Publications by authors named "Luigi Pisani"

39 Publications

General Practitioners as partners for a shared management of chronic HIV infection: An insight into the perspectives of Italian People Living with HIV.

PLoS One 2021 9;16(7):e0254404. Epub 2021 Jul 9.

Department of Clinical and Experimental Medicine, Infectious Diseases Unit, A.O.U. "Policlinico Riuniti", Foggia, Italy.

Is it possible to achieve a collaboration between Infectious Diseases (ID) Specialists and General Practitioners (GPs) in the management of chronic HIV infection? A cross sectional survey was conducted among People Living with HIV (PLWHIV) attending the outpatient services of four Italian Infectious Diseases Centers to understand to which extent patients trust their GPs and involve them in the management of their chronic condition. Information about level of communication with GPs, subjective perception of the disease, and presence of co-medications were collected and matched with socio-demographic data using χ2statistics. A p<0.05 was considered statistically significant. From December 2019 to February 2020, 672 patients completed the survey, 59% males and 56% >50 years. Overall, 508 patients (76%) had informed GPs about HIV-positivity. Communication of diagnosis was significantly associated with age >50years, lower education level, history of disease >10 years and residency in Northern Italy. The "Undetectable = Untrasmittable" (U = U) concept was investigated as an indirect measure of perceived stigma. 23% of subjects was unaware of its meaning. Despite undetectable status, 50% of PLWHIV found difficult to communicate their condition to GPs, especially married (52% vs 48% of unmarried, p = 0.003), well-educated patients (51% vs 48, p = 0.007), living in Southern vs Northern Italy (52% vs 46%, p< 0.001). More than 75% of the participants consulted the ID specialist for co-medications and DDIs management, often complaining a lack of communication of the former with GPs. Overall, a good level of communication between PLWHIV and GPs was outlined, even if a wider involvement of the latter in HIV care is desirable.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0254404PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8270424PMC
July 2021

Ultrasound versus Computed Tomography Assessment of Focal Lung Aeration in Invasively Ventilated ICU Patients.

Ultrasound Med Biol 2021 Jun 22. Epub 2021 Jun 22.

Department of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, The Netherlands.

It is unknown whether and to what extent the penetration depth of lung ultrasound (LUS) influences the accuracy of LUS findings. The current study evaluated and compared the LUS aeration score and two frequently used B-line scores with focal lung aeration assessed by chest computed tomography (CT) at different levels of depth in invasively ventilated intensive care unit (ICU) patients. In this prospective observational study, patients with a clinical indication for chest CT underwent a 12-region LUS examination shortly before CT scanning. LUS images were compared with corresponding regions on the chest CT scan at different subpleural depths. For each LUS image, the LUS aeration score was calculated. LUS images with B-lines were scored as the number of separately spaced B-lines (B-line count score) and the percentage of the screen covered by B-lines divided by 10 (B-line percentage score). The fixed-effect correlation coefficient (β) was presented per 100 Hounsfield units. A total of 40 patients were included, and 372 regions were analyzed. The best association between the LUS aeration score and CT was found at a subpleural depth of 5 cm for all LUS patterns (β = 0.30, p < 0.001), 1 cm for A- and B1-patterns (β = 0.10, p < 0.001), 6 cm for B1- and B2-patterns (β = 0.11, p < 0.001) and 4 cm for B2- and C-patterns (β = 0.07, p = 0.001). The B-line percentage score was associated with CT (β = 0.46, p = 0.001), while the B-line count score was not (β = 0.07, p = 0.305). In conclusion, the subpleural penetration depth of ultrasound increased with decreased aeration reflected by the LUS pattern. The LUS aeration score and the B-line percentage score accurately reflect lung aeration in ICU patients, but should be interpreted while accounting for the subpleural penetration depth of ultrasound.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ultrasmedbio.2021.05.019DOI Listing
June 2021

Accuracy of the Radiographic Assessment of Lung Edema Score for the Diagnosis of ARDS.

Front Physiol 2021 26;12:672823. Epub 2021 May 26.

Department of Intensive Care, Academic Medical Center, Amsterdam, Netherlands.

Bilateral opacities on chest radiographs are part of the Berlin Definition for Acute Respiratory Distress Syndrome (ARDS) but have poor interobserver reliability. The "Radiographic Assessment of Lung Edema" (RALE) score was recently proposed for evaluation of the extent and density of alveolar opacities on chest radiographs of ARDS patients. The current study determined the accuracy of the RALE score for the diagnosis and the prognosis of ARDS. analysis of a cohort of invasively ventilated intensive care unit (ICU) patients expected to need invasive ventilation for >24 h. The Berlin Definition was used as the gold standard. The RALE score was calculated for the first available chest radiograph after start of ventilation in the ICU. The primary endpoint was the diagnostic accuracy for ARDS of the RALE score. Secondary endpoints included the prognostic value of the RALE score for ICU and hospital mortality, and the association with ARDS severity, and the PaO/FiO. Receiver operating characteristic (ROC) curves were constructed, and the optimal cutoff was used to determine sensitivity, specificity and the negative and positive predictive value of the RALE score for ARDS. The study included 131 patients, of whom 30 had ARDS (11 mild, 15 moderate, and 4 severe ARDS). The first available chest radiograph was obtained median 0 [0 to 1] days after start of invasive ventilation in ICU. Compared to patients without ARDS, a higher RALE score was found in patients with ARDS (24 [interquartile range (IQR) 16-30] 6 [IQR 3-11]; < 0.001), with RALE scores of 20 [IQR 14-24], 26 [IQR 16-32], and 32 [IQR 19-36] for mild, moderate and severe ARDS, respectively, ( = 0.166). The area under the ROC for ARDS was excellent (0.91 [0.86-0.96]). The best cutoff for ARDS diagnosis was 10 with 100% sensitivity, 71% specificity, 51% positive predictive value and 100% negative predictive value. The RALE score was not associated with ICU or hospital mortality, and weakly correlated with the PaO/FiO. In this cohort of invasively ventilated ICU patients, the RALE score had excellent diagnostic accuracy for ARDS.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3389/fphys.2021.672823DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8188799PMC
May 2021

Flow Index: a novel, non-invasive, continuous, quantitative method to evaluate patient inspiratory effort during pressure support ventilation.

Crit Care 2021 06 7;25(1):196. Epub 2021 Jun 7.

Department of Anesthesia and Intensive Care, Fondazione Poliambulanza, Brescia, Italy.

Background: The evaluation of patient effort is pivotal during pressure support ventilation, but a non-invasive, continuous, quantitative method to assess patient inspiratory effort is still lacking. We hypothesized that the concavity of the inspiratory flow-time waveform could be useful to estimate patient's inspiratory effort. The purpose of this study was to assess whether the shape of the inspiratory flow, as quantified by a numeric indicator, could be associated with inspiratory effort during pressure support ventilation.

