1
|
Shah NM, Hart N, Kaltsakas G. Prolonged weaning from mechanical ventilation: who, what, when and how? Breathe (Sheff) 2024; 20:240122. [PMID: 39660085 PMCID: PMC11629167 DOI: 10.1183/20734735.0122-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2024] [Accepted: 10/16/2024] [Indexed: 12/12/2024] Open
Abstract
Weaning from invasive mechanical ventilation is an important part of the management of respiratory failure patients. Patients can be classified into those who wean on the first attempt (simple weaning), those who require up to three attempts (difficult weaning) and those who require more than three attempts (prolonged weaning). The process of weaning includes adequately treating the underlying cause of respiratory failure, assessing the readiness to wean, evaluating the response to a reduction in ventilatory support, and eventually liberation from mechanical ventilation and extubation or decannulation. Post-extubation respiratory failure is a contributor to poorer outcomes. Identifying and addressing modifiable risk factors for post-extubation respiratory failure is important; noninvasive ventilation and high-flow nasal cannulae may be useful bridging aids after extubation. Factors to consider in the pathophysiology of prolonged mechanical ventilation include increased respiratory muscle load, reduced respiratory muscle capacity and reduced respiratory drive. Management of these patients involves a multidisciplinary team, to first identify the cause of failed weaning attempts, and subsequently optimise the patient's physiology to improve the likelihood of being successfully weaned from invasive mechanical ventilation.
Collapse
Affiliation(s)
- Neeraj M. Shah
- Lane Fox Respiratory Service, St Thomas’ Hospital, Guy's and St Thomas’ NHS Foundation Trust, London, UK
- Lane Fox Clinical Respiratory Physiology Centre, Guy's and St Thomas’ NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences (CHAPS), King's College London, London, UK
| | - Nicholas Hart
- Lane Fox Respiratory Service, St Thomas’ Hospital, Guy's and St Thomas’ NHS Foundation Trust, London, UK
- Lane Fox Clinical Respiratory Physiology Centre, Guy's and St Thomas’ NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences (CHAPS), King's College London, London, UK
| | - Georgios Kaltsakas
- Lane Fox Respiratory Service, St Thomas’ Hospital, Guy's and St Thomas’ NHS Foundation Trust, London, UK
- Lane Fox Clinical Respiratory Physiology Centre, Guy's and St Thomas’ NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences (CHAPS), King's College London, London, UK
| |
Collapse
|
2
|
Clerk AM, Shah RJ, Kothari J, Sodhi K, Vadi S, Bhattacharya PK, Mishra RC. Position Statement of ISCCM Committee on Weaning from Mechanical Ventilator. Indian J Crit Care Med 2024; 28:S233-S248. [PMID: 39234223 PMCID: PMC11369923 DOI: 10.5005/jp-journals-10071-24716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 04/15/2024] [Indexed: 09/06/2024] Open
Abstract
BACKGROUND AND PURPOSE Weaning from a mechanical ventilator is a milestone in the recovery of seriously ill patients in Intensive care. Failure to wean and re-intubation adversely affects the outcome. The method of mechanical ventilation (MV) varies between different ICUs and so does the practice of weaning. Therefore, updated guidelines based on contemporary literature are designed to guide intensivists in modern ICUs. This is the first ISCCM Consensus Statement on weaning complied by a committee on weaning. The recommendations are intended to be used by all the members of the ICU (Intensivists, Registrars, Nurses, and Respiratory Therapists). METHODS A Committee on weaning from MV, formed by the Indian Society of Critical Care Medicine (ISCCM) has formulated this statement on weaning from mechanical ventilators in intensive care units (ICUs) after a review of the literature. Literature was first circulated among expert committee members and allotted sections to each member. Sections of the statement written by sectional authors were peer-reviewed on multiple occasions through virtual meetings. After the final manuscript is accepted by all the committee members, it is submitted for peer review by central guideline committee of ISCCM. Once approved it has passed through review by the Editorial Board of IJCCM before it is published here as "ISCCM consensus statement on weaning from mechanical ventilator". As per the standard accepted for all its guidelines of ISCCM, we followed the modified grading of recommendations assessment, development and evaluation (GRADE) system to classify the quality of evidence and strength of recommendation. Cost-benefit, risk-benefit analysis, and feasibility of implementation in Indian ICUs are considered by the committee along with the strength of evidence. Type of ventilators and their modes, ICU staffing pattern, availability of critical care nurses, Respiratory therapists, and day vs night time staffing are aspects considered while recommending for or against any aspect of weaning. RESULT This document makes recommendation on various aspects of weaning, namely, definition, timing, weaning criteria, method of weaning, diagnosis of failure to wean, defining difficult to wean, Use of NIV, HFOV as adjunct to weaning, role of tracheostomy in weaning, weaning in of long term ventilated patients, role of physiotherapy, mobilization in weaning, Role of nutrition in weaning, role of diaphragmatic ultrasound in weaning prediction etc. Out of 42 questions addressed; the committee provided 39 recommendations and refrained from 3 questions. Of these 39; 32 are based on evidence and 7 are based on expert opinion of the committee members. It provides 27 strong recommendations and 12 weak recommendations (suggestions). CONCLUSION This guideline gives extensive review on weaning from mechanical ventilator and provides various recommendations on weaning from mechanical ventilator. Though all efforts are made to make is as updated as possible one needs to review any guideline periodically to keep it in line with upcoming concepts and standards. HOW TO CITE THIS ARTICLE Clerk AM, Shah RJ, Kothari J, Sodhi K, Vadi S, Bhattacharya PK, et al. Position Statement of ISCCM Committee on Weaning from Mechanical Ventilator. Indian J Crit Care Med 2024;28(S2):S233-S248.
