Conventional Mechanical Ventilation Research Articles

Early Ventilator Management for Infants With Congenital Diaphragmatic Hernia: Impact of a Standardized Clinical Practice Guideline

BackgroundInfants with congenital diaphragmatic hernia (CDH) experience high morbidity and mortality due to pulmonary arterial hypertension and hypoplasia. Mechanical ventilation is a central component of CDH management. Our objective was to evaluate the impact of a standardized clinical practice guideline (implemented in January 2012) on ventilator management for infants with CDH, and associate management changes with short-term outcomes, specifically extracorporeal membrane oxygenation (ECMO) utilization and survival to discharge. MethodsWe conducted a retrospective pre-post study of 103 CDH infants admitted from January 2007–July 2021, divided pre- (n = 40) and post-guideline (n = 63). Clinical outcomes, ventilator settings, and blood gas values in the first 7 days of mechanical ventilation were compared between the pre- and post-guideline cohorts. ResultsPost-guideline, ECMO utilization decreased (11% vs 38%, p = 0.001) and survival to discharge improved (92% vs 68%, p = 0.001). More post-guideline patients remained on conventional mechanical ventilation without need for escalation to high-frequency ventilation or ECMO, and had higher pressures and PaCO2 with lower FiO2 and PaO2 (p < 0.05). ConclusionsStandardized ventilator management optimizing pressures for adequate lung expansion and minimizing oxygen toxicity improves outcomes for infants with CDH. Level of EvidenceIII.

Long-Term Outcomes of Extracorporeal Life Support in Respiratory Failure.

Although extracorporeal life support is an expensive method with serious risks of complications, it is nowadays a well-established and generally accepted method of organ support. In patients with severe respiratory failure, when conventional mechanical ventilation cannot ensure adequate blood gas exchange, veno-venous extracorporeal membrane oxygenation (ECMO) is the method of choice. An improvement in oxygenation or normalization of acid-base balance by itself does not necessarily mean an improvement in the outcome but allows us to prevent potential negative effects of mechanical ventilation, which can be considered a crucial part of complex care leading potentially to an improvement in the outcome. The disconnection from ECMO or discharge from the intensive care unit should not be viewed as the main goal, and the long-term outcome of the ECMO-surviving patients should also be considered. Approximately three-quarters of patients survive the veno-venous ECMO, but various (both physical and psychological) health problems may persist. Despite these, a large proportion of these patients are eventually able to return to everyday life with relatively little limitation of respiratory function. In this review, we summarize the available knowledge on long-term mortality and quality of life of ECMO patients with respiratory failure.

Characteristics and management of patients with SARS-CoV2 infection admitted to pediatric intensive care units: Data analysis of the Spanish national multicenter registry.

The purpose of this study is to describe the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2) disease characteristics and management in children admitted to the pediatric intensive care units (PICU). The present study was based on a national multicentric prospective registry including PICU patients with SARS-CoV2 infection or symptoms of multisystem inflammatory syndrome in children (MIS-C). A total of 298 patients were admitted to 41 different Spanish PICUs. A total of 76% of them were previously healthy. The most frequent manifestation was MIS-C (69.8%). On admission, 59.4% of patients did not have respiratory distress, and only 17.4% needed conventional mechanical ventilation (MV). The need for MV was associated with age (incidence rate ratios[IRR] 1.21, p < .012), pediatric sequential organ failure assessment score(p-SOFA) Score (IRR 1.12, p = .001), and need for transfusion (IRR 4.5, p < .004) in MIS-C patients, and with vasoactive drug use (IRR 2.73, p = .022) and the diagnosis of acute respiratory distress syndrome (IRR 2.83, p = .018) in patients admitted for other reasons. During the first day of admission, 56% of patients met shock criteria and 50.7% needed vasoactive drugs. In MIS-C patients, their use was associated with higher p-SOFA score (IRR 1.06, p < .001) and with the diagnosis of shock (IRR 5.78, p < .001). In patients without MIS-C, it was associated with higher p-SOFA score (IRR 1.05, p = .022). The mortality rate was 3%, being lower in MIS-C patients compared to patients admitted for other reasons (0.5% vs. 9.4%, p < .001). It was also lower in previously healthy patients compared to patients with previous comorbidities (0.9% vs. 9.7%, p < .001). Severe SARS-CoV2 infection is uncommon in the pediatric population. In our series, respiratory distress was rare, being MIS-C the most frequent cause of PICU admission related to SARS-CoV2. In most cases, the course of the disease was mild except in children with previous diseases.

