Invasive Mechanical Ventilation Support Research Articles

EXPERIENCE OF THE HOME INVASIVE MECHANICAL VENTILATION PROGRAM IN THE KING FAISAL SPECIALIST HOSPITAL AND RESEARCH CENTER: A RETROSPECTIVE AUDIT

SESSION TITLE: Tuesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM PURPOSE: In countries with under developed home health care systems and varying practices around end-of-life, such as Saudi Arabia, home mechanical ventilation (HMV) remains scarcely utilized. A home mechanical ventilation program was started at King Faisal Specialist Hospital & Research Center (KFSH&RC) in 2008, this is a report our experience. METHODS: A retrospective audit of all patients enrolled in the KFSH&RC HMV program was carried out. Data is presented on all patients enrolled in the program from start in 2008 until end of 2018. We collected demographic identifiers, initial diagnosis, type of ventilatory support, number of emergency room (ER) visits and hospital admissions, and inpatients days. The results are presented as frequencies, proportions or rates. RESULTS: Since the establishment of the HMVP in mid-2008 and until the end of 2018, a total of 68 patients have been enrolled in the program. Of those 34 pts (50%) are male, 54 (79%) are adults (Age > 14 years). The most common reasons for instituting HMV were neuromuscular disease 25 patients (37%), followed by pulmonary disease 13 patients (22%), congenital syndromes 15 patients (22%). 22% (15 patients) had miscellaneous conditions including heart disease, pulmonary hypertension, etc. Types of ventilatory supports included nocturnal invasive mechanical ventilation in 13 pts (19%), and continuous invasive mechanical ventilatory support in the remaining 55 patients (81%). Median days of home mechanical ventilation were 871.50 (range 36 – 4020). There was a total of 313 ER visits, with 1.3 ER visits per patient - years. 13 patients (19%) had 0 ER visits, 36 patients (53%) had between 1-5 visits, 11 patients (16%) had 6-10 visits, and 8 patients (12%) had > 10 visits. There was a total of 155 hospitalizations with 0.64 admissions per patient – years. 19 patients (28%) had 0 hospital admissions, 43 patients (63%) had between 1-5 admissions, 5 patients (7%) had 6-10 admissions, and 1 patient (1%) had > 10 visits. Median length of hospitalization was 15 days (range 0 – 1958). The cumulative total number of the HMVP days is 87878 days (240.76 years), of those, the total cumulative number of the hospital admissions while enrolled in HMVP was 6239 days. Accordingly, days of ICU saved during the study period were 81639 days. CONCLUSIONS: The HMV program in KFSH&RC was able to successfully manage mechanically ventilated patients at their home environment, with significantly limited ER visits and hospital admission. CLINICAL IMPLICATIONS: Home mechanical ventilation programs can be very successful in countries with limited domiciliary supportive medical care, such as Saudi Arabia, with significant cost saving and decrease of inpatient ICU days. DISCLOSURES: No relevant relationships by Mohammed Albaqami, source=Web Response No relevant relationships by Eiad Kseibi, source=Web Response

Approach to the Patient with Acute Respiratory Failure

Acute respiratory failure (ARF) is a common reason for admission to the intensive care unit (ICU), and is associated with significant morbidity and mortality. Failure of one or more components of the respiratory system can lead to hypoxemia, hypercabia, or both. Initial evaluation of patients with ARF should include physical examination, chest imaging, and arterial blood gases (ABG) sampling. As ARF is often a life-threatening emergency, a patient’s oxygenation and ventilation will need to be supported at the same time that diagnostic and therapeutic interventions are planned. The priorities for early treatment are essentially those of basic life support: airway and breathing. The first step is to assess a patient’s airway and ascertain that it is patent. This is followed by efforts to support both oxygenation and ventilation. This can include non-invasive or invasive mechanical ventilatory support. As with all interventions, there are risks inherent in the use of mechanical ventilation, which may be minimized by the use of lung protective ventilation (i.e., with low tidal volumes and airway pressures). Finally, due to the potential complications associated with mechanical ventilation, it is important to regularly assess whether a patient continues to require the assistance of the ventilator, and to liberate patients from mechanical ventilation at the earliest opportunity when clinically safe and feasible to do so. Figures depict pressure-time curve. Tables list the clinical causes of hypoxemic respiratory failure, oxygen delivery devices, indications for noninvasive positive pressure support, common causes of abnormal respiratory mechanics, and common causes of acute respiratory distress syndrome (ARDS). This review contains 2 highly rendered figures, 5 tables, and 86 references.

