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Portable chest radiography in mechanically ventilated ICU patients: does synchronizing with end-inspiration improve the quality of films?
A Cheng, K Tang, H Yip, W Kwan, Y Lee, A Lee, K Lee, K Wong, C Gomersall
Critical Care , 2009, DOI: 10.1186/cc7169
Abstract: A pair of CXRs was taken after recruiting intubated, ventilated patients within 24 hours of emergency ICU admission. Intubated post-elective surgical patients were excluded due to the high likelihood of normal lungs. The control film was taken in the usual way, at a random phase of the ventilator cycle. For the synchronized film, the investigator wore a lead apron and dosimeter, stood 1 to 1.5 meters away from the patient, and pressed the inspiratory hold button. The sequence of the paired films was computer-randomized. The ventilator model, settings, patient position and portable X-ray machine settings were kept constant between films. Patients served as their own controls. Films were independently scored (1 = not clear/poorly inflated, 5 = very clear/well inflated) by two specialist radiologists based on five criteria: (i) clarity of lines and tubes, (ii) definition of pulmonary vasculature, (iii) visibility of mediastinum, (iv) definition of the diaphragm and (v) degree of lung inflation. Linear regression, taking two radiologists' scores of each patient into account, was used to examine whether there were any differences in the criteria ratings between random and synchronized films. Radiologists and statistician were blinded.We recruited 110 patients; there were no complications from the breath-hold maneuver. Dosimeter readings were negligible. Synchronized films had higher total scores and mean scores for criteria (ii) to (v), 95% confidence interval. P values were statistically significant: for total score, P < 0.001; and for criteria (ii), P = 0.001; (iii), P < 0.001; (iv), P < 0.01; and (v), P < 0.001.Synchronizing the CXR to end-inspiration improves the quality of the film and is safe.
Heat and moisture exchanger PALLBB22-15F can prevent ventilator-associated pneumonia (VAP) in short term mechanically ventilated ICU patients
MY Yassin
Critical Care , 2000, DOI: 10.1186/cc390
Abstract: Subjects were intubated and attached to the conventional respiratory assistance cascades in the first year of the study (July 1992-June 1993). Retrospectively, cases of VAP were calculated prospectively, during the following year (July l993-June 1994), subjects were intubated and attached to respiratory assistance cascades; but PALL filter, a heat and moisture exchanger, was in-line and the machine humidifiers were bypassed. The cases of VAP were calculated.Intubated ICU patients with normal CXR on admission to the unit.VAP rates decreased in the group of HMEF dramatically in comparison to the conventional humidification method (see Table below).We concluded that heat and moisture exchanger filters can prevent VAP in short term mechanically ventilated ICU patients, and can halve its rate in long term durations.
Bedside measurement of changes in lung impedance to monitor alveolar ventilation in dependent and non-dependent parts by electrical impedance tomography during a positive end-expiratory pressure trial in mechanically ventilated intensive care unit patients
Ido G Bikker, Steffen Leonhardt, Dinis Reis Miranda, Jan Bakker, Diederik Gommers
Critical Care , 2010, DOI: 10.1186/cc9036
Abstract: Functional EIT (fEIT) images and PaO2/FiO2 ratios were obtained at four PEEP levels (15 to 10 to 5 to 0 cm H2O) in 14 ICU patients with or without lung disorders. Patients were pressure-controlled ventilated with constant driving pressure. fEIT images made before each reduction in PEEP were subtracted from those recorded after each PEEP step to evaluate regional increase/decrease in tidal impedance in each EIT pixel (ΔfEIT maps).The response of regional tidal impedance to PEEP showed a significant difference from 15 to 10 (P = 0.002) and from 10 to 5 (P = 0.001) between patients with and without lung disorders. Tidal impedance increased only in the non-dependent parts in patients without lung disorders after decreasing PEEP from 15 to 10 cm H2O, whereas it decreased at the other PEEP steps in both groups.During a decremental PEEP trial in ICU patients, EIT measurements performed just above the diaphragm clearly visualize improvement and loss of ventilation in dependent and non-dependent parts, at the bedside in the individual patient.Mechanical ventilation is critical for the survival of most patients with respiratory failure admitted to the ICU, but it has become clear that it can exaggerate lung damage and may even be the primary factor in lung injury [1]. Protective ventilatory strategies to minimize this lung injury include reduction of tidal volume and prevention or minimization of lung collapse and overdistension by adequate setting of the positive end expiratory pressure (PEEP) [2]. Currently, PEEP setting is often guided by global lung parameters such as arterial oxygenation or global compliance, which are not specific for regional lung collapse or overdistension [3]. If a regional monitoring tool for lung collapse and overdistension would be available at the bedside, this would aid optimization of ventilator settings in individual patients.Electrical impedance tomography (EIT) is a noninvasive, real-time imaging method that provides a cross-sectional ventil
Is PEEP detrimental to splanchnic perfusion in mechanically ventilated patients?
