Dyspnea during tracheostomized weaning from Invasive Mechanical Ventilation

BackgroundLong-term invasive mechanical ventilation (IMV) is a major burden for those affected and causes high costs for the health care system. Early risk assessment is a prerequisite for the best possible support of high-risk patients during the weaning process. We aimed to identify risk factors for long-term IMV within 96 h (h) after the onset of IMV.MethodsThe analysis was based on data from one of Germany's largest statutory health insurance funds; patients who received IMV ≥ 96 h and were admitted in January 2015 at the earliest and discharged in December 2017 at the latest were analysed. OPS and ICD codes of IMV patients were considered, including the 365 days before intubation and 30 days after discharge. Long-term IMV was defined as evidence of invasive home mechanical ventilation (HMV), IMV ≥ 500 h, or readmission with (re)prolonged ventilation.ResultsIn the analysis of 7758 hospitalisations, criteria for long-term IMV were met in 38.3% of cases, of which 13.9% had evidence of HMV, 73.1% received IMV ≥ 500 h and/or 40.3% were re-hospitalised with IMV. Several independent risk factors were identified (p < 0.005 each), including pre-diagnoses such as pneumothorax (OR 2.10), acute pancreatitis (OR 2.64), eating disorders (OR 1.99) or rheumatic mitral valve disease (OR 1.89). Among ICU admissions, previous dependence on an aspirator or respirator (OR 5.13), and previous tracheostomy (OR 2.17) were particularly important, while neurosurgery (OR 2.61), early tracheostomy (OR 3.97) and treatment for severe respiratory failure such as positioning treatment (OR 2.31) and extracorporeal lung support (OR 1.80) were relevant procedures in the first 96 h after intubation.ConclusionThis comprehensive analysis of health claims has identified several risk factors for the risk of long-term ventilation. In addition to the known clinical risks, the information obtained may help to identify patients at risk at an early stage.Trial registration The PRiVENT study was retrospectively registered at ClinicalTrials.gov (NCT05260853). Registered at March 2, 2022.

Reply to: “Focus on the decisions to forego life-sustaining therapies during ICU stay of patients with cirrhosis and COVID-19: A case control study from the prospective COVID-ICU database”

Background: Administration of nebulized medications is a very common practice in the ICU. Although several aerosol generating devices can be selected, most ICUs use the small volume jet nebulizers. Although some recommendations on where to place aerosol generators when administering aerosol treatments to patients undergoing invasive and noninvasive mechanical ventilation or high-flow nasal cannula (HFNC) have been published, there are still many inconsistencies in the clinical setting. Placement of these aerosol generators can be adversely affected by humidification devices and lead to significant changes in pulmonary mechanics. The goal of this study was to determine where respiratory therapists (RTs) place nebulizer when administering a treatment in the ICU. Methods: For this prospective, observational study, pediatric and adult subjects who were placed on invasive mechanical ventilation (IMV), and noninvasive mechanical ventilation (NIV) or high flow nasal cannula (HFNC) with an order to receive a nebulized treatment were included. The study was conducted at a large university-affiliated hospital in Texas and was approved by the IRB. The research team communicated with RTs when it was time to administer an aerosol treatment to subjects in the ICU. Once the subject was identified, the electronic medical record was accessed to collect demographic information and placement of the nebulizer was documented in the data collection form as the treatment was administered. Results: A total of 32 subjects were selected for analysis; 18 from the pediatric ICU and 14 from the adult ICU. The majority of the sample was on IMV (50%), followed by HFNC (28.1%), and NIV (21.9%). The nebulizer was placed on the dry side of the heated humidifier (HH) in every patient on IMV. For all patients on NIV, nebulizers were placed on the inspiratory limb of the circuit between the interface and the exhalation valve. When placed on HFNC, the nebulizer was connected to the dry side of the HH in 3 subjects while 6 subjects had their nebulizers placed on the inspiratory limb of the breathing circuit. Conclusions: The results of this study suggest that while there is variation in regard to where RTs place the aerosol generator when using HFNC, they are consistent in their practice of placing the nebulizer when using IMV or NIV as recommended in published guidelines. Further evaluation of practices while delivering aerosol treatments to patients on HFNC may be required.

