CHEST critical care最新文献

Background

For every critically ill adult receiving invasive mechanical ventilation, clinicians must select a mode of ventilation. The mode of ventilation determines whether the ventilator directly controls the tidal volume or the inspiratory pressure. Newer hybrid modes allow clinicians to set a target tidal volume; the ventilator controls and adjusts the inspiratory pressure. A strategy of low tidal volumes and low plateau pressure improves outcomes, but the optimal mode to achieve these targets is not known.

Research Question

Can a cluster-randomized trial design be used to assess whether the mode of mandatory ventilation affects the number of days alive and free of invasive mechanical ventilation among critically ill adults?

Study Design and Methods

The Mode of Ventilation During Critical Illness (MODE) trial is a cluster-randomized, multiple-crossover pilot trial being conducted in the medical ICU at an academic center. The MODE trial compares the use of volume control, pressure control, and adaptive pressure control. The study ICU is assigned to a single-ventilator mode (volume control vs pressure control vs adaptive pressure control) for continuous mandatory ventilation during each 1-month study block. The assigned mode switches every month in a randomly generated sequence. The primary outcome is ventilator-free days to study day 28, defined as the number of days alive and free of invasive mechanical ventilation from the final receipt of mechanical ventilation to 28 days after enrollment. Enrollment began November 1, 2022, and will end on July 31, 2023.

Results

This manuscript describes the protocol and statistical analysis plan for the MODE trial of ventilator modes comparing volume control, pressure control, and adaptive pressure control.

Interpretation

Prespecifying the full statistical analysis plan prior to completion of enrollment increases rigor, reproducibility, and transparency of the trial results.

Clinical Trial Registration

The trial was registered with clinicaltrials.gov on October 3, 2022, before initiation of patient enrollment on November 1, 2022 (ClinicalTrials.gov identifier: NCT05563779).

Background

The optimal strategy for initial respiratory support in patients with respiratory failure associated with COVID-19 is unclear, and the initial strategy may affect outcomes.

Research Question

Which initial respiratory support strategy is associated with improved outcomes in patients with COVID-19 with acute respiratory failure?

Study Design and Methods

All patients with COVID-19 requiring respiratory support and admitted to a large health care network were eligible for inclusion. We compared patients treated initially with noninvasive respiratory support (NIRS; noninvasive positive pressure ventilation by facemask or high-flow nasal oxygen) with patients treated initially with invasive mechanical ventilation (IMV). The primary outcome was time to in-hospital death analyzed using an inverse probability of treatment weighted Cox model adjusted for potential confounders. Secondary outcomes included unweighted and weighted assessments of mortality, lengths of stay (ICU and hospital), and time to intubation.

Results

Nearly one-half of the 2,354 patients (47%) who met inclusion criteria received IMV first, and 53% received initial NIRS. Overall, in-hospital mortality was 38% (37% for IMV and 39% for NIRS). Initial NIRS was associated with an increased hazard of death compared with initial IMV (hazard ratio, 1.42; 95% CI, 1.03-1.94), but also an increased hazard of leaving the hospital sooner that waned with time (noninvasive support by time interaction: hazard ratio, 0.97; 95% CI, 0.95-0.98).

Interpretation

Patients with COVID-19 with acute hypoxemic respiratory failure initially treated with NIRS showed an increased hazard of in-hospital death.

Background

No international consensus exists for standardized learning objectives (LOs) for curricular development nor certification to recognize clinical qualifications for extracorporeal membrane oxygenation (ECMO).

Research Question

Could consensus on LOs for an international ECMO curriculum and examination be reached?

Study Design and Methods

A modified four-phase Delphi consensus study with 12 international experts aimed to identify comprehensive LOs for curriculum development and high-priority objectives for an examination. In three phases, experts rated the relative importance of objectives using a web-based survey instrument with a four-point Likert scale and opportunities for free-text commentary. In the final phase, experts could agree or disagree with the final product.

Results

All 12 invited experts agreed to participate. An initial set of 64 proposed LOs based on prior ECMO courses was submitted. In phase 1, the experts added, removed, or modified the LOs. Fifty-three LOs with a Likert score of ≥ 3.0 were identified as being of moderate or high importance. In phase 2, experts identified 29 LOs to emphasize on examinations. In phase 3, experts voted on the final list of comprehensive and high-priority LOs and suggested modifications. In phase 4, experts voted to finalize the list generated from phase 3. With 100% consensus in the final phase, we identified 53 LOs of at least moderate importance for inclusion in curricula and 32 of high priority for inclusion in an examination.

Interpretation

A consensus was reached regarding the initial LOs for an international ECMO curriculum and examination, contributing to the creation of the first international certification program developed by the Extracorporeal Life Support Organization (ELSO), the ELSO Adult ECMO Certification. This process paves the way for unified efforts around global ECMO course development and practitioner assessment. This also may strengthen efforts to standardize worldwide ECMO training expectations and practices.

Background

The number of days alive and out of hospital (DAOH) is being used as a primary outcome in clinical trials. Limited data support the contention that it is a patient-important outcome.

Research Question

The primary objective was to assess the association between DAOH and health-related quality of life (HRQoL) at 6 months, as well as to assess the construct validity of DAOH as an outcome measure.

Study Design and Methods

Using data from the Adjunctive Corticosteroid Treatment in Critically Ill Patients With Septic Shock, Australasian Resuscitation in Sepsis Evaluation, and Crystalloid vs Hydroxyethyl Starch trials, we calculated the number of DOAH at day 90 (DAOH-90). HRQoL was estimated with the EQ-5D utility index score (range, –0.59 to 1) and the EQ-5D visual analog scale (range, 0-100) at 6 months. The association between DAOH and HRQoL was assessed using linear models, nonlinear models, and nonparametric measures of association.