Can NT-pro BNP Levels Predict Prognosis of Patients with Acute Exacerbations of Chronic Obstructive Pulmonary Disease in the Intensive Care Unit?

Background:The prognostic value of amino terminal pro-brain natriuretic peptide levels in patients with acute exacerbation of chronic obstructive pulmonary disease has not been fully established.Aims:To investigate the predictive value of amino terminal pro-brain natriuretic peptide levels in terms of mortality, need for noninvasive mechanical ventilation, invasive mechanical ventilation, and weaning success.Study Design:Cohort study.Methods:Patients who were admitted to intensive care unit between December 2015 and December 2016 due to acute exacerbation of chronic obstructive pulmonary disease were included in the study. Demographic data, noninvasive mechanical ventilation application, need for invasive mechanical ventilation, amino terminal pro-brain natriuretic peptide level, duration of mechanical ventilation, intensive care unit and hospital stay, weaning success, and mortality rates were recorded.Results:A total of 110 patients (75 males) were included in the study. The mean age of the participants was 69 (61-76) years, and the mean Acute Physiology and Chronic Health Evaluation II score was 19 (15-23). The mean amino terminal pro-brain natriuretic peptide level was found to be lower in cases with noninvasive mechanical ventilation success than those with noninvasive mechanical ventilation failure (p=0.053). In addition, the mean amino terminal pro-brain natriuretic peptide level was significantly higher (4740 pg/mL vs. 3004 pg/mL, p=0.001) in patients who needed invasive mechanical ventilation support than in patients who did not. The mortality rate was significantly higher in patients who had an increasing trend of amino terminal pro-brain natriuretic peptide levels during hospitalization than in patients who had decreasing levels (59% vs. 23%, p=0.015). Based on the receiver operating characteristic analysis, the increasing trend of amino terminal pro-brain natriuretic peptide levels during intensive care unit stay predicted mortality with area under curve of 0.84 (p<0.0001, 95% CI: 0.75-0.93) and predicted invasive mechanical ventilation need with area under curve of 0.68.Conclusion:In cases of acute exacerbation of chronic obstructive pulmonary disease requiring mechanical ventilation, amino terminal pro-brain natriuretic peptide measurement and monitoring of its trend may be a valuable asset in predicting mortality, noninvasive mechanical ventilation, weaning success, and need for invasive mechanical ventilation.

Potentially modifiable respiratory variables contributing to outcome in ICU patients without ARDS: a secondary analysis of PRoVENT

BackgroundThe majority of critically ill patients do not suffer from acute respiratory distress syndrome (ARDS). To improve the treatment of these patients, we aimed to identify potentially modifiable factors associated with outcome of these patients.MethodsThe PRoVENT was an international, multicenter, prospective cohort study of consecutive patients under invasive mechanical ventilatory support. A predefined secondary analysis was to examine factors associated with mortality. The primary endpoint was all-cause in-hospital mortality.Results935 Patients were included. In-hospital mortality was 21%. Compared to patients who died, patients who survived had a lower risk of ARDS according to the ‘Lung Injury Prediction Score’ and received lower maximum airway pressure (Pmax), driving pressure (ΔP), positive end-expiratory pressure, and FiO2 levels. Tidal volume size was similar between the groups. Higher Pmax was a potentially modifiable ventilatory variable associated with in-hospital mortality in multivariable analyses. ΔP was not independently associated with in-hospital mortality, but reliable values for ΔP were available for 343 patients only. Non-modifiable factors associated with in-hospital mortality were older age, presence of immunosuppression, higher non-pulmonary sequential organ failure assessment scores, lower pulse oximetry readings, higher heart rates, and functional dependence.ConclusionsHigher Pmax was independently associated with higher in-hospital mortality in mechanically ventilated critically ill patients under mechanical ventilatory support for reasons other than ARDS.Trial Registration ClinicalTrials.gov (NCT01868321).

