Tracheal Aspirate as an Alternative Biologic Sample for Pharmacogenomics Testing in Mechanically Ventilated Pediatric Patients.
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SUBMITTER: Hargreaves KA
PROVIDER: S-EPMC7993287 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:ImportanceEndotracheal aspirate cultures are commonly collected from patients with mechanical ventilation to evaluate for ventilator-associated pneumonia or tracheitis. However, the respiratory tract is not sterile, making differentiating between colonization from bacterial infection challenging, and results may be unreliable owing to variable specimen quality and sample processing across laboratories. Despite these limitations, clinicians routinely interpret bacterial growth in endotracheal aspirate cultures as evidence of infection, sometimes regardless of organism significance, prompting antibiotic treatment.ObjectiveTo assess the variability in endotracheal aspirate culture rates and the association between culture rates and antibiotic prescribing among patients with mechanical ventilation across children's hospitals in the US.Design, setting, and participantsCross-sectional retrospective analysis of data obtained from the Children's Hospital Association Pediatric Health Information System database between January 1, 2016, through December 31, 2019. Participants were all patients hospitalized with mechanical ventilation aged less than 18 years.ExposuresA charge for an endotracheal aspirate culture on a ventilated day.Main outcomes and measuresEndotracheal aspirate culture rate and antibiotic days of therapy per ventilated days. For mechanical ventilation, clinical transaction classification codes for mechanical ventilation other unspecified ventilator assistance were used. To identify respiratory cultures, the laboratory test code for aerobic culture was used and relevant keywords (ie, respiratory tract, sputum) were used to identify sources in the hospital charge description master.ResultsA total of 152 132 patients were identified among 31 hospitals. Among these patients, 79 691 endotracheal aspirate cultures were collected on a ventilator-day (patients aged less than 1 year, 44%; 1-4 years, 27%, 5-11 years. 16%, and 12-18 years, 13%; 3% were Asian; 17% Hispanic; 21% non-Hispanic Black; 45% Non-Hispanic White patients; 14% were other; 56% of patients were male, 44% were female). The overall median rate of culture use was 46 per 1000 ventilator-days (IQR, 32-73 cultures per 1000 ventilator-days). The endotracheal aspirate culture rate was positively correlated with the hospital's antibiotic days of therapy rate (R = 0.46; P = .009). In a multivariable model adjusting for patient-level and hospital-level characteristics and among patients with mechanical ventilation, each additional endotracheal aspirate culture was associated with 2.87 (95% CI, 2.74-3.01) higher odds of receiving additional days of therapy compared with patients who did not receive and endotracheal aspirate culture.Conclusions and relevanceIn this study, notable variability was found in endotracheal aspirate culture rates across US pediatric hospitals and pediatric intensive care units, and endotracheal aspirate culture use was associated with increased antibiotic use. These findings suggest an opportunity for diagnostic and antibiotic stewardship to standardize testing and treatment of suspected ventilator-associated infections in pediatric patients with mechanical ventilation pediatric patients.
| S-EPMC8696566 | biostudies-literature
Project description:BackgroundTo compare the microbiological culture within endotracheal aspirate specimens (ETAs) and endotracheal tube specimens (ETTs) in patients undergoing mechanical ventilation (MV) by statistical tools.MethodETAs and ETTs from a total number of 81 patients, who were undergoing MV at the intensive care unit (ICU) of Jiading Central Hospital Affiliated Shanghai University of Medicine & Health Sciences from September 1st, 2017 to August 31st, 2018, were collected for microbiological culture analysis. Correlation of ETAs and ETTs cultures were obtained by Spear-men correlation analysis, while the consistency of the two specimens was determined by Kappa analysis and principal component analysis (PCA).ResultsMicrobiological culture from both ETAs and ETTs showed that Acinetobacter baumannii, Pseudomonas aeruginosa, Staphylococcus aureus, and Klebsiella pneumoniae were the main pathogens, with Spear-man correlation coefficients of 0.676, 0.951, 0.730 and 0.687 respectively (all P < 0.01), and the overall Spear-man correlation coefficient is 0.757 (P < 0.01). This result shows that two samples were positively correlated. Kappa analysis also revealed high consistency of the microbial culture results from the ETAs and the ETTs (overall κ = 0.751, P < 0.01). The κ values for the four bacteria detected were 0.670, 0.949, 0.723, and 0.687, respectively (all P < 0.001). PCA also revealed high similarity.ConclusionCombining microbiological culture and statistical analysis of samples collected from 81 patients who were undergoing MV in ICU, we showed that microbe found in the ETAs had high similarity with that found in the ETTs which collected at the end of the catheters. In clinical practice, ETAs analysis is easily accessible meanwhile provides a valuable information for MV patients.
