Year in review in Intensive Care Medicine 2010: II. Pneumonia and infections, cardiovascular and haemodynamics, organization, education, haematology, nutrition, ethics and miscellanea (original) (raw)
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Noninvasive Ventilation in Severe Hypoxemic Respiratory Failure A Randomized Clinical Trial
The efficacy of non-invasive ventilation in order to avoid intubation and improve survival was assessed in 105 patients with severe acute hypoxemic respiratory failure (arterial O 2 tension or saturation persistently ≤60 mmHg or ≤90%, respectively, breathing conventional Venturi oxygen at maximal concentration (50%)), excluding hypercapnia, admitted into intensive care units of 3 hospitals. Patients were randomly allocated within 24 hours of fulfilling inclusion criteria to receive non-invasive ventilation (n=51), or high concentration oxygen therapy (n=54). The primary end-point variable was the decrease in the intubation rate. Both groups had similar characteristics. Compared with oxygen therapy, non-invasive ventilation decreased the need for intubation (13, 25% vs 28, 52%, p=0.010), the incidence of septic shock (6, 12% vs 17, 31%, p=0.028), and the intensive care unit mortality (9, 18% vs 21, 39%, p=0.028), and increased the cumulative 90-day survival (p=0.025). The improvement of arterial hypoxemia and tachypnea was higher in the non-invasive-ventilation group with time (p=0.029 each).
Acta Anaesthesiologica Scandinavica, 2019
Background: Acutely ill adults with hypoxaemic respiratory failure are at risk of lifethreatening hypoxia, and thus oxygen is often administered liberally. Excessive oxygen use may, however, increase the number of serious adverse events, including death. Establishing the optimal oxygenation level is important as existing evidence is of low quality. We hypothesise that targeting an arterial partial pressure of oxygen (PaO 2) of 8 kPa is superior to targeting a PaO 2 of 12 kPa in adult intensive care unit (ICU) patients with acute hypoxaemic respiratory failure. Methods: The Handling Oxygenation Targets in the ICU (HOT-ICU) trial is an outcome assessment blinded, multicentre, randomised, parallel-group trial targeting PaO 2 in acutely ill adults with hypoxaemic respiratory failure within 12 hours after ICU admission. Patients are randomised 1:1 to one of the two PaO 2 targets throughout ICU stay until a maximum of 90 days. The primary outcome is 90-day mortality. Secondary outcomes are serious adverse events in the ICU, days alive without organ support and days alive out of hospital in the 90-day period; mortality, health-related
Noninvasive Ventilation in Severe Hypoxemic Respiratory Failure
American Journal of Respiratory and Critical Care Medicine, 2003
The efficacy of non-invasive ventilation in order to avoid intubation and improve survival was assessed in 105 patients with severe acute hypoxemic respiratory failure (arterial O 2 tension or saturation persistently ≤60 mmHg or ≤90%, respectively, breathing conventional Venturi oxygen at maximal concentration (50%)), excluding hypercapnia, admitted into intensive care units of 3 hospitals. Patients were randomly allocated within 24 hours of fulfilling inclusion criteria to receive non-invasive ventilation (n=51), or high concentration oxygen therapy (n=54). The primary end-point variable was the decrease in the intubation rate. Both groups had similar characteristics. Compared with oxygen therapy, non-invasive ventilation decreased the need for intubation (13, 25% vs 28, 52%, p=0.010), the incidence of septic shock (6, 12% vs 17, 31%, p=0.028), and the intensive care unit mortality (9, 18% vs 21, 39%, p=0.028), and increased the cumulative 90-day survival (p=0.025). The improvement of arterial hypoxemia and tachypnea was higher in the non-invasive-ventilation group with time (p=0.029 each).
