Tag Archives: critical care

Characteristics and temporality of the ventilatory techniques in the management of acute respiratory distress syndrome: A scoping review

Théo Battalian1, Raúl Escudero Romero1, Arianne Barzaga Molina2

1 Department of Physiotherapy, School of Medicine, Universidad San Pablo-CEU, CEU Universities, Boadilla del Monte, Spain
2 Department of Kinesiology, Faculty of Medicine, Clínica Alemana Universidad del Desarrollo, Santiago, Chile

DOI: 10.2478/jccm-2025-0019

Introduction: Acute Respiratory Distress Syndrome (ARDS) is a critical condition characterised by acute respiratory failure due to increased alveolar-capillary membrane permeability. This leads to non-cardiogenic pulmonary oedema, hypoxemia, and impaired respiratory compliance, significantly impacting patients’ survival and quality of life. The management of ARDS involves various ventilatory and non-ventilatory therapies. Understanding the optimal timing and application of these therapies is crucial for improving patient outcomes.
Aim of the study: This scoping review aims to identify and synthesise the ventilatory techniques used in managing ARDS, focusing on their temporality and the interplay between different therapies. The study seeks to synthesize the available evidence and summarize current management strategies, highlighting areas for further research and improvement in ARDS care.
Material and Methods: A systematic search of PubMed, EBSCO, and ScienceDirect databases was conducted, following the Joanna Briggs Institute guidelines (2015), for articles published between 2013 and 2023. Studies involving adult patients (18 years or older) diagnosed with ARDS and receiving ventilatory support in the ICU were included. Exclusion criteria included other acute respiratory pathologies, clinically extreme obese patients, and patients with tracheostomy.
Results: 437 articles were identified through the database search, of which 23 met the inclusion criteria and were included in the final review. Most articles were published between 2015-2019 (43.5%), originated from the USA (34.78%), and employed observational study designs (73.91%). The included studies reported on patients aged between 23 and 79 years, with intrapulmonary causes being the most common aetiology for ARDS. Various ventilatory strategies were identified, including conventional oxygen therapy, high-flow nasal cannula (HFNC), non-invasive ventilation (NIV), invasive ventilation (IMV), and combined approaches. Temporality was reported in 35% of the articles, but none of them as their primary focus.
Conclusions: The review highlights the diversity of ventilatory techniques employed in ARDS management and the importance of individualizing treatment strategies based on patient response and disease severity. The temporality of these interventions remains a crucial aspect, requiring further investigation to establish clearer guidelines for optimizing the timing and sequence of ventilatory support in ARDS. The findings underscore the need for future research to focus on patient-centred outcomes and the long-term implications of ARDS management, including quality of life and functional status.

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Ability to identify patient-ventilator asynchronies in intensive care unit professionals: A multicenter cross-sectional analytical study

Andrés Mauricio Enríquez Popayán1, Iván Ignacio Ramírez2, Juan Felipe Zúñiga3, Ruvistay Gutierrez-Arias4, Mayda Alejandra Jiménez Pérez5, Henry Mauricio Parada-Gereda6, Luis Fernando Pardo Cocuy7, Ana Lucia Rangel Colmenares8, Nubia Castro Chaparro9, Ana Pinza Ortega10, Jorge Martínez Díaz11, Johanna Hurtado Laverde12, Joismer Alejandro Henao Cruz13

