A Lower Global Lung Ultrasound Score Is Associated with Higher Likelihood of Successful Extubation in Invasively Ventilated COVID-19 Patients.
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ABSTRACT:
SUBMITTER: Pierrakos C
PROVIDER: S-EPMC8641363 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BackgroundHandgrip strength (HGS) is an alternative tool to evaluate respiratory muscle function. HGS cutoff value indicating extubation success or failure has not been investigated. This study aimed to determine HGS cutoff value to predict successful extubation.MethodsA prospective study was conducted. Patients requiring intubated mechanical ventilation with intubation ≥ 48 hours in medical wards were recruited. HGS test was performed at 10 minutes before and 30 minutes after spontaneous breathing trial (SBT). Rapid shallow breathing index (RSBI) was measured at 10 minutes before SBT.ResultsNinety-three patients (58% men) were included. Mean age was 71.6 ± 15.2 years. Weaning failure rate was 6.5%. The area under the ROC curve of 0.84 for the best HGS cutoff value at 10 minutes before SBT was 12.7 kg, with 75.9% sensitivity and 83.3% specificity (P = 0.005). The best HSG cutoff value at 30 minutes after SBT was 14.9 kg, with the area under the ROC curve of 0.82, with 58.6% sensitivity and 83.3% specificity (P = 0.009). The best RSBI cutoff value was 43.5 breaths/min/L, with the area under the ROC curve of 0.46, 33.3% sensitivity and 66.6% specificity (P = 0.737).ConclusionsHGS may be a predictive tool to guide extubation with better sensitivity and specificity than RSBI. A prospective study is needed to verify HGS test as adjunctive to RSBI in ventilator weaning protocol.
| S-EPMC8530306 | biostudies-literature
Project description:BackgroundThe prognosis of critically ill patients with cirrhosis who require mechanical ventilation is guarded. Data are lacking for the optimal therapeutic approach to hepatic encephalopathy (HE) in the ventilated patient.MethodsRetrospective cohort analysis of 314 encounters (298 patients) with cirrhosis who underwent mechanical ventilation in a medical ICU and were ordered at least 1 dose of lactulose. Hazard of extubation alive was determined using a competing risk model. Primary exposures were HE therapy (lactulose and rifaximin) which were adjusted for the indication for ventilation (HE, procedures, respiratory failure), age, MELD-Na, and compensation status.ResultsIndications for ventilation were 22.3% for grade 4 HE, 29.9% for procedures, and 47.8% for respiratory or cardiovascular failure. Median length of intubation was 2.63 days; death rate on ventilator was 31.2%. Relative to intubation for procedure, hazard of extubation for intubation for HE was 0.34 (95% confidence interval (CI): 0.22-0.52) and 0.33 (CI: 0.23-0.47) for respiratory failure. Hazard of extubation for rifaximin administration within 24-h after intubation was significant at 1.74 (1.21-2.50). Lactulose dosing was not significant for hazard of extubation.DiscussionMortality is high for all patients with cirrhosis requiring mechanical ventilation, including those intubated for grade 4 HE. Efforts to optimize the odds of successful extubation are urgently needed. Our findings suggest improved incidence of extubation associated with rifaximin administration in the first 24-h after intubation. Prospective, multi-center data to confirm these findings in this vulnerable population are warranted.
| S-EPMC9343472 | biostudies-literature
Project description:Despite the best efforts of intensive care units (ICUs) professionals, the extubation failure rates in mechanically ventilated patients remain in the range of 5%-30%. Extubation failure is associated with increased risk of death and longer ICU stay. This study aimed to identify respiratory and non-respiratory parameters predictive of extubation outcome, and to use these predictors to develop and validate an "Extubation Predictive Score (ExPreS)" that could be used to predict likelihood of extubation success in patients receiving invasive mechanical ventilation (IMV). Derivation cohort was composed by patients aged ≥18 years admitted to the ICU and receiving IMV through an endotracheal tube for >24 hours. The weaning process followed the established ICU protocol. Clinical signs and ventilator parameters of patients were recorded during IMV, in the end phase of weaning in pressure support ventilation (PSV) mode, with inspiratory pressure of 7 cm H2O over the PEEP (positive end expiratory pressure). Patients who tolerated this ventilation were submitted to spontaneous breathing trial (SBT) with T-tube for 30 minutes. Those who passed the SBT and a subsequent cuff-leak test were extubated. The primary outcome of this study was extubation success at 48 hours. Parameters that showed statistically significant association with extubation outcome were further investigated using the receiver operating characteristics (ROC) analysis to assess their predictive value. The area under the curve (AUC) values were used to select parameters for inclusion in the ExPreS. Univariable logistic regression analysis and ROC analysis were performed to evaluate the performance of ExPreS. Patients' inclusion and statistical analyses for the prospective validation cohort followed the same criteria used for the derivation cohort and the decision to extubate was based on the ExPreS result. In the derivation cohort, a total of 110 patients were extubated: extubation succeeded in 101 (91.8%) patients and failed in 9 (8.2%) patients. Rapid shallow-breathing index (RSBI) in SBT, dynamic lung compliance, duration of IMV, muscle strength, estimated GCS, hematocrit, and serum creatinine were significantly associated with extubation outcome. These parameters, along with another parameter-presence of neurologic comorbidity-were used to create the ExPreS. The AUC value for the ExPreS was 0.875, which was higher than the AUCs of the individual parameters. The total ExPreS can range from 0 to 100. ExPreS ≥59 points indicated high probability of success (OR = 23.07), while ExPreS ≤44 points indicated low probability of success (OR = 0.82). In the prospective validation cohort, 83 patients were extubated: extubation succeeded in 81 (97.6%) patients and failed in 2 (2.4%) patients. The AUC value for the ExPreS in this cohort was 0.971. The multiparameter score that we propose, ExPreS, shows good accuracy to predict extubation outcome in patients receiving IMV in the ICU. In the prospective validation, the use of ExPreS decreased the extubation failure rate from 8.2% to 2.4%, even in a cohort of more severe patients.
