Acute and Critical Care

Guideline

Pulmonary
Liberation from mechanical ventilation in critically ill patients: Korean Society of Critical Care Medicine Clinical Practice Guidelines: Tae Sun Ha, Dong Kyu Oh, Hak-Jae Lee, Youjin Chang, In Seok Jeong, Yun Su Sim, Suk-Kyung Hong, Sunghoon Park, Gee Young Suh, So Young Park; Acute Crit Care. 2024;39(1):1-23. Published online February 28, 2024; DOI: https://doi.org/10.4266/acc.2024.00052

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Abstract PDF Supplementary Material: Background
Successful liberation from mechanical ventilation is one of the most crucial processes in critical care because it is the first step by which a respiratory failure patient begins to transition out of the intensive care unit and return to their own life. Therefore, when devising appropriate strategies for removing mechanical ventilation, it is essential to consider not only the individual experiences of healthcare professionals, but also scientific and systematic approaches. Recently, numerous studies have investigated methods and tools for identifying when mechanically ventilated patients are ready to breathe on their own. The Korean Society of Critical Care Medicine therefore provides these recommendations to clinicians about liberation from the ventilator. Methods: Meta-analyses and comprehensive syntheses were used to thoroughly review, compile, and summarize the complete body of relevant evidence. All studies were meticulously assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) method, and the outcomes were presented succinctly as evidence profiles. Those evidence syntheses were discussed by a multidisciplinary committee of experts in mechanical ventilation, who then developed and approved recommendations. Results: Recommendations for nine PICO (population, intervention, comparator, and outcome) questions about ventilator liberation are presented in this document. This guideline includes seven conditional recommendations, one expert consensus recommendation, and one conditional deferred recommendation. Conclusions: We developed these clinical guidelines for mechanical ventilation liberation to provide meaningful recommendations. These guidelines reflect the best treatment for patients seeking liberation from mechanical ventilation.

Original Articles

Nutrition
Association of malnutrition status with 30-day mortality in patients with sepsis using objective nutritional indices: a multicenter retrospective study in South Korea: Moon Seong Baek, Young Suk Kwon, Sang Soo Kang, Daechul Shim, Youngsang Yoon, Jong Ho Kim; Acute Crit Care. 2024;39(1):127-137. Published online February 20, 2024; DOI: https://doi.org/10.4266/acc.2023.01613

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Abstract PDF Supplementary Material: Background
The Controlling Nutritional Status (CONUT) score and the prognostic nutritional index (PNI) have emerged as important nutritional indices because they provide an objective assessment based on data. We aimed to investigate how these nutritional indices relate to outcomes in patients with sepsis. Methods: Data were collected retrospectively at five hospitals for patients aged ≥18 years receiving treatment for sepsis between January 1, 2017, and December 31, 2021. Serum albumin and total cholesterol concentrations, and peripheral lymphocytes were used to calculate the CONUT score and PNI. To identify predictors correlated with 30-day mortality, analyses were conducted using univariate and multivariate Cox proportional hazards models. Results: The 30-day mortality rate among 9,763 patients was 15.8% (n=1,546). The median CONUT score was 5 (interquartile range [IQR], 3–7) and the median PNI score was 39.6 (IQR, 33.846.4). Higher 30-day mortality rates were associated with individuals with moderate (CONUT score: 5–8; PNI: 35–38) or severe (CONUT: 9–12; PNI: <35) malnutrition compared with those with no malnutrition (CONUT: 0–1; PNI: >38). With CONUT scores, the hazard ratio (HR) associated with moderate malnutrition was 1.52 (95% confidence interval [CI], 1.24–1.87; P<0.001); for severe, HR=2.42 (95% CI, 1.95–3.02; P<0.001). With PNI scores, the HR for moderate malnutrition was 1.29 (95% CI, 1.09–1.53; P=0.003); for severe, HR=1.88 (95% CI, 1.67–2.12; P<0.001). Conclusions: The nutritional indices CONUT score and PNI showed significant associations with mortality of sepsis patients within 30 days.

