scholarly journals Airway Pseudomonas aeruginosa density in mechanically ventilated patients: clinical impact and relation to therapeutic efficacy of antibiotics

Critical Care ◽  
2021 ◽  
Vol 25 (1) ◽  
Author(s):  
Yohei Migiyama ◽  
Shinya Sakata ◽  
Shinji Iyama ◽  
Kentaro Tokunaga ◽  
Koichi Saruwatari ◽  
...  
Keyword(s):  
Risk Factors ◽  
Mechanical Ventilation ◽  
Pseudomonas Aeruginosa ◽  
High Peak ◽  
Weaning From Mechanical Ventilation ◽  
Icu Mortality ◽  
Mechanically Ventilated ◽  
Mechanically Ventilated Patients ◽  
Peak Density ◽  
Ventilated Patients

Abstract Background The bacterial density of Pseudomonas aeruginosa is closely related to its pathogenicity. We evaluated the effect of airway P. aeruginosa density on the clinical course of mechanically ventilated patients and the therapeutic efficacy of antibiotics. Methods We retrospectively analyzed data of mechanically ventilated ICU patients with P. aeruginosa isolated from endotracheal aspirates. Patients were divided into three groups according to the peak P. aeruginosa density during ICU stay: low (≤ 104 cfu/mL), moderate (105‒106 cfu/mL), and high (≥ 107 cfu/mL) peak density groups. The relationship between peak P. aeruginosa density and weaning from mechanical ventilation, risk factors for isolation of high peak density of P. aeruginosa, and antibiotic efficacy were investigated using multivariate and propensity score-matched analyses. Results Four-hundred-and-sixty-one patients were enrolled. Patients with high peak density of P. aeruginosa had higher inflammation and developed more severe respiratory infections. High peak density of P. aeruginosa was independently associated with few ventilator-free days on day 28 (P < 0.01) and increased ICU mortality (P = 0.047). Risk factors for high peak density of P. aeruginosa were prolonged mechanical ventilation (odd ratio [OR] 3.07 95% confidence interval [CI] 1.35‒6.97), non-antipseudomonal cephalosporins (OR 2.17, 95% CI 1.35‒3.49), hyperglycemia (OR 2.01, 95% CI 1.26‒3.22) during ICU stay, and respiratory diseases (OR 1.9, 95% CI 1.12‒3.23). Isolation of commensal colonizer was associated with lower risks of high peak density of P. aeruginosa (OR 0.43, 95% CI 0.26‒0.73). Propensity score-matched analysis revealed that antibiotic therapy for patients with ventilator-associated tracheobronchitis improved weaning from mechanical ventilation only in the high peak P. aeruginosa group. Conclusions Patients with high peak density of P. aeruginosa had worse ventilator outcome and ICU mortality. In patients with ventilator-associated tracheobronchitis, antibiotic therapy was associated with favorable ventilator weaning only in the high peak P. aeruginosa density group, and bacterial density could be a good therapeutic indicator for ventilator-associated tracheobronchitis due to P. aeruginosa.

scholarly journals Airway Pseudomonas aeruginosa Density in Mechanically Ventilated Patients: Clinical Impact and Relation to Therapeutic Efficacy of Antibiotics

2021 ◽  
Author(s):  
Yohei Migiyama ◽  
Shinya Sakata ◽  
Shinji Iyama ◽  
Kentaro Tokunaga ◽  
Koichi Saruwatari ◽  
...  
Keyword(s):  
Risk Factors ◽  
Mechanical Ventilation ◽  
Pseudomonas Aeruginosa ◽  
High Peak ◽  
Weaning From Mechanical Ventilation ◽  
Icu Mortality ◽  
Mechanically Ventilated ◽  
Mechanically Ventilated Patients ◽  
Peak Density ◽  
Ventilated Patients

