Acute and Critical Care

Original Articles

Cardiology
Diaphragm ultrasound for predicting weaning success in post-cardiac surgery acute respiratory distress syndrome patients: a prospective observational study in China: Yuan-Qin Huang, Pei Yu, Dou-Dou Xiang, Quan Gan; Acute Crit Care. 2025;40(3):435-443. Published online August 21, 2025; DOI: https://doi.org/10.4266/acc.004320

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Abstract PDF: Background
To explore the value of the diaphragm thickness fraction (TF) and diaphragm mobility (DM) measured by ultrasound for predicting ventilator withdrawal success in patients with acute respiratory distress syndrome (ARDS) after cardiac surgery. Methods: This study included 246 patients undergoing the spontaneous breathing trial. Diaphragmatic function was evaluated by ultrasound, including the diaphragm thickness at the end of calm breathing (thickness of the diaphragm at functional residual capacity [TdiFRC]) and the maximum diaphragm thickness at the end of inspiration (thickness of the diaphragm at full vital capacity [TdiFVC]); TF=(TdiFVC–TdiFRC)/TdiFRC×100%. DM, the oxygenation index (the ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen), and the rapid shallow breathing index (RSBI) were measured. Results: Successful liberation from mechanical ventilation was observed in 209 patients. There were no significant differences in the TdiFRC (0.3±0.1 cm vs. 0.3±0.1 cm) or TdiFVC (0.3±0.1 cm vs. 0.2±0.1 cm) between the ventilator withdrawal success group and the ventilator withdrawal failure group (P>0.05). The TF was greater in the ventilator withdrawal success group than in the ventilator withdrawal failure group (40.8%±15.8% vs. 37.7%±9.2%, P<0.01). DM in the ventilator withdrawal success group was greater than that in the ventilator withdrawal failure group (1.5±0.5 cm vs. 1.2±0.4 cm, P=0.040). The RSBI was lower in the ventilator withdrawal success group than in the ventilator withdrawal failure group (74.3±25.6 breaths·min–1·L –1 vs. 89.9±34.5 breaths·min–1·L –1, P<0.01). Conclusions: Diaphragmatic ultrasound can be used to predict the success of ventilator withdrawal in patients with ARDS.

Pulmonary
Characteristics and management of mechanically ventilated patients in South Korea compared with other high-income Asian countries and regions: Kyung Hun Nam, Kyeongman Jeon, Suk-Kyung Hong, Ah Young Leem, Jee Hwan Ahn, Hang Jea Jang, Ki Sup Byun, So Hee Park, Sojung Park, Yoon Mi Shin, Jisoo Park, Sung Wook Kang, Jin Hyoung Kim, Jinkyeong Park, Deokkyu Kim, Bo young Lee, Woo Hyun Cho, Kwangha Lee, Song I Lee, Tai Sun Park, Yun Jung Jung, Sang-Hyun Kwak, Sang-Beom Jeon, Sung Hyun Kim, Won Jai Jung, Sang-Min Lee, Sunghoon Park, Yun Su Sim, Young-Jae Cho, Younsuck Koh; Acute Crit Care. 2025;40(3):413-424. Published online August 21, 2025; DOI: https://doi.org/10.4266/acc.003336

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Abstract PDF: Background
This study investigated the characteristics of mechanically ventilated patients in South Korean intensive care units (ICUs). Methods: We conducted a subgroup analysis of a multinational observational study. Data from 271 mechanically ventilated patients in South Korean ICUs were analyzed for demographics, ventilation practices, and mortality, and were compared with those of 327 patients from other high-income Asian countries. Results: South Korean patients were older (mean age: 67 vs. 62 years, P<0.001) and had lower ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (255.5 vs. 306.2, P<0.001). South Korean ICUs exhibited higher patient-to-nurse ratios (2.6 vs. 1.9, P<0.001) and more beds per unit (20.5 vs. 16.0, P=0.017). The use of sufficient positive end-expiratory pressure for patients (PEEP) for acute respiratory distress syndrome (ARDS) was less frequent in South Korea (62.2% vs. 91.2%, P=0.005). Mortality rates were similar between South Korean patients and those in other high-income Asian countries (38.0% vs. 34.2%, P=0.401). Significant mortality predictors in South Korea included age ≥65 years (odds ratio [OR], 4.03; P=0.039) and a Sequential Organ Failure Assessment score ≥8 (OR, 2.36; P=0.031). The presence of respiratory therapists was associated with reduced mortality (OR, 0.52; P=0.034). Conclusions: Despite higher age and patient-to-nurse ratios in South Korean ICUs, outcomes were comparable to those in other high-income Asian countries. The suboptimal use of sufficient PEEP with ARDS indicates potential areas for improvement. Additionally, the beneficial impact of respiratory therapists on mortality rates warrants further investigation.

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.

Infection
Striving for excellence in ventilator bundle compliance through continuous quality improvement initiative in the intensive care unit of a tertiary care hospital in India: Naveen Paliwal, Pooja Bihani, Rishabh Jaju, Sadik Mohammed, Prabhu Prakash, Vidya Tharu; Acute Crit Care. 2024;39(4):535-544. Published online November 12, 2024; DOI: https://doi.org/10.4266/acc.2024.00101

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Abstract PDF

Background
Ventilator-associated pneumonia (VAP) is a significant nosocomial infection in intensive care units (ICUs). Ventilator bundle (VB) implementation has been shown to decrease the incidence of VAP. This study presents a 1-year quality improvement (QI) project conducted in the ICU of a tertiary care hospital with the goal of increasing VB compliance to greater than 90% and evaluating its impact on VAP incidence and ICU length of stay.
Methods
A series of Plan-Do-Study-Act (PDSA) cycles, including educational boot camps, checklist implementation, and simulation-based training, was implemented. Emphasis on standardization and documentation for each VB component further improved compliance. Data were compared using a chi-square test, unpaired t-test, or Mann-Whitney U-Test, as appropriate. A P-value <0.05 was considered statistically significant.
Results
The initial observed compliance was 40.7%, with a significant difference between knowledge and implementation. The compliance increased to 90% after the second PDSA cycle. In the third PDSA cycle, uniformity and standardization of all components of VAP were ensured. After increasing the VB compliance at greater than 90%, there was a significant decline in the incidence of VAP, from 62.4/1,000 ventilatory days to 25.7/1,000 ventilatory days, with a 2.34 times risk reduction in the VAP rate (P= 0.004)
Conclusions
The study highlights the effectiveness of a structured QI approach in enhancing VB compliance and reducing VAP incidence. There is a need for continued education, protocol standardization, and continuous monitoring to ensure the sustainability of this implementation.

Citations

Citations to this article as recorded by

Simulation-based training for fascial plane blocks: A scoping review mapped to the Kirkpatrick evaluation framework
Naveen Paliwal, Dinker Pai, Satyajeet Misra, Devishree Das, Rishabh Jaju, Soma Ganesh R. Neethirajan, Pooja Bihani
Indian Journal of Anaesthesia.2026; 70(1): 115. CrossRef
Evaluation of a multidisciplinary simulation training curriculum for local anesthetic systemic toxicity management: a quasi-experimental study using the Kirkpatrick model in India
Pooja Bihani, Naveen Paliwal, Rishabh Jaju, Vikas Rajpurohit
Anesthesia and Pain Medicine.2025; 20(2): 166. CrossRef
Impact of simulation-based training on difficult airway management among anesthesia trainees and nurses as real team
Naveen Paliwal, Pooja Bihani, Geethanjali Ramachandra, Dinker Pai, Rishabh Jaju, Vivek Chakole
Journal of Anaesthesiology Clinical Pharmacology.2025; 41(4): 641. CrossRef
Actual Preoperative Fasting Duration and its Impact on Hunger, Thirst, Blood Glucose, and Parental Satisfaction in Pediatric Patients: A Prospective Observational Study
Pooja Bihani, Kamal Kishore Chitara, Priyakshi Borah, Naveen Paliwal, Rishabh Jaju, Veswudu Swuro
Journal of Indian Association of Pediatric Surgeons.2025; 30(5): 642. CrossRef
H-ER-O-S: A Quality Improvement Initiative to Reduce Ventilator-Associated Pneumonia in a Level IIIb Neonatal Intensive Care Unit of a Tertiary Care Public Hospital
Shaik Mohammed Munthakheem, Amol Kalyanrao Joshi, Laxmikant Sheshrao Deshmukh, Atul C. Londhe
Indian Pediatrics.2025;[Epub] CrossRef
Bridging the Evidence to Practice Gaps in Public Hospitals: Lessons from a VAP Reduction Quality Improvement Initiative
Praveen Kumar
Indian Pediatrics.2025;[Epub] CrossRef

Review Article

Nursing
Specialized nursing intervention on critically ill patient in the prevention of intubation-associated pneumonia: an integrative literature review: Daniela Fradinho Almeida, Maria do Rosário Pinto, Maria Candida Durao, Helga Rafael Henriques, Joana Ferreira Teixeira; Acute Crit Care. 2024;39(3):341-349. Published online August 12, 2024; DOI: https://doi.org/10.4266/acc.2024.00528

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Abstract PDF: Healthcare-associated infections are adverse events that affect people in critical condition, especially when hospitalized in an intensive care unit. The most prevalent is intubation-associated pneumonia (IAP), a nursing-care-sensitive area. This review aims to identify and analyze nursing interventions for preventing IAP. An integrative literature review was done using the Medline, CINAHL, Scopus and PubMed databases. After checking the eligibility of the studies and using Rayyan software, ten final documents were obtained for extraction and analysis. The results obtained suggest that the nursing interventions identified for the prevention of IAP are elevating the headboard to 30º; washing the teeth, mouth and mucous membranes with a toothbrush and then instilling chlorohexidine 0.12%–0.2% every 8/8 hr; monitoring the cuff pressure of the endotracheal tube (ETT) between 20–30 mm Hg; daily assessment of the need for sedation and ventilatory weaning and the use of ETT with drainage of subglottic secretions. The multimodal nursing interventions identified enable health gains to be made in preventing or reducing IAP. This area is sensitive to nursing care, positively impacting the patient, family, and organizations. Future research is suggested into the effectiveness of chlorohexidine compared to other oral hygiene products, as well as studies into the mortality rate associated with IAP, with and without ETT for subglottic aspiration.

