Using artificial intelligence to predict prolonged mechanical ventilation and tracheostomy placement.

PubMed

Parreco, Joshua; Hidalgo, Antonio; Parks, Jonathan J; Kozol, Robert; Rattan, Rishi

2018-08-01

Early identification of critically ill patients who will require prolonged mechanical ventilation (PMV) has proven to be difficult. The purpose of this study was to use machine learning to identify patients at risk for PMV and tracheostomy placement. The Multiparameter Intelligent Monitoring in Intensive Care III database was queried for all intensive care unit (ICU) stays with mechanical ventilation. PMV was defined as ventilation >7 d. Classifiers with a gradient-boosted decision trees algorithm were created for the outcomes of PMV and tracheostomy placement. The variables used were six different severity-of-illness scores calculated on the first day of ICU admission including their components and 30 comorbidities. Mean receiver operating characteristic curves were calculated for the outcomes, and variable importance was quantified. There were 20,262 ICU stays identified. PMV was required in 13.6%, and tracheostomy was performed in 6.6% of patients. The classifier for predicting PMV was able to achieve a mean area under the curve (AUC) of 0.820 ± 0.016, and tracheostomy was predicted with an AUC of 0.830 ± 0.011. There were 60.7% patients admitted to a surgical ICU, and the classifiers for these patients predicted PMV with an AUC of 0.852 ± 0.017 and tracheostomy with an AUC of 0.869 ± 0.015. The variable with the highest importance for predicting PMV was the logistic organ dysfunction score pulmonary component (13%), and the most important comorbidity in predicting tracheostomy was cardiac arrhythmia (12%). This study demonstrates the use of artificial intelligence through machine-learning classifiers for the early identification of patients at risk for PMV and tracheostomy. Application of these identification techniques could lead to improved outcomes by allowing for early intervention. Copyright © 2018 Elsevier Inc. All rights reserved.

Cost containment and mechanical ventilation in the United States.

PubMed

Cohen, I L; Booth, F V

1994-08-01

In many ICUs, admission and discharge hinge on the need for intubation and ventilatory support. As few as 5% to 10% of ICU patients require prolonged mechanical ventilation, and this patient group consumes > or = 50% of ICU patient days and ICU resources. Prolonged ventilatory support and chronic ventilator dependency, both in the ICU and non-ICU settings, have a significant and growing impact on healthcare economics. In the United States, the need for prolonged mechanical ventilation is increasingly recognized as separate and distinct from the initial diagnosis and/or procedure that leads to hospitalization. This distinction has led to improved reimbursement under the prospective diagnosis-related group (DRG) system, and demands more precise accounting from healthcare providers responsible for these patients. Using both published and theoretical examples, mechanical ventilation in the United States is discussed, with a focus on cost containment. Included in the discussion are ventilator teams, standards of care, management protocols, stepdown units, rehabilitation units, and home care. The expanding role of total quality management (TQM) is also presented.

Predictors of successful weaning from prolonged mechanical ventilation in Taiwan.

PubMed

Wu, Yao-Kuang; Kao, Kuo-Chin; Hsu, Kuang-Hung; Hsieh, Meng-Jer; Tsai, Ying-Huang

2009-08-01

For adult patients on prolonged mechanical ventilation (PMV, >/=21 days), successful weaning has been attributed to various factors. The purpose of this study was to describe patient outcomes, weaning rates and factors in successful weaning at a hospital-based respiratory care center (RCC) in Taiwan. This was a retrospective observational study performed in a 24-bed RCC over six years. A total of 1307 patients on PMV were included in the study. The overall survival rate was 62%. Fifty-six percent of patients were successfully weaned. Unsuccessfully weaned patients had higher MICU transfer rates, higher Acute Physiology and Chronic Health Evaluation II scores, longer duration of RCC stay, higher rates of being bed-ridden prior to admission, increased hemodialysis rates, higher modified Glasgow Coma Scale scores, higher rapid shallow breathing index, lower inspiratory pressure at residual volume (PImax) and lower blood urea nitrogen (BUN) and creatinine levels. Factors found to be associated with unsuccessful weaning were length of RCC stay (OR=1.04, P<0.001), modified GCS score (OR=0.93, P<0.046), PImax (OR=0.97, P<0.001), serum albumin concentration (OR=0.62, P<0.023) and BUN level (OR=1.01, P<0.002). High rates of ventilator independence can be achieved in an RCC setting as an alternative to ICU care. Factors associated with unsuccessful weaning included longer duration of RCC stay, elevated BUN levels and lower modified GCS scores, serum albumin and PImax levels.

The use of tracheostomy speaking valves in mechanically ventilated patients results in improved communication and does not prolong ventilation time in cardiothoracic intensive care unit patients.

PubMed

Sutt, Anna-Liisa; Cornwell, Petrea; Mullany, Daniel; Kinneally, Toni; Fraser, John F

2015-06-01

The aim of this study was to assess the effect of the introduction of in-line tracheostomy speaking valves (SVs) on duration of mechanical ventilation and time to verbal communication in patients requiring tracheostomy for prolonged mechanical ventilation in a predominantly cardiothoracic intensive care unit (ICU). We performed a retrospective preobservational-postobservational study using data from the ICU clinical information system and medical record. Extracted data included demographics, diagnoses and disease severity, mechanical ventilation requirements, and details on verbal communication and oral intake. Data were collected on 129 patients. Mean age was 59 ± 16 years, with 75% male. Demographics, case mix, and median time from intubation to tracheostomy (6 days preimplementation-postimplementation) were unchanged between timepoints. A significant decrease in time from tracheostomy to establishing verbal communication was observed (18 days preimplementation and 9 days postimplementation, P <.05). There was no difference in length of mechanical ventilation (20 days preimplementation-post) or time to decannulation (14 days preimplementation-postimplementation). No adverse events were documented in relation to the introduction of in-line SVs. In-line SVs were successfully implemented in mechanically ventilated tracheostomized patient population. This resulted in earlier verbal communication, no detrimental effect on ventilator weaning times, and no change in decannulation times. The purpose of the study was to compare tracheostomy outcomes in mechanically ventilated patients in a cardiothoracic ICU preintroduction and postintroduction of in-line SVs. It was hypothesized that in-line SVs would improve communication and swallowing specific outcomes with no increase in average time to decannulation or the number of adverse events. Copyright © 2015 Elsevier Inc. All rights reserved.

Integrated Stress Response Mediates Epithelial Injury in Mechanical Ventilation.

PubMed

Dolinay, Tamas; Himes, Blanca E; Shumyatcher, Maya; Lawrence, Gladys Gray; Margulies, Susan S

2017-08-01

Ventilator-induced lung injury (VILI) is a severe complication of mechanical ventilation that can lead to acute respiratory distress syndrome. VILI is characterized by damage to the epithelial barrier with subsequent pulmonary edema and profound hypoxia. Available lung-protective ventilator strategies offer only a modest benefit in preventing VILI because they cannot impede alveolar overdistension and concomitant epithelial barrier dysfunction in the inflamed lung regions. There are currently no effective biochemical therapies to mitigate injury to the alveolar epithelium. We hypothesize that alveolar stretch activates the integrated stress response (ISR) pathway and that the chemical inhibition of this pathway mitigates alveolar barrier disruption during stretch and mechanical ventilation. Using our established rat primary type I-like alveolar epithelial cell monolayer stretch model and in vivo rat mechanical ventilation that mimics the alveolar overdistension seen in acute respiratory distress syndrome, we studied epithelial responses to mechanical stress. Our studies revealed that the ISR signaling pathway is a key modulator of epithelial permeability. We show that prolonged epithelial stretch and injurious mechanical ventilation activate the ISR, leading to increased alveolar permeability, cell death, and proinflammatory signaling. Chemical inhibition of protein kinase RNA-like endoplasmic reticulum kinase, an upstream regulator of the pathway, resulted in decreased injury signaling and improved barrier function after prolonged cyclic stretch and injurious mechanical ventilation. Our results provide new evidence that therapeutic targeting of the ISR can mitigate VILI.

Characteristics and outcomes of ventilated patients according to time to liberation from mechanical ventilation.

PubMed

Peñuelas, Oscar; Frutos-Vivar, Fernando; Fernández, Cristina; Anzueto, Antonio; Epstein, Scott K; Apezteguía, Carlos; González, Marco; Nin, Nicholas; Raymondos, Konstantinos; Tomicic, Vinko; Desmery, Pablo; Arabi, Yaseen; Pelosi, Paolo; Kuiper, Michael; Jibaja, Manuel; Matamis, Dimitros; Ferguson, Niall D; Esteban, Andrés

2011-08-15

A new classification of patients based on the duration of liberation of mechanical ventilation has been proposed. To analyze outcomes based on the new weaning classification in a cohort of mechanically ventilated patients. Secondary analysis included 2,714 patients who were weaned and underwent scheduled extubation from a cohort of 4,968 adult patients mechanically ventilated for more than 12 hours. Patients were classified according to a new weaning classification: 1,502 patients (55%) as simple weaning,1,058 patients (39%) as difficult weaning, and 154 (6%) as prolonged weaning.Variables associated with prolonged weaning(.7d)were: severity at admission (odds ratio [OR] per unit of Simplified Acute Physiology Score II, 1.01; 95% confidence interval [CI], 1.001–1.02), duration of mechanical ventilation before first attempt of weaning (OR per day, 1.10; 95% CI, 1.06–1.13), chronic pulmonary disease other than chronic obstructive pulmonary disease (OR,13.23; 95% CI, 3.44–51.05), pneumonia as the reason to start mechanical ventilation (OR, 1.82; 95% CI, 1.07–3.08), and level of positive end-expiratory pressure applied before weaning (OR per unit,1.09; 95% CI, 1.04–1.14). The prolonged weaning group had a nonsignificant trend toward a higher rate of reintubation (P ¼ 0.08),tracheostomy (P ¼ 0.15), and significantly longer length of stay and higher mortality in the intensive care unit (OR for death, 1.97;95%CI, 1.17–3.31). The adjusted probability of death remained constant until Day 7, at which point it increased to 12.1%.

The influence of music during mechanical ventilation and weaning from mechanical ventilation: A review

PubMed Central

Hetland, Breanna; Lindquist, Ruth; Chlan, Linda L.

2015-01-01

Background Mechanical ventilation (MV) causes many distressing symptoms. Weaning, the gradual decrease in ventilator assistance leading to termination of MV, increases respiratory effort, which may exacerbate symptoms and prolong MV. Music, a non-pharmacological intervention without side effects may benefit patients during weaning from mechanical ventilatory support. Methods A narrative review of OVID Medline, PsychINFO, and CINAHL databases was conducted to examine the evidence for the use of music intervention in MV and MV weaning. Results Music intervention had a positive impact on ventilated patients; 16 quantitative and 2 qualitative studies were identified. Quantitative studies included randomized clinical trials (10), case controls (3), pilot studies (2) and a feasibility study. Conclusions Evidence supports music as an effective intervention that can lesson symptoms related to MV and promote effective weaning. It has potential to reduce costs and increase patient satisfaction. However, more studies are needed to establish its use during MV weaning. PMID:26227333

Development and pilot testing of a decision aid for surrogates of patients with prolonged mechanical ventilation

PubMed Central

Cox, Christopher E.; Lewis, Carmen L.; Hanson, Laura C.; Hough, Catherine L.; Kahn, Jeremy M.; White, Douglas B.; Song, Mi-Kyung; Tulsky, James A.; Carson, Shannon S.

2013-01-01

Objective Shared decision making is inadequate in intensive care units (ICUs). Decision aids can improve decision making quality, though their role in an ICU setting is unclear. We aimed to develop and pilot test a decision aid for shared decision makers of patients undergoing prolonged mechanical ventilation. Setting ICUs at three medical centers. Subjects 53 surrogate decision makers and 58 physicians. Design and interventions We developed the decision aid using defined methodological guidelines. After an iterative revision process, formative cognitive testing was performed among surrogate-physician dyads. Next, we compared the decision aid to usual care control in a prospective, before/after design study. Measurements and main results Primary outcomes were physician-surrogate discordance for expected patient survival, comprehension of relevant medical information, and the quality of communication. Compared to control, the intervention group had lower surrogate-physician discordance (7 [10] vs 43 [21]), greater comprehension (11.4 [0.7] vs 6.1 [3.7]), and improved quality of communication (8.7 [1.3] vs 8.4 [1.3]) (all p<0.05) post-intervention. Hospital costs were lower in the intervention group ($110,609 vs $178,618; p=0.044); mortality did not differ by group (38% vs 50%, p=0.95). 94% of surrogates and 100% of physicians reported that the decision aid was useful in decision making. Conclusion We developed a prolonged mechanical ventilation decision aid that is feasible, acceptable, and associated with both improved decision making quality and less resource utilization. Further evaluation using a randomized controlled trial design is needed to evaluate the decision aid's effect on long-term patient and surrogate outcomes. PMID:22635048

Criteria for Postoperative Mechanical Ventilation After Thymectomy in Patients With Myasthenia Gravis: A Retrospective Analysis.

PubMed

Chigurupati, Keerthi; Gadhinglajkar, Shrinivas; Sreedhar, Rupa; Nair, Muraleedharan; Unnikrishnan, Madathipat; Pillai, Manjusha

2018-02-01

To determine the criteria for postoperative mechanical ventilation after thymectomy in patients with Myasthenia Gravis. Retrospective study. Teritiary care centre. 77 Myasthenia gravis patients operated for thymectomy were studied. After obtaining clearance from Institutional ethics committee, medical records of 77 patients with MG, who were operated for thymectomy between January 2005 and December 2015 were reviewed in a retrospective manner. Perioperative variables collected from the patient records were demographic data, duration of the disease, Osserman and Genkin classification, Anti-acetylcholine antibody (AChR) positivity, preoperative daily dose of drug, history of preoperative myasthenic crisis, preoperative vital capacity, technique of anesthesia, drugs used for anesthesia, perioperative complications, and duration of postoperative mechanical ventilation. The patients were divided into two groups, group I and group II consisting of those who required postoperative ventilation for < 300 minutes and > 300 minutes, respectively. The determinants of prolonged postoperative ventilation were studied. The requirement of mechanical ventilation was higher in patients with higher Osserman's grade of myasthenia gravis. Duration of the disease had no effect on the duration of mechanical ventilation in myasthenic patients post thymectomy (p = 0.89). The patients with a preoperative history of myasthenic crisis had a requirement for prolonged mechanical ventilation (p=0.03). Patients with preoperative vital capacity < 2.9 litres and preoperative CT scan showing thymoma had a requirement for prolonged mechanical ventilation with p values < 0.001 and 0.035, respectively. Patients who showed positivity for anti-acetylcholine antibodies had a prolonged mechanical ventilation (p=0.026). Preoperative dose of pyridostigmine and the choice of continuation or discontinuation of antcholinesterases on the day of surgery had no influence on the duration of mechanical ventilation

Long-term outcome and quality of life of patients requiring prolonged mechanical ventilation after cardiac surgery.

PubMed

Pappalardo, Federico; Franco, Annalisa; Landoni, Giovanni; Cardano, Paola; Zangrillo, Alberto; Alfieri, Ottavio

2004-04-01

To study the long-term survival and quality of life of patients with a complicated post-operative course after cardiac surgery requiring prolonged (>or=7 days) mechanical ventilation (MV), since they represent a heavy burden on hospital resources and their outcome has never been adequately evaluated. Out of 4827 consecutive cardiac surgical patients, 148 (3%) required prolonged post-operative MV: their hospital course was analysed and factors affecting prolonged MV and mortality were identified using multivariate analysis. Long-term survival was assessed using Cox proportional hazard method. Long-term (36+/-12 months) follow-up information was collected and quality of life was assessed by an ad hoc questionnaire. Overall mortality in the study group was 45.3 versus 2% in the control population (P<0.0001). Predictors of death in the prolonged MV group were age (odds ratio, OR 1.049) and diabetes (OR 3.459). Long-term survival was significantly worse in those patients who were extubated after 21 days: 88.9 versus 70.9% at 1 year (P=0.03) and 80.9 versus 64.5% at 5 years (P=0.05). Mild or no limitation in daily living was referred by 69% of the survivors. The hospital mortality of patients requiring prolonged MV is high. The long-term survival of patients who are weaned from MV after 21 days is significantly lower. The great majority of the survivors can enjoy a good quality of life.

Inhibition of forkhead boxO-specific transcription prevents mechanical ventilation-induced diaphragm dysfunction.

PubMed

Smuder, Ashley J; Sollanek, Kurt J; Min, Kisuk; Nelson, W Bradley; Powers, Scott K

2015-05-01

Mechanical ventilation is a lifesaving measure for patients with respiratory failure. However, prolonged mechanical ventilation results in diaphragm weakness, which contributes to problems in weaning from the ventilator. Therefore, identifying the signaling pathways responsible for mechanical ventilation-induced diaphragm weakness is essential to developing effective countermeasures to combat this important problem. In this regard, the forkhead boxO family of transcription factors is activated in the diaphragm during mechanical ventilation, and forkhead boxO-specific transcription can lead to enhanced proteolysis and muscle protein breakdown. Currently, the role that forkhead boxO activation plays in the development of mechanical ventilation-induced diaphragm weakness remains unknown. This study tested the hypothesis that mechanical ventilation-induced increases in forkhead boxO signaling contribute to ventilator-induced diaphragm weakness. University research laboratory. Young adult female Sprague-Dawley rats. Cause and effect was determined by inhibiting the activation of forkhead boxO in the rat diaphragm through the use of a dominant-negative forkhead boxO adeno-associated virus vector delivered directly to the diaphragm. Our results demonstrate that prolonged (12 hr) mechanical ventilation results in a significant decrease in both diaphragm muscle fiber size and diaphragm-specific force production. However, mechanically ventilated animals treated with dominant-negative forkhead boxO showed a significant attenuation of both diaphragm atrophy and contractile dysfunction. In addition, inhibiting forkhead boxO transcription attenuated the mechanical ventilation-induced activation of the ubiquitin-proteasome system, the autophagy/lysosomal system, and caspase-3. Forkhead boxO is necessary for the activation of key proteolytic systems essential for mechanical ventilation-induced diaphragm atrophy and contractile dysfunction. Collectively, these results suggest that

Outcomes of Tracheostomized Subjects Undergoing Prolonged Mechanical Ventilation in an Intermediate-Care Facility.

PubMed

Herer, Bertrand

2018-03-01

The incidence of chronically ill subjects with prolonged mechanical ventilation (PMV) has significantly increased over the last decade because of improvements in acute critical care. The aim of this study was to describe the outcomes and care pathways of subjects receiving PMV through a tracheostomy tube in an intermediate-care facility. Sixty-six subjects with chronic respiratory failure who experienced 109 hospitalizations between December 2010 and December 2012 in a 34-bed post-care unit were retrospectively included and followed for at least 1 y. The median (interquartile range [IQR]) length of stay (LOS) was 42 (26-77) d. Subjects were admitted from home (40.4%), our hospital ICU (40.4%; median [IQR] LOS = 17 [7-38] d), or another hospital (19.2%; median [IQR] LOS = 60 [8-71] d, P = .001 vs LOS in ICU). Thirty-five percent of subjects were readmitted at least once during the follow-up period. Sixteen subjects died in the intermediate-care facility. Discharge destinations of alive subjects were home ( n = 78), another hospital ( n = 6), a skilled-nursing facility ( n = 5), or an ICU ( n = 4). A complete or partial weaning was obtained in 30.3% of subjects. One year after the first day of hospitalization, 57% of subjects were alive. Despite the chance of survival at 1 y and/or weaning from ventilation, the resources needed by subjects with PMV are high, as shown by the number of readmissions and long LOS in our unit and in other hospital units before transfer. Copyright © 2018 by Daedalus Enterprises.

Differences in one-year health outcomes and resource utilization by definition of prolonged mechanical ventilation: a prospective cohort study.

PubMed

Cox, Christopher E; Carson, Shannon S; Lindquist, Jennifer H; Olsen, Maren K; Govert, Joseph A; Chelluri, Lakshmipathi

2007-01-01

The outcomes of patients ventilated for longer than average are unclear, in part because of the lack of an accepted definition of prolonged mechanical ventilation (PMV). To better understand the implications of PMV provision, we compared one-year health outcomes between two common definitions of PMV as well as between PMV patients and those ventilated for shorter periods of time. We conducted a secondary analysis of prospectively collected data from medical and surgical intensive care units at an academic tertiary care medical center. The study included 817 critically ill patients ventilated for > or = 48 hours, 267 (33%) of whom received PMV based on receipt of a tracheostomy and ventilation for > or = 96 hours. A total of 114 (14%) patients met the alternate definition of PMV by being ventilated for > or = 21 days. Survival, functional status, and costs were measured at baseline and at 2, 6, and 12 months after discharge. Of one-year survivors, 71 (17%) were lost to follow up. PMV patients ventilated for > or = 21 days had greater costs ($140,409 versus $143,389) and higher one-year mortality (58% versus 48%) than did PMV patients with tracheostomies who were ventilated for > or = 96 hours. The majority of PMV deaths (58%) occurred after hospital discharge whereas 67% of PMV patients aged 65 years or older had died by one year. At one year PMV patients on average had limitations in two basic and five instrumental elements of functional status that exceeded both their pre-admission status and the one-year disability of those ventilated for < 96 hours. Costs per one-year survivor were $423,596, $266,105, and $165,075 for patients ventilated > or = 21 days, > or = 96 hours with a tracheostomy, and < 96 hours, respectively. Contrasting definitions of PMV capture significantly different patient populations, with > or = 21 days of ventilation specifying the most resource-intensive recipients of critical care. PMV patients, particularly the elderly, suffer from a

Nebulized heparin is associated with fewer days of mechanical ventilation in critically ill patients: a randomized controlled trial.

PubMed

Dixon, Barry; Schultz, Marcus J; Smith, Roger; Fink, James B; Santamaria, John D; Campbell, Duncan J

2010-01-01

Prolonged mechanical ventilation has the potential to aggravate or initiate pulmonary inflammation and cause lung damage through fibrin deposition. Heparin may reduce pulmonary inflammation and fibrin deposition. We therefore assessed whether nebulized heparin improved lung function in patients expected to require prolonged mechanical ventilation. Fifty patients expected to require mechanical ventilation for more than 48 hours were enrolled in a double-blind randomized placebo-controlled trial of nebulized heparin (25,000 U) or placebo (normal saline) 4 or 6 hourly, depending on patient height. The study drug was continued while the patient remained ventilated to a maximum of 14 days from randomization. Nebulized heparin was not associated with a significant improvement in the primary end-point, the average daily partial pressure of oxygen to inspired fraction of oxygen ratio while mechanically ventilated, but was associated with improvement in the secondary end-point, ventilator-free days amongst survivors at day 28 (22.6 ± 4.0 versus 18.0 ± 7.1, treatment difference 4.6 days, 95% CI 0.9 to 8.3, P = 0.02). Heparin administration was not associated with any increase in adverse events. Nebulized heparin was associated with fewer days of mechanical ventilation in critically ill patients expected to require prolonged mechanical ventilation. Further trials are required to confirm these findings. The Australian Clinical Trials Registry (ACTR-12608000121369).

Effect Of Pressure Support Versus Unassisted Breathing Through A Tracheostomy Collar On Weaning Duration In Patients Requiring Prolonged Mechanical Ventilation: A Randomized Trial

PubMed Central

Jubran, Amal; Grant, Brydon J.B.; Duffner, Lisa A.; Collins, Eileen G.; Lanuza, Dorothy M.; Hoffman, Leslie A.; Tobin, Martin J.

2013-01-01

Context Patients requiring prolonged mechanical ventilation (more than 21 days) are commonly weaned at long-term acute care hospitals (LTACHs). The most effective method of weaning such patients has not been investigated. Objective To compare weaning duration with pressure support versus unassisted breathing through a tracheostomy (trach collar) in patients transferred to a LTACH for weaning from prolonged ventilation. Design, Settings, and Participants Between 2000 and 2010, a randomized study was conducted in tracheotomized patients transferred to a single LTACH for weaning from prolonged ventilation. Of 500 patients who underwent a five-day screening procedure, 316 failed and were randomly assigned to wean with pressure support (n=155) or a trach collar (n=161). Six- and twelve-month survival was also determined. Main outcome measure Primary outcome was weaning duration. Secondary outcome was survival at six and twelve months after enrollment. Results Of 316 patients, four were withdrawn and not included in analysis. Of 152 patients in the pressure-support arm, 68 (44.7%) were weaned; 22 (14.5%) died. Of 160 patients in the trach-collar arm, 85 (53.1%) were weaned; 16 (10.0%) died. Median weaning time was shorter with trach collar than with pressure support: 15 [interquartile range, 8–25] versus 19 [12–31] days, p=0.004. The hazard ratio (HR) for successful weaning rate was higher with trach collar than with pressure support (HR, 1.43; 95% confidence interval [CI], 1.03–1.98, p<0.03) after adjusting for baseline clinical covariates. Trach collar achieved faster weaning than did pressure support among subjects who failed the screening procedure at 12–120 hours (HR, 3.33; 95% CI, 1.44–7.70, p<0.01), whereas weaning time was equivalent with the two methods in patients who failed the screening procedure within 0–12 hours. Mortality was equivalent in the pressure-support and trach-collar arms at six months (55.9% versus 51.3%; 4.7 difference, 95% CI −6

Effect of pressure support vs unassisted breathing through a tracheostomy collar on weaning duration in patients requiring prolonged mechanical ventilation: a randomized trial.

PubMed

Jubran, Amal; Grant, Brydon J B; Duffner, Lisa A; Collins, Eileen G; Lanuza, Dorothy M; Hoffman, Leslie A; Tobin, Martin J

2013-02-20

Patients requiring prolonged mechanical ventilation (>21 days) are commonly weaned at long-term acute care hospitals (LTACHs). The most effective method of weaning such patients has not been investigated. To compare weaning duration with pressure support vs unassisted breathing through a tracheostomy collar in patients transferred to an LTACH for weaning from prolonged ventilation. Between 2000 and 2010, a randomized study was conducted in tracheotomized patients transferred to a single LTACH for weaning from prolonged ventilation. Of 500 patients who underwent a 5-day screening procedure, 316 did not tolerate the procedure and were randomly assigned to receive weaning with pressure support (n = 155) or a tracheostomy collar (n = 161). Survival at 6- and 12-month time points was also determined. Primary outcome was weaning duration. Secondary outcome was survival at 6 and 12 months after enrollment. Of 316 patients, 4 were withdrawn and not included in analysis. Of 152 patients in the pressure-support group, 68 (44.7%) were weaned; 22 (14.5%) died. Of 160 patients in the tracheostomy collar group, 85 (53.1%) were weaned; 16 (10.0%) died. Median weaning time was shorter with tracheostomy collar use (15 days; interquartile range [IQR], 8-25) than with pressure support (19 days; IQR, 12-31), P = .004. The hazard ratio (HR) for successful weaning rate was higher with tracheostomy collar use than with pressure support (HR, 1.43; 95% CI, 1.03-1.98; P = .033) after adjusting for baseline clinical covariates. Use of the tracheostomy collar achieved faster weaning than did pressure support among patients who did not tolerate the screening procedure between 12 and 120 hours (HR, 3.33; 95% CI, 1.44-7.70; P = .005), whereas weaning time was equivalent with the 2 methods in patients who did not tolerate the screening procedure within 0 to 12 hours. Mortality was equivalent in the pressure-support and tracheostomy collar groups at 6 months (55.92% vs 51.25%; 4.67% difference, 95

Activation of respiratory muscles during weaning from mechanical ventilation.

PubMed

Walterspacher, Stephan; Gückler, Julia; Pietsch, Fabian; Walker, David Johannes; Kabitz, Hans-Joachim; Dreher, Michael

2017-04-01

Respiratory muscle dysfunction is a key component of weaning failure. Balancing respiratory muscle loading and unloading by applying different ventilation modes along with spontaneous breathing episodes are established weaning strategies. However, the effects of body positioning on the respiratory muscles during weaning remains unclear. This study aimed at assessing respiratory drive by surface electromyography (EMG) of the diaphragm (EMG dia ) and parasternal muscles (EMG para ) in tracheotomized patients during prolonged weaning in 3 randomized body positions-supine, 30° semirecumbent, and 80° sitting-during mechanical ventilation and spontaneous breathing. Nine patients were included for analysis. Cardiorespiratory parameters (heart rate, blood pressure, arterial oxygen saturation, dyspnea) did not change under each condition (all P>.05). EMG para and EMG dia did not change under mechanical ventilation (both P>.05). EMG dia changed under spontaneous breathing from supine to sitting (0.45±0.26 vs 0.32±0.19; P=.012) and between semirecumbent to sitting (0.41±0.23 vs 0.32±0.19; P=.039), whereas EMG para did not change. This is the first study to show that body positioning influences respiratory drive to the diaphragm in tracheotomized patients with prolonged weaning from mechanical ventilation during unassisted breathing. Sitting position reduces respiratory drive compared with semirecumbent and supine positioning and might therefore be favored during spontaneous breathing trials. Copyright © 2016 Elsevier Inc. All rights reserved.

The Association Between Nutritional Adequacy and Long-Term Outcomes in Critically Ill Patients Requiring Prolonged Mechanical Ventilation: A Multicenter Cohort Study.

PubMed

Wei, Xuejiao; Day, Andrew G; Ouellette-Kuntz, Hélène; Heyland, Daren K

2015-08-01

To examine the association between short-term nutritional adequacy received while in the ICU and long-term outcomes including 6-month survival and health-related quality of life in critically ill patients requiring prolonged mechanical ventilation. Retrospective analysis of data prospectively collected in the context of a multicenter randomized controlled trial. An international sample of ICUs. Adult patients who were mechanically ventilated for more than 8 days in the ICU. None. Nutritional adequacy was obtained from the average proportion of prescribed calories received over the amount prescribed during the first 8 days. Survival status and health-related quality of life as assessed using the Short-Form 36 v2 were obtained at 3- and 6 months post ICU admission. Of the 1,223 patients enrolled in the randomized controlled trial, 475 met the inclusion criteria for this study. At 6-month follow-up, 302 of the 475 patients (64%) were alive. Survival time in those who received low nutritional adequacy was significantly shorter than those who received high nutritional adequacy while adjusting for important covariates (adjusted hazard ratio, 1.7; 95% CI, 1.1-2.6). At 3-month follow-up, a 25% increase in nutritional adequacy was associated with improvements in Physical Functioning and Role Physical of 7.3 (p = 0.02) and 8.3 (p = 0.004) points, respectively. At 6-month follow-up, adjusted increases in Physical Functioning and Role Physical scores for every 25% increase in nutrition adequacy became smaller and were no longer statistically significant (adjusted estimate for Physical Functioning = 4.2, p = 0.14; for Role Physical = 3.2, p = 0.25). Greater amounts of nutritional intake received during the first week in the ICU were associated with longer survival time and faster physical recovery to 3 months but not 6 months post ICU discharge in critically ill patients requiring prolonged mechanical ventilation. Current recommendations to underfeed critically ill patients may

Variable mechanical ventilation

PubMed Central

Fontela, Paula Caitano; Prestes, Renata Bernardy; Forgiarini Jr., Luiz Alberto; Friedman, Gilberto

2017-01-01

Objective To review the literature on the use of variable mechanical ventilation and the main outcomes of this technique. Methods Search, selection, and analysis of all original articles on variable ventilation, without restriction on the period of publication and language, available in the electronic databases LILACS, MEDLINE®, and PubMed, by searching the terms "variable ventilation" OR "noisy ventilation" OR "biologically variable ventilation". Results A total of 36 studies were selected. Of these, 24 were original studies, including 21 experimental studies and three clinical studies. Conclusion Several experimental studies reported the beneficial effects of distinct variable ventilation strategies on lung function using different models of lung injury and healthy lungs. Variable ventilation seems to be a viable strategy for improving gas exchange and respiratory mechanics and preventing lung injury associated with mechanical ventilation. However, further clinical studies are necessary to assess the potential of variable ventilation strategies for the clinical improvement of patients undergoing mechanical ventilation. PMID:28444076

Weaning from mechanical ventilation: why are we still looking for alternative methods?

PubMed

Frutos-Vivar, F; Esteban, A

2013-12-01

Most patients who require mechanical ventilation for longer than 24 hours, and who improve the condition leading to the indication of ventilatory support, can be weaned after passing a first spontaneous breathing test. The challenge is to improve the weaning of patients who fail that first test. We have methods that can be referred to as traditional, such as the T-tube, pressure support or synchronized intermittent mandatory ventilation (SIMV). In recent years, however, new applications of usual techniques as noninvasive ventilation, new ventilation methods such as automatic tube compensation (ATC), mandatory minute ventilation (MMV), adaptive support ventilation or automatic weaning systems based on pressure support have been described. Their possible role in weaning from mechanical ventilation among patients with difficult or prolonged weaning remains to be established. Copyright © 2012 Elsevier España, S.L. and SEMICYUC. All rights reserved.

Diaphragm Dysfunction in Mechanically Ventilated Patients.

PubMed

Dot, Irene; Pérez-Teran, Purificación; Samper, Manuel-Andrés; Masclans, Joan-Ramon

2017-03-01

Muscle involvement is found in most critical patients admitted to the intensive care unit (ICU). Diaphragmatic muscle alteration, initially included in this category, has been differentiated in recent years, and a specific type of muscular dysfunction has been shown to occur in patients undergoing mechanical ventilation. We found this muscle dysfunction to appear in this subgroup of patients shortly after the start of mechanical ventilation, observing it to be mainly associated with certain control modes, and also with sepsis and/or multi-organ failure. Although the specific etiology of process is unknown, the muscle presents oxidative stress and mitochondrial changes. These cause changes in protein turnover, resulting in atrophy and impaired contractility, and leading to impaired functionality. The term 'ventilator-induced diaphragm dysfunction' was first coined by Vassilakopoulos et al. in 2004, and this phenomenon, along with injury cause by over-distention of the lung and barotrauma, represents a challenge in the daily life of ventilated patients. Diaphragmatic dysfunction affects prognosis by delaying extubation, prolonging hospital stay, and impairing the quality of life of these patients in the years following hospital discharge. Ultrasound, a non-invasive technique that is readily available in most ICUs, could be used to diagnose this condition promptly, thus preventing delays in starting rehabilitation and positively influencing prognosis in these patients. Copyright © 2016 SEPAR. Publicado por Elsevier España, S.L.U. All rights reserved.

Person-centred care during prolonged weaning from mechanical ventilation, nurses' views: an interview study.

PubMed

Cederwall, Carl-Johan; Olausson, Sepideh; Rose, Louise; Naredi, Silvana; Ringdal, Mona

2018-06-01

To determine: 1) if the three elements of person-centred care (initiating, working and safeguarding the partnership) were present, and 2) to identify evidence of barriers to person-centred care during prolonged weaning from mechanical ventilation. Secondary analysis of semi structured interviews with 19 critical care nurses using theoretical thematic analysis. This study was conducted in three Swedish intensive care units, one in a regional hospital and two in a university hospital. Three themes and nine subthemes related to person-centred care were identified. The three themes included: 1) 'finding a person behind the patient' related to the 'initiating the partnership' phase, 2) 'striving to restore patient́s sense of control' related to 'working the partnership' phase and 3) 'impact of patient involvement' related to 'safeguarding the partnership' phase of person-centred care'. Additionally a further theme 'barriers to person-centred care' was identified. We found evidence of all three person-centred care routines. Barriers to person-centred care comprised of lack team collaboration and resources. Facilitating patients to actively participate in decision-making during the weaning process may optimise weaning outcomes and warrants further research. Copyright © 2017 Elsevier Ltd. All rights reserved.

Modes of mechanical ventilation for the operating room.

PubMed

Ball, Lorenzo; Dameri, Maddalena; Pelosi, Paolo

2015-09-01

Most patients undergoing surgical procedures need to be mechanically ventilated, because of the impact of several drugs administered at induction and during maintenance of general anaesthesia on respiratory function. Optimization of intraoperative mechanical ventilation can reduce the incidence of post-operative pulmonary complications and improve the patient's outcome. Preoxygenation at induction of general anaesthesia prolongs the time window for safe intubation, reducing the risk of hypoxia and overweighs the potential risk of reabsorption atelectasis. Non-invasive positive pressure ventilation delivered through different interfaces should be considered at the induction of anaesthesia morbidly obese patients. Anaesthesia ventilators are becoming increasingly sophisticated, integrating many functions that were once exclusive to intensive care. Modern anaesthesia machines provide high performances in delivering the desired volumes and pressures accurately and precisely, including assisted ventilation modes. Therefore, the physicians should be familiar with the potential and pitfalls of the most commonly used intraoperative ventilation modes: volume-controlled, pressure-controlled, dual-controlled and assisted ventilation. Although there is no clear evidence to support the advantage of any one of these ventilation modes over the others, protective mechanical ventilation with low tidal volume and low levels of positive end-expiratory pressure (PEEP) should be considered in patients undergoing surgery. The target tidal volume should be calculated based on the predicted or ideal body weight rather than on the actual body weight. To optimize ventilation monitoring, anaesthesia machines should include end-inspiratory and end-expiratory pause as well as flow-volume loop curves. The routine administration of high PEEP levels should be avoided, as this may lead to haemodynamic impairment and fluid overload. Higher PEEP might be considered during surgery longer than 3 h

Mechanical ventilator - infants

MedlinePlus

... this page: //medlineplus.gov/ency/article/007240.htm Mechanical ventilator - infants To use the sharing features on this page, please enable JavaScript. A mechanical ventilator is a machine that assists with breathing. ...

Automated Weaning from Mechanical Ventilation after Off-Pump Coronary Artery Bypass Grafting.

PubMed

Fot, Evgenia V; Izotova, Natalia N; Yudina, Angelika S; Smetkin, Aleksei A; Kuzkov, Vsevolod V; Kirov, Mikhail Y

2017-01-01

The discontinuation of mechanical ventilation after coronary surgery may prolong and significantly increase the load on intensive care unit personnel. We hypothesized that automated mode using INTELLiVENT-ASV can decrease duration of postoperative mechanical ventilation, reduce workload on medical staff, and provide safe ventilation after off-pump coronary artery bypass grafting (OPCAB). The primary endpoint of our study was to assess the duration of postoperative mechanical ventilation during different modes of weaning from respiratory support (RS) after OPCAB. The secondary endpoint was to assess safety of the automated weaning mode and the number of manual interventions to the ventilator settings during the weaning process in comparison with the protocolized weaning mode. Forty adult patients undergoing elective OPCAB were enrolled into a prospective single-center study. Patients were randomized into two groups: automated weaning ( n  = 20) using INTELLiVENT-ASV mode with quick-wean option; and protocolized weaning ( n  = 20), using conventional synchronized intermittent mandatory ventilation (SIMV) + pressure support (PS) mode. We assessed the duration of postoperative ventilation, incidence and duration of unacceptable RS, and the load on medical staff. We also performed the retrospective analysis of 102 patients (standard weaning) who were weaned from ventilator with SIMV + PS mode based on physician's experience without prearranged algorithm. Realization of the automated weaning protocol required change in respiratory settings in 2 patients vs. 7 (5-9) adjustments per patient in the protocolized weaning group. Both incidence and duration of unacceptable RS were reduced significantly by means of the automated weaning approach. The FiO 2 during spontaneous breathing trials was significantly lower in the automated weaning group: 30 (30-35) vs. 40 (40-45) % in the protocolized weaning group ( p  < 0.01). The average time until tracheal

Respiratory muscle dysfunction: a multicausal entity in the critically ill patient undergoing mechanical ventilation.

PubMed

Díaz, Magda C; Ospina-Tascón, Gustavo A; Salazar C, Blanca C

2014-02-01

Respiratory muscle dysfunction, particularly of the diaphragm, may play a key role in the pathophysiological mechanisms that lead to difficulty in weaning patients from mechanical ventilation. The limited mobility of critically ill patients, and of the diaphragm in particular when prolonged mechanical ventilation support is required, promotes the early onset of respiratory muscle dysfunction, but this can also be caused or exacerbated by other factors that are common in these patients, such as sepsis, malnutrition, advanced age, duration and type of ventilation, and use of certain medications, such as steroids and neuromuscular blocking agents. In this review we will study in depth this multicausal origin, in which a common mechanism is altered protein metabolism, according to the findings reported in various models. The understanding of this multicausality produced by the same pathophysiological mechanism could facilitate the management and monitoring of patients undergoing mechanical ventilation. Copyright © 2012 SEPAR. Published by Elsevier Espana. All rights reserved.

[Percutaneous tracheostomy in the ventilated patient].

PubMed

Añón, J M; Araujo, J B; Escuela, M P; González-Higueras, E

2014-04-01

The medical indications of tracheostomy comprise the alleviation of upper airway obstruction; the prevention of laryngeal and upper airway damage due to prolonged translaryngeal intubation in patients subjected to prolonged mechanical ventilation; and the facilitation of airway access for the removal of secretions. Since 1985, percutaneous tracheostomy (PT) has gained widespread acceptance as a method for creating a surgical airway in patients requiring long-term mechanical ventilation. Since then, several comparative trials of PT and surgical tracheostomy have been conducted, and new techniques for PT have been developed. The use of percutaneous dilatation techniques under bronchoscopic control are now increasingly popular throughout the world. Tracheostomy should be performed as soon as the need for prolonged intubation is identified. However a validated model for the prediction of prolonged mechanical ventilation is not available, and the timing of tracheostomy should be individualized. The present review analyzes the state of the art of PT in mechanically ventilated patients--this being regarded by many as the technique of choice in performing tracheostomy in critically ill patients. Copyright © 2012 Elsevier España, S.L. and SEMICYUC. All rights reserved.

Clinical challenges in mechanical ventilation.

PubMed

Goligher, Ewan C; Ferguson, Niall D; Brochard, Laurent J

2016-04-30

Mechanical ventilation supports gas exchange and alleviates the work of breathing when the respiratory muscles are overwhelmed by an acute pulmonary or systemic insult. Although mechanical ventilation is not generally considered a treatment for acute respiratory failure per se, ventilator management warrants close attention because inappropriate ventilation can result in injury to the lungs or respiratory muscles and worsen morbidity and mortality. Key clinical challenges include averting intubation in patients with respiratory failure with non-invasive techniques for respiratory support; delivering lung-protective ventilation to prevent ventilator-induced lung injury; maintaining adequate gas exchange in severely hypoxaemic patients; avoiding the development of ventilator-induced diaphragm dysfunction; and diagnosing and treating the many pathophysiological mechanisms that impair liberation from mechanical ventilation. Personalisation of mechanical ventilation based on individual physiological characteristics and responses to therapy can further improve outcomes. Copyright © 2016 Elsevier Ltd. All rights reserved.

Home mechanical ventilation: A Canadian Thoracic Society clinical practice guideline

PubMed Central

McKim, Douglas A; Road, Jeremy; Avendano, Monica; Abdool, Steve; Côté, Fabien; Duguid, Nigel; Fraser, Janet; Maltais, François; Morrison, Debra L; O’Connell, Colleen; Petrof, Basil J; Rimmer, Karen; Skomro, Robert

2011-01-01

Increasing numbers of patients are surviving episodes of prolonged mechanical ventilation or benefitting from the recent availability of user-friendly noninvasive ventilators. Although many publications pertaining to specific aspects of home mechanical ventilation (HMV) exist, very few comprehensive guidelines that bring together all of the current literature on patients at risk for or using mechanical ventilatory support are available. The Canadian Thoracic Society HMV Guideline Committee has reviewed the available English literature on topics related to HMV in adults, and completed a detailed guideline that will help standardize and improve the assessment and management of individuals requiring noninvasive or invasive HMV. The guideline provides a disease-specific review of illnesses including amyotrophic lateral sclerosis, spinal cord injury, muscular dystrophies, myotonic dystrophy, kyphoscoliosis, post-polio syndrome, central hypoventilation syndrome, obesity hypoventilation syndrome, and chronic obstructive pulmonary disease as well as important common themes such as airway clearance and the process of transition to home. The guidelines have been extensively reviewed by international experts, allied health professionals and target audiences. They will be updated on a regular basis to incorporate any new information. PMID:22059178

Daily Goals Formulation and Enhanced Visualization of Mechanical Ventilation Variance Improves Mechanical Ventilation Score.

PubMed

Walsh, Brian K; Smallwood, Craig; Rettig, Jordan; Kacmarek, Robert M; Thompson, John; Arnold, John H

2017-03-01

The systematic implementation of evidence-based practice through the use of guidelines, checklists, and protocols mitigates the risks associated with mechanical ventilation, yet variation in practice remains prevalent. Recent advances in software and hardware have allowed for the development and deployment of an enhanced visualization tool that identifies mechanical ventilation goal variance. Our aim was to assess the utility of daily goal establishment and a computer-aided visualization of variance. This study was composed of 3 phases: a retrospective observational phase (baseline) followed by 2 prospective sequential interventions. Phase I intervention comprised daily goal establishment of mechanical ventilation. Phase II intervention was the setting and monitoring of daily goals of mechanical ventilation with a web-based data visualization system (T3). A single score of mechanical ventilation was developed to evaluate the outcome. The baseline phase evaluated 130 subjects, phase I enrolled 31 subjects, and phase II enrolled 36 subjects. There were no differences in demographic characteristics between cohorts. A total of 171 verbalizations of goals of mechanical ventilation were completed in phase I. The use of T3 increased by 87% from phase I. Mechanical ventilation score improved by 8.4% in phase I and 11.3% in phase II from baseline ( P = .032). The largest effect was in the low risk V T category, with a 40.3% improvement from baseline in phase I, which was maintained at 39% improvement from baseline in phase II ( P = .01). mechanical ventilation score was 9% higher on average in those who survived. Daily goal formation and computer-enhanced visualization of mechanical ventilation variance were associated with an improvement in goal attainment by evidence of an improved mechanical ventilation score. Further research is needed to determine whether improvements in mechanical ventilation score through a targeted, process-oriented intervention will lead to

Prolonged weaning: from the intensive care unit to home.

PubMed

Navalesi, P; Frigerio, P; Patzlaff, A; Häußermann, S; Henseke, P; Kubitschek, M

2014-01-01

Weaning is the process of withdrawing mechanical ventilation which starts with the first spontaneous breathing trial (SBT). Based on the degree of difficulty and duration, weaning is classified as simple, difficult and prolonged. Prolonged weaning, which includes patients who fail 3 SBTs or are still on mechanical ventilation 7 days after the first SBT, affects a relatively small fraction of mechanically ventilated ICU patients but these, however, requires disproportionate resources. There are several potential causes which can lead to prolonged weaning. It is nonetheless important to understand the problem from the point of view of each individual patient in order to adopt appropriate treatment and define precise prognosis. An otherwise stable patient who remains on mechanical ventilation will be considered for transfer to a specialized weaning unit (SWU). Though there is not a precise definition, SWU can be considered as highly specialized and protected environments for patients requiring mechanical ventilation despite resolution of the acute disorder. Proper staffing, well defined short-term and long-term goals, attention to psychological and social problems represent key determinants of SWU success. Some patients cannot be weaned, either partly or entirely, and may require long-term home mechanical ventilation. In these cases the logistics relating to caregivers and the equipment must be carefully considered and addressed. Copyright © 2014 Sociedade Portuguesa de Pneumologia. Published by Elsevier España. All rights reserved.

Mechanical ventilation causes pulmonary mitochondrial dysfunction and delayed alveolarization in neonatal mice.

PubMed

Ratner, Veniamin; Sosunov, Sergey A; Niatsetskaya, Zoya V; Utkina-Sosunova, Irina V; Ten, Vadim S

2013-12-01

Hyperoxia inhibits pulmonary bioenergetics, causing delayed alveolarization in mice. We hypothesized that mechanical ventilation (MV) also causes a failure of bioenergetics to support alveolarization. To test this hypothesis, neonatal mice were ventilated with room air for 8 hours (prolonged) or for 2 hours (brief) with 15 μl/g (aggressive) tidal volume (Tv), or for 8 hours with 8 μl/g (gentle) Tv. After 24 hours or 10 days of recovery, lung mitochondria were examined for adenosine diphosphate (ADP)-phosphorylating respiration, using complex I (C-I)-dependent, complex II (C-II)-dependent, or cytochrome C oxidase (C-IV)-dependent substrates, ATP production rate, and the activity of C-I and C-II. A separate cohort of mice was exposed to 2,4-dinitrophenol (DNP), a known uncoupler of oxidative phosphorylation. At 10 days of recovery, pulmonary alveolarization and the expression of vascular endothelial growth factor (VEGF) were assessed. Sham-operated littermates were used as control mice. At 24 hours after aggressive MV, mitochondrial ATP production rates and the activity of C-I and C-II were significantly decreased compared with control mice. However, at 10 days of recovery, only mice exposed to prolonged-aggressive MV continued to exhibit significantly depressed mitochondrial respiration. This was associated with significantly poorer alveolarization and VEGF expression. In contrast, mice exposed to brief-aggressive or prolonged-gentle MV exhibited restored mitochondrial ADP-phosphorylation, normal alveolarization and pulmonary VEGF content. Exposure to DNP fully replicated the phenotype consistent with alveolar developmental arrest. Our data suggest that the failure of bioenergetics to support normal lung development caused by aggressive and prolonged ventilation should be considered a fundamental mechanism for the development of bronchopulmonary dysplasia in premature neonates.

Tracheostomy and invasive mechanical ventilation in amyotrophic lateral sclerosis: decision-making factors and survival analysis.

PubMed

Kimura, Fumiharu

2016-04-28

Invasive and/or non-invasive mechanical ventilation are most important options of respiratory management in amyotrophic lateral sclerosis. We evaluated the frequency, clinical characteristics, decision-making factors about ventilation and survival analysis of 190 people with amyotrophic lateral sclerosis patients from 1990 until 2013. Thirty-one percentage of patients underwent tracheostomy invasive ventilation with the rate increasing more than the past 20 years. The ratio of tracheostomy invasive ventilation in patients >65 years old was significantly increased after 2000 (25%) as compared to before (10%). After 2010, the standard use of non-invasive ventilation showed a tendency to reduce the frequency of tracheostomy invasive ventilation. Mechanical ventilation prolonged median survival (75 months in tracheostomy invasive ventilation, 43 months in non-invasive ventilation vs natural course, 32 months). The life-extending effects by tracheostomy invasive ventilation were longer in younger patients ≤65 years old at the time of ventilation support than in older patients. Presence of partners and care at home were associated with better survival. Following factors related to the decision to perform tracheostomy invasive ventilation: patients ≤65 years old: greater use of non-invasive ventilation: presence of a spouse: faster tracheostomy: higher progression rate; and preserved motor functions. No patients who underwent tracheostomy invasive ventilation died from a decision to withdraw mechanical ventilation. The present study provides factors related to decision-making process and survival after tracheostomy and help clinicians and family members to expand the knowledge about ventilation.

Enhancing rehabilitation of mechanically ventilated patients in the intensive care unit: a quality improvement project.

PubMed

McWilliams, David; Weblin, Jonathan; Atkins, Gemma; Bion, Julian; Williams, Jenny; Elliott, Catherine; Whitehouse, Tony; Snelson, Catherine

2015-02-01

Prolonged periods of mechanical ventilation are associated with significant physical and psychosocial adverse effects. Despite increasing evidence supporting early rehabilitation strategies, uptake and delivery of such interventions in Europe have been variable. The objective of this study was to evaluate the impact of an early and enhanced rehabilitation program for mechanically ventilated patients in a large tertiary referral, mixed-population intensive care unit (ICU). A new supportive rehabilitation team was created within the ICU in April 2012, with a focus on promoting early and enhanced rehabilitation for patients at high risk for prolonged ICU and hospital stays. Baseline data on all patients invasively ventilated for at least 5 days in the previous 12 months (n = 290) were compared with all patients ventilated for at least 5 days in the 12 months after the introduction of the rehabilitation team (n = 292). The main outcome measures were mobility level at ICU discharge (assessed via the Manchester Mobility Score), mean ICU, and post-ICU length of stay (LOS), ventilator days, and in-hospital mortality. The introduction of the ICU rehabilitation team was associated with a significant increase in mobility at ICU discharge, and this was associated with a significant reduction in ICU LOS (16.9 vs 14.4 days, P = .007), ventilator days (11.7 vs 9.3 days, P < .05), total hospital LOS (35.3 vs 30.1 days, P < .001), and in-hospital mortality (39% vs 28%, P < .05). A quality improvement strategy to promote early and enhanced rehabilitation within this European ICU improved levels of mobility at critical care discharge, and this was associated with reduced ICU and hospital LOS and reduced days of mechanical ventilation. Copyright © 2014 The Authors. Published by Elsevier Inc. All rights reserved.

The Association of Fever with Total Mechanical Ventilation Time in Critically Ill Patients.

PubMed

Park, Dong Won; Egi, Moritoki; Nishimura, Masaji; Chang, Youjin; Suh, Gee Young; Lim, Chae Man; Kim, Jae Yeol; Tada, Keiichi; Matsuo, Koichi; Takeda, Shinhiro; Tsuruta, Ryosuke; Yokoyama, Takeshi; Kim, Seon Ok; Koh, Younsuck

2016-12-01

This research aims to investigate the impact of fever on total mechanical ventilation time (TVT) in critically ill patients. Subgroup analysis was conducted using a previous prospective, multicenter observational study. We included mechanically ventilated patients for more than 24 hours from 10 Korean and 15 Japanese intensive care units (ICU), and recorded maximal body temperature under the support of mechanical ventilation (MAX(MV)). To assess the independent association of MAX(MV) with TVT, we used propensity-matched analysis in a total of 769 survived patients with medical or surgical admission, separately. Together with multiple linear regression analysis to evaluate the association between the severity of fever and TVT, the effect of MAX(MV) on ventilator-free days was also observed by quantile regression analysis in all subjects including non-survivors. After propensity score matching, a MAX(MV) ≥ 37.5°C was significantly associated with longer mean TVT by 5.4 days in medical admission, and by 1.2 days in surgical admission, compared to those with MAX(MV) of 36.5°C to 37.4°C. In multivariate linear regression analysis, patients with three categories of fever (MAX(MV) of 37.5°C to 38.4°C, 38.5°C to 39.4°C, and ≥ 39.5°C) sustained a significantly longer duration of TVT than those with normal range of MAX(MV) in both categories of ICU admission. A significant association between MAX(MV) and mechanical ventilator-free days was also observed in all enrolled subjects. Fever may be a detrimental factor to prolong TVT in mechanically ventilated patients. These findings suggest that fever in mechanically ventilated patients might be associated with worse mechanical ventilation outcome.

AT1 receptor blocker losartan protects against mechanical ventilation-induced diaphragmatic dysfunction

PubMed Central

Kwon, Oh Sung; Smuder, Ashley J.; Wiggs, Michael P.; Hall, Stephanie E.; Sollanek, Kurt J.; Morton, Aaron B.; Talbert, Erin E.; Toklu, Hale Z.; Tumer, Nihal

2015-01-01

Mechanical ventilation is a life-saving intervention for patients in respiratory failure. Unfortunately, prolonged ventilator support results in diaphragmatic atrophy and contractile dysfunction leading to diaphragm weakness, which is predicted to contribute to problems in weaning patients from the ventilator. While it is established that ventilator-induced oxidative stress is required for the development of ventilator-induced diaphragm weakness, the signaling pathway(s) that trigger oxidant production remain unknown. However, recent evidence reveals that increased plasma levels of angiotensin II (ANG II) result in oxidative stress and atrophy in limb skeletal muscles. Using a well-established animal model of mechanical ventilation, we tested the hypothesis that increased circulating levels of ANG II are required for both ventilator-induced diaphragmatic oxidative stress and diaphragm weakness. Cause and effect was determined by administering an angiotensin-converting enzyme inhibitor (enalapril) to prevent ventilator-induced increases in plasma ANG II levels, and the ANG II type 1 receptor antagonist (losartan) was provided to prevent the activation of ANG II type 1 receptors. Enalapril prevented the increase in plasma ANG II levels but did not protect against ventilator-induced diaphragmatic oxidative stress or diaphragm weakness. In contrast, losartan attenuated both ventilator-induced oxidative stress and diaphragm weakness. These findings indicate that circulating ANG II is not essential for the development of ventilator-induced diaphragm weakness but that activation of ANG II type 1 receptors appears to be a requirement for ventilator-induced diaphragm weakness. Importantly, these experiments provide the first evidence that the Food and Drug Administration-approved drug losartan may have clinical benefits to protect against ventilator-induced diaphragm weakness in humans. PMID:26359481

Third-line antiepileptic therapy and outcome in status epilepticus: the impact of vasopressor use and prolonged mechanical ventilation.

PubMed

Kowalski, Robert G; Ziai, Wendy C; Rees, Richard N; Werner, J Kent; Kim, Grace; Goodwin, Haley; Geocadin, Romergryko G

2012-09-01

To characterize associations between antiepileptic drugs with sedating or anesthetic effects (third-line antiepileptic drugs) vs. other antiepileptic agents, and short-term outcomes, in status epilepticus. Furthermore, to evaluate the role of adverse hemodynamic and respiratory effects of these agents in status epilepticus treatment. Retrospective comparative analysis. Tertiary academic medical center with two emergency departments and two neurologic intensive care units. Adults admitted with a diagnosis of status epilepticus defined as seizures lasting continuously >5 mins, or for discrete periods in succession. None. Of 126 patients with 144 separate status epilepticus admissions, 57 were female (45%) with mean age 54.7 ± 15.7 yrs. Status epilepticus was convulsive in 132 cases (92%). Status epilepticus etiologies included subtherapeutic antiepileptic drugs (43%), alcohol or other nonantiepileptic drug (13%), and acute central nervous system disease (12%). Third-line antiepileptic drugs were administered in 47 cases (33%). Seventy-eight status epilepticus episodes (54%) had good outcomes (Glasgow Outcome Score = 1, 2) at the time of hospital discharge. On univariate analysis, poor outcome (Glasgow Outcome Score > 2) was associated with older age (mean 59.8 ± 15.5 vs. 50.5 ± 13.8 yrs, p < .001), acute central nervous system disease (21% vs. 4%, p = .001), mechanical ventilation (76% vs. 53%, p = .004), longer duration of ventilation (median 10 days [range 1-56] vs. 2 days [range 1-10], p < .001), treatment with vasopressors (35% vs. 5%, p < .001), and treatment with third-line antiepileptic drugs (51% vs. 17%, p < .001). Death was associated with acute central nervous system disease, prolonged ventilation, treatment with vasopressors, and treatment with third-line antiepileptic drugs. Predictors of poor outcome among all status epilepticus episodes were older age (odds ratio 1.06; 95% confidence interval 1.03-1.09; p < .001), treatment with third

History of Mechanical Ventilation. From Vesalius to Ventilator-induced Lung Injury.

PubMed

Slutsky, Arthur S

2015-05-15

Mechanical ventilation is a life-saving therapy that catalyzed the development of modern intensive care units. The origins of modern mechanical ventilation can be traced back about five centuries to the seminal work of Andreas Vesalius. This article is a short history of mechanical ventilation, tracing its origins over the centuries to the present day. One of the great advances in ventilatory support over the past few decades has been the development of lung-protective ventilatory strategies, based on our understanding of the iatrogenic consequences of mechanical ventilation such as ventilator-induced lung injury. These strategies have markedly improved clinical outcomes in patients with respiratory failure.

Mechanical ventilation in abdominal surgery.

PubMed

Futier, E; Godet, T; Millot, A; Constantin, J-M; Jaber, S

2014-01-01

One of the key challenges in perioperative care is to reduce postoperative morbidity and mortality. Patients who develop postoperative morbidity but survive to leave hospital have often reduced functional independence and long-term survival. Mechanical ventilation provides a specific example that may help us to shift thinking from treatment to prevention of postoperative complications. Mechanical ventilation in patients undergoing surgery has long been considered only as a modality to ensure gas exchange while allowing maintenance of anesthesia with delivery of inhaled anesthetics. Evidence is accumulating, however, suggesting an association between intraoperative mechanical ventilation strategy and postoperative pulmonary function and clinical outcome in patients undergoing abdominal surgery. Non-protective ventilator settings, especially high tidal volume (VT) (>10-12mL/kg) and the use of very low level of positive end-expiratory pressure (PEEP) (PEEP<5cmH2O) or no PEEP, may cause alveolar overdistension and repetitive tidal recruitment leading to ventilator-associated lung injury in patients with healthy lungs. Stimulated by previous findings in patients with acute respiratory distress syndrome, the use of lower tidal volume ventilation is becoming increasingly more common in the operating room. However, lowering tidal volume, though important, is only part of the overall multifaceted approach of lung protective mechanical ventilation. In this review, we aimed at providing the most recent and relevant clinical evidence regarding the use of mechanical ventilation in patients undergoing abdominal surgery. Copyright © 2014 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.

