Pub Date : 2024-09-19DOI: 10.1186/s13054-024-05094-9
Rongpeng Xu, Ziqiang Shao
<p>Dear Editor,</p><p>Recently, we read with great interest the article by Tan et al. [1], in which the authors demonstrated that compared to high-flow nasal cannula oxygen (HFNC), non-invasive ventilation (NIV) is a better choice for initial respiratory support in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) complicated by acute-moderate hypercapnic respiratory failure. Although this result highlights the efficacy of NIV in the treatment of AECOPD patients, we believe that there are still certain issues that need to be clarified in the study conducted by Tan et al.</p><p>First, the gas flow rate of HFNC during treatment needs to be noticed. Mechanically, the high gas flow rate of HFNC can wash out the dead space of chronic obstructive pulmonary disease (COPD) patients, and effectively decreases pressure of arterial carbon dioxide (PaCO<sub>2</sub>). Studies have shown that HFNC as initial respiratory support is non-inferior to NIV in decreasing PaCO<sub>2</sub> after 2 h of treatment in patients with mild-to-moderate AECOPD [2]. However, carbon dioxide retention was the most common reason for treatment failure in the HFNC group in this study. Therefore, whether raising the initial gas flow rate from 40 L/min to 60 L/min could improve the treatment success rate of HFNC. It is worth noting that study has shown that higher gas flow rate than 30 L/min not only fails to lower PaCO<sub>2</sub> but also increases inspiratory effort [3]. In short, the initial gas flow rate of 40 L/min does not seem to be an optimal setting. In addition, HFNC has the advantage of comfort and is usually used continuously after obtaining the optimal gas flow rate required by the patient. In this study, intermittent downregulation of gas flow rate or even discontinuation of HFNC was adopted in the HFNC group, which may be a key factor leading to the failure of HFNC treatment.</p><p>Additionally, the baseline data lacks of information on the frequency of acute exacerbations in patients. The 2017 Global Strategy for the Diagnosis, Management and Prevention of COPD report noted that that the frequency of previous hospitalizations for acute exacerbations of COPD and concurrent cardiovascular disease comorbidities are associated with poor outcomes in patients [4]. Therefore, it is necessary to list the frequency of acute exacerbations and to describe the cardiovascular comorbidities such as heart failure, hypertension, and arrhythmia in the baseline data, which may significantly affect the success of respiratory therapy in each group of patients.</p><p>Furthermore, Oxygen therapy and ventilatory support are only one part of AECOPD treatment [4]. It is well known that the use of bronchodilators is critical in the treatment of AECOPD. Through dilating the bronchi and bronchioles, bronchodilators not only improve the exchange of oxygen and carbon dioxide, but also facilitate the expulsion of sputum, which is closely related to the success of o
高流量鼻插管氧疗与无创通气治疗慢性阻塞性肺病急性加重伴急性-中度高碳酸血症呼吸衰竭：随机对照非劣效性试验。Crit Care.2024;28:250.Article PubMed PubMed Central Google Scholar Cortegiani A, Longhini F, Madotto F, Groff P, Scala R, Crimi C, et al. High flow nasal therapy versus noninvasive ventilation as initial ventilatory strategy in COPD exacerbation: a multicenter non-inferiority randomized trial.Crit Care.2020;24:692.Article PubMed PubMed Central Google Scholar Rittayamai N, Phuangchoei P, Tscheikuna J, Praphruetkit N, Brochard L. Effects of high-flow nasal cannula and non-invasive ventilation on inspiratory effort in hypercapnic patients with chronic obstructive pulmonary disease: a preliminary study.Ann Intensive Care.2019;9:122.Article PubMed PubMed Central Google Scholar Vogelmeier CF, Criner GJ, Martinez FJ, Anzueto A, Barnes PJ, Bourbeau J, et al. 诊断、管理和预防慢性阻塞性肺病全球战略 2017 年报告：GOLD执行摘要。Eur Respir J. 2017;49:1700214.Article PubMed Google Scholar Wang M, Zhao F, Sun L, Liang Y, Yan W, Sun X, et al. High-flow nasal cannula versus noninvasive ventilation in AECOPD patients with respiratory acidosis: a retrospective propensity score-matched study.Can Respir J. 2023;2023:6377441.Article PubMed PubMed Central Google Scholar Longhini F, Pisani L, Lungu R, Comellini V, Bruni A, Garofalo E, et al. 从高碳酸血症急性呼吸衰竭恢复的患者无创通气中断后的高流量氧疗：生理交叉试验。Crit Care Med.2019;47:e506-11.文章 CAS PubMed Google Scholar 下载参考文献无.作者在本研究中未获得任何资助。作者及单位浙江省杭州市上塘路158号浙江省人民医院（杭州医学院附属人民医院）急危重症医学中心重症医学科徐荣鹏&；邵自强作者简介徐荣鹏查看作者发表的论文您也可以在PubMed Google Scholar中搜索该作者邵自强查看作者发表的论文您也可以在PubMed Google Scholar中搜索该作者供稿RPX和ZQS参与了讨论并撰写了手稿。通讯作者邵自强.伦理批准和参与同意书不适用.发表同意书不适用.利益冲突作者声明他们没有利益冲突.出版者注释Springer Nature对出版地图中的管辖权主张和机构隶属关系保持中立。开放获取本文采用知识共享署名-非商业性-禁止衍生 4.0 国际许可协议进行许可，该协议允许以任何媒介或格式进行非商业性使用、共享、分发和复制，只要您适当注明原作者和来源，提供知识共享许可协议的链接，并说明您是否修改了许可材料。根据本许可协议，您无权分享源自本文或本文部分内容的改编材料。本文中的图片或其他第三方材料均包含在文章的知识共享许可协议中，除非在材料的信用栏中另有说明。如果材料未包含在文章的知识共享许可协议中，且您打算使用的材料不符合法律规定或超出了许可使用范围，则您需要直接获得版权所有者的许可。如需查看该许可的副本，请访问 http://creativecommons.org/licenses/by-nc-nd/4.0/.Reprints and permissionsCite this articleXu, R., Shao, Z. High flow nasal cannula versus non-invasive ventilation in the treatment of acute exacerbations of COPD with acute-moderate hypercapnic respiratory failure.https://doi.org/10.1186/s13054-024-05094-9Download citationReceived：接受：2024 年 8 月 31 日10 September 2024Published: 19 September 2024DOI: https://doi.org/10.1186/s13054-024-05094-9Share 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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Pub Date : 2024-09-19DOI: 10.1186/s13054-024-05100-0
