CHEST critical care最新文献

英文中文

Gastroesophageal Reflux Symptoms and Health-Related Quality of Life Among ICU Survivors ICU幸存者胃食管反流症状与健康相关生活质量

CHEST critical care

Pub Date : 2025-05-19 DOI: 10.1016/j.chstcc.2025.100169

Sachin Wali MD, DNB, DM , Mohan Gurjar MD , Samir Mohindra MD, DM , Prabhaker Mishra PhD , Shreyas H. Gutte MD, DM , Afzal Azim MD , Jitendra S. Chahar MD , Banani Poddar MD

Background

Gastroesophageal reflux disease (GERD) is a common clinical condition in the general population. However, no prospective study is available to estimate the burden of gastroesophageal reflux symptoms (GERSs) among survivors of the ICU.

Research Question

What are the incidence and severity of GERSs among survivors of the ICU?

Study Design and Methods

This prospective observational study was conducted in a 20-bed ICU at a university hospital in India. All adult survivors of the ICU were screened for the presence of GERSs, defined as presence of heartburn, regurgitation symptoms, or both ≥ 2 times/wk. Exclusions were: Glasgow Coma Scale score of < 15, presence of tracheostomy or feeding tube, open abdomen, and pregnancy. The severity of symptoms was assessed through the Gastroesophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL) score (range, 0-50, where 50 is worst) at 2 time points 6 weeks apart.

Results

During the study period, 116 patients were included, with a median age of 44 years (interquartile range [IQR], 26-59 years). Sixty-five patients (56%) were male, and the median admission Sequential Organ Failure Assessment score was 7 (IQR, 4-10). During the ICU stay, 59 patients (50.8%) required mechanical ventilation, 42 patients (36.2%) required vasopressors, and 11 patients (9.4%) received dialysis. Among them, 43 patients (37%) had history of GERSs before the illness. In the remaining 73 patients, 23 patients (31.5%) had new-onset GERSs. The use of medications known to increase the risk of GERD (eg, prednisolone, acetylsalicylic acid, and amlodipine) and the prolonged presence of a feeding tube were associated significantly with new-onset GERSs (OR, 4.49 [95% CI, 1.06-18.9; P = .04] and OR, 1.04 [95% CI, 1.00-1.09; P = .03]), respectively, even after adjusting for age and presence of preexisting known risk factors (diabetes, hypertension, and smoking and alcohol intake). The median GERD-HRQL score among patients with new-onset GERSs at follow-up decreased from 10 (IQR, 2-20) to 4 (IQR, 0-15; P = .01).

Interpretation

In this study, one-third of survivors of the ICU experienced new-onset GERSs. However, symptoms improved significantly at the 6-week follow-up.

Clinical Trial Registration

ClinicalTrials.gov; No.: NCT05193266; URL: www.clinicaltrials.gov

胃食管反流病（GERD）是普通人群常见的临床疾病。然而，目前尚无前瞻性研究评估ICU幸存者胃食管反流症状（gers）的负担。研究问题：ICU幸存者中gers的发生率和严重程度是什么？研究设计和方法本前瞻性观察研究在印度一所大学医院的20个床位的ICU进行。对ICU的所有成年幸存者进行gers筛查，gers的定义是存在烧心、反流症状或两者均存在≥2次/周。排除：格拉斯哥昏迷量表评分为15分，存在气管切开术或喂食管，开放腹部和怀孕。在间隔6周的2个时间点，通过胃食管反流病与健康相关的生活质量（GERD-HRQL）评分（范围0-50，其中50为最差）评估症状的严重程度。结果研究期间纳入116例患者，中位年龄44岁（四分位间距[IQR]， 26-59岁）。65例患者（56%）为男性，入院序贯性器官衰竭评分中位数为7分（IQR, 4-10）。在ICU住院期间，59例（50.8%）患者需要机械通气，42例（36.2%）患者需要血管加压剂，11例（9.4%）患者需要透析。其中43例（37%）患者在发病前有gers病史。其余73例患者中，23例（31.5%）为新发gers。使用已知会增加GERD风险的药物（如泼尼松龙、乙酰水杨酸和氨氯地平）和长时间使用饲管与新发GERD显著相关（OR为4.49 [95% CI, 1.06-18.9; P = 0.04]和OR为1.04 [95% CI, 1.00-1.09; P = 0.03]），即使在调整了年龄和既往已知危险因素（糖尿病、高血压、吸烟和饮酒）的存在后也是如此。随访时新发gers患者的GERD-HRQL评分中位数从10分（IQR, 2-20）降至4分（IQR, 0-15; P = 0.01）。在本研究中，三分之一的ICU幸存者经历了新发gers。然而，在6周的随访中，症状明显改善。临床试验注册网站clinicaltrials .gov；否。: NCT05193266;URL: www.clinicaltrials.gov

