Risk factors of extubation failure in neurocritical patients with the most impaired consciousness.


Association of Noninvasive Respiratory Support with Extubation Outcomes in Brain-injured Patients Receiving Mechanical Ventilation: A Secondary Analysis of the ENIO Prospective Observational Study.

In a large cohort of brain-injured patients undergoing liberation from mechanical ventilation, prophylactic use of HFNC and NIPPV were not associated with reintubation. Prospective trials are needed to confirm treatment effects in this population. Primary study registered with www.clinicaltrials.gov (NCT03400904).

American Journal of Respiratory and Critical Care Medicine


「人工呼吸中の加温加湿」いますぐ知りたい 小児の気道・呼吸管理

「人工呼吸中の加温加湿」いますぐ知りたい 小児の気道・呼吸管理

いますぐ知りたい 小児の気道・呼吸管理

いますぐ知りたい 小児の気道・呼吸管理


Utilization of mechanical power and associations with clinical outcomes in brain injured patients: a secondary analysis of the extubation strategies in neuro-intensive care unit patients and associations with outcome (ENIO) trial.

Exposure to high MP during the first week of MV is associated with poor clinical outcomes in ABI, independent of P/F ratio and neurological severity. Potential benefits of optimizing ventilator settings to limit MP warrant further investigation.

We included 1217 patients (mean age 51.2 years [SD 18.1], 66% male, mean body mass index [BMI] 26.3 [SD 5.18]) hospitalized at 62 intensive care units in 18 countries. Hospital mortality was 11% (n = 139), 44% (n = 536) were extubated by HD7 of which 20% (107/536) required reintubation, 28% (n = 340) underwent tracheostomy placement, and 9% (n = 114) developed ARDS. The median MP on HD1, HD3, and HD7 was 11.9 J/min [IQR 9.2-15.1], 13 J/min [IQR 10-17], and 14 J/min [IQR 11-20], respectively. MP was overall higher in patients with ARDS, especially those with higher ARDS severity. After controlling for same-day pressure of arterial oxygen/fraction of inspired oxygen (P/F ratio), BMI, and neurological severity, MP at HD1, HD3, and HD7 was independently associated with hospital mortality, reintubation and tracheostomy placement. The adjusted relative risk (aRR) was greater at higher MP, and strongest for: mortality on HD1 (compared to the HD1 median MP 11.9 J/min, aRR at 17 J/min was 1.22, 95% CI 1.14-1.30) and HD3 (1.38, 95% CI 1.23-1.53), reintubation on HD1 (1.64; 95% CI 1.57-1.72), and tracheostomy on HD7 (1.53; 95%CI 1.18-1.99). MP was associated with the development of moderate-severe ARDS on HD1 (2.07; 95% CI 1.56-2.78) and HD3 (1.76; 95% CI 1.41-2.22).


Repetitive postoperative extubation failure due to dynamic inspiratory airway collapse concomitant with subglottic stenosis in a patient who previously underwent tracheostomy.

We should be aware of the history of tracheostomy, especially at high tracheostomy sites, even in the absence of respiratory symptoms as risk factors for dynamic inspiratory airway collapse concomitant with subglottic stenosis contributing to repeated respiratory failure after extubation. J. Med. Invest. 70 : 301-305, February, 2023.

The Journal of Medical Investigation : JMI


Extubation in neurocritical care patients: the ENIO international prospective study.

In neurocritical care patients, extubation failure is high and is associated with unfavourable outcomes. A score could predict extubation success in multiple settings. However, it will be mandatory to validate our findings in another prospective independent cohort.

ENIO (NCT03400904) is an international, prospective observational study, in 73 intensive care units (ICUs) in 18 countries from 2018 to 2020. Neurocritical care patients with a Glasgow Coma Score (GCS) ≤ 12, receiving IMV ≥ 24 h, undergoing extubation attempt or tracheostomy were included. The primary endpoint was extubation failure by day 5. An extubation success prediction score was created, with 2/3 of patients randomly allocated to the training cohort and 1/3 to the validation cohort. Secondary endpoints were the duration of IMV and in-ICU mortality.


