Acute and Critical Care

Review Article

Anesthesiology
Rehabilitating the diaphragm: an integrated approach to intensive care unit-acquired dysfunction in critical illness: a narrative review: Ricardo Arriagada, Aaron Pagan, Daniela Nisticò, Francesca Gualdi, Valentina Fassone, Nicolò Antonino Patroniti, Patricia RM Rocco, Denise Battaglini; Received September 18, 2025 Accepted November 12, 2025 Published online March 4, 2026; DOI: https://doi.org/10.4266/acc.004375 [Epub ahead of print]

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Abstract PDF: Improved survival in critical illness has increased recognition of intensive care unit (ICU) complications, particularly ICU-acquired weakness, which affects up to 25% of patients. Diaphragm involvement is common and contributes to prolonged ventilation, difficult weaning, and worse outcomes. Dysfunction arises from ventilator-induced injury, sepsis-related myopathy, or both. Although early mobilization and physiotherapy improve recovery, their effectiveness is often limited by respiratory muscle fatigue and dyspnea. Non-invasive ventilation (NIV) reduces the work of breathing, sustains spontaneous effort, and enhances exercise tolerance, thereby facilitating earlier and safer rehabilitation. This review summarizes the current understanding of the pathophysiology of ICU-acquired diaphragm dysfunction. It explores the role of NIV and other respiratory supports as an adjunct to physiotherapy aimed at optimizing recovery in critically ill patients.

Original Articles

Pediatrics
High-flow nasal cannula for respiratory support in children with severe asthma attack: a systematic review and meta-analysis: Ghea Mangkuliguna, Muhammad Ifan Romli, Adrian Djatikusumo, Nicholas Adrianto; Acute Crit Care. 2026;41(1):148-159. Published online October 24, 2025; DOI: https://doi.org/10.4266/acc.003744

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Abstract PDF: Background
The utility of various adjunctive therapies, including high-flow nasal cannula (HFNC) and bilevel positive airway pressure, to treat severe asthma attacks and avoid invasive mechanical ventilation has recently been investigated. HFNC in particular has received attention as a viable potential alternative to mechanical ventilation. Our goal with this review was to evaluate and compare the clinical outcomes of HFNC with those achieved using conventional oxygen therapy or other non-invasive ventilation (NIV) methods in severe asthma attacks.
Methods
A comprehensive search was conducted of multiple databases, including PubMed/Medline, Scopus, Cochrane Library, and gray literature repositories, for articles published from August 25, 2014, to August 25, 2024. Results of meta-analysis using a random-effects model are presented in a forest plot. Study quality was assessed using the Cochrane Risk of Bias tool (ROB-2) and Newcastle-Ottawa Scale. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 criteria and was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42024558656).
Results
Nine studies involving 14,606 subjects were included in this meta-analysis. Pulmonary scores tended to improve with HFNC therapy, but this improvement did not reach statistical significance (P>0.05). Pediatric intensive care unit (PICU) admission rates and need for escalation of support did not significantly differ from those of standard oxygen therapy or other NIV modalities. HFNC therapy led to a modest but significant increase in readmission (odds ratio, 3.14; 95% CI, 1.07–9.24; P=0.04). PICU length-of-stay was comparable across groups, and mortality among HFNC-treated patients remained less than 1%. Overall evidence quality ranged from very low to low.
Conclusions
HFNC therapy did not result in superior outcomes over standard oxygen therapy and other NIV modalities. Current evidence, however, was of low quality, highlighting the need for further research.

Cardiology
Thoracic fluid content by electrical cardiometry versus diaphragmatic excursion by ultrasound for the prediction of weaning success in patients with lung congestion: Shawky Meselhy Elshaer, Ahmed Mostafa Abdelhamid, Enas Wageh Mahdy, Samar Rafik Amin; Acute Crit Care. 2025;40(4):557-566. Published online October 15, 2025; DOI: https://doi.org/10.4266/acc.003984

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Abstract PDF: Background
Predicting the weaning outcomes is critical, since premature or delayed extubation is associated with an increased risk of mortality. This study aimed to compare two physiological indices, thoracic fluid content (TFC) and diaphragmatic excursion (DE), for predicting weaning success in mechanically ventilated patients.
Methods
This observational cohort study involved 100 mechanically ventilated patients with congested lungs who were eligible for weaning. Patients’ TFC and DE were measured using electrical cardiometry and ultrasonography, respectively, before starting the spontaneous breathing trial. Following extubation, patients were grouped into successful and failed-weaning groups, with failure defined as reintubation or a need for non-invasive ventilation within 48 hours. Respiratory and cardiovascular variables were compared. The receiver operating characteristic (ROC) curve was used to assess the ability of TFC and DE to predict weaning success.
Results
Successful weaning occurred in 73 patients (73%) and failed weaning occurred in 27 patients (27%). The two groups’ baseline characteristics were comparable; however, TFC and DE were significantly different between the failed- and successful-weaning groups (P<0.001). The area under the ROC curve (AUC) exhibited moderate predictive abilities of both the TFC and DE in predicting weaning success (AUC, 0.805, cutoff <40 kΩ−1 and AUC, 0.774, cutoff >1.45 cm). In the cardiac patient subgroup, TFC exhibited high predictive ability (AUC, 0.861), but DE did not achieve comparable results (AUC, 0.750).
Conclusions
Both TFC and DE are significant predictors for successful weaning from mechanical ventilators. In particular, a TFC of <40 kΩ−1 demonstrated an excellent ability to predict weaning success in patients with low ejection fraction.

Nursing
Comparison of the clinimetric properties of the two versions of the HACOR scale for predicting noninvasive ventilation failure in Brazilian patients: Matheus Pereira Nunes da Silva, Adriana Claudia Lunardi; Acute Crit Care. 2025;40(2):322-329. Published online May 28, 2025; DOI: https://doi.org/10.4266/acc.000175

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Abstract PDF: Background
Scales that detect noninvasive ventilation (NIV) failure need to have adequate clinimetric properties to be reliable. This study aimed to compare the clinimetric properties of the Heart rate, Acidosis, Consciousness, Oxygenation, Respiratory rate (HACOR) and updated HACOR scales when applied to hypoxemic adult patients undergoing NIV. Methods: This prospective study applied the HACOR and updated HACOR scales to hypoxemic patients after one hour of NIV in an emergency department setting. A second application of the scales was performed after ten minutes to assess reliability (intraclass correlation coefficient), measurement error (standard error of measurement and minimum detectable difference), ceiling and floor effects, convergent validity by correlation (Pearson’s r) with peripheral oximetry saturation (SpO2), and predictive validity (area under the receiver operating characteristic [ROC] curve) for the outcome of needing invasive mechanical ventilation. Results: Sixty patients were included in this study (59.45±17.48 years; Simplified Acute Physiology Score III, 56.1±13.95; 30% with respiratory disease and 25% with cardiovascular disease). After 1 hour of NIV, patients had a HACOR score of 3 (interquartile range [IQR], 1.0–5.0) and an updated HACOR score of 5 (IQR, 3.0–8.87). Clinimetric properties were adequate for both versions of the HACOR scale but were superior for the updated version, including predictive validity (ROC [95% CI], 0.78 [0.64–0.91] vs. 0.73 [0.57–0.89]) and the absence of the ceiling effect. Conclusions: Both versions of the HACOR scale demonstrated adequate clinimetric properties for predicting NIV failure, with the updated HACOR version showing superior predictive validity and no ceiling effect compared with the original version.

Nursing
Characteristics and associated risk factors of exposure keratopathy among ventilated patients in intensive care units in Jordan: Sajeda Al-Tamimi, Mohammad Y.N. Saleh, Al-Mutez Gharaibeh, Farah Al-A’mar, Rasmieh Al-Amer; Acute Crit Care. 2025;40(2):330-338. Published online April 11, 2025; DOI: https://doi.org/10.4266/acc.003648

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Abstract PDF

Background
Exposure keratopathy is the most common ocular surface disorder in ventilated patients due to poor eyelid closure, decreased blink reflex, and the inability to produce tears. Healthcare providers in intensive care units (ICUs) play a significant role in preventing exposure keratopathy through appropriate eyelid taping and eye ointments.
Methods
This is a cross-sectional study to describe the characteristics and factors associated with exposure keratopathy in all mechanically ventilated patients admitted to an adult ICU between February and June 2023. Patients were examined for corneal changes using a corneal fluorescein staining test with a cobalt blue filter indirect ophthalmoscope.
Results
Of 156 ventilated patients included in this study, 42.3% had exposure keratopathy, 13.5% had lagophthalmos, and 26.9% of patients had chemosis. For patients with a Glasgow Coma Scale (GCS) score of 3, the odds ratio of exposure keratopathy was 21.47 (95% confidence interval [CI], 2.82–163.05). The use of inotropes increased the odds ratio to 35.55 (95% CI, 3.41–369.90), whereas a hospital stay >7.23 days increased the odds ratio to 43.59 (95% CI, 15.66–1,316.32).
Conclusions
The frequency of exposure keratopathy is high and is underestimated in ventilated patients, with lower GCS and increased hospital length of stay as the main risk factors. Prioritizing eye care in ventilated patients with low GCS scores or prolonged ICU stays is essential to reduce exposure keratopathy.