Mechanical ventilation during extracorporeal membrane oxygenation.

PubMed

Schmidt, Matthieu; Pellegrino, Vincent; Combes, Alain; Scheinkestel, Carlos; Cooper, D Jamie; Hodgson, Carol

2014-01-21

The timing of extracorporeal membrane oxygenation (ECMO) initiation and its outcome in the management of respiratory and cardiac failure have received considerable attention, but very little attention has been given to mechanical ventilation during ECMO. Mechanical ventilation settings in non-ECMO studies have been shown to have an effect on survival and may also have contributed to a treatment effect in ECMO trials. Protective lung ventilation strategies established for non-ECMO-supported respiratory failure patients may not be optimal for more severe forms of respiratory failure requiring ECMO support. The influence of positive end-expiratory pressure on the reduction of the left ventricular compliance may be a matter of concern for patients receiving ECMO support for cardiac failure. The objectives of this review were to describe potential mechanisms for lung injury during ECMO for respiratory or cardiac failure, to assess the possible benefits from the use of ultra-protective lung ventilation strategies and to review published guidelines and expert opinions available on mechanical ventilation-specific management of patients requiring ECMO, including mode and ventilator settings. Articles were identified through a detailed search of PubMed, Ovid, Cochrane databases and Google Scholar. Additional references were retrieved from the selected studies. Growing evidence suggests that mechanical ventilation settings are important in ECMO patients to minimize further lung damage and improve outcomes. An ultra-protective ventilation strategy may be optimal for mechanical ventilation during ECMO for respiratory failure. The effects of airway pressure on right and left ventricular afterload should be considered during venoarterial ECMO support of cardiac failure. Future studies are needed to better understand the potential impact of invasive mechanical ventilation modes and settings on outcomes.

Mechanical ventilation during extracorporeal membrane oxygenation

PubMed Central

2014-01-01

The timing of extracorporeal membrane oxygenation (ECMO) initiation and its outcome in the management of respiratory and cardiac failure have received considerable attention, but very little attention has been given to mechanical ventilation during ECMO. Mechanical ventilation settings in non-ECMO studies have been shown to have an effect on survival and may also have contributed to a treatment effect in ECMO trials. Protective lung ventilation strategies established for non-ECMO-supported respiratory failure patients may not be optimal for more severe forms of respiratory failure requiring ECMO support. The influence of positive end-expiratory pressure on the reduction of the left ventricular compliance may be a matter of concern for patients receiving ECMO support for cardiac failure. The objectives of this review were to describe potential mechanisms for lung injury during ECMO for respiratory or cardiac failure, to assess the possible benefits from the use of ultra-protective lung ventilation strategies and to review published guidelines and expert opinions available on mechanical ventilation-specific management of patients requiring ECMO, including mode and ventilator settings. Articles were identified through a detailed search of PubMed, Ovid, Cochrane databases and Google Scholar. Additional references were retrieved from the selected studies. Growing evidence suggests that mechanical ventilation settings are important in ECMO patients to minimize further lung damage and improve outcomes. An ultra-protective ventilation strategy may be optimal for mechanical ventilation during ECMO for respiratory failure. The effects of airway pressure on right and left ventricular afterload should be considered during venoarterial ECMO support of cardiac failure. Future studies are needed to better understand the potential impact of invasive mechanical ventilation modes and settings on outcomes. PMID:24447458

Initial mechanical ventilator settings and lung protective ventilation in the ED.

PubMed

Wilcox, Susan R; Richards, Jeremy B; Fisher, Daniel F; Sankoff, Jeffrey; Seigel, Todd A

2016-08-01

Mechanical ventilation with low tidal volumes has been shown to improve outcomes for patients both with and without acute respiratory distress syndrome. This study aims to characterize mechanically ventilated patients in the emergency department (ED), describe the initial ED ventilator settings, and assess for associations between lung protective ventilation strategies in the ED and outcomes. This was a multicenter, prospective, observational study of mechanical ventilation at 3 academic EDs. We defined lung protective ventilation as a tidal volume of less than or equal to 8 mL/kg of predicted body weight and compared outcomes for patients ventilated with lung protective vs non-lung protective ventilation, including inhospital mortality, ventilator days, intensive care unit length of stay, and hospital length of stay. Data from 433 patients were analyzed. Altered mental status without respiratory pathology was the most common reason for intubation, followed by trauma and respiratory failure. Two hundred sixty-one patients (60.3%) received lung protective ventilation, but most patients were ventilated with a low positive end-expiratory pressure, high fraction of inspired oxygen strategy. Patients were ventilated in the ED for a mean of 5 hours and 7 minutes but had few ventilator adjustments. Outcomes were not significantly different between patients receiving lung protective vs non-lung protective ventilation. Nearly 40% of ED patients were ventilated with non-lung protective ventilation as well as with low positive end-expiratory pressure and high fraction of inspired oxygen. Despite a mean ED ventilation time of more than 5 hours, few patients had adjustments made to their ventilators. Copyright © 2016 Elsevier Inc. All rights reserved.

Recommendations for mechanical ventilation of critically ill children from the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC).

PubMed

Kneyber, Martin C J; de Luca, Daniele; Calderini, Edoardo; Jarreau, Pierre-Henri; Javouhey, Etienne; Lopez-Herce, Jesus; Hammer, Jürg; Macrae, Duncan; Markhorst, Dick G; Medina, Alberto; Pons-Odena, Marti; Racca, Fabrizio; Wolf, Gerhard; Biban, Paolo; Brierley, Joe; Rimensberger, Peter C

2017-12-01

Much of the common practice in paediatric mechanical ventilation is based on personal experiences and what paediatric critical care practitioners have adopted from adult and neonatal experience. This presents a barrier to planning and interpretation of clinical trials on the use of specific and targeted interventions. We aim to establish a European consensus guideline on mechanical ventilation of critically children. The European Society for Paediatric and Neonatal Intensive Care initiated a consensus conference of international European experts in paediatric mechanical ventilation to provide recommendations using the Research and Development/University of California, Los Angeles, appropriateness method. An electronic literature search in PubMed and EMBASE was performed using a combination of medical subject heading terms and text words related to mechanical ventilation and disease-specific terms. The Paediatric Mechanical Ventilation Consensus Conference (PEMVECC) consisted of a panel of 15 experts who developed and voted on 152 recommendations related to the following topics: (1) general recommendations, (2) monitoring, (3) targets of oxygenation and ventilation, (4) supportive measures, (5) weaning and extubation readiness, (6) normal lungs, (7) obstructive diseases, (8) restrictive diseases, (9) mixed diseases, (10) chronically ventilated patients, (11) cardiac patients and (12) lung hypoplasia syndromes. There were 142 (93.4%) recommendations with "strong agreement". The final iteration of the recommendations had none with equipoise or disagreement. These recommendations should help to harmonise the approach to paediatric mechanical ventilation and can be proposed as a standard-of-care applicable in daily clinical practice and clinical research.

[Mechanical ventilation in acute asthma crisis].

PubMed

Barbas, Carmen Sílvia Valente; Pinheiro, Bruno do Valle; Vianna, Arthur; Magaldi, Ricardo; Casati, Ana; José, Anderson; Okamoto, Valdelis Novis

2007-06-01

The II Brazilian Consensus Conference on Mechanical Ventilation was published in 2000. Knowledge on the field of mechanical ventilation evolved rapidly since then, with the publication of numerous clinical studies with potential impact on the ventilatory management of critically ill patients. Moreover, the evolving concept of evidence - based medicine determined the grading of clinical recommendations according to the methodological value of the studies on which they are based. This explicit approach has broadened the understanding and adoption of clinical recommendations. For these reasons, AMIB - Associação de Medicina Intensiva Brasileira and SBPT - Sociedade Brasileira de Pneumologia e Tisiologia - decided to update the recommendations of the II Brazilian Consensus. Mechanical ventilation in the asthma attack has been one of the updated topics. Describe the most important topics on the mechanical ventilation during the asthma attack and suggest the main therapeutic approaches. Systematic review of the published literature and gradation of the studies in levels of evidence, using the key words "mechanical ventilation" and "asthma". We present recommendations on the ventilatory modes and settings to be adopted when ventilating a patient during an asthma attack, as well as the recommended monitoring. Alternative ventilation techniques are also presented. Protective ventilatory strategies are recommended when ventilating a patient during a severe asthma attack.

Lean Six Sigma to Reduce Intensive Care Unit Length of Stay and Costs in Prolonged Mechanical Ventilation.

PubMed

Trzeciak, Stephen; Mercincavage, Michael; Angelini, Cory; Cogliano, William; Damuth, Emily; Roberts, Brian W; Zanotti, Sergio; Mazzarelli, Anthony J

Patients with prolonged mechanical ventilation (PMV) represent important "outliers" of hospital length of stay (LOS) and costs (∼$26 billion annually in the United States). We tested the hypothesis that a Lean Six Sigma (LSS) approach for process improvement could reduce hospital LOS and the associated costs of care for patients with PMV. Before-and-after cohort study. Multidisciplinary intensive care unit (ICU) in an academic medical center. Adult patients admitted to the ICU and treated with PMV, as defined by diagnosis-related group (DRG). We implemented a clinical redesign intervention based on LSS principles. We identified eight distinct processes in preparing patients with PMV for post-acute care. Our clinical redesign included reengineering daily patient care rounds ("Lean ICU rounds") to reduce variation and waste in these processes. We compared hospital LOS and direct cost per case in patients with PMV before (2013) and after (2014) our LSS intervention. Among 259 patients with PMV (131 preintervention; 128 postintervention), median hospital LOS decreased by 24% during the intervention period (29 vs. 22 days, p < .001). Accordingly, median hospital direct cost per case decreased by 27% ($66,335 vs. $48,370, p < .001). We found that a LSS-based clinical redesign reduced hospital LOS and the costs of care for patients with PMV.

Mechanical ventilation for severe asthma.

PubMed

Leatherman, James

2015-06-01

Acute exacerbations of asthma can lead to respiratory failure requiring ventilatory assistance. Noninvasive ventilation may prevent the need for endotracheal intubation in selected patients. For patients who are intubated and undergo mechanical ventilation, a strategy that prioritizes avoidance of ventilator-related complications over correction of hypercapnia was first proposed 30 years ago and has become the preferred approach. Excessive pulmonary hyperinflation is a major cause of hypotension and barotrauma. An appreciation of the key determinants of hyperinflation is essential to rational ventilator management. Standard therapy for patients with asthma undergoing mechanical ventilation consists of inhaled bronchodilators, corticosteroids, and drugs used to facilitate controlled hypoventilation. Nonconventional interventions such as heliox, general anesthesia, bronchoscopy, and extracorporeal life support have also been advocated for patients with fulminant asthma but are rarely necessary. Immediate mortality for patients who are mechanically ventilated for acute severe asthma is very low and is often associated with out-of-hospital cardiorespiratory arrest before intubation. However, patients who have been intubated for severe asthma are at increased risk for death from subsequent exacerbations and must be managed accordingly in the outpatient setting.

Inhalation therapy in mechanical ventilation

PubMed Central

Maccari, Juçara Gasparetto; Teixeira, Cassiano; Gazzana, Marcelo Basso; Savi, Augusto; Dexheimer-Neto, Felippe Leopoldo; Knorst, Marli Maria

2015-01-01

Patients with obstructive lung disease often require ventilatory support via invasive or noninvasive mechanical ventilation, depending on the severity of the exacerbation. The use of inhaled bronchodilators can significantly reduce airway resistance, contributing to the improvement of respiratory mechanics and patient-ventilator synchrony. Although various studies have been published on this topic, little is known about the effectiveness of the bronchodilators routinely prescribed for patients on mechanical ventilation or about the deposition of those drugs throughout the lungs. The inhaled bronchodilators most commonly used in ICUs are beta adrenergic agonists and anticholinergics. Various factors might influence the effect of bronchodilators, including ventilation mode, position of the spacer in the circuit, tube size, formulation, drug dose, severity of the disease, and patient-ventilator synchrony. Knowledge of the pharmacological properties of bronchodilators and the appropriate techniques for their administration is fundamental to optimizing the treatment of these patients. PMID:26578139

Respiratory mechanics in mechanically ventilated patients.

PubMed

Hess, Dean R

2014-11-01

Respiratory mechanics refers to the expression of lung function through measures of pressure and flow. From these measurements, a variety of derived indices can be determined, such as volume, compliance, resistance, and work of breathing. Plateau pressure is a measure of end-inspiratory distending pressure. It has become increasingly appreciated that end-inspiratory transpulmonary pressure (stress) might be a better indicator of the potential for lung injury than plateau pressure alone. This has resulted in a resurgence of interest in the use of esophageal manometry in mechanically ventilated patients. End-expiratory transpulmonary pressure might also be useful to guide the setting of PEEP to counterbalance the collapsing effects of the chest wall. The shape of the pressure-time curve might also be useful to guide the setting of PEEP (stress index). This has focused interest in the roles of stress and strain to assess the potential for lung injury during mechanical ventilation. This paper covers both basic and advanced respiratory mechanics during mechanical ventilation. Copyright © 2014 by Daedalus Enterprises.

Determining delayed admission to intensive care unit for mechanically ventilated patients in the emergency department.

PubMed

Hung, Shih-Chiang; Kung, Chia-Te; Hung, Chih-Wei; Liu, Ber-Ming; Liu, Jien-Wei; Chew, Ghee; Chuang, Hung-Yi; Lee, Wen-Huei; Lee, Tzu-Chi

2014-08-23

The adverse effects of delayed admission to the intensive care unit (ICU) have been recognized in previous studies. However, the definitions of delayed admission varies across studies. This study proposed a model to define "delayed admission", and explored the effect of ICU-waiting time on patients' outcome. This retrospective cohort study included non-traumatic adult patients on mechanical ventilation in the emergency department (ED), from July 2009 to June 2010. The primary outcomes measures were 21-ventilator-day mortality and prolonged hospital stays (over 30 days). Models of Cox regression and logistic regression were used for multivariate analysis. The non-delayed ICU-waiting was defined as a period in which the time effect on mortality was not statistically significant in a Cox regression model. To identify a suitable cut-off point between "delayed" and "non-delayed", subsets from the overall data were made based on ICU-waiting time and the hazard ratio of ICU-waiting hour in each subset was iteratively calculated. The cut-off time was then used to evaluate the impact of delayed ICU admission on mortality and prolonged length of hospital stay. The final analysis included 1,242 patients. The time effect on mortality emerged after 4 hours, thus we deduced ICU-waiting time in ED > 4 hours as delayed. By logistic regression analysis, delayed ICU admission affected the outcomes of 21 ventilator-days mortality and prolonged hospital stay, with odds ratio of 1.41 (95% confidence interval, 1.05 to 1.89) and 1.56 (95% confidence interval, 1.07 to 2.27) respectively. For patients on mechanical ventilation at the ED, delayed ICU admission is associated with higher probability of mortality and additional resource expenditure. A benchmark waiting time of no more than 4 hours for ICU admission is recommended.

46 CFR 154.1200 - Mechanical ventilation system: General.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 46 Shipping 5 2010-10-01 2010-10-01 false Mechanical ventilation system: General. 154.1200 Section... Equipment Cargo Area: Mechanical Ventilation System § 154.1200 Mechanical ventilation system: General. (a... cargo handling equipment must have a fixed, exhaust-type mechanical ventilation system. (b) The...

Mechanical Ventilation: State of the Art.

PubMed

Pham, Tài; Brochard, Laurent J; Slutsky, Arthur S

2017-09-01

Mechanical ventilation is the most used short-term life support technique worldwide and is applied daily for a diverse spectrum of indications, from scheduled surgical procedures to acute organ failure. This state-of-the-art review provides an update on the basic physiology of respiratory mechanics, the working principles, and the main ventilatory settings, as well as the potential complications of mechanical ventilation. Specific ventilatory approaches in particular situations such as acute respiratory distress syndrome and chronic obstructive pulmonary disease are detailed along with protective ventilation in patients with normal lungs. We also highlight recent data on patient-ventilator dyssynchrony, humidified high-flow oxygen through nasal cannula, extracorporeal life support, and the weaning phase. Finally, we discuss the future of mechanical ventilation, addressing avenues for improvement. Copyright © 2017 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.

Mechanical ventilation weaning and extubation after spinal cord injury: a Western Trauma Association multicenter study.

PubMed

Kornblith, Lucy Z; Kutcher, Matthew E; Callcut, Rachael A; Redick, Brittney J; Hu, Charles K; Cogbill, Thomas H; Baker, Christopher C; Shapiro, Mark L; Burlew, Clay C; Kaups, Krista L; DeMoya, Marc A; Haan, James M; Koontz, Christopher H; Zolin, Samuel J; Gordy, Stephanie D; Shatz, David V; Paul, Doug B; Cohen, Mitchell J

2013-12-01

Respiratory failure after acute spinal cord injury (SCI) is well recognized, but data defining which patients need long-term ventilator support and criteria for weaning and extubation are lacking. We hypothesized that many patients with SCI, even those with cervical SCI, can be successfully managed without long-term mechanical ventilation and its associated morbidity. Under the auspices of the Western Trauma Association Multi-Center Trials Group, a retrospective study of patients with SCI at 14 major trauma centers was conducted. Comprehensive injury, demographic, and outcome data on patients with acute SCI were compiled. The primary outcome variable was the need for mechanical ventilation at discharge. Secondary outcomes included the use of tracheostomy and development of acute lung injury and ventilator-associated pneumonia. A total of 360 patients had SCI requiring mechanical ventilation. Sixteen patients were excluded for death within the first 2 days of hospitalization. Of the 344 patients included, 222 (64.5%) had cervical SCI. Notably, 62.6% of the patients with cervical SCI were ventilator free by discharge. One hundred forty-nine patients (43.3%) underwent tracheostomy, and 53.7% of them were successfully weaned from the ventilator, compared with an 85.6% success rate among those with no tracheostomy (p < 0.05). Patients who underwent tracheostomy had significantly higher rates of ventilator-associated pneumonia (61.1% vs. 20.5%, p < 0.05) and acute lung injury (12.8% vs. 3.6%, p < 0.05) and fewer ventilator-free days (1 vs. 24 p < 0.05). When controlled for injury severity, thoracic injury, and respiratory comorbidities, tracheostomy after cervical SCI was an independent predictor of ventilator dependence with an associated 14-fold higher likelihood of prolonged mechanical ventilation (odds ratio, 14.1; 95% confidence interval, 2.78-71.67; p < 0.05). While many patients with SCI require short-term mechanical ventilation, the majority can be successfully

46 CFR 154.1205 - Mechanical ventilation system: Standards.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 46 Shipping 5 2010-10-01 2010-10-01 false Mechanical ventilation system: Standards. 154.1205... Equipment Cargo Area: Mechanical Ventilation System § 154.1205 Mechanical ventilation system: Standards. (a) Each exhaust type mechanical ventilation system required under § 154.1200 (a) must have ducts for...

Clinical factors and incidence of prolonged fever in neurosurgical patients.

PubMed

Wang, Zhuo; Shen, Meifen; Qiao, Meizhen; Zhang, Haiyin; Tang, Zaixiang

2017-02-01

To describe the incidence of prolonged fever in patients admitted to the neurosurgery department, and the corresponding risk indicators. Prolonged fever was defined as a temperature higher than 38·3°C lasting more than five days. Prolonged fever is a common phenomenon and could lead to worsened outcomes in specific patient groups, especially for those with brain injury. However, the studies on prolonged fever in neurosurgical patients are limited and insufficient. A retrospective observational study. Retrospective data were collected from 1 January 2014 to 31 December 2014, at the neurosurgical department of a large teaching hospital. We performed univariate and multivariate analyses to identify independent indicators for prolonged fever vs. short-term fever. Among 2845 patients, prolonged fever occurred in 466 (16%). The older patients were associated with longer duration of mechanical ventilation and hospital stay. It predominantly occurred in patients with subarachnoid haemorrhage (SAH) and traumatic brain injury. Patients receiving antibiotic treatment tended to manifest prolonged fever more frequently. Multivariate analysis revealed that the use of antibiotics, central venous catheter and prolonged mechanical ventilation were independent risk predictors for prolonged fever. Patients diagnosed with brain tumour seemed to be not associated with prolonged fever. Prolonged fever is the common complication in neurosurgical patients. The risks of prolonged fever in patients are attributed to antibiotic therapy, use of central venous catheter and prolonged mechanical ventilation. Indicators of prolonged fever are helpful for better identification of high-risk patients and fever control. A better reveal on the epidemiology and predictable factors of prolonged fever in neurosurgical patients will provide a better understanding on those patients who are most at risk, and therefore contribute to fever control and better outcome. © 2016 John Wiley & Sons Ltd.

Mechanical ventilation for amyotrophic lateral sclerosis/motor neuron disease.

PubMed

Radunovic, Aleksandar; Annane, Djillali; Rafiq, Muhammad K; Mustfa, Naveed

2013-03-28

Amyotrophic lateral sclerosis, also known as motor neuron disease, is a fatal neurodegenerative disease. Neuromuscular respiratory failure is the commonest cause of death, usually within two to five years of the disease onset. Supporting respiratory function with mechanical ventilation may improve survival and quality of life. This is the first update of a review first published in 2009. The primary objective of the review is to examine the efficacy of mechanical ventilation (tracheostomy and non-invasive ventilation) in improving survival in ALS. The secondary objectives are to examine the effect of mechanical ventilation on functional measures of disease progression and quality of life in people with ALS; and assess adverse events related to the intervention. We searched The Cochrane Neuromuscular Disease Group Specialized Register (1 May 2012), CENTRAL (2012, Issue 4), MEDLINE (January 1966 to April 2012), EMBASE (January 1980 to April 2012), CINAHL Plus (January 1937 to April 2012), and AMED (January 1985 to April 2012). We also searched for ongoing studies on ClinicalTrials.gov. Randomised and quasi-randomised controlled trials involving non-invasive or tracheostomy assisted ventilation in participants with a clinical diagnosis of amyotrophic lateral sclerosis, independent of the reported outcomes. We planned to include comparisons with no intervention or the best standard care. For the original review, four authors independently selected studies for assessment and two authors reviewed searches for this update. All authors extracted data independently from the full text of selected studies and assessed the risk of bias in studies that met the inclusion criteria. We attempted to obtain missing data where possible. We planned to collect adverse event data from included studies. For the original Cochrane review, the review authors identified and included two randomised controlled trials involving 54 participants with ALS receiving non-invasive ventilation. There

[Pressure support ventilation and proportional assist ventilation during weaning from mechanical ventilation].

PubMed

Aguirre-Bermeo, H; Bottiroli, M; Italiano, S; Roche-Campo, F; Santos, J A; Alonso, M; Mancebo, J

2014-01-01

To compare tolerance, duration of mechanical ventilation (MV) and clinical outcomes during weaning from MV in patients subjected to either pressure support ventilation (PSV) or proportional assist ventilation (PAV). A prospective, observational study was carried out. Intensive Care Unit. A total of 40 consecutive subjects were allocated to either the PSV or the PAV group until each group contained 20 patients. Patients were included in the study when they met the criteria to begin weaning and the attending physician decided to initiate the weaning process. The physician selected the modality and set the ventilatory parameters. None. Demographic data, respiratory mechanics, ventilatory parameters, duration of MV, and clinical outcomes (reintubation, tracheostomy, mortality). Baseline characteristics were similar in both groups. No significant differences were observed between the PSV and PAV groups in terms of the total duration of MV (10 [5-18] vs. 9 [7-19] days; P=.85), reintubation (5 [31%] vs. 3 [19%]; P=.69), or mortality (4 [20%] vs. 5 [25%] deaths; P=1). Eight patients (40%) in the PSV group and 6 patients (30%) in the PAV group (P=.74) required a return to volume assist-control ventilation due to clinical deterioration. Tolerance, duration of MV and clinical outcomes during weaning from mechanical ventilation were similar in PSV and PAV. Copyright © 2013 Elsevier España, S.L. and SEMICYUC. All rights reserved.

Iatrogenic pneumothorax related to mechanical ventilation

PubMed Central

Hsu, Chien-Wei; Sun, Shu-Fen

2014-01-01

Pneumothorax is a potentially lethal complication associated with mechanical ventilation. Most of the patients with pneumothorax from mechanical ventilation have underlying lung diseases; pneumothorax is rare in intubated patients with normal lungs. Tension pneumothorax is more common in ventilated patients with prompt recognition and treatment of pneumothorax being important to minimize morbidity and mortality. Underlying lung diseases are associated with ventilator-related pneumothorax with pneumothoraces occurring most commonly during the early phase of mechanical ventilation. The diagnosis of pneumothorax in critical illness is established from the patients’ history, physical examination and radiological investigation, although the appearances of a pneumothorax on a supine radiograph may be different from the classic appearance on an erect radiograph. For this reason, ultrasonography is beneficial for excluding the diagnosis of pneumothorax. Respiration-dependent movement of the visceral pleura and lung surface with respect to the parietal pleura and chest wall can be easily visualized with transthoracic sonography given that the presence of air in the pleural space prevents sonographic visualization of visceral pleura movements. Mechanically ventilated patients with a pneumothorax require tube thoracostomy placement because of the high risk of tension pneumothorax. Small-bore catheters are now preferred in the majority of ventilated patients. Furthermore, if there are clinical signs of a tension pneumothorax, emergency needle decompression followed by tube thoracostomy is widely advocated. Patients with pneumothorax related to mechanical ventilation who have tension pneumothorax, a higher acute physiology and chronic health evaluation II score or PaO2/FiO2 < 200 mmHg were found to have higher mortality. PMID:24834397

Incidence of Ventilator-Associated Pneumonia in Critically Ill Children Undergoing Mechanical Ventilation in Pediatric Intensive Care Unit

PubMed Central

Amanati, Ali; Karimi, Abdollah; Fahimzad, Alireza; Shamshiri, Ahmad Reza; Fallah, Fatemeh; Mahdavi, Alireza; Talebian, Mahshid

2017-01-01

Background: Among hospital-acquired infections (HAIs) in children, ventilator-associated pneumonia (VAP) is the most common after blood stream infection (BSI). VAP can prolong length of ventilation and hospitalization, increase mortality rate, and directly change a patient’s outcome in Pediatric Intensive Care Units (PICU). Objectives: The research on VAP in children is limited, especially in Iran; therefore, the identification of VAP incidence and mortality rate will be important for both clinical and epidemiological implications. Materials and Methods: Mechanically ventilated pediatric patients were assessed for development of VAP during hospital course on the basis of clinical, laboratory and imaging criteria. We matched VAP group with control group for assessment of VAP related mortality in the critically ill ventilated children. Results: VAP developed in 22.9% of critically ill children undergoing mechanical ventilation. Early VAP and late VAP were found in 19.3% and 8.4% of VAP cases, respectively. Among the known VAP risk factors that were investigated, immunodeficiency was significantly greater in the VAP group (p = 0.014). No significant differences were found between the two groups regarding use of corticosteroids, antibiotics, PH (potential of hydrogen) modifying agents (such as ranitidine or pantoprazole), presence of nasogastric tube and total or partial parenteral nutrition administration. A substantial number of patients in the VAP group had more than four risk factors for development of VAP, compared to those without VAP (p = 0.087). Mortality rate was not statistically different between the VAP and control groups (p = 0.477). Conclusion: VAP is still one of the major causes of mortality in PICUs. It is found that altered immune status is a significant risk factor for acquiring VAP. Also, occurrence of VAP was high in the first week after admission in PICU. PMID:28671616

Academic Emergency Medicine Physicians' Knowledge of Mechanical Ventilation.

PubMed

Wilcox, Susan R; Strout, Tania D; Schneider, Jeffrey I; Mitchell, Patricia M; Smith, Jessica; Lutfy-Clayton, Lucienne; Marcolini, Evie G; Aydin, Ani; Seigel, Todd A; Richards, Jeremy B

2016-05-01

Although emergency physicians frequently intubate patients, management of mechanical ventilation has not been emphasized in emergency medicine (EM) education or clinical practice. The objective of this study was to quantify EM attendings' education, experience, and knowledge regarding mechanical ventilation in the emergency department. We developed a survey of academic EM attendings' educational experiences with ventilators and a knowledge assessment tool with nine clinical questions. EM attendings at key teaching hospitals for seven EM residency training programs in the northeastern United States were invited to participate in this survey study. We performed correlation and regression analyses to evaluate the relationship between attendings' scores on the assessment instrument and their training, education, and comfort with ventilation. Of 394 EM attendings surveyed, 211 responded (53.6%). Of respondents, 74.5% reported receiving three or fewer hours of ventilation-related education from EM sources over the past year and 98 (46%) reported receiving between 0-1 hour of education. The overall correct response rate for the assessment tool was 73.4%, with a standard deviation of 19.9. The factors associated with a higher score were completion of an EM residency, prior emphasis on mechanical ventilation during one's own residency, working in a setting where an emergency physician bears primary responsibility for ventilator management, and level of comfort with managing ventilated patients. Physicians' comfort was associated with the frequency of ventilator changes and EM management of ventilation, as well as hours of education. EM attendings report caring for mechanically ventilated patients frequently, but most receive fewer than three educational hours a year on mechanical ventilation, and nearly half receive 0-1 hour. Physicians' performance on an assessment tool for mechanical ventilation is most strongly correlated with their self-reported comfort with mechanical

Predictive Associations of Music, Anxiety, and Sedative Exposure on Mechanical Ventilation Weaning Trials

PubMed Central

Hetland, Breanna; Lindquist, Ruth; Weinert, Craig R.; Peden-McAlpine, Cynthia; Savik, Kay; Chlan, Linda

2017-01-01

Background Weaning from mechanical ventilation requires increased respiratory effort, which can heighten anxiety and later prolong the need for mechanical ventilation. Objectives To examine the predictive associations of music intervention, anxiety, sedative exposure, and patients’ characteristics on time to initiation and duration of weaning trials of patients receiving mechanical ventilation. Methods A descriptive, correlational design was used for a secondary analysis of data from a randomized trial. Music listening was defined as self-initiated, patient-directed music via headphones. Anxiety was measured daily with a visual analog scale. Sedative exposure was operationalized as a daily sedation intensity score and a sedative dose frequency. Analyses consisted of descriptive statistics, graphing, survival analysis, Cox proportional hazards regression, and linear regression. Results Of 307 patients, 52% were women and 86% were white. Mean age was 59.3 (SD, 14.4) years, mean Acute Physiology and Chronic Health Evaluation III score was 62.9 (SD, 21.6), mean duration of ventilatory support was 8 (range, 1–52) days, and mean stay in the intensive care unit was 18 (range, 2–71) days. Music listening, anxiety levels, and sedative exposure did not influence time to initial weaning trial or duration of trials. Clinical factors of illness severity, days of weaning trials, and tracheostomy placement influenced weaning patterns in this sample. Conclusions Prospective studies of music intervention and other psychophysiological factors during weaning from mechanical ventilation are needed to better understand factors that promote successful weaning. PMID:28461543

Artificial humidification for the mechanically ventilated patient.

PubMed

Selvaraj, N

Caring for patients who are mechanically ventilated poses many challenges for critical care nurses. It is important to humidify the patient's airways artificially to prevent complications such as ventilator-associated pneumonia. There is no gold standard to determine which type of humidification is best for patients who are artificially ventilated. This article provides an overview of commonly used artificial humidification for mechanically ventilated patients and discusses nurses' responsibilities in caring for patients receiving artificial humidification.

Lung-protective mechanical ventilation does not protect against acute kidney injury in patients without lung injury at onset of mechanical ventilation.

PubMed

Cortjens, Bart; Royakkers, Annick A N M; Determann, Rogier M; van Suijlen, Jeroen D E; Kamphuis, Stephan S; Foppen, Jannetje; de Boer, Anita; Wieland, Cathrien W; Spronk, Peter E; Schultz, Marcus J; Bouman, Catherine S C

2012-06-01

Preclinical and clinical studies suggest that mechanical ventilation contributes to the development of acute kidney injury (AKI), particularly in the setting of lung-injurious ventilator strategies. To determine whether ventilator settings in critically ill patients without acute lung injury (ALI) at onset of mechanical ventilation affect the development of AKI. Secondary analysis of a randomized controlled trial (N = 150), comparing conventional tidal volume (V(T), 10 mL/kg) with low tidal volume (V(T), 6 mL/kg) mechanical ventilation in critically ill patients without ALI at randomization. During the first 5 days of mechanical ventilation, the RIFLE class was determined daily, whereas neutrophil gelatinase-associated lipocalin and cystatin C levels were measured in plasma collected on days 0, 2, and 4. Eighty-six patients had no AKI at inclusion, and 18 patients (21%) subsequently developed AKI, but without significant difference between ventilation strategies. (Cumulative hazard, 0.26 vs 0.23; P = .88.) The courses of neutrophil gelatinase-associated lipocalin and cystatin C plasma levels did not differ significantly between randomization groups. In the present study in critically patients without ALI at onset of mechanical ventilation, lower tidal volume ventilation did not reduce the development or worsening of AKI compared with conventional tidal volume ventilation. Copyright © 2012 Elsevier Inc. All rights reserved.

Duration of Mechanical Ventilation in the Emergency Department.

PubMed

Angotti, Lauren B; Richards, Jeremy B; Fisher, Daniel F; Sankoff, Jeffrey D; Seigel, Todd A; Al Ashry, Haitham S; Wilcox, Susan R

2017-08-01

Due to hospital crowding, mechanically ventilated patients are increasingly spending hours boarding in emergency departments (ED) before intensive care unit (ICU) admission. This study aims to evaluate the association between time ventilated in the ED and in-hospital mortality, duration of mechanical ventilation, ICU and hospital length of stay (LOS). This was a multi-center, prospective, observational study of patients ventilated in the ED, conducted at three academic Level I Trauma Centers from July 2011 to March 2013. All consecutive adult patients on invasive mechanical ventilation were eligible for enrollment. We performed a Cox regression to assess for a mortality effect for mechanically ventilated patients with each hour of increasing LOS in the ED and multivariable regression analyses to assess for independently significant contributors to in-hospital mortality. Our primary outcome was in-hospital mortality, with secondary outcomes of ventilator days, ICU LOS and hospital LOS. We further commented on use of lung protective ventilation and frequency of ventilator changes made in this cohort. We enrolled 535 patients, of whom 525 met all inclusion criteria. Altered mental status without respiratory pathology was the most common reason for intubation, followed by trauma and respiratory failure. Using iterated Cox regression, a mortality effect occurred at ED time of mechanical ventilation > 7 hours, and the longer ED stay was also associated with a longer total duration of intubation. However, adjusted multivariable regression analysis demonstrated only older age and admission to the neurosciences ICU as independently associated with increased mortality. Of interest, only 23.8% of patients ventilated in the ED for over seven hours had changes made to their ventilator. In a prospective observational study of patients mechanically ventilated in the ED, there was a significant mortality benefit to expedited transfer of patients into an appropriate ICU setting.

Antenatal exposure to Ureaplasma species exacerbates bronchopulmonary dysplasia synergistically with subsequent prolonged mechanical ventilation in preterm infants.

PubMed

Inatomi, Tadashi; Oue, Shinya; Ogihara, Tohru; Hira, Seigo; Hasegawa, Masashi; Yamaoka, Shigeo; Yasui, Masako; Tamai, Hiroshi

2012-03-01

The presence of microorganisms in gastric fluid in neonates at birth is postulated to reflect antenatal infection and also to be associated with the development of bronchopulmonary dysplasia (BPD). A logistic regression analysis, after controlling for other risk factors, indicated that Ureaplasma-positive infants were not at increased risk for moderate/severe BPD (adjusted odds ratio (OR): 2.58, 95% confidence interval (CI): 0.57-6.89, P = 0.12). However, the association between the presence of Ureaplasma species and the risk for moderate/severe BPD increased significantly in infants on mechanical ventilation (MV) ≥2 wk (adjusted OR: 4.17, 95% CI: 1.62-44.1, P = 0.009). An analysis using a lung injury marker indicated that Ureaplasma-positive infants with MV ≥2 wk, but not other infants, showed higher serum KL-6 levels in samples taken from cord blood, and that KL-6 levels increased time-dependently up to 4 wk of age. Antenatal exposure to Ureaplasma species induces lung injury prior to birth and synergistically contributes to the development of BPD in infants requiring prolonged MV (≥2 wk). We recovered gastric fluid specimens from 122 infants with gestational age (GA) <29 wk or birth weight <1,000 g to investigate whether these microorganisms influence respiratory outcome of BPD. A PCR analysis was used to detect urease and 16S ribosomal RNA (rRNA) genes to classify neonates into Ureaplasma-positive or Ureaplasma-negative infants.

[Oxidative stress in patients on mechanical ventilation].

PubMed

Marjanović, Vesna; Dordević, Vidosava; Marjanović, Goran

2009-01-01

The appearance and intensity of oxidative stress were analyzed in the course of mechanical ventilation and parameters that could point toward potential lung damage. In three time intervals on day 1, 3 and 7 of mechanical ventilation, parameters such as: triglycerides, cholesterol, lactate, serum lactic dehydrogenase, acid-base balance and lipid peroxidation products--thiobarbituric acid reactive substances, were followed in 30 patients with head injuries. A decrease in the level of partial oxygen pressure (PaO2) (p < 0.01) and PaO2/FiO2 index (p < 0.05) in arterial blood was recorded on day 3 of mechanical ventilation. This was accompanied with an increase in alveolar-arterial difference (AaDO2) (p < 0.05), thiobarbituric acid reactive substances (p < 0.001) and lactic dehydrogenase (p < 0.001) comparing to day 1 of mechanical ventilation. The patients with initial PaO2 > 120 mmHg, had significant increase of thiobarbituric acid reactive substances and AaDO2 (p < 0.05) and fall of PaO2 (p < 0.001) on day 3 of mechanical ventilation. Oxidative stress and lipid peroxide production are increased during third day of mechanical ventilation leading to disruption of oxygen diffusion through alveolar-capillary membrane and reduction of parameters of oxygenation.

New modes of assisted mechanical ventilation.

PubMed

Suarez-Sipmann, F

2014-05-01

Recent major advances in mechanical ventilation have resulted in new exciting modes of assisted ventilation. Compared to traditional ventilation modes such as assisted-controlled ventilation or pressure support ventilation, these new modes offer a number of physiological advantages derived from the improved patient control over the ventilator. By implementing advanced closed-loop control systems and using information on lung mechanics, respiratory muscle function and respiratory drive, these modes are specifically designed to improve patient-ventilator synchrony and reduce the work of breathing. Depending on their specific operational characteristics, these modes can assist spontaneous breathing efforts synchronically in time and magnitude, adapt to changing patient demands, implement automated weaning protocols, and introduce a more physiological variability in the breathing pattern. Clinicians have now the possibility to individualize and optimize ventilatory assistance during the complex transition from fully controlled to spontaneous assisted ventilation. The growing evidence of the physiological and clinical benefits of these new modes is favoring their progressive introduction into clinical practice. Future clinical trials should improve our understanding of these modes and help determine whether the claimed benefits result in better outcomes. Copyright © 2013 Elsevier España, S.L. and SEMICYUC. All rights reserved.

Implementation of a Goal-Directed Mechanical Ventilation Order Set Driven by Respiratory Therapists Improves Compliance With Best Practices for Mechanical Ventilation.

PubMed

Radosevich, Misty A; Wanta, Brendan T; Meyer, Todd J; Weber, Verlin W; Brown, Daniel R; Smischney, Nathan J; Diedrich, Daniel A

2017-01-01

Data regarding best practices for ventilator management strategies that improve outcomes in acute respiratory distress syndrome (ARDS) are readily available. However, little is known regarding processes to ensure compliance with these strategies. We developed a goal-directed mechanical ventilation order set that included physician-specified lung-protective ventilation and oxygenation goals to be implemented by respiratory therapists (RTs). We sought as a primary outcome to determine whether an RT-driven order set with predefined oxygenation and ventilation goals could be implemented and associated with improved adherence with best practice. We evaluated 1302 patients undergoing invasive mechanical ventilation (1693 separate episodes of invasive mechanical ventilation) prior to and after institution of a standardized, goal-directed mechanical ventilation order set using a controlled before-and-after study design. Patient-specific goals for oxygenation partial pressure of oxygen in arterial blood (Pao 2 ), ARDS Network [Net] positive end-expiratory pressure [PEEP]/fraction of inspired oxygen [Fio 2 ] table use) and ventilation (pH, partial pressure of carbon dioxide) were selected by prescribers and implemented by RTs. Compliance with the new mechanical ventilation order set was high: 88.2% compliance versus 3.8% before implementation of the order set ( P < .001). Adherence to the PEEP/Fio 2 table after implementation of the order set was significantly greater (86.0% after vs 82.9% before, P = .02). There was no difference in duration of mechanical ventilation, intensive care unit (ICU) length of stay, and in-hospital or ICU mortality. A standardized best practice mechanical ventilation order set can be implemented by a multidisciplinary team and is associated with improved compliance to written orders and adherence to the ARDSNet PEEP/Fio 2 table.

Quantification of Age-Related Lung Tissue Mechanics under Mechanical Ventilation.

PubMed

Kim, JongWon; Heise, Rebecca L; Reynolds, Angela M; Pidaparti, Ramana M

2017-09-29

Elderly patients with obstructive lung diseases often receive mechanical ventilation to support their breathing and restore respiratory function. However, mechanical ventilation is known to increase the severity of ventilator-induced lung injury (VILI) in the elderly. Therefore, it is important to investigate the effects of aging to better understand the lung tissue mechanics to estimate the severity of ventilator-induced lung injuries. Two age-related geometric models involving human bronchioles from generation G10 to G23 and alveolar sacs were developed. The first is for a 50-year-old (normal) and second is for an 80-year old (aged) model. Lung tissue mechanics of normal and aged models were investigated under mechanical ventilation through computational simulations. Results obtained indicated that lung tissue strains during inhalation (t = 0.2 s) decreased by about 40% in the alveolar sac (G23) and 27% in the bronchiole (G20), respectively, for the 80-year-old as compared to the 50-year-old. The respiratory mechanics parameters (work of breathing per unit volume and maximum tissue strain) over G20 and G23 for the 80-year-old decreased by about 64% (three-fold) and 80% (four-fold), respectively, during the mechanical ventilation breathing cycle. However, there was a significant increase (by about threefold) in lung compliance for the 80-year-old in comparison to the 50-year-old. These findings from the computational simulations demonstrated that lung mechanical characteristics are significantly compromised in aging tissues, and these effects were quantified in this study.

Management and outcome of mechanically ventilated neurologic patients.

PubMed

Pelosi, Paolo; Ferguson, Niall D; Frutos-Vivar, Fernando; Anzueto, Antonio; Putensen, Christian; Raymondos, Konstantinos; Apezteguia, Carlos; Desmery, Pablo; Hurtado, Javier; Abroug, Fekri; Elizalde, José; Tomicic, Vinko; Cakar, Nahit; Gonzalez, Marco; Arabi, Yaseen; Moreno, Rui; Esteban, Andres

2011-06-01

To describe and compare characteristics, ventilatory practices, and associated outcomes among mechanically ventilated patients with different types of brain injury and between neurologic and nonneurologic patients. Secondary analysis of a prospective, observational, and multicenter study on mechanical ventilation. Three hundred forty-nine intensive care units from 23 countries. We included 552 mechanically ventilated neurologic patients (362 patients with stroke and 190 patients with brain trauma). For comparison we used a control group of 4,030 mixed patients who were ventilated for nonneurologic reasons. None. We collected demographics, ventilatory settings, organ failures, and complications arising during ventilation and outcomes. Multivariate logistic regression analysis was performed with intensive care unit mortality as the dependent variable. At admission, a Glasgow Coma Scale score ≤8 was observed in 68% of the stroke, 77% of the brain trauma, and 29% of the nonneurologic patients. Modes of ventilation and use of a lung-protective strategy within the first week of mechanical ventilation were similar between groups. In comparison with nonneurologic patients, patients with neurologic disease developed fewer complications over the course of mechanical ventilation with the exception of a higher rate of ventilator-associated pneumonia in the brain trauma cohort. Neurologic patients showed higher rates of tracheotomy and longer duration of mechanical ventilation. Mortality in the intensive care unit was significantly (p < .001) higher in patients with stroke (45%) than in brain trauma (29%) and nonneurologic disease (30%). Factors associated with mortality were: stroke (in comparison to brain trauma), Glasgow Coma Scale score on day 1, and severity at admission in the intensive care unit. In our study, one of every five mechanically ventilated patients received this therapy as a result of a neurologic disease. This cohort of patients showed a higher mortality

Analysis of a Pediatric Home Mechanical Ventilator Population.

PubMed

Amirnovin, Rambod; Aghamohammadi, Sara; Riley, Carley; Woo, Marlyn S; Del Castillo, Sylvia

2018-05-01

The population of children requiring home mechanical ventilation has evolved over the years and has grown to include a variety of diagnoses and needs that have led to changes in the care of this unique population. The purpose of this study was to provide a descriptive analysis of pediatric patients requiring home mechanical ventilation after hospitalization and how the evolution of this technology has impacted their care. A retrospective, observational, longitudinal analysis of 164 children enrolled in a university-affiliated home mechanical ventilation program over 26 years was performed. Data included each child's primary diagnosis, date of tracheostomy placement, duration of mechanical ventilation during hospitalization that consisted of home mechanical ventilator initiation, total length of pediatric ICU stay, ventilator settings at time of discharge from pediatric ICU, and disposition (home, facility, or died). Univariate, bivariate, and regression analysis was used as appropriate. The most common diagnosis requiring the use of home mechanical ventilation was neuromuscular disease (53%), followed by chronic pulmonary disease (29%). The median length of stay in the pediatric ICU decreased significantly after the implementation of a ventilator ward (70 d [30-142] vs 36 d [18-67], P = .02). The distribution of subjects upon discharge was home (71%), skilled nursing facility (24%), and died (4%), with an increase in the proportion of subjects discharged on PEEP and those going to nursing facilities over time ( P = 0.02). The evolution of home mechanical ventilation has allowed earlier transition out of the pediatric ICU and with increasing disposition to skilled nursing facilities over time. There has also been a change in ventilator management, including increased use of PEEP upon discharge, possibly driven by changes in ventilators and in-patient practice patterns. Copyright © 2018 by Daedalus Enterprises.

Trends in mechanical ventilation: are we ventilating our patients in the best possible way?

PubMed Central

Veneroni, Chiara; Farre’, Ramon

2017-01-01

This review addresses how the combination of physiology, medicine and engineering principles contributed to the development and advancement of mechanical ventilation, emphasising the most urgent needs for improvement and the most promising directions of future development. Several aspects of mechanical ventilation are introduced, highlighting on one side the importance of interdisciplinary research for further development and, on the other, the importance of training physicians sufficiently on the technological aspects of modern devices to exploit properly the great complexity and potentials of this treatment. Educational aims To learn how mechanical ventilation developed in recent decades and to provide a better understanding of the actual technology and practice. To learn how and why interdisciplinary research and competences are necessary for providing the best ventilation treatment to patients. To understand which are the most relevant technical limitations in modern mechanical ventilators that can affect their performance in delivery of the treatment. To better understand and classify ventilation modes. To learn the classification, benefits, drawbacks and future perspectives of automatic ventilation tailoring algorithms. PMID:28620428

Trends in mechanical ventilation: are we ventilating our patients in the best possible way?

PubMed

Dellaca', Raffaele L; Veneroni, Chiara; Farre', Ramon

2017-06-01

This review addresses how the combination of physiology, medicine and engineering principles contributed to the development and advancement of mechanical ventilation, emphasising the most urgent needs for improvement and the most promising directions of future development. Several aspects of mechanical ventilation are introduced, highlighting on one side the importance of interdisciplinary research for further development and, on the other, the importance of training physicians sufficiently on the technological aspects of modern devices to exploit properly the great complexity and potentials of this treatment. To learn how mechanical ventilation developed in recent decades and to provide a better understanding of the actual technology and practice.To learn how and why interdisciplinary research and competences are necessary for providing the best ventilation treatment to patients.To understand which are the most relevant technical limitations in modern mechanical ventilators that can affect their performance in delivery of the treatment.To better understand and classify ventilation modes.To learn the classification, benefits, drawbacks and future perspectives of automatic ventilation tailoring algorithms.

[The prevention and treatment of suppurative-inflammatory complications in the bronchopulmonary system during prolonged artificial ventilation].

PubMed

Mozhaev, G A; Tikhonovskiĭ, I Iu

1992-01-01

The use of physical methods, namely low frequency magnetic field in critically ill patients under respiratory therapy made it possible to prevent and in case of their development to effectively treat pyoinflammatory bronchopulmonary complications that accompany prolonged controlled lung ventilation. The results obtained were due to the elimination of an unfavourable effect of controlled lung ventilation on natural resistance and immune response of the respiratory tract because of normalization of physicochemical properties of the tracheobronchial tree secretion, enhanced functional capacities of phagocytes, repaired bonds between cellular and humoral local immunity in the lungs.

Mechanical Ventilation and Bronchopulmonary Dysplasia.

PubMed

Keszler, Martin; Sant'Anna, Guilherme

2015-12-01

Mechanical ventilation is an important potentially modifiable risk factor for the development of bronchopulmonary dysplasia. Effective use of noninvasive respiratory support reduces the risk of lung injury. Lung volume recruitment and avoidance of excessive tidal volume are key elements of lung-protective ventilation strategies. Avoidance of oxidative stress, less invasive methods of surfactant administration, and high-frequency ventilation are also important factors in lung injury prevention. Copyright © 2015 Elsevier Inc. All rights reserved.

Mechanical ventilation strategies.

PubMed

Keszler, Martin

2017-08-01

Although only a small proportion of full term and late preterm infants require invasive respiratory support, they are not immune from ventilator-associated lung injury. The process of lung damage from mechanical ventilation is multifactorial and cannot be linked to any single variable. Atelectrauma and volutrauma have been identified as the most important and potentially preventable elements of lung injury. Respiratory support strategies for full term and late preterm infants have not been as thoroughly studied as those for preterm infants; consequently, a strong evidence base on which to make recommendations is lacking. The choice of modalities of support and ventilation strategies should be guided by the specific underlying pathophysiologic considerations and the ventilatory approach must be individualized for each patient based on the predominant pathophysiology at the time. Copyright © 2017 Elsevier Ltd. All rights reserved.

[Pulmonary complications associated with mechanical ventilation in neonates].

PubMed

Torres-Castro, Cristabel; Valle-Leal, Jaime; Martínez-Limón, Alba J; Lastra-Jiménez, Zaira; Delgado-Bojórquez, Lesvia Carmina

To determine the incidence of0 associated with mechanical ventilation in patients admitted to a service in a second level hospital NICU. Retrospective analytical study records of newborns admitted to NICU room and receiving mechanical ventilation in a secondary hospital health care. Demographic data, of mechanical ventilation, intubation and complications reported in the clinical record were collected and analyzed in SPSS 20. 53 patients selected a total of 40 complications found. The annual incidence of pulmonary complications associated with mechanical ventilation in the area of service neonatology NICU, at a second level hospital at Sonora was 49.05% (95% CI 0.35 to 0.62). The most frequent pulmonary complications were atelectasis 35%, pneumonia 27.5%, pneumothorax 15%, bronchopulmonary dysplasia 15%, pneumomediastinum 15% and pulmonary hemorrhage 2.5%. The presentation of pulmonary complications secondary to mechanical ventilation in neonatal patients is similar to that reported in developing countries. Atelectasis is the most common pulmonary complication in neonatal patients undergoing mechanical ventilation. Copyright © 2016 Hospital Infantil de México Federico Gómez. Publicado por Masson Doyma México S.A. All rights reserved.

Intraoperative mechanical ventilation for the pediatric patient.

PubMed

Kneyber, Martin C J

2015-09-01

Invasive mechanical ventilation is required when children undergo general anesthesia for any procedure. It is remarkable that one of the most practiced interventions such as pediatric mechanical ventilation is hardly supported by any scientific evidence but rather based on personal experience and data from adults, especially as ventilation itself is increasingly recognized as a harmful intervention that causes ventilator-induced lung injury. The use of low tidal volume and higher levels of positive end-expiratory pressure became an integral part of lung-protective ventilation following the outcomes of clinical trials in critically ill adults. This approach has been readily adopted in pediatric ventilation. However, a clear association between tidal volume and mortality has not been ascertained in pediatrics. In fact, experimental studies have suggested that young children might be less susceptible to ventilator-induced lung injury. As such, no recommendations on optimal lung-protective ventilation strategy in children with or without lung injury can be made. Copyright © 2015 Elsevier Ltd. All rights reserved.

Humidification during invasive and noninvasive mechanical ventilation: 2012.

PubMed

Restrepo, Ruben D; Walsh, Brian K

2012-05-01

We searched the MEDLINE, CINAHL, and Cochrane Library databases for articles published between January 1990 and December 2011. The update of this clinical practice guideline is based on 184 clinical trials and systematic reviews, and 10 articles investigating humidification during invasive and noninvasive mechanical ventilation. The following recommendations are made following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) scoring system: 1. Humidification is recommended on every patient receiving invasive mechanical ventilation. 2. Active humidification is suggested for noninvasive mechanical ventilation, as it may improve adherence and comfort. 3. When providing active humidification to patients who are invasively ventilated, it is suggested that the device provide a humidity level between 33 mg H(2)O/L and 44 mg H(2)O/L and gas temperature between 34°C and 41°C at the circuit Y-piece, with a relative humidity of 100%. 4. When providing passive humidification to patients undergoing invasive mechanical ventilation, it is suggested that the HME provide a minimum of 30 mg H(2)O/L. 5. Passive humidification is not recommended for noninvasive mechanical ventilation. 6. When providing humidification to patients with low tidal volumes, such as when lung-protective ventilation strategies are used, HMEs are not recommended because they contribute additional dead space, which can increase the ventilation requirement and P(aCO(2)). 7. It is suggested that HMEs are not used as a prevention strategy for ventilator-associated pneumonia.

Protective mechanical ventilation, why use it?

PubMed

Seiberlich, Emerson; Santana, Jonas Alves; Chaves, Renata de Andrade; Seiberlich, Raquel Carvalho

2011-01-01

Mechanical ventilation (MV) strategies have been modified over the last decades with a tendency for increasingly lower tidal volumes (VT). However, in patients without acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) the use of high VTs is still very common. Retrospective studies suggest that this practice can be related to mechanical ventilation-associated ALI. The objective of this review is to search for evidence to guide protective MV in patients with healthy lungs and to suggest strategies to properly ventilate lungs with ALI/ARDS. A review based on the main articles that focus on the use of strategies of mechanical ventilation was performed. Consistent studies to determine which would be the best way to ventilate a patient with healthy lungs are lacking. Expert recommendations and current evidence presented in this article indicate that the use of a VT lower than 10 mL.kg(-1), associated with positive end-expiratory pressure (PEEP) ≥ 5 cmH(2)O without exceeding a pressure plateau of 15 to 20 cmH(2)O could minimize alveolar stretching at the end of inspiration and avoid possible inflammation or alveolar collapse. Copyright © 2011 Elsevier Editora Ltda. All rights reserved.

Mechanical ventilation during extracorporeal membrane oxygenation. An international survey.

PubMed

Marhong, Jonathan D; Telesnicki, Teagan; Munshi, Laveena; Del Sorbo, Lorenzo; Detsky, Michael; Fan, Eddy

2014-07-01

In patients with severe, acute respiratory failure undergoing venovenous extracorporeal membrane oxygenation (VV-ECMO), the optimal strategy for mechanical ventilation is unclear. Our objective was to describe ventilation practices used in centers registered with the Extracorporeal Life Support Organization (ELSO). We conducted an international cross-sectional survey of medical directors and ECMO program coordinators from all ELSO-registered centers. The survey was distributed using a commercial website that collected information on center characteristics, the presence of a mechanical ventilator protocol, ventilator settings, and weaning practices. E-mails were sent out to medical directors or coordinators at each ELSO center and their responses were pooled for analysis. We analyzed 141 (50%) individual responses from the 283 centers contacted across 28 countries. Only 27% of centers reported having an explicit mechanical ventilation protocol for ECMO patients. The majority of these centers (77%) reported "lung rest" to be the primary goal of mechanical ventilation, whereas 9% reported "lung recruitment" to be their ventilation strategy. A tidal volume of 6 ml/kg or less was targeted by 76% of respondents, and 58% targeted a positive end-expiratory pressure of 6-10 cm H2O while ventilating patients on VV-ECMO. Centers prioritized weaning VV-ECMO before mechanical ventilation. Although ventilation practices in patients supported by VV-ECMO vary across ELSO centers internationally, the majority of centers used a strategy that targeted lung-protective thresholds and prioritized weaning VV-ECMO over mechanical ventilation.

Heat stress protects against mechanical ventilation-induced diaphragmatic atrophy.

PubMed

Ichinoseki-Sekine, Noriko; Yoshihara, Toshinori; Kakigi, Ryo; Sugiura, Takao; Powers, Scott K; Naito, Hisashi

2014-09-01

Mechanical ventilation (MV) is a life-saving intervention in patients who are incapable of maintaining adequate pulmonary gas exchange due to respiratory failure or other disorders. However, prolonged MV is associated with the development of respiratory muscle weakness. We hypothesized that a single exposure to whole body heat stress would increase diaphragm expression of heat shock protein 72 (HSP72) and that this treatment would protect against MV-induced diaphragmatic atrophy. Adult male Wistar rats (n = 38) were randomly assigned to one of four groups: an acutely anesthetized control group (CON) with no MV; 12-h controlled MV group (CMV); 1-h whole body heat stress (HS); or 1-h whole body heat stress 24 h prior to 12-h controlled MV (HSMV). Compared with CON animals, diaphragmatic HSP72 expression increased significantly in the HS and HSMV groups (P < 0.05). Prolonged MV resulted in significant atrophy of type I, type IIa, and type IIx fibers in the costal diaphragm (P < 0.05). Whole body heat stress attenuated this effect. In contrast, heat stress did not protect against MV-induced diaphragm contractile dysfunction. The mechanisms responsible for this heat stress-induced protection remain unclear but may be linked to increased expression of HSP72 in the diaphragm. Copyright © 2014 the American Physiological Society.

[Monitorization of respiratory mechanics in the ventilated patient].

PubMed

García-Prieto, E; Amado-Rodríguez, L; Albaiceta, G M

2014-01-01

Monitoring during mechanical ventilation allows the measurement of different parameters of respiratory mechanics. Accurate interpretation of these data can be useful for characterizing the situation of the different components of the respiratory system, and for guiding ventilator settings. In this review, we describe the basic concepts of respiratory mechanics, their interpretation, and their potential use in fine-tuning mechanical ventilation. Copyright © 2013 Elsevier España, S.L. y SEMICYUC. All rights reserved.

Intraoperative mechanical ventilation: state of the art.

PubMed

Ball, Lorenzo; Costantino, Federico; Orefice, Giulia; Chandrapatham, Karthikka; Pelosi, Paolo

2017-10-01

Mechanical ventilation is a cornerstone of the intraoperative management of the surgical patient and is still mandatory in several surgical procedures. In the last decades, research focused on preventing postoperative pulmonary complications (PPCs), both improving risk stratification through the use of predictive scores and protecting the lung adopting so-called protective ventilation strategies. The aim of this review was to give an up-to-date overview of the currently suggested intraoperative ventilation strategies, along with their pathophysiologic rationale, with a focus on challenging conditions, such as obesity, one-lung ventilation and cardiopulmonary bypass. While anesthesia and mechanical ventilation are becoming increasingly safe practices, the contribution to surgical mortality attributable to postoperative lung injury is not negligible: for these reasons, the prevention of PPCs, including the use of protective mechanical ventilation is mandatory. Mechanical ventilation should be optimized providing an adequate respiratory support while minimizing unwanted negative effects. Due to the high number of surgical procedures performed daily, the impact on patients' health and healthcare costs can be relevant, even when new strategies result in an apparently small improvement of outcome. A protective intraoperative ventilation should include a low tidal volume of 6-8 mL/kg of predicted body weight, plateau pressures ideally below 16 cmH2O, the lowest possible driving pressure, moderate-low PEEP levels except in obese patients, laparoscopy and long surgical procedures that might benefit of a slightly higher PEEP. The work of the anesthesiologist should start with a careful preoperative visit to assess the risk, and a close postoperative monitoring.

