Dataset Information

How prolonged mechanical ventilation is a neglected disease in chest medicine: a study of prolonged mechanical ventilation based on 6 years of experience in Taiwan.

ABSTRACT:

Background

An increasing number of patients require prolonged mechanical ventilation (PMV) to survive recovery from critical care. It should be emphasized that PMV is a neglected disease in chest medicine. We investigated 6?years of clinical outcomes and long-term survival rates of patients who required PMV.

Methods

We analyzed retrospectively data from patients in respiratory care center (RCC) to investigate the main causes of respiratory failure leading patients to require PMV. We also studied the factors that influence the ventilator weaned rate, factors that influence the long-term ventilator dependence of patients who require PMV, as well as patients' hospital mortality and long-term survival rates.

Results

A total of 574 patients were admitted to RCC during the 6?years. Of these, 428 patients (74.6%) were older than 65 years. A total of 391 patients (68.1%) were successfully weaned from the ventilator while 83 patients (14.4%) were unsuccessfully weaned. A total of 95 patients (16.6%) died during RCC hospitalization. The most common cause of acute respiratory failure leading to patients requiring PMV was pneumonia. The factor that affected whether patients were successfully weaned from the ventilator was the cause of the respiratory failure that lead patients to require PMV. Our hospital mortality rate was 32.4%; the 1-year survival rate was 24.3%. There was a strong correlation between higher patient age and higher hospital mortality rate and poor 1-year survival rate. Patients with no comorbidity demonstrated good 1-year survival rates. Patients with four comorbidities and patients with end-stage renal disease requiring hemodialysis comorbidity showed poor 1-year survival rates.

Conclusions

The factor that affected whether patients were successfully weaned from the ventilator was the cause of the respiratory failure that lead patients to require PMV. Older patients, patients with renal failure requiring hemodialysis, and those with numerous comorbidities demonstrated poor long-term survival. The reviews of this paper are available via the supplemental material section.

SUBMITTER: Huang C

PROVIDER: S-EPMC6769206 | biostudies-literature | 2019 Jan-Dec

REPOSITORIES: biostudies-literature

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How prolonged mechanical ventilation is a neglected disease in chest medicine: a study of prolonged mechanical ventilation based on 6 years of experience in Taiwan.

Huang Chienhsiu C

Therapeutic advances in respiratory disease 20190101

<h4>Background</h4>An increasing number of patients require prolonged mechanical ventilation (PMV) to survive recovery from critical care. It should be emphasized that PMV is a neglected disease in chest medicine. We investigated 6 years of clinical outcomes and long-term survival rates of patients who required PMV.<h4>Methods</h4>We analyzed retrospectively data from patients in respiratory care center (RCC) to investigate the main causes of respiratory failure leading patients to require PMV. ...[more]

PMID: 31566093

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Project description:Background: Prolonged mechanical ventilation (PMV) is common after cardiothoracic surgery, whereas the mechanical ventilation strategy after pulmonary endarterectomy (PEA) has not yet been reported. We aim to identify the incidence and risk factors for PMV and the relationship between PMV and short-term outcomes. Methods: We studied a retrospective cohort of 171 who undergoing PEA surgery from 2014 to 2020. Cox regression with restricted cubic splines was performed to identify the cutoff value for PMV. The Least absolute shrinkage and selection operator regression and logistic regressions were applied to identify risk factors for PMV. The impacts of PMV on the short-term outcomes were evaluated. Results: PMV was defined as the duration of mechanical ventilation exceeding 48 h. Independent risk factors for PMV included female sex (OR 2.911; 95% CI 1.303-6.501; P = 0.009), prolonged deep hypothermic circulatory arrest (DHCA) time (OR 1.027; 95% CI 1.002-1.053; P = 0.036), increased postoperative blood product use (OR 3.542; 95% CI 1.203-10.423; P = 0.022), elevated postoperative total bilirubin levels (OR 1.021; 95% CI 1.007-1.034; P = 0.002), increased preoperative pulmonary artery pressure (PAP) (OR 1.031; 95% CI 1.014-1.048; P < 0.001) and elongated postoperative right ventricular anteroposterior dimension (RVAD) (OR 1.119; 95% CI 1.026-1.221; P = 0.011). Patients with PMV had longer intensive care unit stays, higher incidences of postoperative complications, and higher in-hospital medical expenses. Conclusions: Female sex, prolonged DHCA time, increased postoperative blood product use, elevated postoperative total bilirubin levels, increased preoperative PAP, and elongated postoperative RVAD were independent risk factors for PMV. Identification of risk factors associated with PMV in patients undergoing PEA may facilitate timely diagnosis and re-intervention for some of these modifiable factors to decrease ventilation time and improve patient outcomes.

