Noninvasive vs invasive ventilation in COPD patients with severe acute respiratory failure deemed to require ventilatory assistance

Objective To determine whether non-invasive ventilation (NIV) may be an effective and safe alternative to invasive mechanical ventilation in chronic obstructive pulmonary disease (COPD) patients with acute respiratory failure (ARF) meeting criteria for mechanical ventilation.Design and setting Matched case-control study conducted in ICU.Patients and intervention NIV was prospectively applied to 64 COPD patients with advanced ARF. Their outcomes were compared with those of a control group of 64 COPD patients matched on age, FEV₁, Simplified Acute Physiology Score II, and pH at ICU admission, previously treated in the same ICU with conventional invasive mechanical ventilation.Methods and results NIV failed in 40 patients who required intubation. Mortality rate, duration of mechanical ventilation, and lengths of ICU and post-ICU stay were not different between the two groups. The NIV group had fewer complications (P = 0.01) and showed a trend toward a lower proportion of patients remaining on mechanical ventilation after 30 days (P = 0.056). Compared to the control group, the outcomes of the patients who failed NIV were no different. Compared to the patients who received intubation, those who succeeded NIV had reduced mortality rate and lengths of ICU and post-ICU stay.Conclusions In COPD patients with advanced hypercapnic acute respiratory failure, NIV had a high rate of failure, but, nevertheless, provided some advantages, compared to conventional invasive ventilation. Subgroup analysis suggested that the delay in intubation was not deleterious in the patients who failed NIV, whereas a better outcome was confirmed for the patients who avoided intubation.     

危重肺心病救治时无创和有创通气相互转换时血气监测意义

目的探讨危重慢性阻塞性肺疾病(COPD)救治时无创和有创正压通气相互转换时血气监测的意义.方法 入住ICU病房的危重COPD患者首先应用无创正压通气(NPPV),然后根据血气分析结果及病情情况,及时转换为有创正压通气(IPPV)为A组,维持NPPV治疗为B组.比较两组的病死率、呼吸机相关性肺炎(VAP)发生率、机械通气时间及住ICU时间.结果 A组病死率为13.3%,B组病死率为100%,A组病死率明显低于B组(P＜0.05);A组VAP发生率较B组明显降低(P＜0.05);A组机械通气时间和住ICU时间较B组明显缩短(P＜0.05).结论对危重肺心病患者机械通气治疗期间,根据血气分析的结果及病情准确把握从无创到有创或有创到无创的转换时机,灵活选用NPPV和IPPV,可提高治疗效果,降低VAP发生率和病死率.     

有创与无创序贯性机械通气治疗慢性阻塞性肺疾病所致呼吸衰竭的临床研究

目的探讨有创与无创序贯性机械通气在慢性阻塞性肺疾病（COPD）所致呼吸衰竭患者救治中的方法与疗效。方法对41例COPD呼吸衰竭患者进行气管插管并施行机械通气,出现HC窗后,随机分为序贯治疗组（21例）和对照组（20例）。序贯组治疗方法：出现PIC窗后,立即拔出气管插管,改用口鼻面罩双水平气道正压通气（BiPAP）。对照组治疗方法：出现HC窗后,继续按常规有创机械通气方法治疗,按临床常用压力支持通气（PSV）模式脱机。两组同时进行监护,观察两组患者VAP发生例数、有创通气时间、总机械通气时间、ICU监护时间、住院时间、住院费用和院内死亡例数。结果序贯组与对照组比较,VAP发生少,有创通气时间、总通气时间、ICU监护时间及住院时间短,住院费用减少（P〈0．05）,差异有统计学意义。结论在“肺部感染控制窗”指导下的有创一无创序贯性脱机治疗方法,可以明显降低VAP发病率,缩短机械通气,ICU和总住院时间,提高疗效,降低治疗费用,是具有一定临床实用价值的有效脱机方案。     

