Intubation For Acute Respiratory Failure Research Articles

A pediatric case of Chlamydia psittaci caused severe Acute Respiratory Distress Syndrome (ARDS) in Italy

BackgroundThis case of psittacosis in children, is the first described in literature, in Italy. This respiratory infection can be transmitted to humans from the inhalation of respiratory secretions, feces and plumage aerosol of infected birds (and other animals). Usually it can have an asymptomatic or paucisymptomatic course, and the onset is often flu-like, but in this case the child risked his life for a severe respiratory failure. This report is unique because in children psittacosis is rare, and always misdiagnosed, or could cause a delayed diagnosis because of lack of awareness among the paediatricians and physicians. Furthermore, psittacosis enters a differential diagnosis with SARS-COV2 infection because both diseases may determine dyspnea and atypical pneumonia, up to acute respiratory failure.Case presentationThis clinical case talks about a three-and-a-half-year-old male child affected by psittacosis (or ornithosis), with severe dyspnea and systemic symptoms who required oro-tracheal intubation for acute respiratory failure. The child had slept in a room at home, with some recently bought parrots affected by psittacosis. Initially the child was treated with empiric antibiotic therapy (i.v.ceftriaxone and teicoplanin), but after having isolated the DNA of the germ “Chlamydia psittaci” in both serological and through bronchoalveolar lavage (BAL), he was treated with targeted antibiotic therapy: tetracyclines (doxicillin).ConclusionsPsittacosis is an extremely contagious disease, caused by an intracellular germ, called “Chlamydia psittaci”, a Gram-negative bacterium, transmitted to humans in particular by infected birds, responsible for atypical pneumonia, with acute and chronic respiratory symptoms, sometimes with multi-organ failure and disseminated intravascular coagulation. Even if it is a rare respiratory disease among children, a good doctor must think about psittacosis as cause of respiratory symptoms (and not only flu or SARS-COV2), above all through a correct medical history, in order to provide a targeted antibiotic therapy. An interesting case of psittacosis in a child is being reported here, which has been treated successfully with doxycillin.

Nursing management of the enteral nutrition for a patient with endotracheal intubation for acute respiratory failure complicated with severe pneumonia

Nursing management of the enteral nutrition for a patient with endotracheal intubation for acute respiratory failure complicated with severe pneumonia

ODP470 Compressive Goiter with COVID-19: An Unusual Etiology of Respiratory Distress Requiring Endotracheal Intubation with Surgical Resection

Abstract Introduction Gradual enlargement of multinodular goiter (MNG) may compress surrounding structures which may progressively cause complications of tracheal stenosis and airway compromise. Surgical resection remains the gold standard treatment in MNG patients presenting with respiratory distress. In the current global COVID -19 pandemic, compressive goiter should be a differential diagnosis in patients with stable benign thyroid goiter presenting with dyspnea. We present a case of MNG with life threatening airway obstruction during an active COVID-19 infection. Case presentation A 74-year-old female with a history of hyperthyroidism with multi-nodular goiter and recurrent atrial fibrillation status-post ablation, was transferred to the intensive care unit for treatment after being intubated for respiratory distress at a nearby hospital. She was diagnosed with hyperthyroidism about 40 years ago and managed with methimazole. Over the last two years, thyroid ultrasound and prior imaging showed MNG with patent but moderate tracheal narrowing; fine-needle aspiration (FNA) confirmed benign colloid nodules with cystic degeneration. She was pending cardiac clearance for surgery when symptoms acutely worsened two days before admission. On initial assessment, she was hemodynamically stable, afebrile, with oxygen saturation of 86% on room air. She was alert and able to follow commands. On physical examination, she had stridor and thyromegaly was evident with mild tenderness on palpation. Cardiopulmonary examination was remarkable for coarse breath sounds. Labs showed TSH 4.82 (Normal 0.3 - 4.5 ulU/mL), FT4 0.64 (Normal 0.5- 1.26 ng/dL). Respiratory panel test came back positive for SARS-CoV-2. Racemic epinephrine and albuterol nebulizers were administered to help with her symptoms. CT scan of the neck revealed a severe narrowing and mild rightward shift of the trachea by a large multinodular goiter, prompting the decision to intubate for airway protection. CT scan of the chest with contrast demonstrated the large MNG with tracheal stenosis. Her methimazole dose was adjusted. After cardiac clearance, she underwent thyroidectomy through a transcervical approach. Levothyroxine and calcium supplementation were started post-surgery. She was extubated two days after her thyroidectomy. Pathology results showed no evidence of malignancy. Discussion Acute airway obstruction by large MNG requiring emergent airway protection is rare. Typically airway compromise from large otherwise stable benign goiters results from sudden hemorrhage into a cyst, upper respiratory tract infection leading to tracheal edema, or worseningcomorbid conditions. During the COVID-19 pandemic, acute respiratory failure and shortness of breath is typical of worsening disease course. This case highlights the importance of maintaining wider differentials of respiratory failure even and we need to consider worsening of tracheal narrowing with a large goiter due to tracheal edema from SARS- CoV-2 Infection. Thyroidectomy before SARS-CoV-2 infection may have reduced her need for emergent intubation for acute respiratory failure by improving pre existing airway compression. Presentation: No date and time listed

