Patient-Clinician Alliance during Prolonged Mechanical Ventilation. "Never Give Up on a Dream".
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ABSTRACT:
SUBMITTER: Nava S
PROVIDER: S-EPMC6580677 | biostudies-literature | 2019 Jun
REPOSITORIES: biostudies-literature
Publications
Patient-Clinician Alliance during Prolonged Mechanical Ventilation. "Never Give Up on a Dream".
American journal of respiratory and critical care medicine 20190601 12
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Project description:PurposeTaiwan has implemented an integrated prospective payment program (IPP) for prolonged mechanical ventilation (PMV) patients that consists of four stages of care: intensive care unit (ICU), respiratory care center (RCC), respiratory care ward (RCW), and respiratory home care (RHC). We aimed to investigate the life impact on family caregivers of PMV patients opting for a payment program and compared different care units.MethodA total of 610 questionnaires were recalled. Statistical analyses were conducted by using the chi-square test and multivariate logistic regression model.ResultsThe results indicated no associations between caregivers' stress levels and opting for a payment program. Participants in the non-IPP group spent less time with friends and family owing to caregiver responsibilities. The results of the family domain show that the RHC group (OR = 2.54) had worsened family relationships compared with the ICU group; however, there was less psychological stress in the RCC (OR = 0.54) and RCW (OR = 0.16) groups than in the ICU group. In the social domain, RHC interviewees experienced reduced friend and family interactivity (OR = 2.18) and community or religious activities (OR = 2.06) than the ICU group. The RCW group felt that leisure and work time had less effect (OR = 0.37 and 0.41) than the ICU group. Furthermore, RCW interviewees (OR = 0.43) were less influenced by the reduced family income than the ICU group in the economic domain.ConclusionsRHC family caregivers had the highest level of stress, whereas family caregivers in the RCW group had the lowest level of stress.
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Project description:RationaleAlthough caregiver burden is well described in chronic illness, few studies have examined burden among caregivers of survivors of critical illness. In existing studies, it is unclear whether the observed burden is a consequence of critical illness or of preexisting patient illness.ObjectivesTo describe 1-yr longitudinal outcomes for caregivers of patients who survived critical illness, and to compare depression risk between caregivers of patients with and without pre-intensive care unit (ICU) functional dependency.MethodsProspective, parallel, cohort study of survivors of prolonged (greater than 48 h) mechanical ventilation and their informal caregivers. Caregivers were divided into two cohorts on the basis of whether patients were functionally independent (n = 99, 59%), or dependent (n = 70, 41%) before admission. Functional dependency was defined as dependency in one or more activities of daily living or in three or more instrumental activities of daily living. Patient and caregiver outcomes were measured 2, 6, and 12 mo after mechanical ventilation initiation.Measurements and main resultsWe studied three caregiver outcomes: depression risk, lifestyle disruption, and employment reduction. Most patients were male (59.8%), with a mean (SD) age of 56.6 (19.0) yr. Caregivers were mostly female (75.7%), with a mean (SD) age of 54.6 (14.7) yr. Prevalence of caregiver depression risk was high at all time points (33.9, 30.8, and 22.8%; p = 0.83) and did not vary by patient pre-ICU functional status. Lifestyle disruption and employment reduction were also common and persistent.ConclusionsDepression symptoms, lifestyle disruption, and employment reduction were common among informal caregivers of critical illness survivors. Depression risk was high regardless of patient pre-ICU functional status.
| S-EPMC1899280 | biostudies-literature
Project description:BackgroundAn increasing number of patients require prolonged mechanical ventilation (PMV) to survive recovery from critical care. It should be emphasized that PMV is a neglected disease in chest medicine. We investigated 6 years of clinical outcomes and long-term survival rates of patients who required PMV.MethodsWe analyzed retrospectively data from patients in respiratory care center (RCC) to investigate the main causes of respiratory failure leading patients to require PMV. We also studied the factors that influence the ventilator weaned rate, factors that influence the long-term ventilator dependence of patients who require PMV, as well as patients' hospital mortality and long-term survival rates.ResultsA total of 574 patients were admitted to RCC during the 6 years. Of these, 428 patients (74.6%) were older than 65 years. A total of 391 patients (68.1%) were successfully weaned from the ventilator while 83 patients (14.4%) were unsuccessfully weaned. A total of 95 patients (16.6%) died during RCC hospitalization. The most common cause of acute respiratory failure leading to patients requiring PMV was pneumonia. The factor that affected whether patients were successfully weaned from the ventilator was the cause of the respiratory failure that lead patients to require PMV. Our hospital mortality rate was 32.4%; the 1-year survival rate was 24.3%. There was a strong correlation between higher patient age and higher hospital mortality rate and poor 1-year survival rate. Patients with no comorbidity demonstrated good 1-year survival rates. Patients with four comorbidities and patients with end-stage renal disease requiring hemodialysis comorbidity showed poor 1-year survival rates.ConclusionsThe factor that affected whether patients were successfully weaned from the ventilator was the cause of the respiratory failure that lead patients to require PMV. Older patients, patients with renal failure requiring hemodialysis, and those with numerous comorbidities demonstrated poor long-term survival. The reviews of this paper are available via the supplemental material section.