Maintaining an acceptable indoor air quality of spaces by intentional natural ventilation or intermittent mechanical ventilation with minimum energy use

Ventilation is essential for maintaining good indoor air quality (IAQ). However, many buildings continue to suffer from inadequate ventilation due to a lack of either sufficient natural ventilation or proper operation of mechanical ventilation. During the pandemic of COVID-19, several Chinese guidelines have suggested that the household rooms for isolating infected persons and the classrooms that are not equipped with mechanical ventilation should open the windows for at least 30 min twice a day. This study first investigated whether this way of natural ventilation could ensure an acceptable IAQ. Then, the relationships between ventilation duration, ventilation frequency, and IAQ under different air change rates per hour (ACH) were examined to understand how to optimize ventilation design and operation in an efficient manner. When the ACH is ≥ 6 h−1, an acceptable IAQ can be achieved under the recommended ventilation frequency. An increase in ACH would improve the IAQ and reduce the IAQ difference caused by different CO2 generation rate per unit volume (Gr/V) values. Furthermore, simply increasing single ventilation duration while maintaining constant ventilation frequency is not an effective way to improve IAQ, as the improvement decreases as the ventilation duration is increased. Finally, when total ventilation duration is constant, increasing ventilation frequency can significantly improve the ventilation efficiency and thus IAQ, laying the groundwork for ventilation design that balances IAQ and energy use. The findings provide feasible and economical solutions for ventilation of buildings where conventional mechanical ventilation systems are not affordable.

The effect of prolonged intubation on ventilator associated pneumonia: endotracheal tube cuff is really steril or not?

Aims: Endotracheal tube (ETT) design, size, cuff material, cuff pressure, and intubation duration are critical in preventing nosocomial pneumonia. We aimed to evaluate the possible infection focus potential of ETT cuff and pilot balloon, particularly in prolonged intubated patients. Methods: A total number of 66 patients who underwent orotracheal intubation and received conventional mechanical ventilation more than 48 hours in the intensive care unit (ICU), were included in this prospective cohort study. Results:The mean duration of intubation was 10.36±4.82 days. Bacteriologically confirmed positive tracheal aspirate culture was 18.2% (n=12). The most frequent positive culture was detected inside of ETT lumen with a percentage of 83.3% (n=55) and followed by cuff (27.3%, n=18), pilot balloon (13.6%, n=9), respectively. It was documented that rates of lung infections were significantly increased after 14 days (p = 0.017) and rates of cuff positive cultures were significantly increased after 10 and 14 days of incubation (p= 0.001, p=0.004). The same type of bacteriological strains was identified from both pilot balloon (n=9) and ETT cuff (n=9), simultaneously. In the remaining 9-cuff positive patients pilot balloons were sterile and ETT lumens were positive culture with the same strains as identified from the cuff. There was a statistically significant positive correlation between the intubation duration and the number of infected ETT parts (p&lt;0.001). Conclusion: ETT cuff was demonstrated to be a potential infection focus in the present study. In addition, it was observed that ETT cuff colonization increased in proportion to the intubation duration. We suggest changing ETT at appropriate time intervals in order to reduce ventilator-associated pneumonia in intubated patients.

Cryoextraction via flexible bronchoscopy in children with tracheobronchial obstruction.

Cryoextraction via flexible bronchoscopy (FB) can be used to alleviate airway obstruction due to blood clots, casts, mucus, and foreign bodies. There is limited literature regarding the utility of cryoextraction to restore airway patency in critically ill children, especially on extracorporeal membrane oxygenation (ECMO). The aims of this study were to describe the clinical course and outcomes of children who underwent cryoextraction via FB. A singlecenter retrospective review of children who underwent cryoextraction via FB between 2017 and 2021 was conducted. The analyzed data included diagnoses, indications for cryoextraction, respiratory support modalities, FB and chest imaging results, and outcomes. Eleven patients aged 3-17 years underwent a total of 33 cryoextraction sessions via FB. Patients required ECMO (n = 9) or conventional mechanical ventilation (CMV) for pneumonia, pulmonary hemorrhage, pulmonary embolism, asthma exacerbation, and cardiorespiratory failure following cardiac surgery. One patient underwent elective FB and cryoextraction for plastic bronchitis. Indications for cryoextraction included airway obstruction due to tracheobronchial thrombi (n = 8), mucus plugs (n = 1), or plastic bronchitis (n = 2). Cryoextraction via FB was performed on patients on ECMO (n = 9) and CMV (n = 2) with 6 patients requiring ≥3 cryoextraction sessions for airway obstruction. There were no complications related to cryoextraction. Patient outcomes included partial (n = 5) or complete (n = 6) restoration of airway patency with ECMO decannulation (n = 5) and death (n = 4) due to critical illness. Cryoextraction via FB is an effective intervention that can be utilized in critically ill children with refractory tracheobronchial obstruction to restore airway patency and to facilitate liberation from ECMO.