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引用次数: 0

Response 响应

CHEST critical care

Pub Date : 2025-05-19 DOI: 10.1016/j.chstcc.2025.100174

Yonatan Y. Greenstein MD, FCCP, Keith Guevarra DO, FCCP

引用次数: 0

Impact of a Real-Time Ventilator Management Dashboard With Alerts 带警报的实时呼吸机管理仪表板的影响

CHEST critical care

Pub Date : 2025-05-19 DOI: 10.1016/j.chstcc.2025.100167

Pranai Tandon MD , Kim-Anh-Nhi Nguyen MS , Ganesh Raut MS , Yuxia Ouyang PhD , Satya N. Cheetirala MS , Shamsuddoha Ranginwala MBA, RRT-NPS , Gary Oldenburg MS, RRT-NPS , Neha S. Dangayach MD , Samuel O. Acquah MD , Roopa Kohli-Seth MD , Prem Timsina ScD , Arash M. Kia MD , Robert Freeman DNP , Natalia Egorova PhD , Matthew A. Levin MD , Charles A. Powell MD, MBA

Background

Exposure to high tidal volumes in patients undergoing invasive mechanical ventilation is associated with increased mortality and worse outcomes. However, adherence to lung-protective ventilation (LPV) is suboptimal. No generalizable tool or approach exists that has been demonstrated to optimize implementation of this parameter of mechanical ventilation.

Research Question

We tested whether development and deployment of a real-time ventilator management dashboard with twice-daily alerts communicating synthesized ventilator information to clinicians would improve adherence to LPV (≤ 8 mL/kg ideal body weight).

Study Design and Methods

The Respiratory Insights Dashboard was developed to display key real-time patient and ventilator data for all patients in the ICU of a large academic medical center, as well as to send twice daily email alerts to ICU staff identifying patients with out-of-range parameters. The 5 ICUs with lowest tidal volume adherence were preselected for analysis in a quasiexperimental study comparing the periods before and after the dashboard.

Results

In the period before the intervention, 1,376 patients received ventilation, and in the period after the intervention, 3,064 patients received ventilation. Hourly adherence to LPV rose from 78% to 87% (P < .001). In patients initiated on ventilation with tidal volume (Vt) of > 8 mL/kg, the time to reach adherence fell from a median of 9 hours (interquartile range, 2-26 hours) to 5 hours (interquartile range, 1-15 hours; P = .048). Interrupted time series regression showed that temporal trends both before and after the intervention were not significantly different from zero; however, adherence level change after the intervention was 8.3 (P = .004). Increased adherence to LPV also was observed in multivariable regression (OR, 1.438; P < .001), along with an increase in adherence trend over time after implementation (OR, 1.001; P = .004).

Interpretation

In this study, a real-time ventilator management dashboard with Vt alerts was shown to significantly improve adherence to LPV hospital wide as well as more rapid correction of suboptimal ventilator settings. Implementation was associated with an increase in LPV adherence that has persisted for 15 months of follow-up.

