Regional pleural strain measurements during mechanical ventilation using ultrasound elastography: A randomised, crossover, proof of concept physiologic study

Background Mechanical ventilation is a common therapy in operating rooms and intensive care units. When ill-adapted, it can lead to ventilator-induced lung injury (VILI), which is associated with poor outcomes. Excessive regional pulmonary strain is thought to be a major mechanism responsible for VILI. Scarce bedside methods exist to measure regional pulmonary strain. We propose a novel way to measure regional pleural strain using ultrasound elastography. Research Question The objective of this study was to assess the feasibility and reliability of pleural strain measurement by ultrasound elastography and to determine if elastography parameters would correlate with varying tidal volumes. Study Design and Methods A single-blind randomized crossover proof of concept study was conducted July to October 2017 at a tertiary care referral center. Ten patients requiring general anesthesia for elective surgery were recruited. After induction, patients were received tidal volumes of 6, 8, 10 and 12 mL.kg-1 in random order, while pleural ultrasound cineloops were acquired at 4 standardized locations. Ultrasound radiofrequency speckle tracking allowed computing various pleural translation, strain and shear components. These were screened to identify those with the best dose-response with tidal volumes using linear mixed effect models. Goodness-of-fit was assessed by the coefficient of determination. Intraobserver, interobserver and test-retest reliability were calculated using intraclass correlation coefficients. Results Analysis was possible in 90.7% of ultrasound cineloops. Lateral absolute shear, lateral absolute strain and Von Mises strain varied significantly with tidal volume and offered the best dose-responses and data modelling fits. Point estimates for intraobserver reliability measures were excellent for all 3 parameters (0.94, 0.94 and 0.93, respectively). Point estimates for interobserver (0.84, 0.83 and 0.77, respectively) and test-retest (0.85, 0.82 and 0.76, respectively) reliability measures were good. Interpretation Strain imaging is feasible and reproducible, and may eventually guide mechanical ventilation strategies in larger cohorts of patients.

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Outcome for Cancer Patients Requiring Mechanical Ventilation

Journal of Clinical Oncology ◽

10.1200/jco.1999.17.3.991 ◽

1999 ◽

Vol 17 (3) ◽

pp. 991-991 ◽

Cited By ~ 116

Author(s):

Jeffrey S. Groeger ◽

Peter White ◽

David M. Nierman ◽

Jill Glassman ◽

Weiji Shi ◽

...

Keyword(s):

Mechanical Ventilation ◽

Cancer Patients ◽

Goodness Of Fit ◽

Characteristic Curve ◽

Tertiary Care ◽

Allogeneic Bone Marrow Transplantation ◽

Allogeneic Bone ◽

Risk Of Death ◽

Hospital Survival ◽

Increased Risk

PURPOSE: To describe hospital survival for cancer patients who require mechanical ventilation. MATERIALS AND METHODS: A prospective, multicenter observational study was performed at five academic tertiary care hospitals. Demographic and clinical variables were obtained on consecutive cancer patients at initiation of mechanical ventilation, and information on vital status at hospital discharge was acquired. RESULTS: Our analysis was based on 782 adult cancer patients who met predetermined inclusion criteria. The overall observed hospital mortality was 76%, with no statistically significant differences among the five study centers. Seven variables (intubation after 24 hours, leukemia, progression or recurrence of cancer, allogeneic bone marrow transplantation, cardiac arrhythmias, presence of disseminated intravascular coagulation, and need for vasopressor therapy) were associated with an increased risk of death, whereas prior surgery with curative intent was protective. The predictive model based on these variables had an area under the receiver operating characteristic curve of 0.736, with Hosmer-Lemeshow goodness-of-fit statistics of 7.19; P = .52. CONCLUSION: This model can be used to estimate the probability of hospital survival for classes of adult cancer patients who require mechanical ventilation and can help to guide physicians, patients, and families in deciding goals and direction of treatment. Prospective independent validation in different medical settings is warranted.

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Tracheostomy in Postoperative Pediatric Cardiac Surgical Patients—The Earlier, the Better

Journal of Cardiac Critical Care TSS ◽

10.1055/s-0041-1723749 ◽

2021 ◽

Author(s):

Chalattil Bipin ◽

Manoj K. Sahu ◽

Sarvesh P. Singh ◽

Velayoudam Devagourou ◽

Palleti Rajashekar ◽

...

