Background
Critically ill patients with obesity may have an increased risk of difficult intubation and subsequent severe hypoxemia. We hypothesized that pre-oxygenation with noninvasive ventilation ...before intubation as compared with high-flow nasal cannula oxygen may decrease the risk of severe hypoxemia in patients with obesity.
Methods
Post hoc subgroup analysis of critically ill patients with obesity (body mass index ≥ 30 kg·m
−2
) from a multicenter randomized controlled trial comparing preoxygenation with noninvasive ventilation and high-flow nasal oxygen before intubation of patients with acute hypoxemic respiratory failure (PaO
2
/FiO
2
< 300 mm Hg). The primary outcome was the occurrence of severe hypoxemia (pulse oximetry < 80%) during the intubation procedure.
Results
Among the 313 patients included in the original trial, 91 (29%) had obesity with a mean body mass index of 35 ± 5 kg·m
−2
. Patients with obesity were more likely to experience an episode of severe hypoxemia during intubation procedure than patients without obesity: 34% (31/91) vs. 22% (49/222); difference, 12%; 95% CI 1 to 23%;
P
= 0.03. Among patients with obesity, 40 received preoxygenation with noninvasive ventilation and 51 with high-flow nasal oxygen. Severe hypoxemia occurred in 15 patients (37%) with noninvasive ventilation and 16 patients (31%) with high-flow nasal oxygen (difference, 6%; 95% CI − 13 to 25%;
P
= 0.54). The lowest pulse oximetry values during intubation procedure were 87% interquartile range, 77–93 with noninvasive ventilation and 86% 78–92 with high-flow nasal oxygen (
P
= 0.98). After multivariable analysis, factors independently associated with severe hypoxemia in patients with obesity were intubation difficulty scale > 5 points and respiratory primary failure as reason for admission.
Conclusions
Patients with obesity and acute hypoxemic respiratory failure had an increased risk of severe hypoxemia during intubation procedure as compared to patients without obesity. However, preoxygenation with noninvasive ventilation may not reduce this risk compared with high-flow nasal oxygen.
Trial registration
Clinical trial number: NCT02668458 (
http://www.clinicaltrials.gov
)
Background
Several randomized clinical trials have shown that non-invasive ventilation (NIV) applied immediately after extubation may prevent reintubation in patients at high-risk of extubation ...failure. However, most of studies included patients with chronic respiratory disorders as well as patients without underlying respiratory disease. To date, no study has shown decreased risk of reintubation with prophylactic NIV after extubation among patients with chronic obstructive pulmonary disease (COPD). We hypothesized that prophylactic NIV after extubation may decrease the risk of reintubation in COPD patients as compared with high-flow nasal oxygen. We performed a post hoc subgroup analysis of COPD patients included in a multicenter, randomized, controlled trial comparing prophylactic use of NIV alternating with high-flow nasal oxygen versus high-flow nasal oxygen alone immediately after extubation.
Results
Among the 651 patients included in the original study, 150 (23%) had underlying COPD including 86 patients treated with NIV alternating with high-flow nasal oxygen and 64 patients treated with high-flow nasal oxygen alone
.
The reintubation rate was 13% (11 out of 86 patients) with NIV and 27% (17 out of 64 patients) with high-flow nasal oxygen alone difference, − 14% (95% CI − 27% to − 1%);
p
= 0.03. Whereas reintubation rates were significantly lower with NIV than with high-flow nasal oxygen alone at 72 h and until ICU discharge, mortality in ICU did not differ between groups: 6% (5/86) with NIV vs. 9% (6/64) with high-flow nasal oxygen alone difference − 4% (95% CI − 14% to 5%);
p
= 0.40.
Conclusions
In COPD patients, prophylactic NIV alternating with high-flow nasal oxygen significantly decreased the risk of reintubation compared with high-flow nasal oxygen alone.
