Driving Pressure is Not Predictive of ARDS Outcome in Chest Trauma Patients Under Mechanical Ventilation

2021 ◽  
Author(s):  
severin ramin ◽  
Matteo Arcelli ◽  
Karim Bouchdoug ◽  
Thomas Laumon ◽  
Camille Duflos ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Chest Trauma ◽  
Characteristic Curve ◽  
Group Versus ◽  
Receiver Operator Characteristic Curve ◽  
Driving Pressure ◽  
Trauma Patients ◽  
Medical Patients ◽  
Mechanical Ventilation Duration ◽  
The Relationship

Abstract Background: The relationship between the driving pressure of the respiratory system (ΔPrs) under mechanical ventilation and worse outcome has never been studied specifically in chest trauma patients. The objective of the present study was to assess in cases of chest trauma the relationship between ΔPrs and severity of acute respiratory distress syndrome (ARDS) or death and length of stay. Methods: A retrospective analysis of severe trauma patients (ISS >15) with chest injuries admitted to the Trauma Center from January 2010 to December 2018 was performed. Patients who received mechanical ventilation were included in our analysis. Mechanical ventilation parameters and ΔPrs were recorded during the stay in the intensive care unit. Association of ΔPrs and ARDS with mortality and outcomes was specifically studied at the onset of ARDS (ΔPrs-ARDS) by receiver operator characteristic curve analysis, Kaplan-Meier curves and multivariate analysis.Results: Among the 266 chest trauma patients studied, 194 (73%) developed ARDS. ΔPrs was significantly higher in the ARDS group versus in the no ARDS group (11.6±2.4 cm H2O vs 10.9±1.9 cm H2O, p=0.04). Among the patients with ARDS, no difference according to the duration of mechanical ventilation was found between the high ΔPrs group (ΔPrs-ARDS >14 cm H2O) and the low ΔPrs group (ΔPrs-ARDS ≤14 cm H2O), (p=0.75). ΔPrs-ARDS was not independently associated with the duration of mechanical ventilation (hazard ratio [HR], 1.006; 95% CI, 0.95–1.07; p=0.8) or mortality (HR, 1.07; 95% CI, 0.9–1.28; p=0.45).Conclusion: A high ΔPrs-ARDS was not significantly associated with an increase in mechanical ventilation duration or mortality risk in ARDS patients with chest trauma in contrast with medical patients.

scholarly journals Use of the product of driving pressure and respiratory rate for predicting failure of weaning from mechanical ventilator in medical patients

2020 ◽  
Author(s):  
Ju Gong ◽  
Bibo Zhang ◽  
Xiaowen Huang ◽  
Bin Li ◽  
Jian Huang
Keyword(s):  
Mechanical Ventilation ◽  
Respiratory Rate ◽  
Spontaneous Breathing Trial ◽  
Plateau Pressure ◽  
Driving Pressure ◽  
Medical Patients ◽  
Failure Group ◽  
Weaning Failure ◽  
Weaning Outcome

Abstract Background : Respiratory workload increment in the process of mechanical ventilation withdrawal is critical for the determination of weaning outcome. Pressure, tidal volume (Vt) and respiratory rate (RR ) are considered as patient’s respiratory power, albeit being affected by excessive respiratory load. We aimed to evaluate the performance of driving pressure (DP)×RR to predict the outcome of weaning. Methods : Plateau pressure (Pplat) and positive end-expiratory pressure tot (PEEPtot) were measured during mechanical ventilation, viz., (1) brief deep sedation, (2) on volume support ventilation of MV with Vt 6 ml/kg and a PEEP of 0 cm H 2 O, (3) Pplat and PEEPtot were measured by holding breath for 2s after inhalation and exhalation, respectively. The DP was determined as Pplat minus PEEPtot. The highest RR was recorded within 3 min during spontaneous-breathing trial (SBT). Patients that were able to tolerate SBT for 1 h were directly extubated. These measurements correlated well with weaning outcome. Notably, patients in the “failure” group failed the SBT, died, while others required reintubation or noninvasive ventilation within 48 h of extubation. Results : Out of the 61 patients studied, 22 failed weaning. During the withdrawal of ventilation, DP×RR was 134.2±33.2 cmH 2 O ·breaths/min and 238.5±61.7 cmH 2 O·breaths/min ( P =0.00), DP was 7.9±1.6 cmH 2 O and 9.7±2.3 cmH 2 O ( P =0.00), in the “success” and “failure” groups, respectively. The DP×RR index greater than 170 cmH 2 O·breaths/min had a sensitivity of 95.5% and a specificity of 89.7%, while DP index greater than 8.1 cmH 2 O had 81.8% sensitivity and 64.1% specificity to predict weaning failure. Conclusions : Measurement of DP×RR during withdrawal of ventilation may help predict weaning outcome. Noticeably, high DP×RR increased the likelihood of weaning failure.