Xu Wang, Shilong Lin, Ming Zhong, Jieqiong Song
<p>Sepsis is a critical condition that significantly burdens healthcare systems globally. Given the heterogeneity among sepsis patients, identifying high-risk mortality groups is crucial [1]. Procalcitonin (PCT) is a well-established biomarker for evaluating sepsis severity and guiding antibiotic therapy [2]. In practice, PCT is usually measured repeatedly during the hospital stay. While single PCT values are helpful, dynamic trends through repeated measurements offer deeper insights into patient prognosis. Traditional analysis methods often fail to fully capture the complexity of these data [3]. By employing a hierarchical linear mixed-effects (HLME) model [4], this study aims to explore distinct PCT trajectories in sepsis patients and their association with mortality, providing a refined approach to risk stratification.</p><p>We here report our main findings in this study. The medical ethics committee of Zhongshan Hospital Fudan University reviewed and approved this study (B2021-501R). Informed consent was waived because of the retrospective nature of the study and the analysis used anonymous clinical data. Between Jan 2019 and March 2024, 537 patients (167 females, 370 males; median age 69 years old [IQR 59–77]) were included. The proportion of patients with septic shock is 47.5%. Abdomen (274/51.0%) and respiratory (202/37.6%) were the two main sites of infection. The median length of stay (LOS) was 10 days [IQR 4–20] in ICU and 15 days [IQR 10–25] in hospital. One hundred sixty-five in-hospital deaths were observed.</p><p>A total of 2492 PCT measurements were available for trajectory modeling analyses. Three classes were identified using the HLME model (Fig. 1A). Class 1, also known as the “high-value-slow-decrease” class, included 43 patients (8%) and was characterized by initially high PCT values that remained stable for the first three days before gradually declining. Class 2, the “consistent-low” class, included 354 patients (66%) and displayed low initial PCT values that remained consistently low over the first 7 days in the ICU. Class 3, the “high-value-fast-decrease” class, included 140 patients (26%) and was marked by high initial PCT values that declined rapidly over time. Baseline characteristics differed significantly between the three PCT classes (Table 1). Patients in Class 1 and Class 3 had higher baseline SOFA scores and required more norepinephrine to maintain blood pressure compared to Class 2. In-hospital mortality was highest in Class 1 (42%) compared to Class 2 (32%) and Class 3 (24%) (<i>P</i> = 0.044). Baseline variables (age, sex, baseline SOFA, baseline lactate, presence of septic shock, surgical intervention, infection sites) and PCT classes were included in the Cox proportional hazards model for in-hospital mortality. With Class 1 as the reference level, Class 2 (HR: 0.507 [95% CI 0.287–0.895], <i>P</i> = 0.020) and Class 3 (HR 0.449 [95% CI 0.244–0.827], <i>P</i> = 0.011) were independent protective factors for in-
败血症是一种危重病，给全球医疗系统带来沉重负担。鉴于败血症患者的异质性，识别高危死亡人群至关重要[1]。降钙素原（PCT）是评估败血症严重程度和指导抗生素治疗的公认生物标志物[2]。实际上，PCT 通常在住院期间反复测量。虽然单一的 PCT 值很有帮助，但通过重复测量得出的动态趋势能更深入地了解患者的预后。传统的分析方法往往无法完全捕捉到这些数据的复杂性[3]。通过采用分层线性混合效应（HLME）模型[4]，本研究旨在探索脓毒症患者不同的 PCT 变化轨迹及其与死亡率的关系，为风险分层提供一种完善的方法。复旦大学附属中山医院医学伦理委员会审查并批准了本研究（B2021-501R）。由于本研究为回顾性研究，且分析使用的是匿名临床数据，因此免除了知情同意。在2019年1月至2024年3月期间，共纳入537例患者（女性167例，男性370例；中位年龄69岁[IQR 59-77]）。脓毒性休克患者占 47.5%。腹部（274/51.0%）和呼吸道（202/37.6%）是两个主要感染部位。在重症监护室的中位住院时间（LOS）为 10 天 [IQR 4-20]，住院时间为 15 天 [IQR 10-25]。共有 2492 个 PCT 测量值可用于轨迹模型分析。使用 HLME 模型确定了三个等级（图 1A）。第 1 类也称为 "高值-缓慢下降 "类，包括 43 名患者（8%），其特点是最初的 PCT 值较高，在前三天保持稳定，然后逐渐下降。第 2 类是 "持续低值 "类，包括 354 名患者（66%），其初始 PCT 值较低，在重症监护室的前 7 天内持续保持低值。第 3 类是 "高值-快速下降 "类，包括 140 名患者（占 26%），其特点是初始 PCT 值较高，但随着时间的推移迅速下降。三个 PCT 等级的基线特征差异很大（表 1）。与 2 级相比，1 级和 3 级患者的基线 SOFA 评分较高，需要更多去甲肾上腺素来维持血压。与 2 级（32%）和 3 级（24%）相比，1 级患者的院内死亡率最高（42%）（P = 0.044）。基线变量（年龄、性别、基线 SOFA、基线乳酸、是否存在脓毒性休克、手术干预、感染部位）和 PCT 分级被纳入院内死亡率的 Cox 比例危险模型。以 1 级为参考水平，2 级（HR：0.507 [95% CI 0.287-0.895]，P = 0.020）和 3 级（HR 0.449 [95% CI 0.244-0.827]，P = 0.011）是院内死亡率的独立保护因素。图 1A 显示了 3 个不同的降钙素原等级。B 包含 3 个等级患者的 Kaplan-Meier 曲线。1 级："高值-缓慢-下降 "级；2 级："持续-低值 "级；3 级："高值-快速-下降 "级图片全尺寸表 1 三个 PCT 级之间基线特征的比较表格全尺寸本研究确定了三种不同的 PCT 轨迹。尽管各等级之间存在明显的基线差异，但 "高值-慢减 "PCT轨迹是导致较高院内死亡率的独立风险因素。鉴于 PCT 轨迹与死亡率之间的密切联系，临床医生必须持续监测 PCT 水平，以发现潜在的高危脓毒症患者。这项研究为临床医生提供了优化临床决策的信息，并有助于制定更个性化、更有效的脓毒症管理策略，最终改善患者的预后。Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, McIntyre L, Ostermann M, Prescott HC, et al. Surviving sepsis campaign: International guidelines for management of sepsis and septic shock 2021.Intensive Care Med.2021;47(11):1181-247.Article PubMed PubMed Central Google Scholar Papp M, Kiss N, Baka M, Trásy D, Zubek L, Fehérvári P, Harnos A, Turan C, Hegyi P, Molnár Z. Procalcitonin-guided antibiotic therapy may shorten length of treatment and may improve survival-a systematic review and meta-analysis.Crit Care.2023;27(1):394.
