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Mechanical Ventilation in Patients with Acute Hypoxemic Respiratory Failure

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Mechanical Ventilation in Patients with Acute Hypoxemic Respiratory Failure Mechanical ventilation and AHRF ORIGINAL ARTICLE RAMR 2017;1:63-7063 ISSN 1852 - 236X Mechanical ventilation in patients with acute hypoxemic respiratory failure Authors: Plotnikow Gustavo1, Pratto Romina1, Tiribelli Norberto2, Ilutovich Santiago2, Correspondence: Andrich Emilia1, Gómez Ramiro1, Quiroga Corina1, D’Annunzio Pablo1, Vasquez Daniela1, Gustavo Plotnikow. 1 2 2 2 1 [email protected] Intile Dante , Avaca Graciela , García Andrea , Noval Diego , Desmery Pablo Received: 09.08.2016 1Sanatorio Anchorena. Ciudad Autónoma de Bs. As. Accepted: 11.14.2016 2Sanatorio de la Trinidad Mitre. Ciudad Autónoma de Bs. As. Abstract Objective: To describe the clinical characteristics of patients with AHRF (without ARDS) hospitalized in the ICU who require IMV. To evaluate the association between mortality and different variables. Design: Inception cohort. Scope: This study was conducted in two Argentine ICUs from the private health sector between 07/01/2013 and 12/31/2014. Patients: From a consecutive sample of 2526 patients, 229 individuals aged 18 and upwards were included in the study; they were admitted to the ICU requiring IMV for over 24 hours and developed AHRF (without ARDS). Primary endpoints: Demographic variables and variables associated with the number of days with IMV and at the ICU were documented, as well as the initial setting of the respirator, monitoring variables and evolution at discharge. Likewise, the number and type of complications developed during the period of IMV were documented. Results: 70.7% of admissions were for medical reasons. SAPS II score was 42. The period of IMV and at the ICU was higher in patients with delirium (p<0.0001 in both). In the logistic regression model adjusted by the severity of hypoxemia, age (OR 1.02; 95% CI 1.002-1.04: p = 0.033) and shock (OR 2.37; 95% CI 1.12-5: p = 0.023) acted as independent predictors of mortality. Conclusions: In this group of patients who required IMV for over 24 hours and who developed AHRF (without ARDS) there was a demographic distribution similar to that described in other reports. Mortality was not associated with the severity of hypoxemia, whereas shock and age were independent predictors of mortality. Key words: mechanical ventilation; acute respiratory failure; acute hypoxemic respira- tory failure; intensive care unit Introduction with acute respiratory distress syndrome (ARDS). ARDS is a clinical syndrome characterized by the Invasive mechanical ventilation (IMV) is an essen- emergence of bilateral pulmonary infiltrates, new tial tool to assist patients with acute respiratory respiratory symptoms or the aggravation of these failure and is one of the distinctive procedures at symptoms and a partial pressure of O2 / fraction intensive care units (ICUs). In this regard, cur- of inspired O2 (PaO2/FiO2) ratio with values below rent clinical trials have evidenced that procedures 3006. It can be assumed that the “AHRF (without aimed at preventing lung injury induced by IMV1, ARDS)” diagnosis, a condition many patients with 2, and to improve weaning strategies3, 4, 5, have a IMV present with, can be arrived at with the same significant impact on mortality and the length of criteria, excluding radiographic criteria7. Acute time with IMV. respiratory failure is a frequent condition that ap- Acute hypoxemic respiratory failure (AHRF) proximately 56% of the patients at the ICU have; it requires IMV, which is not exclusive to patients is associated with a significant amount of extrapul- 64 Revista Americana de Medicina Respiratoria Vol 17 Nº 1 - Marzo 2017 monary factors and a high rate of mortality among during the first 72 hours). At the same time, the critical patients8. However, the information linked number and type of complications developed to IMV implementation in patients with AHRF in during the period of IMV were documented in our country is limited. this datasheet, which were the following: This study was created to describe the charac- – Pulmonary thromboembolism (PTE) diagnosed teristics and clinical evolution of patients hospital- by computed axial tomography angiography. ized at the ICU with AHRF (without ARDS) who – Acute myocardial infarction (AMI) diagnosed by require IMV and, at the same time, to evaluate the changes in the electrocardiogram and in cardiac association between population mortality globally enzymes (high-sensitivity troponin >15.6 pg/mL). and by age groups according to the severity of hy- – Cardiac arrest (CA). Asystole or atrial fibrilla- poxemia, the length of time with IMV, the length tion with an effective response to cardiopulmo- of stay at the ICU, the reason for IMV, the number nary resuscitation. and type of complications presented, the driving – ICU-acquired weakness (ICUAW), defined as a pressure within the first 24 hours (DP24hs) and