Ventilation in the prone position for about 7 h/d in patients with acute respiratory distress syndrome (ARDS), acute lung injury, or acute respiratory failure does not decrease mortality. Whether it ...is beneficial to administer prone ventilation early, and for longer periods of time, is unknown.
We enrolled 136 patients within 48 h of tracheal intubation for severe ARDS, 60 randomized to supine and 76 to prone ventilation. Guidelines were established for ventilator settings and weaning. The prone group was targeted to receive continuous prone ventilation treatment for 20 h/d.
The intensive care unit mortality was 58% (35/60) in the patients ventilated supine and 43% (33/76) in the patients ventilated prone (p = 0.12). The latter had a higher simplified acute physiology score II at inclusion. Multivariate analysis showed that simplified acute physiology score II at inclusion (odds ratio OR, 1.07; p < 0.001), number of days elapsed between ARDS diagnosis and inclusion (OR, 2.83; p < 0.001), and randomization to supine position (OR, 2.53; p = 0.03) were independent risk factors for mortality. A total of 718 turning procedures were done, and prone position was applied for a mean of 17 h/d for a mean of 10 d. A total of 28 complications were reported, and most were rapidly reversible.
Prone ventilation is feasible and safe, and may reduce mortality in patients with severe ARDS when it is initiated early and applied for most of the day.
There is limited information available describing the clinical and epidemiological features of Spanish patients requiring hospitalization for coronavirus disease 2019 (COVID-19). In this ...observational study, we aimed to describe the clinical characteristics and epidemiological features of severe (non-ICU) and critically patients (ICU) with COVID-19 at triage, prior to hospitalization. Forty-eight patients (27 non-ICU and 21 ICU) with positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection were analyzed (mean age, 66 years, range, 33–88 years; 67% males). There were no differences in age or sex among groups. Initial symptoms included fever (100%), coughing (85%), dyspnea (76%), diarrhea (42%) and asthenia (21%). ICU patients had a higher prevalence of dyspnea compared to non-ICU patients (95% vs. 61%, p = 0.022). ICU-patients had lymphopenia as well as hypoalbuminemia. Lactate dehydrogenase (LDH), C-reactive protein (CRP), and procalcitonin were significantly higher in ICU patients compared to non-ICU (p < 0.001). Lower albumin levels were associated with poor prognosis measured as longer hospital length (r = −0.472, p < 0.001) and mortality (r = −0.424, p = 0.003). As of 28 April 2020, 10 patients (8 ICU and 2 non-ICU) have died (21% mortality), and while 100% of the non-ICU patients have been discharged, 33% of the ICU patients still remained hospitalized (5 in ICU and 2 had been transferred to ward). Critically ill patients with COVID-19 present lymphopenia, hypoalbuminemia and high levels of inflammation.
Background
Extubation failure is associated with increased morbidity and mortality, but cannot be safely predicted or avoided. High-flow nasal cannula (HFNC) prevents postextubation respiratory ...failure in low-risk patients.
Objective
To demonstrate that HFNC reduces postextubation respiratory failure in high-risk non-hypercapnic patients compared with conventional oxygen.
Methods
Randomized, controlled multicenter trial in patients who passed a spontaneous breathing trial. We enrolled patients meeting criteria for high-risk of failure to randomly receive HFNC or conventional oxygen for 24 h after extubation. Primary outcome was respiratory failure within 72-h postextubation. Secondary outcomes were reintubation, intensive care unit (ICU) and hospital lengths of stay, and mortality. Statistical analysis included multiple logistic regression models.