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

Citations to this article as recorded by

Comparison of programmed sedation care with conventional care in patients receiving mechanical ventilation for acute respiratory failure
Jiantang Wang, Yuntao Li, Yujuan Han, Xinyu Yuan
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
Junho Hyun, In-Cheol Kim, Ah-ram Kim, Hee Jeong Lee, Sang Eun Lee, Sung-Cheol Yun, Min-Seok Kim
International Journal of Heart Failure.2025; 7(2): 79. CrossRef
RELAÇÃO DA FORÇA MUSCULAR PERIFÉRICA COM O DESMAME DA VENTILAÇÃO MECÂNICA
Débora Rillary Duarte Filho, Gabriella Schultz Malagute, Luciana Ferreira Rihs, Priscila Corrêa Cavalcanti
Revista Saúde Dos Vales.2024;[Epub] CrossRef

Original Articles

Pulmonary
Association between mechanical power and intensive care unit mortality in Korean patients under pressure-controlled ventilation: Jae Kyeom Sim, Sang-Min Lee, Hyung Koo Kang, Kyung Chan Kim, Young Sam Kim, Yun Seong Kim, Won-Yeon Lee, Sunghoon Park, So Young Park, Ju-Hee Park, Yun Su Sim, Kwangha Lee, Yeon Joo Lee, Jin Hwa Lee, Heung Bum Lee, Chae-Man Lim, Won-Il Choi, Ji Young Hong, Won Jun Song, Gee Young Suh; Acute Crit Care. 2024;39(1):91-99. Published online January 26, 2024; DOI: https://doi.org/10.4266/acc.2023.00871

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Abstract PDF Supplementary Material

Background
Mechanical power (MP) has been reported to be associated with clinical outcomes. Because the original MP equation is derived from paralyzed patients under volume-controlled ventilation, its application in practice could be limited in patients receiving pressure-controlled ventilation (PCV). Recently, a simplified equation for patients under PCV was developed. We investigated the association between MP and intensive care unit (ICU) mortality.
Methods
We conducted a retrospective analysis of Korean data from the Fourth International Study of Mechanical Ventilation. We extracted data of patients under PCV on day 1 and calculated MP using the following simplified equation: MPPCV = 0.098 ∙ respiratory rate ∙ tidal volume ∙ (ΔPinsp + positive end-expiratory pressure), where ΔPinsp is the change in airway pressure during inspiration. Patients were divided into survivors and non-survivors and then compared. Multivariable logistic regression was performed to determine association between MPPCV and ICU mortality. The interaction of MPPCV and use of neuromuscular blocking agent (NMBA) was also analyzed.
Results
A total of 125 patients was eligible for final analysis, of whom 38 died in the ICU. MPPCV was higher in non-survivors (17.6 vs. 26.3 J/min, P<0.001). In logistic regression analysis, only MPPCV was significantly associated with ICU mortality (odds ratio, 1.090; 95% confidence interval, 1.029–1.155; P=0.003). There was no significant effect of the interaction between MPPCV and use of NMBA on ICU mortality (P=0.579).
Conclusions
MPPCV is associated with ICU mortality in patients mechanically ventilated with PCV mode, regardless of NMBA use.

Citations

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Mechanical power and mortality: analysis of a prospective cohort of ventilated patients
Yudiel Pérez Yero, Ariel Sosa Remón, Jhossmar Cristians Auza-Santivañez, Arian Jesús Cuba Naranjo, Dasha María García Arias, Ana Esperanza Jeréz Alvarez, Mileydys Saborit García, Osman Arteaga Iriarte, Jose Bernardo Antezana-Muñoz
Multidisciplinar (Montevideo).2025; 3: 198. CrossRef
Associations of mechanical power, ventilatory ratio, and other respiratory indices with mortality in patients with acute respiratory distress syndrome undergoing pressure-controlled mechanical ventilation
Tae Wan Kim, Chi Ryang Chung, Miryeo Nam, Ryoung-Eun Ko, Gee Young Suh
Frontiers in Medicine.2025;[Epub] CrossRef
The association of frailty and mechanical power with hospital mortality in critically ill patients: a retrospective study based on the MIMIC-IV and eICU database
Jiacheng Shen, Kun Fang, Yu Qiu, Li Li
European Journal of Medical Research.2025;[Epub] CrossRef
Mechanical power in mechanical ventilation and its association with ventilator-induced lung injury: A systematic review
Tomasz Urbankowski, Raman Pasledni, Marek Darowski
Respiratory Medicine.2025; 250: 108525. CrossRef
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Ida Giorgia Iavarone, Patricia R.M. Rocco, Pedro Leme Silva, Shaurya Taran, Sarah Wahlster, Marcus J. Schultz, Nicolo’ Antonino Patroniti, Chiara Robba
Current Anesthesiology Reports.2024; 14(4): 512. CrossRef

Nursing
Effect of fourth hourly oropharyngeal suctioning on ventilator-associated events in patients requiring mechanical ventilation in intensive care units of a tertiary care center in South India: a randomized controlled trial: Khanjana Borah, Lakshmi Ramamoorthy, Muthapillai Senthilnathan, Rajeswari Murugesan, Hmar Thiak Lalthanthuami, Rani Subramaniyan; Acute Crit Care. 2023;38(4):460-468. Published online November 24, 2023; DOI: https://doi.org/10.4266/acc.2022.01501

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Abstract PDF: Background
Mechanical ventilation (MV) is a necessary life-saving measure for critically ill patients. Ventilator-associated events (VAEs) are potentially avoidable complications associated with MV that can double the rate of death. Oral care and oropharyngeal suctioning, although neglected procedures, play a vital role in the prevention of VAE.
Methods
A randomized controlled trial was conducted in the intensive care units to compare the effect of fourth hourly oropharyngeal suctioning with the standard oral care protocol on VAE among patients on MV. One hundred twenty mechanically ventilated patients who were freshly intubated and expected to be on ventilator support for the next 72 hours were randomly allocated to the control or intervention groups. The intervention was fourth hourly oropharyngeal suctioning along with the standard oral care procedure. The control group received standard oral care (i.e., thrice a day) and on-demand oral suctioning. On the 3rd and 7th days following the intervention, endotracheal aspirates were sent to rule out ventilator-associated pneumonia.
Results
Both groups were homogenous at baseline with respect to their clinical characteristics. The intervention group had fewer VAEs (56.7%) than the control group (78.3%) which was significant at P<0.01. A significant reduction in the status of “positive culture” on ET aspirate also been observed following the 3rd day of the intervention (P<0.001).
Conclusions
One of the most basic preventive strategies is providing oral care. Oropharyngeal suctioning is also an important component of oral care that prevents microaspiration. Hence, fourth-hourly oropharyngeal suctioning with standard oral care significantly reduces the incidence of VAE.

Review Article

Neurosurgery
Brain-lung interaction: a vicious cycle in traumatic brain injury: Ariana Alejandra Chacón-Aponte, Érika Andrea Durán-Vargas, Jaime Adolfo Arévalo-Carrillo, Iván David Lozada-Martínez, Maria Paz Bolaño-Romero, Luis Rafael Moscote-Salazar, Pedro Grille, Tariq Janjua; Acute Crit Care. 2022;37(1):35-44. Published online February 11, 2022; DOI: https://doi.org/10.4266/acc.2021.01193

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Abstract PDF

The brain-lung interaction can seriously affect patients with traumatic brain injury, triggering a vicious cycle that worsens patient prognosis. Although the mechanisms of the interaction are not fully elucidated, several hypotheses, notably the “blast injury” theory or “double hit” model, have been proposed and constitute the basis of its development and progression. The brain and lungs strongly interact via complex pathways from the brain to the lungs but also from the lungs to the brain. The main pulmonary disorders that occur after brain injuries are neurogenic pulmonary edema, acute respiratory distress syndrome, and ventilator-associated pneumonia, and the principal brain disorders after lung injuries include brain hypoxia and intracranial hypertension. All of these conditions are key considerations for management therapies after traumatic brain injury and need exceptional case-by-case monitoring to avoid neurological or pulmonary complications. This review aims to describe the history, pathophysiology, risk factors, characteristics, and complications of brain-lung and lung-brain interactions and the impact of different old and recent modalities of treatment in the context of traumatic brain injury.