Citations

Citations to this article as recorded by

Effect of video-based educational program on ICU nurses’ awareness and practices regarding the prevention and care of exposure keratopathy among unconscious and mechanical ventilated patients: a quasi experimental study
Murad Jkhlab, Ismail A. Elhaty, Imad Fashafsheh, Ahmad I. Miqdadi, Nawras Fashafsheh
BMC Nursing.2025;[Epub] CrossRef

Pediatrics
Effects of rescue airway pressure release ventilation on mortality in severe pediatric acute respiratory distress syndrome: a retrospective comparative analysis from India: Sudha Chandelia, Sunil Kishore, Maansi Gangwal, Devika Shanmugasundaram; Acute Crit Care. 2025;40(1):113-121. Published online February 28, 2025; DOI: https://doi.org/10.4266/acc.002520

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Abstract PDF: Background
Pediatric acute respiratory distress syndrome (PARDS) has a mortality rate of up to 75%, which can be up to 90% in high-risk patients. Even with the use of advanced ventilation strategies, mortality remains unacceptably high at 40%. Airway pressure release ventilation (APRV) mode is a new strategy in PARDS. Our aim was to evaluate whether use of APRV mode in severe PARDS was associated with reduced hospital mortality compared to other modes of ventilation.
Methods
This was a retrospective comparative study using data from case files in a pediatric intensive care unit of a university-affiliated tertiary-care hospital. The study period (January 2014 to December 2019) covered three years before routine use of APRV mode to three years after its implementation. We compared severe PARDS patients in two groups: The APRV group (who received APRV as rescue therapy after failing protective ventilation); and The Non-APRV group, who received other modes of ventilation.
Results
A total of 24 patients in each group were analyzed. Overall in-hospital mortality in the APRV group was 79% versus 91% in the Non-APRV group. In-hospital mortality was significantly lower in the APRV group (univariate analysis: hazard ratio [HR], 0.27; 95% CI, 0.14–0.52; P=0.001 and multivariate analysis: HR, 0.03; 95% CI, 0.005–0.17; P=0.001). Survival times were significantly longer in the APRV group (median time to death: 7.5 days in APRV vs. 4.3 days in non-APRV; P=0.001).
Conclusions
Use of rescue APRV mode in severe PARDS may yield lower mortality rates and longer survival times.

Nursing
Nurses’ knowledge, attitude, and perceived barriers toward protective lung strategies of pediatrics mechanically ventilated patients in a tertiary care hospital in Pakistan: Tasnim Zainib, Salma Rattani, Nimira Asif, Hussain Maqbool Ahmed Maqbool; Acute Crit Care. 2025;40(1):128-135. Published online February 19, 2025; DOI: https://doi.org/10.4266/acc.004761

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Abstract PDF Supplementary Material: Background
Protective lung strategies (PLS) are guidelines about recent clinical advances that deliver an air volume compatible with the patient’s lung capacity and are used to treat acute respiratory distress syndrome. These mechanical ventilation guidelines are not implemented within intensive care units (ICUs) despite strong evidence-based recommendations and a dedicated professional staff. Nurses’ familiarity with clinical guidelines can bridge the gap between actual and recommended practice. However, several barriers undermine this process. The objectives of this study were to identify those barriers and explore the knowledge, attitudes, and behavior of ICU nurses regarding the implementation of PLS.
Methods
This was a descriptive, cross-sectional study. The participants were nurses working in the six ICUs of a pediatric tertiary care hospital in Lahore, Pakistan. Using purposive sampling with random selection, the total sample size was 137 nurses. A summative rating scale was used to identify barriers to the implementation of PLS.
Results
Overall, the nurses’ barrier score was high, with a mean of 66.77±5.36. Across all the barriers subscales, attitude was a much more significant barrier (35.74±3.57) to PLS than behavior (6.53±1.96), perceived knowledge (17.42±2.54), and organizational barriers (7.08±1.39). Knowledge-related barriers were also significantly high.
Conclusion
This study identified important barriers to PLS implementation by nurses, including attitudes and knowledge deficits. Understanding those barriers and planning interventions to address them could help to increase adherence to low tidal volume ventilation and improve patient outcomes. Nurses’ involvement in mechanical ventilation management could help to safely deliver air volumes compatible with recommendations.

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.

Citations

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Comparison of programmed sedation care with conventional care in patients receiving mechanical ventilation for acute respiratory failure
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Irish Journal of Medical Science (1971 -).2025; 194(1): 289. CrossRef
Clinical predictors of extubation failure in postoperative critically ill patients: a post-hoc analysis of a multicenter prospective observational study
Jun Hattori, Aiko Tanaka, Junko Kosaka, Osamu Hirao, Nana Furushima, Yuichi Maki, Daijiro Kabata, Akinori Uchiyama, Moritoki Egi, Hiroshi Morimatsu, Satoshi Mizobuchi, Yoshifumi Kotake, Ayumi Shintani, Yukiko Koyama, Takeshi Yoshida, Yuji Fujino
BMC Anesthesiology.2025;[Epub] CrossRef
Comparison of High Versus Low Positive End-Expiratory Pressure in Mechanically Ventilated Patients With Acute Heart Failure: Rationale and Design of the HELP-AHF Trial
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Revista Saúde Dos Vales.2024;[Epub] CrossRef

Original Articles

Meta-analysis
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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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.

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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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Novel Approaches of Inhalational Therapy for COVID-19: Drugs to Vaccines
Pratiksha Bramhe, Suchita Waghmare, Nilesh Rarokar, Lata Potey, Bhupendra Dibbe, Prafulla Sable, Pramod Khedekar, Vidya Sabale, Bhupendra Prajapati
Coronaviruses.2025;[Epub] CrossRef
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
Evaluating diaphragmatic dysfunction and predicting non-invasive ventilation failure in acute exacerbation of chronic obstructive pulmonary disease in India: Nupur B Patel, Gaurav Jain, Udit Chauhan, Ajeet Singh Bhadoria, Saurabh Chandrakar, Haritha Indulekha; Acute Crit Care. 2023;38(2):200-208. Published online May 25, 2023; DOI: https://doi.org/10.4266/acc.2022.01060

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Abstract PDF

Background
Baseline diaphragmatic dysfunction (DD) at the initiation of non-invasive ventilation (NIV) correlates positively with subsequent intubation. We investigated the utility of DD detected 2 hours after NIV initiation in estimating NIV failure in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients.
Methods
In a prospective-cohort design, we enrolled 60 consecutive patients with AECOPD initiated on NIV at intensive care unit admission, and NIV failure events were noted. The DD was assessed at baseline (T1 timepoint) and 2 hours after initiating NIV (T2 timepoint). We defined DD as ultrasound-assessed change in diaphragmatic thickness (ΔTDI) <20% (predefined criteria [PC]) or its cut-off that predicts NIV failure (calculated criteria [CC]) at both timepoints. A predictive-regression analysis was reported.
Results
In total, 32 patients developed NIV failure, nine within 2 hours of NIV and remaining in next 6 days. The ∆TDI cut-off that predicted NIV failure (DD-CC) at T1 was ≤19.04% (area under the curve [AUC], 0.73; sensitivity, 50%; specificity, 85.71%; accuracy; 66.67%), while that at T2 was ≤35.3% (AUC, 0.75; sensitivity, 95.65%; specificity, 57.14%; accuracy, 74.51%; hazard ratio, 19.55). The NIV failure rate was 35.1% in those with normal diaphragmatic function by PC (T2) versus 5.9% by CC (T2). The odds ratio for NIV failure with DD criteria ≤35.3 and <20 at T2 was 29.33 and 4.61, while that for ≤19.04 and <20 at T1 was 6, respectively.
Conclusions
The DD criterion of ≤35.3 (T2) had a better diagnostic profile compared to baseline and PC in prediction of NIV failure.

Citations

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嘉祺李
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Diaphragm ultrasound as a predictor for the need for respiratory support at discharge in patients with exacerbation of chronic obstructive pulmonary disease
Chitra Veluthat, Kavitha Venkatnarayan, Sumithra Selvam, Uma Devaraj, Priya Ramachandran, Uma Maheswari Krishnaswamy
Monaldi Archives for Chest Disease.2025;[Epub] CrossRef
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Heng Mu, Qunxia Zhang
COPD: Journal of Chronic Obstructive Pulmonary Disease.2024;[Epub] CrossRef
Risk prediction models for non-invasive ventilation failure in patients with chronic obstructive pulmonary disease: A systematic review
Yuming Gao, Bo Yuan, Peng Fan, Mingtao Li, Jiarui Chen
Medicine.2024; 103(51): e40588. CrossRef
Advancing healthcare through thoracic ultrasound research in older patients
Simone Scarlata, Chukwuma Okoye, Sonia Zotti, Fulvio Lauretani, Antonio Nouvenne, Nicoletta Cerundolo, Adriana Antonella Bruni, Monica Torrini, Alberto Finazzi, Tessa Mazzarone, Marco Lunian, Irene Zucchini, Lorenzo Maccioni, Daniela Guarino, Silvia Fabbr
Aging Clinical and Experimental Research.2023; 35(12): 2887. 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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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.

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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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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

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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.

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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.

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Utility of a digital motor speech measurement program using an AI speech recognition module: A pilot study*
Sora Han, Do Hyung Kim, So Young Han, Jaewon Kim, Dae-Hyun Jang
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Epidemiology
Perioperative hemodynamic protective assessment of adaptive support ventilation usage in pediatric surgical patients: Dmytro Dmytriiev, Mykola Melnychenko, Oleksandr Dobrovanov, Oleksandr Nazarchuk, Marian Vidiscak; Acute Crit Care. 2022;37(4):636-643. Published online October 19, 2022; DOI: https://doi.org/10.4266/acc.2022.00297

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Background
The aim of this study was to evaluate the hemodynamic protective effects of perioperative ventilation in pressure-controlled ventilation (PCV) and adaptive support ventilation (ASV) modes based on non-invasive hemodynamic monitoring indicators.
Methods
The study included 32 patients who were scheduled for planned open abdominal surgery. Depending on the chosen ventilation strategy, patients were included in two groups of PCV mode ventilation (n=14) and ASV mode ventilation (n=18). The hemodynamic effects of the ventilation strategies were assessed by estimated continuous cardiac output (esCCO) and cardiac index (esCCI).
Results
Preoperative cardiac output (CO) was 6.1±1.3 L/min in group 1 patients and 6.3±0.8 L/min in group 2 patients, and preoperative cardiac index (CI) was 3.9±0.4 L/min/m2 in group 1 patients and 3.8±0.8 L/min/m2 in group 2 patients. The ejection fraction (EF) in group 1 subjects was 55.4%±0.3%; this rate was 56.5%±0.5% in group 2 subjects. Group 1 patients experienced a 14.7% CO decrease to 5.2±0.7 L/min, a 17.9% CI decrease to 3.2±0.6 L/min/m2 , and a 12.8% mean arterial pressure decrease to 82.3±9.4 mm Hg 30 minutes after the start of surgery. One hour after the start of surgery, the CO mean values of group 2 patients were lower than baseline by 7.9% and differed from the dynamics of patients in group 1, in whom CO was lower than baseline by 13.1%. At the end of the operation, the CO values were lower than baseline by 11.5% and 6.3% in patients of groups 1 and 2, respectively. Our data showed that the changes in EF during and after surgery correlated with CO indicators determined by the esCCO.
Conclusions
In our study, perioperative ventilation in ASV mode was more protective than PCV mode and was characterized by lower tidal volume (16.2%) and driving pressure (12.1%). Hemodynamically-controlled mechanical ventilation reduces the negative impact of cardiopulmonary interactions,

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Trends in the dynamics of morbidity and mortality from hypertension in the Republic of Kazakhstan from 2010 to 2019
Yeldos Makhambetchin, Aigerim Yessembekova, Ardak Nurbakyttana, Aza Galayeva, Saparkul Arinova
Polski Merkuriusz Lekarski.2024; 52(1): 95. CrossRef
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Kozhakhmet Kuneshov, Shora Seidinov, Nurpeis Tulezhanov, Fazladin Tеmurov, Shkurulla Massadikov
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Clinical evaluation of ventilation mode on acute exacerbation of chronic obstructive pulmonary disease with respiratory failure
Jun-Jun Wang, Zhong Zhou, Li-Ying Zhang
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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.

