News
Ian Hooton/Science Photo Library
Patients waking up to the benefits of interrupted sedation
Published Online December 16, 2014 http://dx.doi.org/10.1016/ S2213-2600(14)70304-2 For the “Wake up and Breathe” protocol see Crit Care Med 2014; 42: e791–95
Newly published research has shown the effectiveness of the “Wake up and Breathe” protocol. From January 2010 to June 2013 the study ran in the ICUs of Wishard Memorial Hospital, Indianapolis, IN, USA. By March 2011, 262 patients needing mechanical ventilation had been admitted to the ICU; they formed the control group. The investigators then implemented “Wake up and Breathe”. The 440 patients who were subsequently admitted made up the intervention group. Subject to safety screening, these patients had daily sedation vacations and were woken up to attempt a spontaneous breathing trial. The duration of mechanical ventilation increased after the protocol was introduced, while the length of hospital stay remained the same. However, sedation levels decreased, and the combined prevalence of delirium and coma decreased from
91% to 85% (odds ratio 0·505; 95% CI 0·299–0·853; p=0·01). “Clinicians can take confidence in the protocol”, said lead author Babar Khan (Regenstrief Institute, and Indiana University Center for Aging Research, Indianapolis, IN, USA). “We tested it in real-time, in a real-world setting, utilising the nurses and respiratory care physicians who work on a daily basis in the ICU”. Interrupted sedation is standard practice in the UK—the ventilator bundle of care specifies “daily sedation hold and assessment of readiness to extubate”. National Institute for Health and Care Excellence guidance mandates that rehabilitation for critical care patients should begin as quickly as possible. “If you sedate patients optimally using analgesic-based sedation rather than hypnotic-based sedation, you can rehabilitate them sooner, start them doing exercise, test for delirium using the confusion assessment method
for the ICU and, if they have delirium, treat them while they’re still delirious”, explains Carl Waldmann (Faculty of Intensive Care, London, UK). Heavily sedated patients cannot be assessed for delirium, and patients with untreated delirium are three times more likely to die than those who are treated or who do not have delirium. For the entire duration of Khan’s study, coma prevalence was around 75%. For most patient populations, he thinks that this prevalence could conceivably be reduced to 50%. He hopes that some combination of “Wake up and Breathe” and early mobility protocols will become the US standard-of-care. “[‘Wake up and Breathe’] could be a locally implementable clinical model that people in every hospital can modify based on their requirements”.
Talha Burki
Science Photo Library
Patients with lung disease at risk of bowel disease
Published Online December 12, 2014 http://dx.doi.org/10.1016/ S2213-2600(14)70305-4 For the study by Brassard and colleagues see Eur Respir J 2014; published online Nov 18. DOI:10.1183/09031936.000794 14
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People with asthma and chronic obstructive pulmonary disease (COPD) are more likely to develop inflammatory bowel diseases, such as Crohn’s disease and ulcerative colitis, latest research suggests. Findings from previous studies have shown that inflammatory bowel diseases could be associated with lung diseases through common inflammatory pathways and genetic and environmental factors. The prevalence of inflammatory bowel diseases is known to be substantially increased in patients with airway diseases compared with that of the general population, but the incidence of the disease in patients with airway diseases has never been assessed. For this latest study, Paul Brassard and colleagues did a populationbased retrospective study using the Canadian health databases to retrieve information on the incidence of both
airway and inflammatory bowel disease from 2001 to 2006. They used prescription data to identify 136 178 people with asthma and 143 904 people with COPD. Overall, the researchers found that the incidence of Crohn’s disease was 27% higher in people with asthma and 55% higher in people with COPD than in the general population. The incidence of ulcerative colitis was 30% higher in people with COPD than in the general population. They noted the highest incidence of Crohn’s disease in adults aged 20–29 years for the asthma cohort and 50–59 years for the COPD cohort. For ulcerative colitis, they noted the highest incidence in those aged 30–39 years for the asthma cohort and 60–69 years for the COPD cohort. Isabella Annesi-Maesano, from the European Respiratory Society (Sheffield, UK), said: “All together these
findings suggest that airways diseases and inflammatory bowel diseases may have inflammatory pathways, including genetic variants of genes predisposing for disease, in common and share risk factors. These findings may have implications in earlier detection and adapted management of inflammatory bowel diseases in airway disease patients”. However, Richard Russell, of the British Lung Foundation (London, UK), cautioned: “The weakness of the study is its reliance upon medication use to diagnose the respiratory diseases asthma and COPD, which is not absolutely reliable. Thus, we cannot be sure of any causal link. What has been highlighted is a population association for which we now need to determine a plausible physiological explanation”.
