Chronic Critical Illness: The Limbo Between Life and Death

The entity of chronic critical illness (CCI) has shown a rise in the past decades for popularity and prevalence. CCI is loosely defined as the group of patients who require the intensive care setting for weeks to months; its hallmark is prolonged mechanical ventilation. The outcomes of chronically critically ill patients have been dismal and have not improved over time; 1-year survival hovers at approximately 50%. Given the high mortality, prognostic variables are important when making medical decisions. CCI encompasses a syndrome that includes altered pathophysiology across a variety of organ systems. Another crucial element of CCI is the symptom burden that patients experience which include feelings of dyspnea, difficulty communicating and pain. This patient population necessitates the combined efforts of multiple care teams and the early integration of palliative and critical care. Future directions need to include improving the symptom management and communication for patients with CCI.     

Patient characteristics and outcomes of a provincial prolonged-ventilation weaning centre: A retrospective cohort study

BACKGROUND:

Growing numbers of critically ill patients require prolonged mechanical ventilation and experience difficulty with weaning. Specialized centres may facilitate weaning through focused interprofessional expertise with an emphasis on rehabilitation.

OBJECTIVE:

To characterize the population of a specialized prolonged-ventilation weaning centre (PWC) in Ontario, and to report weaning, mobility, discharge and survival outcomes.

METHODS:

Data from consecutively admitted patients were retrospectively extracted from electronic and paper medical records by research staff and verified by the primary investigator.

RESULTS:

From January 2004 to March 2011, 144 patients were admitted: 115 (80%) required ventilator weaning, and 29 (20%) required tracheostomy weaning or noninvasive ventilation. Intensive care unit length of stay before admission was a median 51 days (interquartile range [IQR] 35 to 86 days). Of the patients admitted for ventilator weaning, 76 of 115 (66% [95% CI 55% to 75%]) achieved a 24 h tracheostomy mask trial in a median of 15 days (IQR eight to 25 days). Weaning success, defined as no further ventilation for seven consecutive days, was achieved by 61 patients (53% [95% CI 44% to 62%]) in a median duration of 62 days (IQR 46 to 95 days) of ventilation, and 14 days (IQR nine to 29 days) after PWC admission. Seventeen patients died during admission. Of the 91 patients discharged from the PWC for one year, 43 (47.3% [95% CI 37.3% to 57.4%]) survived; of the 78 discharged for two years, 27 (34.6% [95% CI 25.0% to 45.7%]) were alive; of the 53 discharged for three years, 19 (35.9% [95% CI 24.3% to 49.3%]) were alive; and seven of 22 (31.8% [95% CI 16.4% to 52.7%]) survived to five years.

CONCLUSIONS:

Weaning success was moderate despite a prolonged intensive care unit stay before admission, but was comparable with studies reporting weaning outcomes from centres in other countries. Few patients survived to five years.     

自主呼吸试验在撤离呼吸机中的作用

目的 探讨自主呼吸试验(SBT)在机械通气的撤离、拔除气管插管过程中的作用.方法 采用前瞻性随机对照方法,选择67例机械通气超过48 h的患者,当所有患者达到撤离呼吸机状态时将其随机(采用从密封信封中抽取随机号的方法)分为自主呼吸试验组(SBT组,35例)和无自主呼吸试验组(NO-SBT组,32例)两组.SBT组患者顺利通过SBT后随即拔除气管插管,NO-SBT组患者在达到撤离呼吸机条件后,不进行SBT,即拔除气管插管.以拔除气管插管的成功率作为评判的主要指标,成功的标志为拔除气管插管后能维持自主呼吸48 h以上.两组均数的比较采用两个独立样本的t检验,频数的比较采用X~2检验.结果 两组患者在拔除气管插管前的一般状况、呼吸生理和血流动力学等指标比较差异无统计学意义;年龄、性别、气管插管的口径、疾病的严重程度和疾病种类相似,机械通气的时间比较差异尢统计学意义.两组各有3例患者再次气管插管(X~2=0.013,P=0.908).两组患者拔除气管插管后,需无创辅助通气的患者NO-SBT组为5例,SBT组为4例(X~2=0.253,P=0.727).两组患者医院内病死率[N0-SBT组为12.5%(4/32),SBT组为9.7%(3/35),X~2=0.311,P=0.600]差异无统计学意义.结论 SBT可能不是拔除气管插管前的必需过程.     

