ObjectiveTo investigate the clinical value of peripheral blood vitamin D level in predicting the outcome of weaning from mechanical ventilation in critically ill patients.MethodsA total of 130 critically ill patients who undergoing mechanical ventilation for more than 48 hours in our hospital were recruited from June 2014 to June 2017. Serum 25(OH)D3 was detected on admission and before spontaneous breathing test (SBT) meanwhile general clinical data and laboratory examination indexes were recorded. The cases were divided into a successful weaning group and a failure weaning group according to the outcome of weaning from mechanical ventilation. Logistic regression equation was used to analyze the relationship between vitamin D level and failure weaning, and a receiver operating characteristic (ROC) curve was used to analyze the predictive value for failure weaning.ResultsThere were 46 patients with failure weaning among 130 patients (35.38%). Compared with the successful weaning group, the failure weaning group had significantly higher Acute Physiology and Chronic Health EvaluationⅡ score, longer duration in intensive care unit, higher respiratory rate, higher rapid shallow breathing index, higher C-reactive protein, higher N-terminal prohormone of brain natriuretic peptide, higher serum creatinine, and significantly lower albumin (all P<0.05). 25(OH)D3 level classifications on admission and before SBT in the failure weaning group were worse than those in the successful weaning group (P<0.05). 25(OH)D3 levels of the failure weaning group were lower than those of the successful weaning group [on admission: (18.16±4.33) ng/ml vs. (21.60±5.25) ng/ml, P<0.05; before SBT: (13.50±3.52) ng/mlvs. (18.61±4.30) ng/ml, P<0.05]. Multivariate logistic regression analysis showed that 25(OH)D3 levels on admission and before SBT were independent risk factors for failure weaning (OR values were 2.257 and 2.613, respectively, both P<0.05). ROC curve analysis showed that areas under ROC curve were 0.772 and 0.836, respectively, with sensitivities of 80.3% and 85.2%, specificities of 69.0% and 71.0%, respectively.Conclusions25(OH)D3 deficiency or insufficiency is common in critically ill patients. The lower the level of vitamin D, the higher the risk of failure weaning. So it may be an independent predictor of failure weaning.
ObjectiveTo compare the difference of respiratory mechanics parameters between three different spontaneous breathing trials on COPD patients in weaning process. Methods17 patients with COPD underwent mechanical ventilation for at least 48 hours who were stable and ready for weaning were enrolled. All patients underwent three spontaneous breathing trials, ie, automatic tube compensation (ATC,compensation level 100%),low level pressure support ventilation (PSV,7 cm H2O) and T-piece. Each spontaneous breathing trials continued for 10 minutes. Before each autonomous respiration experiment ended,the respiratory mechanics parameters including high airway pressure (PIP),breathing rate (RR),blood oxygen saturation (SaO2),airway occlusion pressure at 0.1 second (P0.1),maximal inspiratory mouth pressure(Pimax) and rapid shallow breathing index (RSBI) were measured. Their differences between three spontaneous breathing trials were compared. Results12 patients successfully completed three different methods of spontaneous breathing test. Compared with the T-piece,P0.1,Pimax,RSBI and RR in the COPD patients using low level PSV and ATC were significantly decreased while VT and SaO2 were increased. The difference of each parameter in the low level PSV group and the ATC group had statistical significance compared with T-piece group (P<0.05). Compared with the low PSV group,P0.1,Pimax,RSBI and RR in ATC group were elevated while PIP,VT and SaO2 were reduced. The differences of P0.1,Pimax,RSBI,PIP and RR between two groups were statistically significant (P<0.05). ConclusionFor COPD patients in weaning process with spontaneous breathing trial,both low levels of PSV and ATC are better than T-piece,and the patients are more comfortable with ATC100% than PSV.