| S-EPMC6712863 | biostudies-literature
Project description:UnlabelledBackgroundThis clinical study evaluated the effect of a suctioning maneuver on aspiration past the cuff during mechanical ventilation.MethodsPatients intubated for less than 48 hours with a PVC-cuffed tracheal tube, under mechanical ventilation with a PEEP ≥5 cm H2O and under continuous sedation, were included in the study. At baseline the cuff pressure was set at 30 cm H2O. Then 0.5ml of blue dye diluted with 3 ml of saline was instilled into the subglottic space just above the cuff. Tracheal suctioning was performed using a 16-French suction catheter with a suction pressure of - 400 mbar. A fiberoptic bronchoscopy was performed before and after the suctioning maneuver, looking for the presence of blue dye in the folds within the cuff wall or in the trachea under the cuff. The sealing of the cuff was defined by the absence of leakage of blue dye either in the cuff wall or in the trachea under the cuff.ResultsTwenty-five patients were included. The size of the tracheal tube was 7-mm ID for 5 patients, 7.5-mm ID for 16 patients, and 8-mm ID for four patients. Blue dye was never seen in the trachea under the cuff before suctioning and only in one patient (4%) after the suctioning maneuver. Blue dye was observed in the folds within the cuff wall in 6 of 25 patients before suctioning and 11 of 25 after (p = 0.063). Overall, the incidence of sealing of the cuff was 76% before suctioning and 56% after (p = 0.073).ConclusionsIn patients intubated with a PVC-cuffed tracheal tube and under mechanical ventilation with PEEP ≥5 cm H2O and a cuff pressure set at 30 cm H2O, a single tracheal suctioning maneuver did not increase the risk of aspiration in the trachea under the cuff.Trial registrationClinicalTrials.gov, number NCT01170156.
| S-EPMC3520779 | biostudies-literature
Project description:BackgroundVarious complications may arise from prolonged mechanical ventilation, but the risk of tracheal stenosis occurring late after translaryngeal intubation or tracheostomy is less common. This study aimed to determine the prevalence, type, risk factors, and management of tracheal stenoses in mechanically ventilated tracheotomized patients deemed ready for decannulation following prolonged weaning.MethodsA retrospective observational study on 357 prolonged mechanically ventilated, tracheotomized patients admitted to a specialized weaning center over seven years. Flexible bronchoscopy was used to discern the type, level, and severity of tracheal stenosis in each case. We described the management of these stenoses and used a binary logistic regression analysis to determine independent risk factors for stenosis development.ResultsOn admission, 272 patients (76%) had percutaneous tracheostomies, and 114 patients (32%) presented mild to moderate tracheal stenosis following weaning completion, with a median tracheal cross-section reduction of 40% (IQR 25-50). The majority of stenoses (88%) were located in the upper tracheal region, most commonly resulting from localized granulation tissue formation at the site of the internal stoma (96%). The logistic regression analysis determined that obesity (OR 2.16 [95%CI 1.29-3.63], P < 0.01), presence of a percutaneous tracheostomy (2.02 [1.12-3.66], P = 0.020), and cricothyrotomy status (5.35 [1.96-14.6], P < 0.01) were independently related to stenoses. Interventional bronchoscopy with Nd:YAG photocoagulation was a highly effective first-line treatment, with only three patients (2.6%) ultimately referred to tracheal surgery.ConclusionsTracheal stenosis is commonly observed among prolonged ventilated patients with tracheostomies, characterized by localized hypergranulation and mild to moderate airway obstruction, with interventional bronchoscopy providing satisfactory results.