Setting the Optimal Erythrocyte Protoporphyrin Screening Decision Threshold for Lead Poisoning: A Decision Analytic Approach

PEDIATRICS ◽  
1991 ◽  
Vol 88 (1) ◽  
pp. 121-131
Author(s):  
Michael R. DeBaun ◽  
Harold C. Sox
Keyword(s):  
Lead Poisoning ◽  
Characteristic Curve ◽  
Lead Level ◽  
Blood Lead ◽  
Receiver Operator Characteristic Curve ◽  
Receiver Operator Characteristic ◽  
Decision Threshold ◽  
Erythrocyte Protoporphyrin ◽  
Positive Rate ◽  
The Relationship

Erythrocyte protoporphyrin (EP) was introduced in the 1970s as an inexpensive screening test for lead poisoning. As greater knowledge of lead poisoning has accumulated, the recommended EP level at which further evaluation for lead poisoning should be initiated has been lowered from ≥50 µg/dL to ≥35 µg/dL. The purpose of this study was to evaluate the utility of this EP threshold. A receiver operator characteristic curve was constructed to assess the relationship between the true-positive rate and false-positive rate of EP at various decision thresholds. The receiver operator characteristic curve was constructed with data from the second National Health and Nutrition Examination Survey from 1976 to 1980, which included 2673 children 6 years of age or younger who had both blood lead and EP level determinations. Decision analysis was then used to determine the optimal EP decision threshold for detecting a blood lead level ≥25 µg/dL. The receiver operator characteristic curve demonstrated that EP is a poor predictor of a blood lead level ≥25 µg/dL. At the currently recommended EP decision threshold of 35 µg/dL, the true-positive rates and false-positive rates of EP are 0.23 and 0.04, respectively. As a result of the inadequate performance of EP screening for lead poisoning, when the prevalence of lead poisoning is greater than 8%, there is no EP decision threshold that optimizes the relationship between the cost of screening normal children and the benefit of detecting lead-poisoned children. Erythrocyte protoporphyrin measurement is not sufficiently sensitive to be recommended uniformly as a screening test for lead poisoning.

scholarly journals Use of the product of driving pressure and respiratory rate for predicting failure of weaning from mechanical ventilator in medical patients

2020 ◽  
Author(s):  
Ju Gong ◽  
Bibo Zhang ◽  
Xiaowen Huang ◽  
Bin Li ◽  
Jian Huang
Keyword(s):  
Mechanical Ventilation ◽  
Respiratory Rate ◽  
Deep Sedation ◽  
Spontaneous Breathing Trial ◽  
Plateau Pressure ◽  
Driving Pressure ◽  
Medical Patients ◽  
Weaning Failure ◽  
Weaning Outcome