Methods: Twenty-four patients in pressure support ventilation were enrolled. A mathematical relationship describing the decay pattern of the inspiratory flow profile was developed. The parameter hypothesized to estimate effort was named Flow Index. Esophageal pressure, airway pressure, airflow, and volume waveforms were recorded at three support levels (maximum, minimum and baseline). The association between Flow Index and reference measures of patient effort (pressure time product and pressure generated by respiratory muscles) was evaluated using linear mixed effects models adjusted for tidal volume, respiratory rate and respiratory rate/tidal volume.

Results: Flow Index was different at the three pressure support levels and all group comparisons were statistically significant. In all tested models, Flow Index was independently associated with patient effort (p < 0.001). Flow Index prediction of inspiratory effort agreed with esophageal pressure-based methods.

Conclusions: Flow Index is associated with patient inspiratory effort during pressure support ventilation, and may provide potentially useful information for setting inspiratory support and monitoring patient-ventilator interactions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s13054-021-03624-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8182360PMC
June 2021

Awake Proning as an Adjunctive Therapy for Refractory Hypoxemia in Non-Intubated Patients with COVID-19 Acute Respiratory Failure: Guidance from an International Group of Healthcare Workers.

Am J Trop Med Hyg 2021 Mar 11. Epub 2021 Mar 11.

1Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', Amsterdam, The Netherlands.

Non-intubated patients with acute respiratory failure due to COVID-19 could benefit from awake proning. Awake proning is an attractive intervention in settings with limited resources, as it comes with no additional costs. However, awake proning remains poorly used probably because of unfamiliarity and uncertainties regarding potential benefits and practical application. To summarize evidence for benefit and to develop a set of pragmatic recommendations for awake proning in patients with COVID-19 pneumonia, focusing on settings where resources are limited, international healthcare professionals from high and low- and middle-income countries (LMICs) with known expertise in awake proning were invited to contribute expert advice. A growing number of observational studies describe the effects of awake proning in patients with COVID-19 pneumonia in whom hypoxemia is refractory to simple measures of supplementary oxygen. Awake proning improves oxygenation in most patients, usually within minutes, and reduces dyspnea and work of breathing. The effects are maintained for up to 1 hour after turning back to supine, and mostly disappear after 6-12 hours. In available studies, awake proning was not associated with a reduction in the rate of intubation for invasive ventilation. Awake proning comes with little complications if properly implemented and monitored. Pragmatic recommendations including indications and contraindications were formulated and adjusted for resource-limited settings. Awake proning, an adjunctive treatment for hypoxemia refractory to supplemental oxygen, seems safe in non-intubated patients with COVID-19 acute respiratory failure. We provide pragmatic recommendations including indications and contraindications for the use of awake proning in LMICs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4269/ajtmh.20-1445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8103477PMC
March 2021

Pragmatic Recommendations for the Use of Diagnostic Testing and Prognostic Models in Hospitalized Patients with Severe COVID-19 in Low- and Middle-Income Countries.

Am J Trop Med Hyg 2021 Jan 22. Epub 2021 Jan 22.

10Division of Pulmonary and Critical Care Medicine, Atrium Health, Charlotte, North Carolina.

Management of patients with severe or critical COVID-19 is mainly modeled after care of patients with severe pneumonia or acute respiratory distress syndrome from other causes. These models are based on evidence that primarily originates from investigations in high-income countries, but it may be impractical to apply these recommendations to resource-restricted settings in low- and middle-income countries (LMICs). We report on a set of pragmatic recommendations for microbiology and laboratory testing, imaging, and the use of diagnostic and prognostic models in patients with severe COVID-19 in LMICs. For diagnostic testing, where reverse transcription-PCR (RT-PCR) testing is available and affordable, we recommend using RT-PCR of the upper or lower respiratory specimens and suggest using lower respiratory samples for patients suspected of having COVID-19 but have negative RT-PCR results for upper respiratory tract samples. We recommend that a positive RT-PCR from any anatomical source be considered confirmatory for SARS-CoV-2 infection, but, because false-negative testing can occur, recommend that a negative RT-PCR does not definitively rule out active infection if the patient has high suspicion for COVID-19. We suggest against using serologic assays for the detection of active or past SARS-CoV-2 infection, until there is better evidence for its usefulness. Where available, we recommend the use of point-of-care antigen-detecting rapid diagnostic testing for SARS-CoV-2 infection as an alternative to RT-PCR, only if strict quality control measures are guaranteed. For laboratory testing, we recommend a baseline white blood cell differential platelet count and hemoglobin, creatinine, and liver function tests and suggest a baseline C-reactive protein, lactate dehydrogenase, troponin, prothrombin time (or other coagulation test), and D-dimer, where such testing capabilities are available. For imaging, where availability of standard thoracic imaging is limited, we suggest using lung ultrasound to identify patients with possible COVID-19, but recommend against its use to exclude COVID-19. We suggest using lung ultrasound in combination with clinical parameters to monitor progress of the disease and responses to therapy in COVID-19 patients. We currently suggest against using diagnostic and prognostic models as these models require extensive laboratory testing and imaging, which often are limited in LMICs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4269/ajtmh.20-0730DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7957242PMC
January 2021

Epidemiological Characteristics, Ventilator Management, and Clinical Outcome in Patients Receiving Invasive Ventilation in Intensive Care Units from 10 Asian Middle-Income Countries (PRoVENT-iMiC): An International, Multicenter, Prospective Study.

Am J Trop Med Hyg 2021 01 11. Epub 2021 Jan 11.

Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.

Epidemiology, ventilator management, and outcome in patients receiving invasive ventilation in intensive care units (ICUs) in middle-income countries are largely unknown. PRactice of VENTilation in Middle-income Countries is an international multicenter 4-week observational study of invasively ventilated adult patients in 54 ICUs from 10 Asian countries conducted in 2017/18. Study outcomes included major ventilator settings (including tidal volume [ ] and positive end-expiratory pressure [PEEP]); the proportion of patients at risk for acute respiratory distress syndrome (ARDS), according to the lung injury prediction score (LIPS), or with ARDS; the incidence of pulmonary complications; and ICU mortality. In 1,315 patients included, median was similar in patients with LIPS < 4 and patients with LIPS ≥ 4, but lower in patients with ARDS (7.90 [6.8-8.9], 8.0 [6.8-9.2], and 7.0 [5.8-8.4] mL/kg Predicted body weight; = 0.0001). Median PEEP was similar in patients with LIPS < 4 and LIPS ≥ 4, but higher in patients with ARDS (five [5-7], five [5-8], and 10 [5-12] cmHO; < 0.0001). The proportions of patients with LIPS ≥ 4 or with ARDS were 68% (95% CI: 66-71) and 7% (95% CI: 6-8), respectively. Pulmonary complications increased stepwise from patients with LIPS < 4 to patients with LIPS ≥ 4 and patients with ARDS (19%, 21%, and 38% respectively; = 0.0002), with a similar trend in ICU mortality (17%, 34%, and 45% respectively; < 0.0001). The capacity of the LIPS to predict development of ARDS was poor (ROC AUC of 0.62, 95% CI: 0.54-0.70). In Asian middle-income countries, where two-thirds of ventilated patients are at risk for ARDS according to the LIPS and pulmonary complications are frequent, setting of is globally in line with current recommendations.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4269/ajtmh.20-1177DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7941813PMC
January 2021

Pragmatic Recommendations for Infection Prevention and Control Practices for Healthcare Facilities in Low- and Middle-Income Countries during the COVID-19 Pandemic.

