Patients who were comatose after resuscitation from cardiac arrest with a nonshockable rhythm were randomly assigned to moderate therapeutic hypothermia (33°C) or targeted normothermia (37°C). ...Therapeutic hypothermia improved survival with a favorable neurologic outcome at 90 days.
Patients with acute hypoxemic respiratory failure were assigned to standard oxygen therapy, high-flow oxygen therapy, or noninvasive ventilation. The intubation rate did not differ significantly ...among the groups, but 90-day mortality was lower in the high-flow–oxygen group.
Noninvasive positive-pressure ventilation (hereafter, noninvasive ventilation) reduces the need for endotracheal intubation and mortality among patients with acute exacerbations of chronic obstructive pulmonary disease
1
–
3
or severe cardiogenic pulmonary edema.
4
The physiological effects of noninvasive ventilation include a decrease in the work of breathing and improvement in gas exchange. In patients with acute hypoxemic respiratory failure, the need for mechanical ventilation is associated with high mortality,
5
but data on the overall effects of noninvasive ventilation with respect to the prevention of intubation and improvement in outcome are conflicting.
6
–
10
Previous studies have often included a heterogeneous population of patients with . . .
Once diagnostic work-up and first therapy are completed in patients visiting the emergency department (ED), boarding them within the ED until an in-hospital bed became available is a common practice ...in busy hospitals. Whether this practice may harm the patients remains a debate. We sought to determine whether an ED boarding time longer than 4 h places the patients at increased risk of in-hospital death. This retrospective, propensity score-matched analysis and propensity score-based inverse probability weighting analysis was conducted in an adult ED in a single, academic, 1136-bed hospital in France. All patients hospitalized via the adult ED from January 1, 2013 to March 31, 2018 were included. Hospital mortality (primary outcome) and hospital length of stay (LOS) were assessed in (1) a matched cohort (1:1 matching of ED visits with or without ED boarding time longer than 4 h but similar propensity score to experience an ED boarding time longer than 4 h); and (2) the whole study cohort. Sensitivity analysis to unmeasured confounding and analyses in pre-specified cohorts of patients were conducted. Among 68,632 included ED visits, 17,271 (25.2%) had an ED boarding time longer than 4 h. Conditional logistic regression performed on a 10,581 pair-matched cohort, and generalized estimating equations with adjustment on confounders and stabilized propensity score-based inverse probability weighting applied on the whole cohort showed a significantly increased risk of hospital death in patients experiencing an ED boarding time longer than 4 h: odds ratio (OR) of 1.13 (95% confidence interval 95% CI 1.05–1.22),
P
= 0.001; and OR of 1.12 (95% CI 1.03–1.22),
P
= 0.007, respectively. Sensitivity analyses showed that these findings might be robust to unmeasured confounding. Hospital LOS was significantly longer in patients exposed to ED boarding time longer than 4 h: median difference 2 days (95% CI 1–2) (
P
< 0.001) in matched analysis and mean difference 1.15 days (95% CI 1.02–1.28) (
P
< 0.001) in multivariable unmatched analysis. In this single-center propensity score-based cohort analysis, patients experiencing an ED boarding time longer than 4 h before being transferred to an in-patient bed were at increased risk of hospital death.
Placing patients who require mechanical ventilation in the prone rather than the supine position improves oxygenation. In this trial, the investigators found a benefit with respect to all-cause ...mortality with this change in body position in patients with severe ARDS.
Prone positioning has been used for many years to improve oxygenation in patients who require mechanical ventilatory support for management of the acute respiratory distress syndrome (ARDS). Randomized, controlled trials have confirmed that oxygenation is significantly better when patients are in the prone position than when they are in the supine position.
1
,
2
Furthermore, several lines of evidence have shown that prone positioning could prevent ventilator-induced lung injury.
3
–
6
In several previous trials, these physiological benefits did not translate into better patient outcomes, since no significant improvement was observed in patient survival with prone positioning.
7
–
10
However, meta-analyses
2
,
11
have . . .