Abstract Background : Respiratory workload increment in the process of mechanical ventilation withdrawal is critical for the determination of weaning outcome. Pressure, tidal volume (Vt) and respiratory rate (RR ) are considered as patient’s respiratory power, albeit being affected by excessive respiratory load. We aimed to evaluate the performance of driving pressure (DP)×RR to predict the outcome of weaning. Methods : Plateau pressure (Pplat) and positive end-expiratory pressure tot (PEEPtot) were measured during mechanical ventilation, viz., (1) brief deep sedation, (2) on volume support ventilation of MV with Vt 6 ml/kg and a PEEP of 0 cm H 2 O, (3) Pplat and PEEPtot were measured by holding breath for 2s after inhalation and exhalation, respectively. The DP was determined as Pplat minus PEEPtot. The highest RR was recorded within 3 min during spontaneous-breathing trial (SBT). Patients that were able to tolerate SBT for 1 h were directly extubated . Results : Out of the 61 patients studied, 22 failed weaning. During the withdrawal of ventilation, DP×RR was 134.2±33.2 cmH 2 O ·breaths/min and 238.5±61.7 cmH 2 O·breaths/min ( P =0.00), DP was 7.9±1.6 cmH 2 O and 9.7±2.3 cmH 2 O ( P =0.00), in the “success” and “failure” groups, respectively. The DP×RR index greater than 170 cmH 2 O·breaths/min had a sensitivity of 95.5% and a specificity of 89.7%, while DP index greater than 8.1 cmH 2 O had 81.8% sensitivity and 64.1% specificity to predict weaning failure. Conclusions : Measurement of DP×RR during withdrawal of ventilation may help predict weaning outcome. Noticeably, high DP×RR increased the likelihood of weaning failure.

scholarly journals Age and chest radiography as possible parameters for rapid triage in COVID-19 outbreak surge

2020 ◽  
Author(s):  
Wei Enli Wycliffe ◽  
Tan Cher Heng ◽  
Monica Chan ◽  
Tan Thuan TOng ◽  
Surinder Kaur Pada ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Chest Radiography ◽  
Disease Surveillance ◽  
Characteristic Curve ◽  
Severe Disease ◽  
Clinical Status ◽  
Supplemental Oxygen ◽  
Receiver Operator Characteristic Curve ◽  
Receiver Operator Characteristic ◽  
Oxygen Supplementation

Abstract BackgroundTo evaluate the utility of age and chest radiography(CXR) in triaging COVID-19 patients for hospitalization versus isolation in non-hospital facilities, we examined how age and CXR at diagnosis were associated with clinical needs from late-January to early-April. MethodsClinical status of all COVID-19 cases was monitored for national disease surveillance. Cases were isolated in hospitals until SARS-CoV-2 RNA was undetectable on PCR. Age and CXR results on admission were analysed for association with oxygen supplementation and mechanical ventilation, the outcomes of interest.ResultsTill 4 April 2020, there were 1,481 COVID-19 cases in Singapore. Overall, 11.4% required supplemental oxygen while 4.8% required mechanical ventilation and intensive care. The respective proportions increased to 40.9% and 16.5% for cases aged ≥70 years. As a predictor of subsequent mechanical ventilation, age had an area under the receiver operator characteristic curve(AUROC) of 0.772 (95%CI:0.699-0.845). A combined criterion of either an abnormal CXR or age≥55 years had a sensitivity of 86.7% and specificity of 58.0% for the same outcome. A similar performance was observed for predicting oxygen supplementation needs.ConclusionsAge and CXR at diagnosis may be valuable in excluding severe disease, allowing safe triage for isolation in non-hospital facilities.

scholarly journals Impact of energy deficit calculated by a predictive method on outcome in medical patients requiring prolonged acute mechanical ventilation

2008 ◽  
Vol 101 (7) ◽  
pp. 1079-1087 ◽  
Author(s):  
Christophe Faisy ◽  
Nicolas Lerolle ◽  
Fahmi Dachraoui ◽  
Jean-François Savard ◽  
Imad Abboud ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Energy Balance ◽  
Characteristic Curve ◽  
Resting Energy Expenditure ◽  
Negative Energy ◽  
Energy Deficit ◽  
Medical Patients ◽  
Icu Mortality ◽  
Exclusive Enteral Nutrition ◽  
Predictive Method