Cochrane Database of Systematic Reviews, 2020
Background Supplemental oxygen is frequently administered to patients with acute respiratory distress syndrome (ARDS), including ARDS secondary to viral illness such as coronavirus disease 19 (COVID-19). An up-to-date understanding of how best to target this therapy (e.g. arterial partial pressure of oxygen (PaO 2) or peripheral oxygen saturation (SpO 2) aim) in these patients is urgently required. Objectives To address how oxygen therapy should be targeted in adults with ARDS (particularly ARDS secondary to COVID-19 or other respiratory viruses) and requiring mechanical ventilation in an intensive care unit, and the impact oxygen therapy has on mortality, days ventilated, days of catecholamine use, requirement for renal replacement therapy, and quality of life. Search methods We searched the Cochrane COVID-19 Study Register, CENTRAL, MEDLINE, and Embase from inception to 15 May 2020 for ongoing or completed randomized controlled trials (RCTs). Selection criteria Two review authors independently assessed all records in accordance with standard Cochrane methodology for study selection. We included RCTs comparing supplemental oxygen administration (i.e. different target PaO 2 or SpO 2 ranges) in adults with ARDS and receiving mechanical ventilation in an intensive care setting. We excluded studies exploring oxygen administration in patients with different underlying diagnoses or those receiving non-invasive ventilation, high-flow nasal oxygen, or oxygen via facemask. Data collection and analysis One review author performed data extraction, which a second review author checked. We assessed risk of bias in included studies using the Cochrane 'Risk of bias' tool. We used the GRADE approach to judge the certainty of the evidence for the following outcomes; mortality at longest follow-up, days ventilated, days of catecholamine use, and requirement for renal replacement therapy. Main results We identified one completed RCT evaluating oxygen targets in patients with ARDS receiving mechanical ventilation in an intensive care setting. The study randomized 205 mechanically ventilated patients with ARDS to either conservative (PaO 2 55 to 70 mmHg, or SpO 2 88% to 92%) or liberal (PaO 2 90 to 105 mmHg, or SpO 2 ≥ 96%) oxygen therapy for seven days. Overall risk of bias was high (due to lack of blinding, small numbers of participants, and the trial stopping prematurely), and we assessed the certainty of the evidence as very low. The available data suggested that mortality at 90 days may be higher in those participants receiving a lower oxygen target (odds ratio (OR) 1.83, 95% confidence interval (CI) 1.03 to 3.27). There was no evidence of a difference between the lower and higher target groups in mean number of days ventilated (14.0, 95% CI 10.0 to 18.0 versus 14.5, 95% CI 11.8 to 17.1); number of days of catecholamine use (8.0, 95% CI 5.5 to 10.5 versus 7.2, 95% CI 5.9 to 8.4); or participants receiving renal replacement therapy (13.7%, 95% CI 5.8% to 21.6% versus 12.0%, 95% CI 5.0% to 19.1%). Quality of life was not reported.
Outcome of acute hypoxaemic respiratory failure: insights from the LUNG SAFE Study
European Respiratory Journal, 2020
BackgroundCurrent incidence and outcome of patients with acute hypoxaemic respiratory failure requiring mechanical ventilation in the intensive care unit (ICU) are unknown, especially for patients not meeting criteria for acute respiratory distress syndrome (ARDS).MethodsAn international, multicentre, prospective cohort study of patients presenting with hypoxaemia early in the course of mechanical ventilation, conducted during four consecutive weeks in the winter of 2014 in 459 ICUs from 50 countries (LUNG SAFE). Patients were enrolled with arterial oxygen tension/inspiratory oxygen fraction ratio ≤300 mmHg, new pulmonary infiltrates and need for mechanical ventilation with a positive end-expiratory pressure of ≥5 cmH2O. ICU prevalence, causes of hypoxaemia, hospital survival and factors associated with hospital mortality were measured. Patients with unilateral versus bilateral opacities were compared.Findings12 906 critically ill patients received mechanical ventilation and 34.9% w...
