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Medicine Mar 2023Post-extubation dysphagia is high in critically ill patients and is not easily recognized. This study aimed to identify risk factors for acquired swallowing disorders in... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Post-extubation dysphagia is high in critically ill patients and is not easily recognized. This study aimed to identify risk factors for acquired swallowing disorders in the intensive care unit (ICU).
METHODS
We have retrieved all relevant research published before August 2022 from PubMed, Embase, Web of Science, and the Cochrane Library electronic databases. The studies were selected using inclusion and exclusion criteria. Two reviewers screened studies, extracted data, and independently evaluated the risk of bias. The quality of the study was assessed with the Newcastle-Ottawa Scale, and a meta-analysis was carried out with Cochrane Collaboration's Revman 5.3 software.
RESULTS
A total of 15 studies were included. Age (odds ratio [OR] = 1.04), tracheal intubation time (OR = 1.61), APACHE II (OR = 1.04), and tracheostomy (OR = 3.75) were significant risk factors that contributed to post-extubation dysphagia in ICU.
CONCLUSION
This study provides preliminary evidence that post-extraction dysphagia in ICU is associated with factors such as age, tracheal intubation time, APACHE II, and tracheostomy. The results of this research may improve clinician awareness, risk stratification, and prevention of post-extraction dysphagia in the ICU.
Topics: Humans; Deglutition Disorders; Airway Extubation; Intensive Care Units; Intubation, Intratracheal; Critical Illness; Risk Factors
PubMed: 36897733
DOI: 10.1097/MD.0000000000033153 -
Thorax Aug 2022Extubation to non-invasive ventilation (NIV) has been investigated as a strategy to wean critically ill adults from invasive ventilation and reduce ventilator-related... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Extubation to non-invasive ventilation (NIV) has been investigated as a strategy to wean critically ill adults from invasive ventilation and reduce ventilator-related complications.
METHODS
We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, proceedings of four conferences and bibliographies (to June 2020) for randomised and quasi-randomised trials that compared extubation with immediate application of NIV to continued invasive weaning in intubated adults and reported mortality (primary outcome) or other outcomes. Two reviewers independently screened citations, assessed trial quality and abstracted data.
RESULTS
We identified 28 trials, of moderate-to-good quality, involving 2066 patients, 44.6% with chronic obstructive pulmonary disease (COPD). Non-invasive weaning significantly reduced mortality (risk ratio (RR) 0.57, 95% CI 0.44 to 0.74; high quality), weaning failures (RR 0.59, 95% CI 0.43 to 0.81; high quality), pneumonia (RR 0.30, 95% CI 0.22 to 0.41; high quality), intensive care unit (ICU) (mean difference (MD) -4.62 days, 95% CI -5.91 to -3.34) and hospital stay (MD -6.29 days, 95% CI -8.90 to -3.68). Non-invasive weaning also significantly reduced the total duration of ventilation, duration of invasive ventilation and duration of ventilation related to weaning (MD -0.57, 95% CI -1.08 to -0.07) and tracheostomy rate. Mortality, pneumonia, reintubation and ICU stay were significantly lower in trials enrolling COPD (vs mixed) populations.
CONCLUSION
Non-invasive weaning significantly reduced mortality, pneumonia and the duration of ventilation related to weaning, particularly in patients with COPD. Beneficial effects are less clear (or more careful patient selection is required) in non-COPD patients.
PROSPERO REGISTRATION NUMBER
CRD42020201402.
Topics: Adult; Critical Illness; Humans; Intensive Care Units; Noninvasive Ventilation; Pulmonary Disease, Chronic Obstructive; Respiration, Artificial; Ventilator Weaning
PubMed: 34716282
DOI: 10.1136/thoraxjnl-2021-216993 -
Journal of Critical Care Apr 2022To compare neurally adjusted ventilatory assist (NAVA), proportional assist ventilation (PAV), adaptive support ventilation (ASV) and Smartcare pressure support... (Meta-Analysis)
Meta-Analysis Review
Comparison of advanced closed-loop ventilation modes with pressure support ventilation for weaning from mechanical ventilation in adults: A systematic review and meta-analysis.
PURPOSE
To compare neurally adjusted ventilatory assist (NAVA), proportional assist ventilation (PAV), adaptive support ventilation (ASV) and Smartcare pressure support (Smartcare/PS) with standard pressure support ventilation (PSV) regarding their effectiveness for weaning critically ill adults from invasive mechanical ventilation (IMV).
