Publications by authors named "Detajin Junhasavasdikul"

12 Publications

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Reverse Triggering Dyssynchrony 24 h after Initiation of Mechanical Ventilation.

Anesthesiology 2021 May;134(5):760-769

Background: Reverse triggering is a delayed asynchronous contraction of the diaphragm triggered by passive insufflation by the ventilator in sedated mechanically ventilated patients. The incidence of reverse triggering is unknown. This study aimed at determining the incidence of reverse triggering in critically ill patients under controlled ventilation.

Methods: In this ancillary study, patients were continuously monitored with a catheter measuring the electrical activity of the diaphragm. A method for automatic detection of reverse triggering using electrical activity of the diaphragm was developed in a derivation sample and validated in a subsequent sample. The authors assessed the predictive value of the software. In 39 recently intubated patients under assist-control ventilation, a 1-h recording obtained 24 h after intubation was used to determine the primary outcome of the study. The authors also compared patients' demographics, sedation depth, ventilation settings, and time to transition to assisted ventilation or extubation according to the median rate of reverse triggering.

Results: The positive and negative predictive value of the software for detecting reverse triggering were 0.74 (95% CI, 0.67 to 0.81) and 0.97 (95% CI, 0.96 to 0.98). Using a threshold of 1 μV of electrical activity to define diaphragm activation, median reverse triggering rate was 8% (range, 0.1 to 75), with 44% (17 of 39) of patients having greater than or equal to 10% of breaths with reverse triggering. Using a threshold of 3 μV, 26% (10 of 39) of patients had greater than or equal to 10% reverse triggering. Patients with more reverse triggering were more likely to progress to an assisted mode or extubation within the following 24 h (12 of 39 [68%]) vs. 7 of 20 [35%]; P = 0.039).

Conclusions: Reverse triggering detection based on electrical activity of the diaphragm suggests that this asynchrony is highly prevalent at 24 h after intubation under assist-control ventilation. Reverse triggering seems to occur during the transition phase between deep sedation and the onset of patient triggering.

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http://dx.doi.org/10.1097/ALN.0000000000003726DOI Listing
May 2021

Malignant pleural mesothelioma in a kidney transplant recipient.

Thorac Cancer 2021 Mar 4. Epub 2021 Mar 4.

Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.

Post-transplantation malignancy is one of the most common complication-related mortality in transplant recipients. Here, we report the case of a kidney transplant patient for 2 years with malignant pleural effusion that was subsequently diagnosed as malignant pleural mesothelioma.
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http://dx.doi.org/10.1111/1759-7714.13917DOI Listing
March 2021

Airway Occlusion Pressure As an Estimate of Respiratory Drive and Inspiratory Effort during Assisted Ventilation.

Am J Respir Crit Care Med 2020 05;201(9):1086-1098

Interdepartmental Division of Critical Care Medicine and.

Monitoring and controlling respiratory drive and effort may help to minimize lung and diaphragm injury. Airway occlusion pressure (P0.1) is a noninvasive measure of respiratory drive. To determine ) the validity of "ventilator" P0.1 (P0.1) displayed on the screen as a measure of drive, ) the ability of P0.1 to detect potentially injurious levels of effort, and ) how P0.1 displayed by different ventilators compares to a "reference" P0.1 (P0.1) measured from airway pressure recording during an occlusion. Analysis of three studies in patients, one in healthy subjects, under assisted ventilation, and a bench study with six ventilators. P0.1 was validated against measures of drive (electrical activity of the diaphragm and muscular pressure over time) and P0.1. Performance of P0.1 and P0.1 to detect predefined potentially injurious effort was tested using derivation and validation datasets using esophageal pressure-time product as the reference standard. P0.1 correlated well with measures of drive and with the esophageal pressure-time product (within-subjects  = 0.8). P0.1 >3.5 cm HO was 80% sensitive and 77% specific for detecting high effort (≥200 cm HO ⋅ s ⋅ min); P0.1 ≤1.0 cm HO was 100% sensitive and 92% specific for low effort (≤50 cm HO ⋅ s ⋅ min). The area under the receiver operating characteristics curve for P0.1 to detect potentially high and low effort were 0.81 and 0.92, respectively. Bench experiments showed a low mean bias for P0.1 compared with P0.1 for most ventilators but precision varied; in patients, precision was lower. Ventilators estimating P0.1 without occlusions could underestimate P0.1. P0.1 is a reliable bedside tool to assess respiratory drive and detect potentially injurious inspiratory effort.
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http://dx.doi.org/10.1164/rccm.201907-1425OCDOI Listing
May 2020

Potential for Lung Recruitment Estimated by the Recruitment-to-Inflation Ratio in Acute Respiratory Distress Syndrome. A Clinical Trial.

