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Journal of Critical Care Dec 2018To identify, describe and discuss the parameters used to predict weaning from mechanical ventilation and extubation outcomes.
PURPOSE
To identify, describe and discuss the parameters used to predict weaning from mechanical ventilation and extubation outcomes.
METHODS
Systematic review of scientific articles using four electronic databases: PubMed, Embase, PEDro and Cochrane Library. Search terms included "weaning", "extubation", "withdrawal" and "discontinuation", combined with "mechanical ventilation" and "predictive factors", "predictive parameters" and "predictors for success". In this study, we included original articles that presented predictive factors for weaning or extubation outcomes in adult patients and not restricted to a single disease. Articles not written in English were excluded.
RESULTS
A total of 43 articles were included, with a total of 7929 patients and 56 different parameters related to weaning and extubation outcomes. Rapid Shallow Breathing Index (RSBI) was the most common predictor, discussed in 15 studies (2159 patients), followed by Age and Maximum Inspiratory Pressure in seven studies. The other 53 parameters were found in less than six studies.
CONCLUSION
There are several parameters used to predict weaning and extubation outcomes. RSBI was the most frequently studied and seems to be an important measurement tool in deciding whether to wean/extubate a patient. Furthermore, the results demonstrated that weaning and extubation should be guided by several parameters, and not only to respiratory ones.
Topics: APACHE; Airway Extubation; Critical Illness; Humans; Predictive Value of Tests; Respiration, Artificial; Respiratory Function Tests; Ventilator Weaning
PubMed: 30172034
DOI: 10.1016/j.jcrc.2018.08.023 -
Anaesthesia Sep 2018Awake fibreoptic intubation is often considered the technique of choice when a difficult airway is anticipated. However, videolaryngoscopes are being used more commonly.... (Comparative Study)
Comparative Study Meta-Analysis
Awake fibreoptic intubation is often considered the technique of choice when a difficult airway is anticipated. However, videolaryngoscopes are being used more commonly. We searched the current literature and performed a meta-analysis to compare the use of videolaryngoscopy and fibreoptic bronchoscopy for awake tracheal intubation. Our primary outcome was the time needed to intubate the patient's trachea. Secondary outcomes included: failed intubation; the rate of successful intubation at the first attempt; patient-reported satisfaction with the technique; and any complications resulting from intubation. Eight studies examining 429 patients were included in this review. The intubation time was shorter when videolaryngoscopy was used instead of fibreoptic bronchoscopy (seven trials, 408 participants, mean difference (95%CI) -45.7 (-66.0 to -25.4) s, p < 0.0001, low-quality evidence). There was no significant difference between the two techniques in the failure rate (six studies, 355 participants, risk ratio (95%CI) 1.01 (0.24-4.35), p = 0.99, low-quality evidence) or the first-attempt success rate (six studies, 391 participants, risk ratio (95%CI) 1.01 (0.95-1.06), p = 0.8, moderate quality evidence). The level of patient satisfaction was similar between both groups. No difference was found in two reported adverse events: hoarseness/sore throat (three studies, 167 participants, risk ratio (95%CI) 1.07 (0.62-1.85), p = 0.81, low-quality evidence), and low oxygen saturation (five studies, 337 participants, risk ratio (95%CI) 0.49 (0.22-1.12), p = 0.09, low-quality evidence). In summary, videolaryngoscopy for awake tracheal intubation is associated with a shorter intubation time. It also seems to have a success rate and safety profile comparable to fibreoptic bronchoscopy.
Topics: Bronchoscopy; Fiber Optic Technology; Humans; Intubation, Intratracheal; Laryngoscopy; Patient Satisfaction; Time Factors; Treatment Failure; Video Recording
PubMed: 29687891
DOI: 10.1111/anae.14299 -
JAMA Feb 2019Recognizing patients in whom endotracheal intubation is likely to be difficult can help alert physicians to the need for assistance from a clinician with airway training... (Meta-Analysis)
Meta-Analysis
IMPORTANCE
Recognizing patients in whom endotracheal intubation is likely to be difficult can help alert physicians to the need for assistance from a clinician with airway training and having advanced airway management equipment available.
OBJECTIVE
To identify risk factors and physical findings that predict difficult intubation.
DATA SOURCES
The databases of MEDLINE and EMBASE were searched from 1946 to June 2018 and from 1947 to June 2018, respectively, and the reference lists from the retrieved articles and previous reviews were searched for additional studies.
