Intermittent Mandatory Ventilation Research Articles

Weaning in Neurally Adjusted Ventilatory Assist (NAVA): a prospective interventional study in neonates.

Neurally adjusted ventilatory assist (NAVA) is a respiratory support triggered by the electrical activity of the diaphragm (EAdi). Only few studies evaluated NAVA short-term efficacy and safety in newborns. Aim of this study is to assess efficacy and safety of NAVA in a cohort of newborns and to analyse ventilation parameters helpful to guide weaning. Thirty-four newborns with respiratory failure were ventilated with Synchronized Intermittent Mandatory Ventilation plus pressure-regulated volume control plus pressure support (SIMV(PRVC)+PS) for 12 hours and switched to NAVA until extubation. Ventilator and vital parameters, oxygen saturation (SpO2)/fraction of inspired oxygen (FiO2) ratio (S/F), arterialized capillary blood gases (aCBG), and sedatives dose were recorded. The occurrence of re-intubation within the first 72 hours, pneumothorax and mortality were evaluated. After 6 hours of NAVA, a significant reduction of FiO2 (0.25 versus 0.32), and peak inspiratory pressure (13 versus 18 mmHg), and a significant increase of S/F (383 versus 316) were found, compared to SIMV(PRVC)+PS. Other ventilation, vital and aCBG parameters were similar in both ventilation modes. During NAVA a significant reduction of sedation was shown. All subjects were successfully extubated guided by EAdi peak during weaning. No re- intubation, pneumothorax, or death were recorded. NAVA can be effectively and safely used in neonates. The EAdi peak could be a reliable index to guide the physicians during weaning and extubation.

Approaches to Noninvasive Respiratory Support in Preterm Infants: From CPAP to NAVA

Endotracheal intubation and invasive mechanical ventilation have been mainstays in respiratory care of neonates with respiratory distress syndrome. Together with antenatal steroids and surfactant, this approach has accounted for significant reductions in neonatal mortality. However, with the increased survival of very low birthweight infants, the incidence of bronchopulmonary dysplasia (BPD), the primary respiratory morbidity of prematurity, has also increased. Arrest of alveolar growth and development and the abnormal development of the pulmonary vasculature after birth are the primary causes of BPD. However, invasive ventilation-associated lung inflammation and airway injury have long been believed to be important contributors. In fact, discontinuing invasive ventilation in favor of noninvasive respiratory support has been considered the single best approach that neonatologists can implement to reduce BPD. In this review, we present and discuss the mechanisms, efficacy, and long-term outcomes of the four main approaches to noninvasive respiratory support of the preterm infant currently in use: nasal continuous positive airway pressure, high-flow nasal cannula, nasal intermittent mandatory ventilation, and neurally adjusted ventilatory assist. We show that noninvasive ventilation can decrease rates of intubation and the need for invasive ventilation in preterm infants with respiratory distress syndrome. However, none of these noninvasive approaches decrease rates of BPD. Accordingly, noninvasive respiratory support should be considered for clinical goals other than the reduction of BPD.

Utilization of Neurally Adjusted Ventilatory Assist (NAVA) Mode in Infants and Children Undergoing Congenital Heart Surgery: A Retrospective Review.