Early Measurement of ROX Index in Intermediary Care Unit Is Associated with Mortality in Intubated COVID-19 Patients: A Retrospective Study.

COVID-19 patients often present with rapidly progressing acute hypoxemic respiratory failure, requiring orotracheal intubation with different prognostic issues. However, ICU specialists lack predictive tools to stratify these patients. We conducted a single-center cross-sectional retrospective study to evaluate if the ROX index, measured under non-invasive oxygenation support, can predict ICU mortality in a COVID-19 intubated patient cohort. This study took place in the division of intensive care at the Geneva University Hospitals (Geneva, Switzerland). We included all consecutive adult patients treated by non-invasive oxygenation support and requiring intubation for acute respiratory failure due to COVID-19 between 9 September 2020 and 30 March 2021, corresponding to the second local surge of COVID-19 cases. Baseline demographic data, comorbidities, median ROX between H0 and H8, and clinical outcomes were collected. Overall, 82 patients were intubated after failing a non-invasive oxygenation procedure. Women represented 25.6% of the whole cohort. Median age and median BMI were 70 (60–75) years and 28 (25–33), respectively. Before intubation, the median ROX between H0 and H8 was 6.3 (5.0–8.2). In a multivariate analysis, the median ROX H0–H8 was associated with ICU mortality as a protective factor with an odds ratio (95% CI) = 0.77 (0.60–0.99); p < 0.05. In intubated COVID-19 patients treated initially by non-invasive oxygenation support for acute respiratory failure, the median ROX H0–H8 could be an interesting predictive factor associated with ICU mortality.

