Endotracheal Mechanical Ventilation Research Articles

A simplified acute physiology score in the prediction of acute aluminum phosphide poisoning outcome

Aluminum phosphide (AlP) is used as a fumigant. It produces phosphine gas, which is a mitochondrial poison. Unfortunately, there is no known antidote for AlP intoxication, and also, there are few data about its prognostic factors. The aim of this study was to determine the impact of the Simplified Acute Physiology Score II (SAPS II ) in the prediction of outcome in patients with acute AlP poisoning requiring admission to the Intensive Care Unit (ICU). This was a prospective study in patients with acute AlP poisoning, admitted to the ICU over a period of 12 months. The demographic data were collected and SAPSII was recorded. The patients were divided into survival and non-survival groups due to outcome. The data were expressed as mean ± SD for continuous or discrete variables and as frequency and percentage for categorical variables. The results were compared between the two groups using SPSS software. Results : During the study period, 39 subjects were admitted to the ICU with acute AlP poisoning. All 39 patients required endotracheal intubation and mechanical ventilation in addition to gastric decontamination with sodium bicarbonate, permanganate potassium, and activated charcoal, therapy with MgSO 4 and calcium gluconate and adequate hydration. Among these patients, 26 (66.7%) died. SAPSII was significantly higher in the non-survival group than in the survival group (11.88 ± 4.22 vs. 4.31 ± 2.06, respectively) (P < 0.001). SAPSII calculated within the first 24 hours was recognized as a good prognostic indicator among patients with acute AlP poisoning requiring ICU admission.

Ischemic Preconditioning Augments Survival of Stem Cells via miR-210 Expression by Targeting Caspase-8-associated Protein 2

MicroRNAs (miRs) participate in most cellular functions by posttranscriptional regulation of gene expression albeit with little information regarding their role in ischemic preconditioning (IP) of stem cells. We report that IP of bone marrow-derived mesenchymal stem cells (MSCs) with two cycles of 30-min ischemia/reoxygenation (I/R) supported their survival under subsequent longer exposure to anoxia and following engraftment in the infarcted heart. IP significantly reduced apoptosis in MSCs through activation of Akt (Ser(473)) and ERK1/2 (Thr(202)/Tyr(204)) and nuclear translocation of hypoxia-inducible factor-1alpha (HIF-1alpha). We observed concomitant induction of miR-210 in the preconditioned MSCs ((PC)MSCs). Inhibition of HIF-1alpha or of miR-210 abrogated the cytoprotective effects of preconditioning. Extrapolation of these data to in vivo studies in a rat model of acute myocardial infarction predominantly improved stem cell survival after engraftment with a role for miR-210. Notably, multiple I/R cycles more effectively regulated the miR-210 and hence promoted MSC survival compared with single-cycle hypoxia of an equal duration. Real time PCR array for rat apoptotic genes, computational target gene analyses, and luciferase reporter assay identified FLICE-associated huge protein (FLASH)/caspase-8-associated protein-2 (Casp8ap2) in (PC)MSCs as the target gene of miR-210. Induction of FLASH/CASP8AP2 in miR-210 knocked-down (PC)MSCs resulted in increased cell apoptosis. Taken together, these data demonstrated that cytoprotection afforded by IP was regulated by miR-210 induction via FLASH/Casp8ap2 suppression. These results highlighted that IP by multiple short episodes of I/R is a novel strategy to promote stem cell survival.

Stabilisation of critically ill children at the district general hospital prior to intensive care retrieval: a snapshot of current practice

ObjectiveTo describe current practice during stabilisation of children presenting with critical illness to the district general hospital (DGH), preceding retrieval to intensive care.DesignObservational study using prospectively collected transport data.SettingA centralised...

The ART of caring for patients with HIV infection in the ICU

The ART of caring for patients with HIV infection in the ICU

Comparison between central venous oxygen saturation and tissue oxygenation and perfusion: a case report

Comparison between central venous oxygen saturation and tissue oxygenation and perfusion: a case report

Role of noninvasive ventilation in weaning from mechanical ventilation in patients of chronic obstructive pulmonary disease: an Indian experience.