Am J Trop Med Hyg 2021 Jan 6. Epub 2021 Jan 6.

Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil.

Infection prevention and control (IPC) strategies are key in preventing nosocomial transmission of COVID-19. Several commonly used IPC practices are resource-intensive and may be challenging to implement in resource-constrained settings. An international group of healthcare professionals from or with experience in low- and middle-income countries (LMICs) searched the literature for relevant evidence. We report on a set of pragmatic recommendations for hospital-based IPC practices in resource-constrained settings of LMICs. For cases of confirmed or suspected COVID-19, we suggest that patients be placed in a single isolation room, whenever possible. When single isolation rooms are unavailable or limited, we recommend cohorting patients with COVID-19 on dedicated wards or in dedicated hospitals. We also recommend that cases of suspected COVID-19 be cohorted separately from those with confirmed disease, whenever possible, to minimize the risk of patient-to-patient transmission in settings where confirmatory testing may be limited. We suggest that healthcare workers be designated to care exclusively for patients with COVID-19, whenever possible, as another approach to minimize nosocomial spread. This approach may also be beneficial in conserving limited supplies of reusable personal protective equipment (PPE). We recommend that visitors be restricted for patients with COVID-19. In settings where family members or visitors are necessary for caregiving, we recommend that the appropriate PPE be used by visitors. We also recommend that education regarding hand hygiene and donning/doffing procedures for PPE be provided. Last, we suggest that all visitors be screened for symptoms before visitation and that visitor logs be maintained.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4269/ajtmh.20-1009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7957238PMC
January 2021

Lung Ultrasound for Detection of Pulmonary Complications in Critically Ill Obstetric Patients in a Resource-Limited Setting.

Am J Trop Med Hyg 2020 Dec 14. Epub 2020 Dec 14.

Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.

Critically ill parturients have an increased risk of developing pulmonary complications. Lung ultrasound (LUS) could be effective in addressing the cause of respiratory distress in resource-limited settings with high maternal mortality. We aimed to determine the frequency, timing of appearance, and type of pulmonary complications in critically ill parturients in an obstetric unit in Sierra Leone. In this prospective observational study, LUS examinations were performed on admission, after 24 and 48 hours, and in case of respiratory deterioration. Primary endpoint was the proportion of parturients with one or more pulmonary complications, stratified for the presence of respiratory distress. Secondary endpoints included timing and types of complications, and their association with "poor outcome," defined as a composite of transfer for escalation of care or death. Of 166 patients enrolled, 35 patients (21% [95% CI: 15-28]) had one or more pulmonary complications, the majority diagnosed on admission. Acute respiratory distress syndrome (period prevalence 4%) and hydrostatic pulmonary edema (4%) were only observed in patients with respiratory distress. Pneumonia (2%), atelectasis (10%), and pleural effusion (7%) were present, irrespective of respiratory distress. When ultrasound excluded pulmonary complications, respiratory distress was related to anemia or metabolic acidosis. Pulmonary complications were associated with an increased risk of poor outcome (odds ratio: 5.0; 95% CI: 1.7-14.6; = 0.003). In critically ill parturients in a resource-limited obstetric unit, LUS contributed to address the cause of respiratory distress by identifying or excluding pulmonary complications. These were associated with a poor outcome.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4269/ajtmh.20-0996DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7866347PMC
December 2020

Effect of a Lower vs Higher Positive End-Expiratory Pressure Strategy on Ventilator-Free Days in ICU Patients Without ARDS: A Randomized Clinical Trial.

JAMA 2020 12;324(24):2509-2520

Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands.

Importance: It is uncertain whether invasive ventilation can use lower positive end-expiratory pressure (PEEP) in critically ill patients without acute respiratory distress syndrome (ARDS).

Objective: To determine whether a lower PEEP strategy is noninferior to a higher PEEP strategy regarding duration of mechanical ventilation at 28 days.

Design, Setting, And Participants: Noninferiority randomized clinical trial conducted from October 26, 2017, through December 17, 2019, in 8 intensive care units (ICUs) in the Netherlands among 980 patients without ARDS expected not to be extubated within 24 hours after start of ventilation. Final follow-up was conducted in March 2020.

Interventions: Participants were randomized to receive invasive ventilation using either lower PEEP, consisting of the lowest PEEP level between 0 and 5 cm H2O (n = 476), or higher PEEP, consisting of a PEEP level of 8 cm H2O (n = 493).

Main Outcomes And Measures: The primary outcome was the number of ventilator-free days at day 28, with a noninferiority margin for the difference in ventilator-free days at day 28 of -10%. Secondary outcomes included ICU and hospital lengths of stay; ICU, hospital, and 28- and 90-day mortality; development of ARDS, pneumonia, pneumothorax, severe atelectasis, severe hypoxemia, or need for rescue therapies for hypoxemia; and days with use of vasopressors or sedation.

Results: Among 980 patients who were randomized, 969 (99%) completed the trial (median age, 66 [interquartile range {IQR}, 56-74] years; 246 [36%] women). At day 28, 476 patients in the lower PEEP group had a median of 18 ventilator-free days (IQR, 0-27 days) and 493 patients in the higher PEEP group had a median of 17 ventilator-free days (IQR, 0-27 days) (mean ratio, 1.04; 95% CI, 0.95-∞; P = .007 for noninferiority), and the lower boundary of the 95% CI was within the noninferiority margin. Occurrence of severe hypoxemia was 20.6% vs 17.6% (risk ratio, 1.17; 95% CI, 0.90-1.51; P = .99) and need for rescue strategy was 19.7% vs 14.6% (risk ratio, 1.35; 95% CI, 1.02-1.79; adjusted P = .54) in patients in the lower and higher PEEP groups, respectively. Mortality at 28 days was 38.4% vs 42.0% (hazard ratio, 0.89; 95% CI, 0.73-1.09; P = .99) in patients in the lower and higher PEEP groups, respectively. There were no statistically significant differences in other secondary outcomes.

