Pub Date : 2024-11-11DOI: 10.1186/s13054-024-05145-1
Stuthi Iyer, Jason N. Kennedy, Peter C. Nauka, Mourad H. Senussi, Christopher W. Seymour
<p>β-Blockers are used widely in the outpatient care of chronic disease, but less is known about how to restart chronic therapy during and after hospitalization for septic shock [1, 2]. We sought to characterize the epidemiology of β-blocker treatment during and after septic shock among patients administered chronic β-blocker therapy in the year prior to hospitalization [3].</p><p>We studied patients who received outpatient β-blocker therapy in the 12 months prior to hospitalization at 12 UPMC hospitals from 2010 to 2014 with follow up through 2019. Eligible patients were adults (age ≥ 18 years) with septic shock, defined as suspected infection and sequential organ failure assessment (SOFA) score ≥ 2 within 24 h of admission and receiving vasopressor therapy [4]. Demographics, biomarkers, outpatient and inpatient β-blocker and vasopressor administration were abstracted from outpatient records (EPIC Inc.) for each admission day up to 14 days (CERNER Inc.). Patients were stratified as: (i) those who were administered β-blockers each hospital day (“continued”), (ii) those with cessation of chronic therapy for more than 24 h with or without restart during the hospital stay (“held”), and (iii) those who never received β-blockers (“discontinued”). Descriptive data were compared across groups using the Kruskal–Wallis test and χ<sup>2</sup> test with a Bonferroni adjusted (2-sided) significance level of <i>P</i> < 0.05, as appropriate. All analyses used Stata, version 18.0 (StataCorp).</p><p>Of 22,208 patients, 3748 were hospitalized with septic shock and received chronic β-blockers (mean age 67 ± 14 years, 56% male, 87% White, median SOFA score 9.0 (IQR: 6.0–11.0) (Fig. 1A). Of those who received chronic therapy, 405 (11%) continued, 2,025 (54%) held, and 1,317 (35%) discontinued chronic β-blocker therapy during intensive care. Patients in whom β-blockers were discontinued presented with greater SOFA score (“continued,” median SOFA 8.0 (IQR: 6.0–11.0); “held,” 8.0 (IQR: 6.0–11.0; “discontinued,” 10.0 (IQR: 7.0–12.0); <i>p</i> < 0.001), while first-measured biomarkers, such as serum lactate, troponin, and platelets, were similar across groups.</p><figure><figcaption><b data-test="figure-caption-text">Fig. 1</b></figcaption><picture><source srcset="//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05145-1/MediaObjects/13054_2024_5145_Fig1_HTML.png?as=webp" type="image/webp"/><img alt="figure 1" aria-describedby="Fig1" height="493" loading="lazy" src="//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05145-1/MediaObjects/13054_2024_5145_Fig1_HTML.png" width="685"/></picture><p>Patient characteristics and prescribing patterns. <b>A</b> Patient characteristics of adults with septic shock who received chronic β-blocker therapy prior to hospitalization. Abbreviations include: d, days; ICU, intensive care unit; INR, international normalized ratio; IQR, interquartile range; no, number; SD, sta
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{"title":"Epidemiology of β-blocker use among critically iII patients during and after septic shock","authors":"Stuthi Iyer, Jason N. Kennedy, Peter C. Nauka, Mourad H. Senussi, Christopher W. Seymour","doi":"10.1186/s13054-024-05145-1","DOIUrl":"https://doi.org/10.1186/s13054-024-05145-1","url":null,"abstract":"<p>β-Blockers are used widely in the outpatient care of chronic disease, but less is known about how to restart chronic therapy during and after hospitalization for septic shock [1, 2]. We sought to characterize the epidemiology of β-blocker treatment during and after septic shock among patients administered chronic β-blocker therapy in the year prior to hospitalization [3].</p><p>We studied patients who received outpatient β-blocker therapy in the 12 months prior to hospitalization at 12 UPMC hospitals from 2010 to 2014 with follow up through 2019. Eligible patients were adults (age ≥ 18 years) with septic shock, defined as suspected infection and sequential organ failure assessment (SOFA) score ≥ 2 within 24 h of admission and receiving vasopressor therapy [4]. Demographics, biomarkers, outpatient and inpatient β-blocker and vasopressor administration were abstracted from outpatient records (EPIC Inc.) for each admission day up to 14 days (CERNER Inc.). Patients were stratified as: (i) those who were administered β-blockers each hospital day (“continued”), (ii) those with cessation of chronic therapy for more than 24 h with or without restart during the hospital stay (“held”), and (iii) those who never received β-blockers (“discontinued”). Descriptive data were compared across groups using the Kruskal–Wallis test and χ<sup>2</sup> test with a Bonferroni adjusted (2-sided) significance level of <i>P</i> < 0.05, as appropriate. All analyses used Stata, version 18.0 (StataCorp).</p><p>Of 22,208 patients, 3748 were hospitalized with septic shock and received chronic β-blockers (mean age 67 ± 14 years, 56% male, 87% White, median SOFA score 9.0 (IQR: 6.0–11.0) (Fig. 1A). Of those who received chronic therapy, 405 (11%) continued, 2,025 (54%) held, and 1,317 (35%) discontinued chronic β-blocker therapy during intensive care. Patients in whom β-blockers were discontinued presented with greater SOFA score (“continued,” median SOFA 8.0 (IQR: 6.0–11.0); “held,” 8.0 (IQR: 6.0–11.0; “discontinued,” 10.0 (IQR: 7.0–12.0); <i>p</i> < 0.001), while first-measured biomarkers, such as serum lactate, troponin, and platelets, were similar across groups.</p><figure><figcaption><b data-test=\"figure-caption-text\">Fig. 1</b></figcaption><picture><source srcset=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05145-1/MediaObjects/13054_2024_5145_Fig1_HTML.png?as=webp\" type=\"image/webp\"/><img alt=\"figure 1\" aria-describedby=\"Fig1\" height=\"493\" loading=\"lazy\" src=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05145-1/MediaObjects/13054_2024_5145_Fig1_HTML.png\" width=\"685\"/></picture><p>Patient characteristics and prescribing patterns. <b>A</b> Patient characteristics of adults with septic shock who received chronic β-blocker therapy prior to hospitalization. Abbreviations include: d, days; ICU, intensive care unit; INR, international normalized ratio; IQR, interquartile range; no, number; SD, sta","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"37 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142599741","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Bereaved people experience distinct trajectories of prolonged-grief-disorder (PGD) symptoms. A few studies from outside critical care investigated limited factors of PGD-symptom trajectories without a theoretical framework. We aimed to characterize factors associated with ICU bereaved surrogates’ PGD-symptom trajectories, drawing from the integrative framework of predictors for bereavement outcomes, emphasizing factors modifiable by ICU care. Prospective cohort study of 291 family surrogates. Multinomial logistic regression was used to determine associations of three previously identified PGD-symptom trajectories (resilient [n = 242, 83.2%] as reference group, recovery [n = 35, 12.0%], and chronic [n = 14, 4.8%]) with risk factors. Factors included intrapersonal (demographics, personal vulnerabilities), interpersonal (perceived social support), bereavement-related (patient demographics, clinical characteristics, and patient-surrogate relationship), and death-circumstance (surrogate-perceived quality of patient dying and death [QODD] in ICUs classified as high, moderate, poor-to-uncertain, and worst QODD classes) factors. Most surrogates were female (59.1%), the patient’s adult child (54.0%), and about (standard deviation) 49.63 (12.53) years old. As surrogate age increased, recovery-trajectory membership decreased (adjusted odds ratio [95% confidence interval] = 0.918 [0.849, 0.993]) and chronic-trajectory membership increased (1.230 [1.010, 1.498]). Being married decreased membership in the recovery (0.186 [0.047, 0.729]) trajectory. Higher anxiety symptoms 1 month post loss increased membership in recovery (1.520 [1.256, 1.840]) and chronic (2.022 [1.444, 2.831]) trajectories. Spouses were more likely and adult–child surrogates were less likely than other relationships to be in the two more profound PGD-symptom trajectories. Membership in the chronic trajectory decreased (0.779 [0.614, 0.988]) as patient age increased. The poor-to-uncertain QODD class was associated with a nearly significant increase (4.342 [0.980, 19.248]) in membership in the recovery trajectory compared to the high QODD class. Membership in the PGD-symptom trajectories was associated with factors modifiable by high-quality ICU care, including anxiety symptoms at early bereavement and surrogate-perceived QODD in the ICU. Clinicians should be sensitive to the psychological needs of at-risk family surrogates, provide high-quality end-of-life care to facilitate QODD, and promptly refer bereaved surrogates who suffer anxiety symptoms and profound and/or persistent PGD-symptoms for psychological support.