The Fluid Mechanics of Natural Ventilation

NASA Astrophysics Data System (ADS)

Linden, P. F.

1999-01-01

Natural ventilation of buildings is the flow generated by temperature differences and by the wind. The governing feature of this flow is the exchange between an interior space and the external ambient. Although the wind may often appear to be the dominant driving mechanism, in many circumstances temperature variations play a controlling feature on the ventilation since the directional buoyancy force has a large influence on the flow patterns within the space and on the nature of the exchange with the outside. Two forms of ventilation are discussed: mixing ventilation, in which the interior is at an approximately uniform temperature, and displacement ventilation, where there is strong internal stratification. The dynamics of these buoyancy-driven flows are considered, and the effects of wind on them are examined. The aim behind this work is to give designers rules and intuition on how air moves within a building; the research reveals a fascinating branch of fluid mechanics.

Echocardiographic evaluation during weaning from mechanical ventilation.

PubMed

Schifelbain, Luciele Medianeira; Vieira, Silvia Regina Rios; Brauner, Janete Salles; Pacheco, Deise Mota; Naujorks, Alexandre Antonio

2011-01-01

Echocardiographic, electrocardiographic and other cardiorespiratory variables can change during weaning from mechanical ventilation. To analyze changes in cardiac function, using Doppler echocardiogram, in critical patients during weaning from mechanical ventilation, using two different weaning methods: pressure support ventilation and T-tube; and comparing patient subgroups: success vs. failure in weaning. Randomized crossover clinical trial including patients under mechanical ventilation for more than 48 h and considered ready for weaning. Cardiorespiratory variables, oxygenation, electrocardiogram and Doppler echocardiogram findings were analyzed at baseline and after 30 min in pressure support ventilation and T-tube. Pressure support ventilation vs. T-tube and weaning success vs. failure were compared using ANOVA and Student's t-test. The level of significance was p<0.05. Twenty-four adult patients were evaluated. Seven patients failed at the first weaning attempt. No echocardiographic or electrocardiographic differences were observed between pressure support ventilation and T-tube. Weaning failure patients presented increases in left atrium, intraventricular septum thickness, posterior wall thickness and diameter of left ventricle and shorter isovolumetric relaxation time. Successfully weaned patients had higher levels of oxygenation. No differences were observed between Doppler echocardiographic variables and electrocardiographic and other cardiorespiratory variables during pressure support ventilation and T-tube. However cardiac structures were smaller, isovolumetric relaxation time was larger, and oxygenation level was greater in successfully weaned patients.

Echocardiographic evaluation during weaning from mechanical ventilation

PubMed Central

Schifelbain, Luciele Medianeira; Vieira, Silvia Regina Rios; Brauner, Janete Salles; Pacheco, Deise Mota; Naujorks, Alexandre Antonio

2011-01-01

INTRODUCTION: Echocardiographic, electrocardiographic and other cardiorespiratory variables can change during weaning from mechanical ventilation. OBJECTIVES: To analyze changes in cardiac function, using Doppler echocardiogram, in critical patients during weaning from mechanical ventilation, using two different weaning methods: pressure support ventilation and T‐tube; and comparing patient subgroups: success vs. failure in weaning. METHODS: Randomized crossover clinical trial including patients under mechanical ventilation for more than 48 h and considered ready for weaning. Cardiorespiratory variables, oxygenation, electrocardiogram and Doppler echocardiogram findings were analyzed at baseline and after 30 min in pressure support ventilation and T‐tube. Pressure support ventilation vs. T‐tube and weaning success vs. failure were compared using ANOVA and Student's t‐test. The level of significance was p<0.05. RESULTS: Twenty‐four adult patients were evaluated. Seven patients failed at the first weaning attempt. No echocardiographic or electrocardiographic differences were observed between pressure support ventilation and T‐tube. Weaning failure patients presented increases in left atrium, intraventricular septum thickness, posterior wall thickness and diameter of left ventricle and shorter isovolumetric relaxation time. Successfully weaned patients had higher levels of oxygenation. CONCLUSION: No differences were observed between Doppler echocardiographic variables and electrocardiographic and other cardiorespiratory variables during pressure support ventilation and T‐tube. However cardiac structures were smaller, isovolumetric relaxation time was larger, and oxygenation level was greater in successfully weaned patients. PMID:21437445

Nocturnal mechanical ventilation for chronic hypoventilation in patients with neuromuscular and chest wall disorders.

PubMed

Annane, Djillali; Orlikowski, David; Chevret, Sylvie

2014-12-13

between the study populations. Information on unplanned hospitalisation was available from two studies. The corresponding pooled RR was 0.25 (95% CI 0.08 to 0.82, P value = 0.02) in favour of nocturnal mechanical ventilation. For most of the outcome measures there was no significant long-term difference between nocturnal mechanical ventilation and no ventilation. Most of the secondary outcomes were not assessed in the eligible trials. Three out of the 10 trials, accounting for 39 participants, two with a cross-over design and one with two parallel groups, compared volume- and pressure-cycled non-invasive mechanical ventilation in the short term. From the only trial (16 participants) on parallel groups, there was no difference in mortality (one death in each arm) between volume- and pressure-cycled mechanical ventilation. Data from the two cross-over trials suggested that compared with pressure-cycled ventilation, volume-cycled ventilation was associated with less sleep time spent with an arterial oxygen saturation below 90% (mean difference (MD) 6.83 minutes, 95% CI 4.68 to 8.98, P value = 0.00001) and a lower apnoea-hypopnoea (per sleep hour) index (MD -0.65, 95% CI -0.84 to -0.46, P value = 0.00001). We found no study that compared invasive and non-invasive mechanical ventilation or intermittent positive pressure versus negative pressure ventilation. Current evidence about the therapeutic benefit of mechanical ventilation is of very low quality, but is consistent, suggesting alleviation of the symptoms of chronic hypoventilation in the short term. In four small studies, survival was prolonged and unplanned hospitalisation was reduced, mainly in participants with motor neuron diseases. With the exception of motor neuron disease and Duchenne muscular dystrophy, for which the natural history supports the survival benefit of mechanical ventilation against no ventilation, further larger randomised trials should assess the long-term benefit of different types and modes of

Ethical challenges in home mechanical ventilation: a secondary analysis.

PubMed

Dybwik, Knut; Nielsen, Erik Waage; Brinchmann, Berit Støre

2012-03-01

The aim of this study was to explore the ethical challenges in home mechanical ventilation based on a secondary analysis of qualitative empirical data. The data included perceptions of healthcare professionals in hospitals and community health services and family members of children and adults using home mechanical ventilation. The findings show that a number of ethical challenges, or dilemmas, arise at all levels in the course of treatment: deciding who should be offered home mechanical ventilation, respect for patient and family wishes, quality of life, dignity and equal access to home mechanical ventilation. Other challenges were the impacts home mechanical ventilation had on the patient, the family, the healthcare services and the allocation of resources. A better and broader understanding of these issues is crucial in order to improve the quality of care for both patient and family and assist healthcare professionals involved in home mechanical ventilation to make decisions for the good of the patient and his or her family.

Critical care nurses management of prolonged weaning: an interview study.

PubMed

Cederwall, Carl-Johan; Plos, Kaety; Rose, Louise; Dübeck, Amanda; Ringdal, Mona

2014-09-01

For most critically ill patients requiring mechanical ventilation in the intensive care unit (ICU) weaning is uncomplicated. For the remainder, weaning is a challenge and may result in further complications and increased risk of mortality. Critical care nurses (CCNs) require substantial knowledge and experience to manage patients experiencing prolonged weaning. The aim of this study was to explore CCNs approach for management of patients experiencing prolonged weaning in the ICU. A descriptive qualitative design. Semi-structured interviews with 19 experienced CCNs were conducted. Data were analysed using content analysis. Participants used various strategies for weaning that were grouped into four categories: individualized planning for the weaning process, assessing patient's capacity, managing the process and team interaction. The overall theme that emerged was: CCNs drive the weaning process using both a patient centred and targeted approach. CCNs in these ICUs performed weaning using a patient centred approach to plan, initiate, assess and establish a holistic weaning process. Team collaboration among all health care practitioners was important. CCNs have a key role in prioritizing weaning and driving the process forward. Closeness to the patient and a key role in management of the mechanical ventilated patient in ICU gives the CCN unique potential to develop and create models and tools for prolonged weaning. These tools, specially designed for patients undergoing prolonged weaning, would give focus on continuous planning, collaborating, managing and evaluation in the process of liberating patients from mechanical ventilation. © 2014 British Association of Critical Care Nurses.

Personalizing mechanical ventilation for acute respiratory distress syndrome.

PubMed

Berngard, S Clark; Beitler, Jeremy R; Malhotra, Atul

2016-03-01

Lung-protective ventilation with low tidal volumes remains the cornerstone for treating patient with acute respiratory distress syndrome (ARDS). Personalizing such an approach to each patient's unique physiology may improve outcomes further. Many factors should be considered when mechanically ventilating a critically ill patient with ARDS. Estimations of transpulmonary pressures as well as individual's hemodynamics and respiratory mechanics should influence PEEP decisions as well as response to therapy (recruitability). This summary will emphasize the potential role of personalized therapy in mechanical ventilation.

A taxonomy for mechanical ventilation: 10 fundamental maxims.

PubMed

Chatburn, Robert L; El-Khatib, Mohamad; Mireles-Cabodevila, Eduardo

2014-11-01

The American Association for Respiratory Care has declared a benchmark for competency in mechanical ventilation that includes the ability to "apply to practice all ventilation modes currently available on all invasive and noninvasive mechanical ventilators." This level of competency presupposes the ability to identify, classify, compare, and contrast all modes of ventilation. Unfortunately, current educational paradigms do not supply the tools to achieve such goals. To fill this gap, we expand and refine a previously described taxonomy for classifying modes of ventilation and explain how it can be understood in terms of 10 fundamental constructs of ventilator technology: (1) defining a breath, (2) defining an assisted breath, (3) specifying the means of assisting breaths based on control variables specified by the equation of motion, (4) classifying breaths in terms of how inspiration is started and stopped, (5) identifying ventilator-initiated versus patient-initiated start and stop events, (6) defining spontaneous and mandatory breaths, (7) defining breath sequences (8), combining control variables and breath sequences into ventilatory patterns, (9) describing targeting schemes, and (10) constructing a formal taxonomy for modes of ventilation composed of control variable, breath sequence, and targeting schemes. Having established the theoretical basis of the taxonomy, we demonstrate a step-by-step procedure to classify any mode on any mechanical ventilator. Copyright © 2014 by Daedalus Enterprises.

[The incidence and risk factors of ventilator-associated pneumonia in patients with severe traumatic brain injury].

PubMed

Marjanović, Vesna; Novak, Vesna; Velicković, Ljubinka; Marjanović, Goran

2011-01-01

Patients with severe traumatic brain injury are at a risk of developing ventilator-associated pneumonia. The aim of this study was to describe the incidence, etiology, risk factors for development of ventilator-associated pneumonia and outcome in patients with severe traumatic brain injury. A retrospective study was done in 72 patients with severe traumatic brain injury, who required mechanical ventilation for more than 48 hours. Ventilator-associated pneumonia was found in 31 of 72 (43.06%) patients with severe traumatic brain injury. The risk factors for ventilator-associated pneumonia were: prolonged mechanical ventilation (12.42 vs 4.34 days, p < 0.001), longer stay at intensive care unit (17 vs 5 days, p < 0.001) and chest injury (51.61 vs 19.51%, p < 0.009) compared to patients without ventilator-associated pneumonia. The mortality rate in the patients with ventilator-associated pneumonia was higher (38.71 vs 21.95%, p = 0.12). The development of ventilator-associated pneumonia in patients with severe traumatic brain injury led to the increased morbidity due to the prolonged mechanical ventilation, longer stay at intensive care unit and chest injury, but had no effect on mortality.

Pressure support versus T-tube for weaning from mechanical ventilation in adults.

PubMed

Ladeira, Magdaline T; Vital, Flávia M R; Andriolo, Régis B; Andriolo, Brenda N G; Atallah, Alvaro N; Peccin, Maria S

2014-05-27

Mechanical ventilation is important in caring for patients with critical illness. Clinical complications, increased mortality, and high costs of health care are associated with prolonged ventilatory support or premature discontinuation of mechanical ventilation. Weaning refers to the process of gradually or abruptly withdrawing mechanical ventilation. The weaning process begins after partial or complete resolution of the underlying pathophysiology precipitating respiratory failure and ends with weaning success (successful extubation in intubated patients or permanent withdrawal of ventilatory support in tracheostomized patients). To evaluate the effectiveness and safety of two strategies, a T-tube and pressure support ventilation, for weaning adult patients with respiratory failure that required invasive mechanical ventilation for at least 24 hours, measuring weaning success and other clinically important outcomes. We searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 6); MEDLINE (via PubMed) (1966 to June 2012); EMBASE (January 1980 to June 2012); LILACS (1986 to June 2012); CINAHL (1982 to June 2012); SciELO (from 1997 to August 2012); thesis repository of CAPES (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior) (http://capesdw.capes.gov.br/capesdw/) (August 2012); and Current Controlled Trials (August 2012).We reran the search in December 2013. We will deal with any studies of interest when we update the review. We included randomized controlled trials (RCTs) that compared a T-tube with pressure support (PS) for the conduct of spontaneous breathing trials and as methods of gradual weaning of adult patients with respiratory failure of various aetiologies who received invasive mechanical ventilation for at least 24 hours. Two authors extracted data and assessed the methodological quality of the included studies. Meta-analyses using the random-effects model were

Can Creatinine Height Index Predict Weaning and Survival Outcomes in Patients on Prolonged Mechanical Ventilation After Critical Illness?

PubMed

Datta, Debapriya; Foley, Raymond; Wu, Rong; Grady, James; Scalise, Paul

2018-02-01

Malnutrition is common in chronic critically ill patients on prolonged mechanical ventilation (PMV) and may affect weaning. The creatinine height index (CHI), which reflects lean muscle mass, is regarded as the most accurate indicator of malnutrition. The objective of this study was to determine the impact of CHI in comparison with other traditional nutritional indices on successful weaning and survival in patients on PMV after critical illness. Records of 167 patients on PMV following critical illness, admitted for weaning, were reviewed. Parameters studied included age, gender, body mass index (BMI), percentage ideal body weight (%IBW), total protein, albumin, prealbumin, hemoglobin (Hb), and cause of respiratory failure. Number successfully weaned and number discharged alive and time to wean and time to discharge alive were determined from records. The CHI was calculated from 24-hour urine creatinine using a standard formula. Unpaired 2-sample t test was performed to determine the association between the studied nutritional parameters and outcomes. Predictive value of studied parameters for successful weaning and survival was determined by multivariate logistic regression analysis to model dichotomous outcome of successful weaning and survival. Mean age was 68 ± 14 years, 49% were males, 64% were successfully weaned, and 65.8% survived. Total protein, Hb, and CHI had a significant impact on successful weaning. Weight, %IBW, BMI, and CHI had a significant effect on survival. Of all parameters, CHI was most strongly predictive of successful weaning and survival. The CHI is a strong predictor of successful weaning and survival in patients on PMV.

Comparison between conventional protective mechanical ventilation and high-frequency oscillatory ventilation associated with the prone position.

PubMed

Fioretto, José Roberto; Klefens, Susiane Oliveira; Pires, Rafaelle Fernandes; Kurokawa, Cilmery Suemi; Carpi, Mario Ferreira; Bonatto, Rossano César; Moraes, Marcos Aurélio; Ronchi, Carlos Fernando

2017-01-01

To compare the effects of high-frequency oscillatory ventilation and conventional protective mechanical ventilation associated with the prone position on oxygenation, histology and pulmonary oxidative damage in an experimental model of acute lung injury. Forty-five rabbits with tracheostomy and vascular access were underwent mechanical ventilation. Acute lung injury was induced by tracheal infusion of warm saline. Three experimental groups were formed: healthy animals + conventional protective mechanical ventilation, supine position (Control Group; n = 15); animals with acute lung injury + conventional protective mechanical ventilation, prone position (CMVG; n = 15); and animals with acute lung injury + high-frequency oscillatory ventilation, prone position (HFOG; n = 15). Ten minutes after the beginning of the specific ventilation of each group, arterial gasometry was collected, with this timepoint being called time zero, after which the animal was placed in prone position and remained in this position for 4 hours. Oxidative stress was evaluated by the total antioxidant performance assay. Pulmonary tissue injury was determined by histopathological score. The level of significance was 5%. Both groups with acute lung injury showed worsening of oxygenation after induction of injury compared with the Control Group. After 4 hours, there was a significant improvement in oxygenation in the HFOG group compared with CMVG. Analysis of total antioxidant performance in plasma showed greater protection in HFOG. HFOG had a lower histopathological lesion score in lung tissue than CMVG. High-frequency oscillatory ventilation, associated with prone position, improves oxygenation and attenuates oxidative damage and histopathological lung injury compared with conventional protective mechanical ventilation.

Comparison between conventional protective mechanical ventilation and high-frequency oscillatory ventilation associated with the prone position

PubMed Central

Fioretto, José Roberto; Klefens, Susiane Oliveira; Pires, Rafaelle Fernandes; Kurokawa, Cilmery Suemi; Carpi, Mario Ferreira; Bonatto, Rossano César; Moraes, Marcos Aurélio; Ronchi, Carlos Fernando

2017-01-01

Objective To compare the effects of high-frequency oscillatory ventilation and conventional protective mechanical ventilation associated with the prone position on oxygenation, histology and pulmonary oxidative damage in an experimental model of acute lung injury. Methods Forty-five rabbits with tracheostomy and vascular access were underwent mechanical ventilation. Acute lung injury was induced by tracheal infusion of warm saline. Three experimental groups were formed: healthy animals + conventional protective mechanical ventilation, supine position (Control Group; n = 15); animals with acute lung injury + conventional protective mechanical ventilation, prone position (CMVG; n = 15); and animals with acute lung injury + high-frequency oscillatory ventilation, prone position (HFOG; n = 15). Ten minutes after the beginning of the specific ventilation of each group, arterial gasometry was collected, with this timepoint being called time zero, after which the animal was placed in prone position and remained in this position for 4 hours. Oxidative stress was evaluated by the total antioxidant performance assay. Pulmonary tissue injury was determined by histopathological score. The level of significance was 5%. Results Both groups with acute lung injury showed worsening of oxygenation after induction of injury compared with the Control Group. After 4 hours, there was a significant improvement in oxygenation in the HFOG group compared with CMVG. Analysis of total antioxidant performance in plasma showed greater protection in HFOG. HFOG had a lower histopathological lesion score in lung tissue than CMVG. Conclusion High-frequency oscillatory ventilation, associated with prone position, improves oxygenation and attenuates oxidative damage and histopathological lung injury compared with conventional protective mechanical ventilation. PMID:29236845

Music interventions for mechanically ventilated patients.

PubMed

Bradt, Joke; Dileo, Cheryl

2014-01-01

Mechanical ventilation often causes major distress and anxiety in patients. The sensation of breathlessness, frequent suctioning, inability to talk, uncertainty regarding surroundings or condition, discomfort, isolation from others, and fear contribute to high levels of anxiety. Side effects of analgesia and sedation may lead to the prolongation of mechanical ventilation and, subsequently, to a longer length of hospitalization and increased cost. Therefore, non-pharmacological interventions should be considered for anxiety and stress management. Music interventions have been used to reduce anxiety and distress and improve physiological functioning in medical patients; however, their efficacy for mechanically ventilated patients needs to be evaluated. This review was originally published in 2010 and was updated in 2014. To update the previously published review that examined the effects of music therapy or music medicine interventions (as defined by the authors) on anxiety and other outcomes in mechanically ventilated patients. Specifically, the following objectives are addressed in this review.1. To conduct a meta-analysis to compare the effects of participation in standard care combined with music therapy or music medicine interventions with standard care alone.2. To compare the effects of patient-selected music with researcher-selected music.3. To compare the effects of different types of music interventions (e.g., music therapy versus music medicine). We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 2), MEDLINE (1950 to March 2014), CINAHL (1980 to March 2014), EMBASE (1980 to March 2014), PsycINFO (1967 to March 2014), LILACS (1982 to March 2014), Science Citation Index (1980 to March 2014), www.musictherapyworld.net (1 March 2008) (database is no longer functional), CAIRSS for Music (to March 2014), Proquest Digital Dissertations (1980 to March 2014), ClinicalTrials.gov (2000 to March 2014), Current

Effects of Multiple Ventilation Courses and Duration of Mechanical Ventilation on Respiratory Outcomes in Extremely Low-Birth-Weight Infants.

PubMed

Jensen, Erik A; DeMauro, Sara B; Kornhauser, Michael; Aghai, Zubair H; Greenspan, Jay S; Dysart, Kevin C

2015-11-01

Extubation failure is common in extremely preterm infants. The current paucity of data on the adverse long-term respiratory outcomes associated with reinitiation of mechanical ventilation prevents assessment of the risks and benefits of a trial of extubation in this population. To evaluate whether exposure to multiple courses of mechanical ventilation increases the risk of adverse respiratory outcomes before and after adjustment for the cumulative duration of mechanical ventilation. We performed a retrospective cohort study of extremely low-birth-weight (ELBW; birth weight <1000 g) infants born from January 1, 2006, through December 31, 2012, who were receiving mechanical ventilation. Analysis was conducted between November 2014 and February 2015. Data were obtained from the Alere Neonatal Database. The primary study exposures were the cumulative duration of mechanical ventilation and the number of ventilation courses. The primary outcome was bronchopulmonary dysplasia (BPD) among survivors. Secondary outcomes were death, use of supplemental oxygen at discharge, and tracheostomy. We identified 3343 ELBW infants, of whom 2867 (85.8%) survived to discharge. Among the survivors, 1695 (59.1%) were diagnosed as having BPD, 856 (29.9%) received supplemental oxygen at discharge, and 31 (1.1%) underwent tracheostomy. Exposure to a greater number of mechanical ventilation courses was associated with a progressive increase in the risk of BPD and use of supplemental oxygen at discharge. Compared with a single ventilation course, the adjusted odds ratios for BPD ranged from 1.88 (95% CI, 1.54-2.31) among infants with 2 ventilation courses to 3.81 (95% CI, 2.88-5.04) among those with 4 or more courses. After adjustment for the cumulative duration of mechanical ventilation, the odds of BPD were only increased among infants exposed to 4 or more ventilation courses (adjusted odds ratio, 1.44; 95% CI, 1.04-2.01). The number of ventilation courses was not associated with increased

Controlled invasive mechanical ventilation strategies in obese patients undergoing surgery.

PubMed

Maia, Lígia de Albuquerque; Silva, Pedro Leme; Pelosi, Paolo; Rocco, Patricia Rieken Macedo

2017-06-01

The obesity prevalence is increasing in surgical population. As the number of obese surgical patients increases, so does the demand for mechanical ventilation. Nevertheless, ventilatory strategies in this population are challenging, since obesity results in pathophysiological changes in respiratory function. Areas covered: We reviewed the impact of obesity on respiratory system and the effects of controlled invasive mechanical ventilation strategies in obese patients undergoing surgery. To date, there is no consensus regarding the optimal invasive mechanical ventilation strategy for obese surgical patients, and no evidence that possible intraoperative beneficial effects on oxygenation and mechanics translate into better postoperative pulmonary function or improved outcomes. Expert commentary: Before determining the ideal intraoperative ventilation strategy, it is important to analyze the pathophysiology and comorbidities of each obese patient. Protective ventilation with low tidal volume, driving pressure, energy, and mechanical power should be employed during surgery; however, further studies are required to clarify the most effective ventilation strategies, such as the optimal positive end-expiratory pressure and whether recruitment maneuvers minimize lung injury. In this context, an ongoing trial of intraoperative ventilation in obese patients (PROBESE) should help determine the mechanical ventilation strategy that best improves clinical outcome in patients with body mass index≥35kg/m 2 .

The fluid mechanics of natural ventilation

NASA Astrophysics Data System (ADS)

Linden, Paul

1999-11-01

Natural ventilation of buildings is the flow generated by temperature differences and by the wind. Modern buildings have extreme designs with large, tall open plan spaces and large cooling requirements. Natural ventilation offers a means of cooling these buildings and providing good indoor air quality. The essential feature of ventilation is an exchange between an interior space and the external ambient. Recent work shows that in many circumstances temperature variations play a controlling feature on the ventilation since the directional buoyancy force has a large influence on the flow patterns within the space and on the nature of the exchange with the outside. Two forms of buoyancy-driven ventilation are discussed: mixing ventilation in which the interior is at approximately uniform temperature and displacement ventilation where there is strong internal stratification. The dynamics of these flows are considered and the effects of wind on them are examined both experimentally and theoretically. The aim behind this work is to give designers rules and intuition on how air moves within a building and the research shows a fascinating branch of fluid mechanics.

Mechanical Ventilation and ARDS in the ED

PubMed Central

Mohr, Nicholas M.; Miller, Christopher N.; Deitchman, Andrew R.; Castagno, Nicole; Hassebroek, Elizabeth C.; Dhedhi, Adam; Scott-Wittenborn, Nicholas; Grace, Edward; Lehew, Courtney; Kollef, Marin H.

2015-01-01

BACKGROUND: There are few data regarding mechanical ventilation and ARDS in the ED. This could be a vital arena for prevention and treatment. METHODS: This study was a multicenter, observational, prospective, cohort study aimed at analyzing ventilation practices in the ED. The primary outcome was the incidence of ARDS after admission. Multivariable logistic regression was used to determine the predictors of ARDS. RESULTS: We analyzed 219 patients receiving mechanical ventilation to assess ED ventilation practices. Median tidal volume was 7.6 mL/kg predicted body weight (PBW) (interquartile range, 6.9-8.9), with a range of 4.3 to 12.2 mL/kg PBW. Lung-protective ventilation was used in 122 patients (55.7%). The incidence of ARDS after admission from the ED was 14.7%, with a mean onset of 2.3 days. Progression to ARDS was associated with higher illness severity and intubation in the prehospital environment or transferring facility. Of the 15 patients with ARDS in the ED (6.8%), lung-protective ventilation was used in seven (46.7%). Patients who progressed to ARDS experienced greater duration in organ failure and ICU length of stay and higher mortality. CONCLUSIONS: Lung-protective ventilation is infrequent in patients receiving mechanical ventilation in the ED, regardless of ARDS status. Progression to ARDS is common after admission, occurs early, and worsens outcome. Patient- and treatment-related factors present in the ED are associated with ARDS. Given the limited treatment options for ARDS, and the early onset after admission from the ED, measures to prevent onset and to mitigate severity should be instituted in the ED. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT01628523; URL: www.clinicaltrials.gov PMID:25742126

Decisional responsibility for mechanical ventilation and weaning: an international survey

PubMed Central

2011-01-01

Introduction Optimal management of mechanical ventilation and weaning requires dynamic and collaborative decision making to minimize complications and avoid delays in the transition to extubation. In the absence of collaboration, ventilation decision making may be fragmented, inconsistent, and delayed. Our objective was to describe the professional group with responsibility for key ventilation and weaning decisions and to examine organizational characteristics associated with nurse involvement. Methods A multi-center, cross-sectional, self-administered survey was sent to nurse managers of adult intensive care units (ICUs) in Denmark, Germany, Greece, Italy, Norway, Switzerland, Netherlands and United Kingdom (UK). We summarized data as proportions (95% confidence intervals (CIs)) and calculated odds ratios (OR) to examine ICU organizational variables associated with collaborative decision making. Results Response rates ranged from 39% (UK) to 92% (Switzerland), providing surveys from 586 ICUs. Interprofessional collaboration (nurses and physicians) was the most common approach to initial selection of ventilator settings (63% (95% CI 59 to 66)), determination of extubation readiness (71% (67 to 75)), weaning method (73% (69 to 76)), recognition of weaning failure (84% (81 to 87)) and weaning readiness (85% (82 to 87)), and titration of ventilator settings (88% (86 to 91)). A nurse-to-patient ratio other than 1:1 was associated with decreased interprofessional collaboration during titration of ventilator settings (OR 0.2, 95% CI 0.1 to 0.6), weaning method (0.4 (0.2 to 0.9)), determination of extubation readiness (0.5 (0.2 to 0.9)) and weaning failure (0.4 (0.1 to 1.0)). Use of a weaning protocol was associated with increased collaborative decision making for determining weaning (1.8 (1.0 to 3.3)) and extubation readiness (1.9 (1.2 to 3.0)), and weaning method (1.8 (1.1 to 3.0). Country of ICU location influenced the profile of responsibility for all decisions

[Neurally adjusted ventilatory assist (NAVA). A new mode of assisted mechanical ventilation].

PubMed

Moerer, O; Barwing, J; Quintel, M

2008-10-01

The aim of mechanical ventilation is to assure gas exchange while efficiently unloading the respiratory muscles and mechanical ventilation is an integral part of the care of patients with acute respiratory failure. Modern lung protective strategies of mechanical ventilation include low-tidal-volume ventilation and the continuation of spontaneous breathing which has been shown to be beneficial in reducing atelectasis and improving oxygenation. Poor patient-ventilator interaction is a major issue during conventional assisted ventilation. Neurally adjusted ventilator assist (NAVA) is a new mode of mechanical ventilation that uses the electrical activity of the diaphragm (EAdi) to control the ventilator. First experimental studies showed an improved patient-ventilator synchrony and an efficient unloading of the respiratory muscles. Future clinical studies will have to show that NAVA is of clinical advantage when compared to conventional modes of assisted mechanical ventilation. This review characterizes NAVA according to current publications on this topic.

Noise measurements during high-frequency oscillatory and conventional mechanical ventilation.

PubMed

Berens, R J; Weigle, C G

1995-10-01

To evaluate the noise levels with high-frequency oscillatory ventilation and conventional mechanical ventilation. An observational, prospective study. Pediatric intensive care unit. The caretakers and environment of the pediatric intensive care unit. High-frequency oscillatory and conventional mechanical ventilation. Caretakers evaluated noise using a visual analog scale. Noise was measured with a decibel meter and an octave band frequency filter. There was twice as much noise perceived by the caretakers and as measured on the decibel A scale. All measures showed significantly greater noise, especially at low frequencies, with high-frequency oscillatory ventilation. High-frequency oscillatory ventilation exposes the patient to twice as much noise as does the use of conventional mechanical ventilation.

Music interventions for mechanically ventilated patients.

PubMed

Bradt, Joke; Dileo, Cheryl; Grocke, Denise

2010-12-08

Mechanical ventilation often causes major distress and anxiety in patients. Music interventions have been used to reduce anxiety and distress and improve physiological functioning in medical patients; however its efficacy for mechanically ventilated patients needs to be evaluated. To examine the effects of music interventions with standard care versus standard care alone on anxiety and physiological responses in mechanically ventilated patients. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 1), MEDLINE, CINAHL, AMED, EMBASE, PsycINFO, LILACS, Science Citation Index, www.musictherapyworld.net, CAIRSS for Music, Proquest Digital Dissertations, ClinicalTrials.gov, Current Controlled Trials, the National Research Register, and NIH CRISP (all to January 2010). We handsearched music therapy journals and reference lists and contacted relevant experts to identify unpublished manuscripts. There was no language restriction. We included all randomized and quasi-randomized controlled trials that compared music interventions and standard care with standard care alone for mechanically ventilated patients. Two authors independently extracted the data and assessed the methodological quality. Additional information was sought from the trial researchers, when necessary. Results were presented using mean differences for outcomes measured by the same scale and standardized mean differences for outcomes measured by different scales. Post-test scores were used. In cases of significant baseline difference, we used change scores. We included eight trials (213 participants). Music listening was the main intervention used, and seven of the studies did not include a trained music therapist. Results indicated that music listening may be beneficial for anxiety reduction in mechanically ventilated patients; however, these results need to be interpreted with caution due to the small sample size. Findings indicated that listening to

Special Considerations in Neonatal Mechanical Ventilation.

PubMed

Dalgleish, Stacey; Kostecky, Linda; Charania, Irina

2016-12-01

Care of infants supported with mechanical ventilation is complex, time intensive, and requires constant vigilance by an expertly prepared health care team. Current evidence must guide nursing practice regarding ventilated neonates. This article highlights the importance of common language to establish a shared mental model and enhance clear communication among the interprofessional team. Knowledge regarding the underpinnings of an open lung strategy and the interplay between the pathophysiology and individual infant's response to a specific ventilator strategy is most likely to result in a positive clinical outcome. Copyright © 2016 Elsevier Inc. All rights reserved.

Home Mechanical Ventilation: A 12-Year Population-Based Retrospective Cohort Study.

PubMed

Povitz, Marcus; Rose, Louise; Shariff, Salimah Z; Leonard, Sean; Welk, Blayne; Jenkyn, Krista Bray; Leasa, David J; Gershon, Andrea S

2018-04-01

Increasing numbers of individuals are being initiated on home mechanical ventilation, including noninvasive (bi-level) and invasive mechanical ventilation delivered via tracheostomy due to chronic respiratory failure to enable symptom management and promote quality of life. Given the high care needs of these individuals, a better understanding of the indications for home mechanical ventilation, and health-care utilization is needed. We performed a retrospective cohort study using provincial health administrative data from Ontario, Canada (population ∼13,000,000). Home mechanical ventilation users were characterized using health administrative data to determine the indications for home mechanical ventilation, the need for acute care at the time of ventilation approval, and their health service use and mortality rates following approval. The annual incidence of home mechanical ventilation approval rose from 1.8/100,000 in 2000 to 5.0/100,000 in 2012, or an annual increase of approximately 0.3/100,000 persons/y. The leading indications were neuromuscular disease, thoracic restriction, and COPD. The indication for the remainder could not be determined due to limitations of the administrative databases. Of the 4,670 individuals, 23.0% commenced home mechanical ventilation following an acute care hospitalization. Among individuals who survived at least 1 y, fewer required hospitalization in the year that followed home mechanical ventilation approval (29.9% vs 39.8%) as compared with the year prior. Utilization of home mechanical ventilation is increasing in Ontario, Canada, and further study is needed to clarify the factors contributing to this and to further optimize utilization of health-care resources. Copyright © 2018 by Daedalus Enterprises.

Tracheostomy and mechanical ventilation weaning in children affected by respiratory virus according to a weaning protocol in a pediatric intensive care unit in Argentina: an observational restrospective trial

PubMed Central

2011-01-01

We describe difficult weaning after prolonged mechanical ventilation in three tracheostomized children affected by respiratory virus infection. Although the spontaneous breathing trials were successful, the patients failed all extubations. Therefore a tracheostomy was performed and the weaning plan was begun. The strategy for weaning was the decrease of ventilation support combining pressure control ventilation (PCV) with increasing periods of continuous positive airway pressure + pressure support ventilation (CPAP + PSV) and then CPAP + PSV with increasing intervals of T-piece. They presented acute respiratory distress syndrome on admission with high requirements of mechanical ventilation (MV). Intervening factors in the capabilities and loads of the respiratory system were considered and optimized. The average MV time was 69 days and weaning time 31 days. We report satisfactory results within the context of a directed weaning protocol. PMID:21244710

Pleural liquid and kinetic friction coefficient of mesothelium after mechanical ventilation.

PubMed

Bodega, Francesca; Sironi, Chiara; Porta, Cristina; Zocchi, Luciano; Agostoni, Emilio

2015-01-15

Volume and protein concentration of pleural liquid in anesthetized rabbits after 1 or 3h of mechanical ventilation, with alveolar pressure equal to atmospheric at end expiration, were compared to those occurring after spontaneous breathing. Moreover, coefficient of kinetic friction between samples of visceral and parietal pleura, obtained after spontaneous or mechanical ventilation, sliding in vitro at physiological velocity under physiological load, was determined. Volume of pleural liquid after mechanical ventilation was similar to that previously found during spontaneous ventilation. This finding is contrary to expectation of Moriondo et al. (2005), based on measurement of lymphatic and interstitial pressure. Protein concentration of pleural liquid after mechanical ventilation was also similar to that occurring after spontaneous ventilation. Coefficient of kinetic friction after mechanical ventilation was 0.023±0.001, similar to that obtained after spontaneous breathing. Copyright © 2014 Elsevier B.V. All rights reserved.

Mechanical ventilation interacts with endotoxemia to induce extrapulmonary organ dysfunction

PubMed Central

O'Mahony, D Shane; Liles, W Conrad; Altemeier, William A; Dhanireddy, Shireesha; Frevert, Charles W; Liggitt, Denny; Martin, Thomas R; Matute-Bello, Gustavo

2006-01-01

Introduction Multiple organ dysfunction syndrome (MODS) is a common complication of sepsis in mechanically ventilated patients with acute respiratory distress syndrome, but the links between mechanical ventilation and MODS are unclear. Our goal was to determine whether a minimally injurious mechanical ventilation strategy synergizes with low-dose endotoxemia to induce the activation of pro-inflammatory pathways in the lungs and in the systemic circulation, resulting in distal organ dysfunction and/or injury. Methods We administered intraperitoneal Escherichia coli lipopolysaccharide (LPS; 1 μg/g) to C57BL/6 mice, and 14 hours later subjected the mice to 6 hours of mechanical ventilation with tidal volumes of 10 ml/kg (LPS + MV). Comparison groups received ventilation but no LPS (MV), LPS but no ventilation (LPS), or neither LPS nor ventilation (phosphate-buffered saline; PBS). Results Myeloperoxidase activity and the concentrations of the chemokines macrophage inflammatory protein-2 (MIP-2) and KC were significantly increased in the lungs of mice in the LPS + MV group, in comparison with mice in the PBS group. Interestingly, permeability changes across the alveolar epithelium and histological changes suggestive of lung injury were minimal in mice in the LPS + MV group. However, despite the minimal lung injury, the combination of mechanical ventilation and LPS resulted in chemical and histological evidence of liver and kidney injury, and this was associated with increases in the plasma concentrations of KC, MIP-2, IL-6, and TNF-α. Conclusion Non-injurious mechanical ventilation strategies interact with endotoxemia in mice to enhance pro-inflammatory mechanisms in the lungs and promote extra-pulmonary end-organ injury, even in the absence of demonstrable acute lung injury. PMID:16995930

Outcomes management of mechanically ventilated patients: utilizing informatics technology.

PubMed

Smith, K R

1998-11-01

This article examines an informatics system developed for outcomes management of the mechanically ventilated adult population, focusing on weaning the patient from mechanical ventilation. The link between medical informatics and outcomes management is discussed, along with the development of methods, tools, and data sets for outcomes management of the mechanically ventilated adult population at an acute care academic institution. Pros and cons of this system are identified, and specific areas for improvement of future health care outcomes medical informatics systems are discussed.

Aerosol delivery with two ventilation modes during mechanical ventilation: a randomized study.

PubMed

Dugernier, Jonathan; Reychler, Gregory; Wittebole, Xavier; Roeseler, Jean; Depoortere, Virginie; Sottiaux, Thierry; Michotte, Jean-Bernard; Vanbever, Rita; Dugernier, Thierry; Goffette, Pierre; Docquier, Marie-Agnes; Raftopoulos, Christian; Hantson, Philippe; Jamar, François; Laterre, Pierre-François

2016-12-01

Volume-controlled ventilation has been suggested to optimize lung deposition during nebulization although promoting spontaneous ventilation is targeted to avoid ventilator-induced diaphragmatic dysfunction. Comparing topographic aerosol lung deposition during volume-controlled ventilation and spontaneous ventilation in pressure support has never been performed. The aim of this study was to compare lung deposition of a radiolabeled aerosol generated with a vibrating-mesh nebulizer during invasive mechanical ventilation, with two modes: pressure support ventilation and volume-controlled ventilation. Seventeen postoperative neurosurgery patients without pulmonary disease were randomly ventilated in pressure support or volume-controlled ventilation. Diethylenetriaminepentaacetic acid labeled with technetium-99m (2 mCi/3 mL) was administrated using a vibrating-mesh nebulizer (Aerogen Solo(®), provided by Aerogen Ltd, Galway, Ireland) connected to the endotracheal tube. Pulmonary and extrapulmonary particles deposition was analyzed using planar scintigraphy. Lung deposition was 10.5 ± 3.0 and 15.1 ± 5.0 % of the nominal dose during pressure support and volume-controlled ventilation, respectively (p < 0.05). Higher endotracheal tube and tracheal deposition was observed during pressure support ventilation (27.4 ± 6.6 vs. 20.7 ± 6.0 %, p < 0.05). A similar penetration index was observed for the right (p = 0.210) and the left lung (p = 0.211) with both ventilation modes. A high intersubject variability of lung deposition was observed with both modes regarding lung doses, aerosol penetration and distribution between the right and the left lung. In the specific conditions of the study, volume-controlled ventilation was associated with higher lung deposition of nebulized particles as compared to pressure support ventilation. The clinical benefit of this effect warrants further studies. Clinical trial registration NCT01879488.

Mechanical ventilation and thoracic artificial lung assistance during mechanical circulatory support with PUCA pump: in silico study.

PubMed

De Lazzari, Claudio; Genuini, Igino; Quatember, Bernhard; Fedele, Francesco

2014-02-01

Patients assisted with left ventricular assist device (LVAD) may require prolonged mechanical ventilatory assistance secondary to postoperative respiratory failure. The goal of this work is the study of the interdependent effects LVAD like pulsatile catheter (PUCA) pump and mechanical ventilatory support or thoracic artificial lung (TAL), by the hemodynamic point of view, using a numerical simulator of the human cardiovascular system. In the simulator, different circulatory sections are described using lumped parameter models. Lumped parameter models have been designed to describe the hydrodynamic behavior of both PUCA pump and thoracic artificial lung. Ventricular behavior atrial and septum functions were reproduced using variable elastance model. Starting from simulated pathological conditions we studied the effects produced on some hemodynamic variables by simultaneous PUCA pump, thoracic artificial lung or mechanical ventilation assistance. Thoracic artificial lung was applied in parallel or in hybrid mode. The effects of mechanical ventilation have been simulated by changing mean intrathoracic pressure value from -4 mmHg to +5 mmHg. The hemodynamic variables observed during the simulations, in different assisted conditions, were: left and right ventricular end systolic (diastolic) volume, systolic/diastolic aortic pressure, mean pulmonary arterial pressure, left and right mean atrial pressure, mean systemic venous pressure and the total blood flow. Results show that the application of PUCA (without mechanical ventilatory assistance) increases the total blood flow, reduces the left ventricular end systolic volume and increases the diastolic aortic pressure. Parallel TAL assistance increases the right ventricular end diastolic (systolic) volume reduction both when PUCA is switched "ON" and both when PUCA is switched "OFF". By switching "OFF" the PUCA pump, it seems that parallel thoracic artificial lung assistance produces a greater cardiac output (respect to

Heliox Improves Carbon Dioxide Removal during Lung Protective Mechanical Ventilation.

PubMed

Beurskens, Charlotte J; Brevoord, Daniel; Lagrand, Wim K; van den Bergh, Walter M; Vroom, Margreeth B; Preckel, Benedikt; Horn, Janneke; Juffermans, Nicole P

2014-01-01

Introduction. Helium is a noble gas with low density and increased carbon dioxide (CO2) diffusion capacity. This allows lower driving pressures in mechanical ventilation and increased CO2 diffusion. We hypothesized that heliox facilitates ventilation in patients during lung-protective mechanical ventilation using low tidal volumes. Methods. This is an observational cohort substudy of a single arm intervention study. Twenty-four ICU patients were included, who were admitted after a cardiac arrest and mechanically ventilated for 3 hours with heliox (50% helium; 50% oxygen). A fixed protective ventilation protocol (6 mL/kg) was used, with prospective observation for changes in lung mechanics and gas exchange. Statistics was by Bonferroni post-hoc correction with statistical significance set at P < 0.017. Results. During heliox ventilation, respiratory rate decreased (25 ± 4 versus 23 ± 5 breaths min(-1), P = 0.010). Minute volume ventilation showed a trend to decrease compared to baseline (11.1 ± 1.9 versus 9.9 ± 2.1 L min(-1), P = 0.026), while reducing PaCO2 levels (5.0 ± 0.6 versus 4.5 ± 0.6 kPa, P = 0.011) and peak pressures (21.1 ± 3.3 versus 19.8 ± 3.2 cm H2O, P = 0.024). Conclusions. Heliox improved CO2 elimination while allowing reduced minute volume ventilation in adult patients during protective mechanical ventilation.

Humidification of inspired gases during mechanical ventilation.

PubMed

Gross, J L; Park, G R

2012-04-01

Humidification of inspired gas is mandatory for all mechanically ventilated patients to prevent secretion retention, tracheal tube blockage and adverse changes occurring to the respiratory tract epithelium. However, the debate over "ideal" humidification continues. Several devices are available that include active and passive heat and moisture exchangers and hot water humidifiers Each have their advantages and disadvantages in mechanically ventilated patients. This review explores each device in turn and defines their role in clinical practice.

Preemptive mechanical ventilation can block progressive acute lung injury.

PubMed

Sadowitz, Benjamin; Jain, Sumeet; Kollisch-Singule, Michaela; Satalin, Joshua; Andrews, Penny; Habashi, Nader; Gatto, Louis A; Nieman, Gary

2016-02-04

Mortality from acute respiratory distress syndrome (ARDS) remains unacceptable, approaching 45% in certain high-risk patient populations. Treating fulminant ARDS is currently relegated to supportive care measures only. Thus, the best treatment for ARDS may lie with preventing this syndrome from ever occurring. Clinical studies were examined to determine why ARDS has remained resistant to treatment over the past several decades. In addition, both basic science and clinical studies were examined to determine the impact that early, protective mechanical ventilation may have on preventing the development of ARDS in at-risk patients. Fulminant ARDS is highly resistant to both pharmacologic treatment and methods of mechanical ventilation. However, ARDS is a progressive disease with an early treatment window that can be exploited. In particular, protective mechanical ventilation initiated before the onset of lung injury can prevent the progression to ARDS. Airway pressure release ventilation (APRV) is a novel mechanical ventilation strategy for delivering a protective breath that has been shown to block progressive acute lung injury (ALI) and prevent ALI from progressing to ARDS. ARDS mortality currently remains as high as 45% in some studies. As ARDS is a progressive disease, the key to treatment lies with preventing the disease from ever occurring while it remains subclinical. Early protective mechanical ventilation with APRV appears to offer substantial benefit in this regard and may be the prophylactic treatment of choice for preventing ARDS.

Brazilian recommendations of mechanical ventilation 2013. Part 2

PubMed Central

2014-01-01

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document. PMID:25410835

Brazilian recommendations of mechanical ventilation 2013. Part I

PubMed Central

Barbas, Carmen Sílvia Valente; Ísola, Alexandre Marini; Farias, Augusto Manoel de Carvalho; Cavalcanti, Alexandre Biasi; Gama, Ana Maria Casati; Duarte, Antonio Carlos Magalhães; Vianna, Arthur; Serpa, Ary; Bravim, Bruno de Arruda; Pinheiro, Bruno do Valle; Mazza, Bruno Franco; de Carvalho, Carlos Roberto Ribeiro; Toufen, Carlos; David, Cid Marcos Nascimento; Taniguchi, Corine; Mazza, Débora Dutra da Silveira; Dragosavac, Desanka; Toledo, Diogo Oliveira; Costa, Eduardo Leite; Caser, Eliana Bernardete; Silva, Eliezer; Amorim, Fabio Ferreira; Saddy, Felipe; Galas, Filomena Regina Barbosa Gomes; Silva, Gisele Sampaio; de Matos, Gustavo Faissol Janot; Emmerich, João Claudio; Valiatti, Jorge Luis dos Santos; Teles, José Mario Meira; Victorino, Josué Almeida; Ferreira, Juliana Carvalho; Prodomo, Luciana Passuello do Vale; Hajjar, Ludhmila Abrahão; Martins, Luiz Cláudio; Malbouisson, Luiz Marcelo Sá; Vargas, Mara Ambrosina de Oliveira; Reis, Marco Antonio Soares; Amato, Marcelo Brito Passos; Holanda, Marcelo Alcântara; Park, Marcelo; Jacomelli, Marcia; Tavares, Marcos; Damasceno, Marta Cristina Paulette; Assunção, Murillo Santucci César; Damasceno, Moyzes Pinto Coelho Duarte; Youssef, Nazah Cherif Mohamad; Teixeira, Paulo José Zimmermann; Caruso, Pedro; Duarte, Péricles Almeida Delfino; Messeder, Octavio; Eid, Raquel Caserta; Rodrigues, Ricardo Goulart; de Jesus, Rodrigo Francisco; Kairalla, Ronaldo Adib; Justino, Sandra; Nemer, Sérgio Nogueira; Romero, Simone Barbosa; Amado, Verônica Moreira

2014-01-01

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document. PMID:25028944

Brazilian recommendations of mechanical ventilation 2013. Part 2

PubMed Central

Barbas, Carmen Sílvia Valente; Ísola, Alexandre Marini; Farias, Augusto Manoel de Carvalho; Cavalcanti, Alexandre Biasi; Gama, Ana Maria Casati; Duarte, Antonio Carlos Magalhães; Vianna, Arthur; Serpa Neto, Ary; Bravim, Bruno de Arruda; Pinheiro, Bruno do Valle; Mazza, Bruno Franco; de Carvalho, Carlos Roberto Ribeiro; Toufen Júnior, Carlos; David, Cid Marcos Nascimento; Taniguchi, Corine; Mazza, Débora Dutra da Silveira; Dragosavac, Desanka; Toledo, Diogo Oliveira; Costa, Eduardo Leite; Caser, Eliana Bernadete; Silva, Eliezer; Amorim, Fabio Ferreira; Saddy, Felipe; Galas, Filomena Regina Barbosa Gomes; Silva, Gisele Sampaio; de Matos, Gustavo Faissol Janot; Emmerich, João Claudio; Valiatti, Jorge Luis dos Santos; Teles, José Mario Meira; Victorino, Josué Almeida; Ferreira, Juliana Carvalho; Prodomo, Luciana Passuello do Vale; Hajjar, Ludhmila Abrahão; Martins, Luiz Claudio; Malbouisson, Luis Marcelo Sá; Vargas, Mara Ambrosina de Oliveira; Reis, Marco Antonio Soares; Amato, Marcelo Brito Passos; Holanda, Marcelo Alcântara; Park, Marcelo; Jacomelli, Marcia; Tavares, Marcos; Damasceno, Marta Cristina Paulette; Assunção, Murillo Santucci César; Damasceno, Moyzes Pinto Coelho Duarte; Youssef, Nazah Cherif Mohamed; Teixeira, Paulo José Zimmermann; Caruso, Pedro; Duarte, Péricles Almeida Delfino; Messeder, Octavio; Eid, Raquel Caserta; Rodrigues, Ricardo Goulart; de Jesus, Rodrigo Francisco; Kairalla, Ronaldo Adib; Justino, Sandra; Nemer, Sergio Nogueira; Romero, Simone Barbosa; Amado, Verônica Moreira

2014-01-01

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document. PMID:25295817

Brazilian recommendations of mechanical ventilation 2013. Part I

PubMed Central

2014-01-01

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document. PMID:25210957

Influences of Duration of Inspiratory Effort, Respiratory Mechanics, and Ventilator Type on Asynchrony With Pressure Support and Proportional Assist Ventilation.

PubMed

Vasconcelos, Renata S; Sales, Raquel P; Melo, Luíz H de P; Marinho, Liégina S; Bastos, Vasco Pd; Nogueira, Andréa da Nc; Ferreira, Juliana C; Holanda, Marcelo A

2017-05-01

Pressure support ventilation (PSV) is often associated with patient-ventilator asynchrony. Proportional assist ventilation (PAV) offers inspiratory assistance proportional to patient effort, minimizing patient-ventilator asynchrony. The objective of this study was to evaluate the influence of respiratory mechanics and patient effort on patient-ventilator asynchrony during PSV and PAV plus (PAV+). We used a mechanical lung simulator and studied 3 respiratory mechanics profiles (normal, obstructive, and restrictive), with variations in the duration of inspiratory effort: 0.5, 1.0, 1.5, and 2.0 s. The Auto-Trak system was studied in ventilators when available. Outcome measures included inspiratory trigger delay, expiratory trigger asynchrony, and tidal volume (V T ). Inspiratory trigger delay was greater in the obstructive respiratory mechanics profile and greatest with a effort of 2.0 s (160 ms); cycling asynchrony, particularly delayed cycling, was common in the obstructive profile, whereas the restrictive profile was associated with premature cycling. In comparison with PSV, PAV+ improved patient-ventilator synchrony, with a shorter triggering delay (28 ms vs 116 ms) and no cycling asynchrony in the restrictive profile. V T was lower with PAV+ than with PSV (630 mL vs 837 mL), as it was with the single-limb circuit ventilator (570 mL vs 837 mL). PAV+ mode was associated with longer cycling delays than were the other ventilation modes, especially for the obstructive profile and higher effort values. Auto-Trak eliminated automatic triggering. Mechanical ventilation asynchrony was influenced by effort, respiratory mechanics, ventilator type, and ventilation mode. In PSV mode, delayed cycling was associated with shorter effort in obstructive respiratory mechanics profiles, whereas premature cycling was more common with longer effort and a restrictive profile. PAV+ prevented premature cycling but not delayed cycling, especially in obstructive respiratory mechanics

A new system for understanding modes of mechanical ventilation.

PubMed

Chatburn, R L; Primiano, F P

2001-06-01

Numerous ventilation modes and ventilation options have become available as new mechanical ventilators have reached the market. Ventilator manufacturers have no standardized terminology for ventilator modes and ventilation options, and ventilator operator's manuals do not help the clinician compare the modes of ventilators from different manufacturers. This article proposes a standardized system for classifying ventilation modes, based on general engineering principles and a small set of explicit definitions. Though there may be resistance by ventilator manufacturers to a standardized system of ventilation terminology, clinicians and health care equipment purchasers should adopt such a system in the interest of clear communication--the lack of which prevents clinicians from fully understanding the therapies they administer and could compromise the quality of patient care.

Negative pressure ventilation and positive pressure ventilation promote comparable levels of ventilator-induced diaphragmatic dysfunction in rats.

PubMed

Bruells, Christian S; Smuder, Ashley J; Reiss, Lucy K; Hudson, Matthew B; Nelson, William Bradley; Wiggs, Michael P; Sollanek, Kurt J; Rossaint, Rolf; Uhlig, Stefan; Powers, Scott K

2013-09-01

Mechanical ventilation is a life-saving intervention for patients with respiratory failure. Unfortunately, a major complication associated with prolonged mechanical ventilation is ventilator-induced diaphragmatic atrophy and contractile dysfunction, termed ventilator-induced diaphragmatic dysfunction (VIDD). Emerging evidence suggests that positive pressure ventilation (PPV) promotes lung damage (ventilator-induced lung injury [VILI]), resulting in the release of signaling molecules that foster atrophic signaling in the diaphragm and the resultant VIDD. Although a recent report suggests that negative pressure ventilation (NPV) results in less VILI than PPV, it is unknown whether NPV can protect against VIDD. Therefore, the authors tested the hypothesis that compared with PPV, NPV will result in a lower level of VIDD. Adult rats were randomly assigned to one of three experimental groups (n = 8 each): (1) acutely anesthetized control (CON), (2) 12 h of PPV, and (3) 12 h of NPV. Dependent measures included indices of VILI, diaphragmatic muscle fiber cross-sectional area, diaphragm contractile properties, and the activity of key proteases in the diaphragm. Our results reveal that no differences existed in the degree of VILI between PPV and NPV animals as evidenced by VILI histological scores (CON = 0.082 ± 0.001; PPV = 0.22 ± 0.04; NPV = 0.25 ± 0.02; mean ± SEM). Both PPV and NPV resulted in VIDD. Importantly, no differences existed between PPV and NPV animals in diaphragmatic fiber cross-sectional area, contractile properties, and the activation of proteases. These results demonstrate that NPV and PPV result in similar levels of VILI and that NPV and PPV promote comparable levels of VIDD in rats.

A prospective study of prolonged stay in the intensive care unit: predictors and impact on resource utilization.

PubMed

Arabi, Yaseen; Venkatesh, S; Haddad, Samir; Al Shimemeri, Abdullah; Al Malik, Salim

2002-10-01

To evaluate the predictors of prolonged Intensive Care Unit (ICU) stay and the impact on resource utilization. Prospective study. Adult medical/surgical ICU in a tertiary-care teaching hospital. All admissions to the ICU (numbering 947) over a 20-month period were enrolled. Data on demographic and clinical profile, length of stay, and outcome were collected prospectively. The ICU length of stay and mechanical ventilation days were used as surrogate parameters for resource utilization. Potential predictors were analyzed for possible association with prolonged ICU stay (length of stay > 14 days). Patients with prolonged ICU stay formed only 11% of patients, but utilized 45.1% of ICU days and 55.5% of mechanical ventilation days. Non-elective admissions, readmissions, respiratory or trauma-related reasons for admission, and first 24-hour evidence of infection, oliguria, coagulopathy, and the need for mechanical ventilation or vasopressor therapy had significant association with prolonged ICU stay. Mean APACHE II and SAPS II were slightly higher in patients with prolonged stay. ICU outcome was comparable to patients with < or = 14 days ICU stay. Patients with prolonged ICU stay form a small proportion of ICU patients, yet they consume a significant share of the ICU resources. The outcome of this group of patients is comparable to that of shorter stay patients. The predictors identified in the study can be used in targeting this group to improve resource utilization and efficiency of ICU care.

Numerical investigation of pulmonary drug delivery under mechanical ventilation conditions

NASA Astrophysics Data System (ADS)

Banerjee, Arindam; van Rhein, Timothy

2012-11-01

The effects of mechanical ventilation waveform on fluid flow and particle deposition were studied in a computer model of the human airways. The frequency with which aerosolized drugs are delivered to mechanically ventilated patients demonstrates the importance of understanding the effects of ventilation parameters. This study focuses specifically on the effects of mechanical ventilation waveforms using a computer model of the airways of patient undergoing mechanical ventilation treatment from the endotracheal tube to generation G7. Waveforms were modeled as those commonly used by commercial mechanical ventilators. Turbulence was modeled with LES. User defined particle force models were used to model the drag force with the Cunningham correction factor, the Saffman lift force, and Brownian motion force. The endotracheal tube (ETT) was found to be an important geometric feature, causing a fluid jet towards the right main bronchus, increased turbulence, and a recirculation zone in the right main bronchus. In addition to the enhanced deposition seen at the carinas of the airway bifurcations, enhanced deposition was also seen in the right main bronchus due to impaction and turbulent dispersion resulting from the fluid structures created by the ETT. Authors acknowledge financial support through University of Missouri Research Board Award.

Preemptive mechanical ventilation can block progressive acute lung injury

PubMed Central

Sadowitz, Benjamin; Jain, Sumeet; Kollisch-Singule, Michaela; Satalin, Joshua; Andrews, Penny; Habashi, Nader; Gatto, Louis A; Nieman, Gary

2016-01-01

Mortality from acute respiratory distress syndrome (ARDS) remains unacceptable, approaching 45% in certain high-risk patient populations. Treating fulminant ARDS is currently relegated to supportive care measures only. Thus, the best treatment for ARDS may lie with preventing this syndrome from ever occurring. Clinical studies were examined to determine why ARDS has remained resistant to treatment over the past several decades. In addition, both basic science and clinical studies were examined to determine the impact that early, protective mechanical ventilation may have on preventing the development of ARDS in at-risk patients. Fulminant ARDS is highly resistant to both pharmacologic treatment and methods of mechanical ventilation. However, ARDS is a progressive disease with an early treatment window that can be exploited. In particular, protective mechanical ventilation initiated before the onset of lung injury can prevent the progression to ARDS. Airway pressure release ventilation (APRV) is a novel mechanical ventilation strategy for delivering a protective breath that has been shown to block progressive acute lung injury (ALI) and prevent ALI from progressing to ARDS. ARDS mortality currently remains as high as 45% in some studies. As ARDS is a progressive disease, the key to treatment lies with preventing the disease from ever occurring while it remains subclinical. Early protective mechanical ventilation with APRV appears to offer substantial benefit in this regard and may be the prophylactic treatment of choice for preventing ARDS. PMID:26855896

Epithelial and endothelial damage induced by mechanical ventilation modes.

