation (APACHE) II score, the Sequential Organ Failure Assessment (SOFA) score, the Model for End-stage Liver Disease (MELD) score and the risk index. Methods: We retrospectively studied 183 patients who underwent living donor liver transplantation and we divided them into three groups based on the duration of mechanical ventilation: Group 1: 12 hr. We analyzed the correlation coefficients among the duration of mechanical ventilation, the risk index, and the SOFA, APACHE II and MELD scores. Results: The MELD and preoperative SOFA scores were significantly higher in group 3 (p = 0.003, p = 0.027). The MELD and SOFA scores were correlated with the duration of mechanical ventilation for all the patients (correlation coefficient = 0.22, 0.20, p = 0.003, 0.007, respectively). Yet the APACHE II score shows no correlation. Conclusions: We found that the MELD and SOFA scores were correlated with the duration of mechanical ventilation in liver transplant patients. Thus, these scoring systems may be useful to determine the duration of mechanical ventilation.

Myasthenic crisis (MC) is often associated with prolonged intubation and with respiratory complications. To assess predictors of ventilation duration and to compare the effectiveness of endotracheal intubation and mechanical ventilation (ET-MV) with bilevel positive airway pressure (BiPAP) noninvasive ventilation in MC. Retrospective cohort study. Academic research. Patients We reviewed consecutive episodes of MC treated at the Mayo Clinic, Rochester, Minnesota. Collected information included patients' demographic data, immunotherapy, medical complications, mechanical ventilation duration, and hospital lengths of stay, as well as baseline and preventilation measurements of forced vital capacity, maximal inspiratory and expiratory pressures, and arterial blood gases. We identified 60 episodes of MC in 52 patients. BiPAP was the initial method of ventilatory support in 24 episodes and ET-MV was performed in 36 episodes. There were no differences in patient demographics or in baseline respiratory variables and arterial gases between the groups of episodes initially treated using BiPAP vs ET-MV. In 14 episodes treated using BiPAP, intubation was avoided. The mean duration of BiPAP in these patients was 4.3 days. The only predictor of BiPAP failure (ie, requirement for intubation) was a Pco(2) level exceeding 45 mm Hg on BiPAP initiation (P= .04). The mean ventilation duration was 10.4 days. Longer ventilation duration was associated with intubation (P= .02), atelectasis (P< .005), and lower maximal expiratory pressure on arrival (P= .02). The intensive care unit and hospital lengths of stay statistically significantly increased with ventilation duration (P< .001 for both). The only variable associated with decreased ventilation duration was initial BiPAP treatment (P< .007). BiPAP is effective for the treatment of acute respiratory failure in patients with myasthenia gravis. A BiPAP trial before the development of hypercapnia can prevent intubation and prolonged ventilation, reducing pulmonary complications and lengths of intensive care unit and hospital stay.

