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

1998 ◽  
Vol 7 (5) ◽  
pp. 335-345 ◽  
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.

Persistent hypoxemic respiratory failure is associated with increased mortality, with or without the acute respiratory distress syndrome: a cohort study

2020 ◽  
Author(s):  
Neha Alhad Sathe ◽  
Leila R. Zelnick ◽  
Carmen Mikacenic ◽  
Eric D. Morrell ◽  
Pavan K. Bhatraju ◽  
...  
Keyword(s):  
Acute Respiratory Distress Syndrome ◽  
Respiratory Failure ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Distress Syndrome ◽  
Chronic Respiratory Disease ◽  
Hypoxemic Respiratory Failure ◽  
Acute Hypoxemic Respiratory Failure ◽  
Plasma Biomarkers ◽  
Risk Of Death

Abstract Background Identifying effective therapies in heterogeneous conditions like acute hypoxemic respiratory failure (AHRF) depends on defining sub-phenotypes with distinct prognosis or therapeutic response. Prior efforts have focused on acute respiratory distress syndrome (ARDS), although ARDS is a minority of all AHRF patients, has limited reliability in research, and is similarly heterogeneous. We propose a novel AHRF sub-phenotype called persistent hypoxemic respiratory failure (PHRF), defined by PaO2:FiO2 ratio ≤ 300 in individuals still requiring mechanical ventilation on day 3 following intubation. We hypothesized individuals with PHRF (+ PHRF) have greater mortality than individuals without PHRF (-PHRF), irrespective of ARDS (+/-ARDS). Methods We included mechanically ventilated AHRF patients (n = 768) from a single-center prospective cohort of medical and surgical ICU patients. We estimated the relative risk of 28-day inpatient mortality associated with + PHRF compared to -PHRF using generalized linear models. We also compared mortality and baseline log-transformed plasma biomarkers of inflammation and endothelial activation/dysfunction in + PHRF/-ARDS, -PHRF/+ARDS, and + PHRF/+ARDS compared to -PHRF/-ARDS. Results Cumulative incidence of + PHRF was 53% (n = 408), of whom 51% were + ARDS by ICU day 3 (n = 209). +PHRF was associated with a 1.55-fold higher risk of death (95% CI: 1.02, 2.34) compared to -PHRF, adjusting for demographics, chronic respiratory disease, and APACHE-III. Absolute mortality was higher in + PHRF/+ARDS (23%) and + PHRF/+ARDS (15%) patients than -PHRF/+ARDS (12%) and -PHRF/-ARDS (7%) patients. Interleukin-6 was 2.36-fold (95% CI: 1.47, 3.80) and 2.62-fold (1.63, 4.20) higher in + PHRF/-ARDS and + PHRF/+ARDS compared to -PHRF/-ARDS; granulocyte-colony stimulating factor was 1.96-fold (95% CI: 1.28, 3.01) and 1.82-fold (95% CI: 1.16, 2.85) higher; angiopoeitin-2 was 1.32-fold (95% CI: 1.01, 1.73) and 1.59-fold (95% CI: 1.21, 2.09) higher. In contrast, -PHRF/+ARDS patients did not have significantly different mortality or plasma biomarkers from -PHRF/-ARDS patients in adjusted models. Conclusions PHRF represents a common sub-phenotype of patients with AHRF, characterized by higher mortality and higher biomarkers of inflammation and endothelial dysfunction than -PHRF. PHRF captures many high-risk patients not included in current ARDS definition who may share biologic features with ARDS. Identifying patients with PHRF can support clinical prognostication and targeted trial enrollment for investigational therapies in the broad AHRF population.

scholarly journals Unsuccessful and Successful Clinical Trials in Acute Respiratory Distress Syndrome: Addressing Physiology-Based Gaps

2021 ◽  
Vol 12 ◽  
Author(s):  
Jesús Villar ◽  
Carlos Ferrando ◽  
Gerardo Tusman ◽  
Lorenzo Berra ◽  
Pedro Rodríguez-Suárez ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Clinical Trials ◽  
Acute Respiratory Distress Syndrome ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Distress Syndrome ◽  
Inflammatory Responses ◽  
Positive End Expiratory Pressure ◽  
Hypoxemic Respiratory Failure ◽  
Acute Hypoxemic Respiratory Failure

The acute respiratory distress syndrome (ARDS) is a severe form of acute hypoxemic respiratory failure caused by an insult to the alveolar-capillary membrane, resulting in a marked reduction of aerated alveoli, increased vascular permeability and subsequent interstitial and alveolar pulmonary edema, reduced lung compliance, increase of physiological dead space, and hypoxemia. Most ARDS patients improve their systemic oxygenation, as assessed by the ratio between arterial partial pressure of oxygen and inspired oxygen fraction, with conventional intensive care and the application of moderate-to-high levels of positive end-expiratory pressure. However, in some patients hypoxemia persisted because the lungs are markedly injured, remaining unresponsive to increasing the inspiratory fraction of oxygen and positive end-expiratory pressure. For decades, mechanical ventilation was the only standard support technique to provide acceptable oxygenation and carbon dioxide removal. Mechanical ventilation provides time for the specific therapy to reverse the disease-causing lung injury and for the recovery of the respiratory function. The adverse effects of mechanical ventilation are direct consequences of the changes in pulmonary airway pressures and intrathoracic volume changes induced by the repetitive mechanical cycles in a diseased lung. In this article, we review 14 major successful and unsuccessful randomized controlled trials conducted in patients with ARDS on a series of techniques to improve oxygenation and ventilation published since 2010. Those trials tested the effects of adjunctive therapies (neuromuscular blocking agents, prone positioning), methods for selecting the optimum positive end-expiratory pressure (after recruitment maneuvers, or guided by esophageal pressure), high-frequency oscillatory ventilation, extracorporeal oxygenation, and pharmacologic immune modulators of the pulmonary and systemic inflammatory responses in patients affected by ARDS. We will briefly comment physiology-based gaps of negative trials and highlight the possible needs to address in future clinical trials in ARDS.