{"title":"Factors of prolonged-grief-disorder symptom trajectories for ICU bereaved family surrogates","authors":"Fur-Hsing Wen, Holly G. Prigerson, Li-Pang Chuang, Tsung-Hui Hu, Chung-Chi Huang, Wen-Chi Chou, Siew Tzuh Tang","doi":"10.1186/s13054-024-05160-2","DOIUrl":"https://doi.org/10.1186/s13054-024-05160-2","url":null,"abstract":"Bereaved people experience distinct trajectories of prolonged-grief-disorder (PGD) symptoms. A few studies from outside critical care investigated limited factors of PGD-symptom trajectories without a theoretical framework. We aimed to characterize factors associated with ICU bereaved surrogates’ PGD-symptom trajectories, drawing from the integrative framework of predictors for bereavement outcomes, emphasizing factors modifiable by ICU care. Prospective cohort study of 291 family surrogates. Multinomial logistic regression was used to determine associations of three previously identified PGD-symptom trajectories (resilient [n = 242, 83.2%] as reference group, recovery [n = 35, 12.0%], and chronic [n = 14, 4.8%]) with risk factors. Factors included intrapersonal (demographics, personal vulnerabilities), interpersonal (perceived social support), bereavement-related (patient demographics, clinical characteristics, and patient-surrogate relationship), and death-circumstance (surrogate-perceived quality of patient dying and death [QODD] in ICUs classified as high, moderate, poor-to-uncertain, and worst QODD classes) factors. Most surrogates were female (59.1%), the patient’s adult child (54.0%), and about (standard deviation) 49.63 (12.53) years old. As surrogate age increased, recovery-trajectory membership decreased (adjusted odds ratio [95% confidence interval] = 0.918 [0.849, 0.993]) and chronic-trajectory membership increased (1.230 [1.010, 1.498]). Being married decreased membership in the recovery (0.186 [0.047, 0.729]) trajectory. Higher anxiety symptoms 1 month post loss increased membership in recovery (1.520 [1.256, 1.840]) and chronic (2.022 [1.444, 2.831]) trajectories. Spouses were more likely and adult–child surrogates were less likely than other relationships to be in the two more profound PGD-symptom trajectories. Membership in the chronic trajectory decreased (0.779 [0.614, 0.988]) as patient age increased. The poor-to-uncertain QODD class was associated with a nearly significant increase (4.342 [0.980, 19.248]) in membership in the recovery trajectory compared to the high QODD class. Membership in the PGD-symptom trajectories was associated with factors modifiable by high-quality ICU care, including anxiety symptoms at early bereavement and surrogate-perceived QODD in the ICU. Clinicians should be sensitive to the psychological needs of at-risk family surrogates, provide high-quality end-of-life care to facilitate QODD, and promptly refer bereaved surrogates who suffer anxiety symptoms and profound and/or persistent PGD-symptoms for psychological support. ","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"19 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142598288","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The main aim of the study whether changes in central venous-to-arterial CO2 difference (ΔP(v–a)CO2) and central venous oxygen saturation (ΔScvO2) induced by volume expansion (VE) are reliable parameters to define fluid responsiveness (FR) in sedated and mechanically ventilated septic patients. We also sought to determine whether the degree of FR was related to baseline ScvO2 and P(v–a)CO2 levels. This was a post-hoc analysis of a multicenter prospective study. We included 205 mechanically ventilated patients with acute circulatory failure. Cardiac index (CI), P(v–a)CO2, ScvO2, and other hemodynamic variables were measured before and after VE. A VE-induced increase in CI > 15% defined fluid responders. Areas under the receiver operating characteristic curves (AUCs) and the gray zones were determined for ΔP(v–a)CO2 and ΔScvO2. One hundred fifteen patients (56.1%) were classified as fluid responders. The AUCs for ΔP(v–a)CO2 and ΔScvO2 to define FR were 0.831 (95% CI 0.772–0.880) (p < 0.001) and 0.801 (95% CI 0.739–0.853) (p < 0.001), respectively. ΔP(v–a)CO2 ≤ 2.1 mmHg and ΔScvO2 ≥ 3.4% after VE allowed the categorization between responders and non-responders with positive predictive values of 90% and 86% and negative predictive values of 58% and 64%, respectively. The gray zones for ΔP(v–a)CO2 (− 2 to 0 mmHg) and ΔScvO2 (− 1 to 5%) included 22% and 40.5% of patients, respectively. ΔP(v–a)CO2 and ΔScvO2 were independently associated with FR in multivariable analysis. No significant relationships were found between pre-infusion ScvO2 and P(v–a)CO2 levels and FR. In mechanically critically ill patients, ΔP(v–a)CO2 and ΔScvO2 are reliable parameters to define FR and can be used in the absence of CI measurement. The response to VE was independent of baseline ScvO2 and P(v–a)CO2 levels. Clinical trial registration The study was registered in the ClinicalTrials.gov registry: NCT03225378, date: July 20, 2017.
{"title":"Changes in central venous-to-arterial PCO2 difference and central venous oxygen saturation as markers to define fluid responsiveness in critically ill patients: a pot-hoc analysis of a multi-center prospective study","authors":"Jihad Mallat, Osama Abou-Arab, Malcolm Lemyze, Dahlia Saleh, Pierre-Grégoire Guinot, Marc-Olivier Fischer","doi":"10.1186/s13054-024-05156-y","DOIUrl":"https://doi.org/10.1186/s13054-024-05156-y","url":null,"abstract":"The main aim of the study whether changes in central venous-to-arterial CO2 difference (ΔP(v–a)CO2) and central venous oxygen saturation (ΔScvO2) induced by volume expansion (VE) are reliable parameters to define fluid responsiveness (FR) in sedated and mechanically ventilated septic patients. We also sought to determine whether the degree of FR was related to baseline ScvO2 and P(v–a)CO2 levels. This was a post-hoc analysis of a multicenter prospective study. We included 205 mechanically ventilated patients with acute circulatory failure. Cardiac index (CI), P(v–a)CO2, ScvO2, and other hemodynamic variables were measured before and after VE. A VE-induced increase in CI > 15% defined fluid responders. Areas under the receiver operating characteristic curves (AUCs) and the gray zones were determined for ΔP(v–a)CO2 and ΔScvO2. One hundred fifteen patients (56.1%) were classified as fluid responders. The AUCs for ΔP(v–a)CO2 and ΔScvO2 to define FR were 0.831 (95% CI 0.772–0.880) (p < 0.001) and 0.801 (95% CI 0.739–0.853) (p < 0.001), respectively. ΔP(v–a)CO2 ≤ 2.1 mmHg and ΔScvO2 ≥ 3.4% after VE allowed the categorization between responders and non-responders with positive predictive values of 90% and 86% and negative predictive values of 58% and 64%, respectively. The gray zones for ΔP(v–a)CO2 (− 2 to 0 mmHg) and ΔScvO2 (− 1 to 5%) included 22% and 40.5% of patients, respectively. ΔP(v–a)CO2 and ΔScvO2 were independently associated with FR in multivariable analysis. No significant relationships were found between pre-infusion ScvO2 and P(v–a)CO2 levels and FR. In mechanically critically ill patients, ΔP(v–a)CO2 and ΔScvO2 are reliable parameters to define FR and can be used in the absence of CI measurement. The response to VE was independent of baseline ScvO2 and P(v–a)CO2 levels. Clinical trial registration The study was registered in the ClinicalTrials.gov registry: NCT03225378, date: July 20, 2017.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"62 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142597295","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-07DOI: 10.1186/s13054-024-05128-2
Jana Larissa Koch, Charles Chin Han Lew, Felix Kork, Alexander Koch, Christian Stoppe, Daren K. Heyland, Ellen Dresen, Zheng-Yii Lee, Aileen Hill
Evidence on the benefits of fiber-supplemented enteral nutrition (EN) in critically ill patients is inconsistent, and critical care nutrition guidelines lack recommendations based on high-quality evidence. This systematic review and meta-analysis (SRMA) aims to provide a current synthesis of the literature on this topic. For this SRMA of randomized controlled trials (RCT), electronic databases (MEDLINE, EMBASE, CENTRAL) were searched systematically from inception to January 2024 and updated in June 2024. Trials investigating clinical effects of fiber-supplemented EN versus placebo or usual care in adult critically ill patients were selected. Two independent reviewers extracted data and assessed the risk of bias of the included studies. Random-effect meta-analysis and trial sequential analysis (TSA) were conducted. The primary outcome was overall mortality, and one of the secondary outcomes was diarrhea incidence. Subgroup analyses were also performed for both outcomes. Twenty studies with 1405 critically ill patients were included. In conventional meta-analysis, fiber-supplemented EN was associated with a significant reduction of overall mortality (RR 0.66, 95% CI 0.47, 0.92, p = 0.01, I2 = 0%; 12 studies) and diarrhea incidence (RR 0.70, 95% CI 0.51, 0.96, p = 0.03, I2 = 51%; 11 studies). However, both outcomes were assessed to have very serious risk of bias, and, according to TSA, a type-1 error cannot be ruled out. No subgroup differences were found for the primary outcome. Very low-certainty evidence suggests that fiber-supplemented EN has clinical benefits. High-quality multicenter RCTs with large sample sizes are needed to substantiate any firm recommendation for its routine use in this group of patients. PROSPERO registration number: CRD42023492829.