We assessed the feasibility and the impact of NAVA compared to conventional modes of mechanical ventilation in ventilatory and gas exchange parameters in post-operative children with congenital heart disease. Infants and children (age < 18years) that underwent congenital heart surgery were enrolled. Patients were ventilated with conventional synchronized intermittent mechanical ventilation (SIMV) and subsequently transitioned to NAVA during their cardiovascular intensive care unit (CVICU) stay. The ventilatory and gas exchange parameters for the 24h pre- and post-transition to NAVA were compared. Additional parameters assessed included pain scores and sedation requirements. Eighty-one patients met inclusion criteria with a median age of 21days (interquartile range 13days-2months). The majority of patients enrolled (75.3%) had complex congenital heart disease with high surgical severity scores. The transition to NAVA was tolerated by all patients without complications. The mean peak inspiratory pressure (PIP) was 1.8cm H2O lower (p < 0.001) and mean airway pressure (Paw) was 0.5cm H2O lower (p = 0.009) on NAVA compared to conventional modes of mechanical ventilation. There was no significant difference in patients' respiratory rate, tidal volume, arterial pH, pCO2, and lactate levels between the two modes of ventilation. There was a decreased sedation requirement during the time of NAVA ventilation. Comfort scores did not differ significantly with ventilator mode change. We concluded that NAVA is safe and well-tolerated mode of mechanical ventilation for our cohort of patients after congenital heart surgery. Compared to conventional ventilation there was a statistically significant decrease in PIP and Paw on NAVA.

New modalities for non-invasive positive pressure ventilation: A review article.

Efficiency of non-invasive positive pressure ventilation in the treatment of respiratory failure has been shown in many published studies. In this review article, we introduced new modalities of non-invasive ventilation (NIV), clinical settings in which NIV can be used and a practical summary of the latest official guidelines published by the European Respiratory Clinical Practice. Clinical trials and review articles in four databases up to 25 February 2018 about new modalities of non-invasive positive pressure ventilation were reviewed. Commonly used modalities for treatment of respiratory failure include: CPAP (continuous positive airway pressure) and BiPAP (bilevel positive airway pressure) or NIPSV (noninvasive pressure support ventilation). The limitations of the BiPAP method are the trigger and cycle asynchrony, inadequate volume delivery and increased respiratory rate. Newer methods, such as adaptive servo-ventilation, have been developed to treat central and complex sleep apnea and the NAVA (neutrally adjusted ventilatory assist) to improve the trigger and cycle asynchrony. In the proportional assist ventilation, unlike the pressure support ventilation, with increased patient effort (flow) the tidal volume increases and it prevents the increase in the respiratory rate and respiratory distress. High-flow nasal cannula is a non-invasive technique that does not provide respiratory support, but provides a mixture of oxygen to the patient. The use of non-invasive pursed-lip breathing ventilation in chronic obstructive pulmonary disease (COPD) patients reduces dyspnea (decreases respiratory rate) and increases blood oxygen saturation. New modalities of NIV improve patient comfort and patient–ventilator interactions, and are recommended in patients with respiratory failure.

经鼻同步间歇指令通气对早产儿频发性呼吸暂停的疗效观察

经鼻同步间歇指令通气对早产儿频发性呼吸暂停的疗效观察

Heated Humidified High Flow Nasal Cannula (HHHFNC) is not an effective method for initial treatment of Respiratory Distress Syndrome (RDS) versus nasal intermittent mandatory ventilation (NIMV) and nasal continuous positive airway pressure (NCPAP).

Background:Noninvasive respiratory support techniques are widely used to treat respiratory distress syndrome (RDS) in preterm infants, and the effectiveness of these methods should be compared. In the current study, nasal continuous positive airway pressure (NCPAP), nasal intermittent mandatory ventilation (NIMV), and heated humidified high-flow nasal cannula (HHHFNC) were compared.Materials and Methods:In the current bicenter clinical trial, 109 preterm infants with RDS not treated with surfactant were randomly assigned to three groups: NCPAP, NIMV, and HHHFNC. The initial outcomes including the failure of treatment within the first initial 72 h, and the duration of RDS treatment, and the secondary outcomes including the need for intubation, the need for surfactants, the duration of oxygen dependency, the incidence of pneumothorax, the patent ductus arteriosus, intraventricular hemorrhage, length of stay, and mortality were compared among the groups.Results:The frequency of HHHFNC treatment failure (54.3%) was significantly higher compared with those of NIMV (21.6%) (P < 0.001, hazard ratio [HR] = 9.12, 95% confidence interval [CI] = 2.59 – 32.07) and NCPAP (35.1%) (P = 0.004, HR = 21.25, 95% CI = 2.51–180.08). The median duration of RDS treatment was longer (40 h) in the HHHFNC group, although it was not significantly different from those of NIMV (31.16 h) and NCPAP (38.91 h).Conclusion:Based on the high prevalence of failure of HHHFNC treatment than the other two methods (NCPAP and NIMV), HHHFNC is not recommended as the initial treatment of RDS.