Keyword(s):

Mechanical Ventilation ◽

Cardiac Surgery ◽

Hospital Stay ◽

Pediatric Patients ◽

Tertiary Care ◽

Surgical Patients ◽

Surgical Intensive Care Unit ◽

Care Hospital ◽

Surgical Intensive Care ◽

Nutrition Supplementation

Abstract Objectives This study was aimed to assess the benefits of early tracheostomy (ET) compared with late tracheostomy (LT) on postoperative outcomes in pediatric cardiac surgical patients. Design Present one is a prospective, observational study. Setting The study was conducted at a cardiac surgical intensive care unit (ICU) of a tertiary care hospital. Participants All pediatric patients below 10 years of age, who underwent tracheostomy after cardiac surgery from January2019 to december2019, were subdivided into two groups according to the timing of tracheostomy: “early” if done before 7 days or “late” if done after 7 days postcardiac surgery. Interventions ET versus LT was measured in the study. Results Out of all 1,084 pediatric patients who underwent cardiac surgery over the study period, 41 (3.7%) received tracheostomy. Sixteen (39%) patients underwent ET and 25 (61%) underwent LT. ET had advantages by having reduced risk associations with the following variables: preoperative hospital stay (p = 0.0016), sepsis (p = 0.03), high risk surgery (p = 0.04), postoperative sepsis (p = 0.001), C-reactive protein (p = 0.04), ventilator-associated pneumonia (VAP; p = 0.006), antibiotic escalation (p = 0.006), and antifungal therapy (p = 0.01) requirement. Furthermore, ET was associated with lesser duration of mechanical ventilation (p = 0.0027), length of ICU stay (LOICUS; p = 0.01), length of hospital stay (LOHS; p = 0.001), lesser days of feed interruption (p = 0.0017), and tracheostomy tube change (p = 0.02). ET group of children, who had higher total ventilation-free days (p = 0.02), were decannulated earlier (p = 0.03) and discharged earlier (p = 0.0089). Conclusion ET had significant benefits in reduction of postoperative morbidities with overall shorter mechanical ventilation, LOICUS, and LOHS, better nutrition supplementation, lesser infection, etc. These benefits may promote faster patient convalescence and rehabilitation with reduced hospital costs.

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Risk of Depression among Early Onset Type 2 Diabetes Mellitus Patients

Dubai Diabetes and Endocrinology Journal ◽

10.1159/000515683 ◽

2021 ◽

pp. 1-11

Author(s):

Baizid Khoorshid Riaz ◽

Shahjada Selim ◽

Megan Neo ◽

Md Nazmul Karim ◽

M. Mostafa Zaman

Keyword(s):

Diabetes Mellitus ◽

Type 2 Diabetes ◽

Type 2 Diabetes Mellitus ◽

Early Onset ◽

Tertiary Care ◽

Positive Family History ◽

Depression Symptoms ◽

Mixed Effect ◽

Increased Risk

Methodology: Biochemically confirmed type 2 diabetes mellitus (T2DM) patients (n = 1,114) were recruited from the outpatient department of 2 tertiary care hospitals in Dhaka, Bangladesh. Face-to-face interview was conducted using a semi-structured questionnaire containing sociodemographic parameters and relevant information about depression and diabetes. Biochemical test results and treatment-related information were taken from patients’ records. The Hospital Anxiety and Depression Scale (HADS) was used to screen all patients for psychiatric manifestation. Those diagnosed by HADS were subsequently reassessed using structured clinical interview for DSM-5 Disorders – Clinician Version. T2DM diagnosed at age <40 years were considered as early onset T2DM. Association between age of onset category and depression was assessed using multivariable mixed-effect logistic regression adjusting for random variation of the area of residence and plausible confounders. Results: Around a third of the participants (32.5%) were diagnosed with T2DM before the age of 40 years. Early onset T2DM patients were found to have 57% increase in the risk of developing depression (OR 1.57; 95% CI 1.13–2.28; p = 0.011) in comparison to those with usual onset T2DM (≥40 years). Among other factors a positive family history for diabetes (OR 1.33; 95% CI 1.03–1.78; p = 0.038), poor glycemic control (OR 1.31; 95% CI 1.03–1.68; p = 0.028), presence of 1, or more diabetic complications (OR 1.37; 95% CI 1.03–1.78; p = 0.011) also showed increased risk of depression. Conclusion: Early onset T2DM patients are at greater risk of developing depression. The finding is likely to help in setting preventive strategies aiming to reduce the presence of concomitant depression symptoms among diabetes.