M Myc, J Jastrzebski
Critical Care , 2006, DOI: 10.1186/cc4364
Abstract: A prospective study.Department of Anesthesiology and Intensive Care of Medical Postgraduate Education Center, Warsaw, Poland.Twenty adult ICU patients after laparotomy (hemicolec-tomy, colectomy) (group A) and five nonsurgical ICU patients (group B). All of them did not have serious respiratory and circulatory abnormalities, and did not need adrenergic or any circulatory support. All were mechanically ventilated under sedation with PEEP 0, PEEP 5, PEEP 10, PEEP 15. Each patient ventilated with PEEP 0 was a control for himself/herself. Each ventilation setting period lasted 1 hour. All the measurements were performed twice during that time.PiCO2-PaCO2, pH-pHi, CI, CVP, ITBVI, EVLWI were measured using gastric tonometry and the PiCCO method (pulse contour cardiac output) after each change of PEEP value. No differences in pH-pHi and PiCO2-PaCO2 were observed between groups A and B. PEEP does not compromise gastric mucosal perfusion, as assessed by tonometry. Even the patient's age was not essential. A decrease in cardiac output did not result in necessity of adrenergic support. Only in one case there was a need to use it for more than 1 hour after setting PEEP 10. Mean values of CI were higher in group A compared with nonoperated group B. CI depends on the age and PEEP level. CVP was increased by PEEP in both groups, but ITBVI was almost untouched, the right ventricle preload did not decrease, and EVLWI was slightly lowered under PEEP 15. IAP did not exceed 10 mmHg in any case.PEEP up to 15 cmH2O is well tolerated by the majority of ICU patients. The results of the present study indicate that incremental increases in PEEP do not impact on splanchnic perfusion as assessed by gastric tonometry in patients with adequate fluid loading. In some cases a necessity for adrenergic support might appear. Facing the fact of nonaffecting splanchnic perfusion, we cannot recommend any PEEP value as ideal for perfusing that region. More studies are needed in this area, particularly in
Study of Early Predictors of Fatality in Mechanically Ventilated Neonates in NICU  [cached]
Sangeeta S Trivedi,Rajesh K Chudasama,Anurakti Srivastava
Online Journal of Health & Allied Sciences , 2009,
Abstract: Objective: To evaluate the risk factors associated with fatality in mechanically ventilated neonates using multiple regression analysis. Design & settings: Prospective study conducted at Neonatal ICU at New Civil Hospital, Surat – a tertiary care centre, from December, 2007 to May, 2008 for 6 months. Methods: Fifty neonates in NICU consecutively put on mechanical ventilator during study period were enrolled in the study. The pressure limited time cycled ventilator was used. All admitted neonates were subjected to an arterial blood gas analysis along with a set of investigations to look for pulmonary maturity, infections, renal function, hyperbilirubinemia, intraventricular hemorrhage and congenital anomalies. Different investigation facilities were used as and when required during ventilation of neonates. Multiple logistic regression analysis was done to find out the predictors of fatality among these neonates. Results: Various factors suspected as predictors of fatality of mechanically ventilated neonates were assessed. Hypothermia, prolonged capillary refill time (CRT), initial requirement of oxygen fraction (FiO2) >0.6, alveolar to arterial PO2 difference (AaDO2) >250, alveolar to arterial PO2 ratio (a/A) <0.25, & oxygenation index (OI) >10 were found statistically highly significant predictors of mortality among mechanically ventilated neonates. Conclusion: Hypothermia and prolonged capillary refill time were independent predictors of fatality in neonatal mechanical ventilation. Risk of fatality can be identified in mechanically ventilated neonates
Sleep quality in mechanically ventilated patients: comparison between NAVA and PSV modes
Stéphane Delisle, Paul Ouellet, Patrick Bellemare, Jean-Pierre Tétrault, Pierre Arsenault
Annals of Intensive Care , 2011, DOI: 10.1186/2110-5820-1-42
Abstract: Prospective, comparative crossover study in 14 conscious, nonsedated, mechanically ventilated adults, during weaning in a university hospital medical intensive care unit. Patients were successively ventilated in a random ordered cross-over sequence with neurally adjusted ventilatory assist (NAVA) and pressure support ventilation (PSV). Sleep polysomnography was performed during four 4-hour periods, two with each mode in random order.The tracings of the flow, airway pressure, and electrical activity of the diaphragm were used to diagnose central apneas and ineffective efforts. The main abnormalities were a low percentage of rapid eye movement (REM) sleep, for a median (25th-75th percentiles) of 11.5% (range, 8-20%) of total sleep, and a highly fragmented sleep with 25 arousals and awakenings per hour of sleep. Proportions of REM sleep