STUDY SELECTION
Sixty-two studies with high (level 1-3) methodological quality that evaluated the accuracy of clinical findings for identifying difficult intubation were reviewed.
DATA EXTRACTION AND SYNTHESIS
Two authors independently abstracted data. Bivariate random-effects meta-analyses were used to calculate summary positive likelihood ratios across studies or univariate random-effects models when bivariate models failed to converge.
RESULTS
Among the 62 high-quality studies involving 33 559 patients, 10% (95% CI, 8.2%-12%) of patients were difficult to intubate. The physical examination findings that best predicted a difficult intubation included a grade of class 3 on the upper lip bite test (lower incisors cannot extend to reach the upper lip; positive likelihood ratio, 14 [95% CI, 8.9-22]; specificity, 0.96 [95% CI, 0.93-0.97]), shorter hyomental distance (range of <3-5.5 cm; positive likelihood ratio, 6.4 [95% CI, 4.1-10]; specificity, 0.97 [95% CI, 0.94-0.98]), retrognathia (mandible measuring <9 cm from the angle of the jaw to the tip of the chin or subjectively short; positive likelihood ratio, 6.0 [95% CI, 3.1-11]; specificity, 0.98 [95% CI, 0.90-1.0]), and a combination of physical findings based on the Wilson score (positive likelihood ratio, 9.1 [95% CI, 5.1-16]; specificity, 0.95 [95% CI, 0.90-0.98]). The widely used modified Mallampati score (≥3) had a positive likelihood ratio of 4.1 (95% CI, 3.0-5.6; specificity, 0.87 [95% CI, 0.81-0.91]).
CONCLUSIONS AND RELEVANCE
Although several simple clinical findings are useful for predicting a higher likelihood of difficult endotracheal intubation, no clinical finding reliably excludes a difficult intubation. An abnormal upper lip bite test, which is easily assessed by clinicians, raises the probability of difficult intubation from 10% to greater than 60% for the average-risk patient.
Topics: Airway Obstruction; Humans; Intubation, Intratracheal; Jaw; Likelihood Functions; Mouth; Pharynx; Risk Factors; Sensitivity and Specificity
PubMed: 30721300
DOI: 10.1001/jama.2018.21413 -
The American Journal of Emergency... Mar 2023Airway management during cardiopulmonary resuscitation is particularly important for patients with out-of-hospital cardiac arrest (OHCA). This study was performed to... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
Airway management during cardiopulmonary resuscitation is particularly important for patients with out-of-hospital cardiac arrest (OHCA). This study was performed to compare the efficacy of the most commonly used out-of-hospital airway management methods in increasing the survival to discharge in patients with OHCA.
METHODS
We screened all relevant literature from database inception to 21st January 2019 in PubMed, Web of Science, Embase, and the Cochrane Library. We included all randomized controlled trials (RCTs) of airway management for OHCA in adults (≥16 years of age) with no limitations on publication status, publication date, or language. The primary outcome was survival to discharge. The secondary outcomes were the overall airway technique success rate, return of spontaneous circulation, and survival to hospital admission.
RESULTS
Overall, from 1986 to 2018, 9 RCTs involving 13,949 patients were included in the network meta-analysis, and the efficacy of six airway management methods for patients with OHCA were compared. However, none of the results were statistically significant.
CONCLUSIONS
As the gold standard of airway management for patients with out-of-hospital cardiac arrest in most countries, endotracheal intubation (ETI) has been widely used for many years. However, our systematic review and network meta-analysis showed that ETI is no better than other methods in increasing the survival to discharge. This is not directly proportional to the various preparations required before ETI. Additional randomized controlled trials are needed to identify more effective methods and improve patients' outcome.
Topics: Adult; Humans; Out-of-Hospital Cardiac Arrest; Network Meta-Analysis; Airway Management; Intubation, Intratracheal; Cardiopulmonary Resuscitation; Emergency Medical Services
PubMed: 36630861
DOI: 10.1016/j.ajem.2022.12.029 -
The American Journal of Emergency... Jun 2023Although airway management is important in pediatric resuscitation, the effectiveness of bag-mask ventilation (BMV) and advanced airway management (AAM), such as... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
Although airway management is important in pediatric resuscitation, the effectiveness of bag-mask ventilation (BMV) and advanced airway management (AAM), such as endotracheal intubation (ETI) and supraglottic airway (SGA) devices, for prehospital resuscitation of pediatric out-of-hospital cardiac arrest (OHCA) remains unclear. We aimed to determine the efficacy of AAM during prehospital resuscitation of pediatric OHCA cases.