{"title":"The procalcitonin trajectory as an effective tool for identifying sepsis patients at high risk of mortality","authors":"Xu Wang, Shilong Lin, Ming Zhong, Jieqiong Song","doi":"10.1186/s13054-024-05100-0","DOIUrl":"https://doi.org/10.1186/s13054-024-05100-0","url":null,"abstract":"<p>Sepsis is a critical condition that significantly burdens healthcare systems globally. Given the heterogeneity among sepsis patients, identifying high-risk mortality groups is crucial [1]. Procalcitonin (PCT) is a well-established biomarker for evaluating sepsis severity and guiding antibiotic therapy [2]. In practice, PCT is usually measured repeatedly during the hospital stay. While single PCT values are helpful, dynamic trends through repeated measurements offer deeper insights into patient prognosis. Traditional analysis methods often fail to fully capture the complexity of these data [3]. By employing a hierarchical linear mixed-effects (HLME) model [4], this study aims to explore distinct PCT trajectories in sepsis patients and their association with mortality, providing a refined approach to risk stratification.</p><p>We here report our main findings in this study. The medical ethics committee of Zhongshan Hospital Fudan University reviewed and approved this study (B2021-501R). Informed consent was waived because of the retrospective nature of the study and the analysis used anonymous clinical data. Between Jan 2019 and March 2024, 537 patients (167 females, 370 males; median age 69 years old [IQR 59–77]) were included. The proportion of patients with septic shock is 47.5%. Abdomen (274/51.0%) and respiratory (202/37.6%) were the two main sites of infection. The median length of stay (LOS) was 10 days [IQR 4–20] in ICU and 15 days [IQR 10–25] in hospital. One hundred sixty-five in-hospital deaths were observed.</p><p>A total of 2492 PCT measurements were available for trajectory modeling analyses. Three classes were identified using the HLME model (Fig. 1A). Class 1, also known as the “high-value-slow-decrease” class, included 43 patients (8%) and was characterized by initially high PCT values that remained stable for the first three days before gradually declining. Class 2, the “consistent-low” class, included 354 patients (66%) and displayed low initial PCT values that remained consistently low over the first 7 days in the ICU. Class 3, the “high-value-fast-decrease” class, included 140 patients (26%) and was marked by high initial PCT values that declined rapidly over time. Baseline characteristics differed significantly between the three PCT classes (Table 1). Patients in Class 1 and Class 3 had higher baseline SOFA scores and required more norepinephrine to maintain blood pressure compared to Class 2. In-hospital mortality was highest in Class 1 (42%) compared to Class 2 (32%) and Class 3 (24%) (<i>P</i> = 0.044). Baseline variables (age, sex, baseline SOFA, baseline lactate, presence of septic shock, surgical intervention, infection sites) and PCT classes were included in the Cox proportional hazards model for in-hospital mortality. With Class 1 as the reference level, Class 2 (HR: 0.507 [95% CI 0.287–0.895], <i>P</i> = 0.020) and Class 3 (HR 0.449 [95% CI 0.244–0.827], <i>P</i> = 0.011) were independent protective factors for in-","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"7 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-09-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142245196","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 : 2024-09-18DOI: 10.1186/s13054-024-05091-y
Antenor Rodrigues, Fernando Vieira, Michael C. Sklar, L. Felipe Damiani, Thomas Piraino, Irene Telias, Ewan C. Goligher, W. Darlene Reid, Laurent Brochard
During mechanical ventilation, post-insufflation diaphragm contractions (PIDCs) are non-physiologic and could be injurious. PIDCs could be frequent during reverse-triggering, where diaphragm contractions follow the ventilator rhythm. Whether PIDCs happens with different modes of assisted ventilation is unknown. In mechanically ventilated patients with hypoxemic respiratory failure, we aimed to examine whether PIDCs are associated with ventilator settings, patients’ characteristics or both. One-hour recordings of diaphragm electromyography (EAdi), airway pressure and flow were collected once per day for up to five days from intubation until full recovery of diaphragm activity or death. Each breath was classified as mandatory (without-reverse-triggering), reverse-triggering, or patient triggered. Reverse triggering was further subclassified according to EAdi timing relative to ventilator cycle or reverse triggering leading to breath-stacking. EAdi timing (onset, offset), peak and neural inspiratory time (Tineuro) were measured breath-by-breath and compared to the ventilator expiratory time. A multivariable logistic regression model was used to investigate factors independently associated with PIDCs, including EAdi timing, amplitude, Tineuro, ventilator settings and APACHE II. Forty-seven patients (median[25%-75%IQR] age: 63[52–77] years, BMI: 24.9[22.9–33.7] kg/m2, 49% male, APACHE II: 21[19–28]) contributed 2 ± 1 recordings each, totaling 183,962 breaths. PIDCs occurred in 74% of reverse-triggering, 27% of pressure support breaths, 21% of assist-control breaths, 5% of Neurally Adjusted Ventilatory Assist (NAVA) breaths. PIDCs were associated with higher EAdi peak (odds ratio [OR][95%CI] 1.01[1.01;1.01], longer Tineuro (OR 37.59[34.50;40.98]), shorter ventilator inspiratory time (OR 0.27[0.24;0.30]), high peak inspiratory flow (OR 0.22[0.20;0.26]), and small tidal volumes (OR 0.31[0.25;0.37]) (all P ≤ 0.008). NAVA was associated with absence of PIDCs (OR 0.03[0.02;0.03]; P < 0.001). Reverse triggering was characterized by lower EAdi peak than breaths triggered under pressure support and associated with small tidal volume and shorter set inspiratory time than breaths triggered under assist-control (all P < 0.05). Reverse triggering leading to breath stacking was characterized by higher peak EAdi and longer Tineuro and associated with small tidal volumes compared to all other reverse-triggering phenotypes (all P < 0.05). In critically ill mechanically ventilated patients, PIDCs and reverse triggering phenotypes were associated with potentially modifiable factors, including ventilator settings. Proportional modes like NAVA represent a solution abolishing PIDCs.