Critical care capacity in Canada: results of a national cross-sectional study

IntroductionIntensive Care Units (ICUs) provide life-supporting treatment; however, resources are limited, so demand may exceed supply in the event of pandemics, environmental disasters, or in the context of an aging population. We hypothesized that comprehensive national data on ICU resources would permit a better understanding of regional differences in system capacity.MethodsAfter the 2009–2010 Influenza A (H1N1) pandemic, the Canadian Critical Care Trials Group surveyed all acute care hospitals in Canada to assess ICU capacity. Using a structured survey tool administered to physicians, respiratory therapists and nurses, we determined the number of ICU beds, ventilators, and the ability to provide specialized support for respiratory failure.ResultsWe identified 286 hospitals with 3170 ICU beds and 4982 mechanical ventilators for critically ill patients. Twenty-two hospitals had an ICU that routinely cared for children; 15 had dedicated pediatric ICUs. Per 100,000 population, there was substantial variability in provincial capacity, with a mean of 0.9 hospitals with ICUs (provincial range 0.4-2.8), 10 ICU beds capable of providing mechanical ventilation (provincial range 6–19), and 15 invasive mechanical ventilators (provincial range 10–24). There was only moderate correlation between ventilation capacity and population size (coefficient of determination (R²) = 0.771).ConclusionICU resources vary widely across Canadian provinces, and during times of increased demand, may result in geographic differences in the ability to care for critically ill patients. These results highlight the need to evolve inter-jurisdictional resource sharing during periods of substantial increase in demand, and provide background data for the development of appropriate critical care capacity benchmarks.

Electronic supplementary material

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Early veno-venous extracorporeal membrane oxygenation is associated with lower mortality in patients who have severe hypoxemic respiratory failure: A retrospective multicenter cohort study

PurposeThe purpose of the study is to compare outcomes in patients who had severe hypoxemic respiratory failure (Pao₂/fraction of inspired oxygen < 100) who received early veno-venous extracorporeal membrane oxygenation (ECMO) as an adjunct to mechanical ventilation, to those in patients who received conventional mechanical ventilation alone.Materials and methodsThis is a multicenter, retrospective unmatched and matched cohort study of patients admitted between April 2006 and December 2013. Generalized logistic mixed-effects models and Cox proportional hazards models were used to determine the association between treatment with ECMO that was started within 3 days of intensive care unit (ICU) admission and ICU and hospital mortality and length of stay, respectively.ResultsA total of 2440 patients who had severe hypoxemic respiratory failure due to various etiologies were included, 46 who received early veno-venous ECMO and 2394 unmatched and 398 matched controls who received conventional ventilation alone. Compared to matched controls, ECMO was associated with a lower odds of ICU (odds ratio [95% confidence interval], 0.30 [0.13-0.67]) and inhospital death (odds ratio 0.30 [0.14-0.67]). In addition, ECMO was associated with longer times to discharge from ICU and hospital (hazard ratio, 0.42 [0.37-0.47] and 0.53 [0.38-0.73], respectively).ConclusionsIn this observational study, use of early ECMO compared to conventional mechanical ventilation alone in patients who had severe hypoxemic respiratory failure was associated with a lower risk of mortality and a longer length of stay.     

Mechanical ventilation of patients on long-term oxygen therapy with acute exacerbations of chronic obstructive pulmonary disease: prognosis and cost-utility analysis