Optimal Conventional Mechanical Ventilation in Full-Term Newborns: A Systematic Review.

Most studies examining the best mechanical ventilation strategies in newborn infants have been performed in premature infants with respiratory distress syndrome. To identify and synthesize the evidence regarding optimal mechanical ventilation strategies in full-term newborns. Systematic review carried out according to the methods described in the PRISMA statement. Searches in MEDLINE, EMBASE, CINAHL, and the Cochrane Library in March 2017, with an updated search and hand searches of reference lists of relevant articles in August 2017. Studies were included if they were published between 1996 and 2017, involved newborns with gestational age of 37 to 42 weeks, were randomized controlled trials, intervention or crossover studies, and addressed outcomes affecting oxygenation and/or ventilation, and/or short-term outcomes including duration of mechanical ventilation. Because of the large heterogeneity between the studies, it was not possible to synthesize the results in meta-analyses. The results are presented according to thematic analysis. No individual study reported research exclusively in newborns 37 to 42 weeks of gestation. Eight studies fulfilled the inclusion criteria, but the population in all these studies included both premature and term newborns. Evidence about mechanical ventilation tailored exclusively to full-term newborns is scarce. Synchronized intermittent mandatory ventilation with a 6 mL/kg tidal volume and a positive end-expiratory pressure of 8 cm H2O may be advantageous in full-term newborns. There is an urgent need for high-quality studies, preferably randomized controlled trials, in full-term newborns requiring mechanical ventilation to optimize oxygenation, ventilation, and short-term outcomes, potentially stratified according to the underlying pathology.

Is Inspiratory Muscle Weakness a Determinant of Endurance Exercise Tolerance During NIV-Supported Exercise in Patients With COPD?

Previous research has reported that inspiratory muscle weakness is critical to decreased exercise tolerance and exercise tolerance improves with 10 cmH2O pressure support ventilation in patients with chronic obstructive pulmonary disease (COPD). The purpose of this study was to evaluate the effects of proportional assist ventilation (PAV) and continuous positive airway pressure (CPAP) compared with sham on exercise tolerance in patients with and without inspiratory muscle weakness. In a prospective design, 12 of 54 patients were eligible after clinical and comprehensive lung function evaluation, including maximum inspiratory pressure (MIP) measurement. Using baseline measures, participants were divided into 2 age-matched groups that differed in regard to MIP (Group 1, MIP <60 cmH2O, and Group 2, MIP ≥60 cmH2O). Each participant performed 3 constant work rate tests with noninvasive support (PAV, CPAP, sham) in random order on different days at 80% of maximal incremental power. During the endurance tests, heart rate, peripheral oxygen saturation (SpO2), dyspnea perception scale, and exercise tolerance were measured. There were no significant differences between groups for heart rate, SpO2, dyspnea perception, or exercise tolerance during PAV, CPAP, or sham-supported exercise (P > .05 for all). In this small representative group of patients with COPD, inspiratory muscle weakness was not a determining factor of performance during CPAP or PAV-supported aerobic exercise.

Comparison of Noninvasive Dynamic Indices of Fluid Responsiveness Among Different Ventilation Modes in Dogs Recovering from Experimental Cardiac Surgery.