Potentially modifiable factors contributing to outcome in patients without ARDS under invasive mechanical ventilatory support—A secondary analysis of PRoVENT

Identification of clinical and laboratory predictors related to Infectious Complications (ICs) in patients after Out-of-Hospital Cardiac Arrest (OHCA).Patients, aged > 18, after an OHCA between 9/2013 and 11/2015, surviving > 24 h, were studied.Study group consisted of 42 patients (mean age 63.4 years, 88.1% men). Forty percent of patients had IC; lower respiratory tract infections were most common (87.5% of cases). ICs were more common in patients receiving Targeted Temperature Management (50% vs. 10%; p = 0.032).Antibiotics were used in 85.7% of patients. The mean time to therapy initiation was 9.6 (SD 7.1) hours after admission. The mean course of treatment was 9.0 (SD 6.2) days. Fifty-three percent of patients receiving early antibiotic treatment didn't have IC. Initial antibiotic therapy was changed more often in patients with IC (75% vs. 38.9%; p = 0.045).C-Reactive Protein, Procalcitonin, Troponin and White Blood Cell count values were higher in patients with IC.Early initiated antibiotic treatment is overused in patients after OHCA. This practice is associated with necessitating antibiotic change in the majority of patients with IC. Assessment of clinical and laboratory parameters in the first days after OHCA increases the likelihood of appropriate ATB therapy.

Review of supplemental oxygen and respiratory support for paediatric emergency care in sub-Saharan Africa.

IntroductionIn African countries, respiratory infections and severe sepsis are common causes of respiratory failure and mortality in children under five years of age. Mortality and morbidity in these children could be reduced with adequate respiratory support in the emergency care setting. The purpose of this review is to describe management priorities in the emergency care of critically ill children presenting with respiratory problems. Basic and advanced respiratory support measures are described for implementation according to available resources, work load and skill-levels.MethodsWe did a focused search of respiratory support for critically ill children in resource-limited settings over the past ten years, using the search tools PubMed and Google Scholar, the latest WHO guidelines, international ‘Advanced Paediatric Life Support’ guidelines and paediatric critical care textbooks.ResultsThe implementation of triage and rapid recognition of respiratory distress and hypoxia with pulse oximetry is important to correctly identify critically ill children with increased risk of mortality in all health facilities in resource constrained settings. Basic, effective airway management and respiratory support are essential elements of emergency care. Correct provision of supplemental oxygen is safe and its application alone can significantly improve the outcome of critically ill children. Non-invasive ventilatory support is cost-effective and feasible, with the potential to improve emergency care packages for children with respiratory failure and other organ dysfunctions. Non-invasive ventilation is particularly important in severely under-resourced regions unable to provide intubation and invasive mechanical ventilation support. Malnutrition and HIV-infection are important co-morbid conditions, associated with increased mortality in children with respiratory dysfunction.DiscussionA multi-disciplinary approach is required to optimise emergency care for critically ill children in low-resource settings. In this context, it is important to consider aspects of training of staff, technical support and pragmatic research.