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Original Articles

Pulmonary
Diaphragm ultrasound as a better predictor of successful extubation from mechanical ventilation than rapid shallow breathing index: Mohammad Jhahidul Alam, Simanta Roy, Mohammad Azmain Iktidar, Fahmida Khatun Padma, Khairul Islam Nipun, Sreshtha Chowdhury, Ranjan Kumar Nath, Harun-Or Rashid; Acute Crit Care. 2022;37(1):94-100. Published online January 11, 2022; DOI: https://doi.org/10.4266/acc.2021.01354

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Abstract PDF

Background
In 3%–19% of patients, reintubation is needed 48–72 hours following extubation, which increases intensive care unit (ICU) morbidity, mortality, and expenses. Extubation failure is frequently caused by diaphragm dysfunction. Ultrasonography can be used to determine the mobility and thickness of the diaphragm. This study looked at the role of diaphragm excursion (DE) and thickening fraction in predicting successful extubation from mechanical ventilation.
Methods
Thirty-one patients were extubated with the advice of an ICU consultant using the ICU weaning regimen and diaphragm ultrasonography was performed. Ultrasound DE and thickening fraction were measured three times: at the commencement of the t-piece experiment, at 10 minutes, and immediately before extubation. All patients' parameters were monitored for 48 hours after extubation. Rapid shallow breathing index (RSBI) was also measured at the same time.
Results
Successful extubation was significantly correlated with DE (P=0.01). Receiver curve analysis for DE to predict successful extubation revealed good properties (area under the curve [AUC], 0.83; P<0.001); sensitivity, 77.8%; specificity, 84.6%, positive predictive value (PPV), 87.5%; negative predictive value (NPV), 73.3% while cut-off value, 11.43 mm. Diaphragm thickening fraction (DTF) also revealed moderate curve properties (AUC, 0.69; P=0.06); sensitivity, 61.1%; specificity, 84.6%; PPV, 87.5%; NPV, 61.1% with cut-off value 22.33% although former one was slightly better. RSBI could not reach good receiver operating characteristic value at cut-off points 100 b/min/L (AUC, 0.58; P=0.47); sensitivity, 66.7%; specificity, 53.8%; PPV, 66.7%; NPV, 53.8%).
Conclusions
To decrease the rate of reintubation, DE and DTF are better indicators of successful extubation. DE outperforms DTF.

Citations

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Predicting weaning failure from invasive mechanical ventilation: The promise and pitfalls of clinical prediction scores
Maneesh Gaddam, Dedeepya Gullapalli, Zayaan A Adrish, Arnav Y Reddy, Muhammad Adrish
World Journal of Critical Care Medicine.2025;[Epub] CrossRef
Respiratory Muscle Strength and Mortality in Patients with COPD: A Systematic Review and Meta-Analysis
Hiroki Mizusawa, Kazuki Okura, Masashi Shiraishi, Masaya Noguchi, Yuji Higashimoto
International Journal of Chronic Obstructive Pulmonary Disease.2025; Volume 20: 4205. CrossRef
Progress in Clinical Application of Diaphragm Ultrasound
雨晨甘
Advances in Clinical Medicine.2025; 15(01): 309. CrossRef
Predictive value of bedside diaphragmatic ultrasonography for extubation success in critically ill patients after general anaesthesia: A meta-analysis with trial sequential analysis (TSA)
Lan Ma, Na Zhou, Kaiming Yuan, Zihao Xue, Kai Lv, Jingying Huang
Indian Journal of Anaesthesia.2025; 69(1): 38. CrossRef
Integration of Diaphragmatic Ultrasonography and Intra-Abdominal Pressure Measurement for Optimizing Weaning from Mechanical Ventilation
Dan Su, Ruixin Li, Zhi Chen, Na Cui, Zhanbiao Yu, Xiaoxu Ding, Jiaqian Wu
Risk Management and Healthcare Policy.2025; Volume 18: 1547. CrossRef
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R. Muralidharan, Amarja Ashok Havaldar
Scientific Reports.2025;[Epub] CrossRef
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Amal A. Abd El-Aziz, Mahmoud M. Elhabashy, Mohammed A. Agha, Hanan A. Elgamal, Amal A. El-Koa
The Egyptian Journal of Chest Diseases and Tuberculosis.2025; 74(3): 319. CrossRef
Ventilator-induced diaphragmatic dysfunction: pathophysiology, monitoring and advances in potential treatment and prevention
Wei Fu, Lili Guan, Qi Liu, Zhefan Xie, Junting You, Rongchang Chen
European Respiratory Review.2025; 34(178): 250069. CrossRef
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Hasan Shamsi, Seyedeh Narjes Ahmadizadeh
Journal of Cellular and Molecular Anesthesia.2025;[Epub] CrossRef
Rapid shallow breathing index predicting extubation outcomes: A systematic review and meta-analysis
Donghui Jia, Hengyang Wang, Qian Wang, Wenrui Li, Xuhong Lan, Hongfang Zhou, Zhigang Zhang
Intensive and Critical Care Nursing.2024; 80: 103551. CrossRef
Ultrasonography to Access Diaphragm Dysfunction and Predict the Success of Mechanical Ventilation Weaning in Critical Care
Marta Rafael Marques, José Manuel Pereira, José Artur Paiva, Gonzalo García de Casasola‐Sánchez, Yale Tung‐Chen
Journal of Ultrasound in Medicine.2024; 43(2): 223. CrossRef
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Diego Poddighe, Marine Van Hollebeke, Yasir Qaiser Choudhary, Débora Ribeiro Campos, Michele R. Schaeffer, Jan Y. Verbakel, Greet Hermans, Rik Gosselink, Daniel Langer
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Yashar Iran Pour, Afrooz Zandifar
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Prakash Banjade, Yasoda Rijal, Munish Sharma, Salim Surani
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Fritz Sterr, Michael Reintke, Lydia Bauernfeind, Volkan Senyol, Christian Rester, Sabine Metzing, Rebecca Palm
Critical Care.2024;[Epub] CrossRef
Diaphragmatic Dynamics Assessed by Bedside Ultrasound Predict Extubation in the Intensive Care Unit: A Prospective Observational Study
Tianjie Zhang, Yan Liu, Dongwei Xu, Rui Dong, Ye Song
International Journal of General Medicine.2024; Volume 17: 5373. CrossRef
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Jean Deschamps, Hameid Alenazy, Martin Girard
Journal of Translational Critical Care Medicine.2024;[Epub] CrossRef
Time to Peak Inspiratory Amplitude, A Novel Diaphragm Ultrasound Parameter to Predict Extubation Outcome
Sivakumar MN, Indumathi S, TA Senthilnathan, Senthilkumar RS
Indian Journal of Critical Care Medicine.2024; 28(S1): S393. CrossRef
Ultrasonographic Assessment of Diaphragmatic Function and Its Clinical Application in the Management of Patients with Acute Respiratory Failure
Marina Saad, Stefano Pini, Fiammetta Danzo, Francesca Mandurino Mirizzi, Carmine Arena, Francesco Tursi, Dejan Radovanovic, Pierachille Santus
Diagnostics.2023; 13(3): 411. CrossRef
The ratio of respiratory rate to diaphragm thickening fraction for predicting extubation success
Dararat Eksombatchai, Chalermwut Sukkratok, Yuda Sutherasan, Detajin Junhasavasdikul, Pongdhep Theerawit
BMC Pulmonary Medicine.2023;[Epub] CrossRef
Effectiveness of diaphragmatic ultrasound as a predictor of successful weaning from mechanical ventilation: a systematic review and meta-analysis
Henry M. Parada-Gereda, Adriana L. Tibaduiza, Alejandro Rico-Mendoza, Daniel Molano-Franco, Victor H. Nieto, Wanderley A. Arias-Ortiz, Purificación Perez-Terán, Joan R. Masclans
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T. G. Toledo, M. R. Bacci, Fred A. Luchette
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Role of diaphragm ultrasound in weaning mechanically ventilated patients: A prospective observational study
Ravi Saravanan, Krishnamurthy Nivedita, Krishnamoorthy Karthik, Rajagopalan Venkatraman
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Lokesh Kumar Lalwani, Manjunath B Govindagoudar, Pawan Kumar Singh, Mukesh Sharma, Dhruva Chaudhry
Acute and Critical Care.2022; 37(3): 347. CrossRef
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Domenica Di Costanzo, Mariano Mazza, Antonio Esquinas
Acute and Critical Care.2022; 37(4): 681. CrossRef
Sonographic assessment of diaphragmatic thickening and excursion as predictors of weaning success in the intensive care unit: A prospective observational study
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Indian Journal of Anaesthesia.2022; 66(11): 776. CrossRef
Comparison of assessment of diaphragm function using speckle tracking between patients with successful and failed weaning: a multicentre, observational, pilot study
Qiancheng Xu, Xiao Yang, Yan Qian, Chang Hu, Weihua Lu, Shuhan Cai, Bo Hu, Jianguo Li
BMC Pulmonary Medicine.2022;[Epub] CrossRef
Ultrasonographic assessment of diaphragmatic function in preterm infants on non-invasive neurally adjusted ventilatory assist (NIV-NAVA) compared to nasal intermittent positive-pressure ventilation (NIPPV): a prospective observational study
Mohamed Elkhouli, Liran Tamir-Hostovsky, Jenna Ibrahim, Nehad Nasef, Adel Mohamed
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Pulmonary
Safety and feasibility of hybrid tracheostomy: Daeun Kang, In Beom Jeong, Sun Jung Kwon, Ji Woong Son, Gwan Woo Ku; Acute Crit Care. 2021;36(4):369-373. Published online November 26, 2021; DOI: https://doi.org/10.4266/acc.2021.00801

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Abstract PDF

Background
Percutaneous dilatational tracheostomy (PDT) is widely used in intensive care units, but this conventional method has some disadvantages, such as requirement of a lot of equipment and experts at the site. Especially, in situations where the patient is isolated due to an infectious disease, difficulties in using the equipment may occur, and the number of exposed persons may increase. In this paper, we introduce hybrid tracheostomy that combines the advantages of surgical tracheostomy and PDT and describe our experiences.
Methods
Data from 55 patients who received hybrid tracheostomy without bronchoscopy from January 2020 to February 2021 were collected and reviewed retrospectively. Hybrid tracheostomy was performed at the bedside by a single thoracic surgeon. The hybrid tracheostomy method was as follows: after the skin was incised and the trachea was exposed, only the extent of the endotracheal tube that could not be removed was withdrawn, and then tracheostomy was performed by the Seldinger method using a PDT kit.
Results
The average age was 66.5 years, and the proportion of men was 69.1%. Among the patients, 21.8% were taking antiplatelet drugs and 14.5% were taking anticoagulants. The average duration of the procedure was 13.3 minutes. There was no major bleeding, and there was one case of paratracheal placement of the tracheostomy tube.
Conclusions
In most patients, the procedure can be safely performed without any major complications. However, patients with a short neck, a neck burn or patients who have received radiation therapy to the neck should be treated with conventional methods.

