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Marcus J Schultz - One of the best experts on this subject based on the ideXlab platform.
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Ventilation Management in acute respiratory failure related to covid 19 versus ards from another origin a descriptive narrative review
Expert Review of Respiratory Medicine, 2021Co-Authors: Anissa M Tsonas, Ary Serpa Neto, Marcus J Schultz, Michela Botta, Janneke Horn, Frederique PaulusAbstract:It is uncertain whether Ventilation in patients with acute respiratory failure related to coronavirus disease 2019 (COVID-19) differs from that in patients with acute respiratory distress syndrome ...
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pragmatic recommendations for the Management of acute respiratory failure and mechanical Ventilation in patients with covid 19 in low and middle income countries
American Journal of Tropical Medicine and Hygiene, 2021Co-Authors: Ary Serpa Neto, William Checkley, Chaisith Sivakorn, Madiha Hashmi, Alfred Papali, Marcus J Schultz, Covid Lmic Task ForceAbstract:Management of patients with severe or critical COVID-19 is mainly modeled after care for patients with severe pneumonia or acute respiratory distress syndrome (ARDS) from other causes, and these recommendations are based on evidence that often originates from investigations in resource-rich intensive care units located in high-income countries. Often, it is impractical to apply these recommendations to resource-restricted settings, particularly in low- and middle-income countries (LMICs). We report on a set of pragmatic recommendations for acute respiratory failure and mechanical Ventilation Management in patients with severe/critical COVID-19 in LMICs. We suggest starting supplementary oxygen when SpO2 is persistently lower than 94%. We recommend supplemental oxygen to keep SpO2 at 88-95% and suggest higher targets in settings where continuous pulse oximetry is not available but intermittent pulse oximetry is. We suggest a trial of awake prone positioning in patients who remain hypoxemic; however, this requires close monitoring, and clear failure and escalation criteria. In places with an adequate number and trained staff, the strategy seems safe. We recommend to intubate based on signs of respiratory distress more than on refractory hypoxemia alone, and we recommend close monitoring for respiratory worsening and early intubation if worsening occurs. We recommend low-tidal volume Ventilation combined with FiO2 and positive end-expiratory pressure (PEEP) Management based on a high FiO2/low PEEP table. We recommend against using routine recruitment maneuvers, unless as a rescue therapy in refractory hypoxemia, and we recommend using prone positioning for 12-16 hours in case of refractory hypoxemia (PaO2/FiO2 < 150 mmHg, FiO2 ≥ 0.6 and PEEP ≥ 10 cmH2O) in intubated patients as standard in ARDS patients. We also recommend against sharing one ventilator for multiple patients. We recommend daily assessments for readiness for weaning by a low-level pressure support and recommend against using a T-piece trial because of aerosolization risk.
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Ventilation Management in asian middle income countries
European Respiratory Journal, 2020Co-Authors: Luigi Pisani, Ary Serpa Neto, Arjen M Dondorp, Marcus J SchultzAbstract:On behalf of the ‘PRactice of Ventilation in Middle–income Countries’ (PRoVENT–iMiC) investigators: Background: Protective Ventilation consists of using a low tidal volume (VT) and sufficient positive end–expiratory pressure (PEEP). Limitations in resources may hamper implementation of protective Ventilation. Methods: PRoVENT–iMiC is an international multicentre 4–week study of ventilated adult patients in 54 ICUs from 10 Asian countries. The coprimary endpoints were VT and PEEP. Patients were stratified according to risk for (lung injury prediction score ≥ 4) and actual presence of ARDS; and females were compared to males. Results: Of 1,315 patients, 68% [95%–CI, 66–71%] were at risk for ARDS, and 7% [95%–CI, 6–8%] actually had ARDS. In ARDS patients compared to non-ARDS patients, median VT was 7.0 [5.8–8.4] vs. 7.9 [6.8–9.2] ml/kg PBW (p<0.001) (Figure; cumulative distributions in panel A); median PEEP was 10 [5–12] vs. 5 [5–8] cm H2O (P<0.001) (panel B). In males compared to females, VT was 7.5 [6.5–8.4] vs. 8.6 [7.5–10.0] ml/kg PBW (p<0.001) (panel C), while PEEP was not different (P=0.078). Overall, 53% of patients received Ventilation with a VT ≤ 8 ml/kg PBW; females received low VT less often when at risk for ARDS (40% vs. 77%) but not when having ARDS (panel D). Conclusions: Protective Ventilation is well practiced in this set of ICUs in Asian middle–income countries, also in ARDS patients. Alike in previous studies, females receive higher VT than males.