| S-EPMC7971695 | biostudies-literature
Project description:BackgroundData on SARS-CoV-2 load in lower respiratory tract (LRT) are scarce. Our objectives were to describe the viral shedding and the viral load in LRT and to determine their association with mortality in critically ill COVID-19 patients.MethodsWe conducted a binational study merging prospectively collected data from two COVID-19 reference centers in France and Switzerland. First, we described the viral shedding duration (i.e., time to negativity) in LRT samples. Second, we analyzed viral load in LRT samples. Third, we assessed the association between viral presence in LRT and mortality using mixed-effect logistic models for clustered data adjusting for the time between symptoms' onset and date of sampling.ResultsFrom March to May 2020, 267 LRT samples were performed in 90 patients from both centers. The median time to negativity was 29 (IQR 23; 34) days. Prolonged viral shedding was not associated with age, gender, cardiac comorbidities, diabetes, immunosuppression, corticosteroids use, or antiviral therapy. The LRT viral load tended to be higher in non-survivors. This difference was statistically significant after adjusting for the time interval between onset of symptoms and date of sampling (OR 3.78, 95% CI 1.13-12.64, p = 0.03).ConclusionsThe viral shedding in LRT lasted almost 30 days in median in critically ill patients, and the viral load in the LRT was associated with the 6-week mortality.
| S-EPMC7562762 | biostudies-literature
Project description:BackgroundQuantitative radiological scores for the extent and severity of pulmonary infiltrates based on chest radiography (CXR) and computed tomography (CT) scan are increasingly used in critically ill invasively ventilated patients. This study aimed to determine and compare the prognostic capacity of the Radiographic Assessment of Lung Edema (RALE) score and the chest CT Severity Score (CTSS) in a cohort of invasively ventilated patients with acute respiratory distress syndrome (ARDS) due to COVID-19.MethodsTwo-center retrospective observational study, including consecutive invasively ventilated COVID-19 patients. Trained scorers calculated the RALE score of first available CXR and the CTSS of the first available CT scan. The primary outcome was ICU mortality; secondary outcomes were duration of ventilation in survivors, length of stay in ICU, and hospital-, 28-, and 90-day mortality. Prognostic accuracy for ICU death was expressed using odds ratios and Area Under the Receiver Operating Characteristic curves (AUROC).ResultsA total of 82 patients were enrolled. The median RALE score (22 [15-37] vs. 26 [20-39]; p = 0.34) and the median CTSS (18 [16-21] vs. 21 [18-23]; p = 0.022) were both lower in ICU survivors compared to ICU non-survivors, although only the difference in CTSS reached statistical significance. While no association was observed between ICU mortality and RALE score (OR 1.35 [95%CI 0.64-2.84]; p = 0.417; AUC 0.50 [0.44-0.56], this was noticed with the CTSS (OR, 2.31 [1.22-4.38]; p = 0.010) although with poor prognostic capacity (AUC 0.64 [0.57-0.69]). The correlation between the RALE score and CTSS was weak (r2 = 0.075; p = 0.012).ConclusionsDespite poor prognostic capacity, only CTSS was associated with ICU mortality in our cohort of COVID-19 patients.
