Female ; Humans ; Intensive Care Units ; Male ; Ventilator Weaning ; methods

OBJECTIVE: To develop and validate a mechanical power (MP)-oriented nomogram prediction model of weaning failure in mechanically ventilated patients. METHODS: Patients who underwent invasive mechanical ventilation (IMV) for more than 24 hours and were weaned using a T-tube ventilation strategy were collected from the Medical Information Mart for Intensive Care-IV v1.0 (MIMIC-IV v1.0) database. Demographic information and comorbidities, respiratory mechanics parameters 4 hours before the first spontaneous breathing trial (SBT), laboratory parameters preceding the SBT, vital signs and blood gas analysis during SBT, length of intensive care unit (ICU) stay and IMV duration were collected and all eligible patients were enrolled into the model group. Lasso method was used to screen the risk factors affecting weaning outcomes, which were included in the multivariate Logistic regression analysis. R software was used to construct the nomogram prediction model and build the dynamic web page nomogram. The discrimination and accuracy of the nomogram were assessed by receiver operator characteristic curve (ROC curve) and calibration curves, and the clinical validity was assessed by decision curve analysis (DCA). The data of patients undergoing mechanical ventilation hospitalized in ICU of the First People's Hospital of Lianyungang City and the Second People's Hospital of Lianyungang City from November 2021 to October 2022 were prospectively collected to externally validate the model. RESULTS: A total of 3 695 mechanically ventilated patients were included in the model group, and the weaning failure rate was 38.5% (1 421/3 695). Lasso regression analysis finally screened out six variables, including positive end-expiratory pressure (PEEP), MP, dynamic lung compliance (Cdyn), inspired oxygen concentration (FiO₂), length of ICU stay and IMV duration, with coefficients of 0.144, 0.047, -0.032, 0.027, 0.090 and 0.098, respectively. Logistic regression analysis showed that the six variables were all independent risk factors for predicting weaning failure risk [odds ratio (OR) and 95% confidence interval (95%CI) were 1.155 (1.111-1.200), 1.048 (1.031-1.066), 0.968 (0.963-0.974), 1.028 (1.017-1.038), 1.095 (1.076-1.113), and 1.103 (1.070-1.137), all P < 0.01]. The MP-oriented nomogram prediction model of weaning failure in mechanically ventilated patients showed accurate discrimination both in the model group and external validation group, with area under the ROC curve (AUC) and 95%CI of 0.832 (0.819-0.845) and 0.879 (0.833-0.925), respectively. Furthermore, its predictive accuracy was significantly higher than that of individual indicators such as MP, Cdyn, and PEEP. Calibration curves showed good correlation between predicted and observed outcomes. DCA indicated that the nomogram model had high net benefits, and was clinically beneficial. CONCLUSIONS The MP-oriented nomogram prediction model of weaning failure accurately predicts the risk of weaning failure in mechanical ventilation patients and provides valuable information for clinicians making decisions on weaning.
Humans ; Respiration, Artificial/methods* ; Ventilator Weaning/methods* ; Nomograms ; Lung ; Risk Factors

BACKGROUNDNoninvasive positive pressure ventilation (NIPPV) has been proposed to shorten the duration of mechanical ventilation in intubated patients, especially those who fail initial weaning from invasive mechanical ventilation (IMV). However, there are also some discrepancies in terms of weaning success or failure, incidence of re-intubation, complications observed during study and patient outcomes. The primary objective of this update was to specifically investigate the role of NIPPV on facilitating weaning and avoiding re-intubation in patients intubated for different etiologies of acute respiratory failure, by comparing with conventional invasive weaning approach.

METHODSWe searched randomized controlled trials (RCTs) comparing noninvasive weaning of early extubation and immediate application of NIPPV with invasive weaning in intubated patients from PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Knowledge and Springerlink databases. Records from conference proceedings and reference lists of relevant studies were also identified.

RESULTSA total of 11 RCTs with 623 patients were available for the present analysis. Compared with IMV, NIPPV significantly increased weaning success rates (odds ratio (OR): 2.50, 95% confidence interval (CI): 1.46 - 4.30, P = 0.0009), decreased mortality (OR: 0.39, 95%CI: 0.20 - 0.75, P = 0.005), and reduced the incidence of ventilator associated pneumonia (VAP) (OR: 0.17, 95%CI: 0.08 - 0.37, P < 0.00001) and complications (OR: 0.22, 95%CI: 0.07 - 0.72, P = 0.01). However, effect of NIPPV on re-intubation did not reach statistical difference (OR: 0.61, 95%CI: 0.33 - 1.11, P = 0.11).