Astract Objective: To analyze the prognosis and costs of mechanical ventilation in patients with exacerbations of chronic obstructive pulmonary disease (COPD) treated with long-term oxygen therapy. Design: A prospective cohort study. Follow-up at 1 and 5 years. Cost utility analysis. Setting: A medical-surgical intensive care unit (ICU) in a university hospital. Patients: 20 patients with previous COPD treated with long-term oxygen therapy and needing mechanical ventilation due to acute respiratory failure. Measurements and main results: Mortality in the ICU, in-hospital mortality (ICU plus ward), and mortality at 1 and 5 years, and factors associated with prognosis and cost–utility were assessed. The mean Acute Physiology and Chronic Health Evaluation II score was 20 (median 20 range 12–36). Cumulative mortality was 35 % in the ICU, 50 % in hospital, 75 % at 1 year, and 85 % at 5 years. Factors significantly associated with mortality in the ICU were low levels of albumin (p = 0.05) and sodium (p = 0.01) at admission. Patients who died in hospital and in the first year after discharge had a lower forced expiratory volume in 1 s (FEV₁) than survivors (p = 0.03 and p = 0.05, respectively). The cost per Quality Adjusted Life Year (QALY) was U. S. $ 26 283 and U. S. $ 44 602 in a “best” (cost/QALY calculated for the life expectancy in Spain) and a “worst case scenario” (cost/QALY calculated for a 68-year life expectancy), respectively. Conclusions: Applying mechanical ventilation to COPD patients treated with long-term oxygen therapy carries a high mortality and cost. Factors significantly associated with mortality in the ICU were albumin and sodium concentrations and FEV₁ in hospital and in the first year after discharge. Received: 4 August 1998 Final revision received: 28 January 1999 Accepted: 3 February 1999     

Risk factors for prolonged intensive care unit stays in patients after cardiac surgery with cardiopulmonary bypass: A retrospective observational study

ObjectivesPatients after cardiac surgery with cardiopulmonary bypass (CPB) require a stay in the ICU postoperatively. This study aimed to investigate the incidence of prolonged length of stay (LOS) in the ICU after cardiac surgery with CPB and identify associated risk factors.MethodsThe current investigation was an observational, retrospective study that included 395 ICU patients who underwent cardiac surgery with CPB at a tertiary hospital in Guangzhou from June 2015 to June 2017. Data were obtained from the hospital database. Binary logistic regression modeling was used to analyze risk factors for prolonged ICU LOS.ResultsOf 395 patients, 137 (34.7%) had a prolonged ICU LOS (>72.0 h), and the median ICU LOS was 50.9 h. Several variables were found associated with prolonged ICU LOS: duration of CPB, prolonged mechanical ventilation and non-invasive assisted ventilation use, PaO₂/FiO₂ ratios within 6 h after surgery, type of surgery, red blood cell infusion during surgery, postoperative atrial arrhythmia, postoperative ventricular arrhythmia (all P < 0.05).ConclusionsThese findings are clinically relevant for identifying patients with an estimated prolonged ICU LOS, enabling clinicians to facilitate earlier intervention to reduce the risk and prevent resulting delayed recovery.     

Intensive care unit admission in chronic obstructive pulmonary disease: patient information and the physician’s decision-making process

Introduction

ICU admission is required in more than 25% of patients with chronic obstructive pulmonary disease (COPD) at some time during the course of the disease. However, only limited information is available on how physicians communicate with COPD patients about ICU admission.

Methods

COPD patients and relatives from 19 French ICUs were interviewed at ICU discharge about their knowledge of COPD. French pulmonologists self-reported their practices for informing and discussing intensive care treatment preferences with COPD patients. Finally, pulmonologists and ICU physicians reported barriers and facilitators for transfer of COPD patients to the ICU and to propose invasive mechanical ventilation.

Results

Self-report questionnaires were filled in by 126 COPD patients and 102 relatives, and 173 pulmonologists and 135 ICU physicians were interviewed. For 41% (n = 39) of patients and 54% (n = 51) of relatives, ICU admission had never been expected prior to admission. One half of patients were not routinely informed by their pulmonologist about possible ICU admission at some time during the course of COPD. Moreover, treatment options (that is, non-invasive ventilation, intubation and mechanical ventilation or tracheotomy) were not explained to COPD patients during regular pulmonologist visits. Pulmonologists and ICU physician have different perceptions of the decision-making process pertaining to ICU admission and intubation.

Conclusions

The information provided by pulmonologists to patients and families concerning the prognosis of COPD, the risks of ICU admission and specific care could be improved in order to deliver ICU care in accordance with the patient’s personal values and preferences. Given the discrepancies in the decision-making process between pulmonologists and intensivists, a more collaborative approach should probably be discussed.     

