Epidemiology of Tracheostomized Adult Patients Admitted to Specialized Weaning Centers After Acute COVID-19.

BACKGROUND: Epidemiological data on patients with COVID-19 referred to specialized weaning centers (SWCs) are sparse, particularly in low- and middle-income countries. Our aim was to describe clinical features, epidemiology, and outcomes of subjects admitted to SWCs in Argentina. METHODS: We conducted a prospective, multi-center, observational study between July 2020-December 2021 in 12 SWCs. We collected demographic characteristics, laboratory results, pulmonary function, and dependence on mechanical ventilation at admission, decannulation, weaning from mechanical ventilation, and status at discharge. A multiple logistic model was built to predict home discharge. RESULTS: We enrolled 568 tracheostomized adult subjects after the acute COVID-19 phase who were transferred to SWCs. Age was 62 [52-71], males 70%, Charlson comorbidity index was 2 [0-3], and length of stay in ICU was 42 [32-56] d. Of the 315 ventilator-dependent subjects, 72.4% were weaned, 427 (75.2%) were decannulated, and 366 subjects (64.5%) were discharged home. The mortality rate was 6.0%. In multivariate analysis, age (odds ratio 0.30 [95% CI 0.16-0.56], P < .001), Charlson comorbidity index (odds ratio 0.43 [95% CI 0.22-0.84], P < .01), mechanical ventilation duration in ICU (odds ratio 0.80 [95% CI 0.72-0.89], P < .001), renal failure (odds ratio 0.40 [95% CI 0.22-0.73], P = .003), and expiratory muscle weakness (odds ratio 0.35 [95% CI 0.19-0.62], P < .001) were independently associated with home discharge. CONCLUSIONS: Most subjects with COVID-19 transferred to SWCs were weaned, achieved decannulation, and were discharged to home. Age, high-comorbidity burden, prolonged mechanical ventilation in ICU, renal failure at admission, and expiratory muscle weakness were inversely associated with home discharge.

Tracheostomy Decannulation and Disorders of Consciousness Evolution.

BACKGROUND: Tracheostomy is a frequent surgical procedure in subjects with chronic disorders of consciousness (DOC). There is no consensus about safety of tracheostomy decannulation in this population.The aim of our study was to estimate if DOC improvement is a predictor for tracheostomy decannulation. Secondary outcomes include mortality rate and discharge destination. METHODS: We conducted an observational, retrospective, case-control study at a weaning and rehabilitation center (WRC). We included tracheostomized subjects with DOC admitted between August 2015 and December 2017. We matched groups based on the consciousness level at admission assessed withthe coma recovery scale revised (CRS-R). Subjects who were later decannulated formed the cases, while those that remained tracheostomized at the end of follow-up formed the controls. Improvement of DOC was defined as a progress in the categories of the CRS-R. RESULTS: 22 subjects were included in each group. No significant differences were found in clinical and demographic variables, except that controls had longer neurologic injury evolution (65.5 vs 51 days, P = .047), more tracheostomy days at admission to ourinstitution (53 vs 33.5, P = .02), and higher prevalence of neurological comorbidities (12 vs 4, P = .03). Subjects who improved their DOC had more chances of being decannulated (OR 11.28, 95% CI 1.96-123.08). Tracheostomy decannulation could not be achieved in most subjects who did not improve from vegetative state (VS) (OR 0.13, 95% CI 0.02-0.60). 8 subjects, however, could be decannulated in VS, with only one decannulation failure and no deaths. Mortality was higher in controls (0 vs 6, P = .02), especially among VS (0 vs 5, P = .049). No significant differences were found in discharge destination between groups. CONCLUSIONS: Subjects who improve their DOC are more likely to achieve tracheostomy decannulation. Some subjects in VS were decannulated, with lower mortality than those who remained tracheostomized.