経肺圧を指標としたPEEP設定により，致死的低酸素血症から改善した神経芽細胞種に伴う腹部コンパートメント症候群の一乳児症例

Background : Neuroblastoma is the most common extracranial solid tumor of childhood. Although the prognosis of neuroblastoma is relatively good, newborns less than two months of age with stage 4S neuroblastoma may present with aggressive hypoxia and restrictive respiratory impairment due to abdominal compartment syndrome. Case presentation : Two-month-old girl, height of 63 cm and body weight of 10 kg. She was diagnosed as neuroblastoma with Stage 4S. Because she was suffered from refractory hypoxemia and restrictive respiratory impairment due to abdominal compartment syndrome induced by multiple liver metastasis and massive ascites, she was transferred to our ICU. Her trachea was intubated and ventilated with assist/controlled mode, driving pressure 22 cmH2O, positive end-expiratory pressure(PEEP)8 cmH2O, fraction of inspiratory oxygen(FIO2)1.0, but tidal volume was obtained only 3.2 mL/kg and PaO2/FIO2 ratio of 55 mmHg. Therefore, we insert esophageal sensor and monitored esophageal pressure to performed transpulmonary pressure guided PEEP titration. When we changed PEEP from 8 to 15 cmH2O so that the end-expiratory transpulmonary pressure achieving 0 to 5 cmH2O, her oxygenation(PaO2/FIO2 ratio : 55 to 178 mmHg)and respiratory compliance(1.4 to 3.0 mL/cmH2O)were dramatically improved. Her respiratory condition was further stabilized by ascites puncture and radiotherapy, and the patient was extubated successfully on the 25th ICU day. Conclusions : Although pediatric neuroblastoma with stage 4S may induce severe respiratory efficiency, the responsiveness of treatment for neuroblastoma is promising. Multimodal treatments including optimal ventilator management such as transpulmonary pressure -guided PEEP titration contributes to improved patient's prognosis.


Relationships between double cycling and inspiratory effort with diaphragm thickness during the early phase of mechanical ventilation: A prospective observational study.

Double cycling on the third day of mechanical ventilation was associated with strong inspiratory efforts and, possibly, changes in diaphragm thickness.


Independent lung ventilation for the management of acute allograft rejection after single-lung transplantation for end-stage emphysema.

Background : We herein report the use of independent lung ventilation (ILV) for managing acute allograft rejection after single-lung transplantation (SLT) for end-stage emphysema. Case presentation : A 54-year-old woman was transferred to our hospital with severe hypoxemia and respiratory distress due to unilateral lung disease with diffuse alveolar damage in the right donor lung associated with acute allograft rejection and with hyperinflation of the left native lung due to emphysema. She was unresponsive to immunosuppressive medications and conventional ventilation strategies, so different ventilator settings for each lung were required. A double-lumen endotracheal tube (DLT) was inserted, and ILV was initiated. The right lung was ventilated with high positive end-expiratory pressure (PEEP), intended for lung recruitment, and the left lung was ventilated with lung protective strategies using a low tidal volume and low levels of PEEP to avoid hyperinflation. Two days later, her lung function was dramatically improved, and the DLT was replaced with a single-lumen endotracheal tube. Gas exchange was maintained, and she was successfully weaned from mechanical ventilation on intensive-care unit day 15. Conclusions : ILV appears to be effective and safe for managing acute allograft rejection after SLT for emphysema. J. Med. Invest. 69 : 323-327, August, 2022.


Acquired laryngomalacia as a cause of post-extubation respiratory failure in patient with postoperative seizure and central pontine myelinolysis after craniotomy.

Background : Laryngomalacia is a congenital abnormality of the larynx that commonly occurs in children and rarely in adults. We report the first case of acquired laryngomalacia mainly due to postoperative seizure and central pontine myelinolysis after scheduled craniotomy. Case presentation : A 69-year-old man was admitted to the hospital for elective craniotomy for craniopharyngioma. After the surgery, he developed refractory seizure and required intubation and mechanical ventilation in the intensive-care unit (ICU). After treatment for the seizure, he was extubated. However, immediately after extubation, he developed stridor and respiratory retraction. We performed fiberoptic laryngoscopy and confirmed that the epiglottis had collapsed into the posterior wall of the pharynx during inspiration, which was suspected to be laryngomalacia. He received invasive mechanical ventilation for two days following re-extubation. After the second extubation, he developed stridor again due to acquired laryngomalacia. Six days later, his respiratory condition had worsened, and he received re-intubation and tracheostomy. After ICU discharge, central pontine myelinolysis was diagnosed by magnetic resonance imaging. Conclusions : Adult-onset laryngomalacia is a rare cause of upper airway obstruction but should be considered as a cause of postoperative extubation failure. We should not delay performing fiberoptic laryngoscopy to evaluate this pathology and provide optimal treatment. J. Med. Invest. 69 : 316-319, August, 2022.