Background:Endotracheal intubation and mechanical ventilation (MV) are often needed in patients of chronic obstructive pulmonary disease (COPD) with acute hypercapnic respiratory failure. The rate of weaning failure is high and prolonged MV increases intubation associated complications.Objective:To evaluate the role of Noninvasive ventilation (NIV) in weaning patients of chronic obstructive pulmonary disease (COPD) from MV, after T piece trial failure.Design:A prospective, randomized, controlled study was conducted in a tertiary care centre. 30 patients of acute exacerbation of COPD with acute on chronic hypercapnic respiratory failure, who were mechanically ventilated, were included in the study A T-piece weaning trial was attempted once the patients achieved satisfactory clinical and biochemical parameters. After T-piece failure, defined as pH < 7.35, PaCO2 >50 mmHg, PaO2 <50 mmHg, HR >100/min, RR >35, patients were randomized to receive either NIV or PSV.Results:Demography, severity of disease and clinical profiles were similar in both groups. No significant difference between the two groups in duration of MV (6.20 ± 5.20 days vs. 7.47 ± 6.38 days, P > 0.05), duration of weaning (35.17 ± 16.98 and 47.05 ± 20.98 hours, P > 0.05) or duration of ICU stay (8.47 ± 4.79 and 10.80 ± 5.28 days, P > 0.05) in Gp I and Gp II, respectively. Five patients developed VAP in the PSV group, where as only one patient had pneumonia in the NIV group. Lesser number of deaths in the NIV group at discharge from ICU (3 vs. 5 patients, respectively) and at 30 days (5 vs. 9 patients, respectively), it did not achieve statistical significance (P > 0.05).Conclusion:NIV is as useful as PSV in weaning and can be better in weaning failure especially in COPD for earlier weaning, decrease ICU stay, complications and mortality.

Fibroscopy in patients with hypoxemic respiratory insufficiency: Utility of the high-flow nasal cannula

We report the first case of a patient with severe acute respiratory failure who underwent fibrobronchoscopy with oxygen administration provided by high-flow nasal cannula. We present the case of a patient with severe myasthenia gravis who was admitted to the Department of Intensive Care Medicine of our hospital with severe acute respiratory failure. The muscle weakness inherent to the patient's underlying condition made expectoration of respiratory secretions difficult and led to the development of bilateral atelectasis. Non-invasive mechanical ventilation sessions were established, but there was no significant clinical improvement; hence, oxygen administration by humidified high-flow nasal cannula (Optiflow™, Fisher & Paykel, New Zealand) was decided. The patient experienced a subjective improvement, a decrease in respiratory rate, and an improvement in oxygenation, which, following appropriate premedication, allowed diagnostic–therapeutic bronchoscopy to be performed at bedside, without requiring endotracheal intubation or mechanical ventilation for the procedure. The improvement experienced by the patient with high-flow nasal cannula, following appropriate premedication, allowed diagnostic–therapeutic bronchoscopy to be performed.

Fulminant Unilateral Pulmonary Edema After Insertion of a Chest Tube

The insertion of a chest tube in cases of large pleural effusion or spontaneous pneumothorax is a common surgical procedure often performed by a physician in training under the supervision of a senior physician. The authors report the case of a 35-year-old man with a persistent, complete spontaneous pneumothorax of approximately 30 hours' duration. Within 90 minutes after insertion of a chest tube, he developed severe unilateral pulmonary edema and required mechanical ventilation. FINDINGS AND CLINICAL COURSE: Computerized tomography revealed severe, unilateral pulmonary edema referred to as re-expansion pulmonary edema. After emergency endotracheal intubation and mechanical ventilation with continuous positive airway pressure, the pulmonary edema resolved completely and the patient recovered. Re-expansion edema is a rare, potentially life-threatening complication of the drainage of a spontaneous pneumothorax. With early recognition and timely treatment, complete resolution can be achieved. Risk factors include rapid re-expansion of the lung, young patient age, and a large pneumothorax persisting longer than 24 hours. If these risk factors are present, the chest tube should be inserted without primary suction. Doing so allows the lung to re-expand more slowly and may prevent this severe complication.

Intravenous Ketamine in a Dissociating Dose as a Temporizing Measure to Avoid Mechanical Ventilation in Adult Patient with Severe Asthma Exacerbation

Background: Patients experiencing severe asthma exacerbations occasionally deteriorate to respiratory failure requiring endotracheal intubation and mechanical ventilation. Mechanical ventilation in this setting exposes the patients to substantial iatrogenic risk and should be avoided if at all possible. Objectives: To describe the use of intravenous ketamine in acute asthma exacerbation. Case Report: We present a case of severe asthma exacerbation in an adult female patient who failed to improve with standard therapies, but promptly improved with the administration of intravenous ketamine (0.75 mg/kg i.v. bolus followed by continuous drip of 0.15 mg/kg/h). Summary: This case suggests that intravenous ketamine given in a dissociative dose may be an effective temporizing measure to avoid mechanical ventilation in adult patients with severe asthma exacerbations.