Biophysical function of pulmonary surfactant in liquid ventilation

Liquid ventilation is a mechanical ventilation technique in which the entire or part of the lung is filled with oxygenated perfluorocarbon (PFC) liquids rather than air in conventional mechanical ventilation. Despite its many ideal biophysicochemical properties for assisting liquid breathing, a general misconception about PFC is to use it as a replacement for pulmonary surfactant. Because of the high PFC-water interfacial tension (59 mN/m), pulmonary surfactant is indispensable in liquid ventilation to increase lung compliance. However, the biophysical function of pulmonary surfactant in liquid ventilation is still unknown. Here, we have studied the adsorption and dynamic surface activity of a natural surfactant preparation, Infasurf, at the PFC-water interface using constrained drop surfactometry. The constrained drop surfactometry is capable of simulating the intra-alveolar microenvironment of liquid ventilation under physiologically relevant conditions. It was found that Infasurf adsorbed to the PFC-water interface reduces the PFC-water interfacial tension from 59 mN/m to an equilibrium value of 9 mN/m within seconds. Atomic force microscopy revealed that after de novo adsorption, Infasurf forms multilayered structures at the PFC-water interface with an average thickness of 10–20 nm, depending on the adsorbing surfactant concentration. It was found that the adsorbed Infasurf film is capable of regulating the interfacial tension of the PFC-water interface within a narrow range, between ∼12 and ∼1 mN/m, during dynamic compression-expansion cycles that mimic liquid ventilation. These findings have novel implications in understanding the physiological and biophysical functions of the pulmonary surfactant film at the PFC-water interface, and may offer new translational insights into the development of liquid ventilation and liquid breathing techniques.

Pressure-volume mechanics of inflating and deflating intact whole organ porcine lungs

Pressure-volume curves of the lung are classical measurements of lung function and are impacted by changes in lung structure due to disease or shifts in air-delivery volume or cycling rate. Diseased and preterm infant lungs have been found to show heterogeneous behavior which is highly frequency dependent. This breathing rate dependency has motivated the exploration of multi-frequency oscillatory ventilators to deliver volume oscillation with optimal frequencies for various portions of the lung to provide more uniform air distribution. The design of these advanced ventilators requires the examination of lung function and mechanics, and an improved understanding of the pressure–volume response of the lung. Therefore, to comprehensively analyze whole lung organ mechanics, we investigate six combinations of varying applied volumes and frequencies using ex-vivo porcine specimens and our custom-designed electromechanical breathing apparatus. Lung responses were evaluated through measurements of inflation and deflation slopes, static compliance, peak pressure and volume, as well as hysteresis, energy loss, and pressure relaxation. Generally, we observed that the lungs were stiffer when subjected to faster breathing rates and lower inflation volumes. The lungs exhibited greater inflation volume dependencies compared to frequency dependencies. This study’s reported response of the lung to variations of inflation volume and breathing rate can help the optimization of conventional mechanical ventilators and inform the design of advanced ventilators. Although frequency dependency is found to be minimal in normal porcine lungs, this preliminary study lays a foundation for comparison with pathological lungs, which are known to demonstrate marked rate dependency.