Tracheostomy procedures in the intensive care unit: an international survey

IntroductionPercutaneous dilatational tracheostomy (PDT) is one of the most frequent procedures performed in the intensive care unit (ICU). PDT may add potential benefit to clinical management of critically ill patients. Despite this, no clinical guidelines are available. We sought to characterize current practice in this international survey.MethodsAn international survey, endorsed and peer reviewed by European Society of Intensive Care Medicine (ESICM), was carried out from May to October 2013. The questionnaire was accessible from the ESICM website in the ‘survey of the month’ section.Results429 physicians from 59 countries responded to this survey. Single step dilatational tracheostomy was the most used PDT in ICU. Almost 75 % of PDT’s were performed by intensive care physicians. The main indication for PDT was prolonged mechanical ventilation. Tracheostomies were most frequently performed between 7–15 days after ICU admission. Volume control mechanical ventilation, and a combination of sedation, analgesia, neuromuscular blocking agents and fiberoptic bronchoscopy were used. Surgical tracheostomy was mainly performed in ICU by ENT specialists, and was generally chosen when for patients at increased risk for difficult PDT insertion. Bleeding controlled by compression and stoma infection/inflammation were the most common intra-procedural and late complications, respectively. Informed consent for PDT was obtained in only 60 % of cases.ConclusionsThis first international picture of current practices in regard to tracheostomy insertion demonstrates considerable geographic variation in practice, suggesting a need for greater standardization of approaches to tracheostomy insertion.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-1013-7) contains supplementary material, which is available to authorized users.     

Cathelicidin antimicrobial protein,vitamin D,and risk of death in critically ill patients

IntroductionDecreased production of cathelicidin antimicrobial protein-18 (hCAP18) has been proposed to be a key mechanism linking decreased 25-hydroxyvitamin D (25D) levels with adverse outcomes among critically ill patients. However, few studies in humans have directly assessed plasma hCAP18 levels, and no study has evaluated the association between hCAP18 levels and adverse outcomes among critically ill patients.MethodsWe performed a single-center, prospective cohort study among 121 critically ill patients admitted to intensive care units (ICUs) between 2008 and 2012. We measured plasma hCAP18, 25D, D-binding protein, and parathyroid hormone levels on ICU day 1. The primary endpoint was 90-day mortality. Secondary endpoints included hospital mortality, sepsis, acute kidney injury, duration of mechanical ventilation, and hospital length of stay.ResultsICU day 1 hCAP18 levels were directly correlated with 25D levels (Spearman’s rho (r_s) = 0.30, P = 0.001). In multivariate analyses adjusted for age and Acute Physiology and Chronic Health Evaluation II (APACHE II) score, patients with hCAP18 levels in the lowest compared to highest tertile on ICU day 1 had a 4.49 (1.08 to 18.67) greater odds of 90-day mortality, and also had greater odds of sepsis. ICU day 1 levels of other analytes were not associated with 90-day mortality.ConclusionsLower 25D levels on ICU day 1 are associated with lower hCAP18 levels, which are in turn associated with a greater risk of 90-day mortality. These findings provide a potential mechanistic basis for the frequently observed association between low 25D levels and poor outcomes in critically ill patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0812-1) contains supplementary material, which is available to authorized users.     

The influence of clinical variables on the risk of developing chronic conditions in ICU survivors

PurposeTo assess the association of clinical variables and the development of specified chronic conditions in ICU survivors.Materials and methodsA retrospective cohort study, combining a national health insurance claims database and a national quality registry for ICUs. Claims data from 2012 to 2014 were combined with clinical data of patients admitted to an ICU during 2013. To assess the association of clinical variables (ICU length of stay, mechanical ventilation, acute physiology score, reason for ICU admission, mean arterial pressure score and glucose score) and the development of chronic conditions (i.e. heart diseases, COPD or asthma, Diabetes mellitus type II, depression and kidney diseases), logistic regression was used.Results49,004 ICU patients were included. ICU length of stay was associated with the development of heart diseases, asthma or COPD and depression. The reason for ICU admission was an important risk factor for the development of all chronic conditions with adjusted ORs ranging from 2.05 (CI 1.56; 2.69) for kidney diseases to 5.14 (CI 3.99; 6.62) for depression.ConclusionsClinical variables, especially the reason for ICU admission, are associated with the development of chronic conditions after ICU discharge. Therefore, these clinical variables should be considered when organizing follow-up care for ICU survivors.     

