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Journal of Korean Medical Science Jul 2024Despite medical advancements in neonatal survival rates, many children have poor neurological outcomes. Because the law in Korea restricts the withdrawal of...
BACKGROUND
Despite medical advancements in neonatal survival rates, many children have poor neurological outcomes. Because the law in Korea restricts the withdrawal of life-sustaining treatment to only cases of imminent death, treatment discontinuation may not be an option, even in patients with poor neurological prognosis. This study investigated the opinions of the general population and clinicians regarding life-sustaining treatment withdrawal in such cases using hypothetical scenarios.
METHODS
We conducted a cross-sectional study on the general population and clinicians using a web-based questionnaire. The sample of the general population from an online panel comprised 500 individuals aged 20-69 years selected by quota sampling. The clinician sample comprised 200 clinicians from a tertiary university hospital. We created hypothetical vignettes and questionnaire items to assess attitudes regarding mechanical ventilation withdrawal for an infant at risk of poor neurological prognosis due to birth asphyxia at 2 months and 3 years after the incidence.
RESULTS
Overall, 73% of the general population and 74% of clinicians had positive attitudes toward mechanical ventilator withdrawal at 2 months after birth asphyxia. The proportion of positive attitudes toward mechanical ventilator withdrawal was increased in the general population (84%, < 0.001) and clinicians (80.5%, = 0.02) at 3 years after birth asphyxia. Religion, spirituality, the presence of a person with a disability in the household, and household income were associated with the attitudes of the general population. In the multivariable logistic regression analysis of the general population, respondents living with a person with a disability or having a disability were more likely to find the withdrawal of the ventilator at 2 months and 3 years after birth asphyxia not permissible. Regarding religion, respondents who identified as Christians were more likely to find the ventilator withdrawal at 2 months after birth asphyxia unacceptable.
CONCLUSION
The general population and clinicians shared the perspective that the decision to withdraw life-sustaining treatment in infants with a poor neurological prognosis should be considered before the end of life. A societal discussion about making decisions centered around the best interest of pediatric patients is warranted.
Topics: Humans; Male; Female; Adult; Prognosis; Surveys and Questionnaires; Withholding Treatment; Middle Aged; Cross-Sectional Studies; Respiration, Artificial; Infant; Aged; Young Adult; Infant, Newborn; Asphyxia Neonatorum; Republic of Korea; Attitude of Health Personnel
PubMed: 38952347
DOI: 10.3346/jkms.2024.39.e196 -
Tuberculosis and Respiratory Diseases Jul 2024Successful liberation from mechanical ventilation is one of the most crucial processes in critical care because it is the first step by which a respiratory failure...
BACKGROUND
Successful liberation from mechanical ventilation is one of the most crucial processes in critical care because it is the first step by which a respiratory failure patient begins to transition out of the intensive care unit and return to their own life. Therefore, when devising appropriate strategies for removing mechanical ventilation, it is essential to consider not only the individual experiences of healthcare professionals, but also scientific and systematic approaches. Recently, numerous studies have investigated methods and tools for identifying when mechanically ventilated patients are ready to breathe on their own. The Korean Society of Critical Care Medicine therefore provides these recommendations to clinicians about liberation from the ventilator.
METHOD
Meta-analyses and comprehensive syntheses were used to thoroughly review, compile, and summarize the complete body of relevant evidence. All studies were meticulously assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) method, and the outcomes were presented succinctly as evidence profiles. Those evidence syntheses were discussed by a multidisciplinary committee of experts in mechanical ventilation, who then developed and approved recommendations.
RESULT
Recommendations for nine population, intervention, comparator, outcome (PICO) questions about ventilator liberation are presented in this document. This guideline includes seven conditional recommendations, one expert consensus recommendation, and one conditional deferred recommendation.
CONCLUSIONS
We developed these clinical guidelines for mechanical ventilation liberation to provide meaningful recommendations. These guidelines reflect the best treatment for patients seeking liberation from mechanical ventilation.
PubMed: 38951014
DOI: 10.4046/trd.2024.0039 -
BMJ Open Jul 2024Acute hypoxaemic respiratory failure (AHRF) is associated with high mortality in sub-Saharan Africa. This is at least in part due to critical care-related resource...
Respiratory support with standard low-flow oxygen therapy, high-flow oxygen therapy or continuous positive airway pressure in adults with acute hypoxaemic respiratory failure in a resource-limited setting: protocol for a randomised, open-label, clinical trial - the Acute Respiratory Intervention...