Inhalation injury (IHI) causes significant morbidity and mortality in burn victims due to both local and systemic effects. Nebulized heparin promotes improvement in lung function and decreased mortality in IHI by reducing the inflammatory response and fibrin cast formation. The study objective was to determine if nebulized heparin 10,000 units improves lung function and decreases mechanical ventilation duration, mortality, and hospitalization length in IHI with minimal systemic adverse events. This retrospective, case-control study evaluated efficacy and safety of nebulized heparin administered to mechanically ventilated adults admitted within 48 hr of confirmed IHI. Nebulized heparin 10,000 units was administered Q4H for 7 days, or until extubation if sooner, alternating with albuterol and a mucolytic. Patients were matched on a case-by-case basis based on percent TBSA burn and age to patients from a historical group with IHI before heparin protocol implementation. The primary outcome was duration of mechanical ventilation. Secondary outcomes included lung injury score, ventilator-free days during the first 28 days, 28-day mortality, hospitalization length, ventilator-associated pneumonia incidence, bronchoscopy incidence, and bleeding events. Data were collected in 72 patients, 36 of which received nebulized heparin and 36 historical controls. Two patients from the heparin group and three patients from the control group died/were discharged while on the ventilator. Data were analyzed separately with 1) all subjects included and 2) with subjects who died/were discharged on the ventilator excluded. In the latter comparison, patients receiving nebulized heparin demonstrated a statistically significant decrease in median (interquartile range) duration of initial mechanical ventilation compared with controls [7.0 (4.0, 13.5) vs. 14.5 (5.3, 22.3) days; P = .044]. Patients in the heparin group had a significantly increased number of median (interquartile range) ventilator-free days in the first 28 days [21.0 (14.5-24.0) vs 13.5 (4.3-22.8) days; P = .031]. There were no differences in hospitalization length, lung injury score during the first 7 days post injury, 28-day mortality, ventilator-associated pneumonia rate, or bleeding events. Nebulized heparin 10,000 units in conjunction with a beta-agonist and mucolytic produced a significant decrease in duration of mechanical ventilation and increase in ventilator-free days in adult patients with IHI. Nebulized heparin was safe and did not result in an increase in bleeding events. To our knowledge, this is the first case-control study with matched cohorts based on age and %TBSA which are significant factors contributing to morbidity and mortality in IHI.

Surfactant Delivery Without Intubation in Preterm Infants

It has been proposed that neuromuscular or functional electrical stimulation may have effects on respiratory muscles through its systemic effects, similar to those produced by exercise training. However, its impact on the duration of invasive mechanical ventilation has not been adequately defined. We sought to evaluate the effect of neuromuscular or functional electrical stimulation on the duration of invasive mechanical ventilation in critically ill subjects. We systematically searched 3 databases up to August 2019 (ie, CENTRAL, MEDLINE, and EMBASE) as well as other resources to identify randomized controlled trials (RCTs) that evaluated the effects of neuromuscular or functional electrical stimulation compared to usual care/rehabilitation or placebo of neuromuscular or functional electrical stimulation on the duration of invasive mechanical ventilation. After reviewing 1,200 single records, 12 RCTs (N = 530 subjects) fulfilled our eligibility criteria. Three studies included only subjects with COPD (n = 106 subjects), whereas the rest considered subjects with different diseases. The most frequently stimulated muscle group was the quadriceps. Neuromuscular or functional electrical stimulation may decrease the duration of invasive mechanical ventilation (mean difference = -2.68 d, 95% CI -4.35 to -1.02, I2 = 50%, P = .002; 10 RCTs; low quality of evidence), and we are uncertain whether this effect may be more pronounced in subjects with COPD (mean difference = -2.90 d, 95% CI -4.58 to -1.23, I2 = 9%, P < .001; 3 RCTs; very low quality of evidence). Neuromuscular or functional electrical stimulation may slightly reduce the duration of invasive mechanical ventilation; we are uncertain whether these results are found in subjects with COPD compared to subjects receiving usual care or placebo, and the quality of the body of evidence is low to very low. More RCTs are needed with a larger number of subjects, with more homogeneous diseases and basal conditions, and especially with a more adequate methodological design.

Objective:Although mechanical ventilation is frequently a life-saving therapy, its use can result in unwanted side effects. It has been well documented that the choice of sedating agent may influence the duration of mechanical ventilation. Melatonin is a sedative and analgesic agent without any respiratory depressant effect which makes it an attractive adjuvant for sedation in the intubated patients. The aim of this study is to evaluate the effect of melatonin on the duration of mechanical ventilation in patients with hemorrhagic stroke.Methods:Forty adult intubated patients with hemorrhagic stroke, who were admitted to the Intensive Care Unit (ICU) within 24 h of onset, were enrolled in this randomized double-blind study. Subjects in the melatonin group received 30 mg of melatonin every night throughout the nasogastric tube. Length of ICU stay, mortality, and duration of mechanical ventilation were recorded for all patients.Findings:The duration of mechanical ventilation and length of ICU stay were shorter in patients who received melatonin in comparison with the control group, and this difference was statistically significant for the length of ICU stay and marginally significant for the duration of mechanical ventilation. Although not statistically significant, the mortality rate of the control group was 30%, almost double that of the study group (15%).Conclusion:Melatonin possesses hypnotic, analgesic, anti-inflammatory, and anti-oxidative properties that distinguish it as an attractive adjuvant in patients under mechanical ventilation. In conclusion, the administration of melatonin may facilitate the weaning process through decreasing the consumption of sedatives with respiratory depressant properties as well as preventing ventilator-associated lung injury.