Intensive Care Medicine, 2001
Context: In patients with hypoxemic acute respiratory failure (ARF), randomized studies have shown noninvasive positive pressure ventilation (NPPV) to be associated with lower rates of endotracheal intubation. In these patients, predictors of NPPV failure are not well characterized. Objective: To investigate variables predictive of NPPV failure in patients with hypoxemic ARF. Design: Prospective, multicenter cohort study. Setting: Eight Intensive Care Units (ICU) in Europe and USA. Patients: Of 5,847 patients admitted between October 1996 and December 1998, 2,770 met criteria for hypoxemic ARF. Of these, 2,416 were already intubated and 354 were eligible for the study. Results: NPPV failed in 30 % (108/ 354) of patients. The highest intubation rate was observed in patients with ARDS (51 %) or communityacquired pneumonia (50 %). The lowest intubation rate was observed in patients with cardiogenic pulmonary edema (10 %) and pulmonary contusion (18 %). Multivariate analysis identified age > 40 years (OR 1.72, 95 % CI 0.92±3.23), a simplified acute physiologic score (SAPS II) ³35 (OR 1.81, 95 % CI 1.07±3.06), the presence of ARDS or community-acquired pneumonia (OR 3.75, 95 % CI 2.25±6.24), and a PaO 2 :FiO 2 £146 after 1 h of NPPV (OR 2.51, 95 % CI 1.45±4.35) as factors independently associated with failure of
JAMA, 2018
IMPORTANCE High-flow nasal oxygen therapy is increasingly used for acute hypoxemic respiratory failure (AHRF). OBJECTIVE To determine whether high-flow oxygen therapy decreases mortality among immunocompromised patients with AHRF compared with standard oxygen therapy. DESIGN, SETTING, AND PARTICIPANTS The HIGH randomized clinical trial enrolled 776 adult immunocompromised patients with AHRF (PaO 2 <60 mm Hg or SpO 2 <90% on room air, or tachypnea >30/min or labored breathing or respiratory distress, and need for oxygen Ն6 L/min) at 32 intensive care units (ICUs) in France between May 19, 2016, and December 31, 2017. INTERVENTIONS Patients were randomized 1:1 to continuous high-flow oxygen therapy (n = 388) or to standard oxygen therapy (n = 388). MAIN OUTCOMES AND MEASURES The primary outcome was day-28 mortality. Secondary outcomes included intubation and mechanical ventilation by day 28, PaO 2 :FIO 2 ratio over the 3 days after intubation, respiratory rate, ICU and hospital lengths of stay, ICU-acquired infections, and patient comfort and dyspnea. RESULTS Of 778 randomized patients (median age, 64 [IQR, 54-71] years; 259 [33.3%] women), 776 (99.7%) completed the trial. At randomization, median respiratory rate was 33/min (IQR, 28-39) vs 32 (IQR, 27-38) and PaO 2 :FIO 2 was 136 (IQR, 96-187) vs 128 (IQR, 92-164) in the intervention and control groups, respectively. Median SOFA score was 6 (IQR, 4-8) in both groups. Mortality on day 28 was not significantly different between groups (35.6% vs 36.1%; difference, −0.5% [95% CI, −7.3% to +6.3%]; hazard ratio, 0.98 [95% CI, 0.77 to 1.24]; P = .94). Intubation rate was not significantly different between groups (38.7% vs 43.8%; difference, −5.1% [95% CI, −12.3% to +2.0%]). Compared with controls, patients randomized to high-flow oxygen therapy had a higher PaO 2 :FIO 2 (150 vs 119; difference, 19.5 [95% CI, 4.4 to 34.6]) and lower respiratory rate after 6 hours (25/min vs 26/min; difference, −1.8/min [95% CI, −3.2 to −0.2]). No significant difference was observed in ICU length of stay (8 vs 6 days; difference, 0.6 [95% CI, −1.0 to +2.2]), ICU-acquired infections (10.0% vs 10.6%; difference, −0.6% [95% CI, −4.6 to +4.1]), hospital length of stay (24 vs 27 days; difference, −2 days [95% CI, −7.3 to +3.3]), or patient comfort and dyspnea scores. CONCLUSIONS AND RELEVANCE Among critically ill immunocompromised patients with acute respiratory failure, high-flow oxygen therapy did not significantly decrease day-28 mortality compared with standard oxygen therapy. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02739451.
BMJ open, 2015
A recent update of the definition of acute respiratory distress syndrome (ARDS) proposed an empirical classification based on ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) at ARDS onset. Since the proposal did not mandate PaO2/FiO2 calculation under standardised ventilator settings (SVS), we hypothesised that a stratification based on baseline PaO2/FiO2 would not provide accurate assessment of lung injury severity. A prospective, multicentre, observational study. A network of teaching hospitals. 478 patients with eligible criteria for moderate (100<PaO2/FiO2≤200) and severe (PaO2/FiO2≤100) ARDS and followed until hospital discharge. We examined physiological and ventilator parameters in association with the PaO2/FiO2 at ARDS onset, after 24 h of usual care and at 24 h under a SVS. At 24 h, patients were reclassified as severe, moderate, mild (200<PaO2/FiO2≤300) ARDS and non-ARDS (PaO2/FiO2>300). Group severity and hospital mortality...