Detection and management of dyspnea In mechanically ventilated patients

International audiencePURPOSE OF REVIEW: In ICU patients, dyspnea is one of the most prominent and distressing symptom. We sought to summarize current data on the prevalence and prognostic influence of dyspnea in the ICU setting and to provide concise and useful information for dyspnea detection and management.RECENT FINDINGS: As opposed to pain, dyspnea has been a neglected symptom with regard to detection and management. Many factors contribute to the pathogenesis of dyspnea. Among them, ventilator settings seem to play a major role. Dyspnea affects half of mechanically ventilated patient and causes immediate intense suffering [median dyspnea visual analog scale of 5 (4-7)]. In addition, it is associated with delayed extubation and with an increased risk of intubation and mortality in those receiving noninvasive ventilation. However, one-third of critically ill patients are noncommunicative, and therefore, at high risk of misdiagnosis. Heteroevaluation scales based on physical and behavioral signs of respiratory discomfort are reliable and promising alternatives to self-report.SUMMARY: Dyspnea is frequent and severe in critically ill patients. Implementation of observational scale will help physicians to access to noncommunicative patient's respiratory suffering and tailor its treatment. Further studies on the prognostic impact and management strategies are needed

Plastic bronchitis: An unusual complication of acute chest syndrome in adult

International audiencePlastic bronchitis is used to designate endobronchial plugs of rubber-like consistency that form into bronchial trees. It has been described in several diseases like asthma, cystic fibrosis, pulmonary infection, cyanotic congenital heart disease and in few young children with homozygous sickle cell disease. We report the first sickle cell adult case of plastic bronchitis during acute chest syndrome. He developed severe acute respiratory distress syndrome. This unusual presentation related to obstruction by voluminous casts may alert physicians to focus more on the bronchi in sickle cell patients. Realization of fiberoptic bronchoscopy to diagnose endobronchial injury and preventive measures such as fluidification of sputum at the early stage of thoracic vaso-occlusive crisis are essential

Considering personalized Interferon-β therapy for COVID-19

International audienceDavoudi-Monfared et al. (1) report in this Journal the results from a clinical trial on COVID-19 patients showing that subcutaneous administration of interferon-β (IFN-β) was associated with a more rapid recovery from SARS-CoV-2 infection and decreased mortality.…

Observation scales to suspect dyspnea in non-communicative intensive care unit patients

International audienceDyspnea, like pain, is a major cause of physical suffering and emotional distress. In the intensive care unit, mechanically ventilated patients are at high risk of dyspnea [1], and increasing attention is being given to this symptom [1, 2]. Because its evaluation relies on self-report and self-assessment [3], dyspnea carries the risk of being underestimated or even unrecognized and therefore unattended in many intensive care unit patients. This is particularly so in patients unable to communicate with their caregivers (sedation, delirium, etc.). We have recently developed and validated a specific intensive care unit version of the respiratory distress observation scale (IC-RDOS, http://www.ic-rdos.com) [4]. IC-RDOS, based on respiratory and behavioral signs, correlates strongly with ratings of dyspnea on a visual analogic scale in “communicative” patients, but this is by definition not the most pertinent target population. The present secondary analysis describes IC-RDOS in “non-communicative” intensive care unit patients, as the first step of its clinical and prognostic evaluation in this setting

Prognosis of patients with primary malignant brain tumors admitted to the intensive care unit: a two-decade experience

International audienceThe purpose of this study is to describe the reasons for ICU admission and to evaluate the outcome and prognostic factors of patients with primary malignant brain tumors (PMBT) admitted to the intensive care unit (ICU). This is a retrospective observational cohort study of 196 PMBT patients admitted to two ICUs over a 19-year period. Acute respiratory failure was the main reason for ICU admission (45%) followed by seizures (25%) and non-epileptic coma (14%). Seizures were more common in patients with glial lesions (84 vs. 67%), whereas patients with primary brain lymphoma were more frequently admitted for shock (42 vs. 18%). Overall ICU and 90-day mortality rates were 23 and 50%, respectively. Admission for seizures was independently associated with lower ICU mortality [odds ratio (OR) 0.06], whereas the need for mechanical ventilation (OR 6.85), cancer progression (OR 7.84), respiratory rate (OR 1.11) and Glasgow coma scale (OR 0.85) were associated with higher ICU mortality. Among the 95 patients who received invasive mechanical ventilation, ICU mortality was 37% (n = 35). For these patients, admission for seizures was associated with lower ICU mortality (OR 0.050) whereas cancer progression (OR 7.49) and respiratory rate (OR 1.08) were associated with higher ICU mortality. The prognosis of PMBT patients admitted to the ICU appears relatively favorable compared to that of hematologic malignancies or solid tumors, especially when the patient is admitted for seizures. The presence of a PMBT, therefore, does not appear to be sufficient for refusal of ICU admission. Predictive factors of mortality may help clinicians make optimal triage decisions