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Cristiana P. Von Rekowski, Tiago A. H. Fonseca, Rúben Araújo, Ana Martins, Iola Pinto, M. Conceição Oliveira, Gonçalo C. Justino, Luís Bento, Cecília R. C. Calado
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Guang Zhang, Qingyan Xie, Chengyi Wang, Jiameng Xu, Guanjun Liu, Chen Su
Medical & Biological Engineering & Computing.2024; 62(11): 3445. CrossRef

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.

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Characteristics and prognosis of patients with cirrhosis presenting with acute respiratory distress syndrome: A bicentric retrospective study
Adam Celier, Marie-Amélie Ordan, Aymeric Lanore, Julien Mayaux, Philippe Ichaï, Marika Rudler, Maxens Decavèle, Alexandre Demoule
Journal of Intensive Medicine.2026;[Epub] CrossRef
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
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Iva Kosuta, Madhumita Premkumar, K. Rajender Reddy
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Using machine learning methods to predict 28-day mortality in patients with hepatic encephalopathy
Zhe Zhang, Jian Wang, Wei Han, Li Zhao
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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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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.

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Diaphragmatic ultrasound: A new frontier in weaning from mechanical ventilation
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Pulmonary/Policy
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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Abstract PDF

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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Association between health insurance benefit extension policy and long-term outcomes in ventilated pneumonia patients: Analysis of a nationwide dataset
Wanho Yoo, Hyojin Jang, Min Ki Lee, Yeongdae Kim, Son Jungmin, Kim Jinmi, Kwangha Lee
Medicine.2025; 104(38): e44687. CrossRef
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
Comparison of high-flow nasal oxygen therapy and noninvasive ventilation in COVID-19 patients: a systematic review and meta-analysis: Glenardi Glenardi, Febie Chriestya, Bambang J Oetoro, Ghea Mangkuliguna, Natalia Natalia; Acute Crit Care. 2022;37(1):71-83. Published online February 22, 2022; DOI: https://doi.org/10.4266/acc.2021.01326

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Abstract PDF Supplementary Material

Background
Acute respiratory failure (ARF) is a major adverse event commonly encountered in severe coronavirus disease 2019 (COVID-19). Although noninvasive mechanical ventilation (NIV) has long been used in the management of ARF, it has several adverse events which may cause patient discomfort and lead to treatment complication. Recently, high-flow nasal cannula (HFNC) has the potential to be an alternative for NIV in adults with ARF, including COVID-19 patients. The objective was to investigate the efficacy of HFNC compared to NIV in COVID-19 patients.
Methods
This meta-analysis was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Literature search was carried out in electronic databases for relevant articles published prior to June 2021. The protocol used in this study has been registered in International Prospective Register of Systematic Reviews (CRD42020225186).
Results
Although the success rate of NIV is higher compared to HFNC (odds ratio [OR], 0.39; 95% confidence interval [CI], 0.16–0.97; P=0.04), this study showed that the mortality in the NIV group is also significantly higher compared to HFNC group (OR, 0.49; 95% CI, 0.39–0.63; P<0.001). Moreover, this study also demonstrated that there was no significant difference in intubation rates between the two groups (OR, 1.35; 95% CI, 0.86–2.11; P=0.19).
Conclusions
Patients treated with HFNC showed better outcomes compared to NIV for ARF due to COVID-19. Therefore, HFNC should be considered prior to NIV in COVID-19–associated ARF. However, further studies with larger sample sizes are still needed to better elucidate the benefit of HFNC in COVID-19 patients.

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Trends and management of acute respiratory failure in hospitalized patients: a multicenter retrospective study in South Korea
Won Jin Yang, Yong Jun Choi, Kyung Soo Chung, Ji Soo Choi, Bo Mi Jung, Jae Hwa Cho
Acute and Critical Care.2025; 40(2): 171. CrossRef
2023 Year in Review: High-Flow Nasal Cannula for COVID-19
Michael D Davis
Respiratory Care.2024; 69(12): 1587. CrossRef
High-flow nasal cannula therapy in patients with COVID-19 in intensive care units in a country with limited resources: a single-center experience
Anh-Minh Vu Phan, Hai-Yen Thi Hoang, Thanh-Son Truong Do, Trung Quoc Hoang, Thuan Van Phan, Nguyet-Anh Phuong Huynh, Khoi Minh Le
Journal of International Medical Research.2023;[Epub] CrossRef
Evaluating the use of the respiratory-rate oxygenation index as a predictor of high-flow nasal cannula oxygen failure in COVID-19
Scott Weerasuriya, Savvas Vlachos, Ahmed Bobo, Namitha Birur Jayaprabhu, Lauren Matthews, Adam R Blackstock, Victoria Metaxa
Acute and Critical Care.2023; 38(1): 31. CrossRef
Does the variant positivity and negativity affect the clinical course in COVID-19?: A cohort study
Erkan Yildirim, Levent Kilickan, Suleyman Hilmi Aksoy, Ramazan Gozukucuk, Hasan Huseyin Kilic, Yakup Tomak, Orhan Dalkilic, Ibrahim Halil Tanboga, Fevzi Duhan Berkan Kilickan
Medicine.2023; 102(9): e33132. CrossRef
The COVID-19 Driving Force: How It Shaped the Evidence of Non-Invasive Respiratory Support
Yorschua Jalil, Martina Ferioli, Martin Dres
Journal of Clinical Medicine.2023; 12(10): 3486. CrossRef
Descriptive account of the first use of the LeVe CPAP System, a new frugal CPAP System, in adult patients with COVID-19 Pneumonitis in Uganda
Anna Littlejohns, Helen Please, Racheal Musasizi, Stuart Murdoch, Gorret Nampiina, Ian Waters, William Davis Birch, Gregory de Boer, Nikil Kapur, Tumwesigye Ambrozi, Ninsiima Carol, Nakigudde Noel, Jiten Parmar, Peter Culmer, Tom Lawton, Edith Namulema
Tropical Medicine and Health.2023;[Epub] CrossRef
Mechanical ventilation and outcomes in COVID-19 patients admitted to intensive care unit in a low-resources setting: A retrospective study
Sarakawabalo Assenouwe, Tabana Essohanam Mouzou, Ernest Ahounou, Lidaw Déassoua Bawe, Awèréou Kotosso, Koffi Atsu Aziagbe, Eyram Makafui Yoan Amekoudi, Mamoudou Omourou, Chimene Etonga Anoudem, Komi Séraphin Adjoh
Journal of Acute Disease.2023; 12(5): 186. CrossRef
Comparison between high-flow nasal cannula and noninvasive ventilation in COVID-19 patients: a systematic review and meta-analysis
Yun Peng, Bing Dai, Hong-wen Zhao, Wei Wang, Jian Kang, Hai-jia Hou, Wei Tan
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Does High Flow Nasal Cannula avoid intubation and improve the mortality of adult patients in acute respiratory failure in the intensive care setting, when compared to others methods as Conventional Oxygen Therapy or Non-Invasive Ventilation? A narrative r
P Fosseur, A Renard, P Mateu, J Rosman
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Case Report

Basic science and research
COVID-19–related acute respiratory distress syndrome treated with veno-venous extracorporeal membrane oxygenation and programmed multi-level ventilation: a case report: Filip Depta, Anton Turčan, Pavol Török, Petra Kapraľová, Michael A. Gentile; Acute Crit Care. 2022;37(3):470-473. Published online January 21, 2022; DOI: https://doi.org/10.4266/acc.2021.01109

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Abstract PDF

We report a patient with severe coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) treated with veno-venous extracorporeal membrane oxygenation (VV ECMO) and programmed multi-level ventilation (PMLV). VV ECMO as a treatment modality for severe ARDS has been described multiple times as a rescue therapy for refractory hypoxemia. It is well known that conventional ventilation can cause ventilator-induced lung injury. Protective ventilation during VV ECMO seems to be beneficial, translating to using low tidal volumes, prone positioning with general concept of open lung approach. However, mechanical ventilation is still required as ECMO per se is usually not sufficient to maintain adequate gas exchange due to hyperdynamic state of the patient and limitation of blood flow via VV ECMO. This report describes ventilation strategy using PMLV during “resting” period of the lung. In short, PMLV is a strategy for ventilating non-homogenous lungs that incorporates expiratory time constants and multiple levels of positive end-expiratory pressure. Using this approach, most affected acute lung injury/ARDS areas can be recruited, while preventing overdistension in healthy areas. To our knowledge, case report using such ventilation strategy for lung resting period has not been previously published.

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Treatment of acute respiratory failure: extracorporeal membrane oxygenation
Jin-Young Kim, Sang-Bum Hong
Journal of the Korean Medical Association.2022; 65(3): 157. CrossRef

Original Article

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.