Noninvasive ventilation for acute respiratory failure after lung resection: an observational study

A single prospective randomized study found that, in selected patients with acute respiratory failure (ARF) following lung resection, noninvasive ventilation (NIV) decreases the need for endotracheal mechanical ventilation and improves clinical outcome. We prospectively evaluated early NIV use for ARF after lung resection during a 4-year period in the setting of a medical and a surgical ICU of a university hospital. We documented demographics, initial clinical characteristics and clinical outcomes. NIV failure was defined as the need for tracheal intubation. Among 690 patients at risk of severe complications following lung resection, 113 (16.3%) experienced ARF, which was initially supported by NIV in 89 (78.7%), including 59 with hypoxemic ARF (66.3%) and 30 with hypercapnic ARF (33.7%). The overall success rate of NIV was 85.3% (76/89). In-ICU mortality was 6.7% (6/89). The mortality rate following NIV failure was 46.1%. Predictive factors of NIV failure in univariate analysis were age (P = 0.046), previous cardiac comorbidities (P = 0.0075), postoperative pneumonia (P = 0.0016), admission in the surgical ICU (P = 0.034), no initial response to NIV (P < 0.0001) and occurrence of noninfectious complications (P = 0.037). Only two independent factors were significantly associated with NIV failure in multivariate analysis: cardiac comorbidities (odds ratio, 11.5; 95% confidence interval, 1.9-68.3; P = 0.007) and no initial response to NIV (odds ratio, 117.6; 95% confidence interval, 10.6-1305.8; P = 0.0001). This prospective survey confirms the feasibility and efficacy of NIV in ARF following lung resection.

Champ 5. Procédures de sécurisation au cours de la ventilation mécanique invasive

Invasive or endotracheal mechanical ventilation can lead to numerous complications likely to burden morbidity and mortality of patients in the intensive care unit. Various safety practices for mechanical ventilation may involve intubation, the mechanical ventilation period, weaning and extubation, the use of tracheostomy as well as non-invasive ventilation. The main objective of safety practices described in this chapter is to prevent or avoid the main risks due to invasive mechanical ventilation.

Successful use of short‐term mechanical ventilation to manage respiratory failure secondary to profound hypokalemia in a cat with hyperaldosteronism

AbstractObjective – To report successful management of respiratory failure due to severe hypokalemia in a cat with hyperaldosteronism, including short‐term mechanical ventilation strategies and aspects of medical and surgical treatment.Case Summary – A cat presented with bilateral pelvic limb weakness that rapidly progressed to tetraparesis and respiratory muscle failure. Point‐of‐care testing revealed severe hypokalemia (1.9 mmol/L) and mild azotemia. Initial management included endotracheal intubation, mechanical ventilation, and aggressive potassium supplementation. Spironolactone was started due to a high index of suspicion for hyperaldosteronism. A right adrenal mass visualized during abdominal ultrasonographic examination and a serum aldosterone level greater than 3329 pmol/L confirmed the diagnosis. The cat made a full recovery following surgical removal of a right adrenal adenoma.New or Unique Information Provided – We report successful management of respiratory failure in a cat with hyperaldosteronism using short‐term mechanical ventilation. Respiratory failure due to severe hypokalemia should be considered a complication of hyperaldosteronism in cats and may require mechanical ventilation. However, full recovery is possible.

Acute Bacterial Parotitis Following Acute Stroke

Acute bacterial parotitis (ABP) is a relatively uncommon condition that tends to occur in debilitated older patients. We report a case of an older woman that presented with an acute intracerebral hemorrhage who developed ABP. This morbidity led to endotracheal intubation, mechanical ventilation, tracheostomy and gastrostomy, all of which were not initially needed. We discuss the proposed physiopathology and etiopathogenesis of ABP in adults.