The effect of driving pressure-guided versus conventional mechanical ventilation strategy on pulmonary complications following on-pump cardiac surgery: A randomized clinical trial

Study objectivePostoperative pulmonary complications occur frequently and are associated with worse postoperative outcomes in cardiac surgical patients. The advantage of driving pressure-guided ventilation strategy in decreasing pulmonary complications remains to be definitively established. We aimed to investigate the effect of intraoperative driving pressure-guided ventilation strategy compared with conventional lung-protective ventilation on pulmonary complications following on-pump cardiac surgery. DesignProspective, two-arm, randomized controlled trial. SettingThe West China university hospital in Sichuan, China. PatientsAdult patients who were scheduled for elective on-pump cardiac surgery were enrolled in the study. InterventionsPatients undergoing on-pump cardiac surgery were randomized to receive driving pressure-guided ventilation strategy based on positive end-expiratory pressure (PEEP) titration or conventional lung-protective ventilation strategy with fixed 5 cmH2O of PEEP. MeasurementsThe primary outcome of pulmonary complications (including acute respiratory distress syndrome, atelectasis, pneumonia, pleural effusion, and pneumothorax) within the first 7 postoperative days were prospectively identified. Secondary outcomes included pulmonary complication severity, ICU length of stay, and in-hospital and 30-day mortality. Main resultsBetween August 2020 and July 2021, we enrolled 694 eligible patients who were included in the final analysis. Postoperative pulmonary complications occurred in 140 (40.3%) patients in the driving pressure group and 142 (40.9%) in the conventional group (relative risk, 0.99; 95% confidence interval, 0.82–1.18; P = 0.877). Intention-to-treat analysis showed no significant difference between study groups regarding the incidence of primary outcome. The driving pressure group had less atelectasis than the conventional group (11.5% vs 17.0%; relative risk, 0.68; 95% confidence interval, 0.47–0.98; P = 0.039). Secondary outcomes did not differ between groups. ConclusionAmong patients who underwent on-pump cardiac surgery, the use of driving pressure-guided ventilation strategy did not reduce the risk of postoperative pulmonary complications when compared with conventional lung-protective ventilation strategy.

Infant botulism: a descriptive study in a pediatric intensive care unit

Introduction. Infant botulism (IB) is the most common form of human botulism in Argentina. Our objective was to describe the main aspects of diagnosis and management of patients with IB admitted to the pediatric intensive care unit (PICU). Methods. Observational, descriptive, and retrospective study. The PICU database with IB diagnosis in 2005-2020 period was used. Demographic variables, diagnostic methods, days of conventional mechanical ventilation (CMV), non-invasive ventilation (NIV), length of stay in the PICU and mortality upon hospital discharge were recorded. Results. In total, 21 patients with IB were recorded; 14 were male, their median age was 5 months (IQR: 2-6m). Diagnosis was made by bioassay, and the toxin was identified intheserumof12patients.Only1 patient did not require CMV; 1 patient had a tracheostomy; 18 patients received antibiotics; 5 received NIV. No patient was administered antitoxin and no patient died. The median length of stay in the hospital was 66 days (IQR: 42-76); in the PICU, 48 days (IQR: 29-78); and the median use of CMV, 37 days (IQR:26-64).Thedelayuntildiagnosticconfirmationwas15.8±4.8days. Conclusions. All patients were diagnosed using the bioassay technique, which resulted in a diagnostic delay that exceeds the recommended period for the administration of a specific treatment. No patient received a specific treatment. IB was related to a low mortality, but also to prolonged use o MV and length of hospital stay, which were associated with cross infections and frequent antibiotic use.

Highlights of recent clinically relevant papers

Equine Veterinary EducationVolume 35, Issue 7 p. 338-339 RESEARCH HIGHLIGHTS Highlights of recent clinically relevant papers Sue Wright, Corresponding Author Sue Wright [email protected] orcid.org/0000-0002-5513-8571 EVE Editorial Office Email: [email protected]Search for more papers by this author Sue Wright, Corresponding Author Sue Wright [email protected] orcid.org/0000-0002-5513-8571 EVE Editorial Office Email: [email protected]Search for more papers by this author First published: 01 June 2023 https://doi.org/10.1111/eve.13809Read the full textAboutPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. References Cameron-Whytock, H.A., Parkin, T.D.H., Hobbs, S.J., Brigden, C.V. & Bennet, E.D. (2023) Towards a safer sport: risk factors for cross-country horse falls at British Eventing competition. Equine Veterinary Journal, Epub ahead of print. Available from: https://beva.onlinelibrary.wiley.com/doi/10.1111/evj.13934 Fisher, K., Dodam, J., Bailey, J., Thombs, L., Hodgson, D. & Bukoski, A. (2023) Arterial blood gas tensions during recovery in horses anesthetized with apneustic anesthesia ventilation compared with conventional mechanical ventilation. Journal of Veterinary Anaesthesia Analgesia, Epub ahead of print. Available from: https://doi.org/10.1016/j.vaa.2023.01.004 Goldkuhl, J.E.C., Zablotski, Y., Sill, V., Jahn, W., Lorenz, I., Brunk, J. et al. (2023) Evaluation of cartilage injury in horses with osteochondral fragments in the metacarpo−/metatarsophalangeal joint: a study on 823 arthroscopies. Equine Veterinary Journal, Epub ahead of print. Available from: https://beva.onlinelibrary.wiley.com/doi/10.1111/evj.13937 Goni, J.I., Hendrix, K. & Kritchevsky, J. (2023) Recovery of salmonella bacterial isolates from pooled fecal samples from horses. Journal of Veterinary Internal Medicine., 37(1), 323– 327. Available from: https://doi.org/10.1111/jvim.16586 Terschuur, J.A., Coomer, R.P.C., Handel, I., Pressanto, M.C. & McKane, S.A. (2023) Benefits of cyanoacrylate mesh closure following exploratory laparotomy in horses. Veterinary Record, Epub ahead of print. Available from: https://doi.org/10.1002/vetr.2732 Volume35, Issue7July 2023Pages 338-339 ReferencesRelatedInformation

