Length Of Ventilation Research Articles

Contributing factors to hypophosphatemia development in critically Ill ventilated patients: a retrospective cohort study

Hypophosphatemia (serum phosphate < 2.5 mg/dL) is a major concern when initiating nutritional support. We evaluated which factors contribute to hypophosphatemia development in critically ill patients, as well as the association between hypophosphatemia and mortality. A retrospective cohort study of patients who were ventilated for at least 2 days in a 16-bed mixed ICU. Data collected includes demographics, Acute Physiology & Chronic Health Evaluation 2 (APACHE2) admission score, Sequential Organ Failure Assessment score at 24 h (SOFA24), hourly energy delivery, plasma phosphate levels during the first 2 weeks of admission, ICU length of stay (LOS), length of ventilation (LOV), and mortality (ICU and 90 days). For the hypophosphatemia development model, we considered mortality as a competing risk. For mortality analysis, we used the Cox proportional hazards model considering hypophosphatemia development as a time-varying covariate. 462 patients were used in the analysis. 59.52% of the patients developed hypophosphatemia. Several factors were associated with a decreased risk of hypophosphatemia: age, BMI, pre-admission diabetes diagnosis, APACHE2, SOFA24, first kidney SOFA score, hospital admission time before ICU admission, and admission after liver transplantation. Admission due to trauma was associated with an increased risk of hypophosphatemia. Survival analysis with hypophosphatemia as a time-varying covariate showed a protective effect of hypophosphatemia from mortality (HR 0.447, 95% CI 0.281, 0.712). Age, APACHE2, and SOFA24 score were found to be significantly associated with ICU mortality. Fasting duration in the ICU before nutritional support initiation was not found to be significantly associated with hypophosphatemia. We examined several fasting intervals (12 h, 24 h, 36 h, 48 h, 60 h, 72 h). In each fast interval, we compared the prevalence of hypophosphatemia among patients who fasted the specified length of time, with those who did not fast for the same length of time. In each fasting interval, hypophosphatemia prevalence was lower in the fasting group compared to the non-fasting group. However, this difference was insignificant. BMI, APACHE2, and hospital LOS before ICU admission were inversely associated with hypophosphatemia development. Fasting for up to 72 h in the ICU before starting nutritional support did not affect hypophosphatemia occurrence. Hypophosphatemia was associated with lower mortality.

Controlled enteral nutrition in critical care patients – A randomized clinical trial of a novel management system

Nutritional therapy is essential to ICU care. Successful early enteral feeding is hindered by lack of protocols, gastrointestinal intolerance and feeding interruptions, leading to impaired nutritional intake. smART+ was developed as a nutrition management feeding platform controlling tube positioning, reflux, gastric pressure, and malnutrition. This study evaluated the potential of this new ICU care platform to deliver targeted nutrition and improve ICU outcomes. Critically ill patients ≥18 years-old, mechanically ventilated and enterally fed, were randomized to receive ESPEN-guideline-based nutrition or smART+-guided nutrition for 2-14 days. Primary endpoint was average deviation from daily targeted nutrition determined via calculation of energy targets per calorimetry. Secondary endpoints included gastric residual volumes, length of stay (LOS) and length of ventilation (LOV). smART+achieved a mean deviation from daily targeted nutrition of 10.5% (n=48) versus 34.3% for control (n=50), p<0.0001. LOS and LOV were decreased in the smART+group versus control (mean LOS: 10.4 days versus 13.7; reduction 3.3 days, adjusted HR 1.71, 95% CI:1.13,2.60, p=0.012; mean LOV: 9.5 days versus 12.8 days reduction of 3.3 days, adjusted HR 1.64, 95% CI:1.08-2.51, p=0.021). Feeding goals were met (within ±10%) on 75.7% of days for smART+versus 23.3% for control (p<0.001). No treatment-related adverse events occurred in either group. The study was stopped due to success in a planned interim analysis of the first 100 patients. The smART+Platform improved adherence to feeding goals and reduced LOS and LOV versus standard of care in critically ill patients. NCT04098224; registered September 23, 2019.