METHODS
Electronic databases were searched to identify parallel-group randomized controlled trials (RCTs) comparing NAVA, PAV, ASV, or Smartcare/PS with PSV, in adult patients under IMV through July 28, 2021. Primary outcome was weaning success. Secondary outcomes included weaning time, total MV duration, reintubation or use of non-invasive MV (NIMV) within 48 h after extubation, in-hospital and intensive care unit (ICU) mortality, in-hospital and ICU length of stay (LOS) (PROSPERO registration No:CRD42021270299).
RESULTS
Twenty RCTs were finally included. Compared to PSV, NAVA was associated with significantly lower risk for in-hospital and ICU death and lower requirements for post-extubation NIMV. Moreover, PAV showed significant advantage over PSV in terms of weaning rates, MV duration and ICU LOS. No significant differences were found between ASV or Smart care/PS and PSV.
CONCLUSIONS
Moderate certainty evidence suggest that PAV increases weaning success rates, shortens MV duration and ICU LOS compared to PSV. It is also noteworthy that NAVA seems to improve in-hospital and ICU survival.
Topics: Adult; Humans; Intensive Care Units; Interactive Ventilatory Support; Positive-Pressure Respiration; Respiration, Artificial; Ventilator Weaning
PubMed: 34839229
DOI: 10.1016/j.jcrc.2021.11.010 -
The Cochrane Database of Systematic... Jun 2022Acute respiratory distress syndrome (ARDS) is a significant cause of hospitalisation and death in young children. Positioning and mechanical ventilation have been... (Review)
Review
BACKGROUND
Acute respiratory distress syndrome (ARDS) is a significant cause of hospitalisation and death in young children. Positioning and mechanical ventilation have been regularly used to reduce respiratory distress and improve oxygenation in hospitalised patients. Due to the association of prone positioning (lying on the abdomen) with sudden infant death syndrome (SIDS) within the first six months, it is recommended that young infants be placed on their back (supine). However, prone positioning may be a non-invasive way of increasing oxygenation in individuals with acute respiratory distress, and offers a more significant survival advantage in those who are mechanically ventilated. There are substantial differences in respiratory mechanics between adults and infants. While the respiratory tract undergoes significant development within the first two years of life, differences in airway physiology between adults and children become less prominent by six to eight years old. However, there is a reduced risk of SIDS during artificial ventilation in hospitalised infants. Thus, an updated review focusing on positioning for infants and young children with ARDS is warranted. This is an update of a review published in 2005, 2009, and 2012.
OBJECTIVES
To compare the effects of different body positions in hospitalised infants and children with acute respiratory distress syndrome aged between four weeks and 16 years.
SEARCH METHODS
We searched CENTRAL, which contains the Acute Respiratory Infections Group's Specialised Register, MEDLINE, Embase, and CINAHL from January 2004 to July 2021.
SELECTION CRITERIA
Randomised controlled trials (RCTs) or quasi-RCTs comparing two or more positions for the management of infants and children hospitalised with ARDS.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted data from each study. We resolved differences by consensus, or referred to a third contributor to arbitrate. We analysed bivariate outcomes using an odds ratio (OR) and 95% confidence interval (CI). We analysed continuous outcomes using a mean difference (MD) and 95% CI. We used a fixed-effect model, unless heterogeneity was significant (I statistic > 50%), when we used a random-effects model.