Conclusions And Relevance: Among patients in the ICU without ARDS who were expected not to be extubated within 24 hours, a lower PEEP strategy was noninferior to a higher PEEP strategy with regard to the number of ventilator-free days at day 28. These findings support the use of lower PEEP in patients without ARDS.

Trial Registration: ClinicalTrials.gov Identifier: NCT03167580.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jama.2020.23517DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7726701PMC
December 2020

Continuous assessment of neuro-ventilatory drive during 12 h of pressure support ventilation in critically ill patients.

Crit Care 2020 11 20;24(1):652. Epub 2020 Nov 20.

Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Ospedale Policlinico, Piazza Giulio Cesare 11, Bari, Italy.

Introduction: Pressure support ventilation (PSV) should allow spontaneous breathing with a "normal" neuro-ventilatory drive. Low neuro-ventilatory drive puts the patient at risk of diaphragmatic atrophy while high neuro-ventilatory drive may causes dyspnea and patient self-inflicted lung injury. We continuously assessed for 12 h the electrical activity of the diaphragm (EAdi), a close surrogate of neuro-ventilatory drive, during PSV. Our aim was to document the EAdi trend and the occurrence of periods of "Low" and/or "High" neuro-ventilatory drive during clinical application of PSV.

Method: In 16 critically ill patients ventilated in the PSV mode for clinical reasons, inspiratory peak EAdi peak (EAdi), pressure time product of the trans-diaphragmatic pressure per breath and per minute (PTP and PTP, respectively), breathing pattern and major asynchronies were continuously monitored for 12 h (from 8 a.m. to 8 p.m.). We identified breaths with "Normal" (EAdi 5-15 μV), "Low" (EAdi < 5 μV) and "High" (EAdi > 15 μV) neuro-ventilatory drive.

Results: Within all the analyzed breaths (177.117), the neuro-ventilatory drive, as expressed by the EAdi, was "Low" in 50.116 breath (28%), "Normal" in 88.419 breaths (50%) and "High" in 38.582 breaths (22%). The average times spent in "Low", "Normal" and "High" class were 1.37, 3.67 and 0.55 h, respectively (p < 0.0001), with wide variations among patients. Eleven patients remained in the "Low" neuro-ventilatory drive class for more than 1 h, median 6.1 [3.9-8.5] h and 6 in the "High" neuro-ventilatory drive class, median 3.4 [2.2-7.8] h. The asynchrony index was significantly higher in the "Low" neuro-ventilatory class, mainly because of a higher number of missed efforts.

Conclusions: We observed wide variations in EAdi amplitude and unevenly distributed "Low" and "High" neuro ventilatory drive periods during 12 h of PSV in critically ill patients. Further studies are needed to assess the possible clinical implications of our physiological findings.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s13054-020-03357-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7677450PMC
November 2020

Reliability of ultrasound findings acquired with handheld apparatuses to inform urgent obstetric diagnosis in a high-volume resource-limited setting.

Int J Gynaecol Obstet 2021 May 22;153(2):280-286. Epub 2020 Dec 22.

Princess Christian Maternity Hospital, Freetown, Sierra Leone.

Objective: To evaluate the reliability of obstetric handheld smartphone-based point-of-care ultrasound (POCUS) in a resource-limited high-volume setting.

Methods: A single-center prospective observational study among women requiring urgent diagnosis and admitted to a maternity referral hospital in Sierra Leone from March to April 2019. Pre-specified ultrasound findings were obtained with a handheld POCUS device; a comprehensive ultrasound examination was then performed by an experienced operator using conventional full-feature apparatus. Agreement was assessed by diagnostic accuracy and Cohen κ-statistics.

Results: Overall, there were 307 participants. The mean aggregated diagnostic accuracy was 95.5% (κ-statistic, 0.90; 95% confidence interval [CI], 0.89-0.93; P < 0.001). Highest accuracy was reported for detecting free fluid collection in the abdominal cavity (100%; κ-statistic, 1.00; 95% CI, 1.00-1.00; P < 0.001). Ultrasound findings obtained with the handheld device for intrauterine pregnancy, fetal heartbeat, cephalic presentation, multifetal pregnancy, and assessment of gestational age based on bi-parietal diameter were highly reliable (agreement, >90%; κ-statistic, >0.80). Detection of low-lying placenta or placenta previa was the least reliable (κ-statistic, 0.53; 95% CI, 0.13-0.93; P < 0.001).

Conclusion: Handheld POCUS findings were found to be reliable for detecting pre-specified urgent obstetric findings in a high-volume resource-limited referral hospital.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ijgo.13475DOI Listing
May 2021

Comparison of Linear and Sector Array Probe for Handheld Lung Ultrasound in Invasively Ventilated ICU Patients.

Ultrasound Med Biol 2020 12 19;46(12):3249-3256. Epub 2020 Sep 19.

Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands.

International guidelines do not recommend a specific probe for assessment of lung aeration using lung ultrasound (LUS). The aim of this study was to assess the concordance between linear and sector array probes of a handheld ultrasound device in assessment of lung aeration in invasively ventilated intensive care unit patients. This study included intensive care unit patients who were expected to be ventilated for longer than 24 h. A 12-region LUS exam was performed with a linear and a sector array probe. In each image, the LUS aeration score and number of B-lines were determined. Adding the LUS aeration scores of all regions resulted in a global LUS aeration score. Agreement between the two probes was calculated using intra-class correlation coefficients (ICCs). A total of 30 LUS exams were performed in 19 patients, resulting in a total of 328 pairs of images. Twenty-nine pairs of images were excluded from analysis because the images from the linear probe could not be scored. ICCs calculated for the remaining images revealed good concordance the LUS aeration scores for individual images (ICC = 0.73, 95% confidence interval 0.67-0.78), number of B-lines (ICC = 0.79, 95% confidence interval 0.72-0.83) and global LUS aeration score (ICC = 0.74, 95% confidence interval 0.52-0.87). In conclusion, there is good concordance between linear and sector array probes of a handheld ultrasound device in assessment of lung aeration patterns in mechanically ventilated intensive care unit patients. However, in roughly 10% of the images acquired using the linear probe, the aeration pattern could not be scored.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ultrasmedbio.2020.08.016DOI Listing
December 2020

Effects of Positive End-Expiratory Pressure in "High Compliance" Severe Acute Respiratory Syndrome Coronavirus 2 Acute Respiratory Distress Syndrome.

Crit Care Med 2020 12;48(12):e1332-e1336

Dipartimento di Dipartimento Scienze mediche e chirurgiche, Sezione anestesia e rianimazione, Università degli Studi di Foggia, Foggia, Italy.

