Articles: mechanical-ventilation.
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Tracheostomy for coronavirus disease 2019 pneumonitis patients requiring prolonged invasive mechanical ventilation remains a matter of debate. This study analysed the timing and outcomes of percutaneous tracheostomy, and reports our experience of a dedicated ENT-anaesthetics department led tracheostomy team. ⋯ Outcomes appear favourable when patients are carefully selected. Percutaneous tracheostomy performed via a multidisciplinary approach, with appropriate training, was safe and optimised healthcare resource utilisation.
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Observational Study
CXCL10 could drive longer duration of mechanical ventilation during COVID-19 ARDS.
COVID-19-related ARDS has unique features when compared with ARDS from other origins, suggesting a distinctive inflammatory pathogenesis. Data regarding the host response within the lung are sparse. The objective is to compare alveolar and systemic inflammation response patterns, mitochondrial alarmin release, and outcomes according to ARDS etiology (i.e., COVID-19 vs. non-COVID-19). ⋯ CXCL10 could be one key mediator involved in the dysregulated immune response. It should be evaluated as a candidate biomarker that may predict the duration of MV in COVID-19 ARDS patients. Targeting the CXCL10-CXCR3 axis could also be considered as a new therapeutic approach.
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Multicenter Study
Patterns and impact of arterial CO2 management in patients with Acute Respiratory Distress Syndrome: Insights from the LUNG SAFE study.
Considerable variability exists regarding CO2 management in early ARDS, with the impact of arterial CO2 tension on management and outcomes poorly understood. ⋯ No evidence was found for benefit or harm with hypercapnia. Of concern, ICU mortality was higher with sustained hypocapnia in mild to moderate ARDS.
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What's the deal?
This lab study from Zhong et al. challenges the assumption that low-flow anaesthesia is economically and environmentally superior during TIVA anaesthetics when volatile agents are not used.
What did they do?
Zhong used a test lung model with fixed CO2 inflow (250 ml/min) ventilated via circle systems of two anaesthetic machines (Dräger Primus and GE Aisys CS2). FGF rates of 1, 2, 4, and 6 L/min were tested, measuring the time to CO2 absorbent exhaustion (when inspired CO2 >0.3 kPa).
An inspired 30% O2/air mixture was used, with the test lung volume-control-ventilated at 12 bpm with 500 mL tidal volumes.
Findings
Results showed that increasing FGF from 1 to 6 L/min resulted in over 90% reduction in running costs with minimal net change to global warming potential. The time to absorbent exhaustion increased non-linearly with higher FGFs, taking over 5-8 days at 6 L/min. Notably, removing the CO2 absorbent entirely and using very high FGF (15-18 L/min) provided minimal additional economic benefit while more than doubling the environmental impact.
"We suggest that 'high-flow anaesthesia', with FGF around 6 L/min, is a viable cost-saving strategy when using a circle system for anaesthetic maintenance without inhalational anaesthetic agents in adults."
Hang-on...
The absolute cost saving (due to reduced soda lime consumption) was actually pretty small, being less than 4% of the total non-staff anaesthetic cost. Although this might still be economically significant when scaled across an entire health system, especially given the simplicity of implementation and the lack of drawback.
Bottom-line
When using total intravenous anaesthesia with modern HME filters, higher fresh gas flows (~6 L/min) are more cost-effective than traditional low-flow techniques, without compromising environmental impact or patient safety.
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Am. J. Respir. Crit. Care Med. · Nov 2020
Multicenter Study Observational StudyCompliance Phenotypes in Early ARDS Before the COVID-19 Pandemic.
Rationale: A novel model of phenotypes based on set thresholds of respiratory system compliance (Crs) was recently postulated in context of coronavirus disease (COVID-19) acute respiratory distress syndrome (ARDS). In particular, the dissociation between the degree of hypoxemia and Crs was characterized as a distinct ARDS phenotype. Objectives: To determine whether such Crs-based phenotypes existed among patients with ARDS before the COVID-19 pandemic and to closely examine the Crs-mortality relationship. ⋯ PaO2/FiO2 and Crs were dissociated. Lower Crs was independently associated with higher mortality. The Crs-mortality relationship lacked a clear transition threshold.