闭环通气在常规通气及脱机阶段的进展

闭环通气模式应用于临床已经多年,它在常规通气阶段能有效维持患者呼吸,减轻医护人员的劳动强度,减少血气分析的检查次数.目前应用于l临床的Smartcare模式智能化程度更高,不仅可更早自动识别患者是否具备停机条件,使患者尽快安全脱机,而且还可用于脱机较为困难的患者(如慢性阻塞性肺疾病急性发作),值得临床推荐使用.     

自主呼吸试验在COPD机械通气患者撤机中的作用

目的评估自主呼吸试验（SBT）在COPD机械通气患者撤机过程中的作用。方法选择52例COPD机械通气撤机成功的患者,分为两组：S组24例,采用SBT方式撤机拔管;NS组28例,采用逐渐降低机械通气支持水平的方式撤机拔管。对比两组患者的拔管时间、住重症监护病房（ICU）时间、呼吸机相关性肺炎（VAP）发生率、48 h内再插管率以及住院病死率。结果 S组与NS组的拔出气管插管时间120 min和（300.01±65.23）min）、住ICU时间（9.50±4.20）d和（18.60±10.30）d、VAP发生率12.50%和28.57%,均有统计学差异（P〈0.05）,而48 h内再插管率20.83%和21.43%、ICU病死率16.67%和17.85%,无统计学差异（P〉0.05）。结论应用SBT法撤机比渐减机械通气支持水平的方法具有更早拔出气管插管、住ICU时间短的优点,而且降低了VAP的发生率。     

Comparison of high flow oxygen therapy versus noninvasive mechanical ventilation for successful weaning from invasive ventilation in children: An observational study

Post-extubation respiratory failure is associated with a poor prognosis due to increased ventilator-associated pneumonia, and longer length of stay in the ICU and hospital. In this study, we aimed to evaluate the efficacy of high-flow nasal cannula (HFNC) and noninvasive mechanical ventilation (NIMV) on extubation success in children. A total of 48 patients, aged between 1 month and 18 years, who were weaned to either NIMV or HFNC were included. Patients who had tracheostomy or were not weaned and underwent unplanned extubation were excluded. Age, gender, anthropometric parameters, Pediatric Risk of Mortality and Pediatric Logistic Organ Dysfunction scores, oxygenation index, mechanical ventilation length of stay (LOS), HFNC/NIMV LOS, Modified Downes-Silverman score (MDS), and venous blood gas parameters, pediatric intensive care unit (PICU) LOS were recorded. 24 patients were extubated to NIMV, and 24 patients to HFNC. HFNC LOS and NIMV LOS were similar (P = .621). The failure rates at the 48th hour of HFNC and NIMV were 33% (n = 8), and 33% respectively (n = 8) (P = 1.0). PICU LOS and mortality rate was also similar (P = .06, P = .312 respectively). MDS decreased significantly in both groups (P < .001, P = .02 respectively). Changes in blood gas parameters and MDS within the first 48-hour of device application were similar between the 2 groups. HFNC is not inferior to NIMV in patients with extubation difficulty or those expected to have such difficulty in terms of treatment success, PICU LOS, and mortality. Therefore, HFNC appears to be a weaning technique alternative to NIMV after extubation.     

气道闭合压及其衍生参数在撤离机械通气中的应用研究进展

气道闭合压(P0.1)是一项能够较好的反映呼吸中枢驱动的指标.这一指标及其衍生参数如P0.1与最大吸气压比值(P0.1/MIP)和P0.1与浅快呼吸指数(f/Vt)的乘积(P0.1*f/Vt)可以和其他传统的指标一样用于判断撤离机械通气的预后,并且P01/MIP增加了P0.1单独判断急性呼吸衰竭患者对机械通气需求程度的...     

Inpatient and long‐term outcomes of individuals admitted for weaning from mechanical ventilation at a specialized ventilation weaning unit