Medical Research Council scale9 (MRC) value the evolution of the PaO2/FiO2 ratio during the < 38/60. first 72 hours. – ARDS development defined according to the Berlin definition6. Materials and methods – Barotrauma, defined as the presence of pneu- mothorax in the front chest X-ray. A retrospective case series study conducted in two – Multiple organ dysfunction10 (MOD), defined as health centers from Ciudad Autónoma de Bs. As. the presence of two or more of the following: (two monovalent, referral ICUs from the private a. Respiratory dysfunction: PaO2FiO2 ratio health sector with a total of 32 beds) between ≤ 400. July 1st, 2013 and December 31st, 2014. For this b. Hematological dysfunction: Platelets (platelet study, AHRF was defined as the emergence of count/mm3) ≤ 150000. new respiratory symptoms 24 hours after start- c. Liver dysfunction: Bilirubin (mg/dL) between ing IMV, or the aggravation of these symptoms, 1.2-1.6. PaO2/FiO2 ratio with values below 300, absence of d. Cardiac dysfunction: mean blood pressure new infiltrates in front chest X-rays and absence < 70mmHg. of echocardiographic evidence of left ventricular e. Neurological dysfunction: Glasgow coma failure. All patients aged 18 and upwards who scale between ≤14. were admitted to the ICU during this period and f. Renal dysfunction: Creatinine (mg/dL) ≥1.2. who required IMV for over 24 hours and developed – Unprogrammed extubation. AHRF (without ARDS) were included. – Delirium was defined by positive scores using Patients with incomplete daily monitoring the Confusion Assessment Method for the ICU records on ventilation and those who at the be- (CAM-ICU)11. ginning of or during IMV developed ARDS were – Shock: mean blood pressure <70mmHg despite excluded. of adequate fluid resuscitation, with perfusion – Once the first 24 hours of IMV had elapsed, the alterations that can include lactic acidosis, oli- following variables were prospectively docu- guria or acute altered mental status, but that mented for each patient in a specially designed are not necessarily limited to these12. database: age, gender, severity score during the – Severe renal failure, defined as those patients first 24 hours after admission (Simplified Acute who required dialysis. Physiology Score II [SAPS II]), type of admis- – Ventilator-associated pneumonia (VAP), defined sion to de ICU, reason for IMV, length of time as the presence of a new infiltrate in front X-rays, with IMV, length of stay at the ICU, evolution at fever, increased level of leukocytes, changes in discharge (weaned “YES-NO” during ICU stay, the characteristics of secretions, and bacterial survived “YES-NO”), initial setting variables of culture of tracheal aspirate >105 CFU13. the respirator (tidal volume [TV] and positive Continuous data are presented as mean and end-expiratory pressure [PEEP]) and monitor- standard deviation (SD), or as median and in- ing variables (DP24hs and PaO2/FiO2 evolution terquartile range [IQR25-75], depending on their Mechanical ventilation and AHRF 65 frequency distribution. Categorical data are pre- was 42 [31-57]. The main reasons for IMV were: sented as absolute values and/or percentages. The pneumonia 20.5% (n = 47), shock 20.1% (n = 46) association between potential risk factors and out- and postoperative ARF 18.3% (n = 42). The length come variables was assessed using the chi-square of time with IMV was 7 [3-15] days, and the length test, the Kruskal-Wallis test or the Mann-Whitney of stay at the ICU was 14 [6.2-24] days (table 1). test. Factors linked to severity were included in The initial setting for IMV was with a 7.79 [7- a logistic regression model using mortality as an 8] ml/kg TV and with a PEEP of 7 [5-8] cmH2O. outcome variable. The power of association was After 24 hours of starting IMV, the DP24hs was 12 presented as Odds Ratio and 95% Confidence [10-15] cmH2O and the PaO2/FiO2 ratio was 225 Interval. For the analysis, the sample was classi- [187.4-261] (table 2). fied into 3 severity groups according to the PaO2/ From the patients included, 61.6% (n = 141) FiO2 ratio from the first 24 hours (severe: PaO2/ could be weaned, 14.8% (n = 34) required reintuba- FiO2 ≤ 100; moderate: PaO2/FiO2 > 100 and ≤ 200 tion and 22.7% (n = 52) required a tracheostomy. and mild: PaO2/FiO2 > 200 and ≤ 300). A p < 0.05 Mortality at the ICU was 36.7% (n = 84) (figure 1). value was considered significant. For the statisti- Age (60 ± 18 vs. 67 ± 18; p = 0,002), SAPS II cal analysis we used IBM’s SPSS software 20.0. (39 [26-53] vs. 49 [37-61]; p < 0,0001) and DP24hs Ethical considerations: the study was approved (12 [9,9-14,5] vs. 13 [11-16]; p < 0,02) were higher by the teaching and research committee from both in deceased patients than in survivors. institutions and informed consent forms were not 81% (n = 185) of the patients had at least one required since it was a retrospective study of data complication (table 3), delirium being the most prospectively collected at the ICU as part of the frequent one (45.9%; n = 105).
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