有关重症患者补充纤维素肠内营养（EN）益处的证据并不一致，重症营养指南也缺乏基于高质量证据的建议。本系统综述和荟萃分析（SRMA）旨在提供有关该主题的最新文献综述。为了对随机对照试验（RCT）进行 SRMA，我们对电子数据库（MEDLINE、EMBASE、CENTRAL）进行了系统检索，检索时间从开始检索到 2024 年 1 月，并在 2024 年 6 月进行了更新。研究对象为成年重症患者，研究了纤维素补充EN与安慰剂或常规护理的临床效果。两位独立审稿人提取了数据并评估了纳入研究的偏倚风险。进行了随机效应荟萃分析和试验序列分析（TSA）。主要结果是总死亡率，次要结果之一是腹泻发生率。还对这两项结果进行了分组分析。共纳入了 20 项研究，涉及 1405 名重症患者。在常规荟萃分析中，补充纤维的 EN 可显著降低总死亡率（RR 0.66，95% CI 0.47，0.92，p = 0.01，I2 = 0%；12 项研究）和腹泻发生率（RR 0.70，95% CI 0.51，0.96，p = 0.03，I2 = 51%；11 项研究）。然而，这两项结果都被评估为存在非常严重的偏倚风险，根据 TSA，不能排除 1 型错误。主要结果未发现亚组差异。确定性极低的证据表明，补充纤维的 EN 具有临床益处。需要进行大样本量、高质量的多中心 RCT 研究，以证实在该类患者中常规使用该疗法的任何明确建议。PROSPERO 注册号：CRD42023492829。
{"title":"The efficacy of fiber-supplemented enteral nutrition in critically ill patients: a systematic review and meta-analysis of randomized controlled trials with trial sequential analysis","authors":"Jana Larissa Koch, Charles Chin Han Lew, Felix Kork, Alexander Koch, Christian Stoppe, Daren K. Heyland, Ellen Dresen, Zheng-Yii Lee, Aileen Hill","doi":"10.1186/s13054-024-05128-2","DOIUrl":"https://doi.org/10.1186/s13054-024-05128-2","url":null,"abstract":"Evidence on the benefits of fiber-supplemented enteral nutrition (EN) in critically ill patients is inconsistent, and critical care nutrition guidelines lack recommendations based on high-quality evidence. This systematic review and meta-analysis (SRMA) aims to provide a current synthesis of the literature on this topic. For this SRMA of randomized controlled trials (RCT), electronic databases (MEDLINE, EMBASE, CENTRAL) were searched systematically from inception to January 2024 and updated in June 2024. Trials investigating clinical effects of fiber-supplemented EN versus placebo or usual care in adult critically ill patients were selected. Two independent reviewers extracted data and assessed the risk of bias of the included studies. Random-effect meta-analysis and trial sequential analysis (TSA) were conducted. The primary outcome was overall mortality, and one of the secondary outcomes was diarrhea incidence. Subgroup analyses were also performed for both outcomes. Twenty studies with 1405 critically ill patients were included. In conventional meta-analysis, fiber-supplemented EN was associated with a significant reduction of overall mortality (RR 0.66, 95% CI 0.47, 0.92, p = 0.01, I2 = 0%; 12 studies) and diarrhea incidence (RR 0.70, 95% CI 0.51, 0.96, p = 0.03, I2 = 51%; 11 studies). However, both outcomes were assessed to have very serious risk of bias, and, according to TSA, a type-1 error cannot be ruled out. No subgroup differences were found for the primary outcome. Very low-certainty evidence suggests that fiber-supplemented EN has clinical benefits. High-quality multicenter RCTs with large sample sizes are needed to substantiate any firm recommendation for its routine use in this group of patients. PROSPERO registration number: CRD42023492829.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"70 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142596905","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-06DOI: 10.1186/s13054-024-05144-2
Mattia Docci, Giuseppe Foti, Laurent Brochard, Giacomo Bellani
Pressure support ventilation (PSV) is a form of assisted ventilation which has become frequently used, with the aim of partially unloading the patient’s inspiratory muscles. Both under- and over-assistance should be avoided to target a lung- and diaphragm- protective ventilation. Herein, we propose a conceptual model, supported by actual data, to describe how patient and ventilator share the generation of tidal volume (Vt) in PSV and how respiratory system compliance (Crs) affects this interaction. We describe the presence of a patient-specific range of PSV levels, within which the inspiratory effort (Pmus) is modulated, keeping Vt relatively steady on a desired value (Vttarget). This range of assistance may be considered the “adequate PSV assistance” required by the patient, while higher and lower levels may result in over- and under-assistance respectively. As we also show, the determinants of over- and under- assistance borders depend on the combination of Crs and the inspiratory effort which the patient is able to sustain over a period of time. These concepts can be applied at the bedside to understand if the level of assistance is adequate to patient’s demand, focusing on the variation of relevant parameters (Vt, Pmus and pressure-muscle-index) as patient reaction to a change in the level of assistance.
{"title":"Pressure support, patient effort and tidal volume: a conceptual model for a non linear interaction","authors":"Mattia Docci, Giuseppe Foti, Laurent Brochard, Giacomo Bellani","doi":"10.1186/s13054-024-05144-2","DOIUrl":"https://doi.org/10.1186/s13054-024-05144-2","url":null,"abstract":"Pressure support ventilation (PSV) is a form of assisted ventilation which has become frequently used, with the aim of partially unloading the patient’s inspiratory muscles. Both under- and over-assistance should be avoided to target a lung- and diaphragm- protective ventilation. Herein, we propose a conceptual model, supported by actual data, to describe how patient and ventilator share the generation of tidal volume (Vt) in PSV and how respiratory system compliance (Crs) affects this interaction. We describe the presence of a patient-specific range of PSV levels, within which the inspiratory effort (Pmus) is modulated, keeping Vt relatively steady on a desired value (Vttarget). This range of assistance may be considered the “adequate PSV assistance” required by the patient, while higher and lower levels may result in over- and under-assistance respectively. As we also show, the determinants of over- and under- assistance borders depend on the combination of Crs and the inspiratory effort which the patient is able to sustain over a period of time. These concepts can be applied at the bedside to understand if the level of assistance is adequate to patient’s demand, focusing on the variation of relevant parameters (Vt, Pmus and pressure-muscle-index) as patient reaction to a change in the level of assistance.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"17 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142588766","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-05DOI: 10.1186/s13054-024-05116-6
James Cheng Chung Wei, Poi Kuo, Po-Cheng Shih