Neonatal Respiratory Failure: A 12-Month Clinical Epidemiologic Study From 2004 to 2005 in China

In the past decade, neonatal special care services in China have been established, during which time various therapies for neonatal respiratory failure have been introduced. The objective of this study was to investigate the incidence, management, outcome, and cost of neonatal respiratory failure treated by mechanical ventilation in 23 tertiary NICUs of major hospitals in southeastern and midwestern China. Data were collected over 12 consecutive months from 2004 to 2005 for neonates with neonatal respiratory failure. Eligible infants were those who required endotracheal intubation and mechanical ventilation and/or nasal continuous positive airway pressure for at least 24 hours and infants who died within 24 hours of ventilation during their first 7 days of life. Data characterized demographics, antenatal and perinatal history, illness severity score, primary disease, respiratory care, complications, survival, and clinical burden. From a total of 13,070 NICU admissions, there were 1722 (13.2%) cases of neonatal respiratory failure with respiratory distress syndrome, pneumonia/sepsis, and meconium aspiration syndrome as major causes. For infants who survived until discharge, the median length of ventilation was 70 hours. Overall, in-hospital mortality for neonatal respiratory failure was 32.1%. Logistic regressions showed that lower gestational age, vaginal delivery, fetal distress before delivery, presence of a major anomaly, and high severity score in preterm infants were associated with an increased risk for death. In term and postterm infants, only the presence of a major anomaly and a high severity score were significant risk factors for death. Mean length and cost of stay in hospital were 19.2 +/- 14.6 days and 14,966 +/- 13,465 Yuan in the survivors. Neonatal respiratory failure in the NICU of the provincial cities of China has high mortality and cost that are linked to geographic variability, a male predominance, and low proportion of very preterm infants, characteristic of sociocultural confounding background.

Electroencephalography burst suppression in a patient with dengue encephalopathy: A case report

Objective To report a rare case of dengue fever presenting with reversible encephalopathy and burst suppression in the EEG. Methods We describe an 85-year-old man with dengue encephalopathy and EEG burst suppression and review the related literature. Results The patient presented with an acute comatose state and absent brainstem reflexes. Blood pressure, pulse rate, temperature and oxygen saturation were 94/49 mmHg, 82 beats/min, 34.7 °C, and 83% respectively. Thrombocytopenia and skin rash were found initially. Oxygen saturation was 100% immediately after endotracheal intubation and mechanical ventilation. On the second day he remained comatose with EEG burst suppression but blood pressure and temperature were within normal limits. He regained consciousness and was alert on the 12th day and there was normalization of EEG and thrombocytopenia. Conclusions Patients with dengue fever may present as encephalopathy with EEG burst suppression. Significance EEG burst suppression does not necessarily suggest a poor prognosis in patients with dengue fever.

気管内挿管下にＯＫ‐４３２硬化療法を行った乳児嚢胞状リンパ管腫

Cystic lymphangiomas are congenital malformations of the lymphatic system, such as benign tumors that may be seen in the neck of infants. Surgical therapy entails risk of complications, depending on the location and extent of the tumor. Therefore, alternative treatments such as sclerotherapy with OK-432, have been developed. We report here a case of cystic lymphangioma treated by ultrasonography (US)-guided percutaneous aspiration and intraregional injection of OK-432 under general anesthesia. The difficulty in this case was the location of the tumor, which contacted the trachea. If OK-432 were to induce an inflammatory response in the trachea, it could lead to tracheal stenosis and respiratory disturbances. Therefore, this case required endotracheal Intubation and mechanical ventilation after injection therapy for three days. OK-432 sclerotherapy is an effective treatment for cystic lymphangiomas in infants, and should be considered before surgical excision.

Noninvasive Ventilation in Myasthenic Crisis

Myasthenic crisis (MC) is often associated with prolonged intubation and with respiratory complications. To assess predictors of ventilation duration and to compare the effectiveness of endotracheal intubation and mechanical ventilation (ET-MV) with bilevel positive airway pressure (BiPAP) noninvasive ventilation in MC. Retrospective cohort study. Academic research. Patients We reviewed consecutive episodes of MC treated at the Mayo Clinic, Rochester, Minnesota. Collected information included patients' demographic data, immunotherapy, medical complications, mechanical ventilation duration, and hospital lengths of stay, as well as baseline and preventilation measurements of forced vital capacity, maximal inspiratory and expiratory pressures, and arterial blood gases. We identified 60 episodes of MC in 52 patients. BiPAP was the initial method of ventilatory support in 24 episodes and ET-MV was performed in 36 episodes. There were no differences in patient demographics or in baseline respiratory variables and arterial gases between the groups of episodes initially treated using BiPAP vs ET-MV. In 14 episodes treated using BiPAP, intubation was avoided. The mean duration of BiPAP in these patients was 4.3 days. The only predictor of BiPAP failure (ie, requirement for intubation) was a Pco(2) level exceeding 45 mm Hg on BiPAP initiation (P= .04). The mean ventilation duration was 10.4 days. Longer ventilation duration was associated with intubation (P= .02), atelectasis (P< .005), and lower maximal expiratory pressure on arrival (P= .02). The intensive care unit and hospital lengths of stay statistically significantly increased with ventilation duration (P< .001 for both). The only variable associated with decreased ventilation duration was initial BiPAP treatment (P< .007). BiPAP is effective for the treatment of acute respiratory failure in patients with myasthenia gravis. A BiPAP trial before the development of hypercapnia can prevent intubation and prolonged ventilation, reducing pulmonary complications and lengths of intensive care unit and hospital stay.