Citations

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Adding Newer Paradigms to Percutaneous Dilatational Tracheostomy with Ultrasound Guided and Hybrid Techniques: Stretching the Limits
Amandeep Kaur, Shruti Sharma, Udeyana Singh, Parshotam Lal Gautam, Amandeep Parmar, Rohit Verma, Jasmine Kaur, Harjas Singh, Nishant Sharma
Indian Journal of Otolaryngology and Head & Neck Surgery.2025;[Epub] CrossRef
Minimally-invasive tracheostomy (MIT): A care bundle for safety improvement in high-risk critically ill patients
Dennis Christoph Harrer, Patricia Mester, Clara-Larissa Lang, Tanja Elger, Tobias Seefeldt, Lorenz Wächter, Judith Dönz, Nina Doblinger, Muriel Huss, Georgios Athanasoulas, Lea U. Krauß, Johannes Heymer, Wolfgang Herr, Tobias Schilling, Stephan Schmid, Ma
Journal of Clinical Anesthesia.2024; 99: 111631. CrossRef
A Modified Technique for Percutaneous Dilatational Tracheostomy
Zahra Ghotbi, Mehrdad Estakhr, Mehdi Nikandish, Reza Nikandish
Journal of Intensive Care Medicine.2023; 38(9): 878. CrossRef

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

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Abstract PDF

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

Citations

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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

Nursing
Effect of modified care bundle for prevention of ventilator-associated pneumonia in critically-ill neurosurgical patients: Suphannee Triamvisit, Wassana Wongprasert, Chalermwoot Puttima, Matchima Na Chiangmai, Nawaphan Thienjindakul, Laksika Rodkul, Chumpon Jetjumnong; Acute Crit Care. 2021;36(4):294-299. Published online November 23, 2021; DOI: https://doi.org/10.4266/acc.2021.00983

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Abstract PDF

Background
Care bundles for ventilator-associated pneumonia (VAP) have been shown to minimize the rate of VAP in critically ill patients. Standard care bundles may need to be modified in resource-constrained situations. The goal of this study was to see if our modified VAP-care bundles lowered the risk of VAP in neurosurgical patients.
Methods
A prospective cohort study was conducted in mechanically ventilated neurosurgical patients. The VAP bundle was adjusted in the cohort group by increasing the frequency of intermittent endotracheal tube cuff pressure monitoring to six times a day while reducing oral care with 0.12% chlorhexidine to three times a day. The rate of VAP was compared to the historical control group.
Results
A total of 146 and 145 patients were enrolled in control and cohort groups, respectively. The mean age of patients was 52±16 years in both groups (P=0.803). The admission Glasgow coma scores were 7.79±2.67 and 7.80±2.77 in control and cohort group, respectively (P=0.969). VAP was found in nine patients in control group but only one patient in cohort group. The occurrence rate of VAP was significantly reduced in cohort group compared to control group (0.88/1,000 vs. 6.84/1,000 ventilator days, P=0.036).
Conclusions
The modified VAP bundle is effective in lowering the VAP rate in critically ill neurosurgical patients. It requires low budget and manpower and can be employed in resource-constrained settings.

Citations

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Impact of Modified Ventilator‐Associated Pneumonia Prevention Bundle on Clinical Parameters and Outcomes Among Mechanically Ventilated Patients: An Interventional Study
Yuvaraj Arumugam, Judie Arulappan, Sivakumar M. Nandakumar
Nursing in Critical Care.2026;[Epub] CrossRef
Pharmacotherapy interventions in ventilator care bundles for preventing VAP in adults: A literature review
Neilsen Gazo, Cherie Chu
Journal of Mechanical Ventilation.2025; 6(2): 88. CrossRef
Ventilator-Associated Pneumonia (VAP) in Neurocritical Patients: The Hidden Dialog of Brain and Infection
Alejandro Rodríguez, Laura Claverias, Ignacio Martín-Loeches, Frederic Gómez Bertomeu, Ester Picó Plana, Sara Rosich, Vanessa Blázquez, Dennis H. Céspedes Torrez, Ruth Lau, María Bodí
Biomedicines.2025; 13(12): 3112. CrossRef

Pulmonary
Comparison of characteristics and ventilatory course between coronavirus disease 2019 and Middle East respiratory syndrome patients with acute respiratory distress syndrome: Imran Khalid, Romaysaa M Yamani, Maryam Imran, Muhammad Ali Akhtar, Manahil Imran, Rumaan Gul, Tabindeh Jabeen Khalid, Ghassan Y Wali; Acute Crit Care. 2021;36(3):223-231. Published online July 30, 2021; DOI: https://doi.org/10.4266/acc.2021.00388

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Abstract PDF

Background
Both coronavirus disease 2019 (COVID-19) and Middle East respiratory syndrome (MERS) can cause acute respiratory distress syndrome (ARDS); however, their ARDS course and characteristics have not been compared, which we evaluate in our study.
Methods
MERS patients with ARDS seen during the 2014 outbreak and COVID-19 patients with ARDS admitted between March and December 2020 in our hospital were included, and their clinical characteristics, ventilatory course, and outcomes were compared.
Results
Forty-nine and 14 patients met the inclusion criteria for ARDS in the COVID-19 and MERS groups, respectively. Both groups had a median of four comorbidities with high Charlson comorbidity index value of 5 points (P>0.22). COVID-19 patients were older, obese, had significantly higher initial C-reactive protein (CRP), more likely to get trial of high-flow oxygen, and had delayed intubation (P≤0.04). The postintubation course was similar between the groups. Patients in both groups experienced a prolonged duration of mechanical ventilation, and majority received paralytics, dialysis, and vasopressor agents (P>0.28). The respiratory and ventilatory parameters after intubation (including tidal volume, fraction of inspired oxygen, peak and plateau pressures) and their progression over 3 weeks were similar (P>0.05). Rates of mortality in the ICU (53% vs. 64%) and hospital (59% vs. 64%) among COVID-19 and MERS patients (P≥0.54) were very high.
Conclusions
Despite some distinctive differences between COVID-19 and MERS patients prior to intubation, the respiratory and ventilatory parameters postintubation were not different. The higher initial CRP level in COVID-19 patients may explain the steroid responsiveness in this population.

Citations

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Structure defining of ultrapotent neutralizing nanobodies against MERS-CoV with novel epitopes on receptor binding domain
Sen Ma, Doudou Zhang, Qiwei Wang, Linjing Zhu, Xilin Wu, Sheng Ye, Yaxin Wang, Julie Overbaugh
PLOS Pathogens.2024; 20(8): e1012438. CrossRef
Does COVID-19 Vaccine Impact the Soul? A Pre-post Vaccination Comparison of Health Care Workers’ Infection Control Practices and Perspectives
Imran Khalid, Muhammad Ali Akhtar, Manahil Imran, Maryam Imran, Musaab Ahmed Mujalli, Moayad Sami Qashqari, Abeer N Alshukairi, Amina Nisar, Tabindeh Jabeen Khalid
Infectious Diseases in Clinical Practice.2023;[Epub] CrossRef
Advances in mRNA and other vaccines against MERS-CoV
Wanbo Tai, Xiujuan Zhang, Yang Yang, Jiang Zhu, Lanying Du
Translational Research.2022; 242: 20. CrossRef

Pulmonary
Development of a prognostic scoring system in patients with pneumonia requiring ventilator care for more than 4 days: a single-center observational study: Yeseul Oh, Yewon Kang, Kwangha Lee; Acute Crit Care. 2021;36(1):46-53. Published online February 17, 2021; DOI: https://doi.org/10.4266/acc.2020.00787

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Abstract PDF

Background
The aim of the present study was to develop a prognostic model using demographic characteristics, comorbidities, and clinical variables measured on day 4 of mechanical ventilation (MV) for patients with prolonged acute mechanical ventilation (PAMV; MV for >96 hours).
Methods
Data from 437 patients (70.9% male; median age, 68 years) were obtained over a period of 9 years. All patients were diagnosed with pneumonia. Binary logistic regression identified factors predicting mortality at 90 days after the start of MV. A PAMV prognosis score was calculating ß-coefficient values and assigning points to variables.
Results
The overall 90-day mortality rate was 47.1%. Five factors (age ≥65 years, body mass index <18.5 kg/m², hemato-oncologic diseases as comorbidities, requirement for vasopressors on day 4 of MV and requirement for neuromuscular blocking agents on day 4 of MV) were identified as prognostic indicators. Each factor was valued as +1 point, and used to develop a PAMV prognosis score. This score showed acceptable discrimination (area under the receiver operating characteristic curve of 0.695 for mortality, 95% confidence interval 0.650–0.738, p<0.001), and calibration (Hosmer–Lemeshow chi-square=6.331, with df 7 and p=0.502). The cutoff value for predicting mortality based on the maximum Youden index was ≤2 (sensitivity, 87.5%; specificity, 41.3%). For patients with PAMV scores ≤1, 2, 3 and ≥4, the 90-day mortality rates were 29.2%, 45.7%, 67.9%, and 90.9%, respectively (P<0.001).
Conclusions
Our study developed a PAMV prognosis score for predicting 90-day mortality. Further research is needed to validate the utility of this score.