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Assessment of pressure–volume loop, inflation to precise pressure, minimum occlusive volume, and manual palpation techniques for inflation of endotracheal tube cuff: A randomised clinical study
Soumya Murmu, Jyoti Sharma, Mayank Gupta, Ruhi Sharma, Anju Grewal, Dinesh Kumar Singh
Indian Journal of Anaesthesia.2025; 69(11): 1221. CrossRef
Pressure changes in the endotracheal tube cuff in otorhinolaryngologic surgery: a prospective observational study
Sujung Park, Young In Kwon, Hyun Joo Kim
Frontiers in Medicine.2023;[Epub] CrossRef
Correlación entre la presión del manguito del tubo endotraqueal y los síntomas laringotraqueales en postoperatorio
Wedley Peñaloza, Reyes Cruz Manuel Reyes , Evelin Núñez Wong
Gaceta Médica de la Junta de Beneficencia de Guayaquil.2023; 1(1): 13. CrossRef
Efficacy of using an intravenous catheter to repair damaged expansion lines of endotracheal tubes and laryngeal masks
Tingting Wang, Jiang Wang, Yao Lu, Xuesheng Liu, Shangui Chen
BMC Anesthesiology.2022;[Epub] CrossRef

Case Report

Pulmonary
Successful noninvasive ventilation in a severely acidotic and hypercapnic comatose COVID-19 patient with multiple comorbidities: a case report: Joseph Abraham Poonuraparampil, Habib Md Reazaul Karim, Manu P Kesavankutty, Porika Prashanth Nayak; Acute Crit Care. 2022;37(1):120-123. Published online November 26, 2021; DOI: https://doi.org/10.4266/acc.2020.00983

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Abstract PDF

Effective use of noninvasive ventilation in patients with chronic obstructive pulmonary disease is well-known. However, noninvasive ventilation in patients presenting with altered sensorium and severe acidosis (pH <7.1) has been rarely described. Invasive mechanical ventilation is associated with high mortality in coronavirus disease 2019 (COVID-19), and use of noninvasive ventilation over invasive ventilation is an area of investigation. We report a case of COVID-19-induced acute exacerbation of chronic obstructive pulmonary disease in a 66-year-old male. His past medical history included obstructive sleep apnea, hypertension, cor pulmonale, atrial fibrillation, and amiodarone-induced hypothyroidism. On presentation, he had acute hypercapnic respiratory failure, severe acidosis (partial pressure of carbon dioxide [PCO2], 147 mm Hg; pH, 7.06), and altered mentation. The patient was successfully managed with noninvasive ventilation, avoiding endotracheal intubation, invasive ventilation, and related complications. Although precarious, a trial of noninvasive ventilation can be considered in COVID-19-induced acute exacerbation of chronic obstructive pulmonary disease with hypercapnic respiratory failure, severe acidosis, and altered mentation.

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Lipid Emulsion-Mediated Improvement of Hemodynamic Depression Caused by Amlodipine Toxicity
Ju-Tae Sohn
Pediatric Emergency Care.2023; 39(3): 205. CrossRef

Original Articles

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.

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Mackenzie Scott, Olga Vishnyakova, Lloyd T. Elliott, Gregory Morgan, Selina Casalino, Erika Frangione, Elisa Lapadula, Simona Haller, Shilpa Thakur, Zeeshan Khan, Iris Wong, Romina Nomigolzar, Georgia MacDonald, Saranya Arnoldo, Erin Bearss, Alexandra Bin
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Ana Clara Alcântara Mendes Pereira, Jéssica Cristina Almeida, Beatriz Regina Lima de Aguiar, Elaine Barros Ferreira, Priscilla Roberta Silva Rocha
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Ana Clara Alcântara Mendes Pereira, Jéssica Cristina Almeida, Beatriz Regina Lima de Aguiar, Elaine Barros Ferreira, Priscilla Roberta Silva Rocha
Acta Paulista de Enfermagem.2024;[Epub] CrossRef
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Harsh Vardhan, Megha Saigal, Shyama Shyama, Amresh Krishna
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Daniel Sungku Rim, Byung Sik Kim, Kavita Sharma, Jeong-Hun Shin, Dong Wook Kim
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Nabil Bouguezzi, Imen Ben Saida, Radhouane Toumi, Khaoula Meddeb, Emna Ennouri, Amir Bedhiafi, Dhouha Hamdi, Mohamed Boussarsar
Journal of Clinical Medicine.2023; 12(15): 5127. CrossRef
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Anand Narayanan, Patrick Cunningham, Malavika Mehta, Theodore Lang, Mary Hammes
American Journal of Nephrology.2023; 54(3-4): 156. CrossRef
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Sin-Young Kim, Dae-Young Hong, Jong-Won Kim, Sang-O Park, Kyeong-Ryong Lee, Kwang-Je Baek
Medicina.2022; 58(6): 727. CrossRef
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Shock.2022; 58(5): 426. CrossRef

Pulmonary
Effects of high-flow nasal cannula in patients with mild to moderate hypercapnia: a prospective observational study: Kyung Hun Nam, Hyung Koo Kang, Sung-Soon Lee, So-Hee Park, Sung Wook Kang, Jea Jun Hwang, So Young Park, Won Young Kim, Hee Jung Suh, Eun Young Kim, Ga Jin Seo, Younsuck Koh, Sang-Bum Hong, Jin Won Huh, Chae-Man Lim; Acute Crit Care. 2021;36(3):249-255. Published online July 26, 2021; DOI: https://doi.org/10.4266/acc.2020.01102

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Abstract PDF

Background
Evidence for using high-flow nasal cannula (HFNC) in hypercapnia is still limited. Most of the clinical studies had been conducted retrospectively, and there had been conflicting reports for the effects of HFNC on hypercapnia correction in prospective studies. Therefore, more evidence is needed to understand the effect of the HFNC in hypercapnia.
Methods
We conducted a multicenter prospective observational study after applying HFNC to 45 hospitalized subjects who had moderate hypercapnia (arterial partial pressure of carbon dioxide [PaCO2], 43–70 mm Hg) without severe respiratory acidosis (pH <7.30). The primary outcome was a change in PaCO2 level in the first 24 hours of HFNC use. The secondary outcomes were changes in other parameters of arterial blood gas analysis, changes in respiration rates, and clinical outcomes.
Results
There was a significant decrease in PaCO2 in the first hour of HFNC application (-3.80 mm Hg; 95% confidence interval, -6.35 to -1.24; P<0.001). Reduction of PaCO2 was more prominent in subjects who did not have underlying obstructive lung disease. There was a correction in pH, but no significant changes in respiratory rate, bicarbonate, and arterial partial pressure of oxygen/fraction of inspired oxygen ratio. Mechanical ventilation was not required for 93.3% (42/45) of our study population.
Conclusions
We suggest that HFNC could be a safe alternative for oxygen delivery in hypercapnia patients who do not need immediate mechanical ventilation. With HFNC oxygenation, correction of hypercapnia could be expected, especially in patients who do not have obstructive lung diseases.

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Oguzhan Haciosman, Huseyin Ergenc, Adem Az, Yunus Dogan, Ozgur Sogut
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Successful Asymmetric Nasal High-Flow Therapy in CO₂ Narcosis Triggered by Pneumonia in an Elderly Patient: A Case Report
Keita Takahashi, Shigeto Ishikawa, Akari Kusaka, Hiroyuki Takeuchi, Tomohiko Akahoshi
Cureus.2025;[Epub] CrossRef
Gas composition and pressure in the hypopharynx during high-flow oxygen therapy through a nasal cannula in healthy volunteers with different breathing patterns
Andrey I. Yaroshetskiy, Anna P. Krasnoshchekova, Fedor D. Tkachenko, Alina V. Rubashchenko, Daniil D. Zubarev, Vasiliy D. Konanykhin, Maxim I. Savelenok, Maxim M. Nosenko, Zamira M. Merzhoeva, Sergey N. Avdeev
BMC Anesthesiology.2025;[Epub] CrossRef
Oxygénothérapie nasale à haut débit et insuffisance respiratoire aiguë hypercapnique
C. Girault, E. Artaud-Macari, G. Jolly, D. Carpentier, A. Cuvelier, G. Béduneau
Revue des Maladies Respiratoires.2024; 41(7): 498. CrossRef
Safety and efficacy of high flow nasal canula in patients with mild hypercapnia
Mohammed A. Ibrahim, Magdy Emara, Mohammed Shehta
The Egyptian Journal of Bronchology.2023;[Epub] CrossRef
Current status of treatment of acute respiratory failure in Korea
Yong Jun Choi, Jae Hwa Cho
Journal of the Korean Medical Association.2022; 65(3): 124. CrossRef
High-flow nasal cannula: Evaluation of the perceptions of various performance aspects among Chinese clinical staff and establishment of a multidimensional clinical evaluation system
Ruoxuan Wen, Xingshuo Hu, Tengchen Wei, Kaifei Wang, Zhimei Duan, Zhanqi Zhao, Lixin Xie, Fei Xie
Frontiers in Medicine.2022;[Epub] CrossRef
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Pulmonary
Airway pressure release ventilation in mechanically ventilated patients with COVID-19: a multicenter observational study: John S. Zorbas, Kwok M. Ho, Edward Litton, Bradley Wibrow, Edward Fysh, Matthew H. Anstey; Acute Crit Care. 2021;36(2):143-150. Published online May 4, 2021; DOI: https://doi.org/10.4266/acc.2021.00017