Respiratory support is an essential part of care during clinical course of premature infants. Despite the wide-spread use of non-invasive modes of ventilation today the most vulnerable extremely premature infants are still likely to require invasive mechanical ventilation. Multiple studies have been published addressing advantages and disadvantages of various modes of ventilation in neonates. In this review we critically evaluate data supporting use of different modalities of invasive mechanical ventilation in premature infants. Specific attention is paid to aspects of synchronized-and patient-triggered ventilation, comparison of volume-targeted, pressure-limited modes of ventilation and high frequency ventilation.

Age-Related Differences in Respiratory Outcomes Among Critically Ill Children with Guillain-Barré Syndrome.

Non-invasive mechanical ventilation and mortality in immunocompromised patients hospitalized with pneumonia

Objective To explore the clinical significance of early invasive mechanical ventilation for acute respiratory distress syndrome (ARDS) caused by thoracic trauma.Methods We retrospectively analyzed the clinical data of 93 patients of invasive mechanical ventilation in those with ARDS caused by thoracic trauma,and divided them into delayed invasive mechanical ventilation group (n =45) and timely invasive ventilation group (n =48) by the time of invasive mechanical ventilation.We compared the blood gas analysis,oxygen index,heart rate,lactic acid,muscle use score of the two groups before and after invasive mechanical ventilation and the differences of mechanical ventilation time,incidence of complications,mortality and length of hospital stay between the two groups.Results Each index of the delayed invasive mechanical ventilation group and the timely invasive ventilation group was calculated:PaO2 (63.2 ± 12.3,74.2 ± 12.1)mm Hg,PaCO2 (39.4 ±8.7,38.9 +7.6) mm Hg,PaO2/FiO2 (196.2 ± 17.8,231.4 ± 18.2),respiratory rate (27.4 ±3.7,21.1 ± 3.4) beats/min,heart rate (117.2 ± 26.8,96.0 ± 25.1) beats/min,accessory muscle use score (2.69 ± 0.15,1.67 ± 0.10),lactic acid (4.23 ± 1.70,2.12 ± 0.80) mmol/L Except for PaCO2,the differences of each index were statistically significant (t values were respectively 4.346,9.420,3.949,5.436,38.809,7.736; P ＜ 0.05).The duration of mechanical ventilation treatment (10.21 ± 1.50,6.47 ± 1.20) d and the length of hospital stay (21.53 ± 1.90,16.32 ±2.10) d of the delayed group and the timely group were significantly different (t values were respectively 12.518,13.318; P ＜ 0.01).The timely group had significantly lower mortality rate (26.7％ (12/45),14.6％ (7/48)),VAP (46.7％ (21/45),22.9％(11/48)),acute gastric mucosal lesions (33.3％ (15/45),12.5％ (6/48)),MODS (40.0％ (18/45),16.7％ (8/48)) than the delayed group (x2 values were respectively 3.86,5.81,4.49,5.70; P ＜ 0.05).There is no significant difference on the incidence of pneumothorax between the two groups (11.1％ (5/45),8.3％ (4/48)).Conclusion Invasive mechanical ventilation is an effective treatment of ARDS caused by chest trauma.Early invasive mechanical ventilation can reduce the mortality rate and shorten the duration of mechanical ventilation and hospital stay of the patients with ARDS after severe thoracic trauma. Key words: Chest injury; Acute respiratory distress syndrome; Mechanical ventilation