Postnatal Cytomegalovirus Infection: Is it Important? A 10-Year Retrospective Case-control Study of Characteristics and Outcomes in Very Preterm and Very Low Birth Weight Infants.

To determine the characteristics and outcomes of postnatal cytomegalovirus (pCMV) infection in preterm infants in a neonatal intensive care unit (NICU). A retrospective, matched case-control study in a tertiary NICU. Infants born between January 2009 and December 2019, <32 weeks' gestational age (GA) and/or birth weight (BW) <1500 g with pCMV infection were matched 1:1 with cytomegalovirus-(CMV)-negative infants by year of admission, gender, GA and BW. Primary outcome was death ≤36 weeks' postmenstrual age or bronchopulmonary dysplasia (BPD). Secondary outcomes were length of ventilation (LOV), length of stay (LOS) and neurodevelopmental impairment (NDI) at corrected age 1 and 2 years. Forty-eight pCMV-positive infants (median GA 25.3 weeks, BW 695 g, age 58 days) were identified from 1659 infants (incidence 2.9%). The most common symptoms of pCMV infection were abdominal distension (43.8%), sepsis-like syndrome (29.2%), thrombocytopenia (60.5%) and conjugated hyperbilirubinemia (60.9%). Compared with controls, there were no significant differences in the composite outcome of death or BPD (56.3% vs. 37.5%; P = 0.1) or NDI at 1 and 2 years (51.9% vs. 44%; P = 0.8; 71.4% vs. 50%; P = 0.4). pCMV-positive infants had a significantly longer median LOV (23.5 vs. 12 days)* and LOS (140 vs. 110.5 days)*. Eleven (22.9%) infants received antivirals. Ten improved and 1 died. Two untreated infants died (1 from pCMV infection). Clinically identifiable pCMV infections are significant and associated with increased respiratory support and prolonged hospital stay in vulnerable infants. pCMV screening and preventive measures against transmission merit consideration.*P < 0.05.

Effect of Combined Protein-Enriched Enteral Nutrition and Early Cycle Ergometry in Mechanically Ventilated Critically Ill Patients-A Pilot Study.

Background: Cycle ergometry (CE) is a method of exercise used in clinical practice. Limited data demonstrate its effectiveness in critically ill patients. We aimed to evaluate the combination of CE and a high-protein diet in critically ill patients. Methods: This was an open label pilot trial comparing conventional physiotherapy with enteral nutrition (EN) (control, Group 1), CE with EN (Group 2), and CE with protein-enriched EN (Group 3). The primary outcome was length of ventilation (LOV). Secondary outcomes were intensive care unit (ICU) mortality, length of ICU stay (ICU LOS), length of hospital stay (Hospital LOS), and rate of re-intubation. Results: Per protocol, 41 ICU patients were enrolled. Thirteen patients were randomized to Group 1 (control), fourteen patients to Group 2, and fourteen patients to Group 3 (study groups). We found no statistically significant difference in LOV between the study arms (14.2 ± 9.6 days, 15.8 ± 7.1 days, and 14.9 ± 9.4 days, respectively, p = 0.89). Secondary outcomes did not demonstrate any significant differences between arms. Conclusions: In this pilot trial, CE combined with either standard EN or protein-enriched EN was not associated with better clinical outcomes, as compared to conventional physiotherapy with standard EN. Larger trials are needed in order to further evaluate this combination.

Correlation between nutrition, phosphate level and length of ventilation in critically ill patients who need renal replacement therapy

Rationale: Hypophosphatemia (hP) is associated with prolonged ventilation and may be correlated with increased mortality. Acute kidney injury requiring renal replacement therapy (RRT) is associated with a 50% morality rate and prolonged length of ventilation (LOV). We studied the relationship between nutrition, blood phosphate levels (P), and the LOV in ICU patients on RRT.

Cycle length identifies obstructive sleep apnea and central sleep apnea in heart failure with reduced ejection fraction.