duration were different in the two ventilatory modes (4.5% (range, 3-11%) in PSV and 16.5% (range, 13-29%) during NAVA (p = 0.001)), as well as the fragmentation index, with 40 ± 20 arousals and awakenings per hour in PSV and 16 ± 9 during NAVA (p = 0.001). There were large differences in ineffective efforts (24 ± 23 per hour of sleep in PSV, and 0 during NAVA) and episodes of central apnea (10.5 ± 11 in PSV vs. 0 during NAVA). Minute ventilation was similar in both modes.NAVA improves the quality of sleep over PSV in terms of REM sleep, fragmentation index, and ineffective efforts in a nonsedated adult population.Sleep is severely disturbed in mechanically ventilated ICU patients [1-3]. Sleep alterations are known to have deleterious consequences in healthy subjects, but the paucity of data in the literature [4-7] makes it difficult to determine the impact of sleep abnormalities in ICU patients. Intensive care unit (ICU) patients present disrupted sleep with reduced sleep efficiency and a decrease in slow wave sleep and rapid eye movement (REM) sleep [8-10]. Furthermore, polysomnographic studies performed on mechanically ventilated ICU
Pneumothorax and mortality in the mechanically ventilated SARS patients: a prospective clinical study
Hsin-Kuo Kao, Jia-Horng Wang, Chun-Sung Sung, Ying-Che Huang, Te-Cheng Lien
Critical Care , 2005, DOI: 10.1186/cc3736
Abstract: We conducted a prospective, clinical study. Forty-one mechanically ventilated SARS patients were included in our study. All SARS patients were sedated and received mechanical ventilation in the isolation ICU.The mechanically ventilated SARS patients were divided into two groups either with or without pneumothorax. Their demographic data, clinical characteristics, ventilatory variables such as positive end-expiratory pressure, peak inspiratory pressure, mean airway pressure, tidal volume, tidal volume per kilogram, respiratory rate and minute ventilation and the accumulated mortality rate at 30 days after mechanical ventilation were analyzed. There were no statistically significant differences in the pressures and volumes between the two groups, and the mortality was also similar between the groups. However, patients developing pneumothorax during mechanical ventilation frequently expressed higher respiratory rates on admission, and a lower PaO2/FiO2 ratio and higher PaCO2 level during hospitalization compared with those without pneumothorax.In our study, the SARS patients who suffered pneumothorax presented as more tachypnic on admission, and more pronounced hypoxemic and hypercapnic during hospitalization. These variables signaled a deterioration in respiratory function and could be indicators of developing pneumothorax during mechanical ventilation in the SARS patients. Meanwhile, meticulous respiratory therapy and monitoring were mandatory in these patients.Severe acute respiratory syndrome (SARS) is a transmissible pulmonary infection caused by a novel coronavirus [1,2]. About 20 to 30% of SARS patients may progress to severe hypoxemic respiratory failure that requires mechanical ventilation and intensive care unit (ICU) admission [3-6]. Pneumothorax, a major and potentially lethal complication of SARS and mechanical ventilation, often complicates the management of mechanically ventilated patients, and would be especially hazardous for patients in an individuall
Cisapride decreases gastric content aspiration in mechanically ventilated patients
John Pneumatikos, Basil Koulouras, Christ Frangides, Dian Goe, George Nakos
Critical Care , 1999, DOI: 10.1186/cc305
Abstract: A prospective randomized two-period crossover study.Fourteen-bed polyvalent intensive care unit in a University Hospital.Eighteen intubated, mechanically ventilated patients who were seated in a semirecumbent position were studied.Tc-99 m sulfur colloid (80 megabecquerels) was administered via nasogastric tube on 2 consecutive days. Patients randomly received cisapride (10 mg, via nasogastric tube) one day and a placebo the other. Bronchial secretions were obtained before and for 5 consecutive h after Tc-99 m administration. The radioactivity was measured in a standard amount (1ml) of bronchial fluid using a gamma counter and expressed as counts per min (cpm) after correction for decay.Sixteen out of 18 (88%) patients had increased radioactivity in bronchial secretions. The radioactivity increased over time both with and without cisapride, although it was lower in patients receiving cisapride than in those receiving a placebo. The cumulative bronchial secretion radioactivity obtained when patients received cisapride was significantly lower than when patients received a placebo: 7540 ± 5330 and 21965 ± 16080 cpm, respectively (P <0.05).Our results suggest that aspiration of gastric contents exists even in patients who are kept in a semirecumbent position. Moreover, cisapride decreases the amount of gastric contents aspiration in intubated and mechanically ventilated patients and may play a role in the prevention of ventilator associated pneumonia. Cisapride, even with the patient in the semirecumbent position, did not completely prevent gastric content aspiration.The aspiration of gastric contents induces or exacerbates bronchoconstriction and it is the most commonly recognized pathogenic factor for the development of pneumonia, especially in ventilator-associated pneumonia (VAP) [1,2].The incidence of aspiration of gastric contents is high in intensive care unit (ICU) patients and even higher in intubated and mechanically ventilated patients. Gastrointestinal tract