A CASE OF MYASTHENIA GRAVIS ASSOCIATED WITH APLASTIC ANEMIA

SESSION TITLE: Fellows Critical Care Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Aplastic anemia is an uncommon complication of thymoma. We report a rare case of Myasthenia Gravis with thymoma, concomitant aplastic anemia and primary hyperparathyroidism. CASE PRESENTATION: 68-year-old male presented with back pain and cough, was found to have pancytopenia and an anterior mediastinal mass. Work up was notable for leukopenia of 1.7 K/uL, absolute neutrophil count of 510 K/uL, platelets of 54 k/uL and hemoglobin of 7.6 g/dL. Chest imaging showed an anterior mediastinal soft tissue mass and left para-aortic lymph nodes (Figure 1). On day 2, he required intubation for acute respiratory failure. A bone marrow biopsy revealed hypoplastic bone marrow consistent with aplastic anemia (AA). He then underwent a percutaneous biopsy of the mediastinal mass which confirmed a thymoma. His hospital course was complicated by Staphylococcus aureus bacteremia, new onset atrial fibrillation and ischemic stroke as well as bilateral upper extremity venous thromboemboli. He was started on Filgrastim and Romiplostim His hematological clinical picture was most consistent with aplastic anemia with a component of bone marrow suppression from sepsis contributing to pancytopenia. He was transfusion dependent given refractory anemia and thrombocytopenia. Further work up revealed primary hyperparathyroidism. A positive acetylcholinesterase (5.30 nmol/L) was consistent with myasthenia gravis (MG). He was started on intravenous immunoglobulin for 5 days. He underwent tracheostomy placement on day 21. He was started on prednisone and pyridostigmine and was then evaluated for thymoma resection by cardiothoracic surgery. DISCUSSION: Myasthenia gravis (MG) is an autoimmune disorder characterized by weakness of skeletal muscles, caused by an antibody-mediated attack against the acetylcholine receptor antibody. AA usually precedes the diagnosis of thymoma which is associated with autoimmune disorders, including MG, polymyositis, hypogammaglobulinemia, agranulocytosis, pure red cell aplasia, and AA (1). Our patient was noted to have primary hyperparathyroidism in association with MG with thymoma with concomitant aplastic anemia which is extremely rare (2). MG appears in about 20–40% of patients with thymoma (3). AA is a result of bone marrow failure characterized by hypocellular marrow and peripheral pancytopenia; and is an uncommon complication of thymoma. AA is thought to be an autoimmune manifestation of thymoma as a result of bone marrow suppression in the setting of unbalanced T cell regulation represented by an inverted CD4+ /CD8+ ratio or an increase in cytotoxic and suppressive cells (4). CONCLUSIONS: To the best of our knowledge, this is the first report of a patient with concomitant primary hyperparathyroidism, myasthenia gravis (MG), and aplastic anemia (AA). This case raises awareness of this rare association in order to recognize patients who have this constellation of clinical presentations Reference #1: Mitsumune S, Manabe Y, Yunoki T, et al. Autologous Bone marrow Transplantation for Polymyositis Combined with Myasthenia gravis and aplastic anemia: a case report. Case Rep Neurol. 2018;10(1):108–111. Reference #2: Hong S, Hyeok Cho D, Kang HC, Chung DJ et al. A case of myasthenia gravis associated with primary hyperparathyroidism. Korean J Med 2006. 71:S1039-S1043 Reference #3: Mizobuchi S, Yamashiro T, Nonami Y et al. Pure red cell aplasia and myasthenia gravis with thymoma: A case report and review of the literature. Japanese Journal of Clinical Oncology, 1998, 28(11): 696–701 DISCLOSURES: No relevant relationships by Nasheena Jiwa, source=Web Response no disclosure on file for Asher Qureshi

One-year survival in acute stroke patients requiring mechanical ventilation: a multicenter cohort study

BackgroundMost prognostic studies in acute stroke patients requiring invasive mechanical ventilation are outdated and have limitations such as single-center retrospective designs. We aimed to study the association of ICU admission factors, including the reason for intubation, with 1-year survival of acute stroke patients requiring mechanical ventilation.MethodsWe conducted a secondary data use analysis of a prospective multicenter database (14 ICUs) between 1997 and 2016 on consecutive ICU stroke patients requiring mechanical ventilation at admission. We excluded patients with stroke of traumatic origin, subdural hematoma or cerebral venous thrombosis. The primary outcome was survival 1 year after ICU admission. Factors associated with the primary outcome were identified using a multivariable Cox model stratified on inclusion center.ResultsWe identified 419 patients (age 68 [58–76] years, males 60%) with a Glasgow coma score (GCS) of 4 [3–8] at admission. Stroke subtypes were acute ischemic stroke (AIS, 46%), intracranial hemorrhage (ICH, 42%) and subarachnoid hemorrhage (SAH, 12%). At 1 year, 96 (23%) patients were alive. Factors independently associated with decreased 1-year survival were ICH and SAH stroke subtypes, a lower GCS score at admission, a higher non-neurological SOFA score. Conversely, patients receiving acute-phase therapy had improved 1-year survival. Intubation for acute respiratory failure or coma was associated with comparable survival hazard ratios, whereas intubation for seizure was not associated with a worse prognosis than for elective procedure. Survival did not improve over the study period, but patients included in the most recent period had more comorbidities and presented higher severity scores at admission.ConclusionsIn acute stroke patients requiring mechanical ventilation, the reason for intubation and the opportunity to receive acute-phase stroke therapy were independently associated with 1-year survival. These variables could assist in the decision process regarding the initiation of mechanical ventilation in acute stroke patients.