Trial registration
The study was registered at
http://www.clinicaltrials.gov
with the trial registration number NCT03121482 (20 April 2017)
Biomarkers of disease severity might help with individualizing the management of patients with acute respiratory distress syndrome (ARDS). During sepsis, a sustained decreased expression of the ...antigen-presenting molecule human leucocyte antigen-DR (HLA-DR) on circulating monocytes is used as a surrogate marker of immune failure. This study aimed at assessing whether HLA-DR expression on alveolar monocytes in the setting of a severe lung infection is associated with their functional alterations. BAL fluid and blood from immunocompetent patients with pneumonia-related ARDS admitted between 2016 and 2018 were isolated in a prospective monocentric study. Alveolar and blood monocytes were immunophenotyped using flow cytometry. Functional tests were performed on alveolar and blood monocytes after in vitro lipopolysaccharide (LPS) stimulation. Phagocytosis activity and intracellular tumor necrosis factor (TNF) production were quantified using fluorochrome-conjugated-specific antibodies. Ten ARDS and seven non-ARDS control patients were included. Patients with pneumonia-related ARDS exhibited significantly lower HLA-DR expression both on circulating (
< 0.0001) and alveolar (
= 0.0002) monocytes. There was no statistically significant difference observed between patient groups (ARDS vs. non-ARDS) regarding both alveolar and blood monocytes phagocytosis activity. After LPS stimulation, alveolar (
= 0.027) and blood (
= 0.005) monocytes from pneumonia-related ARDS patients had a significantly lower intracellular TNF expression than non-ARDS patients. Monocytes from pneumonia-related ARDS patients have a deactivated status and an impaired TNF production capacity but display potent phagocytic activity. HLA-DR level expression should not be used as a surrogate marker of the phagocytic activity or the TNF production capacity of alveolar monocytes.
Purpose
At the critical care level, the flu surveillance system is limited in France, with heterogeneous regional modalities of implementation.
Materials, patients and methods
We aimed at assessing ...the relevance of the Assistance Publique-Hôpitaux de Paris (AP-HP) clinical data warehouse for estimating the burden of the influenza epidemic on medical adult critical care units of the AP-HP, and outcome of patients during the flu season 2017–2018. This exploratory multi-site epidemiological study comprised all consecutive adult stays (
n
= 320) in 18 medical intensive care units (ICU) or intermediate care wards (ICW) for probable or confirmed
Influenza
virus infection during the 2017–2018 flu season.
Results
Patients admitted to ICU/ICW had low vaccination coverage (21%), required life support in 60% of cases, stayed in the ICU for a median of 8 days, and had high 28-day mortality rate (19.7%; 95% confidence interval 15.5–24.5). Early prognostic factors included age, core temperature, the acute organ failures score, and the early administration of antiviral therapy.
Conclusions
Data directly extracted from the electronic medical records stored in the data warehouse provide detailed clinical, care pathway and prognosis information. The real-time availability should enable to detect and assess the burden of the most severe cases. By a firmer and more acute monitoring and adjustment of care and patient management, hospitals could generate more ICU/ICW capacities, sensitize their emergency department and contribute to the recommendations from health authorities. This pilot study is of particular relevance in the context of emerging epidemics of severe acute respiratory diseases.
Background
The aims of this study were to prospectively assess the prevalence of sustained (lasting more than 30 s) new-onset supraventricular arrhythmia (NOSVA) during septic shock, identify the ...associated factors (including septic myocardial dysfunction), and evaluate its impact on hemodynamics and prognosis.
Methods
Patients with a diagnosis of septic shock were screened in a medical intensive care unit of a tertiary hospital center in France with a continuous 12-lead EKG for the occurrence of NOSVA. Biological and clinical data (including septic myocardial dysfunction characterized by echocardiography) were collected. We also assessed the hemodynamic tolerance and prognosis of NOSVA.
Results
Among the 71 septic shock episodes assessed during the study, NOSVA occurred in 30 prevalence of 42 %, 95 % confidence interval (CI) 30–53 %. Among all recorded factors, only renal failure (as assessed by renal SOFA score at day 1) was associated with NOSVA and this difference persisted by multivariable analysis (odds ratio of 1.29, 95 % CI 1.03–1.62,
p
= 0.03). There was a significant increase in norepinephrine dosage during the first hour after SVA onset. NOSVA was associated with longer catecholamine use during septic shock as compared with patients in sinus rhythm, whereas ICU mortality was identical between groups.
Conclusions
We found a high prevalence of sustained NOSVA during septic shock. NOSVA was not related to septic myocardial dysfunction, but rather to acute renal failure, raising the hypothesis of an acute renocardiac syndrome.