Objectives: Clinical observation suggests that early acute respiratory distress syndrome induced by the severe acute respiratory syndrome coronavirus 2 may be "atypical" due to a discrepancy between a relatively unaffected static respiratory system compliance and a significant hypoxemia. This would imply an "atypical" response to the positive end-expiratory pressure.

Design: Single-center, unblinded, crossover study.

Setting: ICU of Bari Policlinico Academic Hospital (Italy), dedicated to care patients with confirmed diagnosis of novel coronavirus disease 2019.

Patients: Eight patients with early severe acute respiratory syndrome coronavirus 2 acute respiratory distress syndrome and static respiratory compliance higher than or equal to 50 mL/cm H2O.

Interventions: We compared a "lower" and a "higher" positive end-expiratory pressure approach, respectively, according to the intervention arms of the acute respiratory distress syndrome network and the positive end-expiratory pressure setting in adults with acute respiratory distress syndrome studies.

Measurements And Main Results: Patients were ventilated with the acute respiratory distress syndrome network and, subsequently, with the ExPress protocol. After 1 hour of ventilation, for each protocol, we recorded arterial blood gas, respiratory mechanics, alveolar recruitment, and hemodynamic variables. Comparisons were performed with analysis of variance for repeated measures or Friedman test as appropriate. Positive end-expiratory pressure was increased from 9 ± 3.5 to 17.7 ± 1.7 cm H2O (p < 0.01). Alveolar recruitment was 450 ± 111 mL. Static respiratory system compliance decreased from 58.3 ± 7.6 mL/cm H2O to 47.4 ± 14.5 mL/cm H2O (p = 0.018) and the "stress index" increased from 0.97 ± 0.03 to 1.22 ± 0.07 (p < 0.001). The PaO2/FIO2 ratio increased from 131 ± 22 to 207 ± 41 (p < 0.001), and the PaCO2 increased from 45.9 ± 12.7 to 49.8 ± 13.2 mm Hg (p < 0.001). The cardiac index went from 3.6 ± 0.4 to 2.9 ± 0.6 L/min/m (p = 0.01).

Conclusions: Our data suggest that the "higher" positive end-expiratory pressure approach in patients with severe acute respiratory syndrome coronavirus 2 acute respiratory distress syndrome and high compliance improves oxygenation and lung aeration but may result in alveolar hyperinflation and hemodynamic alterations.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/CCM.0000000000004640DOI Listing
December 2020

Epidemiology, Outcomes, and Risk Factors for Mortality in Critically Ill Women Admitted to an Obstetric High-Dependency Unit in Sierra Leone.

Am J Trop Med Hyg 2020 11;103(5):2142-2148

Section of Operational Research, Doctors with Africa Cuamm, Padova, Italy.

A better understanding of the context-specific epidemiology, outcomes, and risk factors for death of critically ill parturients in resource-poor hospitals is needed to tackle the still alarming in-hospital maternal mortality in African countries. From October 2017 to October 2018, we performed a 1-year retrospective cohort study in a referral maternity hospital in Freetown, Sierra Leone. The primary endpoint was the association between risk factors and high-dependency unit (HDU) mortality. Five hundred twenty-three patients (median age 25 years, interquartile range [IQR]: 21-30 years) were admitted to the HDU for a median of 2 (IQR: 1-3) days. Among them, 65% were referred with a red obstetric early warning score (OEWS) code, representing 1.17 cases per HDU bed per week; 11% of patients died in HDU, mostly in the first 24 hours from admission. The factors independently associated with HDU mortality were ward rather than postoperative referrals (odds ratio [OR]: 3.21; 95% CI: 1.48-7.01; = 0.003); admissions with red (high impairment of patients' vital signs) versus yellow (impairment of vital signs) or green (little or no impairment of patients' vital signs) OEWS (OR: 3.66; 95% CI: 1.15-16.96; = 0.04); responsiveness to pain or unresponsiveness on the alert, voice, pain unresponsive scale (OR: 5.25; 95% CI: 2.64-10.94; ≤ 0.0001); and use of vasopressors (OR: 3.24; 95% CI: 1.32-7.66; = 0.008). Critically ill parturients were predominantly referred with a red OEWS code and usually required intermediate care for 48 hours. Despite the provided interventions, death in the HDU was frequent, affecting one of 10 critically ill parturients. Medical admission, a red OEWS code, and a poor neurological and hemodynamic status were independently associated with mortality, whereas adequate oxygenation was associated with survival.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4269/ajtmh.20-0623DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7646769PMC
November 2020

Cost-Utility of Intermediate Obstetric Critical Care in a Resource-Limited Setting: A Value-Based Analysis.

Ann Glob Health 2020 07 20;86(1):82. Epub 2020 Jul 20.

Centre for Research on Health and Social Care Management (CERGAS), Bocconi University, IT.

Background: Sierra Leone faces among the highest maternal mortality rates worldwide. Despite this burden, the role of life-saving critical care interventions in low-resource settings remains scarcely explored. A value-based approach may be used to question whether it is sustainable and useful to start and run an obstetric intermediate critical care facility in a resource-poor referral hospital. We also aimed to investigate whether patient outcomes in terms of quality of life justified the allocated resources.

Objective: To explore the value-based dimension performing a cost-utility analysis with regard to the implementation and one-year operation of the HDU. The primary endopoint was the quality-adjusted life-years (QALYs) of patients admitted to the HDU, against direct and indirect costs. Secondary endpoints included key procedures or treatments performed during the HDU stay.

Methods: The study was conducted from October 2, 2017 to October 1, 2018 in the obstetric high dependency unit (HDU) of Princess Christian Maternity Hospital (PCMH) in Freetown, Sierra Leone.

Findings: 523 patients (median age 25 years, IQR 21-30) were admitted to HDU. The total 1 year investment and operation costs for the HDU amounted to €120,082 - resulting in €230 of extra cost per admitted patient. The overall cost per QALY gained was of €10; this value is much lower than the WHO threshold defining high cost effectiveness of an intervention, i.e. three times the current Sierra Leone annual per capita GDP of €1416.

Conclusion: With an additional cost per QALY of only €10.0, the implementation and one-year running of the case studied obstetric HDU can be considered a highly cost-effective frugal innovation in limited resource contexts. The evidences provided by this study allow a precise and novel insight to policy makers and clinicians useful to prioritize interventions in critical care and thus address maternal mortality in a high burden scenario.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5334/aogh.2907DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7380057PMC
July 2020

Lung ultrasound scoring in invasive mechanically ventilated children with severe bronchiolitis.

Pediatr Pulmonol 2020 10 30;55(10):2799-2805. Epub 2020 Jul 30.

Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands.