Am J Respir Crit Care Med 2020 01;201(2):178-187

Keenan Research Centre and Li Ka Shing Institute, Department of Critical Care, St. Michael's Hospital, Toronto, Ontario, Canada.

Response to positive end-expiratory pressure (PEEP) in acute respiratory distress syndrome depends on recruitability. We propose a bedside approach to estimate recruitability accounting for the presence of complete airway closure. To validate a single-breath method for measuring recruited volume and test whether it differentiates patients with different responses to PEEP. Patients with acute respiratory distress syndrome were ventilated at 15 and 5 cm HO of PEEP. Multiple pressure-volume curves were compared with a single-breath technique. Abruptly releasing PEEP (from 15 to 5 cm HO) increases expired volume: the difference between this volume and the volume predicted by compliance at low PEEP (or above airway opening pressure) estimated the recruited volume by PEEP. This recruited volume divided by the effective pressure change gave the compliance of the recruited lung; the ratio of this compliance to the compliance at low PEEP gave the recruitment-to-inflation ratio. Response to PEEP was compared between high and low recruiters based on this ratio. Forty-five patients were enrolled. Four patients had airway closure higher than high PEEP, and thus recruitment could not be assessed. In others, recruited volume measured by the experimental and the reference methods were strongly correlated ( = 0.798;  < 0.0001) with small bias (-21 ml). The recruitment-to-inflation ratio (median, 0.5; range, 0-2.0) correlated with both oxygenation at low PEEP and the oxygenation response; at PEEP 15, high recruiters had better oxygenation ( = 0.004), whereas low recruiters experienced lower systolic arterial pressure ( = 0.008). A single-breath method quantifies recruited volume. The recruitment-to-inflation ratio might help to characterize lung recruitability at the bedside.Clinical trial registered with www.clinicaltrials.gov (NCT02457741).
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http://dx.doi.org/10.1164/rccm.201902-0334OCDOI Listing
January 2020

Sleep and Pathological Wakefulness at the Time of Liberation from Mechanical Ventilation (SLEEWE). A Prospective Multicenter Physiological Study.

Am J Respir Crit Care Med 2019 05;199(9):1106-1115

1 Keenan Research Centre, Li Ka Shing Knowledge Institute, and.

Abnormal patterns of sleep and wakefulness exist in mechanically ventilated patients. In this study (SLEEWE [Effect of Sleep Disruption on the Outcome of Weaning from Mechanical Ventilation]), we aimed to investigate polysomnographic indexes as well as a continuous index for evaluating sleep depth, the odds ratio product (ORP), to determine whether abnormal sleep or wakefulness is associated with the outcome of spontaneous breathing trials (SBTs). Mechanically ventilated patients from three sites were enrolled if an SBT was planned the following day. EEG was recorded using a portable sleep diagnostic device 15 hours before the SBT. The ORP was calculated from the power of four EEG frequency bands relative to each other, ranging from full wakefulness (2.5) to deep sleep (0). The correlation between the right and left hemispheres' ORP (R/L ORP) was calculated. Among 44 patients enrolled, 37 had technically adequate signals: 11 (30%) passed the SBT and were extubated, 8 (21%) passed the SBT but were not deemed to be clinically ready for extubation, and 18 (49%) failed the SBT. Pathological wakefulness or atypical sleep were highly prevalent, but the distribution of classical sleep stages was similar between groups. The mean ORP and the proportion of time in which the ORP was >2.2 were higher in extubated patients compared with the other groups ( < 0.05). R/L ORP was significantly lower in patients who failed the SBT, and the area under the receiver operating characteristic curve of R/L ORP to predict failure was 0.91 (95% confidence interval, 0.75-0.98). Patients who pass an SBT and are extubated reach higher levels of wakefulness as indicated by the ORP, suggesting abnormal wakefulness in others. The hemispheric ORP correlation is much poorer in patients who fail an SBT.
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http://dx.doi.org/10.1164/rccm.201811-2119OCDOI Listing
May 2019

High-flow nasal oxygen versus noninvasive ventilation in adult patients with cystic fibrosis: a randomized crossover physiological study.