MAIN RESULTS
We included six trials: four cross-over trials, and two parallel randomised trials, with 198 participants aged between 4 weeks and 16 years, all but 15 of whom were mechanically ventilated. Four trials compared prone to supine positions. One trial compared the prone position to good-lung dependent (where the person lies on the side of the healthy lung, e.g. if the right lung was healthy, they were made to lie on the right side), and independent (or non-good-lung independent, where the person lies on the opposite side to the healthy lung, e.g. if the right lung was healthy, they were made to lie on the left side) position. One trial compared good-lung independent to good-lung dependent positions. When the prone (with ventilators) and supine positions were compared, there was no information on episodes of apnoea or mortality due to respiratory events. There was no conclusive result in oxygen saturation (SaO MD 0.40 mmHg, 95% CI -1.22 to 2.66; 1 trial, 30 participants; very low certainty evidence); blood gases, PCO (MD 3.0 mmHg, 95% CI -1.93 to 7.93; 1 trial, 99 participants; low certainty evidence), or PO (MD 2 mmHg, 95% CI -5.29 to 9.29; 1 trial, 99 participants; low certainty evidence); or lung function (PaO/FiO ratio; MD 28.16 mmHg, 95% CI -9.92 to 66.24; 2 trials, 121 participants; very low certainty evidence). However, there was an improvement in oxygenation index (FiO% X M/ PaO) with prone positioning in both the parallel trials (MD -2.42, 95% CI -3.60 to -1.25; 2 trials, 121 participants; very low certainty evidence), and the cross-over study (MD -8.13, 95% CI -15.01 to -1.25; 1 study, 20 participants). Derived indices of respiratory mechanics, such as tidal volume, respiratory rate, and positive end-expiratory pressure (PEEP) were reported. There was an apparent decrease in tidal volume between prone and supine groups in a parallel study (MD -0.60, 95% CI -1.05 to -0.15; 1 study, 84 participants; very low certainty evidence). When prone and supine positions were compared in a cross-over study, there were no conclusive results in respiratory compliance (MD 0.07, 95% CI -0.10 to 0.24; 1 study, 10 participants); changes in PEEP (MD -0.70 cm HO, 95% CI -2.72 to 1.32; 1 study, 10 participants); or resistance (MD -0.00, 95% CI -0.05 to 0.04; 1 study, 10 participants). One study reported adverse events. There were no conclusive results for potential harm between groups in extubation (OR 0.57, 95% CI 0.13 to 2.54; 1 trial, 102 participants; very low certainty evidence); obstructions of the endotracheal tube (OR 5.20, 95% CI 0.24 to 111.09; 1 trial, 102 participants; very low certainty evidence); pressure ulcers (OR 1.00, 95% CI 0.41 to 2.44; 1 trial, 102 participants; very low certainty evidence); and hypercapnia (high levels of arterial carbon dioxide; OR 3.06, 95% CI 0.12 to 76.88; 1 trial, 102 participants; very low certainty evidence). One study (50 participants) compared supine positions to good-lung dependent and independent positions. There was no conclusive evidence that PaO was different between supine and good-lung dependent positioning (MD 3.44 mm Hg, 95% CI -23.12 to 30.00; 1 trial, 25 participants; very low certainty evidence). There was also no conclusive evidence for supine position and good-lung independent positioning (MD -2.78 mmHg, 95% CI -28.84, 23.28; 25 participants; very low certainty evidence); or between good-lung dependent and independent positioning (MD 6.22, 95% CI -21.25 to 33.69; 1 trial, 25 participants; very low certainty evidence). As most trials did not describe how possible biases were addressed, the potential for bias in these findings is unclear.
AUTHORS' CONCLUSIONS
Although included studies suggest that prone positioning may offer some advantage, there was little evidence to make definitive recommendations. There appears to be low certainty evidence that positioning improves oxygenation in mechanically ventilated children with ARDS. Due to the increased risk of SIDS with prone positioning and lung injury with artificial ventilation, it is recommended that hospitalised infants and children should only be placed in this position while under continuous cardiorespiratory monitoring.
Topics: Adult; Child; Child, Preschool; Humans; Infant; Infant, Newborn; Patient Positioning; Positive-Pressure Respiration; Respiration, Artificial; Respiratory Distress Syndrome; Sudden Infant Death
PubMed: 35661343
DOI: 10.1002/14651858.CD003645.pub4 -
Chest Jan 2022Clinicians use several measures to ascertain whether individual patients will tolerate liberation from mechanical ventilation, including the rapid shallow breathing... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Clinicians use several measures to ascertain whether individual patients will tolerate liberation from mechanical ventilation, including the rapid shallow breathing index (RSBI).
RESEARCH QUESTION
Given varied use of different thresholds, patient populations, and measurement characteristics, how well does RSBI predict successful extubation?
STUDY DESIGN AND METHODS
We searched six databases from inception through September 2019 and selected studies reporting the accuracy of RSBI in the prediction of successful extubation. We extracted study data and assessed quality independently and in duplicate.