<p>We read with great interest the article by You et al., which provides valuable insights into the comparative efficacy of baricitinib and tocilizumab in mechanically ventilated COVID-19 patients [1]. While the study’s findings are important, especially regarding the lower 30-day mortality in the baricitinib group, we believe that the issue of confounding by indication was not sufficiently addressed and may have significantly influenced the results.</p><p>Confounding by indication occurs when treatment assignment is influenced by disease severity, leading to a bias in outcome comparison between treatment groups. In this study, patients in the tocilizumab group appeared to be more severely ill at baseline compared to those in the baricitinib group. Although the authors employed propensity score matching (PSM) to balance baseline characteristics, the data suggest that the tocilizumab group had a higher severity of illness, which could explain some of the observed differences in mortality. Notably, patients in the tocilizumab group had longer durations of mechanical ventilation prior to drug administration, higher use of extracorporeal membrane oxygenation (ECMO), and more severe comorbidities, as detailed in the supplementary tables. These factors strongly suggest that tocilizumab was more likely administered to patients in critical condition, potentially skewing the mortality comparison in favor of baricitinib.</p><p>Furthermore, while PSM is effective at balancing observable variables, it may not fully account for unmeasured or residual confounders, such as the timing of drug administration relative to disease progression or the specific clinical criteria that influenced treatment choices. Baricitinib was administered for a median of 8 days, while tocilizumab was often given as a single dose. This difference in treatment duration and pharmacodynamics could have further impacted the results. Baricitinib, with its broader anti-inflammatory effects and prolonged administration, may have provided a more sustained reduction in inflammation, whereas the single-dose nature of tocilizumab could have limited its efficacy in severely ill patients.</p><p>Additionally, the study does not provide sufficient detail regarding the criteria used to determine whether a patient received baricitinib or tocilizumab beyond the similar indications in general consideration [2]. Without understanding the clinical decision-making process, it is difficult to evaluate the extent to which confounding by indication may have influenced the results. If tocilizumab was preferentially administered to patients with more rapidly progressing or refractory disease, the higher mortality rate in this group might reflect underlying disease severity rather than a difference in drug efficacy [3]. </p><p>It may be beneficial to consider a subgroup analysis excluding patients requiring total parenteral nutrition (TPN), as those unable to tolerate enteral nutrition typically represent a mor
我们饶有兴趣地阅读了You等人的文章，该文对巴利昔尼和妥昔单抗在机械通气的COVID-19患者中的疗效比较提供了有价值的见解[1]。虽然该研究的结果很重要，尤其是巴利替尼组的 30 天死亡率较低，但我们认为适应症混杂问题没有得到充分解决，可能会对结果产生重大影响。在这项研究中，与巴利昔尼组相比，托西珠单抗组患者的基线病情似乎更严重。虽然作者采用了倾向评分匹配（PSM）来平衡基线特征，但数据表明托西珠单抗组患者的病情严重程度更高，这可能是观察到的死亡率差异的部分原因。值得注意的是，托西珠单抗组患者在用药前的机械通气时间更长，体外膜肺氧合（ECMO）的使用率更高，合并症更严重，详见补充表格。这些因素有力地表明，托西珠单抗更有可能用于病情危重的患者，从而有可能使死亡率比较向巴利替尼倾斜。此外，虽然PSM能有效平衡可观察变量，但它可能无法完全考虑未测量或残留的混杂因素，如相对于疾病进展的给药时间或影响治疗选择的特定临床标准。巴利替尼的中位给药时间为 8 天，而托珠单抗通常为单次给药。这种治疗时间和药效学上的差异可能会进一步影响治疗结果。巴利昔尼具有更广泛的抗炎作用，且用药时间较长，可能会更持久地减轻炎症，而托珠单抗的单剂量性质可能会限制其在重症患者中的疗效。此外，除了一般考虑的类似适应症外，该研究没有提供足够详细的资料说明确定患者接受巴利昔尼还是托珠单抗的标准[2]。在不了解临床决策过程的情况下，很难评估适应症对结果的影响程度。如果托珠单抗优先用于病情进展较快或难治性疾病患者，那么该组患者较高的死亡率可能反映了潜在疾病的严重程度，而不是药物疗效的差异[3]。考虑将需要全肠外营养（TPN）的患者排除在外进行亚组分析可能是有益的，因为不能耐受肠内营养的患者通常病情较重，预后指标较差，如序贯器官衰竭评估（SOFA）评分较高[4]。这些患者更有可能接受静脉注射疗法，包括以注射方式给药的托珠单抗。这可能会带来一个潜在的混杂因素，因为在这一重症亚组中偏好使用托西珠单抗可能反映了无法使用巴利替尼等口服药物，而不是直接反映了药物的相对疗效。有鉴于此，我们建议未来的研究考虑在 PSM 中使用 SOFA 或 APACHE II 评分，以更好地控制基线严重程度差异。如果无法获得 SOFA 或 APACHE II 数据，则可根据 ICU 入院或插管时与 SOFA 或 APACHE II 评分相关的实验室数据进行匹配，作为疾病严重程度的替代指标[5,6,7]。纳入这些变量可能有助于减少混杂因素并强化结论。此外，更详细的时间依赖性分析，如机械通气持续时间或给药时间，将明确这些疗法在重症患者中的真正效果。最终，随机对照试验仍是解决这些问题的黄金标准，但在此期间，使用更细致的统计匹配技术可能有助于完善巴利昔尼与托珠单抗在这一人群中的比较。You S-H, Baek MS, Kim TW, Jung S-Y, Kim W-Y. Baricitinib versus tocilizumab in mechanically ventilated patients with COVID-19: a nationwide cohort study.Crit Care.2024;28(1):282.Article PubMed PubMed Central Google Scholar Liu LT, Tsai JJ.揭示免疫功能低下者的 COVID-19 治疗策略：治疗创新与最新发现。 Hoboken：Google Scholar Trøseid M, Arribas JR, Assoumou L, Holten AR, Poissy J, Terzić V, et al. Baricitinib in hospitalized adults with severe or critical COVID-19 (Bari-SolidAct): a randomised, double-blind, placebo controlled phase 3 trial.Crit Care.2023;27(1):9.Article PubMed PubMed Central Google Scholar Lopez-Delgado JC, Servia-Goixart L, Grau-Carmona T, Bordeje-Laguna L, Portugal-Rodriguez E, Lorencio-Cardenas C, et al.Front Nutr. 2023;10:1250305.Article PubMed PubMed Central Google Scholar Vicka V, Januskeviciute E, Miskinyte S, Ringaitiene D, Serpytis M, Klimasauskas A, et al.COVID-19重症患者死亡风险评估工具功效比较。BMC Infect Dis.2021;21:1-7.Article Google Scholar Beigmohammadi MT, Amoozadeh L, Rezaei Motlagh F, Rahimi M, Maghsoudloo M, Jafarnejad B, et al. Mortality predictive value of APACHE II and SOFA scores in COVID-19 patients in the intensive care unit.Can Respir J. 2022;2022(1):5129314.PubMed PubMed Central Google Scholar Roddy J, Wells D, Schenck K, Santosh S, Santosh S. Tocilizumab versus baricitinib in patients in hospitalized with COVID-19 pneumonia and hypoxemia: a multicenter retrospective cohort study.Crit Care Explor.2022;4(5):e0702.Article PubMed PubMed Central Google Scholar Download referencesNo funding involved作者及工作单位中山医学大学附属医院过敏免疫风湿科，台中市建国北路一段1号，402，台湾中山医学大学医学研究所，台中市中山医学大学医学研究所，台中市中山医学大学医学研究所，台中市Po-Cheng Shih 台灣台中，中國醫藥大學中西醫結合研究所 James Cheng Chung Wei 台灣台中，中山醫學大學附設醫院 Poi Kuo 台灣台中，彰化縣立中山醫學大學附設醫院 Allergy, Immunology &；山西省医学科学院山西白求恩医院，山西医科大学第三医院，山西同济医院，太原，030032，中国James Cheng Chung Wei台中，中山医科大学医学研究所/护理学系、台湾James
{"title":"Commenting on baricitinib versus tocilizumab in mechanically ventilated patients with COVID-19: a nationwide cohort study","authors":"James Cheng Chung Wei, Poi Kuo, Po-Cheng Shih","doi":"10.1186/s13054-024-05116-6","DOIUrl":"https://doi.org/10.1186/s13054-024-05116-6","url":null,"abstract":"<p>We read with great interest the article by You et al., which provides valuable insights into the comparative efficacy of baricitinib and tocilizumab in mechanically ventilated COVID-19 patients [1]. While the study’s findings are important, especially regarding the lower 30-day mortality in the baricitinib group, we believe that the issue of confounding by indication was not sufficiently addressed and may have significantly influenced the results.</p><p>Confounding by indication occurs when treatment assignment is influenced by disease severity, leading to a bias in outcome comparison between treatment groups. In this study, patients in the tocilizumab group appeared to be more severely ill at baseline compared to those in the baricitinib group. Although the authors employed propensity score matching (PSM) to balance baseline characteristics, the data suggest that the tocilizumab group had a higher severity of illness, which could explain some of the observed differences in mortality. Notably, patients in the tocilizumab group had longer durations of mechanical ventilation prior to drug administration, higher use of extracorporeal membrane oxygenation (ECMO), and more severe comorbidities, as detailed in the supplementary tables. These factors strongly suggest that tocilizumab was more likely administered to patients in critical condition, potentially skewing the mortality comparison in favor of baricitinib.