Predictors and outcomes of high-flow nasal cannula failure following extubation: A multicentre observational study

INTRODUCTION@#Despite adhering to criteria for extubation, up to 20% of intensive care patients require re-intubation, even with use of post-extubation high-flow nasal cannula (HFNC). This study aims to identify independent predictors and outcomes of extubation failure in patients who failed post-extubation HFNC.@*METHODS@#We conducted a multicentre observational study involving 9 adult intensive care units (ICUs) across 5 public hospitals in Singapore. We included patients extubated to HFNC following spontaneous breathing trials. We compared patients who were successfully weaned off HFNC with those who failed HFNC (defined as re-intubation ≤7 days following extubation). Generalised additive logistic regression analysis was used to identify independent risk factors for failed HFNC.@*RESULTS@#Among 244 patients (mean age: 63.92±15.51 years, 65.2% male, median APACHE II score 23.55±7.35), 41 (16.8%) failed HFNC; hypoxia, hypercapnia and excessive secretions were primary reasons. Stroke was an independent predictor of HFNC failure (odds ratio 2.48, 95% confidence interval 1.83-3.37). Failed HFNC, as compared to successful HFNC, was associated with increased median ICU length of stay (14 versus 7 days, @*CONCLUSION@#Post-extubation HFNC failure, especially in patients with stroke as a comorbidity, remains a clinical challenge and predicts poorer clinical outcomes. Our observational study highlights the need for future prospective trials to better identify patients at high risk of post-extubation HFNC failure.

Impact of Admission Diagnosis on the Smoking Cessation Rate: A Brief Report From a Multi-centre Inpatient Smoking Cessation Programme in Singapore / 예방의학회지

Objectives@#Few studies have been published regarding the relevance of the admission diagnosis to the smoking cessation rate. We studied smoking cessation rates in relation to admission diagnoses in our inpatient smoking cessation programmes. @*Methods@#This retrospective study included all patients recruited into our inpatient smoking cessation programmes at 2 institutions in Singapore between June 2008 and December 2016. Patients were given individualized intensive counselling and were followed up via phone interviews for up to 6-month to assess their smoking status. Multivariable logistic regression was used to analyse potential associations between admission diagnoses and 6-month abstinence. @*Results@#A total of 7194 patients were included in this study. The mean age was 54.1 years, and 93.2% were male. In total, 1778 patients (24.7%) were abstinent at the 6-month follow-up call. Patients who quit smoking tended to be of Chinese ethnicity, have initiated smoking at a later age, be better educated, and have lower Fagerström Test of Nicotine Dependence scores. After adjusting for these factors, patients with a cardiovascular admission diagnosis had a significantly higher probability of quitting tobacco use than patients with a respiratory or other diagnosis. @*Conclusions@#In patients acutely admitted to the hospital, a diagnosis of cardiovascular disease was associated with the highest quit rate. Smoking cessation interventions need to be incorporated into all cardiovascular disease treatment pathways to leverage the patient’s motivation and to improve the quit rate. In addition, patients in groups with lower quit rates may benefit from more intensive programmes to increase the rate of successful cessation.

Sleep, activity and fatigue reported by Postgraduate Year 1 residents: a prospective cohort study comparing the effects of night float versus the traditional overnight on-call system

