Search Results (28)

Acute respiratory distress syndrome (ARDS) is a heterogeneous group of disease entities that are associated with acute hypoxic respiratory failure and significant morbidity and mortality. With a better understanding and phenotyping of lung injury, novel pathophysiologic mechanisms demonstrate the impact of a patient’s excessive spontaneous breathing effort on perpetuating lung injury. Patient self-inflicted lung injury (P-SILI) is a recently identified phenomenon that delves into the impact of spontaneous breathing on respiratory mechanics in patients with lung injury. While the studies are hypothesis-generating and have been demonstrated in animal and human studies, further clinical trials are needed to identify its impact on ARDS management. The purpose of this review article is to highlight the physiologic mechanisms of P-SILI, novel tools and methods to detect P-SILI, and to review the current literature on non-invasive and invasive respiratory management in patients with ARDS. Full article

Background and Objectives: Unassisted breathing through a T-piece was the most used spontaneous breathing trial (SBT) in endotracheal intubated prolonged mechanical ventilation (PMV) patients. However, the optimal duration of an SBT in PMV patients remains uncertain. In this study, we compared the extubation outcome between a 12 h T-piece SBT and a 24 h T-piece SBT in PMV patients. Materials and Methods: We reviewed the medical records of PMV patients who were extubated after passing a 12 h or 24 h T-piece SBT. The extubation, weaning, and hospital outcomes between the 12 h T-piece SBT group and the 24 h T-piece SBT group were compared. Kaplan–Meier survival plots and Cox proportional hazard models were used to evaluate the risk of extubation failure between groups. Results: In this study, 120 patients were extubated after passing the 12 h T-piece SBT and 234 patients were extubated after passing 24 h T-piece SBT. Patients in the 24 h T-piece SBT group had higher APACHE II score and lower Glasgow coma scale upon RCC arrival than patients in the 12 h T-piece SBT group. There was no difference in gender, age, or ventilator days before extubation between these two groups of patients. After extubation, patients in the 12 h T-piece SBT group and 24 h T-piece SBT group had similar extubation failure rates within 5 days (26.7% vs. 26.1%, p = 0.904). There was no difference in the RCC weaning rate (85% vs. 85.5%, p = 0.929) and hospital mortality rate (19.8% vs. 21.8%, p = 0.821) between the 12 h T-piece SBT group and the 24 h T-piece SBT group. Subgroup analysis showed that 24 h T-piece SBT was associated with a lower extubation failure rate in PMV patients with myocardial infarction or heart failure, but not in older PMV patients or those with cerebrovascular disease. Conclusions: The extubation and weaning outcomes were similar in PMV patients extubated after passing 12 h T-piece SBT or 24 h T-piece SBT. Full article

Objectives and Methods: We developed a 10-item VAP care bundle to address the high incidence of VAP in Vietnamese intensive care units (ICUs), comprising (i) hand hygiene, (ii) head elevation (gatch up 30–45°), (iii) oral care, (iv) oversedation avoidance, (v) breathing circuit management, (vi) cuff pressure control, (vii) subglottic suctioning of secretions, (viii) daily assessment for weaning and a spontaneous breath trial (SBT), (ix) early ambulation and rehabilitation, and (x) prophylaxis of peptic ulcers and deep-vein thrombosis (DVT). The VAP incidence (27.0 per 1000 mechanical ventilation days) slightly and not significantly decreased in the six months after the implementation of the care bundle. Methods and Results: However, the VAP incidence (11.3 per 1000 mechanical ventilation days) significantly decreased when we updated the two-item protocol with interactive communication and education (p < 0.001). Conclusions: Although the effectiveness of the interventions via protocol updates with interactive education needs further study, this intervention can make a VAP care bundle work in a resource-constrained and multidrug-resistant environment. Full article

Background: The role of Heart Rate Variability (HRV) indices in predicting the outcome of the weaning process remains a subject of debate. The aim of this study is to investigate HRV analysis in critically ill adult patients undergoing weaning from invasive mechanical ventilation (IMV). Methods: The protocol of this systematic review was registered with PROSPERO (CRD42024485800). We searched PubMed and Scopus databases from inception till March 2023 to identify randomized controlled trials and observational studies investigating HRV analysis in critically ill adult patients undergoing weaning from invasive mechanical ventilation. Our primary outcome was to investigate HRV changes occurring during the weaning from IMV. Results: Seven studies (n = 342 patients) were included in this review. All studies reported significant changes in at least one HRV parameter. The indices Low Frequency (LF), High Frequency (HF), and LF/HF ratio seem to be the most promising in predicting the outcome of weaning with reliability. Some HRV indices showed modification in response to different ventilator settings or modalities. Conclusions: Available data report HRV modifications during the process of weaning and suggest a promising role of some HRV indices in predicting weaning outcomes in critically ill patients. Point-of-care HRV monitoring systems might help to early detect patients at risk of weaning failure. Full article