Collapse
Affiliation(s)
- Anuj M Clerk
- Department of Intensive Care, Sunshine Global Hospital, Surat, Gujarat, India
| | - Ritesh J Shah
- Department of Critical Care Medicine, Sterling Hospital, Vadodara, Gujarat, India
| | - Jay Kothari
- Department of Critical Care Medicine, Apollo International Hospital, Ahmedabad, Gujarat, India
| | | | - Sonali Vadi
- Department of Intensive Care Medicine, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, Maharashtra, India
| | - Pradip K Bhattacharya
- Department of Critical Care Medicine, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Rajesh C Mishra
- Department of MICU, Shaibya Comprehensive Care Clinic, Ahmedabad, Gujarat, India
| |
Collapse
|
3
|
Papaioannou M, Vagiana E, Kotoulas SC, Sileli M, Manika K, Tsantos A, Kapravelos N. Tracheostomy-related data from an intensive care unit for two consecutive years before the COVID-19 pandemic. World J Methodol 2024; 14:91868. [PMID: 38983661 PMCID: PMC11229867 DOI: 10.5662/wjm.v14.i2.91868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 02/24/2024] [Accepted: 04/12/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Tracheostomy is commonly used in intensive care unit (ICU) patients who are expected to be on long-term mechanical ventilation or suffer from emergency upper airway obstruction. However, some studies have conflicting findings regarding the optimal technique and its timing and benefits. AIM To provide evidence of practice, characteristics, and outcome concerning tracheostomy in an ICU of a tertiary care hospital. METHODS This was a retrospective cohort study including adult critical care patients in a single ICU for two consecutive years. Patients' demographic characteristics, severity of illness (APACHE II score), level of consciousness [Glasgow Coma Scale (GCS)], comorbidities, timing and type of tracheostomy procedure performed and outcome were recorded. We defined late as tracheostomy placement after 8 days or no tracheotomy. RESULTS Data of 660 patients were analyzed (median age of 60 years), median APACHE II score of 19 and median GCS score of 12 at admission. Tracheostomy was performed in 115 patients, of whom 63 had early and 52 late procedures. Early tracheostomy was mainly executed in case of altered level of consciousness and severe critical illness polyneuromyopathy, however there were no significant statistical results (47.6% vs 36.5%, P = 0.23) and (23.8% vs 19.2%, P = 0.55) respectively. Regarding the method selected, early surgical tracheostomy (ST) was conducted in patients with maxillofacial injuries (50.0% vs 0.0%, P = 0.033), whereas late surgical tracheostomy was selected for patients with goiter (44.4% vs 0.0% P = 0.033). Patients with early tracheostomy spent significantly fewer days on mechanical ventilation (15.3 ± 8.5 vs 22.8 ± 9.6, P < 0.001) and in ICU in general (18.8 ± 9.1 vs 25.4 ± 11.5, P < 0.001). Percutaneous dilatation tracheostomy (PDT) vs ST was preferable in older critical care patients in the case of Central Nervous System underlying cause of admission (62.5% vs 26.3%, P = 0.004). ST was the method of choice in compromised airway (31.6%, vs 7.3% P = 0.008). A large proportion of patients (88/115) with tracheostomy managed to wean from mechanical ventilation and were transferred out of the ICU (100% vs 17.4%, P < 0.001). CONCLUSION PDT was performed more frequently in our cohort. This technique did not affect mechanical ventilation days, ventilator-associated pneumonia (VAP), ICU length of stay, or survival. No complications were observed in the percutaneous or surgical tracheostomy groups. Patients undergoing early tracheostomy benefited in terms of mechanical ventilation days and ICU length of stay but not of discharge status, presence of VAP, or survival.
Collapse
Affiliation(s)
- Maria Papaioannou
- 1st Intensive Care Unit, G Papanikolaou General Hospital, Exohi, Thessaloniki 57010, Greece
| | - Evdoxia Vagiana
- 2nd Intensive Care Unit, G Papanikolaou General Hospital, Exohi, Thessaloniki 57010, Greece
| | | | - Maria Sileli
- 2nd Intensive Care Unit, G Papanikolaou General Hospital, Exohi, Thessaloniki 57010, Greece
| | - Katerina Manika
- Department of Pulmonary, Medical School, Aristotle University of Thessaloniki, G. Papanikolaou General Hospital, Exohi, Thessaloniki 57010, Greece
| | - Alexandros Tsantos
- 2nd Department of Internal Medicine, General Hospital of Thessaloniki “Ippokration”, Thessaloniki 54642, Greece
| | - Nikolaos Kapravelos
- 2nd Intensive Care Unit, G Papanikolaou General Hospital, Exohi, Thessaloniki 57010, Greece
| |
Collapse
|
4
|
Poddighe D, Van Hollebeke M, Choudhary YQ, Campos DR, Schaeffer MR, Verbakel JY, Hermans G, Gosselink R, Langer D. Accuracy of respiratory muscle assessments to predict weaning outcomes: a systematic review and comparative meta-analysis. Crit Care 2024; 28:70. [PMID: 38454487 PMCID: PMC10919035 DOI: 10.1186/s13054-024-04823-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/29/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND Several bedside assessments are used to evaluate respiratory muscle function and to predict weaning from mechanical ventilation in patients on the intensive care unit. It remains unclear which assessments perform best in predicting weaning success. The primary aim of this systematic review and meta-analysis was to summarize and compare the accuracy of the following assessments to predict weaning success: maximal inspiratory (PImax) and expiratory pressures, diaphragm thickening fraction and excursion (DTF and DE), end-expiratory (Tdiee) and end-inspiratory (Tdiei) diaphragm thickness, airway occlusion pressure (P0.1), electrical activity of respiratory muscles, and volitional and non-volitional assessments of transdiaphragmatic and airway opening pressures. METHODS Medline (via Pubmed), EMBASE, Web of Science, Cochrane Library and CINAHL were comprehensively searched from inception to 04/05/2023. Studies including adult mechanically ventilated patients reporting data on predictive accuracy were included. Hierarchical summary receiver operating characteristic (HSROC) models were used to estimate the SROC curves of each assessment method. Meta-regression was used to compare SROC curves. Sensitivity analyses were conducted by excluding studies with high risk of bias, as assessed with QUADAS-2. Direct comparisons were performed using studies comparing each pair of assessments within the same sample of patients. RESULTS Ninety-four studies were identified of which 88 studies (n = 6296) reporting on either PImax, DTF, DE, Tdiee, Tdiei and P0.1 were included in the meta-analyses. The sensitivity to predict weaning success was 63% (95% CI 47-77%) for PImax, 75% (95% CI 67-82%) for DE, 77% (95% CI 61-87%) for DTF, 74% (95% CI 40-93%) for P0.1, 69% (95% CI 13-97%) for Tdiei, 37% (95% CI 13-70%) for Tdiee, at fixed 80% specificity. Accuracy of DE and DTF to predict weaning success was significantly higher when compared to PImax (p = 0.04 and p < 0.01, respectively). Sensitivity and direct comparisons analyses showed that the accuracy of DTF to predict weaning success was significantly higher when compared to DE (p < 0.01). CONCLUSIONS DTF and DE are superior to PImax and DTF seems to have the highest accuracy among all included respiratory muscle assessments for predicting weaning success. Further studies aiming at identifying the optimal threshold of DTF to predict weaning success are warranted. TRIAL REGISTRATION PROSPERO CRD42020209295, October 15, 2020.