Impacto del SARS-CoV2 en un Centro de desvinculación de la ventilación mecánica y rehabilitación / Impact of SARS-CoV2 on a Center for Mechanical Ventilation Weaning and Rehabilitation

Introducción: Desde diciembre de 2019, el virus SARS-CoV2 se ha propagado por todo el mundo a gran velocidad. Múltiples estudios describen su comportamiento en unidades de terapia intensiva, pero hay poca información sobre su impacto en centro de rehabilitación y cuidados críticos crónicos (CRCCC). Objetivo: Demostrar si la implementación de un protocolo de acción de contingencia podría disminuir la diseminación del virus entre los pacientes internados en un CRCCC. Materiales y Métodos: Estudio observacional, retrospectivo, transversal. Se incluyeron pacientes mayores de 18 años bajo aislamiento respiratorio, ya sea por caso sospechoso de SARS-CoV2, contacto estrecho con caso confirmado o ingreso a la institución, durante mayo de 2020. Los valores se expresaron como mediana y rango intercuantilo o frecuencia y porcentaje, según la variable. Las diferencias entre SARS-CoV2 positivos y negativos se evaluaron con test de la mediana y test exacto de Fisher. Resultados: Durante el periodo de estudio, se colocaron en aislamiento respiratorio 30 pacientes (53% por caso sospechoso, 13% por contacto estrecho y 34% por ingreso). De ellos, 5 fueron positivos para SARS-CoV2, con una mediana de 61 años (18-71), mayoría de sexo masculino (4/5), 80% traqueostomizados y 33% con asistencia ventilatoria mecánica invasiva. Un paciente murió por complicaciones relacionadas al SARS-CoV2. No se hallaron diferencias significativas en cantidad de casos positivos según la causa de aislamiento (p = 0.37) ni en las características clínico-demográficas entre positivos y negativos. Conclusión: La implementación de un protocolo de contingencia para pacientes potencialmente infectados con SARS-CoV2 en una CRCCC podría disminuir su diseminación dentro de la institución.

Impact of SARS-CoV2 on a Center for Mechanical Ventilation Weaning and Rehabilitation / Impacto del SARS-CoV2 en un Centro de desvinculación de la ventilación mecánica y rehabilitación

Introduction: Since December 2019, the SARS-CoV2 virus has propagated throughout the world at great speed. Multiple studies describe its behavior in Intensive Care Units, but there is little information about its impact on a Critical Care Recovery Center (CCRC). Objective: To show if the use of a contingency protocol could reduce virus dissemination among patients hospitalized in a CCRC. Materials and Methods: Observational, retrospective, cross-sectional study. The study included patients older than 18 years on respiratory isolation for being a suspected case of SARS-CoV2, or close contact of a confirmed case or for their admission to theinstitution, during May 2020.The values were expressed as median and interquartile range or frequency and percentage, according to the variable. The differences between positive and negative SARS-CoV2 cases were evaluated with the median test and the Fisher' s Exact Test. Results: During the study period, 30 patients were placed in respiratory isolation (53% suspected cases, 13% close contact and 34% admission to the institution). 5 of them tested positive for SARS-CoV2, with a median of 61 years (18-71), mostly males (4/5), 80% tracheostomized and 33% with invasive mechanical ventilatory assistance. One patient died from complications associated withSARS-CoV2. No significant differences were found in the number of positive cases according to the isolation cause (p = 0.37) or the clinicaldemographic characteristics between positive and negative cases. Conclusion: The use of a contingency protocol for patients potentially infected with SARS-CoV2 in a CCRC could reduce the virus dissemination inside the institution.

Análisis de una cohorte de pacientes decanulados en un centro de cuidados críticos crónicos de Argentina / Analysis of a Cohort of Decannulated Patients in a Critical Care Center for Chronically Ill Patients in Argentina

Objetivos: Describir las características de una cohorte de pacientes decanulados que ingresan a un Centro de Neurorehabilitación y Cuidados Critico Crónicos y su condición al egreso. Como objetivo secundario analizar la existencia de posibles factores de riesgo asociados con su derivación a un centro de mayor complejidad. Materiales y Métodos: Estudio descriptivo, transversal, retrospectivo, en la Clínica de Neurorehabilitación Santa Catalina, Ciudad Autónoma de Buenos Aires, Argentina. Resultados: Se decanularon 87 pacientes. 29 ingresaron con AVMi y pudieron ser desvinculados en su totalidad. La mediana de días de TQT fue de 35 días (RIQ 22-68). De los pacientes decanulados, el 21% continuaba internado en la institución al cierre del estudio. El 53% egresó vivo a su domicilio, mientras que el 23% debió ser derivado a un centro de mayor complejidad. Dos pacientes decanulados fallecieron durante su internación. Se hallaron como variables independientemente asociadas a egresar hacia un centro de mayor complejidad la presencia de antecedentes neurológicos previos a la internación en UTI (OR = 4.22, IC 95% (1.03-10.5), p=0.02) y la internación en UTI por causa respiratoria (OR = 4.44, IC 95% (1.22-16.1), p = 0.02). Conclusión: La mayoría de los pacientes decanulados lograron egresar vivos a su domicilio. Presentar antecedentes neurológicos y patología respiratoria como motivo de ingreso a UTI podrían ser factores de riesgo para ser derivados a un centro de mayor complejidad.