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Project description:Prolonged mechanical ventilation (PMV) after lung transplantation poses several risks, including higher tracheostomy rates and increased in-hospital mortality. Mechanical power (MP) of artificial ventilation unifies the ventilatory variables that determine gas exchange and may be related to allograft function following transplant, affecting ventilator weaning. We retrospectively analyzed consecutive double lung transplant recipients at a national transplant center, ventilated through endotracheal tubes upon ICU admission, excluding those receiving extracorporeal support. MP and derived indexes assessed up to 36 h after transplant were correlated with invasive ventilation duration using Spearman's coefficient, and we conducted receiver operating characteristic (ROC) curve analysis to evaluate the accuracy in predicting PMV (>72 h), expressed as area under the ROC curve (AUROC). PMV occurred in 82 (35%) out of 237 cases. MP was significantly correlated with invasive ventilation duration (Spearman's ρ = 0.252 [95% CI 0.129-0.369], p < 0.01), with power density (MP normalized to lung-thorax compliance) demonstrating the strongest correlation (ρ = 0.452 [0.345-0.548], p < 0.01) and enhancing PMV prediction (AUROC 0.78 [95% CI 0.72-0.83], p < 0.01) compared to MP (AUROC 0.66 [0.60-0.72], p < 0.01). Mechanical power density may help identify patients at risk for PMV after double lung transplantation.
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Project description:BackgroundProlonged mechanical ventilation (MV) should be avoided in neonates. Noninvasive ventilation (NIV) can facilitate weaning from MV but has risks for patients immediately following foregut surgery due to the potential risk of anastomotic leak. We evaluated the risk factors for prolonged MV following intestinal surgery in neonates.MethodsWe retrospectively reviewed 253 neonates undergoing intestinal surgery in 2017-2018 to identify risk factors for prolonged MV, and determine the correlation between NIV and anastomotic leak in a tertiary neonatal intensive care unit that performs the greatest number of neonatal surgeries in Ontario.ResultsThe most common diagnoses were necrotizing enterocolitis/spontaneous intestinal perforation (NEC/SIP) 21%, intestinal atresia 16%, esophageal atresia/tracheoesophageal fistula 14%, ano-rectal malformation 13%, malrotation/volvulus 11%, gastroschisis 9% and omphalocele 4%. The median (IQR) duration of MV post-surgery was 3 (1-8) days with 25.7 % (n=65) of neonates on MV for >7 days. Compared to infants on MV post-surgery for ≤7 days, those with MV>7 days were of lower gestational age, birth weight and weight at surgery, but a higher proportion underwent stoma creation, had a longer duration of opioid administration and higher rates of moderate to severe bronchopulmonary dysplasia (BPD) and mortality (P<0.05). Generalized linear regression analysis showed lower gestational age (GA) and longer opioid administration were associated with longer duration of MV (P<0.001), but indication for surgery, weight at surgery and stoma creation didn't correlate with longer duration of MV (P>0.05). Of the 122 patients handled by one-stage resection with primary anastomosis, 22.1% (n=27) received NIV with 74.1% (n=20) commenced on NIV after 7 days post-surgery, anastomotic leak was detected in 2.5 % (3/122) patients and didn't correlate with NIV.ConclusionsLower GA and longer opioid administration were risk factors for prolonged MV in neonates following intestinal surgery. Further research is needed to investigate modifiable practices around pain assessment/ventilation in these patients, and the correlation between NIV and anastomotic leak.
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Project description:ObjectiveTo compare patient outcomes across body mass index (BMI) subgroups in the setting of recent tracheotomy.MethodsThis retrospective chart review included patients over 18 years old who underwent tracheotomy placement between February 2017 and March 2020. Patients were divided into five groups based on BMI: underweight, normal weight, overweight, obese, and morbidly obese. Data were collected from the electronic medical record (EMR). Statistical analyses were completed via Kruskal-Wallis, Chi-square, log-rank tests, and Cox proportional hazards regression. If significant differences were found between groups, then subsequent pairwise comparisons of BMI were completed.ResultsThere were 391 patients included in the study. There were significant differences in length of stay (p = .015) and duration of mechanical ventilation (p < .001) among the groups. This was mainly driven by comparisons between the normal weight and obese groups, with patients of normal weight having shorter hospital stays and shorter ventilation durations. With each increasing BMI category from normal weight, a greater proportion of patients were ventilator-dependent at the time of discharge (p < .001). Interestingly, after adjustment for comorbidities, the rate of tracheotomy change was 0.86 times lower for every increase in BMI category (95% CI 0.77-0.96). There was a significant difference among the BMI groups with respect to time to tracheotomy collar placement according to both the log-rank test (p < .001) and the Cox model with adjustment for the presence of heart failure (p = .011).ConclusionsAmong patients undergoing tracheotomy, obese and morbidly obese patients have increased lengths of hospital stays. Additionally, they are dependent on ventilators for longer and are more likely to be ventilator-dependent at the time of discharge. It is important to understand how BMI impacts the hospital course for patients undergoing tracheotomy so that patients and their families can be better informed.Level of evidenceLevel 3.
