scholarly journals The Correlation of Respiratory System Compliance and Mortality in COVID-19 Acute Respiratory Distress Syndrome: Do Phenotypes Really Exist?

2021 ◽  
Author(s):  
Rachel L. Choron ◽  
Stephen A. Iacono ◽  
Alexander Cong ◽  
Christopher G. Bargoud ◽  
Amanda L. Teichman ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Respiratory System ◽  
Management Strategies ◽  
Respiratory System Compliance ◽  
Risk Of Death ◽  
Mortality Difference ◽  
Ventilator Management ◽  
Observational Cohort ◽  
Multivariable Regression ◽  
The Mean

Abstract Background: Recent literature suggests respiratory system compliance (Crs) based phenotypes exist among COVID-19 ARDS patients. We sought to determine whether these phenotypes exist and whether Crs predicts mortality. Methods: A retrospective observational cohort study of 111 COVID-19 ARDS patients admitted March 11-July 8, 2020. Crs was averaged for the first 72-hours of mechanical ventilation. Crs < 30ml/cmH2O was defined as poor Crs(phenotype-H) whereas Crs ≥ 30ml/cmH2O as preserved Crs(phenotype-L). Results: 111 COVID-19 ARDS patients were included, 40 phenotype-H and 71 phenotype-L. Both the mean PaO2/FiO2 ratio for the first 72-hours of mechanical ventilation and the PaO2/FiO2 ratio hospital nadir were lower in phenotype-H than L(115[IQR87] vs 165[87], p = 0.016), (63[32] vs 75[59], p = 0.026). There were no difference in characteristics, diagnostic studies, or complications between groups. Twenty-seven (67.5%) phenotype-H patients died vs 37(52.1%) phenotype-L(p = 0.115). Multivariable regression did not reveal a mortality difference between phenotypes; however, a 2-fold mortality increase was noted in Crs < 20 vs > 50ml/cmH2O when analyzing ordinal Crs groups. Moving up one group level (ex. Crs30-39.9ml/cmH2O to 40-49.9ml/cmH2O), was marginally associated with 14% lower risk of death(RR = 0.86, 95%CI 0.72, 1.01, p = 0.065). This attenuated(RR = 0.94, 95%CI 0.80, 1.11) when adjusting for pH nadir and PaO2/FiO2 ratio nadir. Conclusion: We identified a spectrum of Crs in COVID-19 ARDS similar to Crs distribution in non-COVID-19 ARDS. While we identified increasing mortality as Crs decreased, there was no specific threshold marking significantly different mortality based on phenotype. We therefore would not define COVID-19 ARDS patients by phenotypes-H or L and would not stray from traditional ARDS ventilator management strategies.

scholarly journals The correlation of respiratory system compliance and mortality in COVID-19 acute respiratory distress syndrome: do phenotypes really exist?

2021 ◽  
Vol 8 (2) ◽  
pp. 67-74
Author(s):  
Rachel L. Choron ◽  
Stephen A. Iacono ◽  
Alexander Cong ◽  
Christopher G. Bargoud ◽  
Amanda L. Teichman ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Respiratory System ◽  
Management Strategies ◽  
Respiratory System Compliance ◽  
Risk Of Death ◽  
Mortality Difference ◽  
Ventilator Management ◽  
Observational Cohort ◽  
Multivariable Regression ◽  
The Mean

