Circulating Skeletal Troponin During Weaning From Mechanical Ventilation and Their Association to Diaphragmatic Function: A Pilot Study

Background: Patients with acute respiratory failure (ARF) may need mechanical ventilation (MV), which can lead to diaphragmatic dysfunction and muscle wasting, thus making difficult the weaning from the ventilator. Currently, there are no biomarkers specific for respiratory muscle and their function can only be assessed trough ultrasound or other invasive methods. Previously, the fast and slow isoform of the skeletal troponin I (fsTnI and ssTnI, respectively) have shown to be specific markers of muscle damage in healthy volunteers. We aimed therefore at describing the trend of skeletal troponin in mixed population of ICU patients undergoing weaning from mechanical ventilation and compared the value of fsTnI and ssTnI with diaphragmatic ultrasound derived parameters.Methods: In this prospective observational study we enrolled consecutive patients recovering from acute hypoxemic respiratory failure (AHRF) within 24 h from the start of weaning. Every day an arterial blood sample was collected to measure fsTnI, ssTnI, and global markers of muscle damage, such as ALT, AST, and CPK. Moreover, thickening fraction (TF) and diaphragmatic displacement (DE) were assessed by diaphragmatic ultrasound. The trend of fsTnI and ssTnI was evaluated during the first 3 days of weaning.Results: We enrolled 62 consecutive patients in the study, with a mean age of 67 ± 13 years and 43 of them (69%) were male. We did not find significant variations in the ssTnI trend (p = 0.623), but fsTnI significantly decreased over time by 30% from Day 1 to Day 2 and by 20% from Day 2 to Day 3 (p < 0.05). There was a significant interaction effect between baseline ssTnI and DE [F(2) = 4.396, p = 0.015], with high basal levels of ssTnI being associated to a higher decrease in DE. On the contrary, the high basal levels of fsTnI at day 1 were characterized by significant higher DE at each time point.Conclusions: Skeletal muscle proteins have a distinctive pattern of variation during weaning from mechanical ventilation. At day 1, a high basal value of ssTnI were associated to a higher decrease over time of diaphragmatic function while high values of fsTnI were associated to a higher displacement at each time point.

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Approach to the Patient with Acute Respiratory Failure

10.2310/im.1198 ◽

2016 ◽

Author(s):

Eddy Fan ◽

Alice Vendramin

Keyword(s):

Mechanical Ventilation ◽

Respiratory Failure ◽

Acute Respiratory Failure ◽

Life Support ◽

Ventilatory Support ◽

Lung Protective Ventilation ◽

Positive Pressure ◽

Hypoxemic Respiratory Failure ◽

Arterial Blood ◽

Common Causes

Acute respiratory failure (ARF) is a common reason for admission to the intensive care unit (ICU), and is associated with significant morbidity and mortality. Failure of one or more components of the respiratory system can lead to hypoxemia, hypercabia, or both. Initial evaluation of patients with ARF should include physical examination, chest imaging, and arterial blood gases (ABG) sampling. As ARF is often a life-threatening emergency, a patient’s oxygenation and ventilation will need to be supported at the same time that diagnostic and therapeutic interventions are planned. The priorities for early treatment are essentially those of basic life support: airway and breathing. The first step is to assess a patient’s airway and ascertain that it is patent. This is followed by efforts to support both oxygenation and ventilation. This can include non-invasive or invasive mechanical ventilatory support. As with all interventions, there are risks inherent in the use of mechanical ventilation, which may be minimized by the use of lung protective ventilation (i.e., with low tidal volumes and airway pressures). Finally, due to the potential complications associated with mechanical ventilation, it is important to regularly assess whether a patient continues to require the assistance of the ventilator, and to liberate patients from mechanical ventilation at the earliest opportunity when clinically safe and feasible to do so. Figures depict pressure-time curve. Tables list the clinical causes of hypoxemic respiratory failure, oxygen delivery devices, indications for noninvasive positive pressure support, common causes of abnormal respiratory mechanics, and common causes of acute respiratory distress syndrome (ARDS). This review contains 2 highly rendered figures, 5 tables, and 86 references.