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Project description:BackgroundPatients who need prolonged mechanical ventilation (MV) have high resource utilization and relatively poor outcomes. The pathophysiologic mechanisms leading to weaning failure in this group may be complex and multifactorial. The aim of this study was to investigate the factors associated with prolonged weaning based on the Weaning Outcome according to a New Definition (WIND) classification.MethodsThis is a prospective observational study with consecutive adult patients receiving MV for at least two calendar days in medical intensive care units from 1 November 2017 to 30 September 2020. Eligible patients were divided in a non-prolonged weaning group, including short and difficult weaning, and in a prolonged weaning group according to the WIND classification. The risk factors at the time of first separation attempt associated with prolonged weaning were analyzed using a multivariable logistic regression model.ResultsOf the total 915 eligible patients, 172 (18.8%) patients were classified as prolonged weaning. A higher proportion of the prolonged weaning group had previous histories of endotracheal intubation, chronic lung disease, and hematologic malignancies. When compared with the non-prolonged weaning group, the median duration of MV before the first spontaneous breathing trial (SBT) was longer and the proportion of tracheostomized patients was higher in prolonged weaning group. In addition, the prolonged weaning group used higher peak inspiratory pressures and yielded lower PaO2/FiO2 ratios at the day of the first SBT compared with the non-prolonged weaning group. In multivariate analyses, the duration of MV before first SBT (adjusted odds ratio [OR] = 1.14, 95% confidence interval [CI] = 1.06-1.22, p < 0.001), tracheostomy state (adjusted OR = 1.95, 95% CI = 1.04-3.63, p = 0.036), PaO2/FiO2 ratio (adjusted OR = 1.00, 95% CI = 0.99-1.00, p = 0.023), and need for renal replacement therapy (adjusted OR = 2.68, 95% CI = 1.16-6.19, p = 0.021) were independently associated with prolonged weaning. After the exclusion of patients who underwent tracheostomy before the SBTs, similar results were obtained.ConclusionLonger duration of MV before the first SBT, tracheostomy status, poor oxygenation, and need for renal replacement therapy at the time of first SBT can predict prolonged weaning.Trial registrationClinicalTrials.gov Identifier NCT05134467.
| S-EPMC9373110 | biostudies-literature
Project description:BackgroundShort-term mechanical ventilation (MV) protects against sepsis-induced diaphragmatic dysfunction. Prolonged MV induces diaphragmatic dysfunction in non-septic animals, but few reports describe the effects of prolonged MV in sepsis. We hypothesized that prolonged MV is not protective but worsens the diaphragmatic dysfunction induced by a mild sepsis, because MV and sepsis share key signaling mechanisms, such as cytokine upregulation.MethodWe studied the impact of prolonged MV (12 h) in four groups (n = 8) of male Wistar rats: 1) endotoxemia induced by intraperitoneal injection of Escherichia coli lipopolysaccharide, 2) MV without endotoxemia, 3) combination of endotoxemia and MV and 4) sham control. Diaphragm mechanical performance, pro-inflammatory cytokine concentrations (Tumor Necrosis Factor-α, Interleukin-1β, Interleukin-6) in plasma were measured.ResultsProlonged MV and sepsis independtly reduced maximum diaphragm force (-27%, P = 0.003; -37%, P<0.001; respectively). MV and sepsis acted additively to further decrease diaphragm force (-62%, P<0.001). Similar results were observed for diaphragm kinetics (maximum lengthening velocity -47%, P<0.001). Sepsis and MV reduced diaphragm cross sectional area of type I and IIx fibers, which was further increased by the combination of sepsis and MV (all P<0.05). Sepsis and MV were individually associated with the presence of a robust perimysial inflammatory infiltrate, which was more marked when sepsis and MV were both present (all P<0.05). Sepsis and, to a lesser extent, MV increased proinflammatory cytokine production in plasma and diaphragm (all P<0.05); proinflammatory cytokine expression in plasma was increased further by the combination of sepsis and MV (all P<0.05). Maximum diaphragm force correlated negatively with plasma and diaphragmatic cytokine production (all p<0.05).ConclusionsProlonged (12 h) MV exacerbated sepsis-induced decrease in diaphragm performance. Systemic and diaphragmatic overproduction of pro-inflammatory cytokines may contribute to diaphragm weakness.
| S-EPMC6070213 | biostudies-literature