Timing of Intubation in Acute Respiratory Failure Associated With Sepsis: A Mixed Methods Study

ObjectiveTo analyze bedside clinicians' perspectives regarding the decision process to optimize timing of intubation in sepsis-associated acute respiratory failure. Participants and MethodsThis mixed methods study was conducted from March 1, 2015, through June 30, 2016. Using qualitative research methods, factors that influenced variability in the decision to intubate were organized into categories and used to build a theoretical explanatory model grounded in current practice variance. All coding schemes were independently reviewed for accuracy and consistency. Themes and findings were then refined with member checking by feedback from individuals and from an anonymous questionnaire until saturation was achieved. ResultsThe practice of intubation varied according to 3 domains: (1) patient factors included the nature of the acute illness, comorbidities, clinical presentation, severity, trajectory, and values and preferences; (2) clinician factors included background, training, experience, and practice style; and (3) system factors included workload, policies and protocols, hierarchy, communications, culture, and team dynamics. In different contexts, intubation was considered early (elective), just in time (urgent), or late (rescue). The initial assessment, initial decision, and reassessment mattered. ConclusionRecognizing that the variability in both the decision to intubate and its timing depends on many factors, and not on clinical criteria alone, should render the clinician more attentive to the eventual progression of the acute respiratory failure.

The utility of the shock index in patients with acute respiratory failure

The shock index (heart rate divided by systolic blood pressure) reflects the overall cardiovascular status and is usually ≤ 0.7 heart beats per minute per mmHg. An increased shock index in patients undergoing emergent intubation for acute respiratory failure can identify patients who are at risk for post-intubation hypotension.

Wilkie’s Syndrome Causing Acute Gastric Necrosis

SESSION TITLE: Student/Resident Case Report Poster - Critical Care II SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Superior mesenteric artery (SMA) syndrome or Wilkie’s syndrome is compression of the third part of the duodenum between the SMA & abdominal aorta. This compression can lead to acute gastric dilation and necrosis of the stomach. SMA syndrome leading to acute gastric dilation is rare and necrosis of the stomach; an organ with extensive collateral blood supply can be fatal. CASE PRESENTATION: A 26-year-old male with a history of type I diabetes presented with vomiting and abdominal pain of 1 day. Exam was remarkable for BP of 93/60 mm Hg & HR of 106. Patient was cachectic & in distress, abdomen was distended with diffuse tenderness. Labs revealed Hb of 8, leucocytosis of 13000 and lactate of 3.6. IV fluid bolus & antibiotics were started. 6 hours later he had emesis of black fluid with development of shock requiring vasopressors, intubation for acute respiratory failure and intensive care. Abdominal X-ray showed a giant lucency, thought to be the distended stomach. NG tube inserted returned 2.4 liters of black fluid. CT abdomen showed a distended gastric & esophageal lumen with a transition point between the 2nd and 3rd part of duodenum. EGD showed deep ulcerations over the stomach and eschar formation. Upper GI series confirmed SMA syndrome. As patient continued to be in septic shock ,surgery was deferred. Explorative laparotomy done on Day 9 of admission, ended in total gastrectomy and esophago-jejunostomy & a feeding jejunostomy. Post procedure patient had a prolonged recovery. DISCUSSION: SMA syndrome occurs in hyper catabolic states such as malignancy, burns and anorexia nervosa. Acute gastric dilation results in sudden increase in intraluminal gastric pressure and gastric venous insufficiency causing gastric necrosis.1 SMA syndrome is initially treated conservatively with gastric decompression, correction of electrolytes & nutritional support.2 Surgical intervention is needed if there is no resolution or if signs of sepsis develop. In our patient the diagnosis and later the surgical intervention was delayed resulting in increased morbidity. CONCLUSIONS: As the presentation is often non-specific for the above-described entities a high index of suspicion & early abdominal imaging with a KUB, followed by a CT abdomen, if required is the key to diagnosis. Early diagnosis is imperative to prevent onset of necrosis & once identified, early surgical intervention can salvage viable bowel. Reference #1: Steen S, Lamont J, Petrey L. Acute gastric dilation and ischemia secondary to small bowel obstruction. Proc (Bayl Univ Med Cent). 2008 Jan;21(1):15-7. Reference #2: Merrett ND, Wilson RB, Cosman P, Biankin A V. Superior Mesenteric Artery Syndrome: Diagnosis and Treatment Strategies. J Gastrointest Surg. 2009 Feb 23;13(2):287-92. DISCLOSURE: The following authors have nothing to disclose: Nisha Ajit, Kovid Trivedi, Robert Walter No Product/Research Disclosure Information