Management of mechanically ventilated patients with bronchiolitis is not standardized and duration of mechanical ventilation has been shown to vary widely between centers. The aim of this study was to examine practice in a large number of U.K. PICUs with a view to identify if early management choices relating to fluid prescription, sedative agent use, and endotracheal tube (ETT) placement were associated with differences in duration of invasive mechanical ventilation (IMV). Retrospective multicenter cohort study. Primary outcome was duration of IMV. A hierarchical gamma generalized linear model was used to test for associations between practice variables (sedative and neuromuscular blocking agents, route of endotracheal intubation at 24 hr and fluid balance at 48 hr) and duration of IMV after adjustment for known confounders. Thirteen U.K. PICUs. Duration of 2 months between November and December 2019. Three hundred fifty infants receiving IMV for bronchiolitis. Excluded were patients receiving long-term ventilation, extracorporeal life support, or who died before separation from IMV. None. After adjustment for confounders, several variables were associated with an increase in the geometric mean duration of IMV (expressed as a percentage) including: nasal ETT use, 16% (95% CI, 1-32%); neuromuscular blockade use, 39% (95% CI, 21-61%); and fluid balance at 48 hr, 13% per 100 mL/kg positive fluid balance (95% CI, -1% to 28%). The association of sedative use varied with class of agent. The use of an alpha-2 agonist alone was associated with a reduction in duration of IMV by 19% in relation to no sedative agent (95% CI, -31 to -5%), whereas benzodiazepine uses alone or with alpha-2 agonist in combination were similar to using neither agent. Early management strategies for bronchiolitis were associated with the duration of IMV across U.K. centers after adjustment for confounders. Future work should prospectively assess the impact of fluid restriction, route of endotracheal intubation, and alpha-2 agonist use on duration of IMV in infants with bronchiolitis, with the aim of reducing seasonal bed pressure.

Noninvasive Inhaled Nitric Oxide Does Not Prevent Bronchopulmonary Dysplasia in Premature Newborns

Children with asthma exacerbations requiring pediatric ICU (PICU) admission, known as critical asthma (CA), are prescribed a variety of therapeutic interventions including heliox. Delivered invasively and noninvasively, heliox is employed to enhance deposition of aerosolized medications, improve obstructive pulmonary pathophysiology, and avoid complications associated with invasive mechanical ventilation. We used the Virtual Pediatric Systems database to update estimates of heliox prescription and explore for relationships between heliox and mechanical ventilation frequency and duration. We performed a retrospective cohort study using data from 97 PICUs among children 3-17 y of age admitted for CA from 2013-2019. The primary outcome was heliox prescribing rates and trends. Subgroup analyses assessed mechanical ventilation rates and duration by heliox exposure. Of 43,238 subjects studied, 1,070 (2.5%) were prescribed heliox. Mean heliox prescribing rates fell from 4.11% in 2013 to 2.37% in 2019. Heliox use was greater from centers in the South (2.6%) and Midwest (3.3%) as compared to the West (1.6%) and Northeast United States (1.6%, P < .001). In the subgroup assessing mechanical ventilation frequency, mechanical ventilation rates were 273/39,739 (0.7%) and greater for those provided heliox (1.9% vs 0.7%, P < .001). In the subgroup assessing mechanical ventilation duration, no differences in median mechanical ventilation duration were observed (4.94 [interquartile range [IQR] 3.04-6.36] vs 4.63 [IQR 3.11-7.30] d; P = .35) for those with and without heliox. In exploratory adjusted models, noninvasive heliox was not associated with mechanical ventilation. Mortality was rare (206/43,238 [0.47%]) and predominantly among subjects intubated prehospitalization (188/206 [91.3%]). Heliox as adjunctive therapy for children with CA is uncommon (2.5%) and not associated with mechanical ventilation or decreased mechanical ventilation duration in adjusted models. Updated estimates provided herein inform prospective controlled trial development to better define the role of heliox for CA.