Pulmonary
Factors related to lung function outcomes in critically ill COVID-19 patients in South Korea: Tae Hun Kim, Myung Jin Song, Sung Yoon Lim, Yeon Joo Lee, Young-Jae Cho; Acute Crit Care. 2024;39(1):100-107. Published online February 20, 2024; DOI: https://doi.org/10.4266/acc.2023.00668

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Abstract PDF Supplementary Material: Background
New variants of the virus responsible for the coronavirus disease 2019 (COVID-19) pandemic continue to emerge. However, little is known about the effect of these variants on clinical outcomes. This study evaluated the risk factors for poor pulmonary lung function test (PFT). Methods: The study retrospectively analyzed 87 patients in a single hospital and followed up by performing PFTs at an outpatient clinic from January 2020 to December 2021. COVID-19 variants were categorized as either a non-delta variant (November 13, 2020–July 6, 2021) or the delta variant (July 7, 2021–January 29, 2022). Results: The median age of the patients was 62 years, and 56 patients (64.4%) were male. Mechanical ventilation (MV) was provided for 52 patients, and 36 (41.4%) had restrictive lung defects. Forced vital capacity (FVC) and diffusion capacity of the lung for carbon monoxide (DLCO ) were lower in patients on MV. Male sex (odds ratio [OR], 0.228) and MV (OR, 4.663) were significant factors for decreased DLCO . The duration of MV was associated with decreased FVC and DLCO . However, the type of variant did not affect the decrease in FVC (P=0.750) and DLCO (P=0.639). Conclusions: Among critically ill COVID-19 patients, 40% had restrictive patterns with decreased DLCO . The reduction of PFT was associated with MV, type of variants.

Pulmonary
Mechanically ventilated COVID-19 patients admitted to the intensive care unit in the United States with or without respiratory failure secondary to COVID-19 pneumonia: a retrospective comparison of characteristics and outcomes: Jesse A. Johnson, Kashka F. Mallari, Vincent M. Pepe, Taylor Treacy, Gregory McDonough, Phue Khaing, Christopher McGrath, Brandon J. George, Erika J. Yoo; Acute Crit Care. 2023;38(3):298-307. Published online August 23, 2023; DOI: https://doi.org/10.4266/acc.2022.01123

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Abstract PDF Supplementary Material

Background
There is increasing heterogeneity in the clinical phenotype of patients admitted to the intensive care unit (ICU) with coronavirus disease 2019 (COVID-19,) and reasons for mechanical ventilation are not limited to COVID pneumonia. We aimed to compare the characteristics and outcomes of intubated patients admitted to the ICU with the primary diagnosis of acute hypoxemic respiratory failure (AHRF) from COVID-19 pneumonia to those patients admitted for an alternative diagnosis.
Methods
Retrospective cohort study of adults with confirmed SARS-CoV-2 infection admitted to nine ICUs between March 18, 2020, and April 30, 2021, at an urban university institution. We compared characteristics between the two groups using appropriate statistics. We performed logistic regression to identify risk factors for death in the mechanically ventilated COVID-19 population.
Results
After exclusions, the final sample consisted of 319 patients with respiratory failure secondary to COVID pneumonia and 150 patients intubated for alternative diagnoses. The former group had higher ICU and hospital mortality rates (57.7% vs. 36.7%, P<0.001 and 58.9% vs. 39.3%, P<0.001, respectively). Patients with AHRF secondary to COVID-19 pneumonia also had longer ICU and hospital lengths-of-stay (12 vs. 6 days, P<0.001 and 20 vs. 13.5 days, P=0.001). After risk-adjustment, these patients had 2.25 times higher odds of death (95% confidence interval, 1.42–3.56; P=0.001).
Conclusions
Mechanically ventilated COVID-19 patients admitted to the ICU with COVID-19-associated respiratory failure are at higher risk of hospital death and have worse ICU utilization outcomes than those whose reason for admission is unrelated to COVID pneumonia.

Citations

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Bacterial Community- and Hospital-Acquired Pneumonia in Patients with Critical COVID-19—A Prospective Monocentric Cohort Study
Lenka Doubravská, Miroslava Htoutou Sedláková, Kateřina Fišerová, Olga Klementová, Radovan Turek, Kateřina Langová, Milan Kolář
Antibiotics.2024; 13(2): 192. CrossRef

Pulmonary
The role of ROX index–based intubation in COVID-19 pneumonia: a cross-sectional comparison and retrospective survival analysis: Sara Vergis, Sam Philip, Vergis Paul, Manjit George, Nevil C Philip, Mithu Tomy; Acute Crit Care. 2023;38(2):182-189. Published online May 25, 2023; DOI: https://doi.org/10.4266/acc.2022.00206