背景：接受有创机械通气的患者暴露于高潮气量与死亡率增加和预后恶化相关。然而，坚持肺保护性通气（LPV）是不理想的。没有可推广的工具或方法存在，已被证明优化实施机械通气的这一参数。研究问题：我们测试了开发和部署一个实时呼吸机管理仪表板，该仪表板每天两次向临床医生发出警报，将合成的呼吸机信息传达给临床医生，是否会提高LPV（≤8 mL/kg理想体重）的依从性。研究设计和方法开发了Respiratory Insights Dashboard，用于显示某大型学术医疗中心ICU所有患者的关键实时患者和呼吸机数据，并向ICU工作人员发送每日两次的电子邮件提醒，以识别参数超出范围的患者。在一项准实验研究中，预先选择潮汐容量粘附最低的5个icu进行分析，比较仪表板前后的时间。结果干预前通气1376例，干预后通气3064例。LPV的小时依从性从78%上升到87% （P < .001）。在潮气量（Vt）为8ml /kg的患者中，达到依从性的时间从中位数9小时（四分位数范围2-26小时）下降到5小时（四分位数范围1-15小时，P = 0.048）。中断时间序列回归显示，干预前后的时间趋势均与零无显著差异；干预后依从性水平变化为8.3 （P = 0.004）。在多变量回归中也观察到LPV的依从性增加（OR, 1.438; P < .001），以及实施后随时间推移的依从性增加趋势（OR, 1.001; P = .004）。在这项研究中，带有Vt警报的实时呼吸机管理仪表板被证明可以显著提高医院对LPV的依从性，并能更快地纠正不理想的呼吸机设置。实施与LPV依从性的增加相关，并持续了15个月的随访。

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引用次数: 0

Ascorbate for Organ Dysfunction in Critically Ill Patients With Sepsis 抗坏血酸治疗重症败血症患者器官功能障碍

CHEST critical care

Pub Date : 2025-05-19 DOI: 10.1016/j.chstcc.2025.100168

D. Clark Files MD , Michael A. Matthay MD , Lorraine B. Ware MD , Roy G. Brower MD , Neil R. Aggarwal MD , Samuel M. Brown MD , Steven Y. Chang MD , Ivor S. Douglas MD , Abhijit Duggal MD , Kevin W. Gibbs MD , Scott Fields PharmD , Andrea S. Foulkes ScD , Adit Ginde MD , Andrew Goodwin MD , Estelle S. Harris MD , Gregory W. Hendey MD , Kathryn Hibbert MD , R.Duncan Hite MD , Catherine L. Hough MD , Weixing Huang MSPH , Alpha A. Fowler MD

Background

A phase 2 trial of high-dose IV ascorbate suggested reduced mortality in patients with ARDS, although trials in sepsis have failed to show clinical benefit.

Research Question

Does IV high-dose ascorbate improve outcomes in patients with sepsis at risk of or with ARDS?

Study Design and Methods

In this phase 2b multicenter randomized placebo-controlled trial, patients with known or suspected infection and either shock or acute hypoxemic respiratory failure were randomized to ascorbate (50 mg/kg IV every 6 hours for 5 days) or a matching placebo. The primary outcome was days alive and free of respiratory, renal, and circulatory organ support to day 28. Secondary outcomes included clinical and biological end points.

Results

After enrolling 79 participants, the trial was terminated because of the publication of a separate study of septic shock reporting increased mortality with ascorbate. In the current study, days free of organ support were not different for patients receiving ascorbate compared with those receiving placebo: mean (SD), 20.5 (9.5) days vs 19.0 (10.8) days, respectively (P = .528). The 90-day all-cause mortality was 15% in the ascorbate group vs 33% in the placebo group (P = .057). This was 1 of 19 secondary end points. Soluble tumor necrosis factor receptor 1 levels were reduced in the ascorbate group vs placebo from baseline to both day 2 (median, –861 pg/mL [interquartile range (IQR), –3,043 to 128.9 pg/mL] vs 241.4 pg/mL [–820 to 1,671 pg/mL]; P = .005) and day 3 (median, –1,511 pg/mL [IQR, –2,636 to –36.3 pg/mL] vs –131 pg/mL [–986 to 2,202 pg/mL]; P = .008).