To clarify whether unmasking of central sleep apnea during continuous positive airway pressure (CPAP) initiation can be identified from initial diagnostic polysomnography (PSG) in patients with heart failure with reduced ejection fraction (HFREF) and obstructive sleep apnea (OSA) MATERIALS AND METHODS: Forty-three consecutive patients with obstructive sleep apnea and central sleep apnea (OSA/CSA) in HFREF were matched with 43 HFREF patients with OSA and successful CPAP initiation. Obstructive apneas during diagnostic PSG were then analyzed for cycle length (CL), ventilation length (VL), apnea length (AL), time to peak ventilation (TTPV), and circulatory delay (CD). We calculated duty ratio (DR) as the ratio of VL/CL and mathematic loop gain (LG). While AL was similar, CL, VL, TTPV, CD, and DR was significantly longer in patients with OSA/CSA compared to those with OSA, and LG was significantly higher. Receiver operator curves identified optimal cutoff values of 50.2s for CL (area under the curve (AUC) 0.85, 29.2s for VL (AUC 0.92), 11.5s for TTPV (AUC 0.82), 26.4s for CD (AUC 0.79), and 3.96 (AUC 0.78)) respectively for LG to identify OSA/CSA. OSA/CSA in HFREF can be identified by longer CL, VL, TTPV, and CD from obstructive events in initial diagnostic PSG. The underlying mechanisms seem to be the presence of an increased LG.

Ventilator-associated pneumonia in adult intensive care unit prevalence and complications

BackgroundVentilator-associated pneumonia (VAP) remains a common cause of intensive care unit (ICU) and hospital morbidity and mortality despite advances in diagnostic techniques and management. We aimed to determine the prevalence, possible complications and in-hospital prognosis of VAP in mechanically ventilated patients. MethodsThis prospective observational, case-control study, was carried out from September 2012 to August 2013. Forty-eight adult patients maintained on mechanical ventilation for more than 48 h in our ICU were enrolled in the study. VAP was diagnosed as new persistent pulmonary infiltrates on chest radiographs and, at least two of following: (1) fever of ≥38.3°C, (2) leukocytosis of ≥12,000⧹mm3, and (3) purulent tracheobronchial secretions. Endotracheal aspirate (ETA) samples of suspected cases were collected and processed as per standard protocols. ResultsThe primary underlying diagnosis was acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in 25 patients, congestive heart failure in 10, pneumonia in 6, post-operative in 5, neurological diseases in 2 patients. VAP developed in 17 patients (35.4%), gram-negative agents were the major offending pathogen (Pseudomonas aeruginosa accounting for 22.9%). The length of ventilation (LOV) and the length of ICU stay (LOSICU) were significantly higher in the VAP group (P=0.001, 0.0001 respectively). Severe sepsis/septic shock, acute respiratory distress syndrome (ARDS), atelectasis, and infection with multi-drug resistant organisms were more common in the VAP group. Conclusion: Ventilator-associated pneumonia was associated with a significant increase in ICU length of stay, time on mechanical ventilation and different complications.

Resting energy expenditure, calorie and protein consumption in critically ill patients: a retrospective cohort study.

BackgroundIntense debate exists regarding the optimal energy and protein intake for intensive care unit (ICU) patients. However, most studies use predictive equations, demonstrated to be inaccurate to target energy intake. We sought to examine the outcome of a large cohort of ICU patients in relation to the percent of administered calories divided by resting energy expenditure (% AdCal/REE) obtained by indirect calorimetry (IC) and to protein intake.MethodsIncluded patients were hospitalized from 2003 to 2015 at a 16-bed ICU at a university affiliated, tertiary care hospital, and had IC measurement to assess caloric targets. Data were drawn from a computerized system and included the % AdCal/REE and protein intake and other variables. A Cox proportional hazards model for 60-day mortality was used, with the % AdCal/REE modeled to accommodate non-linearity. Length of stay (LOS) and length of ventilation (LOV) were also assessed.ResultsA total of 1171 patients were included. The % AdCal/REE had a significant non-linear (p < 0.01) association with mortality after adjusting for other variables (p < 0.01). Increasing the percentage from zero to 70 % resulted in a hazard ratio (HR) of 0.98 (CI 0.97–0.99) pointing to reduced mortality, while increases above 70 % suggested an increase in mortality with a HR of 1.01 (CI 1.01–1.02). Increasing protein intake was also associated with decreased mortality (HR 0.99, CI 0.98–0.99, p = 0.02). An AdCal/REE >70 % was associated with an increased LOS and LOV.ConclusionsThe findings of this study suggest that both underfeeding and overfeeding appear to be harmful to critically ill patients, such that achieving an Adcal/REE of 70 % had a survival advantage. A higher caloric intake may also be associated with harm in the form of increased LOS and LOV. The optimal way to define caloric goals therefore requires an exact estimate, which is ideally performed using indirect calorimetry. These findings may provide a basis for future randomized controlled trials comparing specific nutritional regimens based on indirect calorimetry measurements.