{"title":"Post-insufflation diaphragm contractions in patients receiving various modes of mechanical ventilation","authors":"Antenor Rodrigues, Fernando Vieira, Michael C. Sklar, L. Felipe Damiani, Thomas Piraino, Irene Telias, Ewan C. Goligher, W. Darlene Reid, Laurent Brochard","doi":"10.1186/s13054-024-05091-y","DOIUrl":"https://doi.org/10.1186/s13054-024-05091-y","url":null,"abstract":"During mechanical ventilation, post-insufflation diaphragm contractions (PIDCs) are non-physiologic and could be injurious. PIDCs could be frequent during reverse-triggering, where diaphragm contractions follow the ventilator rhythm. Whether PIDCs happens with different modes of assisted ventilation is unknown. In mechanically ventilated patients with hypoxemic respiratory failure, we aimed to examine whether PIDCs are associated with ventilator settings, patients’ characteristics or both. One-hour recordings of diaphragm electromyography (EAdi), airway pressure and flow were collected once per day for up to five days from intubation until full recovery of diaphragm activity or death. Each breath was classified as mandatory (without-reverse-triggering), reverse-triggering, or patient triggered. Reverse triggering was further subclassified according to EAdi timing relative to ventilator cycle or reverse triggering leading to breath-stacking. EAdi timing (onset, offset), peak and neural inspiratory time (Tineuro) were measured breath-by-breath and compared to the ventilator expiratory time. A multivariable logistic regression model was used to investigate factors independently associated with PIDCs, including EAdi timing, amplitude, Tineuro, ventilator settings and APACHE II. Forty-seven patients (median[25%-75%IQR] age: 63[52–77] years, BMI: 24.9[22.9–33.7] kg/m2, 49% male, APACHE II: 21[19–28]) contributed 2 ± 1 recordings each, totaling 183,962 breaths. PIDCs occurred in 74% of reverse-triggering, 27% of pressure support breaths, 21% of assist-control breaths, 5% of Neurally Adjusted Ventilatory Assist (NAVA) breaths. PIDCs were associated with higher EAdi peak (odds ratio [OR][95%CI] 1.01[1.01;1.01], longer Tineuro (OR 37.59[34.50;40.98]), shorter ventilator inspiratory time (OR 0.27[0.24;0.30]), high peak inspiratory flow (OR 0.22[0.20;0.26]), and small tidal volumes (OR 0.31[0.25;0.37]) (all P ≤ 0.008). NAVA was associated with absence of PIDCs (OR 0.03[0.02;0.03]; P < 0.001). Reverse triggering was characterized by lower EAdi peak than breaths triggered under pressure support and associated with small tidal volume and shorter set inspiratory time than breaths triggered under assist-control (all P < 0.05). Reverse triggering leading to breath stacking was characterized by higher peak EAdi and longer Tineuro and associated with small tidal volumes compared to all other reverse-triggering phenotypes (all P < 0.05). In critically ill mechanically ventilated patients, PIDCs and reverse triggering phenotypes were associated with potentially modifiable factors, including ventilator settings. Proportional modes like NAVA represent a solution abolishing PIDCs.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"61 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142236435","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 : 2024-09-18DOI: 10.1186/s13054-024-04974-4
Daniel Agustin Godoy, Sergio Brasil, Andres M. Rubiano
<p>The current approach to severe neuro-injury monitoring, especially traumatic brain injury (TBI), has experienced paradigm shifts that open a broad outlook for the future [1]. On one hand, advances in pathophysiological knowledge have made possible establishing today that intracranial pressure (ICP) control is just one more epiphenomenon within other serious events that occur simultaneously such as tissue hypoxia, metabolic crises and cerebral energy dysfunction [1]. On the other hand, the advent of new monitoring techniques (invasive and noninvasive) have allowed a deeper analysis in real time of what is happening in the injured brain [1]. One of the most important advancements in neuromonitoring was the recent popularization of the analysis of the ICP wave (ICPw) morphology. Current studies pointed the changes in ICPw as reliable markers of cerebrospinal compliance and to be followed in clinical environments. In this regard, ICPw was considered the pillar of the intracranial compartmental syndrome (ICCS) concept [2]. So, <i>“ICCS occurs when the compliance of the intracranial system is compromised as a result of the exhaustion of the compensating mechanisms that try to keep it within normal limits’’</i>. ‘<i>’Perfusion, oxygenation and energy utilization compromise are its consequences’’</i> [2]<i>.</i></p><p>Further enlightenments raised from the recent study of Kazimierska et al., which evaluated a series of 130 patients who were victims of severe TBI from the CENTER-TBI database. Those authors analyzed the relationship between parameters obtained from the neuroimaging Computed Tomography (CT) scan upon admission and variables collected from invasive ICP monitoring [3]. Injury mass volume, degree of midline shift, Marshall’s and Rotterdam classifications were the data provided by the CT scans, while mean ICP values, wave amplitude and indices derived from the analysis of ICP recordings. A neural network model (previously tested with 93% accuracy) was applied in order to automatically group ICP waveforms into 4 classes [3]. As a main finding, the pulse shape index—PSI was strongly correlated with the analyzed tomographic parameters (<i>p</i> = 0.001), while mean ICP was correlated with ICPw amplitude, indicating that the morphology of the ICP pulse wave reflects a decrease in the cerebrospinal compensatory reserve therefore of cerebral compliance [3].</p><p>ICP waveform is a result of complex interaction between volumes (blood, brain and cerebrospinal fluid) restrained by meninges and the bony skull box, interacting with dynamic phenomena as blood viscosity, cardiac and respiratory cycles per example [1]. Therefore, several are the ways of exploring and translating ICPw into parameters readable at the bedside to assess compensatory reserve status. Prior to PSI, the compensatory reserve index (RAP) was described by Czosnyka et al. as the moving correlation between ICP values and ICP pulse amplitude variation [4]. Both the PSI and RAP can be a
Article PubMed PubMed Central Google Scholar Czosnyka M, Smielewski P, Timofeev I, Lavinio A, Guazzo E, Hutchinson P, et al. 颅内压：不仅仅是一个数字。神经外科聚焦。https://doi.org/10.3171/foc.2007.22.5.11.Article PubMed Google Scholar Brasil S, Solla DJF, Nogueira RC, Teixeira MJ, Malbouisson LMS, Paiva WDS.重症监护中颅内压波形监测的新型无创技术。J Pers Med.2021;11(12):1302. https://doi.org/10.3390/jpm11121302.Article PubMed PubMed Central Google Scholar Download referencesNone.Not applicable.Authors and AffiliationsNeurointensive Care Unit, Sanatorio Pasteur, Chacabuco 675, 4700, Catamarca, ArgentinaDaniel Agustin GodoyLIM 62, Department of Neurology, University of Sao Paulo Medical School, Sao Paulo, BrazilSergio Brasil & Andres M. RubianoProfessor of Neurology, University of Sao Paulo.Rubiano哥伦比亚波哥大 El Bosque 大学神经科学和神经外科教授Andres M. Rubiano哥伦比亚卡利 MEDITECH 基金会医学和研究主任Daniel Agustin Godoy, Sergio Brasil & Andres M. RubianoRubianoAuthorsDaniel Agustin GodoyView author publications您也可以在PubMed Google ScholarSergio BrasilView author publications您也可以在PubMed Google ScholarAndres M. RubianoView author publications您也可以在PubMed Google Scholar搜索该作者Rubiano查看作者发表的作品您还可以在PubMed Google Scholar中搜索该作者供稿所有作者的供稿均等通讯作者：Daniel Agustin Godoy伦理批准和参与同意书不适用同意发表所有作者同意发表竞业利益DAG和AMR声称没有竞业利益或利益冲突。开放获取本文采用知识共享署名-非商业性-禁止衍生 4.0 国际许可协议进行许可，该协议允许以任何媒介或格式进行任何非商业性使用、共享、分发和复制，只要您适当注明原作者和来源，提供知识共享许可协议的链接，并说明您是否修改了许可材料。根据本许可协议，您无权分享源自本文或本文部分内容的改编材料。本文中的图片或其他第三方材料均包含在文章的知识共享许可协议中，除非在材料的信用栏中另有说明。如果材料未包含在文章的知识共享许可协议中，且您打算使用的材料不符合法律规定或超出了许可使用范围，则您需要直接获得版权所有者的许可。如需查看该许可的副本，请访问 http://creativecommons.org/licenses/by-nc-nd/4.0/.Reprints and permissionsCite this articleGodoy, D.A., Brasil, S. & Rubiano, A.M. Further support for the intracranial compartmental syndrome concept.Crit Care 28, 311 (2024). https://doi.org/10.1186/s13054-024-04974-4Download citationReceived：11 March 2024Accepted: 27 May 2024Published: 18 September 2024DOI: https://doi.org/10.1186/s13054-024-04974-4Share 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
