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Postextubation strategies in obese patients: non-invasive ventilation seems the best choice
Obesity is common in patients admitted to critical care. Their decreased pulmonary and thoracic compliance increases risk of atelectasis and extubation failure, and the optimal strategy to avoid reintubation is not clear. De Jong and colleagues (Lancet Respir Med 2023;11:530) conducted a multicentre randomised controlled trial in 39 French intensive care units (ICUs) comparing non-invasive ventilation (NIV) and oxygen therapy, both conventional and high-flow nasal oxygen (HFNO), as postextubation strategies. A total of 981 obese patients, ventilated for at least 6 hours, were enrolled and randomised into the NIV and oxygen groups. Patients with premorbid OSA, home ventilation or who were hypercapnic were excluded. Within each intervention group (NIV and oxygen), there was a second randomisation of the mode of oxygen therapy (HFNO or conventional oxygen), alternating with NIV in the NIV group. In the intention-to-treat analysis, the composite outcome of treatment failure at 3 days (defined as reintubation, treatment switch or discontinuation), was significantly lower in the NIV group than in the oxygen group (13% vs 26.5%, p<0.001). This was mostly attributable to patients who switched from oxygen to NIV, whereas reintubation rates did not significantly differ. Per-protocol and post hoc cross-over analyses, in which patients who switched treatment were included in the NIV group, were also performed, showing significantly lower reintubation rates with NIV. The subjective nature of the primary outcome must be considered when interpreting the results, adding some caution to the authors conclusion that NIV is superior as postextubation support in obese patients and suggesting widespread adoption of this practice.
Severe community-acquired pneumonia in the ICU: hydrocortisone improves outcomes
Community-acquired pneumonia remains a major cause of morbidity and mortality globally, with overall in-hospital mortality rates of 10%–12%, reaching 30% for patients requiring mechanical ventilation. Although corticosteroids have shown benefits in these patients, the impact on survival remains unproven. Dequin and colleagues (N Engl J Med 2023;388:1931) performed a multicentre trial in French critical care units to evaluate the effect of early hydrocortisone treatment on the mortality of patients with severe pneumonia treated in the ICU. Pneumonia severity criteria required for enrolment were: mechanical ventilation with positive end-expiratory pressure of at least 5 cmH2O; arterial oxygen tension/fractional inspired oxygen (FiO2) ratio lower than 300 (with FiO2≥50%); and Pulmonary Severity Index greater than 130. A notable exclusion criterion was septic shock. Of 5948 screened, 800 adult patients with pneumonia were randomised to either intravenous hydrocortisone (200 mg for 4 or 7 days; dependent on clinical progress followed by a tapering dose over up to 14 days) or placebo on a 1:1 allocation. All patients received standard antibiotics and supportive care. The primary outcome (overall mortality at 28 days) analysis was performed as part of an interim safety analysis and demonstrated a significantly lower mortality rate in the hydrocortisone group (6.2% vs 11.9%, p=0.006) leading to the interruption of the trial. Interestingly, the hydrocortisone group did not experience higher rates of gastrointestinal bleeding or nosocomial infections. The authors concluded that early treatment with hydrocortisone reduced 28-day mortality among patients with severe community-acquired pneumonia.
Management of primary spontaneous pneumothorax: doing nothing may be the most effective strategy
Primary spontaneous pneumothorax (PSP) results from the rupture of bullae under the visceral pleura, in the absence of trauma or pulmonary disease. It represents a high burden on healthcare systems around the world due to its relatively high incidence and the costs associated with therapy. Available guidelines favour aspiration or observation over tube thoracostomy, but the latter continues to be common practice in many countries. Eamer and colleagues (Chest 2023;S0012-3692(23)00756-0) investigated which therapeutic approach to PSP delivered the highest utility. They systematically reviewed evidence from 2000 to 2020 and included 22 articles for analysis of PSP management strategies (observation, aspiration or chest tube placement). Observation was associated with lower rates of PSP resolution when compared with tube thoracostomy and aspiration (risk ratio 0.81, 95% CI 0.71 to 0.91 and 0.73, 95% CI 0.61 to 0.88, respectively). Both observation and aspiration were associated with shorter hospital length of stay when compared with chest tube placement (mean difference 5.2 days, 95% CI 3.8 to 6.6 and 2.7 days, 95% CI 2.4 to 3.0, respectively). Two-year recurrence rates were similar for all three strategies. However, cost–utility modelling, based on Canadian healthcare costs and using Monte Carlo simulations, found observation to be associated with a higher utility value and lower costs. The majority of included studies were not prospective randomised controlled trials and therefore the results should be interpreted carefully. The authors concluded that observation may be a preferred first approach in selected patients, even with large pneumothoraces, followed by aspiration if observation alone fails.
Functional exercise capacity to estimate physical activity: more useful in chronic obstructive pulmonary disease than in interstitial lung disease
Physical activity (PA) is an important predictor of outcomes in chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD), and functional exercise capacity is considered a strong indicator of PA in patients with ILD. Breuls and colleagues (PLoS One 2022;Nov 21;17(11):e0277973) aimed to compare PA, exercise capacity (6 min walking distance; 6MWD) and quadriceps force in patients with COPD and ILD, to determine if the pattern of PA differed. From previous research between 2006 and 2013, they selected 260 subjects, including patients with ILD (mainly idiopathic pulmonary fibrosis (IPF) or hypersensitivity pneumonitis), stable patients with COPD and healthy non-smokers without airflow obstruction. In total, 120 subjects were propensity-matched (45 with COPD, 43 with ILD and 30 healthy controls). Both patient groups undertook fewer steps per day compared with controls (p<0.001), but the ILD group spent less time in moderate-to-vigorous PA than their COPD counterparts. The correlation between 6MWD and PA was weaker in the ILD group (Pearson’s r=0.348) than in the COPD group (r=0.739). Notably, while only patients with COPD on long-term oxygen therapy received oxygen during the 6MWD test, all patients with ILD received oxygen at 2 L/min by default, which may overestimate the results and explain the weaker correlation. Neither group showed a correlation between quadriceps force and PA. The authors concluded that PA in ILD seems less dependent of functional exercise capacity and lung function impairment, and that PA in ILD was of lower intensity, which may impact rehabilitation programmes in these patients. However, they remark that PA outcomes may differ significantly between IPF and non-IPF ILD.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.