To analyze the risk factors of prolonged mechanical ventilation (PMV) in patients with sepsis complicated by abdominal surgery, and to evaluate the predictive value of risk factors for PMV. A retrospective case-control study was conducted. The clinical data of patients with postoperative abdominal sepsis complicated with invasive mechanical ventilation who were admitted to the intensive care unit (ICU) of the Affiliated Hospital of Guizhou Medical University from January 1, 2018 to December 31, 2020 were collected. The patients were divided into PMV group (duration of mechanical ventilation longer than 48 hours) and non-PMV group (duration of mechanical ventilation shorter than 48 hours) according to the duration of mechanical ventilation in ICU. The patient's gender, age, body mass index (BMI), underlying diseases, mean arterial pressure (MAP), complete blood count, blood biochemistry, arterial blood gas, cardiac function indicators, procalcitonin (PCT) at admission to the ICU, the acute physiology and chronic health evaluation II (APACHE II) and the sequential organ failure assessment (SOFA) scores in the first 24 hours of admission to the ICU, and other clinical information were recorded. Univariate and multivariate Logistic regression models were used to analyze the risk factors for PMV. Receiver operator characteristic curve (ROC curve) was drawn to evaluate the predictive value of related indicators for PMV. A total of 195 patients with sepsis after abdominal surgery who received invasive mechanical ventilation were enrolled, including 127 males (65.1%) and 68 females (34.9%), with the median age of 65 (21, 93) years old. There were 91 patients (46.7%) in the non-PMV group and 104 patients (53.3%) in the PMV group. Univariate analysis showed that the APACHE II score, SOFA score, cardiac troponin T (cTnT), N-terminal pro-B type natriuretic peptide (NT-proBNP) in the PMV group were significantly higher than those in the non-PMV group. Oxygenation index (PaO2/FiO2), total protein (TP) and prealbumin (PA) in the PMV group were all lower than those in the non-PMV group when admitted to ICU. In the PMV group, serum creatinine (SCr), blood urea nitrogen (BUN), cystatin C (Cys C) were significantly increased, prothrombin time (PT) was significantly prolonged, the proportion of patients with septic shock and hypertension were significantly increased as compared with those in the non-PMV group. Multivariate analysis showed that low PaO2/FiO2 at ICU admission [odds ratio (OR) = 0.995, 95% confidence interval (95%CI) was 0.992-0.999, P = 0.010], high ln PCT (OR = 1.301, 95%CI was 1.088-1.555, P = 0.004), high ln cTnT (OR = 1.562, 95%CI was 1.079-2.261, P = 0.018) and septic shock (OR = 4.967, 95%CI was 2.461-10.026, P = 0.000) were the independent risk factors for PMV in patients with sepsis after abdominal surgery. ROC curve analysis showed that the PaO2/FiO2, ln cTnT, ln PCT and septic shock had certain predictive value for PMV, the area under the ROC curve (AUC) of the four variables were 0.607, 0.638, 0.690 and 0.711, the sensitivity was 50.0%, 62.5%, 86.5% and 74.0%, and the specificity was 71.4%, 62.6%, 48.3% and 68.1%, respectively. The AUC for the joint prediction of the four variables was 0.803, with a sensitivity of 76.0% and a specificity of 78.0%. It suggested that the multivariate joint prediction of PMV was more accurate. Decreased PaO2/FiO2, increased PCT, increased cTnT and the occurrence of septic shock are independent risk factors for PMV in patients with sepsis complicated by abdominal surgery. The combination of above four indices was more accurate than one single variable in predicting PMV and had higher diagnostic value.