{"title":"Further support for the intracranial compartmental syndrome concept","authors":"Daniel Agustin Godoy, Sergio Brasil, Andres M. Rubiano","doi":"10.1186/s13054-024-04974-4","DOIUrl":"https://doi.org/10.1186/s13054-024-04974-4","url":null,"abstract":"<p>The current approach to severe neuro-injury monitoring, especially traumatic brain injury (TBI), has experienced paradigm shifts that open a broad outlook for the future [1]. On one hand, advances in pathophysiological knowledge have made possible establishing today that intracranial pressure (ICP) control is just one more epiphenomenon within other serious events that occur simultaneously such as tissue hypoxia, metabolic crises and cerebral energy dysfunction [1]. On the other hand, the advent of new monitoring techniques (invasive and noninvasive) have allowed a deeper analysis in real time of what is happening in the injured brain [1]. One of the most important advancements in neuromonitoring was the recent popularization of the analysis of the ICP wave (ICPw) morphology. Current studies pointed the changes in ICPw as reliable markers of cerebrospinal compliance and to be followed in clinical environments. In this regard, ICPw was considered the pillar of the intracranial compartmental syndrome (ICCS) concept [2]. So, <i>“ICCS occurs when the compliance of the intracranial system is compromised as a result of the exhaustion of the compensating mechanisms that try to keep it within normal limits’’</i>. ‘<i>’Perfusion, oxygenation and energy utilization compromise are its consequences’’</i> [2]<i>.</i></p><p>Further enlightenments raised from the recent study of Kazimierska et al., which evaluated a series of 130 patients who were victims of severe TBI from the CENTER-TBI database. Those authors analyzed the relationship between parameters obtained from the neuroimaging Computed Tomography (CT) scan upon admission and variables collected from invasive ICP monitoring [3]. Injury mass volume, degree of midline shift, Marshall’s and Rotterdam classifications were the data provided by the CT scans, while mean ICP values, wave amplitude and indices derived from the analysis of ICP recordings. A neural network model (previously tested with 93% accuracy) was applied in order to automatically group ICP waveforms into 4 classes [3]. As a main finding, the pulse shape index—PSI was strongly correlated with the analyzed tomographic parameters (<i>p</i> = 0.001), while mean ICP was correlated with ICPw amplitude, indicating that the morphology of the ICP pulse wave reflects a decrease in the cerebrospinal compensatory reserve therefore of cerebral compliance [3].</p><p>ICP waveform is a result of complex interaction between volumes (blood, brain and cerebrospinal fluid) restrained by meninges and the bony skull box, interacting with dynamic phenomena as blood viscosity, cardiac and respiratory cycles per example [1]. Therefore, several are the ways of exploring and translating ICPw into parameters readable at the bedside to assess compensatory reserve status. Prior to PSI, the compensatory reserve index (RAP) was described by Czosnyka et al. as the moving correlation between ICP values and ICP pulse amplitude variation [4]. Both the PSI and RAP can be a","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"46 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142236434","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 : 2024-09-17DOI: 10.1186/s13054-024-05075-y
Marry R. Smit, Maud Boumans, William Aerts, Pieter R. Tuinman
We would like to extend our gratitude to Dr. da Hora Passos et al. for their interest in our recently published review and meta-analysis in Critical Care. In this response, we will elaborate on the points raised by the authors. We agree with the authors that LUS, like any other diagnostic technique, is valuable and safe only when utilized by trained operators. The authors expressed uncertainty regarding the sensitivity of LUS in detecting mild ARDS or ARDS at an early stage. This variance in sensitivity is more likely due to diversity in diagnostic thresholds. We advocate for global collaboration among LUS experts to align LUS methodologies and strengthen the evidence supporting LUS in the diagnosis of ARDS and its morphological subphenotypes.
{"title":"Lung ultrasound and ARDS: global collaboration is the way to go","authors":"Marry R. Smit, Maud Boumans, William Aerts, Pieter R. Tuinman","doi":"10.1186/s13054-024-05075-y","DOIUrl":"https://doi.org/10.1186/s13054-024-05075-y","url":null,"abstract":"We would like to extend our gratitude to Dr. da Hora Passos et al. for their interest in our recently published review and meta-analysis in Critical Care. In this response, we will elaborate on the points raised by the authors. We agree with the authors that LUS, like any other diagnostic technique, is valuable and safe only when utilized by trained operators. The authors expressed uncertainty regarding the sensitivity of LUS in detecting mild ARDS or ARDS at an early stage. This variance in sensitivity is more likely due to diversity in diagnostic thresholds. We advocate for global collaboration among LUS experts to align LUS methodologies and strengthen the evidence supporting LUS in the diagnosis of ARDS and its morphological subphenotypes.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"32 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-09-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142235009","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 : 2024-09-17DOI: 10.1186/s13054-024-05095-8
Yuxin Yang, Xuan Xiong, Xiaofei Wang, Qionglan Dong, Lingai Pan
This study aimed to evaluate whether endotracheal tubes (ETTs) with a metal coating reduce the incidence of ventilator-associated pneumonia (VAP) compared to uncoated ETTs. An extensive literature review was conducted to find studies that compared metal-coated ETT with uncoated ETT across four databases: PubMed, Embase, Cochrane Library, and Web of Science. The search parameters were set from the inception of each database until June 2024. The primary outcome measures were the rates of VAP and hospital mortality. Two independent researchers carried out the literature selection, data extraction, and quality evaluation. Data analysis was performed with RevMan 5.4.1. Furthermore, a Deeks funnel plot was used to evaluate potential publication bias in the studies included. Following the screening process, five randomized controlled trials (RCTs) encompassing a total of 2157 patients were identified. In terms of the primary outcome, the VAP incidence was found to be lower in the group utilizing metal-coated ETT compared to those with uncoated ETT, demonstrating a statistically significant difference [RR = 0.71, 95% CI (0.54–0.95), P = 0.02]. No notable difference in mortality rates was observed between the two groups [RR = 1.05, 95% CI (0.86–1.27), P = 0.65]. Concerning secondary outcomes, two studies were evaluated to compare the mechanical ventilation duration (RR = 0.60, 95% CI (− 0.52, 1.72), P = 0.29, I2 = 97%) and intensive care unit (ICU) stay for both patient groups (RR = 0.47, 95% CI (− 1.02, 1.95), P = 0.54, I2 = 50%). Due to the marked heterogeneity, a comparison of mechanical ventilation length between the two patient groups was not feasible. However, both studies suggested no significant difference in ventilation duration between patients using metal-coated ETT and those with uncoated ETT. Metal-coated ETT show a lower occurrence of VAP compared to the uncoated ETT. Nevertheless, they do not considerably decrease the length of mechanical ventilation, the duration of ICU admission, nor do they reduce hospital mortality rates. Systematic review registration: https://www.crd.york.ac.uk/prospero/ , identifier CRD42024560618.