Interpretation

Ascorbate did not improve days free of organ failure, although no safety concerns were identified in this small study. Ascorbate was shown to reduce a biological marker of inflammation associated with adverse outcomes in sepsis and lung injury.

Clinical Trial Registration

ClinicalTrials.gov; No.: NCT04291508; URL: www.clinicaltrials.gov

一项大剂量IV抗坏血酸的2期试验表明，尽管败血症试验未能显示出临床益处，但可降低ARDS患者的死亡率。静脉注射大剂量抗坏血酸能改善有ARDS风险的败血症患者的预后吗？研究设计和方法在这项2b期多中心随机安慰剂对照试验中，已知或疑似感染并伴有休克或急性低氧性呼吸衰竭的患者被随机分配给抗坏血酸（50mg /kg IV，每6小时，持续5天）或匹配安慰剂。主要终点是存活天数和28天无呼吸、肾脏和循环器官支持的天数。次要终点包括临床和生物学终点。结果：在招募了79名参与者后，由于发表了一项关于败血性休克的独立研究报告，抗坏血酸增加了死亡率，该试验被终止。在目前的研究中，接受抗坏血酸治疗的患者与接受安慰剂治疗的患者无器官支持的天数没有差异：平均（SD）分别为20.5（9.5）天和19.0（10.8）天（P = 0.528）。抗坏血酸组90天全因死亡率为15%，安慰剂组为33% （P = 0.057）。这是19个次要终点中的1个。从基线到第2天，抗坏血酸组可溶性肿瘤坏死因子受体1水平与安慰剂相比降低(中位数，-861 pg/mL[四分位数范围（IQR）， - 3043至128.9 pg/mL]与241.4 pg/mL[-820至1671 pg/mL]；P = 0.005)和第3天（中位数，-1,511 pg/mL [IQR, -2,636至-36.3 pg/mL] vs -131 pg/mL[-986至2,202 pg/mL]; P = 0.008）。解释：尽管在这项小型研究中没有发现安全性问题，但抗坏血酸并没有改善无器官衰竭的天数。抗坏血酸被证明可以减少与败血症和肺损伤不良结果相关的炎症的生物标志物。临床试验注册网站clinicaltrials .gov；否。: NCT04291508;URL: www.clinicaltrials.gov

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引用次数: 0

Predictive Markers of Neurological Complications in Patients Treated With Extracorporeal Membrane Oxygenation 体外膜氧合治疗患者神经系统并发症的预测指标

CHEST critical care

Pub Date : 2025-05-19 DOI: 10.1016/j.chstcc.2025.100170

Adeel Abbasi MD, ScM , Linn Ayers , Ron Balczon PhD , Amy R. Nelson PhD , Allison J. Bauman , Maya Cohen MD, ScM , Neelia Abadi , John R. Priest BSRT , Saraschandra Vallabhajosyula MD, FAHA, FACC , Grayson L. Baird PhD , Troy Stevens PhD , Corey E. Ventetuolo MD, FAHA

引用次数: 0

Sepsis in Previously Healthy Adults 先前健康成人的败血症

CHEST critical care

Pub Date : 2025-05-17 DOI: 10.1016/j.chstcc.2025.100172

Fizza Manzoor MD, Michael Klompas MD, MPH, Chanu Rhee MD, MPH

引用次数: 0

Response 响应

CHEST critical care

Pub Date : 2025-05-17 DOI: 10.1016/j.chstcc.2025.100173

Tessa A. Mulder MD , Linda Becude MD , Jorge E. Lopez Matta MD , Wilbert B. van den Hout PhD , David J. van Westerloo MD, PhD , Martijn P. Bauer MD, PhD

引用次数: 0

Parsing Prone Positioning Practices 解析倾向定位实践

CHEST critical care

Pub Date : 2025-05-17 DOI: 10.1016/j.chstcc.2025.100171

Chad H. Hochberg MD, MHS, David N. Hager MD, PhD

引用次数: 0

The Silent Threat 无声的威胁

CHEST critical care

Pub Date : 2025-05-08 DOI: 10.1016/j.chstcc.2025.100166

Wai-Tsan Ng MBChB, FHKCA, FHKCA (Intensive Care), FHKAM, FCICM, FANZCA , Song Wan MD, PhD, FRCS, FACC , Yuk-Hoi Lam MBChB, FRCS , Yu-Yeung Yip MBChB, FHKCA, FHKCA (Intensive Care), FHKAM, FCICM, FANZCA