RESULTS
We included 48 studies involving RSBI measurements of 10,946 patients. Pooled sensitivity for RSBI of < 105 in predicting extubation success was moderate (0.83 [95% CI, 0.78-0.87], moderate certainty), whereas specificity was poor (0.58 [95% CI, 0.49-0.66], moderate certainty) with diagnostic ORs (DORs) of 5.91 (95% CI, 4.09-8.52). RSBI thresholds of < 80 or 80 to 105 yielded similar sensitivity, specificity, and DOR. These findings were consistent across multiple subgroup analyses reflecting different patient characteristics and operational differences in RSBI measurement.
INTERPRETATION
As a stand-alone test, the RSBI has moderate sensitivity and poor specificity for predicting extubation success. Future research should evaluate its role as a permissive criterion to undergo a spontaneous breathing trial (SBT) for patients who are at intermediate pretest probability of passing an SBT.
TRIAL REGISTRY
PROSPERO; No.: CRD42020149196; URL: www.crd.york.ac.uk/prospero/.
Topics: Airway Extubation; Clinical Decision Rules; Clinical Decision-Making; Humans; Respiration, Artificial; Respiratory Rate; Tidal Volume; Ventilator Weaning
PubMed: 34181953
DOI: 10.1016/j.chest.2021.06.030 -
American Journal of Obstetrics and... Oct 2019Elective induction of labor at 39 weeks among low-risk nulliparous women has reduced the chance of cesarean and other adverse maternal and perinatal outcomes in a... (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND
Elective induction of labor at 39 weeks among low-risk nulliparous women has reduced the chance of cesarean and other adverse maternal and perinatal outcomes in a randomized trial, although its clinical effectiveness in nonresearch settings remains uncertain.
OBJECTIVE
To perform a systematic review of observational studies that compared elective induction of labor at 39 weeks among nulliparous women with expectant management and to use meta-analytic techniques to estimate the association of elective induction with cesarean delivery, as well as other maternal and perinatal outcomes.
STUDY DESIGN
Studies were eligible for this meta-analysis only if they: (1) were observational; (2) compared women undergoing labor induction at 39 weeks with women undergoing expectant management beyond that gestational age; (3) included women in the induction group only if they had no other indication for labor induction at 39 weeks; and (4) provided data specifically for nulliparous women. The predefined primary outcome was cesarean delivery, and secondary outcomes representing other maternal and perinatal morbidities also were evaluated. Outcome data from different studies were combined to estimate pooled relative risks with 95% confidence intervals using random-effects models.
RESULTS
Of 375 studies identified by the initial search, 6 cohort studies, which included 66,019 women undergoing elective labor induction at 39 weeks and 584,390 undergoing expectant management, met inclusion criteria. Elective induction of labor at 39 weeks was associated with a significantly lower frequency of cesarean delivery (26.4% vs 29.1%; relative risk, 0.83; 95% confidence interval, 0.74-0.93), as well as of peripartum infection (2.8% vs 5.2%; relative risk, 0.53; 95% confidence interval, 0.39-0.72). Neonates of women in the induction group were less likely to have respiratory morbidity (0.7% vs 1.5%; relative risk, 0.71; 95% confidence interval, 0.59-0.85); meconium aspiration syndrome (0.7% vs 3.0%; relative risk, 0.49; 95% confidence interval, 0.26-0.92); and neonatal intensive care unit admission (3.5% vs 5.5%; relative risk, 0.80; 95% confidence interval, 0.72-0.88). There also was a lower risk of perinatal mortality (0.04% vs 0.2%; relative risk, 0.27; 95% confidence interval, 0.09-0.76).
CONCLUSION
This meta-analysis of 6 cohort studies demonstrates that elective induction of labor at 39 weeks, compared with expectant management beyond that gestational age, was associated with a significantly lower risk of cesarean delivery, maternal peripartum infection, and perinatal adverse outcomes, including respiratory morbidity, intensive care unit admission, and mortality.
Topics: Cesarean Section; Chorioamnionitis; Cohort Studies; Continuous Positive Airway Pressure; Endometritis; Female; Humans; Infant, Newborn; Intensive Care Units, Neonatal; Labor, Induced; Lacerations; Meconium Aspiration Syndrome; Observational Studies as Topic; Oxygen Inhalation Therapy; Parity; Perinatal Mortality; Perineum; Postpartum Hemorrhage; Pregnancy; Respiration, Artificial; Respiratory Insufficiency; Surgical Wound Infection; Watchful Waiting
PubMed: 30817905
DOI: 10.1016/j.ajog.2019.02.046 -
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