</p><p>Furthermore, while PSM is effective at balancing observable variables, it may not fully account for unmeasured or residual confounders, such as the timing of drug administration relative to disease progression or the specific clinical criteria that influenced treatment choices. Baricitinib was administered for a median of 8 days, while tocilizumab was often given as a single dose. This difference in treatment duration and pharmacodynamics could have further impacted the results. Baricitinib, with its broader anti-inflammatory effects and prolonged administration, may have provided a more sustained reduction in inflammation, whereas the single-dose nature of tocilizumab could have limited its efficacy in severely ill patients.</p><p>Additionally, the study does not provide sufficient detail regarding the criteria used to determine whether a patient received baricitinib or tocilizumab beyond the similar indications in general consideration [2]. Without understanding the clinical decision-making process, it is difficult to evaluate the extent to which confounding by indication may have influenced the results. If tocilizumab was preferentially administered to patients with more rapidly progressing or refractory disease, the higher mortality rate in this group might reflect underlying disease severity rather than a difference in drug efficacy [3]. </p><p>It may be beneficial to consider a subgroup analysis excluding patients requiring total parenteral nutrition (TPN), as those unable to tolerate enteral nutrition typically represent a mor","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"1 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142580091","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-04DOI: 10.1186/s13054-024-05114-8
Siyao Zeng, Yue Li, Zhipeng Yao, Junbo Zheng, Hongliang Wang
<p>The mpox virus is a zoonotic orthopoxvirus with a DNA genome. Based on genetic characteristics, the mpox virus is categorized into two main clades: clade I and clade II. Clade I is further subdivided into subclades Ia and Ib [1]. Clade I is predominantly found in Central Africa, while clade II primarily circulates in West Africa [2]. The clade IIb subclade of clade II caused the global mpox outbreak from 2022 to 2023, during which 86% of cases were among men who have sex with men (MSM) [1]. More than half of the reported mpox cases involve individuals who are co-infected with the human immunodeficiency virus (HIV) [3]. The 2024 mpox outbreak in the Democratic Republic of the Congo and neighboring countries is primarily caused by clade Ia [4]. Only in 2024, as of September 15, the Democratic Republic of the Congo has reported 25,757 cases of mpox, with 806 deaths [3]. In April 2024, scientists identified a new variant of clade I, named Ib, by analyzing samples collected in South Kivu Province, Democratic Republic of the Congo, from late 2023 to early 2024. Reports of infections caused by the Ib variant have increased over the past few months. The proportion of women infected with clade Ib was significantly higher (52%), with nearly one-third identifying as sex workers [1]. On August 15, Sweden reported its first case of mpox caused by the Ib variant. Thailand confirmed its first Ib variant mpox case on August 22 [4]. Compared to clade IIb, which caused the global mpox outbreak in 2022, clade Ia exhibits stronger human-to-human transmissibility and higher mortality and severity rates. As for the clade Ib, its characteristics remain unclear [5].</p><p>As the mpox outbreak intensifies, by August 31, 2024, a total of 106,310 confirmed cases have been reported across 123 countries worldwide, resulting in 234 laboratory-confirmed deaths [3]. In Africa, the confirmed and suspected mpox cases in 2024 have surpassed 17,500, far exceeding the 15,000 cases reported in 2023. In response to this escalating situation, the Africa Centers for Disease Control and Prevention (Africa CDC) declared mpox a “Public Health Emergency of Security Concern” (PHESC) for the first time on August 13, 2024. The following day, the World Health Organization (WHO) declared the mpox outbreak a “Public Health Emergency of International Concern” (PHEIC), urging global cooperation to prevent further spread [5]. The current mpox outbreak may pose new challenges for intensivists worldwide.</p><p>Mpox mainly spreads through transmission between animals and humans or from person to person. Animal-to-human transmission can happen through direct contact with an infected animal, being bitten or scratched, or consuming undercooked meat from an infected animal. Human-to-human transmission primarily occurs through direct contact with an infected individual’s skin or mucous membrane lesions, oral secretions, upper respiratory secretions (such as nasal discharge and mucus), and items contamina
mpox 病毒是一种具有 DNA 基因组的人畜共患正痘病毒。根据基因特征，痘病毒被分为两个主要支系：支系 I 和支系 II。支系 I 又分为支系 Ia 和支系 Ib [1]。支系 I 主要分布在中非，而支系 II 主要在西非流行 [2]。Ⅱ支系的Ⅱb亚支系导致了2022年至2023年的全球麻风腮疫情，其间86%的病例发生在男男性行为者（MSM）中[1]。在已报告的痘病病例中，超过一半的人同时感染了人类免疫缺陷病毒（HIV）[3]。2024 年在刚果民主共和国及其邻国爆发的 mpox 主要由 Ia 支原体引起 [4]。仅在 2024 年，截至 9 月 15 日，刚果民主共和国就报告了 25 757 例痘病病例，其中 806 人死亡[3]。2024 年 4 月，科学家通过分析 2023 年底至 2024 年初在刚果民主共和国南基伍省采集的样本，确定了 I 支系的一个新变种，命名为 Ib。在过去几个月中，由 Ib 变种引起的感染报告有所增加。感染 Ib 变体的女性比例明显更高（52%），其中近三分之一的人是性工作者[1]。8 月 15 日，瑞典报告了首例由 Ib 变种引起的麻风病病例。8 月 22 日，泰国确诊了首例 Ib 变种天花病例 [4]。与 2022 年导致全球痘疫情爆发的 IIb 支系相比，Ia 支系具有更强的人际传播性，死亡率和严重程度也更高。随着天花疫情的加剧，截至 2024 年 8 月 31 日，全球 123 个国家共报告 106 310 例确诊病例，234 人经实验室确诊死亡[3]。在非洲，2024 年的确诊和疑似水痘病例已超过 17 500 例，远远超过了 2023 年报告的 15 000 例。面对不断升级的形势，非洲疾病预防控制中心（Africa Centers for Disease Control and Prevention，ADC）于 2024 年 8 月 13 日首次宣布天花为 "安全关注的突发公共卫生事件"（Public Health Emergency of Security Concern，PHESC）。次日，世界卫生组织（WHO）宣布天花疫情为 "国际关注的突发公共卫生事件"（PHEIC），敦促全球合作防止疫情进一步扩散[5]。当前的天花疫情可能会给全球的重症医学专家带来新的挑战。天花主要通过人与动物或人与人之间的传播进行传播。动物与人之间的传播可通过直接接触受感染的动物、被咬伤或抓伤或食用受感染动物未煮熟的肉类而发生。人与人之间的传播主要是通过直接接触感染者的皮肤或粘膜病变、口腔分泌物、上呼吸道分泌物（如鼻涕和粘液）以及被病毒污染的物品（如床上用品）。性接触在传播中起着重要作用，尤其是在 IIb 族疫情和目前的 Ib 族疫情中。此外，长时间近距离接触呼吸道飞沫和母婴传播也是重要的传播途径[6]。在治疗麻风病人时，重症监护医生应穿戴适当的个人防护设备（PPE），包括 N95 呼吸器或同等设备、护眼设备、手套和防护服。应正确穿戴个人防护设备，确保完全覆盖暴露部位，以尽量减少污染。在支气管肺泡灌洗、插管或拔管等可能产生气溶胶的程序 (AGP) 中，建议使用电动空气净化呼吸器 (PAPR) 提供额外保护。在使用插管盒或视频喉镜等防护屏障进行这些操作时应格外小心，以尽量减少接触。在发生长时间密切接触的医疗环境中，尤其是在 AGP 过程中，传播的风险会增加。因此，遵守严格的个人防护设备协议至关重要[7]。为防止空气传播，最好使用带负压的空气传播隔离室（AIIRs）。在高风险环境中，尤其是免疫力严重低下的患者或患有播散性疾病的患者，可使用生物隔离室（BCUs）[7]。然而，必须注意的是，COVID-19 的管理在不同时期和不同地区有很大差异。因此，在流行性腮腺炎中，目前的指导原则强调坚持使用呼吸道防护用品（如 N95 或同等用品），尽量减少 AGPs，优化隔离程序以减少非医院传播[7]。