To assess energy balance in very sick medical patients requiring prolonged acute mechanical ventilation and its possible impact on outcome, we conducted an observational study of the first 14 d of intensive care unit (ICU) stay in thirty-eight consecutive adult patients intubated at least 7 d. Exclusive enteral nutrition (EN) was started within 24 h of ICU admission and progressively increased, in absence of gastrointestinal intolerance, to the recommended energy of 125·5 kJ/kg per d. Calculated energy balance was defined as energy delivered − resting energy expenditure estimated by a predictive method based on static and dynamic biometric parameters. Mean energy balance was − 5439 (sem222) kJ per d. EN was interrupted 23 % of the time and situations limiting feeding administration reached 64 % of survey time. ICU mortality was 72 %. Non-survivors had higher mean energy deficit than ICU survivors (P = 0·004). Multivariate analysis identified mean energy deficit as independently associated with ICU death (P = 0·02). Higher ICU mortality was observed with higher energy deficit (P = 0·003 comparing quartiles). Using receiver operating characteristic curve analysis, the best deficit threshold for predicting ICU mortality was 5021 kJ per d. Kaplan–Meier analysis showed that patients with mean energy deficit ≧5021 kJ per d had a higher ICU mortality rate than patients with lower mean energy deficit after the 14th ICU day (P = 0·01). The study suggests that large negative energy balance seems to be an independent determinant of ICU mortality in a very sick medical population requiring prolonged acute mechanical ventilation, especially when energy deficit exceeds 5021 kJ per d.

scholarly journals The relationship of tidal volume and driving pressure with mortality in hypoxic patients receiving mechanical ventilation

PLoS ONE ◽  
2021 ◽  
Vol 16 (8) ◽  
pp. e0255812
Author(s):  
Robert A. Raschke ◽  
Brenda Stoffer ◽  
Seth Assar ◽  
Stephanie Fountain ◽  
Kurt Olsen ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Regression Analysis ◽  
Hospital Mortality ◽  
Tidal Volume ◽  
Driving Pressure ◽  
Predicted Body Weight ◽  
Mechanically Ventilated ◽  
Referent Group ◽  
Relationship Of ◽  
The Relationship

Purpose To determine whether tidal volume/predicted body weight (TV/PBW) or driving pressure (DP) are associated with mortality in a heterogeneous population of hypoxic mechanically ventilated patients. Methods A retrospective cohort study involving 18 intensive care units included consecutive patients ≥18 years old, receiving mechanical ventilation for ≥3 days, with a PaO2/FiO2 ratio ≤300 mmHg, whether or not they met full criteria for ARDS. The main outcome was hospital mortality. Multiple logistic regression (MLR) incorporated TV/PBW, DP, and potential confounders including age, APACHE IVa® predicted hospital mortality, respiratory system compliance (CRS), and PaO2/FiO2. Predetermined strata of TV/PBW were compared using MLR. Results Our cohort comprised 5,167 patients with mean age 61.9 years, APACHE IVa® score 79.3, PaO2/FiO2 166 mmHg and CRS 40.5 ml/cm H2O. Regression analysis revealed that patients receiving DP one standard deviation above the mean or higher (≥19 cmH20) had an adjusted odds ratio for mortality (ORmort) = 1.10 (95% CI: 1.06–1.13, p = 0.009). Regression analysis showed a U-shaped relationship between strata of TV/PBW and adjusted mortality. Using TV/PBW 4–6 ml/kg as the referent group, patients receiving >10 ml/kg had similar adjusted ORmort, but those receiving 6–7, 7–8 and 8–10 ml/kg had lower adjusted ORmort (95%CI) of 0.81 (0.65–1.00), 0.78 (0.63–0.97) and 0.80 0.67–1.01) respectively. The adjusted ORmort in patients receiving 4–6 ml/kg was 1.26 (95%CI: 1.04–1.52) compared to patients receiving 6–10 ml/kg. Conclusions Driving pressures ≥19 cmH2O were associated with increased adjusted mortality. TV/PBW 4-6ml/kg were used in less than 15% of patients and associated with increased adjusted mortality compared to TV/PBW 6–10 ml/kg used in 82% of patients. Prospective clinical trials are needed to prove whether limiting DP or the use of TV/PBW 6–10 ml/kg versus 4–6 ml/kg benefits mortality.