New method of preoxygenation for orotracheal intubation in patients with hypoxaemic acute respiratory failure in the intensive care unit, non-invasive ventilation combined with apnoeic oxygenation by high flow nasal oxygen: the randomised OPTINIV study protocol

IntroductionTracheal intubation in the intensive care unit (ICU) is associated with severe life-threatening complications including severe hypoxaemia. Preoxygenation before intubation has been recommended in order to decrease such complications. Non-invasive...

Atrophy of Masticatory Muscles in TMD Patients

condition. The authors describe a case of two-month bilateral TMJ dislocation that occurred after intubation for acute respiratory failure, a six-month bilateral TMJ dislocation after a medication-related seizure, and a fivemonth right TMJ dislocation sustained during intubation after head trauma. Relevant radiographic findings are discussed. Management of chronic TMJ dislocation consists of an initial attempt at closed manual reduction of the joint, followed by progressively more invasive surgical procedures, including open reduction, eminectomy, coronoidectomy, condylectomy, or TMJ replacement. Longterm dysfunction can occur after reduction, leading to possible TMJ replacement. The cases described illustrate the importance of early recognition and treatment of TMJ dislocation. Failure to promptly identify and treat dislocation of the TMJ can lead to significant patient morbidity, increased difficulty in management, and long-term TMJ dysfunction.

Benefits of lung-protective ventilation: looking beyond the ICU.

Background Lung-protective ventilation with the use of low tidal volumes and positive end-expiratory pressure is considered best practice in the care of many critically ill patients. However, its role in anesthetized patients undergoing major surgery is not known. Methods Objective: The aim of the study was to determine whether lung-protective ventilation improves outcomes in anesthetized patients undergoing major abdominal surgery. Design: The Intraoperative Protective Ventilation (IMPROVE) trial is a multicenter, open-label double-blind, parallel-group randomized control trial in seven French university hospitals. Setting: The IMPROVE study enrolled 400 adults at intermediate to high risk of pulmonary complications undergoing major abdominal surgeries between 31 January 2011 and 10 August 2012. Intervention: Patients were randomly assigned to receive volume-controlled ventilation in one of two strategies: nonprotective ventilation with a tidal volume of 10 to 12 ml/kg predicted body weight with no positive end-expiratory pressure and no scheduled recruitment maneuver, or lung-protective ventilation with a tidal volume of 6 to 8 ml/kg predicted body weight, a positive end-expiratory pressure of 6 to 8 cmH2O, and recruitment maneuvers every 30 minutes after intubation. Recruitment maneuvers were also standardized and applied as continuous positive airway pressure of 30 cmH2O for 30 seconds. Outcomes: The primary outcome was a composite of major pulmonary and extrapulmonary complications within the first 7 days after surgery. Major pulmonary complications were defined as pneumonia or the need for invasive or noninvasive ventilation for acute respiratory failure. Major extrapulmonary complications were defined as sepsis, severe sepsis, septic shock, and death. Secondary outcomes included components of primary outcome, surgical complications, and healthcare utilization endpoints such as the duration of stay in the ICU and hospital at the end of a 30-day follow-up period. Results The two intervention groups had similar characteristics at baseline. In the intention-to-treat analysis, the primary outcome occurred in 21 of 200 patients (10.5%) assigned to lung-protective ventilation, as compared with 55 of 200 patients (27.5%) assigned to nonprotective ventilation (relative risk, 0.40; 95% confidence interval, 0.24 to 0.68; P = 0.001). Over the 7-day postoperative period, 10 patients (5.0%) assigned to lung-protective ventilation required noninvasive ventilation or intubation for acute respiratory failure, as compared with 34 patients (17.0%) assigned to nonprotective ventilation (relative risk, 0.29; 95% confidence interval, 0.14 to 0.61; P = 0.001). The length of the hospital stay was shorter among patients receiving lung-protective ventilation than among those receiving nonprotective ventilation (mean difference, −2.45 days; 95% confidence interval, 4.17 to −0.72; P = 0.006). Conclusions As compared with a practice of nonprotective mechanical ventilation, the use of a lung-protective ventilation strategy in intermediate-risk and high-risk patients undergoing major abdominal surgery was associated with improved clinical outcomes and reduced healthcare utilization.