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Abstract PDF

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

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Sandra Emily Stoll, Tobias Leupold, Hendrik Drinhaus, Fabian Dusse, Bernd W. Böttiger, Alexander Mathes
BMC Anesthesiology.2025;[Epub] CrossRef
Airway Pressure Release Ventilation in COVID-19-Associated Acute Respiratory Distress Syndrome—A Multicenter Propensity Score–Matched Analysis
Jan-Hendrik Naendrup, Jonathan Steinke, Jorge Garcia Borrega, Sandra Emily Stoll, Per Ole Michelsen, Yannick Assion, Alexander Shimabukuro-Vornhagen, Dennis Alexander Eichenauer, Matthias Kochanek, Boris Böll
Journal of Intensive Care Medicine.2024; 39(1): 84. CrossRef
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Julia M. Fisher, Vignesh Subbian, Patrick Essay, Sarah Pungitore, Edward J. Bedrick, Jarrod M. Mosier
CHEST Critical Care.2024; 2(1): 100030. CrossRef
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Ashraf Roshdy, Ahmad Samy Elsayed, Ahmad Sabry Saleh
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Guy A. Richards, Oliver Smith
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Jiangli Cheng, Aijia Ma, Meiling Dong, Yongfang Zhou, Bo Wang, Yang Xue, Peng Wang, Jing Yang, Yan Kang
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Friedrich Hohmann, Lisa Wedekind, Felicitas Grundeis, Steffen Dickel, Johannes Frank, Martin Golinski, Mirko Griesel, Clemens Grimm, Cindy Herchenhahn, Andre Kramer, Maria-Inti Metzendorf, Onnen Moerer, Nancy Olbrich, Volker Thieme, Astrid Vieler, Falk Fi
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Pulmonary
Effectiveness of online versus in-person structured training program on arterial blood gas, electrolytes, and ventilatory management of critically ill patients: Gaurav Jain, Bhavna Gupta, Priyanka Gupta, Sagarika Panda, Sameer Sharma, Shalinee Rao; Acute Crit Care. 2021;36(1):54-61. Published online February 2, 2021; DOI: https://doi.org/10.4266/acc.2020.00759

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Abstract PDF

Background
Due to the risk of viral transmission during in-person training, a shift toward online platforms is imperative in the current pandemic. Therefore, we compared the effectiveness of an in-person interactive course with a structurally similar online course designed to improve cognitive skills among clinical health professionals in arterial blood gas analysis, management of electrolyte imbalances, and approaches to mechanical ventilation in critically ill patients.
Methods
In an observational, outcome assessor-blinded, cohort trial, group A included participants enrolled prospectively in an online course, while group B included those who took part in an in-person course (retrospective arm). The primary objective was comparison of cognitive skills through a pre and post-test questionnaire. Statistical analysis was performed using Student t-test.
Results
In total, 435 participants were analyzed in group A, while 99 participants were evaluated in group B. The mean pre-test score was 9.48±2.75 and 10.76±2.42, while the mean post-test score was 11.94±1.90 (passing rate, 64.6%) and 12.53±1.63 (passing rate, 73.3%) in groups A and B, respectively. Group B scored significantly higher in both pre-test (P=0.001) and post-test evaluations (P=0.004). The improvement in post-test score was significantly greater (P=0.001) in group A (2.46±2.22) compared to group B (1.77±1.76). The medical specialties fared better in group B, while surgical specialties scored higher in group A. The pre-test vs. post-test scores exhibited a moderate correlation in both groups (P<0.001). The feedback survey showed a Likert score >3.5 for most points in both groups.
Conclusions
The online teaching module exhibited a significant benefit in terms of participant sensitization and knowledge sharing.

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Health Care Simulation as a Training Tool for Epidemic Management
Marcia A. Corvetto, Fernando R. Altermatt, Francisca Belmar, Eliana Escudero
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare.2023; 18(6): 382. CrossRef

Pulmonary
Utilization of pain and sedation therapy on noninvasive mechanical ventilation in Korean intensive care units: a multi-center prospective observational study: Taehee Kim, Jung Soo Kim, Eun Young Choi, Youjin Chang, Won-Il Choi, Jae-Joon Hwang, Jae Young Moon, Kwangha Lee, Sei Won Kim, Hyung Koo Kang, Yun Su Sim, Tai Sun Park, Seung Yong Park, Sunghoon Park, Jae Hwa Cho; Acute Crit Care. 2020;35(4):255-262. Published online November 9, 2020; DOI: https://doi.org/10.4266/acc.2020.00164; Correction in: Acute Crit Care 2021;36(2):172

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Abstract PDF

Background
The use of sedative drugs may be an important therapeutic intervention during noninvasive ventilation (NIV) in intensive care units (ICUs). The purpose of this study was to assess the current application of analgosedation in NIV and its impact on clinical outcomes in Korean ICUs.
Methods
Twenty Korean ICUs participated in the study, and data was collected on NIV use during the period between June 2017 and February 2018. Demographic data from all adult patients, NIV clinical parameters, and hospital mortality were included.
Results
A total of 155 patients treated with NIV in the ICUs were included, of whom 26 received pain and sedation therapy (sedation group) and 129 did not (control group). The primary cause of ICU admission was due to acute exacerbation of obstructed lung disease (45.7%) in the control group and pneumonia treatment (53.8%) in the sedation group. In addition, causes of NIV application included acute hypercapnic respiratory failure in the control group (62.8%) and post-extubation respiratory failure in the sedation group (57.7%). Arterial partial pressure of carbon dioxide (PaCO2) levels before and after 2 hours of NIV treatment were significantly decreased in both groups: from 61.9±23.8 mm Hg to 54.9±17.6 mm Hg in the control group (P<0.001) and from 54.9±15.1 mm Hg to 51.1±15.1 mm Hg in the sedation group (P=0.048). No significant differences were observed in the success rate of NIV weaning, complications, length of ICU stay, ICU survival rate, or hospital survival rate between the groups.
Conclusions
In NIV patients, analgosedation therapy may have no harmful effects on complications, NIV weaning success, and mortality compared to the control group. Therefore, sedation during NIV may not be unsafe and can be used in patients for pain control when indicated.

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Hamdiye Banu Katran, Esma Kandemir, Ümmügülsüm Sezer
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Josiah Butt, Yahya Shehabi, Yaseen M. Arabi, Morten Hylander Møller, Eddy Fan, Sangeeta Mehta, Dan Perri, Deborah Cook, John Basmaji, Vincent I. Lau, Kallirroi Laiya Carayannopoulos, Waleed Alhazzani, Kimberley Lewis
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Pulmonary
Clinical characteristics and outcomes of critically Ill patients with COVID-19 in Northeast Ohio: low mortality and length of stay: Francois Abi Fadel, Mohammed Al-Jaghbeer, Sany Kumar, Lori Griffiths, Xiaofeng Wang, Xiaozhen Han, Robert Burton; Acute Crit Care. 2020;35(4):242-248. Published online October 12, 2020; DOI: https://doi.org/10.4266/acc.2020.00619

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Abstract PDF

Background
Published coronavirus disease 2019 (COVID-19) reports suggest higher mortality with increasing age and comorbidities. Our study describes the clinical characteristics and outcomes for all intensive care unit (ICU) patients admitted across the Cleveland Clinic enterprise, a 10-hospital health care system in Northeast Ohio, serving more than 2.7 million people.
Methods
We analyzed the quality data registry for clinical characteristics and outcomes of all COVID-19-confirmed ICU admissions. Differences in outcomes from other health care systems and published cohorts from other parts of the world were delineated.
Results
Across our health care system, 495 COVID-19 patients were admitted from March 15 to June 1, 2020. Mean patient age was 67.3 years, 206 (41.6%) were females, and 289 (58.4%) were males. Mean Acute Physiology Score was 45.3, and mean Acute Physiology and Chronic Health Evaluation III score was 60.5. In total, 215 patients (43.3%) were intubated for a mean duration of 9.2 days. Mean ICU and hospital length of stay were 7.4 and 13.9 days, respectively, while mean ICU and hospital mortality rates were 18.4% and 23.8%.
Conclusions
Our health care system cohort is the fourth largest to be reported. Lower ICU and hospital mortality and length of stay were seen compared to most other published reports. Better preparedness and state-level control of the surge in COVID-19 infections are likely the reasons for these better outcomes. Future research is needed to further delineate differences in mortality and length of stay across health care systems and over time.

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Review Article

Pulmonary
Critical Care before Lung Transplantation: Jin Gu Lee, Moo Suk Park, Su Jin Jeong, Song Yee Kim, Sungwon Na, Jeongmin Kim, Hyo Chae Paik; Acute Crit Care. 2018;33(4):197-205. Published online November 30, 2018; DOI: https://doi.org/10.4266/acc.2018.00367

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Abstract PDF

Lung transplantation is widely accepted as the only viable treatment option for patients with end-stage lung disease. However, the imbalance between the number of suitable donor lungs available and the number of possible candidates often results in intensive care unit (ICU) admission for the latter. In the ICU setting, critical care is essential to keep these patients alive and to successfully bridge to lung transplantation. Proper management in the ICU is also one of the key factors supporting long-term success following transplantation. Critical care includes the provision of respiratory support such as mechanical ventilation (MV) and extracorporeal life support (ECLS). Accordingly, a working knowledge of the common critical care issues related to these unique patients and the early recognition and management of problems that arise before and after transplantation in the ICU setting are crucial for long-term success. In this review, we discuss the management and selection of candidates for lung transplantation as well as existing respiratory support strategies that involve MV and ECLS in the ICU setting.