ObjectiveTo compare the predictive values of dynamic energy expenditure (EE) monitoring and the traditional method (rapid shallow breath index) for weaning in patient who is suitable for weaning from mechanical ventilation and accepts sequentially reduced support of ventilator.MethodsThis study included a total of 93 patients who were admitted to the Department of Intensive Care Medicine in 2018 to 2019, and were eligible for weaning from mechanical ventilation. The energy expenditure monitoring device of GE ventilator (CARESCAPE R860) was used to record the patient's change rate of EE [δEE(%), T1 (PSV 20/5), T2 (PSV 15/5), T3 (PSV 10-5/5), T4 (PSV 5/5)] while the ventilation support was declined. The differences in δEE were compared between the two groups of patients who were successful weaned (a successful group S) or failed (a failed group) at different phases. The receiver operator characteristic (ROC) curve was used to analyze the predictive value of δEE to the success rate of weaning.ResultA total of 36 patients failed weaning procedure. There was no significant difference in the basic status and disease type between the successful group and the failed group. There was no difference in δEE1 between T1-T2 phases [(5.67±2.31)% vs. (6.40±1.90)%, P>0.05], but significant difference in δEE between T2-T3 and T3-T4 phases [δEE2: (11.35±5.39)% vs. (14.21±6.33)%, P<0.05; δEE3: (8.39±3.90)% vs. (17.32±9.07)%, P<0.05]. The area under the ROC curve predicted by δEE2 and δEE3 for the patient's weaning results was higher than rapid shallow breath index (0.83 and 0.75 vs. 0.64, P<0.05).ConclusionDynamic energy expenditure monitoring can effectively evaluate and predict the success rate of weaning from mechanical ventilation, and can be applied to the clinical treatment process.
Objective To assess the risk factors associated with extubation failure in patients who had successfully passed a spontaneous breathing trial.Methods Patients receiving invasive mechanical ventilation for over 48 h were enrolled in the study，they were admitted into Emergency ICU of Zhongshan Hospital during May 2006 and Oct.2007.A spontaneous breathing trial was conducted by a pressure support of 7 cm H2O for 30 min.Clinical data were prospectively recorded for the patient receiving full ventilatory support before and after the spontaneous breathing trial.Regarding the extubation outcome，patients were divived into extubation success group and extubation failure group.Results A total of 58 patients with a mean（±SD） age of 69.4±12.7 years passed spontaneous breathing trial and were extubated.Extubation failure occurred in 11 patients（19%）.The univariate analysis indicated the following associations with extubation failure：elderly patients（78.1±7.9 years vs 67.4±15.1years，Plt;0.05），higher rapid shallow breathing index（RSBI） value（83±12 breaths·min-1·L-1 vs 68±19 breaths·min-1·L-1，Plt;0.05）and excessive respiratory tract secretions（54.5％ vs 21.3％，Plt;0.05）.Conclusion Among routinely measured clinical variables，elderly patients，higher RSBI value and amount of respiratory tract secretions were the valuable index for predicting extubation failure despite a successful spontaneous breathing trial.
ObjectiveTo investigate the predictive value of diaphragm rapid shallow breathing index (D-RBSI) in weaning from mechanical ventilation in patients with chronic obstructive pulmonary disease (COPD).MethodsSeventy-six patients with COPD who were undergoing mechanical ventilation were enrolled in department of critical care medicine of our hospital from March 2016 to March 2017. The patient underwent spontaneous breathing test (SBT) using CPAP mode after weaning screening. When the SBT had started 10 min or the SBT failed, the patients' respiratory rate (RR) and tidal volume were recorded, and the diaphragmatic displacement (DD) of patients was measured by bedside ultrasound. The ratio of RR to DD (RR/DD) was calculated as D-RBSI, and the predictive value of D-RBSI on weaning results in mechanically ventilated patients with COPD was analyzed by receiver operating characteristic (ROC) curve.ResultsTwenty-eight patients failed weaning procedure. There were no significant differences in age and acute physiology and chronic health evaluation II scores between the successful group and the failed group. The DD of the patients in the successful group was greater than that of the failed group [(22±6) mm vs. (13±5) mm, P<0.001]. RBSI and D-RBSI of the successful group were lower than those of the failure group [RBSI: (40±14) breaths/(min·L)vs. (52±20) breaths/(min·L), P=0.003; D-RBSI: (0.95±0.51) breaths/(min·mm) vs. (1.79±0.83) breaths/(min·mm), P<0.001)]. There was a good correlation between the RBSI and D-RBSI in the two groups (R2=0.778, P<0.001). The area under the ROC curve predicted the weaning result by D-RBSI was higher than RBSI (0.85vs. 0.75, P<0 001="" the="" cutoff="" value="" of="" d-rbsi="">1.13 breaths/(min·mm) to predict weaning failure had a sensitivity of 0.82, and a specificity of 0.81.ConclusionThe rapid shallow breathing index of diaphragm can be effectively used to predict the weaning result of COPD patients during mechanical ventilation.
