Critical care : the official journal of the Critical Care Forum
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Observational Study
Time course of electrical activity of the diaphragm (EAdi) in the peri extubation period and its role as predictor of extubation failure in difficult to wean patients.
Weaning patients from mechanical ventilation is crucial in the management of acute respiratory failure (ARF). Spontaneous breathing trials (SBT) are used to assess readiness for extubation, but extubation failure remains a challenge. Diaphragmatic function, measured by electrical activity of the diaphragm (EAdi), may provide insights into weaning outcomes. ⋯ In difficult-to-wean patients, EAdi increases significantly between the phases before the SBT, the SBT and post-extubation period and is significantly higher in patients experiencing extubation failure. An EAdi > 30 μV during SBT may enhance extubation failure prediction compared to conventional parameters. Advanced monitoring of diaphragmatic function could improve weaning outcomes in critical care settings.
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We would like to extend our gratitude to Dr. da Hora Passos et al. for their interest in our recently published review and meta-analysis in Critical Care. In this response, we will elaborate on the points raised by the authors. ⋯ This variance in sensitivity is more likely due to diversity in diagnostic thresholds. We advocate for global collaboration among LUS experts to align LUS methodologies and strengthen the evidence supporting LUS in the diagnosis of ARDS and its morphological subphenotypes.
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Observational Study
The pleural gradient does not reflect the superimposed pressure in patients with class III obesity.
The superimposed pressure is the primary determinant of the pleural pressure gradient. Obesity is associated with elevated end-expiratory esophageal pressure, regardless of lung disease severity, and the superimposed pressure might not be the only determinant of the pleural pressure gradient. The study aims to measure partitioned respiratory mechanics and superimposed pressure in a cohort of patients admitted to the ICU with and without class III obesity (BMI ≥ 40 kg/m2), and to quantify the amount of thoracic adipose tissue and muscle through advanced imaging techniques. ⋯ In patients with class III obesity, the superimposed pressure does not approximate the pleural pressure gradient, which is higher than in patients with lower BMI. The quantity and distribution of subcutaneous and intrathoracic adiposity also contribute to increased pleural pressure gradients in individuals with BMI ≥ 40. This study introduces a novel physiological concept that provides a solid rationale for tailoring mechanical ventilation in patients with high BMI, where specific guidelines recommendations are lacking.
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To detect preload responsiveness in patients ventilated with a tidal volume (Vt) at 6 mL/kg of predicted body weight (PBW), the Vt-challenge consists in increasing Vt from 6 to 8 mL/kg PBW and measuring the increase in pulse pressure variation (PPV). However, this requires an arterial catheter. The perfusion index (PI), which reflects the amplitude of the photoplethysmographic signal, may reflect stroke volume and its respiratory variation (pleth variability index, PVI) may estimate PPV. We assessed whether Vt-challenge-induced changes in PI or PVI could be as reliable as changes in PPV for detecting preload responsiveness defined by a PLR-induced increase in cardiac index (CI) ≥ 10%. ⋯ In patients under mechanical ventilation with no spontaneous breathing and/or atrial fibrillation, changes in PI detected during Vt-challenge reliably detected preload responsiveness. The reliability was better when PI was measured on the forehead than on the fingertip. Changes in PVI during the Vt-challenge also detected preload responsiveness, but with lower accuracy.
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Too high or too low patient volumes and work amounts may overwhelm health care professionals and obstruct processes or lead to inadequate personnel routine and process flow. We sought to evaluate, whether an association between current caseload, current workload, and outcomes exists in intensive care units (ICU). ⋯ In a system with comparably high intensive care resources and mandatory staffing levels, patients' survival chances are generally not affected by high intensive care unit caseload and workload. However, extraordinary circumstances, such as the COVID-19 pandemic, may lead to higher risk of death, if planned capacities are exceeded. High workload in ICUs in smaller hospitals with lower staffing levels may be associated with increased risk of death.