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Long- and short-term clinical impact of awake extracorporeal membrane oxygenation as bridging therapy for lung transplantation
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Respiratory Research.2021;[Epub] CrossRef

Original Article

Pulmonary
Global and Regional Ventilation during High Flow Nasal Cannula in Patients with Hypoxia: Dong Hyun Lee, Eun Young Kim, Ga Jin Seo, Hee Jung Suh, Jin Won Huh, Sang-Bum Hong, Younsuck Koh, Chae-Man Lim; Acute Crit Care. 2018;33(1):7-15. Published online January 22, 2018; DOI: https://doi.org/10.4266/acc.2017.00507; Correction in: Acute Crit Care 2021;36(2):173

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Abstract PDF

Background
High flow nasal cannula (HFNC) is known to increase global ventilation volume in healthy subjects. We sought to investigate the effect of HFNC on global and regional ventilation patterns in patients with hypoxia.
Methods
Patients were randomized to receive one of two oxygen therapies in sequence: nasal cannula (NC) followed by HFNC or HFNC followed by NC. Global and regional ventilation was assessed using electric impedance tomography.
Results
Twenty-four patients participated. Global tidal variation (TV) in the lung was higher during HFNC (NC, 2,241 ± 1,381 arbitrary units (AU); HFNC, 2,543 ± 1,534 AU; P < 0.001). Regional TVs for four iso-gravitational quadrants of the lung were also all higher during HFNC than NC. The coefficient of variation for the four quadrants of the lung was 0.90 ± 0.61 during NC and 0.77 ± 0.48 during HFNC (P = 0.035). Within the four gravitational layers of the lung, regional TVs were higher in the two middle layers during HFNC when compared to NC. Regional TV values in the most ventral and dorsal layers of the lung were not higher during HFNC compared with NC. The coefficient of variation for the four gravitational layers of the lung were 1.00 ± 0.57 during NC and 0.97 ± 0.42 during HFNC (P = 0.574).
Conclusions
In patients with hypoxia, ventilation of iso-gravitational regions of the lung during HFNC was higher and more homogenized compared with NC. However, ventilation of gravitational layers increased only in the middle layers. (Clinical trials registration number: NCT02943863).

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High-flow nasal cannulae for respiratory support in adult intensive care patients
Sharon R Lewis, Philip E Baker, Roses Parker, Andrew F Smith
Cochrane Database of Systematic Reviews.2021;[Epub] CrossRef
Failure of High-Flow Nasal Cannula Therapy in Pneumonia and Non-Pneumonia Sepsis Patients: A Prospective Cohort Study
Eunhye Kim, Kyeongman Jeon, Dong Kyu Oh, Young-Jae Cho, Sang-Bum Hong, Yeon Joo Lee, Sang-Min Lee, Gee Young Suh, Mi-Hyeon Park, Chae-Man Lim, Sunghoon Park
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High-flow nasal cannulae for respiratory support in adult intensive care patients
Sharon R Lewis, Philip E Baker, Roses Parker, Andrew F Smith
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Review Article

Pulmonary
Patient-Ventilator Dyssynchrony: Elvira-Markela Antonogiannaki, Dimitris Georgopoulos, Evangelia Akoumianaki; Korean J Crit Care Med. 2017;32(4):307-322. Published online November 30, 2017; DOI: https://doi.org/10.4266/kjccm.2017.00535

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Abstract PDF

In mechanically ventilated patients, assisted mechanical ventilation (MV) is employed early, following the acute phase of critical illness, in order to eliminate the detrimental effects of controlled MV, most notably the development of ventilator-induced diaphragmatic dysfunction. Nevertheless, the benefits of assisted MV are often counteracted by the development of patient-ventilator dyssynchrony. Patient-ventilator dyssynchrony occurs when either the initiation and/or termination of mechanical breath is not in time agreement with the initiation and termination of neural inspiration, respectively, or if the magnitude of mechanical assist does not respond to the patient’s respiratory demand. As patient-ventilator dyssynchrony has been associated with several adverse effects and can adversely influence patient outcome, every effort should be made to recognize and correct this occurrence at bedside. To detect patient-ventilator dyssynchronies, the physician should assess patient comfort and carefully inspect the pressure- and flow-time waveforms, available on the ventilator screen of all modern ventilators. Modern ventilators offer several modifiable settings to improve patient-ventilator interaction. New proportional modes of ventilation are also very helpful in improving patient-ventilator interaction.

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Original Article

Pulmonary
Evaluation of Respiratory Dynamics in an Asymmetric Lung Compliance Model: So Hui Yun, Ho-Jin Lee, Yong-Hun Lee, Jong Cook Park; Korean J Crit Care Med. 2017;32(2):174-181. Published online April 14, 2017; DOI: https://doi.org/10.4266/kjccm.2016.00738

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Abstract PDF

Background
Unilateral lung hyperinflation develops in lungs with asymmetric compliance, which can lead to vital instability. The aim of this study was to investigate the respiratory dynamics and the effect of airway diameter on the distribution of tidal volume during mechanical ventilation in a lung model with asymmetric compliance.
Methods
Three groups of lung models were designed to simulate lungs with a symmetric and asymmetric compliance. The lung model was composed of two test lungs, lung1 and lung2. The static compliance of lung1 in C15, C60, and C120 groups was manipulated to be 15, 60, and 120 mL/cmH₂O, respectively. Meanwhile, the static compliance of lung2 was fixed at 60 mL/cmH₂O. Respiratory variables were measured above (proximal measurement) and below (distal measurement) the model trachea. The lung model was mechanically ventilated, and the airway internal diameter (ID) was changed from 3 to 8 mm in 1-mm increments.
Results
The mean ± standard deviation ratio of volumes distributed to each lung (V_L1/V_L2) in airway ID 3, 4, 5, 6, 7, and 8 were in order, 0.10 ± 0.05, 0.11 ± 0.03, 0.12 ± 0.02, 0.12 ± 0.02, 0.12 ± 0.02, and 0.12 ± 0.02 in the C15 group; 1.05 ± 0.16, 1.01 ± 0.09, 1.00 ± 0.07, 0.97 ± 0.09, 0.96 ± 0.06, and 0.97 ± 0.08 in the C60 group; and 1.46 ± 0.18, 3.06 ± 0.41, 3.72 ± 0.37, 3.78 ± 0.47, 3.77 ± 0.45, and 3.78 ± 0.60 in the C120 group. The positive end-expiratory pressure (PEEP) of lung1 was significantly increased at airway ID 3 mm (1.65 cmH₂O) in the C15 group; at ID 3, 4, and 5 mm (2.21, 1.06, 0.95 cmH₂O) in the C60 group; and ID 3, 4, and 5 mm (2.92, 1.84, 1.41 cmH₂O) in the C120 group, compared to ID 8 mm (p < 0.05).
Conclusions
In the C15 and C120 groups, the tidal volume was unevenly distributed to both lungs in a positive relationship with lung compliance. In the C120 group, the uneven distribution of tidal volume was improved when the airway ID was equal to or less than 4 mm, but a significant increase of PEEP was observed.

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Igor Barjaktarevic, Glen Meyerowitz, Onike Williams, I. Obi Emeruwa, Nir Hoftman
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Case Reports

Pulmonary
Successful Treatment with Empirical Erlotinib in a Patient with Respiratory Failure Caused by Extensive Lung Adenocarcinoma: Suk Hyeon Jeong, Sang-Won Um, Hyun Lee, Kyeongman Jeon, Kyung Jong Lee, Gee Young Suh, Man Pyo Chung, Hojoong Kim, O Jung Kwon, Yoon La Choi; Korean J Crit Care Med. 2016;31(1):44-48. Published online February 29, 2016; DOI: https://doi.org/10.4266/kjccm.2016.31.1.44

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Abstract PDF

We herein describe a 70-year-old woman who presented with respiratory failure due to extensive lung adenocarcinoma. Despite advanced disease, care in the intensive care unit with ventilator support was performed because she was a newly diagnosed patient and was considered to have the potential to recover after cancer treatment. Because prompt control of the cancer was needed to treat the respiratory failure, empirical treatment with an oral epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor was initiated before confirmation of EGFR-mutant adenocarcinoma, and the patient was successfully treated. Later, EGFR-mutant adenocarcinoma was confirmed.

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Lazarus effect in a patient initially empirically treated with osimertinib for EGFR L858R mutant non-small cell lung cancer with leptomeningeal disease: a case report
Shreya Bhatia, Manuel G. Cortez, Spencer Lessans, Wade T. Iams
Oncotarget.2024; 15(1): 27. CrossRef
Lung cancer with superior vena cava syndrome diagnosed by intravascular biopsy using EBUS-TBNA
Daegeun Lee, Seong Mi Moon, Dongwuk Kim, Juwon Kim, Haseong Chang, Bumhee Yang, Suk Hyeon Jeong, Kyung Jong Lee
Respiratory Medicine Case Reports.2016; 19: 177. CrossRef

Pulmonary
Barotrauma after Manual Ventilation in a Patient with Life-Threatening Massive Hemoptysis: Hea Yon Lee, Yu Young Joo, Young Seung Oh, Yoo Rim Seo, Hyon Soo Joo, Seok Chan Kim, Chin Kook Rhee; Korean J Crit Care Med. 2015;30(4):308-312. Published online November 30, 2015; DOI: https://doi.org/10.4266/kjccm.2015.30.4.308

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Abstract PDF

A 36-year-old female patient with aplastic anemia developed massive hemoptysis and was placed on ventilator support. However, airway obstruction by blood clots triggered desaturation and ventilator malfunction. Manual ventilation was initiated to improve oxygenation, and emergency flexible bronchoscopy was performed to clear the airway. Nevertheless, the patient developed extensive subcutaneous emphysema, pneumothorax, and pneumomediastinum.

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Clinical Approach to Massive Hemoptysis: Perioperative Focus on Causes and Management
Timothy Weiquan Toh, Jacqueline Hui Fen Goh, Sui An Lie, Carrie Kah Lai Leong, Nian Chih Hwang
Journal of Cardiothoracic and Vascular Anesthesia.2024; 38(10): 2412. CrossRef
Pathophysiology and Prevention of Manual-Ventilation-Induced Lung Injury (MVILI)
Luke A. White, Steven A. Conrad, Jonathan Steven Alexander
Pathophysiology.2024; 31(4): 583. CrossRef
Experimental validation of a portable tidal volume indicator for bag valve mask ventilation
Benjamin S. Maxey, Luke A. White, Giovanni F. Solitro, Steven A. Conrad, J. Steven Alexander
BMC Biomedical Engineering.2022;[Epub] CrossRef

Randomized Controlled Trial

Pharmacology/Pulmonary
Comparison of Morphine and Remifentanil on the Duration of Weaning from Mechanical Ventilation: Jae Myeong Lee, Seong Heon Lee, Sang Hyun Kwak, Hyeon Hui Kang, Sang Haak Lee, Jae Min Lim, Mi Ae Jeong, Young Joo Lee, Chae Man Lim; Korean J Crit Care Med. 2014;29(4):281-287. Published online November 30, 2014; DOI: https://doi.org/10.4266/kjccm.2014.29.4.281; Correction in: Acute Crit Care 2016;31(4):381

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Abstract PDF

BACKGROUND
A randomized, multicenter, open-label, parallel group study was performed to compare the effects of remifentanil and morphine as analgesic drugs on the duration of weaning time from mechanical ventilation (MV).
METHODS
A total of 96 patients with MV in 6 medical and surgical intensive care units were randomly assigned to either, remifentanil (0.1-0.2 mcg/kg/min, n = 49) or morphine (0.8-35 mg/hr, n = 47) from the weaning start. The weaning time was defined as the total ventilation time minus the sum of controlled mode duration.
RESULTS
Compared with the morphine group, the remifentanil-based analgesic group showed a tendency of shorter weaning time (mean 143.9 hr, 89.7 hr, respectively: p = 0.069). Secondary outcomes such as total ventilation time, successful weaning rate at the 7th of MV day was similar in both groups. There was also no difference in the mortality rate at the 7th and 28th hospital day. Kaplan-Meyer curve for weaning was not different between the two groups.
CONCLUSIONS
Remifentanil usage during the weaning phase tended to decrease weaning time compared with morphine usage.