Project description:IntroductionPatients who require prolonged mechanical ventilation (PMV) are increasing and producing financial burdens worldwide. This study determines the cost per QALY (quality-adjusted life year), out-of-pocket expenses, and lifetime costs for PMV patients stratified by underlying diseases and cognition levels.MethodsA nationwide sample of 50,481 patients with continual mechanical ventilation for more than 21 days was collected during 1997-2007. After stratifying the patients according to specific diagnoses, a latent class analysis (LCA) was performed to categorise PMV patients with multiple co-morbidities into several homogeneous groups. The survival functions were estimated for individual groups using the Kaplan-Meier method and extrapolated to 300 months through a semi-parametric method. The survival functions were adjusted using an EQ-5D utility value derived from a convenience sample of 142 PMV patients to estimate quality-adjusted life expectancies (QALE). Another convenience sample of 165 patients was used to estimate the out-of-pocket expenses. The lifetime expenditures paid by the single-payer National Health Insurance (NHI) system and patients' families were estimated by multiplying average monthly expenditures by the survival probabilities and summing the values over lifetime.ResultsPMV therapy costs more than 100,000 U.S. dollars (USD) per QALY for all patients with poor cognition. For patients with partial cognition, PMV therapy costs less than 56,000 USD per QALY for those with liver cirrhosis, intracranial or spinal cord injuries, and 57,000-69,000 USD for patients with multiple co-morbidities under age of 65. The average lifetime cost of PMV was usually below 56,000 USD. The out-of-pocket expenses were often more than one-third of the total cost of treatment.ConclusionsPMV treatment for patients with poor cognition would cost more than 5 times Taiwan's GDP (gross domestic products), or less cost-effective. The out-of-pocket expenses for PMV provision should also be considered in policy decision.

Project description:Objective: The number of patients requiring prolonged mechanical ventilation (PMV) is increasing worldwide, but the weaning outcome prediction model in these patients is still lacking. We hence aimed to develop an explainable machine learning (ML) model to predict successful weaning in patients requiring PMV using a real-world dataset. Methods: This retrospective study used the electronic medical records of patients admitted to a 12-bed respiratory care center in central Taiwan between 2013 and 2018. We used three ML models, namely, extreme gradient boosting (XGBoost), random forest (RF), and logistic regression (LR), to establish the prediction model. We further illustrated the feature importance categorized by clinical domains and provided visualized interpretation by using SHapley Additive exPlanations (SHAP) as well as local interpretable model-agnostic explanations (LIME). Results: The dataset contained data of 963 patients requiring PMV, and 56.0% (539/963) of them were successfully weaned from mechanical ventilation. The XGBoost model (area under the curve [AUC]: 0.908; 95% confidence interval [CI] 0.864-0.943) and RF model (AUC: 0.888; 95% CI 0.844-0.934) outperformed the LR model (AUC: 0.762; 95% CI 0.687-0.830) in predicting successful weaning in patients requiring PMV. To give the physician an intuitive understanding of the model, we stratified the feature importance by clinical domains. The cumulative feature importance in the ventilation domain, fluid domain, physiology domain, and laboratory data domain was 0.310, 0.201, 0.265, and 0.182, respectively. We further used the SHAP plot and partial dependence plot to illustrate associations between features and the weaning outcome at the feature level. Moreover, we used LIME plots to illustrate the prediction model at the individual level. Additionally, we addressed the weekly performance of the three ML models and found that the accuracy of XGBoost/RF was ~0.7 between weeks 4 and week 7 and slightly declined to 0.6 on weeks 8 and 9. Conclusion: We used an ML approach, mainly XGBoost, SHAP plot, and LIME plot to establish an explainable weaning prediction ML model in patients requiring PMV. We believe these approaches should largely mitigate the concern of the black-box issue of artificial intelligence, and future studies are warranted for the landing of the proposed model.

Project description:BackgroundShort-term mechanical ventilation (MV) protects against sepsis-induced diaphragmatic dysfunction. Prolonged MV induces diaphragmatic dysfunction in non-septic animals, but few reports describe the effects of prolonged MV in sepsis. We hypothesized that prolonged MV is not protective but worsens the diaphragmatic dysfunction induced by a mild sepsis, because MV and sepsis share key signaling mechanisms, such as cytokine upregulation.MethodWe studied the impact of prolonged MV (12 h) in four groups (n = 8) of male Wistar rats: 1) endotoxemia induced by intraperitoneal injection of Escherichia coli lipopolysaccharide, 2) MV without endotoxemia, 3) combination of endotoxemia and MV and 4) sham control. Diaphragm mechanical performance, pro-inflammatory cytokine concentrations (Tumor Necrosis Factor-?, Interleukin-1?, Interleukin-6) in plasma were measured.ResultsProlonged MV and sepsis independtly reduced maximum diaphragm force (-27%, P = 0.003; -37%, P<0.001; respectively). MV and sepsis acted additively to further decrease diaphragm force (-62%, P<0.001). Similar results were observed for diaphragm kinetics (maximum lengthening velocity -47%, P<0.001). Sepsis and MV reduced diaphragm cross sectional area of type I and IIx fibers, which was further increased by the combination of sepsis and MV (all P<0.05). Sepsis and MV were individually associated with the presence of a robust perimysial inflammatory infiltrate, which was more marked when sepsis and MV were both present (all P<0.05). Sepsis and, to a lesser extent, MV increased proinflammatory cytokine production in plasma and diaphragm (all P<0.05); proinflammatory cytokine expression in plasma was increased further by the combination of sepsis and MV (all P<0.05). Maximum diaphragm force correlated negatively with plasma and diaphragmatic cytokine production (all p<0.05).ConclusionsProlonged (12 h) MV exacerbated sepsis-induced decrease in diaphragm performance. Systemic and diaphragmatic overproduction of pro-inflammatory cytokines may contribute to diaphragm weakness.

Dataset Information

How prolonged mechanical ventilation is a neglected disease in chest medicine: a study of prolonged mechanical ventilation based on 6 years of experience in Taiwan.

Background

Methods

Results

Conclusions

Publications

How prolonged mechanical ventilation is a neglected disease in chest medicine: a study of prolonged mechanical ventilation based on 6 years of experience in Taiwan.

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