Abstract
Crit Care Sci. 2024;36:e20240210en
DOI 10.62675/2965-2774.20240210-en
Driving pressure has been suggested to be the main driver of ventilator-induced lung injury and mortality in observational studies of acute respiratory distress syndrome. Whether a driving pressure-limiting strategy can improve clinical outcomes is unclear.
To describe the protocol and statistical analysis plan that will be used to test whether a driving pressure-limiting strategy including positive end-expiratory pressure titration according to the best respiratory compliance and reduction in tidal volume is superior to a standard strategy involving the use of the ARDSNet low-positive end-expiratory pressure table in terms of increasing the number of ventilator-free days in patients with acute respiratory distress syndrome due to community-acquired pneumonia.
The ventilator STrAtegy for coMmunIty acquired pNeumoniA (STAMINA) study is a randomized, multicenter, open-label trial that compares a driving pressure-limiting strategy to the ARDSnet low-positive end-expiratory pressure table in patients with moderate-to-severe acute respiratory distress syndrome due to community-acquired pneumonia admitted to intensive care units. We expect to recruit 500 patients from 20 Brazilian and 2 Colombian intensive care units. They will be randomized to a driving pressure-limiting strategy group or to a standard strategy using the ARDSNet low-positive end-expiratory pressure table. In the driving pressure-limiting strategy group, positive end-expiratory pressure will be titrated according to the best respiratory system compliance.
The primary outcome is the number of ventilator-free days within 28 days. The secondary outcomes are in-hospital and intensive care unit mortality and the need for rescue therapies such as extracorporeal life support, recruitment maneuvers and inhaled nitric oxide.
STAMINA is designed to provide evidence on whether a driving pressure-limiting strategy is superior to the ARDSNet low-positive end-expiratory pressure table strategy for increasing the number of ventilator-free days within 28 days in patients with moderate-to-severe acute respiratory distress syndrome. Here, we describe the rationale, design and status of the trial.
Abstract
Rev Bras Ter Intensiva. 2022;34(3):360-366
DOI 10.5935/0103-507X.20220477-en
To investigate the applicability of the Respiratory Rate-Oxygenation Index to identify the risk of high-flow nasal cannula failure in post-extubation pneumonia patients.
This was a 2-year retrospective observational study conducted in a reference hospital in Bogotá, Colombia. All patients in whom post-extubation high-flow nasal cannula therapy was used as a bridge to extubation were included in the study. The Respiratory Rate-Oxygenation Index was calculated to assess the risk of post-extubation high-flow nasal cannula failure.
A total of 162 patients were included in the study. Of these, 23.5% developed high-flow nasal cannula failure. The Respiratory Rate-Oxygenation Index was significantly lower in patients who had high-flow nasal cannula failure [median (IQR): 10.0 (7.7 - 14.4) versus 12.6 (10.1 - 15.6); p = 0.006]. Respiratory Rate-Oxygenation Index > 4.88 showed a crude OR of 0.23 (95%CI 0.17 - 0.30) and an adjusted OR of 0.89 (95%CI 0.81 - 0.98) stratified by severity and comorbidity. After logistic regression analysis, the Respiratory Rate-Oxygenation Index had an adjusted OR of 0.90 (95%CI 0.82 - 0.98; p = 0.026). The area under the Receiver Operating Characteristic curve for extubation failure was 0.64 (95%CI 0.53 - 0.75; p = 0.06). The Respiratory Rate-Oxygenation Index did not show differences between patients who survived and those who died during the intensive care unit stay.
The Respiratory Rate-Oxygenation Index is an accessible tool to identify patients at risk of failing high-flow nasal cannula post-extubation treatment. Prospective studies are needed to broaden the utility in this scenario.