Background: Weaning from invasive mechanical ventilation (IMV) in specialized weaning units has been demonstrated to be safe and cost‐effective. Success rates and outcomes vary widely, probably relating to patient factors and unit expertise. Methods: An audit was undertaken of patients admitted for weaning from IMV at the Austin Hospital Ventilation Weaning Unit (VWU) between March 2002 and January 2008. Weaning success, complications and both in‐hospital and long‐term mortality were examined and regression analysis was undertaken to examine factors related to these outcomes. Results: Seventy‐eight patients were admitted to the VWU after a median of 27 days of IMV at their referring centre. Weaning success rate (ventilator free or nocturnal non‐invasive ventilation only) was 78.2% (n = 61). Inpatient mortality was 10.2% (n = 8) and serious complications were infrequent. Progressive neuromuscular disease (odds ratio 0.10) and sepsis during admission to the VWU (odds ratio 0.09) were predictive of weaning failure at discharge. Overall survival at 12 months following discharge from the VWU was 66.7% (n = 52) with most survivors residing in the community. Increasing age (hazard ratio 1.93), referral from rural or outer metropolitan centres (hazard ratio 3.57 and 2.37 respectively) and a diagnosis of chronic obstructive pulmonary disease were associated with increased long‐term mortality. Conclusion: High rates of weaning success with infrequent complications and low mortality were achieved in this specialized non‐intensive care unit‐based weaning unit. The VWU may provide a useful template for the development of similar units elsewhere.     

PCT及CRP在肺部感染患者机械通气撤机中的预测价值

目的探讨血浆降钙素原(procalcitonin,PCT)及C反应蛋白(CRP)水平与肺部感染患者机械通气撤机结局间的关系。方法回顾性分析入住广安门医院重症监护病房的重症肺部感染患者30例,在患者入院第二天及达到撤机标准行自主呼吸试验(spontaneous breathing trials,SBT)前检测PCT及CRP水平,如通过SBT则予撤机拔管。根据48 h内的撤机结局,将患者分为成功组及失败组。比较两组间性别、年龄、APACHEⅡ评分、机械通气时间、PCT及CRP水平,绘制受试者工作特征曲线(receiver operating characteristic curve,ROC曲线),计算曲线下面积(area under curve,AUC),评价PCT及CRP水平对撤机结局的预测价值。结果 30例患者中,撤机成功组24例,失败组6例,两组男女比例、年龄及APACHEⅡ评分、机械通气时间、入院第二天PCT及CRP水平差异无统计学意义(P0.05)。撤机成功组撤机前PCT及CRP水平均较失败组低(P0.05)。PCT的ROC曲线下面积(AUC)为(0.885±0.061),最佳截点值为0.71 ng/ml,此时的敏感度为83.3%,特异性为20.8%;CRP的ROC曲线下面积(AUC)为(0.382±0.138)(P0.05)。结论 PCT在预测肺部感染患者撤机结局中有一定价值,可作为撤机参考指标之一。     

机械通气患者不同脱机方法的应用研究

目的机械通气患者不同脱机方法效果比较。方法64例患者均予机械通气支持24h以上。首先应用A／C通气模式进行机械通气,获得适合于患者的基础通气参数、基础血流动力学和氧动力学参数。患者病情稳定并具备撤机条件时,随机选用SIMV＋PSV、Bilevel、VS、PSV＋TC脱机模式,相应分为SIMV＋PSV组、Bilevel组、VS组和PSV＋TC组（每组n=16）。结果四种脱机方式患者的疾病严重度、其VT、f、PaO2／FiO2在四种脱机方式间无显著差异（P〉0．05）。呼吸形式和血气的改变差异也无显著性（P均〉0．05）。Bilevel组、VS组、PSV＋1、C组脱机时间比SIMV＋PSV组短,比较差异有统计学意义。PSV＋TC组脱机时间比Bilevel组、VS组短,比较差异有统计学意义（P〈0．05）。四组再插管率比较差异无统计学意义。结论四种脱机方式中Bilevel、VS和PSV＋TC优于SIMV＋PSV方式,且PSV＋TC最好。     

新生儿机械通气撤机失败的影响因素及预测指标分析

目的 探讨导致新生儿机械通气撤机失败的影响因素及寻找预测指标减少撤机失败率.方法 回顾性分析我院2015年1月至2019年12月新生儿重症监护病室350例机械通气时间≥72 h并存活的新生儿.根据撤机48 h内是否再次插管,分为撤机成功组与撤机失败组.比较两组撤机前一般情况、临床变量、呼吸机设置及血气分析,撤机后无创通...     

The association between obesity and outcomes in critically ill patients

BACKGROUND:

Obesity rates are increasing worldwide, particularly in North America. The impact of obesity on the outcome of critically ill patients is unclear.