One-Year Mortality Associations in Hemodialysis Patients after Traumatic Brain Injury—An Eight-Year Population-Based Study

PurposeThis study aimed to investigate the one-year mortality associations in hemodialysis patients who underwent neurosurgical intervention after traumatic brain injury (TBI) using a nationwide database in Taiwan.Materials and MethodsAn age- and gender-matched longitudinal cohort study of 4416 subjects, 1104 TBI patients with end-stage renal disease (ESRD) and 3312 TBI patients without ESRD, was conducted using the National Health Insurance Research Database in Taiwan between January 2000 and December 2007. The demographic characteristics, length of stay (LOS), length of ICU stay, length of ventilation (LOV), and tracheostomy were collected and analyzed. The co-morbidities of hypertension (HTN), diabetes mellitus (DM), myocardial infarction (MI), stroke, and heart failure (HF) were also evaluated.ResultsTBI patients with ESRD presented a shorter LOS, a longer length of ICU stay and LOV, and a higher percentage of comorbidities compared with those without ESRD. TBI patients with ESRD displayed a stable trend of one-year mortality rate, 75.82% to 76.79%, from 2000–2007. For TBI patients with ESRD, the median survival time was 0.86 months, and pre-existing stroke was a significant risk factor of mortality (HR: 1.29, 95% C.I.: 1.08–1.55). Pre-existing DM (HR: 1.35, 95% C.I.: 1.12–1.63) and MI (HR: 1.61, 95% C.I.: 1.07–2.42) effect on the mortality in ESRD patients who underwent TBI surgical intervention in the younger (age<65) and older (age≥65) population, respectively. In addition, the length of ICU stay and tracheostomy may provide important information to predict the mortality risk.ConclusionsThis is the first report indicating an increased risk of one-year mortality among TBI patients with a pre-existing ERSD insult. Comorbidities were more common in TBI patients with ESRD. Physicians should pay more attention to TBI patients with ESRD based on the status of age, comorbidities, length of ICU stay, and tracheostomy to improve their survival.

Improved clinical and economic outcomes in severe bronchiolitis with pre-emptive nCPAP ventilatory strategy

PurposeSevere bronchiolitis is the leading cause of admission to the pediatric intensive care unit (PICU). Nasal continuous positive airway pressure (nCPAP) has become the primary respiratory support, replacing invasive mechanical ventilation (MV). Our objective was to evaluate the economic and clinical consequences following implementation of this respiratory strategy in our unit.MethodsThis was a retrospective cohort analysis of 525 infants with bronchiolitis requiring respiratory support and successively treated during two distinct periods with invasive MV between 1996 and 2000, P1 (n = 193) and nCPAP between 2006 and 2010, P2 (n = 332). Costs were estimated using the hospital cost billing reports.ResultsPatients’ baseline characteristics were similar between the two periods. P2 is associated with a significant decrease in the length of ventilation (LOV) (4.1 ± 3.5 versus 6.9 ± 4.6 days, p < 0.001), PICU length of stay (LOS) (6.2 ± 4.6 versus 9.7 ± 5.5 days, p < 0.001) and hospital LOS. nCPAP was independently associated with a shorter duration of ventilatory support than MV (hazard ratio 1.8, 95 % CI 1.5–2.2, p < 0.001). nCPAP was also associated with a significant decrease in ventilation-associated complications, and less invasive management. The mean cost of acute viral bronchiolitis-related PICU hospitalizations was significantly decreased, from 17,451 to 11,205 € (p < 0.001). Implementation of nCPAP led to a reduction of the total annual cost of acute viral bronchiolitis hospitalizations of 715,000 €.ConclusionnCPAP in severe bronchiolitis is associated with a significant improvement in patient management as shown by the reduction in invasive care, LOV, PICU LOS, hospital LOS, and economic burden.