CONCLUSIONSEarly extubation and immediate application of NIPPV is superior to conventional invasive weaning approach in increasing weaning success rates, decreasing the risk of mortality and reducing the incidence of VAP and complications, in patients who need weaning from IMV. However, it should be applied with caution, as there is insufficient beneficial evidence to definitely recommend it in terms of avoiding re-intubation.

Humans ; Randomized Controlled Trials as Topic ; Respiration, Artificial ; methods ; Ventilator Weaning ; methods

BACKGROUNDWeaning difficulties occur in 31% of total intubated patients, and result in prolonged weaning duration. A computer-driven automated weaning system can perform a spontaneous breathing trial (SBT) automatically and display a message when the trial is successfully passed. Such a system might have a beneficial effect on difficult-to-wean patients. The aim of this study was to examine whether the computer-driven automated weaning system can accelerate discontinuation of mechanical ventilation and improve outcomes in difficult-to-wean patients.

METHODSThis randomized controlled study included 39 difficult-to-wean patients who failed their first spontaneous breathing trial. Before initiating weaning, eligible patients were randomly allocated to wean by computer-driven automated weaning system (CDW group, n = 19) or a physician-controlled local protocol (PW group, n = 20). Weaning duration, defined as the time from inclusion until first extubation, was the primary endpoint. Secondary endpoints were total duration of mechanical ventilation, the length of intensive care unit (ICU) stay, the number of reintubations, the mortality rate in the ICU, the number of noninvasive ventilations, the number of complications in the ICU, and the number of ventilator-associated pneumonia cases.

RESULTSThe weaning duration was reduced with the computer-driven weaning as compared with the usual protocol (median 29.0 hours vs. 45.5 hours, P = 0.044). Total duration of mechanical ventilation and duration of the ICU stay did not differ between the CDW and PW groups. There was no difference in the number of reintubations between the CDW and PW groups (3 and 4 patients, P = 0.732). The study groups showed comparable numbers of tracheostomy, self-extubations, ventilator-associated pneumonia, and non-invasive ventilation. Mortality in the ICU was similar in the CDW and the PW groups (21.1% vs. 20.0%, P = 0.935).

CONCLUSIONThe computer-driven automated weaning system can reduce weaning duration in difficult-to-wean patients as compared with a physician-controlled weaning protocol.

Aged ; Female ; Humans ; Intensive Care Units ; Male ; Middle Aged ; Respiration, Artificial ; methods ; Ventilator Weaning ; methods

OBJECTIVETo investigate the value of electronic bronchoscopy in the etiological diagnosis and treatment of pediatric intensive care patients with difficult ventilator weaning.

METHODSA retrospective analysis was performed for the clinical data of 92 pediatric intensive care patients with difficult ventilator weaning and underwent electronic bronchoscopy.

RESULTSAmong all the 92 children, the most common underlying disease was respiratory system disease (39 children). Electronic bronchoscopy found abnormalities in 87 children (95%), mainly excessive airway secretions and abnormal airway structure. There was no difference in the severity of tracheobronchial stenosis and tracheobronchomalacia shown by electronic bronchoscopy in children suffering from congenital heart disease (CHD), with and without difficult ventilator weaning. When used to predict difficult ventilator weaning in children with CHD, tracheobronchial stenosis or tracheobronchomalacia had a sensitivity of 68.4% and a specificity of 66.7%. Among the 36 children with atelectasis caused by excessive secretion or phlegm-induced airway obstruction, 23 achieved full or partial re-expansion after bronchial lavage and/or one-lung ventilation.

CONCLUSIONSElectronic bronchoscopy helps to clarify the cause of difficult ventilator weaning and perform treatment under an electronic bronchoscope accordingly in pediatric intensive care patients with difficult ventilator weaning. Tracheobronchial stenosis and tracheobronchomalacia shown by electronic bronchoscopy cannot not be used as an index for the prediction of ventilator weaning in children with CHD.

Adolescent ; Bronchoscopy ; Child ; Child, Preschool ; Critical Care ; Female ; Humans ; Infant ; Male ; Retrospective Studies ; Ventilator Weaning ; methods

BACKGROUNDIt is not clear whether the benefits of tracheostomy remain the same in the population. This study aimed to better examine the effect of tracheostomy on clinical outcome among prolonged ventilator patients.

METHODSData were from the medical claims data in Taiwan. A total of 3880 patients with ventilator use for more than 14 days between 2005 and 2009 were identified. Among them, 645 patients with tracheostomy conducted within 30 days of ventilator use were compared to 2715 patients without tracheostomy on death during hospitalization and study period, and successful weaning and medical utilization during hospitalization. Cox proportional hazards and linear regression models were used to examine the associations between tracheostomy and the main outcomes.