Ann Intensive Care 2018 Sep 5;8(1):85. Epub 2018 Sep 5.

Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.

Background: Noninvasive ventilation (NIV) is the first-line treatment of adult patients with exacerbations of cystic fibrosis (CF). High-flow nasal oxygen therapy (HFNT) might benefit patients with hypoxemia and can reduce physiological dead space. We hypothesized that HFNT and NIV would similarly reduce work of breathing and improving breathing pattern in CF patients. Our objective was to compare the effects of HFNT versus NIV in terms of work of breathing, assessed noninvasively by the thickening fraction of the diaphragm (TFdi, measured with ultrasound), breathing pattern, transcutaneous CO (PtcCO), hemodynamics, dyspnea and comfort.

Methods: Adult CF patients who had been stabilized after requiring ventilatory support for a few days were enrolled and ventilated with HFNT and NIV for 30 min in crossover random order.

Results: Fifteen patients were enrolled. Compared to baseline, HFNT, but not NIV, reduced respiratory rate (by 3 breaths/min, p = 0.01) and minute ventilation (by 2 L/min, p = 0.01). Patients also took slightly larger tidal volumes with HFNT compared to NIV (p = 0.02). TFdi per breath was similar under the two techniques and did not change from baseline. MAP increased from baseline with NIV and compared to HFNT (p ≤ 0.01). Comfort was poorer with the application of both HFNT and NIV than baseline. No differences were found for heart rate, SpO, PtcCO or dyspnea.

Conclusions: In adult CF patients stabilized after indication for ventilatory support, HFNT and NIV have similar effects on diaphragmatic work per breath, but high-flow therapy confers additional physiological benefits by decreasing respiratory rate and minute ventilation.

Clinical Trial Registration: Ethics Committee of St. Michael's Hospital (REB #14-338) and clinicaltrial.gov (NCT02262871).
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http://dx.doi.org/10.1186/s13613-018-0432-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6125258PMC
September 2018

Expiratory Flow Limitation During Mechanical Ventilation.

Chest 2018 10 9;154(4):948-962. Epub 2018 Feb 9.

Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada. Electronic address:

Expiratory flow limitation (EFL) is present when the flow cannot rise despite an increase in the expiratory driving pressure. The mechanisms of EFL are debated but are believed to be related to the collapsibility of small airways. In patients who are mechanically ventilated, EFL can exist during tidal ventilation, representing an extreme situation in which lung volume cannot decrease, regardless of the expiratory driving forces. It is a key factor for the generation of auto- or intrinsic positive end-expiratory pressure (PEEP) and requires specific management such as positioning and adjustment of external PEEP. EFL can be responsible for causing dyspnea and patient-ventilator dyssynchrony, and it is influenced by the fluid status of the patient. EFL frequently affects patients with COPD, obesity, and heart failure, as well as patients with ARDS, especially at low PEEP. EFL is, however, most often unrecognized in the clinical setting despite being associated with complications of mechanical ventilation and poor outcomes such as postoperative pulmonary complications, extubation failure, and possibly airway injury in ARDS. Therefore, prompt recognition might help the management of patients being mechanically ventilated who have EFL and could potentially influence outcome. EFL can be suspected by using different means, and this review summarizes the methods to specifically detect EFL during mechanical ventilation.
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http://dx.doi.org/10.1016/j.chest.2018.01.046DOI Listing
October 2018

Cartoon versus traditional self-study handouts for medical students: CARTOON randomized controlled trial.

Med Teach 2017 Aug 24;39(8):836-843. Epub 2017 May 24.

e Medical Education Section, Faculty of Medicine Ramathibodi Hospital , Mahidol University , Bangkok , Thailand.

Objective: The objective of this study is to compare the effectiveness of a "cartoon-style" handout with a "traditional-style" handout in a self-study assignment for preclinical medical students.