Abstract Background: The bacterial density of Pseudomonas aeruginosa is closely related to its pathogenicity. We evaluated the effect of airway P. aeruginosa density on the clinical course of mechanically ventilated patients and the therapeutic efficacy of antibiotics.Methods: We retrospectively analyzed data of mechanically ventilated ICU patients with P. aeruginosa isolated from endotracheal aspirates. Patients were divided into three groups according to the peak P. aeruginosa density during ICU stay: low (≤104 cfu/mL), moderate (105‒106 cfu/mL), and high (≥107 cfu/mL) peak density groups. The relationship between peak P. aeruginosa density and weaning from mechanical ventilation, risk factors for isolation of high peak density of P. aeruginosa, and antibiotic efficacy were investigated using multivariate and propensity score-matched analyses.Results: Four-hundred-and-sixty-one patients were enrolled. Patients with high peak density of P. aeruginosa had higher inflammation and developed more severe respiratory infections. High peak density of P. aeruginosa was independently associated with few ventilator-free days on day 28 (P < 0.01) and increased ICU mortality (P = 0.047). Risk factors for high peak density of P. aeruginosa were prolonged mechanical ventilation (odd ratio [OR] 3.07 95% confidence interval [CI] 1.35‒6.97), non-antipseudomonal cephalosporins (OR 2.17, 95% CI 1.35‒3.49), hyperglycemia (OR 2.01, 95% CI 1.26‒3.22) during ICU stay, and respiratory diseases (OR 1.9, 95% CI 1.12‒3.23). Isolation of commensal colonizer was associated with lower risks of high peak density of P. aeruginosa (OR 0.43, 95% CI 0.26‒0.73). Propensity score-matched analysis revealed that antibiotic therapy for patients with ventilator-associated tracheobronchitis improved weaning from mechanical ventilation only in the high peak P. aeruginosa group.Conclusions: Patients with high peak density of P. aeruginosa had worse ventilator outcome and ICU mortality. In patients with ventilator-associated tracheobronchitis, antibiotic therapy was associated with favorable ventilator weaning only in the high peak P. aeruginosa density group, and bacterial density could be a good therapeutic indicator for ventilator-associated tracheobronchitis due to P. aeruginosa.

scholarly journals Airway Pseudomonas aeruginosa Density in Mechanically Ventilated Patients: Clinical Impact and Relation to Therapeutic Efficacy of Antibiotics

2021 ◽  
Author(s):  
Yohei Migiyama ◽  
Shinya Sakata ◽  
Shinji Iyama ◽  
Kentaro Tokunaga ◽  
Koichi Saruwatari ◽  
...  
Keyword(s):  
Risk Factors ◽  
Mechanical Ventilation ◽  
Pseudomonas Aeruginosa ◽  
Propensity Score ◽  
Therapeutic Efficacy ◽  
Clinical Course ◽  
Weaning From Mechanical Ventilation ◽  
Mechanically Ventilated ◽  
Mechanically Ventilated Patients ◽  
Ventilated Patients

Abstract Background: The bacterial density of Pseudomonas aeruginosa (PA) is closely related to its pathogenicity. We evaluated the effect of airway PA density on the clinical course of mechanically ventilated patients and the therapeutic efficacy of antibiotics.Methods: We retrospectively analyzed data of intensive care unit (ICU) mechanically ventilated patients with PA isolated from endotracheal aspirates. Patients were divided into three groups according to the peak PA density during ICU stay: low-PA (≤ 104 colony-forming units [cfu]/mL), moderate-PA (105‒106 cfu/mL), and high-PA (≥ 107 cfu/mL) groups. The relationship between PA density and weaning from mechanical ventilation, risk factors for high-PA isolation, and antibiotic efficacy were investigated using multivariate and propensity score-matched analyses.Results: A total of 461 patients were enrolled. Patients with high-PA had higher inflammation marker levels and developed more severe respiratory infections. High PA was independently associated with fewer ventilator-free days on day 28 (P < 0.01) and increased ICU mortality (P = 0.047). Risk factors for high PA were prolonged mechanical ventilation (odds ratio [OR] 3.07, 95% confidence interval [CI] 1.35‒6.97), non-antipseudomonal cephalosporins (OR 2.17, 95% CI 1.35‒3.49), hyperglycemia (OR 2.01, 95% CI 1.26‒3.22) during ICU stay, and respiratory diseases (OR 1.9, 95% CI 1.12‒3.23). Isolation of commensal colonizers was associated with lower risks of high PA (OR 0.43, 95% CI 0.26‒0.73). Propensity score-matched analyses revealed that antibiotic therapy for patients with ventilator-associated tracheobronchitis improved weaning from mechanical ventilation only in the high-PA group.Conclusions: High PA significantly affected the clinical course of mechanically ventilated patients and could be a good therapeutic indicator for ventilator-associated tracheobronchitis treatment.

