Search

Objective: To evaluate how ventilatory support, the duration of invasive ventilatory support use and lung mechanics are related to barotrauma development in patients who are severely infected with COVID-19 and who are admitted to the intensive care unit and develop pulmonary barotrauma., Methods: Retrospective cohort study of patients who were severely infected with COVID-19 and who developed pulmonary barotrauma secondary to mechanical ventilation., Results: This study included 60 patients with lung barotrauma who were divided into two groups: 37 with early barotrauma and 23 with late barotrauma. The early barotrauma group included more individuals who needed noninvasive ventilation (62.2% versus 26.1%, p = 0.01). The tidal volume/kg of predicted body weight on the day of barotrauma was measured, and 24 hours later, it was significantly greater in the late barotrauma group than in the early barotrauma group. During the day, barotrauma was accompanied by plateau pressure and driving pressure accompanied by tidal volume, which significantly increased in the late barotrauma group. According to the SAPS 3, patients in the early barotrauma group had more pulmonary thromboembolism and more severe illness. However, the intensive care unit mortality rates did not significantly differ between the two groups (66.7% for early barotrauma versus 76.9% for late barotrauma)., Conclusion: We investigated the effect of respiratory mechanics on barotrauma in patients with severe COVID-19 and found that 25% of patients were on nonprotective ventilation parameters when they developed barotrauma. However, 50% of patients were on protective ventilation parameters, suggesting that other nonventilatory factors may contribute to barotrauma.

Rationale: Hypoxemia during mechanical ventilation might be worsened by expiratory muscle activity, which reduces end-expiratory lung volume through lung collapse. A proposed mechanism of benefit of neuromuscular blockade in acute respiratory distress syndrome (ARDS) is the abolition of expiratory efforts. This may contribute to the restoration of lung volumes. The prevalence of this phenomenon, however, is unknown. Objectives: To investigate the incidence and amount of end-expiratory lung impedance (EELI) increase after the administration of neuromuscular blocking agents (NMBAs), clinical factors associated with this phenomenon, its impact on regional lung ventilation, and any association with changes in pleural pressure. Methods: We included mechanically ventilated patients with ARDS monitored with electrical impedance tomography (EIT) who received NMBAs in one of two centers. We measured changes in EELI, a surrogate for end-expiratory lung volume, before and after NMBA administration. In an additional 10 patients, we investigated the characteristic signatures of expiratory muscle activity depicted by EIT and esophageal catheters simultaneously. Clinical factors associated with EELI changes were assessed. Measurements and Main Results: We included 46 patients, half of whom showed an increase in EELI of >10% of the corresponding Vt (46.2%; IQR, 23.9-60.9%). The degree of EELI increase correlated positively with fentanyl dosage and negatively with changes in end-expiratory pleural pressures. This suggests that expiratory muscle activity might exert strong counter-effects against positive end-expiratory pressure that are possibly aggravated by fentanyl. Conclusions: Administration of NMBAs during EIT monitoring revealed activity of expiratory muscles in half of patients with ARDS. The resultant increase in EELI had a dose-response relationship with fentanyl dosage. This suggests a potential side effect of fentanyl during protective ventilation.

Competing Interests: The authors declare no conflict of interest regarding this work.

Acute respiratory distress syndrome (ARDS) is characterized by severe inflammatory response and hypoxemia. The use of mechanical ventilation (MV) for correction of gas exchange can cause worsening of this inflammatory response, called "ventilator-induced lung injury" (VILI). The process of withdrawing mechanical ventilation, referred to as weaning from MV, may cause worsening of lung injury by spontaneous ventilation. Currently, there are few specific studies in patients with ARDS. Herein, we reviewed the main aspects of spontaneous ventilation and also discussed potential methods to predict the failure of weaning in this patient category. We also reviewed new treatments (modes of mechanical ventilation, neuromuscular blocker use, and extracorporeal membrane oxygenation) that could be considered in weaning ARDS patients from MV.

Objective: To describe the pre-hospital, emergency department, and intensive care unit (ICU) care and prognosis of patients with inhalation injury after exposure to indoor fire and smoke., Materials and Methods: This is a prospective observational cohort study that includes patients admitted to seven ICUs after a fire disaster. The following data were collected: demographic characteristics; use of fiberoptic bronchoscopy; degree of inhalation injury; percentage of burned body surface area; mechanical ventilation parameters; and subsequent events during ICU stay. Patients were followed to determine the ICU and hospital mortality rates., Results: Within 24h of the incident, 68 patients were admitted to seven ICUs. The patients were young and had no comorbidities. Most patients (n=35; 51.5%) only had an inhalation injury. The mean ventilator-free days for patients with an inhalation injury degree of 0 or I was 12.5±8.1 days. For patients with an inhalation injury degree of II or III, the mean ventilator-free days was 9.4±5.8 days (p=0.12). In terms of the length of ICU stay for patients with degrees 0 or I, and patients with degrees II or III, the median was 7.0 days (5.0-8.0 days) and 12.0 days (8.0-23.0 days) (p<0.001), respectively. In addition, patients with a larger percentage of burned surface areas also had a longer ICU stay; however, no association with ventilator-free days was found. The patients with <10% of burned body surface area showed a mean of 9.2±5.4 ventilator-free days. The mean ventilator-free days for patients who had >10% burned body surface area was 11.9±9.5 (p=0.26). The length of ICU stay for the <10% and >10% burned body surface area patients was 7.0 days (5.0-10.0 days) and 23.0 days (11.5-25.5 days) (p<0.001), respectively., Conclusions: We conclude that burn patients with inhalation injuries have different courses of disease, which are mainly determined by the percentage of burned body surface area., (Copyright © 2016 Elsevier Ltd and ISBI. All rights reserved.)