Results

Six thousand two hundred thirteen trial participants included. The median index hospital length of stay was 16 days (interquartile range [IQR], 8-30), and mortality for the index hospitalization was 1,402 of 6,213 (22.6%). The median number of DAOH-90 was 60 days (IQR, 0-77 days). Each additional DAOH-90 was associated with an estimated increase in the 6-month EQ-5D utility index (range, 0-1) of 0.01 (95% CI, 0.01-0.011; P < .001). Adjusted analysis showed that each additional DAOH-90 was associated with an increase of 1.01 (95% CI, 0.99-1.04; P < .001) in the EQ-5D visual analog scale (range, 0-100). Trial participants at higher risk of adverse outcomes showed fewer DAOH-90.

Interpretation

We found a small positive incremental association between the number of DAOH-90 and HRQoL at 6 months and a negative association between the number of DAOH-90 and risk factors for adverse outcomes. These data provide some support for the use of DAOH-90 as an outcome measure in clinical trials of patients with sepsis.

Trial Registry

ClinicalTrials.gov; No.: NCT04567433; URL: www.clinicaltrials.gov

Case Presentation

An 18-year-old G1P0 woman at 9 weeks gestation with no known medical history presented to the ED with complaints of chest pain, shortness of breath, nausea, and vomiting. Nausea and vomiting had been present for 4 weeks and occurred multiple times daily, and the chest pain and shortness of breath had been present intermittently over the past 3 weeks but had worsened 2 days before admission. Chest pain severity was rated 10/10, was made worse with movement, and was associated with increasing shortness of breath. Vomitus was described as brown, occurring multiple times per day, and having no association with oral intake. The patient’s last menstrual cycle was reported to be approximately 3 months earlier, with the exact date unknown. She was evaluated at an outside hospital 1 week before admission for similar complaints. She did not use tobacco and denied recreational drug use. Physical examination showed BP of 105/58 mm Hg, heart rate of 138 beats/min, and normal oxygen saturation on room air without tachypnea. The patient was neurologically intact. Palpation of the chest wall was notable for crepitus, and breath sounds were decreased bilaterally. The patient was moderately hyponatremic and severely hypokalemic, and urine was positive for elevated ketones. An infectious workup, including leukocyte count, blood cultures, and urinalysis, was negative. Urine drug screen was negative. Transvaginal ultrasounds confirmed a single living intrauterine gestation at 9 weeks 4 days.

With the advent of new therapies and improvements in supportive care, survivorship in patients with interstitial lung disease (ILD) is increasing. However, this increase in number of patients living with ILD has resulted in an increase in the number of patients admitted to hospitals with acute exacerbations of ILD, most commonly manifested as advanced hypoxemic respiratory failure. In addition, patients with ILD may be admitted to the hospital as their first manifestation of ILD or progression of an ILD of yet to be diagnosed cause. All of these presentations carry significant risk of severe respiratory failure requiring admission to an ICU. It is therefore necessary for the critical care practitioner to have an approach to the patient with ILD being admitted to the ICU. This review summarizes an approach to the evaluation and management of patients presenting to the ICU through a discussion of: (1) diagnosis of acute exacerbation in patients with previously diagnosed ILD; (2) diagnosis of patients presenting with ILD of unknown cause; (3) treatment of both acute exacerbations and underlying causes of ILD; (4) supportive ICU care for advanced respiratory failure due to ILD; and (5) outcomes of patients with ILD and severe respiratory failure in the ICU. In addition, we offer suggested approaches to determining the cause of respiratory deterioration in patients with ILD and deciding which advanced respiratory support devices are reasonable in managing ILD patients who have progressive respiratory failure.

Background

The clinical benefit of using inhaled epoprostenol (iEpo) through a humidified high-flow nasal cannula (HHFNC) remains unknown for patients with COVID-19.

Research Question

Can iEpo prevent respiratory deterioration for patients with positive SARS-CoV-2 findings receiving HHFNC?

Study Design and Methods

This multicenter retrospective cohort analysis included patients aged 18 years or older with COVID-19 pneumonia who required HHFNC treatment. Patients who received iEpo were propensity score matched to patients who did not receive iEpo. The primary outcome was time to mechanical ventilation or death without mechanical ventilation and was assessed using Kaplan-Meier curves and Cox proportional hazard ratios. The effects of residual confounding were assessed using a multilevel analysis, and a secondary analysis adjusted for outcome propensity also was performed in a multivariable model that included the entire (unmatched) patient cohort.

Results

Among 954 patients with positive SARS-CoV-2 findings receiving HHFNC therapy, 133 patients (13.9%) received iEpo. After propensity score matching, the median number of days until the composite outcome was similar between treatment groups (iEpo: 5.0 days [interquartile range, 2.0-10.0 days] vs no-iEpo: 6.5 days [interquartile range, 2.0-11.0 days]; P = .26), but patients who received iEpo were more likely to meet the composite outcome in the propensity score-matched, multilevel, and multivariable unmatched analyses (hazard ratio, 2.08 [95% CI, 1.73-2.50]; OR, 4.72 [95% CI, 3.01-7.41]; and OR, 1.35 [95% CI, 1.23-1.49]; respectively).

Interpretation

In patients with COVID-19 receiving HHFNC therapy, use of iEpo was associated with the need for invasive mechanical ventilation.