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Abstract PDF: Background
Coronavirus disease 2019 (COVID-19) patients with acute respiratory failure who experience delayed initiation of invasive mechanical ventilation have poor outcomes. The lack of objective measures to define the timing of intubation is an area of concern. We investigated the effect of timing of intubation based on respiratory rate-oxygenation (ROX) index on the outcomes of COVID-19 pneumonia. Methods: This was a retrospective cross-sectional study performed in a tertiary care teaching hospital in Kerala, India. Patients with COVID-19 pneumonia who were intubated were grouped into early intubation (within 12 hours of ROX index <4.88) or delayed intubation (12 hours or more hours after ROX <4.88). Results: A total of 58 patients was included in the study after exclusions. Among them, 20 patients were intubated early, and 38 patients were intubated 12 hours after ROX index <4.88. The mean age of the study population was 57±14 years, and 55.0% of the patients were male; diabetes mellitus (48.3%) and hypertension (50.0%) were the most common comorbidities. The early intubation group had 88.2% successful extubation, while only 11.8% of the delayed group had successful extubation (P<0.001). Survival was also significantly more frequent in the early intubation group. Conclusions: Early intubation within 12 hours of ROX index <4.88 was associated with improved extubation and survival in patients with COVID-19 pneumonia.

Pulmonary
Characteristics and outcomes of patients with chronic obstructive pulmonary disease admitted to the intensive care unit due to acute hypercapnic respiratory failure: Türkay Akbaş, Harun Güneş; Acute Crit Care. 2023;38(1):49-56. Published online February 27, 2023; DOI: https://doi.org/10.4266/acc.2022.01011

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Abstract PDF

Background
The study aimed to describe the clinical course, outcomes, and prognostic factors of chronic obstructive pulmonary disease (COPD) patients with acute hypercapnic respiratory failure. Methods: This retrospective study involved patients with acute hypercapnic respiratory failure due to COPD of any cause admitted to the intensive care unit (ICU) for non-invasive or invasive mechanical ventilation (IMV) support between December 2015 and February 2020. Results: One hundred patients were evaluated. The main causes of acute hypercapnic respiratory failure were bronchitis, pneumonia, and heart failure. The patients’ mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 23.0±7.2, and their IMV rate was 43%. ICU, in-hospital, and 90-day mortality rates were 21%, 29%, and 39%, respectively. Non-survivors had more pneumonia, shock within the first 24 hours of admission, IMV, vasopressor use, and renal replacement therapy, along with higher APACHE II scores, lower admission albumin levels and PaO2/ FiO2 ratios, and longer ICU and hospital stays than survivors. Logistic regression analysis identified APACHE II score (odds ratio [OR], 1.157; 95% confidence interval [CI], 1.017–1.317; P=0.026), admission PaO2/FiO2 ratio (OR, 0.989; 95% CI, 0.978–0.999; P=0.046), and vasopressor use (OR, 8.827; 95% CI, 1.650–47.215; P=0.011) as predictors of ICU mortality. APACHE II score (OR, 1.099; 95% CI, 1.021–1.182; P=0.011) and admission albumin level (OR, 0.169; 95% CI, 0.056–0.514; P=0.002) emerged as predictors of 90-day mortality. Conclusions: APACHE II scores, the PaO2/FiO2 ratio, vasopressor use, and albumin levels are significant short-term mortality predictors in severely ill COPD patients with acute hypercapnic respiratory failure.

Citations

Citations to this article as recorded by

Antibiotics in COPD exacerbations requiring mechanical ventilation: a dogma to be re-evaluated
Sebastian Osorio-Rico, Daniel Perez-Marin, John Cardeño-Sanchez
Internal and Emergency Medicine.2024;[Epub] CrossRef
Opportunities and perspectives of small molecular phosphodiesterase inhibitors in neurodegenerative diseases
Qi Li, Qinghong Liao, Shulei Qi, He Huang, Siyu He, Weiping Lyu, Jinxin Liang, Huan Qin, Zimeng Cheng, Fan Yu, Xue Dong, Ziming Wang, Lingfei Han, Yantao Han
European Journal of Medicinal Chemistry.2024; 271: 116386. CrossRef
COPD Exacerbation: Why It Is Important to Avoid ICU Admission
Irene Prediletto, Gilda Giancotti, Stefano Nava
Journal of Clinical Medicine.2023; 12(10): 3369. CrossRef