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Evaluation of NASA POWER Reanalysis Products to Estimate Daily Weather Variables in a Hot Summer Mediterranean Climate

Agronomy ◽

10.3390/agronomy11061207 ◽

2021 ◽

Vol 11 (6) ◽

pp. 1207

Author(s):

Gonçalo C. Rodrigues ◽

Ricardo P. Braga

Keyword(s):

Wind Speed ◽

Bias Correction ◽

Goodness Of Fit ◽

Mediterranean Climate ◽

Weather Data ◽

Coefficient Of Determination ◽

Mean Bias Error ◽

Bias Error ◽

Weather Variables ◽

Weather Stations

This study aims to evaluate NASA POWER reanalysis products for daily surface maximum (Tmax) and minimum (Tmin) temperatures, solar radiation (Rs), relative humidity (RH) and wind speed (Ws) when compared with observed data from 14 distributed weather stations across Alentejo Region, Southern Portugal, with a hot summer Mediterranean climate. Results showed that there is good agreement between NASA POWER reanalysis and observed data for all parameters, except for wind speed, with coefficient of determination (R2) higher than 0.82, with normalized root mean square error (NRMSE) varying, from 8 to 20%, and a normalized mean bias error (NMBE) ranging from –9 to 26%, for those variables. Based on these results, and in order to improve the accuracy of the NASA POWER dataset, two bias corrections were performed to all weather variables: one for the Alentejo Region as a whole; another, for each location individually. Results improved significantly, especially when a local bias correction is performed, with Tmax and Tmin presenting an improvement of the mean NRMSE of 6.6 °C (from 8.0 °C) and 16.1 °C (from 20.5 °C), respectively, while a mean NMBE decreased from 10.65 to 0.2%. Rs results also show a very high goodness of fit with a mean NRMSE of 11.2% and mean NMBE equal to 0.1%. Additionally, bias corrected RH data performed acceptably with an NRMSE lower than 12.1% and an NMBE below 2.1%. However, even when a bias correction is performed, Ws lacks the performance showed by the remaining weather variables, with an NRMSE never lower than 19.6%. Results show that NASA POWER can be useful for the generation of weather data sets where ground weather stations data is of missing or unavailable.

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Epidemiology and clinical outcome of ventilator-associated events at a tertiary care hospital from North India

Tropical Doctor ◽

10.1177/0049475520982457 ◽

2020 ◽

pp. 004947552098245

Author(s):

Pooja Kumari ◽

Priya Datta ◽

Satinder Gombar ◽

Deepak Sharma ◽

Jagdish Chander

Keyword(s):

Mechanical Ventilation ◽

Tertiary Care Hospital ◽

Late Onset ◽

Tertiary Care ◽

Control Measures ◽

North India ◽

Ventilator Associated Pneumonia ◽

Care Hospital ◽

Infection Control Measures ◽

Utilisation Rate

The aim of our study was to determine the incidence, microbiological profile, risk factors and outcomes of patients diagnosed with ventilator-associated events in our tertiary care hospital. In this prospective study, intensive care patients put on mechanical ventilation for >48 h were enrolled and monitored daily for ventilator-associated event according to Disease Centre Control guidelines. A ventilator-associated event developed in 33/250 (13.2%); its incidence was 3.5/100 mechanical ventilation days. The device utilisation rate was 0.86, 36.4% of patients had early and 63.6% late-onset ventilator-associated pneumonia whose most common causative pathogen was Acinetobacter sp. (63.6%). Various factors were significantly associated with a ventilator-associated event: male gender, COPD, smoking, >2 underlying diseases, chronic kidney disease and elevated acute physiological and chronic health evaluation II scores. Therefore, stringent implementation of infection control measures is necessary to control ventilator-associated pneumonia in critical care units.