BackgroundFluid resuscitation is a cornerstone of minimizing morbidity and mortality in critically ill patients, but the techniques for predicting fluid responsiveness is still a matter of debate. In this study, we aimed to evaluate the utility of noninvasive stroke volume variation (SVV), pulse pressure variation (PPV), and systolic pressure variation (SPV) as a dynamic predictor for assessing fluid responsiveness during different ventilation modes in anaesthetized, intubated dogs recovering from cardiac surgery.Material/MethodsThirty-six adult Beagle dogs undergoing experimental surgery for isolated right ventricular failure were monitored for SVV, PPV, and SPV simultaneously using electrical velocimetry device. The relationships between each indicator and SVI before and after volume loading were compared in 3 ventilatory modes: assist control (A/C), synchronized intermittent mandatory ventilation (SIMV), and continuous positive airway pressure (CPAP). Responders were defined as those whose stroke volume index increased by ≥10%.ResultsIn all of the indices, the baseline values were greater in responders than in nonresponders (P<0.01) under A/C and SIMV. Receiver operating curve analysis confirmed the best predictive value during A/C [area under the curve (AUC): SVV, 0.90; PPV, 0.88; SPV, 0.85; P<0.05] followed by SIMV (AUC: SVV, 0.86; PPV, 0.83; CPAP, 0.80; P<0.05), with their sensitivities and specificities of ≥7 5%. By contrast, no statistically significance detected in any parameter during CPAP (AUC: SVV, 0.71; PPV, 0.66; CPAP, 0.65; P>0.05).ConclusionsSVV, PPV, and SVV are all useful to predict cardiac response to fluid loading in dogs during A/C and SIMV, while their reliabilities during CPAP are poor.

Effect of hemodialysis on respiratory mechanics in acute kidney injury patients.

Hemodialysis (HD) is one treatment for acute kidney injury (AKI) patients. Studies have shown that this dialysis modality may lead to changes in pulmonary function with an impact on prognosis. The aim of our study was to evaluate changes in respiratory mechanics and oxygenation of AKI patients admitted to an intensive care unit who were undergoing intermittent mechanical ventilation (IMV) and daily HD. This prospective cohort study evaluated 94 AKI patients and 234 HD sessions. Pulmonary static compliance (Pcs), resistance (Rsr), and arterial partial pressure of oxygen and the fraction of inspired oxygen (PaO2 /FiO2 ) ratio were assessed during the initial three-day period of daily HD therapy. Psc increased progressively during HD sessions, from 39.4 ± 21.4 mL/cm H2 O prior to the initial dialysis to 55.5 ± 25.2 at the end of the last dialysis during the study period (P = 0.04). Similarly, Rsr and PaO2 /FiO2 ratio also improved, from 11.1 ± 6.3 cm H2 O/L/s prior to the initial dialysis to 8.8 ± 4.2 at the end of the last dialysis (P =0.0027) and from 228 ± 85 prior to the initial dialysis to 312.1 ± 111.5, P < 0.001, to the end of the last dialysis, respectively. This study showed that AKI patients undergoing IMV and daily HD improve their respiratory mechanics and oxygenation.

Clinical characteristics and outcomes associated with nasal intermittent mandatory ventilation in acute pediatric respiratory failure.