Infection
Predicting factors associated with prolonged intensive care unit stay of patients with COVID-19: Won Ho Han, Jae Hoon Lee, June Young Chun, Young Ju Choi, Youseok Kim, Mira Han, Jee Hee Kim; Acute Crit Care. 2023;38(1):41-48. Published online February 22, 2023; DOI: https://doi.org/10.4266/acc.2022.01235

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Abstract PDF

Background
Predicting the length of stay (LOS) for coronavirus disease 2019 (COVID-19) patients in the intensive care unit (ICU) is essential for efficient use of ICU resources. We analyzed the clinical characteristics of patients with severe COVID-19 based on their clinical care and determined the predictive factors associated with prolonged LOS. Methods: We included 96 COVID-19 patients who received oxygen therapy at a high-flow nasal cannula level or above after ICU admission during March 2021 to February 2022. The demographic characteristics at the time of ICU admission and results of severity analysis (Sequential Organ Failure Assessment [SOFA], Acute Physiology and Chronic Health Evaluation [APACHE] II), blood tests, and ICU treatments were analyzed using a logistic regression model. Additionally, blood tests (C-reactive protein, D-dimer, and the PaO2 to FiO2 ratio [P/F ratio]) were performed on days 3 and 5 of ICU admission to identify factors associated with prolonged LOS. Results: Univariable analyses showed statistically significant results for SOFA score at the time of ICU admission, C-reactive protein level, high-dose steroids, mechanical ventilation (MV) care, continuous renal replacement therapy, extracorporeal membrane oxygenation, and prone position. Multivariable analysis showed that MV care and P/F ratio on hospital day 5 were independent factors for prolonged ICU LOS. For D-dimer, no significant variation was observed at admission; however, after days 3 and 5 days of admission, significant between-group variation was detected. Conclusions: MV care and P/F ratio on hospital day 5 are independent factors that can predict prolonged LOS for COVID-19 patients.

Citations

Citations to this article as recorded by

Predictors of prolonged ventilator weaning and mortality in critically ill patients with COVID-19
Marcella M Musumeci, Bruno Valle Pinheiro2, Luciana Dias Chiavegato1, Danielle Silva Almeida Phillip1, Flavia R Machado3, Fabrício Freires3, Osvaldo Shigueomi Beppu1, Jaquelina Sonoe Ota Arakaki1, Roberta Pulcheri Ramos1
Jornal Brasileiro de Pneumologia.2023; : e20230131. CrossRef
The distorted memories of patients treated in the intensive care unit during the COVID-19 pandemic: A qualitative study
Gisela Vogel, Ulla Forinder, Anna Sandgren, Christer Svensen, Eva Joelsson-Alm
Intensive and Critical Care Nursing.2023; 79: 103522. CrossRef

Review Article

Pulmonary
Asynchronies during invasive mechanical ventilation: narrative review and update: Santiago Nicolás Saavedra, Patrick Valentino Sepúlveda Barisich, José Benito Parra Maldonado, Romina Belén Lumini, Alberto Gómez-González, Adrián Gallardo; Acute Crit Care. 2022;37(4):491-501. Published online November 30, 2022; DOI: https://doi.org/10.4266/acc.2022.01158

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Abstract PDF Supplementary Material

Invasive mechanical ventilation is a frequent therapy in critically ill patients in critical care units. To achieve favorable outcomes, patient and ventilator interaction must be adequate. However, many clinical situations could attempt against this principle and generate a mismatch between these two actors. These asynchronies can lead the patient to worst outcomes; that is why it is vital to recognize and treat these entities as soon as possible. Early detection and recognition of the different asynchronies could favor the reduction of the days of mechanical ventilation, the days of hospital stay, and intensive care and improve clinical results.

