A cohort study on the respiratory pathophysiology of mechanically ventilated patients with Covid-19, is investigated. Mortality rates between 26% and 61.5% of hospitalized patients with acute ...respiratory syndrome coronavirus 2 2 (SARS-CoV-2 infection are admitted to the intensive care unit (ICU) are managed with invasive mechanical ventilation. Reports of preserved respiratory system mechanics despite severe hypoxemia in early small series have led some investigators to hypothesize that a significant proportion of Covid-19 respiratory failure is not the typical acute respiratory distress syndrome (ARDS) and warrants alternative management. An overview on the methods, results and characterization of the Covid-19 respiratory failure, is also provided.
Is Mechanical Power the One Ring to Rule Them All? Bihari, Shailesh; Hibbert, Kathryn A; Bersten, Andrew D
American journal of respiratory and critical care medicine,
03/2024, Letnik:
209, Številka:
5
Journal Article
Recenzirano
Odprti dostop
Mechanical power has been proposed as a measure to quantify the risk of lung injury from mechanical ventilation. However, the association between high mechanical power and poor clinical outcomes is ...still not well understood. In a recent study, von Wedel and colleagues examined the ventilator adjustments during the transition from the operating room to the ICU and their impact on mortality. They found that higher mechanical power was associated with a higher 28-day mortality rate. These findings challenge the current paradigm of lung-protective ventilation and suggest that adjustments associated with lower tidal volumes, such as increased respiratory rate, may convey risk. However, the study has limitations, including its retrospective and observational nature. Therefore, further research is needed to determine the optimal way to calculate mechanical power and its clinical significance. Clinical trials targeting mechanical power may provide more insights into ventilator-induced lung injury.
Healthcare acquired infections (HAI's) are a worldwide problem that can be exacerbated by surgery and the implantation of polymeric medical devices. The use of polymer based medical devices which ...incorporate antimicrobial strategies are now becoming an increasingly routine way of trying to prevent the potential for reduce chronic infection and device failure. There are a wide range of potential antimicrobial agents currently being incorporated into such polymers. However, it is difficult to determine which antimicrobial agent provides the greatest infection control. The economics of replacing current methods with impregnated polymer materials further complicates matters. It has been suggested that the use of a holistic system wide approach should to be developed around the implantation of medical devices which minimises the potential risk of infection. However, the use of such different approaches is still being developed. The control of such infections is important for individual patient health and the economic implications for healthcare services.
•Healthcare acquired infections (HAI's) are a worldwide problem.•HAIs can be exacerbated by the implantation of polymeric medical devices.•Polymer based medical devices are becoming increasingly routine.•Chemical additions to polymeric implants have been used to control microbial growth.•Uncertainty of cost-effectiveness in the use of antimicrobial devices has been raised.
There has long been interest in adjunctive therapies in septic shock because this condition continues to carry a significant risk of death and long-term sequelae.
Adjunctive therapy with ...glucocorticoids has been the target of many controlled trials in septic shock on the basis of glucocorticoids' multiple putative benefits, including modulation of an excess inflammatory response to infection and treatment of relative adrenal insufficiency due to imbalance in the hypothalamic-pituitary-adrenal axis. Despite this effort, decades of conflicting trial results have left clinicians without consistent guidance about when, and for whom, to implement glucocorticoid therapy.
Summary In this Series paper, we review the current evidence for the use of high-flow oxygen therapy, inhaled gases, and aerosols in the care of critically ill patients. The available evidence ...supports the use of high-flow nasal cannulae for selected patients with acute hypoxaemic respiratory failure. Heliox might prevent intubation or improve gas flow in mechanically ventilated patients with severe asthma. Additionally, it might improve the delivery of aerosolised bronchodilators in obstructive lung disease in general. Inhaled nitric oxide might improve outcomes in a subset of patients with postoperative pulmonary hypertension who had cardiac surgery; however, it has not been shown to provide long-term benefit in patients with acute respiratory distress syndrome (ARDS). Inhaled prostacyclins, similar to inhaled nitric oxide, are not recommended for routine use in patients with ARDS, but can be used to improve oxygenation in patients who are not adequately stabilised with traditional therapies. Aerosolised bronchodilators are useful in mechanically ventilated patients with asthma and chronic obstructive pulmonary disease, but are not recommended for those with ARDS. Use of aerosolised antibiotics for ventilator-associated pneumonia and ventilator-associated tracheobronchitis shows promise, but the delivered dose can be highly variable if proper attention is not paid to the delivery method.
The acute respiratory distress syndrome (ARDS) remains a common and highly morbid condition despite advances in the understanding and management of this complex critical illness. Recent work has ...illuminated the heterogeneity within ARDS and demonstrated the likely impact of heterogeneity on the identification of effective therapeutic interventions. Despite these challenges, new data have also informed the standard of care for ARDS and have resulted in the re-evaluation of previously established therapies, including ventilation strategies, pharmacologic interventions, and rescue therapies. As the field of ARDS continues to evolve, innovative approaches will be needed to further define phenotypes within ARDS and design targeted clinical trials.