RATIONALE
Acute hypoxaemic respiratory failure (AHRF) is associated with high mortality in sub-Saharan Africa. This is at least in part due to critical care-related resource constraints including limited access to invasive mechanical ventilation and/or highly skilled acute care workers. Continuous positive airway pressure (CPAP) and high-flow oxygen by nasal cannula (HFNC) may prove useful to reduce intubation, and therefore, improve survival outcomes among critically ill patients, particularly in resource-limited settings, but data in such settings are lacking. The aim of this study is to determine whether CPAP or HFNC as compared with standard oxygen therapy, could reduce mortality among adults presenting with AHRF in a resource-limited setting.
METHODS
This is a prospective, multicentre, randomised, controlled, stepped wedge trial, in which patients presenting with AHRF in Uganda will be randomly assigned to standard oxygen therapy delivered through a face mask, HFNC oxygen or CPAP. The primary outcome is all-cause mortality at 28 days. Secondary outcomes include the number of patients with criteria for intubation at day 7, the number of patients intubated at day 28, ventilator-free days at day 28 and tolerance of each respiratory support.
ETHICS AND DISSEMINATION
The study has obtained ethical approval from the Research and Ethics Committee, School of Biomedical Sciences, College of Health Sciences, Makerere University as well as the Uganda National Council for Science and Technology. Patients will be included after informed consent. The results will be submitted for publication in peer-reviewed journals.
TRIAL REGISTRATION NUMBER
NCT04693403.
PROTOCOL VERSION
8 September 2023; version 5.
Topics: Humans; Continuous Positive Airway Pressure; Oxygen Inhalation Therapy; Respiratory Insufficiency; Prospective Studies; Uganda; Adult; Hypoxia; Randomized Controlled Trials as Topic; Multicenter Studies as Topic; Acute Disease; Resource-Limited Settings
PubMed: 38951007
DOI: 10.1136/bmjopen-2023-082223 -
Respiratory Medicine Jun 2024Airway clearance (ACT) and lung volume recruitment (LVR) techniques are used to manage bronchial secretions, increase cough efficiency and lung/chest wall recruitment,...
BACKGROUND
Airway clearance (ACT) and lung volume recruitment (LVR) techniques are used to manage bronchial secretions, increase cough efficiency and lung/chest wall recruitment, to prevent and treat respiratory tract infections. The aim of the study was to review the prescription of ACT/LVR techniques for home use in children in France.
METHODS
All the centers of the national pediatric noninvasive ventilation (NIV) network were invited to fill in an anonymous questionnaire for every child aged ≤20 years who started a treatment with an ACT/LVR device between 2022 and 2023. The devices comprised mechanical in-exsufflation (MI-E), intermittent positive pressure breathing (IPPB), intrapulmonary percussive ventilation (IPV), and/or invasive mechanical ventilation (IMV)/NIV for ACT/LVR.
RESULTS
One hundred and thirty-nine patients were included by 13 centers. IPPB was started in 83 (60%) patients, MI-E in 43 (31%) and IPV in 30 (22%). No patient used IMV/NIV for ACT/LVR. The devices were prescribed mainly by pediatric pulmonologists (103, 74%). Mean age at initiation was 8.9±5.6 (0.4-18.5) years old. The ACT/LVR devices were prescribed mainly in patients with neuromuscular disorders (n=66, 47%) and neurodisability (n=37, 27%). The main initiation criteria were cough assistance (81%) and airway clearance (60%) for MI-E, thoracic mobilization (63%) and vital capacity (47%) for IPPB, and airway clearance (73%) and repeated respiratory exacerbations (57%) for IPV. The parents were the main carers performing the treatment at home.
CONCLUSIONS
IPPB was the most prescribed technique. Diseases and initiation criteria are heterogeneous, underlining the need for studies validating the indications and settings of these techniques.
PubMed: 38950683
DOI: 10.1016/j.rmed.2024.107726 -
The Journal of Asthma : Official... Jul 2024Near-fatal asthma (NFA) is a severe condition that can lead to respiratory arrest or high carbon dioxide levels, often requiring mechanical ventilation. Biologics have...