A Trial of Intraoperative Low-Tidal-Volume Ventilation in Abdominal Surgery

The two intervention groups had similar characteristics at baseline. In the intention-to-treat analysis, the primary outcome occurred in 21 of 200 patients (10.5%) assigned to lung-protective ventilation, as compared with 55 of 200 (27.5%) assigned to nonprotective ventilation (relative risk, 0.40; 95% confidence interval [CI], 0.24 to 0.68; P = 0.001). Over the 7-day postoperative period, 10 patients (5.0%) assigned to lung-protective ventilation required noninvasive ventilation or intubation for acute respiratory failure, as compared with 34 (17.0%) assigned to nonprotective ventilation (relative risk, 0.29; 95% CI, 0.14 to 0.61; P = 0.001). The length of the hospital stay was shorter among patients receiving lung-protective ventilation than among those receiving nonprotective ventilation (mean difference, −2.45 days; 95% CI, −4.17 to −0.72; P = 0.006). CONCLUSIONS As compared with a practice of nonprotective mechanical ventilation, the use of a lung-protective ventilation strategy in intermediate-risk and high-risk patients undergoing major abdominal surgery was associated with improved clinical out comes and reduced health care utilization. (IMPROVE ClinicalTrials.gov number, NCT01282996.)

Anesthesia Literature Review

Anesthesia Literature Review

A Trial of Intraoperative Low-Tidal-Volume Ventilation in Abdominal Surgery

BackgroundLung-protective ventilation with the use of low tidal volumes and positive end-expiratory pressure is considered best practice in the care of many critically ill patients. However, its role in anesthetized patients undergoing major surgery is not known.MethodsIn this multicenter, double-blind, parallel-group trial, we randomly assigned 400 adults at intermediate to high risk of pulmonary complications after major abdominal surgery to either nonprotective mechanical ventilation or a strategy of lung-protective ventilation. The primary outcome was a composite of major pulmonary and extrapulmonary complications occurring within the first 7 days after surgery.ResultsThe two intervention groups had similar characteristics at baseline. In the intention-to-treat analysis, the primary outcome occurred in 21 of 200 patients (10.5%) assigned to lung-protective ventilation, as compared with 55 of 200 (27.5%) assigned to nonprotective ventilation (relative risk, 0.40; 95% confidence interval [CI], 0.24 to 0.68; P=0.001). Over the 7-day postoperative period, 10 patients (5.0%) assigned to lung-protective ventilation required noninvasive ventilation or intubation for acute respiratory failure, as compared with 34 (17.0%) assigned to nonprotective ventilation (relative risk, 0.29; 95% CI, 0.14 to 0.61; P=0.001). The length of the hospital stay was shorter among patients receiving lung-protective ventilation than among those receiving nonprotective ventilation (mean difference, −2.45 days; 95% CI, −4.17 to −0.72; P=0.006).ConclusionsAs compared with a practice of nonprotective mechanical ventilation, the use of a lung-protective ventilation strategy in intermediate-risk and high-risk patients undergoing major abdominal surgery was associated with improved clinical outcomes and reduced health care utilization. (IMPROVE ClinicalTrials.gov number, NCT01282996.)

The Rapid Shallow Breathing Index as a Predictor of Failure of Noninvasive Ventilation for Patients With Acute Respiratory Failure