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Association between mechanical power and intensive care unit mortality in Korean patients under pressure-controlled ventilation
Jae Kyeom Sim, Sang-Min Lee, Hyung Koo Kang, Kyung Chan Kim, Young Sam Kim, Yun Seong Kim, Won-Yeon Lee, Sunghoon Park, So Young Park, Ju-Hee Park, Yun Su Sim, Kwangha Lee, Yeon Joo Lee, Jin Hwa Lee, Heung Bum Lee, Chae-Man Lim, Won-Il Choi, Ji Young Hong
Acute and Critical Care.2024; 39(1): 91. CrossRef

Pulmonary
Predictive value of the negative inspiratory force index as a predictor of weaning success: a crosssectional study: Phuong Hoang Vu, Viet Duc Tran, Minh Cuong Duong, Quyet Thang Cong, Thu Nguyen; Acute Crit Care. 2020;35(4):279-285. Published online November 30, 2020; DOI: https://doi.org/10.4266/acc.2020.00598

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Abstract PDF

Background
Identifying when intubated patients are ready to be extubated remains challenging. The negative inspiratory force (NIF) is a recommended predictor of weaning success. However, little is known about the role of NIF in the weaning process for the Asian surgical intensive population, especially for the Vietnamese population. Here, we aimed to investigate the cutoff threshold and predictive value of the NIF index for predicting the success of ventilator weaning in Vietnamese surgical intensive care patients.
Methods
A cross-sectional study was conducted at the Surgical Intensive Care Unit of Viet Duc Hospital from October 2016 to August 2017. A total of 64 patients aged 16–70 years undergoing ventilatory support through an orotracheal tube satisfied the criteria for readiness to begin weaning. The correlation between the NIF index with outcomes of the weaning process was analyzed. Specificity (Sp), sensitivity (Se), positive predictive value (PPV), negative predictive value (NPV), receiver operating characteristic (ROC) curve, and area under the curve (AUC) were calculated.
Results
The success rate of the entire weaning process was 67.2% (43/64). The median NIF values were –26.0 cm H₂O (interquartile range [IQR], –28.0 to –25.0) in the successful weaning group and –24.0 cm H₂O (IQR, –25.0 to –23.0) in the weaning failure group (P<0.001). According to ROC analysis, an NIF value ≤–25 cm H₂O predicted weaning success (AUC, 0.836) with 91% Se, 62% Sp, 83% PPV, and 77% NPV.
Conclusions
An NIF cutoff threshold ≤–25 cm H₂O can be used as predictor of weaning success in Vietnamese surgical intensive care patients.

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Review Article

Pulmonary
Home mechanical ventilation: back to basics: Sunghoon Park, Eui-Sik Suh; Acute Crit Care. 2020;35(3):131-141. Published online August 31, 2020; DOI: https://doi.org/10.4266/acc.2020.00514

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Abstract PDF

Over recent decades, the use of home mechanical ventilation (HMV) has steadily increased worldwide, with varying prevalence in different countries. The key indication for HMV is chronic respiratory failure with alveolar hypoventilation (e.g., neuromuscular and chest wall disease, obstructive airway diseases, and obesity-related respiratory failure). Most modern home ventilators are pressure-targeted and have sophisticated modes, alarms, and graphics, thereby facilitating optimization of the ventilator settings. However, different ventilators have different algorithms for tidal volume estimation and leak compensation, and there are also several different circuit configurations. Hence, a basic understanding of the fundamentals of HMV is of paramount importance to healthcare workers taking care of patients with HMV. When choosing a home ventilator, they should take into account many factors, including the current condition and prognosis of the primary disease, the patient’s daily performance status, time (hr/day) needed for ventilator support, family support, and financial costs. In this review, to help readers understand the basic concepts of HMV use, we describe the indications for HMV and the factors that influence successful delivery, including interface, circuits, ventilator accessories, and the ventilator itself.

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Original Articles

Pulmonary
Clinical outcomes of difficult-to-wean patients with ventilator dependency at intensive care unit discharge: Jung Mo Lee, Sun-Min Lee, Joo Han Song, Young Sam Kim; Acute Crit Care. 2020;35(3):156-163. Published online August 19, 2020; DOI: https://doi.org/10.4266/acc.2020.00199

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Abstract PDF Supplementary Material

Background
Ventilator-dependent patients in the intensive care unit (ICU) who are difficult to wean from invasive mechanical ventilation (IMV) have been increasing in number. However, data on the clinical outcomes of difficult-to-wean patients are lacking. We aimed to evaluate clinical outcomes in patients discharged from the ICU with tracheostomy and ventilator dependency.
Methods
We retrospectively investigated clinical course and survival in patients requiring home mechanical ventilation (HMV) with a tracheostomy and difficulty weaning from IMV during medical ICU admission from September 2013 through August 2016 at Severance Hospital, Yonsei University, Seoul, Korea.
Results
Of 84 difficult-to-wean patients who were started on HMV in the medical ICU, 72 survived, were discharged from the ICU, and were included in this analysis. HMV was initiated after a median of 23 days of IMV, and the successful weaning rate was 46% (n=33). In-hospital mortality rate was significantly lower in the successfully weaned group than the unsuccessfully weaned group (0% vs. 23.1%, respectively; P=0.010). Weaning rates were similar according to primary diagnosis, but high body mass index (BMI), low Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II score at ICU admission, and absence of neuromuscular disease were associated with weaning success. After a median follow-up of 4.6 months (range, 1–27 months) for survivors, 3-month (n=64) and 6-month (n=59) survival rates were 82.5% and 72.2%, respectively. Survival rates were higher in the successfully weaned group than the unsuccessfully weaned group at 3 months (96.4% vs. 69.0%; P=0.017) and 6 months (84.0% vs. 62.1%; P=0.136) following ICU discharge.
Conclusions
In summary, 46% of patients who started HMV were successfully weaned from the ventilator in general wards. High BMI, low APACHE II score, and absence of neuromuscular disease were factors associated with weaning success.

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Comparison of Application of Home-use Mechanical Ventilator and Facility-use Mechanical Ventilator for Early Discharge of Patient from Intensive Care Units
Sun Young Won, Young Hee Yi
Journal of Korean Critical Care Nursing.2025; 18(1): 13. CrossRef
Long-Term Mortality in Critically Ill Tracheostomized Patients Based on Home Mechanical Ventilation at Discharge
Won-Young Kim, Moon Seong Baek
Journal of Personalized Medicine.2021; 11(12): 1257. CrossRef
Year 2020 in review - Post‑acute intensive care
J Djakow
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Pulmonary
Clinical Application of Modified Burns Wean Assessment Program Scores at First Spontaneous Breathing Trial in Weaning Patients from Mechanical Ventilation: Eun Suk Jeong, Kwangha Lee; Acute Crit Care. 2018;33(4):260-268. Published online November 30, 2018; DOI: https://doi.org/10.4266/acc.2018.00276

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Abstract PDF

Background
The purpose of this study was to evaluate the clinical application of modified Burns Wean Assessment Program (m-BWAP) scoring at first spontaneous breathing trial (SBT) as a predictor of successful liberation from mechanical ventilation (MV) in patients with endotracheal intubation.
Methods
Patients requiring MV for more than 72 hours and undergoing more than one SBT in a medical intensive care unit (ICU) were prospectively enrolled over a 3-year period. The m-BWAP score at first SBT was obtained by a critical care nursing practitioner.
Results
A total of 103 subjects were included in this study. Their median age was 69 years (range, 22 to 87 years) and 72 subjects (69.9%) were male. The median duration from admission to first SBT was 5 days (range, 3 to 26 days), and the rate of final successful liberation from MV was 84.5% (n=87). In the total group of patients, the successful liberation from MV group at first SBT (n=65) had significantly higher m-BWAP scores than did the unsuccessful group (median, 60; range, 43 to 80 vs. median, 53; range, 33 to 70; P<0.001). Also, the area under the m-BWAP curve for predicting successful liberation of MV was 0.748 (95% confidence interval, 0.650 to 0.847), while the cutoff value based on Youden’s index was 53 (sensitivity, 76%; specificity, 64%).
Conclusions
The present data show that the m-BWAP score represents a good predictor of weaning success in patients with an endotracheal tube in place at first SBT.