Background: Recent literature suggests respiratory system compliance (Crs) based phenotypes exist among COVID-19 ARDS patients. We sought to determine whether these phenotypes exist and whether Crs predicts mortality. Methods: A retrospective observational cohort study of 111 COVID-19 ARDS patients admitted March 11-July 8, 2020. Crs was averaged for the first 72-hours of mechanical ventilation. Crs<30ml/cmH2O was defined as poor Crs(phenotype-H) whereas Crs≥30ml/cmH2O as preserved Crs(phenotype-L). Results: 111 COVID-19 ARDS patients were included, 40 phenotype-H and 71 phenotype-L. Both the mean PaO2/FiO2 ratio for the first 72-hours of mechanical ventilation and the PaO2/FiO2 ratio hospital nadir were lower in phenotype-H than L(115[IQR87] vs 165[87], p=0.016), (63[32] vs 75[59], p=0.026). There were no difference in characteristics, diagnostic studies, or complications between groups. Twenty-seven (67.5%) phenotype-H patients died vs 37(52.1%) phenotype-L(p=0.115). Multivariable regression did not reveal a mortality difference between phenotypes; however, a 2-fold mortality increase was noted in Crs<20 vs >50ml/cmH2O when analyzing ordinal Crs groups. Moving up one group level (ex. Crs30-39.9ml/cmH2O to 40-49.9ml/cmH2O), was marginally associated with 14% lower risk of death(RR=0.86, 95%CI 0.72, 1.01, p=0.065). This attenuated (RR=0.94, 95%CI 0.80, 1.11) when adjusting for pH nadir and PaO2/FiO2 ratio nadir. Conclusion: We identified a spectrum of Crs in COVID-19 ARDS similar to Crs distribution in non-COVID-19 ARDS. While we identified increasing mortality as Crs decreased, there was no specific threshold marking significantly different mortality based on phenotype. We therefore would not define COVID-19 ARDS patients by phenotypes-H or L and would not stray from traditional ARDS ventilator management strategies.

scholarly journals Robustness of two different methods of monitoring respiratory system compliance during mechanical ventilation

2017 ◽  
Vol 55 (10) ◽  
pp. 1819-1828 ◽  
Author(s):  
Gaetano Perchiazzi ◽  
Christian Rylander ◽  
Mariangela Pellegrini ◽  
Anders Larsson ◽  
Göran Hedenstierna
Keyword(s):  
Mechanical Ventilation ◽  
Respiratory System ◽  
Respiratory System Compliance

scholarly journals Mechanical Ventilation Boot Camp: A Simulation-Based Pilot Study

2016 ◽  
Vol 2016 ◽  
pp. 1-7 ◽  
Author(s):  
Jennifer Yee ◽  
Charles Fuenning ◽  
Richard George ◽  
Rana Hejal ◽  
Nhi Haines ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
First Year ◽  
Prospective Evaluation ◽  
Mechanically Ventilated ◽  
Education Literature ◽  
Simulation Based ◽  
Ventilator Management ◽  
Critical Action ◽  
The Mean ◽  
Cognitive Knowledge

Objectives. Management of mechanically ventilated patients may pose a challenge to novice residents, many of which may not have received formal dedicated critical care instruction prior to starting their residency training. There is a paucity of data regarding simulation and mechanical ventilation training in the medical education literature. The purpose of this study was to develop a curriculum to educate first-year residents on addressing and troubleshooting ventilator alarms.Methods. Prospective evaluation was conducted of seventeen residents undergoing a twelve-hour three-day curriculum. Residents were assessed using a predetermined critical action checklist for each case, as well as pre- and postcurriculum multiple-choice cognitive knowledge questionnaires and confidence surveys.Results. Significant improvements in cognitive knowledge, critical actions, and self-reported confidence were demonstrated. The mean change in test score from before to after intervention was +26.8%, and a median score increase of 25% was noted. The ARDS and the mucus plugging cases had statistically significant improvements in critical actions,p<0.001. A mean increase in self-reported confidence was realized (1.55 to 3.64),p=0.049.Conclusions. A three-day simulation curriculum for residents was effective in increasing competency, knowledge, and confidence with ventilator management.

Perioperative Respiratory Care and Complications

2015 ◽  
pp. 378-422
Author(s):  
Peter Burrage ◽  
Zinaida Wadhwani ◽  
Michael Nurok
Keyword(s):  
Mechanical Ventilation ◽  
Gas Exchange ◽  
Pulmonary Disease ◽  
Critically Ill ◽  
Respiratory System ◽  
Management Strategies ◽  
Respiratory Physiology ◽  
Respiratory Care ◽  
Pulmonary Mechanics ◽  
Contemporary Management

Clinicians caring for patients with cardio-pulmonary disease invariably must manage the respiratory system. Doing so requires a basic understanding of physiology and the interaction of the heart and lung. The present chapter begins with rudimentary concepts of respiratory physiology, focusing on, gas exchange, pulmonary mechanics, and cardio-pulmonary interactions. These are used to develop an approach to mechanical ventilation and routine perioperative respiratory care of the patient having undergone a cardio-pulmonary procedure. The final section of this chapter addresses specific respiratory challenges encountered in caring for the critically ill cardiothoracic patient in addition to contemporary management strategies.