Surfactant therapy in combination treatment of COVID-19 related acute respiratory distress syndrome

2021 ◽  
pp. 50-56
Author(s):  
Renat R. Gubaidullin ◽  
◽  
Aleksandr P. Kuzin ◽  
Vladimir V. Kulakov ◽  
◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Acute Respiratory Distress Syndrome ◽  
Respiratory Failure ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Standard Therapy ◽  
Distress Syndrome ◽  
Severe Pneumonia ◽  
Lung Ventilation ◽  
Surfactant Therapy

ntroduction. The COVID-19 pandemic caused an outbreak of viral lung infections with severe acute respiratory syndrome complicated with acute respiratory failure. Despite the fact that the pandemic has a lengthened run, none of the therapeutic approaches have proved to be sufficiently effective according to the evidence-based criteria. We consider the use of surfactant therapy in patients with severe viral pneumonia and acute respiratory distress syndrome (ARDS) as one of the possible methods for treating COVID-19 related pneumonia. Objective. To prove the clinical efficacy and safety of orally inhaled Surfactant-BL, an authorized drug, in the combination therapy of COVID-19 related ARDS. Materials and methods. A total of 38 patients with COVID-19 related severe pneumonia and ARDS were enrolled in the study. Of these, 20 patients received the standard therapy in accordance with the temporary guidelines for the prevention, diagnosis and treatment of the novel coronavirus infection (COVID-19) of the Ministry of Health of the Russian Federation, version 9. And 18 patients received the surfactant therapy in addition to the standard therapy. Surfactant-BL was used in accordance with the instructions on how to administer the drug for the indication – prevention of the development of acute respiratory distress syndrome. A step-by-step approach to the build-up of the respiratory therapy aggressiveness was used to manage hypoxia. We used oxygen inhalation via a face mask with an oxygen inflow of 5–15 l/min, highflow oxygen therapy via nasal cannulas using Airvo 2 devices, non-invasive lung ventilation, invasive lung ventilation in accordance with the principles of protective mechanical ventilation. Results and discussion. Significant differences in the frequency of transfers to mechanical ventilation, mortality, Intensive Care Unit (ICU) and hospitalization length of stay (p <0.05) were found between the groups. Patients receiving surfactant therapy who required a transfer to mechanical ventilation accounted for 22% of cases, and the mortality rate was 16%. In the group of patients receiving standard therapy without surfactant inhalation 45% were transferred to mechanical ventilation, and 35% died. For patients receiving surfactant therapy, the hospital stay was reduced by 20% on average, and ICU stay by 30%. Conclusion. The inclusion of surfactant therapy in the treatment of COVID-19 related severe pneumonia and ARDS can reduce the progression of respiratory failure, avoid the use of mechanical ventilation, shorten the ICU and hospitalization length of stay, and improve the survival rate of this patient cohort.

An Evidence-Based Protocol for Manual Prone Positioning of Patients With ARDS

2021 ◽  
Vol 41 (6) ◽  
pp. 55-60
Author(s):  
Patrick Ryan ◽  
Cynthia Fine ◽  
Christine DeForge
Keyword(s):  
Mechanical Ventilation ◽  
Acute Respiratory Distress Syndrome ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Distress Syndrome ◽  
Medical Center ◽  
Academic Medical Center ◽  
Prone Positioning ◽  
Hypoxemic Respiratory Failure ◽  
Unplanned Extubations

Background Manual prone positioning has been shown to reduce mortality among patients with moderate to severe acute respiratory distress syndrome, but it is associated with a high incidence of pressure injuries and unplanned extubations. This study investigated the feasibility of safely implementing a manual prone positioning protocol that uses a dedicated device. Review of Evidence A search of CINAHL and Medline identified multiple randomized controlled trials and meta-analyses that demonstrated both the reduction of mortality when prone positioning is used for more than 12 hours per day in patients with acute respiratory distress syndrome and the most common complications of this treatment. Implementation An existing safe patient-handling device was modified to enable staff to safely perform manual prone positioning with few complications for patients receiving mechanical ventilation. All staff received training on the protocol and use of the device before implementation. Evaluation This study included 36 consecutive patients who were admitted to the medical intensive care unit at a large academic medical center because of hypoxemic respiratory failure/acute respiratory distress syndrome and received mechanical ventilation and prone positioning. Data were collected on clinical presentation, interventions, and complications. Sustainability Using the robust protocol and the low-cost device, staff can safely perform a low-volume, high-risk maneuver. This method provides cost savings compared with other prone positioning methods. Conclusions Implementing a prone positioning protocol with a dedicated device is feasible, with fewer complications and lower costs than anticipated.

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