1 Departamento de Fisioterapia en Cuidado Intensivo, GyO Medical, Yopal, Colombia; Departamento de Fisioterapia en Cuidado Intensivo, Clínica SIMALINK, Yopal, Colombia
2 Departamento de Apoyo en Rehabilitación Cardiopulmonar Integral, Instituto Nacional del Tórax, Santiago, Chile; INTRehab Research Group, Instituto Nacional del Tórax, Santiago, Chile; Escuela de Kinesiología, Facultad de Ciencias de la Salud, Universidad Diego Portales, Santiago, Chile
3 Departamento de Fisioterapia en Cuidado Intensivo, Clínica de Occidente, Cali, Colombia
4 Departamento de Apoyo en Rehabilitación Cardiopulmonar Integral, Instituto Nacional del Tórax, Santiago, Chile; INTRehab Research Group, Instituto Nacional del Tórax, Santiago, Chile; Exercise and Rehabilitation Sciences Institute, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Santiago, Chile
5 Departamento de Fisioterapia en Cuidado Intensivo, Fundación Hospital San Pedro, Pasto, Colombia
6 Unidad de Cuidado Intensivo, Clínica Reina Sofia, Bogotá, Colombia; Clínica Colsanitas, Grupo de Investigación en Nutrición Clínica y Rehabilitación-Keralty, Bogotá, Colombia. ???Especialización de Fisioterapia en Paciente Adulto Critico, Universidad del Rosario, Bogotá, Colombia.
7 Departamento de Fisioterapia en Cuidado Intensivo, Hospital Universitario Mayor Méderi, Bogotá, Colombia; Especialización de Fisioterapia en Paciente Adulto Critico, Universidad del Rosario, Bogotá, Colombia.
8 Departamento de Fisioterapia en Cuidado Intensivo, Clínica Norte, Cúcuta, Colombia; Departamento de Fisioterapia en Cuidado Intensivo, Clínica San José, Cúcuta, Colombia
9 Departamento de Cuidado Intensivo, Lumira SAS, Cali, Colombia
10 Departamento de Fisioterapia en Cuidado Intensivo, Fundación Hospital San Pedro, Pasto, Colombia; Programa de Fisioterapia, Universidad Mariana, Pasto, Colombia; Grupo de Investigación en Medicina Critica GMC, Fundación Hospital San Pedro, Pasto, Colombia
11 Departamento de Cuidado Intensivo, Fundación Hospital San Pedro, Pasto, Colombia; Programa de Medicina, Fundación Universidad San Martin, Pasto, Colombia; Grupo de Investigación en Medicina Critica GMC, Fundación Hospital San Pedro, Pasto, Colombia
12 Programa de Terapia Respiratoria, Universidad Manuela Beltrán, Bogotá, Colombia
13 Departamento de Fisioterapia en Cuidado Intensivo, Hospital Universitario de Caldas, Manizales, Colombia

DOI: 10.2478/jccm-2025-0017

Introduction: Patient-ventilator asynchrony (PVA) is frequent in intensive care. Its presence is associated with prolonged days of mechanical ventilation and may lead to increased mortality in the intensive care unit (ICU) and hospital. Little is known about the ability of Colombian intensive care professionals to identify asynchronies, and the factors associated with their correct identification are not apparent.
Aim of the study: To describe the ability of Colombian intensive care professionals to identify patient-ventilator asynchronies (PVA) using waveform analysis. In addition, to define the characteristics associated with correctly detecting PVA.
Material and methods: We conducted a multicenter, cross-sectional, national survey-based study between January and August 2024. Colombian physiotherapists, respiratory therapists, nurses and intensive care physicians from 24 departments participated in the study. An online survey was used. They were asked to identify six different PVAs presented as videos. The videos were displayed using pressure/time and flow/time waveform of a Puritan Bennett 840 ventilator.
Results: We recruited 900 participants, 60% female, most of whom were physiotherapists (53%). Most professionals had specialty training in critical care (42%), and 32% reported having specific PVA training. Double triggering was the most frequently identified PVA (75%). However, only 3.67% of participants recognized all six PVAs. According to multiple logistic regression analysis, working in a mixed unit (OR 2.59; 95% CI 1.19 – 5.54), caring for neonates (OR 5.19; 95% CI 1.77 – 15.20), and having specific training (OR 2.38; 95% CI 1.16 – 4.76) increases the chance of correctly recognizing all PVAs.
Conclusion: In Colombia, a low percentage of professionals recognize all PVAs. Having specific training in this topic, working in mixed ICUs and neonatal intensive care was significantly associated with identifying all PVAs.