60 A Retrospective Review of High-Frequency Percussive Ventilation in Inhalation Injury

Abstract Introduction Inhalation injury (II) is a major contributor to mortality in burn patients. These patients often require mechanical ventilation, but there is no clear consensus on optimal ventilatory strategy for this population. Previous studies in patients with acute respiratory distress syndrome (ARDS) demonstrated that high frequency percussive ventilation (HFPV) improved oxygenation and mobilization of airway secretions. However, HFPV in the context of II remains poorly studied. We hypothesized that for these patients, use of HFPV in addition to conventional mechanical ventilation (CMV) would reduce complications and decrease mortality compared to patients treated with CMV only. Methods We conducted a retrospective chart review of 200 patients admitted to a burn center from February 2008 - January 2019 with burns and/or II and ventilated either with CMV alone or with CMV + HFPV. Patients who were under the age of 18 or who received mechanical ventilation for less one day were excluded. Information including patient demographics and comorbidities, percent total body surface area burned, ventilation method, length of stay, complications, and outcomes were collected. Two-sample comparisons were performed by using score test for proportions and Wilcoxon rank sum test for continuous variables with significance defined as p&amp;lt; 0.05. Results Of 200 patients studied, 84 received CMV + HFPV and 116 received CMV alone. There was no difference in mortality between groups (CMV+HFPV 39.3% vs CMV 31.0%; p=0.23). There was also similar incidence of pneumonia (CMV+HFPV 53.6% vs CMV alone 63.8%; p=0.15), pneumothorax, ARDS, and sepsis. Patients on CMV + HFPV had a greater incidence of acute kidney injury (CMV+HFPV 60.7% versus CMV alone 43.1%; p=0.014) and reduced development of wound complications (CMV+HFPV 7.1% versus CMV alone 16.4%; p=0.05). In surviving patients (n=131), length of hospital stay was not significantly different between groups. Conclusions These single-center results do not support the use of CMV + HFPV rather than CMV alone in patients with II. Further research in this area, including larger multi-center studies, is warranted. Applicability of Research to Practice This is a hypothesis-generating study that adds to the currently limited understanding of best practice for managing patients with II.

Population Pharmacokinetics and Probability of Target Attainment Analysis of Nadroparin in Different Stages of COVID-19.

The risk of thrombotic complications in critical patients with COVID-19 remains extremely high, and multicenter trials failed to prove a survival benefit of escalated doses of low-molecular-weight heparins (nadroparin calcium) in this group. The aim of this study was to develop a pharmacokinetic model of nadroparin according to different stages of COVID-19 severity. Blood samples were obtained from 43 patients with COVID-19 who received nadroparin and were treated with conventional oxygen therapy, mechanical ventilation, and extracorporeal membrane oxygenation. We recorded clinical, biochemical, and hemodynamic variables during 72h of treatment. The analyzed data comprised 782 serum nadroparin concentrations and 219 anti-Xa levels. We conducted population nonlinear mixed-effects modeling (NONMEM) and performed Monte Carlo simulations of the probability of target attainment for reaching 0.2-0.5IU/mL anti-Xa levels in study groups. We successfully developed a one-compartment model to describe the population pharmacokinetics of nadroparin in different stages of COVID-19. The absorption rate constant of nadroparin was 3.8 and 3.2 times lower, concentration clearance was 2.22 and 2.93 times higher, and anti-Xa clearance was 0.87 and 1.1 times higher in mechanically ventilated patients and the extracorporeal membrane oxygenation group compared with patients treated with conventional oxygen, respectively. The newly developed model indicated that 5.900IU of nadroparin given subcutaneously twice daily in the mechanically ventilated patients led to a similar probability of target attainment of 90% as 5.900IU of subcutaneous nadroparin given once daily in the group supplemented with conventional oxygen. Different nadroparin dosing is required for patients undergoing mechanical ventilation and extracorporeal membrane oxygenation to achieve the same targets as those for non-critically ill patients. ClinicalTrials.gov identifier no. NCT05621915.