Complications and Resource Utilization Associated With Mechanical Ventilation in a Medical Intensive Care Unit in 2013

2016 ◽  
Vol 32 (2) ◽  
pp. 146-150 ◽  
Author(s):  
Kavitha Selvan ◽  
Hawa Edriss ◽  
Mark Sigler ◽  
Kenneth M. Nugent
Keyword(s):  
Mechanical Ventilation ◽  
Intensive Care ◽  
Resource Utilization ◽  
Blood Gases ◽  
X Rays ◽  
Limited Information ◽  
Central Lines ◽  
Arterial Blood ◽  
Ventilator Management ◽  
The Mean

Introduction: Evolving strategies for ventilator management could reduce the frequency of complications, but there is limited information about complications in contemporary intensive care units. Methods: We retrospectively collected information about patient demographics, chest x-ray abnormalities, complications, including pneumothoraces, ventilator-associated events, self-extubation, and resource utilization in 174 patients who required mechanical ventilation in 2013. Results: The mean age was 57.8 ± 16.8 years, the number of ventilator days was 7.5 ± 7, and the overall in-hospital mortality was 32.2%. The mean fluid balance per day during the mechanical ventilation period was 1539 ± 1721 mL. Three (1.7%) patients developed pneumothoraces, and 5 patients required chest tubes. Twenty-five (14.4%) patients had ventilator-associated events. Ten patients had episodes of self-extubation, and 11 had episodes of failed extubation. Chest X-rays showed new or increasing infiltrates in 113 (64.9%) patients and new or increasing pleural effusions in 29 (16.7%) patients. These patients had 1.2 ± 0.4 X-rays per day on the ventilator, and they had 10.0 ± 9.4 arterial blood gases and 0.7 ± 0.7 central lines. Conclusion: The frequency of ventilator-associated complications was low in this study. However, these patients frequently developed increasing infiltrates, and these outcomes need attention during patient management and are a potential focus for future studies.

scholarly journals Static compliance and driving pressure are associated with ICU mortality in intubated COVID-19 ARDS

Critical Care ◽  
2021 ◽  
Vol 25 (1) ◽  
Author(s):  
Annalisa Boscolo ◽  
Nicolò Sella ◽  
Giulia Lorenzoni ◽  
Tommaso Pettenuzzo ◽  
Laura Pasin ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Respiratory System ◽  
Multivariable Analysis ◽  
Ideal Body Weight ◽  
Driving Pressure ◽  
Static Compliance ◽  
Icu Mortality ◽  
Multicenter Cohort Study ◽  
Risk Of Death ◽  
Controlled Mechanical Ventilation

Abstract Background Pathophysiological features of coronavirus disease 2019-associated acute respiratory distress syndrome (COVID-19 ARDS) were indicated to be somewhat different from those described in nonCOVID-19 ARDS, because of relatively preserved compliance of the respiratory system despite marked hypoxemia. We aim ascertaining whether respiratory system static compliance (Crs), driving pressure (DP), and tidal volume normalized for ideal body weight (VT/kg IBW) at the 1st day of controlled mechanical ventilation are associated with intensive care unit (ICU) mortality in COVID-19 ARDS. Methods Observational multicenter cohort study. All consecutive COVID-19 adult patients admitted to 25 ICUs belonging to the COVID-19 VENETO ICU network (February 28th–April 28th, 2020), who received controlled mechanical ventilation, were screened. Only patients fulfilling ARDS criteria and with complete records of Crs, DP and VT/kg IBW within the 1st day of controlled mechanical ventilation were included. Crs, DP and VT/kg IBW were collected in sedated, paralyzed and supine patients. Results A total of 704 COVID-19 patients were screened and 241 enrolled. Seventy-one patients (29%) died in ICU. The logistic regression analysis showed that: (1) Crs was not linearly associated with ICU mortality (p value for nonlinearity = 0.01), with a greater risk of death for values < 48 ml/cmH2O; (2) the association between DP and ICU mortality was linear (p value for nonlinearity = 0.68), and increasing DP from 10 to 14 cmH2O caused significant higher odds of in-ICU death (OR 1.45, 95% CI 1.06–1.99); (3) VT/kg IBW was not associated with a significant increase of the risk of death (OR 0.92, 95% CI 0.55–1.52). Multivariable analysis confirmed these findings. Conclusions Crs < 48 ml/cmH2O was associated with ICU mortality, while DP was linearly associated with mortality. DP should be kept as low as possible, even in the case of relatively preserved Crs, irrespective of VT/kg IBW, to reduce the risk of death.