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ICU patients receiving remifentanil do not experience reduced duration of mechanical ventilation: a systematic review of randomized controlled trials and network meta-analyses based on Bayesian theories
Fangjie Lu, Sirun Qin, Chang Liu, Xunxun Chen, Zhaoqiu Dai, Cong Li
Frontiers in Medicine.2024;[Epub] CrossRef
Comparison between remifentanil and other opioids in adult critically ill patients
Shuguang Yang, Huiying Zhao, Huixia Wang, Hua Zhang, Youzhong An
Medicine.2021; 100(38): e27275. CrossRef

Original Articles

Pulmonary
Predicting Delayed Ventilator Weaning after Lung Transplantation: The Role of Body Mass Index: Sarah Soh, Jin Ha Park, Jeong Min Kim, Min Jung Lee, Shin Ok Koh, Hyo Chae Paik, Moo Suk Park, Sungwon Na; Korean J Crit Care Med. 2014;29(4):273-280. Published online November 30, 2014; DOI: https://doi.org/10.4266/kjccm.2014.29.4.273

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Abstract PDF: BACKGROUND
Weaning from mechanical ventilation is difficult in the intensive care unit (ICU). Many controversial questions remain unanswered concerning the predictors of weaning failure. This study investigates patient characteristics and delayed weaning after lung transplantation.
METHODS
This study retrospectively reviewed the medical records of 17 lung transplantation patients from October 2012 to December 2013. Patients able to be weaned from mechanical ventilation within 8 days after surgery were assigned to an early group (n = 9), and the rest of the patients were assigned to the delayed group (n=8). Patients' intraoperative and postoperative characteristics were collected and analyzed, and conventional weaning predictors, including rapid shallow breathing index (RSBI), were also assessed.
RESULTS
The results of the early group showed a significantly shorter ICU stay in addition to a shorter hospitalization overall. Notably, the early group had a higher body mass index (BMI) than the delayed group (20.7 vs. 16.9, p = 0.004). In addition, reopening occurred more frequently in the delayed group (1/9 vs. 5/8, p = 0.05). During spontaneous breathing trials, tidal volume (TV) and arterial oxygen tension were significantly higher in the early group compared to the delayed weaning group, but differences in RSBI and respiratory rate (RR) between groups were not statistically significant.
CONCLUSIONS
Low BMI might be associated with delayed ventilator weaning in lung transplantation patients. In addition, instead of the traditional weaning predictors of RSBI and RR, TV might be a better predictor for ventilator weaning after lung transplantation.

Thoracic surgery
Clinical Characteristics of the Development of Pneumothorax in Mechanically Ventilated Patients in Intensive Care Units: Wan Chul Kim, Su Jin Lim, Kyong Young Kim, Seung Jun Lee, Yu Ji Cho, Yi Yeong Jeong, Mi Jung Park, Kyoung Nyeo Jeon, Jong Deog Lee, Young Sil Hwang, Ho Cheol Kim; Korean J Crit Care Med. 2014;29(1):13-18. Published online February 28, 2014; DOI: https://doi.org/10.4266/kjccm.2014.29.1.13

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Abstract PDF: Background
Pneumothorax (PTX) can occur as a complication of positive pressure ventilation in mechanically ventilated patients.
Methods
We retrospectively reviewed the clinical characteristics of patients who developed PTX during mechanical ventilation (MV) in the intensive care unit (ICU).
Results
Of the 326 patients admitted (208 men and 118 women; mean age, 65.3 ± 8.74 years), 15 (4.7%) developed PTX, which was MV-associated in 11 (3.3%) cases (6 men and 5 women; mean age, 68.3 ± 9.12 years) and procedure-associated in 4. Among the patients with MV-associated PTX, the underlying lung diseases were acute respiratory distress syndrome in 7 patients, interstitial lung disease in 2 patients, and chronic obstructive pulmonary disease in 2 patients. PTX diagnosis was achieved by chest radiography alone in 9 patients and chest computed tomography alone in 2 patients. Nine patients were using assist-control mode MV with the mean applied positive end-expiratory pressure, 9 ± 4.6 cmH₂O and the mean tidal volume, 361 ± 63.7 ml at the diagnosis of PTX. Two patients died as a result of MV-associated PTX and their systolic pressure was below 80 mmHg and heart rates were less than 80/min. Ten patients were treated by chest tube insertion, and 1 patient was treated by percutaneous pigtail catheter insertion.
Conclusions
PTX can develop in patients undergoing MV, and may cause death. Early recognition and treatment are necessary to prevent hemodynamic compromise in patients who develop PTX.

The Consistency and Clinical Significance between Bronchoscopic Samples and Endotracheal or Tracheostomic Aspirates in Severe Pneumonia Under Mechanical Ventilation: Hye Sung Park, Seo Woo Kim, Yun Su Sim, Ji Hye Kim, Yon Ju Ryu, Jin Hwa Lee, Jung Hyun Chang; Korean J Crit Care Med. 2011;26(2):83-88.; DOI: https://doi.org/10.4266/kjccm.2011.26.2.83

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Abstract PDF

BACKGROUND
Distal airway bacterial colonization occurs more frequently in patients with endotracheal tubes or tracheostomy of intensive care units (ICU) care. In general, bronchoscopic samples are considered more accurate than transtracheal aspirates. In this study, we evaluated the consistency and clinical significance between bronchoscopic samples and transtracheal aspirates (TTA) in severe pneumonia under mechanical ventilation.
METHODS
We investigated the consistency between bronchoscopic samples and transtracheal aspirates among patients with endotracheal tubes or tracheostomy, retrospectively. Fiberoptic bronchoscopy was performed in 212 patients with mechanical ventilation via endotracheal tube or tracheostomy between January 1st, 2004 and December 31th, 2008 in ICU at Ewha Womans University Hospital. We evaluated consistency in terms of true pathogen according to the arbitrary ICU days progress.
RESULTS
Among the 212 enrolled patients, 113 (53%) had consistency between bronchoscopic samples and transtracheal aspirates. When evaluated alteration trends in consistency according to ICU stay, the consistency was maintained for 5 to 9 ICU days with statistical significance (p< 0.05) since adjusting for age, sex, and combined risk factors. Consistency in sampling status between the endotracheal tube and tracheostomy was also evaluated, however, there was no statistical significance (OR 1.9 vs. 1, 95% CI = 0.997-3.582, p = 0.051).
CONCLUSIONS
Shorter hospital stay (within 9 days of ICU stay) had higher probability of consistency between bronchoscopic samples and TTA samples. TTA may be as confident as bronchoscopic samples in patients of pneumonia under mechanical ventilation with shorter ICU stays, especially less than 10 days.

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Comparison of the Pattern in Semi-Quantitative Sputum Cultures Based on Different Endotracheal Suction Techniques
Jiwoong Oh, Kum Whang, Hyenho Jung, Jongtaek Park
Korean Journal of Critical Care Medicine.2012; 27(2): 70. CrossRef

Case Report

A Case of Severe Acute Exacerbation of Bronchial Asthma Treated with Low Minute Ventilation: A Case Report: Young Joo Han, Dong In Suh, Young Seung Lee, June Dong Park; Korean J Crit Care Med. 2010;25(4):257-262.; DOI: https://doi.org/10.4266/kjccm.2010.25.4.257

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Abstract PDF: We report a case of severe status asthmaticus in a 3-year-old boy who required mechanical ventilatory support. He initially presented with rapidly progressing respiratory distress and spontaneous air leaks. Although he was intubated and received mechanical ventilation, dynamic hyperinflation and air leaks were aggravated. We applied the volume control mode, providing sufficient tidal volume (10 ml/kg), a reduced respiratory rate (25/minute), and a prolonged expiratory time (1.8 seconds) to overcome dynamic hyperinflation. After allowing full expiration of trapped air, his over-expanded lung volumes were decreased and the air leaks resolved. He made a complete recovery without sequelae. Dynamic hyperinflation in asthmatic patients occurs from incomplete exhalation throughout narrowed airways. Controlled hypoventilation or permissive hypercapnia is an important lung-protective ventilator strategy and is beneficial in reducing dynamic hyperinflation. We suggest a controlled hypoventilation strategy with a prolonged expiratory time for patients in severe status asthmaticus with dynamic hyperinflation.

