ABSTRACT
RATIONALE: The attempt at direct liberation from mechanical ventilation (MV) using open-circuit oxygen in the tracheostomized patients with prolonged MV might carry a substantial failure rate. Frequent switching between closed-circuit MV support and open-circuit oxygen, such as a T-piece during the liberation attempt, might also carry a risk of dispersing aerosol particles to the care environment, especially during the pandemic era. We aimed to analyze the feasibility and predictability of adding a screening test with automated tube compensation (ATC) or airway resistance compensation (ARC) mode before the attempt of an open-circuit oxygen trial. METHODS: We conducted a retrospective analysis of tracheostomized patients admitted to a medical center's dedicated weaning unit in Taiwan. Because of coronavirus's global pandemic, the unit implemented a universal process to apply ATC/ARC screening tests to patients since April 2020. Before starting the MV liberation trial with continuous spontaneous breathing via open-circuit oxygen (T-piece), the patients received a screening test consisting of 12 hours of ATC/ARC the first day followed by 72 hours of continuous ATC/ARC. Those who passed the test then proceeded to the open-circuit liberation trial. Those who failed the test would receive repeated ATC/ARC or open circuit trials. RESULTS: A total of 79 (51% of the admitted) patients, including 54 male, aged 69 [18-95] years, and averaged 32 days of MV before admission to the weaning unit, received the screening test (59 for ATC;20 for ARC) after MV settings reduction. Of the 79 patients, 48 (61%) succeeded in the test. Upon discharge from the unit, 49 (62%) were liberated from MV, and 43 (54%) were MV-free status 30 days after the ATC/ARC test. Of the 31 who failed ATC/ARC, 22 (71%) remained MV-dependent at 30 days after the ATC/ARC test. Therefore, the sensitivity, specificity, positive predictive value, and negative predictive values of the ATC/ARC test for outcomes of MV-liberation upon discharge from the unit were 90%, 87%, 92%, and 84%, respectively. The sensitivity, specificity, positive predictive value, and negative predictive values of the ATC/ARC test for outcomes of MV-free status 30 days after the test were 93%, 78%, 83%, and 90%, respectively. CONCLUSION: Before proceeding with open-circuit oxygen, a screening test with ATC/ARC provides an optimal prediction for the 30-day outcomes of MV liberation.
ABSTRACT
The novel coronavirus disease (COVID-19) may result in acute respiratory distress syndrome and respiratory failure, necessitating mechanical respiratory support. Healthcare professionals are exposed to a particularly high risk of contracting the virus while providing resuscitation and respiratory support, which may in turn result in grave consequences and even death. Although COVID-19 has been shown to cause milder disease in children, paediatricians and intensivists who provide care for children must be prepared to provide optimal respiratory support without putting themselves or other medical, nursing, and paramedical staff at undue risk. We propose an airway management approach that is especially relevant in the current COVID-19 pandemic and provides instructions for: (1) Elective intubation for respiratory failure; and (2) Emergency intubation during cardiopulmonary resuscitation. To minimise risk, intubation methods must be kept as straightforward as possible and should include the provision of appropriate personal protection and equipment to healthcare workers. We identify two key considerations: that bag-mask ventilation should be avoided if possible and that bacterial and viral filters should be placed in the respiratory circuit. Our novel approach provides a framework for airway management that could benefit paediatric critical care practitioners who provide care for any children with a novel viral illness, with a focus on infection prevention during high-risk airway management procedures.