Automated versus non-automated weaning for reducing the duration of mechanical ventilation for critically ill adults and children: a cochrane systematic review and meta-analysis

IntroductionAutomated weaning systems may improve adaptation of mechanical support for a patient’s ventilatory needs and facilitate systematic and early recognition of their ability to breathe spontaneously and the potential for discontinuation of ventilation. Our objective was to compare mechanical ventilator weaning duration for critically ill adults and children when managed with automated systems versus non-automated strategies. Secondary objectives were to determine differences in duration of ventilation, intensive care unit (ICU) and hospital length of stay (LOS), mortality, and adverse events.MethodsElectronic databases were searched to 30 September 2013 without language restrictions. We also searched conference proceedings; trial registration websites; and article reference lists. Two authors independently extracted data and assessed risk of bias. We combined data using random-effects modelling.ResultsWe identified 21 eligible trials totalling 1,676 participants. Pooled data from 16 trials indicated that automated systems reduced the geometric mean weaning duration by 30% (95% confidence interval (CI) 13% to 45%), with substantial heterogeneity (I² = 87%, P <0.00001). Reduced weaning duration was found with mixed or medical ICU populations (42%, 95% CI 10% to 63%) and Smartcare/PS™ (28%, 95% CI 7% to 49%) but not with surgical populations or using other systems. Automated systems reduced ventilation duration with no heterogeneity (10%, 95% CI 3% to 16%) and ICU LOS (8%, 95% CI 0% to 15%). There was no strong evidence of effect on mortality, hospital LOS, reintubation, self-extubation and non-invasive ventilation following extubation. Automated systems reduced prolonged mechanical ventilation and tracheostomy. Overall quality of evidence was high.ConclusionsAutomated systems may reduce weaning and ventilation duration and ICU stay. Due to substantial trial heterogeneity an adequately powered, high quality, multi-centre randomized controlled trial is needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0755-6) contains supplementary material, which is available to authorized users.     

Cerebral blood flow and cerebral oxygen consumption in patients with COPD on mechanical ventilation

Objective To investigate the effect of PaCO₂ on cerebral blood flow (CBF) in chronic obstructive pulmonary disease (COPD).Design Before-after trial.Setting General ICU in a regional hospital.Patients 7 patients undergoing mechanical ventilation because of an exacerbation of COPD.Intervention CBF and cerebral metabolic rate of oxygen (CMRO₂) of COPD were measured before and after hyperventilation and were compaired by those of normal patients. CBF was measured by the Kety-Schmidt technique using 15% N₂O.Measurements/results Hyperventilation produced a significant reduction in CBF in COPD with no concomitant change in CMRO₂. CMRO₂ in COPD was significantly lower than those in normal patients. The regression equation was shifted significantly more to the right in COPD.Conclusion The sensitivity of CBF in CO₂ remained but CMRO₂ was reduced markedly in COPD patients.     

Incidence and short-term consequences of delirium in critically ill patients: A prospective observational cohort study