Health-related quality of life of COVID-19 two and 12 months after intensive care unit admission

International audienceAbstract Purpose To describe health-related quality of life (HRQoL) and dyspnea of COVID-19, 2 and 12 months after an intensive care unit (ICU) stay . Methods Patients discharged from the ICU between April and June 2020 and subsequently transferred to an inpatient rehabilitation facility were assessed 2 months and 12 months after ICU admission. HRQoL was assessed by the EuroQoL EQ-5D-3L (visual analog scale and time trade-off normalized to the French population algorithm) and dyspnea was assessed by the modified Medical Research Council (mMRC) dyspnea scale. Results We enrolled 94 patients. Median EQ-5D-3L time trade-off was 0.80 (interquartile range, 0.36–0.91) at 2 months and 0.91 (0.52–1.00) at 12 months ( P = 0.12). EQ-5D-3L visual analog scale was 70 (60–85) at 2 months and 70 (60–85) at 12 months ( P = 0.07). The mMRC dyspnea scale was 3 (2–4) at ICU discharge, 1 (0–2), P < 0.001 at 2 months and 1 (1–2) at 12 months. At 12 months, 68 (76%) patients reported at least one symptom that was not present prior to ICU admission and 27 (61%) of the 44 patients who were previously working had returned to work. On multiple linear regression, factors associated with EQ-5D-3L were body mass index on ICU admission, tracheostomy, male gender and active smoking. Conclusions Twelve months after ICU admission for COVID-19 and subsequent rehabilitation, a substantial proportion of patients reported alterations of HRQoL, dyspnea and symptoms that were not present prior to admission and a substantial proportion of these patients had not returned to work. Factors associated with a risk of poorer 12-month quality of life, may help to identify at-risk patients

Dyspnoea in acutely ill mechanically ventilated adult patients:an ERS/ESICM statement

This statement outlines a review of the literature and current practice concerning the prevalence, clinical significance, diagnosis and management of dyspnoea in critically ill, mechanically ventilated adult patients. It covers the definition, pathophysiology, epidemiology, short- and middle-term impact, detection and quantification, and prevention and treatment of dyspnoea. It represents a collaboration of the European Respiratory Society and the European Society of Intensive Care Medicine. Dyspnoea ranks among the most distressing experiences that human beings can endure. Approximately 40% of patients undergoing invasive mechanical ventilation in the intensive care unit (ICU) report dyspnoea, with an average intensity of 45 mm on a visual analogue scale from 0 to 100 mm. Although it shares many similarities with pain, dyspnoea can be far worse than pain in that it summons a primal fear response. As such, it merits universal and specific consideration. Dyspnoea must be identified, prevented and relieved in every patient. In the ICU, mechanically ventilated patients are at high risk of experiencing breathing difficulties because of their physiological status and, in some instances, because of mechanical ventilation itself. At the same time, mechanically ventilated patients have barriers to signalling their distress. Addressing this major clinical challenge mandates teaching and training, and involves ICU caregivers and patients. This is even more important because, as opposed to pain which has become a universal healthcare concern, very little attention has been paid to the identification and management of respiratory suffering in mechanically ventilated ICU patients.</p

Dyspnoea in acutely ill mechanically ventilated adult patients:an ERS/ESICM statement

This statement outlines a review of the literature and current practice concerning the prevalence, clinical significance, diagnosis and management of dyspnoea in critically ill, mechanically ventilated adult patients. It covers the definition, pathophysiology, epidemiology, short- and middle-term impact, detection and quantification, and prevention and treatment of dyspnoea. It represents a collaboration of the European Respiratory Society and the European Society of Intensive Care Medicine. Dyspnoea ranks among the most distressing experiences that human beings can endure. Approximately 40% of patients undergoing invasive mechanical ventilation in the intensive care unit (ICU) report dyspnoea, with an average intensity of 45 mm on a visual analogue scale from 0 to 100 mm. Although it shares many similarities with pain, dyspnoea can be far worse than pain in that it summons a primal fear response. As such, it merits universal and specific consideration. Dyspnoea must be identified, prevented and relieved in every patient. In the ICU, mechanically ventilated patients are at high risk of experiencing breathing difficulties because of their physiological status and, in some instances, because of mechanical ventilation itself. At the same time, mechanically ventilated patients have barriers to signalling their distress. Addressing this major clinical challenge mandates teaching and training, and involves ICU caregivers and patients. This is even more important because, as opposed to pain which has become a universal healthcare concern, very little attention has been paid to the identification and management of respiratory suffering in mechanically ventilated ICU patients.</p