Citations

Citations to this article as recorded by

Patient Self-Inflicted Lung Injury—A Narrative Review of Pathophysiology, Early Recognition, and Management Options
Peter Sklienka, Michal Frelich, Filip Burša
Journal of Personalized Medicine.2023; 13(4): 593. CrossRef
Actualización sobre sedoanalgesia en paciente bajo ventilación mecánica
Onan Emanuel Gregorio
Revista de Postgrados de Medicina.2022; 1(1): 27. CrossRef

Original Articles

Pulmonary
Agreement between two methods for assessment of maximal inspiratory pressure in patients weaning from mechanical ventilation: Emanuelle Olympia Silva Ribeiro, Rik Gosselink, Lizandra Eveline da Silva Moura, Raissa Farias Correia, Wagner Souza Leite, Maria das Graças Rodrigues de Araújo, Armele Dornelas de Andrade, Daniella Cunha Brandão, Shirley Lima Campos; Acute Crit Care. 2022;37(4):592-600. Published online October 27, 2022; DOI: https://doi.org/10.4266/acc.2022.00325

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Abstract PDF: Background
Respiratory muscle strength in patients with an artificial airway is commonly assessed as the maximal inspiratory pressure (MIP) and is measured using analogue or digital manometers. Recently, new electronic loading devices have been proposed to measure respiratory muscle strength. This study evaluates the agreement between the MIPs measured by a digital manometer and those according to an electronic loading device in patients being weaned from mechanical ventilation. Methods: In this prospective study, the standard MIP was obtained using a protocol adapted from Marini, in which repetitive inspiratory efforts were performed against an occluded airway with a one-way valve and were recorded with a digital manometer for 40 seconds (MIPDM). The MIP measured using the electronic loading device (MIPELD) was obtained from repetitively tapered flow resistive inspirations sustained for at least 2 seconds during a 40-second test. The agreement between the results was verified by a Bland-Altman analysis. Results: A total of 39 subjects (17 men, 55.4±17.7 years) was enrolled. Although a strong correlation between MIPDM and MIPELD (R=0.73, P<0.001) was observed, the Bland-Altman analysis showed a high bias of –47.4 (standard deviation, 22.3 cm H2O; 95% confidence interval, –54.7 to –40.2 cm H2O). Conclusions: The protocol of repetitively tapering flow resistive inspirations to measure the MIP with the electronic loading device is not in agreement with the standard protocol using one-way valve inspiratory occlusion when applied in poorly cooperative patients being weaned from mechanical ventilation.

Pulmonary
An algorithm to predict the need for invasive mechanical ventilation in hospitalized COVID-19 patients: the experience in Sao Paulo: Eduardo Atsushi Osawa, Alexandre Toledo Maciel; Acute Crit Care. 2022;37(4):580-591. Published online September 8, 2022; DOI: https://doi.org/10.4266/acc.2022.00283

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Abstract PDF: Background
We aimed to characterize patients hospitalized for coronavirus disease 2019 (COVID-19) and identify predictors of invasive mechanical ventilation (IMV). Methods: We performed a retrospective cohort study in patients with COVID-19 admitted to a private network in Sao Paulo, Brazil from March to October 2020. Patients were compared in three subgroups: non-intensive care unit (ICU) admission (group A), ICU admission without receiving IMV (group B) and IMV requirement (group C). We developed logistic regression algorithm to identify predictors of IMV. Results: We analyzed 1,650 patients, the median age was 53 years (42–65) and 986 patients (59.8%) were male. The median duration from symptom onset to hospital admission was 7 days (5–9) and the main comorbidities were hypertension (42.4%), diabetes (24.2%) and obesity (15.8%). We found differences among subgroups in laboratory values obtained at hospital admission. The predictors of IMV (odds ratio and 95% confidence interval [CI]) were male (1.81 [1.11– 2.94], P=0.018), age (1.03 [1.02–1.05], P<0.001), obesity (2.56 [1.57–4.15], P<0.001), duration from symptom onset to admission (0.91 [0.85–0.98], P=0.011), arterial oxygen saturation (0.95 [0.92– 0.99], P=0.012), C-reactive protein (1.005 [1.002–1.008], P<0.001), neutrophil-to-lymphocyte ratio (1.046 [1.005–1.089], P=0.029) and lactate dehydrogenase (1.005 [1.003–1.007], P<0.001). The area under the curve values were 0.860 (95% CI, 0.829–0.892) in the development cohort and 0.801 (95% CI, 0.733–0.870) in the validation cohort. Conclusions: Patients had distinct clinical and laboratory parameters early in hospital admission. Our prediction model may enable focused care in patients at high risk of IMV.