METHODS:

A prospective observational cohort study of consecutive patients admitted to a tertiary critical care unit in Canada between January 10, 2008 and March 31, 2009 was conducted. Exclusion criteria were age <18 years, admission <24 h, planned cardiac surgery, pregnancy, significant ascites, unclosed surgical abdomen and brain death on admission. Height, weight and abdominal circumference were measured at the time of intensive care unit (ICU) admission. Coprimary end points were ICU mortality and a composite of ICU mortality, reintubation, ventilator-associated pneumonia, line sepsis and ICU readmission. Subjects were stratified as obese or nonobese, using two separate metrics: body mass index (BMI) ≥30 kg/m² and a novel measurement of 75th percentile for waist-to-height ratio (WHR).

RESULTS:

Among 449 subjects with a BMI ≥18.5 kg/m², both BMI and WHR were available for comparative analysis in 348 (77.5%). Neither measure of obesity was associated with the primary end points. BMI ≥30 kg/m² was associated with a lower odds of six-month mortality than the BMI <30 kg/m² group (adjusted OR 0.59 [95% CI 0.36 to 0.97]; P=0.04) but longer intubation times (adjusted RR 1.56 [95% CI 1.17 to 2.07]; P=0.003) and longer ICU length of stay (adjusted RR 1.67 [95% CI 1.21 to 2.31]; P=0.002). Conversely, measurement of 75th percentile for WHR was associated only with decreased ICU readmission (OR 0.23 [95% CI 0.07 to 0.79]; P=0.02).

CONCLUSIONS:

Obesity was not necessarily associated with worse outcomes in critically ill patients.     

神经外科重症监护医学助推神经外科发展得更快、更高、更强

神经外科重症监护在神经外科危重疾病的治疗中起至关重要的作用。由于中国神经外科重症监护的学科建设滞后于西方发达国家,并且受各地区经济发展、神经外科科室规模、技术水平差异较大等因素的制约,故仍处于起步阶段。作者借鉴国外神经外科重症的发展历史,回顾中国神经外科重症监护二十多年的发展历史过程,期待对神经外科重症监护的科室建设、理念的形成以及专业队伍的扩大等方面,起到积极的促进作用,并助推神经外科向更高、更难、更强的领域进步与发展。     

The role of non-invasive home mechanical ventilation in patients with chronic obstructive pulmonary disease requiring prolonged weaning

Background and objective: Patients with COPD who require prolonged weaning from invasive mechanical ventilation show poor long‐term survival. Whether non‐invasive home mechanical ventilation (HMV) has a beneficial effect after prolonged weaning has not yet been clearly determined. Methods: Patients with COPD who required prolonged weaning and were admitted to a specialized weaning centre between January 2002 and February 2008 were enrolled in the study. Long‐term survival and prognostic factors, including the role of non‐invasive HMV, were evaluated. Results: Of 117 patients (87 men, 30 women; mean age 69.5 ± 9.5 years) included in the study, weaning from invasive ventilation was achieved in 82 patients (70.1%). Successful weaning was associated with better survival 1 year after discharge from hospital (hazard ratio (HR) 2.24, 95% CI: 1.16–4.31; P = 0.016). Among the 82 patients who were successfully weaned, non‐invasive HMV was initiated in 39 (47.6%) due to persistent chronic ventilatory failure. Initiation of HMV was associated with a higher rate of survival to 1 year as compared with patients who did not receive ventilatory support (84.2% vs 54.3%; HR 3.68, 95% CI: 1.43–9.43; P = 0.007). In addition, younger age and higher PaO₂, haemoglobin concentration and haematocrit at discharge were associated with better survival. In an adjusted multivariate analysis, initiation of non‐invasive HMV after successful weaning remained an independent prognostic factor for survival to 1 year (HR 3.63, 95% CI: 1.23–10.75; P = 0.019). Conclusions: These findings suggest that based on the potential for improvement in long‐term survival, non‐invasive HMV should be considered in patients with severe COPD and persistent chronic hypercapnic respiratory failure after prolonged weaning.     

Effect of early progressive mobilization on intensive care unit-acquired weakness in mechanically ventilated patients: An observational study

