CHEST critical care最新文献

英文中文

ICU Reintubation Rates ICU再插管率

CHEST critical care

Pub Date : 2025-10-01 DOI: 10.1016/j.chstcc.2025.100219

Akram Khan MBBS, Shewit P. Giovanni MD

引用次数: 0

Continuous Opioid Infusion Among Patients Who Receive Mechanical Ventilation and Who Transition to Comfort-Focused Care 接受机械通气并过渡到以舒适为中心的护理的患者的持续阿片类药物输注

CHEST critical care

Pub Date : 2025-09-30 DOI: 10.1016/j.chstcc.2025.100214

Justin M. Rucci MD , Tenzin Dechen MPH , Ashley O’Donoghue PhD , Emma Lee BA , Nicholas A. Bosch MD , Allan J. Walkey MD , Jennifer P. Stevens MD

引用次数: 0

Analyzing Granular Data to Evaluate a New Indication For an Old Therapy 分析颗粒数据以评估旧疗法的新适应症

CHEST critical care

Pub Date : 2025-09-30 DOI: 10.1016/j.chstcc.2025.100216

Anna K. Barker MD, PhD, Michael W. Sjoding MD

引用次数: 0

Evaluation of Tracheal Pressure During Invasive CPAP Ventilation 有创CPAP通气期间气管压力的评估

CHEST critical care

Pub Date : 2025-09-24 DOI: 10.1016/j.chstcc.2025.100212

Patrick Spraider PhD, Julia Abram MD, Janett Kreutziger MD, Stefan Schmid MD, Christopher Rugg MD

Background

Intubated but spontaneously breathing patients in the ICU frequently are treated with CPAP ventilation during weaning from mechanical ventilation. However, depending on the patient’s inspiratory effort, a pressure gradient along the airway may arise, potentially even leading to negative values at the tracheal space.

Research Question

Does a significant difference exist in tracheal and airway measured inspiratory pressure?

Study Design and Methods

Twenty patients in the ICU were enrolled (median age, 68 years [interquartile range (IQR), 63-73 years]; 4 female patients). During a set positive end-expiratory pressure (PEEP) of 10 cm H₂O, the tracheal pressure course was recorded. Subsequently, a comparison of tracheal and artificial airway pressures was performed during CPAP and after applying a pressure support of 4 cm H₂O (pressure support ventilation [PSV]) or automatic tube compensation (ATC).

Results

As a primary outcome parameter, the median inspiratory pressure measured in the trachea was significantly lower than simultaneously measured airway pressures (median, 2.7 cm H₂O [IQR, 0.2-3.7 cm H₂O] vs 9.0 cm H₂O [IQR, 8.5-9.2 cm H₂O]; P < .001). In 5 patients, negative tracheal pressures were recorded. Secondary outcome parameters revealed comparable end-expiratory pressures, but significantly higher peak and lower mean pressures when measured in the trachea. Adding PSV or ATC slightly attenuated this inspiratory pressure drop, leading to a significant increase in inspiratory tracheal pressures.

Interpretation

Our results show that in intubated, spontaneously breathing patients in the ICU with a set PEEP of 10 cm H₂O, the nadir of tracheal pressures during inspiration is significantly lower than airway pressures measured by the ventilator. Consistently positive tracheal pressures cannot be guaranteed by CPAP throughout the respiratory cycle. Assisted ventilation with PSV or ATC is capable of reducing the pressure drop during inspiration.