RESULTSThe tracheostomy rate was 30%, and 55% of tracheostomies were performed within 30 days of mechanical ventilation. After adjustments, patients with tracheostomy were at a lower risk of death during hospitalization (hazard ratio [HR] =0.51; 95% confidence interval [CI] =0.43-0.61) and 5-year observation (HR = 0.73; 95% CI = 0.66-0.81), and a lower probability of successful weaning (HR = 0.88; 95% CI = 0.79-0.99). Higher medical use was also observed in patients with tracheostomy.

CONCLUSIONSThe beneficial effect for tracheostomy observed in our data was the reduction of death. However, patients with tracheostomy were less likely to wean and more likely to consume medical resources.

Aged ; Aged, 80 and over ; Female ; Hospitalization ; Humans ; Male ; Respiration, Artificial ; adverse effects ; Tracheostomy ; Ventilator Weaning ; methods

OBJECTIVETo investigate the efficacy of heated humidified high-flow nasal cannula (HHHFNC) and nasal continuous positive airway pressure (nCPAP) in preterm infants aged 26-31(+6) weeks with respiratory distress syndrome after ventilator weaning.

METHODSA total of 161 preterm infants were randomly divided into two groups after ventilator weaning: HHHFNC treatment (n=79) and nCPAP treatment (n=82). The two groups were subdivided into 26-28(+6) weeks and 29-31+6 weeks groups according to the gestational age. The treatment failure rate, reintubation rate within 7 days after extubation, incidence of complications, and mortality during hospitalization were compared between the two groups.

RESULTSThe treatment failure rate and reintubation rate showed no significant differences between the HHHFNC and nCPAP groups. The preterm infants aged 26-28(+6) weeks in the HHHFNC group had a significantly higher treatment failure rate than those in the nCPAP group (P<0.05), while the reintubation rate showed no significant difference. As for the preterm infants aged 29-31(+6) weeks, the treatment failure rate and reintubation rate showed no significant differences between the two groups. The incidence of complications and mortality showed no significant differences between the HHHFNC and nCPAP groups.

CONCLUSIONSIn preterm infants aged 29-31(+6) weeks, HHHFNC has a similar efficacy as nCPAP after ventilator weaning, while in those aged less than 29 weeks, HHHFNC should be used with great caution if selected as the first-line noninvasive respiratory support.

Catheters ; Continuous Positive Airway Pressure ; adverse effects ; Female ; Humans ; Infant, Newborn ; Infant, Premature ; Male ; Noninvasive Ventilation ; adverse effects ; methods ; Ventilator Weaning

Apnea ; therapy ; Catheters ; Continuous Positive Airway Pressure ; adverse effects ; instrumentation ; methods ; Humans ; Infant, Newborn ; Infant, Premature ; Infant, Premature, Diseases ; therapy ; Intensive Care Units, Neonatal ; Oxygen Inhalation Therapy ; adverse effects ; instrumentation ; methods ; Respiratory Distress Syndrome, Newborn ; therapy ; Ventilator Weaning

PURPOSETo evaluate midazolam sequential with dexmedetomidine for agitated patients undergoing weaning to implement light sedation in ICU.

METHODSThis randomized, prospective study was conducted in Tianjin Third Central Hospital, China. Using a sealed-envelope method, the patients were randomly divided into 2 groups (40 patients per group). Each patient of group A received an initial loading dose of midazolam at 0.3-3mg/kg·h 24 h before extubation, followed by an infusion of dexmedetomidine at a rate of 0.2-1 μg/kg·h until extubation. Each patient of group B received midazolam at a dose of 0.3-3 mg/kg·h until extubation. The dose of sedation was regulated according to RASS sedative scores maintaining in the range of -2-1. All patients were continuously monitored for 60 min after extubation. During the course, heart rate (HR), mean artery pressure (MAP), extubation time, adverse reactions, ICU stay, and hospital stay were observed and recorded continuously at the following time points: 24 h before extubation (T1), 12 h before extubation (T2), extubation (T3), 30 min after extubation (T4), 60 min after extubation (T5).

RESULTSBoth groups reached the goal of sedation needed for ICU patients. Dexmedetomidine was associated with a significant increase in extubation quality compared with midazolam, reflected in the prevalence of delirium after extubation (20% (8/40) vs 45% (18/40)), respectively (p= 0.017). There were no clinically significant decreases in HR and MAP after infusing dexmedetomidine or midazolam. In the group A, HR was not significantly increased after extubation; however, in the group B, HR was significantly increased compared with the preextubation values (p < 0.05). HR was significantly higher in the group B compared with the group A at 30 and 60 min after extubation (both, p <0.05). Compared with preextubation values, MAP was significantly increased at extubation in the group B (p < 0.05) and MAP was significantly higher at T3, T4, T5 in the group B than group A (p < 0.05). There was a significant difference in extubation time ((3.0 ± 1.5) d vs (4.3 ± 2.2) d, p < 0.05), ICU stay ((5.4 ± 2.1) d vs (8.0 ± 1.4) d, p < 0.05), hospital stay ((10.1 ± 3.0) d vs (15.3 ± 2.6) d, p <0.05) between group A and B.