| S-EPMC9497927 | biostudies-literature
Project description:Sonographic assessment of diaphragmatic thickness and excursion has been found to be an accurate tool in predicting successful extubation of adult patients from invasive mechanical ventilation. We aimed to evaluate the accuracy of sonographic assessment of diaphragmatic thickness and excursion in predicting successful extubation of preterm infants from invasive conventional mechanical ventilation. Preterm infants less than 32 weeks gestation who required invasive conventional mechanical ventilation were evaluated by diaphragmatic sonography within 1 h of their planned extubation. Infants were classified into successful or failed extubation groups based on their ability to stay off invasive mechanical ventilation for 72 h after extubation. Inspiratory and expiratory thickness plus excursion of the right and left hemidiaphragm as well as diaphragmatic thickening fraction (DTF) measures were compared between groups. We included 43 eligible infants, of whom 34 infants succeeded and 9 infants failed extubation. Infants in the successful extubation group had a significantly higher expiratory thickness of the right and left hemidiaphragm, excursion of the right and left hemidiaphragm, inspiratory thickness of the left hemidiaphragm, and DTF of the left hemidiaphragm compared with infants who failed extubation. The receiver-operating characteristic curves showed that excursion of the right and left hemidiaphragm has the highest significant accuracy in predicting successful extubation of preterm infants among all diaphragmatic parameters (AUC is 0.98 and 0.96, respectively; p value < 0.001 for both).Conclusion: We conclude that diaphragmatic excursion is a useful indicator for successful extubation of preterm infants from mechanical ventilation. What is Known: • Invasive mechanical ventilation induces ventilator induced diaphragmatic dysfunction (VIDD) particularly when used for long time. • Assessment of diaphragmatic dimensions and functional activity has been a valuable tool in predicting successful extubation of adult patients from invasive mechanical ventilation. What is New: • Sonographic assessment of diaphragmatic dimensions can be used to predict successful extubation of preterm infants from mechanical ventilation. • Sonographic assessment of diaphragmatic excursion shows the highest sensitivity and specificity in predicting successful extubation of preterm infants.
| S-EPMC7520377 | biostudies-literature
Project description:OBJECTIVE:Identifying children ready for extubation is desirable to minimize morbidity and mortality associated with prolonged mechanical ventilation and extubation failure. We determined the accuracy of an extubation readiness test (Randomized Evaluation of Sedation Titration for Respiratory Failure extubation readiness test) in predicting successful extubation in children with acute respiratory failure from lower respiratory tract disease. DESIGN:Secondary analysis of data from the Randomized Evaluation of Sedation Titration for Respiratory Failure clinical trial, a pediatric multicenter cluster randomized trial of sedation. SETTING:Seventeen PICUs in the intervention arm. PATIENTS:Children 2 weeks to 17 years receiving invasive mechanical ventilation for lower respiratory tract disease. INTERVENTION:Extubation readiness test in which spontaneously breathing children with oxygenation index less than or equal to 6 were placed on FIO2 of 0.50, positive end-expiratory pressure of 5?cm H2O, and pressure support. MEASUREMENTS AND MAIN RESULTS:Of 1,042 children, 444 (43%) passed their first extubation readiness test. Of these, 295 (66%) were extubated within 10 hours of starting the extubation readiness test, including 272 who were successfully extubated, for a positive predictive value of 92%. Among 861 children who were extubated for the first time within 10 hours of performing an extubation readiness test, 788 passed their extubation readiness test and 736 were successfully extubated for a positive predictive value of 93%. The median time of day for extubation with an extubation readiness test was 12:15 hours compared with 14:54 hours for extubation without an extubation readiness test within 10 hours (p < 0.001). CONCLUSIONS:In children with acute respiratory failure from lower respiratory tract disease, an extubation readiness test, as described, should be considered at least daily if the oxygenation index is less than or equal to 6. If the child passes the extubation readiness test, there is a high likelihood of successful extubation.
| S-EPMC5541896 | biostudies-literature
Project description:BackgroundLung ultrasound (LUS) in an emerging technique used in the intensive care unit (ICU). The derivative LUS aeration score has been shown to have associations with mortality in invasively ventilated patients. This study assessed the predictive value of baseline and early changes in LUS aeration scores in critically ill invasively ventilated patients with and without ARDS (Acute Respiratory Distress Syndrome) on 30- and 90-day mortality.MethodsThis is a post hoc analysis of a multicenter prospective observational cohort study, which included patients admitted to the ICU with an expected duration of ventilation for at least 24 h. We restricted participation to patients who underwent a 12-region LUS exam at baseline and had the primary endpoint (30-day mortality) available. Logistic regression was used to analyze the primary and secondary endpoints. The analysis was performed for the complete patient cohort and for predefined subgroups (ARDS and no ARDS).ResultsA total of 442 patients were included, of whom 245 had a second LUS exam. The baseline LUS aeration score was not associated with mortality (1.02 (95% CI: 0.99 - 1.06), p = 0.143). This finding was not different in patients with and in patients without ARDS. Early deterioration of the LUS score was associated with mortality (2.09 (95% CI: 1.01 - 4.3), p = 0.046) in patients without ARDS, but not in patients with ARDS or in the complete patient cohort.ConclusionIn this cohort of critically ill invasively ventilated patients, the baseline LUS aeration score was not associated with 30- and 90-day mortality. An early change in the LUS aeration score was associated with mortality, but only in patients without ARDS.Trial registrationClinicalTrials.gov, ID NCT04482621.