Clinical Trial Registration

ClinicalTrials.gov; No.: NCT05679635; URL: www.clinicaltrials.gov

背景：ICU中插管但自主呼吸的患者在脱离机械通气时经常使用CPAP通气治疗。然而，根据患者的吸气力度，沿气道可能出现压力梯度，甚至可能导致气管间隙出现负值。研究问题：气管和气道吸气压测量值是否存在显著差异？研究设计与方法纳入20例ICU患者(中位年龄68岁[四分位间距63-73岁]；女性4例)。在设定呼气末正压（PEEP）为10 cm H2O时，记录气管压力过程。随后，在CPAP期间和施加4cm H2O压力支持（压力支持通气[PSV]）或自动管道补偿（ATC）后，进行气管和人工气道压力的比较。结果作为主要结局参数，气管内测量的吸气压力中位数明显低于同时测量的气道压力（中位数，2.7 cm H2O [IQR, 0.2-3.7 cm H2O] vs 9.0 cm H2O [IQR, 8.5-9.2 cm H2O]; P < .001）。5例患者出现气管负压。次要结局参数显示类似的呼气末压力，但在气管测量时明显更高的峰值和更低的平均压力。添加PSV或ATC可轻微减弱吸气压降，导致吸气气管压力显著增加。我们的研究结果表明，在ICU中插管，自主呼吸的患者，设定PEEP为10 cm H2O时，吸气时气管压力的最低点明显低于呼吸机测量的气道压力。在整个呼吸周期中，CPAP不能保证持续的气管正压。使用PSV或ATC辅助通气能够减少吸气时的压降。临床试验注册网站clinicaltrials .gov；否。: NCT05679635;URL: www.clinicaltrials.gov

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引用次数: 0

Predictors of Patient-Reported Financial Hardship in Patients Hospitalized With Critical Illness and Its Association With Patient Outcomes 危重疾病住院患者报告经济困难的预测因素及其与患者预后的关系

CHEST critical care

Pub Date : 2025-09-24 DOI: 10.1016/j.chstcc.2025.100213

Alison M. Uyeda MD , Peter May PhD , C. Clare Pytel MPA , Elizabeth L. Nielsen MPH , Ruth A. Engelberg PhD , Nita Khandelwal MD

Background

A high burden of financial hardship has been demonstrated in critically ill patients. Understanding the sociodemographic and clinical risk factors for financial hardship and its association with patient outcomes can help to guide future interventions to mitigate financial hardship in this patient population.

Research Question

What are the sociodemographic and clinical risk factors for financial hardship in critically ill patients and its association with patient-reported outcomes?

Study Design and Methods

This prospective cohort study enrolled adults with chronic, life-limiting illness, acute severe illness, or both hospitalized in the ICU. Twenty-six sociodemographic and clinical variables were measured using electronic health record or patient questionnaire data collected at either 1 or 3 months after ICU admission. Risk factors for patient-reported financial hardship were evaluated using linear regression. The association between financial hardship and 4 patient-reported outcomes was tested with probit and linear regression.

Results

We enrolled 171 patients with a median age of 58 years (interquartile range, 45, 70 years), including 64 female (37%) patients and 44 patients (26%) from racial or ethnic minority groups. Illness-related change in work status (β = 3.5; P = .02) and poorer self-reported health status (β = 2.4; P = .003) were associated with greater patient-reported financial hardship. Higher education level (β = –2.6; P = .001) was associated with less financial hardship. Higher financial hardship was associated with all 4 patient-reported outcomes (P < .001): feelings of depression (β = 0.2) and anxiety (β = 0.3), poorer quality of life (β = 0.04), and lower emotional preparedness for the future (β = 0.05).

Interpretation

This study demonstrated an association between patient-reported financial hardship and negative patient-reported outcomes in critically ill patients. Our findings also highlight important risk factors for financial hardship and suggest that sociodemographic factors, including education level, illness-related change in work status, and poorer self-reported health status, could contribute more than clinical factors. Our findings provide a foundation for future development of screening tools and interventions to mitigate financial hardship in critically ill patients.