Approach to the Patient with Acute Respiratory Failure

Acute respiratory failure (ARF) is a common reason for admission to the intensive care unit (ICU), and is associated with significant morbidity and mortality. Failure of one or more components of the respiratory system can lead to hypoxemia, hypercabia, or both. Initial evaluation of patients with ARF should include physical examination, chest imaging, and arterial blood gases (ABG) sampling. As ARF is often a life-threatening emergency, a patient’s oxygenation and ventilation will need to be supported at the same time that diagnostic and therapeutic interventions are planned. The priorities for early treatment are essentially those of basic life support: airway and breathing. The first step is to assess a patient’s airway and ascertain that it is patent. This is followed by efforts to support both oxygenation and ventilation. This can include non-invasive or invasive mechanical ventilatory support. As with all interventions, there are risks inherent in the use of mechanical ventilation, which may be minimized by the use of lung protective ventilation (i.e., with low tidal volumes and airway pressures). Finally, due to the potential complications associated with mechanical ventilation, it is important to regularly assess whether a patient continues to require the assistance of the ventilator, and to liberate patients from mechanical ventilation at the earliest opportunity when clinically safe and feasible to do so. Figures depict pressure-time curve. Tables list the clinical causes of hypoxemic respiratory failure, oxygen delivery devices, indications for noninvasive positive pressure support, common causes of abnormal respiratory mechanics, and common causes of acute respiratory distress syndrome (ARDS). This review contains 2 highly rendered figures, 5 tables, and 86 references.

Acid-base balance, serum electrolytes and need for non-invasive ventilation in patients with hypercapnic acute exacerbation of chronic obstructive pulmonary disease admitted to an internal medicine ward.

BackgroundHypoventilation produces or worsens respiratory acidosis in patients with hypercapnia due to acute exacerbations of chronic obstructive pulmonary disease (AECOPD). In these patients acid–base and hydroelectrolite balance are closely related. Aim of the present study was to evaluate acid–base and hydroelectrolite alterations in these subjects and the effect of non-invasive ventilation and pharmacological treatment.MethodsWe retrospectively analysed 110 patients consecutively admitted to the Internal Medicine ward of Cava de’ Tirreni Hospital for acute exacerbation of hypercapnic chronic obstructive pulmonary disease. On admission all patients received oxygen with a Venturi mask to maintain arterial oxygen saturation at least >90 %, and received appropriate pharmacological treatment. Non-Invasive Ventilation (NIV) was started when, despite optimal therapy, patients had severe dyspnea, increased work of breathing and respiratory acidosis. Based on Arterial Blood Gas (ABG) data, we divided the 110 patients in 3 groups: A = 51 patients with compensated respiratory acidosis; B = 36 patients with respiratory acidosis + metabolic alkalosis; and C = 23 patients with respiratory acidosis + metabolic acidosis. 55 patients received only conventional therapy and 55 had conventional therapy plus NIV.ResultsThe use of NIV support was lower in the patients belonging to group B than in those belonging to group A and C (25 %, vs 47 % and 96 % respectively; p < 0.01). A statistically significant association was found between pCO2 values and serum chloride concentrations both in the entire cohort and in the three separate groups.ConclusionsOur study shows that in hypercapnic respiratory acidosis due to AECOPD, differently from previous studies, the metabolic alkalosis is not a negative prognostic factor neither determines greater NIV support need, whereas the metabolic acidosis in addition to respiratory acidosis is an unfavourable element, since it determines an increased need of NIV and invasive mechanical ventilation support.

Acid–base balance, serum electrolytes and need for non-invasive ventilation in patients with hypercapnic acute exacerbation of chronic obstructive pulmonary disease admitted to an internal medicine ward