Invasive ventilation modes in children: a systematic review and meta-analysis

IntroductionThe purpose of the present study was to critically review the existing body of evidence on ventilation modes for infants and children up to the age of 18 years.MethodsThe PubMed and EMBASE databases were searched using the search terms 'artificial respiration', 'instrumentation', 'device', 'devices', 'mode', and 'modes'. The review included only studies comparing two ventilation modes in a randomized controlled study and reporting one of the following outcome measures: length of ventilation (LOV), oxygenation, mortality, chronic lung disease and weaning. We quantitatively pooled the results of trials where suitable.ResultsFive trials met the inclusion criteria. They addressed six different ventilation modes in 421 children: high-frequency oscillation (HFO), pressure control (PC), pressure support (PS), volume support (VS), volume diffusive respirator (VDR) and biphasic positive airway pressure. Overall there were no significant differences in LOV and mortality or survival rate associated with the different ventilation modes. Two trials compared HFO versus conventional ventilation. In the pooled analysis, the mortality rate did not differ between these modes (odds ratio = 0.83, 95% confidence interval = 0.30 to 1.91). High-frequency ventilation (HFO and VDR) was associated with a better oxygenation after 72 hours than was conventional ventilation. One study found a significantly higher PaO2/FiO2 ratio with the use of VDR versus PC ventilation in children with burns. Weaning was studied in 182 children assigned to either a PS protocol, a VS protocol or no protocol. Most children could be weaned within 2 days and the weaning time did not significantly differ between the groups.ConclusionsThe literature provides scarce data for the best ventilation mode in critically ill children beyond the newborn period. There is no evidence, however, that high-frequency ventilation reduced mortality and LOV. Longer-term outcome measures such as pulmonary function, neurocognitive development, and cost-effectiveness should be considered in future studies.

Efficacy and safety of parenteral omega 3 fatty acids in ventilated patients with acute lung injury

Objective:To determine the effects of parenteral omega 3 fatty acids (10% fatty acids) on respiratory parameters and outcome in ventilated patients with acute lung injury.Measurements and Main Results:Patients were randomized into two groups – one receiving standard isonitrogenous isocaloric enteral diet and the second receiving standard diet supplemented with parenteral omega 3 fatty acids (Omegaven, Fresenius Kabi) for 14 days. Patients demographics, APACHE IV, Nutritional assessment and admission category was noted at the time of admission. No significant difference was found in nutritional variables (BMI, Albumin). Compared with baseline PaO2/FiO2 ratio (control vs. drug group: 199 ± 124 vs. 145 ± 100; P = 0.06), by days 4, 7, and 14, patients receiving the drug did not show a significant improvement in oxygenation (PaO2/FiO2: 151.83 ± 80.19 vs. 177.19 ± 94.05; P = 0.26, 145.20 ± 109.5 vs. 159.48 ± 109.89; P = 0.61 and 95.97 ± 141.72 vs. 128.97 ± 140.35; P = 0.36). However, the change in oxygenation from baseline to day 14 was significantly better in the intervention as compared to control group (145/129 vs. 199/95; P < 0.0004). There was no significant difference in the length of ventilation (LOV) and length of ICU stay (LOS). There was no difference in survival at 28 days. Also, there was no significant difference in the length of ventilation and ICU stay in the survivors group as compared to the non survivors group.Conclusions:In ventilated patients with acute respiratory distress syndrome, intravenous Omega 3 fatty acids alone do not improve ventilation, length of ICU stay, or survival.