引用次数: 0

The Relationship Between Neighborhood Deprivation and Mortality in a Sepsis Cohort in England 英格兰脓毒症队列中邻里剥夺与死亡率的关系

CHEST critical care

Pub Date : 2025-05-02 DOI: 10.1016/j.chstcc.2025.100165

Ritesh Maharaj MD, PhD , Ishan Rola , Irene Papanicolas PhD

Background

Worse health outcomes have been described for patients with sepsis from more deprived neighborhoods, but it is unclear if this disparity gap has narrowed. Moreover, the mechanisms by which neighborhood disadvantage influences sepsis outcomes are not understood fully.

Research Question

What is the trajectory of mortality among patients with sepsis in England across varying levels of neighborhood deprivation, and to what extent do patterns of ICU admission and treatment explain observed differences?

Study Design and Methods

This retrospective observational study using multivariable logistic regression included 519,789 patients older than 16 years admitted to the ICU with sepsis between April 1, 2009, and December 31, 2023, from 304 ICUs of 207 acute hospitals in England. The primary outcome was hospital mortality. The secondary outcomes were direct ICU admission from the emergency department; use of mechanical ventilation, renal replacement therapy, and vasopressor therapy; and decisions to limit life-sustaining therapy.

Results

Mortality improved across all groups of neighborhood deprivation from the baseline period from 2009 through 2011, and was 4.5% lower from 2022 through 2023 in the most deprived and 4.4% lower in the least deprived quartile, with no significant narrowing of the disparity gap over time (P = .833). Direct ICU admission from the emergency department was similar for patients across groups of neighborhood deprivation at baseline and increased similarly over time with no significant between-group difference. The gap in mechanical ventilation, renal placement therapy, and vasopressor use narrowed over time. Mortality trends were driven primarily by within-hospital improvements in care, and only a minor component was attributable to shift of patients from lower-quality to higher-quality hospitals.

Interpretation

Although sepsis mortality has improved across England, a persistent disparity associated with neighborhood deprivation exists. Further investigation is required to evaluate other potential contributory factors to help understand better how living in deprived areas contributes to the mortality gap.

来自贫困社区的败血症患者的健康状况更差，但尚不清楚这种差距是否已经缩小。此外，邻里不利影响败血症结果的机制尚不完全清楚。研究问题：在不同程度的邻里剥夺中，英国败血症患者的死亡率轨迹是什么？ ICU入院和治疗模式在多大程度上解释了观察到的差异？研究设计与方法采用多变量logistic回归的回顾性观察研究纳入了2009年4月1日至2023年12月31日期间英国207家急症医院304个ICU收治的519,789例16岁以上脓毒症患者。主要终点是住院死亡率。次要结局为急诊科直接入ICU；使用机械通气、肾脏替代治疗和血管加压治疗；以及决定限制维持生命的治疗。结果从2009年到2011年的基线期，所有社区贫困群体的死亡率都有所改善，从2022年到2023年，最贫困人群的死亡率降低了4.5%，最贫困人群的死亡率降低了4.4%，但随着时间的推移，差距没有显著缩小（P = 0.833）。从急诊科直接入住ICU的患者在基线时邻里剥夺组相似，随着时间的推移也相似地增加，组间无显著差异。随着时间的推移，机械通气、肾脏放置治疗和血管加压药物的使用差距逐渐缩小。死亡率趋势主要是由医院内护理的改善推动的，只有一小部分可归因于患者从低质量医院转到高质量医院。尽管脓毒症的死亡率在整个英格兰都有所改善，但与邻里剥夺相关的持续差异仍然存在。需要进一步调查来评估其他潜在的促成因素，以帮助更好地了解生活在贫困地区是如何导致死亡率差距的。

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