Results
The study was stopped due to low recruitment after 155 patients were enrolled (78 received high-flow and 77 received conventional oxygen). Groups were similar at enrollment, and all patients tolerated 24-h HFNC. Postextubation respiratory failure developed in 16 (20%) HFNC patients and in 21 (27%) conventional patients OR 0.69 (0.31–1.54),
p
= 0.2. Reintubation was needed in 9 (11%) HFNC patients and in 12 (16%) conventional patients OR 0.71 (0.25–1.95),
p
= 0.5. No difference was found in ICU or hospital length of stay, or mortality. Logistic regression models suggested HFNC OR 0.43 (0.18–0.99),
p
= 0.04 and cancer OR 2.87 (1.04–7.91),
p
= 0.04 may be independently associated with postextubation respiratory failure.
Conclusion
Our study is inconclusive as to a potential benefit of HFNC over conventional oxygen to prevent occurrence of respiratory failure in non-hypercapnic patients at high risk for extubation failure.
Registered at Clinicaltrials.gov NCT01820507.
Acute respiratory failure due to COVID-19 pneumonia often requires a comprehensive approach that includes non-pharmacological strategies such as non-invasive support (including positive pressure ...modes, high flow therapy or awake proning) in addition to oxygen therapy, with the primary goal of avoiding endotracheal intubation. Clinical issues such as determining the optimal time to initiate non-invasive support, choosing the most appropriate modality (based not only on the acute clinical picture but also on comorbidities), establishing criteria for recognition of treatment failure and strategies to follow in this setting (including palliative care), or implementing de-escalation procedures when improvement occurs are of paramount importance in the ongoing management of severe COVID-19 cases. Organizational issues, such as the most appropriate setting for management and monitoring of the severe COVID-19 patient or protective measures to prevent virus spread to healthcare workers in the presence of aerosol-generating procedures, should also be considered. While many early clinical guidelines during the pandemic were based on previous experience with acute respiratory distress syndrome, the landscape has evolved since then. Today, we have a wealth of high-quality studies that support evidence-based recommendations to address these complex issues. This document, the result of a collaborative effort between four leading scientific societies (SEDAR, SEMES, SEMICYUC, SEPAR), draws on the experience of 25 experts in the field to synthesize knowledge to address pertinent clinical questions and refine the approach to patient care in the face of the challenges posed by severe COVID-19 infection.
Studies of mechanically ventilated critically ill patients that combine populations that are at high and low risk for reintubation suggest that conditioned high-flow nasal cannula oxygen therapy ...after extubation improves oxygenation compared with conventional oxygen therapy. However, conclusive data about reintubation are lacking.
To determine whether high-flow nasal cannula oxygen therapy is superior to conventional oxygen therapy for preventing reintubation in mechanically ventilated patients at low risk for reintubation.
Multicenter randomized clinical trial conducted between September 2012 and October 2014 in 7 intensive care units (ICUs) in Spain. Participants were 527 adult critical patients at low risk for reintubation who fulfilled criteria for planned extubation. Low risk for reintubation was defined as younger than 65 years; Acute Physiology and Chronic Health Evaluation II score less than 12 on day of extubation; body mass index less than 30; adequate secretions management; simple weaning; 0 or 1 comorbidity; and absence of heart failure, moderate-to-severe chronic obstructive pulmonary disease, airway patency problems, and prolonged mechanical ventilation.
Patients were randomized to undergo either high-flow or conventional oxygen therapy for 24 hours after extubation.
The primary outcome was reintubation within 72 hours, compared with the Cochran-Mantel-Haenszel χ2 test. Secondary outcomes included postextubation respiratory failure, respiratory infection, sepsis and multiorgan failure, ICU and hospital length of stay and mortality, adverse events, and time to reintubation.
Of 527 patients (mean age, 51 years range, 18-64; 62% men), 264 received high-flow therapy and 263 conventional oxygen therapy. Reintubation within 72 hours was less common in the high-flow group (13 patients 4.9% vs 32 12.2% in the conventional group; absolute difference, 7.2% 95% CI, 2.5% to 12.2%; P = .004). Postextubation respiratory failure was less common in the high-flow group (22/264 patients 8.3% vs 38/263 14.4% in the conventional group; absolute difference, 6.1% 95% CI, 0.7% to 11.6%; P = .03). Time to reintubation was not significantly different between groups (19 hours interquartile range, 12-28 in the high-flow group vs 15 hours interquartile range, 9-31 in the conventional group; absolute difference, -4 95% CI, -54 to 46; P = .66. No adverse effects were reported.