Cheyne–Stokes respiration in heart failure: Cycle length is dependent on left ventricular ejection fraction

Background Cheyne–Stokes respiration (CSR) is common in patients with congestive heart failure (CHF) and is associated with poor prognosis. The aim of this study was to analyse the characteristics of CSR in patients with varying degrees of impaired left ventricular ejection fraction (LVEF). Methods A total of 104 patients with CSR (apnea–hypopnea index [AHI] ⩾ 15/h) and exertional dyspnea were divided into FIVE groups according to their LVEF (<20% upto ⩾50%). A subgroup of 22 patients was studied twice: 15 in whom LVEF improved between studies and 7 in whom LVEF deteriorated. Using cardiorespiratory polygraphy recordings, cycle length (CL), apnea length (AL), ventilation length (VL), time to peak ventilation (TTPV), circulatory delay (CD) and VL:AL ratio were determined. Results There was no relationship between AHI and impairment of LVEF, but the characteristics of CSR were related to LV function. Comparing the groups with the best LVEF (>50%) and the worst LVEF (<20%), there were significant increases in CL (49 ± 17–86 ± 23 s), AL (21 ± 9–31 ± 10 s), VL (28 ± 10–55 ± 17 s), TTPV (19 ± 5–32 ± 11 s), VL:AL ratio (1.5 ± 0.4–1.9 ± 0.7 s) and CD (29 ± 8–49 ± 16 s). In the subgroup of patients who were studied twice, improvement in EF was associated with a decrease in these parameters. Conclusion The current classification of CSR in CHF patients using AHI may be overly simplistic. Parameters such as CL, VL, TTPV and CD are related to cardiac function and could potentially be used for disease monitoring.

Predictors for good functional outcome after neurocritical care

IntroductionThere are only limited data on the long-term outcome of patients receiving specialized neurocritical care. In this study we analyzed survival, long-term mortality and functional outcome after neurocritical care and determined predictors for good functional outcome.MethodsWe retrospectively investigated 796 consecutive patients admitted to a non-surgical neurologic intensive care unit over a period of two years (2006 and 2007). Demographic and clinical parameters were analyzed. Depending on the diagnosis, we grouped patients according to their diseases (cerebral ischemia, intracranial hemorrhage (ICH), subarachnoid hemorrhage (SAH), meningitis/encephalitis, epilepsy, Guillain-Barré syndrome (GBS) and myasthenia gravis (MG), neurodegenerative diseases and encephalopathy, cerebral neoplasm and intoxication). Clinical parameters, mortality and functional outcome of all treated patients were analyzed. Functional outcome (using the modified Rankin Scale, mRS) one year after discharge was assessed by a mailed questionnaire or telephone interview. Outcome was dichotomized into good (mRS ≤ 2) and poor (mRS ≥ 3). Logistic regression analyses were calculated to determine independent predictors for good functional outcome.ResultsOverall in-hospital mortality amounted to 22.5% of all patients, and a good long-term functional outcome was achieved in 28.4%. The parameters age, length of ventilation (LOV), admission diagnosis of ICH, GBS/MG, and inoperable cerebral neoplasm as well as Therapeutic Intervention Scoring System (TISS)-28 on Day 1 were independently associated with functional outcome after one year.ConclusionsThis investigation revealed that age, LOV and TISS-28 on Day 1 were strongly predictive for the outcome. The diagnoses of hemorrhagic stroke and cerebral neoplasm leading to neurocritical care predispose for functional dependence or death, whereas patients with GBS and MG are more likely to recover after neurocritical care.

Prospective evaluation of a multi-factorial prevention strategy on the impact of nosocomial infection in very-low-birthweight infants

The aim of this study was to examine the impact of a multi-factorial intervention on nosocomial infection in very-low-birthweight infants. Consecutive infants with a birth weight less than 1500 g, born between February 2002 and February 2003, were included in this prospective study. The first six-month period (control) included surveillance of current practice. The intervention began in the seventh month and included: (i) changes to handwashing solutions with hand hygiene education; (ii) standardization of intravascular device (IV) insertion with specialized packs; (iii) changes to skin antiseptic solutions (2% aqueous chlorhexidine and 1% chlorhexidine in ethanol); and (iv) mandatory removal or replacement of peripheral IV after 48 hours and removal once enteral intake was > 120 mL/kg/day. Demographic data and details of every device were collected prospectively. Bloodstream infections (BSIs), length of stay (LOS), length of ventilation (LOV) and death were recorded and the rate of nosocomial BSI was calculated. Overall, 174 newborns required 1359 devices. The two cohorts were similar for birth weight and gestation. There was a reduction in nosocomial BSIs from 21% to 9% (control vs. intervention) (P = 0.05, confidence intervals 0.19-1.0). There was no significant difference in LOS, LOV, or mortality. Four infants had complications from 2% chlorhexidine. In conclusion, implementation of the multi-factorial prevention strategy reduced nosocomial BSIs. Alternative antiseptic solutions are needed to reduce the complications caused by 2% aqueous chlorhexidine.