Liver
Early mechanical ventilation for grade IV hepatic encephalopathy is associated with increased mortality among patients with cirrhosis: an exploratory study: Saad Saffo, Guadalupe Garcia-Tsao; Acute Crit Care. 2022;37(3):355-362. Published online August 18, 2022; DOI: https://doi.org/10.4266/acc.2022.00528

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Abstract PDF

Background
Unresponsive patients with toxic-metabolic encephalopathies often undergo endotracheal intubation for the primary purpose of preventing aspiration events. However, among patients with pre-existing systemic comorbidities, mechanical ventilation itself may be associated with numerous risks such as hypotension, aspiration, delirium, and infection. Our primary aim was to determine whether early mechanical ventilation for airway protection was associated with increased mortality in patients with cirrhosis and grade IV hepatic encephalopathy.
Methods
The National Inpatient Sample was queried for hospital stays due to grade IV hepatic encephalopathy among patients with cirrhosis between 2016 and 2019. After applying our exclusion criteria, including cardiopulmonary failure, data from 1,975 inpatient stays were analyzed. Patients who received mechanical ventilation within 2 days of admission were compared to those who did not. Univariable and multivariable logistic regression analyses were performed to identify clinical factors associated with in-hospital mortality.
Results
Of 162 patients who received endotracheal intubation during the first 2 hospital days, 64 (40%) died during their hospitalization, in comparison to 336 (19%) of 1,813 patients in the comparator group. In multivariable logistic regression analysis, mechanical ventilation was the strongest predictor of in-hospital mortality in our primary analysis (adjusted odds ratio, 3.00; 95% confidence interval, 2.14–4.20; P<0.001) and in all sensitivity analyses.
Conclusions
Mechanical ventilation for the sole purpose of airway protection among patients with cirrhosis and grade IV hepatic encephalopathy may be associated with increased in-hospital mortality. Future studies are necessary to confirm and further characterize our findings.

Citations

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Development and validation of a nomogram for predicting in-hospital mortality of intensive care unit patients with liver cirrhosis
Xiao-Wei Tang, Wen-Sen Ren, Shu Huang, Kang Zou, Huan Xu, Xiao-Min Shi, Wei Zhang, Lei Shi, Mu-Han Lü
World Journal of Hepatology.2024; 16(4): 625. CrossRef
Using machine learning methods to predict 28-day mortality in patients with hepatic encephalopathy
Zhe Zhang, Jian Wang, Wei Han, Li Zhao
BMC Gastroenterology.2023;[Epub] CrossRef
Experience in Non-invasive Ventilation in Grade 3 Hepatic Encephalopathy
İlhan Ocak, Mustafa Çolak, Erdem Kınacı
Istanbul Medical Journal.2023; 24(3): 295. CrossRef

Pulmonary
The role of diaphragmatic thickness measurement in weaning prediction and its comparison with rapid shallow breathing index: a single-center experience: Lokesh Kumar Lalwani, Manjunath B Govindagoudar, Pawan Kumar Singh, Mukesh Sharma, Dhruva Chaudhry; Acute Crit Care. 2022;37(3):347-354. Published online July 25, 2022; DOI: https://doi.org/10.4266/acc.2022.00108

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Abstract PDF Supplementary Material

Background
Acute respiratory failure (ARF) is commonly managed with invasive mechanical ventilation (IMV). The majority of the time that a patient spends on IMV is in the process of weaning. Prediction of the weaning outcome is of paramount importance, as untimely/delayed extubation is associated with a high risk of mortality. Diaphragmatic ultrasonography is a promising tool in the intensive care unit, and its utility in predicting the success of weaning remains understudied.
Methods
In this prospective-observational study, we recruited 54 ARF patients on IMV, along with 50 healthy controls. During a spontaneous breathing trial, all subjects underwent diaphragmatic ultrasonography along with a rapid shallow breathing index (RSBI) assessment.
Results
The mean age was 41.8±17.0 and 37.6±10.5 years among the cases and control group, respectively. Demographic variables were broadly similar in the two groups. The most common cause of ARF was obstructive airway disease. The average duration of IMV was 5.41±2.81 days. Out of 54 subjects, 45 were successfully weaned, while nine patients failed weaning. Age, body mass index, and severity of disease were similar in the successful and failed weaning patients. The sensitivity in predicting successful weaning of percent change in diaphragmatic thickness (Δtdi%) >29.71% was high (93.33%), while specificity was 66.67%. The sensitivity and specificity of mean diaphragmatic thickness (tdi) end-expiratory >0.178 cm was 60.00% and 77.78%, respectively. RSBI at 1 minute of <93.75 had an equally high sensitivity (93.33%) but a lower specificity (22.22%). Similar results were also found for RSBI measured at 5 minutes.
Conclusions
During the weaning assessment, the purpose is to minimize both premature as well as delayed extubation. We found that diaphragmatic ultrasonography, in particular Δtdi%, is better than RSBI in predicting weaning outcomes.