scholarly journals Comparative study of incidence, risk factors, etiological agents and outcome of early and late ventilator associated pneumonia in paediatric intensive care unit at a tertiary care centre

2018 ◽  
Vol 5 (3) ◽  
pp. 708
Author(s):  
Preeti Malhotra ◽  
Naresh Kumar ◽  
Karuna Thapar ◽  
Amanjeet Kaur Bagga
Keyword(s):  
Risk Factors ◽  
Mechanical Ventilation ◽  
Paediatric Intensive Care Unit ◽  
Gram Negative Bacteria ◽  
Ventilator Associated Pneumonia ◽  
Acinetobacter Baumanii ◽  
Gram Negative ◽  
Mechanically Ventilated ◽  
Mechanically Ventilated Patients ◽  
Ventilated Patients

Background: Ventilator Associated Pneumonia (VAP), the nosocomial pneumonia developing in mechanically ventilated patients after 48 hours of mechanical ventilation, is the second most common nosocomial infection in the paediatric intensive care unit (PICU). VAP occurring within 96 hours of initiation of mechanical ventilation is termed as early VAP and later than that is known as late VAP. The aim of this study was to determine the incidence rate, risk factors and bacteriological profile and outcome of early and late ventilator associated pneumonia in PICU.Methods: The study was conducted from December 2015 to November 2017 in which 89 children beyond 1 year of age were ventilated for more than 48 hours of which those who developed VAP as per CDC criteria were enrolled in the study. The endotracheal secretions were collected, processed and recorded as per standard microbiological methods. Statistical associations were further evaluated between various parameters of VAP and time of development of VAP.Results: Of all the mechanically ventilated patients, 33.7% developed VAP. Incidence of Early VAP was 23.3% and that of Late VAP was 76.67%. Duration of mechanical ventilation and re-intubation were significantly associated with the time of development of VAP. Micro-organisms identified by culture, involved in the aetiology of VAP were: gram-negative bacteria in 74.9% and gram-positive bacteria in 25.1%. The overall mortality rate was 43.33%.Conclusions: Re-intubation and duration of mechanical ventilation are a significant risk factor for development of late VAP. Overall the most common Gram-negative bacteria associated with VAP was Acinetobacter baumanii. The most common isolate in early VAP was Acinetobacter baumanii whereas infections by Pseudomonas and E. coli are common in late VAP. population.

scholarly journals A comparative study between effect of combined intravenous and nebulized amikacin versus intravenous amikacin alone in mechanically ventilated patients with ventilator-associated pneumonia (VAP)

2020 ◽  
Vol 12 (1) ◽  
Author(s):  
Dalia M. El Fawy ◽  
Azza Yousef Ibrahim ◽  
Ahmed Mostafa Mohamed Abdulmageed ◽  
Eman Abo Bakr El Seddek
Keyword(s):  
Mechanical Ventilation ◽  
Ventilator Associated Pneumonia ◽  
Icu Mortality ◽  
Mechanically Ventilated ◽  
Mechanically Ventilated Patients ◽  
Icu Stay ◽  
Drug Concentrations ◽  
Group A ◽  
Group B ◽  
Ventilated Patients

Abstract Background Aerosolized antibiotic administration offers the theoretical advantages of achieving high drug concentrations at the infection site together with lower systemic absorption. This study aims to compare the effect of combining nebulized amikacin with intravenous amikacin to the effect of the usual intravenous route alone in the treatment of patients with ventilator-associated pneumonia and its impact on the duration of mechanical ventilation, laboratory, and clinical picture of the patients. Results This study was carried out on 64 mechanically ventilated patients with Gram-negative VAP. The patients were divided into 2 groups. Group A included 32 patients treated with nebulized amikacin plus IV amikacin, and group B included 32 patients treated with IV amikacin alone. The duration of treatment for both groups was 8 days with a daily assessment of Clinical Pulmonary Infection Score (CPIS) and monitoring of clinical and laboratory parameters. Sputum cultures were obtained thereafter. In our study, the CPIS score and overall ICU mortality were less in the nebulized than in the IV group but the difference failed to be statistically significant. Increase of oxygenation level (Pao2/Fio2 ratio), organism clearance, decrease in serum creatinine level, duration of mechanical ventilation, and length of ICU stay were significantly different in favor of group A than group B. Conclusion Nebulized and IV amikacin offered better oxygenation, organism clearance, less nephrotoxicity, and less duration of mechanical ventilation and ICU stay than the IV group. Combined and IV routes were comparable regarding the decrease in CPIS score and ICU mortality with no significant difference between them. However, we prefer to use the combined regimen for the mentioned reasons. Further large-scale studies are required to confirm these findings and to establish a definite conclusion.