Original Articles

Physician Compliance with Tube Feeding Protocol Improves Nutritional and Clinical Outcomes in Acute Lung Injury Patients: Sungwon Na, Hosun Lee, Shin Ok Koh, Ai Soon Park, A Reum Han; Korean J Crit Care Med. 2010;25(3):136-143.; DOI: https://doi.org/10.4266/kjccm.2010.25.3.136

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Abstract PDF

BACKGROUND
Nutrition delivery is frequently interrupted or delayed by physicians' ordering patterns. We conducted this study to investigate the effect of physician compliance with tube feeding (TF) protocol on the nutritional and clinical outcomes in acute lung injury (ALI) patients.
METHODS
After implementing a TF protocol, 71 ALI patients with mechanical ventilation (MV) for > or = 7 days were observed. A dietician assessed the nutritional status of the patients and established individualized nutrition plans according to the protocol. If the physicians followed the dietician's recommendation within 48 hours, the patients were classified under the compliant group (Group 1).
RESULTS
Forty patients (56.3%) were classified into Group 1. Prealbumin was comparable in both groups at ICU admission but higher in Group 1 at the time of discharge from the ICU (228 +/- 81 vs 157 +/- 77 mg/dl, p = 0.025). Nitrogen balance was only improved in Group 1. The time to reach calorie goal was shorter and non-feeding days were reduced in Group 1. The proportion of parenteral nutrition to nutritional support days was lower and delivered calories on the 4th and 7th day of TF were higher in Group 1 (p < 0.001). ICU mortality/stay and hospital mortality failed to show differences but hospital stay was prolonged in the noncompliant group (Group 2) (p = 0.023). Arterial oxygen tension and PaO2/FiO2 were maintained during the 1st week of ICU stay in Group 1 but were decreased in Group 2.
CONCLUSIONS
Physicians' compliance with the TF protocol contributed to the likelihood of nutritional improvement and a shorter hospital stay in ALI patients with prolonged MV.

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Barriers to the Implementation of Prospective Studies Evaluating the Benefits of Early Tube Feeding on Hip Fracture Outcomes: Lessons and Future Directions from a Failed Pilot Study
Fernando Huyke-Hernández, Megan Sorich, Julie Switzer
Journal of the American Osteopathic Academy of Orthopedics.2023;[Epub] CrossRef
Nutritional Assessment of ICU Inpatients with Tube Feeding
Yu-Jin Kim, Jung-Sook Seo
Journal of the Korean Dietetic Association.2015; 21(1): 11. CrossRef
Identifying Barriers to Implementing Nutrition Recommendations
Nancy Stamp, Anne M. Davis
Topics in Clinical Nutrition.2013; 28(3): 249. CrossRef

Evaluating the Relationship between the Scoring Systems of Intensive Care Units (ICUs) and the Duration of Mechanical Ventilation after Liver Transplantation: Jeong Eun Kim, Sang Hoon Lee, Jong Ho Choi; Korean J Crit Care Med. 2009;24(2):69-74.; DOI: https://doi.org/10.4266/kjccm.2009.24.2.69

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Abstract PDF: 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: <8 hr, Group 2: 8-12 hr and Group 3: >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.

Effects of Ventilation Modes and Levels of PEEP on Respiratory Mechanics during Controlled Ventilation under General Anesthesia: Jong Cook Park, Sang Hyun Park, Hyun Jun Kwag, Soo Young Park; Korean J Crit Care Med. 2006;21(2):89-94.

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Abstract PDF: BACKGROUND
Application of PEEP increases lung volume and improves oxygenation. High PEEP levels may cause alveolar overdistension or barotrauma. It was hypothesized that there will be an effect of level of PEEP on respiratory resistance and an effect of ventilatory mode on respiratory compliance. This study aimed to investigate the effects of ventilation modes and levels of PEEP on respiratory mechanics during controlled ventilation under general anesthesia.
METHODS
In 14 mechanically ventilated patients without cardiopulmonary symptoms and signs, we measured the respiratory mechanics using the inspiration interrupter technique during a constant flow. Dynamic and static compliance, airway resistance, visco-elastic tissue and total respiratory system resistance were calculated at 0, 5, 10, 15, and 20 cmH2O of positive end-expiratory pressure (PEEP) in VCV mode, VCV with inspiratory pause mode, and PCV mode, respectively.
RESULTS
The dynamic compliance of the PCV mode was higher than that of the VCV mode. The highest static compliance was at 10 cmH2O PEEP. At 20 cmH2O PEEP, pulmonary compliance was decreased and the tissue resistance was increased.
CONCLUSIONS
These results suggest that the respiratory mechanics including respiratory resistance should be monitored for applying PEEP. Further studies on clinical condition such as acute lung injury and ARDS were needed.

Randomized Controlled Trial

Alteration of Lung Mechanics Depending on Expiratory Sensitivity (ESENS) during Pressure Support Ventilation: Kwang Won Seo, Gyu Rak Chon, Jong Joon Ahn, Yangjin Jega, Sang Bum Hong, Chae Man Lim, Younsuck Koh; Korean J Crit Care Med. 2006;21(1):8-16.

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Abstract PDF: BACKGROUND
To evaluate effects of 5 expiratory sensitivity (ESENS) levels (5%; 15%; 25%; 35%; 45%) on lung mechanics and the effects depending on the two P(0.1) levels (<3 cm H2O; > or =3 cm H2O).
METHODS
Prospective, randomized, physiologic study for intubated adult patients during weaning from mechanical ventilation. Patients were randomly submitted to the 5 settings of ESENS in the Galileo ventilator (Galileo Gold, Hamilton Medical AG, Switzerland). Physiologic variables were continuously measured using a Bicore CP-100 pulmonary mechanics monitor (CP-100, Bicore, USA).
RESULTS
Thirteen patients, ten men and three women, with a mean age of 65.2+/-16.1 yr were studied. Tidal volume (V(T)) decreased significantly from ESENS 5% to 45%. With increasing levels of ESENS, respiratory rates (RR) steadily increased from ESENS 5% to 35% and 45%. Shallow breath index (F/V(T)) increased significantly from ESENS 5% to 45%. Inspiratory time (T(I)) decreased gradually significantly from ESENS 5% to 45%. RR and F/V(T) increased from ESENS 5% to 15% and 45% and V(T) decreased gradually in patients with P(0.1)<3 cm H2O group, but not in patients with P(0.1)> or =3 cm H2O.
CONCLUSIONS
The proper adjustment of expiratory sensitivity (ESENS) levels improved patient-ventilator synchrony and decreased respiratory rates and shallow breath index, especially in P(0.1)<3 cm H2O during PSV in ventilator weaning patients. Lower ESENS level would be more appropriate in terms of lung mechanics in patients with less than 3 cm H2O of P(0.1).

Case Report

One-lung Ventilation using Wire-guided Endobronchial Blocker and Single Lumen Endotracheal Tube: A Case Report: Hee Zoo Kim, Seung Hwan Oh, Chung Guk Park, Eun Hye Koo, Hye Ran Oh, Mi Kyoung Lee, Sang Ho Lim; Korean J Crit Care Med. 2005;20(1):92-96.

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Abstract PDF: We had done one-lung ventilation using 9 Fr wire-guided endobronchial blocker and outer diameter 41-mm flexible fiberoptic bronchoscope in ruptured esophageal patient who expected difficult tracheal intubation and in esophageal cancer patient who was in need of mechanical ventilation during and after the operation.

Original Articles

Clinical Findings of Critical Illness Polyneuropathy in Patients with Mechanical Ventilator Treatment: Sung Soon Lee, Jae Yong Chin, Chae Man Lim, Younsuck Koh; Korean J Crit Care Med. 2005;20(1):38-43.

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Abstract PDF: BACKGROUND
Critical illness polyneuropathy (CIP) is a primary distal axonal degeneration of motor and sensory fibers leading to severe limb weakness and difficulty in weaning from ventilator in critically ill patients. The object of this study is to evaluate the clinical findings of CIP and the risk factors associated with CIP development in patients with mechanical ventilator treatment. METHODS: We examined 40 patients, between March 2002 to February 2003, who manifested muscular weakness and received mechanical ventilation (MV) more than three days, prospectively. Nerve conduction velocity (NCV) and electromyography (EMG) were performed in all patients in the ICU. We examined the use of drugs (neuromuscular blocking agents, corticosteroid, and aminoglycoside), duration of MV and weaning, and APACHE II score. RESULTS: We observed 40 patients who showed muscular weakness, 9 patients were diagnosed as CIP. NCV study demonstrated decreased action potential amplitude, predominantly in motor nerve, distal part. There was no significant difference in duration of MV and weaning, drug use, APACHE II score between the groups with CIP and without CIP. CONCLUSIONS: CIP is an important neuromuscular complication of the patients in ICU. We should consider the possibility of the development of CIP in patients who showed muscular weakness and difficult weaning in critically ill patients.

Influence of Collapse and Re-ventilation of Lung on the Development of Pulmonary Edema: Sang Hyun Kwak, Won Jong Jin, Hong Beom Bae, Seong Wook Jeong, Sung Su Chung, Chang Young Jeong; Korean J Crit Care Med. 2004;19(1):8-19.

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Abstract PDF: BACKGROUND
This study was to clarify the influence of collapse and re-ventilation of lung on the development of pulmonary edema in rabbit. METHODS: Animals were randomly assigned to one of three groups: Sham group receiving two lung ventilation (n=14), Collapse group receiving collapse of right lung (n=14), Reventilation group receiving collapse of right lung for 3 hours followed by reventilation of collapsed right lung for 3 hours (n=14). The lung of rabbits were ventilated with 50% oxygen through the tracheostomy. Right main bronchus was secured by thoracotomy in all animal. Collapse and reventilation were performed using by bulldog forcep. Mean arterial pressure, heart rate, arterial oxygen tension (PaO2), peripheral blood leukocyte and platelet counts were recorded at 0, 1, 2, 3, 4, 5 and 6 hour after the start of experiment. The wet to dry (W/D) weight ratio of lung, lung injury score and leukocyte counts, percentage of polymorphonuclear leukocyte (PMNL), concentration of albumin, and interleukin-8 (IL-8) in bronchoalveolar lavage fluid (BALF) were measured 6 hour after the start of experiment in both lung. RESULTS: W/D weight ratio of lung, lung injury score and leukocyte counts, percentage of PMNL, concentration of albumin and IL-8 in BALF were significantly increased in both lung of reventilation group. And the degree of increases is more significant in right than left lung. CONCLUSIONS: These findings suggest that reventilation of collapsed lung causes the bilateral pulmonary edema in rabbit mainly by activating neutrophil and IL-8 responses, which may play a central role in non cardiogenic pulmonary edema.

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