Collapse
Affiliation(s)
- Diego Poddighe
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Marine Van Hollebeke
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Yasir Qaiser Choudhary
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
| | - Débora Ribeiro Campos
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Prêto, Brazil
| | - Michele R Schaeffer
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
| | - Jan Y Verbakel
- Department of Public Health and Primary Care, EPI-Centre, KU Leuven, Leuven, Belgium
- NIHR Community Healthcare Medtech and IVD Cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Greet Hermans
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Rik Gosselink
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Health and Rehabilitation Sciences, Faculty of Medicine, Stellenbosch University, Stellenbosch, South Africa
| | - Daniel Langer
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium.
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium.
| |
Collapse
|
5
|
Alhazmi RA, Omer NF, Hameed FA, Khan S, Khawajah M, Alabdullah HA, Althenayan TO, Alhithlool AW, Kharaba AM. Impact of Tracheostomy on COVID-19 ICU Patients in Saudi Arabia: A Retrospective Analysis. Cureus 2024; 16:e52766. [PMID: 38389619 PMCID: PMC10882215 DOI: 10.7759/cureus.52766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2024] [Indexed: 02/24/2024] Open
Abstract
Introduction The COVID-19 pandemic has prompted the development of novel medical interventions, including tracheostomy, a surgical procedure for a direct airway. This study investigates the intricacies of managing critically ill patients in the ICU, focusing on its debated utility in the global crisis. Methods The study assessed the impact of tracheostomy on COVID-19 patients at Al-Ahsa Hospital, Saudi Arabia, using a retrospective cohort design and data from electronic health records and databases. It aimed to provide insights into treatment outcomes and practices. Results The findings of this study shed light on the significant impact of tracheostomy on the course of ICU treatment for COVID-19 patients. Total number of participants were 1389. The study cohort consisted of predominantly non-pregnant individuals with an average body mass index reflective of the regional population. Among the COVID-19 patients, only a small percentage, 63 (4.5%), required tracheostomy, while the majority, 1326 (95.5%), did not undergo this procedure. Analysis of ICU outcomes revealed that a substantial proportion of patients, 223 (16.1%), achieved total cure, while the remaining patients did not. After a 28-day ICU stay, the majority of individuals, 1287 (92.7%), were discharged, while a smaller percentage remained in the ICU, with 77 (5.5%) still requiring mechanical ventilation. Notably, patients who underwent tracheostomy had a significantly longer ICU stay compared to those who did not, with an average of 59 days versus 19 days, respectively. Furthermore, the study found that tracheostomy did not significantly impact ICU discharge outcomes, including death, discharge home, and transfer to another facility. However, it did influence hospital discharge outcomes, with lower mortality rates and a higher rate of transfer to another facility among patients who underwent tracheostomy. These results provide valuable insights into the management and outcomes of critically ill COVID-19 patients in the ICU, particularly in relation to the use of tracheostomy as a treatment intervention. Conclusion The study highlights the dual benefits of tracheostomy in COVID-19 care, extending hospital stays but not increasing ICU discharge rates, emphasizing the need for tailored clinical strategies.
Collapse
Affiliation(s)
| | - Neeveen F Omer
- Medicine, Fakeeh College for Medical Sciences, Jeddah, SAU
| | | | - Sara Khan
- Medicine, Fakeeh College for Medical Sciences, Jeddah, SAU
| | | | | | | | - Amjad W Alhithlool
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | | |
Collapse
|
6
|
Karic E, Mitwally H, Alansari LM, Ganaw A, Saad MO, Azhaghdani A. Impact of Early Tracheostomy on Weaning From Ventilation and Sedation in COVID-19 Pregnant and Early Postpartum Patient: Two Case Reports. Cureus 2022; 14:e29633. [PMID: 36320992 PMCID: PMC9606483 DOI: 10.7759/cureus.29633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2022] [Indexed: 11/20/2022] Open
Abstract
Pregnant women are at high risk of coronavirus disease 2019 (COVID-19) complications, including acute respiratory distress syndrome (ARDS) and the need for mechanical ventilation. There is no literature on the optimal strategy for the management of difficult-to-wean pregnant and early postpartum patients. We report two cases of pregnant women with COVID-19 pneumonia and ARDS, who required mechanical ventilation and high doses of analgesia, and sedation with neuromuscular blocking agents to facilitate ventilation and oxygenation. Both patients had a tracheostomy procedure to facilitate weaning from mechanical ventilation and sedation. Shortly after tracheostomy, sedation and analgesia, along with ventilatory support were weaned off. Both patients were discharged home. These cases propose early tracheostomy as a strategy to facilitate weaning from mechanical ventilation and sedation in pregnant and early postpartum patients.