Abstract
Rev Bras Ter Intensiva. 2020;32(1):133-142
DOI 10.5935/0103-507X.20200019
This systematic review of longitudinal studies aimed to evaluate the effect of enteral feeding of critically ill adult and pediatric patients in the prone position on gastric residual volume and other clinical outcomes. A literature search was conducted in the databases PubMed, Scopus and Embase using terms related to population and intervention. Two independent reviewers analyzed the titles and abstracts, and data collection was performed using a standardized form. Discrepancies were resolved by a third reviewer. The methodological quality of the studies was evaluated considering the potential for systematic errors, and the data were qualitatively analyzed. Four studies with adult patients and one with preterm patients were included. The gastric residual volume was evaluated as the main outcome: three studies did not show differences in the gastric residual volume between the prone and supine positions (p > 0.05), while one study showed a higher gastric residual volume during enteral feeding in the prone position (27.6mL versus 10.6mL; p < 0.05), and another group observed a greater gastric residual volume in the supine position (reduction of the gastric residual volume by 23.3% in the supine position versus 43.9% in the prone position; p < 0.01). Two studies evaluated the frequency of vomiting; one study found that it was higher in the prone position (30 versus 26 episodes; p < 0.001), while the other study found no significant difference (p > 0.05). The incidence of aspiration pneumonia and death were evaluated in one study, with no difference between groups (p > 0.05). The literature on the administration of enteral feeding in the prone position in critically ill patients is sparse and of limited quality, and the results regarding gastric residual volume are contradictory. Observational studies with appropriate sample sizes should be conducted to support conclusions on the subject.
Abstract
Rev Bras Ter Intensiva. 2019;31(4):541-547
DOI 10.5935/0103-507X.20190079
Ventilator-associated lower respiratory tract infection is one of the most frequent complications in mechanically ventilated patients. Ventilator-associated tracheobronchitis has been considered a disease that does not warrant antibiotic treatment by the medical community for many years. In the last decade, several studies have shown that tracheobronchitis could be considered an intermediate process that leads to ventilator-associated pneumonia. Furthermore, ventilator-associated tracheobronchitis has a limited impact on overall mortality but shows a significant association with increased patient costs, length of stay, antibiotic use, and duration of mechanical ventilation. Although we still need clear evidence, especially concerning treatment modalities, the present study on ventilator-associated tracheobronchitis highlights that there are important impacts of including this condition in clinical management and epidemiological and infection surveillance.
Abstract
Rev Bras Ter Intensiva. 2014;26(4):379-383
DOI 10.5935/0103-507X.20140058
To describe the oral health status of patients hospitalized in an intensive care unit.
Clinical assessment of the oral cavity was performed in 35 patients at two time-points (up to 48 hours after admission and 72 hours after the first assessment) and recorded in data collection forms. The following data were collected: plaque index, condition of the mucosa, presence or absence of dental prosthesis, number of teeth present, and tongue coating index.
The prevalence of nosocomial infection was 22% (eight patients), with 50% respiratory tract infections. All patients exhibited oral biofilm, and 20 (57%) showed biofilm visible to the naked eye; tongue coating was present on more than two thirds of the tongue in 24 patients (69%) and was thick in most cases. A significant increase in plaque index (p=0.007) occurred after 72 hours, although the tongue coating index was p<0.001 regarding the area and p=0.5 regarding the thickness.
The plaque and tongue coating indices increased with the length of hospital stay at the intensive care unit.
Abstract
Rev Bras Ter Intensiva. 2011;23(4):499-506
DOI 10.1590/S0103-507X2011000400016
Community-acquired pneumonia (CAP) is the most common infectious disease requiring admission to intensive care units (ICUs), and achieving an early and precise diagnosis of CAP remains a challenge. Biomarkers play an important role in improving clinical judgment in the emergency room and are adjuvant in evaluating treatment responses. Novel biomarkers, such as cortisol, pro-adrenomedullin and endothelin-1, have been shown to be associated with disease severity and short-term outcomes. This review article focuses on the clinical use of novel biomarkers, severity prediction and treatment monitoring as well as future directions of the field.