PubMed

Suki, Béla; Hubmayr, Rolf

2014-02-01

The adult respiratory distress syndrome (ARDS) is a common cause of respiratory failure with substantial impact on public health. Patients with ARDS generally require mechanical ventilation, which risks further lung damage. Recent improvements in ARDS outcomes have been attributed to reductions in deforming stress associated with lung protective mechanical ventilation modes and settings. The following review details the mechanics of the lung parenchyma at different spatial scales and the response of its resident cells to deforming stress in order to provide the biologic underpinnings of lung protective care. Although lung injury is typically viewed through the lens of altered barrier properties and mechanical ventilation-associated immune responses, in this review, we call attention to the importance of heterogeneity and the physical failure of the load bearing cell and tissue elements in the pathogenesis of ARDS. Specifically, we introduce a simple elastic network model to better understand the deformations of lung regions, intra-acinar alveoli and cells within a single alveolus, and consider the role of regional distension and interfacial stress-related injury for various ventilation modes. Heterogeneity of stiffness and intercellular and intracellular stress failure are fundamental components of ARDS and their development also depends on the ventilation mode.

Management of mechanical ventilation during laparoscopic surgery.

PubMed

Valenza, Franco; Chevallard, Giorgio; Fossali, Tommaso; Salice, Valentina; Pizzocri, Marta; Gattinoni, Luciano

2010-06-01

Laparoscopy is widely used in the surgical treatment of a number of diseases. Its advantages are generally believed to lie on its minimal invasiveness, better cosmetic outcome and shorter length of hospital stay based on surgical expertise and state-of-the-art equipment. Thousands of laparoscopic surgical procedures performed safely prove that mechanical ventilation during anaesthesia for laparoscopy is well tolerated by a vast majority of patients. However, the effects of pneumoperitoneum are particularly relevant to patients with underlying lung disease as well as to the increasing number of patients with higher-than-normal body mass index. Moreover, many surgical procedures are significantly longer in duration when performed with laparoscopic techniques. Taken together, these factors impose special care for the management of mechanical ventilation during laparoscopic surgery. The purpose of the review is to summarise the consequences of pneumoperitoneum on the standard monitoring of mechanical ventilation during anaesthesia and to discuss the rationale of using a protective ventilation strategy during laparoscopic surgery. The consequences of chest wall derangement occurring during pneumoperitoneum on airway pressure and central venous pressure, together with the role of end-tidal-CO2 monitoring are emphasised. Ventilatory and non-ventilatory strategies to protect the lung are discussed.

Numerical simulation of volume-controlled mechanical ventilated respiratory system with 2 different lungs.

PubMed

Shi, Yan; Zhang, Bolun; Cai, Maolin; Zhang, Xiaohua Douglas

2017-09-01

Mechanical ventilation is a key therapy for patients who cannot breathe adequately by themselves, and dynamics of mechanical ventilation system is of great significance for life support of patients. Recently, models of mechanical ventilated respiratory system with 1 lung are used to simulate the respiratory system of patients. However, humans have 2 lungs. When the respiratory characteristics of 2 lungs are different, a single-lung model cannot reflect real respiratory system. In this paper, to illustrate dynamic characteristics of mechanical ventilated respiratory system with 2 different lungs, we propose a mathematical model of mechanical ventilated respiratory system with 2 different lungs and conduct experiments to verify the model. Furthermore, we study the dynamics of mechanical ventilated respiratory system with 2 different lungs. This research study can be used for improving the efficiency and safety of volume-controlled mechanical ventilation system. Copyright © 2016 John Wiley & Sons, Ltd.

The use of mechanical ventilation in the ED.

PubMed

Easter, Benjamin D; Fischer, Christopher; Fisher, Jonathan

2012-09-01

Although EDs are responsible for the initial care of critically ill patients and the amount of critical care provided in the ED is increasing, there are few data examining mechanical ventilation (MV) in the ED. In addition, characteristics of ED-based ventilation may affect planning for ventilator shortages during pandemic influenza or bioterrorist events. The study examined the epidemiology of MV in US EDs, including demographic, clinical, and hospital characteristics; indications for MV; ED length of stay (LOS); and in-hospital mortality. This study was a retrospective review of the 1993 to 2007 National Hospital Ambulatory Medical Care Survey ED data sets. Ventilated patients were compared with ED patients admitted to the intensive care unit (ICU) and to all other ED visits. There were 3.6 million ED MV visits (95% confidence interval [CI], 3.2-4.0 million) over the study period. Sex, age, race, and payment source were similar for mechanically ventilated and ICU patients (P > .05 for all). Approximately 12.5% of ventilated patients underwent cardiopulmonary resuscitation compared with 1.7% of ICU admissions and 0.2% of all other ED visits (P < .0001). Accordingly, in-hospital mortality was significantly higher for ventilated patients (24%; 95% CI, 13.1%-34.9%) than both comparison groups (9.3% and 2.5%, respectively). Median LOS for ventilated patients was 197 minutes (interquartile range, 112-313 minutes) compared with 224 minutes for ICU admissions and 140 minutes for all other ED visits. Patients undergoing ED MV have particularly high in-hospital mortality rates, but their ED LOS is sufficient for implementation of evidence-based ventilator interventions. Copyright © 2012 Elsevier Inc. All rights reserved.

Humidification during mechanical ventilation in the adult patient.

PubMed

Al Ashry, Haitham S; Modrykamien, Ariel M

2014-01-01

Humidification of inhaled gases has been standard of care in mechanical ventilation for a long period of time. More than a century ago, a variety of reports described important airway damage by applying dry gases during artificial ventilation. Consequently, respiratory care providers have been utilizing external humidifiers to compensate for the lack of natural humidification mechanisms when the upper airway is bypassed. Particularly, active and passive humidification devices have rapidly evolved. Sophisticated systems composed of reservoirs, wires, heating devices, and other elements have become part of our usual armamentarium in the intensive care unit. Therefore, basic knowledge of the mechanisms of action of each of these devices, as well as their advantages and disadvantages, becomes a necessity for the respiratory care and intensive care practitioner. In this paper, we review current methods of airway humidification during invasive mechanical ventilation of adult patients. We describe a variety of devices and describe the eventual applications according to specific clinical conditions.

Humidification during Mechanical Ventilation in the Adult Patient

PubMed Central

Al Ashry, Haitham S.; Modrykamien, Ariel M.

2014-01-01

Humidification of inhaled gases has been standard of care in mechanical ventilation for a long period of time. More than a century ago, a variety of reports described important airway damage by applying dry gases during artificial ventilation. Consequently, respiratory care providers have been utilizing external humidifiers to compensate for the lack of natural humidification mechanisms when the upper airway is bypassed. Particularly, active and passive humidification devices have rapidly evolved. Sophisticated systems composed of reservoirs, wires, heating devices, and other elements have become part of our usual armamentarium in the intensive care unit. Therefore, basic knowledge of the mechanisms of action of each of these devices, as well as their advantages and disadvantages, becomes a necessity for the respiratory care and intensive care practitioner. In this paper, we review current methods of airway humidification during invasive mechanical ventilation of adult patients. We describe a variety of devices and describe the eventual applications according to specific clinical conditions. PMID:25089275

Airway Strain during Mechanical Ventilation in an Intact Animal Model

PubMed Central

Sinclair, Scott E.; Molthen, Robert C.; Haworth, Steve T.; Dawson, Christopher A.; Waters, Christopher M.

2007-01-01

Rationale: Mechanical ventilation with large tidal volumes causes ventilator-induced lung injury in animal models. Little direct evidence exists regarding the deformation of airways in vivo during mechanical ventilation, or in the presence of positive end-expiratory pressure (PEEP). Objectives: To measure airway strain and to estimate airway wall tension during mechanical ventilation in an intact animal model. Methods: Sprague-Dawley rats were anesthetized and mechanically ventilated with tidal volumes of 6, 12, and 25 cm3/kg with and without 10–cm H2O PEEP. Real-time tantalum bronchograms were obtained for each condition, using microfocal X-ray imaging. Images were used to calculate circumferential and longitudinal airway strains, and on the basis of a simplified mathematical model we estimated airway wall tensions. Measurements and Main Results: Circumferential and longitudinal airway strains increased with increasing tidal volume. Levels of mechanical strain were heterogeneous throughout the bronchial tree. Circumferential strains were higher in smaller airways (less than 800 μm). Airway size did not influence longitudinal strain. When PEEP was applied, wall tensions increased more rapidly than did strain levels, suggesting that a “strain limit” had been reached. Airway collapse was not observed under any experimental condition. Conclusions: Mechanical ventilation results in significant airway mechanical strain that is heterogeneously distributed in the uninjured lung. The magnitude of circumferential but not axial strain varies with airway diameter. Airways exhibit a “strain limit” above which an abrupt dramatic rise in wall tension is observed. PMID:17626911

Comparative analysis of respiratory systems compliance in three different positioning (lateral, dorsal and sitting) in patients in prolonged invasive mechanical ventilation.

PubMed

Porto, Elias Ferreira; Castro, Antonio Adolfo Matos de; Leite, José Renato de Oliveira; Miranda, Saul Vitoriano; Lancauth, Auristela; Kumpel, Claudia

2008-09-01

This study is justified by the fact that in clinical practice, changes occur in patient's positioning in the bed during hospitalization in intensive care unity, it's necessary better understanding about possible adverse effects that such changes might cause mainly on the respiratory system condition. The objective this study was to evaluate if the patients positioning in bed can to alter the pulmonary complacency. All included patients were submitted to mechanical ventilation and were sedated and curarized respiratory system compliance was assessed in three different positioning: lateral, dorsal and sitting. After an alveolar recruitment maneuver, patients were placed to a position throughout two hours, and in the last five minutes the data was collected from the mechanical ventilator display. twenty eight patients were prospectively assessed. Values of respiratory system compliance in the lateral position were 37,07 ± 12,9 in the dorsal were 39,2 ± 10,5 and in the sitting 43,4 ± 9,6 mL/cmH2O. There were a statistical difference when we compared to the sitting and dorsal with lateral positioning for respiratory system compliance (p = 0.0052) and tidal volume (p < 0.001). There was a negative correlation between mean values of positive end expiratory pressure a respiratory system compliance (r = 0.59, p = 0.002). The FIO2 administered was 0.6 for the lateral positioning and 0.5 for the dorsal and sitting positioning (p = 0.049). That body positioning in patients restrained to a bed and submitted to invasive mechanical ventilation leads to pulmonary compliance, tidal volume and SpO2 oscillations. In the sitting position the pulmonary compliance is higher than in others positions.

Prone versus supine position in mechanically ventilated children: a pilot study.

PubMed

Sawhney, Ashu; Kumar, Nirmal; Sreenivas, Vishnubhatla; Gupta, Sangeeta; Tyagi, Vineet; Puliyel, Jacob M

2005-05-01

It is known that mechanically ventilated patients in the prone position have improved oxygenation compared with those supine. We did a prospective, randomized, controlled trial to evaluate the effect of prone position during mechanical ventilation, on survival in critically ill children. Forty-two children needing mechanical ventilation for various illnesses were randomized to receive initial ventilation for four hours prone or supine by drawing lots. Initial severity of illness and blood gases in all children were noted. In a crossover design, after the initial four hours the children were turned over and ventilated in the alternate posture for an hour. Oxygenation parameters and mean airway pressures were noted at one hour, four hours, and five hours. Mortality, duration of ventilation, and the above parameters were compared in the two groups. Initial PRISM scores were similar in the two groups. Mortality in the prone group was less than in the supine group. The odds ratio of mortality was 0.20 (95% CI 0.05-0.75). Duration of ventilation was similar in the two groups. The oxygenation index was significantly lower in the prone group at one, four, and five hours after onset of ventilation. Prone position in the first few hours of ventilation significantly improves gas exchange and oxygenation, reduces the mean airway pressures required to ventilate children, and may cause significant improvement in survival. Our study protocol allowed ventilator settings to be changed as needed during ventilation.

[Analgesia, sedation and relaxation in the child with mechanical ventilation].

PubMed

Valdivielso-Serna, A

2008-02-01

The basic concepts of sedation and analgesia and the tools to asses the level of sedation and analgesia are review. The different methods of sedation and the non pharmacological interventions are described. Sedatives, analgesics and muscle relaxants, their pharmacodynamics and pharmacokinetics in children, their indications in specific situations (intubation, pain control, sedation and neuromuscular blocking) are reviewed. The etiology of patient-ventilator asynchrony in ventilated children and how to treat it are analyzed, giving guides of how to adapt sedation to the level of mechanical ventilation therapy. Finally, general recommendations are given for the analgesia and sedation in mechanically ventilated children.

Resistive pressure of a condenser humidifier in mechanically ventilated patients.

PubMed

Manthous, C A; Schmidt, G A

1994-11-01

Heat and moisture exchangers (or "nose" humidifiers) are commonly used to aid in the humidification of inspired gases of mechanically ventilated patients. These devices add resistance to the ventilator circuit that has heretofore not been quantified in critically ill patients. Accordingly, we determined the resistive pressures associated with new and old (but < 24 hrs in the circuit) humidifiers in 23 critically ill, mechanically ventilated patients. Prospective study. Adult medical and surgical intensive care units at a university center. Twenty-three critically ill, mechanically ventilated patients using a condenser humidifier between the wye and the endotracheal tube. Peak and plateau airway pressures were determined with the humidifier in place. These measurements were repeated without the humidifier, then after insertion of a fresh humidifier into the circuit. In five patients, measurements were repeated after humidifiers had remained in place for a full 24 hrs. The new humidifiers increased the resistive pressure of the ventilator circuit by 4.8 +/- 2.6 cm H2O compared with no humidifier (p < .01) and had a mean resistance of 4.2 +/- 1.5 cm H2O/L/sec. Old humidifiers increased resistive pressure by 6.3 +/- 3.6 cm H2O compared with no humidifier (p < .01) and had a mean resistance of 5.1 +/- 1.8 cm H2O/L/sec. The resistive pressure doubled from 3.4 +/- 1.2 to 7.0 +/- 1.8 cm H2O (p < .01) in five patients in whom the humidifiers were left in the ventilator circuit for a full 24 hrs. The humidifier adds a significant resistance to the ventilator circuit which may lead to incorrect assessment of respiratory system mechanics, to inappropriate therapy (e.g., bronchodilators), or to difficulty in weaning from mechanical ventilation.

A miniature mechanical ventilator for newborn mice.

PubMed

Kolandaivelu, K; Poon, C S

1998-02-01

Transgenic/knockout mice with pre-defined mutations have become increasingly popular in biomedical research as models of human diseases. In some instances, the resulting mutation may cause cardiorespiratory distress in the neonatal or adult animals and may necessitate resuscitation. Here we describe the design and testing of a miniature and versatile ventilator that can deliver varying ventilatory support modes, including conventional mechanical ventilation and high-frequency ventilation, to animals as small as the newborn mouse. With a double-piston body chamber design, the device circumvents the problem of air leakage and obviates the need for invasive procedures such as endotracheal intubation, which are particularly important in ventilating small animals. Preliminary tests on newborn mice as early as postnatal day O demonstrated satisfactory restoration of pulmonary ventilation and the prevention of respiratory failure in mutant mice that are prone to respiratory depression. This device may prove useful in the postnatal management of transgenic/knockout mice with genetically inflicted respiratory disorders.

Occult pneumothorax in the mechanically ventilated trauma patient

PubMed Central

Ball, Chad G.; Hameed, S. Morad; Evans, Dave; Kortbeek, John B.; Kirkpatrick, Andrew W.

2003-01-01

The term occult pneumothorax (OP) describes a pneumothorax that is not suspected on the basis of clinical examination or plain radiography but is ultimately detected with thoracoabdominal computed tomography (CT). This situation is increasingly common in trauma care with the increased use of CT. The rate is approximately 5% in injured people presenting to hospital, with CT revealing at least twice as many pneumothoraces as suspected on plain radiography. Whereas pneumothorax is a common and treatable cause of mortality and morbidity, there is substantial disagreement regarding the appropriate treatment of OP. The greatest controversy is in patients in the critical care unit who require positive-pressure ventilation. There is little current evidence to direct the proper management of ventilated trauma patients with OP, and no studies have focussed specifically on these patients. Future randomized trials will need to consider the potential effects of OP on pulmonary mechanics and potential influences on the known risks of ventilator-induced lung injury associated with mechanical ventilation. PMID:14577712

Indoor Environmental Quality in Mechanically Ventilated, Energy-Efficient Buildings vs. Conventional Buildings.

PubMed

Wallner, Peter; Munoz, Ute; Tappler, Peter; Wanka, Anna; Kundi, Michael; Shelton, Janie F; Hutter, Hans-Peter

2015-11-06

Energy-efficient buildings need mechanical ventilation. However, there are concerns that inadequate mechanical ventilation may lead to impaired indoor air quality. Using a semi-experimental field study, we investigated if exposure of occupants of two types of buildings (mechanical vs. natural ventilation) differs with regard to indoor air pollutants and climate factors. We investigated living and bedrooms in 123 buildings (62 highly energy-efficient and 61 conventional buildings) built in the years 2010 to 2012 in Austria (mainly Vienna and Lower Austria). Measurements of indoor parameters (climate, chemical pollutants and biological contaminants) were conducted twice. In total, more than 3000 measurements were performed. Almost all indoor air quality and room climate parameters showed significantly better results in mechanically ventilated homes compared to those relying on ventilation from open windows and/or doors. This study does not support the hypothesis that occupants in mechanically ventilated low energy houses are exposed to lower indoor air quality.

Exhaled Breath Condensate Collection in the Mechanically Ventilated Patient

PubMed Central

Carter, Stewart R; Davis, Christopher S; Kovacs, Elizabeth J

2012-01-01

Collection of exhaled breath condensate (EBC) is a non-invasive means of sampling the airway-lining fluid of the lungs. EBC contains numerous measurable mediators, whose analysis could change the management of patients with certain pulmonary diseases. While initially popularized in investigations involving spontaneously breathing patients, an increasing number of studies have been performed using EBC in association with mechanical ventilation. Collection of EBC in mechanically ventilated patients follows basic principles of condensation, but is influenced by multiple factors. Effective collection requires selection of a collection device, adequate minute ventilation, low cooling temperatures, and sampling times of greater than ten minutes. Condensate can be contaminated by saliva, which needs to be filtered. Dilution of samples occurs secondary to distilled water in vapors and humidification in the ventilator circuit. Dilution factors may need to be employed when investigating non-volatile biomarkers. Storage and analysis should occur promptly at −70° C to −80° C to prevent rapid degradation of samples. The purpose of this review is to examine and describe methodologies and problems of EBC collection in mechanically ventilated patients. A straightforward and safe framework has been established to investigate disease processes in this population, yet technical aspects of EBC collection still exist that prevent clinical practicality of this technology. These include a lack of standardization of procedure and analysis of biomarkers, and of normal reference ranges for mediators in healthy individuals. Once these procedural aspects have been addressed, EBC could serve as a non-invasive alternative to invasive evaluation of lungs in mechanically ventilated patients. PMID:22398157

"Living with dying": the evolution of family members' experience of mechanical ventilation.

PubMed

Sinuff, Tasnim; Giacomini, Mita; Shaw, Rhona; Swinton, Marilyn; Cook, Deborah J

2009-01-01

Communication with families about mechanical ventilation may be more effective once we gain a better understanding of what families experience and understand about this life support technology when their loved ones are admitted to the intensive care unit (ICU). We conducted in-depth interviews with family members of 27 critically ill patients who required mechanical ventilation for > or = 7 days and had an estimated ICU mortality of > or = 50%. Team members reviewed transcripts independently and used grounded theory analysis. The central theme of family members' experience with mechanical ventilation was "living with dying." Initial reactions to the ventilator were of shock and surprise. Family members perceived no option except mechanical ventilation. Although the ventilator kept the patient alive, it also symbolized proximity to death. In time, families became accustomed to images of the ICU as ventilation became more familiar and routine. Their shock and horror were replaced by hope that the ventilator would allow the body to rest, heal, and recover. However, ongoing exposure to their loved one's critical illness and the new role as family spokesperson were traumatizing. Family members' experiences and their understanding of mechanical ventilation change over time, influenced by their habituation to the ICU environment and its routines. They face uncertainty about death, but maintain hope. Understanding these experiences may engender more respectful, meaningful communication about life support with families.

Amyotrophic lateral sclerosis: impact of pulmonary follow-up and mechanical ventilation on survival. A study of 114 cases.

PubMed

Sanjuán-López, Pilar; Valiño-López, Paz; Ricoy-Gabaldón, Jorge; Verea-Hernando, Héctor

2014-12-01

To study the impact of ventilatory management and treatment on the survival of patients with amyotrophic lateral sclerosis (ALS). Retrospective analysis of 114 consecutive patients admitted to a general hospital, evaluating demographic data, type of presentation, clinical management, treatment with mechanical ventilation and survival. descriptive and Kaplan-Meier estimator. Sixty four patients presented initial bulbar involvement. Overall mean survival after diagnosis was 28.0 months (95%CI, 21.1-34.8). Seventy patients were referred to the pulmonary specialist (61.4%) and 43 received non-invasive ventilation (NIV) at 12.7 months (median) after diagnosis. Thirty seven patients continued to receive NIV with no subsequent invasive ventilation. The mean survival of these patients was 23.3 months (95%CI, 16.7-28.8), higher in those without bulbar involvement, although below the range of significance. Survival in the 26 patients receiving programmed NIV was higher than in the 11 patients in whom this was indicated without prior pulmonary assessment (considered following diagnosis, P<.012, and in accordance with the start of ventilation, P<.004). A total of 7 patients were treated invasively; mean survival in this group was 72 months (95%CI, 14.36-129.6), median 49.6±17.5 (95%CI, 15.3-83.8), and despite the difficulties involved in home care, acceptance and tolerance was acceptable. Long-term mechanical ventilation prolongs survival in ALS. Programmed pulmonary assessment has a positive impact on survival of ALS patients and is key to the multidisciplinary management of this disease. Copyright © 2014 SEPAR. Published by Elsevier Espana. All rights reserved.

Flow measurement in mechanical ventilation: a review.

PubMed

Schena, Emiliano; Massaroni, Carlo; Saccomandi, Paola; Cecchini, Stefano

2015-03-01

Accurate monitoring of flow rate and volume exchanges is essential to minimize ventilator-induced lung injury. Mechanical ventilators employ flowmeters to estimate the amount of gases delivered to patients and use the flow signal as a feedback to adjust the desired amount of gas to be delivered. Since flowmeters play a crucial role in this field, they are required to fulfill strict criteria in terms of dynamic and static characteristics. Therefore, mechanical ventilators are equipped with only the following kinds of flowmeters: linear pneumotachographs, fixed and variable orifice meters, hot wire anemometers, and ultrasonic flowmeters. This paper provides an overview of these sensors. Their working principles are described together with their relevant advantages and disadvantages. Furthermore, the most promising emerging approaches for flowmeters design (i.e., fiber optic technology and three dimensional micro-fabrication) are briefly reviewed showing their potential for this application. Copyright © 2015 IPEM. Published by Elsevier Ltd. All rights reserved.

Music therapy as an adjunctive treatment in the management of stress for patients being weaned from mechanical ventilation.

PubMed

Hunter, Bryan C; Oliva, Rosemary; Sahler, Olle Jane Z; Gaisser, D'Arcy; Salipante, Diane M; Arezina, Clare H

2010-01-01

This project investigated music therapy (MT) in managing anxiety associated with weaning from mechanical ventilation. The use of sedation to treat anxiety during weaning is problematic because side effects (e.g., respiratory depression) are precisely the symptoms that cause the weaning process to be interrupted and consequently prolonged. Study goals were to determine the feasibility of incorporating MT into the weaning process and to evaluate the efficacy of the intervention, based on levels of anxiety, Days to Wean (DTW), and patient/nurse satisfaction. Adult patients received multiple MT sessions per week while undergoing weaning trials from mechanical ventilation. Feasibility was determined by successful enrollment in the study and nurse survey. Efficacy was evaluated through anxiety, as measured by heart rate, respiratory rate, and patient/nurse survey; DTW; and patient/nurse satisfaction. Nurse surveys reported that MT was successfully incorporated into the milieu and 61 subjects were enrolled. Significant differences in heart rate and respiratory rate were found from the beginning to the end of MT sessions (p < .05 and p < .0001, respectively), indicating a more relaxed state. No significant difference in mean DTW was found between study and control subjects. Patient/nurse satisfaction was high. Music therapy can be used successfully to treat anxiety associated with weaning from mechanical ventilation. Limitations and suggestions for further research are discussed.

Equation Discovery for Model Identification in Respiratory Mechanics of the Mechanically Ventilated Human Lung

NASA Astrophysics Data System (ADS)

Ganzert, Steven; Guttmann, Josef; Steinmann, Daniel; Kramer, Stefan

Lung protective ventilation strategies reduce the risk of ventilator associated lung injury. To develop such strategies, knowledge about mechanical properties of the mechanically ventilated human lung is essential. This study was designed to develop an equation discovery system to identify mathematical models of the respiratory system in time-series data obtained from mechanically ventilated patients. Two techniques were combined: (i) the usage of declarative bias to reduce search space complexity and inherently providing the processing of background knowledge. (ii) A newly developed heuristic for traversing the hypothesis space with a greedy, randomized strategy analogical to the GSAT algorithm. In 96.8% of all runs the applied equation discovery system was capable to detect the well-established equation of motion model of the respiratory system in the provided data. We see the potential of this semi-automatic approach to detect more complex mathematical descriptions of the respiratory system from respiratory data.

Evaluation of Mechanical Ventilator Use with Liquid Oxygen Systems

DTIC Science & Technology

2017-02-22

patients using long-term liquid oxygen differ from those on traditional treatment with oxygen concentrators and/or compressed gas cylinders? A...AFRL-SA-WP-SR-2017-0006 Evaluation of Mechanical Ventilator Use with Liquid Oxygen Systems Thomas Blakeman, MSc, RRT; Dario...To) August 2014 – September 2016 4. TITLE AND SUBTITLE Evaluation of Mechanical Ventilator Use with Liquid Oxygen Systems 5a. CONTRACT NUMBER

Evidence-based clinical improvement for mechanically ventilated patients.

PubMed

Hampton, Debra C; Griffith, Deborah; Howard, Alan

2005-01-01

Bundling or grouping together evidence-based interventions to improve care for the mechanically ventilated patient was piloted by a 10-bed medical-surgical critical care unit of a hospital. The bundled care interventions included: (a) keeping the head of bed elevated at 30 degrees, (b) instituting daily interruption of continuous sedative infusion, (c) assessing readiness to wean using a rapid-wean assessment guide, (d) initiating deep venous thrombosis prophylaxis, and (e) implementing peptic ulcer disease prophylaxis. The interventions were implemented using a plan-do-check-act quality-improvement methodology. Results indicated that the use of bundled interventions for mechanically ventilated patients could decrease average ventilator times and average length of stay with no concomitant increase in reintubations. Average mortality rates and the number of adverse events per 100 patient days also were reduced.

Respiratory mechanics to understand ARDS and guide mechanical ventilation.

PubMed

Mauri, Tommaso; Lazzeri, Marta; Bellani, Giacomo; Zanella, Alberto; Grasselli, Giacomo

2017-11-30

As precision medicine is becoming a standard of care in selecting tailored rather than average treatments, physiological measurements might represent the first step in applying personalized therapy in the intensive care unit (ICU). A systematic assessment of respiratory mechanics in patients with the acute respiratory distress syndrome (ARDS) could represent a step in this direction, for two main reasons. Approach and Main results: On the one hand, respiratory mechanics are a powerful physiological method to understand the severity of this syndrome in each single patient. Decreased respiratory system compliance, for example, is associated with low end expiratory lung volume and more severe lung injury. On the other hand, respiratory mechanics might guide protective mechanical ventilation settings. Improved gravitationally dependent regional lung compliance could support the selection of positive end-expiratory pressure and maximize alveolar recruitment. Moreover, the association between driving airway pressure and mortality in ARDS patients potentially underlines the importance of sizing tidal volume on respiratory system compliance rather than on predicted body weight. The present review article aims to describe the main alterations of respiratory mechanics in ARDS as a potent bedside tool to understand severity and guide mechanical ventilation settings, thus representing a readily available clinical resource for ICU physicians.

Metabolic Requirement of Septic Shock Patients Before and After Liberation From Mechanical Ventilation.

PubMed

Lee, Peggy Siu-Pik; Lee, Kar Lung; Betts, James A; Law, Kin Ip

2017-08-01

This study identified the difference in energy expenditure and substrate utilization of patients during and upon liberation from mechanical ventilation. Patients under intensive care who were diagnosed with septic shock and dependent on mechanical ventilation were recruited. Indirect calorimetry measurements were performed during and upon liberation from mechanical ventilation. Thirty-five patients were recruited (20 men and 15 women; mean age, 69 ± 10 years). Measured energy expenditures during ventilation and upon liberation were 2090 ± 489 kcal·d -1 and 1910 ± 579 kcal·d -1 , respectively ( P < .05). Energy intake was provided at 1148 ± 495 kcal·d -1 and differed significantly from all measured energy expenditures ( P < .05). Mean carbohydrate utilization was 0.19 ± 0.1 g·min -1 when patients were on mechanical ventilation compared with 0.15 ± 0.09 g·min -1 upon liberation ( P < .05). Mean lipid oxidation was 0.08 ± 0.05 g·min -1 during and 0.09 ± 0.07 g·min -1 upon liberation from mechanical ventilation ( P > .05). Measured energy expenditure was higher during than upon liberation from mechanical ventilation. This could be the increase in work of breathing from the continuous positive pressure support, repeated weaning cycles from mechanical ventilation, and/or the asynchronization between patients' respiration and ventilator support. Future studies should examine whether more appropriately matching energy expenditure with energy intake would promote positive health outcomes.

Complementary home mechanical ventilation techniques. SEPAR Year 2014.

PubMed

Chiner, Eusebi; Sancho-Chust, José N; Landete, Pedro; Senent, Cristina; Gómez-Merino, Elia

2014-12-01

This is a review of the different complementary techniques that are useful for optimizing home mechanical ventilation (HMV). Airway clearance is very important in patients with HMV and many patients, particularly those with reduced peak cough flow, require airway clearance (manual or assisted) or assisted cough techniques (manual or mechanical) and suctioning procedures, in addition to ventilation. In the case of invasive HMV, good tracheostomy cannula management is essential for success. HMV patients may have sleep disturbances that must be taken into account. Sleep studies including complete polysomnography or respiratory polygraphy are helpful for identifying patient-ventilator asynchrony. Other techniques, such as bronchoscopy or nutritional support, may be required in patients on HMV, particularly if percutaneous gastrostomy is required. Information on treatment efficacy can be obtained from HMV monitoring, using methods such as pulse oximetry, capnography or the internal programs of the ventilators themselves. Finally, the importance of the patient's subjective perception is reviewed, as this may potentially affect the success of the HMV. Copyright © 2014 SEPAR. Published by Elsevier Espana. All rights reserved.

Efficacy of respiratory muscle training in weaning of mechanical ventilation in patients with mechanical ventilation for 48hours or more: A Randomized Controlled Clinical Trial.

PubMed

Sandoval Moreno, L M; Casas Quiroga, I C; Wilches Luna, E C; García, A F

2018-02-02

To evaluate the efficacy of respiratory muscular training in the weaning of mechanical ventilation and respiratory muscle strength in patients on mechanical ventilation of 48hours or more. Randomized controlled trial of parallel groups, double-blind. Ambit: Intensive Care Unit of a IV level clinic in the city of Cali. 126 patients in mechanical ventilation for 48hours or more. The experimental group received daily a respiratory muscle training program with treshold, adjusted to 50% of maximal inspiratory pressure, additional to standard care, conventional received standard care of respiratory physiotherapy. MAIN INTEREST VARIABLES: weaning of mechanical ventilation. Other variables evaluated: respiratory muscle strength, requirement of non-invasive mechanical ventilation and frequency of reintubation. intention-to-treat analysis was performed with all variables evaluated and analysis stratified by sepsis condition. There were no statistically significant differences in the median weaning time of the MV between the groups or in the probability of extubation between groups (HR: 0.82 95% CI: 0.55-1.20 P=.29). The maximum inspiratory pressure was increased in the experimental group on average 9.43 (17.48) cmsH20 and in the conventional 5.92 (11.90) cmsH20 (P=.48). The difference between the means of change in maximal inspiratory pressure was 0.46 (P=.83 95%CI -3.85 to -4.78). respiratory muscle training did not demonstrate efficacy in the reduction of the weaning period of mechanical ventilation nor in the increase of respiratory muscle strength in the study population. Registered study at ClinicalTrials.gov (NCT02469064). Copyright © 2017 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.

The Effect of Pressure-Controlled Ventilation and Volume-Controlled Ventilation in Prone Position on Pulmonary Mechanics and Inflammatory Markers.

PubMed

Şenay, Hasan; Sıvacı, Remziye; Kokulu, Serdar; Koca, Buğra; Bakı, Elif Doğan; Ela, Yüksel

2016-08-01

The aim of this present study is to compare the effect of pressure-controlled ventilation and volume-controlled ventilation on pulmonary mechanics and inflammatory markers in prone position. The study included 41 patients undergoing to vertebrae surgery. The patients were randomized into two groups: Group 1 received volume-controlled ventilation, while group 2 received pressure-controlled ventilation. The demographic data, pulmonary mechanics, the inflammatory marker levels just after the induction of anesthetics, at the 6th and 12th hours, and gas analysis from arterial blood samples taken at the beginning and the 30th minute were recorded. The inflammatory marker levels increased in both groups, without any significant difference among groups. Peak inspiratory pressure level was higher in the volume-controlled ventilation group. This study revealed that there is no difference regarding inflammatory marker levels between volume- and pressure-controlled ventilation.

Education on invasive mechanical ventilation involving intensive care nurses: a systematic review.

PubMed

Guilhermino, Michelle C; Inder, Kerry J; Sundin, Deborah

2018-03-26

Intensive care unit nurses are critical for managing mechanical ventilation. Continuing education is essential in building and maintaining nurses' knowledge and skills, potentially improving patient outcomes. The aim of this study was to determine whether continuing education programmes on invasive mechanical ventilation involving intensive care unit nurses are effective in improving patient outcomes. Five electronic databases were searched from 2001 to 2016 using keywords such as mechanical ventilation, nursing and education. Inclusion criteria were invasive mechanical ventilation continuing education programmes that involved nurses and measured patient outcomes. Primary outcomes were intensive care unit mortality and in-hospital mortality. Secondary outcomes included hospital and intensive care unit length of stay, length of intubation, failed weaning trials, re-intubation incidence, ventilation-associated pneumonia rate and lung-protective ventilator strategies. Studies were excluded if they excluded nurses, patients were ventilated for less than 24 h, the education content focused on protocol implementation or oral care exclusively or the outcomes were participant satisfaction. Quality was assessed by two reviewers using an education intervention critical appraisal worksheet and a risk of bias assessment tool. Data were extracted independently by two reviewers and analysed narratively due to heterogeneity. Twelve studies met the inclusion criteria for full review: 11 pre- and post-intervention observational and 1 quasi-experimental design. Studies reported statistically significant reductions in hospital length of stay, length of intubation, ventilator-associated pneumonia rates, failed weaning trials and improvements in lung-protective ventilation compliance. Non-statistically significant results were reported for in-hospital and intensive care unit mortality, re-intubation and intensive care unit length of stay. Limited evidence of the effectiveness of

Toll-like receptor 4 knockout ameliorates neuroinflammation due to lung-brain interaction in mechanically ventilated mice.

PubMed

Chen, Ting; Chen, Chang; Zhang, Zongze; Zou, Yufeng; Peng, Mian; Wang, Yanlin

2016-08-01

Toll-like receptor 4 (TLR4) is a crucial receptor in the innate immune system, and increasing evidence supports its role in inflammation, stress, and tissue injury, including injury to the lung and brain. We aimed to investigate the effects of TLR4 on neuroinflammation due to the lung-brain interaction in mechanically ventilated mice. Male wild-type (WT) C57BL/6 and TLR4 knockout (TLR4 KO) mice were divided into three groups: (1) control group (C): spontaneous breathing; (2) anesthesia group (A): spontaneous breathing under anesthesia; and (3) mechanical ventilation group (MV): 6h of MV under anesthesia. The behavioral responses of mice were tested with fear conditioning tests. The histological changes in the lung and brain were assessed using hematoxylin-eosin (HE) staining. The level of TLR4 mRNA in tissue was measured using reverse transcription-polymerase chain reaction (RT-PCR). The levels of inflammatory cytokines were measured with an enzyme-linked immunosorbent assay (ELISA). Microgliosis, astrocytosis, and the TLR4 immunoreactivity in the hippocampus were measured by double immunofluorescence. MV mice exhibited impaired cognition, and this impairment was less severe in TLR4 KO mice than in WT mice. In WT mice, MV increased TLR4 mRNA expression in the lung and brain. MV induced mild lung injury, which was prevented in TLR4 KO mice. MV mice exhibited increased levels of inflammatory cytokines, increased microglia and astrocyte activation. Microgliosis was alleviated in TLR4 KO mice. MV mice exhibited increased TLR4 immunoreactivity, which was expressed in microglia and astrocytes. These results demonstrate that TLR4 is involved in neuroinflammation due to the lung-brain interaction and that TLR4 KO ameliorates neuroinflammation due to lung-brain interaction after prolonged MV. In addition, Administration of a TLR4 antagonist (100μg/mice) to WT mice also significantly attenuated neuroinflammation of lung-brain interaction due to prolonged MV. TLR4 antagonism

Recurrent Recruitment Manoeuvres Improve Lung Mechanics and Minimize Lung Injury during Mechanical Ventilation of Healthy Mice

PubMed Central

Reiss, Lucy Kathleen; Kowallik, Anke; Uhlig, Stefan

2011-01-01

Introduction Mechanical ventilation (MV) of mice is increasingly required in experimental studies, but the conditions that allow stable ventilation of mice over several hours have not yet been fully defined. In addition, most previous studies documented vital parameters and lung mechanics only incompletely. The aim of the present study was to establish experimental conditions that keep these parameters within their physiological range over a period of 6 h. For this purpose, we also examined the effects of frequent short recruitment manoeuvres (RM) in healthy mice. Methods Mice were ventilated at low tidal volume VT = 8 mL/kg or high tidal volume VT = 16 mL/kg and a positive end-expiratory pressure (PEEP) of 2 or 6 cmH2O. RM were performed every 5 min, 60 min or not at all. Lung mechanics were followed by the forced oscillation technique. Blood pressure (BP), electrocardiogram (ECG), heart frequency (HF), oxygen saturation and body temperature were monitored. Blood gases, neutrophil-recruitment, microvascular permeability and pro-inflammatory cytokines in bronchoalveolar lavage (BAL) and blood serum as well as histopathology of the lung were examined. Results MV with repetitive RM every 5 min resulted in stable respiratory mechanics. Ventilation without RM worsened lung mechanics due to alveolar collapse, leading to impaired gas exchange. HF and BP were affected by anaesthesia, but not by ventilation. Microvascular permeability was highest in atelectatic lungs, whereas neutrophil-recruitment and structural changes were strongest in lungs ventilated with high tidal volume. The cytokines IL-6 and KC, but neither TNF nor IP-10, were elevated in the BAL and serum of all ventilated mice and were reduced by recurrent RM. Lung mechanics, oxygenation and pulmonary inflammation were improved by increased PEEP. Conclusions Recurrent RM maintain lung mechanics in their physiological range during low tidal volume ventilation of healthy mice by preventing atelectasis and

The Effect of Listening to Holy Quran Recitation on Weaning Patients Receiving Mechanical Ventilation in the Intensive Care Unit: A Pilot Study.

PubMed

Yadak, Mohammad; Ansari, Khalid Aziz; Qutub, Hatem; Al-Otaibi, Hajed; Al-Omar, Omar; Al-Onizi, Nawal; Farooqi, Faraz Ahmed

2017-09-30

Mechanical ventilation (MV) causes high level of stress in hospitalized patients. Weaning is the gradual process of decreasing ventilator support that in turn lead to termination of MV and increased respiratory effort, which may exacerbate symptoms and prolong MV. This study aimed to investigate the effect of listening to Holy Quran recitation (HQR) as a non-pharmacological intervention in patients during weaning from mechanical ventilation. This is a randomized controlled trial in which 55 patients admitted in the intensive care unit (ICU) and on mechanical ventilation were recruited. Patients were divided into experimental (case) and control group. In the experimental group, patients received 30 min of HQR, whereas in the control group, patients had 30 min of rest in bed before the start of the weaning. The physiological and/or clinical parameters of weaning were recorded. These parameters include rapid shallow breathing index, respiratory rate, heart rate, oxygen saturation, exhaled carbon dioxide, and blood pressure. The baseline demographic data for groups were presented in tables. The mean age was 54 ± 0.5 years for the experimental and 56.4 ± 18.5 years for the control groups. The physiological and clinical parameters were compared between case and control and found no significant difference. The preliminary findings of this pilot study suggest that there is no negative effect of HQR on weaning patients from mechanical ventilation in the ICU. The results also outline and explorthe possible utility of HQR further in ICU patients as an intervention in weaning patients off from ventilator in the ICU. Although there remains much to be done, our work generates important findings in the field of critical care management.

Effect of Dexmedetomidine on Mortality and Ventilator-Free Days in Patients Requiring Mechanical Ventilation With Sepsis

PubMed Central

Kawazoe, Yu; Miyamoto, Kyohei; Morimoto, Takeshi; Yamamoto, Tomonori; Fuke, Akihiro; Hashimoto, Atsunori; Koami, Hiroyuki; Beppu, Satoru; Katayama, Yoichi; Itoh, Makoto; Ohta, Yoshinori

2017-01-01

Importance Dexmedetomidine provides sedation for patients undergoing ventilation; however, its effects on mortality and ventilator-free days have not been well studied among patients with sepsis. Objectives To examine whether a sedation strategy with dexmedetomidine can improve clinical outcomes in patients with sepsis undergoing ventilation. Design, Setting, and Participants Open-label, multicenter randomized clinical trial conducted at 8 intensive care units in Japan from February 2013 until January 2016 among 201 consecutive adult patients with sepsis requiring mechanical ventilation for at least 24 hours. Interventions Patients were randomized to receive either sedation with dexmedetomidine (n = 100) or sedation without dexmedetomidine (control group; n = 101). Other agents used in both groups were fentanyl, propofol, and midazolam. Main Outcomes and Measures The co–primary outcomes were mortality and ventilator-free days (over a 28-day duration). Sequential Organ Failure Assessment score (days 1, 2, 4, 6, 8), sedation control, occurrence of delirium and coma, intensive care unit stay duration, renal function, inflammation, and nutrition state were assessed as secondary outcomes. Results Of the 203 screened patients, 201 were randomized. The mean age was 69 years (SD, 14 years); 63% were male. Mortality at 28 days was not significantly different in the dexmedetomidine group vs the control group (19 patients [22.8%] vs 28 patients [30.8%]; hazard ratio, 0.69; 95% CI, 0.38-1.22; P = .20). Ventilator-free days over 28 days were not significantly different between groups (dexmedetomidine group: median, 20 [interquartile range, 5-24] days; control group: median, 18 [interquartile range, 0.5-23] days; P = .20). The dexmedetomidine group had a significantly higher rate of well-controlled sedation during mechanical ventilation (range, 17%-58% vs 20%-39%; P = .01); other outcomes were not significantly different between groups. Adverse events

Invasive Mechanical Ventilation and Mortality in Pediatric Hematopoietic Stem Cell Transplantation: A Multicenter Study.

PubMed

Rowan, Courtney M; Gertz, Shira J; McArthur, Jennifer; Fitzgerald, Julie C; Nitu, Mara E; Loomis, Ashley; Hsing, Deyin D; Duncan, Christine N; Mahadeo, Kris M; Smith, Lincoln S; Moffet, Jerelyn; Hall, Mark W; Pinos, Emily L; Cheifetz, Ira M; Tamburro, Robert F

2016-04-01

To establish the current respiratory practice patterns in pediatric hematopoietic stem cell transplant patients and investigate their associations with mortality across multiple centers. Retrospective cohort between 2009 and 2014. Twelve children's hospitals in the United States. Two hundred twenty-two pediatric allogeneic hematopoietic stem cell transplant recipients with acute respiratory failure using invasive mechanical ventilation. None. PICU mortality of our cohort was 60.4%. Mortality at 180 days post PICU discharge was 74%. Length of PICU stay prior to initiation of invasive mechanical ventilation was significantly lower in survivors, and the odds of mortality increased for longer length of PICU stay prior to intubation. A total of 91 patients (41%) received noninvasive ventilation at some point during their PICU stay prior to intubation. Noninvasive ventilation use preintubation was associated with increased mortality (odds ratio, 2.1; 95% CI, 1.2-3.6; p = 0.010). Patients ventilated longer than 15 days had higher odds of death (odds ratio, 2.4; 95% CI, 1.3-4.2; p = 0.004). Almost 40% of patients (n = 85) were placed on high-frequency oscillatory ventilation with a mortality of 76.5% (odds ratio, 3.3; 95% CI, 1.7-6.5; p = 0.0004). Of the 20 patients who survived high-frequency oscillatory ventilation, 18 were placed on high-frequency oscillatory ventilation no later than the third day of invasive mechanical ventilation. In this subset of 85 patients, transition to high-frequency oscillatory ventilation within 2 days of the start of invasive mechanical ventilation resulted in a 76% decrease in the odds of death compared with those who transitioned to high-frequency oscillatory ventilation later in the invasive mechanical ventilation course. This study suggests that perhaps earlier more aggressive critical care interventions in the pediatric hematopoietic stem cell transplant patient with respiratory failure requiring invasive mechanical ventilation may

A Contemporary Assessment of Acute Mechanical Ventilation in Beijing: Description, Costs, and Outcomes.

PubMed

Ye, Yanping; Zhu, Bo; Jiang, Li; Jiang, Qi; Wang, Meiping; Hua, Lin; Xi, Xiuming

2017-07-01

To evaluate the contemporary practice, outcomes, and costs related to mechanical ventilation among ICUs in China. A prospective observational cohort study. Fourteen ICUs among 13 hospitals in Beijing, China. Seven hundred ninety-three patients who received at least 24 hours of mechanical ventilation within the first 48 hours of ICU stay. None. The mean age was 64 years. Sixty-three percent were male. New acute respiratory failure accounted for 85.5% of mechanical ventilation cases. Only 4.7% of the patients received mechanical ventilation for acute exacerbation of chronic obstructive pulmonary disease. The most widely used ventilation mode was the combination of synchronized intermittent mandatory ventilation and pressure support (43.6%). Use of lung-protective ventilation is widespread with tidal volumes of 7.1 mL/kg (2.1 mL/kg). The ICU/hospital mortality was 27.6%/29.3%, respectively (8.5%/9.7% for surgical patients and 41.3%/43.2% for medical patients, respectively). The mean level of ICU/hospital cost per patient was $15,271 (18,940)/$22,946 (25,575), respectively. The mean daily ICU cost per patient was $1,212. For the first time, we obtained a preliminary epidemiology data of mechanical ventilation in Beijing, China, through the study. Compared with the other nations, our patients are older, predominantly male, and treated according to prevailing international guidelines yet at a relatively high cost and high mortality. The expanding elderly population predicts increase demand for mechanical ventilation that must be met by continuous improvement in quality and efficiency of critical care services.

[Non-invasive mechanical ventilation in the pre- and intraoperative period and difficult airway].

PubMed

Esquinas, A M; Jover, J L; Úbeda, A; Belda, F J

2015-11-01

Non-invasive mechanical ventilation is a method of ventilatory assistance aimed at increasing alveolar ventilation, thus achieving, in selected subjects, the avoidance of endotracheal intubation and invasive mechanical ventilation, with the consequent improvement in survival. There has been a systematic review and study of the technical, clinical experiences, and recommendations concerning the application of non-invasive mechanical ventilation in the pre- and intraoperative period. The use of prophylactic non-invasive mechanical ventilation before surgery that involves significant alterations in the ventilatory function may decrease the incidence of postoperative respiratory complications. Its intraoperative use will mainly depend on the type of surgery, type of anaesthetic technique, and the clinical status of the patient. Its use allows greater anaesthetic depth without deterioration of oxygenation and ventilation of patients. Copyright © 2015 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

A dual closed-loop control system for mechanical ventilation.

PubMed

Tehrani, Fleur; Rogers, Mark; Lo, Takkin; Malinowski, Thomas; Afuwape, Samuel; Lum, Michael; Grundl, Brett; Terry, Michael

2004-04-01

Closed-loop mechanical ventilation has the potential to provide more effective ventilatory support to patients with less complexity than conventional ventilation. The purpose of this study was to investigate the effectiveness of an automatic technique for mechanical ventilation. Two closed-loop control systems for mechanical ventilation are combined in this study. In one of the control systems several physiological data are used to automatically adjust the frequency and tidal volume of breaths of a patient. This method, which is patented under US Patent number 4986268, uses the criterion of minimal respiratory work rate to provide the patient with a natural pattern of breathing. The inputs to the system include data representing CO2 and O2 levels of the patient as well as respiratory compliance and airway resistance. The I:E ratio is adjusted on the basis of the respiratory time constant to allow for effective emptying of the lungs in expiration and to avoid intrinsic positive end expiratory pressure (PEEP). This system is combined with another closed-loop control system for automatic adjustment of the inspired fraction of oxygen of the patient. This controller uses the feedback of arterial oxygen saturation of the patient and combines a rapid stepwise control procedure with a proportional-integral-derivative (PID) control algorithm to automatically adjust the oxygen concentration in the patient's inspired gas. The dual closed-loop control system has been examined by using mechanical lung studies, computer simulations and animal experiments. In the mechanical lung studies, the ventilation controller adjusted the breathing frequency and tidal volume in a clinically appropriate manner in response to changes in respiratory mechanics. The results of computer simulations and animal studies under induced disturbances showed that blood gases were returned to the normal physiologic range in less than 25 s by the control system. In the animal experiments understeady

Methicillin-resistant Staphylococcus aureus prolongs intensive care unit stay in ventilator-associated pneumonia, despite initially appropriate antibiotic therapy.

PubMed

Shorr, Andrew F; Combes, Alain; Kollef, Marin H; Chastre, Jean

2006-03-01

To determine the impact of methicillin-resistant Staphylococcus aureus (MRSA) on length of stay in the intensive care unit (ICU) for patients with ventilator-associated pneumonia (VAP) and to control for the effect of initially inappropriate antibiotic treatment on outcomes by focusing only on persons who were given appropriate antibiotic therapy for their infection. Retrospective analysis of pooled, patient-level data from multiple clinical trials in VAP. Multiple ICUs in France. Persons with bronchoscopically confirmed VAP due to either MRSA or methicillin-susceptible S. aureus (MSSA) and who received initially appropriate antibiotic treatment. All persons with MRSA VAP received vancomycin (15 mg/kg intravenously, twice daily). None. We compared patients with MRSA VAP to persons with MSSA VAP. ICU length of stay represented the primary end point and ICU-free days served as a secondary end point. We recorded information regarding multiple confounders, including demographics, reasons for ICU admission and mechanical ventilation (MV), severity of illness at both ICU admission and time of diagnosis of VAP, and duration of mechanical ventilation before and following the onset of VAP. The final cohort included 107 patients, and one third of cases were due to MRSA. Despite receiving initially appropriate antibiotic treatment, median ICU length of stay was significantly longer for persons with MRSA infection (33 days vs. 22 days; p=.047). The median number of ICU-free days was concomitantly lower in MRSA VAP (0 days vs. 5 days; p=.011). Survival analysis employing a Cox proportional hazards model identified several predictors of remaining in the ICU: Pao2/Fio2 ratio at diagnosis of VAP, duration of MV before VAP, duration of MV after diagnosis of VAP, and reason for MV. Additionally, infection with MRSA as opposed MSSA doubled the probability of needing continued ICU care (hazard ratio, 2.08; 95% confidence interval, 1.09-3.95; p=.025). MRSA VAP independently prolongs

A model of neonatal tidal liquid ventilation mechanics.

PubMed

Costantino, M L; Fiore, G B

2001-09-01

Tidal liquid ventilation (TLV) with perfluorocarbons (PFC) has been proposed to treat surfactant-deficient lungs of preterm neonates, since it may prevent pulmonary instability by abating saccular surface tension. With a previous model describing gas exchange, we showed that ventilator settings are crucial for CO(2) scavenging during neonatal TLV. The present work is focused on some mechanical aspects of neonatal TLV that were hardly studied, i.e. the distribution of mechanical loads in the lungs, which is expected to differ substantially from gas ventilation. A new computational model is presented, describing pulmonary PFC hydrodynamics, where viscous losses, kinetic energy changes and lung compliance are accounted for. The model was implemented in a software package (LVMech) aimed at calculating pressures (and approximately estimate shear stresses) within the bronchial tree at different ventilator regimes. Simulations were run taking the previous model's outcomes into account. Results show that the pressure decrease due to high saccular compliance may compensate for the increased pressure drops due to PFC viscosity, and keep airway pressure low. Saccules are exposed to pressures remarkably different from those at the airway opening; during expiration negative pressures, which may cause airway collapse, are moderate and appear in the upper airways only. Delivering the fluid with a slightly smoothed square flow wave is convenient with respect to a sine wave. The use of LVMech allows to familiarize with LV treatment management taking the lungs' mechanical load into account, consistently with a proper respiratory support.

Non-invasive mechanical ventilation with spinal anesthesia for cesarean delivery.

PubMed

Erdogan, G; Okyay, D Z; Yurtlu, S; Hanci, V; Ayoglu, H; Koksal, B; Turan, I O

2010-10-01

We present the successful use of perioperative non-invasive mechanical ventilation in a morbidly obese pregnant woman with bronchial asthma, severe preeclampsia and pulmonary edema undergoing an emergency cesarean delivery with spinal anesthesia. The combination of non-invasive mechanical ventilation with neuraxial anesthesia may be of value in selected parturients with acute or chronic respiratory insufficiency requiring surgery. Copyright © 2010 Elsevier Ltd. All rights reserved.

Inadequate humidification of respiratory gases during mechanical ventilation of the newborn.

PubMed Central

Tarnow-Mordi, W O; Sutton, P; Wilkinson, A R

1986-01-01

Proximal airway humidity was measured during mechanical ventilation in 14 infants using an electronic hygrometer. Values below recommended minimum humidity of adult inspired gas were recorded on 251 of 396 occasions. Inadequate humidification, largely due to inadequate proximal airway temperature, is commoner than recognised in infants receiving mechanical ventilation. PMID:3740912

Measurement of changes in respiratory mechanics during partial liquid ventilation using jet pulses.

PubMed

Schmalisch, Gerd; Schmidt, Mario; Proquitté, Hans; Foitzik, Bertram; Rüdiger, Mario; Wauer, Roland R

2003-05-01

To compare the changes in respiratory mechanics within the breathing cycle in healthy lungs between gas ventilation and partial liquid ventilation using a special forced-oscillation technique. Prospective animal trial. Animal laboratory in a university setting. A total of 12 newborn piglets (age, <12 hrs; mean weight, 725 g). After intubation and instrumentation, lung mechanics of the anesthetized piglets were measured by forced-oscillation technique at the end of inspiration and the end of expiration. The measurements were performed during gas ventilation and 80 mins after instillation of 30 mL/kg perfluorocarbon PF 5080. Brief flow pulses (width, 10 msec; peak flow, 16 L/min) were generated by a jet generator to measure the end-inspiratory and the end-expiratory respiratory input impedance in the frequency range of 4-32 Hz. The mechanical variables resistance, inertance, and compliance were determined by model fitting, using the method of least squares. At least in the lower frequency range, respiratory mechanics could be described adequately by an RIC single-compartment model in all piglets. During gas ventilation, the respiratory variables resistance and inertance did not differ significantly between end-inspiratory and end-expiratory measurements (mean [sd]: 4.2 [0.7] vs. 4.1 [0.6] kPa x L(-1) x sec, 30.0 [3.2] vs. 30.7 [3.1] Pa x L(-1) x sec2, respectively), whereas compliance decreased during inspiration from 14.8 (2.0) to 10.2 (2.4) mL x kPa(-1) x kg(-1) due to a slight lung overdistension. During partial liquid ventilation, the end-inspiratory respiratory mechanics was not different from the end-inspiratory respiratory mechanics measured during gas ventilation. However, in contrast to gas ventilation during partial liquid ventilation, compliance rose from 8.2 (1.0) to 13.0 (3.0) mL x kPa(-1) x kg(-1) during inspiration. During expiration, when perfluorocarbon came into the upper airways, both resistance and inertance increased considerably (mean with 95

Impact of whole-body rehabilitation in patients receiving chronic mechanical ventilation.

PubMed

Martin, Ubaldo J; Hincapie, Luis; Nimchuk, Mark; Gaughan, John; Criner, Gerard J

2005-10-01

To evaluate the prevalence and magnitude of weakness in patients receiving chronic mechanical ventilation and the impact of providing aggressive whole-body rehabilitation on conventional weaning variables, muscle strength, and overall functional status. Retrospective analysis of 49 consecutive patients. Multidisciplinary ventilatory rehabilitation unit in an academic medical center. Forty-nine consecutive chronic ventilator-dependent patients referred to a tertiary care hospital ventilator rehabilitation unit. None. Patients were 58 +/- 7 yrs old with multiple etiologies for respiratory failure. On admission, all patients were bedridden and had severe weakness of upper and lower extremities measured by a 5-point muscle strength score and a 7-point Functional Independence Measurement. Postrehabilitation, patients had increases in upper and lower extremity strength (p < .05) and were able to stand and ambulate. All weaned from mechanical ventilation, but three required subsequent intermittent support. Six patients died before hospital discharge. Upper extremity strength on admission inversely correlated with time to wean from mechanical ventilation (R = .72, p < .001). : Patients receiving chronic ventilation are weak and deconditioned but respond to aggressive whole-body and respiratory muscle training with an improvement in strength, weaning outcome, and functional status. Whole-body rehabilitation should be considered a significant component of their therapy.

History of mechanical ventilation may affect respiratory mechanics evolution in acute respiratory distress syndrome.

PubMed

Koutsoukou, Antonia; Perraki, Helen; Orfanos, Stylianos E; Koulouris, Nikolaos G; Tromaropoulos, Andreas; Sotiropoulou, Christina; Roussos, Charis

2009-12-01

The aim of this study was to investigate the effect of mechanical ventilation (MV) before acute respiratory distress syndrome (ARDS) on subsequent evolution of respiratory mechanics and blood gases in protectively ventilated patients with ARDS. Nineteen patients with ARDS were stratified into 2 groups according to ARDS onset relative to the onset of MV: In group A (n = 11), MV was applied at the onset of ARDS; in group B (n = 8), MV had been initiated before ARDS. Respiratory mechanics and arterial blood gas were assessed in early (ventilated patients with ARDS, late alteration of respiratory mechanics occurs more commonly in patients who have been ventilated before ARDS onset, suggesting that the history of MV affects the subsequent progress of ARDS even when using protective ventilation.