Objective To analyze the risk factors for duration of mechanical ventilation in critically ill patients. Methods Ninety-six patients who received mechanical ventilation from January 2011 to December 2011 in intensive care unit were recruited in the study. The clinical data were collected retrospectively including the general condition, underlying diseases, vital signs before ventilation, laboratory examination, and APACHEⅡ score of the patients, etc. According to ventilation time, the patients were divided into a long-term group ( n = 41) and a short-term group ( n = 55) . Risk factors were screened by univariate analysis, then analyzed by logistic regression method.Results Univariate analysis revealed that the differences of temperature, respiratory index, PaCO2 , white blood cell count ( WBC) , plasma albumin ( ALB) , blood urea nitrogen ( BUN) , pulmonary artery wedge pressure ( PAWP) , APACHEⅡ, sex, lung infection in X-ray, abdominal distention, and complications between two groups were significant.With logistic multiple regression analysis, the lower level of ALB, higher level of PAWP, lung infection in X-ray, APACHE Ⅱ score, abdominal distention, and complications were independent predictors of long-term mechanical ventilation ( P lt;0. 05) . Conclusion Early improving the nutritional status and cardiac function, control infection effectively, keep stool patency, and avoid complications may shorten the duration of mechanical ventilation in critically ill patients.
ObjectiveTo investigate the clinical efficacy of AIRVO2 respiratory humidification apparatus in patients with tracheotomy after successful weaning from mechanical ventilation in intensive care unit (ICU).MethodsOne hundred subjects were randomly divided into a control group (treated with the tracheotomy mask joint oxygen inhalation by heating humidifier, n=50) and an observation group (treated with AIRVO2 model, n=50) on the basis of conventional therapy. Blood gas indexes (pH, PaO2, PaCO2, PaO2/FiO2) and clinical data (heart rate, respiratory rate, SpO2, sputum viscosity) were recorded at 0 h, 6 h, 12 h, 24 h, 48 h, 72 h after weaning. Besides, the incidence of postoperative pulmonary infection, rapid shallow breathing index (RSBI), successful weaning rate from mechanical ventilation and daily cost of weaning between the two groups were compared at 72 h after weaning.ResultsAfter treatment, all observed data of the patients were obviously improved compared with those before treatment. The differences of humidification effects between the observation group and the control group at the same time point were statistically significant (P<0.05). The differences of heart rate, respiratory rate, and SpO2 between the observation group and the control group at the same time point were statistically significant (P<0.05). The improvement of PaO2 and PaCO2 at the same time point were statistically different between the observation group and the control group (P<0.05). Seventy-two hours after weaning, the incidence of postoperative pulmonary infection and RSBI in the observation group were significantly lower than those in the control group (P<0.05), successful weaning rate from mechanical ventilation in the observation group was significantly higher than that in the control group (P<0.05), and the average daily cost of weaning from mechanical ventilation in the observation group was lower than that in the control group (P<0.05). Nine patients in the control group and 1 patient in the observation group needed secondary mechanical ventilation due to hypoxemia.ConclusionThe therapy of AIRVO2 respiratory humidification apparatus combined with conventional treatment may achieve satisfactory effect for patients of successful weaning from mechanical ventilation with tracheotomy, and it is worthy of promotion in clinical use.