Noninvasive ventilation (NIV) may reduce the need for intubation in acute respiratory failure (ARF). However, there is no standard method to predict success or failure with NIV. The rapid shallow breathing index (RSBI) is a validated tool for predicting readiness for extubation. We evaluated the ability of the RSBI to predict failure of NIV and mortality in ARF. Prospective, observational trial of patients with ARF treated with NIV. NIV was initiated at the discretion of the clinicians, and an RSBI was recorded on the initial level of support (designated as assisted RSBI [aRSBI]). Patients were categorized by initial aRSBI value as either high (aRSBI > 105) or low (aRSBI ≤ 105). The primary end point was need for intubation, and the secondary end point was in-hospital mortality. Patients in the low and high aRSBI groups were compared using univariate analysis, followed by multivariable logistic regression to determine the association between aRSBI groups and outcome. A total of 101 patients were included. The majority of patients had an inspiratory pressure of 5-10 cm H(2)O in addition to an expiratory pressure of 5-8 cm H(2)O. Of 83 patients with an aRSBI ≤ 105, 26 (31%) required intubation, compared to 10/18 (55%) with an aRSBI > 105 (multivariate odds ratio 3.70, 95% CI 1.14-11.99, P = .03). When comparing mortality, 7/83 patients (8.4%) with an aRSBI ≤ 105 died, compared to 6/18 (33%) patients in the group with an aRSBI > 105 (multivariate odds ratio 4.51, 95% CI 1.19-17.11, P = .03). An aRSBI of > 105 is associated with need for intubation and increased in-hospital mortality. Whether patients with an elevated aRSBI could also have benefitted from an increase in NIV settings remains unclear. Validation of this concept in a larger patient population is warranted.

Predictors of the complication of postintubation hypotension during emergency airway management

ObjectiveArterial hypotension is a recognized complication of emergency intubation that is independently associated with increased morbidity and mortality. Our aim was to identify factors associated with postintubation hypotension after emergency intubation. MethodsRetrospective cohort study of tracheal intubations performed in a large, urban emergency department over a 1-year period. Patients were included if they were older than 17 years and had no systolic blood pressure measurements below 90 mm Hg for 30 consecutive minutes before intubation. Patients were analyzed in 2 groups, those with postintubation hypotension (PIH), defined as any recorded systolic blood pressure less than 90 mm Hg within 60 minutes of intubation, and those with no PIH. Multiple logistic regression modeling was used to define predictors of PIH. ResultsA total 465 patients underwent emergency intubation during the study period, and 300 met inclusion criteria for this study. Postintubation hypotension occurred in 66 (22%) of 300 patients, and these patients experienced significantly higher in-hospital mortality (35% vs 20%; odds ratio [OR] 2.1; 95% confidence interval [CI], 1.2-3.9). Multiple logistic regression analysis demonstrated that preintubation shock index (SI), chronic renal disease, intubation for acute respiratory failure, and age were independently associated with PIH. Of these, SI was the most strongly associated factor (OR, 55; 95% CI, 13-232). Receiver operating characteristic plot showed optimized SI 0.8 or higher predicting PIH with 67% sensitivity and 80% specificity. Rapid sequence intubation paralysis was associated with a lower incidence of PIH (OR, 0.04; 95% CI, 0.003-0.4). ConclusionsPreintubation and peri-intubation factors predict the complication of PIH. Elevated SI strongly and independently forewarned of cardiovascular deterioration after emergency intubation with pre-RSI SI 0.8 or higher as the optimal threshold to identify patients at risk.

Prevention of extubation failure in high-risk patients with neuromuscular disease

BackgroundA substantial proportion of patients with neuromuscular disease (NMD) who undergo positive pressure ventilation via endotracheal intubation for acute respiratory failure fail to pass spontaneous breathing trials and should be considered at high risk for extubation failure. In our study, we prospectively investigated the efficacy of early application of noninvasive ventilation (NIV) combined with assisted coughing as an intervention aimed at preventing extubation failure in patients with NMD. MethodsThis study is a prospective analysis of the short-term outcomes of 10 patients with NMD who were treated by NIV and assisted coughing immediately after extubation and comparison with the outcomes of a population of 10 historical control patients who received standard medical therapy (SMT) alone. The participants were composed of 10 patients with NMD who were submitted to NIV and assisted coughing after extubation (group A) and 10 historical control patients who were administered SMT (group B), who were admitted to a 4-bed respiratory intensive care unit (RICU) in a university hospital. Need for reintubation despite treatment was evaluated. Mortality during RICU stay, need for tracheostomy, and length of stay in the RICU were also compared. ResultsSignificantly fewer patients who received the treatment protocol required reintubation and tracheostomy compared with those who received SMT (reintubation, 3 vs 10; tracheostomy, 3 vs 9; P = .002 and .01, respectively). Mortality did not differ significantly between the 2 groups. Patients in group A remained for a shorter time in the RICU compared with group B (7.8 ± 3.9 vs 23.8 ± 15.8 days; P = .006). ConclusionsPreventive application of NIV combined with assisted coughing after extubation provides a clinically important advantage to patients with NMD by averting the need for reintubation or tracheostomy and shortening their stay in the RICU; its use should be included in the routine approach to patients with NMD at high risk for postextubation respiratory failure.