Respirator triggering of electron-beam computed tomography (EBCT): differences in dynamic changes between augmented ventilation and controlled mechanical ventilation

NASA Astrophysics Data System (ADS)

Recheis, Wolfgang A.; Kleinsasser, Axel; Schuster, Antonius H.; Loeckinger, Alexander; Frede, Thomas; Springer, Peter; Hoermann, Christoph; zur Nedden, Dieter

2000-04-01

The purpose was to evaluate differences in dynamic changes of the lung aeration (air-tissue ratio) between augmented modes of ventilation (AMV) and controlled mechanical ventilation (CMV) in normal subjects. 4 volunteers, ventilated with the different respirator protocols via face mask, were scanned using the EBCT in the 50 ms mode. A software analyzed the respirator's digitized pressure and volume signals of two subsequent ventilation phases. Using these values it was possible to calculate the onset of inspiration or expiration of the next respiratory phase. The calculated starting point was then used to trigger the EBCT. The dynamic changes of air- tissue ratios were evaluated in three separate regions: a ventral, an intermediate and a dorsal area. AMV results in increase of air-tissue ratio in the dorsal lung area due to the active contraction of the diaphragm, whereas CMV results in a more pronounced increase in air-tissue ratio of the ventral lung area. This study gives further insight into the dynamic changes of the lung's biomechanics by comparing augmented ventilation and controlled mechanical ventilation in the healthy proband.

Mechanical breath profile of airway pressure release ventilation: the effect on alveolar recruitment and microstrain in acute lung injury.

PubMed

Kollisch-Singule, Michaela; Emr, Bryanna; Smith, Bradford; Roy, Shreyas; Jain, Sumeet; Satalin, Joshua; Snyder, Kathy; Andrews, Penny; Habashi, Nader; Bates, Jason; Marx, William; Nieman, Gary; Gatto, Louis A

2014-11-01

Improper mechanical ventilation settings can exacerbate acute lung injury by causing a secondary ventilator-induced lung injury. It is therefore important to establish the mechanism by which the ventilator induces lung injury to develop protective ventilation strategies. It has been postulated that the mechanism of ventilator-induced lung injury is the result of heterogeneous, elevated strain on the pulmonary parenchyma. Acute lung injury has been associated with increases in whole-lung macrostrain, which is correlated with increased pathology. However, the effect of mechanical ventilation on alveolar microstrain remains unknown. To examine whether the mechanical breath profile of airway pressure release ventilation (APRV), consisting of a prolonged pressure-time profile and brief expiratory release phase, reduces microstrain. In a randomized, nonblinded laboratory animal study, rats were randomized into a controlled mandatory ventilation group (n = 3) and an APRV group (n = 3). Lung injury was induced by polysorbate lavage. A thoracotomy was performed and an in vivo microscope was placed on the lungs to measure alveolar mechanics. In the controlled mandatory ventilation group, multiple levels of positive end-expiratory pressure (PEEP; 5, 10, 16, 20, and 24 cm H2O) were tested. In the APRV group, decreasing durations of expiratory release (time at low pressure [T(low)]) were tested. The T(low) was set to achieve ratios of termination of peak expiratory flow rate (T-PEFR) to peak expiratory flow rate (PEFR) of 10%, 25%, 50%, and 75% (the smaller this ratio is [ie, 10%], the more time the lung is exposed to low pressure during the release phase, which decreases end-expiratory lung volume and potentiates derecruitment). Alveolar perimeters were measured at peak inspiration and end expiration using digital image analysis, and strain was calculated by normalizing the change in alveolar perimeter length to the original length. Macrostrain was measured by volume

Tracheo-bronchitis and pneumonia associated with mechanical ventilation by Chryseobacterium indologenes.

PubMed

González-Castro, A; Alsasua, A; Peñasco, Y; Rodríguez, J C; Duerto, J

2017-05-01

The development of nosocomial infections by germs resistant to carbapenems inherently increases mortality, and causes an increase in health spending. The knowledge and study of these infections is important in improving epidemiological and therapeutic performance protocols. We present a descriptive study of eight patients diagnosed with tracheobronchitis (TAVM) and pneumonia (NAVM) associated with mechanical ventilation Chryseobacterium indologenes (CBI), over a period of five years. CBI isolation occurred at 11 days on average (rank 7-18) of remaining patients connected to mechanical ventilation. The average length of patients on mechanical ventilation was 36 days (range 10-140). The average ICU stay was 49 days (range 14-180). There was no death at 28 days, but the intra-hospital mortality was 2 cases (25%). Nosocomial respiratory infection secondary to CBI in mechanically ventilated patients has increased in recent years, so that should be included in the differential diagnostic of NAMV. Copyright © 2017 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

Defining a Ventilation Strategy for Flexible Bronchoscopy on Mechanically Ventilated Patients in the Medical Intensive Care Unit.

PubMed

Greenstein, Yonatan Y; Shakespeare, Eric; Doelken, Peter; Mayo, Paul H

2017-07-01

Flexible bronchoscopy (FB) in intubated patients on mechanical ventilation increases airway resistance. During FB, two ventilatory strategies are possible: maintaining tidal volume (VT) while maintaining baseline CO2 or allowing reduction of VT. The former strategy carries risk of hyperinflation due to expiratory flow limitation with FB. The aim of the authors was too study end expiratory lung volume (EELV) during FB of intubated subjects while limiting VT. We studied 16 subjects who were intubated on mechanical ventilation and required FB. Changes in EELV were measured by respiratory inductance plethysmography. Ventilator mechanics, EELV, and arterial blood gases, were measured. FB insertions decreased EELV in 64% of cases (-325±371 mL) and increased it in 32% of cases (65±59 mL). Suctioning decreased EELV in 76% of cases (-120±104 mL) and increased it in 16% of cases (29±33 mL). Respiratory mechanics were unchanged. Pre-FB and post-FB, PaO2 decreased by 61±96 mm Hg and PaCO2 increased by 15±7 mm Hg. There was no clinically significant increase in EELV in any subject during FB. Decreases in EELV coincided with FB-suctioning maneuvers. Peak pressure limiting ventilation protected the subject against hyperinflation with a consequent, well-tolerated reduction in VT, and hypercapnea. Suctioning should be limited, especially in patients vulnerable to derecruitment effect.

Noninvasive Mechanical Ventilation in Acute Ventilatory Failure: Rationale and Current Applications.

PubMed

Esquinas, Antonio M; Benhamou, Maly Oron; Glossop, Alastair J; Mina, Bushra

2017-12-01

Noninvasive ventilation plays a pivotal role in acute ventilator failure and has been shown, in certain disease processes such as acute exacerbation of chronic obstructive pulmonary disease, to prevent and shorten the duration of invasive mechanical ventilation, reducing the risks and complications associated with it. The application of noninvasive ventilation is relatively simple and well tolerated by patients and in the right setting can change the course of their illness. Copyright © 2017 Elsevier Inc. All rights reserved.

Prolonged acute mechanical ventilation and hospital bed utilization in 2020 in the United States: implications for budgets, plant and personnel planning

PubMed Central

Zilberberg, Marya D; Shorr, Andrew F

2008-01-01

Background Adult patients on prolonged acute mechanical ventilation (PAMV) comprise 1/3 of all adult MV patients, consume 2/3 of hospital resources allocated to MV population, and are nearly twice as likely to require a discharge to a skilled nursing facility (SNF). Their numbers are projected to double by year 2020. To aid in planning for this growth, we projected their annualized days and costs of hospital use and SNF discharges in year 2020 in the US. Methods We constructed a model estimating the relevant components of hospital utilization. We computed the total days and costs for each component; we also applied the risk for SNF discharge to the total 2020 PAMV population. The underlying assumption was that process of care does not change over the time horizon. We performed Monte Carlo simulations to establish 95% confidence intervals (CI) for the point estimates. Results Given 2020 projected PAMV volume of 605,898 cases, they will require 3.6 (95% CI 2.7–4.8) million MV, 5.5 (95% CI 4.3–7.0) million ICU and 10.3 (95% CI 8.1–13.0) million hospital days, representing an absolute increase of 2.1 million MV, 3.2 million ICU and 6.5 million hospital days over year 2000, at a total inflation-adjusted cost of over $64 billion. Expected discharges to SNF are 218,123 (95% CI 177,268–266,739), compared to 90,928 in 2000. Conclusion Our model suggest that the projected growth in the US in PAMV population by 2020 will result in annualized increases of more than 2, 3, and 6 million MV, ICU and hospital days, respectively, over year 2000. Such growth requires careful planning efforts and attention to efficiency of healthcare delivery. PMID:19032766

Case-Mix, Care Processes, and Outcomes in Medically-Ill Patients Receiving Mechanical Ventilation in a Low-Resource Setting from Southern India: A Prospective Clinical Case Series.

PubMed

Karthikeyan, Balasubramanian; Kadhiravan, Tamilarasu; Deepanjali, Surendran; Swaminathan, Rathinam Palamalai

2015-01-01

Mechanical ventilation is a resource intensive organ support treatment, and historical studies from low-resource settings had reported a high mortality. We aimed to study the outcomes in patients receiving mechanical ventilation in a contemporary low-resource setting. We prospectively studied the characteristics and outcomes (disease-related, mechanical ventilation-related, and process of care-related) in 237 adults mechanically ventilated for a medical illness at a teaching hospital in southern India during February 2011 to August 2012. Vital status of patients discharged from hospital was ascertained on Day 90 or later. Mean age of the patients was 40 ± 17 years; 140 (51%) were men. Poisoning and envenomation accounted for 98 (41%) of 237 admissions. In total, 87 (37%) patients died in-hospital; 16 (7%) died after discharge; 115 (49%) were alive at 90-day assessment; and 19 (8%) were lost to follow-up. Weaning was attempted in 171 (72%) patients; most patients (78 of 99 [79%]) failing the first attempt could be weaned off. Prolonged mechanical ventilation was required in 20 (8%) patients. Adherence to head-end elevation and deep vein thrombosis prophylaxis were 164 (69%) and 147 (62%) respectively. Risk of nosocomial infections particularly ventilator-associated pneumonia was high (57.2 per 1,000 ventilator-days). Higher APACHE II score quartiles (adjusted HR [95% CI] quartile 2, 2.65 [1.19-5.89]; quartile 3, 2.98 [1.24-7.15]; quartile 4, 5.78 [2.45-13.60]), and new-onset organ failure (2.98 [1.94-4.56]) were independently associated with the risk of death. Patients with poisoning had higher risk of reintubation (43% vs. 20%; P = 0.001) and ventilator-associated pneumonia (75% vs. 53%; P = 0.001). But, their mortality was significantly lower compared to the rest (24% vs. 44%; P = 0.002). The case-mix considerably differs from other settings. Mortality in this low-resource setting is similar to high-resource settings. But, further improvements in care processes

Persistent elastase/proteinase inhibitor imbalance during prolonged ventilation of infants with bronchopulmonary dysplasia: evidence for the role of nosocomial infections.

PubMed

Walti, H; Tordet, C; Gerbaut, L; Saugier, P; Moriette, G; Relier, J P

1989-10-01

Acute imbalance between elastase and alpha-1-proteinase inhibitor (alpha 1Pi) may contribute to the development of bronchopulmonary dysplasia (BPD). The question of whether such an imbalance persists in BPD infants still requiring mechanical ventilation after 4 wk of life has not been previously addressed. We studied 14 infants still on mechanical ventilation at 4 wk of age: nine had BPD and five did not. Weekly (4 to 9 wk) serum and bronchoalveolar lavage (BAL) specimens were taken. alpha 1Pi and alpha-2-macroglobulin were measured in serum and BAL by immunoturbidimetric assay. BAL elastase activity was measured by cleavage of a synthetic substrate and expressed as ng of porcine pancreatic elastase equivalent. Infants with BPD had higher levels of serum alpha 1Pi and alpha-2-macroglobulin than those without BPD. In contrast, the corresponding BAL levels were either similar or even decreased (alpha 1Pi). Moreover, there was a 3-fold increase in elastase-1Pi imbalance expressed as the BAL ng of porcine pancreatic elastase equivalent/2 alpha 1Pi ratio. The role of nosocomial infections was evident in a subgroup of 11 infected BAL aspirates in BPD infants. In such cases we found a 3-fold increase in the BAL ng of porcine pancreatic elastase equivalent/alpha 1Pi ratio as compared to 35 noninfected BAL in BPD infants. These data suggest a persistent alveolitis with imbalance between elastase and proteinase inhibitors in prolonged severe BPD. Such an imbalance is, in part, explained by a local destruction and/or inactivation of alpha 1Pi. Our results also emphasize the increase in proteolysis with nosocomial pneumonia.

Amyotrophic Lateral Sclerosis Patients' Perspectives on Use of Mechanical Ventilation.

ERIC Educational Resources Information Center

Young, Jenny M.; And Others

1994-01-01

Interviewed 13 amyotrophic lateral sclerosis patients. All believed that they alone should make decision regarding use of mechanical ventilation. Factors they considered important were quality of life, severity of disability, availability of ventilation by means of nasal mask, possible admission to long-term care facility, ability to discontinue…

Ultrasonographic Evaluation of Diaphragm Thickness During Mechanical Ventilation in Intensive Care Patients.

PubMed

Francis, Colin Anthony; Hoffer, Joaquín Andrés; Reynolds, Steven

2016-01-01

Mechanical ventilation is associated with atrophy and weakness of the diaphragm. Ultrasound is an easy noninvasive way to track changes in thickness of the diaphragm. To validate ultrasound as a means of tracking thickness of the diaphragm in patients undergoing mechanical ventilation by evaluating interobserver and interoperator reliability and to collect initial data on the relationship of mode of ventilation to changes in the diaphragm. Daily ultrasound images of the quadriceps and the right side of the diaphragm were acquired in 8 critically ill patients receiving various modes of mechanical ventilation. Thickness of the diaphragm and the quadriceps was measured, and changes with time were noted. Interoperator and interobserver reliability were measured. Intraclass correlation coefficients between operators and between observers for thickness of the diaphragm and quadriceps were greater than 0.95, indicating excellent interoperator and interobserver reliability. Patients receiving assist-control ventilation (n = 4) showed a mean decline in diaphragm thickness of 4.7% per day. Patients receiving pressure support ventilation (n = 8) showed a mean increase in diaphragm thickness of 1.5% per day. Quadriceps thickness declined in all participants (n = 8) at a mean rate of 2.0% per day. Use of ultrasound to measure thickness of the diaphragm in 8 intensive care patients undergoing various modes of mechanical ventilation was feasible and yielded reproducible results. Ultrasound tracking of changes in thickness of the diaphragm in this small sample indicated that the thickness decreased during assist-control mode and increased during pressure support mode. ©2016 American Association of Critical-Care Nurses.

Replicating human expertise of mechanical ventilation waveform analysis in detecting patient-ventilator cycling asynchrony using machine learning.

PubMed

Gholami, Behnood; Phan, Timothy S; Haddad, Wassim M; Cason, Andrew; Mullis, Jerry; Price, Levi; Bailey, James M

2018-06-01

- Acute respiratory failure is one of the most common problems encountered in intensive care units (ICU) and mechanical ventilation is the mainstay of supportive therapy for such patients. A mismatch between ventilator delivery and patient demand is referred to as patient-ventilator asynchrony (PVA). An important hurdle in addressing PVA is the lack of a reliable framework for continuously and automatically monitoring the patient and detecting various types of PVA. - The problem of replicating human expertise of waveform analysis for detecting cycling asynchrony (i.e., delayed termination, premature termination, or none) was investigated in a pilot study involving 11 patients in the ICU under invasive mechanical ventilation. A machine learning framework is used to detect cycling asynchrony based on waveform analysis. - A panel of five experts with experience in PVA evaluated a total of 1377 breath cycles from 11 mechanically ventilated critical care patients. The majority vote was used to label each breath cycle according to cycling asynchrony type. The proposed framework accurately detected the presence or absence of cycling asynchrony with sensitivity (specificity) of 89% (99%), 94% (98%), and 97% (93%) for delayed termination, premature termination, and no cycling asynchrony, respectively. The system showed strong agreement with human experts as reflected by the kappa coefficients of 0.90, 0.91, and 0.90 for delayed termination, premature termination, and no cycling asynchrony, respectively. - The pilot study establishes the feasibility of using a machine learning framework to provide waveform analysis equivalent to an expert human. Copyright © 2018 Elsevier Ltd. All rights reserved.

[Determination of resting energy expenditure in critically ill children experiencing mechanical ventilation].

PubMed

Dong, Hong-ba; Yang, Yan-wen; Wang, Ying; Hong, Li

2012-11-01

Energy metabolism of critically ill children has its own characteristics, especially for those undergoing mechanical ventilation. We tried to assess the energy expenditure status and evaluate the use of predictive equations in such children. Moreover, the characteristics of the energy metabolism among various situation were explored. Fifty critically ill children undergoing mechanical ventilation were selected in this study. Data produced during the 24 hours of mechanical ventilation were collected for computation of severity of illness. Resting energy expenditure (REE) was determined at 24 hours after mechanical ventilation (MREE). Predictive resting energy expenditure (PREE) was calculated for each subject using age-appropriate equations (Schofield-HTWT, White). The study was approved by the hospital medical ethics committee and obtained parental written informed consent. The pediatric risk of mortality score 3 (PRISM3) and pediatric critical illness score (PCIS) were (7 ± 3) and (82 ± 4), respectively. MREE, Schofield-HTWT equation PREE and White equation PREE were (404.80 ± 178.28), (462.82 ± 160.38) and (427.97 ± 152.30) kcal/d, respectively; 70% were hypometabolic and 10% were hypermetabolic. MREE and PREE which were calculated using Schofield-HTWT equation and White equation, both were higher than MREE (P = 0.029). Correlation analysis was performed between PRISM3 and PCIS with MREE. There were no statistically significant correlation (P > 0.05). The hypometabolic response is apparent in critically ill children with mechanical ventilation; Schofield-HTWT equation and White equation could not predict energy requirements within acceptable clinical accuracy. In critically ill children undergoing mechanical ventilation, the energy expenditure is not correlated with the severity of illness.

Automatic control of arterial carbon dioxide tension in mechanically ventilated patients.

PubMed

Fernando, Tyrone; Cade, John; Packer, John

2002-12-01

This paper presents a method of controlling the arterial carbon dioxide tension of patients receiving mechanical ventilation. Controlling of the CO2 tension is achieved by regulating the ventilator initiated breath frequency and also volume per breath.

Particle size concentration distribution and influences on exhaled breath particles in mechanically ventilated patients.

PubMed

Wan, Gwo-Hwa; Wu, Chieh-Liang; Chen, Yi-Fang; Huang, Sheng-Hsiu; Wang, Yu-Ling; Chen, Chun-Wan

2014-01-01

Humans produce exhaled breath particles (EBPs) during various breath activities, such as normal breathing, coughing, talking, and sneezing. Airborne transmission risk exists when EBPs have attached pathogens. Until recently, few investigations had evaluated the size and concentration distributions of EBPs from mechanically ventilated patients with different ventilation mode settings. This study thus broke new ground by not only evaluating the size concentration distributions of EBPs in mechanically ventilated patients, but also investigating the relationship between EBP level and positive expiratory end airway pressure (PEEP), tidal volume, and pneumonia. This investigation recruited mechanically ventilated patients, with and without pneumonia, aged 20 years old and above, from the respiratory intensive care unit of a medical center. Concentration distributions of EBPs from mechanically ventilated patients were analyzed with an optical particle analyzer. This study finds that EBP concentrations from mechanically ventilated patients during normal breathing were in the range 0.47-2,554.04 particles/breath (0.001-4.644 particles/mL). EBP concentrations did not differ significantly between the volume control and pressure control modes of the ventilation settings in the mechanically ventilated patients. The patient EBPs were sized below 5 µm, and 80% of them ranged from 0.3 to 1.0 µm. The EBPs concentrations in patients with high PEEP (> 5 cmH₂O) clearly exceeded those in patients with low PEEP (≤ 5 cmH₂O). Additionally, a significant negative association existed between pneumonia duration and EBPs concentration. However, tidal volume was not related to EBPs concentration.

Autophagy in pulmonary macrophages mediates lung inflammatory injury via NLRP3 inflammasome activation during mechanical ventilation

PubMed Central

Zhang, Yang; Liu, Gongjian; Dull, Randal O.; Schwartz, David E.

2014-01-01

The inflammatory response is a primary mechanism in the pathogenesis of ventilator-induced lung injury. Autophagy is an essential, homeostatic process by which cells break down their own components. We explored the role of autophagy in the mechanisms of mechanical ventilation-induced lung inflammatory injury. Mice were subjected to low (7 ml/kg) or high (28 ml/kg) tidal volume ventilation for 2 h. Bone marrow-derived macrophages transfected with a scrambled or autophagy-related protein 5 small interfering RNA were administered to alveolar macrophage-depleted mice via a jugular venous cannula 30 min before the start of the ventilation protocol. In some experiments, mice were ventilated in the absence and presence of autophagy inhibitors 3-methyladenine (15 mg/kg ip) or trichostatin A (1 mg/kg ip). Mechanical ventilation with a high tidal volume caused rapid (within minutes) activation of autophagy in the lung. Conventional transmission electron microscopic examination of lung sections showed that mechanical ventilation-induced autophagy activation mainly occurred in lung macrophages. Autophagy activation in the lungs during mechanical ventilation was dramatically attenuated in alveolar macrophage-depleted mice. Selective silencing of autophagy-related protein 5 in lung macrophages abolished mechanical ventilation-induced nucleotide-binding oligomerization domain-like receptor containing pyrin domain 3 (NLRP3) inflammasome activation and lung inflammatory injury. Pharmacological inhibition of autophagy also significantly attenuated the inflammatory responses caused by lung hyperinflation. The activation of autophagy in macrophages mediates early lung inflammation during mechanical ventilation via NLRP3 inflammasome signaling. Inhibition of autophagy activation in lung macrophages may therefore provide a novel and promising strategy for the prevention and treatment of ventilator-induced lung injury. PMID:24838752

NanoClusters Enhance Drug Delivery in Mechanical Ventilation

NASA Astrophysics Data System (ADS)

Pornputtapitak, Warangkana

The overall goal of this thesis was to develop a dry powder delivery system for patients on mechanical ventilation. The studies were divided into two parts: the formulation development and the device design. The pulmonary system is an attractive route for drug delivery since the lungs have a large accessible surface area for treatment or drug absorption. For ventilated patients, inhaled drugs have to successfully navigate ventilator tubing and an endotracheal tube. Agglomerates of drug nanoparticles (also known as 'NanoClusters') are fine dry powder aerosols that were hypothesized to enable drug delivery through ventilator circuits. This Thesis systematically investigated formulations of NanoClusters and their aerosol performance in a conventional inhaler and a device designed for use during mechanical ventilation. These engineered powders of budesonide (NC-Bud) were delivered via a MonodoseRTM inhaler or a novel device through commercial endotracheal tubes, and analyzed by cascade impaction. NC-Bud had a higher efficiency of aerosol delivery compared to micronized stock budesonide. The delivery efficiency was independent of ventilator parameters such as inspiration patterns, inspiration volumes, and inspiration flow rates. A novel device designed to fit directly to the ventilator and endotracheal tubing connections and the MonodoseRTM inhaler showed the same efficiency of drug delivery. The new device combined with NanoCluster formulation technology, therefore, allowed convenient and efficient drug delivery through endotracheal tubes. Furthermore, itraconazole (ITZ), a triazole antifungal agent, was formulated as a NanoCluster powder via milling (top-down process) or precipitation (bottom-up process) without using any excipients. ITZ NanoClusters prepared by wet milling showed better aerosol performance compared to micronized stock ITZ and ITZ NanoClusters prepared by precipitation. ITZ NanoClusters prepared by precipitation methods also showed an amorphous state

Mechanical Ventilation in Acute Hypoxemic Respiratory Failure: A Review of New Strategies for the Practicing Hospitalist

PubMed Central

Wilson, Jennifer G.; Matthay, Michael A.

2014-01-01

BACKGROUND The goal of mechanical ventilation in acute hypoxemic respiratory failure is to support adequate gas exchange without harming the lungs. How patients are mechanically ventilated can significantly impact their ultimate outcomes. METHODS This review focuses on emerging evidence regarding strategies for mechanical ventilation in patients with acute hypoxemic respiratory failure including: low tidal volume ventilation in the acute respiratory distress syndrome (ARDS), novel ventilator modes as alternatives to low tidal volume ventilation, adjunctive strategies that may enhance recovery in ARDS, the use of lung-protective strategies in patients without ARDS, rescue therapies in refractory hypoxemia, and an evidence-based approach to weaning from mechanical ventilation. RESULTS Once a patient is intubated and mechanically ventilated, low tidal volume ventilation remains the best strategy in ARDS. Adjunctive therapies in ARDS include a conservative fluid management strategy, as well as neuromuscular blockade and prone positioning in moderate-to-severe disease. There is also emerging evidence that a lung-protective strategy may benefit non-ARDS patients. For patients with refractory hypoxemia, extracorporeal membrane oxygenation should be considered. Once the patient demonstrates signs of recovery, the best approach to liberation from mechanical ventilation involves daily spontaneous breathing trials and protocolized assessment of readiness for extubation. CONCLUSIONS Prompt recognition of ARDS and use of lung-protective ventilation, as well as evidence-based adjunctive therapies, remain the cornerstones of caring for patients with acute hypoxemic respiratory failure. In the absence of contraindications, it is reasonable to consider lung-protective ventilation in non-ARDS patients as well, though the evidence supporting this practice is less conclusive. PMID:24733692

[Lung-brain interaction in the mechanically ventilated patient].

PubMed

López-Aguilar, J; Fernández-Gonzalo, M S; Turon, M; Quílez, M E; Gómez-Simón, V; Jódar, M M; Blanch, L

2013-10-01

Patients with acute lung injury or acute respiratory distress syndrome (ARDS) admitted to the ICU present neuropsychological alterations, which in most cases extend beyond the acute phase and have an important adverse effect upon quality of life. The aim of this review is to deepen in the analysis of the complex interaction between lung and brain in critically ill patients subjected to mechanical ventilation. This update first describes the neuropsychological alterations occurring both during the acute phase of ICU stay and at discharge, followed by an analysis of lung-brain interactions during mechanical ventilation, and finally explores the etiology and mechanisms leading to the neurological disorders observed in these patients. The management of critical patients requires an integral approach focused on minimizing the deleterious effects over the short, middle or long term. Copyright © 2012 Elsevier España, S.L. y SEMICYUC. All rights reserved.

Analysis of Complaints from Patients During Mechanical Ventilation After Cardiac Surgery: A Retrospective Study.

PubMed

Wang, Yi; Li, Hua; Zou, Honglin; Li, Yaxiong

2015-08-01

This study analyzed major complaints from patients during mechanical ventilation after cardiac surgery and identified the most common complaints to reduce adverse psychologic responses. Retrospective. A single tertiary university hospital. Patients with heart disease who were on mechanical ventilation after cardiac surgery (N = 800). The major complaints of the patients during mechanical ventilation after cardiac surgery were analyzed. Patients' comfort was evaluated using a visual analog scale, and the factors affecting comfort were analyzed. The average visual analog scale score in all patients was 5.8±2.0, and most patients presented moderate discomfort. The factors affecting comfort included dry mouth, thirst, tracheal intubation, aspiration of sputum, communication barriers, limited mobility, fear/anxiety, patient-ventilator dyssynchrony, and poor environmental conditions. Of these factors, 8 were independent predictors of the visual analog scale score. Patients considered mechanical ventilation to be the worst part of their hospitalization. The study identified 8 independent factors causing discomfort in patients during mechanical ventilation after cardiac surgery. Clinicians should take appropriate measures and implement nursing interventions to reduce suffering, physical and psychologic trauma, and adverse psychologic responses and to promote recovery. Copyright © 2015 Elsevier Inc. All rights reserved.

Protective mechanical ventilation does not exacerbate lung function impairment or lung inflammation following influenza A infection.

PubMed

Zosky, Graeme R; Cannizzaro, Vincenzo; Hantos, Zoltan; Sly, Peter D

2009-11-01

The degree to which mechanical ventilation induces ventilator-associated lung injury is dependent on the initial acute lung injury (ALI). Viral-induced ALI is poorly studied, and this study aimed to determine whether ALI induced by a clinically relevant infection is exacerbated by protective mechanical ventilation. Adult female BALB/c mice were inoculated with 10(4.5) plaque-forming units of influenza A/Mem/1/71 in 50 microl of medium or medium alone. This study used a protective ventilation strategy, whereby mice were anesthetized, tracheostomized, and mechanically ventilated for 2 h. Lung mechanics were measured periodically throughout the ventilation period using a modification of the forced oscillation technique to obtain measures of airway resistance and coefficients of tissue damping and tissue elastance. Thoracic gas volume was measured and used to obtain specific airway resistance, tissue damping, and tissue elastance. At the end of the ventilation period, a bronchoalveolar lavage sample was collected to measure inflammatory cells, macrophage inflammatory protein-2, IL-6, TNF-alpha, and protein leak. Influenza infection caused significant increases in inflammatory cells, protein leak, and deterioration in lung mechanics that were not exacerbated by mechanical ventilation, in contrast to previous studies using bacterial and mouse-specific viral infection. This study highlighted the importance of type and severity of lung injury in determining outcome following mechanical ventilation.

Pulmonary Mechanics and Mortality in Mechanically Ventilated Patients Without Acute Respiratory Distress Syndrome: A Cohort Study.

PubMed

Fuller, Brian M; Page, David; Stephens, Robert J; Roberts, Brian W; Drewry, Anne M; Ablordeppey, Enyo; Mohr, Nicholas M; Kollef, Marin H

2018-03-01

Driving pressure has been proposed as a major determinant of outcome in patients with acute respiratory distress syndrome (ARDS), but there is little data examining the association between pulmonary mechanics, including driving pressure, and outcomes in mechanically ventilated patients without ARDS. Secondary analysis from 1,705 mechanically ventilated patients enrolled in a clinical study that examined outcomes associated with the use of early lung-protective mechanical ventilation. The primary outcome was mortality and the secondary outcome was the incidence of ARDS. Multivariable models were constructed to: define the association between pulmonary mechanics (driving pressure, plateau pressure, and compliance) and mortality; and evaluate if driving pressure contributed information beyond that provided by other pulmonary mechanics. The mortality rate for the entire cohort was 26.0%. Compared with survivors, non-survivors had significantly higher driving pressure [15.9 (5.4) vs. 14.9 (4.4), P = 0.005] and plateau pressure [21.4 (5.7) vs. 20.4 (4.6), P = 0.001]. Driving pressure was independently associated with mortality [adjusted OR, 1.04 (1.01-1.07)]. Models related to plateau pressure also revealed an independent association with mortality, with similar effect size and interval estimates as driving pressure. There were 152 patients who progressed to ARDS (8.9%). Along with driving pressure and plateau pressure, mechanical power [adjusted OR, 1.03 (1.00-1.06)] was also independently associated with ARDS development. In mechanically ventilated patients, driving pressure and plateau pressure are risk factors for mortality and ARDS, and provide similar information. Mechanical power is also a risk factor for ARDS.

Neurodevelopmental Outcomes of Extremely Low Birth Weight Infants Ventilated With Continuous Positive Airway Pressure vs. Mechanical Ventilation

PubMed Central

Thomas, Cameron W.; Meinzen-Derr, Jareen; Hoath, Steven B.; Narendran, Vivek

2012-01-01

OBJECTIVE To compare continuous positive airway pressure (CPAP) vs. traditional mechanical ventilation (MV) at 24 h of age as predictors of neurodevelopmental (ND) outcomes in extremely low birth weight (ELBW) infants at 18-22 mo corrected gestational age (CGA). METHODS Infants ≤ 1000g birth weight born from January 2000 through December 2006 at two hospitals at the Cincinnati site of the National Institute of Child Health and Human Development Neonatal Research Network were evaluated comparing CPAP (N = 198) vs. MV (N = 109). Primary outcomes included the Bayley Score of Infant Development Version II (BSID-II), presence of deafness, blindness, cerebral palsy, bronchopulmonary dysplasia and death. RESULTS Ventilatory groups were similar in gender, rates of preterm prolonged rupture of membranes, antepartum hemorrhage, use of antenatal antibiotics, steroids, and tocolytics. Infants receiving CPAP weighed more, were older, were more likely to be non-Caucasian and from a singleton pregnancy. Infants receiving CPAP had better BSID-II scores, and lower rates of BPD and death. CONCLUSIONS After adjusting for acuity differences, ventilatory strategy at 24 h of age independently predicts long-term neurodevelopmental outcome in ELBW infants. PMID:21853318

Mechanical Ventilation-Related Safety Incidents in General Care Wards and ICU Settings.

PubMed

Kamio, Tadashi; Masamune, Ken

2018-05-29

Although the ICU is the most appropriate place to care for mechanically ventilated patients, a considerable number are ventilated in general medical care wards all over the world. However, adverse events focusing on mechanically ventilated patients in general care have not been explored. Data from the Japan Council for Quality Health Care database were analyzed. Patient safety incidents from January 2010 to November 2017 regarding mechanical ventilation were collected, and comparisons of patient safety incidents between ICUs/high care units (HCUs) and general care wards were made. We identified 261 adverse events (with at least 20 adverse events resulting in death) and 702 near-miss events related to mechanical ventilation in Japan between 2010 and 2017. Furthermore, among all adverse events, 19% (49 of 261 events) caused serious harm (residual disability or death). Human-factor issues were most frequent in both ICU/HCU and general care settings (55% and 53%, respectively), while knowledge-based errors were higher in the general care setting. Human-factor issues were the most frequent reasons in both settings, while knowledge-based error rates were higher in general care. Our results suggest that proper education and training is needed to minimize patient safety incidents in facilities without respiratory therapists. Copyright © 2018 by Daedalus Enterprises.

The comparison of manual and LabVIEW-based fuzzy control on mechanical ventilation.

PubMed

Guler, Hasan; Ata, Fikret

2014-09-01

The aim of this article is to develop a knowledge-based therapy for management of rats with respiratory distress. A mechanical ventilator was designed to achieve this aim. The designed ventilator is called an intelligent mechanical ventilator since fuzzy logic was used to control the pneumatic equipment according to the rat's status. LabVIEW software was used to control all equipments in the ventilator prototype and to monitor respiratory variables in the experiment. The designed ventilator can be controlled both manually and by fuzzy logic. Eight female Wistar-Albino rats were used to test the designed ventilator and to show the effectiveness of fuzzy control over manual control on pressure control ventilation mode. The anesthetized rats were first ventilated for 20 min manually. After that time, they were ventilated for 20 min by fuzzy logic. Student's t-test for p < 0.05 was applied to the measured minimum, maximum and mean peak inspiration pressures to analyze the obtained results. The results show that there is no statistical difference in the rat's lung parameters before and after the experiments. It can be said that the designed ventilator and developed knowledge-based therapy support artificial respiration of living things successfully. © IMechE 2014.

The Clinical Utilisation of Respiratory Elastance Software (CURE Soft): a bedside software for real-time respiratory mechanics monitoring and mechanical ventilation management.

PubMed

Szlavecz, Akos; Chiew, Yeong Shiong; Redmond, Daniel; Beatson, Alex; Glassenbury, Daniel; Corbett, Simon; Major, Vincent; Pretty, Christopher; Shaw, Geoffrey M; Benyo, Balazs; Desaive, Thomas; Chase, J Geoffrey

2014-09-30

Real-time patient respiratory mechanics estimation can be used to guide mechanical ventilation settings, particularly, positive end-expiratory pressure (PEEP). This work presents a software, Clinical Utilisation of Respiratory Elastance (CURE Soft), using a time-varying respiratory elastance model to offer this ability to aid in mechanical ventilation treatment. CURE Soft is a desktop application developed in JAVA. It has two modes of operation, 1) Online real-time monitoring decision support and, 2) Offline for user education purposes, auditing, or reviewing patient care. The CURE Soft has been tested in mechanically ventilated patients with respiratory failure. The clinical protocol, software testing and use of the data were approved by the New Zealand Southern Regional Ethics Committee. Using CURE Soft, patient's respiratory mechanics response to treatment and clinical protocol were monitored. Results showed that the patient's respiratory elastance (Stiffness) changed with the use of muscle relaxants, and responded differently to ventilator settings. This information can be used to guide mechanical ventilation therapy and titrate optimal ventilator PEEP. CURE Soft enables real-time calculation of model-based respiratory mechanics for mechanically ventilated patients. Results showed that the system is able to provide detailed, previously unavailable information on patient-specific respiratory mechanics and response to therapy in real-time. The additional insight available to clinicians provides the potential for improved decision-making, and thus improved patient care and outcomes.

Mechanical Ventilation during Extracorporeal Membrane Oxygenation in Patients with Acute Severe Respiratory Failure.

PubMed

Zhang, Zhongheng; Gu, Wan-Jie; Chen, Kun; Ni, Hongying

2017-01-01

Conventionally, a substantial number of patients with acute respiratory failure require mechanical ventilation (MV) to avert catastrophe of hypoxemia and hypercapnia. However, mechanical ventilation per se can cause lung injury, accelerating the disease progression. Extracorporeal membrane oxygenation (ECMO) provides an alternative to rescue patients with severe respiratory failure that conventional mechanical ventilation fails to maintain adequate gas exchange. The physiology behind ECMO and its interaction with MV were reviewed. Next, we discussed the timing of ECMO initiation based on the risks and benefits of ECMO. During the running of ECMO, the protective ventilation strategy can be employed without worrying about catastrophic hypoxemia and carbon dioxide retention. There is a large body of evidence showing that protective ventilation with low tidal volume, high positive end-expiratory pressure, and prone positioning can provide benefits on mortality outcome. More recently, there is an increasing popularity on the use of awake and spontaneous breathing for patients undergoing ECMO, which is thought to be beneficial in terms of rehabilitation.

Mechanical Ventilation during Extracorporeal Membrane Oxygenation in Patients with Acute Severe Respiratory Failure

PubMed Central

Gu, Wan-Jie; Chen, Kun; Ni, Hongying

2017-01-01

Conventionally, a substantial number of patients with acute respiratory failure require mechanical ventilation (MV) to avert catastrophe of hypoxemia and hypercapnia. However, mechanical ventilation per se can cause lung injury, accelerating the disease progression. Extracorporeal membrane oxygenation (ECMO) provides an alternative to rescue patients with severe respiratory failure that conventional mechanical ventilation fails to maintain adequate gas exchange. The physiology behind ECMO and its interaction with MV were reviewed. Next, we discussed the timing of ECMO initiation based on the risks and benefits of ECMO. During the running of ECMO, the protective ventilation strategy can be employed without worrying about catastrophic hypoxemia and carbon dioxide retention. There is a large body of evidence showing that protective ventilation with low tidal volume, high positive end-expiratory pressure, and prone positioning can provide benefits on mortality outcome. More recently, there is an increasing popularity on the use of awake and spontaneous breathing for patients undergoing ECMO, which is thought to be beneficial in terms of rehabilitation. PMID:28127231

Effects of ventilation on hearing loss in preterm neonates: Nasal continuous positive pressure does not increase the risk of hearing loss in ventilated neonates.

PubMed

Rastogi, Shantanu; Mikhael, Michel; Filipov, Panayot; Rastogi, Deepa

2013-03-01

There is increased risk of hearing loss in preterm neonates. This risk is further increased by environmental noise exposure especially from life support equipment such as ventilation. Nasal continuous positive airway pressure (NCPAP) used for respiratory support of preterm neonates is known to be associated with prolonged exposure to high levels of noise. However, there is paucity of information on the effect of NCPAP as compared to mechanical ventilation on hearing loss among preterm neonates. A retrospective chart review was performed on neonates with birth weight (BW) <1500g. Association of clinical factors including the use of NCPAP and mechanical ventilation with failure of hearing screen were studied. Those who failed hearing screen were followed for 2 years to observe long term effects of NCPAP on the hearing loss. Of 344 neonates included in the study, 61 failed hearing screen. Gestational age (p=0.008), BW (p=0.03), ventilation (p=0.02), intrauterine growth retardation (p=0.02), necrotizing enterocolitis (NEC) (p=0.02), apnea (p<0.001), use of vancomycin (p=0.01) and furosemide (p=0.01) were associated with failure of hearing screen. On multivariate analysis, ventilation (OR 4.56, p=0.02), apnea (OR 2.2, p<0.001) and NEC (OR 2.4, p=0.02) were predictors of failed hearing screen. As compared to those not ventilated, the odds of failing hearing screen was 4.53 (p<0.01) and 4.59 (p<0.01) for those treated with NCPAP and mechanical ventilation respectively, with there being no difference between these two ventilatory modalities. Of the 61 neonates, 42 were followed for 2 years, of which 19 had confirmed hearing loss. Among these 19 neonates, there was no difference (p=0.12) between those who were treated with NCPAP or with mechanical ventilation. There is no increase in the hearing loss in preterm neonates treated with NCPAP as compared to mechanical ventilation despite being exposed to higher environmental noise generated by the NCPAP. Copyright © 2012

Outcome of ventilated infants born at term without major congenital abnormalities.

PubMed

Ramadan, Ghada; Paul, Nicola; Morton, Margaret; Peacock, Janet L; Greenough, Anne

2012-02-01

The longer-term outcome of term-born infants without congenital anomalies requiring ventilation in the first 24 h after birth has rarely been reported. Our aims were to determine the mortality and long-term morbidity of such infants and identify risk factors for adverse outcome. The outcomes of 43 of 45 infants born at term consecutively requiring mechanical ventilation were reviewed. The infants had: meconium aspiration syndrome (n = 11), hypoxic ischaemic encephalopathy (HIE) (n = 11), respiratory depression (n = 12), sepsis (n = 5), persistent pulmonary hypertension of the newborn (n = 3) and middle cerebral artery infarction (n = 1). Eleven infants developed seizures (26%), 13 (30%) had abnormal electroencephalograms and 11 (26%) had abnormal MRI scans; 26% had an adverse outcome: six died, and five had severe neurodisability at 2 years. The infants with congenital toxoplasmosis and a middle cerebral artery infarction were excluded from the prediction analysis. In the remaining 41 patients, requirement for anticonvulsants (relative risk, RR = 4.44, 95% CI = 1.48 to 12.70; p = 0.014) and prolonged ventilation (longer than 3 days) (RR 4.83, 95% CI 1.51 to 15.64) predicted adverse outcome. Infants with HIE had an increased risk of adverse outcome (relative risk 5.45, 95% CI 1.01 to 33.85), but an adverse outcome occurred in infants with other diagnoses. Mortality and neurodisability at follow-up were common in infants born at term without major congenital anomalies who required mechanical ventilation in the first 24 h after birth, particularly in those who developed seizures requiring treatment and prolonged ventilation.

Microbial profiling of dental plaque from mechanically ventilated patients

PubMed Central

Twigg, Joshua A.; Lewis, Michael A. O.; Wise, Matt P.; Marchesi, Julian R.; Smith, Ann; Wilson, Melanie J.; Williams, David W.

2016-01-01

Micro-organisms isolated from the oral cavity may translocate to the lower airways during mechanical ventilation (MV) leading to ventilator-associated pneumonia (VAP). Changes within the dental plaque microbiome during MV have been documented previously, primarily using culture-based techniques. The aim of this study was to use community profiling by high throughput sequencing to comprehensively analyse suggested microbial changes within dental plaque during MV. Bacterial 16S rDNA gene sequences were obtained from 38 samples of dental plaque sampled from 13 mechanically ventilated patients and sequenced using the Illumina platform. Sequences were processed using Mothur, applying a 97 % gene similarity cut-off for bacterial species level identifications. A significant ‘microbial shift’ occurred in the microbial community of dental plaque during MV for nine out of 13 patients. Following extubation, or removal of the endotracheal tube that facilitates ventilation, sampling revealed a decrease in the relative abundance of potential respiratory pathogens and a compositional change towards a more predominantly (in terms of abundance) oral microbiota including Prevotella spp., and streptococci. The results highlight the need to better understand microbial shifts in the oral microbiome in the development of strategies to reduce VAP, and may have implications for the development of other forms of pneumonia such as community-acquired infection. PMID:26690690

Microbial profiling of dental plaque from mechanically ventilated patients.

PubMed

Sands, Kirsty M; Twigg, Joshua A; Lewis, Michael A O; Wise, Matt P; Marchesi, Julian R; Smith, Ann; Wilson, Melanie J; Williams, David W

2016-02-01

Micro-organisms isolated from the oral cavity may translocate to the lower airways during mechanical ventilation (MV) leading to ventilator-associated pneumonia (VAP). Changes within the dental plaque microbiome during MV have been documented previously, primarily using culture-based techniques. The aim of this study was to use community profiling by high throughput sequencing to comprehensively analyse suggested microbial changes within dental plaque during MV. Bacterial 16S rDNA gene sequences were obtained from 38 samples of dental plaque sampled from 13 mechanically ventilated patients and sequenced using the Illumina platform. Sequences were processed using Mothur, applying a 97% gene similarity cut-off for bacterial species level identifications. A significant 'microbial shift' occurred in the microbial community of dental plaque during MV for nine out of 13 patients. Following extubation, or removal of the endotracheal tube that facilitates ventilation, sampling revealed a decrease in the relative abundance of potential respiratory pathogens and a compositional change towards a more predominantly (in terms of abundance) oral microbiota including Prevotella spp., and streptococci. The results highlight the need to better understand microbial shifts in the oral microbiome in the development of strategies to reduce VAP, and may have implications for the development of other forms of pneumonia such as community-acquired infection.

Acute respiratory failure requiring mechanical ventilation in severe chronic obstructive pulmonary disease (COPD)

PubMed Central

Gadre, Shruti K.; Duggal, Abhijit; Mireles-Cabodevila, Eduardo; Krishnan, Sudhir; Wang, Xiao-Feng; Zell, Katrina; Guzman, Jorge

2018-01-01

Abstract There are limited data on the epidemiology of acute respiratory failure necessitating mechanical ventilation in patients with severe chronic obstructive pulmonary disease (COPD). The prognosis of acute respiratory failure requiring invasive mechanical ventilation is believed to be grim in this population. The purpose of this study was to illustrate the epidemiologic characteristics and outcomes of patients with underlying severe COPD requiring mechanical ventilation. A retrospective study of patients admitted to a quaternary referral medical intensive care unit (ICU) between January 2008 and December 2012 with a diagnosis of severe COPD and requiring invasive mechanical ventilation for acute respiratory failure. We evaluated 670 patients with an established diagnosis of severe COPD requiring mechanical ventilation for acute respiratory failure of whom 47% were male with a mean age of 63.7 ± 12.4 years and Acute physiology and chronic health evaluation (APACHE) III score of 76.3 ± 27.2. Only seventy-nine (12%) were admitted with a COPD exacerbation, 27(4%) had acute respiratory distress syndrome (ARDS), 78 (12%) had pneumonia, 78 (12%) had sepsis, and 312 (47%) had other causes of respiratory failure, including pulmonary embolism, pneumothorax, etc. Eighteen percent of the patients received a trial of noninvasive positive pressure ventilation. The median duration of mechanical ventilation was 3 days (interquartile range IQR 2–7); the median duration for ICU length of stay (LOS) was 5 (IQR 2–9) days and the median duration of hospital LOS was 12 (IQR 7–22) days. The overall ICU mortality was 25%. Patients with COPD exacerbation had a shorter median duration of mechanical ventilation (2 vs 4 days; P = .04), ICU (3 vs 5 days; P = .01), and hospital stay (10 vs 13 days; P = .01). The ICU mortality (9% vs 27%; P < .001), and the hospital mortality (17% vs 32%; P = .004) for mechanically ventilated patients with an acute

Acute respiratory failure requiring mechanical ventilation in severe chronic obstructive pulmonary disease (COPD).

PubMed

Gadre, Shruti K; Duggal, Abhijit; Mireles-Cabodevila, Eduardo; Krishnan, Sudhir; Wang, Xiao-Feng; Zell, Katrina; Guzman, Jorge

2018-04-01

There are limited data on the epidemiology of acute respiratory failure necessitating mechanical ventilation in patients with severe chronic obstructive pulmonary disease (COPD). The prognosis of acute respiratory failure requiring invasive mechanical ventilation is believed to be grim in this population. The purpose of this study was to illustrate the epidemiologic characteristics and outcomes of patients with underlying severe COPD requiring mechanical ventilation.A retrospective study of patients admitted to a quaternary referral medical intensive care unit (ICU) between January 2008 and December 2012 with a diagnosis of severe COPD and requiring invasive mechanical ventilation for acute respiratory failure.We evaluated 670 patients with an established diagnosis of severe COPD requiring mechanical ventilation for acute respiratory failure of whom 47% were male with a mean age of 63.7 ± 12.4 years and Acute physiology and chronic health evaluation (APACHE) III score of 76.3 ± 27.2. Only seventy-nine (12%) were admitted with a COPD exacerbation, 27(4%) had acute respiratory distress syndrome (ARDS), 78 (12%) had pneumonia, 78 (12%) had sepsis, and 312 (47%) had other causes of respiratory failure, including pulmonary embolism, pneumothorax, etc. Eighteen percent of the patients received a trial of noninvasive positive pressure ventilation. The median duration of mechanical ventilation was 3 days (interquartile range IQR 2-7); the median duration for ICU length of stay (LOS) was 5 (IQR 2-9) days and the median duration of hospital LOS was 12 (IQR 7-22) days. The overall ICU mortality was 25%. Patients with COPD exacerbation had a shorter median duration of mechanical ventilation (2 vs 4 days; P = .04), ICU (3 vs 5 days; P = .01), and hospital stay (10 vs 13 days; P = .01). The ICU mortality (9% vs 27%; P < .001), and the hospital mortality (17% vs 32%; P = .004) for mechanically ventilated patients with an acute exacerbation of severe

A Medical Student Workshop in Mechanical Ventilation.

ERIC Educational Resources Information Center

And Others; Kushins, Lawrence G.

1980-01-01

In order to teach applied respiratory physiology to medical students, the anesthesiology faculty at the University of Florida College of Medicine has designed and implemented a course that includes a laboratory workshop in mechanical ventilation of an animal model that allows students to apply and expand their knowledge. (JMD)

Comparison of usual and alternative methods to measure height in mechanically ventilated patients: potential impact on protective ventilation.

PubMed

Bojmehrani, Azadeh; Bergeron-Duchesne, Maude; Bouchard, Carmelle; Simard, Serge; Bouchard, Pierre-Alexandre; Vanderschuren, Abel; L'Her, Erwan; Lellouche, François

2014-07-01

Protective ventilation implementation requires the calculation of predicted body weight (PBW), determined by a formula based on gender and height. Consequently, height inaccuracy may be a limiting factor to correctly set tidal volumes. The objective of this study was to evaluate the accuracy of different methods in measuring heights in mechanically ventilated patients. Before cardiac surgery, actual height was measured with a height gauge while subjects were standing upright (reference method); the height was also estimated by alternative methods based on lower leg and forearm measurements. After cardiac surgery, upon ICU admission, a subject's height was visually estimated by a clinician and then measured with a tape measure while the subject was supine and undergoing mechanical ventilation. One hundred subjects (75 men, 25 women) were prospectively included. Mean PBW was 61.0 ± 9.7 kg, and mean actual weight was 30.3% higher. In comparison with the reference method, estimating the height visually and using the tape measure were less accurate than both lower leg and forearm measurements. Errors above 10% in calculating the PBW were present in 25 and 40 subjects when the tape measure or visual estimation of height was used in the formula, respectively. With lower leg and forearm measurements, 15 subjects had errors above 10% (P < .001). Our results demonstrate that significant variability exists between the different methods used to measure height in bedridden patients on mechanical ventilation. Alternative methods based on lower leg and forearm measurements are potentially interesting solutions to facilitate the accurate application of protective ventilation. Copyright © 2014 by Daedalus Enterprises.

Protective mechanical ventilation in United Kingdom critical care units: A multicentre audit

PubMed Central

Martin, Matthew J; Richardson, Neil; Bourdeaux, Christopher P

2016-01-01

Lung protective ventilation is becoming increasingly used for all critically ill patients being mechanically ventilated on a mandatory ventilator mode. Compliance with the universal application of this ventilation strategy in intensive care units in the United Kingdom is unknown. This 24-h audit of ventilation practice took place in 16 intensive care units in two regions of the United Kingdom. The mean tidal volume for all patients being ventilated on a mandatory ventilator mode was 7.2(±1.4) ml kg−1 predicted body weight and overall compliance with low tidal volume ventilation (≤6.5 ml kg−1 predicted body weight) was 34%. The mean tidal volume for patients ventilated with volume-controlled ventilation was 7.0(±1.2) ml kg−1 predicted body weight and 7.9(±1.8) ml kg−1 predicted body weight for pressure-controlled ventilation (P < 0.0001). Overall compliance with recommended levels of positive end-expiratory pressure was 72%. Significant variation in practice existed both at a regional and individual unit level. PMID:28979556

Protective mechanical ventilation in United Kingdom critical care units: A multicentre audit.

PubMed

Newell, Christopher P; Martin, Matthew J; Richardson, Neil; Bourdeaux, Christopher P

2017-05-01

Lung protective ventilation is becoming increasingly used for all critically ill patients being mechanically ventilated on a mandatory ventilator mode. Compliance with the universal application of this ventilation strategy in intensive care units in the United Kingdom is unknown. This 24-h audit of ventilation practice took place in 16 intensive care units in two regions of the United Kingdom. The mean tidal volume for all patients being ventilated on a mandatory ventilator mode was 7.2(±1.4) ml kg -1 predicted body weight and overall compliance with low tidal volume ventilation (≤6.5 ml kg -1 predicted body weight) was 34%. The mean tidal volume for patients ventilated with volume-controlled ventilation was 7.0(±1.2) ml kg -1 predicted body weight and 7.9(±1.8) ml kg -1 predicted body weight for pressure-controlled ventilation ( P  < 0.0001). Overall compliance with recommended levels of positive end-expiratory pressure was 72%. Significant variation in practice existed both at a regional and individual unit level.

Airway Humidification Reduces the Inflammatory Response During Mechanical Ventilation.

PubMed

Jiang, Min; Song, Jun-Jie; Guo, Xiao-Li; Tang, Yong-Lin; Li, Hai-Bo

2015-12-01

Currently, no clinical or animal studies have been performed to establish the relationship between airway humidification and mechanical ventilation-induced lung inflammatory responses. Therefore, an animal model was established to better define this relationship. Rabbits (n = 40) were randomly divided into 6 groups: control animals, sacrificed immediately after anesthesia (n = 2); dry gas group animals, subjected to mechanical ventilation for 8 h without humidification (n = 6); and experimental animals, subjected to mechanical ventilation for 8 h under humidification at 30, 35, 40, and 45°C, respectively (n = 8). Inflammatory cytokines in the bronchi alveolar lavage fluid (BALF) were measured. The integrity of the airway cilia and the tracheal epithelium was examined by scanning and transmission electron microscopy, respectively. Peripheral blood white blood cell counts and the wet to dry ratio and lung pathology were determined. Dry gas group animals showed increased tumor necrosis factor alpha levels in BALF compared with control animals (P < .05). The tumor necrosis factor alpha and interleukin-8 levels in the BALF reached baseline levels when the humidification temperature was increased to 40°C. Scanning and transmission electron microscopy analysis revealed that cilia integrity was maintained in the 40°C groups. Peripheral white blood cell counts were not different among those groups. Compared with control animals, the wet to dry ratio was significantly elevated in the dry gas group (P < .05). Moreover, humidification at 40°C resulted in reduced pathologic injury compared with the other groups based on the histologic score. Pathology and reduced inflammation observed in animals treated at 40°C was similar to that observed in the control animals, suggesting that appropriate humidification reduced inflammatory responses elicited as a consequence of mechanical ventilation, in addition to reducing damage to the cilia and reducing water loss in the airway

Mechanical ventilation in patients subjected to extracorporeal membrane oxygenation (ECMO).

PubMed

López Sanchez, M

2017-11-01

Mechanical ventilation (MV) is a crucial element in the management of acute respiratory distress syndrome (ARDS), because there is high level evidence that a low tidal volume of 6ml/kg (protective ventilation) improves survival. In these patients with refractory respiratory insufficiency, venovenous extracorporeal membrane oxygenation (ECMO) can be used. This salvage technique improves oxygenation, promotes CO 2 clearance, and facilitates protective and ultraprotective MV, potentially minimizing ventilation-induced lung injury. Although numerous trials have investigated different ventilation strategies in patients with ARDS, consensus is lacking on the optimal MV settings during venovenous ECMO. Although the concept of "lung rest" was introduced years ago, there are no evidence-based guidelines on its use in application to MV in patients supported by ECMO. How MV in ECMO patients can promote lung recovery and weaning from ventilation is not clear. The purpose of this review is to describe the ventilation strategies used during venovenous ECMO in clinical practice. Copyright © 2017 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.

Noninvasive mechanical ventilation in patients with obesity hypoventilation syndrome. Long-term outcome and prognostic factors.

PubMed

Ojeda Castillejo, Elena; de Lucas Ramos, Pilar; López Martin, Soledad; Resano Barrios, Pilar; Rodríguez Rodríguez, Paula; Morán Caicedo, Liliana; Bellón Cano, José María; Rodriguez Gonzalez-Moro, José Miguel

2015-02-01

Obesity is associated with 2 closely related respiratory diseases: obesity hypoventilation syndrome (OHS) and obstructive sleep apnea-hypopnea syndrome (OSAHS). It has been shown that noninvasive ventilation during sleep produces clinical and functional improvement in these patients. The long-term survival rate with this treatment, and the difference in clinical progress in OHS patients with and without OSAHS are analyzed. Longitudinal, observational study with a cohort of patients diagnosed with OHS, included in a home ventilation program over a period of 12 years, divided into 2 groups: pure OHS and OSAHS-associated OHS. Bi-level positive airway pressure ventilation was administered. During the follow-up period, symptoms, exacerbations and hospitalizations, blood gas tests and pulmonary function tests, and survival rates were monitored and compared. Eighty-three patients were eligible for analysis, 60 women (72.3%) and 23 men (27.7%), with a mean survival time of 8.47 years. Fifty patients (60.2%) were included in the group without OSAHS (OHS) and 33 (39.8%) in the OSAHS-associated OHS group (OHS-OSAHS). PaCO₂ in the OHS group was significantly higher than in the OHS-OSAHS group (P<.01). OHS patients also had a higher hospitalization rate (P<.05). There was a significant improvement in both groups in FEV₁ and FVC, and no differences between groups in PaCO₂ and PaO₂ values. There were no differences in mortality between the 2 groups, but low FVC values were predictive of mortality. The use of mechanical ventilation in patients with OHS, with or without OSAHS, is an effective treatment for the correction of blood gases and functional alterations and can achieve prolonged survival rates. Copyright © 2013 SEPAR. Published by Elsevier Espana. All rights reserved.

Mechanical ventilation in disaster situations: a new paradigm using the AGILITIES Score System.

PubMed

Wilkens, Eric P; Klein, Gary M

2010-01-01

The failure of life-critical systems such as mechanical ventilators in the wake of a pandemic or a disaster may result in death, and therefore, state and federal government agencies must have precautions in place to ensure availability, reliability, and predictability through comprehensive preparedness and response plans. All 50 state emergency preparedness response plans were extensively examined for the attention given to the critically injured and ill patient population during a pandemic or mass casualty event. Public health authorities of each state were contacted as well. Nine of 51 state plans (17.6 percent) included a plan or committee for mechanical ventilation triage and management in a pandemic influenza event. All 51 state plans relied on the Centers for Disease Control and Prevention Flu Surge 2.0 spreadsheet to provide estimates for their influenza planning. In the absence of more specific guidance, the authors have developed and provided guidelines recommended for ventilator triage and the implementation of the AGILITIES Score in the event of a pandemic, mass casualty event, or other catastrophic disaster. The authors present and describe the AGILITIES Score Ventilator Triage System and provide related guidelines to be adopted uniformly by government agencies and hospitals. This scoring system and the set ofguidelines are to be used iA disaster settings, such as Hurricane Katrina, and are based on three key factors: relative health, duration of time on mechanical ventilation, and patients' use of resources during a disaster. For any event requiring large numbers of ventilators for patients, the United States is woefully unprepared. The deficiencies in this aspect of preparedness include (1) lack of accountability for physical ventilators, (2) lack of understanding with which healthcare professionals can safely operate these ventilators, (3) lack of understanding from where additional ventilator resources exist, and (4) a triage strategy to provide

The muscular basis of aerial ventilation of the primitive lung of Amia calva.