AIMTo characterize the clinical course and outcomes of nasal intermittent mandatory ventilation (NIMV) use in acute pediatric respiratory failure.METHODSWe identified all patients treated with NIMV in the pediatric intensive care unit (PICU) or inpatient general pediatrics between January 2013 and December 2015 at two academic centers. Patients who utilized NIMV with other modes of noninvasive ventilation during the same admission were included. Data included demographics, vital signs on admission and prior to initiation of NIMV, pediatric risk of mortality III (PRISM-III) scores, complications, respiratory support characteristics, PICU and hospital length of stays, duration of respiratory support, and complications. Patients who did not require escalation to mechanical ventilation were defined as NIMV responders; those who required escalation to mechanical ventilation (MV) were defined as NIMV non-responders. NIMV responders were compared to NIMV non-responders.RESULTSForty-two patients met study criteria. Six (14%) failed treatment and required MV. The majority of the patients (74%) had a primary diagnosis of bronchiolitis. The median age of these 42 patients was 4 mo (range 0.5-28.1 mo, IQR 7, P = 0.69). No significant difference was measured in other baseline demographics and vitals on initiation of NIMV; these included age, temperature, respiratory rate, O2 saturation, heart rate, systolic blood pressure, diastolic blood pressure, and PRISM-III scores. The duration of NIMV was shorter in the NIMV non-responder vs NIMV responder group (6.5 h vs 65 h, P < 0.0005). Otherwise, NIMV failure was not associated with significant differences in PICU length of stay (LOS), hospital LOS, or total duration of respiratory support. No patients had aspiration pneumonia, pneumothorax, or skin breakdown.CONCLUSIONMost of our patients responded to NIMV. NIMV failure is not associated with differences in hospital LOS, PICU LOS, or duration of respiratory support.

Role of Pulmonary Sonography in Evaluation of Artificially Ventilated Neonates

AbstractBackground: Several neonatal chest conditions require Invasive mechanical ventilation, which is lifesaving for the critically ill neonates. Limiting the duration of airway intuba-tion and mechanical ventilator support is crucial. Weaning from mechanical ventilation induces significant changes in lung aeration which can be easily detected by lung sonography.Aim of the Work: Is to identify the role of pulmonary sonography in evaluation of the artificially ventilated neonates.Patients and Methods: The study included 40 neonates suffering from peripheral diseases requiring mechanical ventilation. All patients had chest ultrasound studies after clinical assessment. Chest ultrasound was performed during the different modes of mechanical ventilation including Assisted Controlled Ventilation (AC), Synchronized Intermit-tent Mechanical Ventilation (SIMV) and before extubation, follow-up the patients for 48 hours postextubation to assess if its failure occurred. Lung ultrasound was done using a standardized evaluation of lung aeration, i.e. Lung Ultrasound Score (LUS). Other traditional investigations including blood gases and chest X-ray were performed as well.Results: LUS was significantly higher in the 10 patients with post extubation failure. A cut off value of LUS of >13 was highly sensitive and specific for failure of switching from AC to SIMV mode and >6 prior to extubation was indicative of post extubation failure.Conclusion: Chest ultrasound provides a rapid, non inva-sive, objective and reliable tool for guiding the mechanical ventilation weaning process in neonates through the LUS with high confidence even when compared to other traditional indices as blood gases and respiratory mechanics. A cut off value of LUS of >13 was highly sensitive and specific for failure of switching from AC to SIMV mode and >6 prior to extubation was indicative of post extubation failure.

Utility of electrical velocimetry-based noninvasive stroke volume variation in predicting fluid responsiveness under different ventilation modes in anaesthetized dogs.

We evaluated the utility of noninvasive stroke volume variation (SVV) as a functional haemodynamic predictor for fluid responsiveness under different ventilation modes [assist control (A/C), synchronized intermittent mandatory ventilation (SIMV), and continuous positive airway pressure (CPAP)] in 45 anaesthetized dogs, using an electrical velocimetry device. Receiver operating curve analysis confirmed the best predictive value during SVVA/C (12.5% of cut-off value; 75% sensitivity and 86% specificity) followed by SVVSIMV (13.5% of cut-off value; 75% sensitivity and 75% specificity), while no statistically significance detected during SVVCPAP (P > .05). These data suggest that SVV is useful for the prediction of fluid responsiveness in laboratory dogs during A/C and SIMV, while its reliability during CPAP is poor. This article is protected by copyright. All rights reserved.

Vitamin A Protects the Preterm Lamb Diaphragm Against Adverse Effects of Mechanical Ventilation.