scholarly journals Conservative management of Occult Hemothorax in trauma patients requiring assisted ventilation: An observational descriptive study

2021 ◽  
Vol 2021 (3) ◽  
Author(s):  
Ismail Mahmood ◽  
Khalid Ahmed ◽  
Fuad Mustafa ◽  
Zahoor Ahmed ◽  
Syed Nabir ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Conservative Management ◽  
Blunt Chest Trauma ◽  
Chest Trauma ◽  
Assisted Ventilation ◽  
Tube Thoracostomy ◽  
Trauma Patients ◽  
Respiratory Compromise ◽  
Mechanically Ventilated

Background: Traumatic hemothorax is a common consequence of blunt chest trauma. A hemothorax that is missed by initial chest X-ray, but diagnosed by computed tomography (CT), is known as an occult hemothorax. The present study aims at investigating the clinical outcomes of conservative management of occult hemothorax in mechanically ventilated trauma patients. Methods: A retrospective study of all adult blunt chest trauma patients with occult hemothorax requiring mechanical ventilation in a level 1 trauma center was conducted (2010- 2017). Data were obtained from the trauma registry and electronic medical records. Patients were categorized into (a) successful conservative treatment group, and (b) tube thoracostomy group. Results: During the study period, 78 blunt chest trauma patients who had occult hemothorax required mechanical ventilation. Occult hemothorax was managed conservatively in 69% of the patients, while 31% underwent tube thoracostomy. The main indication for tube thoracostomy was the progression of hemothorax on follow-up chest radiographs. Comparison between groups showed that pulmonary contusions (59% vs. 83%), bilateral hemothorax (26% vs. 58%) and chest infections (9% vs. 29%) were lower in conservatively treated group (p < 0.05). Length of stays in ICU and hospital were also lower (p < 0.05). Longer duration of mechanical ventilation and maximum PEEP were significantly associated with tube thoracostomy. Overall mortality was 12% and was comparable between groups. Conclusion: Mechanically ventilated patients with occult hemothorax following blunt chest trauma can be managed conservatively without tube thoracostomy. Tube thoracostomy can be restricted to patients who had evidence of progression of hemothorax on follow-up or developed respiratory compromise.

scholarly journals Performance of TOTAL, in medical patients attending a resource-poor hospital in sub-Saharan Africa and a small Irish rural hospital

2013 ◽  
Vol 12 (3) ◽  
pp. 135-140
Author(s):  
Martin Otyek Opio ◽  
◽  
Gertrude Nansubuga ◽  
John Kellett ◽  
M Cliffor ◽  
...  
Keyword(s):  
Characteristic Curve ◽  
Altered Mental Status ◽  
Receiver Operator Characteristic Curve ◽  
Rural Hospital ◽  
Sub Saharan Africa ◽  
Early Warning Score ◽  
Medical Patients ◽  
Resource Poor ◽  
Hospital Patients ◽  
African Patients

Background: Recently a very simple, easy to remember early warning score (EWS) dubbed TOTAL has been reported. The score was derived from 309 acutely ill medical patients admitted to a Malawian hospital and awards one point for Tachypnea >30 breaths per minute, one point for Oxygen saturation <90%, two points for a Temperature <35°C, one point for Altered mental status, and one point for Loss of independence as indicated by the inability to stand or walk without help. TOTAL has an area under the receiver operator characteristic curve (AUROC) for death within 72 hours of 78%. Methods: We compared the performance of the TOTAL score in 849 medical patients attending a resource poor hospital in Uganda and 2935 patients admitted to a small rural hospital in Ireland. Results: TOTAL’s AUROC for death within 24 hours was the same in both hospital populations: 85.1% (95% CI 78.6 – 91.6%) for Kitovu Hospital patients and 84.7% (95% CI 77.1 – 92.2%) for Nenagh Hospital patients. Conclusion: The discrimination of TOTAL is exactly the same in elderly Irish patients as it is in young African patients. The score is easy to remember, easy to calculate, and works over a broad range of patients.