| S-EPMC8740413 | biostudies-literature
Project description:ObjectivesThis study examines the histological findings of tracheal tissue samples obtained from COVID-19 positive mechanically ventilated patients, to assess the degree of tracheal inflammation/ulceration present.Design and participantsRetrospective single-centre observational cohort study. All patients admitted to Adult Intensive Care Unit (AICU) with COVID-19 infection, requiring mechanical ventilation and surgical tracheostomy between 1 April and 1 May 2020, were included (Group 1). Tracheal windows excised at tracheostomy underwent histological analysis. Comparison was made with: tracheal windows from COVID-19 positive AICU ventilated patients admitted between 1 January and 1 March 2021 (Group 2); tracheal windows from COVID-19 negative AICU ventilated patients (Group 3); and, tracheal autopsy samples from COVID-19 positive patients that died without undergoing prolonged mechanical ventilation (Group 4).ResultsGroup 1 demonstrated mild/moderate inflammation (tracheitis) in nearly all samples (15/16, 93.8%), with infrequent micro-ulceration (2/16, 12.5%). Group 2 demonstrated similar mild/moderate inflammation in all samples (17/17, 100%), with no ulceration. Histological findings of Groups 1 and 2 COVID-19 positive patients were similar to Group 3 COVID-19 negative patients, which demonstrated mild/moderate inflammation (5/5, 100%), with uncommon superficial erosion (1/5, 20%). Group 4 demonstrated mild chronic inflammation or no significant inflammation, with uncommon micro-ulceration (1/4, 25%).ConclusionsSevere tracheal inflammation was not demonstrated in mechanically ventilated COVID-19 positive patients at the level of the second/third tracheal rings, at the stage of disease patients underwent tracheostomy. Histological findings were similar between mechanically ventilated COVID-19 positive and negative patients. Tracheal ulceration may be a feature of early or severe COVID-19 disease.
| S-EPMC8653284 | biostudies-literature
Project description:BackgroundVentilator-associated pneumonia (VAP) is a well-known, life-threatening disease that persists despite preventative measures and approved antibiotic therapies. This prospective observational study investigated bacterial airway colonization, and whether its detection and quantification in the endotracheal aspirate (ETA) is useful for identifying mechanically ventilated ICU patients who are at risk of developing VAP.Methods240 patients admitted to 3 ICUs at the Lahey Hospital and Medical Center (Burlington, MA) between June 2014 and June 2015 and mechanically ventilated for > 2 days were included. ETA samples and clinical data were collected. Airway colonization was assessed, and subsequently categorized into "heavy" and "light" by semi-quantitative microbiological analysis of ETAs. VAP was diagnosed retrospectively by the study sponsor according to a pre-specified pneumonia definition.ResultsPathogenic bacteria were isolated from ETAs of 125 patients. The most common species isolated was S. aureus (56.8%), followed by K. pneumoniae, P. aeruginosa, and E. coli (35.2% combined). VAP was diagnosed in 85 patients, 44 (51.7%) with no bacterial pathogen, 18 associated with S. aureus and 18 Gram-negative-only cases, and 5 associated with other Gram-positive or mixed species. A higher proportion of patients who were heavily colonized with S. aureus developed VAP (32.4%) associated with S. aureus compared to those lightly colonized (17.6%). The same tendency was seen for patients heavily and lightly colonized with Gram-negative pathogens (30.0 and 0.0%, respectively). Detection of S. aureus in the ETA preceded S. aureus VAP by approximately 4 days, while Gram-negative organisms were first detected 2.5 days prior to Gram-negative VAP. VAP was associated with significantly longer duration of mechanical ventilation and hospitalization regardless of microbiologic cause when compared to patients who did not develop VAP.ConclusionsThe overall VAP rate was 35%. Heavy tracheal colonization supported identification of patients at higher risk of developing a corresponding S. aureus or Gram-negative VAP. Detection of bacterial ETA-positivity tended to precede VAP.
| S-EPMC6716855 | biostudies-literature
Project description: Not available
| S-EPMC6517146 | biostudies-literature
Project description:Objective There is recent interest in the association between hyperchloremic metabolic acidosis and adverse outcomes. In vitro, hyperchloremia causes renal vasoconstriction and fall in glomerular filtration rate (GFR). The objective of this retrospective, observational study is to examine associations between chloride level at admission to pediatric intensive care (PICU) and worst GFR and requirement for renal replacement therapy. Materials and Methods All admissions to PICU between 2009 and 2019 who received invasive mechanical ventilation and had blood gas analysis performed were included. Data analyzed included patient characteristics (age, gender, diagnosis, pediatric index of mortality [PIM]-2 score); results of initial blood gas; and maximum serum creatinine (then used to calculate minimum GFR). Primary outcome measure was worst GFR during PICU stay. Secondary outcome measures were requirement for renal replacement therapy and PICU mortality. Multivariable regression analysis was used to assess if admission chloride level was independently predictive of minimum GFR during PICU stay and to examine associations between hyperchloremia (>110 mEq/L) at admission and requirement for renal replacement therapy after adjustment for confounders. Results Data were available for 2,217 patients. Median age was 16.4 months and 39% of patients were hyperchloremic at admission to PICU. Admission chloride level was independently predictive of worst GFR during PICU stay after adjustment for known confounders. Patients with hyperchloremia were not more likely to require renal replacement therapy or die than patients with normochloremia. Conclusion Prospective studies are necessary to determine if high chloride, specifically chloride containing resuscitation fluids, have a causal relationship with poor outcomes.