本研究旨在评估与无涂层气管插管（ETT）相比，有金属涂层的气管插管（ETT）是否能降低呼吸机相关性肺炎（VAP）的发病率。我们进行了广泛的文献综述，在四个数据库中找到了比较金属涂层 ETT 和无涂层 ETT 的研究：PubMed、Embase、Cochrane Library 和 Web of Science。搜索参数设置从每个数据库建立之初到 2024 年 6 月。主要结果指标为 VAP 发生率和住院死亡率。两名独立研究人员进行了文献筛选、数据提取和质量评估。数据分析使用 RevMan 5.4.1 进行。此外，还使用 Deeks 漏斗图评估了纳入研究中潜在的发表偏倚。经过筛选，确定了五项随机对照试验（RCT），共涉及 2157 名患者。在主要结果方面，使用金属涂层 ETT 组的 VAP 发生率低于使用无涂层 ETT 组，差异具有统计学意义[RR = 0.71，95% CI (0.54-0.95)，P = 0.02]。两组死亡率无明显差异[RR = 1.05，95% CI (0.86-1.27)，P = 0.65]。关于次要结果，对两项研究进行了评估，以比较两组患者的机械通气持续时间（RR = 0.60，95% CI (- 0.52, 1.72)，P = 0.29，I2 = 97%）和重症监护室（ICU）停留时间（RR = 0.47，95% CI (- 1.02, 1.95)，P = 0.54，I2 = 50%）。由于存在明显的异质性，因此无法对两组患者的机械通气时间进行比较。不过，两项研究均表明，使用金属涂层 ETT 的患者与使用无涂层 ETT 的患者在通气时间上没有明显差异。与无涂层 ETT 相比，金属涂层 ETT 的 VAP 发生率较低。尽管如此，金属涂层 ETT 并没有显著缩短机械通气时间和重症监护病房的住院时间，也没有降低住院死亡率。系统综述注册：https://www.crd.york.ac.uk/prospero/ ，标识符为 CRD42024560618。
{"title":"Prevention of ventilator-associated pneumonia by metal-coated endotracheal tubes: a meta-analysis","authors":"Yuxin Yang, Xuan Xiong, Xiaofei Wang, Qionglan Dong, Lingai Pan","doi":"10.1186/s13054-024-05095-8","DOIUrl":"https://doi.org/10.1186/s13054-024-05095-8","url":null,"abstract":"This study aimed to evaluate whether endotracheal tubes (ETTs) with a metal coating reduce the incidence of ventilator-associated pneumonia (VAP) compared to uncoated ETTs. An extensive literature review was conducted to find studies that compared metal-coated ETT with uncoated ETT across four databases: PubMed, Embase, Cochrane Library, and Web of Science. The search parameters were set from the inception of each database until June 2024. The primary outcome measures were the rates of VAP and hospital mortality. Two independent researchers carried out the literature selection, data extraction, and quality evaluation. Data analysis was performed with RevMan 5.4.1. Furthermore, a Deeks funnel plot was used to evaluate potential publication bias in the studies included. Following the screening process, five randomized controlled trials (RCTs) encompassing a total of 2157 patients were identified. In terms of the primary outcome, the VAP incidence was found to be lower in the group utilizing metal-coated ETT compared to those with uncoated ETT, demonstrating a statistically significant difference [RR = 0.71, 95% CI (0.54–0.95), P = 0.02]. No notable difference in mortality rates was observed between the two groups [RR = 1.05, 95% CI (0.86–1.27), P = 0.65]. Concerning secondary outcomes, two studies were evaluated to compare the mechanical ventilation duration (RR = 0.60, 95% CI (− 0.52, 1.72), P = 0.29, I2 = 97%) and intensive care unit (ICU) stay for both patient groups (RR = 0.47, 95% CI (− 1.02, 1.95), P = 0.54, I2 = 50%). Due to the marked heterogeneity, a comparison of mechanical ventilation length between the two patient groups was not feasible. However, both studies suggested no significant difference in ventilation duration between patients using metal-coated ETT and those with uncoated ETT. Metal-coated ETT show a lower occurrence of VAP compared to the uncoated ETT. Nevertheless, they do not considerably decrease the length of mechanical ventilation, the duration of ICU admission, nor do they reduce hospital mortality rates. Systematic review registration: https://www.crd.york.ac.uk/prospero/ , identifier CRD42024560618.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"329 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-09-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142236438","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 : 2024-09-17DOI: 10.1186/s13054-024-05092-x
Francisco José Parrilla-Gómez, Ferran Roche-Campo, Stefano Italiano, Andrés Parrilla-Gómez, Indalecio Morán, Jordi Mancebo, Tommaso Maraffi
Weaning patients from mechanical ventilation is crucial in the management of acute respiratory failure (ARF). Spontaneous breathing trials (SBT) are used to assess readiness for extubation, but extubation failure remains a challenge. Diaphragmatic function, measured by electrical activity of the diaphragm (EAdi), may provide insights into weaning outcomes. This prospective, observational study included difficult-to-wean patients undergoing invasive mechanical ventilation. EAdi was recorded before, during, and after extubation. Patients were categorized into extubation success and failure groups based on reintubation within 48 h. Statistical analysis assessed EAdi patterns and predictive value. Thirty-one patients were analyzed, with six experiencing extubation failure. Overall, EAdi increased significantly between the phases before the SBT, the SBT and post-extubation period, up to 24 h (p < 0.001). EAdi values were higher in the extubation failure group during SBT (p = 0.01). An EAdi > 30 μV during SBT predicted extubation failure with 92% sensitivity and 67% specificity. Multivariable analysis confirmed EAdi as an independent predictor of extubation failure. In difficult-to-wean patients, EAdi increases significantly between the phases before the SBT, the SBT and post-extubation period and is significantly higher in patients experiencing extubation failure. An EAdi > 30 μV during SBT may enhance extubation failure prediction compared to conventional parameters. Advanced monitoring of diaphragmatic function could improve weaning outcomes in critical care settings.
{"title":"Time course of electrical activity of the diaphragm (EAdi) in the peri extubation period and its role as predictor of extubation failure in difficult to wean patients","authors":"Francisco José Parrilla-Gómez, Ferran Roche-Campo, Stefano Italiano, Andrés Parrilla-Gómez, Indalecio Morán, Jordi Mancebo, Tommaso Maraffi","doi":"10.1186/s13054-024-05092-x","DOIUrl":"https://doi.org/10.1186/s13054-024-05092-x","url":null,"abstract":"Weaning patients from mechanical ventilation is crucial in the management of acute respiratory failure (ARF). Spontaneous breathing trials (SBT) are used to assess readiness for extubation, but extubation failure remains a challenge. Diaphragmatic function, measured by electrical activity of the diaphragm (EAdi), may provide insights into weaning outcomes. This prospective, observational study included difficult-to-wean patients undergoing invasive mechanical ventilation. EAdi was recorded before, during, and after extubation. Patients were categorized into extubation success and failure groups based on reintubation within 48 h. Statistical analysis assessed EAdi patterns and predictive value. Thirty-one patients were analyzed, with six experiencing extubation failure. Overall, EAdi increased significantly between the phases before the SBT, the SBT and post-extubation period, up to 24 h (p < 0.001). EAdi values were higher in the extubation failure group during SBT (p = 0.01). An EAdi > 30 μV during SBT predicted extubation failure with 92% sensitivity and 67% specificity. Multivariable analysis confirmed EAdi as an independent predictor of extubation failure. In difficult-to-wean patients, EAdi increases significantly between the phases before the SBT, the SBT and post-extubation period and is significantly higher in patients experiencing extubation failure. An EAdi > 30 μV during SBT may enhance extubation failure prediction compared to conventional parameters. Advanced monitoring of diaphragmatic function could improve weaning outcomes in critical care settings.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"13 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-09-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142236436","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}
To detect preload responsiveness in patients ventilated with a tidal volume (Vt) at 6 mL/kg of predicted body weight (PBW), the Vt-challenge consists in increasing Vt from 6 to 8 mL/kg PBW and measuring the increase in pulse pressure variation (PPV). However, this requires an arterial catheter. The perfusion index (PI), which reflects the amplitude of the photoplethysmographic signal, may reflect stroke volume and its respiratory variation (pleth variability index, PVI) may estimate PPV. We assessed whether Vt-challenge-induced changes in PI or PVI could be as reliable as changes in PPV for detecting preload responsiveness defined by a PLR-induced increase in cardiac index (CI) ≥ 10%. In critically ill patients ventilated with Vt = 6 mL/kg PBW and no spontaneous breathing, haemodynamic (PICCO2 system) and photoplethysmographic (Masimo-SET technique, sensor placed on the finger or the forehead) data were recorded during a Vt-challenge and a PLR test. Among 63 screened patients, 21 (33%) were excluded because of an unstable PI signal and/or atrial fibrillation and 42 were included. During the Vt-challenge in the 16 preload responders, CI decreased by 4.8 ± 2.8% (percent change), PPV increased by 4.4 ± 1.9% (absolute change), PIfinger decreased by 14.5 ± 10.7% (percent change), PVIfinger increased by 1.9 ± 2.6% (absolute change), PIforehead decreased by 18.7 ± 10.9 (percent change) and PVIforehead increased by 1.0 ± 2.5 (absolute change). All these changes were larger than in preload non-responders. The area under the ROC curve (AUROC) for detecting preload responsiveness was 0.97 ± 0.02 for the Vt-challenge-induced changes in CI (percent change), 0.95 ± 0.04 for the Vt-challenge-induced changes in PPV (absolute change), 0.98 ± 0.02 for Vt-challenge-induced changes in PIforehead (percent change) and 0.85 ± 0.05 for Vt-challenge-induced changes in PIfinger (percent change) (p = 0.04 vs. PIforehead). The AUROC for the Vt-challenge-induced changes in PVIforehead and PVIfinger was significantly larger than 0.50, but smaller than the AUROC for the Vt-challenge-induced changes in PPV. In patients under mechanical ventilation with no spontaneous breathing and/or atrial fibrillation, changes in PI detected during Vt-challenge reliably detected preload responsiveness. The reliability was better when PI was measured on the forehead than on the fingertip. Changes in PVI during the Vt-challenge also detected preload responsiveness, but with lower accuracy.