Background/Objectives: In vitro fertilization (IVF) is an assisted reproductive technique for women and couples experiencing difficulties in achieving a spontaneous pregnancy, often due to stressors that negatively affect fertility. Humor can be beneficial in these stressful situations, helping to reduce symptoms of anxiety and depression. The primary aim was to analyze the effectiveness of laughter therapy in increasing pregnancy rates in women undergoing IVF. The secondary aims were to identify different types of laughter therapy interventions and evaluate their benefits. Methods: A systematic review was conducted using Medline, Web of Science, Scopus, Cinahl, ProQuest and Lilacs, with the search terms “laughter”, “laughter therapy”, “fertilization in vitro” and “fertilization”. Intervention studies published in English, Spanish, or Portuguese were included, with no limits on the date of publication. Studies with other designs, those conducted with animals and grey literature were excluded. The quality of the included studies was assessed using the Joanna Briggs Institute critical appraisal tools. Results: In total, n = 3 studies (1 randomized clinical trial and 2 quasi-experimental) were included, evaluating pregnancy rates and symptoms of depression and anxiety. The interventions included clowns performing magic tricks and interpreting comic situations. Additionally, they incorporated hand clapping, breathing exercises, childlike playfulness, drinking milk, muscle relaxation exercises, candles, and music. Conclusions: This review does not provide clear evidence on the effectiveness of laughter therapy in increasing pregnancy success in IVF. Although it may have some positive effects in reducing symptoms of depression and anxiety, it is important to note that while the reduction of these symptoms may enhance the emotional well-being of patients, it has not been demonstrated to directly lead to an increase in pregnancy rates. Laughter therapy is an innovative, non-pharmacological intervention that is simple, non-invasive, easy to implement and cost-effective; however, the number of available studies is insufficient. More research is needed to provide better and higher-quality evidence using rigorous designs to evaluate this intervention in IVF clinical practice. Full article

Background: This study analyzed weaning characteristics and assessed the association of clinical and ultrasonographic indices—maximum inspiratory pressure (MIP), rapid shallow breathing index (RSBI), peak flow expiratory (PFE), diaphragm-thickening fraction (DTF), diaphragm thickness (DT), diaphragm excursion (DE), diaphragm-RSBI (D-RSBI), and lung ultrasound (LUS) patterns—with weaning failure. Methods: This retrospective cohort study included critically ill COVID-19 patients aged 18 and older who had been on invasive mechanical ventilation for at least 48 h and undergoing weaning. Exclusion criteria included absence of ultrasound assessments, neuromuscular diseases, and chronic cardio-respiratory dysfunction. Results: Among 61 patients, 44.3% experienced weaning failure, 27.9% failed the spontaneous breathing trial (SBT), 16.4% were re-intubated within 48 h, and 28% required tracheostomy. Weaning failure was associated with prolonged ventilation (29 vs. 7 days, p < 0.001), extended oxygen therapy, longer ICU stays, and higher ICU mortality. These patients had higher pressure support, lower oxygenation levels, a higher RSBI, and a lower MIP. While PEF, DTF, DE, and D-RSBI showed no significant differences, both right and left diaphragm thicknesses and the inspiratory thickness of the left diaphragm were reduced in failure cases. LUS scores were significantly higher before and after SBT in the failure group. Bivariate analysis identified RSBI [OR = 1.04 (95% CI = 1.01–1.07), p = 0.010], MIP [OR = 0.92 (95% CI = 0.86–0.99), p = 0.018], and LUS [OR = 1.15 (95% CI = 0.98–1.35), p = 0.025] as predictors of weaning failure; however, these associations were not confirmed in multivariate analysis. Conclusions: Ultrasound provides supplementary information during weaning, but no definitive association between ultrasound indices and weaning failure was confirmed in this study. Full article