Introduction: Increased mortality due to COVID-19 in the intensive care unit (ICU) raised questions about the best way and time to use invasive mechanical ventilation (IMV). The purpose of this study is to analyze effectiveness of IMV in COVID-19 patients. Methods: We performed a retrospective analysis of adult patients admitted to our hospital with COVID-19 infection from May 2020 to December 2021. We reviewed the need of IMV in patients admitted to the ICU with APACHE II scores higher than 12.5. Outcomes from the IMV-receiving patients were compared to outcomes from patients on non-invasive mechanical ventilation (NIMV). The second analysis of IMV aimed to determine the best initiation time for IMV. Patients were divided into Group1: early intubation (IMV within the first 24hrs of admission) and Group2: late intubation (IMV later than 24hrs after admission). Primary outcomes included mortality and length of stay (LOS) in the ICU. Descriptive statistics, Mann-Whitney-U and Chi-square methods were used. Results: For the first part of the analysis, 82 patients were included. They were divided into 2 groups (IMV and NIMV) of 41 patients each. Median age in IMV group was 67 [51.5-75.5] vs 64 [47.5-73.5]. 21 (51.2%) patients died in the IMV group vs 22 (53.7%) X2(1, N=82)=0.049, p=0.5. Median LOS in the IMV group was 10 [6-16] days vs 11 [5-19.5] days U(NIMV group=41, NNIMV group=41)=819, z=-0.2, p=0.84. For the second analysis, 68 patients were included. They were divided into 2 groups (Group1 and 2) of 34 patients each. Median age in group1 was 53.5 [25-90] vs 53.5 [37.75-65.25]. 19 (55.9%) patients in group1 were male vs. 26 (76.5%). The median APACHE II, SOFA and ICHIKADO scores on admission in group1 were 8 [6-10.5], 1.5 [1-2], 120 [110-165] points respectively vs 9.5 [6-16.5], 2 [1-4], 150 [132.5-200] points. 3 (8.8%) patients died in group1 vs 11 (32.4%) X2(1, N=68)=5.76,p=0.033. Median LOS in group1 was 4.5 [3-8.5] days vs 6 [3.75-10.5] days U(NGroup1=34, NGroup2=34)=450, z=-1.59, p=0.113. Conclusions: In COVID-19 patients admitted to the ICU with APACHE II score higher than 12.5, mortality and LOS were not significantly different in patients that received IMV vs those that received NIMV. Early intubation correlated with improved mortality, but not with length of ICU stay.

Objective To observe the effect of invasive mechanical ventilation in different times for chronic obstructive pulmonary disease (AECOPD) combined with severe respiratory failure. Methods 136 patients with AECOPD combining severe respiratory failure treated at our hospital from August, 2014 to September, 2017 were selected, and were divided into an observation group and a control group by random number table method, 68 cases for each group. The observation group were treated with invasive mechanical ventilation within 6 h and the control group after 6 h. The changes of blood gas indexes, clinical indicators, and complications were compared. Results The PaCO2 was lower and the PaO2 and PaO2/FiO2 were higher after than before the treatment in both groups, and they were in the observation group than in the control group after the treatment, with statistical differences (all P < 0.05). The total invasive mechanical ventilation time, total mechanical ventilation time, and the ICU stay were (57.67±14.14) h, (152.57±27.74) h, and (6.71±1.36) d in the observation group, which were shorter than those in the control group, with statistical differences (all P < 0.05). The incidence ventilator associated pneumonia was lower in the observation group than in the control group (10.29% vs. 25.00%), with a statistical difference (P < 0.05). Conclusions Patients with AECOPD complicating severe respiratory failure and clear invasive mechanical ventilation related indications taking invasive mechanical ventilation therapy as early as possible can better improve their blood gas indexes and reduce mechanical ventilation time and the incidence of related complications, and is safe. Key words: Chronic obstructive pulmonary disease; Acute exacerbation; Severe respiratory failure; Invasive mechanical ventilation.