Ary Serpa Neto - One of the best experts on this subject based on the ideXlab platform.
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Ventilation Management in acute respiratory failure related to covid 19 versus ards from another origin a descriptive narrative review
Expert Review of Respiratory Medicine, 2021Co-Authors: Anissa M Tsonas, Ary Serpa Neto, Marcus J Schultz, Michela Botta, Janneke Horn, Frederique PaulusAbstract:It is uncertain whether Ventilation in patients with acute respiratory failure related to coronavirus disease 2019 (COVID-19) differs from that in patients with acute respiratory distress syndrome ...
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pragmatic recommendations for the Management of acute respiratory failure and mechanical Ventilation in patients with covid 19 in low and middle income countries
American Journal of Tropical Medicine and Hygiene, 2021Co-Authors: Ary Serpa Neto, William Checkley, Chaisith Sivakorn, Madiha Hashmi, Alfred Papali, Marcus J Schultz, Covid Lmic Task ForceAbstract:Management of patients with severe or critical COVID-19 is mainly modeled after care for patients with severe pneumonia or acute respiratory distress syndrome (ARDS) from other causes, and these recommendations are based on evidence that often originates from investigations in resource-rich intensive care units located in high-income countries. Often, it is impractical to apply these recommendations to resource-restricted settings, particularly in low- and middle-income countries (LMICs). We report on a set of pragmatic recommendations for acute respiratory failure and mechanical Ventilation Management in patients with severe/critical COVID-19 in LMICs. We suggest starting supplementary oxygen when SpO2 is persistently lower than 94%. We recommend supplemental oxygen to keep SpO2 at 88-95% and suggest higher targets in settings where continuous pulse oximetry is not available but intermittent pulse oximetry is. We suggest a trial of awake prone positioning in patients who remain hypoxemic; however, this requires close monitoring, and clear failure and escalation criteria. In places with an adequate number and trained staff, the strategy seems safe. We recommend to intubate based on signs of respiratory distress more than on refractory hypoxemia alone, and we recommend close monitoring for respiratory worsening and early intubation if worsening occurs. We recommend low-tidal volume Ventilation combined with FiO2 and positive end-expiratory pressure (PEEP) Management based on a high FiO2/low PEEP table. We recommend against using routine recruitment maneuvers, unless as a rescue therapy in refractory hypoxemia, and we recommend using prone positioning for 12-16 hours in case of refractory hypoxemia (PaO2/FiO2 < 150 mmHg, FiO2 ≥ 0.6 and PEEP ≥ 10 cmH2O) in intubated patients as standard in ARDS patients. We also recommend against sharing one ventilator for multiple patients. We recommend daily assessments for readiness for weaning by a low-level pressure support and recommend against using a T-piece trial because of aerosolization risk.
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Ventilation Management in asian middle income countries
European Respiratory Journal, 2020Co-Authors: Luigi Pisani, Ary Serpa Neto, Arjen M Dondorp, Marcus J SchultzAbstract:On behalf of the ‘PRactice of Ventilation in Middle–income Countries’ (PRoVENT–iMiC) investigators: Background: Protective Ventilation consists of using a low tidal volume (VT) and sufficient positive end–expiratory pressure (PEEP). Limitations in resources may hamper implementation of protective Ventilation. Methods: PRoVENT–iMiC is an international multicentre 4–week study of ventilated adult patients in 54 ICUs from 10 Asian countries. The coprimary endpoints were VT and PEEP. Patients were stratified according to risk for (lung injury prediction score ≥ 4) and actual presence of ARDS; and females were compared to males. Results: Of 1,315 patients, 68% [95%–CI, 66–71%] were at risk for ARDS, and 7% [95%–CI, 6–8%] actually had ARDS. In ARDS patients compared to non-ARDS patients, median VT was 7.0 [5.8–8.4] vs. 7.9 [6.8–9.2] ml/kg PBW (p<0.001) (Figure; cumulative distributions in panel A); median PEEP was 10 [5–12] vs. 5 [5–8] cm H2O (P<0.001) (panel B). In males compared to females, VT was 7.5 [6.5–8.4] vs. 8.6 [7.5–10.0] ml/kg PBW (p<0.001) (panel C), while PEEP was not different (P=0.078). Overall, 53% of patients received Ventilation with a VT ≤ 8 ml/kg PBW; females received low VT less often when at risk for ARDS (40% vs. 77%) but not when having ARDS (panel D). Conclusions: Protective Ventilation is well practiced in this set of ICUs in Asian middle–income countries, also in ARDS patients. Alike in previous studies, females receive higher VT than males.