Background: The aim of this study is to investigate and compare the effects of administering a surfactant through a fine intra-tracheal catheter during spontaneous breathing with the usual INSURE method in premature infants. Materials and Methods: In this clinical trial, premature babies with respiratory distress syndrome who required surfactant administration were randomly assigned to two groups: an intervention group (MIST) and a control group (INSURE). The treatment results were compared in terms of complications related to treatment (desaturation, apnea, bradycardia, and surfactant reflux), respiratory complications (requirement for mechanical ventilation, duration of nCPAP, duration of oxygen requirement, frequency of pneumothorax, and pulmonary hemorrhage), complications related to prematurity (incidence of IVH, NEC, BPD, and PDA), the need for a second dose of surfactant, and the duration of hospitalization. Results: a total of 160 premature babies with a gestational age of 26–34 weeks were randomly divided into two groups. The results showed that the need for mechanical ventilation, the duration of CPAP needed, and the duration of oxygen therapy were significantly lower in the MIST group than in the INSURE group. Additionally, the incidence of BPD was less common in the MIST group compared to the INSURE group. However, surfactant reflux was more common in the MIST group than in the INSURE group. There were no significant differences between the two groups in other outcomes, including the length of hospital stay and complications such as IVH, PDA, NEC, pneumothorax, and pulmonary hemorrhage. Conclusion: The results of this research demonstrate that the less invasive method of surfactant therapy (MIST) is a feasible, effective, and low-risk alternative to the INSURE method. Full article

Background: Diaphragmatic dysfunction correlates with weaning failure, highlighting the need to independently assess the diaphragm’s effects on weaning. We modified the rapid shallow breathing index (RSBI), a predictor of successful weaning, by incorporating temporal variables into existing ultrasound-derived diaphragm index to create a simpler index closer to tidal volume. Methods: We conducted a prospective observational study of patients who underwent a spontaneous breathing trial in the medical intensive care unit (ICU) at Severance Hospital between October 2022 and June 2023. Diaphragmatic displacement (DD) and diaphragm inspiratory time (Ti) were measured using lung ultrasonography. The modified RSBI was defined as follows: respiratory rate (RR) divided by DD was defined as D-RSBI, and RR divided by the sum of the products of DD and Ti on both sides was defined as DTi-RSBI. Results: Among the sonographic indices, DTi-RSBI had the highest area under the receiver operating characteristic (ROC) curve of 0.774 in ROC analysis, and a correlation was found between increased DTi-RSBI and unsuccessful extubation in a multivariable logistic regression analysis (adjusted odds ratio 0.02, 95% confidence interval 0.00–0.97). Conclusions: The DTi-RSBI is beneficial in predicting successful weaning in medical ICU patients. Full article

Background: It is unclear whether other cardiac biomarkers than NT-proBNP can be useful in the risk stratification of patients weaning from mechanical ventilation. The aim of this study is to summarize the role of ischemic cardiac biomarkers in predicting spontaneous breathing trial (SBT) or extubation failure. Methods: We systematically searched Embase, MEDLINE, Web of Science, and Cochrane Central for studies published before January 2024 that reported the association between ischemic cardiac biomarkers and SBT or extubation failure. Data were extracted using a standardized form and methodological assessment was performed using the QUIPS tool. Results: Seven observational studies investigating four ischemic cardiac biomarkers (Troponin-T, Troponin-I, CK-MB, Myoglobin) were included. One study reported a higher peak Troponin-I in patients with extubation failure compared to extubation success (50 ng/L [IQR, 20–215] versus 30 ng/L [IQR, 10–86], p = 0.01). A second study found that Troponin-I measured before the SBT was higher in patients with SBT failure in comparison to patients with SBT success (100 ± 80 ng/L versus 70 ± 130 ng/L, p = 0.03). A third study reported a higher CK-MB measured at the end of the SBT in patients with weaning failure (SBT or extubation failure) in comparison to weaning success (8.77 ± 20.5 ng/mL versus 1.52 ± 1.42 ng/mL, p = 0.047). Troponin-T and Myoglobin as well as Troponin-I and CK-MB measured at other time points were not found to be related to SBT or extubation failure. However, most studies were underpowered and with high risk of bias. Conclusions: The association with SBT or extubation failure is limited for Troponin-I and CK-MB and appears absent for Troponin-T and Myoglobin, but available studies are hampered by significant methodological drawbacks. To more definitively determine the role of ischemic cardiac biomarkers, future studies should prioritize larger sample sizes, including patients at risk of cardiac disease, using stringent SBTs and structured timing of laboratory measurements before and after SBT. Full article