Among extubated patients at low risk for reintubation, the use of high-flow nasal cannula oxygen compared with conventional oxygen therapy reduced the risk of reintubation within 72 hours.
clinicaltrials.gov Identifier: NCT01191489.
To evaluate incidence, factors associated with unplanned endotracheal extubation (UEE), and prognostic factors for reintubation.
A prospective study over a 32-mo period.
A 16-bed general intensive ...care unit of a tertiary university hospital.
Adult subjects undergoing endotracheal intubation for >48 hrs.
Observation of patients who presented unplanned extubation.
Over the 32-mo period, there were 59 episodes of UEE in 55 patients (frequency 7.3%). Deliberate self-extubation occurred in 46 episodes (77.9%), while there were 13 episodes (22.1%) of accidental extubation. Twenty-seven (45.8%) episodes occurred in patients who were receiving full mechanical ventilatory support and 32 (54.2%) episodes occurred during the weaning period from mechanical ventilation. Reintubation was required in 27 (45.8%) episodes of UEE. The need for reintubation after UEE was 36.9% in deliberate self-extubation patients and 76.9% in accidental extubation patients (p = .01). Only 15.6% (5/32) of patients who presented UEE during weaning required reintubation, while reintubation was mandatory in 81.5% (22/27) of patients who presented UEE during full mechanical ventilatory support (p < .001). A multiple logistic regression analysis was performed to determine the variables independently associated with the need for reintubation: days of mechanical ventilation were significantly associated with the need for reintubation, and weaning was associated with no need for reintubation. The model correctly classified the need for reintubation in 84.7% (50/59) of cases.
Reintubation in UEE patients strongly depends on the type of mechanical ventilatory support. The probability of requiring reintubation if UEE occurs during full ventilatory support is higher than if UEE occurs during weaning. These data suggest that some patients are under mechanical ventilation longer than necessary.
Purpose
This study aimed to determine the best strategy to achieve fast and safe extubation.
Methods
This multicenter trial randomized patients with primary respiratory failure and ...low-to-intermediate risk for extubation failure with planned high-flow nasal cannula (HFNC) preventive therapy. It included four groups: (1) conservative screening with ratio of partial pressure of arterial oxygen (PaO
2
) to fraction of inspired oxygen (FiO
2
) ≥ 150 and positive end-expiratory pressure (PEEP) ≤ 8 cmH
2
O plus conservative spontaneous breathing trial (SBT) with pressure support 5 cmH
2
O + PEEP 0 cmH
2
O); (2) screening with ratio of partial pressure of arterial oxygen (PaO
2
) to fraction of inspired oxygen (FiO
2
) ≥ 150 and PEEP ≤ 8 plus aggressive SBT with pressure support 8 + PEEP 5; (3) aggressive screening with PaO
2
/FiO
2
> 180 and PEEP 10 maintained until the SBT with pressure support 8 + PEEP 5; (4) screening with PaO
2
/FiO
2
> 180 and PEEP 10 maintained until the SBT with pressure support 5 + PEEP 0. Primary outcomes were time-to-extubation and simple weaning rate. Secondary outcomes included reintubation within 7 days after extubation.
Results
Randomization to the aggressive-aggressive group was discontinued at the interim analysis for safety reasons. Thus, 884 patients who underwent at least 1 SBT were analyzed (conservative-conservative group, n = 256; conservative-aggressive group, n = 267; aggressive-conservative group, n = 261; aggressive-aggressive, n = 100). Median time to extubation was lower in the groups with aggressive screening (p < 0.001). Simple weaning rates were 45.7%, 76.78% (205 patients), 71.65%, and 91% (p < 0.001), respectively. Reintubation rates did not differ significantly (p = 0.431).