ObjectiveTo evaluate the predictive value of the diaphragm ultrasound for weaning from mechanical ventilation.MethodsThe patients who received mechanical ventilation in Fujian Provincial Hospital between February 2016 to December 2017 and met the criteria for a T-tube spontaneous breathing trial were included in the study. Then right diaphragmatic displacement (DD) and diaphragmatic thickening fraction (DTF) were evaluated using M-mode ultrasonography as well as the rapid shallow breathing index (RSBI, the ratio of respiratory rate to tidal volume). A new index was named as the diaphragmatic-RSBI (D-RSBI, the ratio of respiratory rate to DD). The patients were classified into a success group or a failure group according to the weaning outcomes. The receiver operating characteristic (ROC) curves were calculated to evaluate the predictive performance of each index.ResultsFifty-nine patients were weaned successfully and failure of weaning was found in 29 patients. There were no statistically significant differences in pre-weaning parameters including age, sex, systolic blood pressure, diastolic blood pressure, blood lipid index (total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglyceride), or fast blood glucose between the weaning success group and the weaning failure group (P>0.05), but there were statistically significant differences in body mass index and acute physiology and chronic health condition Ⅱ score between two groups (P<0.05). DD [(13.44±3.23)mm vs. (10.28±2.82)mm, DTF [(32.43±12.35)% vs. (27.64±5.77)%, P<0.05] and D-RSBI [(1.49±0.47) breaths·min–1·mm–1 vs. (2.55±0.87) breaths·min–1·mm–1, P<0.05] differed significantly between the weaning success group and the weaning failure group. A cutoff of DTF≥27.9% yielded a sensitivity of 98.3%, a specificity of 62.1%, and an area under the ROC curve (AUC) of 0.873. A cutoff of D-RSBI≤1.73 breaths·min–1·mm–1 yielded a sensitivity of 76.3%, a specificity of 93.1%, and an AUC of 0.887. By comparison, when RSBI was ≤50.9 breaths·min–1·mm–1, there was a sensitivity of 91.5%, a specificity of 86.2%, and an AUC of 0.927. There was no statistically significant difference in AUC between D-RSBI and RSBI (P>0.05).ConclusionsDiaphragm ultrasound is feasible to predict the outcome of weaning. DTF and D-RSBI are as same accurate as the traditional RSBI in predicting the weaning outcome, but more objective and suitable for clinical application.
Objective To examine the adrenal function of critically ill patients received mechanical ventilation, and explore the relationship between the occurrence of relative adrenal insufficiency ( RAI) and weaning outcome.Methods Critically ill patients who were mechanically ventilated over 48 hours were enrolled in this study. Every patient was given one shot of corticotrophin 250 μg intravenously on the first day of admission and the first day of spontaneous-breathing-trial ( SBT) . Plasma contisol level was detected by radio-immunoassay before ( T0 ) and 30 minutes ( T30 ) after the shot. Meanwhile the following parameters were recorded including APACHEⅡ, age, and cause of disease, etc. RAI was defined as the difference between T0 and T30 ≤9 μg/dL. Receiver operating characteristic ( ROC) curve was used to evaluate the accuracy of the indicators towards the weaning outcome. Results A total of 45 patients with mechanical ventilation were recruited. The successful weaning group consisted 29 patients and the failure weaning group consisted 16 patients. The incidence of RAI in the successful weaning group ( 37.9% , 11/ 29) was significantly lower than that in the failure weaning group ( 75.0% , 12 /16) ( P=0. 017) . On the first day of admission, there was no significant difference of Δcortisol between the successful weaning group and the failure weaning group [ ( 10.3 ±5.7) μg/dL vs. ( 7.5 ±4.5) μg/dL, P=0.100) . On the first SBT day, Δcortisol of the successful weaning group was significantly higher than that in the failure weaning group [ ( 10.9 ±5.1) μg/dL vs. ( 4.9 ±2.9) μg/dL, P= 0.043] . Logistic regression analysis showed that Δcortisol was an independent risk factor of weaning. ROC curve analysis showed that on the first SBT day, the area under the curve of Δcortisol was 0.872; The sensitivity and the specificity of accurate judgmentwere 0.813 and 0.828 if Δcortisol ≤6. 95 μg/dL. Conclusions The occurrence of RAI is common in critically ill patients with mechanical ventilation. The adrenal function affects the outcome of weaning, and Δcortisol may be used as an important predictive indicator for weaning outcome.
Weaning difficulty is common in critically ill patients. Prolonged mechanical ventilation and weaning failure adversely affect the clinical outcome. How to better promote and achieve the early extubation is a very important subject. As a multi-dimensional monitoring method of important structure, function and morphology, critical care ultrasound which is helpful to improve our understanding and grasp of the core links in the respiratory circuit can comprehensively evaluate the state and reserve capacity of some important organs, such as the heart, lungs and diaphragm. It has great value in assessment of weaning and guided treatment. This paper will review the application of severe ultrasound in weaning.