Citations

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Ultrasonography to Access Diaphragm Dysfunction and Predict the Success of Mechanical Ventilation Weaning in Critical Care
Marta Rafael Marques, José Manuel Pereira, José Artur Paiva, Gonzalo García de Casasola‐Sánchez, Yale Tung‐Chen
Journal of Ultrasound in Medicine.2024; 43(2): 223. CrossRef
Accuracy of respiratory muscle assessments to predict weaning outcomes: a systematic review and comparative meta-analysis
Diego Poddighe, Marine Van Hollebeke, Yasir Qaiser Choudhary, Débora Ribeiro Campos, Michele R. Schaeffer, Jan Y. Verbakel, Greet Hermans, Rik Gosselink, Daniel Langer
Critical Care.2024;[Epub] CrossRef
Ultrasonographic evaluation of diaphragm thickness and excursion: correlation with weaning success in trauma patients: prospective cohort study
Golnar Sabetian, Mandana Mackie, Naeimehossadat Asmarian, Mahsa Banifatemi, Gregory A. Schmidt, Mansoor Masjedi, Shahram Paydar, Farid Zand
Journal of Anesthesia.2024;[Epub] CrossRef
Diaphragmatic ultrasound: A new frontier in weaning from mechanical ventilation
Manoj Kamal, Saikat Sengupta
Indian Journal of Anaesthesia.2023; 67(Suppl 4): S205. CrossRef

Policy/Pulmonary
Association between the National Health Insurance coverage benefit extension policy and clinical outcomes of ventilated patients: a retrospective study: Wanho Yoo, Saerom Kim, Soohan Kim, Eunsuk Jeong, Kwangha Lee; Acute Crit Care. 2022;37(1):53-60. Published online February 22, 2022; DOI: https://doi.org/10.4266/acc.2021.01389

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Background
This study aimed to investigate the association between the Korean National Health Insurance coverage benefit extension policy and clinical outcomes of patients who were ventilated owing to various respiratory diseases. Methods: Data from 515 patients (male, 69.7%; mean age, 69.8±12.1 years; in-hospital mortality rate, 28.3%) who were hospitalized in a respiratory intensive care unit were retrospectively analyzed over 5 years. Results: Of total enrolled patients, 356 (69.1%) had one benefit items under this policy during their hospital stay. They had significantly higher medical expenditure (total: median, 23,683 vs. 12,742 U.S. dollars [USD], P<0.001), out-of-pocket (median, 5,932 vs. 4,081 USD; P<0.001), and a lower percentage of out-of-pocket medical expenditure relative to total medical expenditure (median, 26.0% vs. 32.2%; P<0.001). Patients without benefit items associated with higher in-hospital mortality (hazard ratio [HR], 2.794; 95% confidence interval [CI], 1.980–3.941; P<0.001). In analysis of patients with benefit items, patients with three items (“cancer,” “tuberculosis,” and “disability”) had significantly lower out-of-pocket medical expenditure (3,441 vs. 6,517 USD, P<0.001), and a lower percentage of out-of-pocket medical expenditure relative to total medical expenditure (17.2% vs. 27.7%, P<0.001). They were associated with higher in-hospital mortality (HR, 3.904; 95% CI, 2.533–6.039; P<0.001). Conclusions: Our study showed patients with benefit items had more medical resources and associated improved in-hospital survival. Patients with the aforementioned three benefit items had lower out-of-pocket medical expenditure due to the implementation of this policy, but higher in-hospital mortality.