Methods: Third-year medical students (n = 93) at the Faculty of Medicine Ramathibodi Hospital, Mahidol University, took a pre-learning assessment of their knowledge of intercostal chest drainage. They were then randomly allocated to receive either a "cartoon-style" or a "traditional-style" handout on the same topic. After studying these over a 2-week period, students completed a post-learning assessment and estimated their levels of reading completion.

Results: Of the 79 participants completing the post-learning test, those in the cartoon-style group achieved a score 13.8% higher than the traditional-style group (p = 0.018). A higher proportion of students in the cartoon-style group reported reading ≥75% of the handout content (70.7% versus 42.1%). In post-hoc analyses, students whose cumulative grade point averages (GPA) from previous academic assessments were in the middle and lower range achieved higher scores with the cartoon-style handout than with the traditional one. In the lower-GPA group, the use of a cartoon-style handout was independently associated with a higher score.

Conclusions: Students given a cartoon-style handout reported reading more of the material and achieved higher post-learning test scores than students given a traditional handout.
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http://dx.doi.org/10.1080/0142159X.2017.1324137DOI Listing
August 2017

Lactate and combined parameters for triaging sepsis patients into intensive care facilities.

J Crit Care 2016 06 28;33:71-7. Epub 2016 Jan 28.

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama 6 Rd., Rajthevi, Bangkok, 10400, Thailand.

Purpose: To find predictors of intensive care unit (ICU) requirement within the first 48 hours in newly diagnosed sepsis patients presenting at the emergency department.

Materials And Methods: Analysis of a prospective observational cohort was performed. We recruited new sepsis patients at the emergency department, and collected baseline characteristics and parameters. Variables were compared between patients: those that required ICU within 48 hours and those that did not. Multivariate analysis was performed to identify independent predictors.

Results: Out of 719 patients enrolled, 275 were confirmed to have sepsis. There were 107 patients (39%) that required ICU admission within 48 hours. Independent predictors for ICU requirement were: lower body temperature (P = .019), initial lactate (P = .02), 2-hour lactate clearance (P = .035), and the Sequential Organ Failure Assessment (SOFA) score without cardiovascular component (SOFA no CVS) (P < .001). The optimal cutoff values for the two strongest predictors were: SOFA no CVS ≥5 (adjusted OR, 5.3; 95% CI, 1.9-14.7) and initial lactate ≥1.9 mmol/L (adjusted OR, 3.3; 95% CI, 1.2-8.9). We also proposed a combined "LACTIC score" with higher predictive ability.

Conclusions: We suggested a way to predict ICU requirement in sepsis patients and proposed a combined score that might be better than individual parameters. Further validation should be performed before using them clinically.
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http://dx.doi.org/10.1016/j.jcrc.2016.01.019DOI Listing
June 2016

Association between admission delay and adverse outcome of emergency medical patients.

Emerg Med J 2013 Apr 5;30(4):320-3. Epub 2012 May 5.

Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, MahidolUniversity, Bangkok, Thailand.

Aim: To determine whether admission delay (lead-time) and other factors are associated with hospital mortality rates of emergency medical patients.

Methods: Patients presenting with emergency conditions during August to November 2009, and admitted to medical wards, including intensive care units, were enrolled. The time each patient spent in the ED, and other parameters were recorded. The primary outcome was the association between lead-time and hospital mortality. The secondary outcome was the association between lead-time and delta Modified Early Warning Score (MEWS) (MEWS at ward - MEWS at ED).

Results: 381 cases were analysed. The overall mortality rate was 8.9%. By univariate analysis, the significant factors associated with mortality outcome were lead-time, ECOG (Eastern Cooperative Oncology Group) score, MEWS at ED, delta MEWS and sepsis. By multivariate analysis, the remaining significant factors were MEWS at ED, delta MEWS and sepsis. There was no significant relationship between delta MEWS and lead-time. In a sub-group of patients admitted to intensive care units, however, there was a positive correlation between lead-time and delta MEWS.

Conclusion: MEWS, delta MEWS and sepsis were predictors of hospital mortality in emergency medical patients. Lead-time was not associated with mortality, which could be due to benefits of various treatments initiated in the ED. In patients requiring intensive care, however, the longer lead-time probably led to higher MEWS and mortality.
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http://dx.doi.org/10.1136/emermed-2011-200788DOI Listing
April 2013