INTRODUCTION@#As the traditional overnight call system was shown to contribute to fatigue, Singapore implemented a shift system in 2014. We aimed to compare activity levels, sleep (using a wrist actigraph), fatigue and professional quality of life between residents working on night float and those on overnight calls.@*METHODS@#All Postgraduate Year 1 (PGY1) residents at our institution were invited to participate. Participants were required to wear a wrist actigraph for four months and complete two validated surveys (Epworth Sleepiness Scale [ESS] and Professional Quality of Life [ProQOL] scale) once each at the start and end of the study.@*RESULTS@#49 residents were recruited. Night float and on-call residents showed a comparable median (range) number of steps (10,061 [1,195-15,923] vs. 10,649 [308-21,910]; p = 0.429), amount of sleep logged (361 [149-630] minutes vs. 380 [175-484] minutes; p = 0.369) and time taken to fall asleep (6 [0-14] minutes vs. 6 [range 0-45] minutes; p = 0.726), respectively. Night float residents had less efficient sleep, with 90.5% having sleep efficiency of over 85% compared to 100% of on-call residents (p = 0.127). More night float residents reported ESS scores > 10 (73.1% vs. 38.5%) and higher burnout scores on ProQOL scale (41.4% vs. 21.4%) at the start of the study. However, this was similar to the end of the study and not statistically significant.@*CONCLUSION@#Physical activity and amount of sleep were not significantly different between night float and on-call residents. Residents on night float reported comparatively more fatigue and burnout.

Trigger factors in asthma and chronic obstructive pulmonary disease: a single-centre cross-sectional survey

<p><b>INTRODUCTION</b>The presence of trigger factors may help to distinguish asthma from chronic obstructive pulmonary disease (COPD). Knowing and avoiding trigger factors for both asthma and COPD can facilitate the design of comprehensive management programmes that can aid disease control. This study aimed to describe the relative frequency and range of various trigger factors in asthma and COPD.</p><p><b>METHODS</b>We conducted a telephone-based survey involving asthma and COPD patients on follow-up at a university hospital in Singapore.</p><p><b>RESULTS</b>A total of 779 asthma patients and 129 COPD patients participated in this study. Among these patients, 93.8% of those with asthma and 42.6% of those with COPD had trigger factors (p < 0.001). The median number of trigger factors was greater among asthma patients than among those with COPD (3 vs. 0, p < 0.001). Trigger factors found to be significantly more prevalent among asthma patients compared to those with COPD include tobacco smoke, alcohol, upper respiratory tract infections, incense smoke, perfume, laughter, a dusty environment, air-conditioning, heavy rain, heavy traffic fumes, citrus fruits, gastro-oesophageal reflux, household pets, flowers/pollen, medications and psychological triggers. Trigger factors that were not previously described, such as bathing, fatigue, insufficient sleep, crowded places and overeating, were also reported.</p><p><b>CONCLUSION</b>Trigger factors, although found in both groups of patients, were more common among asthma patients. Knowledge of these trigger factors may be useful in distinguishing between the two diseases and optimising disease management.</p>

Characteristics of distractions in the intensive care unit: how serious are they and who are at risk?

<p><b>INTRODUCTION</b>Distractions and interruptions of doctor's work, although common and potentially deleterious in the intensive care unit (ICU), are not well studied.</p><p><b>METHODS</b>We used a simple observational method to describe the frequency, sources and severity of such distractions, and explore at-risk situations in the ICU. Independent paired observers separately shadowed eight residents and three fellows for 38 sessions (over 100 hrs) in a 20-bed medical ICU.</p><p><b>RESULTS</b>In total, 444 distractions were noted. Interobserver agreement was excellent at 99.1%. The mean number of distractions/doctor/hr was 4.36 ± 2.27. Median duration of each distraction was 2 mins (interquartile range 2-4 mins; range 1-20 mins). The top three initiators of distractions were other doctors (35.1%), nurses (30.4%) and oneself (18.7%). Of the 444 distractions, 107 (24.1%) were prolonged (lasting ≥ 5 mins), 210 (47.3%) led to a complete pause of current activity and 85 (19.1%) led to complete abandonment of the current activity. On multivariate analysis, physician seniority, time of session and day of week did not predict frequency of distraction. After adjusting for time of session, day of week and type of current activity, urgent distractions (to see another patient, perform immediate procedures or administer medications) and physician juniority were associated with major distractions (complete interruption or termination of current activity), while only urgent distractions were associated with prolonged distractions.</p><p><b>CONCLUSION</b>Distractions are common in the ICU and junior doctors are particularly susceptible to major distractions.</p>