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Evaluation of factors influencing the reduction of home mechanical ventilation dependency in patients planned to receive home health care
Gökmen Özceylan, Ayşe Coşkun Beyan, Giray Kolcu
BMC Palliative Care.2026;[Epub] CrossRef
Impact of tracheostomy on clinical outcomes in ventilated patients with severe pneumonia: a propensity-matched cohort study
Hayoung Seong, Hyojin Jang, Wanho Yoo, Saerom Kim, Soo Han Kim, Kwangha Lee
The Korean Journal of Internal Medicine.2025; 40(2): 286. CrossRef
Clinical prediction scores predicting weaning failure from invasive mechanical ventilation: Role and limitations
Anish Gupta, Omender Singh, Deven Juneja
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André Filipe Ribeiro, Sandra Martins Pereira, Rui Nunes, Pablo Hernández-Marrero
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Effect of a Japanese Version of the Burns Wean Assessment Program e-Learning Materials on Ventilator Withdrawal for Intensive Care Unit Nurses
Rika KIMURA, Naoko HAYASHI, Akemi UTSUNOMIYA
Journal of Nursing Research.2023; 31(4): e287. CrossRef
The Effect of Nursing Interventions Based on Burns Wean Assessment Program on Successful Weaning from Mechanical Ventilation
Maryam Sepahyar, Shahram Molavynejad, Mohammad Adineh, Mohsen Savaie, Elham Maraghi
Iranian Journal of Nursing and Midwifery Research.2021; 26(1): 34. CrossRef
Value of modified Burns Wean Assessment Program scores in the respiratory intensive care unit: An Egyptian study
Nermeen A. Abdelaleem, Sherif A.A. Mohamed, Azza S. Abd ElHafeez, Hassan A. Bayoumi
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Protecting Postextubation Respiratory Failure and Reintubation by High-Flow Nasal Cannula Compared to Low-Flow Oxygen System: Single Center Retrospective Study and Literature Review
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Infection
High-dose Sulbactam Treatment for Ventilator-Associated Pneumonia Caused by Carbapenem-Resistant Acinetobacter Baumannii: In Beom Jeong, Moon Jun Na, Ji Woong Son, Do Yeon Jo, Sun Jung Kwon; Korean J Crit Care Med. 2016;31(4):308-316. Published online November 30, 2016; DOI: https://doi.org/10.4266/kjccm.2015.00703

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Abstract PDF

Background
Several antibiotics can be used to treat ventilator-associated pneumonia caused by carbapenem-resistant A. baumannii (CRAB-VAP) including high-dose sulbactam. However, the effectiveness of high-dose sulbactam therapy is not well known. We report our experience with high-dose sulbactam for treatment of CRAB-VAP.
Methods
Medical records of patients with CRAB-VAP who were given high-dose sulbactam between May 2013 and June 2015 were reviewed.
Results
Fifty-eight patients with CRAB-VAP were treated with high-dose sulbactam. The mean age was 72.0 ± 15.2 years, and the acute physiology and chronic health evaluation II (APACHE II) score was 15.1 ± 5.10 at the time of CRAB-VAP diagnosis. Early clinical improvement was observed in 65.5% of patients, and 30-day mortality was 29.3%. Early clinical failure (odds ratio [OR]: 8.720, confidence interval [CI]: 1.346-56.484; p = 0.023) and APACHE II score ≥ 14 at CRAB-VAP diagnosis (OR: 10.934, CI: 1.047-114.148; p = 0.046) were associated with 30-day mortality.
Conclusions
High-dose sulbactam therapy may be effective for the treatment of CRAB-VAP. However, early clinical failure was observed in 35% of patients and was associated with poor outcome.

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Acinetobacter baumannii treatment strategies: a review of therapeutic challenges and considerations
Christine J. Kubin, Christopher Garzia, Anne-Catrin Uhlemann, Pranita D. Tamma
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Chutchawan Ungthammakhun, Vasin Vasikasin, Dhitiwat Changpradub
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Meropenem/colistin versus meropenem/ampicillin–sulbactam in the treatment of carbapenem-resistant pneumonia
Hossein Khalili, Lida Shojaei, Mostafa Mohammadi, Mohammad-Taghi Beigmohammadi, Alireza Abdollahi, Mahsa Doomanlou
Journal of Comparative Effectiveness Research.2018; 7(9): 901. CrossRef

Guideline

Pulmonary
Clinical Practice Guideline of Acute Respiratory Distress Syndrome: Young-Jae Cho, Jae Young Moon, Ein-Soon Shin, Je Hyeong Kim, Hoon Jung, So Young Park, Ho Cheol Kim, Yun Su Sim, Chin Kook Rhee, Jaemin Lim, Seok Jeong Lee, Won-Yeon Lee, Hyun Jeong Lee, Sang Hyun Kwak, Eun Kyeong Kang, Kyung Soo Chung, Won-Il Choi, The Korean Society of Critical Care Medicine and the Korean Academy of Tuberculosis and Respiratory Diseases Consensus Group; Korean J Crit Care Med. 2016;31(2):76-100. Published online May 31, 2016; DOI: https://doi.org/10.4266/kjccm.2016.31.2.76

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Abstract PDF

There is no well-stated practical guideline for mechanically ventilated patients with or without acute respiratory distress syndrome (ARDS). We generate strong (1) and weak (2) grade of recommendations based on high (A), moderate (B) and low (C) grade in the quality of evidence. In patients with ARDS, we recommend low tidal volume ventilation (1A) and prone position if it is not contraindicated (1B) to reduce their mortality. However, we did not support high-frequency oscillatory ventilation (1B) and inhaled nitric oxide (1A) as a standard treatment. We also suggest high positive end-expiratory pressure (2B), extracorporeal membrane oxygenation as a rescue therapy (2C), and neuromuscular blockage for 48 hours after starting mechanical ventilation (2B). The application of recruitment maneuver may reduce mortality (2B), however, the use of systemic steroids cannot reduce mortality (2B). In mechanically ventilated patients, we recommend light sedation (1B) and low tidal volume even without ARDS (1B) and suggest lung protective ventilation strategy during the operation to lower the incidence of lung complications including ARDS (2B). Early tracheostomy in mechanically ventilated patients can be performed only in limited patients (2A). In conclusion, of 12 recommendations, nine were in the management of ARDS, and three for mechanically ventilated patients.

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Association between mechanical power and intensive care unit mortality in Korean patients under pressure-controlled ventilation
Jae Kyeom Sim, Sang-Min Lee, Hyung Koo Kang, Kyung Chan Kim, Young Sam Kim, Yun Seong Kim, Won-Yeon Lee, Sunghoon Park, So Young Park, Ju-Hee Park, Yun Su Sim, Kwangha Lee, Yeon Joo Lee, Jin Hwa Lee, Heung Bum Lee, Chae-Man Lim, Won-Il Choi, Ji Young Hong
Acute and Critical Care.2024; 39(1): 91. CrossRef
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Original Article

Pulmonary
The Adequacy of a Conventional Mechanical Ventilator as a Ventilation Method during Cardiopulmonary Resuscitation: A Manikin Study: Hong Joon Ahn, Kun Dong Kim, Won Joon Jeong, Jun Wan Lee, In Sool Yoo, Seung Ryu; Korean J Crit Care Med. 2015;30(2):89-94. Published online May 31, 2015; DOI: https://doi.org/10.4266/kjccm.2015.30.2.89

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Abstract PDF

BACKGROUND
We conducted this study to verify whether a mechanical ventilator is adequate for cardiopulmonary resuscitation (CPR). Background: We conducted this study to verify whether a mechanical ventilator is adequate for cardiopulmonary resuscitation (CPR). Methods: A self-inflating bag resuscitator and a mechanical ventilator were used to test two experimental models: Model 1 (CPR manikin without chest compression) and Model 2 (CPR manikin with chest compression). Model 2 was divided into three subgroups according to ventilator pressure limits (Plimit). The self-inflating bag resuscitator was set with a ventilation rate of 10 breaths/min with the volume-marked bag-valve procedure. The mode of the mechanical ventilator was set as follows: volume-controlled mandatory ventilation of tidal volume (Vt) 600 mL, an inspiration time of 1.2 seconds, a constant flow pattern, a ventilation rate of 10 breaths/minute, a positive end expiratory pressure of 3 cmH2O and a maximum trigger limit. Peak airway pressure (Ppeak) and Vt were measured by a flow analyzer. Ventilation adequacy was determined at a Vt range of 400-600 mL with a Ppeak of ≤ 50 cmH2O. Results: In Model 1, Vt and Ppeak were in the appropriate range in the ventilation equipments. In Model 2, for the self-inflating bag resuscitator, the adequate Vt and Ppeak levels were 17%, and the Ppeak adequacy was 20% and the Vt was 65%. For the mechanical ventilator, the adequate Vt and Ppeak levels were 85%; the Ppeak adequacy was 85%; and the Vt adequacy was 100% at 60 cmH2O of Plimit. Conclusions: In a manikin model, a mechanical ventilator was superior to self-inflating bag resuscitator for maintaining adequate ventilation during chest compression.

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Emilia Clementi, Anirudh Chitale, Brian J. O’Neil, Anthony T. Lagina
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Muthapillai Senthilnathan, Ramya Ravi, Srinivasan Suganya, Ranjith Kumar Sivakumar
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Kosin Medical Journal.2021; 36(2): 100. CrossRef
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Jung Wan Kim, Jin Woong Lee, Seung Ryu, Jung Soo Park, InSool Yoo, Yong Chul Cho, Hong Joon Ahn
World Journal of Emergency Medicine.2020; 11(2): 97. CrossRef
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Tillmann Speer, Wolfgang Dersch, Björn Kleine, Christian Neuhaus, Clemens Kill
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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

Clinical Characteristics and Prognosis of Patients with Intracranial Hemorrhage during Mechanical Ventilation: Go Woon Kim, Jin Won Huh, Younsuck Koh, Chae Man Lim, Sang Bum Hong; Korean J Crit Care Med. 2012;27(2):94-101.; DOI: https://doi.org/10.4266/kjccm.2012.27.2.94

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Abstract PDF: BACKGROUND
Intracranial hemorrhage is a serious disease associated with high mortality and morbidity, and develops suddenly without warning. Although there were known risk factors, it is difficult to prevent brain hemorrhage from critically ill patients in the intensive care unit (ICU). There are several reports that brain hemorrhage, in critically ill patients, occurred in connection with respiratory diseases. The aim of our study is to describe the baseline characteristics and prognosis of patients with intracranial hemorrhage during mechanical ventilation in the ICU.
METHODS
We retrospectively reviewed the medical records of 56 patients, who developed intracranial hemorrhage in a medical ICU, from May 2008 to December 2011. During the mechanical ventilation in the ICU, patients were implemented with a weaning process, following ACCP (American College of Chest Physicians) criteria. Also, we compared patients with brain hemorrhage to those without brain hemorrhage.
RESULTS
Thirty two of the 56 patients (57.1%) were male, and median ages were 63 (17-90) years. The common type of brain hemorrhage confirmed was intracerebral hemorrhage/intraventricular hemorrhage (52.2%). The duration from mechanical ventilation to brain hemorrhage was 6 (0-58) days. Overall hospital mortality was 57.1%, and ICU mortality was 44.6%. The most common cause of death was brain hemorrhage (40.6%). In comparison to patients without brain hemorrhage, study patients showed less use of anticoagulants and lower ventilator pressure. Our study showed that the use of vasopressor, systolic blood pressure, peak airway pressure, and platelet count were associated with brain hemorrhage.
CONCLUSIONS
Intracranial hemorrhage showed high mortality in critically ill patients with mechanical ventilation. In the future, large case-control study will be needed to evaluate the risk factors of cerebral hemorrhage.