Abstract
Rev Bras Ter Intensiva. 2006;18(1):38-44
DOI 10.1590/S0103-507X2006000100008
BACKGROUND AND OBJECTIVES: The ventilator-associated pneumonia (VAP) is a severe infection that presents multiple causes which can vary depending on the type of intensive care unit, type of patients, emphasizing the needs for vigilance measures with local data. The aim of this study is to describe the incidence, risk factors and mortality of VAP in patients in a surgical ICU. METHODS: Prospective cohort conducted from January 2004 to January 2005. It was included all the patients in mechanical ventilation, followed daily to collect data about demographics, diagnostic, APACHE II and TISS 28 scores, duration of mechanical ventilation, length of stay, incidence of VAP and mortality. RESULTS: 462 patients were studied; age 57.2 ± 16.6 years, 55% men. The mean APACHE II score was 18.3 and the incidence of VAP was 18.8%. The TISS score at admission OR = 1.050 (IC 95%: 1.003-1.050) and the enteral nutrition OR = 5.609 (IC 3.351-9.388) were factors associated with VAP and the prophylactic use of antibiotics was a factor of protection OR = 0.399 (IC95%: 0.177-0.902). The patients with VAP had longer length of stay in ICU (10.3 ± 10.7 vs 4.9 ± 3.3 days), higher median of duration of mechanical ventilation (4 vs 1 days), higher mean of TISS 28 (24.4 ± 4.6 vs 22.8 ± 4.5), and higher crude mortality (46 vs 28.8%) when compared with the patients without VAP. CONCLUSIONS: VAP was a frequent infection in surgical patients in mechanical ventilation. Enteral nutrition and admission TISS were risk factors and the previous use of antibiotics was protection factor to develop VAP. In our sample the results demonstrate that VAP is associated with higher duration in mechanical ventilation, longer length of stay and higher mortality.
Abstract
Rev Bras Ter Intensiva. 2006;18(4):344-350
DOI 10.1590/S0103-507X2006000400005
BACKGROUND AND OBJECTIVES: Variable magnitude of impact on the outcomes of the critically ill patients has been credited to ventilation-associated pneumonia, in terms of mortality, length of hospital stay and mechanic ventilation days. Three objectives have been defined in this study: mortality and incidence of ventilation-associated pneumonia before and after the implantation of a prophylaxis protocol (primary objectives); microbiologic mapping (secondary objective) as an instrument to optimize therapy. METHODS: A historical cohort was followed during the period of August 2001 to January 2004, fragmented in two segments, pre (until January 2003, n = 52) and post-implantation of the mentioned protocol, the analysis of mortality and microbiologic mapping been performed in the second segment (control group n = 39 and case group n = 14). RESULTS: The incidence rates from 2001 to 2003 were respectively 28.05‰ ± 12.92‰, 22.45‰ ± 10.18‰ and 10.75‰ ± 7.61‰. The decrease in this rate after the intervention did not reach statistical significance (p > 0.4). Mortality rates were 49% in the control group (CI 95 = 33% to 65%) and 43% in the case group (CI 95 = 14% to 72%), OR = 0.88 (CI 95 = 0.26 to 2.94), without statistical significance either (p = 0.65). Eight bronco-alveolar lavage were obtained (57%), 50% with multiple flora. Pseudomonas aeruginosa was isolated in six patients (75%), Acinetobacter sp in one case (12.5 %) and methicilin-resistent Staphylococcus aureus (MRSA) in one (12.5%). Other Gram negative bacilli producers of extended spectrum betalactamase (ESBL) were isolated in two cases (25%) and Stenotrophomonas maltophilia in another (12.5%). CONCLUSIONS: The incidence rate of ventilation-associated pneumonia revealed a tendency to considerable reduction after the utilization of the prophylaxis protocol, while the results suggest no impact on mortality rates. Further prospective evaluation of a greater sample is required, in order to get to definite conclusions regarding prognosis. The isolated germs were, in its majority, high risk pathogens to multiresistance to antibiotics, pointing the necessity of knowledge of local susceptibility profile, so that an adequate initial therapeutic strategy can be undertaken.
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