Background: Mechanical ventilation significantly improves patient survival but is associated with complications, increasing healthcare costs and morbidity. Identifying optimal weaning times is paramount to minimize these risks, yet current methods rely heavily on clinical judgment, lacking specificity. Methods: This study introduces a novel multiparametric predictive score, the MUSVIP (MUltiparametric Score for Ventilation discontinuation in Intensive care Patients), aimed at accurately predicting successful extubation. Conducted at Santo Stefano Hospital’s ICU, this single-center, observational, prospective cohort study will span over 12 months, enrolling adult patients undergoing invasive mechanical ventilation. The MUSVIP integrates variables measured before and during a spontaneous breathing trial (SBT) to formulate a predictive score. Results: Preliminary analyses suggest an Area Under the Curve (AUC) of 0.815 for the MUSVIP, indicating high predictive capacity. By systematically applying this score, we anticipate identifying patients likely to succeed in weaning earlier, potentially reducing ICU length of stay and associated healthcare costs. Conclusion: This study’s findings could significantly influence clinical practices, offering a robust, easy-to-use tool for optimizing weaning processes in ICUs. Full article

We aimed to evaluate the effectiveness of an intensive care unit (ICU) round checklist, FAST HUGS BID (Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head-of-bed elevation, Ulcer prophylaxis, Glycemic control, Spontaneous breathing trial, Bowel regimen, Indwelling catheter removal, and De-escalation of antibiotics—abbreviated as FD hereafter), in improving clinical outcomes in patients with severe trauma. We included patients admitted to our trauma ICU from 2016 to 2020 and divided them into two groups: before (before-FD, 2016–2017) and after (after-FD, 2019–2020) implementation of the checklist. We compared patient characteristics and clinical outcomes, including ICU and hospital length of stay (LOS) and in-hospital mortality. Survival analysis was performed using Kaplan–Meier curves and multivariable logistic regression models; furthermore, multiple linear regression analysis was used to identify independent factors associated with ICU and hospital LOS. Compared with the before-FD group, the after-FD group had significantly lower in-hospital mortality and complication rates, shorter ICU and hospital LOS, and reduced duration of mechanical ventilation. Moreover, implementation of the checklist was a significant independent factor in reducing ICU and hospital LOS and in-hospital mortality. Implementation of the FD checklist is associated with decreased ICU and hospital LOS and in-hospital mortality. Full article

A positive fluid balance may evolve to fluid overload and associate with organ dysfunctions, weaning difficulties, and increased mortality in ICU patients. We explored whether individualized fluid management, assessing fluid responsiveness via a passive leg-raising maneuver (PLR) before a spontaneous breathing trial (SBT), is associated with less extubation failure in ventilated patients with a high fluid balance admitted to the ICU after liver transplantation (LT). We recruited 15 LT patients in 2023. Their postoperative fluid balance was +4476 {3697, 5722} mL. PLR maneuvers were conducted upon ICU admission (T1) and pre SBT (T2). Cardiac index (CI) changes were recorded before and after each SBT (T3). Seven patients were fluid-responsive at T1, and twelve were responsive at T2. No significant differences occurred in hemodynamic, respiratory, and perfusion parameters between the fluid-responsive and fluid-unresponsive patients at any time. Fluid-responsive patients at T1 and T2 increased their CI during SBT from 3.1 {2.8, 3.7} to 3.7 {3.4, 4.1} mL/min/m² (p = 0.045). All fluid-responsive patients at T2 were extubated after the SBTs and consolidated extubation. Two out of three of the fluid-unresponsive patients experienced weaning difficulties. We concluded that fluid-responsive patients post LT may start weaning earlier and achieve successful extubation despite a high postoperative fluid balance. This highlights the profound impact of personalized assessments of cardiovascular state on critical surgical patients. Full article

