Spontaneous Breathing in Early Acute Respiratory Distress Syndrome: Insights From the Large Observational Study to UNderstand the Global Impact of Severe Acute Respiratory FailurE Study

OBJECTIVES: To describe the characteristics and outcomes of patients with acute respiratory distress syndrome with or without spontaneous breathing and to investigate whether the effects of spontaneous breathing on outcome depend on acute respiratory distress syndrome severity. DESIGN: Planned secondary analysis of a prospective, observational, multicentre cohort study. SETTING: International sample of 459 ICUs from 50 countries. PATIENTS: Patients with acute respiratory distress syndrome and at least 2 days of invasive mechanical ventilation and available data for the mode of mechanical ventilation and respiratory rate for the 2 first days. INTERVENTIONS: Analysis of patients with and without spontaneous breathing, defined by the mode of mechanical ventilation and by actual respiratory rate compared with set respiratory rate during the first 48 hours of mechanical ventilation. MEASUREMENTS AND MAIN RESULTS: Spontaneous breathing was present in 67% of patients with mild acute respiratory distress syndrome, 58% of patients with moderate acute respiratory distress syndrome, and 46% of patients with severe acute respiratory distress syndrome. Patients with spontaneous breathing were older and had lower acute respiratory distress syndrome severity, Sequential Organ Failure Assessment scores, ICU and hospital mortality, and were less likely to be diagnosed with acute respiratory distress syndrome by clinicians. In adjusted analysis, spontaneous breathing during the first 2 days was not associated with an effect on ICU or hospital mortality (33% vs 37%; odds ratio, 1.18 [0.92-1.51]; p = 0.19 and 37% vs 41%; odds ratio, 1.18 [0.93-1.50]; p = 0.196, respectively ). Spontaneous breathing was associated with increased ventilator-free days (13 [0-22] vs 8 [0-20]; p = 0.014) and shorter duration of ICU stay (11 [6-20] vs 12 [7-22]; p = 0.04). CONCLUSIONS: Spontaneous breathing is common in patients with acute respiratory distress syndrome during the first 48 hours of mechanical ventilation. Spontaneous breathing is not associated with worse outcomes and may hasten liberation from the ventilator and from ICU. Although these results support the use of spontaneous breathing in patients with acute respiratory distress syndrome independent of acute respiratory distress syndrome severity, the use of controlled ventilation indicates a bias toward use in patients with higher disease severity. In addition, because the lack of reliable data on inspiratory effort in our study, prospective studies incorporating the magnitude of inspiratory effort and adjusting for all potential severity confounders are required

Identifying associations between diabetes and acute respiratory distress syndrome in patients with acute hypoxemic respiratory failure: an analysis of the LUNG SAFE database

Background: Diabetes mellitus is a common co-existing disease in the critically ill. Diabetes mellitus may reduce the risk of acute respiratory distress syndrome (ARDS), but data from previous studies are conflicting. The objective of this study was to evaluate associations between pre-existing diabetes mellitus and ARDS in critically ill patients with acute hypoxemic respiratory failure (AHRF). Methods: An ancillary analysis of a global, multi-centre prospective observational study (LUNG SAFE) was undertaken. LUNG SAFE evaluated all patients admitted to an intensive care unit (ICU) over a 4-week period, that required mechanical ventilation and met AHRF criteria. Patients who had their AHRF fully explained by cardiac failure were excluded. Important clinical characteristics were included in a stepwise selection approach (forward and backward selection combined with a significance level of 0.05) to identify a set of independent variables associated with having ARDS at any time, developing ARDS (defined as ARDS occurring after day 2 from meeting AHRF criteria) and with hospital mortality. Furthermore, propensity score analysis was undertaken to account for the differences in baseline characteristics between patients with and without diabetes mellitus, and the association between diabetes mellitus and outcomes of interest was assessed on matched samples. Results: Of the 4107 patients with AHRF included in this study, 3022 (73.6%) patients fulfilled ARDS criteria at admission or developed ARDS during their ICU stay. Diabetes mellitus was a pre-existing co-morbidity in 913 patients (22.2% of patients with AHRF). In multivariable analysis, there was no association between diabetes mellitus and having ARDS (OR 0.93 (0.78-1.11); p = 0.39), developing ARDS late (OR 0.79 (0.54-1.15); p = 0.22), or hospital mortality in patients with ARDS (1.15 (0.93-1.42); p = 0.19). In a matched sample of patients, there was no association between diabetes mellitus and outcomes of interest. Conclusions: In a large, global observational study of patients with AHRF, no association was found between diabetes mellitus and having ARDS, developing ARDS, or outcomes from ARDS. Trial registration: NCT02010073. Registered on 12 December 2013

Epidemiology and patterns of tracheostomy practice in patients with acute respiratory distress syndrome in ICUs across 50 countries