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Midodrine initiation criteria, dose titration, and adverse effects when administered to treat shock: A systematic review and semi-quantitative analysis

Madeleine M. Puissant, Kaitlin J Armstrong, Richard R Riker, Samir Haydar, Tania D Strout, Kathryn E Smith, David B Seder, David J Gagnon

Maine Medical Center, Portland, USA

DOI: 10.2478/jccm-2025-0007

Objective: Systematically examine the literature describing midodrine to treat shock and to summarize current administration and dosing strategies.
Data sources: Structured literature search conducted in MEDLINE (PubMed) from inception through May 10, 2023.
Study Selection and Data Extraction: Abstracts and full texts were assessed for inclusion by two blinded, independent reviewers. English-language publications describing use of midodrine in adult patients with shock were included. Data were extracted by two blinded, independent abstractors using a standardized extraction tool. Quality assessments were completed by paired reviewers using JBI methodology.
Data Synthesis: Fifteen of 698 (2%) screened manuscripts were included with 1,714 patients with a variety of shock types. Seven studies (47%) were retrospective, two (13%) prospective observational, and six (40%) randomized controlled studies. Midodrine was initiated to facilitate intravenous vasopressor (IVP) weaning in most (11, 73%) studies; only two (13%) reported IVP weaning protocol use. Starting doses were 10 mg every 8 hours (4, 27%) or three times a day (3, 20%), 20 mg every 8 hours (2, 13%); six studies (40%) did not report initial midodrine dosing. A midodrine titration protocol was reported in 6 (40%) studies. Thirteen (87%) studies evaluated for bradycardia, identified in 6 (46%) studies among 204 patients; only one (0.5%) patient required midodrine discontinuation. Three (20%) studies reported on hypertension with an incidence of 7-11%. Four (27%) studies assessed for ischemia; 5/1128 (0.4%) patients experienced mesenteric ischemia requiring midodrine discontinuation.
Relevance to Patient care and Clinical Practice: This review explores the pragmatic details involved in initiating, titrating, and weaning midodrine for the bedside clinician and identifies rates of adverse events and complications.
Conclusions: Published literature describing midodrine use for shock is heterogeneous and comprised primarily of low or very low quality data. Future controlled trials addressing the shortcomings identified in this systematic review are warranted.

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Clinical Profile and Course of Patients with Acute Respiratory Distress Syndrome due to Covid-19 in a Middle-Income Region in Mexico

José Antonio Villalobos-Silva, Gladis Lucia Acros-López, Gracia Lizbeth Velázquez-Estrada, Camilo José Muñoz-Chavez, German Antonio Aguirre-Gómez, Obed Isaí Aguilera-Olvera, Alfredo Sánchez-González

Hospital Regional de Alta Especialidad de Ciudad Victoria, Ciudad Victoria, Tamaulipas, Mexico

DOI: 10.2478/jccm-2024-0022

Introduction: COVID-19 leads to severe clinical complications that culminate in respiratory failure and acute respiratory distress syndrome (ARDS). Despite reports of some comorbidities that contribute to the development of COVID-19-mediated ARDS, there is great variation in mortality rates among critical COVID-19 patients in the world. To date, no studies have described the incidence and comorbidities associated with ARDS due to COVID-19 in the northeastern region of Mexico.
Aim of the study: To describe patients diagnosed with ARDS due to COVID-19 in the northeastern region of Mexico, as well as its variations in comparison with other regions of the country.
Material and Methods: We conducted a prospective and observational study in a tertiary care center in Northeastern Mexico. All patients diagnosed with SARS-CoV-2 infection and requiring management in the intensive care unit were included. We developed a database that was updated daily with the patients´ demographic information, pre-existing diseases, disease severity, and clinical variables.
Results: The incidence of ARDS secondary to COVID-19 in HRAEV was high in comparison with other reports. Diabetes mellitus was the risk factor most associated with COVID-19-mediated ARDS.
Conclusion: Based on our findings and those previously reported in the literature, there are differences that we discuss between northeastern and central Mexico, and analyze other areas evaluated around the world.

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Extracorporeal Membrane Oxygenation as Circulatory Support in Adult Patients with Septic Shock: A Systematic Review

Muhammad Faisal Khan1, Mohsin Nazir1, Muhammad Khuzzaim Khan2, Raj Kumar Rajendram3, Faisal Shamim1*

1 Department of Anesthesiology, Aga Khan University Hospital, Karachi, Pakistan
2 Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
3 College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