Sanjay Tanday www.thelancet.com/respiratory Vol 3 January 2015
Ian Hooton/Science Photo Library
Patients waking up to the benefits of interrupted sedation
Published Online December 16, 2014 http://dx.doi.org/10.1016/ S2213-2600(14)70304-2 For the “Wake up and Breathe” protocol see Crit Care Med 2014; 42: e791–95
Newly published research has shown the effectiveness of the “Wake up and Breathe” protocol. From January 2010 to June 2013 the study ran in the ICUs of Wishard Memorial Hospital, Indianapolis, IN, USA. By March 2011, 262 patients needing mechanical ventilation had been admitted to the ICU; they formed the control group. The investigators then implemented “Wake up and Breathe”. The 440 patients who were subsequently admitted made up the intervention group. Subject to safety screening, these patients had daily sedation vacations and were woken up to attempt a spontaneous breathing trial. The duration of mechanical ventilation increased after the protocol was introduced, while the length of hospital stay remained the same. However, sedation levels decreased, and the combined prevalence of delirium and coma decreased from
91% to 85% (odds ratio 0·505; 95% CI 0·299–0·853; p=0·01). “Clinicians can take confidence in the protocol”, said lead author Babar Khan (Regenstrief Institute, and Indiana University Center for Aging Research, Indianapolis, IN, USA). “We tested it in real-time, in a real-world setting, utilising the nurses and respiratory care physicians who work on a daily basis in the ICU”. Interrupted sedation is standard practice in the UK—the ventilator bundle of care specifies “daily sedation hold and assessment of readiness to extubate”. National Institute for Health and Care Excellence guidance mandates that rehabilitation for critical care patients should begin as quickly as possible. “If you sedate patients optimally using analgesic-based sedation rather than hypnotic-based sedation, you can rehabilitate them sooner, start them doing exercise, test for delirium using the confusion assessment method
for the ICU and, if they have delirium, treat them while they’re still delirious”, explains Carl Waldmann (Faculty of Intensive Care, London, UK). Heavily sedated patients cannot be assessed for delirium, and patients with untreated delirium are three times more likely to die than those who are treated or who do not have delirium. For the entire duration of Khan’s study, coma prevalence was around 75%. For most patient populations, he thinks that this prevalence could conceivably be reduced to 50%. He hopes that some combination of “Wake up and Breathe” and early mobility protocols will become the US standard-of-care. “[‘Wake up and Breathe’] could be a locally implementable clinical model that people in every hospital can modify based on their requirements”.
Talha Burki
Science Photo Library
Patients with lung disease at risk of bowel disease
Published Online December 12, 2014 http://dx.doi.org/10.1016/ S2213-2600(14)70305-4 For the study by Brassard and colleagues see Eur Respir J 2014; published online Nov 18. DOI:10.1183/09031936.000794 14
16
People with asthma and chronic obstructive pulmonary disease (COPD) are more likely to develop inflammatory bowel diseases, such as Crohn’s disease and ulcerative colitis, latest research suggests. Findings from previous studies have shown that inflammatory bowel diseases could be associated with lung diseases through common inflammatory pathways and genetic and environmental factors. The prevalence of inflammatory bowel diseases is known to be substantially increased in patients with airway diseases compared with that of the general population, but the incidence of the disease in patients with airway diseases has never been assessed. For this latest study, Paul Brassard and colleagues did a populationbased retrospective study using the Canadian health databases to retrieve information on the incidence of both
airway and inflammatory bowel disease from 2001 to 2006. They used prescription data to identify 136 178 people with asthma and 143 904 people with COPD. Overall, the researchers found that the incidence of Crohn’s disease was 27% higher in people with asthma and 55% higher in people with COPD than in the general population. The incidence of ulcerative colitis was 30% higher in people with COPD than in the general population. They noted the highest incidence of Crohn’s disease in adults aged 20–29 years for the asthma cohort and 50–59 years for the COPD cohort. For ulcerative colitis, they noted the highest incidence in those aged 30–39 years for the asthma cohort and 60–69 years for the COPD cohort. Isabella Annesi-Maesano, from the European Respiratory Society (Sheffield, UK), said: “All together these
findings suggest that airways diseases and inflammatory bowel diseases may have inflammatory pathways, including genetic variants of genes predisposing for disease, in common and share risk factors. These findings may have implications in earlier detection and adapted management of inflammatory bowel diseases in airway disease patients”. However, Richard Russell, of the British Lung Foundation (London, UK), cautioned: “The weakness of the study is its reliance upon medication use to diagnose the respiratory diseases asthma and COPD, which is not absolutely reliable. Thus, we cannot be sure of any causal link. What has been highlighted is a population association for which we now need to determine a plausible physiological explanation”.
Sanjay Tanday www.thelancet.com/respiratory Vol 3 January 2015