METHODS
We searched four databases from their inception to November 2022 and included randomized controlled trials and observational studies with appropriate adjustments for confounders that evaluated prehospital AAM for OHCA in children aged <18 years in quantitative synthesis. We compared three interventions (BMV, ETI, and SGA) via network meta-analysis using the GRADE Working Group approach. The outcome measures were survival and favorable neurological outcomes at hospital discharge or 1 month after cardiac arrest.
RESULTS
Five studies (including one clinical trial and four cohort studies with rigorous confounding adjustment) involving 4852 patients were analyzed in our quantitative synthesis. Compared with ETI, BMV was associated with survival (relative risk [RR] 0.44 [95% confidence intervals (CI) 0.25-0.77]) (very low certainty). There were no significant association with survival in the other comparisons (SGA vs. BMV: RR 0.62 [95% CI 0.33-1.15] [low certainty], ETI vs. SGA: RR 0.71 [95% CI 0.39-1.32] [very low certainty]). There was no significant association with favorable neurological outcomes in any comparison (ETI vs. BMV: RR 0.33 [95% CI 0.11-1.02]; SGA vs. BMV: RR 0.50 [95% CI 0.14-1.80]; ETI vs. SGA: RR 0.66 [95% CI 0.18-2.46]) (all very low certainty). In the ranking analysis, the hierarches for efficacy for survival and favorable neurological outcome were BMV > SGA > ETI.
CONCLUSION
Although the available evidence is from observational studies and its certainty is low to very low, prehospital AAM for pediatric OHCA did not improve outcomes.
Topics: Humans; Child; Out-of-Hospital Cardiac Arrest; Network Meta-Analysis; Cardiopulmonary Resuscitation; Airway Management; Intubation, Intratracheal; Emergency Medical Services
PubMed: 37027937
DOI: 10.1016/j.ajem.2023.03.049 -
Ugeskrift For Laeger Apr 2024This review provides an overview of home-based respiratory support modalities for patients with chronic lung diseases. It discusses the increasing use of long-term... (Review)
Review
This review provides an overview of home-based respiratory support modalities for patients with chronic lung diseases. It discusses the increasing use of long-term high-flow nasal cannula (LT-HFNC) and long-term non-invasive ventilation (LT-NIV) and their potential to enhance patient quality of life. This review addresses various types of respiratory failure and their respective treatments, emphasising the significance of monitoring and telemedicine in home care. This comprehensive review underscores the clinical relevance of these interventions in the management of chronic lung diseases.
Topics: Humans; Cannula; Lung Diseases; Noninvasive Ventilation; Quality of Life; Respiration, Artificial; Respiratory Insufficiency
PubMed: 38606701
DOI: 10.61409/V09230613 -
Pulmonology 2019Chronic Obstructive Pulmonary Disease (COPD) history is characterized by episodes of exacerbation of varying severity, featured by acute worsening of respiratory...
Chronic Obstructive Pulmonary Disease (COPD) history is characterized by episodes of exacerbation of varying severity, featured by acute worsening of respiratory symptoms, commonly precipitated by respiratory tract infection. The recent ERS/ATS clinical practice guidelines strongly recommend the application of non invasive ventilation (NIV) for patients with acute respiratory failure (ARF) leading to acute or acute-on-chronic respiratory acidosis (pH 7.35) and not for those patients with acute exacerbation of COPD (AECOPD) and hypercapnia who are not acidotic. In recent years, High-Flow through Nasal Cannula (HFNC) has been introduced in the clinical practice. We designed the present systematic review of the literature to assess all effects of HFNC use reported in exacerbated COPD patients. In this setting, HFNC is able to keep PaCO2 unmodified, while oxygenation slightly deteriorates as opposed to NIV. Furthermore, the work of breathing is reduced with HFNC by a similar extent to NIV, while it increases by 40-50% during conventional oxygen therapy (COT). HFNC is also reported to be more comfortable than COT and NIV. Despite these results, little and limited evidence for improved clinical outcomes is currently available.