Collapse
|
7
|
Na SJ, Ko RE, Nam J, Ko MG, Jeon K. Comparison between pressure support ventilation and T-piece in spontaneous breathing trials. Respir Res 2022; 23:22. [PMID: 35130914 PMCID: PMC8822807 DOI: 10.1186/s12931-022-01942-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 01/28/2022] [Indexed: 12/16/2022] Open
Abstract
Background Recent guidelines recommended conducting spontaneous breathing trial (SBT) with modest inspiratory pressure augmentation rather than T-piece or continuous positive airway pressure. However, it was based on few studies focused on the outcomes of extubation rather than the weaning process, despite the existence of various weaning situations in clinical practice. This study was designed to investigate the effects of SBT with pressure support ventilation (PSV) or T-piece on weaning outcomes. Methods All consecutive patients admitted to two medical intensive care units (ICUs) and those requiring mechanical ventilation (MV) for more than 24 h from November 1, 2017 to September 30, 2020 were prospectively registered. T-piece trial was used until March 2019, and then, pressure support of 8 cmH2O and 0 positive end-expiratory pressure were used for SBT since July 2019, after a 3-month transition period for the revised SBT protocol. The primary outcome of this study was successful weaning defined according to the WIND (Weaning according to a New Definition) definition and were compared between the T-piece group and PSV group. The association between the SBT method and weaning outcome was evaluated with logistic regression analysis. Results In this study, 787 eligible patients were divided into the T-piece (n = 473) and PSV (n = 314) groups after excluding patients for a 3-month transition period. Successful weaning was not different between the two groups (85.0% vs. 86.3%; p = 0.607). However, the PSV group had a higher proportion of short weaning (70.1% vs. 59.0%; p = 0.002) and lower proportion of difficult weaning (13.1% vs. 24.1%; p < 0.001) than the T-piece group. The proportion of prolonged weaning was similar between the two groups (16.9% vs. 16.9%; p = 0.990). After excluding patients who underwent tracheostomy before the SBTs, similar results were found. Reintubation rates at 48 h, 72 h, and 7 days following the planned extubation were not different between the PSV and T-piece groups. Moreover, no significant differences in intensive care unit and hospital mortality and length of stay were observed. Conclusions In critically ill medical patients, SBT using PSV was not associated with a higher rate of successful weaning compared with SBT using T-piece. However, PSV could shorten the weaning process without increasing the risk of reintubation. Supplementary Information The online version contains supplementary material available at 10.1186/s12931-022-01942-w.
Collapse
|
8
|
Chiang DH, Huang CC, Cheng SC, Cheng JC, Wu CH, Huang SS, Yang YY, Yang LY, Kao SY, Chen CH, Shulruf B, Lee FY. Immersive virtual reality (VR) training increases the self-efficacy of in-hospital healthcare providers and patient families regarding tracheostomy-related knowledge and care skills: A prospective pre-post study. Medicine (Baltimore) 2022; 101:e28570. [PMID: 35029229 PMCID: PMC8757958 DOI: 10.1097/md.0000000000028570] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 12/23/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Virtual reality (VR)-based simulation in hospital settings facilitates the acquisition of skills without compromising patient safety. Despite regular text-based training, a baseline survey of randomly selected healthcare providers revealed deficiencies in their knowledge, confidence, comfort, and care skills regarding tracheostomy. This prospective pre-post study compared the effectiveness of regular text- and VR-based intervention modules in training healthcare providers' self-efficacy in tracheostomy care skills. METHODS Between January 2018 and January 2020, 60 healthcare providers, including physicians, nurses, and respiratory therapists, were enrolled. For the intervention, a newly developed head-mounted display (HMD) and web VR materials were implemented in training and clinical services. Subsequently, in-hospital healthcare providers were trained using either text or head-mounted display virtual reality (HMD-VR) materials in the regular and intervention modules, respectively. For tracheostomy care skills, preceptors directly audited the performance of trainees and provided feedback. RESULTS At baseline, the degree of trainees' agreement with the self-efficacy-related statements, including the aspects of familiarity, confidence, and anxiety about tracheostomy-related knowledge and care skills, were not different between the control and intervention groups. At follow-up stage, compared with the regular group, a higher percentage of intervention group' trainees reported that they are "strongly agree" or "somewhat agree" that the HMD-VR simulation increases their self-efficacy, including the aspects of familiarity and confidence, and reduced their anxiety about tracheostomy-related knowledge and care skills. After implementation, a higher degree of trainees' average satisfaction with VR-based training and VR materials was observed in the intervention group than in the regular group. Most reported that VR materials enabled accurate messaging and decreased anxiety. The increasing trend of the average written test and hands-on tracheostomy care skills scores among the intervention group trainees was significant compared to those in the regular group. The benefits of HMD-VR simulations and web-VR material-based clinical services for in-hospital healthcare providers and patient families persisted until 3 to 4 weeks later. CONCLUSION The current study suggests that VR materials significantly enhance trainees' self-efficacy (increased familiarity, increased confidence, and reduced anxiety) and their satisfaction with the training, while motivating them to use acquired knowledge and skills in clinical practice.