The quality and quantity of sleep on dexmedetomidine during high-flow nasal cannula oxygen therapy in critically ill patients.

Purpose : High-flow nasal cannula oxygen therapy (HFNC) is a new type of non-invasive respiratory support for acute respiratory failure patients. However, patients receiving HFNC often develop sleep disturbances. We therefore examined whether dexmedetomidine could preserve the sleep characteristics in patients who underwent HFNC. Patients and Methods : This was a pilot, randomized controlled study. We assigned critically ill patients treated with HFNC to receive dexmedetomidine (0.2 to 0.7 µg / kg / h, DEX group) or not (non-DEX group) at night (9:00 p.m. to 6:00 a.m.). Polysomnograms were monitored during the study period. The primary outcomes were total sleep time (TST), sleep efficiency and duration of stage 2 non-rapid eye movement (stage N2) sleep. Results : Of the 28 patients who underwent randomization, 24 were included in the final analysis (12 patients per group). Dexmedetomidine increased the TST (369 min vs. 119 min, p = 0.024) and sleep efficiency (68% vs. 22%, P = 0.024). The duration of stage N2 was increased in the DEX group compared with the non-DEX group, but this finding did not reach statistical significance. The incidences of respiratory depression and hemodynamic instability were similar between the two groups. Conclusions : In critically ill patients who underwent HFNC, dexmedetomidine may optimize the sleep quantity without any adverse events. J. Med. Invest. 69 : 266-272, August, 2022.


人工呼吸器のウィーニングと抜管

人工呼吸器のウィーニングと抜管


ARDS に対する長期人工呼吸管理中に不動に伴う高 Calcium 血症を呈した 1例

Immobilization hypercalcemia is a rare complication in critically ill patients and causes weakness and gastrointestinal symptoms, symptoms that may lead to delayed rehabilitation and mobilization. A45-year-old woman developed ARDS and received prolonged mechanical ventilation. She received deep sedation to control excessive inspiratory effort and agitation until the 10th day. She developed hypercalcemia, which induced nausea and vomiting, on the fifth day. It was difficult to implement early physical rehabilitation and mobilization due to hypercalcemic symptoms. She was diagnosed with immobilization hypercalcemia and received alendronate sodium and elcatonin. The serum corrected calcium rapidly normalized and nausea disappeared after these drugs administration. After that, she underwent rehabilitation and was liberated from mechanical ventilation on the 63rd day. For the diagnosis of immobilization hypercalcemia, it is important to recognize risk factors such as long-term immobility, obesity, and an internal history of antiestrogens preparation. We should consider pharmacological intervention if it is difficult to implement early rehabilitation and mobilization due to symptoms of hypercalcemia.


Effect of Electrical Muscle Stimulation on Upper and Lower Limb Muscles in Critically Ill Patients: A Two-Center Randomized Controlled Trial.

In critically ill patients, electrical muscle stimulation prevented upper and lower limb muscle atrophy and attenuated proteolysis and decreased the length of hospitalization.


Effect of High-Flow Nasal Cannula on Sleep-disordered Breathing and Sleep Quality in Patients With Acute Stroke.