Barotrauma Not Related to Type of Positive Pressure Ventilation During Severe Asthma Exacerbations in Children

Background: Children with impending respiratory failure due to severe asthma may be treated with endotracheal intubation and mechanical ventilation. Barotrauma occurs in a significant number of these children. Non-invasive positive pressure ventilation (NPPV) has been used as an alternative intermediary therapy and potentially prevents intubation. However, the comparative risk of barotrauma associated with the use of NPPV has not been evaluated in this population. Objective: To determine if the mode of positive pressure delivery per se affects the likelihood of development of barotrauma. Methods: We retrospectively examined data from all children older than 2 years of age admitted to the Intensive Care Unit (ICU) with an asthma exacerbation between April 1997 and August 2006. Results: Of the 293 children admitted to the ICU with asthma, 45 (17%) received treatment with positive pressure ventilation: 11 received only NPPV, 29 were intubated and mechanically ventilated, and 7 children received both of these therapies. Compared with those not requiring positive pressure, children receiving positive pressure were significantly more likely to develop barotrauma during hospitalization (OR 8.9; 95% CI 2.4–32.7). However, the incidence of barotrauma did not significantly differ according to the mode of positive pressure delivery: 9% in those who received only NPPV, 14% in those who were intubated, and 14% in those who received both therapies (p = 0.92). Conclusions: The use of positive pressure is associated with an increased risk of barotrauma in children with asthma, regardless of the mode of delivery.

Measuring the Cost-Effectiveness of Technologic Change in the Treatment of Pediatric Traumatic Brain Injury

Substantial variation exists with respect to the management of traumatic brain injuries (TBI) in children. Centers that practice aggressive treatment of TBI may improve survival, but it is not clear that the outcomes can be justified using cost-effectiveness criteria. This study illustrates the use of cost-effectiveness analysis to assess interventions for improving outcomes in children by assessing the cost per quality-adjusted life year (QALY) gained from technological change in the treatment of TBI. Cost and survival data associated with technological change in the treatment of pediatric TBI was based on nationally representative hospital administrative data for all children <21 years with a TBI who required endotracheal intubation or mechanical ventilation. With QALYs of pediatric TBI survivors based on life expectancies ranging between 5 and 30 years and on an estimated preference score of approximately 0.5, the estimated incremental cost-effectiveness ratio ranges between $19,000 and $109,000 per QALY gained. Adding estimated rehabilitation costs increases the cost-effectiveness ratio to between $57,000 and $244,000 per QALY. Sensitivity analysis indicates that estimates of life years gained are critical to the estimated ratio. If TBI survivors live more than 5 years, then the estimated cost-effectiveness ratio seems favorable.

Early continuous positive airway pressure in acute cardiogenic pulmonary oedema

Acute heart failure (AHF) syndromes are the most frequent cause of urgent consultation in patients with heart disease.1 In nearly 20% of cases the clinical presentation is acute pulmonary oedema.2 Although the diagnostic criteria of this syndrome have not been universally established, it is frequently defined by the sudden onset of severe dyspnoea and the presence of typical signs on physical examination, alveolar oedema on chest radiograph, and signs of acute respiratory failure. The latter is essential for the diagnosis. Consequently, different forms of AHF presenting with acute respiratory failure, such as hypertensive AHF,3 hypertensive pulmonary oedema,4 flash pulmonary oedema,1,5 and pulmonary oedema without hypertension or associated with acute coronary syndromes,1 may also be considered as acute pulmonary oedema. Approximately half of the patients with acute pulmonary oedema show hypercapnia on admission. Together with severe acidosis and systemic arterial hypotension, this constitutes the main risk parameter for failure of medical treatment and the subsequent need for endotracheal intubation and mechanical ventilation.6 Until the early 1990s, the percentage of patients requiring these procedures was ∼10–25%.7–9 However, several studies have since shown a decrease in the intubation rate as a result of the use of non-invasive ventilation (NIV). This technique delivers ventilatory support, generally applied via a face mask, without the need for an invasive … *Corresponding author. Tel: +34 93 5072700; fax: +34 93 4367131. E-mail address : jmasip{at}ub.edu