PubMed

Deyst, K A; Liem, K F

1985-02-01

Anatomical analysis, electromyography, pressure recordings, high-speed X-ray and light movies of the mechanism of air ventilation in Amia calva reveal that aerial ventilation proceeds by the action of a specialized pulse pump. The interhyoideus muscle is the dominant muscle being active during both the preparatory phase and the final, prolonged compressive phase during which new air is forced into the lung. Amia retains a relatively large residual volume in the lung and does not repeat inhalation. It often expels excess air from the buccal cavity after the lung has been fully reinflated. The pressure, kinematic and air flow patterns during air ventilation in Amia closely resemble those of the air breath in the lungfish Protopterus. We hypothesize that the basically similar electromyographic profiles of homologous muscles so characteristic for the air ventilation mechanism of Protopterus and Amia reflect a homologous anatomical as well as functional neuromuscular pattern, which has had a common and early evolutionary origin among the Teleostomi.

Low tidal volume mechanical ventilation against no ventilation during cardiopulmonary bypass heart surgery (MECANO): study protocol for a randomized controlled trial.

PubMed

Nguyen, Lee S; Merzoug, Messaouda; Estagnasie, Philippe; Brusset, Alain; Law Koune, Jean-Dominique; Aubert, Stephane; Waldmann, Thierry; Grinda, Jean-Michel; Gibert, Hadrien; Squara, Pierre

2017-12-02

Postoperative pulmonary complications are a leading cause of morbidity and mortality after cardiac surgery. There are no recommendations on mechanical ventilation associated with cardiopulmonary bypass (CPB) during surgery and anesthesiologists perform either no ventilation (noV) at all during CPB or maintain low tidal volume (LTV) ventilation. Indirect evidence points towards better pulmonary outcomes when LTV is performed but no large-scale prospective trial has yet been published in cardiac surgery. The MECANO trial is a single-center, double-blind, randomized, controlled trial comparing two mechanical ventilation strategies, noV and LTV, during cardiac surgery with CPB. In total, 1500 patients are expected to be included, without any restrictions. They will be randomized between noV and LTV on a 1:1 ratio. The noV group will receive no ventilation during CPB. The LTV group will receive 5 breaths/minute with a tidal volume of 3 mL/kg and positive end-expiratory pressure of 5 cmH2O. The primary endpoint will be a composite of all-cause mortality, early respiratory failure defined as a ratio of partial pressure of oxygen/fraction of inspired oxygen <200 mmHg at 1 hour after arrival in the ICU, heavy oxygenation support (defined as a patient requiring either non-invasive ventilation, mechanical ventilation or high-flow oxygen) at 2 days after arrival in the ICU or ventilator-acquired pneumonia defined by the Center of Disease Control. Lung recruitment maneuvers will be performed in the noV and LTV groups at the end of surgery and at arrival in ICU with an insufflation at +30 cmH20 for 5 seconds. Secondary endpoints are those composing the primary endpoint with the addition of pneumothorax, CPB duration, quantity of postoperative bleeding, red blood cell transfusions, revision surgery requirements, length of stay in the ICU and in the hospital and total hospitalization costs. Patients will be followed until hospital discharge. The MECANO trial is the first of

Injurious mechanical ventilation in the normal lung causes a progressive pathologic change in dynamic alveolar mechanics.

PubMed

Pavone, Lucio A; Albert, Scott; Carney, David; Gatto, Louis A; Halter, Jeffrey M; Nieman, Gary F

2007-01-01

Acute respiratory distress syndrome causes a heterogeneous lung injury, and without protective mechanical ventilation a secondary ventilator-induced lung injury can occur. To ventilate noncompliant lung regions, high inflation pressures are required to 'pop open' the injured alveoli. The temporal impact, however, of these elevated pressures on normal alveolar mechanics (that is, the dynamic change in alveolar size and shape during ventilation) is unknown. In the present study we found that ventilating the normal lung with high peak pressure (45 cmH(2)0) and low positive end-expiratory pressure (PEEP of 3 cmH(2)O) did not initially result in altered alveolar mechanics, but alveolar instability developed over time. Anesthetized rats underwent tracheostomy, were placed on pressure control ventilation, and underwent sternotomy. Rats were then assigned to one of three ventilation strategies: control group (n = 3, P control = 14 cmH(2)O, PEEP = 3 cmH(2)O), high pressure/low PEEP group (n = 6, P control = 45 cmH(2)O, PEEP = 3 cmH(2)O), and high pressure/high PEEP group (n = 5, P control = 45 cmH(2)O, PEEP = 10 cmH(2)O). In vivo microscopic footage of subpleural alveolar stability (that is, recruitment/derecruitment) was taken at baseline and than every 15 minutes for 90 minutes following ventilator adjustments. Alveolar recruitment/derecruitment was determined by measuring the area of individual alveoli at peak inspiration (I) and end expiration (E) by computer image analysis. Alveolar recruitment/derecruitment was quantified by the percentage change in alveolar area during tidal ventilation (%I - E Delta). Alveoli were stable in the control group for the entire experiment (low %I - E Delta). Alveoli in the high pressure/low PEEP group were initially stable (low %I - E Delta), but with time alveolar recruitment/derecruitment developed. The development of alveolar instability in the high pressure/low PEEP group was associated with histologic lung injury. A large change in

Mechanical ventilation for amyotrophic lateral sclerosis/motor neuron disease.

PubMed

Radunovic, Aleksandar; Annane, Djillali; Rafiq, Muhammad K; Brassington, Ruth; Mustfa, Naveed

2017-10-06

Amyotrophic lateral sclerosis (ALS), also known as motor neuron disease, is a fatal neurodegenerative disease. Neuromuscular respiratory failure is the most common cause of death, which usually occurs within two to five years of the disease onset. Supporting respiratory function with mechanical ventilation may improve survival and quality of life. This is the second update of a review first published in 2009. To assess the effects of mechanical ventilation (tracheostomy-assisted ventilation and non-invasive ventilation (NIV)) on survival, functional measures of disease progression, and quality of life in ALS, and to evaluate adverse events related to the intervention. We searched the Cochrane Neuromuscular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL Plus, and AMED on 30 January 2017. We also searched two clinical trials registries for ongoing studies. Randomised controlled trials (RCTs) and quasi-RCTs involving non-invasive or tracheostomy-assisted ventilation in participants with a clinical diagnosis of ALS, independent of the reported outcomes. We included comparisons with no intervention or the best standard care. For the original review, four review authors independently selected studies for assessment. Two review authors reviewed searches for this update. All review authors independently extracted data from the full text of selected studies and assessed the risk of bias in studies that met the inclusion criteria. We attempted to obtain missing data where possible. We planned to collect adverse event data from the included studies. For the original Cochrane Review, the review authors identified two RCTs involving 54 participants with ALS receiving NIV. There were no new RCTs or quasi-RCTs at the first update. One new RCT was identified in the second update but was excluded for the reasons outlined below.Incomplete data were available for one published study comparing early and late initiation of

The influence of mechanical ventilation on physiological parameters in ball pythons (Python regius).

PubMed

Jakobsen, Sashia L; Williams, Catherine J A; Wang, Tobias; Bertelsen, Mads F

2017-05-01

Mechanical ventilation is widely recommended for reptiles during anesthesia, and while it is well-known that their low ectothermic metabolism requires much lower ventilation than in mammals, very little is known about the influence of ventilation protocol on the recovery from anesthesia. Here, 15 ball pythons (Python regius) were induced and maintained with isoflurane for 60min at one of three ventilation protocols (30, 125, or 250mlmin -1 kg -1 body mass) while an arterial catheter was inserted, and ventilation was then continued on 100% oxygen at the specified rate until voluntary extubation. Mean arterial blood pressure and heart rate (HR) were measured, and arterial blood samples collected at 60, 80, 180min and 12 and 24h after intubation. In all three groups, there was evidence of a metabolic acidosis, and snakes maintained at 30mlmin -1 kg -1 experienced an additional respiratory acidosis, while the two other ventilation protocols resulted in normal or low arterial PCO 2 . In general, normal acid-base status was restored within 12h in all three protocols. HR increased by 143±64% during anesthesia with high mechanical ventilation (250mlmin -1 kg -1 ) in comparison with recovered values. Recovery times after mechanical ventilation at 30, 125, or 250mlmin -1 kg -1 were 289±70, 126±16, and 68±7min, respectively. Mild overventilation may result in a faster recovery, and the associated lowering of arterial PCO 2 normalised arterial pH in the face of metabolic acidosis. Copyright © 2017 Elsevier Inc. All rights reserved.

Effects of staff training on the care of mechanically ventilated patients: a prospective cohort study.

PubMed

Bloos, F; Müller, S; Harz, A; Gugel, M; Geil, D; Egerland, K; Reinhart, K; Marx, G

2009-08-01

Adherence to guidelines to avoid complications associated with mechanical ventilation is often incomplete. The goal of this study was to assess whether staff training in pre-defined interventions (bundle) improves the quality of care in mechanically ventilated patients. This study was performed on a 50-bed intensive care unit of a tertiary care university hospital. Application of a ventilator bundle consisting of semirecumbent positioning, lung protective ventilation in patients with acute lung injury (ALI), ulcer prophylaxis, and deep vein thrombosis prophylaxis (DVTP) was assessed before and after staff training in post-surgical patients requiring mechanical ventilation for at least 24 h. A total of 133 patients before and 141 patients after staff training were included. Overall bundle adherence increased from 15 to 33.8% (P<0.001). Semirecumbent position was achieved in 24.9% of patient days before and 46.9% of patient days after staff training (P<0.001). Administration of DVTP increased from 89.5 to 91.5% (P=0.048). Ulcer prophylaxis of >90% was achieved in both groups. Median tidal volume in patients with ALI remained unaltered. Days on mechanical ventilation were reduced from 6 (interquartile range 2.0-15.0) to 4 (2.0-9.0) (P=0.017). Rate of ventilator-associated pneumonia (VAP), ICU length of stay, and ICU mortality remained unaffected. In patients with VAP, the median ICU length of stay was reduced by 9 days (P=0.04). Staff training by an ICU change team improved compliance to a pre-defined ventilator bundle. This led to a reduction in the days spent on mechanical ventilation, despite incomplete bundle implementation.

[Oesophagitis during mechanical ventilation].

PubMed

Gastinne, H; Canard, J M; Pillegand, B; Voultoury, J C; Catanzano, A; Claude, R; Gay, R

1982-10-16

Twenty-one patients whose condition required mechanical ventilation with nasogastric intubation were investigated for oesophagitis before the 3rd day and on the 15th day of treatment, including endoscopy and biopsy. Lesions of oesophagitis were detected in 14 cases during the initial examination and in 19 cases on the second endoscopy. The course of the lesions varied from one patient to another and appeared to be unrelated to the course of the primary disease. Oesophagitis in these patients is probably due to frequent episodes of gastro-oesophageal reflux encouraged by cough, impaired consciousness and the presence of a tube. Reflux may also be the cause of inapparent and recurrent lung aspiration.

Mechanical ventilation and management of an adult horse with presumptive botulism.

PubMed

Taylor, Sandra D; Toth, Balazs; Townsend, Wendy M; Bentley, Robin Timothy

2014-01-01

To describe the clinical course, management, and outcome of a horse with a presumptive diagnosis of botulism treated with long-term mechanical ventilation. A 6-year-old Quarter Horse gelding with a history of esophageal obstruction was evaluated for progressive tetraparesis. Generalized and progressive skeletal muscle weakness characterized by recumbency, decreased tongue, tail, eyelid, and anal tone, and respiratory failure was observed. Anticholinergic signs including decreased salivation, xerophthalmia, and ileus were also noted. A presumptive diagnosis of botulism was made, although mouse inoculation and spore identification testing were negative. Pentavalent botulism antitoxin was administered on Day 3. The horse was maintained on a water mattress and was managed with mechanical ventilation for 2 weeks. Complications encountered included necrotic rhinitis, intertrigo, decubital ulceration, jugular and cephalic vein thrombophlebitis, corneal ulceration, and transient ventricular tachycardia. The horse showed marked improvement in skeletal muscle strength and parasympathetic nervous system function, allowing it to be successfully weaned from the ventilator but suffered large colon volvulus on Day 21 and was euthanized. To the authors' knowledge, this is the first report of successful weaning from long-term mechanical ventilation and management of recumbency using a water mattress in an adult horse with presumptive botulism. © Veterinary Emergency and Critical Care Society 2014.

Testing of mechanical ventilators and infant incubators in healthcare institutions.

PubMed

Badnjevic, Almir; Gurbeta, Lejla; Jimenez, Elvira Ruiz; Iadanza, Ernesto

2017-01-01

The medical device industry has grown rapidly and incessantly over the past century. The sophistication and complexity of the designed instrumentation is nowadays rising and, with it, has also increased the need to develop some better, more effective and efficient maintenance processes, as part of the safety and performance requirements. This paper presents the results of performance tests conducted on 50 mechanical ventilators and 50 infant incubators used in various public healthcare institutions. Testing was conducted in accordance to safety and performance requirements stated in relevant international standards, directives and legal metrology policies. Testing of output parameters for mechanical ventilators was performed in 4 measuring points while testing of output parameters for infant incubators was performed in 7 measuring points for each infant incubator. As performance criteria, relative error of output parameters for mechanical ventilators and absolute error of output parameters for infant incubators was calculated. The ranges of permissible error, for both groups of devices, are regulated by the Rules on Metrological and Technical Requirements published in the Official Gazette of Bosnia and Herzegovina No. 75/14, which are defined based on international recommendations, standards and guidelines. All ventilators and incubators were tested by etalons calibrated in an ISO 17025 accredited laboratory, which provides compliance to international standards for all measured parameters.The results show that 30% of the tested medical devices are not operating properly and should be serviced, recalibrated and/or removed from daily application.

Non-invasive mechanical ventilation and mortality in elderly immunocompromised patients hospitalized with pneumonia: a retrospective cohort study.

PubMed

Johnson, Christopher S; Frei, Christopher R; Metersky, Mark L; Anzueto, Antonio R; Mortensen, Eric M

2014-01-27

Mortality after pneumonia in immunocompromised patients is higher than for immunocompetent patients. The use of non-invasive mechanical ventilation for patients with severe pneumonia may provide beneficial outcomes while circumventing potential complications associated with invasive mechanical ventilation. The aim of our study was to determine if the use of non-invasive mechanical ventilation in elderly immunocompromised patients with pneumonia is associated with higher all-cause mortality. In this retrospective cohort study, data were obtained from the Department of Veterans Affairs administrative databases. We included veterans age ≥65 years who were immunocompromised and hospitalized due to pneumonia. Multilevel logistic regression analysis was used to determine the relationship between the use of invasive versus non-invasive mechanical ventilation and 30-day and 90-day mortality. Of 1,946 patients in our cohort, 717 received non-invasive mechanical ventilation and 1,229 received invasive mechanical ventilation. There was no significant association between all-cause 30-day mortality and non-invasive versus invasive mechanical ventilation in our adjusted model (odds ratio (OR) 0.85, 95% confidence interval (CI) 0.66-1.10). However, those patients who received non-invasive mechanical ventilation had decreased 90-day mortality (OR 0.66, 95% CI 0.52-0.84). Additionally, receipt of guideline-concordant antibiotics in our immunocompromised cohort was significantly associated with decreased odds of 30-day mortality (OR 0.31, 95% CI 0.24-0.39) and 90-day mortality (OR 0.41, 95% CI 0.31-0.53). Our findings suggest that physicians should consider the use of non-invasive mechanical ventilation, when appropriate, for elderly immunocompromised patients hospitalized with pneumonia.

Key considerations on nebulization of antimicrobial agents to mechanically ventilated patients.

PubMed

Rello, J; Rouby, J J; Sole-Lleonart, C; Chastre, J; Blot, S; Luyt, C E; Riera, J; Vos, M C; Monsel, A; Dhanani, J; Roberts, J A

2017-09-01

Nebulized antibiotics have an established role in patients with cystic fibrosis or bronchiectasis. Their potential benefit to treat respiratory infections in mechanically ventilated patients is receiving increasing interest. In this consensus statement of the European Society of Clinical Microbiology and Infectious Diseases, the body of evidence of the therapeutic utility of aerosolized antibiotics in mechanically ventilated patients was reviewed and resulted in the following recommendations: Vibrating-mesh nebulizers should be preferred to jet or ultrasonic nebulizers. To decrease turbulence and limit circuit and tracheobronchial deposition, we recommend: (a) the use of specifically designed respiratory circuits avoiding sharp angles and characterized by smooth inner surfaces, (b) the use of specific ventilator settings during nebulization including use of a volume controlled mode using constant inspiratory flow, tidal volume 8 mL/kg, respiratory frequency 12 to 15 bpm, inspiratory:expiratory ratio 50%, inspiratory pause 20% and positive end-expiratory pressure 5 to 10 cm H 2 O and (c) the administration of a short-acting sedative agent if coordination between the patient and the ventilator is not obtained, to avoid patient's flow triggering and episodes of peak decelerating inspiratory flow. A filter should be inserted on the expiratory limb to protect the ventilator flow device and changed between each nebulization to avoid expiratory flow obstruction. A heat and moisture exchanger and/or conventional heated humidifier should be stopped during the nebulization period to avoid a massive loss of aerosolized particles through trapping and condensation. If these technical requirements are not followed, there is a high risk of treatment failure and adverse events in mechanically ventilated patients receiving nebulized antibiotics for pneumonia. Copyright © 2017 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights

Outcomes for patients with Guillain-Barré syndrome requiring mechanical ventilation: a literature review.

PubMed

de Boisanger, L

2016-02-01

This is a literature review of outcomes for patients with Guillain-Barré Syndrome (GBS) who require admission to the intensive care unit for mechanical ventilation. Respiratory distress is the leading cause of death in the acute phase, and occurs in about 25 % of patients. The aim of this review is to compile, analyse, and summarise the most relevant literature looking at outcomes for Guillain-Barré (GB) patients requiring admission to the intensive care unit and mechanical ventilation. A PubMed and Google-Scholar literature search was performed using the key words 'Guillain-Barré, Outcomes, Mechanical Ventilation, Prognosis, Mortality, ICU. All 7 papers from the years 2000-2014 which assessed outcomes for GBS patients requiring mechanical ventilation were included, and critically analysed. The parameters recorded by these studies looked at mortality, disability, length of hospitalisation, and complications. The mortality of GB patients requiring mechanical ventilation varied from 8.3 to 20 %, Disability was primarily measured by the GBS disability scale. One study deemed that a score of 0-1 was a positive outcome, and found that slightly over half 53.8 % of the patients fulfilled that criteria. Over half of the mechanically ventilated patients were required to be admitted for over 3 weeks. Complications during ICU admission are common, with bed-sores (40 %), pneumonia (30.2 %) and sepsis (17.4) being the most frequently encountered in one study. Accurate data are limited by the fact that these studies are retrospective, often covering long periods in the past. Larger, more recent, prospective, multi-centre studies will be required.

Impact of fiber-optic laryngoscopy on the weaning process from mechanical ventilation in high-risk patients for postextubation stridor.

PubMed

Lemyze, Malcolm; Durville, Emmanuelle; Meddour, Mehdi; Jonard, Marie; Temime, Johanna; Barailler, Stéphanie; Thevenin, Didier; Mallat, Jihad

2017-02-01

The objective of this study was to assess the impact of fiber-optic laryngoscopy (FOL) on the weaning process from mechanical ventilation in critically ill patients with a positive cuff leak test (CLT) as compared with the current recommended strategy based on corticosteroids.In this prospective observational pilot study conducted over a 1-year period in a 15-bed ICU, CLT was systematically performed before extubation in all intubated patients having passed a spontaneous breathing trial (SBT). After the endotracheal tube cuff was deflated, cuff leak volume (CLVol) was assessed during assisted controlled ventilation. When CLT was positive (CLVol < 110 mL), patients either were evaluated using FOL by our half-time FOL-practitioner when present, or received corticosteroids.Among the 233 patients included, 34 (14.6%) had a positive CLT that hampered extubation. Seventeen were treated by corticosteroids and 17 were evaluated by FOL. In the corticosteroids group, the CLVol was still <110 mL at 24 hours in 9 patients (53%). Corticosteroids strategy merely prolonged the total duration of mechanical ventilation (7 [4-11] vs 4 [2-6] days, P = 0.01) by increasing the time between successful SBT and the moment when extubation was effectively achieved (30 [24-60] vs 1.5 [1-2] hours, P < 0.001). This resulted in 2 self-extubations (12%) and 9 FOL-guided extubations (53%) in the corticosteroids group. Massive swelling of the arytenoids was the most common feature shown by FOL. The patients evaluated by FOL who exhibited the thin anterior V-shaped opening of the vocal cords-the V sign-(n = 26, 100%) were immediately extubated without any stridor or respiratory failure afterward.In this pilot study, a FOL-based extubation strategy was feasible and reliable, and significantly reduced the duration of mechanical ventilation in patients with a positive CLT. We describe the "V sign" of FOL that safely allows a successful prompt extubation in patients considered at

Respiratory Mechanics and Plasma Levels of Tumor Necrosis Factor Alpha and Interleukin 6 Are Affected by Gas Humidification during Mechanical Ventilation in Dogs

PubMed Central

Hernández-Jiménez, Claudia; García-Torrentera, Rogelio; Olmos-Zúñiga, J. Raúl; Jasso-Victoria, Rogelio; Gaxiola-Gaxiola, Miguel O.; Baltazares-Lipp, Matilde; Gutiérrez-González, Luis H.

2014-01-01

The use of dry gases during mechanical ventilation has been associated with the risk of serious airway complications. The goal of the present study was to quantify the plasma levels of TNF-alpha and IL-6 and to determine the radiological, hemodynamic, gasometric, and microscopic changes in lung mechanics in dogs subjected to short-term mechanical ventilation with and without humidification of the inhaled gas. The experiment was conducted for 24 hours in 10 dogs divided into two groups: Group I (n = 5), mechanical ventilation with dry oxygen dispensation, and Group II (n = 5), mechanical ventilation with oxygen dispensation using a moisture chamber. Variance analysis was used. No changes in physiological, hemodynamic, or gasometric, and radiographic constants were observed. Plasma TNF-alpha levels increased in group I, reaching a maximum 24 hours after mechanical ventilation was initiated (ANOVA p = 0.77). This increase was correlated to changes in mechanical ventilation. Plasma IL-6 levels decreased at 12 hours and increased again towards the end of the study (ANOVA p>0.05). Both groups exhibited a decrease in lung compliance and functional residual capacity values, but this was more pronounced in group I. Pplat increased in group I (ANOVA p = 0.02). Inhalation of dry gas caused histological lesions in the entire respiratory tract, including pulmonary parenchyma, to a greater extent than humidified gas. Humidification of inspired gases can attenuate damage associated with mechanical ventilation. PMID:25036811

Respiratory mechanics and plasma levels of tumor necrosis factor alpha and interleukin 6 are affected by gas humidification during mechanical ventilation in dogs.

PubMed

Hernández-Jiménez, Claudia; García-Torrentera, Rogelio; Olmos-Zúñiga, J Raúl; Jasso-Victoria, Rogelio; Gaxiola-Gaxiola, Miguel O; Baltazares-Lipp, Matilde; Gutiérrez-González, Luis H

2014-01-01

The use of dry gases during mechanical ventilation has been associated with the risk of serious airway complications. The goal of the present study was to quantify the plasma levels of TNF-alpha and IL-6 and to determine the radiological, hemodynamic, gasometric, and microscopic changes in lung mechanics in dogs subjected to short-term mechanical ventilation with and without humidification of the inhaled gas. The experiment was conducted for 24 hours in 10 dogs divided into two groups: Group I (n = 5), mechanical ventilation with dry oxygen dispensation, and Group II (n = 5), mechanical ventilation with oxygen dispensation using a moisture chamber. Variance analysis was used. No changes in physiological, hemodynamic, or gasometric, and radiographic constants were observed. Plasma TNF-alpha levels increased in group I, reaching a maximum 24 hours after mechanical ventilation was initiated (ANOVA p = 0.77). This increase was correlated to changes in mechanical ventilation. Plasma IL-6 levels decreased at 12 hours and increased again towards the end of the study (ANOVA p>0.05). Both groups exhibited a decrease in lung compliance and functional residual capacity values, but this was more pronounced in group I. Pplat increased in group I (ANOVA p = 0.02). Inhalation of dry gas caused histological lesions in the entire respiratory tract, including pulmonary parenchyma, to a greater extent than humidified gas. Humidification of inspired gases can attenuate damage associated with mechanical ventilation.

Weaning from mechanical ventilation in paediatrics. State of the art.

PubMed

Valenzuela, Jorge; Araneda, Patricio; Cruces, Pablo

2014-03-01

Weaning from mechanical ventilation is one of the greatest volume and strength issues in evidence-based medicine in critically ill adults. In these patients, weaning protocols and daily interruption of sedation have been implemented, reducing the duration of mechanical ventilation and associated morbidity. In paediatrics, the information reported is less consistent, so that as yet there are no reliable criteria for weaning and extubation in this patient group. Several indices have been developed to predict the outcome of weaning. However, these have failed to replace clinical judgement, although some additional measurements could facilitate this decision. Copyright © 2012 SEPAR. Published by Elsevier Espana. All rights reserved.

Collective fluid mechanics of honeybee nest ventilation

NASA Astrophysics Data System (ADS)

Gravish, Nick; Combes, Stacey; Wood, Robert J.; Peters, Jacob

2014-11-01

Honeybees thermoregulate their brood in the warm summer months by collectively fanning their wings and creating air flow through the nest. During nest ventilation workers flap their wings in close proximity in which wings continuously operate in unsteady oncoming flows (i.e. the wake of neighboring worker bees) and near the ground. The fluid mechanics of this collective aerodynamic phenomena are unstudied and may play an important role in the physiology of colony life. We have performed field and laboratory observations of the nest ventilation wing kinematics and air flow generated by individuals and groups of honeybee workers. Inspired from these field observations we describe here a robotic model system to study collective flapping wing aerodynamics. We microfabricate arrays of 1.4 cm long flapping wings and observe the air flow generated by arrays of two or more fanning robotic wings. We vary phase, frequency, and separation distance among wings and find that net output flow is enhanced when wings operate at the appropriate phase-distance relationship to catch shed vortices from neighboring wings. These results suggest that by varying position within the fanning array honeybee workers may benefit from collective aerodynamic interactions during nest ventilation.

Closed-loop mechanical ventilation for lung injury: a novel physiological-feedback mode following the principles of the open lung concept.

PubMed

Schwaiberger, David; Pickerodt, Philipp A; Pomprapa, Anake; Tjarks, Onno; Kork, Felix; Boemke, Willehad; Francis, Roland C E; Leonhardt, Steffen; Lachmann, Burkhard

2018-06-01

Adherence to low tidal volume (V T ) ventilation and selected positive end-expiratory pressures are low during mechanical ventilation for treatment of the acute respiratory distress syndrome. Using a pig model of severe lung injury, we tested the feasibility and physiological responses to a novel fully closed-loop mechanical ventilation algorithm based on the "open lung" concept. Lung injury was induced by surfactant washout in pigs (n = 8). Animals were ventilated following the principles of the "open lung approach" (OLA) using a fully closed-loop physiological feedback algorithm for mechanical ventilation. Standard gas exchange, respiratory- and hemodynamic parameters were measured. Electrical impedance tomography was used to quantify regional ventilation distribution during mechanical ventilation. Automatized mechanical ventilation provided strict adherence to low V T -ventilation for 6 h in severely lung injured pigs. Using the "open lung" approach, tidal volume delivery required low lung distending pressures, increased recruitment and ventilation of dorsal lung regions and improved arterial blood oxygenation. Physiological feedback closed-loop mechanical ventilation according to the principles of the open lung concept is feasible and provides low tidal volume ventilation without human intervention. Of importance, the "open lung approach"-ventilation improved gas exchange and reduced lung driving pressures by opening atelectasis and shifting of ventilation to dorsal lung regions.

Mechanical Ventilation

MedlinePlus

... to stay in as long as needed. At times a person can talk with a trach tube in place by using a special adapter called a speaking valve . (For more information on having a tracheostomy see ATS patient information series at www. thoracic. org/ patients) . The ventilator blows ...

Field and Laboratory Testing of Approaches to Smart Whole-House Mechanical Ventilation Control

DOE Office of Scientific and Technical Information (OSTI.GOV)

Martin, Eric; Fenaughty, Karen; Parker, Danny

Whole-house mechanical ventilation is a critical component to a comprehensive strategy for good indoor air quality (IAQ). However, due to lack of integration with standard heating and cooling systems, and perceptions from a portion of the homebuilding industry about risks related to increased energy use, increased cost, and decreased comfort, voluntary and code-required adoption varies among regions. Smart ventilation controls (SVC) balance energy consumption, comfort, and IAQ by optimizing mechanical ventilation operation to reduce the heating and/or cooling loads, improve management of indoor moisture, and maintain IAQ equivalence according to ASHRAE 62.2.

Field and Laboratory Testing of Approaches to Smart Whole-House Mechanical Ventilation Control

DOE Office of Scientific and Technical Information (OSTI.GOV)

Martin, Eric; Fenaughty, Karen; Parker, Danny

Whole-house mechanical ventilation is a critical component to a comprehensive strategy for good indoor air quality (IAQ). However, due to lack of integration with standard heating and cooling systems, and perceptions from a portion of the homebuilding industry about risks related to increased energy use, increased cost, and decreased comfort, voluntary and code-required adoption varies amongst regions. Smart ventilation controls (SVC) balance energy consumption, comfort, and IAQ by optimizing mechanical ventilation operation to reduce the heating and/or cooling loads, improve management of indoor moisture, and maintain IAQ equivalence according to ASHRAE 62.2.

[Nasal CPAP versus mechanical ventilation in 28 to 32-week preterm infants with early surfactant administration].

PubMed

Pérez, Luis Alfonso; González, Diana Marcela; Álvarez, Karen Margarita de Jesús; Díaz-Martínez, Luis Alfonso

2014-01-01

Continuous positive airway pressure (CPAP) is useful in low birth weight infants with respiratory distress, but it is not known if it is a better alternative to mechanical ventilation after early pulmonary surfactant administration. To compare the incidence of adverse events in 28 to 32-week newborns with respiratory distress managed with mechanical ventilation or CPAP after early surfactant administration. In total, 176 newborns were treated with CPAP and 147 with mechanical ventilation, all with Apgar scores >3 at five minutes and without apnea. The incidence of CPAP failure was 6.5% (95% CI: 11.3-22.8%); 29 patients died: 7 with CPAP (4.0%) and 22 with mechanical ventilation (15.0%, p<0.001). The relative risk of dying with CPAP versus mechanical ventilation was 0.27 (95% CI: 0.12-0.61), but after adjusting for confounding factors, CPAP use did not imply a higher risk of dying (RR=0.60; 95% CI: 0.29-1.24). Mechanical ventilation fatality rate was 5.70 (95% CI: 3.75-8.66) deaths/1,000 days-patient, while with CPAP it was 1.37 (95% CI: 0.65-2.88, p<0.001). Chronic lung disease incidence was lower with CPAP than with mechanical ventilation (RR=0.71; 95% CI: 0.54-0.96), as were intracranial hemorrhage (RR=0.28, 95% CI: 0.09-0.84) and sepsis (RR=0.67; 95%CI: 0.52-0.86), and it was similar for air leaks (RR=2.51; 95% CI: 0.83-7.61) and necrotizing enterocolitis (RR=1.68, 95% CI: 0.59-4.81). CPAP exposure of premature infants with respiratory distress syndrome is protective against chronic lung disease, intraventricular hemorrhage and sepsis compared to mechanical ventilation. No differences were observed regarding air leak syndrome or death.

46 CFR 154.1200 - Mechanical ventilation system: General.

Code of Federal Regulations, 2011 CFR

2011-10-01

... gas-safe space in the cargo area. (4) Each space that contains inert gas generators, except main...) Each cargo compressor room, pump room, gas-dangerous cargo control station, and space that contains... following must have a supply-type mechanical ventilation system: (1) Each space that contains electric...

Humidification and secretion volume in mechanically ventilated patients.

PubMed

Solomita, Mario; Palmer, Lucy B; Daroowalla, Feroza; Liu, Jeffrey; Miller, Dori; LeBlanc, Deniese S; Smaldone, Gerald C

2009-10-01

To determine potential effects of humidification on the volume of airway secretions in mechanically ventilated patients. Water vapor delivery from devices providing non-heated-wire humidification, heated-wire humidification, and heat and moisture exchanger (HME) were quantified on the bench. Then, patients requiring 24-hour mechanical ventilation were exposed sequentially to each of these humidification devices, and secretions were removed and measured by suctioning every hour during the last 4 hours of the 24-hour study period. In vitro water vapor delivery was greater using non-heated-wire humidification, compared to heated-wire humidification and HME. In vivo, a total of 9 patients were studied. Secretion volume following humidification by non-heated-wire humidification was significantly greater than for heated-wire humidification and HME (P=.004). The volume of secretions appeared to be linked to humidification, as greater water vapor delivery measured in vitro was associated with greater secretion volume in vivo.

Actual performance of mechanical ventilators in ICU: a multicentric quality control study.

PubMed

Govoni, Leonardo; Dellaca', Raffaele L; Peñuelas, Oscar; Bellani, Giacomo; Artigas, Antonio; Ferrer, Miquel; Navajas, Daniel; Pedotti, Antonio; Farré, Ramon

2012-01-01

Even if the performance of a given ventilator has been evaluated in the laboratory under very well controlled conditions, inappropriate maintenance and lack of long-term stability and accuracy of the ventilator sensors may lead to ventilation errors in actual clinical practice. The aim of this study was to evaluate the actual performances of ventilators during clinical routines. A resistance (7.69 cmH(2)O/L/s) - elastance (100 mL/cmH(2)O) test lung equipped with pressure, flow, and oxygen concentration sensors was connected to the Y-piece of all the mechanical ventilators available for patients in four intensive care units (ICUs; n = 66). Ventilators were set to volume-controlled ventilation with tidal volume = 600 mL, respiratory rate = 20 breaths/minute, positive end-expiratory pressure (PEEP) = 8 cmH(2)O, and oxygen fraction = 0.5. The signals from the sensors were recorded to compute the ventilation parameters. The average ± standard deviation and range (min-max) of the ventilatory parameters were the following: inspired tidal volume = 607 ± 36 (530-723) mL, expired tidal volume = 608 ± 36 (530-728) mL, peak pressure = 20.8 ± 2.3 (17.2-25.9) cmH(2)O, respiratory rate = 20.09 ± 0.35 (19.5-21.6) breaths/minute, PEEP = 8.43 ± 0.57 (7.26-10.8) cmH(2)O, oxygen fraction = 0.49 ± 0.014 (0.41-0.53). The more error-prone parameters were the ones related to the measure of flow. In several cases, the actual delivered mechanical ventilation was considerably different from the set one, suggesting the need for improving quality control procedures for these machines.

Atelectasis and mechanical ventilation mode during conservative oxygen therapy: A before-and-after study.

PubMed

Suzuki, Satoshi; Eastwood, Glenn M; Goodwin, Mark D; Noë, Geertje D; Smith, Paul E; Glassford, Neil; Schneider, Antoine G; Bellomo, Rinaldo

2015-12-01

The purpose of the study is to assess the effect of a conservative oxygen therapy (COT) (target SpO2 of 90%-92%) on radiological atelectasis and mechanical ventilation modes. We conducted a secondary analysis of 105 intensive care unit patients from a pilot before-and-after study. The primary outcomes of this study were changes in atelectasis score (AS) of 555 chest radiographs assessed by radiologists blinded to treatment allocation and time to weaning from mandatory ventilation and first spontaneous ventilation trial (SVT). There was a significant difference in overall AS between groups, and COT was associated with lower time-weighted average AS. In addition, in COT patients, change from mandatory to spontaneous ventilation or time to first SVT was shortened. After adjustment for baseline characteristics and interactions between oxygen therapy, radiological atelectasis, and mechanical ventilation management, patients in the COT group had significantly lower "best" AS (adjusted odds ratio, 0.28 [95% confidence interval {CI}, 0.12-0.66]; P=.003) and greater improvement in AS in the first 7 days (adjusted odds ratio, 0.42 [95% CI, 0.17-0.99]; P=.049). Moreover, COT was associated with significantly earlier successful weaning from a mandatory ventilation mode (adjusted hazard ratio, 2.96 [95% CI, 1.73-5.04]; P<.001) and with shorter time to first SVT (adjusted hazard ratio, 1.77 [95% CI, 1.13-2.78]; P=.013). In mechanically ventilated intensive care unit patients, COT might be associated with decreased radiological evidence of atelectasis, earlier weaning from mandatory ventilation modes, and earlier first trial of spontaneous ventilation. Copyright © 2015 Elsevier Inc. All rights reserved.

Older patients with late-stage COPD: Their illness experiences and involvement in decision-making regarding mechanical ventilation and noninvasive ventilation.

PubMed

Jerpseth, Heidi; Dahl, Vegard; Nortvedt, Per; Halvorsen, Kristin

2018-02-01

To explore the illness experiences of older patients with late-stage chronic obstructive pulmonary disease and to develop knowledge about how patients perceive their preferences to be taken into account in decision-making processes concerning mechanical ventilation and/or noninvasive ventilation. Decisions about whether older patients with late-stage chronic obstructive pulmonary disease will benefit from noninvasive ventilation treatment or whether the time has come for palliative treatment are complicated, both medically and ethically. Knowledge regarding patients' values and preferences concerning ventilation support is crucial yet often lacking. Qualitative design with a hermeneutic-phenomenological approach. The data consist of qualitative in-depth interviews with 12 patients from Norway diagnosed with late-stage chronic obstructive pulmonary disease. The data were analysed within the three interpretative contexts described by Kvale and Brinkmann. The participants described their lives as fragile and burdensome, frequently interrupted by unpredictable and frightening exacerbations. They lacked information about their diagnosis and prognosis and were often not included in decisions about noninvasive ventilation or mechanical ventilation. Findings indicate that these patients are highly vulnerable and have complex needs in terms of nursing care and medical treatment. Moreover, they need access to proactive advanced care planning and an opportunity to discuss their wishes for treatment and care. To provide competent care for these patients, healthcare personnel must be aware of how patients experience being seriously ill. Advanced care planning and shared decision-making should be initiated alongside the curative treatment. © 2017 John Wiley & Sons Ltd.

[Cases and duration of mechanical ventilation in German hospitals : An analysis of DRG incentives and developments in respiratory medicine].

PubMed

Biermann, A; Geissler, A

2016-09-01

Diagnosis-related groups (DRGs) have been used to reimburse hospitals services in Germany since 2003/04. Like any other reimbursement system, DRGs offer specific incentives for hospitals that may lead to unintended consequences for patients. In the German context, specific procedures and their documentation are suspected to be primarily performed to increase hospital revenues. Mechanical ventilation of patients and particularly the duration of ventilation, which is an important variable for the DRG-classification, are often discussed to be among these procedures. The aim of this study was to examine incentives created by the German DRG-based payment system with regard to mechanical ventilation and to identify factors that explain the considerable increase of mechanically ventilated patients in recent years. Moreover, the assumption that hospitals perform mechanical ventilation in order to gain economic benefits was examined. In order to gain insights on the development of the number of mechanically ventilated patients, patient-level data provided by the German Federal Statistical Office and the German Institute for the Hospital Remuneration System were analyzed. The type of performed ventilation, the total number of ventilation hours, the age distribution, mortality and the DRG distribution for mechanical ventilation were calculated, using methods of descriptive and inferential statistics. Furthermore, changes in DRG-definitions and changes in respiratory medicine were compared for the years 2005-2012. Since the introduction of the DRG-based payment system in Germany, the hours of ventilation and the number of mechanically ventilated patients have substantially increased, while mortality has decreased. During the same period there has been a switch to less invasive ventilation methods. The age distribution has shifted to higher age-groups. A ventilation duration determined by DRG definitions could not be found. Due to advances in respiratory medicine, new

Comparison of exogenous surfactant therapy, mechanical ventilation with high end-expiratory pressure and partial liquid ventilation in a model of acute lung injury.

PubMed

Hartog, A; Vazquez de Anda, G F; Gommers, D; Kaisers, U; Verbrugge, S J; Schnabel, R; Lachmann, B

1999-01-01

We have compared three treatment strategies, that aim to prevent repetitive alveolar collapse, for their effect on gas exchange, lung mechanics, lung injury, protein transfer into the alveoli and surfactant system, in a model of acute lung injury. In adult rats, the lungs were ventilated mechanically with 100% oxygen and a PEEP of 6 cm H2O, and acute lung injury was induced by repeated lung lavage to obtain a PaO2 value < 13 kPa. Animals were then allocated randomly (n = 12 in each group) to receive exogenous surfactant therapy, ventilation with high PEEP (18 cm H2O), partial liquid ventilation or ventilation with low PEEP (8 cm H2O) (ventilated controls). Blood-gas values were measured hourly. At the end of the 4-h study, in six animals per group, pressure-volume curves were constructed and bronchoalveolar lavage (BAL) was performed, whereas in the remaining animals lung injury was assessed. In the ventilated control group, arterial oxygenation did not improve and protein concentration of BAL and conversion of active to non-active surfactant components increased significantly. In the three treatment groups, PaO2 increased rapidly to > 50 kPa and remained stable over the next 4 h. The protein concentration of BAL fluid increased significantly only in the partial liquid ventilation group. Conversion of active to non-active surfactant components increased significantly in the partial liquid ventilation group and in the group ventilated with high PEEP. In the surfactant group and partial liquid ventilation groups, less lung injury was found compared with the ventilated control group and the group ventilated with high PEEP. We conclude that although all three strategies improved PaO2 to > 50 kPa, the impact on protein transfer into the alveoli, surfactant system and lung injury differed markedly.

Respiratory pathogen colonization of dental plaque, the lower airways, and endotracheal tube biofilms during mechanical ventilation.

PubMed

Sands, Kirsty M; Wilson, Melanie J; Lewis, Michael A O; Wise, Matt P; Palmer, Nicki; Hayes, Anthony J; Barnes, Rosemary A; Williams, David W

2017-02-01

In mechanically ventilated patients, the endotracheal tube is an essential interface between the patient and ventilator, but inadvertently, it also facilitates the development of ventilator-associated pneumonia (VAP) by subverting pulmonary host defenses. A number of investigations suggest that bacteria colonizing the oral cavity may be important in the etiology of VAP. The present study evaluated microbial changes that occurred in dental plaque and lower airways of 107 critically ill mechanically ventilated patients. Dental plaque and lower airways fluid was collected during the course of mechanical ventilation, with additional samples of dental plaque obtained during the entirety of patients' hospital stay. A "microbial shift" occurred in dental plaque, with colonization by potential VAP pathogens, namely, Staphylococcus aureus and Pseudomonas aeruginosa in 35 patients. Post-extubation analyses revealed that 70% and 55% of patients whose dental plaque included S aureus and P aeruginosa, respectively, reverted back to having a predominantly normal oral microbiota. Respiratory pathogens were also isolated from the lower airways and within the endotracheal tube biofilms. To the best of our knowledge, this is the largest study to date exploring oral microbial changes during both mechanical ventilation and after recovery from critical illness. Based on these findings, it was apparent that during mechanical ventilation, dental plaque represents a source of potential VAP pathogens. Copyright © 2016 Elsevier Inc. All rights reserved.

Increasing the inspiratory time and I:E ratio during mechanical ventilation aggravates ventilator-induced lung injury in mice.

PubMed

Müller-Redetzky, Holger C; Felten, Matthias; Hellwig, Katharina; Wienhold, Sandra-Maria; Naujoks, Jan; Opitz, Bastian; Kershaw, Olivia; Gruber, Achim D; Suttorp, Norbert; Witzenrath, Martin

2015-01-28

Lung-protective ventilation reduced acute respiratory distress syndrome (ARDS) mortality. To minimize ventilator-induced lung injury (VILI), tidal volume is limited, high plateau pressures are avoided, and positive end-expiratory pressure (PEEP) is applied. However, the impact of specific ventilatory patterns on VILI is not well defined. Increasing inspiratory time and thereby the inspiratory/expiratory ratio (I:E ratio) may improve oxygenation, but may also be harmful as the absolute stress and strain over time increase. We thus hypothesized that increasing inspiratory time and I:E ratio aggravates VILI. VILI was induced in mice by high tidal-volume ventilation (HVT 34 ml/kg). Low tidal-volume ventilation (LVT 9 ml/kg) was used in control groups. PEEP was set to 2 cm H2O, FiO2 was 0.5 in all groups. HVT and LVT mice were ventilated with either I:E of 1:2 (LVT 1:2, HVT 1:2) or 1:1 (LVT 1:1, HVT 1:1) for 4 hours or until an alternative end point, defined as mean arterial blood pressure below 40 mm Hg. Dynamic hyperinflation due to the increased I:E ratio was excluded in a separate group of animals. Survival, lung compliance, oxygenation, pulmonary permeability, markers of pulmonary and systemic inflammation (leukocyte differentiation in lung and blood, analyses of pulmonary interleukin-6, interleukin-1β, keratinocyte-derived chemokine, monocyte chemoattractant protein-1), and histopathologic pulmonary changes were analyzed. LVT 1:2 or LVT 1:1 did not result in VILI, and all individuals survived the ventilation period. HVT 1:2 decreased lung compliance, increased pulmonary neutrophils and cytokine expression, and evoked marked histologic signs of lung injury. All animals survived. HVT 1:1 caused further significant worsening of oxygenation, compliance and increased pulmonary proinflammatory cytokine expression, and pulmonary and blood neutrophils. In the HVT 1:1 group, significant mortality during mechanical ventilation was observed. According to the "baby lung

Opioid analgesia in mechanically ventilated children: results from the multicenter Measuring Opioid Tolerance Induced by Fentanyl study.

PubMed

Anand, Kanwaljeet J S; Clark, Amy E; Willson, Douglas F; Berger, John; Meert, Kathleen L; Zimmerman, Jerry J; Harrison, Rick; Carcillo, Joseph A; Newth, Christopher J L; Bisping, Stephanie; Holubkov, Richard; Dean, J Michael; Nicholson, Carol E

2013-01-01

To examine the clinical factors associated with increased opioid dose among mechanically ventilated children in the pediatric intensive care unit. Prospective, observational study with 100% accrual of eligible patients. Seven pediatric intensive care units from tertiary-care children's hospitals in the Collaborative Pediatric Critical Care Research Network. Four hundred nineteen children treated with morphine or fentanyl infusions. None. Data on opioid use, concomitant therapy, demographic and explanatory variables were collected. Significant variability occurred in clinical practices, with up to 100-fold differences in baseline opioid doses, average daily or total doses, or peak infusion rates. Opioid exposure for 7 or 14 days required doubling of the daily opioid dose in 16% patients (95% confidence interval 12%-19%) and 20% patients (95% confidence interval 16%-24%), respectively. Among patients receiving opioids for longer than 3 days (n = 225), this occurred in 28% (95% confidence interval 22%-33%) and 35% (95% confidence interval 29%-41%) by 7 or 14 days, respectively. Doubling of the opioid dose was more likely to occur following opioid infusions for 7 days or longer (odds ratio 7.9, 95% confidence interval 4.3-14.3; p < 0.001) or co-therapy with midazolam (odds ratio 5.6, 95% confidence interval 2.4-12.9; p < 0.001), and it was less likely to occur if morphine was used as the primary opioid (vs. fentanyl) (odds ratio 0.48, 95% confidence interval 0.25-0.92; p = 0.03), for patients receiving higher initial doses (odds ratio 0.96, 95% confidence interval 0.95-0.98; p < 0.001), or if patients had prior pediatric intensive care unit admissions (odds ratio 0.37, 95% confidence interval 0.15-0.89; p = 0.03). Mechanically ventilated children require increasing opioid doses, often associated with prolonged opioid exposure or the need for additional sedation. Efforts to reduce prolonged opioid exposure and clinical practice variation may prevent the complications of

Inspired gas humidity and temperature during mechanical ventilation with the Stephanie ventilator.

PubMed

Preo, Bianca L; Shadbolt, Bruce; Todd, David A

2013-11-01

To measure inspired gas humidity and temperature delivered by a Stephanie neonatal ventilator with variations in (i) circuit length; (ii) circuit insulation; (iii) proximal airway temperature probe (pATP) position; (iv) inspiratory temperature (offset); and (v) incubator temperatures. Using the Stephanie neonatal ventilator, inspired gas humidity and temperature were measured during mechanical ventilation at the distal inspiratory limb and 3 cm down the endotracheal tube. Measurements were made with a long or short circuit; with or without insulation of the inspiratory limb; proximal ATP (pATP) either within or external to the incubator; at two different inspiratory temperature (offset) of 37(-0.5) and 39(-2.0)°C; and at three different incubator temperatures of 32, 34.5, and 37°C. Long circuits produced significantly higher inspired humidity than short circuits at all incubator settings, while only at 32°C was the inspired temperature higher. In the long circuits, insulation further improved the inspired humidity especially at 39(-2.0)°C, while only at incubator temperatures of 32 and 37°C did insulation significantly improve inspired temperature. Positioning the pATP outside the incubator did not result in higher inspired humidity but did significantly improve inspired temperature. An inspiratory temperature (offset) of 39(-2.0)°C delivered significantly higher inspired humidity and temperature than the 37(-0.5)°C especially when insulated. Long insulated Stephanie circuits should be used for neonatal ventilation when the infant is nursed in an incubator. The recommended inspiratory temperature (offset) of 37(-0.5)°C produced inspired humidity and temperature below international standards, and we suggest an increase to 39(-2.0)°C. © 2013 John Wiley & Sons Ltd.

Shortening the length of stay and mechanical ventilation time by using positive suggestions via MP3 players for ventilated patients.

PubMed

K Szilágyi, Adrienn; Diószeghy, Csaba; Fritúz, Gábor; Gál, János; Varga, Katalin

2014-03-01

Long stay in intensive care unit (ICU) and prolonged ventilation are deleterious for subsequent quality of life and surcharge financial capacity. We have already demonstrated the beneficial effects of using suggestive communication on recovery time during intensive care. The aim of our present study was to prove the same effects with standardized positive suggestive message delivered by an MP3 player. Patients ventilated in ICU were randomized into a control group receiving standard ICU treatment and two groups with a standardized pre-recorded material delivered via headphones: a suggestive message about safety, self-control, and recovery for the study group and a relaxing music for the music group. Groups were similar in terms of age, gender, and mortality, but the SAPS II scores were higher in the study group than that in the controls (57.8 ± 23.6 vs. 30.1 ± 15.5 and 33.7 ± 17.4). Our post-hoc analysis results showed that the length of ICU stay (134.2 ± 73.3 vs. 314.2 ± 178.4 h) and the time spent on ventilator (85.2 ± 34.9 vs. 232.0 ± 165.6 h) were significantly shorter in the study group compared to the unified control. The advantage of the structured positive suggestive message was proven against both music and control groups.

Shortening the length of stay and mechanical ventilation time by using positive suggestions via MP3 players for ventilated patients

PubMed Central

Diószeghy, Csaba; Fritúz, Gábor; Gál, János; Varga, Katalin

2014-01-01

Long stay in intensive care unit (ICU) and prolonged ventilation are deleterious for subsequent quality of life and surcharge financial capacity. We have already demonstrated the beneficial effects of using suggestive communication on recovery time during intensive care. The aim of our present study was to prove the same effects with standardized positive suggestive message delivered by an MP3 player. Patients ventilated in ICU were randomized into a control group receiving standard ICU treatment and two groups with a standardized pre-recorded material delivered via headphones: a suggestive message about safety, self-control, and recovery for the study group and a relaxing music for the music group. Groups were similar in terms of age, gender, and mortality, but the SAPS II scores were higher in the study group than that in the controls (57.8 ± 23.6 vs. 30.1 ± 15.5 and 33.7 ± 17.4). Our post-hoc analysis results showed that the length of ICU stay (134.2 ± 73.3 vs. 314.2 ± 178.4 h) and the time spent on ventilator (85.2 ± 34.9 vs. 232.0 ± 165.6 h) were significantly shorter in the study group compared to the unified control. The advantage of the structured positive suggestive message was proven against both music and control groups. PMID:24672669

Low tidal volume and high positive end-expiratory pressure mechanical ventilation results in increased inflammation and ventilator-associated lung injury in normal lungs.

PubMed

Hong, Caron M; Xu, Da-Zhong; Lu, Qi; Cheng, Yunhui; Pisarenko, Vadim; Doucet, Danielle; Brown, Margaret; Aisner, Seena; Zhang, Chunxiang; Deitch, Edwin A; Delphin, Ellise

2010-06-01

Protective mechanical ventilation with low tidal volume (Vt) and low plateau pressure reduces mortality and decreases the length of mechanical ventilation in patients with acute respiratory distress syndrome. Mechanical ventilation that will protect normal lungs during major surgical procedures of long duration may improve postoperative outcomes. We performed an animal study comparing 3 ventilation strategies used in the operating room in normal lungs. We compared the effects on pulmonary mechanics, inflammatory mediators, and lung tissue injury. Female pigs were randomized into 3 groups. Group H-Vt/3 (n = 6) was ventilated with a Vt of 15 mL/kg predicted body weight (PBW)/positive end-expiratory pressure (PEEP) of 3 cm H(2)O, group L-Vt/3 (n = 6) with a Vt of 6 mL/kg PBW/PEEP of 3 cm H(2)O, and group L-Vt/10 (n = 6) with a Vt of 6 mL/kg PBW/PEEP of 10 cm H(2)O, for 8 hours. Hemodynamics, airway mechanics, arterial blood gases, and inflammatory markers were monitored. Bronchoalveolar lavage (BAL) was analyzed for inflammatory markers and protein concentration. The right lower lobe was assayed for mRNA of specific cytokines. The right lower lobe and right upper lobe were evaluated histologically. In contrast to groups H-Vt/3 and L-Vt/3, group L-Vt/10 exhibited a 6-fold increase in inflammatory mediators in BAL (P < 0.001). Cytokines in BAL were similar in groups H-Vt/3 and L-Vt/3. Group H-Vt/3 had a significantly lower lung injury score than groups L-Vt/3 and L-Vt/10. Comparing intraoperative strategies, ventilation with high PEEP resulted in increased production of inflammatory markers. Low PEEP resulted in lower levels of inflammatory markers. High Vt/low PEEP resulted in less histologic lung injury.

Home tracheotomy mechanical ventilation in patients with amyotrophic lateral sclerosis: causes, complications and 1-year survival.

PubMed

Sancho, Jesús; Servera, Emilio; Díaz, José Luis; Bañuls, Pilar; Marín, Julio

2011-11-01

Home tracheotomy mechanical ventilation (HTMV) can prolong survival in patients with amyotrophic lateral sclerosis (ALS) when non-invasive ventilation (NIV) fails, but knowledge about HTMV is scarce. The aim of this study was to determine the causes of tracheotomy and the main issues of 1-year HTMV in a cohort of patients with ALS. A prospective study of all patients needing HTMV was performed in a referral respiratory care unit (RCU) from April 2001 to January 2010. Patients' informed decisions about HTMV were fully respected. Caregivers were trained and could telephone the RCU. Hospital staff made home visits. All patients (n=116) agreed to participate and a tracheotomy was needed for 76, mainly due to bulbar dysfunction. Of the 38 who had a tracheotomy, in 21 it was performed in an acute setting and in 17 as a non-emergency procedure. In 19 patients the tracheotomy was related to the inadequacy of mechanically assisted coughing (MAC) to maintain normal oxygen saturation. During HTMV, 19 patients required hospitalisation, 12 with respiratory problems. The 1-year survival rate was 78.9%, with a mean survival of 10.39 months (95% CI 9.36 to 11.43). Sudden death was the main cause of death (n=9) and only one patient died from respiratory causes. No predictive factors for survival were found. Besides NIV inadequacy, the ineffectiveness of mechanically assisted coughing appears to be a relevant cause of tracheotomy for patients with ALS with severe bulbar dysfunction. Patients choosing HTMV provided by a referral RCU could have a good 1-year survival rate, respiratory problems being the main cause of hospitalisation but not of death.

The effects of prone position ventilation in patients with acute respiratory distress syndrome. A systematic review and metaanalysis.

PubMed

Mora-Arteaga, J A; Bernal-Ramírez, O J; Rodríguez, S J

2015-01-01

Prone position ventilation has been shown to improve oxygenation and ventilatory mechanics in patients with acute respiratory distress syndrome. We evaluated whether prone ventilation reduces the risk of mortality in adult patients with acute respiratory distress syndrome versus supine ventilation. A metaanalysis of randomized controlled trials comparing patients in supine versus prone position was performed. A search was conducted of the Pubmed, Embase, Cochrane Library, and LILACS databases. Mortality, hospital length of stay, days of mechanical ventilation and adverse effects were evaluated. Seven randomized controlled trials (2,119 patients) were included in the analysis. The prone position showed a nonsignificant tendency to reduce mortality (OR: 0.76; 95%CI: 0.54 to 1.06; P=.11, I(2) 63%). When stratified by subgroups, a significant decrease was seen in the risk of mortality in patients ventilated with low tidal volume (OR: 0.58; 95%CI: 0.38 to 0.87; P=.009, I(2) 33%), prolonged pronation (OR: 0.6; 95%CI: 0.43 to 0.83; p=.002, I(2) 27%), start within the first 48hours of disease evolution (OR 0.49; 95%CI 0.35 to 0.68; P=.0001, I(2) 0%) and severe hypoxemia (OR: 0.51: 95%CI: 0.36 to 1.25; P=.0001, I(2) 0%). Adverse effects associated with pronation were the development of pressure ulcers and endotracheal tube obstruction. Prone position ventilation is a safe strategy and reduces mortality in patients with severely impaired oxygenation. It should be started early, for prolonged periods, and should be associated to a protective ventilation strategy. Copyright © 2014 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.

Accuracy of tidal volume delivered by home mechanical ventilation during mouthpiece ventilation

PubMed Central

Prigent, Helene; Falaize, Line; Leroux, Karl; Santos, Dante; Vaugier, Isabelle; Orlikowski, David; Lofaso, Frederic

2016-01-01

The aim of our study was to evaluate efficacy and reliability of currently available ventilators for mouthpiece ventilation (MPV). Five life-support home ventilators were assessed in a bench test using different settings simulating the specificities of MPV, such as intermittent circuit disconnection and presence of continuous leaks. The intermittent disconnection of the circuit caused relevant swings in the delivered tidal volume (VT), showing a VT overshoot during the disconnection periods and a VT decrease when the interface was reconnected to the test lung. The five ventilators showed substantial differences in the number of respiratory cycles necessary to reach a stable VT in the volume-controlled setting, ranging from 1.3 ± 0.6 to 7.3 ± 1.2 cycles. These differences were less accentuated in the volume-assisted setting (MPV-dedicated mode, when available). Our data show large differences in the capacity of the different ventilators to deal with the rapidly changing respiratory load features that characterize MPV, which can be further accentuated according to the used ventilator setting. The dedicated MPV modes allow improvement in the performance of ventilators only in some defined situations. This has practical consequences for the choice of the ventilator to be used for MPV in a specific patient. PMID:27146811

Music preferences of mechanically ventilated patients participating in a randomized controlled trial.

PubMed

Heiderscheit, Annie; Breckenridge, Stephanie J; Chlan, Linda L; Savik, Kay

2014-01-01

Mechanical ventilation (MV) is a life-saving measure and supportive modality utilized to treat patients experiencing respiratory failure. Patients experience pain, discomfort, and anxiety as a result of being mechanically ventilated. Music listening is a non-pharmacological intervention used to manage these psychophysiological symptoms associated with mechanical ventilation. The purpose of this secondary analysis was to examine music preferences of 107 MV patients enrolled in a randomized clinical trial that implemented a patient-directed music listening protocol to help manage the psychophysiological symptom of anxiety. Music data presented includes the music genres and instrumentation patients identified as their preferred music. Genres preferred include: classical, jazz, rock, country, and oldies. Instrumentation preferred include: piano, voice, guitar, music with nature sounds, and orchestral music. Analysis of three patients' preferred music received throughout the course of the study is illustrated to demonstrate the complexity of assessing MV patients and the need for an ongoing assessment process.