Objective To study the efficacy of T-piece resuscitator on the very preterm infants in the delivery room. Method Very preterm infants (gestational age 28~31 weeks) who needed positive pressure ventilation during delivery room resuscitation were included in the study between January 2010 and December 2015. Enrolled infants were randomly assigned to self-inflating bag group and T-piece group.Tracheal intubation ratio, duration of mechanical ventilation, continuous positive airway pressure (CPAP), supplementary oxygen through a nasal cannula and total oxygen requirement were compared between groups. The percentages of pneumothorax, sepsis, necrotizing enterocolitis (NEC), bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), intracranial hemorrhage and patent ductus arteriosus (PDA) between groups were also compared. Data were analyzed using independent sample t test and chi-square test. Result A total of 51 preterm infants were enrolled in this study, with 25 infants in the self-inflating bag group and 26 in the T-piece group. There was no statistically significant difference in the gender, gestational age, birth weight, Apgar scores, delivery mode and antenatal glucocorticoids between the two groups (P>0.05). The ratio of intubation in T-piece group was significantly lower than that in self-inflating bag group (15.4% vs. 44.0%, P 0.05). Conclusion Compared with the self-inflating bag group, the use of the T-piece in delivery room decrease the rate of tracheal intubation and the duration of mechanical ventilation and total oxygen requirement. Key words: Resuscitation; Delivery rooms; Masks; T-Piece Resuscitator; Infant, premature

Is mechanical ventilation associated with intraventricular hemorrhage in preterm infants?

Clinical utility of rapid shallow breathing index in predicting successful weaning: secondary analysis of the COBRE-US trial

IntroductionNosocomial pneumonia is the most important infectious complication in patients admitted to intensive care units. Kinetic bed therapy may reduce the incidence of nosocomial pneumonia in mechanically ventilated patients. The objective of this study was to investigate whether kinetic bed therapy reduces the incidence of nosocomial pneumonia and improves outcomes in critically ill mechanically ventilated patients.MethodsWe searched Medline, EMBASE, CINAHL, CENTRAL, and AMED for studies, as well as reviewed abstracts of conference proceedings, bibliographies of included studies and review articles and contacted the manufacturers of medical beds. Studies included were randomized or pseudo-randomized clinical trials of kinetic bed therapy compared to standard manual turning in critically ill mechanically ventilated adult patients. Two reviewers independently applied the study selection criteria and extracted data regarding study validity, type of bed used, intensity of kinetic therapy, and population under investigation. Outcomes assessed included the incidence of nosocomial pneumonia, mortality, duration of ventilation, and intensive care unit and hospital length of stay.ResultsFifteen prospective clinical trials were identified, which included a total of 1,169 participants. No trial met all the validity criteria. There was a significant reduction in the incidence of nosocomial pneumonia (pooled odds ratio (OR) 0.38, 95% confidence interval (CI) 0.28 to 0.53), but no reduction in mortality (pooled OR 0.96, 95%CI 0.66 to1.14), duration of mechanical ventilation (pooled standardized mean difference (SMD) -0.14 days, 95%CI, -0.29 to 0.02), duration of intensive care unit stay (pooled SMD -0.064 days, 95% CI, -0.21 to 0.086) or duration of hospital stay (pooled SMD 0.05 days, 95% CI -0.18 to 0.27).ConclusionWhile kinetic bed therapy has been purported to reduce the incidence of nosocomial pneumonia in mechanically ventilated patients, the overall body of evidence is insufficient to support this conclusion. There appears to be a reduction in the incidence of nosocomial pneumonia, but no effect on mortality, duration of mechanical ventilation, or intensive care or hospital length of stay. Given the lack of consistent benefit and the poor methodological quality of the trials included in this analysis, definitive recommendations regarding the use of this therapy cannot be made at this time.