Objectives: To determine the characteristics, the frequency and the mortality rates of patients needing mechanical ventilation and to identify the risk factors associated with mortality in the intensive care unit (ICU) of a general university hospital in southern Brazil., Method: Prospective cohort study in patients admitted to the ICU who needed mechanical ventilation for at least 24 hours between March 2004 and April 2007., Results: A total of 1,115 patients admitted to the ICU needed mechanical ventilation. The mortality rate was 51%. The mean age (± standard deviation) was 57±18 years, and the mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 22.6±8.3. The variables independently associated with mortality were (i) conditions present at the beginning of mechanical ventilation, age (hazard ratio: 1.01; p<0.001); the APACHE II score (hazard ratio: 1.01; p<0.005); acute lung injury/acute respiratory distress syndrome (hazard ratio: 1.38; p=0.009), sepsis (hazard ratio: 1.33; p=0.003), chronic obstructive pulmonary disease (hazard ratio: 0.58; p=0.042), and pneumonia (hazard ratio: 0.78; p=0.013) as causes of mechanical ventilation; and renal (hazard ratio: 1.29; p=0.011) and neurological (hazard ratio: 1.25; p=0.024) failure, and (ii) conditions occurring during the course of mechanical ventilation, acute lung injuri/acute respiratory distress syndrome (hazard ratio: 1.31; p<0.010); sepsis (hazard ratio: 1.53; p<0.001); and renal (hazard ratio: 1.75; p<0.001), cardiovascular (hazard ratio: 1.32; p≤0.009), and hepatic (hazard ratio: 1.67; p≤0.001) failure., Conclusions: This large cohort study provides a comprehensive profile of mechanical ventilation patients in South America. The mortality rate of patients who required mechanical ventilation was higher, which may have been related to the severity of illness of the patients admitted to our ICU. Risk factors for hospital mortality included conditions present at the start of mechanical ventilation conditions that occurred during mechanical support.

Objective: Studies suggest an association between vitamin D deficiency and morbidity/mortality in critically ill patients. Several issues remain unexplained, including which vitamin D levels are related to morbidity and mortality and the relevance of vitamin D kinetics to clinical outcomes. We conducted this study to address the association of baseline vitamin D levels and vitamin D kinetics with morbidity and mortality in critically ill patients., Method: In 135 intensive care unit (ICU) patients, vitamin D was prospectively measured on admission and weekly until discharge from the ICU. The following outcomes of interest were analyzed: 28-day mortality, mechanical ventilation, length of stay, infection rate, and culture positivity., Results: Mortality rates were higher among patients with vitamin D levels <12 ng/mL (versus vitamin D levels >12 ng/mL) (32.2% vs. 13.2%), with an adjusted relative risk of 2.2 (95% CI 1.07-4.54; p< 0.05). There were no differences in the length of stay, ventilation requirements, infection rate, or culture positivity., Conclusions: This study suggests that low vitamin D levels on ICU admission are an independent risk factor for mortality in critically ill patients. Low vitamin D levels at ICU admission may have a causal relationship with mortality and may serve as an indicator for vitamin D replacement among critically ill patients.

Context: Sepsis is a disease with high incidence and mortality. Among the interventions of the resuscitation bundle, the early goal-directed therapy (EGDT) is recommended., Aims: The aim was to evaluate outcomes in patients with severe sepsis and septic shock using EGDT in real life compared with patients who did not undergo it in the Intensive Care Unit (ICU) setting., Settings and Design: retrospective and observational cohort study at tertiary hospital., Subjects and Methods: All the patients admitted to ICU were screened for severe sepsis or septic shock and included in a registry and followed. The patients were allocated in two groups according to submission or not to EGDT., Results: A total of 268 adult patients with severe sepsis or septic shock were included. EGDT was employed in 97/268 patients. The general mortality was higher in no early goal-directed therapy (no-EGDT) then in EGDT groups (49.7% vs. 37.1% [P = 0.04] in hospital and 40.4% vs. 29.9% [P = 0.08] in the ICU, respectively. The general length of stay [LOS] in the no-EGDT and EGDT groups was 45.0 ± 59.8 vs. 29.1 ± 30.1 days [P = 0.002] in hospital and 17.4 ± 19.4 vs. 9.1 ± 9.8 days [P < 0.001] in the ICU, respectively)., Conclusions: Our study shows reduced mortality and LOS in patients submitted to EGDT in the ICU setting. A simplified EGDT without central venous oxygen saturation is an important tool for sepsis management.

Objective: To assess the incidence, costs, and mortality associated with chronic critical illness (CCI), and to identify clinical predictors of CCI in a general intensive care unit., Methods: This was a prospective observational cohort study. All patients receiving supportive treatment for over 20 days were considered chronically critically ill and eligible for the study. After applying the exclusion criteria, 453 patients were analyzed., Results: There was an 11% incidence of CCI. Total length of hospital stay, costs, and mortality were significantly higher among patients with CCI. Mechanical ventilation, sepsis, Glasgow score <15, inadequate calorie intake, and higher body mass index were independent predictors for CCI in the multivariate logistic regression model., Conclusions: CCI affects a distinctive population in intensive care units with higher mortality, costs, and prolonged hospitalization. Factors identifiable at the time of admission or during the first week in the intensive care unit can be used to predict CCI., (Copyright © 2013 Elsevier Editora Ltda. All rights reserved.)