scholarly journals Computed tomography assessment of PEEP-induced alveolar recruitment in patients with severe COVID-19 pneumonia

Critical Care ◽  
2021 ◽  
Vol 25 (1) ◽  
Author(s):  
Lorenzo Ball ◽  
◽  
Chiara Robba ◽  
Lorenzo Maiello ◽  
Jacob Herrmann ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Respiratory System ◽  
Clinical Characteristics ◽  
Alveolar Recruitment ◽  
Respiratory System Compliance ◽  
Positive End Expiratory Pressure ◽  
Lung Weight ◽  
Ventilator Management ◽  
Gas Volume ◽  
Exchange Data

Abstract Background There is a paucity of data concerning the optimal ventilator management in patients with COVID-19 pneumonia; particularly, the optimal levels of positive-end expiratory pressure (PEEP) are unknown. We aimed to investigate the effects of two levels of PEEP on alveolar recruitment in critically ill patients with severe COVID-19 pneumonia. Methods A single-center cohort study was conducted in a 39-bed intensive care unit at a university-affiliated hospital in Genoa, Italy. Chest computed tomography (CT) was performed to quantify aeration at 8 and 16 cmH2O PEEP. The primary endpoint was the amount of alveolar recruitment, defined as the change in the non-aerated compartment at the two PEEP levels on CT scan. Results Forty-two patients were included in this analysis. Alveolar recruitment was median [interquartile range] 2.7 [0.7–4.5] % of lung weight and was not associated with excess lung weight, PaO2/FiO2 ratio, respiratory system compliance, inflammatory and thrombophilia markers. Patients in the upper quartile of recruitment (recruiters), compared to non-recruiters, had comparable clinical characteristics, lung weight and gas volume. Alveolar recruitment was not different in patients with lower versus higher respiratory system compliance. In a subgroup of 20 patients with available gas exchange data, increasing PEEP decreased respiratory system compliance (median difference, MD − 9 ml/cmH2O, 95% CI from − 12 to − 6 ml/cmH2O, p < 0.001) and the ventilatory ratio (MD − 0.1, 95% CI from − 0.3 to − 0.1, p = 0.003), increased PaO2 with FiO2 = 0.5 (MD 24 mmHg, 95% CI from 12 to 51 mmHg, p < 0.001), but did not change PaO2 with FiO2 = 1.0 (MD 7 mmHg, 95% CI from − 12 to 49 mmHg, p = 0.313). Moreover, alveolar recruitment was not correlated with improvement of oxygenation or venous admixture. Conclusions In patients with severe COVID-19 pneumonia, higher PEEP resulted in limited alveolar recruitment. These findings suggest limiting PEEP strictly to the values necessary to maintain oxygenation, thus avoiding the use of higher PEEP levels.

scholarly journals Ventilated Patients With COVID-19 Show Airflow Obstruction

2021 ◽  
pp. 088506662110006
Author(s):  
Vikas S. Koppurapu ◽  
Maksym Puliaiev ◽  
Kevin C. Doerschug ◽  
Gregory A. Schmidt
Keyword(s):  
Mechanical Ventilation ◽  
Respiratory System ◽  
Invasive Mechanical Ventilation ◽  
Airflow Obstruction ◽  
Plateau Pressure ◽  
Control Mode ◽  
Volume Control ◽  
Respiratory System Compliance ◽  
University Of Iowa ◽  
The University