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Weaning from mechanical ventilation: patterns in young children recovering from acute hypoxemic respiratory failure

American Journal of Critical Care ◽

10.4037/ajcc1998.7.5.335 ◽

1998 ◽

Vol 7 (5) ◽

pp. 335-345 ◽

Cited By ~ 7

Author(s):

MA Curley ◽

JC Fackler

Keyword(s):

Mechanical Ventilation ◽

Acute Respiratory Distress Syndrome ◽

Respiratory Failure ◽

Young Children ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Distress Syndrome ◽

Weaning From Mechanical Ventilation ◽

Hypoxemic Respiratory Failure ◽

Acute Hypoxemic Respiratory Failure

OBJECTIVE: The purpose of the study was to describe the patterns of weaning from mechanical ventilation in young children recovering from acute hypoxemic respiratory failure. METHODS: Decision-making rules on progressive weaning were developed and applied to existing data on 82 patients 2 weeks to 6 years old in the Pediatric Acute Respiratory Distress Syndrome Data Set. RESULTS: Three patterns of weaning progress were detected: sprint, consistent, and inconsistent. Length of ventilation and weaning progressively increased from the sprint, to the consistent, to the inconsistent subset. Patients in the inconsistent subset were most likely to have a systemic (sepsis or shock) trigger of acute respiratory distress syndrome and to be rated as having at least moderate disability at discharge. Hypothesis-generating univariate and then multivariate logistic regression analyses indicated that patients who experienced more days of mechanical ventilation before the start of weaning and who had a higher oxygenation index during the weaning process were most likely to have an inconsistent pattern of weaning. CONCLUSION: Patterns of weaning are discernible in a population of young children and indicate a subset at risk for inconsistent weaning. Knowing the patterns of weaning may help clinicians anticipate, perhaps plot, and then modulate a patient's weaning trajectory.

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Approach to the Patient with Acute Respiratory Failure

10.2310/tywc.1198 ◽

2018 ◽

Author(s):

Eddy Fan ◽

Alice Vendramin

Keyword(s):

Mechanical Ventilation ◽

Respiratory Failure ◽

Acute Respiratory Failure ◽

Life Support ◽

Ventilatory Support ◽

Lung Protective Ventilation ◽

Positive Pressure ◽

Hypoxemic Respiratory Failure ◽

Arterial Blood ◽

Common Causes

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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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Drotrecogin Alpha (Activated) in Two Patients with the Hantavirus Cardiopulmonary Syndrome

Canadian Respiratory Journal ◽

10.1155/2006/359891 ◽

2006 ◽

Vol 13 (5) ◽

pp. 272-274 ◽

Cited By ~ 3

Author(s):

Robert C McDermid ◽

RT Noel Gibney ◽

Ronald J Brisebois ◽

Neil M Skjodt

Keyword(s):

Septic Shock ◽

Mechanical Ventilation ◽

Respiratory Failure ◽

Extracorporeal Membrane Oxygenation ◽

Definitive Diagnosis ◽

Endothelial Injury ◽

Capillary Leak ◽

Hypoxemic Respiratory Failure ◽

Vasoactive Medications ◽

Drotrecogin Alpha

Hantavirus cardiopulmonary syndrome (HCPS) is associated with rapid cardiopulmonary collapse from endothelial injury, resulting in massive capillary leak, shock and severe hypoxemic respiratory failure. To date, treatment remains supportive and includes mechanical ventilation, vasopressors and extracorporeal membrane oxygenation, with mortality approaching 50%. Two HCPS survivors initially given drotrecogin alpha (activated) (DAA) for presumed bacterial septic shock are described. Vasoactive medications were required for a maximum of 52 h, whereas creatinine levels and platelet counts normalized within seven to nine days. Given the similar presentations of HCPS and bacterial septic shock, empirical DAA therapy will likely be initiated before a definitive diagnosis of HCPS is made. Further observations of DAA in HCPS seem warranted.

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Use of High-Flow Nasal Cannula in Patients With Pneumonia and Hypoxemic Respiratory Failure at Altitudes Above 2600 m: What Is the Best Predictor of Success?

Journal of Intensive Care Medicine ◽

10.1177/08850666211057503 ◽

2021 ◽

pp. 088506662110575

Author(s):

Molano Franco Daniel ◽

Gómez Duque Mario ◽

Beltrán Edgar ◽

Villabon Mario ◽

Hurtado Alejandra ◽

...