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Surgical tracheostomy in a cohort of COVID-19 patients

HNO ◽

10.1007/s00106-021-01021-4 ◽

2021 ◽

Author(s):

Patrick J. Schuler ◽

Jens Greve ◽

Thomas K. Hoffmann ◽

Janina Hahn ◽

Felix Boehm ◽

...

Keyword(s):

Mechanical Ventilation ◽

Respiratory Failure ◽

Prolonged Mechanical Ventilation ◽

Tertiary Care ◽

Lung Compliance ◽

Hypoxemic Respiratory Failure ◽

Surgical Tracheostomy ◽

Increased Risk ◽

Open Surgical Tracheostomy ◽

Sedative Drugs

Abstract Background One of the main symptoms of severe infection with the new coronavirus‑2 (SARS-CoV-2) is hypoxemic respiratory failure because of viral pneumonia with the need for mechanical ventilation. Prolonged mechanical ventilation may require a tracheostomy, but the increased risk for contamination is a matter of considerable debate. Objective Evaluation of safety and effects of surgical tracheostomy on ventilation parameters and outcome in patients with COVID-19. Study design Retrospective observational study between March 27 and May 18, 2020, in a single-center coronavirus disease-designated ICU at a tertiary care German hospital. Patients Patients with COVID-19 were treated with open surgical tracheostomy due to severe hypoxemic respiratory failure requiring mechanical ventilation. Measurements Clinical and ventilation data were obtained from medical records in a retrospective manner. Results A total of 18 patients with confirmed SARS-CoV‑2 infection and surgical tracheostomy were analyzed. The age range was 42–87 years. All patients received open tracheostomy between 2–16 days after admission. Ventilation after tracheostomy was less invasive (reduction in PEAK and positive end-expiratory pressure [PEEP]) and lung compliance increased over time after tracheostomy. Also, sedative drugs could be reduced, and patients had a reduced need of norepinephrine to maintain hemodynamic stability. Six of 18 patients died. All surgical staff were equipped with N99-masks and facial shields or with powered air-purifying respirators (PAPR). Conclusion Our data suggest that open surgical tracheostomy can be performed without severe complications in patients with COVID-19. Tracheostomy may reduce invasiveness of mechanical ventilation and the need for sedative drugs and norepinehprine. Recommendations for personal protective equipment (PPE) for surgical staff should be followed when PPE is available to avoid contamination of the personnel.

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526. Clinical Presenting Characteristics of Pediatric COVID-19 Infection in a Tertiary Care Children’s Hospital in Detroit

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.720 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S330-S330

Author(s):

Jocelyn Y Ang ◽

Nirupama Kannikeswaran ◽

Basim Asmar

Keyword(s):

Mechanical Ventilation ◽

Severe Disease ◽

Tertiary Care ◽

Retrospective Chart Review ◽

Signs And Symptoms ◽

Pediatric Emergency ◽

Study Cohort ◽

Mild Disease ◽

Presenting Symptoms ◽

Patient Disposition

Abstract Background There is limited data regarding the presenting clinical characteristics of COVID-19 in children. Our objective is to describe the clinical presentations and outcomes of COVID-19 infection early in the pandemic at our institution. Methods We performed a retrospective chart review of children up to 18 years who underwent testing for SARS CoV-2 from March 1st to May 10th 2020 at our pediatric emergency department. We abstracted patient’s demographics, clinical presentation, diagnostic studies and patient disposition. We classified the severity of clinical illness based on published criteria. We excluded patients diagnosed with Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19. Results SARS CoV-2 testing was performed on 481 patients of whom 43 (8.9%) tested positive. Of these, 4 were diagnosed with MIS-C. Data of 39 patients were analyzed. Patients’ demographics, co-morbidities, presenting signs and symptoms and disposition are shown in Table 1. Age range was 47 days – 18 years. Infants representing one third (14/39; 35.9%) of our study cohort. There was equal sex distribution. Asthma or obesity was present in 17 (44%). The most common presenting symptoms included fever, cough, shortness of breath and diarrhea. Chest radiograph showed pneumonia in 12 (30.8%) patients. Two thirds (27/39; 69.2%) were asymptomatic or had mild disease; six patients (15.4%) had severe or critical illness (Figure 1). Nineteen (48%) patients were admitted to the general pediatric service. Eleven (28%) were admitted to the Intensive Care Units (ICU). The characteristics, presenting symptoms and interventions performed in the PICU cohort are shown in Table 2. Half of these patients required mechanical ventilation. There was one death in a 3 month old infant unrelated to SARS CoV-2. Majority of the infants required hospitalization (12/14; 85.7%), including 4 to the PICU (one each for non accidental trauma, ingestion, seizure and pneumonia). Table 1. Patient demographics, signs and symptoms of COVID-19 infection in Children Table 2: PICU patients: Characteristics, Interventions and pharmacotherapy Figure 1: Severity of Ill ness in the study cohort Conclusion Majority (17; 43%) of our children with COVID-19 had a mild disease. Eleven (28%) including 4 infants required critical care; 5 required mechanical ventilation. There was no COVID-19 related mortality. Larger studies are needed to further define the spectrum of COVID- 19 and risk factors associated with severe disease in children. Disclosures All Authors: No reported disclosures