{"title":"Testing preload responsiveness by the tidal volume challenge assessed by the photoplethysmographic perfusion index","authors":"Chiara Bruscagnin, Rui Shi, Daniela Rosalba, Gaelle Fouqué, Julien Hagry, Christopher Lai, Katia Donadello, Tài Pham, Jean-Louis Teboul, Xavier Monnet","doi":"10.1186/s13054-024-05085-w","DOIUrl":"https://doi.org/10.1186/s13054-024-05085-w","url":null,"abstract":"To detect preload responsiveness in patients ventilated with a tidal volume (Vt) at 6 mL/kg of predicted body weight (PBW), the Vt-challenge consists in increasing Vt from 6 to 8 mL/kg PBW and measuring the increase in pulse pressure variation (PPV). However, this requires an arterial catheter. The perfusion index (PI), which reflects the amplitude of the photoplethysmographic signal, may reflect stroke volume and its respiratory variation (pleth variability index, PVI) may estimate PPV. We assessed whether Vt-challenge-induced changes in PI or PVI could be as reliable as changes in PPV for detecting preload responsiveness defined by a PLR-induced increase in cardiac index (CI) ≥ 10%. In critically ill patients ventilated with Vt = 6 mL/kg PBW and no spontaneous breathing, haemodynamic (PICCO2 system) and photoplethysmographic (Masimo-SET technique, sensor placed on the finger or the forehead) data were recorded during a Vt-challenge and a PLR test. Among 63 screened patients, 21 (33%) were excluded because of an unstable PI signal and/or atrial fibrillation and 42 were included. During the Vt-challenge in the 16 preload responders, CI decreased by 4.8 ± 2.8% (percent change), PPV increased by 4.4 ± 1.9% (absolute change), PIfinger decreased by 14.5 ± 10.7% (percent change), PVIfinger increased by 1.9 ± 2.6% (absolute change), PIforehead decreased by 18.7 ± 10.9 (percent change) and PVIforehead increased by 1.0 ± 2.5 (absolute change). All these changes were larger than in preload non-responders. The area under the ROC curve (AUROC) for detecting preload responsiveness was 0.97 ± 0.02 for the Vt-challenge-induced changes in CI (percent change), 0.95 ± 0.04 for the Vt-challenge-induced changes in PPV (absolute change), 0.98 ± 0.02 for Vt-challenge-induced changes in PIforehead (percent change) and 0.85 ± 0.05 for Vt-challenge-induced changes in PIfinger (percent change) (p = 0.04 vs. PIforehead). The AUROC for the Vt-challenge-induced changes in PVIforehead and PVIfinger was significantly larger than 0.50, but smaller than the AUROC for the Vt-challenge-induced changes in PPV. In patients under mechanical ventilation with no spontaneous breathing and/or atrial fibrillation, changes in PI detected during Vt-challenge reliably detected preload responsiveness. The reliability was better when PI was measured on the forehead than on the fingertip. Changes in PVI during the Vt-challenge also detected preload responsiveness, but with lower accuracy.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"53 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142234501","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 : 2024-09-16DOI: 10.1186/s13054-024-05097-6
Stefano Spina, Lea Mantz, Yi Xin, David C. Moscho, Roberta Ribeiro De Santis Santiago, Luigi Grassi, Alice Nova, Sarah E. Gerard, Edward A. Bittner, Florian J. Fintelmann, Lorenzo Berra, Maurizio Cereda
The superimposed pressure is the primary determinant of the pleural pressure gradient. Obesity is associated with elevated end-expiratory esophageal pressure, regardless of lung disease severity, and the superimposed pressure might not be the only determinant of the pleural pressure gradient. The study aims to measure partitioned respiratory mechanics and superimposed pressure in a cohort of patients admitted to the ICU with and without class III obesity (BMI ≥ 40 kg/m2), and to quantify the amount of thoracic adipose tissue and muscle through advanced imaging techniques. This is a single-center observational study including ICU-admitted patients with acute respiratory failure who underwent a chest computed tomography scan within three days before/after esophageal manometry. The superimposed pressure was calculated from lung density and height of the largest axial lung slice. Automated deep-learning pipelines segmented lung parenchyma and quantified thoracic adipose tissue and skeletal muscle. N = 18 participants (50% female, age 60 [30–66] years), with 9 having BMI < 30 and 9 ≥ 40 kg/m2. Groups showed no significant differences in age, sex, clinical severity scores, or mortality. Patients with BMI ≥ 40 exhibited higher esophageal pressure (15.8 ± 2.6 vs. 8.3 ± 4.9 cmH2O, p = 0.001), higher pleural pressure gradient (11.1 ± 4.5 vs. 6.3 ± 4.9 cmH2O, p = 0.04), while superimposed pressure did not differ (6.8 ± 1.1 vs. 6.5 ± 1.5 cmH2O, p = 0.59). Subcutaneous and intrathoracic adipose tissue were significantly higher in subjects with BMI ≥ 40 and correlated positively with esophageal pressure and pleural pressure gradient (p < 0.05). Muscle areas did not differ between groups. In patients with class III obesity, the superimposed pressure does not approximate the pleural pressure gradient, which is higher than in patients with lower BMI. The quantity and distribution of subcutaneous and intrathoracic adiposity also contribute to increased pleural pressure gradients in individuals with BMI ≥ 40. This study introduces a novel physiological concept that provides a solid rationale for tailoring mechanical ventilation in patients with high BMI, where specific guidelines recommendations are lacking.