Funding Acknowledgements None. Background Invasive mechanical ventilation (IMV) is commonly used in the Cardiac Intensive Care Unit (CICU) in patients with cardiogenic shock (CS). IMV causes hemodynamic changes that may impact outcomes based upon a patient’s profile. Our aim is to characterize the clinical profile and detailed serial hemodynamic parameters in the first 24-hours according to the use of IMV in patients with shock admitted to the CICU. Methods Retrospective analysis of consecutive patients with shock admitted to the CICU at Bellevue Hospital, undergoing pulmonary artery catheter (PAC) placement within the first 24 hours of admission, from February 2022 to June 2023. Clinical characteristics, as well as specific hemodynamic parameters collected and curated at times 0, 6, 12, 18 and 24 hours were from PAC placement compared between patients with and without IMV. Results A total of 101 patients were included (95% with cardiogenic shock), 59 receiving IMV (age 64 ± 15, 24% women) and 42 non-intubated (61 ± 13, 33% women). Non-intubated patients had higher prevalence of hypertension, prior coronary artery disease and heart failure with reduced ejection fraction (HFrEF), while acute coronary syndromes (44%) and cardiac arrest (12%) were more common causes of admission in patients undergoing IMV. Mixed shock predominated in IMV patients (51 vs 17%, p &amp;lt;0.001), whereas cardiogenic shock (CS) was more common in non-intubated patients (83 vs 41%, p &amp;lt;0.01). Patients with acute myocardial infarction CS (AMI-CS) were more likely to undergo IMV, while patients with heart failure CS (HF-CS) were more likely to be non-intubated. Patients undergoing IMV were more likely to have mechanical circulatory support (MCS) and ventricular dilatation compared to non-intubated patients (LVEDD 5.7 cm vs 4.9 cm, p 0.002). Patients undergoing IMV had a higher incidence of severe shock compared to the non-intubated group (31% vs 19% SCAI Shock D), higher lactate levels and greater use of vasoactive drugs (figure 1A). Patients undergoing IMV had significant improvements in cardiac power output (CPO), diastolic blood pressure and systemic vascular resistance (SVR) (figure 1B). Shock severity by SCAI SHOCK classification had a more notable improvement at 24 hours in patients with IMV compared to non-intubated patients (figure 1C), with a non-statistically significant improvement in lactate clearance in the first 24 hours (Figure 1D). Conclusions IMV in patients with CS is more commonly seen in patients with AMI-CS and among those with higher baseline shock severity and greater use of vasoactive medications. IMV is associated with significant improvements in shock severity, CPO and SVR at 24 hours when compared to patients with shock who are not intubated, which could be related to higher use of vasopressors. Further investigations are warranted to understand the impact of IMV on outcomes of patients with CS and how they might vary according to hemodynamic profile.

Objective To discuss the clinical features and risk factors of death in children with severe pneumonia treated with invasive mechanical ventilation. Methods Through a retrospective analysis of children with severe pneumonia treated with invasive mechanical ventilation, who were hospitalized in PICU of Tianjin Children′s Hospital from Jan 2011 to Dec 2014, we analyzed the distribution of age, etiologic characteristics, mechanical ventilation, complications and background diseases.The single factor analysis and multiple factors Logistic regression analysis were performed to evaluate the risk factors of death. Results A total of 214 pediatric patients were included, 134 were male, and 80 were female.The case fatality rate was 6.17%, the relevance ratio of pathogenic microorganism was 16.36%.The median age of death group was older than that of the survival group(4 mouths vs 2 mouths, P=0.039). The pediatric patients who were more than 1 year old in death group were more than the survival group(21.43% vs 15.8%, P<0.001). The common complications included dencephalopathy(11.68%) and electrolyte imbalance(8.41%). Anemia, cardiopathy and alloplasia of respiratory system were the top background diseases.The results of Logistic multivariate regression analysis showed that there were significant differences in the age above 1 year old(OR: 1.019, 95%CI: 1.003-1.030, P=0.019), secondary acute respiratory distress syndrome(OR: 7.254, 95%CI: 1.581-33.277, P=0.011) and accompanying cardiopathy(OR: 0.47, 95%CI: 0.273-0.81, P=0.007). Conclusion The risk factors of death in children with severe pneumonia treated with invasive mechanical ventilation are the following: the age above 1 year old, secondary acute respiratory distress syndrome or accompanying cardiopathy. Key words: Severe pneumonia; Invasive mechanical ventilation; Clinical feature; Risk factors of death,