Collapse
Affiliation(s)
- Dung-Hung Chiang
- Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, Taipei, Taiwan
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
| | - Chia-Chang Huang
- Faculty of Medicine, Taipei, Taiwan
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
- Medical Innovation Research Office, Clinical Innovation Center, Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shu-Chuan Cheng
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Division of Respiratory Therapy, Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jui-Chun Cheng
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Division of Respiratory Therapy, Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Cheng-Hsien Wu
- Faculty of Medicine, Taipei, Taiwan
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shiau-Shian Huang
- Faculty of Medicine, Taipei, Taiwan
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
- Medical Innovation Research Office, Clinical Innovation Center, Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ying-Ying Yang
- Faculty of Medicine, Taipei, Taiwan
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
- Medical Innovation Research Office, Clinical Innovation Center, Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ling-Yu Yang
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shou-Yen Kao
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Division of Family Dentistry, Department of Stomatology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chen-Huan Chen
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | | | - Fa-Yauh Lee
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| |
Collapse
|
9
|
Almutairi D, Alqahtani R, Alghamdi A, Binammar D, Alzaidi S, Ghafori A, Alsharif H. Tracheotomy Outcomes in 71 COVID-19 Patients: A Multi-Centric Study in Saudi Arabia. Clin Pract 2021; 11:947-953. [PMID: 34940008 PMCID: PMC8700003 DOI: 10.3390/clinpract11040109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 12/03/2022] Open
Abstract
Since its outbreak in late 2019, the COVID-19 pandemic has seen a sharp rise in the demand for oxygen and ventilation facilities due to the associated extensive damage that it causes to the lungs. This study is considered the first and largest study in Saudi Arabia to evaluate the outcomes of tracheostomy in intubated COVID-19 patients. This is a retrospective, observational cohort study that was conducted at King Abdulaziz Medical City (KAMC) in Jeddah, Western Region, Saudi Arabia and King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia. The findings of the study revealed that seventy-one patients with COVID-19 underwent tracheotomy between 1 March 2020 and 31 October 2020. The average period between intubation and tracheostomy was 9.97 days. Hypertension, diabetes, lung disease and obesity (BMI > 30) were significant risk factors of mortality. The overall 30-day mortality rate was 38.4%.
Collapse
Affiliation(s)
- Dakheelallah Almutairi
- Department of Otorhinolaryngology-Head and Neck Surgery, King Abdulaziz Medical City, Jeddah 21423, Saudi Arabia;
- College of Medicine, King Saud Bin-Abdul-Aziz University for Health Sciences, Ministry of National Guard, Jeddah 14611, Saudi Arabia; (A.A.); (D.B.)
| | - Raneem Alqahtani
- College of Medicine, King Saud Bin-Abdul-Aziz University for Health Sciences, Ministry of National Guard, Jeddah 14611, Saudi Arabia; (A.A.); (D.B.)
- Correspondence: ; Tel.: +966-55-352-1010
| | - Arwa Alghamdi
- College of Medicine, King Saud Bin-Abdul-Aziz University for Health Sciences, Ministry of National Guard, Jeddah 14611, Saudi Arabia; (A.A.); (D.B.)
| | - Dina Binammar
- College of Medicine, King Saud Bin-Abdul-Aziz University for Health Sciences, Ministry of National Guard, Jeddah 14611, Saudi Arabia; (A.A.); (D.B.)
| | - Suzan Alzaidi
- Department of Otorhinolaryngology-Head and Neck Surgery, King Fahad Armed Forces Hospital, Jeddah 23311, Saudi Arabia; (S.A.); (A.G.)
| | - Abdullah Ghafori
- Department of Otorhinolaryngology-Head and Neck Surgery, King Fahad Armed Forces Hospital, Jeddah 23311, Saudi Arabia; (S.A.); (A.G.)
| | - Hassan Alsharif
- Intensive Care Department (ICD), King Fahad Armed Forces Hospital, Jeddah 23311, Saudi Arabia;
| |
Collapse
|
10
|
Early Percutaneous Tracheostomy in Coronavirus Disease 2019: Association With Hospital Mortality and Factors Associated With Removal of Tracheostomy Tube at ICU Discharge. A Cohort Study on 121 Patients. Crit Care Med 2021; 49:261-270. [PMID: 33201005 DOI: 10.1097/ccm.0000000000004752] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Early tracheotomy, defined as a procedure performed within 10 days from intubation, is associated with more ventilator free days, shorter ICU stay, and lower mortality than late tracheotomy. During the coronavirus disease 2019 pandemic, it was especially important to save operating room resources and to have a shorter ICU stay for patients, when ICUs had insufficient beds. In this context of limited resources, early percutaneous tracheostomy could be an effective way to manage mechanically ventilated patients. Nevertheless, current recommendations suggest delaying or avoiding the tracheotomy in coronavirus disease 2019 patients. Aim of the study was to analyze the hospital mortality of coronavirus disease 2019 patients who had received early percutaneous tracheostomy and factors associated with removal of tracheostomy cannula at ICU discharge. DESIGN Cohort study. SETTING Coronavirus disease 2019 ICU. PATIENTS Adult patients with coronavirus disease 2019 3 days after ICU admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Three days after ICU admission, 164 patients were present in ICU and included in the analysis. One-hundred and twenty-one patients (74%) were tracheostomized, whereas the other 43 (26%) were managed with translaryngeal intubation only. In multivariable analysis, early percutaneous tracheostomy was associated with lower hospital mortality. Sixty-six of tracheostomized patients (55%) were discharged alive from the hospital. Age and male sex were the only characteristics that were independently associated with mortality in the tracheostomized patients (45.5% and 62.8% in tracheostomized and nontracheostomized patients, respectively; p = 0.009). Tracheostomy tube was removed in 47 of the tracheostomized patients (71%). The only variable independently associated with weaning from tracheostomy at ICU discharge was a faster start of spontaneous breathing after tracheotomy was performed. CONCLUSIONS Early percutaneous tracheostomy was safe and effective in coronavirus disease 2019 patients, giving a good chance of survival and of weaning from tracheostomy cannula at ICU discharge.