Objective: Lung ultrasound (LUS) is an emerging tool that may be used in the diagnosis and follow-up of children with viral bronchiolitis. In this study, we describe LUS abnormalities in children receiving invasive mechanical ventilation (IMV) for severe bronchiolitis in the pediatric intensive care unit (PICU). Our aim was to semiquantify the loss of aeration and examine the association between serial LUS scores and oxygenation anomaly, as a marker of disease severity.

Design: Prospective, observational study in a single-center PICU.

Methods: LUS was performed by multiple observers using two different LUS scoring systems (counting B-lines and aeration score) in 17 patients in the PICU, generating 320 images. Oxygen saturation index (OSI) was the primary outcome marker to describe the severity of oxygenation anomaly.

Results: Pulmonary aeration was moderately impaired with a homogeneous anterolateral pattern. LUS scores worsened after 24 hours, to improve in subsequent days. Both LUS scores were positively correlated with OSI on the first day of IMV (counting B-lines P = .034, r = .52 and LUS aeration score P = .017, r = .57), but not thereafter. There was considerable variability in the LUS scores despite moderate to high agreement between the observers.

Conclusions: In children receiving IMV for severe bronchiolitis, pulmonary aeration is moderately impaired. LUS scores positively correlate with severity of oxygenation anomaly only in the acute phase of disease. We speculate that with the progression of disease other factors affect LUS patterns (eg, fluid overload, atelectasis), which may complicate the interpretation of LUS in follow-up of this specific cohort in the PICU.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ppul.24974DOI Listing
October 2020

Non-invasive assessment of respiratory muscle activity during pressure support ventilation: accuracy of end-inspiration occlusion and least square fitting methods.

J Clin Monit Comput 2021 Aug 2;35(4):913-921. Epub 2020 Jul 2.

Department of Intensive Care and Anesthesiology, Fondazione Poliambulanza, Brescia, Italy.

Pressure support ventilation (PSV) should be titrated considering the pressure developed by the respiratory muscles (P) to prevent under- and over-assistance. The esophageal pressure (P) is the clinical gold standard for P assessment, but its use is limited by alleged invasiveness and complexity. The least square fitting method and the end-inspiratory occlusion method have been proposed as non-invasive alternatives for P assessment. The aims of this study were: (1) to compare the accuracy of P estimation using the end-inspiration occlusion (P) and the least square fitting (P) against the reference method based on P; (2) to test the accuracy of P and of P to detect overassistance, defined as P ≤ 1 cmHO. We studied 18 patients at three different PSV levels. At each PSV level, P, P, P were calculated on the same breaths. Differences among P, P, P were analyzed with linear mixed effects models. Bias and agreement were assessed by Bland-Altman analysis for repeated measures. The ability of P and P to detect overassistance was assessed by the area under the receiver operating characteristics curve. Positive and negative predictive values were calculated using cutoff values that maximized the sum of sensitivity and specificity. At each PSV level, P was not different from P (p = 0.96), whereas P was significantly lower than P. The bias between P and P was zero, whereas P systematically underestimated P of 6 cmHO. The limits of agreement between P and P and between P and P were ± 12 cmHO across bias. Both P ≤ 4 cmHO and P ≤ 1 cmHO had excellent negative predictive value [0.98 (95% CI 0.94-1) and 0.96 (95% CI 0.91-0.99), respectively)] to identify over-assistance. The inspiratory effort during PSV could not be accurately estimated by the least square fitting or end-inspiratory occlusion method because the limits of agreement were far above the signal size. These non-invasive approaches, however, could be used to screen patients at risk for absent or minimal respiratory muscles activation to prevent the ventilator-induced diaphragmatic dysfunction.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10877-020-00552-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7330529PMC
August 2021

Assessing Extravascular Lung Water in Critically Ill Patients Using Lung Ultrasound: A Systematic Review on Methodological Aspects in Diagnostic Accuracy Studies.

Ultrasound Med Biol 2020 07 3;46(7):1557-1564. Epub 2020 Apr 3.

Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Amsterdam Leiden IC Focused Echography (ALIFE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands. Electronic address:

Lung ultrasound (LUS) is a non-invasive bedside method used to quantify extravascular lung water (EVLW). To evaluate the methodology and diagnostic accuracy of LUS in studies assessing EVLW in intensive care unit patients, PubMed and Embase were searched for studies comparing LUS with imaging modalities. In 14 relevant studies a wide variety of equipment used and training of examiners were noted. Four scoring systems were reported: (i) a binary score (the presence of three or more B-lines); (ii) a categorical score; (iii) a numerical score; (iv) a quantitative LUS score using software. The diagnostic accuracy of LUS varied: sensitivity ranged from 50%-98%, specificity from 76%-100% and r² from 0.20-0.91. Methodology and diagnostic accuracy varies substantially in published reports. Further research is needed to correlate methodological factors with diagnostic accuracy. Hospitals should standardize LUS methodology. Consensus is needed to harmonize LUS methodology for lung water assessment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ultrasmedbio.2020.02.014DOI Listing
July 2020

ERS International Congress, Madrid, 2019: highlights from the Respiratory Intensive Care Assembly.

ERJ Open Res 2020 Jan 9;6(1). Epub 2020 Mar 9.

Intensive Care, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands.

The Respiratory Intensive Care Assembly of the European Respiratory Society is delighted to present the highlights from the 2019 International Congress in Madrid, Spain. We have selected four sessions that discussed recent advances in a wide range of topics: from acute respiratory failure to cough augmentation in neuromuscular disorders and from extra-corporeal life support to difficult ventilator weaning. The subjects are summarised by early career members in close collaboration with the Assembly leadership. We aim to give the reader an update on the most important developments discussed at the conference. Each session is further summarised into a short list of take-home messages.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1183/23120541.00331-2019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7061203PMC
January 2020

The diagnostic accuracy for ARDS of global versus regional lung ultrasound scores - a post hoc analysis of an observational study in invasively ventilated ICU patients.

Intensive Care Med Exp 2019 Jul 25;7(Suppl 1):44. Epub 2019 Jul 25.

Department of Intensive Care, Amsterdam University Medical Centers, AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.

Background: Semi-quantification of lung aeration by ultrasound helps to assess presence and extent of pulmonary pathologies, including the acute respiratory distress syndrome (ARDS). It is uncertain which lung regions add most to the diagnostic accuracy for ARDS of the frequently used global lung ultrasound (LUS) score. We aimed to compare the diagnostic accuracy of the global versus those of regional LUS scores in invasively ventilated intensive care unit patients.