Neonatal Assisted Ventilation: Predictors, Frequency, and Duration in a Mature Managed Care Organization

Reference data are lacking on the frequency and duration of assisted ventilation in neonates. This information is essential for determining resource needs and planning clinical trials. As mortality becomes uncommon, ventilator utilization is increasingly used as a measure for assessing therapeutic effect and quality of care in intensive care medicine. Valid comparisons require adjustments for differences in a patient's baseline risk for assisted ventilation and prolonged ventilator support. The aims of this study were to determine the frequency and length of ventilation (LOV) in preterm and term infants and to develop models for predicting the need for assisted ventilation and length of ventilator support. We performed a retrospective, population-based cohort study of 77 576 inborn live births at 6 Northern California hospitals with level 3 intensive care nurseries in a group-model managed care organization. The gestational age-specific frequency and duration of assisted ventilation among surviving infants was determined. Multivariable regression was performed to determine predictors for assisted ventilation and LOV. Of 77 576 inborn live births in the study, 11 199 required admission to the neonatal intensive care unit and of these, 1928 survivors required ventilator support. The proportion of infants requiring assisted ventilation and the median LOV decreased markedly with increasing gestational age. In addition to gestational age, admission illness severity, 5-minute Apgar scores, presence of anomalies, male sex, and white race were important predictors for the need for assisted ventilation. The ability of the models to predict need for ventilation was high, and significantly better than birth weight alone with an area under the receiver operating characteristic curve of.90 versus.70 for preterm infants, and.88 versus.50 for term infants. For preterm infants, gestational age, admission illness severity, oxygenation index, anomalies, and small-for-gestational age status were significant predictors for LOV, accounting for 60% of the variance in the length of assisted ventilation. For term infants, oxygenation index and anomalies were significant predictors but only accounted for 29% of the variance. Considerable variation exists in the utilization of ventilator support among infants of closely related gestational age. In addition, a number of medical risk factors influence the need for, and length of, assisted ventilation. These models explain much of the variance in LOV among preterm infants but explain substantially less among term infants.neonatal intensive care, assisted ventilation, Score for Neonatal Acute Physiology, resource consumption, prematurity.

The use of continuous positive airway pressure by face mask and thoracic epidural analgesia after lung transplantation

Objective: To evaluate the clinical use of continuous positive airway pressure (CPAP) and thoracic epidural analgesia (TEA) after lung transplantation (LTx). Design: Retrospective case series. Setting: Cardiothoracic intensive care unit (ICU) at a university hospital. Participants: All heart-lung, bilateral, and single-lung transplant recipients between 1990 and 1996 at this institution (n = 102). Interventions: Postoperative pain was controlled by a thoracic epidural infusion of bupivacaine, 1 mg/mL, and sufentanil, 1 μg/mL. After extubation, CPAP, 5 to 10 cm H 2O by face mask, was used to prevent reperfusion edema. Measurements and Main Results: In 99 patients, the length of ventilation (LOV) was a median of 4.3 hours (range, 1.0 to 312.0 hours). The median LOV was 8.0 hours (range, 1.5 to 41.0 hours) in the heart-lung recipients, 4.5 hours (range, 2.0 to 47.0 hours) in the bilateral-lung recipients, and 3.5 hours (range, 1.0 to 312.0 hours) in the single-lung recipients. Three transplant recipients, all with primary pulmonary hypertension, were prematurely extubated and reintubated because of pulmonary edema. Twelve hours after extubation, the median oxygenation index (PaO 2/F 1O 2, PaO 2 in kilopascal units) was greater than 35. The median ICU length of stay for all transplant recipients was 4 days (range, 2 to 270 days). Conclusion: The postoperative use of CPAP and TEA is associated with early and safe tracheal extubation after LTx and may shorten ICU stay.