Collapse
|
11
|
Schönhofer B, Geiseler J, Dellweg D, Fuchs H, Moerer O, Weber-Carstens S, Westhoff M, Windisch W. Prolonged Weaning: S2k Guideline Published by the German Respiratory Society. Respiration 2020; 99:1-102. [PMID: 33302267 DOI: 10.1159/000510085] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/28/2023] Open
Abstract
Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.
Collapse
Affiliation(s)
- Bernd Schönhofer
- Klinikum Agnes Karll Krankenhaus, Klinikum Region Hannover, Laatzen, Germany,
| | - Jens Geiseler
- Klinikum Vest, Medizinische Klinik IV: Pneumologie, Beatmungs- und Schlafmedizin, Marl, Germany
| | - Dominic Dellweg
- Fachkrankenhaus Kloster Grafschaft GmbH, Abteilung Pneumologie II, Schmallenberg, Germany
| | - Hans Fuchs
- Universitätsklinikum Freiburg, Zentrum für Kinder- und Jugendmedizin, Neonatologie und Pädiatrische Intensivmedizin, Freiburg, Germany
| | - Onnen Moerer
- Universitätsmedizin Göttingen, Klinik für Anästhesiologie, Göttingen, Germany
| | - Steffen Weber-Carstens
- Charité, Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Virchow-Klinikum und Campus Mitte, Berlin, Germany
| | - Michael Westhoff
- Lungenklinik Hemer, Hemer, Germany
- Universität Witten/Herdecke, Herdecke, Germany
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Universität Witten/Herdecke, Herdecke, Germany
| |
Collapse
|
12
|
Gosling AF, Bose, S, Gomez E, Parikh, M, Cook C, Sarge T, Shaefi S, Leibowitz A. Perioperative Considerations for Tracheostomies in the Era of COVID-19. Anesth Analg 2020; 131:378-386. [PMID: 32459668 PMCID: PMC7273938 DOI: 10.1213/ane.0000000000005009] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2020] [Indexed: 01/06/2023]
Abstract
The morbidity, mortality, and blistering pace of transmission of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to an unprecedented worldwide health crisis. Coronavirus disease 2019 (COVID-19), the disease produced by SARS-CoV-2 infection, is remarkable for persistent, severe respiratory failure requiring mechanical ventilation that places considerable strain on critical care resources. Because recovery from COVID-19-associated respiratory failure can be prolonged, tracheostomy may facilitate patient management and optimize the use of mechanical ventilators. Several important considerations apply to plan tracheostomies for COVID-19-infected patients. After performing a literature review of tracheostomies during the severe acute respiratory syndrome (SARS) and Middle East Respiratory Syndrome (MERS) outbreaks, we synthesized important learning points from these experiences and suggested an approach for perioperative teams involved in these procedures during the COVID-19 pandemic. Multidisciplinary teams should be involved in decisions regarding timing and appropriateness of the procedure. As the theoretical risk of disease transmission is increased during aerosol-generating procedures (AGPs), stringent infectious precautions are warranted. Personal protective equipment (PPE) should be available and worn by all personnel present during tracheostomy. The number of people in the room should be limited to those absolutely necessary. Using the most experienced available operators will minimize the total time that staff is exposed to an infectious aerosolized environment. An approach that secures the airway in the safest and quickest manner will minimize the time any part of the airway is open to the environment. Deep neuromuscular blockade (train-of-four ratio = 0) will facilitate surgical exposure and prevent aerosolization due to patient movement or coughing. For percutaneous tracheostomies, the bronchoscopist should be able to reintubate if needed. Closed-loop communication must occur at all times among members of the team. If possible, after tracheostomy is performed, waiting until the patient is virus-free before changing the cannula or downsizing may reduce the chances of health care worker infection. Tracheostomies in COVID-19 patients present themselves as extremely high risk for all members of the procedural team. To mitigate risk, systematic meticulous planning of each procedural step is warranted along with strict adherence to local/institutional protocols.
Collapse
Affiliation(s)
- Andre F. Gosling
- From the Department of Anesthesia, Critical Care and Pain Medicine
| | - Somnath Bose,
- From the Department of Anesthesia, Critical Care and Pain Medicine
| | - Ernest Gomez
- Department of Surgery, Division of Otolaryngology/Head and Neck Surgery
| | - Mihir Parikh,
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine
- Department of Surgery, Chest Disease Center
| | - Charles Cook
- Division of Acute Care Surgery, Trauma and Critical Care, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Todd Sarge
- From the Department of Anesthesia, Critical Care and Pain Medicine
| | - Shahzad Shaefi
- From the Department of Anesthesia, Critical Care and Pain Medicine
| | - Akiva Leibowitz
- From the Department of Anesthesia, Critical Care and Pain Medicine
| |
Collapse
|
13
|
Mecham JC, Thomas OJ, Pirgousis P, Janus JR. Utility of Tracheostomy in Patients With COVID-19 and Other Special Considerations. Laryngoscope 2020; 130:2546-2549. [PMID: 32368799 PMCID: PMC7267632 DOI: 10.1002/lary.28734] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/20/2020] [Accepted: 04/22/2020] [Indexed: 01/08/2023]
Abstract
Introduction Patients who become severely ill from coronavirus disease 2019 (COVID‐19) have a high likelihood of needing prolonged intubation, making tracheostomy a likely consideration. The infectious nature of COVID‐19 poses an additional risk of transmission to healthcare workers that should be taken into consideration. Methods We explore current literature and recommendations for tracheostomy in patients with COVID‐19 and look back at previous data from severe acute respiratory syndrome coronavirus 1 (SARS‐CoV‐1), the virus responsible for the SARS outbreak of 2003. Results Given the severity and clinical uncertainty of patients with COVID‐19 and the increased risk of transmission to clinicians, careful consideration should be taken prior to performing tracheostomy. If tracheostomy is performed, we recommend a bedside approach to limit exposure time and number of exposed personnel. Bronchoscopy use with a percutaneous approach should be limited in order to decrease viral exposure. Conclusion Thorough preprocedural planning, use of experienced personnel, enhanced personal protective equipment where available, and a thoughtful anesthesia approach are instrumental in maximizing positive patient outcomes while successfully protecting the safety of healthcare personnel. Laryngoscope, 130:2546–2549, 2020