Veno-Pulmonary Arterial Extracorporeal Membrane Oxygenation in Severe Acute Respiratory Distress Syndrome: Should We Consider Mechanical Support of the Pulmonary Circulation From the Outset?

Veno-Pulmonary Arterial Extracorporeal Membrane Oxygenation in Severe Acute Respiratory Distress Syndrome: Should We Consider Mechanical Support of the Pulmonary Circulation From the Outset?

Noninvasive versus conventional mechanical ventilation in bronchiolitis

Noninvasive versus conventional mechanical ventilation in bronchiolitis

MODERN CONCEPTS OF ARTIFICIAL LUNG VENTILATION DURING GENERAL ANESTHESIA IN CANCER PATIENTS: А LITERATURE REVIEW

Relevance: Among patients who have undergone extensive surgical interventions under general anesthesia with artificial ventilation (ventilator), various postoperative respiratory complications of an obstructive or restrictive nature are often found&#x0D; The study aimed to generalizе current data from systematic reviews, meta-analyses, and scientific publications on the use of preventive and therapeutic strategies for lung ventilation to improve the quality of anesthetic care for cancer patients.&#x0D; Methods: The PubMed Electronic Database (NCBI) was searched to identify randomized controlled and prospective observational studies, systematic reviews, and meta-analyses, as well as scientific articles published in English between 2016 and 2023 that focused on the results of application and comparison of lung protective ventilation strategies with conventional mechanical ventilation in patients undergoing major and prolonged surgery.&#x0D; Results: As a result of a comparison of data from a review of large-scale scientific studies and articles, a relationship was established between the use of a protective lung ventilation strategy with a low tidal volume (6-8 ml/kg of ideal body weight), in combination with individualized PEEP, periodic lung recruitment maneuvers and significant improvement in clinical outcomes, respiratory complications, early mortality and length of hospital stay in patients undergoing surgery.&#x0D; Conclusion: Using protective lung ventilation during anesthesia during major surgical interventions reduces the incidence of postoperative pulmonary complications.

MODERN CONCEPTS OF ARTIFICIAL LUNG VENTILATION DURING GENERAL ANESTHESIA IN CANCER PATIENTS: А LITERATURE REVIEW

Relevance: Among patients who have undergone extensive surgical interventions under general anesthesia with artificial ventilation (ventilator), various postoperative respiratory complications of an obstructive or restrictive nature are often found&#x0D; The study aimed to generalizе current data from systematic reviews, meta-analyses, and scientific publications on the use of preventive and therapeutic strategies for lung ventilation to improve the quality of anesthetic care for cancer patients.&#x0D; Methods: The PubMed Electronic Database (NCBI) was searched to identify randomized controlled and prospective observational studies, systematic reviews, and meta-analyses, as well as scientific articles published in English between 2016 and 2023 that focused on the results of application and comparison of lung protective ventilation strategies with conventional mechanical ventilation in patients undergoing major and prolonged surgery.&#x0D; Results: As a result of a comparison of data from a review of large-scale scientific studies and articles, a relationship was established between the use of a protective lung ventilation strategy with a low tidal volume (6-8 ml/kg of ideal body weight), in combination with individualized PEEP, periodic lung recruitment maneuvers and significant improvement in clinical outcomes, respiratory complications, early mortality and length of hospital stay in patients undergoing surgery.&#x0D; Conclusion: Using protective lung ventilation during anesthesia during major surgical interventions reduces the incidence of postoperative pulmonary complications.