Methods: This was a post-hoc analysis of a single-center observational study in the mixed medical-surgical intensive care unit of a university-affiliated hospital in the Netherlands. Consecutive patients, aged ≥ 18 years, and are expected to receive invasive ventilation for > 24 h underwent a LUS examination within the first 2 days of ventilation. The Berlin Definition was used to diagnose ARDS, and to classify ARDS severity. From the 12-region LUS examinations, the global score (minimum 0 to maximum 36) and 3 regional scores (the 'anterior,' 'lateral,' and 'posterior' score, minimum 0 to maximum 12) were computed. The area under the receiver operating characteristic (AUROC) curve was calculated and the best cutoff for ARDS discrimination was determined for all scores.

Results: The study enrolled 152 patients; 35 patients had ARDS. The global score was higher in patients with ARDS compared to patients without ARDS (median 19 [15-23] vs. 5 [3-9]; P < 0.001). The posterior score was the main contributor to the global score, and was the only score that increased significantly with ARDS severity. However, the posterior score performed worse than the global score in diagnosing ARDS, and it had a positive predictive value of only 50 (41-59)% when using the optimal cutoff. The combined anterolateral score performed as good as the global score (AUROC of 0.91 [0.85-0.97] vs. 0.91 [0.86-0.95]).

Conclusions: While the posterior score increases with ARDS severity, its diagnostic accuracy for ARDS is hampered due to an unfavorable signal-to-noise ratio. An 8-region 'anterolateral' score performs as well as the global score and may prove useful to exclude ARDS in invasively ventilated ICU patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s40635-019-0241-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6658630PMC
July 2019

Point-of-care lung ultrasound for the detection of pulmonary manifestations of malaria and sepsis: An observational study.

PLoS One 2018 12;13(12):e0204832. Epub 2018 Dec 12.

Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.

Introduction: Patients with severe malaria or sepsis are at risk of developing life-threatening acute respiratory distress syndrome (ARDS). The objective of this study was to evaluate point-of-care lung ultrasound as a novel tool to determine the prevalence and early signs of ARDS in a resource-limited setting among patients with severe malaria or sepsis.

Materials And Methods: Serial point-of-care lung ultrasound studies were performed on four consecutive days in a planned sub study of an observational cohort of patients with malaria or sepsis in Bangladesh. We quantified aeration patterns across 12 lung regions. ARDS was defined according to the Kigali Modification of the Berlin Definition.

Results: Of 102 patients enrolled, 71 had sepsis and 31 had malaria. Normal lung ultrasound findings were observed in 44 patients on enrolment and associated with 7% case fatality. ARDS was detected in 10 patients on enrolment and associated with 90% case fatality. All patients with ARDS had sepsis, 4 had underlying pneumonia. Two patients developing ARDS during hospitalisation already had reduced aeration patterns on enrolment. The SpO2/FiO2 ratio combined with the number of regions with reduced aeration was a strong prognosticator for mortality in patients with sepsis (AUROC 91.5% (95% Confidence Interval: 84.6%-98.4%)).

Conclusions: This study demonstrates the potential usefulness of point-of-care lung ultrasound to detect lung abnormalities in patients with malaria or sepsis in a resource-constrained hospital setting. LUS was highly feasible and allowed to accurately identify patients at risk of death in a resource limited setting.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0204832PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6291079PMC
April 2019

Patient-ventilator asynchronies: types, outcomes and nursing detection skills.

Acta Biomed 2018 12 7;89(7-S):6-18. Epub 2018 Dec 7.

Fondazione Poliambulanza Hospital, Brescia (Italy).

Background: Mechanical ventilation is often employed as partial ventilatory support where both the patient and the ventilator work together. The ventilator settings should be adjusted to maintain a harmonious patient-ventilator interaction. However, this balance is often altered by many factors able to generate a patient ventilator asynchrony (PVA). The aims of this review were: to identify PVAs, their typologies and classifications; to describe how and to what extent their occurrence can affect the patients' outcomes; to investigate the levels of nursing skill in detecting PVAs.

Methods: Literature review performed on Cochrane Library, Medline and CINAHL databases.

Results: 1610 records were identified; 43 records were included after double blind screening. PVAs have been classified with respect to the phase of the respiratory cycle or based on the circumstance of occurrence. There is agreement on the existence of 7 types of PVAs: ineffective effort, double trigger, premature cycling, delayed cycling, reverse triggering, flow starvation and auto-cycling. PVAs can be identified through the ventilator graphics monitoring of pressure and flow waveforms.  The influence on patient outcomes varies greatly among studies but PVAs are mostly associated with poorer outcomes. Adequately trained nurses can learn and retain how to correctly detect PVAs.

Conclusions: Since its challenging interpretation and the potential advantages of its implementation, ventilator graphics monitoring can be classified as an advanced competence for ICU nurses. The knowledge and skills to adequately manage PVAs should be provided by specific post-graduate university courses.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.23750/abm.v89i7-S.7737DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6502136PMC
December 2018

Potential Diagnostic Properties of Chest Ultrasound in Thoracic Tuberculosis-A Systematic Review.

Int J Environ Res Public Health 2018 10 12;15(10). Epub 2018 Oct 12.

Mahidol Oxford Tropical Medicine Research Unit, Bangkok 10400, Thailand.

: Chest ultrasound (CUS) has been shown to be a sensitive and specific imaging modality for pneumothorax, pneumonia, and pleural effusions. However, the role of chest ultrasound in the diagnosis of thoracic tuberculosis (TB) is uncertain. We performed a systematic search in the medical literature to better define the potential role and value of chest ultrasound in diagnosing thoracic tuberculosis. : To describe existing literature with regard to the diagnostic value of chest ultrasound in thoracic tuberculosis. : MEDLINE, EMBASE, and Scopus databases were searched for relevant articles. We included studies that used chest ultrasound for the diagnosis or management of any form of thoracic tuberculosis, including pulmonary, pleural, mediastinal, and military forms. : We identified five main fields of chest ultrasound application: (1) Detection, characterization, and quantification of TB; (2) detection of residual pleural thickening after evacuation; (3) chest ultrasound-guided needle biopsy; (4) identification of pathologic mediastinal lymph nodes in children; and (5) identification of parenchymal ultrasound patterns. Effusion was also detected, in early stages, with signs of organization in 24⁻100% of patients. A low to moderate (10⁻23%), false negative rate was reported for chest ultrasound-guided needle biopsy. CUS was able to identify mediastinal lymph nodes in as many as 67% of patients with negative chest radiography. : Very few studies with important methodological limitations analyze the role of chest ultrasound in the diagnosis of TB. The scarce available data suggests potential targets of future diagnostic or feasibility trials, such as the detection of tuberculosis⁻related pleural effusion, residual pleural thickening, lymphadenopathy, TB parenchymal patterns, or the use of CUS in biopsy guidance.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/ijerph15102235DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6210728PMC
October 2018

Risk Factors for Mortality in Children Admitted for Suspected Malaria to a Pediatric Emergency Ward in a Low-Resource Setting: A Case-Control Study.