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63 Characterizing Organizational Risk Factors and Clinical Impacts of Unplanned Extubations among Infants in the Neonatal Intensive Care Unit

Paediatrics & Child Health ◽

10.1093/pch/pxab061.048 ◽

2021 ◽

Vol 26 (Supplement_1) ◽

pp. e44-e45

Author(s):

Gabriella Le Blanc ◽

Elias Jabbour ◽

Sharina Patel ◽

Marco Zeid ◽

Wissam Shalish ◽

...

Keyword(s):

Mechanical Ventilation ◽

Intensive Care ◽

Neonatal Intensive Care ◽

Tertiary Care ◽

Organizational Factors ◽

Subject Area ◽

Administrative Databases ◽

Perinatal Medicine ◽

Unplanned Extubations ◽

Increased Risk

Abstract Primary Subject area Neonatal-Perinatal Medicine Background Organizational factors in neonatal intensive care units (NICUs) can increase the risk of adverse events, such as unplanned extubations (UPEs). UPE is the premature and unanticipated removal of an endotracheal tube. UPE and subsequent reintubation may increase the risk for lung injury and bronchopulmonary dysplasia (BPD) among preterm infants. Objectives First, we aimed to assess the association between daily nursing overtime and UPEs in the NICU. Second, we aimed to evaluate the association between UPE, re-intubation after UPE, and BPD in the sub-group of infants born < 29 weeks’ gestational age (GA). Design/Methods We conducted a retrospective cohort study including infants admitted to a tertiary care NICU between 2016-2019. Daily nursing hours were obtained from local administrative databases. Patient data was collected from the local Canadian Neonatal Network database. Association between ratio of daily nursing overtime hours/total nursing hours (OTR) was compared between days with and without UPEs, using logistic regression analyses. Associations between UPE and BPD among infants born <29 weeks requiring mechanical ventilation was evaluated in a 1:1 propensity-score matched (PSM) cohort. Infants were matched based on GA ± 2 weeks, mechanical ventilation days at time of UPE ± 5 days and SNAPII>20. Results There were 108/1370 (7.8%) days with ≥ 1 UPE, for a total of 116 UPE events from 87 patients (23-42 weeks GA). Higher median OTR was observed on days with UPE compared to days without (3.3% vs. 2.5%, p=0.01). OTR was associated with higher adjusted odds of UPE (aOR 1.09, 95% CI 1.01-1.18), while other organizational variables were not (Table 1). Among ventilated infants <29 weeks’ GA (n=XX), UPE rate was 31% (59), BPD rate was 42% (81) and re-intubation rate after UPE was 59% (35). In the PSM cohort of infants <29 weeks, re-intubation after UPE, was associated with increased length of mechanical ventilation (aOR 16.45; CI 6.18, 26.72) as well as increased odds of BPD, when compared to infants not requiring re-intubation (aOR 4.97, 95% CI 1.54-18.27) (Table 2). Conclusion Higher nursing overtime was associated with increased UPEs in the NICU. Re-intubation was frequently required after a UPE. Among the infants born < 29 weeks’ GA, UPE requiring reintubation was associated with increased total length of mechanical ventilation and increased risk of BPD. Our findings highlight the role of workforce management in improving outcomes in the NICU, through reducing the incidence of UPEs.