Topics: Acidosis, Respiratory; Blood Gas Analysis; Disease Progression; Humans; Hypercapnia; Noninvasive Ventilation; Positive-Pressure Respiration; Pulmonary Disease, Chronic Obstructive; Respiratory Insufficiency; Respiratory Rate; Respiratory Therapy; Treatment Outcome; Work of Breathing
PubMed: 31591056
DOI: 10.1016/j.pulmoe.2019.08.001 -
Diabetes & Metabolic Syndrome 2015To provide updated knowledge regarding the airway management and the possibility of difficult intubation in diabetic patients. (Review)
Review
AIMS
To provide updated knowledge regarding the airway management and the possibility of difficult intubation in diabetic patients.
MATERIALS AND METHODS
We preformed a systematic literature review of the English language literature, published over the past 10 years which deals with this subject.
RESULTS
The vast majority of the modern literature data supports the fact that diabetic population has higher risk for difficult intubation occurrence. The most important characteristics of diabetic patients that are considered to be contributing factors for the difficult intubation are obesity, increased neck circumference and stiff joint syndrome.
CONCLUSION
A special attention and thorough preoperative preparation should be given to patients with diabetes. In order to predict and prevent difficult intubation in these patients, further studies are needed to investigate this issue closely.
Topics: Airway Management; Anesthesia; Body Mass Index; Contraindications; Diabetes Complications; Diabetes Mellitus; Humans; Intraoperative Complications; Joint Diseases; Neck; Obesity; Risk Factors
PubMed: 25943410
DOI: 10.1016/j.dsx.2015.04.001 -
European Respiratory Review : An... Mar 2022Tracheobronchial injury is a heterogeneous entity comprising multiple rare and potentially life-threatening scenarios. We performed a systematic literature review... (Review)
Review
Tracheobronchial injury is a heterogeneous entity comprising multiple rare and potentially life-threatening scenarios. We performed a systematic literature review focusing on post-intubation tracheal injuries (PiTIs) and post-traumatic tracheobronchial injuries (PTTBIs).PiTIs are often longitudinal lacerations of the middle third of the membranous trachea. Subcutaneous emphysema of the face and trunk following tracheal intubation should immediately trigger the diagnosis. Diagnosis may be suspected on the chest computed tomography (CT) and should be confirmed by bronchoscopic examination. Conservative management is encouraged for a spontaneously breathing or stable patient on noninvasive ventilation. Surgical repair is mandatory when mechanical ventilation is required and if bridging of the injury is impossible.PTTBIs are often associated with other severe injuries. Patients often present with massive subcutaneous emphysema and intractable pneumothorax. Diagnosis may be suspected on the chest CT and should be confirmed by bronchoscopic examination. Early surgical repair is indicated. In selected patients, conservative management can be considered.
Topics: Bronchi; Humans; Intubation, Intratracheal; Noninvasive Ventilation; Tomography, X-Ray Computed; Trachea
PubMed: 35082126
DOI: 10.1183/16000617.0126-2021 -
International Journal of Pediatric... Oct 2017Tracheal atresia (TA) is a rare congenital condition that typically requires an unexpected and emergent resuscitation in the delivery room. The mortality rate associated... (Review)
Review
OBJECTIVES
Tracheal atresia (TA) is a rare congenital condition that typically requires an unexpected and emergent resuscitation in the delivery room. The mortality rate associated is very high, with only a few long-term survival cases reported. We describe the findings of a systematic review on the clinical presentation and airway management of TA.
METHODS
Using the keywords "tracheal atresia", "tracheal agenesis" and "tracheal hypoplasia" a search through Embase and Pubmed databases was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Articles published from 1950 to 2015 in English, French, Italian, Portuguese and Spanish were included. Exclusion criteria were cases of stillborn, and unclear diagnosis or outcome.
RESULTS
149 cases of TA were identified after reviewing 1125 initial references. There was a male preponderance (65%), and associated malformations were described in 94.2% of patients. Prenatal ultrasound was abnormal in 56.3% of cases, with polyhydramnios being the most common finding. The most frequent type of TA was Faro Type C. 94 (41.3%) patients did not survive beyond the first 24 h of life. Only 13 (8.4%) patients survived more than three months of life, after undergoing a variety of surgical approaches.
CONCLUSION
This review, which to our knowledge is the largest one to date, confirms that TA is a rare malformation, occurs more frequently in males, and has a very high mortality rate. Depending on the presence and type of concomitant malformation, as well of the length of the remaining trachea, different surgical management options are described.
Topics: Airway Management; Constriction, Pathologic; Female; Humans; Infant, Newborn; Male; Pregnancy; Survival Rate; Trachea
PubMed: 28964311
DOI: 10.1016/j.ijporl.2017.07.028