Objective: Many patients with coronavirus disease 2019 (COVID-19) need mechanical ventilation secondary to acute respiratory distress syndrome. Information on the respiratory system mechanical characteristics of this disease is limited. The aim of this study is to describe the respiratory system mechanical properties of ventilated COVID-19 patients. Design, Setting, and Patients: Patients consecutively admitted to the medical intensive care unit at the University of Iowa Hospitals and Clinics in Iowa City, USA, from April 19 to May 1, 2020, were prospectively studied; final date of follow-up was May 1, 2020. Measurements: At the time of first patient contact, ventilator information was collected including mode, settings, peak airway pressure, plateau pressure, and total positive end expiratory pressure. Indices of airflow resistance and respiratory system compliance were calculated and analyzed. Main Results: The mean age of the patients was 58 years. 6 out of 12 (50%) patients were female. Of the 21 laboratory-confirmed COVID-19 patients on invasive mechanical ventilation, 9 patients who were actively breathing on the ventilator were excluded. All the patients included were on volume-control mode. Mean [±standard deviation] ventilator indices were: resistive pressure 19 [±4] cmH2O, airway resistance 20 [±4] cmH2O/L/s, and respiratory system static compliance 39 [±16] ml/cmH2O. These values are consistent with abnormally elevated resistance to airflow and reduced respiratory system compliance. Analysis of flow waveform graphics revealed a pattern consistent with airflow obstruction in all patients. Conclusions: Severe respiratory failure due to COVID-19 is regularly associated with airflow obstruction.

scholarly journals Syncope Time Frames for Adverse Events after Emergency Department Presentation: An Individual Patient Data Meta-Analysis

Medicina ◽  
2021 ◽  
Vol 57 (11) ◽  
pp. 1235
Author(s):  
Ludovico Furlan ◽  
Lucia Trombetta ◽  
Giovanni Casazza ◽  
Franca Dipaola ◽  
Raffaello Furlan ◽  
...  
Keyword(s):  
Adverse Event ◽  
Adverse Events ◽  
Meta Analysis ◽  
Management Strategies ◽  
Common Adverse Event ◽  
Ecg Monitoring ◽  
Risk Of Death ◽  
Life Threatening ◽  
The Mean ◽  
Time Frames

Background and Objectives: Knowledge of the incidence and time frames of the adverse events of patients presenting syncope at the ED is essential for developing effective management strategies. The aim of the present study was to perform a meta-analysis of the incidence and time frames of adverse events of syncope patients. Materials and Methods: We combined individual patients’ data from prospective observational studies including adult patients who presented syncope at the ED. We assessed the pooled rate of adverse events at 24 h, 72 h, 7–10 days, 1 month and 1 year after ED evaluation. Results: We included nine studies that enrolled 12,269 patients. The mean age varied between 53 and 73 years, with 42% to 57% females. The pooled rate of adverse events was 5.1% (95% CI 3.4% to 7.7%) at 24 h, 7.0% (95% CI 4.9% to 9.9%) at 72 h, 8.4% (95% CI 6.2% to 11.3%) at 7–10 days, 10.3% (95% CI 7.8% to 13.3%) at 1 month and 21.3% (95% CI 15.8% to 28.0%) at 1 year. The pooled death rate was 0.2% (95% CI 0.1% to 0.5%) at 24 h, 0.3% (95% CI 0.1% to 0.7%) at 72 h, 0.5% (95% CI 0.3% to 0.9%) at 7–10 days, 1% (95% CI 0.6% to 1.7%) at 1 month and 5.9% (95% CI 4.5% to 7.7%) at 1 year. The most common adverse event was arrhythmia, for which its rate was 3.1% (95% CI 2.0% to 4.9%) at 24 h, 4.8% (95% CI 3.5% to 6.7%) at 72 h, 5.8% (95% CI 4.2% to 7.9%) at 7–10 days, 6.9% (95% CI 5.3% to 9.1%) at 1 month and 9.9% (95% CI 5.5% to 17) at 1 year. Ventricular arrhythmia was rare. Conclusions: The risk of death or life-threatening adverse event is rare in patients presenting syncope at the ED. The most common adverse events are brady and supraventricular arrhythmias, which occur during the first 3 days. Prolonged ECG monitoring in the ED in a short stay unit with ECG monitoring facilities may, therefore, be beneficial.

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