Background: Hypoventilation produces or worsens respiratory acidosis in patients with hypercapnia due to acute exacerbations of chronic obstructive pulmonary disease (AECOPD). In these patients acid–base and hydroelectrolite balance are closely related. Aim of the present study was to evaluate acid–base and hydroelectrolite alterations in these subjects and the effect of non-invasive ventilation and pharmacological treatment. Methods: We retrospectively analysed 110 patients consecutively admitted to the Internal Medicine ward of Cava de’ Tirreni Hospital for acute exacerbation of hypercapnic chronic obstructive pulmonary disease. On admission all patients received oxygen with a Venturi mask to maintain arterial oxygen saturation at least &gt;90 %, and received appropriate pharmacological treatment. Non-Invasive Ventilation (NIV) was started when, despite optimal therapy, patients had severe dyspnea, increased work of breathing and respiratory acidosis. Based on Arterial Blood Gas (ABG) data, we divided the 110 patients in 3 groups: A = 51 patients with compensated respiratory acidosis; B = 36 patients with respiratory acidosis + metabolic alkalosis; and C = 23 patients with respiratory acidosis + metabolic acidosis. 55 patients received only conventional therapy and 55 had conventional therapy plus NIV. Results: The use of NIV support was lower in the patients belonging to group B than in those belonging to group A and C (25 %, vs 47 % and 96 % respectively; p &lt; 0.01). A statistically significant association was found between pCO2 values and serum chloride concentrations both in the entire cohort and in the three separate groups. Conclusions: Our study shows that in hypercapnic respiratory acidosis due to AECOPD, differently from previous studies, the metabolic alkalosis is not a negative prognostic factor neither determines greater NIV support need, whereas the metabolic acidosis in addition to respiratory acidosis is an unfavourable element, since it determines an increased need of NIV and invasive mechanical ventilation support.

Too Passive to Prevent Ventilator-Associated Pneumonia

Ventilator-associated pneumonia (VAP) is a common complication of patients receiving invasive mechanical ventilation support. VAP continues to be associated with high morbidity, mortality, hospital cost ($10,000 to $25,000) and ICU stay.[1][1] Depending on the definition used, the VAP rate ranges

Intervenção educacional relacionada à rotina de mensuração do balonete endotraqueal em um hospital universitário

The invasive mechanical ventilation support promotes clear benefits. However, procedures involved in its institution can generate lesions in varying degrees. The cuff pressure surrounding the tracheal tube prevents air leakage and should not exceed tracheal perfusion pressure and should not be reduced also, allowing the passage of L ivia Pinheiro Carvalho e R osmar i A par ecida R osa A lm eida de Oliveira Revista Cultura e Extensao USPVolume 976 microorganisms, causing tissue damage and aspiration pneumonia, respectively. Monitoring this pressure, as prevention routine of pulmonary complications, is not held in various intensive care units. Thus, emphasis on preventive strategies seems to be a reasonable way to minimize them. The educational intervention aims to spread knowledge and promote important aspects to improve the quality of health care and the reduction of reintubation rates, length of hospital stay, mortality and hospital costs. The goal was to promote an educational action, through the dissemination of informative tool nonverbal in a hospital environment. Values within the normal range of expected cuff pressures increased from 11.36% to 20.51% after intervention. Thus, the model of educational intervention reached the expected objective, although it is recommended and desirable that other interventions are associated in the future, to complement and emphasize the importance of the technique so that we could obtain more expressive results in this context.

Severe Guillain–Barré syndrome in a patient receiving anti-TNF therapy. Consequence or coincidence. A case-based review

The adverse effects of anti-tumour necrosis factor alpha (TNFα) drugs include an increase in the risk of infections, congestive heart failure, lupus-like syndrome, and the onset or worsening of various demyelinating diseases such as, multiple sclerosis, optic neuritis, and Guillain-Barrè syndrome (GBS), among others. We describe the case of a patient who developed GBS while she was on treatment with adalimumab. A 50-year-old woman with rheumatoid arthritis (RA) was admitted to the hospital due to progressive severe bilateral symmetric weakness of the legs, which quickly extended to the upper limbs and to the respiratory muscles. Adalimumab was started 13months before. GBS was diagnosed and the anti-TNFα therapy discontinued. The serological test for Campylobacter jejuni was positive. She required invasive mechanical ventilatory support for 9months. Twelve months later, the patient was using a wheelchair following a rehabilitation programme, and at 24months she was walking a few steps with assistive devices. The relevant literature on the relationship between GBS and anti-TNFα is reviewed. Twenty three cases of GBS occurring during anti-TNFα therapy have been reported so far in the literature. In several cases, there was no clear temporal association, more than half had a possible previous infection, and in two cases the drug was reintroduced without recurrence of GBS. Our case, which is best explained by C. jejuni infection, as well as some of the cases described are probably not a direct result of anti-TNFα treatment, but an accidental coincidence. We also discuss the potential therapeutic options after anti-TNFα discontinuation.