Citations

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The effect of socioeconomic status, insurance status, and insurance coverage benefits on mortality in critically ill patients admitted to the intensive care unit
Moo Suk Park
Acute and Critical Care.2022; 37(1): 118. CrossRef

Pulmonary
Under or overpressure: an audit of endotracheal cuff pressure monitoring at the tertiary care center: Biju Viswambharan, Manjini Jeyaram Kumari, Gopala Krishnan, Lakshmi Ramamoorthy; Acute Crit Care. 2021;36(4):374-379. Published online November 26, 2021; DOI: https://doi.org/10.4266/acc.2021.00024

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Abstract PDF

Background
Mechanical ventilation is a lifesaving intervention for critically ill patients but can produce the major complication of ventilator-associated pneumonia (VAP). Inappropriately inflated endotracheal tubes cause potential harm due to high or low pressure; this can be prevented through monitoring protocols.
Methods
A cross-sectional study of 348 cuff pressure readings was performed with intubated and mechanically ventilated patients to evaluate the exact proportion of patients in intensive care units (ICUs) where the cuff pressure is optimal and to identify the ICUs where device-based monitoring is available to produce a lower proportion of sub-optimal cuff pressure cases. Every three days, cuff pressure was assessed with a handheld cuff pressure manometer. The corresponding VAP rates of those ICUs were obtained from the hospital infection control department.
Results
Cuff pressure of 40.2% was the lower cutoff for the high category, that of optimal was 35.3%, and the highest cutoff of sub-optimal was 24.4%. This study also showed ICUs that had cuff pressure monitoring devices and protocols. Active measurement protocols had a higher proportion of optimal cuff pressure (58.5%) and a lower proportion of sub-optimal and high cuff pressure (19.5% and 22.0%) compared to ICUs with no device-based monitoring protocols. Furthermore, the VAP rate of ICUs exhibited a weak positive correlation with sub-optimal cuff pressure.
Conclusions
Device-based cuff pressure monitoring is essential in maintaining adequate cuff pressure but often is inadequate, resulting in high readings. Therefore, this study suggests that device-based cuff pressure monitoring be practiced.

Citations

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Pressure changes in the endotracheal tube cuff in otorhinolaryngologic surgery: a prospective observational study
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Nephrology
COVID-19–induced acute kidney injury in critically ill patients: epidemiology, risk factors, and outcome: Ahlem Trifi, Sami Abdellatif, Yosri Masseoudi, Asma Mehdi, Oussama Benjima, Eya Seghir, Fatma Cherif, Yosr Touil, Bedis Jeribi, Foued Daly, Cyrine Abdennebi, Adel Ammous, Salah Ben Lakhal; Acute Crit Care. 2021;36(4):308-316. Published online November 22, 2021; DOI: https://doi.org/10.4266/acc.2021.00934

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Abstract PDF

Background
The kidney represents a potential target for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Acute kidney injury (AKI) can occur through several mechanisms and includes intrinsic tissue injury by direct viral invasion. Clinical data about the clinical course of AKI are lacking. We aimed to investigate the proportion, risk factors, and prognosis of AKI in critical patients affected with coronavirus disease 2019 (COVID-19).
Methods
A case/control study conducted in two intensive care units of a tertiary teaching hospital from September to December 2020.
Results
Among 109 patients, 75 were male (69%), and the median age was 64 years (interquartile range [IQR], 57–71 years); 48 (44%) developed AKI within 4 days (IQR, 1–9). Of these 48 patients, 11 (23%), 9 (19%), and 28 (58%) were classified as stage 1, 2, and 3, respectively. Eight patients received renal replacement therapy. AKI patients were older and had more frequent sepsis, acute respiratory distress syndrome, and rhabdomyolysis; higher initial urea and creatinine; more marked inflammatory syndrome and hematological disorders; and required more frequent mechanical ventilation and vasopressors. An elevated level of D-dimers (odds ratio [OR], 12.83; 95% confidence interval [CI], 1.9–85) was an independent factor of AKI. Sepsis was near to significance (OR, 5.22; 95% CI, 0.94–28; P=0.058). Renal recovery was identified in three patients. AKI, hypoxemia with the ratio of the arterial partial pressure of oxygen and the inspiratory concentration of oxygen <70, and vasopressors were identified as mortality factors.
Conclusions
AKI occurred in almost half the patients with critical COVID-19. A high level of D-dimers and sepsis contributed significantly to its development. AKI significantly worsened the prognosis in these patients.

Citations

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