在危重病人中，经济困难的负担已经被证明是很高的。了解经济困难的社会人口学和临床风险因素及其与患者预后的关系可以帮助指导未来的干预措施，以减轻这一患者群体的经济困难。研究问题：危重病人经济困难的社会人口学和临床危险因素是什么？它与病人报告的结果有什么关系？研究设计和方法本前瞻性队列研究纳入了患有慢性、限制生命的疾病、急性重症疾病或两者均在ICU住院的成年人。在ICU入院后1或3个月收集电子健康记录或患者问卷数据，测量26个社会人口学和临床变量。使用线性回归评估患者报告的经济困难的危险因素。经济困难与患者报告的4个结果之间的关系用probit和线性回归进行检验。结果纳入171例患者，中位年龄为58岁（四分位数间距为45 ~ 70岁），其中女性64例（37%），少数民族44例（26%）。与疾病相关的工作状态变化（β = 3.5; P = 0.02）和较差的自我报告健康状况（β = 2.4; P = 0.003）与患者报告的较大经济困难相关。较高的教育水平（β = -2.6; P = .001）与较少的经济困难相关。较高的经济困难与患者报告的所有4种结局相关（P < .001）：抑郁感（β = 0.2）和焦虑感（β = 0.3），较差的生活质量（β = 0.04），以及对未来的情绪准备较低（β = 0.05）。本研究证明了危重患者报告的经济困难与患者报告的负面结果之间的关联。我们的研究结果还强调了经济困难的重要风险因素，并表明社会人口因素，包括教育水平、与疾病相关的工作状态变化和较差的自我报告健康状况，可能比临床因素贡献更大。我们的研究结果为未来发展筛查工具和干预措施提供了基础，以减轻危重患者的经济困难。

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引用次数: 0

Interhospital Transfers in Critical Illness 危重疾病的医院间转院

CHEST critical care

Pub Date : 2025-09-19 DOI: 10.1016/j.chstcc.2025.100202

Rachel A. Hadler MD , Rachel Kohn MD, MSCE, ATS

引用次数: 0

ARDS After Spinal Cord Injury 脊髓损伤后ARDS

CHEST critical care

Pub Date : 2025-09-14 DOI: 10.1016/j.chstcc.2025.100211

Christopher S. Lozano MD , Vishwathsen Karthikeyan MD , Michael C. Sklar MD , Ahmad Essa MD, MPH , Francois Mathieu MD , Husain Shakil MD , Armaan K. Malhotra MD , Vincent Ye MD , Alexandra De Sequeira BSc , Andrew S. Jack MD , Ying Shi He MSc , Eva Y. Yuan MSc , Jetan H. Badhiwala MD, PhD , Michael G. Fehlings MD, PhD , Jefferson R. Wilson MD, PhD , Christopher D. Witiw MD

Background

ARDS is a life-threatening respiratory complication after traumatic spinal cord injury (SCI), yet contemporary, large-scale estimates of its frequency, determinants, and impact on inpatient outcomes are scarce.

Research Question

Among adults with acute traumatic SCI, what is the incidence of ARDS; which patient, injury, and hospital factors are associated with it; and how does ARDS influence inpatient mortality and adverse events?

Study Design and Methods

We retrospectively analyzed data from 2010 through 2020 from the Trauma Quality Improvement Program. Adults ≥ 16 years of age with SCI were identified by Abbreviated Injury Scale (AIS) codes. Multivariable logistic regression identified covariates associated with the development of ARDS and quantified the associations of ARDS with mortality and adverse events. Sensitivity analyses excluded patients with AIS code ≥ 3 extraspinal injuries and examined the Berlin criteria era after 2012.

Results

Of 55,643 SCI admissions, 1,791 patients (3.2%) demonstrated ARDS; yearly incidence fell from 7% to 2% over the study period. Covariates associated with ARDS included COPD (OR, 1.34; 95% CI, 1.08-1.66), diabetes (OR, 1.36; 95% CI, 1.15-1.62), smoking (OR, 1.19; 95% CI, 1.06-1.34), severe thoracic (OR, 1.79; 95% CI, 1.57-2.04) or lower-extremity (OR, 1.23; 95% CI, 1.02-1.48) injury, motor vehicle mechanism (OR, 1.18; 95% CI, 1.03-1.36), and spine surgery (OR, 1.37; 95% CI, 1.21-1.54). Negatively associated factors were Glasgow Coma Scale score of 15 on presentation, incomplete SCI, and thoracic or lumbar levels affected. ARDS was associated with increased mortality (OR, 5.11; 95% CI, 4.37-5.97), ventilator-associated pneumonia (OR, 4.51; 95% CI, 4.00-5.09), sepsis (OR, 6.22; 95% CI, 5.21-7.44), cardiac arrest (OR, 4.02; 95% CI, 3.46-4.68), immobility-related complications (OR, 2.45; 95% CI, 2.18-2.76), and prolonged ICU stay or mechanical ventilation (lasting ≥ 14 days; OR, 5.49; 95% CI, 4.57-6.60). In the subgroup excluding AIS code ≥ 3 extraspinal injuries, ARDS incidence fell to 1.8% with persistently elevated mortality and complication rates.