Early progressive mobilization is usually considered as an effective method for intensive care unit-acquired weakness (ICU-AW), but the controversies on this topic remain debatable, especially in initiation time, safety profile, and other implementation details. So, more studies should be performed to solve these disputes. A set of critically ill patients underwent mechanical ventilation in intensive care unit (ICU) of our hospital from March 2018 to September 2020 were included as study object. Patients received early progressive mobilization were included into the intervention group (n = 160), and another patients matched with the intervention group by gender, age, and APACHE II score, and these patients received routine intervention were included into the control group (n = 160). Then, indexes involving muscle strength, Barthel index, functional independence, incidence rates of ICU-AW and other complications were comparatively analyzed between the 2 groups. The Medical Research Council score and Barthel index score in the intervention group were significantly higher than those in the control group (all P < .05). The percentages of patients who were able to complete taking a shower, wearing clothes, eating, grooming, moving from bed to chair and using the toilet by alone in the intervention group were significantly higher than those in the control group (69.38% vs 49.38%, 73.13% vs 51.88%, 81.25% vs 55.63%, 74.38% vs 48.75%, 82.50% vs 65.63%, 78.13% vs 63.13%, respectively, all P < .05). The incidence rate of ICU-AW and overall incidence rate of complications in the intervention group were significantly lower than those in the control group (6.88% vs 28.13% and 23.13% vs 48.13%, both P < .05). Early progressive mobilization can effectively increase muscle strength and daily basic motion ability, improve functional status, and decrease risk of ICU-AW in critically ill patients underwent mechanical ventilation, and it has an attractive application value in clinic.     

重症监护室住院机械通气患者GER与呼吸机相关性肺炎相关性分析

目的分析重症监护室住院机械通气患者GER与呼吸机相关性肺炎（VAP）发生的相关性。 方法收集2016年5月至2017年6月,新疆维吾尔自治区人民医院重症监护室住院并进行机械通气治疗的65例重症患者,分别在机械通气治疗第1、2、3及5天时收取气管分泌物,采用ELISA法检测标本中胃蛋白酶浓度,并对患者进行临床肺部感染分析,以分析胃蛋白酶浓度与VAP关系。 结果65例患者在第1天气管胃蛋白酶阳性检出率为12.31%,第2天阳性检出率为40.00%,第3天阳性检出率为66.15％,第5天阳性检出率80.00%,随机械通气时间延长而阳性检出率增高（P<0.05）;65例患者中有28例发生VAP,VAP患者第2、3及5天时气管分泌物中胃蛋白酶浓度均显著高于非VAP患者,差异有统计学意义（P<0.05）;VAP患者气管胃蛋白酶浓度与VAP发生呈正相关（R>0,P<0.05）。 结论随机械通气时间延长而阳性检出率增高,VAP患者气管胃蛋白酶浓度显著高于非VAP患者,VAP患者气管胃蛋白酶浓度与CPIS评分正相关。     

The clinical course of critically ill COVID-19 patients receiving invasive mechanical ventilation with subsequent terminal weaning: Primary data from 11 cases

The coronavirus disease (COVID-19) outbreak was first reported in December 2019 in Wuhan, China. Specific information about critically ill COVID-19 patients receiving invasive mechanical ventilation (IMV) is rare.To describe the clinical course and complications of critically ill patients with COVID-19 who received IMV and were successfully weaned from it.This retrospective study included patients admitted to 3 intensive care units (ICUs) and 1 sub-ICU of Renmin Hospital of Wuhan University and Wuhan Jin Yin-tan Hospital between December 24, 2019, and March 12, 2020. Eleven patients who had been diagnosed with critically ill COVID-19 according to the World Health Organization interim guidance, received invasive ventilation, and were finally successfully weaned from it, were enrolled in our study. Their presenting symptoms, comorbidity conditions, laboratory values, ICU course, ventilator parameters, treatments, and relative complications were recorded.Of 108 critically ill COVID-19 patients who received invasive ventilation, 11 patients who underwent tracheal extubation or terminal weaning were included. The mean age of the 11 patients was 52.8 years (range, 38–70 years), 8 (72.7%) were male, and 2 were health care workers. The median time from onset of symptoms to dyspnea was 6.6 days (range, 3–13 days), and the median duration of IMV was 15.7 days (range, 6–29 days). All 11 patients presented with acute severe hypoxemic respiratory failure and received IMV, and 1 patient switched to extracorporeal membrane oxygenation assistance. A lung-protective strategy with lower tidal volume ventilation and proper driving pressure is the main strategy of IMV. All patients had extrapulmonary manifestations, including acute kidney injury, hepatic dysfunction, myocardial damage, and/or lymphopenia. Hospital-acquired infections occurred in 7 (63.6%) patients.Critical COVID-19 illness is characterized by acute hypoxemic respiratory failure and subsequent dysfunction of other organs with a high mortality rate. Correct ventilation strategies and other clinical strategies to improve oxygenation based on the skilled trained group and the availability of equipment are the key methods to rescue lives.