A Quality Improvement Initiative to Reduce Unnecessary Screening Chest Radiographs in a Pediatric ICU.

The Critical Care Societies Collaborative included not ordering diagnostic tests at regular intervals as one of their Choosing Wisely initiatives. A reduction in unnecessary chest radiographs (CXRs) can help reduce exposure to radiation and eliminate health care waste. We aimed to reduce daily screening CXRs in a pediatric ICU (PICU) by 20% from baseline within 4 months of implementation of CXR criteria. All intubated patients in the PICU were included in this quality improvement project. Patients with tracheostomies were excluded. We developed criteria delineating which patients were most likely to benefit from a daily screening CXR, and these criteria were discussed for each patient on rounds. Patients on extracorporeal membrane oxygenation, on high-frequency oscillatory ventilation, or on high support on conventional mechanical ventilation were included as needing a daily screening CXR. We tracked the percentage of intubated subjects receiving a screening CXR as an outcome measure. Unplanned extubations and the number of non-screening CXRs per intubated subject were followed as balancing measures. The percentage of intubated subjects receiving a daily screening CXR was reduced from 79% to 31%. There was no increase in frequency of unplanned extubations or number of non-screening CXRs. With an estimated subject charge of roughly $270 and hospital cost of $54 per CXR, this project led to an estimated $300,000 in patient charge savings and $60,000 in hospital cost savings. Adopting criteria to delineate which patients are most likely to benefit from screening CXRs can lead to a reduction in the percentage of intubated patients receiving screening CXRs without appearing to increase harm.

Hemodynamic Effects of a High-Frequency Oscillatory Ventilation Open-Lung Strategy in Critically Ill Children With Acquired or Congenital Cardiac Disease.

To study the hemodynamic consequences of an open-lung high-frequency oscillatory ventilation (HFOV) strategy in patients with an underlying cardiac anomaly with or without intracardiac shunt or primary pulmonary hypertension with severe lung injury. Secondary analysis of prospectively collected data. Medical-surgical PICU. Children less than 18 years old with cardiac anomalies (± intracardiac shunt) or primary pulmonary hypertension. None. Data from 52 subjects were analyzed, of whom 39 of 52 with cardiac anomaly (23/39 with intracardiac shunt) and 13 of 52 with primary pulmonary hypertension. Fourteen patients were admitted postoperatively, and 26 patients were admitted with acute respiratory failure. Five subjects (9.6%) were canulated for ECMO (of whom four for worsening respiratory status). Ten patients (19.2%) died during PICU stay. Median conventional mechanical ventilation settings prior to HFOV were peak inspiratory pressure 30 cm H 2 O (27-33 cm H 2 O), positive end-expiratory pressure 8 cm H 2 O (6-10 cm H 2 O), and F io2 0.72 (0.56-0.94). After transitioning to HFOV, there was no negative effect on mean arterial blood pressure, central venous pressure, or arterial lactate. Heart rate decreased significantly over time ( p < 0.0001), without group differences. The percentage of subjects receiving a fluid bolus decreased over time ( p = 0.003), especially in those with primary pulmonary hypertension ( p = 0.0155) and without intracardiac shunt ( p = 0.0328). There were no significant differences in the cumulative number of daily boluses over time. Vasoactive Infusion Score did not increase over time. Pa co2 decreased ( p < 0.0002) and arterial pH significantly improved ( p < 0.0001) over time in the whole cohort. Neuromuscular blocking agents were used in all subjects switched to HFOV. Daily cumulative sedative doses were unchanged, and no clinically apparent barotrauma was found. No negative hemodynamic consequences occurred with an individualized, physiology-based open-lung HFOV approach in patients with cardiac anomalies or primary pulmonary hypertension suffering from severe lung injury.

Combination of Mechanical Ventilation and Ceiling Fin to Reduce Airborne Infection Risk

This study evaluated the effects of various combinations of ventilation system and ceiling fin implementations for the prevention of airborne infections. The computational fluid dynamics program, STAR-CCM+, was used to analyze the airborne infection risk. The results indicate that implementation of ceiling fins with conventional mechanical ventilation and with exhaust diffuser at the center of the room reduced airborne infection risk. However, other cases with implementation of ceiling fins showed an increased risk at the breathing level (1.0 m height from the bottom). It is concluded that the application of ceiling fins can be both advantageous and disadvantageous depending on the types of combinations and all aspects should be carefully considered before implementation.