Clinical Outcomes of Children Receiving Intensive Cardiopulmonary Support During Hematopoietic Stem Cell Transplant*

We investigated the short-term and 1-year clinical outcomes of 129 children who received intensive cardiopulmonary support during hematopoietic stem cell transplant. Intensive cardiopulmonary support was defined as receiving at least one of the following interventions: continuous positive pressure ventilation, dopamine infusion greater than or equal to 10 mcg/kg/minute, or the use of any other vasoactive infusion. Duration of intensive cardiopulmonary support, survival to hospital discharge, and predictors of these outcome variables were compared with 387 hematopoietic stem cell transplant patients who did not receive intensive support during the same period. We also report the 1-year survival; presence of chronic graft-versus-host disease; and renal, cardiac, and pulmonary function for all patients. A multicenter retrospective cohort study. The ICU and hematopoietic stem cell transplant unit of nine pediatric tertiary care centers. Children undergoing hematopoietic stem cell transplant who required intensive cardiopulmonary support. None. Predictors of the need for intensive support included unrelated donor allogeneic transplant, glomerular filtration rate less than 85 mL/minute/1.73 m, and nonmalignant disease as the indication for transplant. The survival to discontinuation of intensive support for all patients was 62% and 58% for patients who received invasive mechanical ventilatory support. The duration of mechanical ventilation was not predictive of survival. Predictors of intensive support mortality included macroscopic bleeding, engraftment, and pediatric logistic organ dysfunction score greater than one in two domains. Survival to hospital discharge was 50% for the intensive support group and 99% for the nonintensive support group. Overall 1-year survival was 40% in the intensive support population and 65% in the nonintensive support group. There were no significant differences in the survival, rates of chronic graft-versus-host disease, creatinine, forced expiratory volume in 1-minute, cardiac shortening fraction, or performance status in intensive and nonintensive support patients who survived to hospital discharge. Intensive cardiopulmonary support plays an important and potentially life-saving role in the care of pediatric stem cell transplant patients. Survivors of intensive support do not have compromised 1-year survival or organ function compared with children who did not receive intensive support.

Diffuse Alveolar Hemorrhage-Induced Respiratory Failure

This case study discusses the management of type I respiratory failure (RF) secondary to diffuse alveolar-induced acute lung injury. Type I RF occurs with ventilation-perfusion mismatch resulting in inadequate oxygenation. Arterial oxygen saturation is usually less than 90% despite supplemental fraction of inspired oxygen (FIO(2)) greater than 60%. Type I RF may occur as a result of injury to the lung parenchyma caused by infection, toxins, pulmonary edema, pulmonary hemorrhage, aspiration of gastric contents, and respiratory distress syndrome. Whatever the inciting element, the typical pathophysiology of type I RF involves damage to the alveolar-capillary membrane causing an inflammatory cascade of events. The extent of lung injury determines its severity as well as management. Invasive mechanical ventilation support is required in most cases, but when the patient is hemodynamically stable and lung injury is mild or moderate, noninvasive positive pressure ventilation may provide adequate ventilation support. Despite the ventilation type chosen, management requires a multidisciplinary team approach and a high level of care.