Music preferences of mechanically ventilated patients participating in a randomized controlled trial

PubMed Central

Heiderscheit, Annie; Breckenridge, Stephanie J.; Chlan, Linda L.; Savik, Kay

2014-01-01

Mechanical ventilation (MV) is a life-saving measure and supportive modality utilized to treat patients experiencing respiratory failure. Patients experience pain, discomfort, and anxiety as a result of being mechanically ventilated. Music listening is a non-pharmacological intervention used to manage these psychophysiological symptoms associated with mechanical ventilation. The purpose of this secondary analysis was to examine music preferences of 107 MV patients enrolled in a randomized clinical trial that implemented a patient-directed music listening protocol to help manage the psychophysiological symptom of anxiety. Music data presented includes the music genres and instrumentation patients identified as their preferred music. Genres preferred include: classical, jazz, rock, country, and oldies. Instrumentation preferred include: piano, voice, guitar, music with nature sounds, and orchestral music. Analysis of three patients’ preferred music received throughout the course of the study is illustrated to demonstrate the complexity of assessing MV patients and the need for an ongoing assessment process. PMID:25574992

Early application of airway pressure release ventilation may reduce the duration of mechanical ventilation in acute respiratory distress syndrome.

PubMed

Zhou, Yongfang; Jin, Xiaodong; Lv, Yinxia; Wang, Peng; Yang, Yunqing; Liang, Guopeng; Wang, Bo; Kang, Yan

2017-11-01

Experimental animal models of acute respiratory distress syndrome (ARDS) have shown that the updated airway pressure release ventilation (APRV) methodologies may significantly improve oxygenation, maximize lung recruitment, and attenuate lung injury, without circulatory depression. This led us to hypothesize that early application of APRV in patients with ARDS would allow pulmonary function to recover faster and would reduce the duration of mechanical ventilation as compared with low tidal volume lung protective ventilation (LTV). A total of 138 patients with ARDS who received mechanical ventilation for <48 h between May 2015 to October 2016 while in the critical care medicine unit (ICU) of the West China Hospital of Sichuan University were enrolled in the study. Patients were randomly assigned to receive APRV (n = 71) or LTV (n = 67). The settings for APRV were: high airway pressure (P high ) set at the last plateau airway pressure (P plat ), not to exceed 30 cmH 2 O) and low airway pressure ( P low ) set at 5 cmH 2 O; the release phase (T low ) setting adjusted to terminate the peak expiratory flow rate to ≥ 50%; release frequency of 10-14 cycles/min. The settings for LTV were: target tidal volume of 6 mL/kg of predicted body weight; P plat not exceeding 30 cmH 2 O; positive end-expiratory pressure (PEEP) guided by the PEEP-FiO 2 table according to the ARDSnet protocol. The primary outcome was the number of days without mechanical ventilation from enrollment to day 28. The secondary endpoints included oxygenation, P plat , respiratory system compliance, and patient outcomes. Compared with the LTV group, patients in the APRV group had a higher median number of ventilator-free days {19 [interquartile range (IQR) 8-22] vs. 2 (IQR 0-15); P < 0.001}. This finding was independent of the coexisting differences in chronic disease. The APRV group had a shorter stay in the ICU (P = 0.003). The ICU mortality rate was 19.7% in the APRV group versus 34.3% in the

[Intraoperative monitoring in artificial respiration of premature and newborn infants. I. Monitoring of respiratory parameters and alveolar ventilation].

PubMed

Lenz, G; Heipertz, W; Leidig, E; Madee, S

1986-06-01

Monitoring of ventilation serves to ensure adequate alveolar ventilation and arterial oxygenation, and to avoid pulmonary damage due to mechanical ventilation. Basic clinical monitoring, i.e., inspection, auscultation (including precordial or oesophageal stethoscope) and monitoring of heart rate and blood pressure, is mandatory. Mechanical ventilation is monitored by ventilation pressures (peak pressure, plateau pressure and endexpiratory pressure), ventilation volumes (measured at the in/expiratory valve of the respirator and by hot-wire anemometry at the tube connector), ventilation rate, and inspiratory oxygen concentration (FiO2). Alveolar ventilation should be continuously and indirectly recorded by capnometry (pECO2) and by measurement of transcutaneous pCO2 (tcpCO2), whereas oxygenation is determined via measurement of transcutaneous pO2 (tcpO2). Invasive monitoring of gas exchange is essential in prolonged or intrathoracic interventions as well as in neonates with cardiopulmonary problems. paCO2 may be estimated by capillary or venous blood gas analysis; arterial blood gas analysis is required for exact determination of paCO2 as well as arteriocutaneous pCO2 (atcDCO2) and arterio-end-expiratory (aEDCO2) gradients.

[Likeness between respiratory responses on CO2 in conditions of natural breathing and voluntary-controlled mechanical ventilation].

PubMed

Pogodin, M A; Granstrem, M P; Dimitrienko, A I

2007-04-01

We did Read CO2 rebreathing tests in 8 adult males. Both at natural breathing, and at self-controlled mechanical ventilation, volunteers increased ventilation proportionally to growth end-tidal PCO2. Inside individual distinctions of responses to CO2 during controlled mechanical ventilation are result of the voluntary motor control.

Mechanical Ventilation and ARDS in the ED: A Multicenter, Observational, Prospective, Cross-sectional Study.

PubMed

Fuller, Brian M; Mohr, Nicholas M; Miller, Christopher N; Deitchman, Andrew R; Levine, Brian J; Castagno, Nicole; Hassebroek, Elizabeth C; Dhedhi, Adam; Scott-Wittenborn, Nicholas; Grace, Edward; Lehew, Courtney; Kollef, Marin H

2015-08-01

There are few data regarding mechanical ventilation and ARDS in the ED. This could be a vital arena for prevention and treatment. This study was a multicenter, observational, prospective, cohort study aimed at analyzing ventilation practices in the ED. The primary outcome was the incidence of ARDS after admission. Multivariable logistic regression was used to determine the predictors of ARDS. We analyzed 219 patients receiving mechanical ventilation to assess ED ventilation practices. Median tidal volume was 7.6 mL/kg predicted body weight (PBW) (interquartile range, 6.9-8.9), with a range of 4.3 to 12.2 mL/kg PBW. Lung-protective ventilation was used in 122 patients (55.7%). The incidence of ARDS after admission from the ED was 14.7%, with a mean onset of 2.3 days. Progression to ARDS was associated with higher illness severity and intubation in the prehospital environment or transferring facility. Of the 15 patients with ARDS in the ED (6.8%), lung-protective ventilation was used in seven (46.7%). Patients who progressed to ARDS experienced greater duration in organ failure and ICU length of stay and higher mortality. Lung-protective ventilation is infrequent in patients receiving mechanical ventilation in the ED, regardless of ARDS status. Progression to ARDS is common after admission, occurs early, and worsens outcome. Patient- and treatment-related factors present in the ED are associated with ARDS. Given the limited treatment options for ARDS, and the early onset after admission from the ED, measures to prevent onset and to mitigate severity should be instituted in the ED. ClinicalTrials.gov; No.: NCT01628523; URL: www.clinicaltrials.gov.

[Lung protective ventilation. Ventilatory modes and ventilator parameters].

PubMed

Schädler, Dirk; Weiler, Norbert

2008-06-01

Mechanical ventilation has a considerable potential for injuring the lung tissue. Therefore, attention has to be paid to the proper choice of ventilatory mode and settings to secure lung-protective ventilation whenever possible. Such ventilator strategy should account for low tidal volume ventilation (6 ml/kg PBW), limited plateau pressure (30 to 35 cm H2O) and positive end-expiratory pressure (PEEP). It is unclear whether pressure controlled or volume controlled ventilation with square flow profile is beneficial. The adjustment of inspiration and expiration time should consider the actual breathing mechanics and anticipate the generation of intrinsic PEEP. Ventilatory modes with the possibility of supporting spontaneous breathing should be used as soon as possible.

Validation of Intensive Care and Mechanical Ventilation Codes in Medicare Data.

PubMed

Wunsch, Hannah; Kramer, Andrew; Gershengorn, Hayley B

2017-07-01

To assess the reliability of codes relevant to critically ill patients in administrative data. Retrospective cohort study linking data from Acute Physiology and Chronic Health Evaluation Outcomes, a clinical database of ICU patients with data from Medicare Provider Analysis and Review. We linked data based on matching for sex, date of birth, hospital, and date of admission to hospital. Forty-six hospitals in the United States participating in Acute Physiology and Chronic Health Evaluation Outcomes. All patients in Acute Physiology and Chronic Health Evaluation Outcomes greater than or equal to 65 years old who could be linked with hospitalization records in Medicare Provider Analysis and Review from January 1, 2009, through September 30, 2012. Of 62,451 patients in the Acute Physiology and Chronic Health Evaluation Outcomes dataset, 80.1% were matched with data in Medicare Provider Analysis and Review. All but 2.7% of Acute Physiology and Chronic Health Evaluation Outcomes ICU patients had either an ICU or coronary care unit charge in Medicare Provider Analysis and Review. In Acute Physiology and Chronic Health Evaluation Outcomes, 37.0% received mechanical ventilation during the ICU stay versus 24.1% in Medicare Provider Analysis and Review. The Medicare Provider Analysis and Review procedure codes for mechanical ventilation had high specificity (96.0%; 95% CI, 95.8-96.2), but only moderate sensitivity (58.4%; 95% CI, 57.7-59.1), with a positive predictive value of 89.6% (95% CI, 89.1-90.1) and negative predictive value of 79.7% (95% CI, 79.4-80.1). For patients with mechanical ventilation codes, Medicare Provider Analysis and Review overestimated the percentage with a duration greater than 96 hours (36.6% vs 27.3% in Acute Physiology and Chronic Health Evaluation Outcomes). There was discordance in the hospital discharge status (alive or dead) for only 0.47% of all linked records (κ = 1.00). Medicare Provider Analysis and Review data contain robust information

Effects of assisted and variable mechanical ventilation on cardiorespiratory interactions in anesthetized pigs.

PubMed

Beda, Alessandro; Güldner, Andreas; Simpson, David M; Carvalho, Nadja C; Franke, Susanne; Uhlig, Christopher; Koch, Thea; Pelosi, Paolo; de Abreu, Marcelo Gama

2012-03-01

The physiological importance of respiratory sinus arrhythmia (RSA) and cardioventilatory coupling (CVC) has not yet been fully elucidated, but these phenomena might contribute to improve ventilation/perfusion matching, with beneficial effects on gas exchange. Furthermore, decreased RSA amplitude has been suggested as an indicator of impaired autonomic control and poor clinical outcome, also during positive-pressure mechanical ventilation (MV). However, it is currently unknown how different modes of MV, including variable tidal volumes (V(T)), affect RSA and CVC during anesthesia. We compared the effects of pressure controlled (PCV) versus pressure assisted (PSV) ventilation, and of random variable versus constant V(T), on RSA and CVC in eight anesthetized pigs. At comparable depth of anesthesia, global hemodynamics, and ventilation, RSA amplitude increased from 20 ms in PCV to 50 ms in PSV (p < 0.05). CVC was detected (using proportional Shannon entropy of the interval between each inspiration onset and the previous R-peak in ECG) in two animals in PCV and seven animals in PSV. Variable V(T) did not significantly influence these phenomena. Furthermore, heart period and systolic arterial pressure oscillations were in phase during PCV but in counter-phase during PSV. At the same depth of anesthesia in pigs, PSV increases RSA amplitude and CVC compared to PCV. Our data suggest that the central respiratory drive, but not the baroreflex or the mechano-electric feedback in the heart, is the main mechanism behind the RSA increase. Hence, differences in RSA and CVC between mechanically ventilated patients might reflect the difference in ventilation mode rather than autonomic impairment. Also, since gas exchange did not increase from PCV to PSV, it is questionable whether RSA has any significance in improving ventilation/perfusion matching during MV.

Predictors for mechanical ventilation and short-term prognosis in patients with Guillain-Barré syndrome.

PubMed

Wu, Xiujuan; Li, Chunrong; Zhang, Bing; Shen, Donghui; Li, Ting; Liu, Kangding; Zhang, Hong-Liang

2015-09-02

Guillain-Barré syndrome (GBS) is an immune-mediated disorder of the peripheral nervous system. Respiratory failure requiring mechanical ventilation (MV) is a serious complication of GBS. Identification of modifiable risk factors for MV and poor short-term prognosis in mechanically ventilated patients with GBS may contribute to the individualized management and may help improve the outcome of the patients. We retrospectively analyzed the clinical data of 541 patients who were diagnosed with GBS from 2003 to 2014. Independent predictors for MV and short-term prognosis in mechanically ventilated patients were identified via multivariate logistic regression analysis. The mean age was 41.6 years with a male predilection (61.2%). Eighty patients (14.8%) required MV. Multivariate analysis revealed that shorter interval from onset to admission (p < 0.05), facial nerve palsy (p < 0.01), glossopharyngeal and vagal nerve deficits (p < 0.01) and lower Medical Research Council (MRC) sum score at nadir (p < 0.01) were risk factors for MV; disease occurrence in summer (p < 0.01) was a protective factor. As to prognostic factors, absence of antecedent infections (p < 0.01) and lower MRC sum score at nadir (p < 0.01) were predictors of poor short-term prognosis in mechanically ventilated patients regardless of treatment modality. We further investigated the predictors of poor short-term prognosis in patients requiring MV with different nadir MRC sum scores. Combined use of intravenous corticosteroids with intravenous immunoglobulin (odds ratio 10.200, 95% confidence interval 1.068-97.407, p < 0.05) was an independent predictor of poor short-term prognosis in mechanically ventilated patients with a nadir MRC sum score from 0 to 12 points, regardless of existence of antecedent infection. Clinical predictors of MV and poor short-term prognosis in mechanically ventilated GBS patients were distinct. Add-on use of intravenous corticosteroids was a risk factor for poor short

Efficacy of continuous versus intermittent subglottic secretion drainage in preventing ventilator-associated pneumonia in patients requiring mechanical ventilation: A single-center randomized controlled trial.

PubMed

Fujimoto, Hiroko; Yamaguchi, Osamu; Hayami, Hajime; Shimosaka, Mika; Tsuboi, Sayaka; Sato, Mitsunori; Takebayashi, Shigeo; Morita, Satoshi; Saito, Mari; Goto, Takahisa; Kurahashi, Kiyoyasu

2018-03-23

Aspiration of subglottic secretion is a widely used intervention to prevent ventilator-associated pneumonia (VAP). This study aimed to compare the efficacy of continuous and intermittent subglottic secretion drainage (SSD) in preventing VAP. A single-center randomized controlled trial was conducted on adult postoperative patients who were expected to undergo mechanical ventilation for more than 48 hours. Primary outcome measure was incidence of VAP and secondary outcome measures were length of mechanical ventilation and intensive-care unit (ICU) stay. Fifty-nine patients received continuous SSD, while 60 patients received intermittent SSD. Of these 119 patients, 88 (74%) were excluded and 15 and 16 patients were allocated to receive continuous and intermittent SSD, respectively. VAP was detected in 4 (26.7%) and 7 (43.8%) patients in the continuous and intermittent groups, respectively, (p=0.320). The length of mechanical ventilation was significantly shorter (p=0.034) in the continuous group (99.5±47.1 h) than in the intermittent group (159.9±94.5 h). The length of ICU stay was also shorter (p=0.0097) in the continuous group (6.3±2.1 days) than the intermittent group (9.8±4.8 days). Although continuous SSD did not reduce the incidence of VAP, it reduced the length of mechanical ventilation and ICU stay when compared to intermittent SSD.

Studying the Power of the Integrative Weaning Index in Predicting the Success Rate of the Spontaneous Breathing Trial in Patients under Mechanical Ventilation.

PubMed

Ebrahimabadi, Sahar; Moghadam, Ahmad Bagheri; Vakili, Mohammadali; Modanloo, Mahnaz; Khoddam, Homeira

2017-08-01

The use of weaning predictive indicators can avoid early extubation and wrongful prolonged mechanical ventilation. This study aimed to determine the power of the integrative weaning index (IWI) in predicting the success rate of the spontaneous breathing trial (SBT) in patients under mechanical ventilation. In this prospective study, 105 patients undergoing mechanical ventilation for over 48 h were enrolled. Before weaning initiation, the IWI was calculated and based on the defined cutoff point (≥25), the success rate of the SBT was predicted. In case of weaning from the device, 2-h SBT was performed and the physiologic and respiratory indices were continuously studied while being intubated. If they were in the normal range besides the patient's tolerance, the test was considered as a success. The result was then compared with the IWI and further analyzed. The SBT was successful in 90 (85.7%) and unsuccessful in 15 (14.3%) cases. The difference between the true patient outcome after SBT, and the IWI prediction was 0.143 according to the Kappa agreement coefficient ( P < 0.001). Moreover, regarding the predictive power, IWI had high sensitivity (95.6%), specificity (40%), positive and negative predictive values (90.5% and 60), positive and negative likelihood ratios (1.59 and 0.11), and accuracy (86.7%). The IWI as a more objective indicator has acceptable accuracy and power for predicting the 2-h SBT result. Therefore, in addition to the reliable prediction of the final weaning outcome, it has favorable power to predict if the patient is ready to breathe spontaneously as the first step to weaning.

The Society for Translational Medicine: clinical practice guidelines for mechanical ventilation management for patients undergoing lobectomy.

PubMed

Gao, Shugeng; Zhang, Zhongheng; Brunelli, Alessandro; Chen, Chang; Chen, Chun; Chen, Gang; Chen, Haiquan; Chen, Jin-Shing; Cassivi, Stephen; Chai, Ying; Downs, John B; Fang, Wentao; Fu, Xiangning; Garutti, Martínez I; He, Jianxing; He, Jie; Hu, Jian; Huang, Yunchao; Jiang, Gening; Jiang, Hongjing; Jiang, Zhongmin; Li, Danqing; Li, Gaofeng; Li, Hui; Li, Qiang; Li, Xiaofei; Li, Yin; Li, Zhijun; Liu, Chia-Chuan; Liu, Deruo; Liu, Lunxu; Liu, Yongyi; Ma, Haitao; Mao, Weimin; Mao, Yousheng; Mou, Juwei; Ng, Calvin Sze Hang; Petersen, René H; Qiao, Guibin; Rocco, Gaetano; Ruffini, Erico; Tan, Lijie; Tan, Qunyou; Tong, Tang; Wang, Haidong; Wang, Qun; Wang, Ruwen; Wang, Shumin; Xie, Deyao; Xue, Qi; Xue, Tao; Xu, Lin; Xu, Shidong; Xu, Songtao; Yan, Tiansheng; Yu, Fenglei; Yu, Zhentao; Zhang, Chunfang; Zhang, Lanjun; Zhang, Tao; Zhang, Xun; Zhao, Xiaojing; Zhao, Xuewei; Zhi, Xiuyi; Zhou, Qinghua

2017-09-01

Patients undergoing lobectomy are at significantly increased risk of lung injury. One-lung ventilation is the most commonly used technique to maintain ventilation and oxygenation during the operation. It is a challenge to choose an appropriate mechanical ventilation strategy to minimize the lung injury and other adverse clinical outcomes. In order to understand the available evidence, a systematic review was conducted including the following topics: (I) protective ventilation (PV); (II) mode of mechanical ventilation [e.g., volume controlled (VCV) versus pressure controlled (PCV)]; (III) use of therapeutic hypercapnia; (IV) use of alveolar recruitment (open-lung) strategy; (V) pre-and post-operative application of positive end expiratory pressure (PEEP); (VI) Inspired Oxygen concentration; (VII) Non-intubated thoracoscopic lobectomy; and (VIII) adjuvant pharmacologic options. The recommendations of class II are non-intubated thoracoscopic lobectomy may be an alternative to conventional one-lung ventilation in selected patients. The recommendations of class IIa are: (I) Therapeutic hypercapnia to maintain a partial pressure of carbon dioxide at 50-70 mmHg is reasonable for patients undergoing pulmonary lobectomy with one-lung ventilation; (II) PV with a tidal volume of 6 mL/kg and PEEP of 5 cmH 2 O are reasonable methods, based on current evidence; (III) alveolar recruitment [open lung ventilation (OLV)] may be beneficial in patients undergoing lobectomy with one-lung ventilation; (IV) PCV is recommended over VCV for patients undergoing lung resection; (V) pre- and post-operative CPAP can improve short-term oxygenation in patients undergoing lobectomy with one-lung ventilation; (VI) controlled mechanical ventilation with I:E ratio of 1:1 is reasonable in patients undergoing one-lung ventilation; (VII) use of lowest inspired oxygen concentration to maintain satisfactory arterial oxygen saturation is reasonable based on physiologic principles; (VIII) Adjuvant drugs

Development of an Outdoor Temperature-Based Control Algorithm for Residential Mechanical Ventilation Control

DOE Office of Scientific and Technical Information (OSTI.GOV)

Less, Brennan; Walker, Iain; Tang, Yihuan

2014-06-01

Smart ventilation systems use controls to ventilate more during those periods that provide either an energy or IAQ advantage (or both) and less during periods that provide a dis advantage. Using detailed building simulations, this study addresses one of the simplest and lowest cost types of smart controllers —outdoor temperature- based control. If the outdoor temperature falls below a certain cut- off, the fan is simply turned off. T he main principle of smart ventilation used in this study is to shift ventilation from time periods with large indoor -outdoor temperature differences, to periods where these differences are smaller, andmore » their energy impacts are expected to be less. Energy and IAQ performance are assessed relative to a base case of a continuously operated ventilation fan sized to comply with ASHRAE 62.2-2013 whole house ventilation requirements. In order to satisfy 62.2-2013, annual pollutant exposure must be equivalent between the temperature controlled and continuous fan cases. This requires ventilation to be greater than 62.2 requirements when the ventilation system operates. This is achieved by increasing the mechanical ventilation system air flow rates.« less

Lung protective mechanical ventilation and two year survival in patients with acute lung injury: prospective cohort study.

PubMed

Needham, Dale M; Colantuoni, Elizabeth; Mendez-Tellez, Pedro A; Dinglas, Victor D; Sevransky, Jonathan E; Dennison Himmelfarb, Cheryl R; Desai, Sanjay V; Shanholtz, Carl; Brower, Roy G; Pronovost, Peter J

2012-04-05

To evaluate the association of volume limited and pressure limited (lung protective) mechanical ventilation with two year survival in patients with acute lung injury. Prospective cohort study. 13 intensive care units at four hospitals in Baltimore, Maryland, USA. 485 consecutive mechanically ventilated patients with acute lung injury. Two year survival after onset of acute lung injury. 485 patients contributed data for 6240 eligible ventilator settings, as measured twice daily (median of eight eligible ventilator settings per patient; 41% of which adhered to lung protective ventilation). Of these patients, 311 (64%) died within two years. After adjusting for the total duration of ventilation and other relevant covariates, each additional ventilator setting adherent to lung protective ventilation was associated with a 3% decrease in the risk of mortality over two years (hazard ratio 0.97, 95% confidence interval 0.95 to 0.99, P=0.002). Compared with no adherence, the estimated absolute risk reduction in two year mortality for a prototypical patient with 50% adherence to lung protective ventilation was 4.0% (0.8% to 7.2%, P=0.012) and with 100% adherence was 7.8% (1.6% to 14.0%, P=0.011). Lung protective mechanical ventilation was associated with a substantial long term survival benefit for patients with acute lung injury. Greater use of lung protective ventilation in routine clinical practice could reduce long term mortality in patients with acute lung injury. Clinicaltrials.gov NCT00300248.

Mechanical delivery of aerosolized gadolinium-DTPA for pulmonary ventilation assessment in MR imaging.

PubMed

Haage, P; Adam, G; Karaagac, S; Pfeffer, J; Glowinski, A; Döhmen, S; Günther, R W

2001-04-01

To evaluate a new technique with mechanical administration of aerosolized gadolinium (Gd)-DTPA for MR visualization of lung ventilation. Ten experimental procedures were performed in six domestic pigs. Gd-DTPA was aerosolized by a small-particle generator. The intubated animals were mechanically aerosolized with the nebulized contrast agent and studied on a 1.5-T MR imager. Respiratory gated T1-weighted turbo spin-echo images were obtained before, during, and after contrast administration. Pulmonary signal intensity (SI) changes were calculated for corresponding regions of both lungs. Homogeneity of aerosol distribution was graded independently by two radiologists. To achieve a comparable SI increase as attained in previous trials that used manual aerosol ventilation, a ventilation period of 20 minutes (formerly 30 minutes) was sufficient. Mean SI changes of 116% were observed after that duration. Contrast delivery was rated evenly distributed in all cases by the reviewers. The feasibility of applying Gd-DTPA as a contrast agent to demonstrate pulmonary ventilation in large animals has been described before. The results of this refined technique substantiate the potential of Gd-based ventilation MR imaging by improving aerosol distribution and shortening the nebulization duration in the healthy lung.

Hyperventilation assists proarrhythmia development during delayed repolarization in clofilium-treated, anaesthetized, mechanically ventilated rabbits.

PubMed

Papp, H; Sarusi, A; Farkas, A S; Takacs, H; Kui, P; Vincze, D; Ivany, E; Varro, A; Papp, J G; Forster, T; Farkas, A

2016-10-01

Hyperventilation reduces partial pressure of CO 2 (PCO 2 ) in the blood, which results in hypokalaemia. Hypokalaemia helps the development of the life-threatening torsades de pointes type ventricular arrhythmia (TdP) evoked by repolarization delaying drugs. This implies that hyperventilation may assist the development of proarrhythmic events. Therefore, this study experimentally investigated the effect of hyperventilation on proarrhythmia development during delayed repolarization. Phenylephrine (an α 1 -adrenoceptor agonist) and clofilium (as a representative repolarization delaying agent inhibiting the rapid component of the delayed rectifier potassium current, I Kr ) were administered intravenously to pentobarbital-anaesthetized, mechanically ventilated, open chest rabbits. ECG was recorded, and the onset times and incidences of the arrhythmias were determined. Serum K + , pH and PCO 2 were measured in arterial blood samples. Clofilium prolonged the rate corrected QT interval. TdP occurred in 15 animals (TdP+ group), and did not occur in 14 animals (TdP- group). We found a strong, positive, linear correlation between serum K + and PCO 2 . There was no relationship between the occurrence of TdP and the baseline K + and PCO 2 values. However, a positive, linear correlation was found between the onset time of the first arrhythmias and the K + and PCO 2 values. The regression lines describing the relationship between PCO 2 and onset time of first arrhythmias were parallel in the TdP+ and TdP- groups, but the same PCO 2 resulted in earlier arrhythmia onset in the TdP+ group than in the TdP- group. We conclude that hyperventilation and hypocapnia with the resultant hypokalaemia assist the multifactorial process of proarrhythmia development during delayed repolarization. This implies that PCO 2 and serum K + should be controlled tightly during mechanical ventilation in experimental investigations and clinical settings when repolarization-delaying drugs are applied.

Antibiotic Therapy in Comatose Mechanically Ventilated Patients Following Aspiration: Differentiating Pneumonia From Pneumonitis.

PubMed

Lascarrou, Jean Baptiste; Lissonde, Floriane; Le Thuaut, Aurélie; Bachoumas, Konstantinos; Colin, Gwenhael; Henry Lagarrigue, Matthieu; Vinatier, Isabelle; Fiancette, Maud; Lacherade, Jean Claude; Yehia, Aihem; Joret, Aurélie; Lebert, Christine; Bourdon, Sandra; Martin Lefèvre, Laurent; Reignier, Jean

2017-08-01

To determine the proportion of patients with documented bacterial aspiration pneumonia among comatose ICU patients with symptoms suggesting either bacterial aspiration pneumonia or non-bacterial aspiration pneumonitis. Prospective observational study. University-affiliated 30-bed ICU. Prospective cohort of 250 patients admitted to the ICU with coma (Glasgow Coma Scale score ≤ 8) and treated with invasive mechanical ventilation. None. The primary outcome was the proportion of patients with microbiologically documented bacterial aspiration pneumonia. Patients meeting predefined criteria for aspiration syndrome routinely underwent telescopic plugged catheter sampling during bronchoscopy before starting probabilistic antibiotic treatment. When cultures were negative, the antibiotic treatment was stopped. Of 250 included patients, 98 (39.2%) had aspiration syndrome, including 92 before mechanical ventilation discontinuation. Telescopic plugged catheter in these 92 patients showed bacterial aspiration pneumonia in 43 patients (46.7%). Among the remaining 49 patients, 16 continued to receive antibiotics, usually for infections other than pneumonia; of the 33 patients whose antibiotics were discontinued, only two subsequently showed signs of lung infection. In the six patients with aspiration syndrome after mechanical ventilation, and therefore without telescopic plugged catheter, antibiotic treatment was continued for 7 days. Mechanical ventilation duration, ICU length of stay, and mortality did not differ between the 43 patients with bacterial aspiration pneumonia and the 49 patients with non-bacterial aspiration pneumonitis. The 152 patients without aspiration syndrome did not receive antibiotics. Among comatose patients receiving mechanical ventilation, those without clinical, laboratory, or radiologic evidence of bacterial aspiration pneumonia did not require antibiotics. In those with suspected bacterial aspiration pneumonia, stopping empirical antibiotic therapy

Influence of Mechanical Ventilation on the Incidence of Pneumothorax During Infraclavicular Subclavian Vein Catheterization: A Prospective Randomized Noninferiority Trial.

PubMed

Kim, Eugene; Kim, Hyun Joo; Hong, Deok Man; Park, Hee-Pyoung; Bahk, Jae-Hyon

2016-09-01

It remains unclear whether we have to interrupt mechanical ventilation during infraclavicular subclavian venous catheterization. In practice, the clinicians' choice about lung deflation depends on their own discretion. The purpose of this study was to assess the influence of mechanical ventilation on the incidence of pneumothorax during infraclavicular subclavian venous catheterization. A total of 332 patients, who needed subclavian venous catheterization, were randomly assigned to 1 of the 2 groups: catheterizations were performed with the patients' lungs under mechanical ventilation (ventilation group, n = 165) or without mechanical ventilation (deflation group, n = 167). The incidences of pneumothorax and other complications such as arterial puncture, hemothorax, or catheter misplacements and the success rate of catheterization were compared. The incidences of pneumothorax were 0% (0/165) in the ventilation group and 0.6% (1/167) in the deflation group. The incidence of pneumothorax in the deflation group was 0.6% higher than that in the ventilation group and the 2-sided 90% confidence interval for the difference was (-1.29% to 3.44%). Because the lower bound for the 2-sided 90% confidence interval, -1.29%, was higher than the predefined noninferiority margin of -3%, the inferiority of the ventilation group over the deflation group was rejected at the .05 level of significance. Other complication rates and success rates of catheterization were comparable between 2 groups. The oxygen saturation dropped below 95% in 9 patients in the deflation group, while none in the ventilation group (P = .007). The success and complication rates were similar regardless of mechanical ventilation. During infraclavicular subclavian venous catheterization, interruption of mechanical ventilation does not seem to be necessary for the prevention of pneumothorax.

Nebulized antibiotics in mechanically ventilated patients: roadmap and challenges.

PubMed

Poulakou, G; Siakallis, G; Tsiodras, S; Arfaras-Melainis, A; Dimopoulos, G

2017-03-01

Nebulized antibiotics use has become common practice in the therapeutics of pneumonia in cystic fibrosis patients. There is an increasing interest in their use for respiratory infections in mechanically ventilated (MV) patients in order to a) overcome pharmacokinetic issues in the lung compartment with traditional systemic antibiotic use and b) prevent the emergence of multi-drug-resistant (MDR) pathogens. Areas covered: The beneficial effects of antibiotic nebulization in MV patients e.g. increasing efficacy, reduced toxicity and prevention of resistance are described. Physicochemical parameters of optimal lung deposition, characteristics of currently available nebulizers, practical aspects of the procedure, including drug preparation and adjustments of ventilator and circuit parameter are presented. Antibiotics used in nebulized route, along with efficacy in various clinical indications and safety issues are reviewed. Expert commentary: The safety of nebulization of antibiotics has been proven in numerous studies; efficacy as adjunctive treatment to intravenous regimens or as monotherapy has been demonstrated in ventilator-associated pneumonia or ventilator-associated tracheobronchitis due to MDR or susceptible pathogens. However, due to the heterogeneity of studies, multiple meta-analyses fail to demonstrate a clear effect. Clarification of indications, standardization of technique and implementation of clinical practice guidelines, based on new large-scale trials will lead to the optimal use of nebulized antibiotics.

Reduction of duration and cost of mechanical ventilation in an intensive care unit by use of a ventilatory management team.

PubMed

Cohen, I L; Bari, N; Strosberg, M A; Weinberg, P F; Wacksman, R M; Millstein, B H; Fein, I A

1991-10-01

To test the hypothesis that a formal interdisciplinary team approach to managing ICU patients requiring mechanical ventilation enhances ICU efficiency. Retrospective review with cost-effectiveness analysis. A 20-bed medical-surgical ICU in a 450-bed community referral teaching hospital with a critical care fellowship training program. All patients requiring mechanical ventilation in the ICU were included, comparing patients admitted 1 yr before the inception of the ventilatory management team (group 1) with those patients admitted for 1 yr after the inception of the team (group 2). Group 1 included 198 patients with 206 episodes of mechanical ventilation and group 2 included 165 patients with 183 episodes of mechanical ventilation. A team consisting of an ICU attending physician, nurse, and respiratory therapist was formed to conduct rounds regularly and supervise the ventilatory management of ICU patients who were referred to the critical care service. The two study groups were demographically comparable. However, there were significant reductions in resource use in group 2. The number of days on mechanical ventilation decreased (3.9 days per episode of mechanical ventilation [95% confidence interval 0.3 to 7.5 days]), as did days in the ICU (3.3 days per episode of mechanical ventilation [90% confidence interval 0.3 to 6.3 days]), numbers of arterial blood gases (23.2 per episode of mechanical ventilation; p less than .001), and number of indwelling arterial catheters (1 per episode of mechanical ventilation; p less than .001). The estimated cost savings from these reductions was $1,303 per episode of mechanical ventilation. We conclude that a ventilatory management team, or some component thereof, can significantly and safely expedite the process of "weaning" patients from mechanical ventilatory support in the ICU.

Evaluation of a flexible bronchoscope prototype designed for bronchoscopy during mechanical ventilation: a proof-of-concept study.

PubMed

Nay, M-A; Auvet, A; Mankikian, J; Herve, V; Dequin, P-F; Guillon, A

2017-06-01

Bronchoscopy during mechanical ventilation of patients' lungs significantly affects ventilation because of partial obstruction of the tracheal tube, and may thus be omitted in the most severely ill patients. It has not previously been possible to reduce the external diameter of the bronchoscope without reducing the diameter of the suction channel, thus reducing the suctioning capacity of the device. We believed that a better-designed bronchoscope could improve the safety of bronchoscopy in patients whose lungs were ventilated. We designed a flexible bronchoscope prototype with a drumstick-shaped head consisting of a long, thin proximal portion; a short and large distal portion for camera docking; and a large suction channel throughout the length of the device. The aims of our study were to test the impact of our prototype on mechanical ventilation when inserted into the tracheal tube, and to assess suctioning capacity. We first tested the efficiency of the suction channel, and demonstrated that the suction flow of the prototype was similar to that of conventional adult bronchoscopes. We next evaluated the consequences of bronchoscopy when using the prototype on minute ventilation and intrathoracic pressures during mechanical ventilation: firstly, in vitro using a breathing simulator; and secondly, in vivo using a porcine model of pulmonary ventilation. The insertion of adult bronchoscopes into the tracheal tube immediately impaired the protective ventilation strategy employed, whereas the prototype preserved it. For the first time, we have developed an innovative flexible bronchoscope designed for bronchoscopy during invasive mechanical ventilation, that both preserved the protective ventilation strategy, and enabled efficient suction flow. © 2017 The Association of Anaesthetists of Great Britain and Ireland.

Mechanical ventilation-associated lung fibrosis in acute respiratory distress syndrome: a significant contributor to poor outcome.

PubMed

Cabrera-Benitez, Nuria E; Laffey, John G; Parotto, Matteo; Spieth, Peter M; Villar, Jesús; Zhang, Haibo; Slutsky, Arthur S

2014-07-01

One of the most challenging problems in critical care medicine is the management of patients with the acute respiratory distress syndrome. Increasing evidence from experimental and clinical studies suggests that mechanical ventilation, which is necessary for life support in patients with acute respiratory distress syndrome, can cause lung fibrosis, which may significantly contribute to morbidity and mortality. The role of mechanical stress as an inciting factor for lung fibrosis versus its role in lung homeostasis and the restoration of normal pulmonary parenchymal architecture is poorly understood. In this review, the authors explore recent advances in the field of pulmonary fibrosis in the context of acute respiratory distress syndrome, concentrating on its relevance to the practice of mechanical ventilation, as commonly applied by anesthetists and intensivists. The authors focus the discussion on the thesis that mechanical ventilation-or more specifically, that ventilator-induced lung injury-may be a major contributor to lung fibrosis. The authors critically appraise possible mechanisms underlying the mechanical stress-induced lung fibrosis and highlight potential therapeutic strategies to mitigate this fibrosis.

A randomized clinical trial comparing an extended-use hygroscopic condenser humidifier with heated-water humidification in mechanically ventilated patients.

PubMed

Kollef, M H; Shapiro, S D; Boyd, V; Silver, P; Von Harz, B; Trovillion, E; Prentice, D

1998-03-01

To determine the safety and cost-effectiveness of mechanical ventilation with an extended-use hygroscopic condenser humidifier (Duration; Nellcor Puritan-Bennett; Eden Prairie, Minn) compared with mechanical ventilation with heated-water humidification. Prospective randomized clinical trial. Medical and surgical ICUs of Barnes-Jewish Hospital, St. Louis, a university-affiliated teaching hospital. Three hundred ten consecutive qualified patients undergoing mechanical ventilation. Patients requiring mechanical ventilation were randomly assigned to receive humidification with either an extended-use hygroscopic condenser humidifier (for up to the first 7 days of mechanical ventilation) or heated-water humidification. Occurrence of ventilator-associated pneumonia, endotracheal tube occlusion, duration of mechanical ventilation, lengths of intensive care and hospitalization, acquired multiorgan dysfunction, and hospital mortality. One hundred sixty-three patients were randomly assigned to receive humidification with an extended-use hygroscopic condenser humidifier, and 147 patients were randomly assigned to receive heated-water humidification. The two groups were similar at the time of randomization with regard to demographic characteristics, ICU admission diagnoses, and severity of illness. Risk factors for the development of ventilator-associated pneumonia were also similar during the study period for both treatment groups. Ventilator-associated pneumonia was seen in 15 (9.2%) patients receiving humidification with an extended-use hygroscopic condenser humidifier and in 15 (10.2%) patients receiving heated-water humidification (relative risk, 0.90; 95% confidence interval=0.46 to 1.78; p=0.766). No statistically significant differences for hospital mortality, duration of mechanical ventilation, lengths of stay in the hospital ICU, or acquired organ system derangements were found between the two treatment groups. No episode of endotracheal tube occlusion occurred during

Lung protective mechanical ventilation and two year survival in patients with acute lung injury: prospective cohort study

PubMed Central

Colantuoni, Elizabeth; Mendez-Tellez, Pedro A; Dinglas, Victor D; Sevransky, Jonathan E; Dennison Himmelfarb, Cheryl R; Desai, Sanjay V; Shanholtz, Carl; Brower, Roy G; Pronovost, Peter J

2012-01-01

Objective To evaluate the association of volume limited and pressure limited (lung protective) mechanical ventilation with two year survival in patients with acute lung injury. Design Prospective cohort study. Setting 13 intensive care units at four hospitals in Baltimore, Maryland, USA. Participants 485 consecutive mechanically ventilated patients with acute lung injury. Main outcome measure Two year survival after onset of acute lung injury. Results 485 patients contributed data for 6240 eligible ventilator settings, as measured twice daily (median of eight eligible ventilator settings per patient; 41% of which adhered to lung protective ventilation). Of these patients, 311 (64%) died within two years. After adjusting for the total duration of ventilation and other relevant covariates, each additional ventilator setting adherent to lung protective ventilation was associated with a 3% decrease in the risk of mortality over two years (hazard ratio 0.97, 95% confidence interval 0.95 to 0.99, P=0.002). Compared with no adherence, the estimated absolute risk reduction in two year mortality for a prototypical patient with 50% adherence to lung protective ventilation was 4.0% (0.8% to 7.2%, P=0.012) and with 100% adherence was 7.8% (1.6% to 14.0%, P=0.011). Conclusions Lung protective mechanical ventilation was associated with a substantial long term survival benefit for patients with acute lung injury. Greater use of lung protective ventilation in routine clinical practice could reduce long term mortality in patients with acute lung injury. Trial registration Clinicaltrials.gov NCT00300248. PMID:22491953

Open-lung protective ventilation with pressure control ventilation, high-frequency oscillation, and intratracheal pulmonary ventilation results in similar gas exchange, hemodynamics, and lung mechanics.

PubMed

Sedeek, Khaled A; Takeuchi, Muneyuki; Suchodolski, Klaudiusz; Vargas, Sara O; Shimaoka, Motomu; Schnitzer, Jay J; Kacmarek, Robert M

2003-11-01

Pressure control ventilation (PCV), high-frequency oscillation (HFO), and intratracheal pulmonary ventilation (ITPV) may all be used to provide lung protective ventilation in acute respiratory distress syndrome, but the specific approach that is optimal remains controversial. Saline lavage was used to produce acute respiratory distress syndrome in 21 sheep randomly assigned to receive PCV, HFO, or ITPV as follows: positive end-expiratory pressure (PCV and ITPV) and mean airway pressure (HFO) were set in a pressure-decreasing manner after lung recruitment that achieved a ratio of Pao2/Fio2 > 400 mmHg. Respiratory rates were 30 breaths/min, 120 breaths/min, and 8 Hz, respectively, for PCV, ITPV, and HFO. Eucapnia was targeted with peak carinal pressure of no more than 35 cm H2O. Animals were then ventilated for 4 h. There were no differences among groups in gas exchange, lung mechanics, or hemodynamics. Tidal volume (PCV, 8.9 +/- 2.1 ml/kg; ITPV, 2.7 +/- 0.8 ml/kg; HFO, approximately 2.0 ml/kg) and peak carinal pressure (PCV, 30.6 +/- 2.6 cm H2O; ITPV, 22.3 +/- 4.8 cm H2O; HFO, approximately 24.3 cm H2O) were higher in PCV. Pilot histologic data showed greater interstitial hemorrhage and alveolar septal expansion in PCV than in HFO or ITPV. These data indicate that HFO, ITPV, and PCV when applied with an open-lung protective ventilatory strategy results in the same gas exchange, lung mechanics, and hemodynamic response, but pilot data indicate that lung injury may be greater with PCV.

Communication of mechanically ventilated patients in intensive care units

PubMed Central

Martinho, Carina Isabel Ferreira; Rodrigues, Inês Tello Rato Milheiras

2016-01-01

Objective The aim of this study was to translate and culturally and linguistically adapt the Ease of Communication Scale and to assess the level of communication difficulties for patients undergoing mechanical ventilation with orotracheal intubation, relating these difficulties to clinical and sociodemographic variables. Methods This study had three stages: (1) cultural and linguistic adaptation of the Ease of Communication Scale; (2) preliminary assessment of its psychometric properties; and (3) observational, descriptive-correlational and cross-sectional study, conducted from March to August 2015, based on the Ease of Communication Scale - after extubation answers and clinical and sociodemographic variables of 31 adult patients who were extubated, clinically stable and admitted to five Portuguese intensive care units. Results Expert analysis showed high agreement on content (100%) and relevance (75%). The pretest scores showed a high acceptability regarding the completion of the instrument and its usefulness. The Ease of Communication Scale showed excellent internal consistency (0.951 Cronbach's alpha). The factor analysis explained approximately 81% of the total variance with two scale components. On average, the patients considered the communication experiences during intubation to be "quite hard" (2.99). No significant correlation was observed between the communication difficulties reported and the studied sociodemographic and clinical variables, except for the clinical variable "number of hours after extubation" (p < 0.05). Conclusion This study translated and adapted the first assessment instrument of communication difficulties for mechanically ventilated patients in intensive care units into European Portuguese. The preliminary scale validation suggested high reliability. Patients undergoing mechanical ventilation reported that communication during intubation was "quite hard", and these communication difficulties apparently existed regardless of the

Effects of pleural effusion drainage on oxygenation, respiratory mechanics, and hemodynamics in mechanically ventilated patients.

PubMed

Razazi, Keyvan; Thille, Arnaud W; Carteaux, Guillaume; Beji, Olfa; Brun-Buisson, Christian; Brochard, Laurent; Mekontso Dessap, Armand

2014-09-01

In mechanically ventilated patients, the effect of draining pleural effusion on oxygenation is controversial. We investigated the effect of large pleural effusion drainage on oxygenation, respiratory function (including lung volumes), and hemodynamics in mechanically ventilated patients after ultrasound-guided drainage. Arterial blood gases, respiratory mechanics (airway, pleural and transpulmonary pressures, end-expiratory lung volume, respiratory system compliance and resistance), and hemodynamics (blood pressure, heart rate, and cardiac output) were recorded before and at 3 and 24 hours (H24) after pleural drainage. The respiratory settings were kept identical during the study period. The mean volume of effusion drained was 1,579 ± 684 ml at H24. Uncomplicated pneumothorax occurred in two patients. Respiratory mechanics significantly improved after drainage, with a decrease in plateau pressure and a large increase in end-expiratory transpulmonary pressure. Respiratory system compliance, end-expiratory lung volume, and PaO2/FiO2 ratio all improved. Hemodynamics were not influenced by drainage. Improvement in the PaO2/FiO2 ratio from baseline to H24 was positively correlated with the increase in end-expiratory lung volume during the same time frame (r = 0.52, P = 0.033), but not with drained volume. A high value of pleural pressure or a highly negative transpulmonary pressure at baseline predicted limited lung expansion following effusion drainage. A lesser improvement in oxygenation occurred in patients with ARDS. Drainage of large (≥500 ml) pleural effusion in mechanically ventilated patients improves oxygenation and end-expiratory lung volume. Oxygenation improvement correlated with an increase in lung volume and a decrease in transpulmonary pressure, but was less so in patients with ARDS.

Mechanical ventilation with lower tidal volumes and positive end-expiratory pressure prevents pulmonary inflammation in patients without preexisting lung injury.

PubMed

Wolthuis, Esther K; Choi, Goda; Dessing, Mark C; Bresser, Paul; Lutter, Rene; Dzoljic, Misa; van der Poll, Tom; Vroom, Margreeth B; Hollmann, Markus; Schultz, Marcus J

2008-01-01

Mechanical ventilation with high tidal volumes aggravates lung injury in patients with acute lung injury or acute respiratory distress syndrome. The authors sought to determine the effects of short-term mechanical ventilation on local inflammatory responses in patients without preexisting lung injury. Patients scheduled to undergo an elective surgical procedure (lasting > or = 5 h) were randomly assigned to mechanical ventilation with either higher tidal volumes of 12 ml/kg ideal body weight and no positive end-expiratory pressure (PEEP) or lower tidal volumes of 6 ml/kg and 10 cm H2O PEEP. After induction of anesthesia and 5 h thereafter, bronchoalveolar lavage fluid and/or blood was investigated for polymorphonuclear cell influx, changes in levels of inflammatory markers, and nucleosomes. Mechanical ventilation with lower tidal volumes and PEEP (n = 21) attenuated the increase of pulmonary levels of interleukin (IL)-8, myeloperoxidase, and elastase as seen with higher tidal volumes and no PEEP (n = 19). Only for myeloperoxidase, a difference was found between the two ventilation strategies after 5 h of mechanical ventilation (P < 0.01). Levels of tumor necrosis factor alpha, IL-1alpha, IL-1beta, IL-6, macrophage inflammatory protein 1alpha, and macrophage inflammatory protein 1beta in the bronchoalveolar lavage fluid were not affected by mechanical ventilation. Plasma levels of IL-6 and IL-8 increased with mechanical ventilation, but there were no differences between the two ventilation groups. The use of lower tidal volumes and PEEP may limit pulmonary inflammation in mechanically ventilated patients without preexisting lung injury. The specific contribution of both lower tidal volumes and PEEP on the protective effects of the lung should be further investigated.

Community analysis of dental plaque and endotracheal tube biofilms from mechanically ventilated patients.

PubMed

Marino, Poala J; Wise, Matt P; Smith, Ann; Marchesi, Julian R; Riggio, Marcello P; Lewis, Michael A O; Williams, David W

2017-06-01

Mechanically ventilated patients are at risk for developing ventilator-associated pneumonia, and it has been reported that dental plaque provides a reservoir of respiratory pathogens that may aspirate to the lungs and endotracheal tube (ETT) biofilms. For the first time, metataxonomics was used to simultaneously characterize the microbiome of dental plaque, ETTs, and non-directed bronchial lavages (NBLs) in mechanically ventilated patients to determine similarities in respective microbial communities and therefore likely associations. Bacterial 16S rRNA gene sequences from 34 samples of dental plaque, NBLs, and ETTs from 12 adult mechanically ventilated patients were analyzed. No significant differences in the microbial communities of these samples were evident. Detected bacteria were primarily oral species (e.g., Fusobacterium nucleatum, Streptococcus salivarius, Prevotella melaninogenica) with respiratory pathogens (Staphylococcus aureus, Pseudomonas aeruginosa, Streptococcuspneumoniae, and Haemophilus influenzae) also in high abundance. The high similarity between the microbiomes of dental plaque, NBLs, and ETTs suggests that the oral cavity is indeed an important site involved in microbial aspiration to the lower airway and ETT. As such, maintenance of good oral hygiene is likely to be highly important in limiting aspiration of bacteria in this vulnerable patient group. Copyright © 2017 Elsevier Inc. All rights reserved.

Pulmonary blood flow distribution in sheep: effects of anesthesia, mechanical ventilation, and change in posture

NASA Technical Reports Server (NTRS)

Walther, S. M.; Domino, K. B.; Glenny, R. W.; Hlastala, M. P.

1997-01-01

BACKGROUND: Recent studies providing high-resolution images of pulmonary perfusion have questioned the classical zone model of pulmonary perfusion. Hence the present work was undertaken to provide detailed maps of regional pulmonary perfusion to examine the influence of anesthesia, mechanical ventilation, and posture. METHODS: Pulmonary perfusion was analyzed with intravenous fluorescent microspheres (15 microm) in six sheep studied in four conditions: prone and awake, prone with pentobarbital-anesthesia and breathing spontaneously, prone with anesthesia and mechanical ventilation, and supine with anesthesia and mechanical ventilation. Lungs were air dried at total lung capacity and sectioned into approximately 1,100 pieces (about 2 cm3) per animal. The pieces were weighed and assigned spatial coordinates. Fluorescence was read on a spectrophotometer, and signals were corrected for piece weight and normalized to mean flow. Pulmonary blood flow heterogeneity was assessed using the coefficient of variation of flow data. RESULTS: Pentobarbital anesthesia and mechanical ventilation did not influence perfusion heterogeneity, but heterogeneity increased when the animals were in the supine posture (P < 0.01). Gravitational flow gradients were absent in the prone position but present in the supine (P < 0.001 compared with zero). Pulmonary perfusion was distributed with a hilar-to-peripheral gradient in animals breathing spontaneously (P < 0.05). CONCLUSIONS: The influence of pentobarbital anesthesia and mechanical ventilation on pulmonary perfusion heterogeneity is small compared with the effect of changes in posture. Analysis of flow gradients indicate that gravity plays a small role in determining pulmonary blood flow distribution.

[Non-invasive mechanical ventilation in the treatment of acute heart failure].

PubMed

Alfonso Megido, Joaquín; González Franco, Alvaro

2014-03-01

When acute heart failure progresses and there is acute cardiogenic pulmonary edema, routine therapeutic measures should be accompanied by other measures that help to correct oxygenation of the patient. The final and most drastic step is mechanical ventilation. Non-invasive ventilation has been developed in the last few years as a method that attempts to improve oxygenation without the need for intubation, thus, in theory, reducing morbidity and mortality in these patients. The present article describes the controversies surrounding the results of this technique and discusses its indications. The article also discusses how to start non-invasive ventilation in patients with acute pulmonary edema from a practical point of view. Copyright © 2014 Elsevier España, S.L. All rights reserved.

A new system for continuous and remote monitoring of patients receiving home mechanical ventilation

NASA Astrophysics Data System (ADS)

Battista, L.

2016-09-01

Home mechanical ventilation is the treatment of patients with respiratory failure or insufficiency by means of a mechanical ventilator at a patient's home. In order to allow remote patient monitoring, several tele-monitoring systems have been introduced in the last few years. However, most of them usually do not allow real-time services, as they have their own proprietary communication protocol implemented and some ventilation parameters are not always measured. Moreover, they monitor only some breaths during the whole day, despite the fact that a patient's respiratory state may change continuously during the day. In order to reduce the above drawbacks, this work reports the development of a novel remote monitoring system for long-term, home-based ventilation therapy; the proposed system allows for continuous monitoring of the main physical quantities involved during home-care ventilation (e.g., differential pressure, volume, and air flow rate) and is developed in order to allow observations of different remote therapy units located in different places of a city, region, or country. The developed remote patient monitoring system is able to detect various clinical events (e.g., events of tube disconnection and sleep apnea events) and has been successfully tested by means of experimental tests carried out with pulmonary ventilators typically used to support sick patients.

A new system for continuous and remote monitoring of patients receiving home mechanical ventilation.

PubMed

Battista, L

2016-09-01

Home mechanical ventilation is the treatment of patients with respiratory failure or insufficiency by means of a mechanical ventilator at a patient's home. In order to allow remote patient monitoring, several tele-monitoring systems have been introduced in the last few years. However, most of them usually do not allow real-time services, as they have their own proprietary communication protocol implemented and some ventilation parameters are not always measured. Moreover, they monitor only some breaths during the whole day, despite the fact that a patient's respiratory state may change continuously during the day. In order to reduce the above drawbacks, this work reports the development of a novel remote monitoring system for long-term, home-based ventilation therapy; the proposed system allows for continuous monitoring of the main physical quantities involved during home-care ventilation (e.g., differential pressure, volume, and air flow rate) and is developed in order to allow observations of different remote therapy units located in different places of a city, region, or country. The developed remote patient monitoring system is able to detect various clinical events (e.g., events of tube disconnection and sleep apnea events) and has been successfully tested by means of experimental tests carried out with pulmonary ventilators typically used to support sick patients.

Variability in Usual Care Mechanical Ventilation for Pediatric Acute Respiratory Distress Syndrome: Time for a Decision Support Protocol?

PubMed

Newth, Christopher J L; Sward, Katherine A; Khemani, Robinder G; Page, Kent; Meert, Kathleen L; Carcillo, Joseph A; Shanley, Thomas P; Moler, Frank W; Pollack, Murray M; Dalton, Heidi J; Wessel, David L; Berger, John T; Berg, Robert A; Harrison, Rick E; Holubkov, Richard; Doctor, Allan; Dean, J Michael; Jenkins, Tammara L; Nicholson, Carol E

2017-11-01

Although pediatric intensivists philosophically embrace lung protective ventilation for acute lung injury and acute respiratory distress syndrome, we hypothesized that ventilator management varies. We assessed ventilator management by evaluating changes to ventilator settings in response to blood gases, pulse oximetry, or end-tidal CO2. We also assessed the potential impact that a pediatric mechanical ventilation protocol adapted from National Heart Lung and Blood Institute acute respiratory distress syndrome network protocols could have on reducing variability by comparing actual changes in ventilator settings to those recommended by the protocol. Prospective observational study. Eight tertiary care U.S. PICUs, October 2011 to April 2012. One hundred twenty patients (age range 17 d to 18 yr) with acute lung injury/acute respiratory distress syndrome. Two thousand hundred arterial and capillary blood gases, 3,964 oxygen saturation by pulse oximetry, and 2,757 end-tidal CO2 values were associated with 3,983 ventilator settings. Ventilation mode at study onset was pressure control 60%, volume control 19%, pressure-regulated volume control 18%, and high-frequency oscillatory ventilation 3%. Clinicians changed FIO2 by ±5 or ±10% increments every 8 hours. Positive end-expiratory pressure was limited at ~10 cm H2O as oxygenation worsened, lower than would have been recommended by the protocol. In the first 72 hours of mechanical ventilation, maximum tidal volume/kg using predicted versus actual body weight was 10.3 (8.5-12.9) (median [interquartile range]) versus 9.2 mL/kg (7.6-12.0) (p < 0.001). Intensivists made changes similar to protocol recommendations 29% of the time, opposite to the protocol's recommendation 12% of the time and no changes 56% of the time. Ventilator management varies substantially in children with acute respiratory distress syndrome. Opportunities exist to minimize variability and potentially injurious ventilator settings by using a

The Society for Translational Medicine: clinical practice guidelines for mechanical ventilation management for patients undergoing lobectomy

PubMed Central

Zhang, Zhongheng; Brunelli, Alessandro; Chen, Chang; Chen, Chun; Chen, Gang; Chen, Haiquan; Chen, Jin-Shing; Cassivi, Stephen; Chai, Ying; Downs, John B.; Fang, Wentao; Fu, Xiangning; Garutti, Martínez I.; He, Jianxing; Hu, Jian; Huang, Yunchao; Jiang, Gening; Jiang, Hongjing; Jiang, Zhongmin; Li, Danqing; Li, Gaofeng; Li, Hui; Li, Qiang; Li, Xiaofei; Li, Yin; Li, Zhijun; Liu, Chia-Chuan; Liu, Deruo; Liu, Lunxu; Liu, Yongyi; Ma, Haitao; Mao, Weimin; Mao, Yousheng; Mou, Juwei; Ng, Calvin Sze Hang; Petersen, René H.; Qiao, Guibin; Rocco, Gaetano; Ruffini, Erico; Tan, Lijie; Tan, Qunyou; Tong, Tang; Wang, Haidong; Wang, Qun; Wang, Ruwen; Wang, Shumin; Xie, Deyao; Xue, Qi; Xue, Tao; Xu, Lin; Xu, Shidong; Xu, Songtao; Yan, Tiansheng; Yu, Fenglei; Yu, Zhentao; Zhang, Chunfang; Zhang, Lanjun; Zhang, Tao; Zhang, Xun; Zhao, Xiaojing; Zhao, Xuewei; Zhi, Xiuyi; Zhou, Qinghua

2017-01-01

Patients undergoing lobectomy are at significantly increased risk of lung injury. One-lung ventilation is the most commonly used technique to maintain ventilation and oxygenation during the operation. It is a challenge to choose an appropriate mechanical ventilation strategy to minimize the lung injury and other adverse clinical outcomes. In order to understand the available evidence, a systematic review was conducted including the following topics: (I) protective ventilation (PV); (II) mode of mechanical ventilation [e.g., volume controlled (VCV) versus pressure controlled (PCV)]; (III) use of therapeutic hypercapnia; (IV) use of alveolar recruitment (open-lung) strategy; (V) pre-and post-operative application of positive end expiratory pressure (PEEP); (VI) Inspired Oxygen concentration; (VII) Non-intubated thoracoscopic lobectomy; and (VIII) adjuvant pharmacologic options. The recommendations of class II are non-intubated thoracoscopic lobectomy may be an alternative to conventional one-lung ventilation in selected patients. The recommendations of class IIa are: (I) Therapeutic hypercapnia to maintain a partial pressure of carbon dioxide at 50–70 mmHg is reasonable for patients undergoing pulmonary lobectomy with one-lung ventilation; (II) PV with a tidal volume of 6 mL/kg and PEEP of 5 cmH2O are reasonable methods, based on current evidence; (III) alveolar recruitment [open lung ventilation (OLV)] may be beneficial in patients undergoing lobectomy with one-lung ventilation; (IV) PCV is recommended over VCV for patients undergoing lung resection; (V) pre- and post-operative CPAP can improve short-term oxygenation in patients undergoing lobectomy with one-lung ventilation; (VI) controlled mechanical ventilation with I:E ratio of 1:1 is reasonable in patients undergoing one-lung ventilation; (VII) use of lowest inspired oxygen concentration to maintain satisfactory arterial oxygen saturation is reasonable based on physiologic principles; (VIII) Adjuvant drugs

Abdominal Muscle Activity during Mechanical Ventilation Increases Lung Injury in Severe Acute Respiratory Distress Syndrome

PubMed Central

Zhang, Xianming; Wu, Weiliang; Zhu, Yongcheng; Jiang, Ying; Du, Juan; Chen, Rongchang

2016-01-01

Objective It has proved that muscle paralysis was more protective for injured lung in severe acute respiratory distress syndrome (ARDS), but the precise mechanism is not clear. The purpose of this study was to test the hypothesis that abdominal muscle activity during mechanically ventilation increases lung injury in severe ARDS. Methods Eighteen male Beagles were studied under mechanical ventilation with anesthesia. Severe ARDS was induced by repetitive oleic acid infusion. After lung injury, Beagles were randomly assigned into spontaneous breathing group (BIPAPSB) and abdominal muscle paralysis group (BIPAPAP). All groups were ventilated with BIPAP model for 8h, and the high pressure titrated to reached a tidal volume of 6ml/kg, the low pressure was set at 10 cmH2O, with I:E ratio 1:1, and respiratory rate adjusted to a PaCO2 of 35–60 mmHg. Six Beagles without ventilator support comprised the control group. Respiratory variables, end-expiratory volume (EELV) and gas exchange were assessed during mechanical ventilation. The levels of Interleukin (IL)-6, IL-8 in lung tissue and plasma were measured by qRT-PCR and ELISA respectively. Lung injury scores were determined at end of the experiment. Results For the comparable ventilator setting, as compared with BIPAPSB group, the BIPAPAP group presented higher EELV (427±47 vs. 366±38 ml) and oxygenation index (293±36 vs. 226±31 mmHg), lower levels of IL-6(216.6±48.0 vs. 297.5±71.2 pg/ml) and IL-8(246.8±78.2 vs. 357.5±69.3 pg/ml) in plasma, and lower express levels of IL-6 mRNA (15.0±3.8 vs. 21.2±3.7) and IL-8 mRNA (18.9±6.8 vs. 29.5±7.9) in lung tissues. In addition, less lung histopathology injury were revealed in the BIPAPAP group (22.5±2.0 vs. 25.2±2.1). Conclusion Abdominal muscle activity during mechanically ventilation is one of the injurious factors in severe ARDS, so abdominal muscle paralysis might be an effective strategy to minimize ventilator-induce lung injury. PMID:26745868

Abdominal Muscle Activity during Mechanical Ventilation Increases Lung Injury in Severe Acute Respiratory Distress Syndrome.