| S-EPMC9894692 | biostudies-literature
Project description:Protocolized sedation improves clinical outcomes in critically ill adults, but its effect in children is unknown.To determine whether critically ill children managed with a nurse-implemented, goal-directed sedation protocol experience fewer days of mechanical ventilation than patients receiving usual care.Cluster randomized trial conducted in 31 US pediatric intensive care units (PICUs). A total of 2449 children (mean age, 4.7 years; range, 2 weeks to 17 years) mechanically ventilated for acute respiratory failure were enrolled in 2009-2013 and followed up until 72 hours after opioids were discontinued, 28 days, or hospital discharge.Intervention PICUs (17 sites; n = 1225 patients) used a protocol that included targeted sedation, arousal assessments, extubation readiness testing, sedation adjustment every 8 hours, and sedation weaning. Control PICUs (14 sites; n = 1224 patients) managed sedation per usual care.The primary outcome was duration of mechanical ventilation. Secondary outcomes included time to recovery from acute respiratory failure, duration of weaning from mechanical ventilation, neurological testing, PICU and hospital lengths of stay, in-hospital mortality, sedation-related adverse events, measures of sedative exposure (wakefulness, pain, and agitation), and occurrence of iatrogenic withdrawal.Duration of mechanical ventilation was not different between the 2 groups (intervention: median, 6.5 [IQR, 4.1-11.2] days; control: median, 6.5 [IQR, 3.7-12.1] days). Sedation-related adverse events including inadequate pain and sedation management, clinically significant iatrogenic withdrawal, and unplanned endotracheal tube/invasive line removal were not significantly different between the 2 groups. Intervention patients experienced more postextubation stridor (7% vs 4%; P =?.03) and fewer stage 2 or worse immobility-related pressure ulcers (<1% vs 2%; P =?.001). In exploratory analyses, intervention patients had fewer days of opioid administration (median, 9 [IQR, 5-15] days vs 10 [IQR, 4-21] days; P =?.01), were exposed to fewer sedative classes (median, 2 [IQR, 2-3] classes vs 3 [IQR, 2-4] classes; P <?.001), and were more often awake and calm while intubated (median, 86% [IQR, 67%-100%] of days vs 75% [IQR, 50%-100%] of days; P =?.004) than control patients, respectively; however, intervention patients had more days with any report of a pain score ? 4 (median, 50% [IQR, 27%-67%] of days vs 23% [IQR, 0%-46%] of days; P <?.001) and any report of agitation (median, 60% [IQR, 33%-80%] vs 40% [IQR, 13%-67%]; P =?.003), respectively.Among children undergoing mechanical ventilation for acute respiratory failure, the use of a sedation protocol compared with usual care did not reduce the duration of mechanical ventilation. Exploratory analyses of secondary outcomes suggest a complex relationship among wakefulness, pain, and agitation.clinicaltrials.gov Identifier: NCT00814099.
| S-EPMC4955566 | biostudies-literature
Project description:PurposeDiaphragm weakness induced by mechanical ventilation may contribute to difficult weaning from the ventilator. For optimal force generation the muscle proteins myosin and titin are indispensable. The present study investigated if myosin and titin loss or dysfunction are involved in mechanical ventilation-induced diaphragm weakness.MethodsMale Wistar rats were either assigned to a control group (n = 10) or submitted to 18 h of mechanical ventilation (MV, n = 10). At the end of the experiment, diaphragm and soleus muscle were excised for functional and biochemical analysis.ResultsMaximal specific active force generation of muscle fibers isolated from the diaphragm of MV rats was lower than controls (128 ± 9 vs. 165 ± 13 mN/mm(2), p = 0.02) and was accompanied by a proportional reduction of myosin heavy chain concentration in these fibers. Passive force generation upon stretch was significantly reduced in diaphragm fibers from MV rats by ca. 35%. Yet, titin content was not significantly different between control and MV diaphragm. In vitro pre-incubation with phosphatase-1 decreased passive force generation upon stretch in diaphragm fibers from control, but not from MV rats. Mechanical ventilation did not affect active or passive force generation in the soleus muscle.ConclusionsMechanical ventilation leads to impaired diaphragm fiber active force-generating capacity and passive force generation upon stretch. Loss of myosin contributes to reduced active force generation, whereas reduced passive force generation is likely to result from a decreased phosphorylation status of titin. These impairments were not discernable in the soleus muscle of 18 h mechanically ventilated rats.
| S-EPMC3308006 | biostudies-literature