DOI: 10.2478/jccm-2024-0017

Introduction: The utilization of extracorporeal membrane oxygenation (ECMO) in adult patients experiencing septic shock is a subject of ongoing debate within the medical community. This study aims to comprehensively address this issue through a systematic review conducted in accordance with the PRISMA guidelines.
Aim of Study: The primary objective of this study is to assess the outcomes of ECMO utilization in adult patients diagnosed with septic shock, thereby providing insights into the potential benefits and uncertainties associated with this treatment modality.
Materials and Methods: Our research encompassed a thorough search across electronic databases for relevant English-language articles published up until April 2023. The inclusion criteria were based on studies reporting on ECMO usage in adult patients with septic shock. Among the eligible studies meeting these criteria, a total of eleven were included in our analysis, involving a cohort of 512 patients. The mean age of the participants was 53.4 years, with 67.38% being male.
Results: In the pooled analysis, the mean survival rate following ECMO treatment was found to vary significantly across different ECMO modalities. Patients receiving venovenous-ECMO (VV-ECMO) and veno-venous-arterial ECMO (VVA-ECMO) demonstrated higher survival rates (44.5% and 44.4%, respectively) compared to those receiving venoarterial-ECMO (VA-ECMO) at 25% (p<0.05). A chi-square test of independence indicated that the type of ECMO was a significant predictor of survival (χ²(2) = 6.63, p=0.036). Additionally, patients with septic shock stemming from respiratory failure demonstrated survival rates ranging from 39% to 70%. Predictors of mortality were identified as older age and the necessity for cardiopulmonary resuscitation (CPR).
Conclusions: In septic shock patients, ECMO outcomes align with established indications like respiratory and cardiogenic shock. VV-ECMO and VVA-ECMO suggest better prognoses, though the optimal mode remains uncertain. Patient selection should weigh age and CPR need. Further research is vital to determine ECMO’s best approach for this population.

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Weaning Outcome is Associated with ELWI and Impaired Diastolic Function

Dimitra Bagka1, George Zakynthynos2, Vasiliki Tsolaki1, Jonh Papanikolaou3, Vasilis Vazgiourakis1, Maria Baka1, Konstantinos Pratsas1, Demosthenes Makris1

1 General University Hospital of Larissa, Larisa, Greece
2 University of Athens, Athens, Greece
3 General Hospital of Trikala, Greece

DOI: 10.2478/jccm-2024-0008

Objectives: To evaluate hemodynamic profiles of critical care patients undergoing spontaneous t-piece trial (SBT) and present weaning failure.
Methods: Prospective observational study conducted in ready-to-wean non-cardiac ICU patients. Clinical, echocardiographic and thermodilution-derived variables were recorded before and after a 2-hour SBT. Weaning from mechanical ventilation was defined as preservation of spontaneous breathing for 48 hours following successful SBT.
Results: Fourteen patients succeeded weaning, five manifested T-trial-failure and six late-failure. Weaning outcome was significantly associated with ELWI(Extravascular lung-water index), global-end-diastolic index and impaired diastolic function, as indicated by pre-T Doppler early wave velocities (E/Em); Fifty-six percent of participants presented ELWI≥7mL/kg when fulfilling predetermined criteria for weaning. ELWI, impaired pulmonary permeability and left ventricular diastolic dysfunction were independent determinants of ELWI.
Conclusions: ELWI before SBT and impaired diastolic function (as indicated by pre-T E/Em) might be weaning outcome determinants and their assessment may allow better risk stratification in weaning decision making.

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Post-Operative Delirium Masking Acute Angle Closure Glaucoma

Zariel Jiaying Sim1, Xing Jieyin2, Thangavelautham Suhitharan2

1 Singhealth, Singapore, Singapore
2 Singapore General Hospital, Singapore, Singapore

DOI: 10.2478/jccm-2023-0016

Introduction: Acute angle closure glaucoma (AACG) is an ophthalmological emergency, and can lead to the devastating consequence of permanent vision loss if not detected and treated promptly. We present a case of an atypical presentation of unilateral AACG on post operative day (POD) 1, after a prolonged operation under general anaesthesia (GA).
Case presentation: A 65-year-old female underwent a 16 hour long operation for breast cancer and developed an altered mental status with a left fixed dilated pupil on POD 1. She was intubated to secure her airway in view of a depressed consciousness level and admitted to the intensive care unit. Initial blood investigations and brain imaging were unremarkable. On subsequent review by the ophthalmologist, a raised intraocular pressure was noted and she was diagnosed with acute angle closure glaucoma. She was promptly started on intravenous acetazolamide and pressure-lowering ophthalmic drops. Her intraocular pressure normalized in the next 24 hours with improvement in her mental status to baseline.
Conclusion: AACG needs to be consistently thought of as one of the top differentials in any post-operative patient with eye discomfort or abnormal ocular signs on examination. A referral to the ophthalmologist should be made promptly once AACG is suspected.

