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The development and evolution of the endotracheal tube (ETT) have been closely related to advances in surgery and anesthesia. Modifications were made to accomplish many tasks, including minimizing gross aspiration, isolating a lung, providing a clear facial surgical field during general anesthesia, monitoring laryngeal nerve damage during surgery, preventing airway fires during laser surgery, and administering medications. In critical care management, ventilator-associated pneumonia (VAP) is a major concern, as it is associated with increased morbidity, mortality, and cost. It is increasingly appreciated that the ETT itself is a primary causative risk for developing VAP. Unfortunately, contaminated oral and gastric secretions leak down past the inflated ETT cuff into the lung. Bacteria can also grow within the ETT in biofilm and re-enter the lung. Modifications to the ETT that attempt to prevent bacteria from entering around the ETT include maintaining an adequate cuff pressure against the tracheal wall, changing the material and shape of the cuff, and aspirating the secretions that sit above the cuff. Attempts to reduce bacterial entry through the tube include antimicrobial coating of the ETT and mechanically scraping the biofilm from within the ETT. Studies evaluating the effectiveness of these modifications and techniques demonstrate mixed results, and clear recommendations for which modification should be implemented are weak.

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Background: COVID-19 has led to an unprecedented strain on health care facilities across the United States. Accurately identifying patients at an increased risk of deterioration may help hospitals manage their resources while improving the quality of patient care. Here, we present the results of an analytical model, Predicting Intensive Care Transfers and Other Unforeseen Events (PICTURE), to identify patients at high risk for imminent intensive care unit transfer, respiratory failure, or death, with the intention to improve the prediction of deterioration due to COVID-19.Objective: This study aims to validate the PICTURE model's ability to predict unexpected deterioration in general ward and COVID-19 patients, and to compare its performance with the Epic Deterioration Index (EDI), an existing model that has recently been assessed for use in patients with COVID-19. Methods:The PICTURE model was trained and validated on a cohort of hospitalized non-COVID-19 patients using electronic health record data from 2014 to 2018. It was then applied to two holdout test sets: non-COVID-19 patients from 2019 and patients testing positive for COVID-19 in 2020. PICTURE results were aligned to EDI and NEWS scores for head-to-head comparison via area under the receiver operating characteristic curve (AUROC) and area under the precision-recall curve. We compared the models' ability to predict an adverse event (defined as intensive care unit transfer, mechanical ventilation use, or death). Shapley values were used to provide explanations for PICTURE predictions.

BACKGROUND: “Lung-protective ventilation” describes a ventilation strategy involving low tidal volumes (VTs) and/or low driving pressure/plateau pressure and has been associated with improved outcomes after mechanical ventilation. We evaluated the association between intraoperative ventilation parameters (including positive end-expiratory pressure [PEEP], driving pressure, and VT) and 3 postoperative outcomes: (1) Pao 2/fractional inspired oxygen tension (Fio 2), (2) postoperative pulmonary complications, and (3) 30-day mortality. METHODS: We retrospectively analyzed adult patients who underwent major noncardiac surgery and remained intubated postoperatively from 2006 to 2015 at a single US center. Using multivariable regressions, we studied associations between intraoperative ventilator settings and lowest postoperative Pao 2/Fio 2 while intubated, pulmonary complications identified from discharge diagnoses, and in-hospital 30-day mortality. RESULTS: Among a cohort of 2096 cases, the median PEEP was 5 cm H2O (interquartile range = 4–6), median delivered VT was 520 mL (interquartile range = 460–580), and median driving pressure was 15 cm H2O (13–19). After multivariable adjustment, intraoperative median PEEP (linear regression estimate [B] = −6.04; 95% CI, −8.22 to −3.87; P < .001), median Fio 2 (B = −0.30; 95% CI, −0.50 to −0.10; P = .003), and hours with driving pressure >16 cm H2O (B = −5.40; 95% CI, −7.2 to −4.2; P < .001) were associated with decreased postoperative Pao 2/Fio 2. Higher postoperative Pao 2/Fio 2 ratios were associated with a decreased risk of pulmonary complications (adjusted odds ratio for each 100 mm Hg = 0.495; 95% CI, 0.331–0.740; P = .001, model C-statistic of 0.852) and mortality (adjusted odds ratio = 0.495; 95% CI, 0.366–0.606; P < .001, model C-statistic of 0.820). Intraoperative time with VT >500 mL was also associated with an increased likelihood of developing a postoperative pulmonary complication (adjusted odds ratio = 1.06/hour; 95% CI, 1.00–1.20; P = .042). CONCLUSIONS: In patients requiring postoperative intubation after noncardiac surgery, increased median Fio 2, increased median PEEP, and increased time duration with elevated driving pressure predict lower postoperative Pao 2/Fio 2. Intraoperative duration of VT >500 mL was independently associated with increased postoperative pulmonary complications. Lower postoperative Pao 2/Fio 2 ratios were independently associated with pulmonary complications and mortality. Our findings suggest that postoperative Pao 2/Fio 2 may be a potential target for future prospective trials investigating the impact of specific ventilation strategies for reducing ventilator-induced pulmonary injury.