Background: Preterm infants are deficient in vitamin A, which is essential for growth and development of the diaphragm. Preterm infants often require mechanical ventilation (MV) for respiratory distress. In adults, MV is associated with the development of ventilation-induced diaphragm dysfunction and difficulty weaning from the ventilator. We assessed the impact of MV on the preterm diaphragm and the protective effect of vitamin A during MV.Methods: Preterm lambs delivered operatively at ∼131 days gestation (full gestation: 150 days) received respiratory support by synchronized intermittent mandatory ventilation for 3 days. Lambs in the treated group received daily (24 h) enteral doses of 2500 IU/kg/day vitamin A combined with 250 IU/kg/day retinoic acid (VARA) during MV, while MV control lambs received saline. Unventilated fetal reference lambs were euthanized at birth, without being allowed to breathe. The fetal diaphragm was collected to quantify mRNA levels of myosin heavy chain (MHC) isoforms, atrophy genes, antioxidant genes, and pro-inflammatory genes; to determine ubiquitin proteasome pathway activity; to measure the abundance of protein carbonyl, and to investigate metabolic signaling.Results: Postnatal MV significantly decreased expression level of the neonatal MHC gene but increased expression level of MHC IIx mRNA level (p < 0.05). Proteasome activity increased after 3 days MV, accompanied by increased MuRF1 mRNA level and accumulated protein carbonyl abundance. VARA supplementation decreased proteasome activity and FOXO1 signaling, down-regulated MuRF1 expression, and reduced reactive oxidant production.Conclusion: These findings suggest that 3 days of MV results in abnormal myofibrillar composition, activation of the proteolytic pathway, and oxidative injury of diaphragms in mechanically ventilated preterm lambs. Daily enteral VARA protects the preterm diaphragm from these adverse effects.

Case 2: Acute Respiratory Distress, Hypoxia, and Pulmonary Hypertension in the Nursery

A female infant is born at 39 weeks’ gestation to a 28-year-old, gravida 3, para 2 woman who received regular prenatal care. Her history is significant for blood type O negativity (for which she received Rho(D) immunoglobulin at 28 weeks), hypothyroidism (treated with levothyroxine), polycystic ovarian syndrome (treated with metformin), and anxiety. The neonate is born via repeat cesarean section with vacuum assistance. The infant’s Apgar scores are 9 and 9 at 1 and 5 minutes, respectively. In the well-child nursery, the infant is hypoxic and has an oxygen saturation of 40%, requiring nasal continuous positive airway pressure of 5 cm H2O and fraction of inspired oxygen (FiO2) of 50%; she is transferred to the NICU. In the NICU, she was noted to have increased work of breathing, and required nasal intermittent mandatory ventilation and FiO2 of 50%. Chest radiography suggested respiratory distress syndrome versus pneumonia. Blood and urine samples were obtained for culture, and she was started on empirical antibiotic treatment for clinical pneumonia in the setting of presumed sepsis. Pediatric cardiology was consulted because of the clinical suggestion of pulmonary hypertension. Hyperoxia test, electrocardiography, and echocardiography showed no evidence of congenital heart disease. An incidental finding of ductus arteriosus thrombus extending to the main pulmonary artery and left pulmonary artery was uncovered on echocardiography (Figs 1 and 2). Figure 1. Echocardiographic parasternal short-axis view shows a cross-sectional image of the heart. Here the thrombus is protruding from the patent ductus arteriosus into the main pulmonary artery (MPA) and left pulmonary artery (LPA). Figure 2. Echocardiographic images captured along the suprasternal notch view demonstrate the aortic arch. Here the patent ductus …

Sedation during minimal invasive surfactant therapy: a randomised controlled trial

Background and aimsAlthough sedation for endotracheal intubation of infants is widely adopted, there is no consensus whether sedation should be used for minimal invasive surfactant therapy (MIST). We compared, in...