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Variation in Cervical Length over Time during a Single Transvaginal Ultrasound Examination

American Journal of Perinatology ◽

10.1055/s-0038-1676616 ◽

2018 ◽

Vol 36 (08) ◽

pp. 781-784

Author(s):

Katherine A. Connolly ◽

Luciana Vieira ◽

Elizabeth M. Yoselevsky ◽

Stephanie Pan ◽

Joanne L. Stone

Keyword(s):

Correlation Coefficient ◽

Intraclass Correlation Coefficient ◽

Ultrasound Examination ◽

Transvaginal Ultrasound ◽

Intraclass Correlation ◽

Cervical Length ◽

Linear Mixed Effect Model ◽

Mixed Effect ◽

Time Points ◽

Significant Difference

Objective To quantify the degree of change in cervical length (CL) over a 3-minute transvaginal ultrasound. Study Design We conducted a prospective observational study of nulliparous patients who underwent routine transvaginal CL screening at the time of their second-trimester ultrasound. We recorded CL at four time points (0, 1, 2, 3 minutes) and compared these values to determine the minute-to-minute change within a single patient. Results A total of 771 patients were included. The mean gestational age was 20.8 weeks (±0.84). We used a linear mixed effect model to assess if each minute during the ultrasound is associated with a change in CL. The intraclass correlation coefficient between minute 0 to minute 3 was 0.82 (95% confidence interval: 0.80, 0.84). This indicates that there is a relatively high within-patient correlation in CL during their ultrasound. Additionally, we stratified patients based on their starting CL; the intraclass correlation coefficient remained high for all groups. We additionally compared CL at each minute. Although there is a statistically significant difference between several time points, the actual difference is small and not clinically meaningful. Conclusion The variation in CL over a 3-minute transvaginal ultrasound examination is not clinically significant. It may be reasonable to conduct this examination over a shorter period.

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Role of BAP 65 (Blood Urea Nitrogen, Altered Mental Status, Pulse, Age 65 Years) Scoring System in Risk Stratification of Patients with Acute Exacerbation of Chronic Obstructive Lung Disease in Tertiary Care Hospital

Nepal Medical Journal ◽

10.37080/nmj.62 ◽

2019 ◽

Vol 2 (2) ◽

pp. 5-10

Author(s):

Ashish Thapa

Keyword(s):

Mechanical Ventilation ◽

Acute Exacerbation ◽

Severe Disease ◽

Tertiary Care ◽

Chronic Obstructive Lung Disease ◽

Institutional Review Boards ◽

Mortality Data ◽

Chronic Obstructive ◽

P Value ◽

Care Hospital

Introduction: Exacerbations are important events in the management of COPD because they negatively impact health status, rates of hospitalization and readmission, and disease progression. COPD AE is one of the commonest case presenting to the TUTH Emergency, average being 5 patients a day. The aim of the study was to co-relate the BAP 65 score, mortality and mechanical ventilation in patients with acute exacerbation of COPD. Methods: It was an observational study, 648 patients from emergency of TUTH were screened for the study from Magh 2073 to Asar 2074 after getting approval from the institutional review boards, among them 114 were included after applying inclusion and exclusion criteria and BAP 65 score was calculated. The patients were followed till discharge, mechanical ventilation or mortality. Data entry was done in MS EXCEL and statistical analysis was done using SPSS version 24. Results: Total of 114 patients enrolled for the study from the emergency of TUTH. There were total 16 mortality and 12 patients were mechanically ventilated. Most of the mortality and mechanical ventilation were from severe group ie BAP class IV and V. We used Pearson Chi-squared test to compare between BAP 65 class and Mortality, and found that mortality rate increased with increasing BAP 65 class with a p value of < 0.0001. The need of Mechanical Ventilation increased as well, as the BAP 65 Class increased, less than 1% of the patients with BAP class I needed MV, the cause being Type II Respiratory Failure, while around 50% of the patients with BAP class V needed MV. Conclusions: BAP 65 score is an effective and simple tool to classify the patients presenting with AECOPD, it correlated well with both the need of mechanical ventilation and mortality. Higher the score higher the chances of severe disease.

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