INTRODUCTION
Near-fatal asthma (NFA) is a severe condition that can lead to respiratory arrest or high carbon dioxide levels, often requiring mechanical ventilation. Biologics have revolutionized the management of severe asthma, significantly improving symptom severity, reducing the number of exacerbations and hospitalizations, and decreasing the need for oral corticosteroids. However, their effectiveness in acute settings, particularly for ICU patients experiencing severe respiratory failure, is not well-studied. More research is needed to determine if biologics can improve recovery during severe asthma exacerbations.Case Study: We report a case of NFA in a patient with severe allergic eosinophilic asthma, who experienced global respiratory failure necessitating hospitalization, intubation, and veno-venous extracorporeal membrane oxygenation (VV-ECMO). Given the severity of the clinical condition, compassionate administration of Benralizumab, which targets the IL-5 receptor, was attempted.
RESULTS
Five days from anti-IL5 receptor treatment start, the patient was extubated and the ECMO stopped. After the stepdown to the respiratory intensive care unit (RICU), the patient was weaned from oxygen therapy and subsequently discharged from hospital.
CONCLUSION
Benralizumab demonstrated rapid effectiveness in improving respiratory failure leading to successful weaning from VV-ECMO and subsequent extubation.
PubMed: 38949856
DOI: 10.1080/02770903.2024.2375287 -
Annals of the American Thoracic Society Jul 2024
Topics: Humans; Sleep Apnea, Obstructive; Machine Learning; Precision Medicine; Continuous Positive Airway Pressure; Male; Middle Aged; Female
PubMed: 38949604
DOI: 10.1513/AnnalsATS.202403-308ED -
Medical Science Monitor : International... Jul 2024Muscle relaxants have broad application in anesthesiology. They can be used for safe intubation, preparing the patient for surgery, or improving mechanical ventilation.... (Review)
Review
Muscle relaxants have broad application in anesthesiology. They can be used for safe intubation, preparing the patient for surgery, or improving mechanical ventilation. Muscle relaxants can be classified based on their mechanism of action into depolarizing and non-depolarizing muscle relaxants and centrally acting muscle relaxants. Non-depolarizing neuromuscular blocking drugs (NMBDs) (eg, tubocurarine, atracurium, pipecuronium, mivacurium, pancuronium, rocuronium, vecuronium) act as competitive antagonists of nicotine receptors. By doing so, these drugs hinder the depolarizing effect of acetylcholine, thereby eliminating the potential stimulation of muscle fibers. Depolarizing drugs like succinylcholine and decamethonium induce an initial activation (depolarization) of the receptor followed by a sustained and steady blockade. These drugs do not act as competitive antagonists; instead, they function as more enduring agonists compared to acetylcholine itself. Many factors can influence the duration of action of these drugs. Among them, electrolyte disturbances and disruptions in acid-base balance can have an impact. Acidosis increases the potency of non-depolarizing muscle relaxants, while alkalosis induces resistance to their effects. In depolarizing drugs, acidosis and alkalosis produce opposite effects. The results of studies on the impact of acid-base balance disturbances on non-depolarizing relaxants have been conflicting. This work is based on the available literature and the authors' experience. This article aimed to review the use of anesthetic muscle relaxants in patients with acid-base disturbances.
Topics: Humans; Acid-Base Equilibrium; Neuromuscular Depolarizing Agents; Neuromuscular Blocking Agents; Anesthetics; Neuromuscular Nondepolarizing Agents; Succinylcholine; Rocuronium
PubMed: 38949163
DOI: 10.12659/MSM.944510 -
JPMA. the Journal of the Pakistan... Jun 2024To determine the predisposing factors for lengthy intensive care unit stay of chronic obstructive pulmonary disease patients with acute exacerbation.
OBJECTIVES
To determine the predisposing factors for lengthy intensive care unit stay of chronic obstructive pulmonary disease patients with acute exacerbation.
METHODS
The retrospective study was conducted after approval from the ethics review committee of Atatürk Sanatorium Training and Research Hospital, Turkey, and comprised data from January 1, 2017, to August 31, 2022, related to acute exacerbation chronic obstructive pulmonary disease patients receiving intensive care unit treatment. Demographics, comorbidities, treatment, length of stay in hospital and in intensive care unit, and nutritional status were evaluated. Data of patients who spent <10 days in intensive care unit formed Group 1, while those having spent 10 days or more formed Group 2 for comparison purposes. Data was analysed using SPSS 22.