Dynamics of indices of cerebral oximetry in various procedures of general anesthesia on stages of transduodenal endoscopic operative interventions in patients, suffering obturation jaundice

Objective. To study the impact of separate anesthesiological procedures on cerebral oxygenation on stages of transduodenal endoscopic operative interventions in patients, suffering obturation jaundice.&#x0D; Маterials and methods. A monitoring investigation for the cerebral oxygenation state was conducted in patients of three investigated groups in conditions of various procedures of general anesthesia. Моnitoring of cerebral oxygenation was done, using the monitoring system, named INVOS 500B. In patients of Group I the intravenous general anesthesia with propofol and fentanyl in conditions of a secured spontaneous respiration with the oxygen inhalation was applied; in patients of Group II - intravenous general anesthesia, using propofol, fentanyl and atracurium besylate in conditions of a controlled mechanical ventilation (СМV) via a standard endotracheal tube; in patients of Group III - a deep analgosedation, using propofol and fentanyl in conditions of supportive pulmonary ventilation in a regime of synchronized intermittent mandatory ventilation (SIMV) via gastrolaryngeal tube.&#x0D; Results. In patients of Group I on the main stage of the operative intervention the cerebral oxygenation index (rSpO2) have lowered by 24.2% respectively initial value and by 37.8% - repectively the value while beginning of the operation. In patients of Groups ІІ and ІІІ a controlled index on all stages of the operation persisted stable.&#x0D; Conclusion. Advantage must be given to general anesthesia in a SIMV pulmonary regime via gastrolaryngeal tube.

Analysis on treatment of extremely severe burn patients with severe inhalation injury in August 2nd Kunshan factory aluminum dust explosion accident

Objective: To summarize the measures and experience in diagnosis and treatment of extremely severe burn patients with severe inhalation injury in dust explosion accident. Methods: The medical records of 13 patients with extremely severe burn complicated with severe inhalation injury in August 2nd Kunshan factory aluminum dust explosion accident who were treated at the First Affiliated Hospital of Soochow University (hereinafter referred to as our hospital) on August 2nd, 2014, were retrospectively analyzed. All the patients were transferred to our hospital 3-8 hours after injury under the condition of inhalation of pure oxygen. Twelve patients underwent tracheotomy within 5 hours after admission, while 1 patient underwent tracheotomy before admission. All the patients were in ventilator-assisted respiration, with synchronized intermittent mandatory ventilation combined with positive end expiratory pressure. All the patients underwent thorax or limbs escharotomy on the second day after admission, so as to reduce the restrictive ventilatory dysfunction caused by the contraction of thorax eschar and the terminal circulation disorder caused by the contraction of limbs eschar. All the patients underwent electronic bronchoscopy within 48 hours after admission, airway secretion were cleared and airway lavage were carried out under electronic bronchoscope according to the patients' condition, and the sputum, lavage solution, pathological tissue were collected for microbiological culture. All the patients underwent chest X-ray examination on the second day after admission and reexamination as required. Patients were all treated with a combination of broad-spectrum antibiotics early after admission to control lung and systemic infection. One patient was treated with extracorporeal membrane oxygenation for acute respiratory distress syndrome 1 week after admission. Results: One patient suffered from cardiopulmonary arrest during tracheotomy, which recovered autonomous respiration and cardiac impulse after cardiopulmonary resuscitation. Three patients showed decreased pulse oxygen saturation (SpO(2)) within 48 hours after injury, and the SpO(2) returned to normal after sputum aspiration, scab removal and lavage under electronic bronchoscope. During the course of disease, bacteria were cultured from wound exudate of 7 patients, bacteremia occurred in 10 patients, and sputum microbiological culture results of 13 patients were positive. Eight of the 13 patients in this group survived, and 5 died. One patient died 19 days after injury, and 4 patients died 33-46 days after injury. The main cause of death was multiple organ dysfunction syndrome induced by severe septic shock eventually. Conclusions: For this batch of patients with extremely severe burn complicated with severe inhalation injury caused by dust explosion accident, the treatment and cure measures including early definite diagnosis and timely tracheotomy, the application of effective ventilation, the effective treatment of respiratory system complications, and rational use of antibiotics for the control of lung infection obtained quite good curative effect.