Analysis of a Cohort of Decannulated Patients in a Critical Care Center for Chronically Ill Patients in Argentina

Objectives: To describe the characteristics of a cohort of decannulated patients admitted to a Neuro-rehabilitation and Critical Care Center and their condition upon discharge. The secondary objective was to analyze the existence of possible risk factors associated with referral of patients to a high complexity center. Materials and Method: Descriptive, cross-sectional, retrospective study in the Clínica de Neurorehabilitación Santa Catalina, Autonomous City of Buenos Aires, Argentina. Results: 87 patients were decannulated. 29 patients were admitted with IMVA and could be completely weaned. The median of TQT days was 35 days (IQR 22-68). 21% of decannulated patients were still hospitalized at the institution upon the end of the study. 53% were discharged home alive, whereas 23% had to be referred to a high complexity center. Two decannulated patients died while they were hospitalized. Some variables independently associated with referral to a high complexity center were found, the presence of a neurological history before ICU admission (OR [odds ratio] = 4.22, 95% CI [confidence interval] (1.03-10.5), p = 0.02) and ICU admission for respiratory causes (OR = 4.44, 95% CI (1.22-16.1), p = 0.02). Conclusion: Most decannulated patients were discharged home alive. Neurological history and respiratory disease as reasons for ICU admission could be risk factors to be referred to a high complexity center.

Evaluation of an active humidification system for inspired gas.

OBJECTIVES: The effectiveness of the active humidification systems (AHS) in patients already weaned from mechanical ventilation and with an artificial airway has not been very well described. The objective of this study was to evaluate the performance of an AHS in chronically tracheostomized and spontaneously breathing patients. METHODS: Measurements were quantified at three levels of temperature (T°) of the AHS: level I, low; level II, middle; and level III, high and at different flow levels (20 to 60 L/minute). Statistical analysis of repeated measurements was performed using analysis of variance and significance was set at a P<0.05. RESULTS: While the lowest temperature setting (level I) did not condition gas to the minimum recommended values for any of the flows that were used, the medium temperature setting (level II) only conditioned gas with flows of 20 and 30 L/minute. Finally, at the highest temperature setting (level III), every flow reached the minimum absolute humidity (AH) recommended of 30 mg/L. CONCLUSION: According to our results, to obtain appropiate relative humidity, AH and T° of gas one should have a device that maintains water T° at least at 53℃ for flows between 20 and 30 L/m, or at T° of 61℃ at any flow rate.

Evaluation of tracheal cuff pressure variation in spontaneously breathing patients.

BACKGROUND: Most of the studies referring cuff tubes' issues were conducted on intubated patients. Not much is known about the cuff pressure performance in chronically tracheostomized patients disconnected from mechanical ventilation. OBJECTIVE: To evaluate cuff pressure (CP) variation in tracheostomized, spontaneously breathing patients in a weaning rehabilitation center. MATERIALS AND METHODS: Experimental setup to test instruments in vitro, in which the gauge (TRACOE) performance at different pressure levels was evaluated in six tracheostomy tubes, and a clinical setupin which CP variation over 24 h, every 4 h, and for 6 days was measured in 35 chronically tracheostomized clinically stable, patients who had been disconnected from mechanical ventilation for at least 72 h. The following data were recorded: Tube brand, type, and size; date of the tube placed; the patient's body position; the position of the head; axillary temperature; pulse and respiration rates; blood pressure; and pulse oximetry. RESULTS: In vitro difference between the initial pressure (IP) and measured pressure (MP) was statistically significant (P < 0.05). The difference between the IP and MP was significant when selecting for various tube brands (P < 0.05). In the clinical set-up, 207 measurements were performed and the CP was >30 cm H2O in 6.28% of the recordings, 20-30 cm H2O in 42.0% of the recordings, and <20 cm H2O in 51.69% of the recordings. CONCLUSION: The systematic CP measurement in chronically tracheostomized, spontaneously breathing patients showed high variability, which was independent of tube brand, size, type, or time of placement. Consequently, measurements should be made more frequently.