Exercise increases the cost of breathing (COB) due to increased lung ventilation ($\dot{\mathrm{V}}$E), inducing respiratory muscles deoxygenation ($\nabla$SmO₂), while the increase in workload implies $\nabla$SmO₂ in locomotor muscles. This phenomenon has been proposed as a leading cause of exercise intolerance, especially in clinical contexts. The use of high-flow nasal cannula (HFNC) during exercise routines in rehabilitation programs has gained significant interest because it is proposed as a therapeutic intervention for reducing symptoms associated with exercise intolerance, such as fatigue and dyspnea, assuming that HFNC could reduce exercise-induced $\nabla$SmO₂. SmO₂ can be detected using optical wearable devices provided by near-infrared spectroscopy (NIRS) technology, which measures the changes in the amount of oxygen bound to chromophores (e.g., hemoglobin, myoglobin, cytochrome oxidase) at the target tissue level. We tested in a study with a cross-over design whether the muscular desaturation of m.vastus lateralis and m.intercostales during a high-intensity constant-load exercise can be reduced when it was supported with HFNC in non-physically active adults. Eighteen participants (nine women; age: 22 ± 2 years, weight: 65.1 ± 11.2 kg, height: 173.0 ± 5.8 cm, BMI: 21.6 ± 2.8 kg·m⁻²) were evaluated in a cycle ergometer (15 min, 70% maximum watts achieved in ergospirometry ($\dot{\mathrm{V}}$O₂-peak)) breathing spontaneously (control, CTRL) or with HFNC support (HFNC; 50 L·min⁻¹, fiO₂: 21%, 30 °C), separated by seven days in randomized order. Two-way ANOVA tests analyzed the $\nabla$SmO₂ (m.intercostales and m.vastus lateralis), and changes in $\dot{\mathrm{V}}$E and $\nabla$SmO₂·$\dot{\mathrm{V}}$E⁻¹. Dyspnea, leg fatigue, and effort level (RPE) were compared between trials by the Wilcoxon matched-paired signed rank test. We found that the interaction of factors (trial × exercise-time) was significant in $\nabla$SmO₂-m.intercostales, $\dot{\mathrm{V}}$E, and ($\nabla$SmO₂-m.intercostales)/$\dot{\mathrm{V}}$E (p < 0.05, all) but not in $\nabla$SmO₂-m.vastus lateralis. $\nabla$SmO₂-m.intercostales was more pronounced in CTRL during exercise since 5′ (p < 0.05). Hyperventilation was higher in CTRL since 10′ (p < 0.05). The $\nabla$SmO₂·$\dot{\mathrm{V}}$E⁻¹ decreased during exercise, being lowest in CTRL since 5′. Lower dyspnea was reported in HFNC, with no differences in leg fatigue and RPE. We concluded that wearable optical biosensors documented the beneficial effect of HFNC in COB due to lower respiratory $\nabla$SmO₂ induced by exercise. We suggest incorporating NIRS devices in rehabilitation programs to monitor physiological changes that can support the clinical impact of the therapeutic intervention implemented. Full article

Background: Tactile stimulation manoeuvres stimulate spontaneous breathing in preterm newborns. The aim of this study is to evaluate the effect of early respiratory physiotherapy on the need for mechanical ventilation during the first week of life in preterm infants with respiratory failure. Methods: This is a monocentric, randomised controlled trial. Preterm infants (gestational age ≤ 30 weeks) not intubated in the delivery room and requiring non-invasive respiratory support at birth were eligible for the study. The intervention group received early respiratory physiotherapy, while the control group received only a daily physiotherapy program (i.e., modifying the infant’s posture in accordance with the patient’s needs). Results: between October 2019 and March 2021, 133 preterm infants were studied, 68 infants in the study group and 65 in routine care. The study group showed a reduction in the need for mechanical ventilation (not statistically significant) and a statistically significant reduction in hemodynamically significant patent ductus arteriosus with respect to the control group (19/68 (28%) vs. 35/65 (54%), respectively, p = 0.03). Conclusions: early respiratory physiotherapy in preterm infants requiring non-invasive respiratory support at birth is safe and has proven to be protective against haemodynamically significant PDA. Full article

Discontinuing mechanical ventilation remains challenging. We developed a machine learning model to predict weaning outcomes using only continuous monitoring parameters obtained from ventilators during spontaneous breathing trials (SBTs). Patients who received mechanical ventilation in the medical intensive care unit at a tertiary university hospital from 2019–2021 were included in this study. During the SBTs, three waveforms and 25 numerical data were collected as input variables. The proposed convolutional neural network (CNN)-based weaning prediction model extracts features from input data with diverse lengths. Among 138 enrolled patients, 35 (25.4%) experienced weaning failure. The dataset was randomly divided into training and test sets (8:2 ratio). The area under the receiver operating characteristic curve for weaning success by the prediction model was 0.912 (95% confidence interval [CI], 0.795–1.000), with an area under the precision-recall curve of 0.767 (95% CI, 0.434–0.983). Furthermore, we used gradient-weighted class activation mapping technology to provide visual explanations of the model’s prediction, highlighting influential features. This tool can assist medical staff by providing intuitive information regarding readiness for extubation without requiring any additional data collection other than SBT data. The proposed predictive model can assist clinicians in making ventilator weaning decisions in real time, thereby improving patient outcomes. Full article