Interpretation

Our results show that although ARDS incidence after SCI has declined, it remains linked to adverse in-hospital outcomes. Key associated factors include patient comorbidities and injury-related factors.

dards是创伤性脊髓损伤（SCI）后危及生命的呼吸系统并发症，但目前对其频率、决定因素和对住院患者预后影响的大规模估计很少。研究问题：成人急性外伤性脊髓损伤中，ARDS的发生率是多少？哪些患者、损伤和医院因素与之相关；ARDS如何影响住院患者死亡率和不良事件？研究设计和方法我们回顾性分析了创伤质量改善项目2010年至2020年的数据。年龄≥16岁的SCI患者采用简易损伤量表（AIS）编码进行鉴定。多变量逻辑回归确定了与ARDS发展相关的协变量，并量化了ARDS与死亡率和不良事件的关联。敏感性分析排除AIS代码≥3的脊柱外损伤患者，并检查2012年后的柏林标准时代。结果55,643例SCI入院患者中，1,791例（3.2%）表现为ARDS；在研究期间，年发病率从7%下降到2%。与ARDS相关的协变量包括COPD （OR, 1.34; 95% CI, 1.08-1.66）、糖尿病（OR, 1.36; 95% CI, 1.15-1.62）、吸烟（OR, 1.19; 95% CI, 1.06-1.34）、严重胸椎（OR, 1.79; 95% CI, 1.57-2.04）或下肢（OR, 1.23; 95% CI, 1.02-1.48）损伤、机动车机制（OR, 1.18; 95% CI, 1.03-1.36）和脊柱手术（OR, 1.37; 95% CI, 1.21-1.54）。负相关因素是格拉斯哥昏迷量表评分为15分的表现，不完全性脊髓损伤，以及受影响的胸椎或腰椎水平。ARDS与死亡率增加（OR, 5.11; 95% CI, 4.37-5.97）、呼吸机相关性肺炎（OR, 4.51; 95% CI, 4.00-5.09）、败血症（OR, 6.22; 95% CI, 5.21-7.44）、心脏骤停（OR, 4.02; 95% CI, 3.46-4.68）、不活动相关并发症（OR, 2.45; 95% CI, 2.18-2.76）、延长ICU住院时间或机械通气（持续≥14天；OR, 5.49; 95% CI, 4.57-6.60）相关。在排除AIS代码≥3的棘外损伤的亚组中，ARDS发病率下降至1.8%，死亡率和并发症发生率持续升高。我们的研究结果表明，尽管脊髓损伤后ARDS的发病率已经下降，但它仍然与不良的住院结果有关。关键相关因素包括患者合并症和损伤相关因素。

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引用次数: 0

What Is the Optimal Reintubation Rate? 什么是最佳的再插管率？

CHEST critical care

Pub Date : 2025-09-13 DOI: 10.1016/j.chstcc.2025.100210

Yuki Arita MD , Daisuke Kawakami MD, PhD , Hidenobu Koga MT, MMSc , Shumpei Yoshino MD

引用次数: 0

Investigation of Skin Pigmentation Effect on Performance of Pulse Oximetry 皮肤色素沉着对脉搏血氧仪性能影响的研究

CHEST critical care

Pub Date : 2025-09-10 DOI: 10.1016/j.chstcc.2025.100209

Alison B. Travers MD , Charles R. Terry MD, MSCR , Will P. Merrell , Marc E. Heincelman MD, MPH , Ashley D. Warden , Andrew J. Goodwin MD, MSCR

Background

The accuracy of blood oxygen saturation measured by pulse oximetry (Spo₂) in critically ill patients with darkly pigmented skin remains controversial, with accuracy studies that are either retrospective or laboratory based among healthy volunteers.