Introduction Sleep-disordered breathing (SDB) is common after stroke. Although the standard treatment of SDB is continuous positive airway pressure (CPAP) ventilation, the patient's intolerance and discomfort result in low adherence rates. Alternatively, high-flow nasal cannula (HFNC) may be useful as it reduces upper airway collapse with low level of positive pressure and well tolerability. The aim of this study was to investigate whether HFNC therapy reduces SDB and improves sleep quality with higher compliance rate. Methods We included acute stroke patients with SDB for the assessment of apnea-hypopnea index (AHI) >5/h using WatchPAT 200 (Itamar Medical Ltd, Caesarea, Israel). Patients who met inclusion criteria received HFNC therapy (40 L/min) with monitoring by WatchPAT. AHI, oxygen desaturation index (ODI), sleep efficiency, and rapid eye movement (REM) sleep were compared in patients with and without HFNC therapy. We also evaluated the patient's comfort of HFNC therapy (discomfort or not). Results Among 17 patients assessed for AHI, 12 received HFNC therapy. HFNC therapy was not adhered in two patients due to intolerance. Eight patients remained for final analysis. There were no differences in SDB and sleep quality with and without HFNC therapy as follows: HFNC therapy vs control; AHI 24.9 ± 20.1 vs 21.3 ± 15.0/h (p = 0.63), ODI 16.2 ± 16.5 vs 12.9 ± 12.3/h (p = 0.54), sleep efficiency 80.4 ± 12.9 vs 87.1 ± 6.2 (p = 0.28), percentage of REM sleep 19.4% ± 9.6% vs 27.6% ± 8.9% (p = 0.07). Two patients (17%) complained of discomfort among eight patients. Conclusion HFNC therapy did not improve SDB and sleep quality. Nonadherence and discomfort were observed in HFNC therapy. We need a large trial to confirm this result.


側弯矯正固定術後の急性換気不全に対し気管支鏡による選択的気管支拡張術が奏功した1例

日本集中治療医学会第4回中国・四国支部学術集会

日本集中治療医学会第4回中国・四国支部学術集会


急性呼吸不全を合併した免疫不全患者に対する呼吸療法がICU転帰に与える影響∼NPPVとHFNCの比較∼

Background : Non-invasive positive pressure ventilation (NPPV) is highly recommended for immunocompromised patients with acute respiratory failure. In this population it remains uncertain, however, whether high flow nasal canula(HFNC)is as beneficial as NPPV. Methods : We retrospectively studied immunocompromised patients with acute respiratory failure admitted to our ICU from 2011 to 2018. The background and clinical outcomes of patients initially treated with HFNC and NPPV were compared. Results : Upon admission, 12 patients were treated with HFNC and 10 with NPPV. While the length of ICU stay was significantly shorter in HFNC group (HFNC4．6days vs. NPPV13．8days, p=0．02), no intergroup difference was seen in ICU mortality (16．7% vs.30．0%, p=0．46)or intubation rate(33．3% vs.50．0%, p=0．43). Conclusions : For immunocompromised patients with acute respiratory failure, HFNC may be an alternative to NPPV. Further prospective investigation is warranted.


当院ICUにおけるカルバペネム系抗菌薬の使用状況とde-escalationに関する検討．

第47回日本集中治療医学会学術集会

第47回日本集中治療医学会学術集会


目標換気量の表示が人工呼吸患者の低一回換気量/肺保護換気の順守率に与える影響．

目標換気量の表示が人工呼吸患者の低一回換気量/肺保護換気の順守率に与える影響．

第47回日本集中治療医学会学術集会

第47回日本集中治療医学会学術集会


人工呼吸開始後早期の患者-人工呼吸器非同調が横隔膜厚の変化に与える影響．

人工呼吸開始後早期の患者-人工呼吸器非同調が横隔膜厚の変化に与える影響．

第47回日本集中治療医学会学術集会

第47回日本集中治療医学会学術集会


Change in diaphragm and intercostal muscle thickness in mechanically ventilated patients: A prospective observational ultrasougraphy study


Monitoring of muscle mass in criticaly ill patients: comparison of ultrasound and two bioelectrical impedance analysis devices