BackgroundInsight into COVID-19 intensive care unit (ICU) patient characteristics, rates and risks of invasive mechanical ventilation (IMV) and associated outcomes as well as any regional discrepancies is critical in this pandemic for individual case management and overall resource planning.Methods and findingsElectronic searches were performed for reports through May 1 2020 and reports on COVID-19 ICU admissions and outcomes were included using predefined search terms. Relevant data was subsequently extracted and pooled using fixed or random effects meta-analysis depending on heterogeneity. Study quality was assessed by the NIH tool and heterogeneity was assessed by I2 and Q tests. Baseline patient characteristics, ICU and IMV outcomes were pooled and meta-analyzed. Pooled odds ratios (pOR) were calculated for clinical features against ICU, IMV mortality. Subgroup analysis was carried out based on patient regions. A total of twenty-eight studies comprising 12,437 COVID-19 ICU admissions from seven countries were meta-analyzed. Pooled ICU admission rate was 21% [95% CI 0.12–0.34] and 69% of cases needed IMV [95% CI 0.61–0.75]. ICU and IMV mortality were 28.3% [95% CI 0.25–0.32], 43% [95% CI 0.29–0.58] and ICU, IMV duration was 7.78 [95% CI 6.99–8.63] and 10.12 [95% CI 7.08–13.16] days respectively. Besides confirming the significance of comorbidities and clinical findings of COVID-19 previously reported, we found the major correlates with ICU mortality were IMV [pOR 16.46, 95% CI 4.37–61.96], acute kidney injury (AKI) [pOR 12.47, 95% CI 1.52–102.7], and acute respiratory distress syndrome (ARDS) [pOR 6.52, 95% CI 2.66–16.01]. Subgroup analyses confirm significant regional discrepancies in outcomes.ConclusionsThis is a comprehensive systematic review and meta-analysis of COVID-19 ICU and IMV cases and associated outcomes. The significant association of AKI, ARDS and IMV with mortality has implications for ICU resource planning for AKI and ARDS as well as suggesting the need for further research into optimal ventilation strategies for COVID-19 patients in the ICU setting. Regional differences in outcome implies a need to develop region specific protocols for ventilatory support as well as overall treatment.

Aerosol delivery in models of pediatric high flow nasal oxygen and mechanical ventilation.

To characterize trends in noninvasive ventilation (NIV) and invasive mechanical ventilation (IMV) use over time in children with hematologic malignancy admitted to the PICU with acute respiratory failure (ARF), and to identify risk factors associated with NIV failure requiring transition to IMV. Retrospective cohort analysis using the Virtual Pediatric Systems (VPS, LLC) between January 1, 2010 and December 31, 2019. One hundred thirteen North American PICUs participating in VPS. Two thousand four hundred eighty children 0-21 years old with hematologic malignancy admitted to participating PICUs for ARF requiring respiratory support. None. There were 3013 total encounters, of which 868 (28.8%) received first-line NIV alone (NIV only), 1544 (51.2%) received first-line IMV (IMV only), and 601 (19.9%) required IMV after a failed NIV trial (NIV failure). From 2010 to 2019, the NIV only group increased from 9.6% to 43.1% and the IMV only group decreased from 80.1% to 34.2% (p < 0.001). The NIV failure group had the highest mortality compared with NIV only and IMV only (36.6% vs. 8.1%, vs. 30.5%, p < 0.001). However, risk-of-mortality (ROM) was highest in the IMV only group compared with NIV only and NIV failure (median Pediatric Risk of Mortality III ROM 8.1% vs. 2.8% vs. 5.5%, p < 0.001). NIV failure patients also had the longest median PICU length of stay compared with the other two study groups (15.2 d vs. 6.1 and 9.0 d, p < 0.001). Higher age was associated with significantly decreased odds of NIV failure, and diagnosis of non-Hodgkin lymphoma was associated with significantly increased odds of NIV failure compared with acute lymphoid leukemia. For children with hematologic malignancy admitted to the PICU with ARF, NIV has replaced IMV as the most common initial therapy. NIV failure rate remains high with high-observed mortality despite lower PICU admission ROM.