The use of non-invasive ventilation is controversial in immunocompromised patients with acute respiratory failure, whereas the use of high-flow nasal cannula oxygen therapy is growing as an ...alternative to standard oxygen. We aimed to compare outcomes of immunocompromised patients with acute respiratory failure treated with standard oxygen with those treated with high-flow nasal cannula oxygen alone or high-flow nasal cannula oxygen associated with non-invasive ventilation.
We did a post-hoc subgroup analysis in a subset of immunocompromised patients with non-hypercapnic acute respiratory failure from a multicentre, randomised, controlled trial. In the trial, patients from 23 intensive care units in France and Belgium were randomly assigned (1:1:1) to receive either standard oxygen, high-flow nasal cannula alone, or non-invasive ventilation interspaced with high-flow nasal cannula between non-invasive ventilation sessions (non-invasive ventilation group). Patients with profound neutropenia, acute-on-chronic respiratory failure, cardiogenic pulmonary oedema, shock, or altered consciousness were excluded. The primary outcome was the proportion of patients who required endotracheal intubation within 28 days after randomisation.
Of the 82 immunocompromised patients, 30 were treated with standard oxygen, 26 with high-flow nasal cannula alone, and 26 with non-invasive ventilation plus interspaced high-flow nasal cannula. 8 (31%) of 26 patients treated with high-flow nasal cannula alone, 13 (43%) of 30 patients treated with standard oxygen, and 17 (65%) of 26 patients treated with non-invasive ventilation required intubation at 28 days (p=0·04). Odds ratios (ORs) for intubation were higher in patients treated with non-invasive ventilation than in those treated with high-flow nasal cannula: OR 4·25 (95% CI 1·33-13·56). ORs were not significantly different between patients treated with high-flow nasal cannula alone and standard oxygen: OR 1·72 (0·57-5·18). After multivariable logistic regression, the two factors independently associated with endotracheal intubation and mortality were age and use of non-invasive ventilation as first-line therapy.
Non-invasive ventilation might be associated with an increased risk of intubation and mortality and should be used cautiously in immunocompromised patients with acute hypoxaemic respiratory failure.
French Ministry of Health, the French societies of intensive care (Société de Réanimation de Langue Française, SRLF) and pneumology (Société de Pneumologie de Langue Française, SPLF), La Mutuelle de Poitiers, AADAIRC (Association pour l'Assistance à Domicile Aux Insuffisants Respiratoires Chroniques), and Fisher&Paykel Healthcare.
IntroductionChildren with sickle cell disease show a significant decrease in bone mineral density, an increase in resting energy expenditure of more than 15%, a decrease in fat and lean mass as well ...as a significant increase in protein turnover, particularly in bone tissue. This study aims to evaluate the effectiveness of an increase in food intake on bone mineral density and the clinical and biological complications of paediatric sickle cell disease.Methods and analysisThe study is designed as an open-label randomised controlled clinical trial conducted in the Paediatrics Unit of the Orléans University Hospital Centre. Participants aged 3–16 years will be randomly divided into two groups: the intervention group will receive oral nutritional supplements (pharmacological nutritional hypercaloric products) while the control group will receive age-appropriate and gender-appropriate nutritional intake during 12 months. Total body less head bone mineral density will be measured at the beginning and the end of the trial. A rigorous nutritional follow-up by weekly 24 hours recall dietary assessment and planned contacts every 6 weeks will be carried out throughout the study. A school absenteeism questionnaire, intended to reflect the patient’s school productivity, will be completed by participants and parents every 3 months. Blood samples of each patient of both groups will be stocked at the beginning and at the end of the trial, for future biological trial. Clinical and biological complications will be regularly monitored.Ethics and disseminationThe protocol has been approved by the French ethics committee (Comité de Protection des Personnes Sud-Ouest et Outre-Mer 2, Toulouse; approval no: 2-20-092 id9534). Children and their parents will give informed consent to participate in the study before taking part. Results will be disseminated through peer-reviewed journals or international academic conferences.Trial registration numberNCT04754711.
We assessed the sensitivity and specificity of SARS-CoV-2 detection by polymerase chain reaction in heat and moisture exchange filters (HMEF) in mechanically ventilated COVID-19 patients. We showed ...that testing HMEF might obviate the need for a tracheal sample to affirm that a patient is not ready to end isolation.