Tuberculous pneumonia-induced severe ARDS complicated with DIC in a female child: a case of successful treatment

BackgroundTuberculous (TB) pneumonia can induce acute respiratory distress syndrome (ARDS). Although TB pneumonia is one of the causes of disease and death among children worldwide, the literature on TB pneumonia-induced ARDS is limited. We report herein on the successful treatment of a two-year-old female child with TB pneumonia-induced severe ARDS complicated with disseminated intravascular coagulation (DIC).Case presentationA two-year-old Vietnamese female child with sustained fever and cough for 20 days was transferred to our hospital. She had severe dyspnea and a chest X-ray showed bilateral infiltration without findings of heart failure. After tracheal intubation, her oxygenation index (OI) and PaO2/FiO2 (PF) ratio were 29 and 60 mmHg, respectively. Mycobacterium tuberculosis was detected by real-time polymerase chain reaction (rPCR) assay of tracheal lavage fluid. She was diagnosed as having severe ARDS that developed from TB pneumonia. Anti-tuberculous therapy and cardiopulmonary support were started. However, her respiratory condition deteriorated despite treatment with high-frequency oscillating ventilation (HFO), vasopressor support, and 1 g/kg of immunoglobulin. On the third day after admission, her International Society on Thrombosis and Hemostasis DIC score had increased to 5. Recombinant human soluble thrombomodulin (rTM) was administered to treat the DIC. After the administration of rTM was completed, OI gradually decreased, after which the mechanical ventilation mode was changed from HFO to synchronized intermittent mandatory ventilation. The DIC score also gradually decreased. Plasma levels of soluble receptor for advanced glycan end products (sRAGE) and high mobility group box 1 (HMGB-1), which are reported to be associated with ARDS severity, also decreased. In addition, inflammatory biomarkers, including interferon-gamma (IFN-γ) and interleukin-6 (IL-6), decreased after the administration of rTM. Although severe ARDS (P/F ratio ≦ 100 mmHg) continued for 19 days, the patient’s OI and P/F ratio improved gradually, and she was extubated on the 27th day after admission. The severe ARDS with DIC was successfully treated, and she was discharged from hospital on day 33 post-admission.ConclusionsWe successfully treated a female child suffering from TB pneumonia-induced severe ARDS complicated with DIC using multimodal interventions. (338/350).

Evaluating the Cost-Effectiveness of Proportional-Assist Ventilation Plus vs. Pressure Support Ventilation in the Intensive Care Unit in Two Countries.

Background: Mechanical ventilation is an integral, but expensive, part of the intensive care unit (ICU). Optimal use of mechanical ventilation could save costs and improve patient outcomes. Here, the cost effectiveness of proportional assist ventilation (PAV™ ventilation by Medtronic) is estimated relative to pressure support ventilation (PSV).Methods: A cohort-level, clinical model was built using data from clinical trials. The model estimates patient-ventilator asynchrony >10%, tracheostomy, ventilator-associated pneumonia, other nosocomial infections, spontaneous breathing trial success, hypoxemia, and death. Cost and quality of life are associated with all events, with cost effectiveness defined as the cost per quality-adjusted life year (QALY) gained in the US and UK.Results: The mean cost of ICU care was lower with PAV™ than with PSV in the US and UK, but the total cost of care over 40 years was higher due to more patients surviving and incurring future care costs. Reduced time on mechanical ventilation, fewer nosocomial infections, and extended life expectancy with PAV™ drove QALY improvement. The cost per QALY gained with PAV™ was $8,628 and £2,985.Conclusion: PAV™ improves quality of life and reduces short-term costs. PAV™ is likely to be considered cost-effective over 40-years in the US and UK.