{"title":"The pleural gradient does not reflect the superimposed pressure in patients with class III obesity","authors":"Stefano Spina, Lea Mantz, Yi Xin, David C. Moscho, Roberta Ribeiro De Santis Santiago, Luigi Grassi, Alice Nova, Sarah E. Gerard, Edward A. Bittner, Florian J. Fintelmann, Lorenzo Berra, Maurizio Cereda","doi":"10.1186/s13054-024-05097-6","DOIUrl":"https://doi.org/10.1186/s13054-024-05097-6","url":null,"abstract":"The superimposed pressure is the primary determinant of the pleural pressure gradient. Obesity is associated with elevated end-expiratory esophageal pressure, regardless of lung disease severity, and the superimposed pressure might not be the only determinant of the pleural pressure gradient. The study aims to measure partitioned respiratory mechanics and superimposed pressure in a cohort of patients admitted to the ICU with and without class III obesity (BMI ≥ 40 kg/m2), and to quantify the amount of thoracic adipose tissue and muscle through advanced imaging techniques. This is a single-center observational study including ICU-admitted patients with acute respiratory failure who underwent a chest computed tomography scan within three days before/after esophageal manometry. The superimposed pressure was calculated from lung density and height of the largest axial lung slice. Automated deep-learning pipelines segmented lung parenchyma and quantified thoracic adipose tissue and skeletal muscle. N = 18 participants (50% female, age 60 [30–66] years), with 9 having BMI < 30 and 9 ≥ 40 kg/m2. Groups showed no significant differences in age, sex, clinical severity scores, or mortality. Patients with BMI ≥ 40 exhibited higher esophageal pressure (15.8 ± 2.6 vs. 8.3 ± 4.9 cmH2O, p = 0.001), higher pleural pressure gradient (11.1 ± 4.5 vs. 6.3 ± 4.9 cmH2O, p = 0.04), while superimposed pressure did not differ (6.8 ± 1.1 vs. 6.5 ± 1.5 cmH2O, p = 0.59). Subcutaneous and intrathoracic adipose tissue were significantly higher in subjects with BMI ≥ 40 and correlated positively with esophageal pressure and pleural pressure gradient (p < 0.05). Muscle areas did not differ between groups. In patients with class III obesity, the superimposed pressure does not approximate the pleural pressure gradient, which is higher than in patients with lower BMI. The quantity and distribution of subcutaneous and intrathoracic adiposity also contribute to increased pleural pressure gradients in individuals with BMI ≥ 40. This study introduces a novel physiological concept that provides a solid rationale for tailoring mechanical ventilation in patients with high BMI, where specific guidelines recommendations are lacking.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"36 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142235010","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 : 2024-09-14DOI: 10.1186/s13054-024-05090-z
Paul Zajic, Teresa Engelbrecht, Alexandra Graf, Barbara Metnitz, Rui Moreno, Martin Posch, Andrew Rhodes, Philipp Metnitz
Too high or too low patient volumes and work amounts may overwhelm health care professionals and obstruct processes or lead to inadequate personnel routine and process flow. We sought to evaluate, whether an association between current caseload, current workload, and outcomes exists in intensive care units (ICU). Retrospective cohort analysis of data from an Austrian ICU registry. Data on patients aged ≥ 18 years admitted to 144 Austrian ICUs between 2013 and 2022 were included. A Cox proportional hazards model with ICU mortality as the outcome of interest adjusted with patients’ respective SAPS 3, current ICU caseload (measured by ICU occupancy rates), and current ICU workload (measured by median TISS-28 per ICU) as time-dependent covariables was constructed. Subgroup analyses were performed for types of ICUs, hospital care level, and pre-COVID or intra-COVID period. 415 584 patient admissions to 144 ICUs were analysed. Compared to ICU caseloads of 76 to 100%, there was no significant relationship between overuse of ICU capacity and risk of death [HR (95% CI) 1.06 (0.99–1.15), p = 0.110 for > 100%], but for lower utilisation [1.09 (1.02–1.16), p = 0.008 for ≤ 50% and 1.10 (1.05–1.15), p < 0.0001 for 51–75%]. Exceptions were significant associations for caseloads > 100% between 2020 and 2022 [1.18 (1.06–1.30), p = 0.001], i.e., the intra-COVID period. Compared to the reference category of median TISS-28 21–30, lower [0.88 (0.78–0.99), p = 0.049 for ≤ 20], but not higher workloads were significantly associated with risk of death. High workload may be associated with higher mortality in local hospitals [1.09 (1.01–1.19), p = 0.035 for 31–40, 1.28 (1.02–1.60), p = 0.033 for > 40]. In a system with comparably high intensive care resources and mandatory staffing levels, patients’ survival chances are generally not affected by high intensive care unit caseload and workload. However, extraordinary circumstances, such as the COVID-19 pandemic, may lead to higher risk of death, if planned capacities are exceeded. High workload in ICUs in smaller hospitals with lower staffing levels may be associated with increased risk of death.
{"title":"Intensive care unit caseload and workload and their association with outcomes in critically unwell patients: a large registry-based cohort analysis","authors":"Paul Zajic, Teresa Engelbrecht, Alexandra Graf, Barbara Metnitz, Rui Moreno, Martin Posch, Andrew Rhodes, Philipp Metnitz","doi":"10.1186/s13054-024-05090-z","DOIUrl":"https://doi.org/10.1186/s13054-024-05090-z","url":null,"abstract":"Too high or too low patient volumes and work amounts may overwhelm health care professionals and obstruct processes or lead to inadequate personnel routine and process flow. We sought to evaluate, whether an association between current caseload, current workload, and outcomes exists in intensive care units (ICU). Retrospective cohort analysis of data from an Austrian ICU registry. Data on patients aged ≥ 18 years admitted to 144 Austrian ICUs between 2013 and 2022 were included. A Cox proportional hazards model with ICU mortality as the outcome of interest adjusted with patients’ respective SAPS 3, current ICU caseload (measured by ICU occupancy rates), and current ICU workload (measured by median TISS-28 per ICU) as time-dependent covariables was constructed. Subgroup analyses were performed for types of ICUs, hospital care level, and pre-COVID or intra-COVID period. 415 584 patient admissions to 144 ICUs were analysed. Compared to ICU caseloads of 76 to 100%, there was no significant relationship between overuse of ICU capacity and risk of death [HR (95% CI) 1.06 (0.99–1.15), p = 0.110 for > 100%], but for lower utilisation [1.09 (1.02–1.16), p = 0.008 for ≤ 50% and 1.10 (1.05–1.15), p < 0.0001 for 51–75%]. Exceptions were significant associations for caseloads > 100% between 2020 and 2022 [1.18 (1.06–1.30), p = 0.001], i.e., the intra-COVID period. Compared to the reference category of median TISS-28 21–30, lower [0.88 (0.78–0.99), p = 0.049 for ≤ 20], but not higher workloads were significantly associated with risk of death. High workload may be associated with higher mortality in local hospitals [1.09 (1.01–1.19), p = 0.035 for 31–40, 1.28 (1.02–1.60), p = 0.033 for > 40]. In a system with comparably high intensive care resources and mandatory staffing levels, patients’ survival chances are generally not affected by high intensive care unit caseload and workload. However, extraordinary circumstances, such as the COVID-19 pandemic, may lead to higher risk of death, if planned capacities are exceeded. High workload in ICUs in smaller hospitals with lower staffing levels may be associated with increased risk of death.","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"61 1","pages":""},"PeriodicalIF":15.1,"publicationDate":"2024-09-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142231452","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}
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