Benefit of early awake prone positioning for COVID-19 patients hospitalised in medical wards and who need oxygen therapy remains to be demonstrated. The question was considered at the time of ...COVID-19 pandemic to avoid overloading the intensive care units. We aimed to determine whether prone position plus usual care could reduce the rate of non-invasive ventilation (NIV) or intubation or death as compared to usual care alone.
In this multicentre randomised clinical trial, 268 patients were randomly assigned to awake prone position plus usual care (N = 135) or usual care alone (N = 132). The primary outcome was the proportion of patients who underwent NIV or intubation or died within 28 days. Main secondary outcomes included the rates of NIV, of intubation or death, within 28 days.
Median time spent each day in the prone position within 72 h of randomisation was 90 min (IQR 30-133). The proportion of NIV or intubation or death within 28 days was 14.1% (19/135) in the prone position group and 12.9% (17/132) in the usual care group odds ratio adjusted for stratification (aOR) 0.43; 95% confidence interval (CI) 0.14-1.35. The probability of intubation, or intubation or death (secondary outcomes) was lower in the prone position group than in the usual care group (aOR 0.11; 95% CI 0.01-0.89 and aOR 0.09; 95% CI 0.01-0.76, respectively) in the whole study population and in the prespecified subgroup of patients with SpO
≥ 95% on inclusion (aOR 0.11; 95% CI 0.01-0.90, and aOR 0.09; 95% CI 0.03-0.27, respectively).
Awake prone position plus usual care in COVID-19 patients in medical wards did not decrease the composite outcome of need for NIV or intubation or death. Trial registration ClinicalTrials.gov Identifier: NCT04363463 . Registered 27 April 2020.
Background
The clinical impact and outcomes of ventilator-associated pneumonia (VAP) have been scarcely investigated in patients with the acute respiratory distress syndrome (ARDS).
Methods
Patients ...admitted over an 18-month period in two intensive care units (ICU) of a university-affiliated hospital and meeting the Berlin criteria for ARDS were retrospectively included. The association between VAP and the probability of death at day 90 (primary endpoint) was appraised through a Cox proportional hazards model handling VAP as a delay entry variable. Secondary endpoints included (i) potential changes in the PaO
2
/FiO
2
ratio and SOFA score values around VAP (linear mixed modelling), and (ii) mechanical ventilation (MV) duration, numbers of ventilator- and vasopressor-free days at day 28, and length of stay (LOS) in patients with and without VAP (median or absolute risk difference calculation). Subgroup analyses were performed in patients with COVID-19-related ARDS and those with ARDS from other causes.
Results
Among the 336 included patients (101 with COVID-19 and 235 with other ARDS), 176 (52.4%) experienced a first VAP. VAP induced a transient and moderate decline in the PaO
2
/FiO
2
ratio without increase in SOFA score values. VAP was associated with less ventilator-free days (median difference and 95% CI, − 19 − 20; − 13.5 days) and vasopressor-free days (− 5 − 9; − 2 days) at day 28, and longer ICU (+ 13 + 9; + 15 days) and hospital (+ 11.5 + 7.5; + 17.5 days) LOS. These effects were observed in both subgroups. Overall day-90 mortality rates were 35.8% and 30.0% in patients with and without VAP, respectively (
P
= 0.30). In the whole cohort, VAP (adjusted HR 3.16, 95% CI 2.04–4.89,
P
< 0.0001), the SAPS-2 value at admission, chronic renal disease and an admission for cardiac arrest predicted death at day 90, while the COVID-19 status had no independent impact. When analysed separately, VAP predicted death in non-COVID-19 patients (aHR 3.43, 95% CI 2.11–5.58,
P
< 0.0001) but not in those with COVID-19 (aHR 1.19, 95% CI 0.32–4.49,
P
= 0.80).
Conclusions
VAP is an independent predictor of 90-day mortality in ARDS patients. This condition exerts a limited impact on oxygenation but correlates with extended MV duration, vasoactive support, and LOS.
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