Background
Intensive care unit (ICU) patients are exposed to many sources of discomfort. Although increasing attention is being given to the detection and treatment of pain, very little is given to ...the detection and treatment of dyspnea (defined as “breathing discomfort”).
Methods
Published information on the prevalence, mechanisms, and potential negative impacts of dyspnea in mechanically ventilated patients are reviewed. The most appropriate tools to detect and quantify dyspnea in ICU patients are also assessed.
Results/Conclusions
Growing evidence suggests that dyspnea is a frequent issue in mechanically ventilated ICU patients, is highly associated with anxiety and pain, and is improved in many patients by altering the ventilator settings.
Conclusions
Future studies are needed to better delineate the impact of dyspnea in the ICU and to define diagnostic, monitoring and therapeutic protocols.
Long-term outcomes of patients treated with venoarterial-extracorporeal membrane oxygenation for acute decompensated heart failure (i.e., cardiogenic shock complicating chronic cardiomyopathy) have ...not yet been reported. This study was undertaken to describe their outcomes and determine mortality-associated factors.
Retrospective analysis of data prospectively collected.
Twenty-six-bed tertiary hospital ICU.
One hundred five patients implanted with venoarterial-extracorporeal membrane oxygenation for acute decompensated heart failure.
None.
From March 2007 to January 2015, 105 patients were implanted with venoarterial-extracorporeal membrane oxygenation for acute decompensated heart failure in our ICU (67% of them had an intraaortic balloon pump to unload the left ventricle). Their 1-year survival rate was 42%; most of the survivors were transplanted either directly or after switching to central bilateral centrifugal pump, ventricular-assist device, or total artificial heart. Most deaths occurred early after multiple organ failure. Multivariable analyses retained (odds ratio 95% CI) pre-extracorporeal membrane oxygenation Sequential Organ Failure Assessment score of more than 11 (3.3 1.3-8.3), idiopathic cardiomyopathy (0.4 0.2-1), cardiac disease duration greater than 2 years pre-extracorporeal membrane oxygenation (2.8 1.2-6.9), and pre-extracorporeal membrane oxygenation blood lactate greater than 4 mmol/L (2.6 1.03-6.4) as independent predictors of 1-year mortality. Only 17% of patients with pre-extracorporeal membrane oxygenation Sequential Organ Failure Assessment scores of 14 or more survived, whereas 52% of those with scores less than 7 and 60% of those with scores 7 or more and less than 11 were alive 1 year later.
Among this selected cohort of 105 patients implanted with venoarterial-extracorporeal membrane oxygenation for acute decompensated heart failure, 1-year survival was 42%, but better for patients with pre-extracorporeal membrane oxygenation Sequential Organ Failure Assessment scores of less than 11. Venoarterial-extracorporeal membrane oxygenation should be considered for patients with acute decompensated heart failure, but timing of implantation is crucial.
In this retrospective and bicentric study conducted on a 10 year period, we investigate the in-hospital mortality in patients with ASA requiring IMV. We compare this mortality to that of patients ...with other types of respiratory distress using a standardized mortality ratio (SMR) model. Eighty-one episodes of ASA requiring IMV were evaluated. Factors significantly associated with in-hospital mortality were cardiac arrest on day of admission, cardiac arrest as the reason for intubation, absence of decompensation risk factors, need for renal replacement therapy on day of admission, and intubation in pre-hospital setting. Non-survivors had higher SAPS II, SOFA, creatinine and lactate levels as well as lower blood pressure, pH, and HCO.sub.3 on day of admission. In-hospital mortality was 15% (n = 12). Compared to a reference population of 2,670 patients, the SMR relative to the SAPS II was very low at 0.48 (95% CI, 0.25-0.84). The only factor independently associated with in-hospital mortality was cardiac arrest on day of admission. In-hospital mortality was 69% in patients with cardiac arrest on day of admission and 4% in others (p < 0.01). Salvage therapies were given to 7 patients, sometimes in combination with each other: ECMO (n = 6), halogenated gas (n = 1) and anti-IL5 antibody (n = 1). Death occurred in only 2 of these 7 patients, both of whom had cardiac arrest on day of admission. Nowadays, the mortality of patients with ASA requiring IMV is low. Death is due to multi-organ failure, with cardiac arrest on day of admission being the most important risk factor. In patients who did not have cardiac arrest on day of admission the mortality is even lower (4%) which allows an aggressive management.
Background
Diaphragm dysfunction is defined by a value of twitch tracheal pressure in response to magnetic phrenic stimulation (twitch pressure) amounting to less than 11 cmH
2
O. This study assessed ...whether this threshold or a lower one would predict accurately weaning failure from mechanical ventilation. Twitch pressure was compared to ultrasound measurement of diaphragm function.