BackgroundDelirium is a serious and frequent psycho-organic disorder in critically ill patients. Reported incidence rates vary to a large extent and there is a paucity of data concerning delirium incidence rates for the different subgroups of intensive care unit (ICU) patients and their short-term health consequences.ObjectivesTo determine the overall incidence and duration of delirium, per delirium subtype and per ICU admission diagnosis. Furthermore, we determined the short-term consequences of delirium.DesignProspective observational study.Participants and settingAll adult consecutive patients admitted in one year to the ICU of a university medical centre.MethodsDelirium was assessed using the Confusion Assessment Method-ICU three times a day. Delirium was divided in three subtypes: hyperactive, hypoactive and mixed subtype. As measures for short-term consequences we registered duration of mechanical ventilation, re-intubations, incidence of unplanned removal of tubes, length of (ICU) stay and in-hospital mortality.Results1613 patients were included of which 411 (26%) developed delirium. The incidence rate in the neurosurgical (10%) and cardiac surgery group (12%) was the lowest, incidence was intermediate in medical patients (40%), while patients with a neurological diagnosis had the highest incidence (64%). The mixed subtype occurred the most (53%), while the hyperactive subtype the least (10%). The median delirium duration was two days [IQR 1–7], but significantly longer (P < 0.0001) for the mixed subtype. More delirious patients were mechanically ventilated and for a longer period of time, were more likely to remove their tube and catheters, stayed in the ICU and hospital for a longer time, and had a six times higher chance of dying compared to non-delirium ICU patients, even after adjusting for their severity of illness score. Delirium was associated with an extended duration of mechanical ventilation, length of stay in the ICU and in-hospital, as well as with in-hospital mortality.ConclusionsThe delirium incidence in a mixed ICU population is high and differs importantly between ICU admission diagnoses and the subtypes of delirium. Patients with delirium had a significantly higher incidence of short-term health problems, independent from their severity of illness and this was most pronounced in the mixed subtype of delirium. Delirium is significantly associated with worse short-term outcome.     

Incidence of and risk factors for post–intensive care syndrome among Chinese respiratory intensive care unit patients: A cross-sectional,prospective study

BackgroundPatients transferred from the respiratory intensive care unit (ICU) can experience post–intensive care syndrome (PICS), which comprises cognitive, psychological, and physical disorders that seriously affect the quality of life. Therefore, it was necessary to explore the incidence of and the risk factors for PICS among respiratory ICU patients.ObjectivesThis study evaluated PICS among respiratory ICU patients and explored the risk factors for PICS.MethodsThis cross-sectional, prospective study was performed at one hospital in China. Using convenience sampling, 125 respiratory ICU patients from August 2018 to June 2019 were recruited for the study. The Mini-Mental State Examination, Confusion Assessment Method for the Intensive Care Unit, Hospital Anxiety and Depression Scale, Medical Research Council Scale, activities of daily living scale, Pittsburgh Sleep Quality Index, and the 14-item fatigue scale were used to comprehensively assess the patients' cognitive status, psychological status, and physiological status when entering the ICU and 2 weeks after leaving the ICU. Factors affecting PICS were measured using researcher-created questionnaires of patients’ general information and disease-related information.ResultsFifteen patients were lost to follow-up. Fifty-nine patients had PICS (incidence rate, 53.6%). Logistic regression showed that risk factors for PICS were age, invasive mechanical ventilation, noninvasive ventilator-assisted ventilation, and coronary heart disease (P < 0.05).ConclusionThe PICS incidence was high. Older age, longer invasive mechanical ventilation times, longer noninvasive ventilator times, and coronary heart disease were risk factors for PICS. ICU medical workers in China should pay more attention on PICS, know the risk factors, and implement preventive measures.     

Virus infection in exacerbations of chronic obstructive pulmonary disease requiring ventilation

Objectives We aimed to characterise and quantify the incidence of common infectious agents in acute exacerbations of chronic obstructive pulmonary disease (COPD) requiring ventilation, with a focus on respiratory viruses.Design An epidemiological study conducted over 3 years.Setting A 12-bed intensive care unit (ICU).Participants ICU patients over 45 years of age with a primary diagnosis of COPD exacerbation requiring non-invasive ventilation (NIV) or ventilation via endotracheal tube (ETT).Materials and methods Nasopharyngeal aspirates (NPA) and posterior pharyngeal swabs (PS) were tested for viruses with immunofluorescence assay (IFA), virus culture (VC) and polymerase chain reaction (PCR). Paired virus and atypical pneumonia serology assays were taken. Blood, sputum and endotracheal aspirates were cultured for bacteria.Results 107 episodes in 105 patients were recorded. Twenty-three (21%) died within 28 days. A probable infectious aetiology was found in 69 patient episodes (64%). A virus was identified in 46 cases (43%), being the sole organism in 35 cases (33%) and part of a mixed infection in 11 cases (10%). A probable bacterial aetiology was found in 25 cases (23%). There was no statistically significant difference in clinical characteristics or outcomes between the group with virus infections and that without.Conclusion Forty-six (43%) of the patients with COPD exacerbation requiring mechanical ventilation had a probable viral pathogen. Prodromal, clinical and outcome parameters did not distinguish virus from non-virus illness. PCR was the most sensitive whilst virus culture was the least of virus assays.Electronic supplementary material The electronic reference of this article is . The online full-text version of this article includes electronic supplementary material. This material is available to authorised users and can be accessed by means of the ESM button beneath the abstract or in the structured full-text article. To cite or link to this article you can use the above reference.The study was self-funded by internal grants from the Central Coast Health Services Research Fund and the Hunter Area Pathology Service. There was no funding from pharmaceutical or other commercial organisations or agencies.There was no conflict of interest.This article is discussed in the editorial available at:     