Keyword(s):

Mechanical Ventilation ◽

Respiratory Failure ◽

Respiratory Rate ◽

High Flow ◽

Nasal Cannula ◽

High Flow Nasal Cannula ◽

Multicenter Cohort Study ◽

Hypoxemic Respiratory Failure ◽

Severity Scores ◽

High Flow Oxygen

Introduction: The use of high-flow nasal cannulas (HFNC) in patients with hypoxemic ventilatory failure reduces the need for mechanical ventilation and does not increase mortality when intubation is promptly applied. The aim of the study is to describe the behavior of HFNC in patients who live at high altitudes, and the performance of predictors of success/failure of this strategy. Methods: Prospective multicenter cohort study, with patients aged over 18 years recruited for 12 months in 2020 to 21. All had a diagnosis of hypoxemic respiratory failure secondary to pneumonia, were admitted to intensive care units, and were receiving initial management with a high-flow nasal cannula. The variables assessed included need for intubation, mortality in ICU, and the validation of SaO2, respiratory rate (RR) and ROX index (IROX) as predictors of HFNC success / failure. Results: One hundred and six patients were recruited, with a mean age of 59 years and a success rate of 74.5%. Patients with treatment failure were more likely to be obese (BMI 27.2 vs 25.5; OR: 1.03; 95% CI: .95-1.1) and had higher severity scores at admission (APACHE II 12 vs 20; OR 1.15; 95% CI: 1.06-1.24). Respiratory rates after 12 (AUC .81 CI: .70-.92) and 18 h (AUC .85 CI: .72-0.90) of HFNC use were the best predictors of failure, performing better than those that included oxygenation. ICU mortality was higher in the failure group (6% vs 29%; OR 8.8; 95% CI:1.75-44.7). Conclusions: High-flow oxygen cannula therapy in patients with hypoxemic respiratory failure living at altitudes above 2600 m is associated with low rates of therapy failure and a reduced need for mechanical ventilation in the ICU. The geographical conditions and secondary physiological changes influence the performance of the traditionally validated predictors of therapy success. Respiratory rate <30 proved to be the best indicator of early success of the device at 12 h of use.

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Soluble Triggering Receptor Expressed on Myeloid Cells-1 (sTREM-1) is Highly Associated With Mortality and Persistent Organ Dysfunction in the Critically Ill: a Cohort Study

10.21203/rs.3.rs-45875/v1 ◽

2020 ◽

Author(s):

Neha Alhad Sathe ◽

Pavan K. Bhatraju ◽

Carmen Mikacenic ◽

Eric D. Morrell ◽

W. Conrad Liles ◽

...

Keyword(s):

Mechanical Ventilation ◽

Respiratory Failure ◽

Critically Ill ◽

Organ Dysfunction ◽

Critically Ill Patients ◽

Academic Medical Center ◽

Myeloid Cells ◽

Soluble Form ◽

Hypoxemic Respiratory Failure ◽

Study Enrollment

Abstract Background. The triggering receptor expressed on myeloid cells-1 (TREM-1) mediates fatal septic shock in murine models, but studies linking the soluble form of TREM-1 (sTREM-1) to mortality in clinical sepsis are inconclusive, and few have examined its relationship to organ dysfunction. We sought to identify associations between circulating sTREM-1 and both mortality and organ dysfunction among a broad cohort of critically ill medical, post-surgical and trauma patients. Methods. We enrolled a prospective cohort of patients who met two or more criteria for the systemic inflammatory response syndrome (SIRS) within 24 hours of intensive care unit (ICU) admission at a large academic medical center. sTREM-1 concentrations were measured at study enrollment. We used relative risk regression, adjusted for age, sex, and Charlson comorbidity index, to determine associations between sTREM-1 and the primary outcome of 28-day mortality. We also examined secondary outcomes of prevalent organ dysfunction on enrollment, and composites of persistent organ dysfunction or death at day 7. Results. Among 231 critically ill patients, non-survivors (n=19, 8%) had a higher proportion of pre-existing comorbidities, mechanical ventilation (79% vs. 44%) and shock (58% vs. 28%) compared to survivors. At study enrollment, increasing sTREM-1 was associated with a higher risk of severe acute kidney injury (AKI), shock, and acute hypoxemic respiratory failure requiring mechanical ventilation. sTREM-1 was higher among non-survivors than survivors (885 vs 336 pg/mL); each doubling of sTREM-1 concentration was associated with a 2.41-fold higher risk of 28-day mortality (95% CI 1.57, 3.72). Among 92 patients with shock on enrollment, doubling of sTREM-1 was associated with a 3.89-fold higher risk of persistent shock or death by day 7 (95% CI 1.85, 8.17). Higher sTREM-1 was also associated with a higher risk of both persistent AKI and persistent hypoxemic respiratory failure or death. Conclusions. Elevated plasma sTREM-1 is highly associated with 28-day mortality and organ dysfunction across a diverse critically ill population. These data support that early activation of the innate immune system plays a role in the development of organ dysfunction and death. Further studies should address whether modulation of the TREM-1 pathway might be beneficial in critically ill patients.

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