Methods
In patients undergoing a first spontaneous breathing trial, diaphragm function was evaluated by twitch pressure and by diaphragm ultrasound (thickening fraction). Receiver operating characteristics curves were computed to determine the best thresholds predicting failure of spontaneous breathing trial.
Results
Seventy-six patients were evaluated, 48 (63%) succeeded and 28 (37%) failed the spontaneous breathing trial. The optimal thresholds of twitch pressure and thickening fraction to predict failure of the spontaneous breathing trial were, respectively, 7.2 cmH
2
O and 25.8%, respectively. The receiver operating characteristics curves were 0.80 (95% CI 0.70–0.89) for twitch pressure and 0.82 (95% CI 0.73–0.93) for thickening fraction. Both receiver operating characteristics curves were similar (
p
= 0.83). A twitch pressure value lower than 11 cmH
2
O (the traditional cutoff for diaphragm dysfunction) predicted failure of the spontaneous breathing trial with a sensitivity of 89% (95% CI 72–98%) and a specificity of 45% (95% CI 30–60%).
Conclusions
Failure of spontaneous breathing trial can be predicted with a lower value of twitch pressure than the value defining diaphragm dysfunction. Twitch pressure and thickening fraction had similar strong performance in the prediction of failure of the spontaneous breathing trial.
Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) is an efficient ventilatory support in patients with refractory Covid-19-related Acute Respiratory Distress Syndrome (ARDS), however the ...duration of invasive mechanical ventilation (IMV) before ECMO initiation as a contraindication is still controversial. The aim of this study was to investigate the impact of prolonged IMV prior to VV-ECMO in patients suffering from refractory Covid-19-related ARDS.
This single-center retrospective study included all patients treated with VV-ECMO for refractory Covid-19-related ARDS between January 1, 2020 and May 31, 2022. The impact of IMV duration was investigated by comparing patients on VV-ECMO during the 7 days (and 10 days) following IMV with those assisted after 7 days (and 10 days). The primary endpoint was in-hospital mortality.
Sixty-four patients were hospitalized in the ICU for Covid-19-related refractory ARDS requiring VV-ECMO. Global in-hospital mortality was 55 %. Median duration of IMV was 4 2; 8 days before VV-ECMO initiation. There was no significant difference in in-hospital mortality between patients assisted with IMV pre-VV-ECMO for a duration of ≤7 days (≤10 days) and those assisted after 7 days (and 10 days) ((p = 0.59 and p = 0.45).
This study suggests that patients assisted with VV-ECMO after prolonged IMV had the same prognosis than those assisted earlier in refractory Covid-19-related ARDS. Therefore, prolonged mechanical ventilation of more than 7–10 days should not contraindicate VV-ECMO support. An individual approach is necessary to balance the risks and benefits of ECMO in this population.
•VV-ECMO is an efficient ventilatory support in patient with refractory ARDS.•Duration of invasive mechanical ventilation (IMV) before ECMO as contraindication is controversial in Covid-19-related ARDS.•Patients assisted after 7 or 10 days of (IMV) had the same prognosis as those assisted earlier.
BACKGROUND Patients with systemic rheumatic diseases (SRDs) may require ICU management for SRD exacerbation or treatment-related infections or toxicities. METHODS This was an observational study at ...10 university-affiliated ICUs in France. Consecutive patients with SRDs were included. Determinants of ICU mortality were identified through multivariable logistic analysis. RESULTS Three hundred sixty-three patients (65.3% women; median age, 59 years interquartile range, 42-70 years) accounted for 381 admissions. Connective tissue disease (primarily systemic lupus erythematosus) accounted for 66.1% of SRDs and systemic vasculitides for 26.2% (chiefly antineutrophil cytoplasm antibodies-associated vasculitides). SRDs were newly diagnosed in 43 cases (11.3%). Direct admission to the ICU occurred in 143 cases (37.9%). Reasons for ICU admissions were infection (39.9%), SRD exacerbation (34.4%), toxicity (5.8%), or miscellaneous (19.9%). Respiratory involvement was the leading cause of admission (56.8%), followed by shock (41.5%) and acute kidney injury (42.2%). Median Sequential Organ Failure Assessment (SOFA) score on day 1 was 5 (3-8). Mechanical ventilation was required in 57% of cases, vasopressors in 33.9%, and renal replacement therapy in 28.1%. ICU mortality rate was 21.0% (80 deaths). Factors associated with ICU mortality were shock (OR, 3.77; 95% CI, 1.93-7.36), SOFA score at day 1 (OR, 1.19; 95% CI, 1.10-1.30), and direct admission (OR, 0.52; 95% CI, 0.28-0.97). Neither comorbidities nor SRD characteristics were associated with survival. CONCLUSIONS In patients with SRDs, critical care management is mostly needed only in patients with a previously known SRD; however, diagnosis can be made in the ICU for 12% of patients. Infection and SRD exacerbation account for more than two-thirds of these situations, both targeting chiefly the lungs. Direct admission to the ICU may improve outcomes.