scholarly journals Risk Factors for 28-Day in-Hospital Mortality in Mechanically Ventilated Patients with COVID-19: An International Cohort Study

2021 ◽  
Author(s):  
Gianluigi Li Bassi ◽  
Jacky Y. Suen ◽  
Nicole White ◽  
Heidi J. Dalton ◽  
Jonathon Fanning ◽  
...  
Keyword(s):  
Risk Factors ◽  
Mechanical Ventilation ◽  
Cohort Study ◽  
Intensive Care ◽  
Hospital Mortality ◽  
Time Dependent ◽  
Mechanically Ventilated ◽  
Cox Regression Analysis ◽  
Mechanically Ventilated Patients ◽  
Ventilated Patients

Abstract Background: Risk factors associated with mortality in patients with coronavirus disease 2019 (COVID-19) on mechanical ventilation are still not fully elucidated. Thus, we aimed to identify patient-level factors, readily available at the bedside, associated with the risk of in-hospital mortality within 28 days from commencement of invasive mechanical ventilation (28-day IMV mortality) in patients with COVID-19. Methods Prospective observational cohort study in 148 intensive care units in the global COVID-19 Critical Care Consortium. Patients with clinically suspected or laboratory confirmed COVID-19 infection admitted to the intensive care unit (ICU) from February 2nd through December 29th, 2020, requiring IMV. No study-specific interventions were performed. Patient characteristics and clinical data were assessed upon ICU admission, the commencement of IMV and for 28 days thereafter. We primarily aimed to identify time-independent and time-dependent risk factors for 28-day IMV mortality. Results: A total of 1713 patients were included in the survival analysis, 588 patients died in hospital within 28 days of commencing IMV (34.3%). Cox-regression analysis identified associations between the hazard of 28-day IMV mortality with age (HR 1.27 per 10-year increase in age, 95% CI 1.17 to 1.37, P<0.001), PEEP upon commencement of IMV (HR 0.78 per 5-cmH2O increase, 95% CI 0.66-0.93, P=0.005). Time-dependent parameters associated with 28-day IMV mortality were serum creatinine (HR 1.30 per doubling, 95% CI 1.19-1.42, P<0.001), lactate (HR 1.16 per doubling, 95% CI 1.06-1.27 P=0.001), PaCO2 (HR 1.31 per doubling, 95% CI 1.05-1.64, P=0.015), pH (HR 0.82 per 0.1 increase, 95% CI 0.74-0.91, P<0.001), PaO2/FiO2 (HR 0.56 per doubling, 95% CI 0.50-0.62, P<0.001) and mean arterial pressure (HR 0.92 per 10 mmHg increase, 95% CI 0.88-0.97, P=0.002).Conclusions: This international study establishes that in mechanically ventilated patients with COVID-19, older age and clinically relevant variables monitored at the bedside are risk factors for 28-day IMV mortality. Further investigation is warranted to validate any causative roles these parameters might play in influencing clinical outcomes.

scholarly journals Mortality Rates in Mechanically Ventilated Patients with COVID-19

2020 ◽  
Vol 3 ◽  
Author(s):  
Jonathan Class ◽  
Sikandar Khan ◽  
Babar Khan
Keyword(s):  
Risk Factors ◽  
Mechanical Ventilation ◽  
Length Of Stay ◽  
Hospital Mortality ◽  
Significant Risk ◽  
Mortality Rates ◽  
Study Cohort ◽  
Mechanically Ventilated ◽  
Mechanically Ventilated Patients ◽  
Ventilated Patients