Research Question

Can a pragmatically-designed prospective study feasibly enroll critically ill patients across the full skin pigmentation spectrum within a real-world ICU setting while applying the technical rigor of a laboratory-based study?

Study Design and Methods

A feasibility analysis was performed after 50 patients across 2 ICUs contributed samples. Feasibility was defined as (1) coverage of skin pigmentation, with a range of > 100° using an objective measure (individual topology angle [ITA]) and (2) ≥ 80% of collected blood samples generate a valid Spo₂ and Sao₂ pair fulfilling predefined technical criteria. Exploratory analysis was performed through Bland-Altman analysis, with standard-of-care blood draws used for Sao₂ measurements. Rates of occult hypoxemia (Sao₂ < 88% when Spo₂ was 92%-96%) were compared among skin pigmentation groups.

Results

Eighty-four blood samples collected from 50 patients (52% male; median age, 55 years [interquartile range, 46-61.8 years]) yielded 80 valid pairs (95%) from 49 patients. Feasibility thresholds were met for skin pigmentation (ITA range, –66° to 59°), with 52% of patients classified as dark-skinned overall. In the exploratory analysis, overall pulse oximeter root-mean-square accuracy was 1.47%, with a median bias of –0.6% (mean, –0.7%). Dark-skinned and light-skinned patients did not differ significantly, with a median bias of –0.2% vs –0.9% (mean, –0.1% vs –1.1%), respectively. Nearly one-half the data pairs were collected when patients were at risk of occult hypoxemia (Spo₂, 92%-96%), yet no occult hypoxemic events occurred.

Interpretation

This feasibility study demonstrated high fidelity and efficient data collection from pulse oximeter sensors and reference blood gas analyzers in critically ill patients across varying skin pigments while applying requisite technical criteria within an ICU setting.

Clinical Trial Registration

ClinicalTrials.gov; No.: NCT06432881; URL: www.clinicaltrials.gov

背景：对于患有深色皮肤的危重患者，脉搏血氧仪（Spo2）测量血氧饱和度的准确性仍然存在争议，其准确性研究要么是回顾性的，要么是基于健康志愿者的实验室研究。研究问题：一项实用设计的前瞻性研究能否可行地在现实世界的ICU环境中招募所有皮肤色素谱的危重患者，同时应用基于实验室的研究的严格技术？研究设计与方法对2个icu的50例患者进行了可行性分析。可行性定义为：(1)皮肤色素沉着的覆盖范围，使用客观测量（个体拓扑角[ITA]）为>； 100°；(2)≥80%采集的血液样本产生符合预定义技术标准的有效Spo2和Sao2对。通过Bland-Altman分析进行探索性分析，采用标准护理抽血测量Sao2。隐匿性低氧血症（Spo2为92% ~ 96%时Sao2为88%）在皮肤色素沉着组间的发生率比较。结果50例患者共采集84份血样（男性52%，中位年龄55岁[四分位数间距46 ~ 61.8岁]），49例患者共获得80对有效血样（95%）。皮肤色素沉着符合可行性阈值（ITA范围，-66°至59°），52%的患者被分类为深色皮肤。在探索性分析中，总体脉搏血氧仪均方根精度为1.47%，中位偏差为-0.6%（平均值-0.7%）。深肤色和浅肤色患者没有显著差异，中位偏倚分别为-0.2% vs -0.9%（平均，-0.1% vs -1.1%）。近一半的数据对是在患者有隐匿性低氧血症风险时收集的（Spo2, 92%-96%），但没有发生隐匿性低氧血症事件。本可行性研究展示了在ICU环境中应用必要的技术标准时，从不同皮肤色素的危重患者的脉搏血氧计传感器和参考血气分析仪中高保真和高效的数据收集。临床试验注册网站clinicaltrials .gov；否。: NCT06432881;URL: www.clinicaltrials.gov