Short-term outcomes of cadaveric lung transplantation in ventilator-dependent patients

IntroductionSurvival after cadaveric lung transplantation (LTx) in respiratory failure recipients who were already dependent on ventilation support prior to transplantation is poor, with a relatively high rate of surgical mortality and morbidity. In this study, we sought to describe the short-term outcomes of bilateral sequential LTx (BSLTx) under extracorporeal membrane oxygenation (ECMO) support in a consecutive series of preoperative respiratory failure patients.MethodsBetween July 2006 and July 2008, we performed BSLTx under venoarterious (VA) ECMO support in 10 respiratory failure patients with various lung diseases. Prior to transplantation, 6 patients depended on invasive mechanical ventilation support and the others (40%) needed noninvasive positive pressure ventilation to maintain adequate gas exchange. Their mean age was 40.9 years and the mean observation period was 16.4 months.ResultsExcept for 1 ECMO circuit that had been set up in the intensive care unit for pulmonary crisis 5 days prior to transplantation, most ECMO (90%) circuits were set up in the operating theater prior to pneumonectomy of native lung during transplantation. Patients were successfully weaned off ECMO circuits immediately after transplantation in 8 cases, and within 1 day (1/10 patients) and after 9 days (1/10 patients) due to severe reperfusion lung edema following transplantation. The mean duration of ECMO support in those successfully weaned off in the operating theater (n = 8) was 7.8 hours. The average duration of intensive care unit stay (n = 10) was 43.1 days (range, 35 to 162 days) and hospital stay (n = 10) was 70 days (range, 20 to 86 days). Although 4 patients (40%) had different degrees of complicated postoperative courses unrelated to ECMO, all patients were discharged home postoperatively. The mean forced vital capacity and the forced expiratory volume in 1 second both increased significantly postoperatively. The cumulative survival rates at 3 months and at 12 months post-transplantation were 100% and 90%.ConclusionsAlthough BSLTx in this critical population has varied surgical complications and prolonged length of postoperative ICU and hospital stays, all the patients observed in this study could tolerate the transplant procedures under VA ECMO support with promising pulmonary function and satisfactory short-term outcome.

Edema pulmonar por pressão negativa após extubação traqueal: relato de caso

Negative pressure pulmonary edema after acute upper airway obstruction is a well-described event, thought infrequently diagnosed and reported. This report aimed at presenting a case of postextubation negative pressure pulmonary edema refractory to use of diuretics and with successful therapeutic after using positive pressure noninvasive mechanic ventilation. A 22-year-old-woman underwent an operation to opened colecistectomy. The preoperative exams were abnormality us. Immediately after the extubation the patient presented with dyspnea and lungs stertors. The treatment for the acute pulmonary edema started with oxygen therapy under Venturi mask, lifting up chest and diuretic. The patient was transferred to Intensive Care Unit due to the lack of success with the treatment. A noninvasive ventilation (NIV) was started with support pressure of 15 cmH2O and PEEP of 5 cmH2O with resolution of symptoms. The patient was maintained under observation for 24 hours after the event with good conditions and received discharge to room without symptoms. Negative pressure pulmonary edema (NPPE) is a difficult diagnosed event and it must be always considered when patient develop with symptoms and signals of respiratory insufficiency postextubation. In our case was possible to treat with positive pressure non-invasive mechanical ventilation, but in case of the NIV failure the tracheal intubation and the invasive mechanical ventilatory support be initiated to improve the oxygen levels of the patient.

The impact of noninvasive versus invasive mechanical ventilatory support on survival in hematological patients with acute respiratory failure

The impact of noninvasive versus invasive mechanical ventilatory support on survival in hematological patients with acute respiratory failure

Current Understanding of Severe Acute Respiratory Syndrome (SARS)