Pre-existing atrial fibrillation and risk of arterial thromboembolism and death in intensive care unit patients: a population-based cohort study

IntroductionPre-existing atrial fibrillation (AF) may worsen prognosis in patients admitted to the intensive care unit (ICU).MethodsIn a cohort study (2005–2011) including all patients with first-time ICU admissions in Denmark (n=57,110), we compared patients with and without pre-existing AF and estimated absolute risks and relative risks (RRs) of arterial thromboembolism and death within 30 days and 365 days following admission, using Kaplan-Meier methods and multivariate regression analyses. We analysed the prognostic impact of AF within strata of patient age, sex, coexisting cardiac diseases, and ICU therapies.ResultsAmong ICU patients, 5065 (9 %) had pre-existing AF. Compared with patients without AF, those with AF were older (median age 75 vs. 62 years) and had more comorbidity. The risk of arterial thromboembolism was 2.8 % in patients with AF and 2.0 % in non-AF patients at 30 days, and 4.3 % and 2.9 %, respectively, at 365 days. Corresponding RRs were 1.41 crude and 1.14 (95 % confidence interval [CI] 0.93–1.40) adjusted at 30 days, and 1.50 crude and 1.20 (95 % CI 1.02–1.41) adjusted at 365 days. Thirty-day mortality was 27 % in patients with pre-existing AF and 16 % in non-AF patients (crude RR 1.67, adjusted RR 1.04, 95 % CI 0.99–1.10). Corresponding mortality estimates at 365 days were 40.9 % and 25.4 %, respectively (crude RR 1.61, adjusted RR 1.03, 95 % CI 1.00–1.07). In stratified analyses, pre-existing AF increased mortality in ICU patients aged <55 years (adjusted RR at 30 days 1.73, 95 % CI 1.29–2.32; adjusted RR at 365 days 1.34, 95 % CI 1.06–1.69) and in ICU patients treated with mechanical ventilation (adjusted RR at 30 days 1.12, 95 % CI 1.05–1.20, adjusted RR at 365 days 1.09, 95 % CI: 1.04–1.15). Analyses stratified by sex and coexisting cardiac diseases yielded adjusted RRs close to 1.ConclusionsIn ICU patients, pre-existing AF was associated with modestly increased risk of arterial thromboembolism when adjusted for the substantially higher age and comorbidity levels in patients with AF, whereas there was no overall association with mortality. In ICU patients aged <55 years and in those treated with mechanical ventilation, AF predicted increased mortality.

Electronic supplementary material

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Early deep sedation is associated with decreased in-hospital and two-year follow-up survival