Background/Objective:   High mortality rates among mechanically ventilated COVID-19 intensive care unit (ICU) patients have raised concerns regarding use of mechanical ventilation in management of patients with COVID-19. Additional data is needed in this discussion to better understand treatment strategies for this vulnerable population. We conducted a study to examine length of stay, duration of mechanical ventilation, mortality, and risk factors for death in critically ill patients with COVID-19.    Methods:  Observational study in patients admitted to Eskenazi Health and Indiana University Health Methodist ICUs. Participants were 18 years and older patients admitted to the ICU from March 1 2020 to April 27, 2020 who tested positive for COVID-19. Primary outcomes for this study were in-hospital mortality, duration of mechanical ventilation, and the length of stay in the ICU.     Results:  The study cohort was made up of 242 patients. The mortality rate was 19.8% (48/242) for the overall cohort and 20.5% (38/185) for mechanically ventilated patients. Age was a significant risk factor for in-hospital mortality [increased hazard in in-hospital mortality: age 65-74 years (HR: 3.1, 95%Cl=1.2-7.9, p=0.021), age 75+ (HR: 4.1, 95%CI=1.6-10.5, p=0.003) compared to those younger than 65]. In our Cox’s proportional hazard model, ESRD (HR:5.9, 95%CI=1.3-26.9, p=0.021) along with age were the only risk factors with statistical significance. The median duration of mechanical ventilation in the overall cohort was 9.3 days (IQR=-5.7-13.7). In patients that died, median ICU length of stay was 8.7 days (IQR=4.0-14.9), compared to 9.2 days (IQR=4.0-14.0) in those discharged alive.    Conclusion/Clinical Impact:  We found lower mortality rates and longer length of stays in our cohort than in previous studies. While more data is needed, this study supports continued use of mechanical ventilation ARDS recommendations for treating patients with ARDS from COVID-19. Further, this data potentially shows a benefit to not having a strained healthcare system.   

scholarly journals Long-Term Survival of Mechanically Ventilated Patients with Severe COVID-19: An Observational Cohort Study

2021 ◽  
Author(s):  
Oscar Penuelas ◽  
Laura del Campo-Albendea ◽  
Amanda Lesmes González de Aledo ◽  
José Manuel Añón ◽  
Carmen Rodríguez-Solís ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Cohort Study ◽  
Invasive Mechanical Ventilation ◽  
Icu Mortality ◽  
Term Survival ◽  
Long Term Survival ◽  
Mechanically Ventilated ◽  
Mechanically Ventilated Patients ◽  
Ventilated Patients

Abstract Background: Information is lacking regarding long-term survival and predictive factors for mortality in patients with acute hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19) and undergoing invasive mechanical ventilation. We aimed to estimate 90-day and 180-day survival of patients with COVID-19 requiring invasive ventilation and to develop a predictive model for intensive care unit mortality.Methods: Retrospective, multicentre, national cohort study between March 8 and April 30, 2020 in 16 intensive care units (ICU) in Spain. Participants were consecutive adults who received invasive mechanical ventilation for COVID–19. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection detected in positive testing of a nasopharyngeal sample and confirmed by real time reverse-transcriptase polymerase chain reaction (rt-PCR). The primary outcomes were 90-day and 180-day survival after hospital admission. Secondary outcomes were length of ICU and hospital stay, and ICU and in-hospital mortality. A predictive model and a nomogram were developed to estimate the probability of ICU mortality. Results: 868 patients were included (median age, 64 years [interquartile range [IQR], 56-71 years]; 72% male). Severity at ICU admission, estimated by SAPS3, was 56 points [IQR 50-63]. Prior to intubation, 26% received some type of noninvasive respiratory support. The 90-day and 180-day survival rates were 69% (95% confidence interval [CI] 66%-72%) and 59% (95% CI 56%-62%) respectively. The predictive factors associated with ICU mortality were: age (odds ratio [OR] 1.049 [95% CI 1.032-1.066] per 1-year increase), SAPS3 (OR 1.025 [95% CI 1.008-1.041] per 1-point increase), neutrophil to lymphocyte ratio (OR 1.009 [95% CI 1.002-1.016]), a failed attempt of noninvasive positive pressure ventilation previous to orotracheal intubation(OR 2.131 [95% CI 1.279-3.550]), and use of selective digestive decontamination (OR 0.587 [95% CI 0.358-0.963]).Conclusion: The long-term survival of mechanically ventilated patients with severe COVID-19 reaches more than 50% and may help to provide individualized risk stratification and potential treatments.Trial registration: ClinicalTrials.gov Identifier: NCT04379258. Registered 10 April 2020 (retrospectively registered).