scholarly journals Fluctuations of driving pressure during mechanical ventilation indicates elevated central venous pressure and poor outcomes

2020 ◽  
Vol 10 (4) ◽  
pp. 204589402097036
Author(s):  
Jia-Yu Mao ◽  
Dong-Kai Li ◽  
Xin Ding ◽  
Hong-Min Zhang ◽  
Yun Long ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Central Venous Pressure ◽  
Airway Pressure ◽  
Venous Pressure ◽  
Driving Pressure ◽  
Hospital Length Of Stay ◽  
Central Venous ◽  
College Hospital ◽  
Wide Range ◽  
The Relationship

Inappropriate mechanical ventilation may induce hemodynamic alterations through cardiopulmonary interactions. The aim of this study was to explore the relationship between airway pressure and central venous pressure during the first 72 h of mechanical ventilation and its relevance to patient outcomes. We conducted a retrospective study of the Department of Critical Care Medicine of Peking Union Medical College Hospital and a secondary analysis of the MIMIC-III clinical database. The relationship between the ranges of driving pressure and central venous pressure during the first 72 h and their associations with prognosis were investigated. Data from 2790 patients were analyzed. Wide range of driving airway pressure (odds ratio, 1.0681; 95% CI, 1.0415–1.0953; p < 0.0001) were independently associated with mortality, ventilator-free time, intensive care unit and hospital length of stay. Furthermore, wide range of driving pressure and elevated central venous pressure exhibited a close correlation. The area under receiver operating characteristic demonstrated that range of driving pressure and central venous pressure were measured at 0.689 (95% CI, 0.670–0.707) and 0.681 (95% CI, 0.662–0.699), respectively. Patients with high ranges of driving pressure and elevated central venous pressure had worse outcomes. Post hoc tests showed significant differences in 28-day survival rates (log-rank (Mantel–Cox), 184.7; p < 0.001). In conclusion, during the first 72 h of mechanical ventilation, patients with hypoxia with fluctuating driving airway pressure have elevated central venous pressure and worse outcomes.

scholarly journals Outcome of Concurrent Occult Hemothorax and Pneumothorax in Trauma Patients Who Required Assisted Ventilation

2015 ◽  
Vol 2015 ◽  
pp. 1-6 ◽  
Author(s):  
Ismail Mahmood ◽  
Zainab Tawfeek ◽  
Ayman El-Menyar ◽  
Ahmad Zarour ◽  
Ibrahim Afifi ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Chest Trauma ◽  
Ventilatory Support ◽  
Ct Scanning ◽  
Assisted Ventilation ◽  
Tube Thoracostomy ◽  
Hospital Length Of Stay ◽  
Positive Pressure ◽  
Trauma Patients ◽  
Respiratory Compromise

Background. The management and outcomes of occult hemopneumothorax in blunt trauma patients who required mechanical ventilation are not well studied. We aimed to study patients with occult hemopneumothorax on mechanical ventilation who could be carefully managed without tube thoracostomy.Methods. Chest trauma patients with occult hemopneumothorax who were on mechanical ventilation were prospectively evaluated. The presence of hemopneumothorax was confirmed by CT scanning. Hospital length of stay, complications, and outcome were recorded.Results. A total of 56 chest trauma patients with occult hemopneumothorax who were on ventilatory support were included with a mean age of 36 ± 13 years. Hemopneumothorax was managed conservatively in 72% cases and 28% underwent tube thoracostomy as indicated. 29% of patients developed pneumonia, 16% had Acute Respiratory Distress Syndrome (ARDS), and 7% died. Thickness of hemothorax, duration of mechanical ventilation, and development of ARDS were significantly associated with tube thoracostomy in comparison to no-chest tube group.Conclusions. The majority of occult hemopneumothorax can be carefully managed without tube thoracostomy in patients who required positive pressure ventilation. Tube thoracotomy could be restricted to those who had evidence of increase in the size of the hemothorax or pneumothorax on follow-up chest radiographs or developed respiratory compromise.

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