Acute chest syndrome (ACS) is a major complication of sickle-cell disease. Bacterial infection is one cause of ACS, so current guidelines recommend the routine use of antibiotics. We performed a ...prospective before–after study in medical wards and an intensive-care unit (ICU). During the control phase, clinicians were blinded to procalcitonin concentration results. We built an algorithm using the obtained measurements to hasten antibiotic cessation after three days of treatment if bacterial infection was not documented, and procalcitonin concentrations were all <0.5 μg/L. During the intervention period, the procalcitonin algorithm was suggested to physicians as a guide for antibiotic therapy. The primary endpoint was the number of days alive without antibiotics at Day 21. One-hundred patients were analyzed (103 ACS episodes, 60 in intervention phase). Possible or proven lung infection was diagnosed during 13% of all ACS episodes. The number of days alive without antibiotics at Day 21 was higher during the intervention phase: 15 14–18 vs. 13 13,14 days (p = 0.001). More patients had a short (≤3 days) antibiotic course during intervention phase: 31% vs 9% (p = 0.01). There was neither infection relapse nor pulmonary superinfection in the entire cohort. A procalcitonin-guided strategy to prescribe antibiotics in patients with ACS may reduce antibiotic exposure with no apparent adverse outcomes.
Abstract Study Objective The aim of the study was to compare the effectiveness of drainage via a single-lumen (5F catheter) central venous catheter (CVC) to a conventional (14-20F catheter) chest ...tube (CT) for the management of pneumothoraces, including primary spontaneous pneumothorax (PSP), secondary spontaneous pneumothorax (SSP), and traumatic and iatrogenic pneumothoraces. Patients All consecutive patients admitted to the intermediate intensive care unit of a university hospital for pneumothorax were retrospectively screened over an 8-year period. Patients were preferentially treated using CT from 2003 to 2007 and using CVC from 2008 to 2010. Drainage failure was defined as the need for a second drainage procedure or for surgery. Results Of 212 patients included, 117 (55%) had PSP, 28 (13%) had SSP associated with chronic obstructive pulmonary disease, 19 (9%) had traumatic pneumothorax, and 48 (23%) had iatrogenic pneumothorax. The failure rate was 23% in PSP, 36% in SSP, 16% in traumatic pneumothorax, and only 2% in iatrogenic pneumothorax. After adjustment, iatrogenic pneumothorax was the only factor that had an influence on drainage failure. The failure rate was similar between the 112 patients treated using CVC and the 100 patients treated using CT (18% vs 21%, P = .60). However, the durations of drainage (3.3 ± 1.9 vs 4.6 ± 2.6 days, P < .01) and of hospital stay were significantly shorter in patients treated using CVC as compared with CT. Conclusion Our findings suggest that drainage via a catheter or via a CT is similarly effective in the management of pneumothorax. We recommend considering drainage via a small-bore catheter as a first-line treatment in patients with pneumothorax, whatever its cause.
We report a rare case of emphysematous pyelonephritis complicated by septic shock and multiple gas emboli in the pulmonary artery (with transient cor pulmonale), coronary artery (with transient acute ...coronary syndrome).
A 57-year-old woman hospitalized for a COVID-19 (coronavirus disease-2019)–related refractory acute respiratory distress syndrome developed a few days later anteroseptal ST-segment elevation with ...acute systolic dysfunction. Coronary angiography was performed with the patient in prone (face down) position, owing to the necessity to maintain a reasonable oxygen saturation during the examination. (Level of Difficulty: Intermediate.)
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A 57-year-old woman hospitalized for a COVID-19 (coronavirus disease-2019)–related refractory acute respiratory distress syndrome developed a few…
Haudebourg et al discuss the study on the respiratory mechanics of COVID-19-versus non-COVID-19-associated acute respiratory distress syndrome. Most patients admitted to the ICU with a severe ...presentation of coronavirus disease (COVID-19) fulfill the acute respiratory distress syndrome (ARDS) criteria and require invasive mechanical ventilation. In such patients, knowledge of respiratory mechanics and potential for lung recruitability may provide valuable information to guide adjustments in ventilator settings. Some authors have regularly reported from their clinical experience that the key feature of COVID-19 respiratory mechanics would be an uncommon association of severe hypoxemia and preserved respiratory system compliance, altogether with poor recruitability (3-5). However, a dramatic decrease in respiratory system compliance has also been reported in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related ARDS.
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