{"title":"What every intensivist needs to know about mpox","authors":"Siyao Zeng, Yue Li, Zhipeng Yao, Junbo Zheng, Hongliang Wang","doi":"10.1186/s13054-024-05114-8","DOIUrl":"https://doi.org/10.1186/s13054-024-05114-8","url":null,"abstract":"<p>The mpox virus is a zoonotic orthopoxvirus with a DNA genome. Based on genetic characteristics, the mpox virus is categorized into two main clades: clade I and clade II. Clade I is further subdivided into subclades Ia and Ib [1]. Clade I is predominantly found in Central Africa, while clade II primarily circulates in West Africa [2]. The clade IIb subclade of clade II caused the global mpox outbreak from 2022 to 2023, during which 86% of cases were among men who have sex with men (MSM) [1]. More than half of the reported mpox cases involve individuals who are co-infected with the human immunodeficiency virus (HIV) [3]. The 2024 mpox outbreak in the Democratic Republic of the Congo and neighboring countries is primarily caused by clade Ia [4]. Only in 2024, as of September 15, the Democratic Republic of the Congo has reported 25,757 cases of mpox, with 806 deaths [3]. In April 2024, scientists identified a new variant of clade I, named Ib, by analyzing samples collected in South Kivu Province, Democratic Republic of the Congo, from late 2023 to early 2024. Reports of infections caused by the Ib variant have increased over the past few months. The proportion of women infected with clade Ib was significantly higher (52%), with nearly one-third identifying as sex workers [1]. On August 15, Sweden reported its first case of mpox caused by the Ib variant. Thailand confirmed its first Ib variant mpox case on August 22 [4]. Compared to clade IIb, which caused the global mpox outbreak in 2022, clade Ia exhibits stronger human-to-human transmissibility and higher mortality and severity rates. As for the clade Ib, its characteristics remain unclear [5].</p><p>As the mpox outbreak intensifies, by August 31, 2024, a total of 106,310 confirmed cases have been reported across 123 countries worldwide, resulting in 234 laboratory-confirmed deaths [3]. In Africa, the confirmed and suspected mpox cases in 2024 have surpassed 17,500, far exceeding the 15,000 cases reported in 2023. In response to this escalating situation, the Africa Centers for Disease Control and Prevention (Africa CDC) declared mpox a “Public Health Emergency of Security Concern” (PHESC) for the first time on August 13, 2024. The following day, the World Health Organization (WHO) declared the mpox outbreak a “Public Health Emergency of International Concern” (PHEIC), urging global cooperation to prevent further spread [5]. The current mpox outbreak may pose new challenges for intensivists worldwide.</p><p>Mpox mainly spreads through transmission between animals and humans or from person to person. Animal-to-human transmission can happen through direct contact with an infected animal, being bitten or scratched, or consuming undercooked meat from an infected animal. Human-to-human transmission primarily occurs through direct contact with an infected individual’s skin or mucous membrane lesions, oral secretions, upper respiratory secretions (such as nasal discharge and mucus), and items contamina","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"63 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142574402","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-04DOI: 10.1186/s13054-024-05125-5
Ola Stenqvist
<p>In a recent pro/con review on transpulmonary pressure by Ball, Talmor and Pelosi [1], the authors describe in detail positioning, inflation, and calibration of the esophageal balloon catheter and different interpretations of absolute esophageal and transpulmonary pressure measurements. They also briefly describe the only method that does not require esophageal pressure for separation of lung and chest wall mechanics, the PEEP-step method (PSM). However, they dismiss PSM invoking completely erroneous assumptions that the method “assumes implicitly that the end-expiratory transpulmonary pressure estimated with esophageal manometry is zero regardless of the applied PEEP level”. But PEEP causes an increase in EELV, and during inflation of the lung, transpulmonary pressure increases in relation to the volume inflated and the elastic properties of the lung, ΔV × EL. In five successful PSM validation studies, based strictly on tidal airway and esophageal pressure variations [2,3,4,5,6], we have shown that calculated end-expiratory transpulmonary pressure (PLEE) increases as much as PEEP (= PAWEE) is increased. Consequently, the change in end-expiratory esophageal pressure, calculated as ΔPAWEE - ΔPLEE , is zero, which proves that the chest wall does not impede PEEP inflation and therefore lung elastance can be determined as ΔPEEP/ΔEELV. Thus, it is not transpulmonary pressure, but tidally calculated esophageal pressure that remains zero and the dismissal statement is completely erroneous and misleading.</p><p>In data on absolute esophageal and transpulmonary pressure from the Brochard group, analysis of tidal variation in esophageal and transpulmonary pressure fully confirms the validity of PSM (for details, see, Figs. S2, S3, S4 in e-supplement).</p><p>Below, I give a correct description of the background physiology, validation, mathematical derivation and measurement procedure of the PEEP-step method.</p><h3>Background physiology</h3><p>The PEEP step method (PSM) is a non-invasive, esophageal pressure free method for separation of lung and chest wall mechanics, based on the physiological conditions at functional residual capacity (FRC), where the contra-directional forces of the elastic recoil of the lung, striving to lower lung volume, and the rib cage spring out force, striving to expand the chest wall, balance each other. Thus, the chest wall complex does not lean on, or squeeze the lung at end-expiration at FRC. In case of a pneumothorax, the chest wall expands to 70–80% of total lung capacity (TLC). If end-expiratory lung volume instead is increased by PEEP, the rib cage spring out force will move the chest wall complex outwards in parallel with the lung volume increase, i.e., the ΔPEEP (= ΔPAWEE) of the ventilator only has to overcome the recoil of the lung. Consequently, the end-expiratory transpulmonary pressure (PLEE) will increase as much as PEEP is increased and EELV will increase in relation to the size of ΔPEEP and the elastic properti
由于 EELV 的变化为 ΔPEEP/EL，因此在不考虑食管压力的情况下，可通过增加 PEEP 并确定 ΔEELV 来确定肺弹性为 ΔPEEP/ΔEELV。右图：累积 ΔPEEP 和累积 ΔPLEE 之间的相关图，计算公式为 ΔEELV x EL，[3,5,6,7,8,9,10,11,12]中逐级 PEEP，显示 PLEE 随 PEEP 的增加而增加。潮气量等于 ΔEELV 时的跨肺驱动压（ΔPL）等于 ΔPEEPFull size image图 2左侧面板：44 个 PEEP 步骤，平均 ΔPEEP 为 5.1 cmH2O，与图 1 中列出的研究相同。呼气末跨肺压的增加按 ΔEELV × EL 计算，其中 EL = (ΔPAW - ΔPES)/VT。呼气末食管压力变化（ΔPPLEE）的计算公式为 ΔPEEP - ΔPLEE。右图：在潮气量等于 PEEP 引起的呼气末肺容量变化（VT = ΔEELV）时，ΔPEEP 与跨肺驱动压力（由食管压力确定的 ΔPLconv）的比较。根据 ΔEELV 和相应潮气量的大小将数值分为三组。全尺寸图片潮气压力变化方程用于分离肺和胸壁力学，用于验证 PSMA 气道驱动压力 = ΔPAWE 食管驱动压力 = ΔPEST 肺驱动压力 = ΔPAW - ΔPES = ΔPL呼吸系统弹性：ERS = ΔPAW/VTC 胸壁弹性：ECW = ΔPES/VTLung elastance：EL = ΔPL/VT = ERS - ECWE呼气末气道压力：PAWEE = PEEP末期呼气肺容积变化：ΔEELV = ΔPEEP/ELE 末期呼气跨肺压力变化：ΔPLEE = ΔEELV × ELE末期呼气食管压力变化：ΔPESEE = ΔPAWEE - ΔPLEET数学推导基于PES的肺弹性为$${text{EL}} = Delta {text{PL}}/{text{VT}}$ 而基于PEEP的肺弹性为$${text{EL}} = Delta {text{PL}}/{text{VT}}$因此${text{PL}}/{text{VT}} = Delta {text{PEEP}}/Delta {text{EELV}}$Thus$Delta {text{PL}}/{text{VT}} = Delta {text{PEEP}}/Delta {text{EELV}}$(△{text{EELV}}={text{VT}})$$△{text{PL}}=△{text{PEEP}}$$因此、潮气量等于 ΔEELV 时的跨肺驱动压等于 ΔPEEP。由于呼气末跨肺压力（ΔPLEE）的增加也等于ΔPEEP，因此在一定肺容量下的跨肺压力是相同的，无论该肺容量是通过潮气量还是 PEEP 充气达到的。ΔEELV的总和为$$Δ{text/{PEEP}}/{text{EL}}$这两个体积之差构成了PEEP膨胀的第二阶段多呼阶段，即$$left( {Δ{text{PEEP }} times {{text{ ECW}}} right)/left( {{text{ERS }} times {{text{ EL}}} right)。times , Delta {text/{PEEP/ERS}}$第二阶段 PEEP 充气期间呼气末转肺压的增加值为$${text{EL }}times , left( {Delta {text{PEEP }} times {text{ ECW}}} right)/left( {{text{ERS }} times {text{ EL}}} right) , = {text{ECW }}因此，在 ΔEELV 增加的第二阶段多呼期间，跨肺压的增加等于增加 PEEP 后第一次呼气期间呼气末食管压的增加。这证明了在 PEEP 充气过程中，由于肋骨的弹出力，胸壁在呼气末从肺部卸载。图 3 左侧面板：离体肺中的 PEEP 步骤。气道压力（红色箭头）等于跨肺压力（蓝色箭头）。低 PEEP 时的潮气量为 500 毫升，ΔPAW 为 10 cmH2O。增加 PEEP 10 cmH2O 会导致 EELV 增加 500 毫升。