CHEST critical care最新文献

Background

Induction agents are administered to decrease the risk of discomfort, awareness, and psychological sequelae during procedural paralysis (eg, rapid sequence intubation). The expected duration of nondepolarizing neuromuscular blocking agents exceeds that of induction sedatives. The resulting sedation gap may increase the risk of awake paralysis.

Research Question

The objective of this study was to elucidate the prevalence and duration of sedation gaps in critically ill patients undergoing bedside procedural paralysis.

Study Design and Methods

This was a retrospective cross-sectional study of critically ill adults who received rocuronium for a bedside procedure. The primary outcome was the sedation gap, which was the cumulative time of inadequate sedation during presumed paralysis (ie, 60 min after rocuronium). Secondary outcomes included the sedation gap when a pharmacist was present at the bedside. Descriptive statistics were used for baseline characteristics and the primary outcome. Log-rank and Mann-Whitney U tests were used to analyze secondary outcomes.

Results

Eighty patients were included in the final analysis. The average age was 60 years and 57% of patients were male. The most common indication for procedural paralysis was rapid sequence intubation (99%). Most procedures were performed in the ED (55%), followed by the ICU (43.8%). Eighty-five percent of patients experienced a sedation gap of any duration. The median sedation gap was 19 min (interquartile range [IQR], 4-47.5 min). The probability of initiating adequate sedation was higher when a pharmacist was present at the bedside (hazard ratio, 1.49 [95% CI, 1.42-1.55], bootstrapping log-rank test). The median sedation gap with a pharmacist (11 min [IQR, 3-27.5 min]) was significantly lower than without a pharmacist (40 min [IQR, 17-55 min]; P = .0115, Mann-Whitney U test).

Interpretation

In this critically ill cohort, a substantial prevalence and duration of inadequate sedation was experienced after receiving rocuronium for bedside procedures. Further study is needed to identify if sedation gaps correlate with an increased risk of psychological morbidities.

Background

More than 90,000 children and adults in the United States are hospitalized with an asthma exacerbation annually, and between 5% and 34% of these hospitalizations include admission to an ICU. It is unclear how adolescent and young adults with severe asthma exacerbations are triaged in the inpatient setting between PICUs and adult ICUs. Using a large multicenter US cohort, we characterized how hospitals triage adolescents and young adults with asthma exacerbations between PICUs and adult ICUs.

Research Question

How do hospitals across the United States triage adolescents and young adults with asthma exacerbations between PICUs and adult ICUs?

Study Design and Methods

This was a retrospective cohort study carried out from 2016 through 2022 using the enhanced-claims PINC AI database. Participants were patients aged 12 to 26 years who were hospitalized with an asthma exacerbation and admitted to a PICU or adult ICU. We used nested hierarchical multivariable regression models to quantify changes in the intraclass correlation coefficient (ICC; a measure of variation in triage decisions attributable to hospital of admission after accounting for covariables).

Results

Analyses included 3,946 admissions from 93 hospitals. Stratified by age, the percent of patients admitted to PICUs dropped by 26.9% between 17 and 18 years of age. In the nested models, the ICC showed a large decrease going from the empty model (28.7%) to the age-adjusted model (4.5%), but was similar between the age-adjusted and fully adjusted model (3.4%).

Interpretation

Our results showed that among adolescents and young adults with asthma exacerbations, age of 18 years or younger was a strong determinant of PICU triage. Further research is needed to understand differences in asthma care and outcomes between PICUs and adult ICUs, as well as how intermediate care units affect triage decision-making from wards and the ED.

Background

Pulmonary complications such as chest infection and pulmonary atelectasis may lead to respiratory failure, prolonged ICU stay, and poor outcomes. Routine application of respiratory physiotherapy interventions is not supported by the current body of evidence. Intrapulmonary percussive ventilation (IPV) is used to treat various clinical conditions; however, the evidence to support its effectiveness in the ICU remains weak. This study aimed to evaluate the effectiveness of IPV in improving outcomes in patients admitted to intensive care.

Research Question

What is the effect of IPV on ICU length of stay, oxygenation, and pulmonary complications in nonventilated patients who are critically ill compared with commonly applied chest physiotherapy (CPT)?

Methods

This was a randomized controlled trial. Of 201 patients screened, 106 were recruited. Participants with a respiratory impairment were randomly allocated to either the IPV or the CPT group. Both groups received two treatment sessions daily. Data were analyzed for 100 participants for ICU length of stay, changes in oxygenation, respiratory rate, and radiologic findings.

Results

The median length of stay in the IPV group was 3.5 days (1.9, 5.9); in the CPT group, the length of stay was 5.2 days (3.4, 9.9). The mean difference in length of stay was 1.56 days (95% CI, 1.2-2.1; P = .002). The between-group difference (IPV minus CPT) for preintervention to postintervention peripheral oxygen saturation was 0.94% (95% CI, 0.43-1.45; P < .001). The between-group difference (IPV minus CPT) in respiratory rate was 2.1 breaths/minute (95% CI, 0.9-3.2; P < 0.001). No significant difference in radiologic atelectasis score was observed (P = .65).

Interpretation

This study showed that the IPV intervention reduced ICU length of stay and respiratory rate, with a small improvement in oxygenation compared with CPT interventions in nonventilated patients. The use of IPV intervention may improve outcomes in patients who are critically ill with impaired respiratory function.

Background

The characteristics and course of endotracheal secretions have scarcely been studied in patients under mechanical ventilation (MV) at risk of developing ventilator-associated pneumonia (VAP).

Research Question

Can endotracheal secretions be exhaustively described and what is their predictive value for the diagnosis of VAP during MV?