PubMed

Zhang, Xianming; Wu, Weiliang; Zhu, Yongcheng; Jiang, Ying; Du, Juan; Chen, Rongchang

2016-01-01

It has proved that muscle paralysis was more protective for injured lung in severe acute respiratory distress syndrome (ARDS), but the precise mechanism is not clear. The purpose of this study was to test the hypothesis that abdominal muscle activity during mechanically ventilation increases lung injury in severe ARDS. Eighteen male Beagles were studied under mechanical ventilation with anesthesia. Severe ARDS was induced by repetitive oleic acid infusion. After lung injury, Beagles were randomly assigned into spontaneous breathing group (BIPAPSB) and abdominal muscle paralysis group (BIPAPAP). All groups were ventilated with BIPAP model for 8h, and the high pressure titrated to reached a tidal volume of 6ml/kg, the low pressure was set at 10 cmH2O, with I:E ratio 1:1, and respiratory rate adjusted to a PaCO2 of 35-60 mmHg. Six Beagles without ventilator support comprised the control group. Respiratory variables, end-expiratory volume (EELV) and gas exchange were assessed during mechanical ventilation. The levels of Interleukin (IL)-6, IL-8 in lung tissue and plasma were measured by qRT-PCR and ELISA respectively. Lung injury scores were determined at end of the experiment. For the comparable ventilator setting, as compared with BIPAPSB group, the BIPAPAP group presented higher EELV (427±47 vs. 366±38 ml) and oxygenation index (293±36 vs. 226±31 mmHg), lower levels of IL-6(216.6±48.0 vs. 297.5±71.2 pg/ml) and IL-8(246.8±78.2 vs. 357.5±69.3 pg/ml) in plasma, and lower express levels of IL-6 mRNA (15.0±3.8 vs. 21.2±3.7) and IL-8 mRNA (18.9±6.8 vs. 29.5±7.9) in lung tissues. In addition, less lung histopathology injury were revealed in the BIPAPAP group (22.5±2.0 vs. 25.2±2.1). Abdominal muscle activity during mechanically ventilation is one of the injurious factors in severe ARDS, so abdominal muscle paralysis might be an effective strategy to minimize ventilator-induce lung injury.

Non-sedation versus sedation with a daily wake-up trial in critically ill patients receiving mechanical ventilation--effects on physical function: study protocol for a randomized controlled trial: a substudy of the NONSEDA trial.

PubMed

Nedergaard, Helene Korvenius; Jensen, Hanne Irene; Lauridsen, Jørgen T; Sjøgaard, Gisela; Toft, Palle

2015-07-23

Critically ill patients rapidly loose much of their muscle mass and strength. This can be attributed to prolonged admission, prolonged mechanical ventilation and increased mortality, and it can have a negative impact on the degree of independence and quality of life. In the NONSEDA trial we randomize critically ill patients to non-sedation or sedation with a daily wake-up trial during mechanical ventilation in the intensive care unit. It has never been assessed whether non-sedation affects physical function. The aim of this study is to assess the effects of non-sedation versus sedation with a daily wake-up trial on physical function after discharge from intensive care unit. Investigator-initiated, randomized, clinical, parallel-group, superiority trial, including 700 patients in total, with a substudy concerning 200 of these patients. Inclusion criteria will be intubated, mechanically ventilated patients with expected duration of mechanical ventilation >24 h. Exclusion criteria will be patients with severe head trauma, coma at admission or status epilepticus, patients treated with therapeutic hypothermia, patients with PaO2/FiO2<9 where sedation might be necessary to ensure sufficient oxygenation or placing the patient in a prone position. The experimental intervention will be non-sedation supplemented with pain management during mechanical ventilation. The control intervention will be sedation with a daily wake-up trial. The co-primary outcome will be quality of life regarding physical function (SF-36, physical component) and degree of independence in activities of daily living (Barthel Index), and this will be assessed for all 700 patients participating in the NONSEDA trial. The secondary outcomes, which will be assessed for the subpopulation of 200 NONSEDA patients in the trial site, Kolding, will be 6-min walking distance, handgrip strength, muscle size (ultrasonographic measurement of the rectus femoris muscle cross-sectional area) and biomechanical data on

[A young child with respiratory acidosis and hypoxia from mechanical ventilation with equipment made for adults].

PubMed

Joor, Fleur; Markhorst, Dick G; Kneyber, Martin C J; van Heerde, Marc

2011-01-01

During mechanical ventilation of young children, problems may arise due to the additional dead space of the ventilation circuit. This may lead to respiratory acidosis and even hypoxia in the child. A 3-month-old boy suffered from frequent apnoea. He was mechanically ventilated for this. Shortly after its initiation, he developed severe respiratory acidosis, hypoxemia and circulatory insufficiency. This was due to a large additional dead space caused by the use of equipment components made for adults. After he was switched to a circuit suitable for himself, he recovered rapidly. As a rule of thumb, an additional dead space of 1.5-2 ml/kg body weight is acceptable in young children. Emergency wards for young children should have specific equipment to mechanically ventilate them, and have a protocol paying explicit attention to the dead space.

Variability in the Use of Protective Mechanical Ventilation During General Anesthesia.

PubMed

Ladha, Karim S; Bateman, Brian T; Houle, Timothy T; De Jong, Myrthe A C; Vidal Melo, Marcos F; Huybrechts, Krista F; Kurth, Tobias; Eikermann, Matthias

2018-02-01

The purpose of this study was to determine whether significant variation exists in the use of protective ventilation across individual anesthesia providers and whether this difference can be explained by patient, procedure, and provider-related characteristics. The cohort consisted of 262 anesthesia providers treating 57,372 patients at a tertiary care hospital between 2007 and 2014. Protective ventilation was defined as a median positive end-expiratory pressure of 5 cm H2O or more, tidal volume of <10 mL/kg of predicted body weight and plateau pressure of <30 cm H2O. Analysis was performed using mixed-effects logistic regression models with propensity scores to adjust for covariates. The definition of protective ventilation was modified in sensitivity analyses. In unadjusted analysis, the mean probability of administering protective ventilation was 53.8% (2.5th percentile of provider 19.9%, 97.5th percentile 80.8%). After adjustment for a large number of covariates, there was little change in the results with a mean probability of 51.1% (2.5th percentile 24.7%, 97.5th percentile 77.2%). The variations persisted when the thresholds for protective ventilation were changed. There was significant variability across individual anesthesia providers in the use of intraoperative protective mechanical ventilation. Our data suggest that this variability is highly driven by individual preference, rather than patient, procedure, or provider-related characteristics.

Semi-recumbent position versus supine position for the prevention of ventilator-associated pneumonia in adults requiring mechanical ventilation.

PubMed

Wang, Li; Li, Xiao; Yang, Zongxia; Tang, Xueli; Yuan, Qiang; Deng, Lijing; Sun, Xin

2016-01-08

Ventilator-associated pneumonia (VAP) is associated with increased mortality, prolonged length of hospital stay and increased healthcare costs in critically ill patients. Guidelines recommend a semi-recumbent position (30º to 45º) for preventing VAP among patients requiring mechanical ventilation. However, due to methodological limitations in existing systematic reviews, uncertainty remains regarding the benefits and harms of the semi-recumbent position for preventing VAP. To assess the effectiveness and safety of semi-recumbent positioning versus supine positioning to prevent ventilator-associated pneumonia (VAP) in adults requiring mechanical ventilation. We searched CENTRAL (2015, Issue 10), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1946 to October 2015), EMBASE (2010 to October 2015), CINAHL (1981 to October 2015) and the Chinese Biomedical Literature Database (CBM) (1978 to October 2015). We included randomised controlled trials (RCTs) comparing semi-recumbent versus supine positioning (0º to 10º), or RCTs comparing alternative degrees of positioning in mechanically ventilated patients. Our outcomes included clinically suspected VAP, microbiologically confirmed VAP, intensive care unit (ICU) mortality, hospital mortality, length of ICU stay, length of hospital stay, duration of ventilation, antibiotic use and any adverse events. Two review authors independently and in duplicate screened titles, abstracts and full texts, assessed risk of bias and extracted data using standardised forms. We calculated the mean difference (MD) and 95% confidence interval (95% CI) for continuous data and the risk ratio (RR) and 95% CI for binary data. We performed meta-analysis using the random-effects model. We used the grading of recommendations, assessment, development and evaluation (GRADE) approach to grade the quality of evidence. We included 10 trials involving 878 participants, among which 28 participants in two

Sedation during mechanical ventilation: a trial of benzodiazepine and opiate in combination.

PubMed

Richman, Paul S; Baram, Daniel; Varela, Marie; Glass, Peter S

2006-05-01

To compare the efficacy of continuous intravenous sedation with midazolam alone vs. midazolam plus fentanyl ("co-sedation") during mechanical ventilation. A randomized, prospective, controlled trial. A ten-bed medical intensive care unit at a university hospital. Thirty patients with respiratory failure who were expected to require >48 hrs of mechanical ventilation and who were receiving a sedative regimen that did not include opiate pain control. An intravenous infusion of either midazolam alone or co-sedation was administered by a nurse-implemented protocol to achieve a target Ramsay Sedation Score set by the patient's physician. Study duration was 3 days, with a brief daily "wake-up." We recorded the number of hours/day that patients were "off-target" with their Ramsay Sedation Scores, the number of dose titrations per day, the incidence of patient-ventilator asynchrony, and the time required to achieve adequate sedation as measures of sedative efficacy. We also recorded sedative cost in U.S. dollars and adverse events including hypotension, hypoventilation, ileus, and coma. Compared with the midazolam-only group, the co-sedation group had fewer hours per day with an "off-target" Ramsay Score (4.2 +/- 2.4 and 9.1 +/- 4.9, respectively, p < .002). Fewer episodes per day of patient-ventilator asynchrony were noted in the co-sedation group compared with midazolam-only (0.4 +/- 0.1 and 1.0 +/- 0.2, respectively, p < .05). Co-sedation also showed nonsignificant trends toward a shorter time to achieve sedation, a need for fewer dose titrations per day, and a lower total sedative drug cost. There was a trend toward more episodes of ileus with co-sedation compared with midazolam-only (2 vs. 0). In mechanically ventilated patients, co-sedation with midazolam and fentanyl by constant infusion provides more reliable sedation and is easier to titrate than midazolam alone, without significant difference in the rate of adverse events.

Interactive simulation system for artificial ventilation on the internet: virtual ventilator.

PubMed

Takeuchi, Akihiro; Abe, Tadashi; Hirose, Minoru; Kamioka, Koichi; Hamada, Atsushi; Ikeda, Noriaki

2004-12-01

To develop an interactive simulation system "virtual ventilator" that demonstrates the dynamics of pressure and flow in the respiratory system under the combination of spontaneous breathing, ventilation modes, and ventilator options. The simulation system was designed to be used by unexperienced health care professionals as a self-training tool. The system consists of a simulation controller and three modules: respiratory, spontaneous breath, and ventilator. The respiratory module models the respiratory system by three resistances representing the main airway, the right and left lungs, and two compliances also representing the right and left lungs. The spontaneous breath module generates inspiratory negative pressure produced by a patient. The ventilator module generates driving force of pressure or flow according to the combination of the ventilation mode and options. These forces are given to the respiratory module through the simulation controller. The simulation system was developed using HTML, VBScript (3000 lines, 100 kB) and ActiveX control (120 kB), and runs on Internet Explorer (5.5 or higher). The spontaneous breath is defined by a frequency, amplitude and inspiratory patterns in the spontaneous breath module. The user can construct a ventilation mode by setting a control variable, phase variables (trigger, limit, and cycle), and options. Available ventilation modes are: controlled mechanical ventilation (CMV), continuous positive airway pressure, synchronized intermittent mandatory ventilation (SIMV), pressure support ventilation (PSV), SIMV + PSV, pressure-controlled ventilation (PCV), pressure-regulated volume control (PRVC), proportional assisted ventilation, mandatory minute ventilation (MMV), bilevel positive airway pressure (BiPAP). The simulation system demonstrates in a graph and animation the airway pressure, flow, and volume of the respiratory system during mechanical ventilation both with and without spontaneous breathing. We developed a web

Evaluation of delivery of enteral nutrition in mechanically ventilated Malaysian ICU patients.

PubMed

Yip, Keng F; Rai, Vineya; Wong, Kang K

2014-01-01

There are numerous challenges in providing nutrition to the mechanically ventilated critically ill ICU patient. Understanding the level of nutritional support and the barriers to enteral feeding interruption in mechanically ventilated patients are important to maximise the nutritional benefits to the critically ill patients. Thus, this study aims to evaluate enteral nutrition delivery and identify the reasons for interruptions in mechanically ventilated Malaysian patients receiving enteral feeding. A cross sectional prospective study of 77 consecutive patients who required mechanical ventilation and were receiving enteral nutrition was done in an open 14-bed intensive care unit of a tertiary hospital. Data were collected prospectively over a 3 month period. Descriptive statistical analysis were made with respect to demographical data, time taken to initiate feeds, type of feeds, quantification of feeds attainment, and reasons for feed interruptions. There are no set feeding protocols in the ICU. The usual initial rate of enteral nutrition observed in ICU was 20 ml/hour, assessed every 6 hours and the decision was made thereafter to increase feeds. The target calorie for each patient was determined by the clinician alongside the dietitian. The use of prokinetic agents was also prescribed at the discretion of the attending clinician and is commonly IV metoclopramide 10 mg three times a day. About 66% of patients achieved 80% of caloric requirements within 3 days of which 46.8% achieved full feeds in less than 12 hours. The time to initiate feeds for patients admitted into the ICU ranged from 0 - 110 hours with a median time to start feeds of 15 hours and the interquartile range (IQR) of 6-59 hours. The mean time to achieve at least 80% of nutritional target was 1.8 days ± 1.5 days. About 79% of patients experienced multiple feeding interruptions. The most prevalent reason for interruption was for procedures (45.1%) followed by high gastric residual volume (38

A quasi-experimental, before-after trial examining the impact of an emergency department mechanical ventilator protocol on clinical outcomes and lung-protective ventilation in acute respiratory distress syndrome

PubMed Central

Fuller, Brian M.; Ferguson, Ian T.; Mohr, Nicholas M.; Drewry, Anne M.; Palmer, Christopher; Wessman, Brian T.; Ablordeppey, Enyo; Keeperman, Jacob; Stephens, Robert J.; Briscoe, Cristopher C.; Kolomiets, Angelina A.; Hotchkiss, Richard S.; Kollef, Marin H.

2017-01-01

Objective To evaluate the impact of an emergency department (ED) mechanical ventilation protocol on clinical outcomes and adherence to lung-protective ventilation in patients with acute respiratory distress syndrome (ARDS). Design Quasi-experimental, before-after trial. Setting ED and intensive care units (ICU) of an academic center. Patients Mechanically ventilated ED patients experiencing ARDS while in the ED or after admission to the ICU. Interventions An ED ventilator protocol which targeted parameters in need of quality improvement, as identified by prior work: 1) lung-protective tidal volume; 2) appropriate setting of positive end-expiratory pressure (PEEP); 3) oxygen weaning; and 4) head-of-bed elevation. Measurements and Main Results A total of 229 patients (186 pre-intervention group, 43 intervention group) were studied. In the ED, the intervention was associated with significant changes (P < 0.01 for all) in tidal volume, PEEP, respiratory rate, oxygen administration, and head-of-bed elevation. There was a reduction in ED tidal volume from 8.1 mL/kg PBW (7.0 – 9.1) to 6.4 mL/kg PBW (6.1 – 6.7), and an increase in lung-protective ventilation from 11.1% to 61.5%, P < 0.01. The intervention was associated with a reduction in mortality from 54.8% to 39.5% (OR 0.38, 95% CI 0.17 – 0.83, P = 0.02), and a 3.9 day increase in ventilator-free days, P = 0.01. Conclusions This before-after study of mechanically ventilated patients with ARDS demonstrates that implementing a mechanical ventilator protocol in the ED is feasible, and associated with improved clinical outcomes. PMID:28157140

A Quasi-Experimental, Before-After Trial Examining the Impact of an Emergency Department Mechanical Ventilator Protocol on Clinical Outcomes and Lung-Protective Ventilation in Acute Respiratory Distress Syndrome.

PubMed

Fuller, Brian M; Ferguson, Ian T; Mohr, Nicholas M; Drewry, Anne M; Palmer, Christopher; Wessman, Brian T; Ablordeppey, Enyo; Keeperman, Jacob; Stephens, Robert J; Briscoe, Cristopher C; Kolomiets, Angelina A; Hotchkiss, Richard S; Kollef, Marin H

2017-04-01

To evaluate the impact of an emergency department mechanical ventilation protocol on clinical outcomes and adherence to lung-protective ventilation in patients with acute respiratory distress syndrome. Quasi-experimental, before-after trial. Emergency department and ICUs of an academic center. Mechanically ventilated emergency department patients experiencing acute respiratory distress syndrome while in the emergency department or after admission to the ICU. An emergency department ventilator protocol which targeted variables in need of quality improvement, as identified by prior work: 1) lung-protective tidal volume, 2) appropriate setting of positive end-expiratory pressure, 3) oxygen weaning, and 4) head-of-bed elevation. A total of 229 patients (186 preintervention group, 43 intervention group) were studied. In the emergency department, the intervention was associated with significant changes (p < 0.01 for all) in tidal volume, positive end-expiratory pressure, respiratory rate, oxygen administration, and head-of-bed elevation. There was a reduction in emergency department tidal volume from 8.1 mL/kg predicted body weight (7.0-9.1) to 6.4 mL/kg predicted body weight (6.1-6.7) and an increase in lung-protective ventilation from 11.1% to 61.5%, p value of less than 0.01. The intervention was associated with a reduction in mortality from 54.8% to 39.5% (odds ratio, 0.38; 95% CI, 0.17-0.83; p = 0.02) and a 3.9 day increase in ventilator-free days, p value equals to 0.01. This before-after study of mechanically ventilated patients with acute respiratory distress syndrome demonstrates that implementing a mechanical ventilator protocol in the emergency department is feasible and associated with improved clinical outcomes.

Multicenter comparative study of conventional mechanical gas ventilation to tidal liquid ventilation in oleic acid injured sheep.

PubMed

Wolfson, Marla R; Hirschl, Ronald B; Jackson, J Craig; Gauvin, France; Foley, David S; Lamm, Wayne J E; Gaughan, John; Shaffer, Thomas H

2008-01-01

We performed a multicenter study to test the hypothesis that tidal liquid ventilation (TLV) would improve cardiopulmonary, lung histomorphological, and inflammatory profiles compared with conventional mechanical gas ventilation (CMV). Sheep were studied using the same volume-controlled, pressure-limited ventilator systems, protocols, and treatment strategies in three independent laboratories. Following baseline measurements, oleic acid lung injury was induced and animals were randomized to 4 hours of CMV or TLV targeted to "best PaO2" and PaCO2 35 to 60 mm Hg. The following were significantly higher (p < 0.01) during TLV than CMV: PaO2, venous oxygen saturation, respiratory compliance, cardiac output, stroke volume, oxygen delivery, ventilatory efficiency index; alveolar area, lung % gas exchange space, and expansion index. The following were lower (p < 0.01) during TLV compared with CMV: inspiratory and expiratory pause pressures, mean airway pressure, minute ventilation, physiologic shunt, plasma lactate, lung interleukin-6, interleukin-8, myeloperoxidase, and composite total injury score. No significant laboratories by treatment group interactions were found. In summary, TLV resulted in improved cardiopulmonary physiology at lower ventilatory requirements with more favorable histological and inflammatory profiles than CMV. As such, TLV offers a feasible ventilatory alternative as a lung protective strategy in this model of acute lung injury.

An experimental study on the impacts of inspiratory and expiratory muscles activities during mechanical ventilation in ARDS animal model

PubMed Central

Zhang, Xianming; Du, Juan; Wu, Weiliang; Zhu, Yongcheng; Jiang, Ying; Chen, Rongchang

2017-01-01

In spite of intensive investigations, the role of spontaneous breathing (SB) activity in ARDS has not been well defined yet and little has been known about the different contribution of inspiratory or expiratory muscles activities during mechanical ventilation in patients with ARDS. In present study, oleic acid-induced beagle dogs’ ARDS models were employed and ventilated with the same level of mean airway pressure. Respiratory mechanics, lung volume, gas exchange and inflammatory cytokines were measured during mechanical ventilation, and lung injury was determined histologically. As a result, for the comparable ventilator setting, preserved inspiratory muscles activity groups resulted in higher end-expiratory lung volume (EELV) and oxygenation index. In addition, less lung damage scores and lower levels of system inflammatory cytokines were revealed after 8 h of ventilation. In comparison, preserved expiratory muscles activity groups resulted in lower EELV and oxygenation index. Moreover, higher lung injury scores and inflammatory cytokines levels were observed after 8 h of ventilation. Our findings suggest that the activity of inspiratory muscles has beneficial effects, whereas that of expiratory muscles exerts adverse effects during mechanical ventilation in ARDS animal model. Therefore, for mechanically ventilated patients with ARDS, the demands for deep sedation or paralysis might be replaced by the strategy of expiratory muscles paralysis through epidural anesthesia. PMID:28230150

Studying the Power of the Integrative Weaning Index in Predicting the Success Rate of the Spontaneous Breathing Trial in Patients under Mechanical Ventilation

PubMed Central

Ebrahimabadi, Sahar; Moghadam, Ahmad Bagheri; Vakili, Mohammadali; Modanloo, Mahnaz; Khoddam, Homeira

2017-01-01

Background and Aims: The use of weaning predictive indicators can avoid early extubation and wrongful prolonged mechanical ventilation. This study aimed to determine the power of the integrative weaning index (IWI) in predicting the success rate of the spontaneous breathing trial (SBT) in patients under mechanical ventilation. Materials and Methods: In this prospective study, 105 patients undergoing mechanical ventilation for over 48 h were enrolled. Before weaning initiation, the IWI was calculated and based on the defined cutoff point (≥25), the success rate of the SBT was predicted. In case of weaning from the device, 2-h SBT was performed and the physiologic and respiratory indices were continuously studied while being intubated. If they were in the normal range besides the patient's tolerance, the test was considered as a success. The result was then compared with the IWI and further analyzed. Results: The SBT was successful in 90 (85.7%) and unsuccessful in 15 (14.3%) cases. The difference between the true patient outcome after SBT, and the IWI prediction was 0.143 according to the Kappa agreement coefficient (P < 0.001). Moreover, regarding the predictive power, IWI had high sensitivity (95.6%), specificity (40%), positive and negative predictive values (90.5% and 60), positive and negative likelihood ratios (1.59 and 0.11), and accuracy (86.7%). Conclusion: The IWI as a more objective indicator has acceptable accuracy and power for predicting the 2-h SBT result. Therefore, in addition to the reliable prediction of the final weaning outcome, it has favorable power to predict if the patient is ready to breathe spontaneously as the first step to weaning. PMID:28904477

Novel analysis of 4DCT imaging quantifies progressive increases in anatomic dead space during mechanical ventilation in mice.

PubMed

Kim, Elizabeth H; Preissner, Melissa; Carnibella, Richard P; Samarage, Chaminda R; Bennett, Ellen; Diniz, Marcio A; Fouras, Andreas; Zosky, Graeme R; Jones, Heather D

2017-09-01

Increased dead space is an important prognostic marker in early acute respiratory distress syndrome (ARDS) that correlates with mortality. The cause of increased dead space in ARDS has largely been attributed to increased alveolar dead space due to ventilation/perfusion mismatching and shunt. We sought to determine whether anatomic dead space also increases in response to mechanical ventilation. Mice received intratracheal lipopolysaccharide (LPS) or saline and mechanical ventilation (MV). Four-dimensional computed tomography (4DCT) scans were performed at onset of MV and after 5 h of MV. Detailed measurements of airway volumes and lung tidal volumes were performed using image analysis software. The forced oscillation technique was used to obtain measures of airway resistance, tissue damping, and tissue elastance. The ratio of airway volumes to total tidal volume increased significantly in response to 5 h of mechanical ventilation, regardless of LPS exposure, and airways demonstrated significant variation in volumes over the respiratory cycle. These findings were associated with an increase in tissue elastance (decreased lung compliance) but without changes in tidal volumes. Airway volumes increased over time with exposure to mechanical ventilation without a concomitant increase in tidal volumes. These findings suggest that anatomic dead space fraction increases progressively with exposure to positive pressure ventilation and may represent a pathological process. NEW & NOTEWORTHY We demonstrate that anatomic dead space ventilation increases significantly over time in mice in response to mechanical ventilation. The novel functional lung-imaging techniques applied here yield sensitive measures of airway volumes that may have wide applications. Copyright © 2017 the American Physiological Society.

A study of the protective effect and mechanism of ketamine on acute lung injury induced by mechanical ventilation.

PubMed

Wang, W-F; Liu, S; Xu, B

2017-03-01

To investigate the protective effects and mechanism of ketamine on acute lung injury induced by mechanical ventilation. 63 patients with acute lung injury caused by mechanical ventilation in our hospital between June 2014 and May 2015 were chosen and divided into three groups: group A, B, and C. Group A (20 cases) received conventional treatment. Group B (21 cases) was treated with propofol and group C (22 cases) with ketamine. The ventilator application time, the success rate of weaning, the mortality rate, inflammation index (IL-1, Caspase-1, and NF-κB), pulmonary function index and oxygen saturation were compared. The ventilator application time and the mortality rate of group B and group C were significantly (p < 0.05) lower than those of group A. The success rate of weaning of groups B and C was higher (p < 0.05) than that of group A. There was no difference between groups B and C. After intervention, the levels of PaO2 and SpO2 in the three groups increased, while the level of PaCO2decreased with better improvement in group B and group C than in group A (p < 0.05), groups B and C being similar (p > 0.05). After the intervention, the levels of FEV1, FEV1/FVC, FVC and PEER in the three groups increased, but more remarkably in group B and group C (p < 0.05), in which there was no difference. After the intervention, the levels of IL-1β, Caspase-1, and NF-κB in the three groups decreased with the levels of group C obviously lower (p < 0.05) than those of groups B and A, the highest. Both ketamine and propofol can improve the blood gas and pulmonary function index of patients with acute lung injury caused by mechanical ventilation. They shorten the application time of ventilator, improve the success rate of weaning and reduce the mortality rate which is probably related to the reduction of the degree of inflammatory reaction. Ketamine is more effective in reducing inflammatory factors including IL-1β, Caspase-1, and NF-κB than propofol.

Effect of acute kidney injury on weaning from mechanical ventilation in critically ill patients.

PubMed

Vieira, José M; Castro, Isac; Curvello-Neto, Américo; Demarzo, Sérgio; Caruso, Pedro; Pastore, Laerte; Imanishe, Marina H; Abdulkader, Regina C R M; Deheinzelin, Daniel

2007-01-01

Acute kidney injury (AKI) worsens outcome in various scenarios. We sought to investigate whether the occurrence of AKI has any effect on weaning from mechanical ventilation. Observational, retrospective study in a 23-bed medical/surgical intensive care unit (ICU) in a cancer hospital from January to December 2003. The inclusion criterion was invasive mechanical ventilation for > or =48 hrs. AKI was defined as at least one measurement of serum creatinine of > or =1.5 mg/dL during the ICU stay. Patients were then separated into AKI and non-AKI patients (control group). The criterion for weaning was the combination of positive end-expiratory pressure of < or =8 cm H2O, pressure support of < or =10 cm H2O, and Fio2 of < or =0.4, with spontaneous breathing. The primary end point was duration of weaning and the secondary end points were rate of weaning failure, total length of mechanical ventilation, length of stay in the ICU, and ICU mortality. A total of 140 patients were studied: 93 with AKI and 47 controls. The groups were similar in regard to age, sex, and type of tumor. Diagnosis of acute lung injury/acute respiratory distress syndrome as cause of respiratory failure and Simplified Acute Physiology Score II at admission did not differ between groups. During ICU stay, AKI patients had markers of more severe disease: increased occurrence of severe sepsis or septic shock, higher number of antibiotics, and longer use of vasoactive drugs. The median (interquartile range) duration of mechanical ventilation (10 [6-17] vs. 7 [2-12] days, p = .017) and duration of weaning from mechanical ventilation (41 [16-97] vs. 21 [7-33.5] hrs, p = .018) were longer in AKI patients compared with control patients. Cox regression analysis demonstrated that a > or =85% increase in baseline serum creatinine (hazard rate, 2.30; 95% confidence interval, 1.30-4.08), oliguria (hazard rate, 2.51; 95% confidence interval, 1.24-5.08), and the number of antibiotics (hazard rate, 2.64; 95

Intraoperative mechanical ventilation strategies in patients undergoing one-lung ventilation: a meta-analysis.

PubMed

Liu, Zhen; Liu, Xiaowen; Huang, Yuguang; Zhao, Jing

2016-01-01

Postoperative pulmonary complications (PPCs), which are not uncommon in one-lung ventilation, are among the main causes of postoperative death after lung surgery. Intra-operative ventilation strategies can influence the incidence of PPCs. High tidal volume (V T) and increased airway pressure may lead to lung injury, while pressure-controlled ventilation and lung-protective strategies with low V T may have protective effects against lung injury. In this meta-analysis, we aim to investigate the effects of different ventilation strategies, including pressure-controlled ventilation (PCV), volume-controlled ventilation (VCV), protective ventilation (PV) and conventional ventilation (CV), on PPCs in patients undergoing one-lung ventilation. We hypothesize that both PV with low V T and PCV have protective effects against PPCs in one-lung ventilation. A systematic search (PubMed, EMBASE, the Cochrane Library, and Ovid MEDLINE; in May 2015) was performed for randomized trials comparing PCV with VCV or comparing PV with CV in one-lung ventilation. Methodological quality was evaluated using the Cochrane tool for risk. The primary outcome was the incidence of PPCs. The secondary outcomes included the length of hospital stay, intraoperative plateau airway pressure (Pplateau), oxygen index (PaO2/FiO2) and mean arterial pressure (MAP). In this meta-analysis, 11 studies (436 patients) comparing PCV with VCV and 11 studies (657 patients) comparing PV with CV were included. Compared to CV, PV decreased the incidence of PPCs (OR 0.29; 95 % CI 0.15-0.57; P < 0.01) and intraoperative Pplateau (MD -3.75; 95 % CI -5.74 to -1.76; P < 0.01) but had no significant influence on the length of hospital stay or MAP. Compared to VCV, PCV decreased intraoperative Pplateau (MD -1.46; 95 % CI -2.54 to -0.34; P = 0.01) but had no significant influence on PPCs, PaO2/FiO2 or MAP. PV with low V T was associated with the reduced incidence of PPCs compared to CV. However, PCV and VCV had similar

Spontaneous Breathing Trials and Conservative Sedation Practices Reduce Mechanical Ventilation Duration in Subjects With ARDS.

PubMed

Kallet, Richard H; Zhuo, Hanjing; Yip, Vivian; Gomez, Antonio; Lipnick, Michael S

2018-01-01

Spontaneous breathing trials (SBTs) and daily sedation interruptions (DSIs) reduce both the duration of mechanical ventilation and ICU length of stay (LOS). The impact of these practices in patients with ARDS has not previously been reported. We examined whether implementation of SBT/DSI protocols reduce duration of mechanical ventilation and ICU LOS in a retrospective group of subjects with ARDS at a large, urban, level-1 trauma center. All ARDS survivors from 2002 to 2016 ( N = 1,053) were partitioned into 2 groups: 397 in the pre-SBT/DSI group (June 2002-December 2007) and 656 in the post-SBT/DSI group (January 2009-April 2016). Patients from 2008, during the protocol implementation period, were excluded. An additional SBT protocol database (2008-2010) was used to assess the efficacy of SBT in transitioning subjects with ARDS to unassisted breathing. Comparisons were assessed by either unpaired t tests or Mann-Whitney tests. Multiple comparisons were made using either one-way analysis of variance or Kruskal-Wallis and Dunn's tests. Linear regression modeling was used to determine variables independently associated with mechanical ventilation duration and ICU LOS; differences were considered statistically significant when P < .05. Compared to the pre-protocol group, subjects with ARDS managed with SBT/DSI protocols experienced pronounced reductions both in median (IQR) mechanical ventilation duration (14 [6-29] vs 9 [4-17] d, respectively, P < .001) and median ICU LOS (18 [8-33] vs 13 [7-22] d, respectively P < .001). In the final model, only treatment in the SBT/DSI period and higher baseline respiratory system compliance were independently associated with reduced mechanical ventilation duration and ICU LOS. Among subjects with ARDS in the SBT performance database, most achieved unassisted breathing with a median of 2 SBTs. Evidenced-based protocols governing weaning and sedation practices were associated with both reduced mechanical ventilation duration and ICU

Variable versus conventional lung protective mechanical ventilation during open abdominal surgery: study protocol for a randomized controlled trial.

PubMed

Spieth, Peter M; Güldner, Andreas; Uhlig, Christopher; Bluth, Thomas; Kiss, Thomas; Schultz, Marcus J; Pelosi, Paolo; Koch, Thea; Gama de Abreu, Marcelo

2014-05-02

General anesthesia usually requires mechanical ventilation, which is traditionally accomplished with constant tidal volumes in volume- or pressure-controlled modes. Experimental studies suggest that the use of variable tidal volumes (variable ventilation) recruits lung tissue, improves pulmonary function and reduces systemic inflammatory response. However, it is currently not known whether patients undergoing open abdominal surgery might benefit from intraoperative variable ventilation. The PROtective VARiable ventilation trial ('PROVAR') is a single center, randomized controlled trial enrolling 50 patients who are planning for open abdominal surgery expected to last longer than 3 hours. PROVAR compares conventional (non-variable) lung protective ventilation (CV) with variable lung protective ventilation (VV) regarding pulmonary function and inflammatory response. The primary endpoint of the study is the forced vital capacity on the first postoperative day. Secondary endpoints include further lung function tests, plasma cytokine levels, spatial distribution of ventilation assessed by means of electrical impedance tomography and postoperative pulmonary complications. We hypothesize that VV improves lung function and reduces systemic inflammatory response compared to CV in patients receiving mechanical ventilation during general anesthesia for open abdominal surgery longer than 3 hours. PROVAR is the first randomized controlled trial aiming at intra- and postoperative effects of VV on lung function. This study may help to define the role of VV during general anesthesia requiring mechanical ventilation. Clinicaltrials.gov NCT01683578 (registered on September 3 3012).

Mechanical Ventilation as a Therapeutic Tool to Reduce ARDS Incidence.

PubMed

Nieman, Gary F; Gatto, Louis A; Bates, Jason H T; Habashi, Nader M

2015-12-01

Trauma, hemorrhagic shock, or sepsis can incite systemic inflammatory response syndrome, which can result in early acute lung injury (EALI). As EALI advances, improperly set mechanical ventilation (MV) can amplify early injury into a secondary ventilator-induced lung injury that invariably develops into overt ARDS. Once established, ARDS is refractory to most therapeutic strategies, which have not been able to lower ARDS mortality below the current unacceptably high 40%. Low tidal volume ventilation is one of the few treatments shown to have a moderate positive impact on ARDS survival, presumably by reducing ventilator-induced lung injury. Thus, there is a compelling case to be made that the focus of ARDS management should switch from treatment once this syndrome has become established to the application of preventative measures while patients are still in the EALI stage. Indeed, studies have shown that ARDS incidence is markedly reduced when conventional MV is applied preemptively using a combination of low tidal volume and positive end-expiratory pressure in both patients in the ICU and in surgical patients at high risk for developing ARDS. Furthermore, there is evidence from animal models and high-risk trauma patients that superior prevention of ARDS can be achieved using preemptive airway pressure release ventilation with a very brief duration of pressure release. Preventing rather than treating ARDS may be the way forward in dealing with this recalcitrant condition and would represent a paradigm shift in the way that MV is currently practiced.

Optimizing Oxygenation in the Mechanically Ventilated Patient: Nursing Practice Implications.

PubMed

Barton, Glenn; Vanderspank-Wright, Brandi; Shea, Jacqueline

2016-12-01

Critical care nurses constitute front-line care provision for patients in the intensive care unit (ICU). Hypoxemic respiratory compromise/failure is a primary reason that patients require ICU admission and mechanical ventilation. Critical care nurses must possess advanced knowledge, skill, and judgment when caring for these patients to ensure that interventions aimed at optimizing oxygenation are both effective and safe. This article discusses fundamental aspects of respiratory physiology and clinical indices used to describe oxygenation status. Key nursing interventions including patient assessment, positioning, pharmacology, and managing hemodynamic parameters are discussed, emphasizing their effects toward mitigating ventilation-perfusion mismatch and optimizing oxygenation. Copyright © 2016 Elsevier Inc. All rights reserved.

[The clinical and microbiological comparison of the use of heated humidifiers and heat and moisture exchanger filters with Booster in mechanically ventilated patients].

PubMed

Nadir Oziş, Türkan; Ozcan Kanat, Derya; Oğuzülgen, Ipek Kivilcim; Aydoğdu, Müge; Hizel, Kenan; Gürsel, Gül

2009-01-01

Ventilator associated pneumonia (VAP) is the most frequent nosocomial infection in intensive care units that is associated with prolonged mechanical ventilation, hospitalization and increased health-care costs. Various humidifiers can be used for humidification during mechanical ventilation. Many studies were conducted to identify the effects of two different humidifiers, i.e. heated humidifiers and heat and moisture exchanger filters (HME), on VAP development; and HME filters were found to decrease the VAP frequency. In this study we aimed to compare the efficacy and safety of heated humidifiers and HME-Booster. Heated humidifier with conventional microbiologic filter (CMF-HH) or HME-Booster were used in randomization to 41 mechanically ventilated patients of our intensive care unit, and patients were divided into two groups as group 1 receiving CMF-HH (20 patients) and group 2 (21 patients) receiving HME-Booster. Daily secretion scores, endotracheal tube occlusion due to secretions, VAP development rate for the assessment of microbiological safety of humidifiers and differences in PETCO(2) and PaCO(2) values for the assessment of their effect on arterial blood gas were recorded prospectively. The measurement of PETCO(2) and PaCO(2) values were performed with the presence of humidifiers and after removing them in both groups. In both groups with the removal of CMF-HH and HME-Booster, a decrease in PETCO(2) value was identified, but the decrease in group 2 was statistically significant (p= 0.016). The decrease in PaCO(2) after removal of humidifiers was greater in group 2 than in group 1, but the difference was not significant (p> 0.05).The rate of VAP and endotracheal tube occlusion was not significantly different between the groups. The mean secretion score was lower in group 1 (p= 0.041). In conclusion, although both humidifiers have similar microbiological effects, heated humidifiers could be preferred particularly for the patients with an underlying chronic

Change-over natural and mechanical ventilation system energy consumption in single-family buildings

NASA Astrophysics Data System (ADS)

Kostka, Maria; Szulgowska-Zgrzywa, Małgorzata

2017-11-01

The parameters of the outside air in Poland cause that in winter it is reasonable to use a mechanical ventilation equipped with a heat recovery exchanger. The time of spring, autumn, summer evenings and nights are often characterized by the parameters of the air, which allow for a natural ventilation and reduce the electricity consumption. The article presents the possibilities of energy consumption reduction for three energy standards of buildings located in Poland, ventilated by a change-over hybrid system. The analysis was prepared on the assumption that the air-to-water heat pump is the heat source for the buildings.

Pulmonary Contusion in Mechanically Ventilated Subjects After Severe Trauma.

PubMed

Dhar, Sakshi Mathur; Breite, Matthew D; Barnes, Stephen L; Quick, Jacob A

2018-03-13

Pulmonary contusions are thought to worsen outcomes. We aimed to evaluate the effects of pulmonary contusion on mechanically ventilated trauma subjects with severe thoracic injuries and hypothesized that contusion would not increase morbidity. We conducted a single-center, retrospective review of 163 severely injured trauma subjects (injury severity score ≥ 15) with severe thoracic injury (chest abbreviated injury score ≥ 3), who required mechanical ventilation for >24 h at a verified Level 1 trauma center. Subject data were analyzed for those with radiographic documentation of pulmonary contusion and those without. Statistical analysis was performed to determine the effects of coexisting pulmonary contusion in severe thoracic trauma. Pulmonary contusion was present in 91 subjects (55.8%), whereas 72 (44.2%) did not have pulmonary contusions. Mean chest abbreviated injury score (3.54 vs 3.47, P = .53) and mean injury severity score (32.6 vs 30.2, P = .12) were similar. There was no difference in mortality (11 [12.1%] vs 9 [12.5%], P > .99) or length of stay (16.29 d vs 17.29 d, P = .60). Frequency of ventilator-associated pneumonia was comparable (43 [47.3%] vs 32 [44.4%], P = .75). Subjects with contusions were more likely to grow methicillin-sensitive Staphylococcus aureus in culture (33 vs 10, P = .004) as opposed to Pseudomonas aeruginosa in culture (6 vs 13, P = .003). Overall, no significant differences were noted in mortality, length of stay, or pneumonia rates between severely injured trauma subjects with and without pulmonary contusions. Copyright © 2018 by Daedalus Enterprises.

Inspiratory muscle training increases inspiratory muscle strength in patients weaning from mechanical ventilation: a systematic review.

PubMed

Moodie, Lisa; Reeve, Julie; Elkins, Mark

2011-01-01

Does inspiratory muscle training improve inspiratory muscle strength and endurance, facilitate weaning, improve survival, and reduce the rate of reintubation and tracheostomy in adults receiving mechanical ventilation? Systematic review of randomised or quasi-randomised controlled trials. Adults over 16 years of age receiving mechanical ventilation. Inspiratory muscle training versus sham or no inspiratory muscle training. Data were extracted regarding inspiratory muscle strength and endurance, the duration of unassisted breathing periods, weaning success and duration, reintubation and tracheostomy, survival, adverse effects, and length of stay. Three studies involving 150 participants were included in the review. The studies varied in time to commencement of the training, the device used, the training protocol, and the outcomes measured. Inspiratory muscle training significantly increased inspiratory muscle strength over sham or no training (weighted mean difference 8 cmH(2)O, 95% CI 6 to 9). There were no statistically significant differences between the groups in weaning success or duration, survival, reintubation, or tracheostomy. Inspiratory muscle training was found to significantly increase inspiratory muscle strength in adults undergoing mechanical ventilation. Despite data from a substantial pooled cohort, it is not yet clear whether the increase in inspiratory muscle strength leads to a shorter duration of mechanical ventilation, improved weaning success, or improved survival. Further large randomised studies are required to clarify the impact of inspiratory muscle training on patients receiving mechanical ventilation. PROSPERO CRD42011001132. Copyright © 2011 Australian Physiotherapy Association. Published by .. All rights reserved.

Nurses' communication with patients who are mechanically ventilated in intensive care: the Botswana experience.

PubMed

Dithole, K S; Sibanda, S; Moleki, M M; Thupayagale-Tshweneagae, G

2016-09-01

Communication is an integral part of nursing practice not just only for therapeutic reasons but also for sharing information. Nurses working in intensive care experience challenges when communicating with patients who are mechanically ventilated due to lack of knowledge and skill. These challenges infringe on the patients' rights to receive information and as such they may impact negatively on the patients' outcomes. This study determined the existing knowledge and skills of intensive care nurses working with mechanically ventilated patients in Botswana. A retrospective descriptive and explorative research design with a quantitative approach was used to audit patients' records. This was augmented by further interviewing nurses for their knowledge and skills when communicating with ventilated patients within the two intensive care units in Botswana. The American Association of Critical Nurses Synergy Model was used to guide the study. One hundred and fifty-nine (159) patients' files were audited and 50 nurses chosen by purposive sampling completed a self-administered 42-item questionnaire. Statistical Package for Social Sciences version 10 and Microsoft Excel were used to analyse the data. Assessment of patients' ability to communicate was recorded in more than 90% of files audited. Four per cent (4%) of the respondents only communicated essential information and no other strategies or devices were used to aid communication. Communication with ventilated patients can be quite challenging to nurses working in the intensive care unit. There is a need for communication skills training to ensure that all nurses working with mechanically ventilated patients are properly trained, equipped and capable of communicating effectively with the patient. A greater understanding of communication dynamics with the intensive care unit with patients who are mechanically ventilated is crucial to enable nurses to improve their care and improve patients' comfort. Incorporating

Transient-state mechanisms of wind-induced burrow ventilation.

PubMed

Turner, J Scott; Pinshow, Berry

2015-01-15

Burrows are common animal habitations, yet living in a burrow presents physiological challenges for its inhabitants because the burrow isolates them from sources and sinks for oxygen, carbon dioxide, water vapor and ammonia. Conventionally, the isolation is thought to be overcome by either diffusion gas exchange within the burrow or some means of capturing wind energy to power steady or quasi-steady bulk flows of air through it. Both are examples of what may be called 'DC' models, namely steady to quasi-steady flows powered by steady to quasi-steady winds. Natural winds, however, are neither steady nor quasi-steady, but are turbulent, with a considerable portion of the energy contained in so-called 'AC' (i.e. unsteady) components, where wind velocity varies chaotically and energy to power gas exchange is stored in some form. Existing DC models of burrow gas exchange do not account for this potentially significant source of energy for ventilation. We present evidence that at least two AC mechanisms operate to ventilate both single-opening burrows (of the Cape skink, Trachylepis capensis) and double-opening model burrows (of Sundevall's jird, Meriones crassus). We propose that consideration of the physiological ecology and evolution of the burrowing habit has been blinkered by the long neglect of AC ventilation. © 2015. Published by The Company of Biologists Ltd.

Holistic Care for Patients During Weaning from Mechanical Ventilation: A Qualitative Study.

PubMed

Khalafi, Ali; Elahi, Nasrin; Ahmadi, Fazlollah

2016-11-01

Weaning patients from mechanical ventilation is a complex and highly challenging process. It requires continuity of care, the overall assessment of patients, and a focus on all aspects of patients' needs by critical care nurses. The aim of the present study was to explore holistic care while patients are being weaned from mechanical ventilation from the perspective of the critical care nurses. The study was carried out in the intensive care units (ICUs) of six hospitals in Ahvaz, Iran, from 2014 to 2015. In this qualitative study, 25 ICU staff including nurses, nurse managers, and nurse educators were selected by means of purposive sampling. Semi-structured interviews were used for data collection. The interview transcripts were then analyzed using qualitative content analysis. The four main themes that emerged to explain nurses' experiences of holistic care when weaning patients from mechanical ventilation include continuous care, a holistic overview of the patient, promoting human dignity, and the overall development of well-being. It was found that avoiding routine pivotal expertise, increasing consciousness of the nonphysical aspects of patients while providing treatment and presenting exclusive care, utilizing experienced ICU nurses, and placing more emphasis on effective communication with patients in order to honor them as human beings can all enhance the holistic quality of care.

Protective mechanical ventilation during general anesthesia for open abdominal surgery improves postoperative pulmonary function.

PubMed

Severgnini, Paolo; Selmo, Gabriele; Lanza, Christian; Chiesa, Alessandro; Frigerio, Alice; Bacuzzi, Alessandro; Dionigi, Gianlorenzo; Novario, Raffaele; Gregoretti, Cesare; de Abreu, Marcelo Gama; Schultz, Marcus J; Jaber, Samir; Futier, Emmanuel; Chiaranda, Maurizio; Pelosi, Paolo

2013-06-01

The impact of intraoperative ventilation on postoperative pulmonary complications is not defined. The authors aimed at determining the effectiveness of protective mechanical ventilation during open abdominal surgery on a modified Clinical Pulmonary Infection Score as primary outcome and postoperative pulmonary function. Prospective randomized, open-label, clinical trial performed in 56 patients scheduled to undergo elective open abdominal surgery lasting more than 2 h. Patients were assigned by envelopes to mechanical ventilation with tidal volume of 9 ml/kg ideal body weight and zero-positive end-expiratory pressure (standard ventilation strategy) or tidal volumes of 7 ml/kg ideal body weight, 10 cm H2O positive end-expiratory pressure, and recruitment maneuvers (protective ventilation strategy). Modified Clinical Pulmonary Infection Score, gas exchange, and pulmonary functional tests were measured preoperatively, as well as at days 1, 3, and 5 after surgery. Patients ventilated protectively showed better pulmonary functional tests up to day 5, fewer alterations on chest x-ray up to day 3 and higher arterial oxygenation in air at days 1, 3, and 5 (mmHg; mean ± SD): 77.1 ± 13.0 versus 64.9 ± 11.3 (P = 0.0006), 80.5 ± 10.1 versus 69.7 ± 9.3 (P = 0.0002), and 82.1 ± 10.7 versus 78.5 ± 21.7 (P = 0.44) respectively. The modified Clinical Pulmonary Infection Score was lower in the protective ventilation strategy at days 1 and 3. The percentage of patients in hospital at day 28 after surgery was not different between groups (7 vs. 15% respectively, P = 0.42). A protective ventilation strategy during abdominal surgery lasting more than 2 h improved respiratory function and reduced the modified Clinical Pulmonary Infection Score without affecting length of hospital stay.

Lung protective mechanical ventilation strategies in cardiothoracic critical care: a retrospective study.

PubMed

Zochios, Vasileios; Hague, Matthew; Giraud, Kimberly; Jones, Nicola

2016-01-01

A body of evidence supports the use of low tidal volumes in ventilated patients without lung pathology to slow progress to acute respiratory distress syndrome (ARDS) due to ventilator associated lung injury. We undertook a retrospective chart review and tested the hypothesis that tidal volume is a predictor of mortality in cardiothoracic (medical and surgical) critical care patients receiving invasive mechanical ventilation. Independent predictors of mortality in our study included: type of surgery, albumin, H + , bilirubin, and fluid balance. In particular, it is important to note that cardiac, thoracic, and transplant surgical patients were associated with lower mortality. However, our study did not sample equally from The Berlin Definition of ARDS severity categories (mild, moderate, and severe hypoxemia). Although our study was not adequately powered to detect a difference in mortality between these groups, it will inform the development of a large prospective cohort study exploring the role of low tidal volume ventilation in cardiothoracic critically ill patients.

Comparison of invasive and noninvasive positive pressure ventilation delivered by means of a helmet for weaning of patients from mechanical ventilation.

PubMed

Carron, Michele; Rossi, Sandra; Carollo, Cristiana; Ori, Carlo

2014-08-01

The effectiveness of noninvasive positive pressure ventilation delivered by helmet (H-NPPV) as a weaning approach in patients with acute respiratory failure is unclear. We randomly and evenly assigned 64 patients intubated for acute respiratory failure to conventional weaning with invasive mechanical ventilation (IMV) or H-NPPV. The primary end point was a reduction in IMV duration by 6 days between the 2 groups. Secondary end points were the occurrence of ventilator-associated pneumonia and major complications, duration of mechanical ventilation and weaning, intensive care unit and hospital length of stay, and survival. The mean duration of IMV was significantly reduced in the H-NPPV group compared with the IMV group (P<.0001), without significant difference in duration of weaning (P=.26) and total ventilatory support (P=.45). In the H-NPPV group, the incidence of major complications was less than the IMV group (P=.032). Compared with the H-NPPV group, the IMV group was associated with a greater incidence of VAP (P=.018) and an increased risk of nosocomial pneumonia (P=.049). The mortality rate was similar between the groups, with no significant difference in overall intensive care unit (P=.47) or hospital length of stay (P=.37). H-NPPV was well tolerated and effective in patients who were difficult to wean. Copyright © 2014 Elsevier Inc. All rights reserved.

[Sedation with stimulative circadian rhythm in mechanically ventilation patients in intensive care unit].

PubMed

Guo, Jian-ying; Deng, Qun; Guo, Xu-sheng; Liu, Shuang-qing; Zhang, Yu-hong; He, Zhong-jie; Yao, Yong-ming; Lin, Hong-yuan

2012-07-01

To sedate the mechanically ventilation patients in intensive care unit (ICU) with stimulative circadian rhythm, and evaluate whether the protocol has advantages in recovering natural circadian rhythm, duration of mechanical ventilation, and length of ICU stay after weaning of sedation. A prospective random control trial was conducted. One hundred and twenty ventilated patients in ICU were randomly assigned to four groups: circadian rhythm (CR), daily interruption (DI), continuous sedation (CS) or demand sedation (DS) group, each n = 30. Given more complications, DS group was deleted after recruiting 10 cases and 90 patients were admitted ultimately. Patients' age, gender, body weight, acute physiology and chronic health evaluation II (APACHE II) scores, sedatives dosages, daily arousal time, duration of mechanical ventilation, length of ICU stay, complications (ventilator-associated pneumonia, barotrauma with intrathoracic drain tube) and untoward reactions (accidental extubation, reintubation, tracheotomy, death) were recorded, the biochemical indicators were determined, as well as number of nurses on duty at 10:00 and 22:00. The patients' sex ratio, age, body weight, APACHEII scores, duration of mechanical ventilation, length of ICU stay showed no difference among CR, DI and CS groups. The total sedatives dosages (mg: 5466.7 ± 620.4) and average sedatives dosages [mg×h(-1) ×kg(-1): 2.19 ± 0.61] in CS group were significantly higher than those in CR group (4344.5 ± 816.0, 1.00 ± 0.51) and DI group (4154.3 ± 649.4, 1.23 ± 0.62, all P < 0.01), and there was no difference between CR group and DI group. Daily arousal time in the CR group (hours: 4.40 ± 1.30) was significantly lengthened compared with that in DI group (0.59 ± 0.26) and CS group (0.15 ± 0.02, both P < 0.05). The complications showed no differences in each group, but incidences of the untoward reactions in DI group (2 cases) were significantly increased compared with that in CR group (1 case

The effect of helium-oxygen-assisted mechanical ventilation on chronic obstructive pulmonary disease exacerbation: A systemic review and meta-analysis.

PubMed

Wu, Xu; Shao, Chuan; Zhang, Liang; Tu, Jinjing; Xu, Hui; Lin, Zhihui; Xu, Shuguang; Yu, Biyun; Tang, Yaodong; Li, Shanqun

2018-03-01

Chronic obstructive pulmonary disease (COPD) is often accompanied by acute exacerbations. Patients of COPD exacerbation suffering from respiratory failure often need the support of mechanical ventilation. Helium-oxygen can be used to reduce airway resistance during mechanical ventilation. The aim of this study is to evaluate the effect of helium-oxygen-assisted mechanical ventilation on COPD exacerbation through a meta-analysis. A comprehensive literature search through databases of Pub Med (1966∼2016), Ovid MEDLINE (1965∼2016), Cochrane EBM (1991∼2016), EMBASE (1974∼2016) and Ovid MEDLINE was performed to identify associated studies. Randomized clinical trials met our inclusion criteria that focus on helium-oxygen-assisted mechanical ventilation on COPD exacerbation were included. The quality of the papers was evaluated after inclusion and information was extracted for meta-analysis. Six articles and 392 patients were included in total. Meta-analysis revealed that helium-oxygen-assisted mechanical ventilation reduced Borg dyspnea scale and increased arterial PH compared with air-oxygen. No statistically significant difference was observed between helium-oxygen and air-oxygen as regards to WOB, PaCO 2 , OI, tracheal intubation rates and mortality within hospital. Our study suggests helium-oxygen-assisted mechanical ventilation can help to reduce Borg dyspnea scale. In terms of the tiny change of PH, its clinical benefit is negligible. There is no conclusive evidence indicating the beneficial effect of helium-oxygen-assisted mechanical ventilation on clinical outcomes or prognosis of COPD exacerbation. © 2017 John Wiley & Sons Ltd.

Intraoperative protective mechanical ventilation and risk of postoperative respiratory complications: hospital based registry study.

PubMed

Ladha, Karim; Vidal Melo, Marcos F; McLean, Duncan J; Wanderer, Jonathan P; Grabitz, Stephanie D; Kurth, Tobias; Eikermann, Matthias

2015-07-14

To evaluate the effects of intraoperative protective ventilation on major postoperative respiratory complications and to define safe intraoperative mechanical ventilator settings that do not translate into an increased risk of postoperative respiratory complications. Hospital based registry study. Academic tertiary care hospital and two affiliated community hospitals in Massachusetts, United States. 69,265 consecutively enrolled patients over the age of 18 who underwent a non-cardiac surgical procedure between January 2007 and August 2014 and required general anesthesia with endotracheal intubation. Protective ventilation, defined as a median positive end expiratory pressure (PEEP) of 5 cmH2O or more, a median tidal volume of less than 10 mL/kg of predicted body weight, and a median plateau pressure of less than 30 cmH2O. Composite outcome of major respiratory complications, including pulmonary edema, respiratory failure, pneumonia, and re-intubation. Of the 69,265 enrolled patients 34,800 (50.2%) received protective ventilation and 34,465 (49.8%) received non-protective ventilation intraoperatively. Protective ventilation was associated with a decreased risk of postoperative respiratory complications in multivariable regression (adjusted odds ratio 0.90, 95% confidence interval 0.82 to 0.98, P=0.013). The results were similar in the propensity score matched cohort (odds ratio 0.89, 95% confidence interval 0.83 to 0.97, P=0.004). A PEEP of 5 cmH2O and median plateau pressures of 16 cmH2O or less were associated with the lowest risk of postoperative respiratory complications. Intraoperative protective ventilation was associated with a decreased risk of postoperative respiratory complications. A PEEP of 5 cmH2O and a plateau pressure of 16 cmH2O or less were identified as protective mechanical ventilator settings. These findings suggest that protective thresholds differ for intraoperative ventilation in patients with normal lungs compared with those used for patients