scholarly journals Selection strategy for sedation depth in critically ill patients on mechanical ventilation

2021 ◽  
Vol 21 (S2) ◽  
Author(s):  
Longxiang Su ◽  
Chun Liu ◽  
Fengxiang Chang ◽  
Bo Tang ◽  
Lin Han ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Dimensionality Reduction ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Latent Profile Analysis ◽  
Profile Analysis ◽  
Mechanically Ventilated ◽  
Mechanically Ventilated Patients ◽  
Sedation And Analgesia ◽  
Ventilated Patients

Abstract Background Analgesia and sedation therapy are commonly used for critically ill patients, especially mechanically ventilated patients. From the initial nonsedation programs to deep sedation and then to on-demand sedation, the understanding of sedation therapy continues to deepen. However, according to different patient’s condition, understanding the individual patient’s depth of sedation needs remains unclear. Methods The public open source critical illness database Medical Information Mart for Intensive Care III was used in this study. Latent profile analysis was used as a clustering method to classify mechanically ventilated patients based on 36 variables. Principal component analysis dimensionality reduction was used to select the most influential variables. The ROC curve was used to evaluate the classification accuracy of the model. Results Based on 36 characteristic variables, we divided patients undergoing mechanical ventilation and sedation and analgesia into two categories with different mortality rates, then further reduced the dimensionality of the data and obtained the 9 variables that had the greatest impact on classification, most of which were ventilator parameters. According to the Richmond-ASS scores, the two phenotypes of patients had different degrees of sedation and analgesia, and the corresponding ventilator parameters were also significantly different. We divided the validation cohort into three different levels of sedation, revealing that patients with high ventilator conditions needed a deeper level of sedation, while patients with low ventilator conditions required reduction in the depth of sedation as soon as possible to promote recovery and avoid reinjury. Conclusion Through latent profile analysis and dimensionality reduction, we divided patients treated with mechanical ventilation and sedation and analgesia into two categories with different mortalities and obtained 9 variables that had the greatest impact on classification, which revealed that the depth of sedation was limited by the condition of the respiratory system.

scholarly journals Effectiveness of Communication Board on Level of Satisfaction Over Communication among Mechanically Venitlated Patients

2020 ◽  
Vol 5 (9) ◽  
pp. 311-316
Author(s):  
Dr. Metilda ◽  
Dr. A. Jaganath
Keyword(s):  
Mechanical Ventilation ◽  
Control Group ◽  
Mechanically Ventilated ◽  
Mechanically Ventilated Patients ◽  
Level Of Satisfaction ◽  
Significant Difference ◽  
Group 15 ◽  
Experimental Group ◽  
Ventilated Patients ◽  
Communication Board

Mechanical ventilation is widely used to treat patients with critical conditions. This treatment is usually applied for difficulty in breathing. The use of mechanical ventilation devices has unique benefits to the patient. However, it can also cause various problems. Reduction in communication rank as one of the most negative experiences in mechanically ventilated patients. Effective communication with ventilator-based patients is essential. Nursing management of a mechanically ventilated patient is challenging on many levels, requiring a wealth of high technical skills. The Patient Communications Board improves communication, maintains information and creates a comfortable, attractive setting for patient, family and health care workers. The research methodology used for the study is a Quasi experimental approach, post-test only design with a comparison group to assess the effect of the communication board on the level of satisfaction over communication among clients on mechanical ventilator. The sample was selected by purposive sampling technique and included 30 (experimental group-15, control group-15), mechanically ventilated patients in PESIMR hospital, Kuppam. The control group patients were provided with routine communication methods, while the experimental group were communicated with communication board. The level of satisfaction on communication was assessed by a 15items rating scale. Data was analysed using both the descriptive and inferential statistics. There was a significant difference in the level of satisfaction on communication among the patients who were communicated using communication board compared to the routine method of communication. The communication board had significantly improved the communication pattern and increased the satisfaction among the patients who are mechanically ventilated.

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