Background: To better understand the epidemiology and patterns of tracheostomy practice for patients with acute respiratory distress syndrome (ARDS), we investigated the current usage of tracheostomy in patients with ARDS recruited into the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG-SAFE) study. Methods: This is a secondary analysis of LUNG-SAFE, an international, multicenter, prospective cohort study of patients receiving invasive or noninvasive ventilation in 50 countries spanning 5 continents. The study was carried out over 4 weeks consecutively in the winter of 2014, and 459 ICUs participated. We evaluated the clinical characteristics, management and outcomes of patients that received tracheostomy, in the cohort of patients that developed ARDS on day 1-2 of acute hypoxemic respiratory failure, and in a subsequent propensity-matched cohort. Results: Of the 2377 patients with ARDS that fulfilled the inclusion criteria, 309 (13.0%) underwent tracheostomy during their ICU stay. Patients from high-income European countries (n = 198/1263) more frequently underwent tracheostomy compared to patients from non-European high-income countries (n = 63/649) or patients from middle-income countries (n = 48/465). Only 86/309 (27.8%) underwent tracheostomy on or before day 7, while the median timing of tracheostomy was 14 (Q1-Q3, 7-21) days after onset of ARDS. In the subsample matched by propensity score, ICU and hospital stay were longer in patients with tracheostomy. While patients with tracheostomy had the highest survival probability, there was no difference in 60-day or 90-day mortality in either the patient subgroup that survived for at least 5 days in ICU, or in the propensity-matched subsample. Conclusions: Most patients that receive tracheostomy do so after the first week of critical illness. Tracheostomy may prolong patient survival but does not reduce 60-day or 90-day mortality. Trial registration: ClinicalTrials.gov, NCT02010073. Registered on 12 December 2013

Prognostic factors in patients with systemic lupus erythematosus admitted to the intensive care unit

The objectives of this study were to identify risk factors associated with mortality in patients with systemic lupus erythematosus (SLE) admitted to the intensive care unit (ICU) and to evaluate the usefulness of Acute Physiologic and Chronic Health Evaluation (APACHE) II score to predict outcomes in these patients, through the use of a retrospective patient record review from a multidisciplinary intensive care unit in a teaching hospital. One hundred and four patients with SLE admitted to the ICU were included in the study. The mean age of patients was 32.44 years, 96.2% were female and 61.5% were admitted with infection. The mean APACHE II score was 19.7, 46.2% had acute renal dysfunction, 67.3% received inotropics/ vasopressors, 27.9% pulmonary artery catheter and 74% invasive mechanical ventilation. The mean length of stay in ICU was 18.5 days and mortality rate was 32.7%. In the univariate logistic regression analysis, factors associated with mortality were high APACHE II score, use of inotropics/vasopressors, pulmonary artery catheter and invasive mechanical ventilation. High APACHE II score and use of inotropics/vasopressors remained significant in the multi-variate analysis. The area under the receiver operating characteristic curve of the APACHE II score to predict mortality was 0.689 (95% CI 0.586—0.791 p = 0.002) and the Hosmer— Lemeshow χ 2 was 5.094 (p = 0.747). We conclude that the mortality rate in patients with SLE admitted to the ICU is high. The most common cause of admission was infection. The factors associated with mortality were high APACHE II score and the use of inotropics/vasopressors. APACHE II score was unable to accurately predict mortality. Lupus (2009) 18, 1252—1258. </jats:p

Tumor lysis syndrome in the emergency department: challenges and solutions

Silvio A &Ntilde;amendys-Silva,1,2 Juan M Arredondo-Armenta,1 Erika P Plata-Menchaca,2 Humberto Guevara-Garc&iacute;a,1 Francisco J Garc&iacute;a-Guill&eacute;n,1 Eduardo Rivero-Sigarroa,2 Angel Herrera-G&oacute;mez,1 1Department of Critical Care Medicine, Instituto Nacional de Cancerolog&iacute;a, 2Department of Critical Care Medicine, Instituto Nacional de Ciencias M&eacute;dicas y Nutrici&oacute;n Salvador Zubir&aacute;n, Mexico City, Mexico Abstract: Tumor lysis syndrome (TLS) is the most common oncologic emergency. It is caused by rapid tumor cell destruction and the resulting nucleic acid degradation during or days after initiation of cytotoxic therapy. Also, a spontaneous form exists. The metabolic abnormalities associated with this syndrome include hyperkalemia, hyperphosphatemia, hypocalcemia, hyperuricemia, and acute kidney injury. These abnormalities can lead to life-threatening complications, such as heart rhythm abnormalities and neurologic manifestations. The emergency management of overt TLS involves proper fluid resuscitation with crystalloids in order to improve the intravascular volume and the urinary output and to increase the renal excretion of potassium, phosphorus, and uric acid. With this therapeutic strategy, prevention of calcium phosphate and uric acid crystal deposition within renal tubules is achieved. Other measures in the management of overt TLS are prescription of hypouricemic agents, renal replacement therapy, and correction of electrolyte imbalances. Hyperkalemia should be treated quickly and aggressively as its presence is the most hazardous acute complication that can cause sudden death from cardiac arrhythmias. Treatment of hypocalcemia is reserved for patients with electrocardiographic changes or symptoms of neuromuscular irritability. In patients who are refractory to medical management of electrolyte abnormalities or with severe cardiac and neurologic manifestations, early dialysis is recommended.Keywords: tumor lysis syndrome, emergency department, emergency management, intensive care, oncologic emergenc