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epidemiological characteristics practice of Ventilation and clinical outcome in patients at risk of acute respiratory distress syndrome in intensive care units from 16 countries provent an international multicentre prospective study
The Lancet Respiratory Medicine, 2016Co-Authors: Ary Serpa Neto, Carmen Silvia Valente Barbas, Fabienne D Simonis, Antonio Artigasraventos, J Canet, Rogier M Determann, James Anstey, Goran Hedenstierna, Sabrine N T Hemmes, Greet HermansAbstract:Summary Background Scant information exists about the epidemiological characteristics and outcome of patients in the intensive care unit (ICU) at risk of acute respiratory distress syndrome (ARDS) and how Ventilation is managed in these individuals. We aimed to establish the epidemiological characteristics of patients at risk of ARDS, describe Ventilation Management in this population, and assess outcomes compared with people at no risk of ARDS. Methods PRoVENT (PRactice of Ventilation in critically ill patients without ARDS at onset of Ventilation) is an international, multicentre, prospective study undertaken at 119 ICUs in 16 countries worldwide. All patients aged 18 years or older who were receiving mechanical Ventilation in participating ICUs during a 1-week period between January, 2014, and January, 2015, were enrolled into the study. The Lung Injury Prediction Score (LIPS) was used to stratify risk of ARDS, with a score of 4 or higher defining those at risk of ARDS. The primary outcome was the proportion of patients at risk of ARDS. Secondary outcomes included ventilatory Management (including tidal volume [V T ] expressed as mL/kg predicted bodyweight [PBW], and positive end-expiratory pressure [PEEP] expressed as cm H 2 O), development of pulmonary complications, and clinical outcomes. The PRoVENT study is registered at ClinicalTrials.gov, NCT01868321. The study has been completed. Findings Of 3023 patients screened for the study, 935 individuals fulfilled the inclusion criteria. Of these critically ill patients, 282 were at risk of ARDS (30%, 95% CI 27–33), representing 0·14 cases per ICU bed over a 1-week period. V T was similar for patients at risk and not at risk of ARDS (median 7·6 mL/kg PBW [IQR 6·7–9·1] vs 7·9 mL/kg PBW [6·8–9·1]; p=0·346). PEEP was higher in patients at risk of ARDS compared with those not at risk (median 6·0 cm H 2 O [IQR 5·0–8·0] vs 5·0 cm H 2 O [5·0–7·0]; p vs 17/556 [3%]; p=0·004). Compared with individuals not at risk of ARDS, patients at risk of ARDS had higher in-hospital mortality (86/543 [16%] vs 74/232 [32%]; p vs 66/227 [29%]; p vs 88/282 [31%]; p T did not differ between patients who did and did not develop ARDS (p=0·471 for those at risk of ARDS; p=0·323 for those not at risk). Interpretation Around a third of patients receiving mechanical Ventilation in the ICU were at risk of ARDS. Pulmonary complications occur frequently in patients at risk of ARDS and their clinical outcome is worse compared with those not at risk of ARDS. There is potential for improvement in the Management of patients without ARDS. Further refinements are needed for prediction of ARDS. Funding None.
Ira M Cheifetz - One of the best experts on this subject based on the ideXlab platform.
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ventilatory support in children with pediatric acute respiratory distress syndrome proceedings from the pediatric acute lung injury consensus conference
Pediatric Critical Care Medicine, 2015Co-Authors: Peter C Rimensberger, Ira M CheifetzAbstract:To describe the recommendations of the Pediatric Acute Lung Injury Consensus Conference for mechanical Ventilation Management of pediatric patients with acute respiratory distress syndrome.
Tai Pham - One of the best experts on this subject based on the ideXlab platform.