IntroductionThere is increasing evidence that deep sedation is detrimental to critically ill patients. The aim of this study was to examine effects of deep sedation during the early period after ICU admission on short- and long-term survival.MethodsIn this observational, matched-pair analysis, patients receiving mechanical ventilation that were admitted to ICUs of a tertiary university hospital in six consecutive years were grouped as either lightly or deeply sedated within the first 48 hours after ICU admission. The Richmond Agitation-Sedation Score (RASS) was used to assess sedation depth (light sedation: −2 to 0; deep: −3 or below). Multivariate Cox regression was conducted to investigate the impact of early deep sedation within the first 48 hours of admission on in-hospital and two-year follow-up survival.ResultsIn total, 1,884 patients met inclusion criteria out of which 27.2% (n = 513) were deeply sedated. Deeply sedated patients had longer ventilation times, increased length of stay and higher rates of mortality. Early deep sedation was associated with a hazard ratio of 1.661 (95% CI: 1.074 to 2.567; P = 0.022) for in-hospital survival and 1.866 (95% CI: 1.351 to 2.576; P <0.001) for two-year follow-up survival.ConclusionsEarly deep sedation during the first 48 hours of intensive care treatment was associated with decreased in-hospital and two-year follow-up survival. Since early deep sedation is a modifiable risk factor, this data shows an urgent need for prospective clinical trials focusing on light sedation in the early phase of ICU treatment.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0929-2) contains supplementary material, which is available to authorized users.     

Long-term survival according to ventilation mode in acute respiratory failure secondary to chronic obstructive pulmonary disease: A multicenter,inception cohort study

Purpose

The aim of the study was to investigate 5-year survival stratified by mechanical ventilation modality in chronic obstructive pulmonary disease (COPD) patients treated in the ICU.

Materials and Methods

Prospective, observational study of COPD patients with acute respiratory failure admitted to 9 multidisciplinary ICUs in Sweden. Characteristics on admission, including illness severity scores and the first blood gas, and survival were analyzed stratified by ventilation modality (noninvasive [NIV] vs invasive mechanical ventilation).

Results

Ninety-three patients, mean age of 70.6 (SD, 9.6) years, were included. Sixteen patients were intubated immediately, whereas 77 were started on NIV. Patients who were started on NIV had a lower median body mass index (BMI) (21.9 vs 27.0; P < .01) and were younger compared to those who were intubated immediately (median age, 70 vs 74.5 years; P < .05). There were no differences in the initial blood gas results between the groups. Long-term survival was greater in patients with NIV (P < .05, log rank). The effect of NIV on survival remained after including age, Acute Physiology and Chronic Health Evaluation II score, and BMI in a multivariate Cox regression model (NIV hazard ratio, 0.44; 95% confidence interval, 0.21-0.92). Fifteen patients with failed NIV were intubated and mechanically ventilated. Long-term survival in patients with failed NIV was not significantly different from patients who were intubated immediately.

Conclusion

The short-term survival benefit of NIV previously found in randomized controlled trials still applies after 5 years of observation.     

Subglottic secretion drainage for preventing ventilator associated pneumonia: A meta-analysis

BackgroundVentilator associated pneumonia (VAP) in the intensive care unit (ICU) has been shown to be associated with significant morbidity and mortality.1, 2, 3 It has been reported to affect between 9 and 27% of intubated patients receiving mechanical ventilation.4, 5, 6ObjectiveA meta-analysis was undertaken to combine information from published studies of the effect of subglottic drainage of secretions on the incidence of ventilated associated pneumonia in adult ICU patients.Data sourcesStudies were identified by searching MEDLINE (1966 to January 2011), EMBASE (1980–2011), and CINAHL (1982 to January 2011).Review methodsRandomized trials of subglottic drainage of secretions compared to usual care in adult mechanically ventilated ICU patients were included in the meta-analysis.ResultsSubglottic drainage of secretions was estimated to reduced the risk of VAP by 48% (fixed-effect relative risk (RR) = 0.52, 95% confidence interval (CI), 0.42–0.65). When comparing subglottic drainage and control groups, the summary relative risk for ICU mortality was 1.05 (95% CI, 0.86–1.28) and for hospital mortality was 0.96 (95% CI, 0.81–1.12). Overall subglottic drainage effect on days of mechanical ventilation was ?1.04 days (95% CI, ?2.79–0.71).ConclusionThis meta-analysis of published randomized control trials shows that almost one-half of cases of VAP may be prevented with the use of specialized endotracheal tubes designed to drain subglottic secretions. Time on mechanical ventilation may be reduced and time to development of VAP may be increased, but no reduction in ICU or hospital mortality has been observed in published trials.