低 PEEP 时的吸气末转肺（= 气道）P/V 点等于高 PEEP 时的呼气末转肺（= 气道）P/V 点（蓝色环表示）。在孤立肺中，肺弹性为 ∆PAW/VT 和 ∆PEEP/ ∆EELV。右图：原位 PEEP 阶跃。低 PEEP 水平的潮气量等于 PEEP 引起的呼气末肺容积变化。来自 ZEEP 的吸气末气道平台压力与离体肺的位置（蓝色环）相比右移（黑色箭头）。低 PEEP 水平的潮气量吸气末高原压与高 PEEP 水平的呼气末跨肺压之差等于潮气胸膜压变化（绿色箭头，ΔPPL）。 由于 EL/ERS 的平均比率（ΔPL/ΔAW）≈ 0.70，因此ΔEELV 平均等于潮气量。ΔEELV 是根据 PEEP 水平之间呼气潮气量的累积差值确定的，肺弹性的计算公式为 ΔPEEP/ΔEELV。跨肺驱动压力的计算公式为 PSM 导出 EL 乘以潮气量。为了考虑肺压/容积曲线的非线性，需要采用两级 PEEP 程序来评估从基线 PEEP 时的呼气末到最高 PEEP 水平时的吸气末高原压力曲线。根据两个较低 PEEP 推断出的潮气胸膜压力变化，对三个呼气末气道 P/V 点进行两度多项式拟合，并估算出程序中最高 PEEP 水平时的吸气末跨肺 P/V 点（图 4）：通过两级 PEEP 程序确定的肺 P/V 曲线（蓝色）。三个 PEEP 水平下的潮气道 P/V 曲线（红色箭头）。在两个最低 PEEP 水平下，分别确定吸气末气道高原压与同一容积水平下的肺转压之间的压力差，即胸膜压力的潮气变化。最高 PEEP 水平下的跨肺高原压是根据两个较低 PEEP 水平下的潮气胸膜压力变化推算出来的。最高 PEEP 水平下的跨肺高原压计算方法为气道高原压减去外推胸膜压力变化[14]。在重症监护室的 ARF 患者和手术室的肺热患者中，估计的跨肺高原压与食管压力测量的高原压之间的差异分别为 0.2 ± 1.4 和 0.1 ± 0.8 cmH2O [14，15]。右图：最佳 PEEP，即提供最低跨肺驱动压力的 PEEP 水平，可通过将曲线最陡峭的点确定为多项式二次导数的根，并将所需潮气量对称分布在该 P/V 点周围来确定[14]。根据多项式可以计算出呼气末容积对应的压力。由于潮气量肺 P/V 曲线（与容量和 PEEP 水平无关）叠加在总肺 P/V 曲线上，因此可以根据肺 P/V 曲线方程计算出任何 PEEP 和潮气量组合的跨肺驱动压力和高原压力。这样就可以估计 PEEP 和潮气量任何组合的机械后果，并确定呼吸机诱发肺损伤（VILI）的风险，以及何时可以使用更积极的设置来避免 ECMO 治疗，而不会有 VILI 的风险（图 5）。图 5 PEEP 无反应者和反应者的最佳拟合肺 P/V 曲线（浅灰色），肺总顺应性（CLoa）分别为 54 和 112 ml/cmH2O[14]。在 PEEP 为 8 和 13 cmH2O 时，VT 为 6 毫升/千克 IBW（70 千克 IBW 患者为 500 毫升）时的潮气肺 P/V 曲线（蓝色箭头）与总肺 P/V
{"title":"Transpulmonary pressure monitoring in critically ill patients: pros and cons—correction of description of the non-invasive PEEP-step method for separation of lung and chest wall mechanics","authors":"Ola Stenqvist","doi":"10.1186/s13054-024-05125-5","DOIUrl":"https://doi.org/10.1186/s13054-024-05125-5","url":null,"abstract":"<p>In a recent pro/con review on transpulmonary pressure by Ball, Talmor and Pelosi [1], the authors describe in detail positioning, inflation, and calibration of the esophageal balloon catheter and different interpretations of absolute esophageal and transpulmonary pressure measurements. They also briefly describe the only method that does not require esophageal pressure for separation of lung and chest wall mechanics, the PEEP-step method (PSM). However, they dismiss PSM invoking completely erroneous assumptions that the method “assumes implicitly that the end-expiratory transpulmonary pressure estimated with esophageal manometry is zero regardless of the applied PEEP level”. But PEEP causes an increase in EELV, and during inflation of the lung, transpulmonary pressure increases in relation to the volume inflated and the elastic properties of the lung, ΔV × EL. In five successful PSM validation studies, based strictly on tidal airway and esophageal pressure variations [2,3,4,5,6], we have shown that calculated end-expiratory transpulmonary pressure (PLEE) increases as much as PEEP (= PAWEE) is increased. Consequently, the change in end-expiratory esophageal pressure, calculated as ΔPAWEE - ΔPLEE , is zero, which proves that the chest wall does not impede PEEP inflation and therefore lung elastance can be determined as ΔPEEP/ΔEELV. Thus, it is not transpulmonary pressure, but tidally calculated esophageal pressure that remains zero and the dismissal statement is completely erroneous and misleading.</p><p>In data on absolute esophageal and transpulmonary pressure from the Brochard group, analysis of tidal variation in esophageal and transpulmonary pressure fully confirms the validity of PSM (for details, see, Figs. S2, S3, S4 in e-supplement).</p><p>Below, I give a correct description of the background physiology, validation, mathematical derivation and measurement procedure of the PEEP-step method.</p><h3>Background physiology</h3><p>The PEEP step method (PSM) is a non-invasive, esophageal pressure free method for separation of lung and chest wall mechanics, based on the physiological conditions at functional residual capacity (FRC), where the contra-directional forces of the elastic recoil of the lung, striving to lower lung volume, and the rib cage spring out force, striving to expand the chest wall, balance each other. Thus, the chest wall complex does not lean on, or squeeze the lung at end-expiration at FRC. In case of a pneumothorax, the chest wall expands to 70–80% of total lung capacity (TLC). If end-expiratory lung volume instead is increased by PEEP, the rib cage spring out force will move the chest wall complex outwards in parallel with the lung volume increase, i.e., the ΔPEEP (= ΔPAWEE) of the ventilator only has to overcome the recoil of the lung. Consequently, the end-expiratory transpulmonary pressure (PLEE) will increase as much as PEEP is increased and EELV will increase in relation to the size of ΔPEEP and the elastic properti","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"87 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142574405","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Necrotizing soft tissue infections (NSTI) are rapidly progressing and life-threatening conditions that require prompt diagnosis. However, differentiating NSTI from other non-necrotizing skin and soft tissue infections (SSTIs) remains challenging. We aimed to evaluate the diagnostic value of the biochemical analysis of soft tissue infectious fluid in distinguishing NSTIs from non-necrotizing SSTIs. This cohort study prospectively enrolled adult patients between May 2023 and April 2024, and retrospectively included patients from April 2019 to April 2023. Patients with a clinical suspicion of NSTI in the limbs who underwent successful ultrasound-guided aspiration to obtain soft tissue infectious fluid for biochemical analysis were evaluated and classified into the NSTI and non-necrotizing SSTI groups based on their final discharge diagnosis. Common extravascular body fluid (EBF) criteria were applied. Of the 72 patients who met the inclusion criteria, 10 patients with abscesses identified via ultrasound-guided aspiration were excluded. Based on discharge diagnoses, 39 and 23 patients were classified into the NSTI and non-necrotizing SSTI groups, respectively. Biochemical analysis revealed significantly higher albumin, lactate, lactate dehydrogenase (LDH), and total protein levels in the NSTI group than in the non-necrotizing SSTI group, and the NSTI group had significantly lower glucose levels and pH in soft tissue fluids. In the biochemical analysis, LDH demonstrated outstanding discrimination (area under the curve (AUC) = 0.955; p < 0.001) among the biochemical markers. Albumin (AUC = 0.884; p < 0.001), lactate (AUC = 0.891; p < 0.001), and total protein (AUC = 0.883; p < 0.001) levels also showed excellent discrimination. Glucose level (AUC = 0.774; p < 0.001) and pH (AUC = 0.780; p < 0.001) showed acceptable discrimination. When the EBF criteria were evaluated, the total scores of Light’s criteria (AUC = 0.925; p < 0.001), fluid-to-serum LDH ratio (AUC = 0.929; p < 0.001), and fluid-to-serum total protein ratio (AUC = 0.927; p < 0.001) demonstrated outstanding discrimination. Biochemical analysis and EBF criteria demonstrated diagnostic performances ranging from acceptable to outstanding for NSTI when analyzing soft tissue infectious fluid. These findings provide valuable diagnostic insights into the recognition of NSTI. Further research is required to validate these findings.