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mechanical Ventilation Management during extracorporeal membrane oxygenation for acute respiratory distress syndrome an international multicenter prospective cohort
American Journal of Respiratory and Critical Care Medicine, 2019Co-Authors: Matthieu Schmidt, Tai Pham, Antonio Arcadipane, Cara Agerstrand, Shinichiro Ohshimo, Vincent Pellegrino, Alain Vuylsteke, Christophe Guervilly, Shay McguinnessAbstract:Rationale: Current practices regarding mechanical Ventilation in patients treated with extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome are unknown.Objectives: To report current practices regarding mechanical Ventilation in patients treated with ECMO for severe acute respiratory distress syndrome (ARDS) and their association with 6-month outcomes.Methods: This was an international, multicenter, prospective cohort study of patients undergoing ECMO for ARDS during a 1-year period in 23 international ICUs.Measurements and Main Results: We collected demographics, daily pre- and per-ECMO mechanical Ventilation settings and use of adjunctive therapies, ICU, and 6-month outcome data for 350 patients (mean ± SD pre-ECMO PaO2/FiO2 71 ± 34 mm Hg). Pre-ECMO use of prone positioning and neuromuscular blockers were 26% and 62%, respectively. Vt (6.4 ± 2.0 vs. 3.7 ± 2.0 ml/kg), plateau pressure (32 ± 7 vs. 24 ± 7 cm H2O), driving pressure (20 ± 7 vs. 14 ± 4 cm H2O), respiratory rate (26 ± 8 vs. 14 ± 6 breaths/min), and mechanical power (26.1 ± 12.7 vs. 6.6 ± 4.8 J/min) were markedly reduced after ECMO initiation. Six-month survival was 61%. No association was found between ventilator settings during the first 2 days of ECMO and survival in multivariable analysis. A time-varying Cox model retained older age, higher fluid balance, higher lactate, and more need for renal-replacement therapy along the ECMO course as being independently associated with 6-month mortality. A higher Vt and lower driving pressure (likely markers of static compliance improvement) across the ECMO course were also associated with better outcomes.Conclusions: Ultraprotective lung Ventilation on ECMO was largely adopted across medium- to high-case volume ECMO centers. In contrast with previous observations, mechanical Ventilation settings during ECMO did not impact patients' prognosis in this context.
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mechanical Ventilation Management during extracorporeal membrane oxygenation for acute respiratory distress syndrome an international multicenter prospective cohort
American Journal of Respiratory and Critical Care Medicine, 2019Co-Authors: Matthieu Schmidt, Tai Pham, Antonio Arcadipane, Cara Agerstrand, Shinichiro Ohshimo, Vincent Pellegrino, Alain Vuylsteke, Christophe Guervilly, Shay McguinnessAbstract:Rationale: Current practices regarding mechanical Ventilation in patients treated with extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome are unknown.Objectives: To ...
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epidemiology patterns of care and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries
JAMA, 2016Co-Authors: Giacomo Bellani, Tai Pham, John G Laffey, Eddy Fan, Laurent Brochard, Andres EstebanAbstract:Importance Limited information exists about the epidemiology, recognition, Management, and outcomes of patients with the acute respiratory distress syndrome (ARDS). Objectives To evaluate intensive care unit (ICU) incidence and outcome of ARDS and to assess clinician recognition, Ventilation Management, and use of adjuncts—for example prone positioning—in routine clinical practice for patients fulfilling the ARDS Berlin Definition. Design, Setting, and Participants The Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) was an international, multicenter, prospective cohort study of patients undergoing invasive or noninvasive Ventilation, conducted during 4 consecutive weeks in the winter of 2014 in a convenience sample of 459 ICUs from 50 countries across 5 continents. Exposures Acute respiratory distress syndrome. Main Outcomes and Measures The primary outcome was ICU incidence of ARDS. Secondary outcomes included assessment of clinician recognition of ARDS, the application of ventilatory Management, the use of adjunctive interventions in routine clinical practice, and clinical outcomes from ARDS. Results Of 29 144 patients admitted to participating ICUs, 3022 (10.4%) fulfilled ARDS criteria. Of these, 2377 patients developed ARDS in the first 48 hours and whose respiratory failure was managed with invasive mechanical Ventilation. The period prevalence of mild ARDS was 30.0% (95% CI, 28.2%-31.9%); of moderate ARDS, 46.6% (95% CI, 44.5%-48.6%); and of severe ARDS, 23.4% (95% CI, 21.7%-25.2%). ARDS represented 0.42 cases per ICU bed over 4 weeks and represented 10.4% (95% CI, 10.0%-10.7%) of ICU admissions and 23.4% of patients requiring mechanical Ventilation. Clinical recognition of ARDS ranged from 51.3% (95% CI, 47.5%-55.0%) in mild to 78.5% (95% CI, 74.8%-81.8%) in severe ARDS. Less than two-thirds of patients with ARDS received a tidal volume 8 of mL/kg or less of predicted body weight. Plateau pressure was measured in 40.1% (95% CI, 38.2-42.1), whereas 82.6% (95% CI, 81.0%-84.1%) received a positive end-expository pressure (PEEP) of less than 12 cm H 2 O. Prone positioning was used in 16.3% (95% CI, 13.7%-19.2%) of patients with severe ARDS. Clinician recognition of ARDS was associated with higher PEEP, greater use of neuromuscular blockade, and prone positioning. Hospital mortality was 34.9% (95% CI, 31.4%-38.5%) for those with mild, 40.3% (95% CI, 37.4%-43.3%) for those with moderate, and 46.1% (95% CI, 41.9%-50.4%) for those with severe ARDS. Conclusions and Relevance Among ICUs in 50 countries, the period prevalence of ARDS was 10.4% of ICU admissions. This syndrome appeared to be underrecognized and undertreated and associated with a high mortality rate. These findings indicate the potential for improvement in the Management of patients with ARDS. Trial Registration clinicaltrials.gov Identifier:NCT02010073
Janneke Horn - One of the best experts on this subject based on the ideXlab platform.
