Acute and Critical Care

Guideline

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

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

Original Articles

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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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

Citations to this article as recorded by

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
The Role of Ultrasonography in the Process of Weaning from Mechanical Ventilation in Critically Ill Patients
Lou’i Al-Husinat, Basil Jouryyeh, Ahlam Rawashdeh, Chiara Robba, Pedro Silva, Patricia Rocco, Denise Battaglini
Diagnostics.2024; 14(4): 398. CrossRef
Critical illness-associated limb and diaphragmatic weakness
Valentine Le Stang, Nicola Latronico, Martin Dres, Michele Bertoni
Current Opinion in Critical Care.2024; 30(2): 121. CrossRef
Accuracy of respiratory muscle assessments to predict weaning outcomes: a systematic review and comparative meta-analysis
Diego Poddighe, Marine Van Hollebeke, Yasir Qaiser Choudhary, Débora Ribeiro Campos, Michele R. Schaeffer, Jan Y. Verbakel, Greet Hermans, Rik Gosselink, Daniel Langer
Critical Care.2024;[Epub] CrossRef
Ultrasonographic 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
Critical Care.2023;[Epub] CrossRef
Value of Diaphragm Ultrasonography for Extubation: A Single-Blinded Randomized Clinical Trial
T. G. Toledo, M. R. Bacci, Fred A. Luchette
Critical Care Research and Practice.2023; 2023: 1. CrossRef
Role of diaphragm ultrasound in weaning mechanically ventilated patients: A prospective observational study
Ravi Saravanan, Krishnamurthy Nivedita, Krishnamoorthy Karthik, Rajagopalan Venkatraman
Indian Journal of Anaesthesia.2022; 66(8): 591. CrossRef
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 and Critical Care.2022; 37(3): 347. CrossRef
Diaphragm ultrasound in weaning from mechanical ventilation: a last step to predict successful extubation?
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
Amandeep Kaur, Shruti Sharma, VikramP Singh, MRavi Krishna, ParshotamL Gautam, Gagandeep Singh
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
European Journal of Pediatrics.2022; 182(2): 731. CrossRef

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

Citations to this article as recorded by

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
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.

Citations

Citations to this article as recorded by

Pendelluft as a predictor of weaning in critically ill patients: An observational cohort study
Danqiong Wang, Yaxin Ning, Linya He, Keqi Pan, Xiaohua Xiong, Shanshan Jing, Jianhua Hu, Jian Luo, Dehua Ye, Zubing Mei, Weiwen Zhang
Frontiers in Physiology.2023;[Epub] CrossRef
Morphological and Functional Alterations of Respiratory Muscle Performance and Spirometry Parameters in Patients with Congestive Heart Failure
V. S. Shabaev, I. V. Orazmagomedova, V. A. Mazurok, A. V. Berezina, A. E. Bautin, L. G. Vasilyeva, D. A. Aleksandrova
General Reanimatology.2023; 19(5): 39. CrossRef
Diaphragmatic dysfunction in patients with chronic heart failure
V.S. Shabaev, I.V. Orazmagomedova, V.A. Mazurok, A.V. Berezina, A.E. Bautin, L.G. Vasilyeva, D.A. Aleksandrova
Anesteziologiya i reanimatologiya.2023; (5): 44. CrossRef
Biosignal-Based Digital Biomarkers for Prediction of Ventilator Weaning Success
Ji Eun Park, Tae Young Kim, Yun Jung Jung, Changho Han, Chan Min Park, Joo Hun Park, Kwang Joo Park, Dukyong Yoon, Wou Young Chung
International Journal of Environmental Research and Public Health.2021; 18(17): 9229. CrossRef

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.

Citations

Citations to this article as recorded by

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
Anesteziologie a intenzivní medicína.2020; 31(6): 305. CrossRef

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.

Citations

Citations to this article as recorded by

What do we know about experiencing end-of-life in burn intensive care units? A scoping review
André Filipe Ribeiro, Sandra Martins Pereira, Rui Nunes, Pablo Hernández-Marrero
Palliative and Supportive Care.2023; 21(4): 741. CrossRef
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
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
Multidisciplinary Respiratory Medicine.2020;[Epub] CrossRef
Protecting Postextubation Respiratory Failure and Reintubation by High-Flow Nasal Cannula Compared to Low-Flow Oxygen System: Single Center Retrospective Study and Literature Review
Minhyeok Lee, Ji Hye Kim, In Beom Jeong, Ji Woong Son, Moon Jun Na, Sun Jung Kwon
Acute and Critical Care.2019; 34(1): 60. 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.

Citations

Citations to this article as recorded by

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 Article

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.

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