Exhaled Nitric Oxide in Patients with Ventilator Associated Pneumonia: Hyun Jung Kwak, Sang Heon Kim, Tae Hyung Kim, Ho Joo Yoon, Dong Ho Shin, Sung Soo Park, Jang Won Sohn; Korean J Crit Care Med. 2012;27(2):82-88.; DOI: https://doi.org/10.4266/kjccm.2012.27.2.82

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Abstract PDF

BACKGROUND
Fraction of exhaled nitric oxide (FENO) is known as a marker of inflammation in asthma, cystic fibrosis and exacerbation of COPD. However, its importance has not been established in patients using mechanical ventilation. We assessed whether FENO is elevated in patients with ventilator associated pneumonia (VAP), and physiologic or pathologic factors affecting levels of FENO in patients with mechanical ventilation.
METHODS
All patients (over 18-year-old) using mechanical ventilation were included, and among them, VAP patients were diagnosed on the basis of clinical pulmonary infection score (CPIS). We measured FENO in air collected during the end-expiratory pause via an off-line method. We compared the levels of FENO between patients with VAP and without, and assessed the relationship between FENO and other physiologic or pathologic characteristics; age, gender, PaO2, oxygenation index, CPIS.
RESULTS
A total of 43 patients (23 male, mean age 67.7 +/- 10.7) in an ICU were enrolled; 19 of them were VAP-patients (10 male, mean age 64.8 +/- 12.9). The level of FENO in the VAP-patients was substantially higher than in the non-VAP group (55.8 +/- 25.3 ppb Vs. 31.8 +/- 13.5 ppb, p < 0.001). CPIS on day 1 and day 3, and duration of mechanical ventilation, were associated with the level of FENO, but oxygenation index, PaO2, PaO2/FiO2, and the mean PEEP were not.
CONCLUSIONS
FENO may be useful for the diagnosis of VAP, and is related to CPIS, as well as the duration of mechanical ventilation.

Citations

Citations to this article as recorded by

Exhaled nitric oxide in intubated ICU patients on mechanical ventilation—a feasibility study
Andreas Kofoed, Mathias Hindborg, Jeppe Hjembæk-Brandt, Christian Dalby Sørensen, Mette Kolpen, Morten H Bestle
Journal of Breath Research.2023; 17(4): 046014. CrossRef
Clinical Application of Exhaled Nitric Oxide Measurements in a Korean Population
Woo-Jung Song, Ji-Won Kwon, Eun-Jin Kim, Sang-Min Lee, Sae-Hoon Kim, So-Yeon Lee, Sang-Heon Kim, Heung-Woo Park, Yoon-Seok Chang, Woo Kyung Kim, Jung Yeon Shim, Ju-Hee Seo, Byoung-Ju Kim, Hyo Bin Kim, Dae Jin Song, Gwang Cheon Jang, An-Soo Jang, Jung-Won
Allergy, Asthma & Immunology Research.2015; 7(1): 3. CrossRef
Exhaled breath analysis in the differentiation of pneumonia from acute pulmonary oedema
Silvie Prazakova, Nadine Elias, Paul S Thomas, Deborah H Yates
Pulmonology and Respiratory Research.2015; 3(1): 3. CrossRef

Atelectasis and the Risk Factors in the Patients Admitted to Pediatric Intensive Care Unit: Woo Jin Chung, Jae Wook Choi, Young Ju Han, Ju Kyung Lee, Dong In Suh, Young Yull Koh, June Dong Park; Korean J Crit Care Med. 2011;26(4):238-244.; DOI: https://doi.org/10.4266/kjccm.2011.26.4.238

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Abstract PDF: BACKGROUND
Atelectasis is a state of a collapsed and non-aerated region of the lung parenchyma, which is otherwise normal. This condition is usually associated with pulmonary disorders. The purpose of this study is to analyze the incidence and risk factors of atelectasis in patients admitted to the pediatric intensive care unit (PICU).
METHODS
We retrospectively analyzed the clinical characteristics and chest radiography of 280 PICU patients under 18 years old. We analyzed the incidence and pattern of atelectasis and compared the incidence according to the phase and mode of mechanical ventilation. We compared the incidence of ventilator care need and respiratory disease in 93 atelectasis patients.
RESULTS
Atelectasis incidence was 33.2%. The age (4.9 +/- 4.4 years) was younger and the admission-duration (17.8 +/- 25.1 days) was significantly longer in atelectasis patients (p < 0.01). Ventilator care need and respiratory disease in atelectasis patients (86.0%, 66.7% respectively) was significantly higher than in non-atelectasis patients (62.6%, 43.3% respectively) (p < 0.01). Atelectasis incidence in ventilator-required patients and respiratory-diagnosed patients (40.6%, 43.4% respectively) was significantly higher than that in non ventilator-required patients and non respiratory-diagnosed patients (15.7%, 22.6% respectively) (p < 0.01). Atelectasis was more common in the right upper lobe (55.6%) and during or after ventilator care (62.6%) (p < 0.05). Atelectasis incidence in ventilator care did not differ between the assist-control and intermittent mandatory ventilation modes.
CONCLUSIONS
In the PICU, atelectasis incidence was higher in patients with ventilator care and respiratory disease. Atelectasis was more common in the right upper lobe and in the phase after ventilator initiation. Atelectasis incidence in ventilator care did not differ between ventilation modes.

Case Report

Successful Recovery after Drowning by Early Prone Ventilatory Positioning and Use of Nitric Oxide Gas: A Case Report: Joo Myung Lee, Jae Ho Lee, Choon Taek Lee, Young Jae Cho; Korean J Crit Care Med. 2011;26(3):196-199.; DOI: https://doi.org/10.4266/kjccm.2011.26.3.196

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Abstract PDF: Drowning is the third leading cause of unintentional accidental death globally. The most serious pathophysiologic consequence of drowning is hypoxemia from acute respiratory distress syndrome. Herein, we report a drowning victim who presented with hypothermia and cardiac arrest, followed by acute respiratory distress syndrome, rhabdomyolysis (with acute kidney injury), and disseminated intravascular coagulopathy. Aided by advanced cardiac life support and mechanical ventilation in a prone position, the patient fully recovered after two days of hospitalization. Recovery was largely attributed to early prone ventilatory positioning and use of nitric oxide gas.

Original Articles

Implementation of the Head of Bed (HOB) Elevation Protocol on Clinical and Nutritional Outcomes in Critically Ill Patients with Mechanical Ventilator Support: Se Hee Na, Hosun Lee, Shin Ok Koh, Hyun Sim Lee, Sung Won Na; Korean J Crit Care Med. 2011;26(3):128-133.; DOI: https://doi.org/10.4266/kjccm.2011.26.3.128

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Abstract PDF

BACKGROUND
Although head of bed (HOB) elevation is an important strategy to prevent ventilator associated pneumonia (VAP), some observational studies have reported that the application of the semi-recumbent position was lower in patients receiving mechanical ventilator support. We performed this study to assess the effect of implementation of the HOB elevation protocol in the intensive care unit (ICU) on clinical and nutritional outcomes.
METHODS
We developed a HOB elevation protocol including a flow chart to determine whether the HOB of newly admitted patients to ICU could be elevated. We measured the level of HOB elevation in patients with mechanical ventilator twice a day and 2 days a week for 5 weeks before and after the implementation of the protocol, respectively. Hemodynamic, respiratory and nutritional data were also collected, resulting in 251 observations from 35 patients and 467 observations from 66 patients before and after implementation.
RESULTS
After implementing the protocol, the level of HOB elevation (16.7 +/- 9.9 vs. 23.6 +/-1 2.9, p < 0.0001) and observations of HOB elevation > 30degrees increased significantly (34 vs. 151, p < 0.0001). There was no significant difference in the incidence of VAP. Arterial oxygen tension/fraction of inspired oxygen ratio improved (229 +/- 115 vs. 262 +/- 129, p = 0.02). Mean arterial blood pressure decreased after the implementation of the protocol, but remained within the normal limits. Calorie intake from tube feeding increased significantly (672 +/- 649 vs. 798 +/- 670, p = 0.021) and the events of high gastric residual volume (> 100 ml) occurred less frequently after implementing the protocol (50% vs. 17%, p = 0.001) CONCLUSIONS: Implementation of the protocol for HOB elevation could improve the level of HOB elevation, oxygenation parameter and enteral nutrition delivery.