Pediatr Crit Care Med 2018 09;19(9):e479-e485

Department of Women and Children Health, University of Padua, Azienda Ospedaliera di Padova, Padova, Italy.

Objectives: To identify the risk factors for mortality after admission for suspected malaria in a pediatric emergency ward in Sierra Leone.

Design: Retrospective case-control.

Setting: Pujehun Hospital Pediatric Ward in Pujehun, Sierra Leone.

Patients: All cases were pediatric deaths after admission for suspected malaria at the Pujehun Hospital Pediatric Ward between January 1, 2015, and May 31, 2016. The case-control ratio was 1:1. The controls were infants admitted at Pujehun Hospital Pediatric Ward for malaria and discharged alive during the same period. Controls were selected as the next noncase infant admitted for malaria and discharged alive, as recorded in local medical records.

Interventions: None.

Measurements And Main Results: Children characteristics, vital variables on hospital access, comorbidity status at admission, antibiotic and antimalarial therapy at admission; presence of hematemesis, respiratory arrest or bradypnea, abrupt worsening, and emergency interventions during hospital stay; final diagnosis before discharge or death. In total, 320 subjects (160 cases and 160 controls) were included in the study. Multivariable analysis identified being referred from peripheral health units (odds ratio, 4.00; 95% CI, 1.98-8.43), cerebral malaria (odds ratio, 6.28; 95% CI, 2.19-21.47), malnutrition (odds ratio, 3.14; 95% CI, 1.45-7.15), dehydration (odds ratio, 3.94; 95% CI, 1.50-11.35), being unresponsive or responsive to pain (odds ratio, 2.17; 95% CI, 1.15-4.13), and hepatosplenomegaly (odds ratio, 3.20; 95% CI, 1.74-6.03) as independent risk factors for mortality.

Conclusions: Risk factors for mortality in children with suspected malaria include cerebral malaria and severe clinical conditions at admission. Being referred from peripheral health units, as proxy of logistics issue, was also associated with increased risk of mortality. These findings suggest that appropriate interventions should focus on training and resources, including the increase of dedicated personnel and available equipment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PCC.0000000000001655DOI Listing
September 2018

RELAx - REstricted versus Liberal positive end-expiratory pressure in patients without ARDS: protocol for a randomized controlled trial.

Trials 2018 May 9;19(1):272. Epub 2018 May 9.

Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands.

Background: Evidence for benefit of high positive end-expiratory pressure (PEEP) is largely lacking for invasively ventilated, critically ill patients with uninjured lungs. We hypothesize that ventilation with low PEEP is noninferior to ventilation with high PEEP with regard to the number of ventilator-free days and being alive at day 28 in this population.  METHODS/DESIGN: The "REstricted versus Liberal positive end-expiratory pressure in patients without ARDS" trial (RELAx) is a national, multicenter, randomized controlled, noninferiority trial in adult intensive care unit (ICU) patients with uninjured lungs who are expected not to be extubated within 24 h. RELAx will run in 13 ICUs in the Netherlands to enroll 980 patients under invasive ventilation. In all patients, low tidal volumes are used. Patients assigned to ventilation with low PEEP will receive the lowest possible PEEP between 0 and 5 cm HO, while patients assigned to ventilation with high PEEP will receive PEEP of 8 cm HO. The primary endpoint is the number of ventilator-free days and being alive at day 28, a composite endpoint for liberation from the ventilator and mortality until day 28, with a noninferiority margin for a difference between groups of 0.5 days. Secondary endpoints are length of stay (LOS), mortality, and occurrence of pulmonary complications, including severe hypoxemia, major atelectasis, need for rescue therapies, pneumonia, pneumothorax, and development of acute respiratory distress syndrome (ARDS). Hemodynamic support and sedation needs will be collected and compared.

Discussion: RELAx will be the first sufficiently sized randomized controlled trial in invasively ventilated, critically ill patients with uninjured lungs using a clinically relevant and objective endpoint to determine whether invasive, low-tidal-volume ventilation with low PEEP is noninferior to ventilation with high PEEP.

Trial Registration: ClinicalTrials.gov , ID: NCT03167580 . Registered on 23 May 2017.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s13063-018-2640-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5941564PMC
May 2018

PRactice of VENTilation in Middle-Income Countries (PRoVENT-iMIC): rationale and protocol for a prospective international multicentre observational study in intensive care units in Asia.

BMJ Open 2018 04 28;8(4):e020841. Epub 2018 Apr 28.

Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands.

Introduction: Current evidence on epidemiology and outcomes of invasively mechanically ventilated intensive care unit (ICU) patients is predominantly gathered in resource-rich settings. Patient casemix and patterns of critical illnesses, and probably also ventilation practices are likely to be different in resource-limited settings. We aim to investigate the epidemiological characteristics, ventilation practices and clinical outcomes of patients receiving mechanical ventilation in ICUs in Asia.

Methods And Analysis: PRoVENT-iMIC (study of PRactice of VENTilation in Middle-Income Countries) is an international multicentre observational study to be undertaken in approximately 60 ICUs in 11 Asian countries. Consecutive patients aged 18 years or older who are receiving invasive ventilation in participating ICUs during a predefined 28-day period are to be enrolled, with a daily follow-up of 7 days. The primary outcome is ventilatory management (including tidal volume expressed as mL/kg predicted body weight and positive end-expiratory pressure expressed as cm HO) during the first 3 days of mechanical ventilation-compared between patients at no risk for acute respiratory distress syndrome (ARDS), patients at risk for ARDS and in patients with ARDS (in case the diagnosis of ARDS can be made on admission). Secondary outcomes include occurrence of pulmonary complications and all-cause ICU mortality.

Ethics And Dissemination: PRoVENT-iMIC will be the first international study that prospectively assesses ventilation practices, outcomes and epidemiology of invasively ventilated patients in ICUs in Asia. The results of this large study, to be disseminated through conference presentations and publications in international peer-reviewed journals, are of ultimate importance when designing trials of invasive ventilation in resource-limited ICUs. Access to source data will be made available through national or international anonymised datasets on request and after agreement of the PRoVENT-iMIC steering committee.

Trial Registration Number: NCT03188770; Pre-results.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjopen-2017-020841DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5931304PMC
April 2018

Correction to: External confirmation and exploration of the Kigali modification for diagnosing moderate or severe ARDS.

Intensive Care Med 2018 03;44(3):403-404

Department of Intensive Care, Academic Medical Center, C3-423, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.

In Table 1 of this article, the numerical data were correct but the graphic part was imprecise.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00134-018-5098-8DOI Listing
March 2018
-->