RESULTS
Of the 460 patients, 366(79.6%) were in Group 1; 224(61.2%) males and 64(38.8%) females with mean age 70.81±11.57 years. There were 94(20.4%) patients in Group 2; 62(66%) males and 32(34%) females with mean age 72.38±10.88 years (p>0.05). Inotropic agent support, need for haemodialysis, timeframe of invasive mechanical ventilation, length of stay in hospital, 1-month mortality, antibiotic use, use of diuretic agent, acute physiology and chronic health evaluation-ii score, nutrition risk in the critically ill score, history of lung malignancy, and pneumonic infiltration on chest radiograph were significantly more frequenttly observed in Group 2 patients (p<0.05). Age, timeframe of invasive mechanical ventilation, and length of stay in hospital were the factors prolonging intensive care unit stay (p<0.05).
CONCLUSIONS
Higher age, longer invasive mechanical ventilation timeframe and hospital stay with acute exacerbation chronic obstructive pulmonary disease caused a prolonged stay in intensive care unit.
Topics: Humans; Male; Pulmonary Disease, Chronic Obstructive; Female; Aged; Length of Stay; Retrospective Studies; Middle Aged; Aged, 80 and over; Risk Factors; Disease Progression; Intensive Care Units; Critical Care; Respiration, Artificial; Turkey; Nutritional Status; Anti-Bacterial Agents; Renal Dialysis
PubMed: 38948972
DOI: 10.47391/JPMA.9418 -
JPMA. the Journal of the Pakistan... Jun 2024To determine the effect of disease activity on clinical outcomes of coronavirus disease-2019 in patients with rheumatic diseases.
OBJECTIVES
To determine the effect of disease activity on clinical outcomes of coronavirus disease-2019 in patients with rheumatic diseases.
METHODS
The prospective, cohort study was conducted from January 1st to June 30th, 2021, at Rheumatology department, Fauji Foundation Hospital, Rawalpindi. It comprised patients of rheumatic disorders who were affected by coronavirus disease-2019. The patients were categorised according to rheumatic disease activity into remission group I, low disease activity group II, moderate group III and high-activity group IV. Coronavirus disease-2019 outcomes compared included recovered vs death, hospitalisation yes vs no, mechanical ventilation yes vs no. The association of disease activity status with coronavirus disease-2019 outcomes was explored. Data was analysed using SPSS 23.
RESULTS
Of the 100 patients, 78(78%) were females and 22(22%) were males. The overall mean age was 45.60±13.7 years. There were 23(23%) patients in group I, 42(42%) patients in group II, 21(21%) patients in group III and 14(14%) patients in group IV. Overall,17(17%) patients died and 83(83%) patients survived. In group III, 7(33.3%) patients died, followed by 6(42.9%) in group IV (p<0.05). In total, 7(7%) patients needed mechanical ventilation, with 3(21.4%) being in group IV (p<0.05). Hospitalisation was needed in 33(33%) cases, and intergroup comparison was non-significant (p>0.05).
CONCLUSIONS
Patients with severe rheumatic autoimmune disease affected by coronavirus disease-2019 were more likely to die and require invasive ventilation.
Topics: Humans; COVID-19; Male; Female; Rheumatic Diseases; Middle Aged; Adult; Prospective Studies; SARS-CoV-2; Respiration, Artificial; Hospitalization; Severity of Illness Index; Pakistan
PubMed: 38948971
DOI: 10.47391/JPMA.9371 -
Journal of Family Medicine and Primary... May 2024To determine the association between vaccination status and mortality among critically ill patients admitted in a dedicated Covid hospital of Tripura who required...
OBJECTIVE
To determine the association between vaccination status and mortality among critically ill patients admitted in a dedicated Covid hospital of Tripura who required invasive mechanical ventilation.
MATERIAL AND METHODS
This study was conducted at a dedicated Covid hospital of Tripura for a period of six months, i.e., from June 2021 to November 2021. A total of 304 patients were enrolled for this study. Baseline epidemiological, radiological data along with other information like heart rate, pulse rate, oxygen saturation (SpO), etc., were collected through patient record sheet in all cases during hospitalization. Statistical analysis was done by using SPSS 25 version.
RESULTS
Admission and mortality rates in hospital and advanced oxygen support like bi-level positive airway pressure (BiPAP), high-flow nasal cannula (HFNOC), and ventilator use incidences were higher in non-vaccinated patients (17.1%) in comparison to double-dose-vaccinated (0.98%) and single-dose (2.3%)-vaccinated patients.
CONCLUSION
This retrospective data analysis of Covid-19 positive patients admitted in the dedicated Covid Hospital of Tripura suggests that severe infection, need for invasive and non-invasive ventilation, and death were significantly less in the vaccinated patients as compared to the vaccine-naive one.
PubMed: 38948609
DOI: 10.4103/jfmpc.jfmpc_1643_23