Skeletal muscle atrophy commonly occurs in critically ill patients, and decreased muscle mass is associated with worse clinical outcomes. Muscle mass can be assessed using various tools, including ultrasound and bioelectrical impedance analysis (BIA). However, the effectiveness of muscle mass monitoring is unclear in critically ill patients. This study was conducted to compare ultrasound and BIA for the monitoring of muscle mass in critically ill patients. We recruited adult patients who were expected to undergo mechanical ventilation for > 48 h and to remain in the intensive care unit (ICU) for > 5 days. On days 1, 3, 5, 7, and 10, muscle mass was evaluated using an ultrasound and two BIA devices (Bioscan: Malton International, England; Physion: Nippon Shooter, Japan). The influence of fluid balance was also evaluated between each measurement day. We analyzed 93 images in 21 patients. The age of the patients was 69 (interquartile range, IQR, 59-74) years, with 16 men and 5 women. The length of ICU stay was 11 days (IQR, 9-25 days). The muscle mass, monitored by ultrasound, decreased progressively by 9.2% (95% confidence interval (CI), 5.9-12.5%), 12.7% (95% CI, 9.3-16.1%), 18.2% (95% CI, 14.7-21.6%), and 21.8% (95% CI, 17.9-25.7%) on days 3, 5, 7, and 10 ( < 0.01), respectively, with no influence of fluid balance ( = 0.04, = 0.74). The muscle mass did not decrease significantly in both the BIA devices (Bioscan, = 0.14; Physion, = 0.60), and an influence of fluid balance was observed (Bioscan, = 0.37, < 0.01; Physion, = 0.51, < 0.01). The muscle mass assessment at one point between ultrasound and BIA was moderately correlated (Bioscan, = 0.51, < 0.01; Physion, = 0.37, < 0.01), but the change of muscle mass in the same patient did not correlate between these two devices (Bioscan, = - 0.05, = 0.69; Physion, = 0.23, = 0.07). Ultrasound is suitable for sequential monitoring of muscle atrophy in critically ill patients. Monitoring by BIA should be carefully interpreted owing to the influence of fluid change. UMIN000031316. Retrospectively registered on 15 February 2018.


Effect of controlled ventilation during assist-control ventilation on diaphragm thickness : a post hoc analysis of an observational study.

Background : Since diaphragm passivity induces oxidative stress that leads to rapid atrophy of diaphragm, we investigated the effect of controlled ventilation on diaphragm thickness during assist-control ventilation (ACV). Methods : Previously, we measured end-expiratory diaphragm thickness (Tdiee) of patients mechanically ventilated for more than 48 hours on days 1, 3, 5 and 7 after the start of ventilation. We retrospectively investigated the proportion of controlled ventilation during the initial 48-hour ACV (CV48%). Patients were classified according to CV48% : Low group, less than 25% ; High group, higher than 25%. Results : Of 56 patients under pressure-control ACV, Tdiee increased more than 10% in 6 patients (11%), unchanged in 8 patients (14%) and decreased more than 10% in 42 patients (75%). During the first week of ventilation, Tdiee decreased in both groups : Low (difference, -7.4% ; 95% confidence interval [CI], -10.1% to -4.6% ; p < 0.001) and High group (difference, -5.2% ; 95% CI, -8.5% to -2.0% ; p = 0.049). Maximum Tdiee variation from baseline did not differ between Low (-15.8% ; interquartile range [IQR], -22.3 to -1.5) and High group (-16.7% ; IQR, -22.6 to -11.1, p = 0.676). Conclusions : During ACV, maximum variation in Tdiee was not associated with proportion of controlled ventilation higher than 25%. J. Med. Invest. 67 : 332-337, August, 2020.

The Journal of Medical Investigation : JMI


第47回日本救急医学会総会

第47回日本救急医学会総会


当院脳卒中センターにおける急性脳主幹動脈閉塞症例での病院前皮質症状評価の検討．

当院脳卒中センターにおける急性脳主幹動脈閉塞症例での病院前皮質症状評価の検討．

第47回日本救急医学会総会

第47回日本救急医学会総会


ステロイドパルス療法により未診断の重症筋無力症の初期増悪から呼吸不全をきたした一症例

Journal of Japanese Association for Acute Medicine


Changes of diaphragm function before and after withdrawal of high flow nasal cannula in patients with acute respiratory failure.

The 32nd Annual Congress of European Society of Intensive Care Medicine, Berlin, Germany


Effect of controlled ventilation on diaphragm atrophy during assist-control ventilation: a post hoc analysis.

6th SG-ANZICS Intensive Care Forum, Singapore


Timing of tracheostomy in acute stroke patients.


Reverse triggering induced by endotracheal tube leak in lightly sedated ARDS patient.

Reverse triggering is respiratory entrainment triggered by the ventilator especially seen among heavily sedated patients. We confirmed reverse triggering induced by auto-triggering in lightly sedated patient through an esophageal pressure monitoring. The reverse triggering frequently caused breath stacking with increased tidal volume. Physicians should be aware, even at an optimal level of sedation, that reverse triggering can develop, possibly caused by auto-triggering.


人工呼吸に付随する諸問題:鎮痛鎮静薬 --- 呼吸管理2020-21 ガイドライン，スタンダード，論点そして私見