CONCLUSIONMidazolam sequential with dexmedetomidine can reach the goal of sedation for ICU agitated patients, meanwhile it can maintain the respiratory and circulation parameters and reduce adverse reactions.

Adult ; Aged ; Critical Care ; methods ; Delirium ; drug therapy ; etiology ; Dexmedetomidine ; administration & dosage ; Female ; Humans ; Hypnotics and Sedatives ; administration & dosage ; Intensive Care Units ; Length of Stay ; Male ; Midazolam ; administration & dosage ; Middle Aged ; Prognosis ; Prospective Studies ; Respiration, Artificial ; adverse effects ; methods ; Risk Assessment ; Statistics, Nonparametric ; Treatment Outcome ; Ventilator Weaning ; adverse effects ; psychology

OBJECTIVENon-invasive positive pressure ventilation has increasingly been chosen as the primary ventilation mode in respiratory distress syndrome (RDS) in preterm infants. In order to further understand the application of various non-invasive positive pressure ventilation modes, we compared the advantages and disadvantages of three modes as a primary mode of ventilation in premature infants with RDS.

METHODFrom December 2011 to March 2013, 107 preterm infants with RDS who received intubation-pulmonary surfactant (PS) -extubation in our NICU were randomly divided (by means of random number table) into three groups based on the primary mode of ventilation: nasal continuous positive airway pressure [NCPAP, n = 39, male/female ratio was 27/12, mean gestational age (GA) was (32.0 ± 2.1)weeks, mean birth weight (BW) was (1752 ± 457)g], bi-level positive airway pressure [BiPAP, n = 35, male/female ratio was 25/10, GA was (31.4 ± 2.0) weeks, BW was (1530 ± 318) g], and synchronized bi-level positive airway pressure [SBiPAP, n = 33, male/female rate was 25/8, GA was (31.5 ± 2.2) weeks, BW was (1622 ± 447) g]. Ventilation settings including FiO(2) were adjusted according to transcutaneous SPO(2) monitoring or blood gas analysis. Various settings and adverse events were recorded as well. The main parameter was the FiO(2) at 24 h post-positive-pressure ventilation. Statistical analyses were performed using χ(2) test, rank sum test, one-way analysis of variance for least-significant difference value, paired-sample t-test, two related sample Wilcoxon signed rank sum test and Logistic regression.

RESULTThe PaCO(2) (mmHg, 1 mmHg = 0.133 kPa), oxygen index (OI) at 12-24 h, and FiO(2) at 24 h post-ventilation in BiPAP and SBiPAP groups were lower than that in NCPAP groups with significant difference (44 ± 9 and 45 ± 9 vs. 50 ± 9, 2.76 ± 0.96 and 2.79 ± 0.60 vs. 3.24 ± 0.72, 0.34 ± 0.10 and 0.35 ± 0.07 vs. 0.39 ± 0.07; F = 4.456, 5.146 and 4.123; P = 0.014, 0.007 and 0.019, respectively). There was no significant difference between BiPAP and SBiPAP groups. There was no significant difference among three groups (all P > 0.05) in the following events: respiratory index (RI) at 12-24 h post-ventilation, abdominal distension, period of non-invasive ventilation, ratio of intubation for invasive ventilation if failed noninvasive ventilation, air-leak syndrome, neonatal necrotizing enterocolitis, periventricular-intraventricular haemorrhage, bronchopulmonary dysplasia, retinopathy of prematurity, mortality rate after 36 h of age or rate of abandon for discharge. The independent risk factors for failure of non-invasive positive pressure ventilation were gender, gestational age, antepartum steroid at 24 h before birth to 7 d, and birth weight, with the OR (95% confidence interval) being 14.120 (1.135, 175.662), 2.862 (1.479, 5.535), 61.084 (3.115, 1 198.031), and 8.306 (1.488, 46.383), respectively.

CONCLUSIONAs the primary mode of ventilation in premature infants with RDS, both BiPAP and SBiPAP are more beneficial than NCPAP in improving oxygenation and reducing CO(2) retention without increasing the incidence of adverse events.

Blood Gas Analysis ; Carbon Dioxide ; blood ; Continuous Positive Airway Pressure ; methods ; Female ; Gestational Age ; Humans ; Infant, Newborn ; Infant, Premature ; Intensive Care Units, Neonatal ; Intubation, Intratracheal ; Male ; Oxygen ; blood ; Pulmonary Surfactants ; therapeutic use ; Respiratory Distress Syndrome, Newborn ; therapy ; Risk Factors ; Treatment Outcome ; Ventilator Weaning