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Background: Whereas data from the pre-pandemic era have demonstrated that tracheostomy can accelerate liberation from the ventilator, reduce need for sedation, and facilitate rehabilitation, concerns for healthcare worker safety have led to disagreement on tracheostomy placement in COVID-19 patients. Data on COVID-19 patients undergoing tracheostomy may inform best practices. Thus, we report a retrospective institutional cohort experience with tracheostomy in ventilated patients with COVID-19, examining associations between time to tracheostomy and duration of mechanical ventilation in relation to patient characteristics, clinical course, and survival. Methods: Clinical data were extracted for all COVID-19 tracheostomies performed at a quaternary referral center from April-July 2020. Outcomes studied included mortality, adverse events, duration of mechanical ventilation, and time to decannulation. Results: Among 64 COVID-19 tracheostomies (13% of COVID-19 hospitalizations), patients were 64% male and 42% African American, with a median age of 54 (range, 20-89). Median time to tracheostomy was 22 days (range, 7-60) and median duration of mechanical ventilation was 39.4 days (range, 20-113). Earlier tracheostomy was associated with shortened mechanical ventilation (R 2 =0.4, P<0.01). Median decannulation time was 35.3 days (range, 7-79). There was 19% mortality and adverse events in 45%, mostly from bleeding in therapeutically anticoagulated patients.Conclusions: Tracheostomy was associated with swifter liberation from the ventilator and acceptable safety for physicians in this series of critically ill COVID-19 patients. Patient mortality was not increased relative to historical data on acute respiratory distress syndrome (ARDS). Future studies are required to establish conclusions of causality regarding tracheostomy timing with mechanical ventilation, complications, or mortality in COVID-19 patients.

Percutaneous and surgical tracheostomy is safe in critically ill patients requiring prolonged mechanical ventilation (1, 2, 3). However, existing trial data are inconclusive on optimal timing of tracheostomy (4, 5). This uncertainty has grown during the COVID-19 pandemic (6). Guidelines have recommended that tracheostomy be delayed later than most "late tracheostomy" arms of recent trials (1, 5, 7, 8, 9, 10, 11, 12). This delay arises from uncertainty of patient benefit as well as concern for healthcare workers during aerosol-generating procedures (5, 13). The relatively younger, less comorbid populations with COVID-19 may be more challenging to sedate or achieve ventilator synchrony (14). We reviewed our institution's experience with COVID-19 patients undergoing tracheostomy placement at the discretion of the attending intensivist, to evaluate whether tracheostomy was associated with a reduction in sedation and analgesia administration. Methods Patients were included if they were at least 18 years old; positive for COVID-19 on a reversetranscriptase polymerase chain reaction SARS-CoV-2 test; and did not have another indication for deep sedation. Timing of tracheostomy was determined by attending intensivist. Data were collected for the day of tracheostomy and five days pre-and post-procedure by two independent trained data abstractors blinded to each other's results; differences were reconciled. Drug dosages were obtained by a pharmacist via electronic data abstraction. Opioids included fentanyl, oxycodone, morphine, and hydromorphone. Opioid doses were converted into intravenous (IV) fentanyl equivalents (100 mcg [0.1 mg] IV fentanyl = 1.5 mg IV hydromorphone = 5 mg oral hydromorphone = 20 mg oxycodone = 30 mg oral morphine = 10