Intensive care unit (ICU)-acquired weakness often develops in patients who are undergoing invasive mechanical ventilation. Early active mobilization may mitigate ICU-acquired weakness, increase ...survival, and reduce disability.
We randomly assigned 750 adult patients in the ICU who were undergoing invasive mechanical ventilation to receive increased early mobilization (sedation minimization and daily physiotherapy) or usual care (the level of mobilization that was normally provided in each ICU). The primary outcome was the number of days that the patients were alive and out of the hospital at 180 days after randomization.
The median number of days that patients were alive and out of the hospital was 143 (interquartile range, 21 to 161) in the early-mobilization group and 145 days (interquartile range, 51 to 164) in the usual-care group (absolute difference, -2.0 days; 95% confidence interval CI, -10 to 6; P = 0.62). The mean (±SD) daily duration of active mobilization was 20.8±14.6 minutes and 8.8±9.0 minutes in the two groups, respectively (difference, 12.0 minutes per day; 95% CI, 10.4 to 13.6). A total of 77% of the patients in both groups were able to stand by a median interval of 3 days and 5 days, respectively (difference, -2 days; 95% CI, -3.4 to -0.6). By day 180, death had occurred in 22.5% of the patients in the early-mobilization group and in 19.5% of those in the usual-care group (odds ratio, 1.15; 95% CI, 0.81 to 1.65). Among survivors, quality of life, activities of daily living, disability, cognitive function, and psychological function were similar in the two groups. Serious adverse events were reported in 7 patients in the early-mobilization group and in 1 patient in the usual-care group. Adverse events that were potentially due to mobilization (arrhythmias, altered blood pressure, and desaturation) were reported in 34 of 371 patients (9.2%) in the early-mobilization group and in 15 of 370 patients (4.1%) in the usual-care group (P = 0.005).
Among adults undergoing mechanical ventilation in the ICU, an increase in early active mobilization did not result in a significantly greater number of days that patients were alive and out of the hospital than did the usual level of mobilization in the ICU. The intervention was associated with increased adverse events. (Funded by the National Health and Medical Research Council of Australia and the Health Research Council of New Zealand; TEAM ClinicalTrials.gov number, NCT03133377.).
High-flow nasal oxygen may prevent postextubation respiratory failure in the intensive care unit (ICU). The combination of high-flow nasal oxygen with noninvasive ventilation (NIV) may be an optimal ...strategy of ventilation to avoid reintubation.
To determine whether high-flow nasal oxygen with prophylactic NIV applied immediately after extubation could reduce the rate of reintubation, compared with high-flow nasal oxygen alone, in patients at high risk of extubation failure in the ICU.
Multicenter randomized clinical trial conducted from April 2017 to January 2018 among 641 patients at high risk of extubation failure (ie, older than 65 years or with an underlying cardiac or respiratory disease) at 30 ICUs in France; follow-up was until April 2018.
Patients were randomly assigned to high-flow nasal oxygen alone (n = 306) or high-flow nasal oxygen alternating with NIV (n = 342) immediately after extubation.
The primary outcome was the proportion of patients reintubated at day 7; secondary outcomes included postextubation respiratory failure at day 7, reintubation rates up until ICU discharge, and ICU mortality.
Among 648 patients who were randomized (mean SD age, 70 10 years; 219 women 34%), 641 patients completed the trial. The reintubation rate at day 7 was 11.8% (95% CI, 8.4%-15.2%) (40/339) with high-flow nasal oxygen and NIV and 18.2% (95% CI, 13.9%-22.6%) (55/302) with high-flow nasal oxygen alone (difference, -6.4% 95% CI, -12.0% to -0.9%; P = .02). Among the 11 prespecified secondary outcomes, 6 showed no significant difference. The proportion of patients with postextubation respiratory failure at day 7 (21% vs 29%; difference, -8.7% 95% CI, -15.2% to -1.8%; P = .01) and reintubation rates up until ICU discharge (12% vs 20%, difference -7.4% 95% CI, -13.2% to -1.8%; P = .009) were significantly lower with high-flow nasal oxygen and NIV than with high-flow nasal oxygen alone. ICU mortality rates were not significantly different: 6% with high-flow nasal oxygen and NIV and 9% with high-flow nasal oxygen alone (difference, -2.4% 95% CI, -6.7% to 1.7%; P = .25).
In mechanically ventilated patients at high risk of extubation failure, the use of high-flow nasal oxygen with NIV immediately after extubation significantly decreased the risk of reintubation compared with high-flow nasal oxygen alone.
ClinicalTrials.gov Identifier: NCT03121482.
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