Study Design and Methods

This single-center prospective study included neuro-injured patients with neurologic injury requiring MV for at least 7 days. Patients with pulmonary and infectious diseases were ineligible. All endotracheal aspirates (ETAs) collected between tracheal intubation and day 7 were analyzed. Macroscopic characteristics and microbiology were assessed. Clinical Pulmonary Infection Score was calculated daily. An anonymized adjudication committee validated all VAP events.

Results

Forty-eight patients and 1,544 ETAs were analyzed. Overall, 81% of the ETAs were purulent, and 50% were thick. Culture results showed high interindividual and intraindividual variability. Ten patients (21%) developed early-onset VAP. Eight patients (80%) with VAP and 14 (37%) without VAP had a Clinical Pulmonary Infection Score > 6. The day prior to VAP diagnosis, a 20 mL increase in ETA volume detected VAP with a sensitivity of 67% and a specificity of 93%.

Interpretation

This study provides new information regarding the course of respiratory colonization in patients who are mechanically ventilated and suggests that ETA color/aspects and pathogen kinetics cannot predict VAP. Traditional VAP criteria (Clinical Pulmonary Infection Score and bacterial load) also had a low diagnostic specificity. Conversely, an increase in secretion volume should alert for VAP development.

Cardiogenic shock (CS) is a heterogenous syndrome broadly characterized by inadequate cardiac output leading to tissue hypoperfusion and multisystem organ dysfunction that carries an ongoing high mortality burden. The management of CS has advanced rapidly, especially with the incorporation of temporary mechanical circulatory support (tMCS) devices. A thorough understanding of how to approach a patient with CS and to select appropriate monitoring and treatment paradigms is essential in modern ICUs. Timely characterization of CS severity and hemodynamics is necessary to optimize outcomes, and this may be performed best by multidisciplinary shock-focused teams. In this article, we provide a review of CS aimed to inform both the cardiology-trained and non-cardiology-trained intensivist provider. We briefly describe the causes, pathophysiologic features, diagnosis, and severity staging of CS, focusing on gathering key information that is necessary for making management decisions. We go on to provide a more detailed review of CS management principles and practical applications, with a focus on tMCS. Medical management focuses on appropriate medication therapy to optimize perfusion—by enhancing contractility and minimizing afterload—and to facilitate decongestion. For more severe CS, or for patients with decompensating hemodynamic status despite medical therapy, initiation of the appropriate tMCS increasingly is common. We discuss the most common devices currently used for patients with CS—phenotyping patients as having left ventricular failure, right ventricular failure, or biventricular failure—and highlight key available data and particular points of consideration that inform tMCS device selection. Finally, we highlight core components of sedation and respiratory failure management for patients with CS.

Background

Respiratory failure is a life-threatening condition affecting millions of individuals in the United States annually. Survivors experience persistent functional impairments, decreased quality of life, and cognitive impairments. However, no established standard exists for measuring functional recovery among survivors of respiratory failure.

Research Question

What outcomes are being used to measure and characterize functional recovery among survivors of respiratory failure?

Study Design and Methods

In this scoping review, we developed a review protocol following International Prospective Register of Systematic Reviews (PROSPERO) guidelines. Two independent reviewers assessed titles and abstracts, followed by full-text review. Articles were included if study participants were aged 18 years or older, survived a hospitalization for acute respiratory failure, and received invasive mechanical ventilation as an intervention; identified function or functional recovery after respiratory failure as a study outcome; were peer-reviewed; and used any type of quantitative study design.

Results

We reviewed 5,873 abstracts and identified 56 eligible articles. Among these articles, 28 distinct measures were used to assess functional recovery among survivors, including both performance-based measures (n = 8) and self-reported and proxy-reported measures (n = 20). Before 2019, 12 of the 28 distinct outcome measures (43%) were used, whereas 25 distinct measures (89%) were used from 2019 through 2024. The 6-min walk test appeared most frequently (46%) across the studies, and only 34 of 56 studies measured outcomes ≥ 6 months after discharge or study enrollment.

Interpretation

Heterogeneity exists in how functional recovery is measured among survivors of respiratory failure, which highlights a need to establish a gold standard to ensure effective and consistent measurement.

Background

Respiratory therapist (RT)-driven spontaneous breathing trial (SBT) protocols have been shown to improve patient outcomes.

Research Question

Can an RT-driven SBT protocol be implemented and sustained to improve outcomes?

Study Design and Methods

This quality improvement (QI) project aimed to standardize and re-establish RT-driven protocol for screening patients for SBT readiness and administering SBTs to appropriate patients. Endotracheally intubated and mechanically ventilated adult patients admitted to an academic medical center ICU were screened daily by RTs for SBT readiness. Eligible patients received an SBT with extubation decisions made by the physician team. Patient demographics, indications for intubation, SBT eligibility and exclusionary indications, SBT ventilator settings, start times, duration, and outcomes were collected from the electronic health record. QI interventions included staff re-education, documentation tips, creation of process maps, and interdisciplinary open forum discussions.

Results

One hundred twenty-eight patients representing 759 safety screen weaning assessment opportunities were included over a baseline sample and three plan-do-study-act (PDSA) cycles. Documentation of SBT eligibility increased from 25% at baseline to 86% in PDSA cycle 3 (P ≤ .001). Patients assessed to be eligible for and who received an SBT constituted 42% at baseline, 35% at PDSA cycle 1, 36% at PDSA cycle 2, and 51% at PDSA cycle 3 (P = .092). Use of the protocolized SBT ventilator settings improved significantly from 18% to 83% (P ≤ .001). Patients who started an SBT before 9 am increased from 41% to 67% (P = .097), and the median duration of SBT decreased from 211 to 64 min (P = .008).

Interpretation

This study shows that standardization of an RT-driven SBT protocol is feasible despite multiple obstacles, including staffing and communication challenges and poor shared understanding of terminology.