Conclusion
Among patients at low or intermediate risk for extubation failure with planned HFNC, combining aggressive screening with preventive PEEP and a conservative SBT reduced the time to extubation without increasing the reintubation rate.
During the first wave of the COVID-19 pandemic, shortages of ventilators and ICU beds overwhelmed health care systems. Whether early tracheostomy reduces the duration of mechanical ventilation and ...ICU stay is controversial.
Can failure-free day outcomes focused on ICU resources help to decide the optimal timing of tracheostomy in overburdened health care systems during viral epidemics?
This retrospective cohort study included consecutive patients with COVID-19 pneumonia who had undergone tracheostomy in 15 Spanish ICUs during the surge, when ICU occupancy modified clinician criteria to perform tracheostomy in Patients with COVID-19. We compared ventilator-free days at 28 and 60 days and ICU- and hospital bed-free days at 28 and 60 days in propensity score-matched cohorts who underwent tracheostomy at different timings (≤ 7 days, 8-10 days, and 11-14 days after intubation).
Of 1,939 patients admitted with COVID-19 pneumonia, 682 (35.2%) underwent tracheostomy, 382 (56%) within 14 days. Earlier tracheostomy was associated with more ventilator-free days at 28 days (≤ 7 days vs > 7 days 116 patients included in the analysis: median, 9 days interquartile range (IQR), 0-15 days vs 3 days IQR, 0-7 days; difference between groups, 4.5 days; 95% CI, 2.3-6.7 days; 8-10 days vs > 10 days 222 patients analyzed: 6 days IQR, 0-10 days vs 0 days IQR, 0-6 days; difference, 3.1 days; 95% CI, 1.7-4.5 days; 11-14 days vs > 14 days 318 patients analyzed: 4 days IQR, 0-9 days vs 0 days IQR, 0-2 days; difference, 3 days; 95% CI, 2.1-3.9 days). Except hospital bed-free days at 28 days, all other end points were better with early tracheostomy.
Optimal timing of tracheostomy may improve patient outcomes and may alleviate ICU capacity strain during the COVID-19 pandemic without increasing mortality. Tracheostomy within the first work on a ventilator in particular may improve ICU availability.
Abstract Introduction The use of noninvasive ventilation (NIV) in non-COPD patients with pneumonia is controversial due to its high rate of failure and the potentially harmful effects when NIV fails. ...The purpose of the study was to evaluate outcomes of the first ventilatory treatment applied, NIV or invasive mechanical ventilation (MV), and to identify predictors of NIV failure. Methods Historical cohort study of 159 non-COPD patients with pneumonia admitted to the ICU with ventilatory support. Subjects were divided into 2 groups: invasive MV or NIV. Univariate and multivariate analyses with demographic and clinical data were performed. Analysis of mortality was adjusted for the propensity of receiving first-line invasive MV. Results One hundred and thirteen subjects received first-line invasive MV and 46 received first-line NIV, of which 27 needed intubation. Hospital mortality was 35%, 37% and 56%, respectively, with no significant differences among groups. In the propensity-adjusted analysis (expressed as OR 95% CI), hospital mortality was associated with age (1.05 1.02–1.08), SAPS3 (1.03 1.00–1.07), immunosuppression (2.52 1.02–6.27) and NIV failure compared to first-line invasive MV (4.3 1.33–13.94). Compared with invasive MV, NIV failure delayed intubation ( P =.004), and prolonged the length of invasive MV ( P =.007) and ICU stay ( P =.001). NIV failure was associated with need for vasoactive drugs (OR 7.8 95% CI, 1.8–33.2, P =.006). Conclusions In non-COPD subjects with pneumonia, first-line NIV was not associated with better outcome compared with first-line invasive MV. NIV failure was associated with longer duration of MV and hospital stay, and with increased hospital mortality. The use of vasoactive drugs predicted NIV failure.
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