In Brief Severe acute respiratory syndrome (SARS) is a newly described infectious disease due to a new strain of coronavirus. Patients usually present with fever, chills/rigors, myalgias, malaise, dry cough, headache, and dyspnea. This infection results in significant morbidity and mortality, especially in the elderly with comorbidity. About one fifth of adult patients develop progressive respiratory distress syndrome, requiring invasive mechanical ventilatory support. Infected young children usually develop very mild disease. None of the treatments used have been subjected to proper clinical trials, and the treatment used in the 2003 epidemic was largely empirical. Other antiviral treatment, RNA interference, monoclonal antibody, synthetic peptides, and vaccines are being developed. This review describes the current understanding of the epidemiology, clinical features, and therapeutic options for this infection. Severe acute respiratory syndrome (SARS) is a newly described infectious disease caused by a new strain of coronavirus. This highly contagious infection results in significant morbidity and mortality, especially in the elderly with comorbidity. Many adult patients develop progressive respiratory distress syndrome, requiring invasive mechanical ventilatory support. There is currently no proven specific treatment of this infection. Rapid identification of the infected individuals and prompt isolation of the infected cases are the key to controlling this devastating disease.

An overview on Severe Acute Respiratory Syndrome (SARS)

Severe acute respiratory syndrome (SARS) is a newly emerged infectious disease that has caught the medical profession by surprise in 2003. The major clinical features include persistent fever, chills/rigor, myalgia, malaise, dry cough, headache and dyspnoea but diarrhea occurs in 40-70% of patients after hospital admission. Respiratory failure is the major complication of SARS; at least half of the patients require supplemental oxygen during the acute phase whereas about 20% of patients progress to acute respiratory distress syndrome requiring invasive mechanical ventilatory support. In contrast, the severity is generally mild in infected young children. Due to our limited understanding of this new disease, treatment of SARS was empirical in 2003. Protease inhibitor (Lopinavir/ritonavir) in combination with ribavirin may play a role as antiviral therapy in the early phase whereas nelfinavir is a promising alternative. The role of interferon and systemic steroid in preventing immune-mediated lung injury deserves further investigation. In addition, other anti-viral treatment, RNA interference, monoclonal antibody, synthetic peptides, and vaccines are being developed. Rapid diagnosis, early isolation, and good infection control measures are important in preventing spread of the infection.

International Consensus Conferences in Intensive Care Medicine: Non-invasive positive pressure ventilation in acute respiratory failure

Noninvasive positive pressure ventilation (NPPV) was applied first to patients with chronic pulmonary disease but is now being used to support those with acute respiratory failure (ARF). An International Consensus Conference in Intensive Care Medicine considering the role of NPPV in ARF was held in Paris, France, from April 13‐14, 2000; sponsored by the Critical Care Assembly of the American Thoracic Society (ATS), the European Respiratory Society (ERS), the European Society of Intensive Care Medicine (ESICM), and the Societe de Reanimation de Langue Fran aise (SRLF). The methods of the Consensus were established by the National Institutes of Health (1) and adapted subsequently for use in critical care medicine (2). Briefly, the process comprised four phases. First, five key questions were formulated by the scientific advisors designed to address issues integral to the evaluation of noninvasive ventilatory support in its current and future roles. Second, a comprehensive literature search was performed and key articles precirculated to a jury of 10 clinician scientists who were not experts in the field under discussion. Third, authorities in NPPV selected by the Organizing Committee and scientific advisors delivered focused presentations during a two-day symposium attended by the jury and about 150 delegates. Each presentation was followed by debate and discussion. Finally, the jury summarized the available evidence in response to the questions over the two days immediately after the conference. For the purposes of this report, NPPV was defined as any form of ventilatory support applied without the use of an endotracheal tube, and was considered to include continuous c positive airway pressure (CPAP), with or without inspiratory pressure support; volume- and pressure-cycled systems, proportional assist ventilation (PAV), and adjuncts such as the use of helium‐oxygen (heliox) gas mixtures. The term acute respiratory failure (ARF) was considered to include patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), those with acute exacerbations of obstructive airflow limitation (i.e., asthma and COPD); acutely decompensated patients with the obesity hypoventilation syndrome (OHS) and cardiogenic pulmonary edema (CPE); patients developing ARF in the perioperative period; and those with either difficulty weaning from invasive mechanical ventilatory support, or in whom endotracheal intubation (ETI) was considered inappropriate. The information presented to the jury was designed to address the following five questions.