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Nutrition Support in the Intensive Care Unit of 6 Korean Tertiary Teaching Hospitals: A National Multicenter Observational Study
Song Mi Lee, Seon Hyeung Kim, Yoon Kim, Eunmee Kim, Hee Joon Baek, Seungmin Lee, Hosun Lee, Chul Ho Chang, Cheung Soo Shin
Korean Journal of Critical Care Medicine.2012; 27(3): 157. CrossRef

VAP (Ventilator-associated Pneumonia) in Patients with Pulmonary Contusion: Jong Hyun Jeong, Sung Youl Hyun, Jin Joo Kim, Jae Hyuk Kim, Yong Su Lim, Jin Seong Cho, Sung Yeon Hwang, Hyuk Jun Yang; Korean J Crit Care Med. 2010;25(4):224-229.; DOI: https://doi.org/10.4266/kjccm.2010.25.4.224

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Abstract PDF: BACKGROUND
This study was conducted to determine the incidence, risk factors, and outcome of ventilator-associated pneumonia in patients with pulmonary contusion.
METHODS
The study was conducted at an urban teaching hospital emergency department with an annual volume of 80,000 patient visits. A retrospective analysis was conducted on thoracic injury patients admitted between Jan 2007 and Dec 2009. Among 122 patients investigated, 30 patients were excluded. Patient data included basal characteristics and information related to development of ventilator-associated pneumonia and ultimate mortality. Statistical methods included the Chi-square test and the Mann-Whitney test. Study data were stored and processed using Microsoft Office Excel 2007 & SPSS 18.0 for Windows.
RESULTS
Ventilator-associated pneumonia developed in 46 patients (50%). The patients with ventilator-associated pneumonia were more likely to have a longer duration of hospitalization, longer length of ICU stay, longer duration of mechanical ventilation, a low initial GCS, a higher APACHE II score, and were more likely to require emergency intubation or tracheostomy. Factors associated with mortality included longer duration of hospitalization, longer duration of mechanical ventilation, low intial GCS and the need for dialysis.
CONCLUSIONS
Ventilator-associated pneumonia in the patients with pulmonary contusion was not relevant to mortality, but was relevant to longer hospitalization, length of ICU stay and duration of mechanical ventilation.

Case Report

Extreme Drug Resistant Acinetobacter Nosocomial Ventilator-Associated Pneumonia Treated Successfully with Tigecycline and Amikacin in Intensive Care Unit: A Case Report: So Yeon Lim, So Young Park, Kyeongman Jeon, Gee Young Suh, Suhyun Kim, Kyong Ran Peck, Doo Ryeon Chung; Korean J Crit Care Med. 2009;24(3):176-180.; DOI: https://doi.org/10.4266/kjccm.2009.24.3.176

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Abstract PDF

Infections due to multidrug resistant Acinetobacter baumannii have become a challenging problem in intensive care units. Tigecycline is a derivative of minocyline, and has provided new hope for the treatment of multidrug-resistant A. baumannii infections. Because isolates showing reduced susceptibility to minocycline or tigecycline have emerged in many countries, empirical combination therapy has become common practice to treat patients infected with extreme drug-resistant A. baumannii. Herein we report a case of extreme drug-resistant A. baumannii infection successfully treated with tigecycline and amikacin.

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Clinical Characteristics in Patients with Carbapenem-ResistantAcinetobacter baumanniiIsolates from Tracheal Secretions
Jeong Ha Mok, Mi Hyun Kim, Kwangha Lee, Ki Uk Kim, Hye-Kyung Park, Min Ki Lee
Korean Journal of Critical Care Medicine.2013; 28(3): 173. CrossRef

Original Articles

Analysis of the Description of Ventilator Parameters in Recent Papers Relating Artificial Ventilation Using Anesthesia Machine: Jiyeon Sim, Hee Yeon Park, Wonsik Ahn; Korean J Crit Care Med. 2007;22(1):7-14.

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Abstract PDF: BACKGROUND
Procedures in medical papers should be described in sufficient detail to allow other researchers to reproduce the results. The apparatus including anesthesia machine should be given, too. Anesthesia machine has dramatically improved as bioengineering has developed. There are several ventilator settings in modern anesthesia machines. However, it seems that only a few ventilator settings are described even though modern ventilators are used in research. The purpose of this study is to investigate that how many ventilator parameters were described in the papers of the Korean Journal of Anesthesiology from 2001 to 2006. METHODS: All of papers with human general anesthesia were reviewed except case reports, and papers regarding only induction or intubation procedures. Recruited articles were grouped into papers with strongly related to respiratory parameters (STP), and into ones with slightly related to them based on the research topics. The description of following categories was counted in each paper; the type of anesthesia machine, tidal volume, respiratory rate, inspiratory:expiratory ratio, mode of ventilation, pressure set in pressure targeted ventilation, positive end expiratory pressure, inspiratory pause, and inspiratory rising rate. RESULTS: The description rate of each parameters in STP were 36% in the type of anesthesia machine, 66% in tidal volume, 54% in respiratory rate, and 24% in inspiratory:expiratory ratio. The other settings were seldomly mentioned. CONCLUSIONS: Description on the ventilator parameters was sometimes missed. We should describe adequate ventilator settings to reproduce the results because the modern anesthesia machine has additional ventilator options.

Collagen Synthesis in an in Vivo Rat Model of Ventilator-induced Lung Injury: Won Il Choi; Korean J Crit Care Med. 2006;21(2):109-115.

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Abstract PDF: BACKGROUND
Experimentally, maintaining high pressure or high volume ventilation in animal models produces an acute lung injury, however, there was little information on remodeling. We investigated the collagen synthesis in a rat model of ventilator-induced lung injury.
METHODS
Rats were ventilated with room air at 85 breaths/minute for 2 hours either tidal volume 7 ml/kg or 20 ml/kg (V(T)7 or V(T)20, respectively). After 2 hours of ventilation, rats were placed in the chamber for 24 hours. Lung collagen was evaluated by immunohistochemistry (n=5) and collagen was quantitated by collagen assay (n=5). Static compliance (Csta) of the whole lung as obtained from the pressure volume curves.
RESULTS
Type I collagen was an increase in expression in the interstitium with large V(T) (20 ml/ kg) ventilation after 2 hours of mechanical ventilation (MV), and further increased expression after 24 hours of recovery period. Static lung compliance was significantly (p<0.05) decreased in the V(T)20 compared with V(T)7 (0.221+/-0.05 vs 0.305+/-0.06 ml/cm H2O) after 2 hours of MV. There was a further decrease in lung compliance after 24 hours of recovery period (0.144+/-0.07 vs 0.221+/-0.05, p<0.05) in the V(T)20.
CONCLUSIONS
Large tidal volume ventilation causes an increase in type 1 collagen expression with reduction of lung compliance.

Predictors for Reintubation after Unplanned Endotracheal Extubation in Multidisciplinary Intensive Care Unit: Bon Nyeo Koo, Shin Ok Koh, Tae Dong Kwon; Korean J Crit Care Med. 2003;18(1):20-25.

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Abstract PDF: BACKGROUND
Unplanned endotracheal extubation is a potentially serious complication, as some patients may need reintubation while in very critical conditions that may increase the morbidity and mortality rates. We conducted a study to evaluate the predictors for reintubation after unplanned extubation. METHODS: Patients who presented unplanned extubation over a 35-month period in two multidisciplinary intensive care units of university affiliated hospital were included. Any replacement of an endotracheal tube within 48 hours after unplanned extubation was considered as reintubation. RESULTS: There were 62 episodes of unplanned endotracheal extubation in 56 patients (incidence rate 2.8%). Fifty seven episodes (91.9%) were deliberate self-extubation, while 5 episodes (8.1%) were accidental extubation. Reintubation was required in 42 episodes (67.7%). Only 44.4% (12/27) of the patients who presented unplanned extubation required reintubation during weaning period, while reintubation was mandatory in 85.7% (30/35) of the patients who presented unplanned extubation during full ventilatory support (P<0.001). The multiple logistic regression analysis was made to obtain a model to predict the need for reintubation as a dependent variable: ventilatory support mode (odds ratio: 12.0) was significantly associated with the need for reintubation. The model correctly classified the need of reintubation in 72.6% (45/62) of the patients. CONCLUSIONS: Reintubation in unplanned extubation strongly depended on the type of the mechanical ventilatory support. The probability of requiring reintubation after unplanned extubation was higher during full ventilatory support than during weaning period.

Case Report

Continuous Infusion of Ketamine in Mechanically Ventilated Patient in Septic Shock with Status Asthmaticus: Bon Nyeo Koo, Shin Ok Koh, Sung Yong Park, Jae Kwang Shim, Sung Sik Chon; Korean J Crit Care Med. 2000;15(2):108-112.

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Abstract PDF: Ketamine is well known for its analgesic, bronchodilating and sympathetic stimulating effect. Hence, it has been widely used for induction of patients with hypotension or asthma and also for analgesic and sedating purposes in the ICU. We presented a 62 year old female patient with ventilator support in septic shock with refractory asthma whom we managed successfully with continuous intravenous infusion of ketamine postoperatively in the ICU. The patient had a history of asthma but had been asymptomatic recently and was scheduled for an emergent explo-laparotomy under the diagnosis of acute panperitonitis. Before the induction of anesthesia, the patient was in septic shock but no wheezing could be auscultated. After the induction of general anesthesia and endotracheal intubation, wheezing was apparent in both lung fields with a high peak inspiratory pressure. Inotropics, vasopressors and bronchodilators were promptly instituted without any improvement of asthma and the patient had to be transferred to the ICU with intubated after the operation. Clinical symptoms of asthma continued throughout the first day despite using bronchodilators under mechanical ventilation but, after starting the IV infusion of ketamine, there were decrease in the peak inspiratory pressure and wheezing with a subsequent improvement in the arterial blood gas analysis findings. We could also achieve considerable analgesic and sedating effect without any decrease in the blood pressure. The patient's general physical status improved and weaning with extubation was successfully done on the 21st day and was transferred to the general ward on the 28th day.

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