Objective
Recent cohort studies have identified obesity as a risk factor for poor outcomes in coronavirus disease 2019 (COVID‐19). To further explore the relationship between obesity and critical ...illness in COVID‐19, the association of BMI with baseline demographic and intensive care unit (ICU) parameters, laboratory values, and outcomes in a critically ill patient cohort was examined.
Methods
In this retrospective study, the first 277 consecutive patients admitted to Massachusetts General Hospital ICUs with laboratory‐confirmed COVID‐19 were examined. BMI class, initial ICU laboratory values, physiologic characteristics including gas exchange and ventilatory mechanics, and ICU interventions as clinically available were measured. Mortality, length of ICU admission, and duration of mechanical ventilation were also measured.
Results
There was no difference found in respiratory system compliance or oxygenation between patients with and without obesity. Patients without obesity had higher initial ferritin and D‐dimer levels than patients with obesity. Standard acute respiratory distress syndrome management, including prone ventilation, was equally distributed between BMI groups. There was no difference found in outcomes between BMI groups, including 30‐ and 60‐day mortality and duration of mechanical ventilation.
Conclusions
In this cohort of critically ill patients with COVID‐19, obesity was not associated with meaningful differences in respiratory physiology, inflammatory profile, or clinical outcomes.
Patients with severe coronavirus disease 2019 (COVID-19) have respiratory failure with hypoxemia and acute bilateral pulmonary infiltrates, consistent with ARDS. Respiratory failure in COVID-19 might ...represent a novel pathologic entity.
How does the lung histopathology described in COVID-19 compare with the lung histopathology described in SARS and H1N1 influenza?
We conducted a systematic review to characterize the lung histopathologic features of COVID-19 and compare them against findings of other recent viral pandemics, H1N1 influenza and SARS. We systematically searched MEDLINE and PubMed for studies published up to June 24, 2020, using search terms for COVID-19, H1N1 influenza, and SARS with keywords for pathology, biopsy, and autopsy. Using PRISMA-Individual Participant Data guidelines, our systematic review analysis included 26 articles representing 171 COVID-19 patients; 20 articles representing 287 H1N1 patients; and eight articles representing 64 SARS patients.
In COVID-19, acute-phase diffuse alveolar damage (DAD) was reported in 88% of patients, which was similar to the proportion of cases with DAD in both H1N1 (90%) and SARS (98%). Pulmonary microthrombi were reported in 57% of COVID-19 and 58% of SARS patients, as compared with 24% of H1N1 influenza patients.
DAD, the histologic correlate of ARDS, is the predominant histopathologic pattern identified in lung pathology from patients with COVID-19, H1N1 influenza, and SARS. Microthrombi were reported more frequently in both patients with COVID-19 and SARS as compared with H1N1 influenza. Future work is needed to validate this histopathologic finding and, if confirmed, elucidate the mechanistic underpinnings and characterize any associations with clinically important outcomes.
An 81-year-old man presented with fever, cough, and shortness of breath. Within a few hours after presentation, chest pain and respiratory distress developed. A chest radiograph showed bilateral ...patchy airspace opacities, with predominance in the peripheral lower lung zone and with relative sparing of the perihilar region. A diagnostic test was performed.
Objective and early identification of hospitalized patients, and particularly those with novel coronavirus disease 2019 (COVID-19), who may require mechanical ventilation (MV) may aid in delivering ...timely treatment.
Can a transparent deep learning (DL) model predict the need for MV in hospitalized patients and those with COVID-19 up to 24 h in advance?
We trained and externally validated a transparent DL algorithm to predict the future need for MV in hospitalized patients, including those with COVID-19, using commonly available data in electronic health records. Additionally, commonly used clinical criteria (heart rate, oxygen saturation, respiratory rate, Fio2, and pH) were used to assess future need for MV. Performance of the algorithm was evaluated using the area under receiver operating characteristic curve (AUC), sensitivity, specificity, and positive predictive value.
We obtained data from more than 30,000 ICU patients (including more than 700 patients with COVID-19) from two academic medical centers. The performance of the model with a 24-h prediction horizon at the development and validation sites was comparable (AUC, 0.895 vs 0.882, respectively), providing significant improvement over traditional clinical criteria (P < .001). Prospective validation of the algorithm among patients with COVID-19 yielded AUCs in the range of 0.918 to 0.943.
A transparent deep learning algorithm improves on traditional clinical criteria to predict the need for MV in hospitalized patients, including in those with COVID-19. Such an algorithm may help clinicians to optimize timing of tracheal intubation, to allocate resources and staff better, and to improve patient care.
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