Collapse
Affiliation(s)
- Jeffrey C Mecham
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, Arizona, U.S.A
| | - Olivia J Thomas
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, Arizona, U.S.A
| | - Phillip Pirgousis
- Department of Otorhinolaryngology/Head and Neck Surgery, Mayo Clinic, Jacksonville, Florida, U.S.A
| | - Jeffrey R Janus
- Department of Otorhinolaryngology/Head and Neck Surgery, Mayo Clinic, Jacksonville, Florida, U.S.A
| |
Collapse
|
14
|
Almario Alvarez JA, Okoye O, Tulla K, Spaggiari M, Di Cocco P, Benedetti E, Tzvetanov I. Tracheostomy Following Liver Transplantation. Transplant Proc 2020; 52:932-937. [PMID: 32139274 DOI: 10.1016/j.transproceed.2020.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 11/08/2019] [Accepted: 01/22/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND With increased demand for liver transplantation, sicker patients are being transplanted frequently. These patients are at a higher risk of significant postoperative morbidity, including respiratory failure. This study evaluated the phenotype that characterizes liver transplant candidates who may benefit from early tracheostomy. METHODS A single center retrospective review of all liver transplant candidates between January 2012 and December 2017. Patients who eventually required tracheostomies were identified and compared to their counterparts. RESULTS Of the 130 liver transplants performed during the study period, 11 patients required tracheostomy. Although patients in the tracheostomized population (TP) did not have significantly worse preoperative functional status (<4 metabolic equivalents; 64% vs 42%, P = .21), they had a higher native model for end-stage liver disease (MELD) score (37 vs 30, P < .05) at the time of transplantation. Patients who eventually succumbed to respiratory failure had lower arterial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) ratios at the start of surgery and remained unchanged for the duration of surgery compared with the nontracheostomy group (P < .05). TP patients required more net fluid intraoperatively (7.3 vs 5.0 L, P < .05), increased length of time to attempted extubation (3.5 vs 1 day, P < .05), longer ventilation days (15 vs 1 day, P < .05), increased length of stay (37 vs 9 days, P < .05), and higher 1-year mortality (36% vs 8%, P < .05). CONCLUSIONS Based on our findings, patients with a high MELD score (>30), net postoperative fluid balance >6 L, and PaO2/FiO2 ratio ≤300 who fail to wean off mechanical ventilation after 72 hours may benefit from tracheostomy during the postoperative period.
Collapse
Affiliation(s)
| | - Obi Okoye
- Department of General Surgery, University of Illinois at Chicago, Chicago, IL
| | - Kiara Tulla
- Department of General Surgery, University of Illinois at Chicago, Chicago, IL
| | - Mario Spaggiari
- Department of General Surgery, University of Illinois at Chicago, Chicago, IL
| | - Pierpaolo Di Cocco
- Department of General Surgery, University of Illinois at Chicago, Chicago, IL
| | - Enrico Benedetti
- Department of General Surgery, University of Illinois at Chicago, Chicago, IL
| | - Ivo Tzvetanov
- Department of General Surgery, University of Illinois at Chicago, Chicago, IL
| |
Collapse
|
15
|
Lin SJ, Jerng JS, Kuo YW, Wu CL, Ku SC, Wu HD. Maximal expiratory pressure is associated with reinstitution of mechanical ventilation after successful unassisted breathing trials in tracheostomized patients with prolonged mechanical ventilation. PLoS One 2020; 15:e0229935. [PMID: 32155187 PMCID: PMC7064239 DOI: 10.1371/journal.pone.0229935] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 02/17/2020] [Indexed: 01/01/2023] Open
Abstract
Objective Reinstitution of mechanical ventilation (MV) for tracheostomized patients after successful weaning may occur as the care setting changes from critical care to general care. We aimed to investigate the occurrence, consequence and associated factors of MV reinstitution. Methods We analyzed the clinical data and physiological measurements of tracheostomized patients with prolonged MV discharged from the weaning unit to general wards after successful weaning to compare between those with and without in-hospital MV reinstitution within 60 days. Results Of 454 patients successfully weaned, 116 (25.6%) reinstituted MV at general wards within 60 days; at hospital discharge, 42 (36.2%) of them were eventually liberated from MV, 51 (44.0%) remained MV dependent, and 33 (28.4%) died. Of the 338 patients without reinstitution within 60 days, only 3 (0.9%) were later reinstituted with MV before discharge (on day 67, 89 and 136 at general wards, respectively), and 322 (95.2%) were successfully weaned again at discharge, while 13 (3.8%) died. Patients with MV reinstitution had a significantly lower level of maximal expiratory pressure (PEmax) before unassisted breathing trial compared to those without reinstitution. Multivariable Cox regression analysis showed fever at RCC discharge (hazard ratio [HR] 14.00, 95% confidence interval [CI] 3.2–61.9) chronic obstructive pulmonary disease (HR 2.37, 95% CI 1.34–4.18), renal replacement therapy at the ICU (HR 2.29, 95% CI 1.50–3.49) and extubation failure before tracheostomy (HR 1.76, 95% CI 1.18–2.63) were associated with increased risks of reinstitution, while PEmax > 30 cmH2O (HR 0.51, 95% CI 0.35–0.76) was associated with a decreased risk of reinstitution. Conclusions The reinstitution of MV at the general ward is significant, with poor outcomes. The PEmax measured before unassisted breathing trial was significantly associated with the risk of reinstituting MV at the general wards.