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Brain Tissue Oxygen Levels as a Perspective Therapeutic Target in Traumatic Brain Injury. Retrospective Cohort Study

Gal Roman1, Ondrej Hrdy1, Kamil Vrbica1, Jan Hudec1, Andrej Mrlian2, Martin Smrcka2

1 Department of Anaesthesiology and Intensive Care Medicine, Masaryk University and University Hospital Brno, Brno, Czech Republic
2 Department of Neurosurgery, Masaryk University and University Hospital Brno, Brno, Czech Republic

DOI: 10.2478/jccm-2023-0001

Introduction: Management of traumatic brain injury (TBI) requires a multidisciplinary approach and represents a significant challenge for both neurosurgeons and intensivists. The role of brain tissue oxygenation (PbtO2) monitoring and its impact on posttraumatic outcomes remains a controversial topic.
Aim of the study: Our study aimed to evaluate the impact of PbtO2 monitoring on mortality, 30 days and 6 months neurological outcomes in patients with severe TBI compared with those resulting from standard intracranial pressure (ICP) monitoring.
Material and methods: In this retrospective cohort study, we analysed the outcomes of 77 patients with severe TBI who met the inclusion criteria. These patients were divided into two groups, including 37 patients who were managed with ICP and PbtO2 monitoring protocols and 40 patients who were managed using ICP protocols alone.
Results: There were no significant differences in demographic data between the two groups. We found no statistically significant differences in mortality or Glasgow Outcome Scale (GOS) scores one month after TBI. However, our results revealed that GOS scores at 6 months had improved significantly among patients managed with PbtO2; this finding was particularly notable for Glasgow Outcome Scale (GOS) scores of 4–5. Close monitoring and management of reductions in PbtO2, particularly by increasing the fraction of inspired oxygen, was associated with higher partial pressures of oxygen in this group.
Conclusions: Monitoring of PbtO2 may facilitate the appropriate evaluation and treatment of low PbtO2 and represents a promising tool for the management of patients with severe TBI. Additional studies will be needed to confirm these findings.

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Treatment of Lethal Caffeine Overdose with Haemodialysis: A Case Report and Review

Christian C Toquica Gahona, Ashwin Kodagnur Bharadwaj, Monarch Shah, Umesh Bhagat, Paul Sterman, William Vasquez

Saint Peter’s University Hospital, New Brunswick, NJ, USA

DOI: 10.2478/jccm-2022-0019

Caffeine, chemically 1,3,7-trimethylxanthine, is the most widely consumed central nervous system stimulant in the world with pleiotropic effects on the cardiovascular, pulmonary, and renal systems. The advent of over the counter (OTC) caffeine formulations has opened the window for potential toxicity, either by inadvertent or intentional overdosing. We present the case of a patient who attempted suicide by caffeine overdose treated with emergent haemodialysis and a review of the literature.

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Inhaled Nitric Oxide in Patients with Severe COVID-19 Infection at Intensive Care Unit – A Cross-Sectional Study

Laura Herranz, Juliana Gurgel da Silveira, Luis Filipe Lannes Trocado, Anna Luiza Alvaraes, Juliana Fittipaldi

Instituto D’Or de Pesquisa e Ensino, Rio de Janeiro, Brazil

DOI: 10.2478/jccm-2021-0033

In adults with severe hypoxemia, inhaled nitric oxide (iNO) is known to reduce pulmonary shunt and pulmonary hypertension, improving V/Q matching [1]. Studies in refractory hypoxemia among patients with severe acute respiratory distress syndrome (ARDS) suggest that iNO may be allied to other ventilatory strategies as a bridge to clinical improvement [2, 3].
A trial from the 2004 Beijing Coronavirus Outbreak showed that low dose iNO could shorten the time of ventilatory support [4]. Additionally, preclinical studies suggest an inhibitory effect of iNO on viral replication [5]. To date, the role of iNO in COVID19 infection is still unclear. [More]

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