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Ventilation Management in acute respiratory failure related to covid 19 versus ards from another origin a descriptive narrative review
Expert Review of Respiratory Medicine, 2021Co-Authors: Anissa M Tsonas, Ary Serpa Neto, Marcus J Schultz, Michela Botta, Janneke Horn, Frederique PaulusAbstract:It is uncertain whether Ventilation in patients with acute respiratory failure related to coronavirus disease 2019 (COVID-19) differs from that in patients with acute respiratory distress syndrome ...
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Ventilation Management and clinical outcomes in invasively ventilated patients with covid 19 provent covid a national multicentre observational cohort study
The Lancet Respiratory Medicine, 2021Co-Authors: Michela Botta, Anissa M Tsonas, Janesh Pillay, Leonoor S Boers, Anna Geke Algera, Lieuwe D J Bos, Dave A Dongelmans, M W Hollmann, Janneke HornAbstract:BACKGROUND: Little is known about the practice of Ventilation Management in patients with COVID-19. We aimed to describe the practice of Ventilation Management and to establish outcomes in invasively ventilated patients with COVID-19 in a single country during the first month of the outbreak. METHODS: PRoVENT-COVID is a national, multicentre, retrospective observational study done at 18 intensive care units (ICUs) in the Netherlands. Consecutive patients aged at least 18 years were eligible for participation if they had received invasive Ventilation for COVID-19 at a participating ICU during the first month of the national outbreak in the Netherlands. The primary outcome was a combination of ventilator variables and parameters over the first 4 calendar days of Ventilation: tidal volume, positive end-expiratory pressure (PEEP), respiratory system compliance, and driving pressure. Secondary outcomes included the use of adjunctive treatments for refractory hypoxaemia and ICU complications. Patient-centred outcomes were ventilator-free days at day 28, duration of Ventilation, duration of ICU and hospital stay, and mortality. PRoVENT-COVID is registered at ClinicalTrials.gov (NCT04346342). FINDINGS: Between March 1 and April 1, 2020, 553 patients were included in the study. Median tidal volume was 6·3 mL/kg predicted bodyweight (IQR 5·7-7·1), PEEP was 14·0 cm H2O (IQR 11·0-15·0), and driving pressure was 14·0 cm H2O (11·2-16·0). Median respiratory system compliance was 31·9 mL/cm H2O (26·0-39·9). Of the adjunctive treatments for refractory hypoxaemia, prone positioning was most often used in the first 4 days of Ventilation (283 [53%] of 530 patients). The median number of ventilator-free days at day 28 was 0 (IQR 0-15); 186 (35%) of 530 patients had died by day 28. Predictors of 28-day mortality were gender, age, tidal volume, respiratory system compliance, arterial pH, and heart rate on the first day of invasive Ventilation. INTERPRETATION: In patients with COVID-19 who were invasively ventilated during the first month of the outbreak in the Netherlands, lung-protective Ventilation with low tidal volume and low driving pressure was broadly applied and prone positioning was often used. The applied PEEP varied widely, despite an invariably low respiratory system compliance. The findings of this national study provide a basis for new hypotheses and sample size calculations for future trials of invasive Ventilation for COVID-19. These data could also help in the interpretation of findings from other studies of Ventilation practice and outcomes in invasively ventilated patients with COVID-19. FUNDING: Amsterdam University Medical Centers, location Academic Medical Center.