Noninvasive Ventilation in Acute Exacerbation of Idiopathic Pulmonary Fibrosis

The outcome of acute exacerbation of idiopathic pulmonary fibrosis (AE-IPF) is usually very poor, and it has been suggested that mechanical ventilation does not benefit AE-IPF patients. Noninvasive ventilation (NIV) has attracted attention as a means to avoid intubation in acute respiratory failure, including acute respiratory distress syndrome (ARDS). This study describes the outcome of patients with AE-IPF who were treated with NIV. Patients included in the study were those who fulfilled the criteria for AE-IPF during the periods between April 1998 and June 2004 at Tosei General Hospital, and in whom NIV was introduced. Clinical data were obtained retrospectively from patient records. This study included 11 patients. The initial NIV settings were continuous positive airway pressure (CPAP) mode in 6 patients (mean 10.1+/-2.5 cmH(2)O) and Spontaneous/Timed mode in 5 (mean inspiratory positive airway pressure/expiratory positive airway pressure; 15.0+/-3.3/10.2+/-2.9 cmH(2)O). Five patients avoided intubation and survived more than 3 months after AE-IPF. Six patients who failed NIV died within 3 months. In these 6 patients, 4 required intubation. The other 2 patients, who refused endotracheal intubation, died without intubation. Median survival time and 3-month survivals after acute exacerbation were 30 days, and 45.5%, respectively. Considering extremely poor prognosis of AE-IPF, our findings suggest that NIV is a viable option for the respiratory management in AE-IPF, and should be studied in a large, well-controlled trial.

Early detection of type III procollagen peptide in acute lung injury. Pathogenetic and prognostic significance.

The fibroproliferative reaction to acute lung injury may limit restoration of normal lung function and increase mortality in patients with acute lung injury. A biologic marker of collagen synthesis in the lung may be useful for studying the pathogenesis of acute lung injury and for identifying patients with acute lung injury who are at high risk for death and might benefit from new therapeutic modalities. Using an immunoassay, type III procollagen NH2 terminal peptide was measured in the pulmonary edema fluid of 44 patients with either acute lung injury or hydrostatic pulmonary edema (control group) within the first 24 h after endotracheal intubation for acute respiratory failure. Patients with acute lung injury (n = 33) or hydrostatic edema (n = 11) had the same degree of lung dysfunction as measured by the severity of oxygenation defect, the level of positive end-expiratory pressure, the decrease in static lung compliance, and the extent of infiltrates on the chest radiograph. However, the median procollagen III level was 5-fold higher in the pulmonary edema fluid of patients with acute lung injury than in the patients with hydrostatic pulmonary edema (p = 0.0001). Of the 33 patients with acute lung injury, 21 patients died and 12 lived. Nonsurvivors had significantly higher procollagen III levels than did survivors (p = 0.05). The positive and negative predictive values for nonsurvival for a procollagen III level > or = 1.75 U/ml were 74 and 83%, respectively. The relative risk of dying in the presence of a procollagen III value > or = 1.75 U/ml was 4.5 (95% CI, 0.7 to 27). Collagen synthesis in the lung, as reflected by elevated levels of procollagen III in pulmonary edema fluid, begins within the first 24 h of acute lung injury concurrent with the acute phase of increased endothelial and epithelial permeability to protein. This evidence suggests that fibrosing alveolitis begins much earlier in the course of clinical acute lung injury than has previously been appreciated. In addition, the presence of an elevated level of procollagen III is an early predictor of poor outcome. Thus, elevation of procollagen III in pulmonary edema fluid may have both pathogenetic and prognostic significance in patients with acute lung injury.