{"title":"Biochemical analysis of soft tissue infectious fluids and its diagnostic value in necrotizing soft tissue infections: a 5-year cohort study","authors":"Kai-Hsiang Wu, Po-Han Wu, Hung-Sheng Wang, Hsiu-Mei Shiau, Yung-Sung Hsu, Chih-Yi Lee, Yin-Ting Lin, Cheng-Ting Hsiao, Leng-Chieh Lin, Chia-Peng Chang, Pey-Jium Chang","doi":"10.1186/s13054-024-05146-0","DOIUrl":"https://doi.org/10.1186/s13054-024-05146-0","url":null,"abstract":"Necrotizing soft tissue infections (NSTI) are rapidly progressing and life-threatening conditions that require prompt diagnosis. However, differentiating NSTI from other non-necrotizing skin and soft tissue infections (SSTIs) remains challenging. We aimed to evaluate the diagnostic value of the biochemical analysis of soft tissue infectious fluid in distinguishing NSTIs from non-necrotizing SSTIs. This cohort study prospectively enrolled adult patients between May 2023 and April 2024, and retrospectively included patients from April 2019 to April 2023. Patients with a clinical suspicion of NSTI in the limbs who underwent successful ultrasound-guided aspiration to obtain soft tissue infectious fluid for biochemical analysis were evaluated and classified into the NSTI and non-necrotizing SSTI groups based on their final discharge diagnosis. Common extravascular body fluid (EBF) criteria were applied. Of the 72 patients who met the inclusion criteria, 10 patients with abscesses identified via ultrasound-guided aspiration were excluded. Based on discharge diagnoses, 39 and 23 patients were classified into the NSTI and non-necrotizing SSTI groups, respectively. Biochemical analysis revealed significantly higher albumin, lactate, lactate dehydrogenase (LDH), and total protein levels in the NSTI group than in the non-necrotizing SSTI group, and the NSTI group had significantly lower glucose levels and pH in soft tissue fluids. In the biochemical analysis, LDH demonstrated outstanding discrimination (area under the curve (AUC) = 0.955; p < 0.001) among the biochemical markers. Albumin (AUC = 0.884; p < 0.001), lactate (AUC = 0.891; p < 0.001), and total protein (AUC = 0.883; p < 0.001) levels also showed excellent discrimination. Glucose level (AUC = 0.774; p < 0.001) and pH (AUC = 0.780; p < 0.001) showed acceptable discrimination. When the EBF criteria were evaluated, the total scores of Light’s criteria (AUC = 0.925; p < 0.001), fluid-to-serum LDH ratio (AUC = 0.929; p < 0.001), and fluid-to-serum total protein ratio (AUC = 0.927; p < 0.001) demonstrated outstanding discrimination. Biochemical analysis and EBF criteria demonstrated diagnostic performances ranging from acceptable to outstanding for NSTI when analyzing soft tissue infectious fluid. These findings provide valuable diagnostic insights into the recognition of NSTI. Further research is required to validate these findings.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"32 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142562090","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 10.1186/s13054-024-05133-5
Masahiko Hara, Masatake Tamaki
<p>Non-invasive ventilation (NIV) is critical in the treatment of several respiratory diseases [1, 2]. However, interface air leakage and resultant pressure injury from tight-fitting can lead to intolerance or unsuccessful implementation of NIV [3, 4]. In response to these challenges, we have developed a new type of oronasal mask with full accordion cushioning designed to achieve effective sealing at lower pressures (Fig. 1 and Video. S1). Our mask incorporates six innovations: full accordion cushioning, turtle shell cover, nasal groove, folding function, visual pressure indicator, and soft medical-grade silicone (Videos. S2, S3, and S4). The mask is tapered toward the face, and it also incorporates multiple elastic adjustment lines to improve adaptability and fit, allowing the mask to “fold” snugly around the face. These elements enhance the mask’s ability to evenly distribute pressure and conform to different facial shapes, providing a secure fit at low pressures. The thickness of the accordion cushion decreases toward the face side, providing a visual indication of pressure application through the compression of the accordion valleys.</p><figure><figcaption><b data-test="figure-caption-text">Fig. 1</b></figcaption><picture><source srcset="//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05133-5/MediaObjects/13054_2024_5133_Fig1_HTML.png?as=webp" type="image/webp"/><img alt="figure 1" aria-describedby="Fig1" height="433" loading="lazy" src="//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05133-5/MediaObjects/13054_2024_5133_Fig1_HTML.png" width="685"/></picture><p>Structural and Functional Features of Our Novel Respiratory Mask with Full Accordion Cushioning. Overview of the mask (<b>A</b>). The rear view of the mask from the face side shows the nasal groove (<b>B</b>). Elastic adjustment lines are symmetrically aligned with six on the nasal side and eight on the chin side (<b>C</b>). An illustration of the mask in clinical use (<b>D</b>). A detailed view of the accordion structure, showing the five outermost ridges defined as accordion lines (<b>E</b>). These ridges are sequentially labeled from the face side (first line, purple) to the cover side (fifth line, blue). Mechanical testing provided visual cues for the estimated pressure at which the mask would adhere to the skin (<b>F</b>). See Video. S1 for the 3-dimensional computer-aided design data of the mask, Video. S2 for a frontal view of the mask in use, Video. S3 for a visualization of the nasal groove, and Video. S4 for the folding function</p><span>Full size image</span><svg aria-hidden="true" focusable="false" height="16" role="img" width="16"><use xlink:href="#icon-eds-i-chevron-right-small" xmlns:xlink="http://www.w3.org/1999/xlink"></use></svg></figure><p>To assess the mask’s performance, a mechanical bench test was conducted to evaluate sealing efficiency and to estimate skin pressure at various visual pressure ind
无创通气（NIV）是治疗多种呼吸系统疾病的关键[1, 2]。然而，界面漏气和紧身佩戴造成的压力损伤会导致患者不耐受或无法成功实施 NIV [3，4]。为了应对这些挑战，我们开发了一种新型口鼻面罩，其全风琴式缓冲设计可在较低压力下实现有效密封（图 1 和视频 S1）。我们的喉罩采用了六项创新技术：全风琴式缓冲、龟甲盖、鼻槽、折叠功能、可视压力指示器和医用软硅胶（视频 S2、S3 和 S4）。面罩朝向脸部呈锥形，还包含多条弹性调节线，以提高适应性和贴合度，使面罩能紧贴脸部 "折叠"。这些元素增强了面罩均匀分布压力和适应不同脸型的能力，在低压下也能提供安全的贴合。风琴式缓冲垫的厚度向脸部一侧减小，通过压缩风琴式凹谷提供压力应用的视觉指示。面罩概览（A）。从面罩背面看，可以看到鼻腔凹槽 (B)。弹性调节线对称排列，鼻侧六条，下巴侧八条（C）。面罩临床使用示意图（D）。手风琴结构的详细视图，显示最外侧的五条脊线被定义为手风琴线（E）。这些脊线从面部（第一条线，紫色）到盖面（第五条线，蓝色）依次标注。机械测试为面罩附着在皮肤上的估计压力提供了视觉提示（F）。参见视频。S1 为面具的三维计算机辅助设计数据，视频.S2 为面罩使用时的正面视图，视频.S3 为鼻槽的可视化，视频为评估面罩的性能，进行了机械台架测试，以评估密封效率，并估算各种视觉压力指示器情况下的皮肤压力。还进行了烟雾泄漏测试，以直观地确认密封性（视频 S5）。面罩能有效贴合各种人体模型的头部形状，并在估计皮肤压力为 2.2 mmHg 时实现完全密封。最外侧的脊线从面部开始依次标注。当第一条和第二条风琴线粘合时，估计皮肤压力为 5.3 ± 0.4 mmHg；当第一条至第三条线粘合时，估计皮肤压力为 10.8 ± 0.6 mmHg；当第一条至第四条线粘合时，估计皮肤压力为 16.8 ± 0.7 mmHg。林氏一致性相关系数为 0.987（95% 置信区间，0.963-0.995），表明不同观察者的测量结果高度一致。根据这些结果，我们开发了一种特殊的绑带（图 S1），可使面罩以最小的压力固定在面部，从而提高了可用性。该面罩在日本注册为医疗设备，产品名称为 "javalla"（iDevice, Inc.，日本大阪）。面罩的设计可重复使用，每个面罩最多可保证为 10 名患者提供耐用性。最初的临床反馈非常积极，强调了面罩的易贴合性和舒适性，而无需特定尺寸。一刀切的设计符合各种脸型，包括不同的鼻部轮廓，因此无需调整尺寸。用户反映漏气较少，不适感减轻，呼吸机报警减少。折叠功能使脸部无齿或脸颊凹陷的患者受益匪浅。在试销阶段，74 家医院中有 33 家（44.6%）采用了我们的产品，尽管其价格比他们最常用的面罩高出一倍多。然而，一些用户指出，他们需要学习如何放置面罩，担心面罩较松，以及保持呼吸机管道无张力（无重力）的重要性，以防止因面罩佩戴过软而脱落。此外，还观察到一些使用者倾向于将面罩固定得太紧，就像传统面罩一样，导致过度收紧，造成第 1 至第 4 条风琴线粘连。这种新型喉罩解决了 NIV 面临的关键挑战，如漏气和压力损伤，这往往与高发病率和医疗成本增加有关 [3，4]。当持续外力超过组织灌注压力（通常约为 30-35 mmHg）时，就会发生压力损伤[4, 5]。我们的面罩能够在低压下提供有效的密封，这表明它具有减少此类伤害发生的潜力。 如果文章的知识共享许可中没有包含材料，而您的使用意图又不符合法律规定或超出了许可使用范围，您需要直接从版权所有者处获得许可。要查看此许可的副本，请访问 http://creativecommons.org/licenses/by/4.0/.Reprints and permissionsCite this articleHara, M., Tamaki, M. Development and functional characterization of a novel respiratory mask with full accordion cushion to prevent air leaks and pressure injuries during non-invasive ventilation.https://doi.org/10.1186/s13054-024-05133-5Download citationReceived：13 October 2024Accepted：15 October 2024Published: 01 November 2024DOI: https://doi.org/10.1186/s13054-024-05133-5Share this articleAnyone you share the following link with will be able to read this content:Get shareable linkSorry, a shareable link is not currently available for this article.Copy to clipboard Provided by the Springer Nature SharedIt content-sharing initiative.
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