End-of-life care is costly, and decedents often experience overtreatment or low-quality care. Noninvasive ventilation (NIV) may be a palliative approach to avoid invasive mechanical ventilation (IMV) among select patients who are hospitalized at the end of life. To examine the trends in NIV and IMV use among decedents with a hospitalization in the last 30 days of life. This population-based cohort study used a 20% random sample of Medicare fee-for-service beneficiaries who had an acute care hospitalization in the last 30 days of life and died between January 1, 2000, and December 31, 2017. Sociodemographic, diagnosis, and comorbidity data were obtained from Medicare claims data. Data analysis was performed from September 2019 to July 2020. Use of NIV or IMV. Validated International Classification of Diseases, Ninth Revision, Clinical Modification or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification procedure codes were reviewed to identify use of NIV, IMV, both NIV and IMV, or none. Four subcohorts of Medicare beneficiaries were identified using primary admitting diagnosis codes (chronic obstructive pulmonary disease [COPD], congested heart failure [CHF], cancer, and dementia). Measures of end-of-life care included in-hospital death (acute care setting), hospice enrollment at death, and hospice enrollment in the last 3 days of life. Random-effects logistic regression examined NIV and IMV use adjusted for sociodemographic characteristics, admitting diagnosis, and comorbidities. A total of 2 470 435 Medicare beneficiaries (1 353 798 women [54.8%]; mean [SD] age, 82.2 [8.2] years) were hospitalized within 30 days of death. Compared with 2000, the adjusted odds ratio (AOR) for the increase in NIV use was 2.63 (95% CI, 2.46-2.82; % receipt: 0.8% vs 2.0%) for 2005 and 11.84 (95% CI, 11.11-12.61; % receipt: 0.8% vs 7.1%) for 2017. Compared with 2000, the AOR for the increase in IMV use was 1.04 (95% CI, 1.02-1.06; % receipt: 15.0% vs 15.2%) for 2005 and 1.63 (95% CI, 1.59-1.66; % receipt: 15.0% vs 18.2%) for 2017. In subanalyses comparing 2017 with 2000, similar trends found increased NIV among patients with CHF (% receipt: 1.4% vs 14.2%; AOR, 14.14 [95% CI, 11.77-16.98]) and COPD (% receipt: 2.7% vs 14.5%; AOR, 8.22 [95% CI, 6.42-10.52]), with reciprocal stabilization in IMV use among patients with CHF (% receipt: 11.1% vs 7.8%; AOR, 1.07 [95% CI, 0.95-1.19]) and COPD (% receipt: 17.4% vs 13.2%; AOR, 1.03 [95% CI, 0.88-1.21]). The AOR for increased NIV use was 10.82 (95% CI, 8.16-14.34; % receipt: 0.4% vs 3.5%) among decedents with cancer and 9.62 (95% CI, 7.61-12.15; % receipt: 0.6% vs 5.2%) among decedents with dementia. The AOR for increased IMV use was 1.40 (95% CI, 1.26-1.55; % receipt: 6.2% vs 7.6%) among decedents with cancer and 1.28 (95% CI, 1.17-1.41; % receipt: 5.7% vs 6.2%) among decedents with dementia. Among decedents with NIV vs IMV use, lower rates of in-hospital death (50.3% [95% CI, 49.3%-51.3%] vs 76.7% [95% CI, 75.9%-77.5%]) and hospice enrollment in the last 3 days of life (57.7% [95% CI, 56.2%-59.3%] vs 63.0% [95% CI, 60.9%-65.1%]) were observed along with higher rates of hospice enrollment (41.3% [95% CI, 40.4%-42.3%] vs 20.0% [95% CI, 19.2%-20.7%]). This study found that the use of NIV rapidly increased from 2000 through 2017 among Medicare beneficiaries at the end of life, especially among persons with cancer and dementia. The findings suggest that trials to evaluate the outcomes of NIV are warranted to inform discussions about the goals of this therapy between clinicians and patients and their health care proxies.