| S-EPMC11232207 | biostudies-literature
Project description:BackgroundLung ultrasound (LUS) can detect pulmonary edema and it is under consideration to be added to updated acute respiratory distress syndrome (ARDS) criteria. However, it remains uncertain whether different LUS scores can be used to quantify pulmonary edema in patient with ARDS.ObjectivesThis study examined the diagnostic accuracy of four LUS scores with the extravascular lung water index (EVLWi) assessed by transpulmonary thermodilution in patients with moderate-to-severe COVID-19 ARDS.MethodsIn this predefined secondary analysis of a multicenter randomized-controlled trial (InventCOVID), patients were enrolled within 48 hours after intubation and underwent LUS and EVLWi measurement on the first and fourth day after enrolment. EVLWi and ∆EVLWi were used as reference standards. Two 12-region scores (global LUS and LUS-ARDS), an 8-region anterior-lateral score and a 4-region B-line score were used as index tests. Pearson correlation was performed and the area under the receiver operating characteristics curve (AUROCC) for severe pulmonary edema (EVLWi > 15 mL/kg) was calculated.Results26 out of 30 patients (87%) had complete LUS and EVLWi measurements at time point 1 and 24 out of 29 patients (83%) at time point 2. The global LUS (r = 0.54), LUS-ARDS (r = 0.58) and anterior-lateral score (r = 0.54) correlated significantly with EVLWi, while the B-line score did not (r = 0.32). ∆global LUS (r = 0.49) and ∆anterior-lateral LUS (r = 0.52) correlated significantly with ∆EVLWi. AUROCC for EVLWi > 15 ml/kg was 0.73 for the global LUS, 0.79 for the anterior-lateral and 0.85 for the LUS-ARDS score.ConclusionsOverall, LUS demonstrated an acceptable diagnostic accuracy for detection of pulmonary edema in moderate-to-severe COVID-19 ARDS when compared with PICCO. For identifying patients at risk of severe pulmonary edema, an extended score considering pleural morphology may be of added value.Trial registrationClinicalTrials.gov identifier NCT04794088, registered on 11 March 2021. European Clinical Trials Database number 2020-005447-23.
| S-EPMC10545605 | biostudies-literature
Project description:ObjectivesTo identify variables associated with successful elective extubation, and to determine neonatal morbidities associated with extubation failure in extremely preterm neonates.Study designThis study was a secondary analysis of the National Institute of Child Health and Human Development Neonatal Research Network's Surfactant, Positive Pressure, and Oxygenation Randomized Trial that included extremely preterm infants born at 240/7 to 276/7 weeks' gestation. Patients were randomized either to a permissive ventilatory strategy (continuous positive airway pressure group) or intubation followed by early surfactant (surfactant group). There were prespecified intubation and extubation criteria. Extubation failure was defined as reintubation within 5 days of extubation.ResultsOf 1316 infants in the trial, 1071 were eligible; 926 infants had data available on extubation status; 538 were successful and 388 failed extubation. The rate of successful extubation was 50% (188/374) in the continuous positive airway pressure group and 63% (350/552) in the surfactant group. Successful extubation was associated with higher 5-minute Apgar score, and pH prior to extubation, lower peak fraction of inspired oxygen within the first 24 hours of age and prior to extubation, lower partial pressure of carbon dioxide prior to extubation, and non-small for gestational age status after adjustment for the randomization group assignment. Infants who failed extubation had higher adjusted rates of mortality (OR 2.89), bronchopulmonary dysplasia (OR 3.06), and death/ bronchopulmonary dysplasia (OR 3.27).ConclusionsHigher 5-minute Apgar score, and pH prior to extubation, lower peak fraction of inspired oxygen within first 24 hours of age, lower partial pressure of carbon dioxide and fraction of inspired oxygen prior to extubation, and nonsmall for gestational age status were associated with successful extubation. Failed extubation was associated with significantly higher likelihood of mortality and morbidities.Trial registrationClinicalTrials.gov: NCT00233324.
| S-EPMC5657557 | biostudies-literature