Collapse
Affiliation(s)
- Shwu-Jen Lin
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Jih-Shuin Jerng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- * E-mail:
| | - Yao-Wen Kuo
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Chao-Ling Wu
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Shih-Chi Ku
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Huey-Dong Wu
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| |
Collapse
|
16
|
|
17
|
Abstract
This article discusses the history, types and essential components of mechanical ventilation. It addresses the potential complications associated with mechanical ventilation and outlines the nurse's role in the recognition and prevention of such complications. This article provides an overview of some of the advances in mechanical ventilation and emphasises the importance of patient safety through an awareness of the associated risks and limiting or avoiding mechanical ventilation where possible.
Collapse
|
18
|
Wu SH, Shyu LJ, Li CH, Yu CH, Chen HC, Kor CT, Wang CH, Lin KH. Better airway resistance reduction profile in intubated COPD patients by personalized bronchodilator dosing: A pilot randomized control trial. Pulm Pharmacol Ther 2018; 49:134-139. [PMID: 29474893 DOI: 10.1016/j.pupt.2018.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 02/14/2018] [Accepted: 02/19/2018] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The optimal dose of inhaled metered-dose bronchodilators for intubated patients with chronic obstructive pulmonary disease (COPD) is unknown. In this study, we proposed a bronchodilator dosing schedule based on an individual's airway resistance (Raw) and tested its efficacy in reducing Raw. METHODS A total of 51 newly admitted patients with invasively ventilated COPD were randomly assigned to receive personalized or fixed bronchodilator dosing. Personal target Raw was defined by measuring each individual's Raw after maximal pharmacologic bronchodilatation. Thereafter, Raw was measured every 8 h until the 28th day. Patients in the fixed-dosing group received only predetermined doses. Additional doses of bronchodilators were given to patients in the personalized-dosing group when the measured Raw exceeded their target Raw. RESULTS The median daily doses of salmeterol/fluticasone were 9.2 (personalized-dosing) vs 7.6 (fixed-dosing) puffs (P < 0.001). The relative deviation of Raw from the personal target was expressed as (measured Raw - target Raw)/target Raw. The experimental group showed a smaller relative Raw deviation than the control group (0.09 ± 0.10 vs 0.44 ± 0.11, P = 0.02). There were no differences between the two groups in terms of ventilator-free days from day 1 to day 28, number of episodes of nosocomial pneumonia, total number of puffs of rescue bronchodilator, number of drug-related adverse effects or mortality rate at day 180. CONCLUSION Personalized dosing of inhaled bronchodilator administered to invasively ventilated COPD patients can produce a better reduction in Raw. Further studies with larger sample size are required to verify the conclusion of this pilot study.
Collapse
Affiliation(s)
- Shin-Hwar Wu
- Division of Critical Care Medicine, Department of Medicine, Changhua Christian Hospital, 135 Nan-Hsiao Street, Changhua 50006, Taiwan, ROC.
| | - Lih-Jen Shyu
- Department of Pharmacy, Changhua Christian Hospital, 135 Nan-Hsiao Street, Changhua 50006, Taiwan, ROC.
| | - Chin-Hsing Li
- Section of Respiratory Therapy, Department of Medicine, Changhua Christian Hospital, 135 Nan-Hsiao Street, Changhua 50006, Taiwan, ROC.
| | - Chao-Hung Yu
- Division of Cardiovascular Medicine, Department of Medicine, Changhua Christian Hospital, 135 Nan-Hsiao Street, Changhua 50006, Taiwan, ROC.
| | - Huang-Chi Chen
- Division of Chest Medicine, Yuanlin Christian Hospital, 465, Juguang Rd., Yuanlin City, Changhua 510, Taiwan, ROC.
| | - Chew-Teng Kor
- Internal Medicine Research Center, Changhua Christian Hospital, 135 Nan-Hsiao Street, Changhua 50006, Taiwan, ROC.
| | - Chu-Hsien Wang
- Division of Critical Care Medicine, Department of Medicine, Changhua Christian Hospital, 135 Nan-Hsiao Street, Changhua 50006, Taiwan, ROC.
| | - Kai-Huang Lin
- Division of Critical Care Medicine, Department of Medicine, Changhua Christian Hospital, 135 Nan-Hsiao Street, Changhua 50006, Taiwan, ROC.
| |
Collapse
|
19
|
Postoperative Tracheotomie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2016. [DOI: 10.1007/s00398-016-0120-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
20
|
Ward D, Fulbrook P. Nursing Strategies for Effective Weaning of the Critically Ill Mechanically Ventilated Patient. Crit Care Nurs Clin North Am 2016; 28:499-512. [PMID: 28236395 DOI: 10.1016/j.cnc.2016.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The risks imposed by mechanical ventilation can be mitigated by nurses' use of strategies that promote early but appropriate reduction of ventilatory support and timely extubation. Weaning from mechanical ventilation is confounded by the multiple impacts of critical illness on the body's systems. Effective weaning strategies that combine several interventions that optimize weaning readiness and assess readiness to wean, and use a weaning protocol in association with spontaneous breathing trials, are likely to reduce the requirement for mechanical ventilatory support in a timely manner. Weaning strategies should be reviewed and updated regularly to ensure congruence with the best available evidence.
Collapse
Affiliation(s)
- Darian Ward
- Education, Training and Research, Wide Bay Hospital and Health Service, 65 Main Street, Hervey Bay, Queensland 4655, Australia.
| | - Paul Fulbrook
- Nursing Research and Practice Development Centre, The Prince Charles Hospital, Brisbane 4032, Australia; School of Nursing, Midwifery and Paramedicine, Australian Catholic University, 1100 Nudgee Road, Brisbane 4014, Australia
| |
Collapse
|