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引用次数: 0

A Thematic Analysis of Family Perspectives on Traumatic Stress and Critical Illness of a Loved One 家庭视角对亲人创伤压力和危重疾病的专题分析

CHEST critical care

Pub Date : 2025-09-10 DOI: 10.1016/j.chstcc.2025.100208

Deepshikha Charan Ashana MD , Greer Tiver MPH , Christopher E. Cox MD, MPH , Nicholas Madamidola , Joseph H. Neiman MD, MPH , Christian Noval , Bassam Syed , Heta Patel , Shewit Jaynes MSPH, BSN, RN , Jennie Jaggers , Ernestine C. Briggs PhD , Karen Steinhauser PhD , Joanna L. Hart MD, MSHP

Background

Trauma-informed care is a promising framework for understanding and ultimately mitigating traumatic stress associated with critical care. Specific components of trauma-informed adult critical care have not been defined.

Research Question

How do family members with traumatic stress experience ICU care of a loved one?

Study Design and Methods

Family members of mechanically ventilated patients who endorsed substantial historical trauma or current traumatic stress during their loved one’s ICU stay were recruited from 9 ICUs in 1 urban and 1 suburban-rural health system. Family members participated in semistructured interviews eliciting their perceptions of traumatic stress during ICU care and aspects of critical care that modified stress. Interviews were transcribed and emergent themes were captured through iterative coding, case narrative memos, and abductive thematic analyses. Interviews continued until, through concurrent analyses, both thematic saturation and information power were reached.

Results

Among 26 family members, the median age was 53.2 years (interquartile range [IQR] 48.3-61.1 years) and most were female (n = 20 [76.9%]) and Black (n = 14 [53.8%]). Family members endorsed a median of 9 (IQR, 5-13) potentially traumatic events in their lifetimes. Emergent themes included: (1) behaviors suggestive of possible trauma responses (eg, vigilance) during ICU stays, (2) reluctance to disclose prior trauma to ICU clinicians because of concerns about bias or lack of support, (3) perception that surrogate decision-making and caregiving responsibilities exacerbated stress, and (4) structural and procedural aspects of ICU care reduced or amplified stress, including presence (visitation) policies, physical hospital and ICU environment, and family support resources.

Interpretation

Family members of critically ill patients described potential traumatic stress responses during ICU experiences and identified components of critical care that may complement and expand existing models of family-centered ICU care to incorporate trauma-informed approaches.

背景创伤知情护理是一个很有前景的框架，可以理解并最终减轻与重症监护相关的创伤应激。创伤知情成人重症监护的具体组成部分尚未定义。研究问题：创伤性应激的家庭成员如何体验亲人的ICU护理？研究设计和方法从1个城市和1个郊区卫生系统的9个ICU中招募在其所爱的ICU住院期间承认有重大历史创伤或当前创伤应激的机械通气患者的家庭成员。家庭成员参加了半结构化访谈，以了解他们在ICU护理期间对创伤压力的看法，以及危重病护理中改变压力的方面。访谈被记录下来，通过迭代编码、案例叙述备忘录和溯因性主题分析捕捉突发主题。采访继续进行，直到通过同时进行的分析，达到主题饱和和信息力量。结果26例家庭成员中，年龄中位数为53.2岁（四分位数间距[IQR] 48.3 ~ 61.1岁），以女性20例（76.9%）和黑人14例（53.8%）居多。家庭成员在其一生中承认的潜在创伤事件中位数为9 （IQR, 5-13）。紧急主题包括：(1)在ICU住院期间可能有创伤反应的行为（如警惕）；(2)由于担心偏见或缺乏支持而不愿向ICU临床医生披露先前的创伤；(3)认为替代决策和护理责任加剧了压力；(4)ICU护理的结构和程序方面减少或放大了压力，包括存在（探视）政策、医院和ICU的物理环境以及家庭支持资源。危重患者的家庭成员描述了重症监护期间潜在的创伤应激反应，并确定了重症监护的组成部分，这些组成部分可以补充和扩展现有的以家庭为中心的重症监护模式，以纳入创伤知情方法。

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