Impact of nosocomial pneumonia on the outcome of mechanically-ventilated patients
J Solé Violán, C Sánchez-Ramírez, A Padrón Mújica, JA Carde?osa Cendrero, J Arroyo Fernández, F Rodríguez de Castro
Critical Care , 1998, DOI: 10.1186/cc119
Abstract: Pneumonia was diagnosed in 82 patients. The overall mortality rate was 34% for patients with NP compared to 17% in those without NP. Multivariate analysis selected the following three prognostic factors as being significantly associated with a higher risk of death: the presence of multiple organ failure [odds ratio (OR) 6.71, 95% CI, P < 0.001]; the presence of adult respiratory distress syndrome (ARDS) (OR 3.03, 95% CI, P < 0.01), and simplified acute physiology score (SAPS)> 9(OR 2.89, 95% CI, P < 0.05).In mechanically-ventilated patients NP does not represent an independent risk factor for mortality. Markers of severity of illness were the strongest predictors for mortality.Nosocomial pneumonia (NP) is a common complication in mechanically-ventilated patients, and despite some advances in antibiotic therapy it remains one of the most common causes of morbidity and mortality [1,2,3]. However, the assessment of mortality is not straightforward as it shares several risk factors with NP, confounding the relationship. Although several studies have been undertaken in order to clarify this relationship [4,5,6,7,8,9,10,11,12,13], definite conclusions have not been reached. Moreover, recent studies have shown that appropriate antibiotic therapy can have a favorable impact on the outcome of NP [14]. The purpose of this study was to evaluate the prognostic factors in patients with ventilator-associated pneumonia, and determine whether attributable mortality would be absent in the setting of adequate empiric therapy.From January to December 1995, all mechanically-ventilated patients admitted to our ICU were prospectively entered into the study. At the time of entry, age, sex, admitting service, smoking history, serum albumin level, history of chronic obstructive pulmonary disease (COPD), severity of illness according to the method of McCabe and Jackson [15], indication for ventilatory support, altered level of consciousness (Glasgow Coma Score < 8), the acute physiology and
The Impact of Acute Brain Dysfunction in the Outcomes of Mechanically Ventilated Cancer Patients  [PDF]
Isabel C. T. Almeida, Márcio Soares, Fernando A. Bozza, Cassia Righy Shinotsuka, Renata Bujokas, Vicente Cés Souza-Dantas, E. Wesley Ely, Jorge I. F. Salluh
PLOS ONE , 2014, DOI: 10.1371/journal.pone.0085332
Abstract: Introduction Delirium and coma are a frequent source of morbidity for ICU patients. Several factors are associated with the prognosis of mechanically ventilated (MV) cancer patients, but no studies evaluated delirium and coma (acute brain dysfunction). The present study evaluated the frequency and impact of acute brain dysfunction on mortality. Methods The study was performed at National Cancer Institute, Rio de Janeiro, Brazil. We prospectively enrolled patients ventilated >48 h with a diagnosis of cancer. Acute brain dysfunction was assessed during the first 14 days of ICU using RASS/CAM-ICU. Patients were followed until hospital discharge. Univariate and multivariable analysis were performed to evaluate factors associated with hospital mortality. Results 170 patients were included. 73% had solid tumors, age 65 [53–72 (median, IQR 25%–75%)] years. SAPS II score was 54[46–63] points and SOFA score was (7 [6]–[9]) points. Median duration of MV was 13 (6–21) days and ICU stay was 14 (7.5–22) days. ICU mortality was 54% and hospital mortality was 66%. Acute brain dysfunction was diagnosed in 161 patients (95%). Survivors had more delirium/coma-free days [4(1,5–6) vs 1(0–2), p<0.001]. In multivariable analysis the number of days of delirium/coma-free days were associated with better outcomes as they were independent predictors of lower hospital mortality [0.771 (0.681 to 0.873), p<0.001]. Conclusions Acute brain dysfunction in MV cancer patients is frequent and independently associated with increased hospital mortality. Future studies should investigate means of preventing or mitigating acute brain dysfunction as they may have a significant impact on clinical outcomes.
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